Amboceptor

Microbiological, virological, bacteriological, immunological, medical, epidemiological, historical, anecdotal

Tag: tuberculosis

Sure, put tuberculin in everyone’s eyes.

If you’ve worked in a health care facility, you’ve probably been given the tuberculin skin test. You get a little injection under the top layer of your skin, forming a bubble, and an allergic reaction means you’ve been infected in the past by the tubercle bacillus, or Mycobacterium tuberculosis as we now know it. If you haven’t been infected in the past, you’ll have slight discoloration and maybe slight pain.

Or it may mean you’ve been infected by another species of Mycobacterium. There’s a separate skin test for Mycobacterium avium complex, the “MAC infection” that’s becoming more common, but cases of M. avium often turn up positive from the M. tuberculosis test as well. The material used for the test consists of a purified solution of protein (PPD, or purified protein derivative) extracted from the bacteria.

* * *

The tuberculin skin test is also known as the Mantoux test, and has been for over a century, since Mantoux’s practical application of the hypersensitivity reaction discovered by von Pirquet. There were alternatives for much of that time, all variations on the theme of a small skin injection. The Heaf test, for example, was easier to administer consistently, and probably easier to interpret, but harder to manufacture.

And there were more unusual alternatives, early in the 20th century.

In 1908 three Philadelphia physicians, Samuel McClintock Hamill, Howard C. Carpenter and Thomas A. Cope reported the results of comparisons of several diagnostic tests for tuberculosis. These tests involved administration of tuberculin to different sites in the body: conjuctiva (Calmette); deep muscle (Moro); and skin (von Pirquet).

(from “Orphans as guinea pigs: American children and medical experimenters, 1890-1930” by Susan E. Lederer)

Conjunctiva? That’s… the eye, right? They put tuberculin in the eye, creating an irritation at worst, and a major allergic reaction and possible scar tissue if the test was positive? This was done to people, just as a screening test?

Indeed. Remember, back then a simple injection was not as trivial as it is now. Needles and syringes were not disposable, so the Pirquet test involved scarifying the skin and applying tuberculin into the wound. And if a routine injection led to a hospital-acquired infection, there were no antibiotics to treat it. Dropping some liquid in the eye was easier. More from Lederer’s monograph:

 The physicians explained that before beginning the conjunctival test, they were unacquainted with any adverse effects associated with the procedure. The ease of implementing the test (application of a few drops of tuberculin to the surface of the eye) and the relatively quicker results obtained thereby made it attractive to clinicians in search of an effective diagnostic tool. However, in the course of testing, several disadvantages quickly became manifest. The reaction produced a ‘decidedly uncomfortable lesion’ and in several cases, serious inflammations of the eye resulted. In addition, the possibility that permanent impairment of vision might result for several children worried the physicians.

The test proved useful, revealing that many of the children had had undiagnosed cases of tuberculosis. But it was unpopular.

from the Reading Eagle newspaper, 1910

from the Reading Eagle newspaper, 1910

* * *

What were the arguments for and against the eye test?

In the Journal of the Missouri State Medical Association (November 1908), L. M. Warfield explains that the skin test is more sensitive, as it gives positive results from people who have already recovered from tuberculosis, or who show no signs of disease.

tuberculin-warfield

This goes along with his instinct for which one is safer: “I have used the cutaneous reaction more than the ocular reaction, for the eye is too delicate an organ to be played with.”

Another complaint about Calmette’s ocular test is that it should not be done on eyes that are suffering any other malady, which is hard to guarantee. In the New England Journal of Medicine (August 27, 1908) Dr. Egbert LeFevre illustrates how complications may arise.

tuberculin-lefevre

* * *

Within the first year of its introduction the eye test for tuberculosis was already losing fans.

In February 1908, an article by Floyd and Hawes saw the eye test as safer than the skin test — they could be summarized to say “the advantages of the ophthalmo-tuberculin reaction over the cutaneous or subcutaneous methods is that it is absolutely painless, whereas both of the others are painful or disagreeable to say the least. Practically no constitutional symptoms follow the use of the eye, whereas in the subcutaneous test they are important to obtain and often very distressing, and also occasionally occur in the cutaneous method.”

Six months later, doctors were abandoning the procedure. T. Harrison Butler of Coventry, England laid out the empirical observations that changed his mind in the August 8, 1908 British Medical Journal.

tuberculin-butler-dangers

Further argument against the eye test came from L. Emmett Holt of New York, whose paper in the January 1909 Archives of Pediatrics (along with the Philadelphia one mentioned above) became a massive controversy when publicized by “anti-vivisection” activists. The title is a bit alarming. (“Babies Hospital” is now called Children’s Hospital of New York-Presbyterian.)

tuberculin-holt-columbia

According to Holt, not only does the eye test produce unnecessary discomfort, it’s actually harder to perform.

In ease of application there is a decided advantage in the skin test. The scarification is a trifling thing. The patient does not require continuous observation before or after, and the reaction lasts a considerable time. The ophthalmic cases need closer watching, the reaction is shorter and may be missed. It cannot be used well in ambulatory patients.

The 1909 Eye, Ear, Nose and Throat annual points out yet another practical limitation.

tuberculin-cocain

Still optimistic about the eye test, the New York State Journal of Medicine blames problems on improper technique.

In considering the ophthalmic test we must call attention to the fact that harmful results are in all probability due to the instillation of tuberculin into diseased eyes, to infection after instillation, or mechanical irritation, to the introduction of secretion by the fingers of careless patients into the untested eye and to the use of poor or faultily prepared tuberculin.

Calmette reports 13,000 instillations and states that in no case in which the tests were properly applied and controlled were there serious complications. Petit tabulated 2,974 instillations with no ill effects in 698 positive reactions. Smithies and Walker in 450 instillations in 377 patients had four stubborn reactions. It is wise to remind the profession that the eye needs to be thoroughly examined before the test is made and with the slightest abnormality, tuberculin should not be used.

It’s agreed that the test shouldn’t be given to people with any eye problems, and it can’t be given more than once on the same eye (in a lifetime?), and it shouldn’t be given to old people. And maybe you should keep some cocaine around to numb the eyes of children and “sensitive adults” so they don’t squeeze the irritant out of their eyes.

With all these limitations, you’ll have to learn how to use the skin test anyway. So you might as well use it all the time. By 1911 Theodore Potter of Indiana University writes that “the eye reaction has already largely fallen into disuse, being replaced by the von Pirquet test.”

The eye test is still good for cattle, though!

 

 

 

Can nose-picking give you lupus?

lupus-0-julius-bruess

As stereotype would predict (34% of the city’s residents were German as of the 1900 census), the Milwaukee Medical Journal had regular reports on what physicians were up to in the German and Austrian empires.

In addition to the dispatch from Marosvasarkely (a Hungarian city now part of Romania and called Târgu Mureș), Julius Bruess summarizes two German articles about “lupus”. There were two types of lupus at the time. He doesn’t need to specify which one, because only one is contagious.

lupus-1-resorcin

Here we see “lupus” grouped with “scropholoderma” and “tuberculosis verrucosa cutis” as skin conditions that can be treated with a paste containing resorcin, also known as resorcinol or 1,3-dihydrobenezene. “This paste destroys all lupus tissue, but does not affect the healthy tissues. After 3 days a scab is formed. After this, for several days, application of Kaolin compound.”

The pros and cons of resorcin were covered in a review by Augustus Ravogli in the September 5, 1891 Cincinnati Lancet-Clinic. Ravogli says it often causes as much dermatitis as it cures, but is useful for contagious diseases like impetigo. Wikipedia calls it a “disinfectant” and “antiseptic”, but says it’s now given for eczema, psoriasis, dandruff and even allergies, none of which are caused by infections.

But back to lupus. As suggested above, this form of lupus is one of the many cutaneous manifestations of tuberculosis. Even today, there are several important types of cutaneous TB, with “lupus vulgaris” the most common. It’s generally found in people who have already suffered from TB in the lungs. And from the 19th century to today it’s been described as starting out as a soft “apple jelly” nodule, eventually turning into ulcers or dry lesions similar to “scropholoderma” (scrofuloderma).

lupus-2-apple-jelly

The apple jelly nodule, in F.J. Gant’s Science and Practice of Surgery (1886) and Narasimhalu et al., Infectious Diseases in Clinical Practice 21(3):183-184 (2013).

* * *

Tuberculosis, also known as “consumption,” “phthisis,” or the “white plague,” was the cause of more deaths in industrialized countries than any other disease during the 19th and early 20th centuries. By the late 19th century, 70 to 90% of the urban populations of Europe and North America were infected with the TB bacillus, and about 80% of those individuals who developed active tuberculosis died of it.

For most of the 19th century, tuberculosis was thought to be a hereditary, constitutional disease rather than a contagious one. By the end of the 19th century, when infection rates in some cities were thought by public health officials to be nearly 100%, tuberculosis was also considered to be a sign of poverty or an inevitable outcome of the process of industrial civilization. About 40% of working-class deaths in cities were from tuberculosis.

(from Harvard University Library’s CONTAGION: Historical Views of Diseases and Epidemics)

In the 1880s it became accepted that TB was a contagious disease, thanks to the work of Robert Koch. Both his discovery of the “tubercle bacillus” and his preparation of sterilized extracts that can be used to test people for immune reactions against the bacillus. Thus the disease could be more objectively diagnosed… but not really treated, except by rest and fresh air in the sanatoria that quickly cropped up throughout the Western world.

Knowledge may not provide power, or freedom. In the absence of any effective treatment, it wasn’t necessarily helpful to find out that TB was unquestionably contagious. People tend to become more and more paranoid about ways we “know” the disease can be transmitted, whether AIDS via toilet seats and pay phones during the 1980s, or via dry sputum particles stirred up by street sweepers in the 1890s.

lupus-3-sprinkle

People also become fixated on ways we “know” the disease can be controlled. We rationalize draconian measures, ranging from segregating infected people in the Carville Leprosarium to pursuing siege campaigns against badgers. And just like the Wassermann test for syphilis, covered in our very first post, the Mantoux test for tuberculosis often provided unwelcome and unhelpful information, no matter how accurate. If someone has recovered from their symptoms, but tests positive, what does that mean? What are their chances of manifesting more symptoms? Will they ever test negative?

* * *

Another indication that the tubercle bacillus remains within the body, even after lung infection clears up, is when it reemerges as lupus vulgaris. Today in countries where TB is rare, we use “lupus” as shorthand for “systemic lupus erythermatosus”, but lupus vulgaris still exists. And though many investigations, from Dr. Henry G. Anthony in 1903 to Dr. Harry Keil in 1933, failed to find a conclusive link between TB and lupus erythematosus, there has never been a doubt about TB’s role in lupus vulgaris.

The last excerpt from the Milwaukee Medical Journal’s German dispatches:

A contribution to the hygiene of schools with reference to the jurisdiction of school physicians is furnished by Prof. Lassar in reporting a case in point on the etiology of tuberculosis of the skin. It is a known fact that teachers will with preference, in order to inflict a mild punishment, pull the ears of their scholars. This proportionately considered harmless encouragement may be followed by severe consequences. If the teacher is tubercular he cannot prevent impregnating his finger nails with sputum containing tubercular bacilli.

For any number of diseases, you could say “Hey, if you treat someone roughly and your fingers are contaminated, you might infect that person.” Right? Even in 1902 there was scarlet fever, tetanus, ringworm, the aforementioned impetigo, and so on. But to get people’s attention, you warned them about tuberculosis.

Prof. Lassar’s main case study, a woman who traced her longstanding case of lupus vulgaris back to a teacher’s habitual ear-related punishments, was picked up by some other journals. And he made one other point — which the Hahnemannian Monthly, for example, ignored, but the Milwaukee Medical Journal passed along to its subscribers.

lupus-4-sputum

Really, you COULD transmit any number of diseases by abusing the mucous membrane of the nose with the finger nails. But how often does it happen?

So you want to be an industrial glassblower

So, you’re interested in a job as a glassblower. That’s no surprise. For 50 years glassblowing has been a good way for a skilled industrial laborer to earn a comfortable living, and today as we enter the 1920s, demand for these workmen shows no signs of lessening. But what are the risks?

Since there are so many glassblowers around, it’s important for society to properly assess what diseases they are likely to suffer. Frederick L. Hoffman writes, in the 231st Bulletin of the United States Bureau of Labor Statistics (“Mortality from Respiratory Diseases in Dusty Trades”, 17th in the Industrial Accidents and Hygiene Series):

The hygiene of glass blowers with special reference to pulmonary tuberculosis is of exceptional interest as a labor problem in the glass industry. The number of blowers employed proportionate to the total number of wage earners is relatively large, and, from a wage point of view, the employment is of the first order of importance.

From this US government document we can see some statistics on the prevalence of tuberculosis in this population. It’s not so much that they are exposed to the bacteria to a high degree. But continual low-level lung damage by inhaling high-temperature air containing various dusts means that once the bacteria are inevitably inhaled, they have a place to roost. The lung equivalent of abrasions, you might say.

glassblowers-table-118

So they have higher mortality rates than men in general of the same age. With regard to tuberculosis in particular, here’s a table compiled by Prudential Insurance researchers.

glassblowers-table-119

Carboy blowing? Carboys are huge! It’s hard to contemplate the human lungs being the engines of inflation for one of these. Or thisHand Blown Monumental Demijohn.

Some other recent statistics, from the Chicago Tuberculosis Institute. This table is on page 153 of the July 1915 – June 1916 annual report of the Illinois Chief State Factory Inspector.

glassblowers-chicago-tuberculosis-institute

So as a glassblower you’re not as likely to fall prey to the dread tubercular bacillus as you would be as a marbleworker or upholsterer, but it’s a concern.

* * *

What about other lung conditions?

This turns out to be controversial. As a person with no medical training, I’d imagine that the risk factors for tuberculosis and emphysema are pretty similar. Inhaling poisons or microscopic things that damage the alveoli (alveoli are tiny air sacs which combine to make up a massive surface area for oxygen to enter the blood). However, the evidence regarding glassblowers suggests that the two diseases are uncorrelated.

In 1904 Prettin and Leibkind of the Stadtkrankenhaus Dresden-Friedrichstadt analyzed 230 glassblowers for an article entitled “Kann durch Glasblasen ein Lungenemphysem erzeugt werden?” JAMA (the Journal of the American Medical Association) deemed this an important finding, a perfect example of the sort of science-based result that supersedes old-fashioned beliefs that were based only on common sense.

emphysema-in-glass-blowers-1904

* * *

We already know that the southeastern regions of New Jersey are great for making wines and wine-related medicinal concoctions. Meanwhile southwestern New Jersey was a hotbed of glass production, as seen in the history of the large town of Glassboro in Gloucester County. To the northeast are two townships called Waterford and Winslow, both of which are named for large glassworks that existed in the 1860s.

In 2006 Erik Schwartz of the Cherry Hill Courier-Post wrote about the long-gone legacy of glass in areas including Waterford and Winslow townships. And in 1869 Dr. John Snowden sent in some observations about the health of workers at the Waterford and Winslow glassworks, included in the Camden County report (p. 134-136) in the Transactions of the Medical Society of New Jersey. “Phthisis” means tuberculosis.

trans-med-soc-nj-1868

A very interesting communication on the subject of Phthisis has been received from Dr. John W. Snowden, who had practiced for more than twenty-three years at the seat of two of the largest manufactories of glass in this State — at the Waterford and Winslow glass manufactories, where several hundred hands are employed in the manufacture of glass. Dr. Snowden says that among the glass-blowers themselves Phthisis is not at all frequent; but that many of these operatives suffer from emphysema of the lungs. But that among the batch-makers (those who prepare and mix the materials of which the glass is composed), and also among the pot-makers, who make the pots in which the glass is melted in the furnaces, Phthisis is very common indeed, and that few can follow this branch of the business for many years without being liable to Phthisis.

Dr. Snowden says that many of those men, months after they have been compelled by the progress of the disease to leave off work, expectorate with tuberculous matter small masses of German clay, one of the materials of which the pots are made. This undoubtedly being drawn into the lungs by inspiration, in a state of fine powder, and being insoluble, is deposited in the tissue of the lung, where it serves as a point of irritation around which the tubercle is first deposited.

So now glass-blowers don’t get tuberculosis, but they do get emphysema? I guess it depends on the facility.

There is a lot of clay powder involved in glass-making, that’s for sure. Here are the ads at the top of three straight pages of the August 25, 1917 National Glass Budget.

pittsburg-clay-pot-co highlands-fire-clay-co-st-louis laclede-christy-clay-products

* * *

Really, a lot of risks that apply to other glassworkers do not apply to glassblowers. In terms of health hazards, one of the longest assessments was written in this series of articles for insurance men, highlighting how to avoid physical accidents and the subsequent payouts for broken bones, burns, deafness, that sort of thing. I don’t know exactly what it means by “Live Articles”. Maybe it means “This is the current standard of what we expect”.

weekly-underwriter-1917-18

Here’s a typical illustration.

carrying-sheet-of-glass-wrong-way

The Travelers Insurance agent who wrote “Glass Manufacturing Hazards” for this series agrees that emphysema is not a major problem for glassblowers, despite what one might expect. The men who work with the raw glass ingredients, and the “bottle-breakers” who smash undesirable glass so it can be re-melted, are more at risk for this — as they are for skin irritation, painful abrasions, burns from molten glass, and foot lacerations.

Glass-blowers do sometimes break their teeth when the iron blow-pipe strikes some hard object. They slip on the smooth, worn wooden foot-benches that are often without railings. They drink too much water, causing cramps. They get blisters, which should, but usually aren’t, dealt with by puncturing the blister with a needle threaded with white sewing silk, to provide drainage before the blister bursts. And they get infectious diseases from the shared water cup used to cool down between blows, and more importantly, from the shared mouthpiece on the blow-pipe. This has been the subject of several studies. Studies of syphilis.

* * *

The first link between glass-blowers’ pipes and syphilis I can find is from 1862, when the British Medical Journal relayed a report from France. Apparently in “Giers and Vernasion” (which probably means Rive-de-Gier and Vernaison), transmitting diseases is virtually inevitable because the normal procedure is for three men to collaborate (taking turns in quick succession) on blowing a single piece of glass. Is this the normal method? Anyway, this leads to the men giving each other “the three syphilitic disease of the mouth”.

1862-syphilis-bmj

In a 1904 issue of the Indianapolis Medical and Surgical Monitor, Dr. Nelson D. Brayton of the Indiana Medical College collects a large number of reports under the title “Syphilis, a Non-Venereal Disease”. Along with dozens of other anecdotes of people acquiring the dreaded disease through innocent means, he mentions a 162-person outbreak of syphilis among glass-blowers, along with other professions where people risk disease by putting common instruments in their mouths (assayers, weavers, goldsmiths, train conductors, music teachers).

In his 1906 dissertation at the University of Würzburg, Joseph Kaesbohrer described 290 cases of syphilis in which the first observed chancre (hard sore) was seen in the tonsillar region. These frequently occurred from kissing and from nursing, as well as from medical instruments, shared eating utensils, and tobacco pipes. In a summary in the Medical Review of Reviews, the only occupation listed as a risk factor is glass-blowing. So be cautious. But should you acquire this or other so-called venereal disease from your blow-pipe, don’t fear rumors and innuendo, as Kaesbohrer found that “sexual perversion, which many have assumed to be a frequent cause, is, as a matter of fact, an infrequent cause of tonsillar chancre.”

* * *

Depending on what sort of glass works you find yourself in, the risk factors can be different. Most glass doesn’t have lead in it, but some does, and that’ll be bad if it ends up in your lungs, as seen in this 1920 case from Italy.

Unshielded eyes are at risk for “glass-blowers’ cataract”. One reason why we can’t see long-wavelength “infrared” light is that the lens of the eye absorbs this light instead of letting it through to the retina where we could perceive it. Long-term exposure to this light, which we can sense only as heat radiation, can lead to a forty-year-old having the cataracts of a man of eighty. According to the Illinois Medical Journal, the eminent Dr. de Schweinitz can look at the clouding of a furnace-worker’s eyes and tell if he is right- or left-handed.

Finally, a health consequence of glassblowing that may be the most obvious of all if you know someone who’s spent a couple decades in the job. From The Sanitarian, March 1892:

According to Le Progres Medicale, the Societe de Biologie, of which M. Brown-Sequard is president, received from M. Regnault, of Marseilles, at its session on November 7th, 1891, a communication on a disease which is met with in about one third of the workmen. This condition does not attain complete development until the men have been from ten to fifteen years in the business. They are taken into the glass factories, usually, about fifteen years of age; and at first the young workmen complain of great fatigue and a painful feeling in the cheeks which extends to the ears; later, the cheek becomes gradually weakened, is easily puffed out, and the deformity, of which the cases presented were in an advanced stage, progresses steadily. This deformity is caused principally by the weakness of the buccinator muscle, whereby the cheek becomes swollen and permanently enlarged.

The swelling is limited by the masseter muscle. There is also a special dilation of the duct of Steno, the calibre of which is increased and the orifice enlarged. This duct is filled with air, which may be forced out by pressure on the external surface, when a distinct gassy sound is heard.

In short, after years of glass-blowing, your face may be altered. The buccinator muscle is weakened, the cheeks expand into jowls, and the inner mucous lining “is thrown up into vertical and circular folds, giving it an appearance which has been likened to that of a tobacco-pouch.”

Neither M. Regnault of Marseilles nor Dr. Liaras of Bordeaux, summarized in “The Mouths of Glass-Blowers” in the June 1898 Medical Bulletin, see these altered facial features as a serious problem. But in severe cases, the primary salivary duct (the parotid duct, a.k.a. duct of Stensen, a.k.a. duct of Steno) is forced open by the intense pressure in the mouth, and it becomes dilated, forcing air into the salivary gland. I can’t imagine what that feels like. Maybe not painful, but certainly weird. It sounds like a fun party trick to be able to puff up your salivary glands on command… but when it happens unbidden at work, it’s a problem. The final citation on this subject comes from JAMA of November 23, 1912.

jama-glass-blowers-tumor

So, the word “Tumor”. This is not “tumor” as in cancer, it’s the form that simply means “swelling”. As in the four elements of inflammation, rubor/calor/dolor/tumor, defined by Celsus in the first century A.D. Air goes into the parotid gland, and then you have “tumor” in the parotid gland. As described here by the surgeon Narath, you may have to quit your job if the “chronically stretched duct and gland” get too bad. But you’ll always have the party trick.

* * *

And one more thing. Yet another German article paraphrased by a English-language journal, in this case the March 1899 Canada Lancet.

luxation-of-eye-from-blowing-the-nose

“Luxation of the eye”? “Proptosis”? Does that mean… yes, just search for some images. So with your newly enhanced lung power as a glass-blower, just make sure that when you sneeze, really let that sneeze escape. Don’t keep it bottled up, if you value your eyeballs’ position behind their eyelids. And good luck!

Asheville: Paradise of Pestilence

A hundred years ago Asheville, North Carolina contained possibly the biggest concentration of sanitariums* and other tuberculosis facilities in America, including resorts, hospitals and boarding houses catering mostly to sufferers of the consumptive disease. The known healthful ozonic properties of mountain air, the nearby hot springs (in Hot Springs, 30 miles north), the coming of the railroad in the early 1880s, the city’s comfortable position between the climatic nightmares of North and South, and the enthusiasm of wealthy families like the Vanderbilts and the Groves made this small city the trendiest place to try and reverse the wasting effects of phthisis.

The National Register of Historic Places’ booklet about Asheville has a brief, very good section about Asheville’s role as resort and health destination. From the link:

Dr. Joseph Gleitsmann, a German born and trained doctor, arrived in Asheville to establish the Mountain Sanitarium for Pulmonary Diseases. … Gleitsmann systematically studied the United States and “selected Asheville as having an optimum combination of barometric pressure, temperature, humidity and sunlight” which he believed to be conducive to healing tuberculosis. Gleitsmann is credited with helping to establish Asheville as a center for tuberculosis treatment, not because of his sanitarium, but because of the many articles he wrote and talks he gave at medical gatherings promoting the benefits of the Asheville climate

from Knopf's 1899 "Pulmonary Tuberculosis"

from Knopf’s 1899 “Pulmonary Tuberculosis”

A typical assessment of Asheville’s charms is found in an 1899 book called Pulmonary Tuberculosis: Its Modern Prophylaxis and the Treatment in Special Institutions and at Home. In this work, Dr. Sigard Adolphus Knopf goes through all aspects of the disease, including history, symptoms, contagion, prevention, sanitary laws, and all kinds of ideas for treatment, along with a list of good sanitariums and details on how the best ones function.

Knopf sez (pp. 173-175):

The view from the sanatorium is one of surprising loveliness – a panorama of city, rivers, valleys, forests, and distant mountains. The building is a substantial and ornamental structure, of three stories and basement, designed for sanatorium purposes, and contains eighty rooms. The appointments are modern, with elevator, electric lights, etc. The basement, which is on the level of the ground, is devoted to the bath establishment and gymnasium, including a swimming-pool. The house is provided above and below with numerous sunny, sheltered verandas and porches.

The grounds consist of fifteen acres of park land covered with an open growth of handsome oaks, interspersed with pines. The adjacent territory is especially suited for exercise on foot or horse-back, mountain-climbing, etc.

The treatment in the sanatorium is, of course, the hygienic and dietetic, with all its various adjuncts (hydrotherapy, massage, etc.). The sanatorium is bountifully supplied with remarkably pure water for drinking and all other purposes, from its own spring, the large stream from which does not vary perceptibly in quality or quantity during wet or dry weather. In addition, the perfect system of sewerage will be flushed with water form the city water-works, and all sewage, after having been disinfected, will be discharged into the French Broad River, one mile away.

Sounds pretty nice. And yet, Dr. George D. Barney takes a rather more cynical approach in an essay for the July 15, 1899 issue of the weekly New York Medical Journal, volume 70 (pp. 86-90).

phthisis-its-aetiology-and-treatment

“Phthisis” isn’t exactly a synonym for “tuberculosis”. It refers to the progressive wasting and weakening that happens late in infection. If you get infected by tuberculosis and manage to nip it in the bud, you can avoid phthisis. Also I don’t think it refers to complications outside the lungs, like osteomyelitis. But I’m no medical historian. (Well, I am an amateur historian, I guess. I’m no expert.)

Anyway, Dr. Barney’s piece first goes through the best ways of treating tuberculosis, and then starts denigrating lazy doctors and charlatans who provide false hope and recommend unnecessary therapy. Here’s an excerpt:

It is a mistaken idea to send patients that are advanced into the second and third stages of the disease off on a globe trot when rest and home comforts are in greater demand. I do not believe in the specific curative quality of any climate, but do believe very strongly that it is essential to the majority of phthisical patients to be treated and cured in the same climate that they have to live and work in after their restoration to health.

The features of “consumptive resorts” are greatly overestimated and dangerous. Asheville, North Carolina is no exception. … Asheville, North Carolina, is a city where thousands of phthisical patients gather from all over the country, the majority being in the second and third stages of the disease. These poor, misled patients are advised to go to Asheville, because “a change of climate will cure them,” and so they make every effort possible to reach that haven; and the home physician draws a sigh of relief when they have gone.

And so the patient arrives in Asheville to find thousands there for the same purpose–i.e., “to be cured without physician’s aid, as climate will do it all.” Here we find thousands without a medical adviser, going about the city streets, depositing expectoration that contains millions of tubercle bacilli upon the sidewalks every few feet, which, being exposed to the sun’s rays, dry and pass off into the atmosphere, to be inhaled into the air-passages of the inhabitants. Flies alight upon these deposits of expectoration and then go from dinner table to dinner table, drop into the milk, alight upon prepared food, and so infect the masses. Such a state of affairs is most dangerous, and the profession should know the condition, that they may govern themselves accordingly.

The concerns about dust and flies are overblown, but still, this does not sound so great. Those who can afford a sanitarium enjoy clean sheets, nourishing provisions, clean floors, and so on. But then there are the boarding houses, and people who rent out a room, and surely some desperate people camping outdoors, all drawn to the promise of wholesome climatic healthfulness.

At some point both nature parks and fine restaurants, when they get too crowded and noisy, go from alleviating your workaday stress to aggravating it. This would be even more true with a health resort, even though you supposedly benefit just by spending time in the place, rather than by pursuing any particular course of healthful activities.

T.E. Linn, a doctor who lived and practiced in Asheville, is aware of these concerns. But in a piece for the February 1901 Medical Century (volume IX, issue 2, pp. 46-48) he pooh-poohs the horrors of contagious flies or dust or food miasmas:

Asheville has well deserved its reputation as a mecca for the consumptive: as thousands of them have been restored to health here, some of whom had been well advanced in this disastrous disease. The objection is raised by some that there being so many consumptives here, it would be dangerous for the pleasure-seeker or tourist to visit here. This is greatly exaggerated, as I for one can not believe that this disease is so contagious or infectious as that would indicate. I base my opinions upon this fact, that there are hundreds of families here who have had dozens of the most advanced cases of phthisis in their homes, as boarders, year after year for ten or twenty years, and not one member of those families, to my knowledge, has contracted phthisis.

On the other hand, he seems somewhat doubtful of the germ theory of disease in the first place.

If phthisis be on the increase, I would certainly look for other causes than contagion. … As long as people neglect the most ordinary laws of healthy and hygienic dressing, so long will this disease develop. So long as our tenements are crowded, poorly lghted by the sun’s rays and poorly ventilated; so long as people are ill-fed and bolt their food; so long as the house is so improperly heated in cold weather, and so long as the climate shall be so changeable,– just so long will there be thousands dying each year from phthisis.

How seldom, comparatively, do we find this disease among the farming element, and when we do, it can almost invariably be traced directly to neglected colds. Another factor which may be a cause is the prevalance of indigestion among the country people, owing to coarse food and the habit of cramming the stomach with such food in five minutes or less.

Farmers and their families, as a rule, have enormous appetites from working in the fields, and then sit down to their meals greatly fatigued and eat rapidly great quantities of pork, cabbage, radishes, cucumbers, corn and pie, drink several glasses of cold water to hasten the food to the stomack without masticating it sufficiently, and then getting up from the table, being as they so often say “full up to the neck,” are in a few moments hard at work. No wonder that the great boon of the quack and patent medicine man is the farming element.

Yeah! Farmers, stop stuffing your faces with cucumbers and pies, and you won’t end up poisoning yourself by swilling Father Nazarian’s Rheumatic Cure or Mayr’s Wonderful Stomach Remedy. But at least you don’t have to worry about phthisis.

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In the end, it’s really the judgment of the marketplace that determines whether a town becomes more livable by being filled with consumptives. Revealed preference will dictate whether the concentration of such people becomes a nuisance that outweighs the salubrious air, elevation, barometric pressure, breezes and so forth. And for that sort of data, we turn to The Survey, a “Journal of Constructive Philanthropy” published by the Charity Organization Society of New York.

“Charity Organization Societies” were founded in many cities in the late 19th century, as part of an effort to use economic principles to stop wasting the money and effort of well-wishers. Modern enlightened charities would direct charitable resources to people who could potentially be pulled out of poverty rather than hopeless cases and moral degenerates, and also try to get able-bodied people to work for their handout without establishing Dickensian workhouses of enslavement. In the June 12, 1909 issue of The Survey (volume XXII, issue 11, page 422), an unknown writer points out that in Asheville and other cities, real estate convenient to sanitariums has gone way up in value in the years since the cities became known hotbeds of tuberculosis treatment.

the-survey-sanatoriums

At Aiken, S.C., property in the neighborhood of the local sanatorium has increased 400 per cent since the institution was built. At Hebron, Me., surrounding property has increased twenty per cent as a direct result of the presence of a tuberculosis sanatorium. The effect upon land values has been similar in Luzerne, Pa.**; Liberty, N.Y.; Saranac Lake, N.Y.; Pittsford, Vt.; Mt. Vernon, Mo.; and Silver City, N.M. At Asheville, N.C., vacant lots near one of the sanatoriums sell at four times their price in 1900, and others farther from the institution but nearer the city are less valuable.

There you have it. There was probably a burst in this property bubble, but I don’t know where to look for evidence. Asheville did try to shift its economy from “medical tourism” to “tourism in general”, with the pivot point probably being the July 1913 founding of the palatial Grove Park Inn. Here’s a good article by Jason Sandford of the Asheville Citizen-Times, from July 2013.

…before he pulled up his St. Louis stakes and moved to Asheville to build his grand hotel, the Grove Park Inn, wealthy pharmaceutical-maker Edwin Wiley Grove began working to turn city leaders away from that idea and toward better serving tourists.

“Grove was one of the individuals who recognized what a mistake that would be, that Asheville could literally become a leper colony for tuberculosis,” said Bruce Johnson, author of two books about the history of Grove Park Inn, which opened 100 years ago this month.

Asheville was one of the hardest-hit cities by the Depression, as voluntary tourism was not as recession-proof as medically prescribed tourism. But it continued to be a city!

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* “sanitorium”, “sanitarium”, “sanatorium” are all the same word. I can’t stand ambiguous spellings, and there aren’t many in English, but this is one.

** A note to those who, like me, grew up five miles from Luzerne, Pa., and recognize it as a small town on the edge of Wilkes-Barre’s suburbs, with no particular bucolic attributes or beauty of setting, currently containing nothing of note but Hops & Barleys and a lumberyard. You’re probably right in doubting it was once a health resort. I can find no evidence of a “Luzerne” sanitarium other than the one in White Haven, a far more picturesque and out-of-the-way location in Luzerne County, which may not technically be in the Poconos but is close enough.