How We Defeated Tuberculosis : THE LAST CRUSADE : The War on Consumption 1862-1954 <i> by Mark Caldwell (Atheneum: $19.95; 288 pp.) </i>

In the 1800s, tuberculosis killed one seventh of the American population. But who beyond the morbidly curious would want to read its detailed history today? The answer lies in the analogies between the nation’s experience with TB and our current medical preoccupations: heart disease, cancer and AIDS. Mark Caldwell, a literary critic at Fordham University, has written a book that attempts to draw out the similarities by combining medical and social history with literary criticism.

The book’s strength is its ability to indicate how the image of TB in the popular mind and media both influenced and responded to developments in medicine. Much of Caldwell’s attention is focused on the rise of the sanatorium movement. A single sanatorium in 1885 grew to 889 separate hospitals and wings of hospitals with almost 100,000 beds by 1935. The author provides a very detailed examination of the movement’s leadership and day-to-day life inside the sanatoriums. Even now there is no clear assessment of whether sanatoriums did much good. A quarter of the patients died and half of those released succumbed within five years. Yet the movement was single-minded, and highly effective, in presenting itself as a great success.

Caldwell also presents much about the history of surgical and drug therapy for TB that is fascinating and will be of interest to lay and professional readers. For example, when Koch isolated the TB bacillus in 1882, he was ridiculed in The New York Times and completely ignored by the AMA despite the fact that both organizations were calling for an amalgamation of medicine and science in the battle against TB. Later when Koch’s claim to have developed a cure was shown to be fraudulent, the resulting scandal brought joy to leading American physicians who were strongly opposed to the inroads that bacteriology was making on medical science at the expense of pathology. Similar episodes of professional jealousy and greed have marked the history of TB therapies right up to isoniazid, the current “treatment of choice.”

Furthermore, Caldwell presents data that, while puzzling and troubling to him, clearly show that the impact of these drugs on TB mortality has been, like the sanatoriums, unclear. For example, we know that the death rate from TB started dropping by the mid 1800s. When good record-keeping began in 1904, it was 188 per 100,000. By 1945, when “effective” drug treatment was first introduced, the rate had already dropped almost 80% to 40 per 100,000. Yet in both the popular and medical mind, these drugs are held responsible for eradicating TB.

Caldwell is at his best in specifying how, despite all claims to the contrary, at every point in its history medicine’s approach to TB has been “improvisation.” Not surprisingly, the forms this improvisation took were often decisively influenced by the strivings of physicians, hospitals and public health authorities for money, status and the ability to control their patients. There are valuable descriptions of how TB doctors tried to control the most minute aspects of their patients’ mental and physical lives in the sanatorium, as well as their attempt to dominate the lives of the healthy by positing a vast range of “risk factors” for the disease which demanded all sorts of dietary, recreational, attitudinal and political monitoring and conformity.

The book’s weaknesses come in two areas. First is Caldwell’s attempt to integrate his analysis of TB’s appearance in literature as well as the diaries written by sufferers with the disease’s social impact and medical history. While this works well sometimes, it just as often comes across as forced and arbitrary. For example, we have no idea how representative the diary writers are.

More troubling is the author’s somewhat idealized view of medicine’s capability. The story he tells about medical “improvisation” and the lack of evidence that treatment has had much influence on mortality could be repeated for measles, scarlet fever, typhoid and a score of other diseases. Today, mortality from the leading killer of men, coronary heart disease, is rapidly falling and no one really knows why.

The tales Caldwell relates in this worthwhile volume are in no way specific to TB. Most hospitals for the chronically ill are “total institutions.” Medical specialties, institutions and researchers are often locked in bitter rivalries for money, patients and recognition. There are always those in and out of medicine who use illness as a way of stigmatizing its victims, or blaming them for its onset. And, of course, the poor always suffer most and are treated least. The analogies Caldwell seeks between TB and the afflictions of today exist in abundance. We may not like to hear it, but the history of medicine is the history of improvisation.