Bargaining for Life - A Social History of Tuberculosis, 1876-1938  by Barbara Bates, MD, 1992.

Review by Del Meyer, MD

The University of Pennsylvania Press is publishing a series with the general topic of Studies in Health, Illness, and Caregiving in America under the general editorship of Joan E. Lynaugh.  Dr. Bates' book is the seventh in that series.

Bates introduces tuberculosis as the most common cause of death in the United States and in Western Europe throughout the nineteenth century.  During the last decade of the nineteenth century, there emerged a new optimism about the disease and more aggressive attempts to deal with it.  In 1882, Robert Koch discovered the tubercle bacillus, and as physicians and social leaders recognized that consumption was infectious, they promulgated new laws, educational programs, and institutions with which to combat it.  In 1885, Edward L. Trudeau opened the first successful sanatorium in the United States.  It was thought that, if TB was infectious, controlling the patientsí behavior and separating the afflicted from their families and from the rest of society could stop the spread of the disease.

Bates notes that historians have traditionally focused on either the medical knowledge of tuberculosis or on the social movement to control the disease.  The protagonists are usually physicians or social reformers who led the campaign against tuberculosis.  The story of the experiences of the patients, their families, and those who took care of the sick has been told in part.  A collection of letters preserved by Dr. Lawrence F. Flick, a tubercular himself, and his family helps to correct this deficiency.

Bates shows how anti-tuberculosis activities convinced both physicians and the public to support tuberculosis institutions through such methods as the Christmas Seal Campaign and films like The White Terror.  She also points out with graphs that the campaigns to control TB had little impact on the disease.  Henry P. Phipps, a steel industrialist, funded an institute in Philadelphia in 1903 that included a dispensary.  Dr. Flick, who had a life-long commitment to provide care for poor patients with TB, was its medical director and was able to serve a broader city community.  In 1910, Phipps became convinced that his institute could be properly run only by an elite research-oriented university.  When he transferred it to the University of Pennsylvania, Flick lost his position as director, and the institute gradually lost its commitment to patient care.

Dr. Bates, an internist and historian at the University of Pennsylvania, examines the development of scientific medicine, the growth of health-related institutions and voluntary organizations, the development of trained nursing, the calls upon government to provide medical care, and a highly competitive society in which opportunity was stratified by class, race and gender.  In this microcosm, she develops the interplay among individual experiences, family relationships, professional behaviors and interests, values, politics and social structure.

In a TB sanatorium, the patients always put on a mask when a doctor or nurse entered the room without a mask.  This stops the spread of TB in that room and is less intimidating to the patient who can see the faces of all visitors.  In this community, some hospitals require gown, gloves and boots in examining a tubercular patient.  It takes a long time to change behavior, as Dr Bates points out.  Letís hope this excellent, well-researched book with nearly 100 pages of endnotes and bibliography will help dispel some of the witchcraft around TB.