1.1.1: Tuberculous Metaphors

Susan Sontag’s Illness as Metaphor examines the ways sick individuals are viewed following a diagnosis with a disease. Written after her own experience with breast cancer, the essay reflects on how isolating and stigmatizing it was to go through chemotherapy treatment in the 1970s. She thought about the kinds of language that was used around cancer, and the ways the disease was represented in the contemporary discourse. Her essay was, also, a comparative one, using tuberculosis at the turn of the twentieth century as a foil. Tuberculosis was popularly conceived as a wasting disease, for Romantics, poets and artists who burnt out young, as they frenziedly lost weight until they were left bedridden and on death’s door (1.2.1). She writes,

TB sufferers may be represented as passionate but are, more characteristically, deficient in vitality, in life force. . . . TB is celebrated as the disease of born victims, of sensitive, passive people who are not quite life-loving enough to survive. . . . And while the standard representation of a death from TB places the emphasis on the perfected sublimation of feeling, the recurrent figure of the tubercular courtesan indicates that TB was also thought to make the sufferer sexy.¹

Figure 1. A photo of a girl selling Christmas seals. These stamps were used to fundraise for the National Association for the Study and Prevention of Tuberculosis, and are still sold as part of the American Lung Association’s yearly fundraising efforts. Knopf, S. Adolphus. Some Additional Notes on the Prevention of Relapses in Cases of Arrested Tuberculosis. 1921. Image courtesy of the New York Academy of Medicine.

Sontag played with popular imaginations of tuberculosis not only to comparatively reflect on the alienation she felt as a cancer patient, but also to think about how the sick are conisidered at a cultural scale: the ideas about specific diseases manifest in discourses outside the realm of medicine, scientific literature, and hospital wards. In some ways the essay fits well next to the critiques of Phillipe Ariés, Elizabeth Kübler-Ross, and Cisely Saunders, death studies thinkers who penned research in the post-war period that critiqued the medicalization of sick patients, and the mediation of death in medical contexts (2.1.4).² Biomedicine—the dominant medical knowledge system which guides contemporary discourses around health and wellness globally—has been attacked for decades because of its often cruel, ambivalent, and alienating practices. Sontag’s essay, as well as its follow-up essay on the metaphors around AIDS, critiques both the medicalization and isolation of cancer patients and the stigmas which swirl about the disease that emerge from both medical sources and the broader public’s understanding about the disease.

Tuberculosis is an excellent choice to use as a prop and contrast for Sontag’s essay. The disease is not a straw man in Sontag’s argument, as it is broad enough and so present in the public consciousness that, even after the advent of antibiotics, most people are aware of its history and cultural impact.³ Not unlike its recurring infection in the body of a patient, tuberculosis always returns: by way of the AIDS crisis, the advancement of drug resistant TB, and global inequities in care.⁴ The disease remains in the public consciousness, both in the recollections of loved ones who have memories of family members with the disease,⁵ but also in the ways tuberculosis is leveraged as a exclusion agent (1.3.5). Many of my colleagues who traveled to the United States for school have told me about the mandatory TB screenings they had to take before they could be allowed in the country.⁶ The popular imagination of the disease resides as an afterimage, nestled into discourses of public health, care standards, popular media, and xenophobic debates around immigration. This luminescent remnant was produced as a result of broader cultural, scientific, and governmental forces, which focused on tuberculosis in the late nineteenth century. Such images of tuberculosis were produced in equal measure by a change in knowledge around the disease (2.1.3), by the popularization of the sanatorium⁷ treatment (1.2.1; 1.2.3), by the adoption of germ theory (2.1.1; 2.1.2), by the emergence of public health approaches to medicine (1.3.1; 1.3.4; 1.3.5), and by an active volunteer network fighting to rid the nation of tuberculosis.

Figure 2. Children doing schoolwork in an open air school. In the winter they would study with the windows open to the outside air. The City of Chicago Municipal Tuberculosis Sanatorium had received a significant donation fo the heavy coats the kids are wearing in this photograph. City of Chicago Municipal Tuberculosis Sanatorium Monthly Bulletin. 1917-1924.

Figure 3. “The Little Red Cottage”, the first building in which Edward Livingston Trudeau treated patients at the Adirondack Cottage Sanitorium. Knopf, S. Adolphus. Some Additional Notes on the Prevention of Relapses in Cases of Arrested Tuberculosis. 1921. Image courtesy of the New York Academy of Medicine.

Figure 4. An image showing the fresh air cure. These images often contrast a more wild or untamed wilderness with some accouterments of relaxation, often an Adirondack chair or other lounging equipment. Jaquerod, Marc. Pulmonary Tuberculosis.Translated by Scott. London: S. H. Benson Limited, 1921.

Figure 5. An example of an architectural drawing as they appear in the tuberculosis corpus (X.1.0). Brandt, Lilian. A Directory of Institutions and Societies Dealing with Tuberculosis in the United States and Canada. New York, 1904.

Figure 6. An example of the way dirty spaces are shown in hygienic discourses around tuberculosis. The Charity Organization Society of the City of New York. A Handbook on the Prevention of Tuberculosis. New York: The Charity Organization Society of New York City, 1903.

Figure 7. Many of the sanatoria that served patients with tuberculosis were found in remote locations, and would require patients to travel to get to them. This remoteness gives their visual character a striking contrast to an urban setting of which the hygienic conversations were most concerned (1.3.1). Jabez H. Elliot. “The Anti-Tuberculosis Movement in Canada” The British Journal of Tuberculosis 4. 1910. 73-89.

This popular and social understanding was informed by, and in turn influenced, the scientific imagination of the disease. I use the phrase scientific imagination to stress the social construction of health (0.1.3),⁸ and to note the cultural influence of the disease prior to Robert Koch’s bacteriological studies (2.1.1; 2.1.2; 2.1.3), when it had been considered a hereditary, wasting disease.⁹ For the majority of the nineteenth century, tuberculosis was associated with those with an artistic disposition—the Romantic poet John Keats being the most cited example.¹⁰ Those with the disease were thought to burn bright and fast and be consumed over months or years. These conceptions of heredity, as well as ideas regarding a set limit of energy a human had in their lifespan, persisted into the twentieth century, with familial disposition to the disease becoming a central conceit for germ versus soil arguments¹¹—where the embodied disposition of a patient was thought to be more important for a tuberculosis infection than Mycobacterium tuberculosis itself (1.3.5).¹²

An imagined version of tuberculosis does not loom large in the medical memory alone, though. It is also present in the popular imagination, in part due to these cultural influences and in part due to its ebb and flow as a problem in global health.¹³ While readers of this dissertation may have lingering memories of the disease, it is also situated in a significant in a broader historical and cultural context which an interdisciplinary audience may only be aware of in passing.

Perhaps most important is that, in the development of the dataset for this dissertation (X.1.3), I found myself inundated with images that did not correspond to my own assumptions about medicine’s visual culture (1.1.2; 2.2.2). I had assumed that the majority of images would depict to the specimen at different scales—cellular images, wet specimens, and full body pathological portraits—and in different media—illustrations, photographs, and x-rays. What I did not expect was that scientific journals also published about sanatoria, arguing about the merits of specific floor plans (1.2.4); promoting their facilities (1.2.3); gazing at poor, disabled, or otherwise othered patients (1.3.1; 1.3.4; 1.3.5). They were looking at and defining the broader cultures around tuberculosis beyond the remit of the specimen.

Figure 8. This kind of publication and image was actually quite rare in the tuberculosis corpus (X.1.3), but represents kind of professional image that is otherwise absent. These images represent the medical researchers and workers in a professional, and explicitly higher classed, context. The American International Congress on Tuberculosis. New York: Medico-Legal Journal, 1904.



Figure 9. Some monographs have portraits of the author in the first few pages. This was not a universal practice, but not an uncommon one either. These images work to prove the authority of the writer, and correspond with the kinds professional posturing of prominent authors like E. L. Trudeau and Robert Koch. (1.4.1). Keyes, Thomas Bassett. The Renewal of Life: Arguments for Subcutaneous Injections of Oil in the Cure and Prevention of Senility and Disease: for Making of the Acme of Abundant Health, Stamina, Vigor, Vitality and Constitution; for the Cure of Consumption and Other Diseases, Particularly those of A Chronic Nature. Chicago: The Tubercule Press Bureau, 1909-1910.



Figure 10. Many of the illustrations in the image dataset that were made as graphics or cartoons during the 1920’s had iconography that directly reference the flapper culture of the period. Associating poor health outcomes with the young women tied to this imagery appears to be sexist in origin. Sigard Adolphus Knopf. An Alarming Increase in the Morbidity and Mortality of Tuberculosis Among Young Women. 1928. Image Courtesy of the New York Academy of Medicine.

This chapter, then, works to foreground the non-specimen images which litter the tuberculosis image data set (X.1.3). What does a child selling postage seals (fig. 1), an architectural floor plan for a sanatorium (fig. 5), an image of a filthy room (fig. 6), images of children studying in heavy coats (fig. 2), and a photograph of a cottage (fig. 3) have to do with the scientific understandings of the disease? What about a photograph of an idyllic mountain resort (figs. 4 & 7), a portrait of a doctor taken for a conference (figs. 8 & 9), or a graphic of a flapper dancing with death (fig. 10) have to do with the ways doctors saw and treated their patients?

Figure 11. The cover of an issue of The Journal of Outdoor Life. The Journal of the Outdoor Life: The Anti-Tuberculosis Magazine 14(9). New York: Journal of the Outdoor Life Publishing Company, 1917.

Figure 12. Mary Mack Blair’s publication shows before and after images of patients who traveled for a cure. Of note in this publication is that the images were taped or glued into place, rather than being printed on the page itself. Mary Mack Blair. Outwitting the "T.B. Bugs": A Little Message of Hope, Help and Common Sense for Those Who Seek Better Health. San Francisco: Cahill Publishing Company, 1920.

Early on in my research, I had assumed that scientific medicine was defined by the clinical gaze. This singular way of seeing the sick patient emphasizes contrasts between a healthy ‘normal’ anatomy and unhealthy ‘abnormal’ pathology, resulting in the alienation and objectification of a sick patient (1.1.2; 2.2.2). Visual culture scholars like Katherine Waldby, Jose van Djick, Erin O’Connor, and Lisa Cartwright have convincingly articulated the ways clinical visuality has been embraced in medical practice and in diagnostic technologies.¹⁴ My assumption was that most of the images in the corpus would correspond with the alienating, dehumanizing clinical gaze and its technological mediation in the clinical photograph.¹⁵ These images, being non-specimen images,¹⁶ were outside the scope of my initial research, but muscled their way in as a prominent practice which deserved attention.

This chapter addresses this surprising observation with a series of questions: what are some of the broader assumptions which encircle the treatment of tuberculosis? How are these reproduced in visual media? How do they display differing visual practices in the history of medicine (1.1.2; 2.2.2)? And in what ways do these images reinforce the classist, racist, and ableist ideologies in the health sciences (1.3.5)?

I ask these questions first because of the implicit connections between tuberculosis research and the other cultural actors producing images. Some of the visual material is closely related to scientific research, as with the cases of material in public-facing magazines published by sanatoria with research capabilities (The Sanatorium and the first few volumes of The Journal of Outdoor Life) (fig. 11). Other materials were linked to public health and volunteer organizations like the Anti-Tuberculosis Health League or the Charity Organization Society of the City of New York, and even more were public-facing books that were meant to help patients with tuberculosis find sanatoria, understand how to treat their loved ones, or provide knowledge regarding hygiene (1.3.4). Beyond this, even more images came from self-published or regionally published materials that may or may not have any association with the scientific discourses around the disease (fig. 12). This broad range of publications speaks also to a wide array of writers and readers. Where a visual practice—like the clinical gaze—may be trained by a majority of the actors in the discourse, many of the other actors—public health officials, volunteers, lay people, and patients—bring their own ideologies, preconceptions, and visual approaches into the broader conversation.

In this chapter I will wrangle the sometimes disparate threads which knot around the non-scientific representations of tuberculosis in this period. I pursue two arguments: first, in building on the excellent but narrow scholarship by my peers who analyze medicine and its ways of seeing, I stress a need to look at medicine’s visual cultures in the plural. Medicine has never practiced a singular visual culture, one overtly defined by the clinical gaze. By opening this discourse to competing, overlapping, contested visual practices, I encourage future scholars to explore the idiosyncratic visual modes leveraged by medical doctors, patients, and others working in healthcare.¹⁷ Moreover, where this chapter addresses tuberculosis, I acknowledge that the cultural landscape which emerged around other diseases—like the AIDS epidemic, cancer research, the 1918 influenza epidemic, or Covid-19—is quite different than the one I describe in this chapter. The modes of seeing and being seen in these discourses are probably quite different for these health crises, and they deserve equal attention. Future scholarship will help nuance, rebuke, or clarify the claims I make.¹⁸

To foreground the broader cultures around tuberculosis, I am going to follow three case studies—on the sanatorium (1.2.1), hygiene (1.3.1), and the medical practitioner at work (1.4.1)—to define some ideological through-lines which will reappear in the next chapter (2.0.0). In doing this, my hope is to articulate in clear detail the eugenicist and capitalistic ideas which were reified in the process of fighting the disease (1.2.4; 1.3.5). Concepts of class, ability, cleanliness, and health appear in relation to the cultural conception of tuberculosis, as well as the popular and scientific understandings regarding treatment. As Linda Bryder has argued, tuberculosis doctors in the early twentieth century “showed themselves to be very much a product of the middle-class society from which they came, with its fixed assumptions about the poor.”¹⁹ This chapter extends this claim to think about how discourses around the disease, made possible by medical professionals, patients, and the lay public, reinforced these structures. By examining the profusion of gazes which saw tuberculosis, patients with tuberculosis, the sanitarium, and the doctors themselves, this chapter expands and complicates medical vision beyond the clinical (1.1.2; 2.1.2).