THE AILING CITY

Health, Tuberculosis, and Culture in Buenos Aires, 1870–1950By DIEGO ARMUS

DUKE UNIVERSITY PRESS

Copyright © 2011 DUKE UNIVERSITY PRESS
All right reserved.
ISBN: 978-0-8223-4999-0

Contents

LIST OF FIGURES…………………………………………………………………………………ixACKNOWLEDGMENTS…………………………………………………………………………………1INTRODUCTION A History of Tuberculosis in Modern Buenos Aires……………………………………….23ONE. People with Tuberculosis Looking for Cures…………………………………………………….49TWO. From Being Sick to Becoming a Patient…………………………………………………………84THREE. Unruly and Well-Adjusted Patients…………………………………………………………..115FOUR. The Fight against Tuberculosis and the Culture of Hygiene………………………………………141FIVE. The Obsession with Contagion………………………………………………………………..189SIX. A Disease of Excesses……………………………………………………………………….221SEVEN. Immigration, Race, and Tuberculosis…………………………………………………………251EIGHT. A Female Disease………………………………………………………………………….276NINE. Forging the Healthy Body Physical Education, Soccer, Childhood, and Tuberculosis………………….307TEN. Tuberculosis and Regeneration Imaginary Cities, Green Spaces, and Hygienic Housing…………………345EPILOGUE……………………………………………………………………………………….351ABBREVIATIONS…………………………………………………………………………………..353NOTES………………………………………………………………………………………….397SELECTED BIBLIOGRAPHY……………………………………………………………………………409

Chapter One

People with Tuberculosis Looking for Cures

At the beginning of the twentieth century, the reputable physician Clemente Álvarez described what he called the “via crucis of the tubercular”:

First, an apparently insignificant cough is treated, at best, with home remedies or expectorants obtained after consulting with the pharmacist. When symptoms worsen, or when one is alarmed by a bloody cough, the sick person goes to the doctor. This usually happens several months after the onset of the disease. Once the diagnosis is confirmed, the via crucis of the tubercular begins. On the one hand, treatment requires quitting one’s job, rest, fresh air, good diet, good hygiene. On the other, the overwhelming demands of the home force the sick person to keep working in order to support his family. Compromises are made; work is temporarily suspended, objects of value pawned, and friends and relatives are asked to contribute as much as possible. As soon as his condition improves, the person with tuberculosis goes back to work to make up the losses. But tuberculosis is unforgiving: soon, the person falls sick again, his condition just as bad as before or even worse. Relapses vary in number and duration according to the intensity of the infection and the patient’s lifestyle. Some people know that city life affords little chance of recovery, and manage to spend a season in the countryside …; however, this does them little good. Short stays, lack of medical supervision, and the concerns about leaving the family behind make this solution largely useless …; next, patients are admitted to the hospital, which are generally overcrowded … there, they wait-usually not very long—for death.

The gloomy scenario described by Álvarez still persisted in the 1920s. Hospital statistics in Buenos Aires show that few tubercular inpatients were cured. At the Hospital Tornú during late 1920s, for instance, 80 percent of hospitalized tuberculars died. Fear was rampant and resilient among those who survived. Perhaps that is why the doctor Antonio Cetrángolo wrote in the mid-1940s that “having, or having had tuberculosis, changes people’s lives,” an observation he illustrated with the case of one of his former patients who, twenty years after being cured, still wrestled with the idea of how to keep on living in a supposedly disease-infested city like Buenos Aires.

Tuberculosis challenged biomedicine until well into the 1940s. Early diagnosis was difficult, and there were many entirely asymptomatic but ultimately fatal cases. Frequent coughs and sputum, irregular appetite, paleness, and weight loss were some of the possible signs. Only fever was a definite symptom, though it was hard to record at that time and hardly a sure basis for diagnosis. Once diagnosed, tuberculosis could be acute and advance rapidly, leading to death within a matter of weeks; or chronic, slowly weakening the patient over the course of several years; or moderate and controllable but with further recurrences. Of mild cases, particularly those detected early, it was said there was a 50 percent chance of being cured.

Thanks to antibiotics, in the late 1940s and early 1950s the slow decline in the tuberculosis mortality rate since the beginning of the century accelerated, but morbidity remained constant, and people lived longer after contracting the disease. In those years treatment by medical professionals likely displaced that by nonprofessionals. Between the 1870s and the late 1940s the experience of tuberculosis was marked by a lack of effective therapy. Commonly, every tubercular, once home care and self-medication had proven insufficient, devised his or her own course of therapy. These attempts at finding a cure did not follow pre-established steps and were not necessarily practiced by other people with tuberculosis. They could include treatments provided by healers, herbalists, and quacks as well as institutional care at hospitals, sanatoriums, neighborhood antituberculosis dispensaries, and, for those who could afford it, visits to doctors’ offices.

Perhaps sick persons with some exposure to formal education were less willing, from the beginning of their recovery efforts, to try alternative treatments. However, once so-called acceptable cures had failed, few could resist trying alternative ones. In any case, over the course of the first half of the twentieth century institutionalized health care became more and more dominant. Biomedical therapies offered a remarkable variety of remedies—some dubious, some innocuous, and some even harmful. Doctors often resorted to changing the medication in order to generate some improvement derived from the psychological action of the change. They might prescribe balms, pills, and invigorating tonics advertised in the newspapers and available at drugstores. In addition, throughout this period doctors recommended the rest cure in the mountains; or an array of preventive or supposedly curative resources, from eating crushed eggshells and inhaling crushed garlic to being injected with sucrose, gold, and calcium salts; or serums and vaccines that were all the rage but only for a single season; or heliotherapy, exposing the body to sunlight; or, starting in the 1920s, specific surgical interventions in the lungs.

Most certainly, from the 1870s to the 1950s death from tuberculosis and health care for people with tuberculosis entered the realm of medicine. In 1880 “terminal consumptives” or the chronically sick could not access an impoverished and precarious, if not downright pathetic, hospital infrastructure. In 1900 the hygienist Samuel Gache reported that rich people with tuberculosis went to great lengths to die at home. However, as the twentieth century proceeded, fewer people died at home, many more died in hospitals, and the figures of the doctor, the nurse, and the social worker became more influential. For the wealthy, home care was followed by seasons in the Swiss Alps, luxury hotels, and private sanatoriums in the city or in the countryside, preferably the Córdoba foothills. Middle-and working-class tuberculars who were able to get some treatment found institutionalized health care restricted to dispensaries and hospitals in Buenos Aires; boardinghouses; or less expensive, sometimes free, Córdoba sanatoriums, usually managed by the state, private individuals, or mutual aid and philanthropic organizations. At least in theory these institutions shared an ambitious agenda aimed not only at curing the sick, but also at radically reforming their lifestyle.

Yet before such institutionalized therapies became real alternatives in the tuberculars’ search for a cure, home medicine and self-medication were the two most obvious ways to confront tuberculosis.

Domestic Care: Home Remedies and Over-the-Counter Medication

Remembering his medical practice in poor and middle-class neighborhoods in Buenos Aires during the 1930s and 1940s, José Alejandro López wrote, “If an adult gets sick or has a fever, he’s put to bed, given an aspirin and, if in a couple days he doesn’t get better, a doctor might be called.” His words reveal how medicalization had expanded but also the limits of that expansion. In the intimate environs of the tenement room or the single-family home, the sick, before they consulted a doctor or went to the hospital, were not yet patients. They were, rather, individuals facing more or less confusing symptoms, usually connected at the beginning with ordinary, familiar pains.

The sick person received first aid and attention at home, from cloths soaked in vinegar to potato slices placed on the temples, cups of tea, remedies that could be bought without doctors’ prescriptions at the neighborhood drugstore, and leftover medicines people had from previous bouts of similar symptoms. Also at home some very specific antituberculosis prevention measures were taken. María L., whose mother was the youngest of five and the only one not to die of tuberculosis, recalls being forced to “drink cod liver oil mixed with an egg yolk, sugar, and port every day, or to eat finely chopped raw liver that was buttered to make it easier to swallow.”

Tuberculars with mild cases who could keep working at least for awhile were, to a great extent, home tuberculars whose care was in the hands of their families and neighbors. By the mid-1930s, the popular biweekly magazine Ahora referred to them and elaborated on the home care scenario, indicating that reactions to having a person with tuberculosis in the house went from “understanding and solidarity to marginalization and rejection.” Also around that time some doctors—highly critical of the idea that tuberculosis was a very contagious disease—didn’t hesitate to encourage “wives to give their husbands the most attentive care at home, without fearing for their own health.” Among wealthy families tuberculosis home care consisted of hygiene, relative isolation, a good diet, rest, and the services of trained nurses. Among the less wealthy things were much more complicated. Medical booklets urged people to think about caring for a person with tuberculosis as a collective endeavor: the sick person and his or her relatives had to learn the rituals of rest, of ventilation, and, especially, of personal hygiene, such as properly disposing of a sick person’s collected sputum on a daily basis; washing the bed sheets, handkerchiefs, and food utensils separately from those of the rest of the family; and disinfecting the room frequently. However, and despite the discipline of the sick person and the vigilance of the relatives, poor living conditions often worked against such efforts. The physician Eduardo Wilde had warned in a turn-of-the-century hygiene manual about this, pointing out that “in a working-class family where the father has tuberculosis, hygiene is inevitably overshadowed by hardship, poverty, and the risks of contagion.”

Other factors contributed to making the household the primary site of health care for tuberculars. In the last third of the nineteenth century and the first years of the twentieth many people, including doctors and the infirm, rejected hospitals as places where one could catch other ills and even die. This attitude also contributed to the widespread preference for home care. In the 1920s, once those prejudices had been overcome, hospitals were overwhelmed by the increasing demands of the chronically ill, most of them with tuberculosis. But because of hospitals’ inability to meet these demands, the household once again became a central site of primary health care. In any case, home care for a person with mild tuberculosis was the least onerous option for the family budget, an option supported and encouraged not only by common sense but also by home medicine and home economics manuals, radio broadcasts focused on health issues, and the growing supply of over-the-counter medications.

An article published in 1915 in the magazine El Hogar acknowledged the importance of home medicine. It stated that “medical knowledge has become so popularized that is difficult to find a home where it is not applied, whether correctly or incorrectly … and the cause for the voracity [for this knowledge] should be found in tuberculosis.” The article ended by inviting the reader to become an active agent of his or her own health care and that of his relatives: “The sick person and his family must actively collaborate with the doctor and the hygienic and sanitary ordinances, rather than mechanically carrying out orders and indications; … people must be capable of recognizing symptoms and signals that announce health problems … and everybody must have the rudiments in order to avoid tuberculosis contagion.”

Home medicine manuals were available during the second half of the nineteenth century and well into the twentieth. Medicina doméstica o sea el arte de conservar la salud, de conocer las enfermedades, sus remedios y aplicación al alcance de todos (which translates to “domestic medicine, or the art of preserving health, recognizing illnesses, their remedies and application within the reach of everyone”) circulated in Buenos Aires during the 1850s. Its lengthy subtitle underlined its role in helping everyone preserve health and recognize and cure diseases. In the 1870s the Diccionario de medicina popular y ciencias accesorias by Pedro Chernovitz recommended raw meat, wine, and liquor as a remedy for phthisis and tuberculosis. The Almanaque medical y guía para la salud by Dr. Jayne recommended “Jayne’s Expectorant, a remedy that could be bought at drugstores and administered at home” following the instructions given in the almanac. In 1918 El médico en casa: Libro para las madres by Hugo W. O’Gorman proposed homemade medicines as a complement to doctors’ services. In the 1920s the “new and expanded edition” of Medicina casera (which translates to “homemade medicine”) by Juan Igón was advertised frequently in the socialist newspaper La Vanguardia, underlining that the manual contained a list of “all the diseases and the medicinal plants” that cure them and offering instructions on “how to prepare homemade remedies,” as well as general hygienic principles and tips on “how to create a home drugstore with all the essentials.”

In the 1930s Carlos Kozel’s book Salud y curación por yerbas exalted the use of lemon, flax flour, and bananas to treat tuberculosis. And in the 1940s the Revista Farmacéutica informed its readers, most certainly pharmacists, about the advantages of concoctions based on palo santo and culantrillo as well as other medicinal herbs that were later advertised and sold in pharmacies, a practice that medical journals like La Semana Médica compared to the illegal practice of medicine. Starting in the late 1920s radio broadcasts encouraged and supported home medicine. Broadcasting was a resource used by both professional and unlicensed doctors. The Department of Tuberculosis Pathology and Clinic at the University of Buenos Aires Medical School offered a series of conferences on Radio Belgrano in which celebrated specialists presented—in a language they deemed simple and plain—the importance of observing the hygiene code that was supposed to prevent tuberculosis. On the other hand, the radio show called La hora de la salud also informed listeners about “diets and formulas to prepare medicines to cure tuberculosis at home” while inviting them to disregard what professional medicine was offering.

Throughout the first half of the twentieth century, advocates of naturalism encouraged home health care. Some anarchists believed in “natural cures” as part of an austere lifestyle in which vegetarianism and ideology merged for the “physical and moral” regeneration of workers. Other voices articulating a message based on commercial, modern, and naturalistic reasons, and certainly with less radical political positions than those of the anarchists, made similar recommendations. For example, the director of the Instituto de Fisioterapia de Buenos Aires criticized “classic pharmacopoeia unable to cure chronic diseases” and advocated that “the best doctor resides within us,” while praising home care and recommending treatments based on “electrotherapy, heliotherapy, and phototherapy” that, of course, were offered at his institute as a way of “helping nature in her spontaneous healing process.”

Remedies for the Modern Consumer

Increased access to over-the-counter medications was a key factor in reaffirming and renewing the importance of the household in treating tuberculosis. Numerous fortifying medications were supposedly offering cures to vaguely defined maladies like loss of energy, exhaustion, and cachexia, as well as blood diseases, weakness, scrofula, chlorosis, anemia, and tuberculosis. Along with these tonics, laxatives, diuretics, and purgatives there were other over-the-counter remedies to cure venereal diseases, skin problems, headaches, and colds. Taken as a whole, these medicines were probably among the first goods Buenos Aires residents bought as modern consumers, that is, as buyers who could choose between products with similar attributes but different brand names. As the century advanced, the supply of medicines expanded with greater networks of imports, more commercialization, and, to a lesser extent, local production.

In the last three decades of the nineteenth century the pharmaceutical sector depended entirely on foreign suppliers. Local drugstores sent their orders to the mostly French and Italian import agents and then manipulated several ingredients in order to prepare medicines that for awhile were called specifics. As the local market expanded, some of these foreign firms set up concessionaires and local offices. Though this was the dominant business model until the First World War, some drugstores in Buenos Aires began to manufacture preparations using formulas for which they had obtained a license from a foreign company; others followed suit but did so without licenses or with dubious or fake ingredients. The war years made it difficult to import drugs and chemicals, facilitating the local production of serums, vaccines, and specifics. Moreover, the First World War facilitated not only a much greater influx of basic ingredients for preparations made in the United States but also the local development of ways to dissolve, compress, mix, and fractionate them. Once the war was over local pharmaceutical production was temporarily put on hold. In the 1920s imports dominated the market once again; former commercial agents, who used to simply convey the orders of the local drugstores to their headquarters, became exclusive retailers, built large stocks, and began to sell directly to the local pharmacies. In the 1930s a large segment of the exclusive retail concessionaires—by then not only French and Italian, but also American and German—turned into laboratories that produced under license and enjoyed the benefits of increased custom duties on imports that competed with locally produced medications.

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