I am a big fan of nonfiction for young people, particularly when it deals with science, medicine, or the study of disease. This is why I was so excited to hear that Jim Murphy --- the award-winning author of An American Plague: The True and Terrifying Story of the Yellow Fever Epidemic of 1793 --- has a new book out called Invincible Microbe: Tuberculosis and the Never-Ending Search for a Cure.

Tuberculosis, or “consumption” as it was called in the 19th century, has long been associated with literature. Many wrtiers, musicians, and artists had it, making it a primary plot point of much of 19th-century art and literature. Alexandre Dumas --- famous for the creation of The Three Musketeers --- once commented that "It was the fashion to suffer from the lungs; everybody was consumptive, poets especially." The disease was highly romanticized in this period as weak and pallid heroines (and occasionally heroes) would slowly “waste” into pale, thin corpses. Some women even went as far as to take small quantities of arsenic to imitate the pallor of its victims, though actual death by tuberculosis was quite grim. According to Murphy, its final stages would include "constant coughing to expel fluid from the lungs, foul-smelling night sweats, and frequent bouts of diarrhea and vomiting." (p. 26)

We associate the disease with the 19th century, but tuberculosis has been with us far longer. The first few chapters of Invincible Microbe deal with the prehistory of the disease. We know from fossil samples that tuberculosis is likely more than three million years old. But the bacteria has evolved over the years into much more virulent forms. Even within the last century, the bacteria has grown resistant to antibiotics used in its treatment, meaning we now have MDR-TB (multi-drug-resistant) and XDR-TB (extreme-drug-resistant) strains of the disease. The antibiotic treatment developed in the 1940s that gave millions of sufferers a cure is no longer as effective as it used to be. Doctors and scientists are developing new drugs and methods of treatment in places where this disease is still found. Invincible Microbe traces tuberculosis from its prehistoric origins to its drug resistant present, stopping along the way for a fascinating social and medical history of the disease.

 For me, the fascination with tuberculosis is both in its literary roots --- (children's literature is not exempt in portrayals of the disease. Who can forget the tragic death of the beautiful and vibrant Ruby Gillis in L.M. Montgomery's Anne of the Island, the third book in her Anne of Green Gables series?) --- and the strange methods of treatment that evolved out of the crowded and unsanitary conditions of 19th-century industrialization. Tuberculosis, which had always been a problem, reached epidemic proportions in crowded cities where the conditions of poverty bred the disease, but could not contain it. Spread primarily through droplets expelled through the mouth, TB runs rampant in crowded conditions that are difficult to clean. The history of tuberculosis is part and parcel of our understanding of germ theory, the development of epidemiology --- the study of disease in large populations --- and the discovery of a wide range of antibiotics with which we treat infection today. Invincible Microbes deals with all these aspects --- focusing primarily on tuberculosis of the lungs --- but its strength is in examining the sanitarium system that dominated treatment of the disease for the century between its development in 1855 and the closure of the sanitariums in the 1950s after an antibiotic treatment had been found.

The sanitarium cure was invented in 1853 by Hermann Brehmer, a medical student in Berlin who came across the theory that TB was caused by a weak heart. According to the theory, it was thought that blood was not pumped through the body with enough force to expel the disease. His idea for treatment --- with no scientific evidence --- was to take the patient into the mountains where "the reduced atmospheric pressure would ease the pumping action of the heart muscle." Brehmer's cure included a specially regimented diet and exercise along with plenty of bed rest. Although his treatment --- and others like it --- were only moderately successful, it offered hope where there had been no treatment before. Scientists now surmise that fresh air did make it easier for afflicted patients to breathe and that an improved diet and rest allowed the body to heal in a way patients --- even the wealthiest ones --- would not have been able to do at home. This treatment, with variation, was to become the dominant “cure” for the next 100 years. By the time streptomycin --- the first antibiotic used to treat TB --- was discovered in 1943, a patient entering a sanitarium had a 50/50 chance of surviving the disease. Germ theory made it clear that the treatment was to get the infection back into an “inactive” state, allowing lesions in the lungs to heal so the patient could get on with a normal life, but alternative treatments could be brutal and deadly.

The most fascinating and difficult chapters to read in the book cover some of the strange methods of treatment developed in addition to the sanitarium cure. Pneumothorax was a painful procedure in which doctors would surgically collapse infected lungs by pumping air into the chest cavity by hypodermic needle. The idea was to allow the diseased lung to “rest,” though it limited the patients’ intake of oxygen, came with significant risks, and the painful treatment would have to be repeated every few weeks for several years! To prevent re-inflation of the lungs, a second procedure was developed called thoracoplasty, in which the chest cavity was packed with fat, wax, or, Murphy reports, Ping Pong balls to prevent the lung from re-inflating. The author reports that this procedure was so traumatic that 30-40% of patients undergoing this surgery did not survive.

It was clear that some other approach was needed. Murphy covers several of the attempts to create a TB vaccination, including that of Robert Koch. Already famous for his work with anthrax, the serum he invented --- and tested on himself --- was heralded as a miracle cure, despite its severe side effects. Desperate to get access to the treatment, it went public with little testing. "Within a few weeks," Murphy writes, "newspaper headlines screamed the news that many patients had died as the result of treatments." In a trial involving 1,010 patients, only 13 were cured while 46 died. (p. 86) While further cures involving inoculation were attempted --- and one developed by French scientists Albert Calmette and Camille Guerin was found to be moderately successful --- Koch's reputation was ruined, and many considered any vaccination involving the bacteria to be too dangerous to attempt again.

The eventual discovery of streptomycin was brought about when a farmer brought a sick chicken to the agricultural school at Rutgers University. Prof. Selman Waksman and his two graduate students, Albert Schatz and Elizabeth Bugie, had been studying soil samples for years hoping to find a new antibiotic able to kill bacteria and fungi. They analyzed a culture from the sick chicken and eventually discovered a new kind of ground mold able to kill bacteria without harming the host. While they published their findings in 1944, it took a second scientist studying a form of TB in animals to apply the new antibiotic to TB. Dr. William Hugh Felman and his research partner, Dr. H. Corwin Hinshaw, tested it on guinea pigs only to discover that it not only inhibited TB, but eliminated it.

Even in the 1940s, doctors were discovering resistance and recurrence of the TB bacteria in patients. Initially, this was not deemed to be a problem. Stronger doses taken for longer periods of time and alternative antibiotics seemed to do the trick. It wasn’t until the early 1980s that MDR-TB emerged, and since then, XDR-TB, requiring months of treatment with a cocktail of antibiotics, often with uncomfortable side effects. What’s more, increasingly virulent strains of TB are emerging, especially in parts of the world where treatment is not closely monitored or available. Murphy and Blank report one case where an airline passenger was found to have the disease, requiring extensive detective work to locate, test, and treat other passengers on the plane. Of the people on the plane, only the 11 passengers closest to the patient had all been infected, but the scare brought new awareness to the disease and the dangers it poses in a world where --- due to air travel --- any given place in the world is only 24 hours from another.

It is possible that we have not seen the last of TB, but Murphy and Blank’s account is not intended to scare. Instead, it offers a fascinating, enlightened, and informative account of the ways humans have tackled disease throughout history. Invincible Microbe has an extensive bibliography and cites numerous works that each offer a different window through which to view the disease. While I’m aware not every reader is as fascinated with this subject as I am, Invincible Microbe offers an invaluable account of a disease most of us have only encountered in fiction.

For readers interested in more personal accounts of the disease, the following resources may be of interest:

The Plague and I  is children's author Betty MacDonald's account of her stay in a sanitarium for TB treatment. Riffing on the title of her most famous book for young readers The Egg and I, MacDonald brings her trademark wit and humor to this debilitating disease. In addition to being highly readable The Plague and I an invaluable first person account of the sanitarium experience and treatment of TB prior to the arrival of antibiotics. While probably not appropriate for the youngest readers who adore her classic titles like Mrs. Piggle-Wiggle, if you are an grown up reader who's loved Betty MacDonald's other work, this is one not to be missed.

This summer brings a brand new historical fiction title with Breathing Room  by Marsha Hayles about thirteen-year-old Evvy Hoffmeister who is sent to Loon Lake Sanatorium in 1940. Bored and lonely, Evvy eventually overcomes her isolation to learn about the people around her. The backdrop of WWII adds some tension to the novel --- Evvy's roommate hides her Jewish ancestry, while Evvy herself is teased about her German name --- but most of the novel revolves around the attempt for all the characters to heal enough so they can be released. Hayles covers a wide variety of TB scenarios, keeping the novel both interesting and educational.

A comparable title to Breathing Room is Ella Thorp Ellis's The Year of My Indian Prince about a sixteen-year-old April who goes into a sanatarium in 1945 just after the war has ended. April meets Ravi at the sanitarium, an actual prince from India, who is undergoing his treatment as his own country is experiencing the upheaval of post-war partition as the British leave India and hand over the reins of political power. The Year of My Indian Prince is based on the author's own experiences as a sanitarium patient for three years, as well as the actual people she met while she was there. April's slow recovery is mirrored by the outside world slowly recovering from war. While currently out-of-print it's certainly a title worth seeking out for readers interested in the topic.

One of the most difficult and heartbreaking titles on this topic is Martha Brooks's Queen of Hearts also set in a WWII era sanitarium. Canadian Marie Claire and her brother are both stricken with TB and sent from the wide open vistas of the prairie to the closed wards of the sanitarium. Of all the heroines in the books mentioned, Marie Claire is the most contentious, resenting the constant inactivity demanded of her and her complete lack of privacy, furious at her lack of health and the toll it takes on the people she loves. This book, more than any of the others, isn't just about the 'cure,' it's about the fight people face in confronting serious or even terminal illness in themselves or others. Difficult to read, but also deeply moving and rewarding, this is a book about the ferocity with which people fight for life and the people they love.