Just about 100 years ago, American medical students were being taught the "germ theory" of infectious disease for the first time as scientific orthodoxy. This theory replaced the older "zymotic theory," which was based on the concept that the agents of infection were chemical ferments, the products of decaying filth that could, with the right atmospheric conditions, be generated spontaneously. Although this concept led to the preventive strategy of sanitary science, a great paradox emerged. Despite the material and scientific progress of the 19th century, urban Americans of all ages, classes, and races had an all-too-personal knowledge of infectious disease.
Nancy Tomes describes how the germ theory led to the spread across the United States of what she calls "`the gospel of germs,' that is, the belief that microbes cause disease and can be avoided by certain protective behaviors." Her evangelical terminology is retained throughout the book, and rightly so. She makes clear that this message was spread across America with evangelical zeal by "apostles of the germ" and "disciples of the laboratory."
Tomes's account is divided into five historical periods. She describes the gospel emergent (1870 to 1890), the gospel triumphant (1890 to 1920), the gospel in practice (1900 to 1930), and the gospel in retreat, concluding with an epilogue on the gospel in the age of AIDS. This is an exciting and vivid story based on careful analysis of oral histories, advertisements, patent applications, books of advice, and other sources. Tomes tells how this gospel transformed the thinking of ordinary Americans and how it often also transformed their domestic arrangements. Although similar changes occurred in other Western countries, Tomes presents evidence that the American experience was distinctive because of the influence of advertising and the special role of crusades against disease in American political culture.
In the last two decades of the 19th century, there was fear even at the highest level of society that a "filth disease" such as typhoid fever could be acquired by people living in "clean houses." In 1884, Martha Roosevelt died of typhoid fever in her clean, elegant home on West 57th Street in New York. Such tragic events led to the concept of sick houses and revolutionized domestic arrangements. With the advent of the china toilet and the ventilated soil pipe, which replaced the old "pan closet" and its circuitous and unventilated soil pipe, the tiled bathroom replaced carpeted and wooden fittings. The germ theory thus fed into the momentous changes in personal and domestic hygiene that had begun with sanitary science. The practical applications fell into the areas of housecleaning, child care, and food preparation -- the traditional domain of women. The vital role of the housewife and public health nurse in the spread of the gospel is an important part of Tomes's account.
Although no immediate cure emerged, once it was known that tuberculosis was spread by the tubercle bacillus, it was clear that the disease could be prevented. So antituberculosis crusades were begun. These crusades often helped people understand what it was to be Americans fighting together against an invisible enemy, the tubercle bacillus.
The gospel of germs proved triumphant by 1920 and thereafter became part of American life. However, by the 1930s, there was a slow waning of enthusiasm. Public health policy began to emphasize the importance of the discovery and isolation of contagious cases while maintaining an emphasis on clean water and food supplies. There was also a distancing of the authorities from their previous evangelical tone. By the 1930s, the antituberculosis societies were emphasizing the funding of basic research and early detection by x-ray screening.
The germ menace became much less of a fear for Americans with the advent of the "Pax antibiotica," which also began slowly in the 1930s but triumphed with the introduction of penicillin during the Second World War. The idea thus arose that antibiotics were magic bullets that made "the consequences of transgressing the gospel of germs... seem less and less serious."
By the 1980s, the rituals of germ avoidance were a little-noticed part of daily life. All this changed with the arrival of AIDS. The failure to find a cure for this disorder destroyed the confidence bred by the Pax antibiotica, and the gospel of germs was born again. Tragically, a campaign of harassment and abuse against people with AIDS was related to this gospel. Indeed, for Americans, this epidemic has taxed the limits of the concept of public health citizenship. There is also the tragic irony that people with AIDS are at great personal risk from breaches of sanitary protection (e.g., their great susceptibility to tuberculosis), a risk far greater than any risk they pose to those who harass them.
This is a fascinating story and a fascinating book. It is written in a scholarly manner with ample references for the use of the historian and the physician, as well as the casual reader. Members of the medical profession and the general public will find that this book makes for compelling and exciting reading. It gives a vital perspective for comprehending the continuing problems that infectious disease poses for society and public health. It seems to me that the compassionate application of the gospel of germs is as important as ever for human welfare not only in the United States but also throughout the world.
Reviewed by J.A. Walker-Smith, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
Looking at the U.S. from 1870 to 1930, Tomes strove to find out how laypeople changed the ways they lived once they had accepted the existence of germs. She not only dug deeply and widely into popular literature, advertising, and novels but organized her findings carefully. The resulting, engaging book explores all rooms of the home, public buildings, and transportation carriers. Tomes presents information and analysis in readily understandable terms, aided by a wry sense of humor. Since women were the primary housekeepers and thereby were, in a way, closer to bacteriology than were medical students, their attitudes toward germs affected how they dressed, cleaned house, cooked, and raised children; Tomes shows especially well how the antituberculosis crusade and domestic science merged to the benefit of everyone. Readers who gratefully moved from an outdoor privy to a shiny white porcelain-fixtured bathroom will have many memories stirred while reading Tomes, and laypersons and physicians alike will appreciate her thoroughly documented report.
William Beatty
