Johns Hopkins Magazine -- February 1998
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In which a Hopkins historian shows how language became a matter of life and death a century ago for an American nation ravaged by tuberculosis.

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Why Metaphor Matters
By Dale Keiger
Illustration by Jordin Isip

We have become so used to the language, we no longer notice it: "The war on drugs." "The war on cancer." "Battling" the spread of AIDS.

Martial metaphors have become so ingrained in our discussion of disease and public health, it's all but impossible not to use them. Try to write a paragraph about research against AIDS, for example, and avoid words like campaign, target, weapon, battle, fight, or crusade.

JoAnne Brown, associate professor of history at Hopkins, became fascinated by military language as she studied American efforts to cope with tuberculosis in the late-19th and early-20th centuries. Martial metaphors, which emerged after the Civil War, shaped how consumptives thought of themselves, how products like soap were sold, the ways in which public health reformers publicized their cause, and the laws that government enacted in its attempts to contain the disease. This language and its historical effects are at the heart of Brown's recently completed book manuscript, "Matters of Life and Death: Political Hygiene and Historical Memory in the United States, 1865-1945."

She spent six years studying how ordinary people, in their confrontation with tuberculosis, used everyday language to think about the disease, respond to its contagiousness, and--in many cases--cope with their own illness. She devoted her study less to the established, canonical literature of the period's great thinkers and researchers than to what she calls "the flotsam and jetsam of print culture": advertisements, ordinary correspondence, health textbooks, popular literature, scrapbooks, daily newspapers, and periodicals called "san mags" that circulated to tuberculosis sanitoriums. Struck by the high incidence of battlefield metaphors, she scrutinized the language of these sources, trying to reconstruct what that language meant to the people who used it.

Metaphor channels thinking, Brown asserts. If enough people think of a public health effort as a war on disease, it becomes easier to enact policies that curtail civil liberties. A war, after all, is a crisis that sometimes calls for extraordinary measures. As Brown notes, "Military language gives priority to the immediate crisis, and trivializes other concerns." She is convinced, and so argues in her book, that public health policies meant to separate carriers of tuberculosis from the general public eventually helped legitimate racist measures like the statutory segregation of drinking fountains.

"If you treat metaphors as just mere flourishes of language, then you don't make the connections between the metaphors that people use and their historical experience," she says. "Metaphor is too important to be understood only in narrative terms. It is too fundamental to how language works, to how politics works."

As she wrote in a summary of her book: "Political language acquires direct historical import when it is written into public-health law, and becomes a matter of life and death for those affected."

If enough people think of a public health effort as a "war" on disease, Brown notes, it becomes easier to curtail civil liberties.
FROM THE 1860S TO THE 1940s, tuberculosis killed more people each year in the United States than any other contagious disease. One out of every seven deaths was from consumption, as it was formerly known. The disease took most of its victims from among young people in the prime of their lives. For decades, it frustrated medical researchers in their search for a cure. As late as 1951, the U.S. census counted more than 119,000 new cases annually, a rate of infection three times that of the polio epidemic that monopolized public attention at the time. Tuberculosis clouded the lives of millions of people, in ways that have new resonance in the era of AIDS.

In the early part of the 19th century, when consumption, smallpox, and diphtheria were daily facts of life, the dominant metaphors for disease were agrarian. Disease arose from "seeds" of illness that took root in the "soil" of the body. Metaphors were a way for medical theorists to understand what could not be seen, to comprehend the complexities and mysteries of disease in the context of what they presumed to be a moral, organic universe.

By the late 19th century, Louis Pasteur, Robert Koch, and other researchers developed germ theory. For a while, agrarian metaphors endured. Germs were the seeds in the seed-and-soil construct. But as Brown read more of her "flotsam and jetsam," she noticed that in the latter half of the 19th century, martial metaphors for illness began proliferating. Pasteur, for example, referred to scientists outside their laboratories as "unarmed soldiers on the field of battle." Brown was struck by this new prevalence of military tropes in the material she was studying. "It's no accident that a woman historian looked at this stuff and said, `What are you guys talking about?'" she says. "It's not my language."

Brown found that like a linguistic contagion, martial metaphors spread among a receptive populace in postbellum America. She combed through the papers of prominent physicians like Henry Ingersoll Bowditch and Oliver Wendell Holmes, the archives of the Atlanta Lung Association and the Wisconsin Anti-Tuberculosis Association, old newspapers and magazines. Everywhere she looked, she found hygiene conceptualized as a form of warfare, often holy warfare.

"Knights" in this "holy war" bought "little Christmas bullets"-- Christmas seals--to fund the war on contagion. One woman writing in a san mag rewrote Alfred Lord Tennyson's "The Charge of the Light Brigade," turning it into a bit of doggerel titled "The Stand of the Fresh-Air Brigade." In 1904, a collection of physicians and lay people organized the National Association for the Study and Prevention of Tuberculosis (NASPT). Its announcement read, in part: "It is called the `Crusade,' the `Warfare,' the `Struggle' against consumption. The great awakening is at hand." In 1915, the association created the Modern Health Crusade, which used medieval pageantry to enlist children in a campaign for better hygienic habits. Children became "pages," "squires," "knights," and "knights banneret" by selling special Red Cross seals and by performing 10 "health chores."

Brown began to ask why military language gained such widespread currency. What was going on here?

"I had to pan for gold," Brown says. She had to mine the discourse of everyday people, noting how they expressed themselves, looking up obsolete meanings of words still in use a century ago, trying to piece together the memories that people brought to bear on their lives. "Metaphors are to ordinary language what precedents are to the law," she says. "They borrow from past experience. What historians sometimes do is see people in the past as somewhat inert figures moving through time. But those people carry with them a storehouse of memory and experience beyond their time. You need to understand the social links between individual personal experiences and the large events of history." In this case, the individual experiences were often of the Civil War and deadly contagion.

A young "knight" decorates Modern Health Crusader General Pershing with the double-barred cross.
Photo from Journal of the Outdoor Life, Vol. XIX, January 1922
IT WOULD BE HARD TO OVERESTIMATE the impact of the Civil War on late 19th-century American culture. Few people, if any, were untouched by the carnage. Brown cites some remarkable statistics in her book. In some states of the North, 37 percent of draft-age white males served in the Union army. In some Southern states, a staggering 75 percent of their counterparts joined the Confederate forces. The country had never experienced such casualties: 620,000 died, and hundreds of thousands were left maimed or seriously ill. In a single day at the battle of Antietam, more Americans fell than in all previous American wars combined.

The medical horrors created vivid collective memories. Field hospitals and emergency surgeries were not remote from civilian life. Military surgeons commandeered schools, churches, and houses, bringing the gruesome effects of battle right into town. As frightful as the plight of the wounded was--amputations without anesthetic and wounds infested with maggots--disease left an even larger imprint on the American memory. More Civil War soldiers died from sickness than from battle. Contagion traveled with the armies and spread as they marched through towns. As veterans returned home at war's end and people began to reconstruct their lives, disease and war were irrevocably linked in the popular imagination.

Much of Brown's task was to understand the individual memories of these people, and reinvest those memories with the importance they had at the time. "One way to do history," she says, "is to study the things that happened in the past. If you want to explain what people were thinking in 1917, you look at documents from 1917. That will tell you certain things. What it won't tell you is the life experiences that those people brought to the production of the documents. But if you think, `How old was the author? What clues are there in the document about what he's been doing the last 20 years?' If you ask these questions, it dawns on you that if you have two people on a committee in 1917, and one is 65 years old and the other is 35, then the former would have lived through the Civil War. We should begin by assuming that that makes a difference."

That may sound obvious. "But many of us have forgotten to do it," Brown says. "Historians assume that we `own' memory, that we're the keepers. I'm investing my cast of characters with their own memories, not those of the historian."

After the war, the victims of tuberculosis, many of them Civil War veterans, developed an identity as soldiers in an honorable losing battle, creating what Brown identifies as a "commemorative culture." She quotes historian Pierre Nora on how a commemorative culture arises when "an immense and intimate fund of memory disappears." A cataclysm such as the Civil War wipes out a large group of people, along with their individual active memories. What then arises is a movement to replace those living memories with acts of commemoration, designated memorials, and anniversary observances. Consumptives, says Brown, engaged in just such a movement, using martial metaphors to symbolically link themselves to the Civil War.

Tuberculosis victims usually wasted away slowly. They had time to create a body of literature as part of their commemorative culture. They published essays, poetry, and songs, many of them in the san mags. Instead of victims and carriers of infection, they recreated themselves as part of a noble lineage, engaged in a valiant, centuries-old struggle against consumption, with its own pantheon of heroes and martyrs.

Some of the heroes were claimed by economist Irving Fischer. Diagnosed with tuberculosis in 1898, Fischer stated, with a bit of equivocation, that Napoleon, Goethe, Cecil Rhodes, and Ralph Waldo Emerson had been "practically...certain cases of cures." If Goethe is listed as a fellow sufferer, consumption becomes a disease of genius. Its victims have a sort of familial link to greatness.

Concurrent with this imaginative linkage to a noble war was a national infatuation with medievalism. People in the 19th century read popular novels set in the Middle Ages. Civil War soldiers had drawn inspiration from tales of knighthood and chivalry. In 1861, Oliver Wendell Holmes referred to consumption as "the white plague." By 1880, says Brown, a variety of reformers had seized on this image and assigned medieval overtones to recast their efforts against the disease as a modern Crusade, a romanticized endeavor at once martial and holy.

Medicine eagerly took to this idea. Brown points out that by making consumption an enemy of mythical proportions--she found one period illustration that portrayed the bacteriologist Robert Koch in armor and on horseback, battling a dragon--physicians and medical researchers could accommodate their frustration over their largely ineffectual efforts at a cure. They weren't failures. They were noble heroes engaged in a sanctified struggle against the overwhelming beast of infection.

THE CONFIRMATION, IN 1882, that tuberculosis was a contagious disease galvanized public health activists. As they searched for ways to promote reforms, these activists noted how well the purveyors of patent medicine, who found ready customers among consumptives, reached the public through advertising in newspapers and magazines. If advertising worked for quacks, they figured, it would work for reformers, too.

Those in the nascent advertising business were eager to help. Brown points out that the anti-tuberculosis crusade came at a time when advertising was under attack as a social evil. Printers, billposters, and advertising professionals, Brown says, eagerly lent their services to public health reformers to change the image of advertising from moral blight to practical solution.

A parading Joan of Arc crusades against the "white plague of consumption."
Photo from Bulletin of the National Tuberculosis Foundation, May 1920
Brown turned up thousands of examples of their work. She studied print ads, public hygiene posters, street-car placards, and other advertising and publicity artifacts. After the 1908 Tuberculosis Congress in Washington, D.C., reformers boasted that anti-tuberculosis advertising now amounted to 50,000 column inches per week in American publications, what the NASPT called "a half-mile of advertising."

Not all the advertising was of the public service variety. Brown combed through the Warshaw Collection of Business Americana, housed at the Smithsonian's National Museum of American History. There she found numerous examples of how various manufacturers exploited public concerns about germs. For example, beginning in 1900, the makers of Sapolio all-purpose household soap created serial advertisements posted inside streetcars. These ads featured "Spotless Town" and its hygienic citizens, who used Sapolio to ward off the uncleanliness that characterized the neighboring "Dingeytown." During the six years that the ads ran, Brown says, actual communities voted to become "Spotless Towns."

Advertisers had to convince people to worry about something that they couldn't see--germs. Brown says that it is telling how they chose to do so. For example, she came across a 1914 poster from California that portrayed "the cold that hangs on." A well-dressed, coughing white man carries on his back another man, clearly Chinese, who is named "A. Hangon Cold," and who wears an overcoat bearing the word "tuberculosis." Brown found another ad, this one for Borax, that showed white, uniformed soldiers of the "20-Mule Team Brigade" protecting a nursery room from a threatening horde of black imps drawn with African features. She turned up example after example of advertisers personifying germs as characters with dark skins and the facial features associated with Africans, Italians, Chinese, Slavs, and Jews. Advertisers and reformers were more than willing to play on racism and nativist fears of immigrants to get their message across.

One of Brown's more provocative findings in "Matters of Life and Death" is the link she makes between public health reform and segregation. In 1896, Frederick Hoffman published a study titled Race Traits and Tendencies of the American Negro, which associated blacks with high tuberculosis morbidity. Medical literature began portraying African-Americans as "careless consumptives" and "promiscuous spitters" (tuberculosis could be spread by sputum). In 1905, the St. Louis Society for the Prevention of Tuberculosis called consumption "the plague of the white race," seemingly ignoring the fact that it struck all races indiscriminately.

Racism and public health coalesced in explicit terms in Washington, D.C., at the 1908 International Congress on Tuberculosis, where certain white Southern experts were allowed to present their racial understanding of the disease. Not all the racism came from Southerners. An exhibit at the congress by the Philadelphia Visiting Nurses' Association used before-and-after photographs. The "before" picture showed a "negress" and her tubercular son in a grimy, rag-strewn tenement room. In the "after" shot, the nurses have properly cleansed the room of all filth--and, tellingly, the mother and son. Two years later, the Virginia Health Bulletin publicized the dangers of the public water pump with an illustration of a healthy little white girl and a consumptive white man. Looming over them was the menacing caricature of a large black man.

Brown traces how this racism coincided with government's growing assumption of public health police powers. Massachusetts had organized the first state public health board in 1869; by 1873, more than 130 cities enforced some sort of public health oversight. Advocates of state-mandated public hygiene argued that unhygienic habits such as spitting were really crimes against the people and should be policed. Cities wrote ordinances against expectoration, and police imposed fines on perpetrators.

This new state role, Brown believes, was made more acceptable to the public by advertising, with its portrayal of jolly health cops protecting little white kids from germs that looked suspiciously like immigrants and slumdwellers. The martial language played its part, as well; if society is to wage war on contagion, it needs troops, and those troops need authority.

In a society trying to deal with an incurable disease and a rudimentary grasp of contagion, medical segregation of the afflicted was not without logic. It had proven effective in dealing with other contagious diseases such as leprosy. But in the early 20th century, hygienic concerns and racism became conflated. In 1907, John Temple Graves, an editor famous for his radical racist views, editorialized in the Atlanta Georgian in favor of segregating consumptives in state-funded sanitoriums, emphasizing that the TB death rate for blacks was "three times as great as that of the white race." In 1908, Mary Lent, the Hopkins-trained head nurse of the Visiting Nurse Association, advocated segregating indigent consumptives, whom she believed could not be educated about hygiene. To help drive home her point, she provided a photo of an African-American family with the caption, "Four generations of consumptives. No one in this family could be taught the use of any precautions."

Advertisers played on fear of industrialization and immigrants to get their message across.
Brown traced the changes in meaning of the word "segregation." Before 1890, the term was used in medical contexts to mean the removal of sick people from proximity to healthy people. After 1899, the word appeared more frequently as a synonym for racial separation. She believes that a growing understanding of germ theory, combined with publicity about contagious diseases such as tuberculosis, raised the stakes of contact between the races. When justifiable fear of contagion combines with racism, it is not a big leap to legally enforce separate drinking fountains.

"I'm careful to say that not everything these people did was wrong," Brown adds. For example, she says, anti-spitting ordinances made sense: "If you don't spit, you don't spread TB. But it works for all races, not just blacks." If racism can be legislated in the name of public hygiene, then hygiene has become political, Brown says, and it's important to understand how the everyday language of 19th-century public health smoothed the way for 20th-century racial segregation.

BEFORE SHE BECAME A HISTORIAN, Brown pondered a career as an artist. When she can, she still paints detailed representational pictures. Like any serious painter, she devotes attention not just to the objects of her composition, but to the spaces between them that define shapes and relationships.

As she researched "Matters of Life and Death," she again found herself examining the spaces between things. She's more likely to use another word--interstices--but the concept is the same. In studying how public health efforts could be linked to segregation, Brown was working among the interstices of medical history and political history. Segregation has been studied by historians before, of course, but by political historians who, says Brown, have viewed it purely as racial. By going back to the century-old medical definition of "segregation," Brown could demonstrate how politics and public hygiene (usually the province of medical historians) had intersected 90 years ago.

She believes that after the advent of antibiotics in the 1950s, many historians seemed to have trouble comprehending a time when one's life could be abruptly shattered by contagion. In studying the period between the Civil War and the First World War, they seemed to lose sight, Brown says, of the fact that during that time hundreds of thousands of people were getting sick, and everyone else feared getting sick. She notes, for example, that when historian Nina Silber studied the "Yankee travellers" who wandered through the South after the Civil War, Silber attributed their wandering to romantic sensibilities, neurasthenia, and the vague malaise spawned by industrialization. Silber didn't seem to see the abundant evidence that some of these former Union soldiers had tuberculosis and were searching for a more healthful climate. Cultural historians left the study of disease to medical historians, and seemed oblivious, at times, to the fact that hundreds of thousands of people actually got sick.

A new disease has changed all of that. "I don't think I could have done this book had it not been for the AIDS epidemic," Brown says. "AIDS makes some of us who are practicing history now better able to see what people working in the time of antibiotics have had trouble seeing."

Brown's own eyes were opened as she completed her research. "People kept asking me, `Why are you studying a 19th-century disease?'" she says. Then, while talking about the disease one day to her hairdresser, Brown was startled when the hairdresser said, "Oh yeah, my cousin has that." Brown subsequently learned that several of her colleagues in the History Department had consumptive relatives. And she suspects that her own grandmother suffered from it.

The World Health Organization (WHO), in its 1997 annual report on tuberculosis, states that 30 million people could die from tuberculosis in the next 10 years. It remains, worldwide, the leading infectious killer of youth and adults. A third of the world's population, says the WHO, is infected with the TB bacillus. Most frightening is the possible emergence of what the WHO calls MDR TB--multiple-drug resistant tuberculosis. If that happens, its report warns, "everyone who breathes air, from Wall Street to the Great Wall of China, needs to worry about this risk. Once MDR TB is unleashed, we may never be able to stop it."

Says Brown, "For comfortable Americans living in the post-World War II era, it has tended to be difficult for us to imagine what life was like in the face of epidemic diseases that were incurable." That difficulty may be about to end.

Dale Keiger is a senior writer at Johns Hopkins Magazine.