Toxic Shock

A Social History

Sharra L. Vostral

• Publisher: NYU Press
• Year: 2018
• Print ISBN: 9781479815494
• eBook ISBN: 9781479870158
• Topic: Social Sciences
• Subtopic: Gender Studies
• Index: Social Sciences

A history of Toxic Shock Syndrome

In 1978, doctors in Denver, Colorado observed several healthy children who suddenly and mysteriously developed a serious, life-threatening illness with no visible source. Their condition, which doctors dubbed 'toxic shock syndrome' (TSS) was rare, but observed with increasing frequency over the next few years in young women, and was soon learned to be associated with a bacterium and the use of high-absorbency tampons that had only recently gone on the market. In 1980, the Centers for Disease Control identified Rely tampons, produced by Procter & Gamble, as having the greatest association with TSS over every other tampon, and the company withdrew them from the market. To this day, however, women are frequently warned about contracting TSS through tampon use, even though very few cases are diagnosed each year.

Historian Sharra Vostral's Toxic Shock is the first and definitive history of TSS. Vostral shows how commercial interests negatively affected women's health outcomes; the insufficient testing of the first super-absorbency tampon; how TSS became a 'women's disease,' for which women must constantly monitor their own bodies. Further, Vostral discusses the awkward, veiled and vague ways public health officials and the media discussed the risks of contracting TSS through tampon use because of social taboos around discussing menstruation, and how this has hampered regulatory actions and health communication around TSS, tampon use, and product safety.

A study at the intersection of public health and social history, Toxic Shock brings to light the complexities behind a stigmatized and under-discussed issue in women's reproductive health. Importantly, Vostral warns that as we move forward with more and more joint replacements, implants, and internal medical devices, we must understand the relationship of technology to bacteria and recognize that both can be active agents within the human body. In other words, unexpected consequences and risks of bacteria and technology interacting with each other remain.

1

Unexpected Consequences

A tampon is a thing. A bacterium is a life form. These assertions, however, are shortsighted. As it turns out, and as toxic shock syndrome (TSS) came to attest, both are quite more dynamic together than anyone ever imagined. This was difficult to envision because of the overwhelming assumption that tampons were inert, disposable objects. They sometimes caused irritation, an allergic reaction from embedded perfumes, or lacerations from an applicator, but they were not conceptualized as dynamic. That a bacterium typically associated with food poisoning or boils might possibly develop into a strain that could produce septic shock seemed like a stretch, but it became accepted knowledge. Agreeing on a new ailment of TSS and further specifying it as tampon-related TSS became part of a repertoire of illnesses predominantly affecting women.

What is not well conceptualized, and an idea that I propose here, is that during this process a bacterium became the overlooked and unintended user of tampons, thus changing the relationship of user/technology. The bacterium advantageously capitalized on the technological innovation to reproduce and multiply. Though tampons were intended for menstruating women to be the dominant users of the technology, it is constructive to think of bacteria as users, too. This changes subject/object orientation, thus shifting the conditions of agency. It is here that the relational activity of technology and bacterium must be far better conceptualized and understood as co-agents of unintended illness.

This chapter focuses on this relational activity. There are many conceptual underpinnings that need to be addressed to better understand this techno-bacteriological relationship. First, tampons are a technology, with a history of design and development during the twentieth century. Second, they share in common the ability to cause gendered injury, like many other technologies used to manage and regulate women’s reproductive bodies. As such, and third, they fall into a loosely woven safety net of the Medical Device Amendments (MDA), which in theory provide a process by which therapeutic technology undergoes testing to assess its compatibility with the human body and its proclivity to do harm. Fourth, what these tests do not predict is how other organisms in and of the human body will interact with medical devices, because technology is not neutral or inert. This has a direct effect on the next important concept: that bacteria possess the ability to become technological users, and, as users, create unintended consequences for humans with which they share an ecological space. Finally, this techno-bacteriological interface has been poorly anticipated in terms of design and risk, so that resultant injury appears unexpectedly, as a surprise. The indecorous subject of tampons and menstruation made it difficult for many to willingly concede the game-changing scope of this technobiological illness.1

Tampons as Technologies

Tampons were neither regulated nor particularly trusted technologies when they first commercially appeared in the form of Tampax in 1936. They required a good degree of domestication as emergent technologies, accompanied by educational advertising teaching women about the benefits of the technology.2 Because tampons were phallic-like in shape and a perceived threat to the virginal hymen, some educators, nurses, and parents felt convinced to leave well enough alone. They promoted the use of disposable sanitary napkins instead for adolescent girls.3 Yet, by the 1940s, many young women were early adopters, because they recognized how tampons relieved them of the physical encumbrance of elastic belts, long tabs, and uncomfortably thick pads worn between the thighs.4 Advertising, menstrual hygiene education films, and word of mouth shifted many women’s opinions about tampons from dubious to acceptable; under certain circumstances such as dancing, swimming, or working long shifts, many embraced them as a useful tool of physical liberation.5 Still, there was much cloaking, double entendre, and indirect language about how and when to use a tampon. To the uninitiated, the cryptic language of advertising made tampons seem like magic in a box; I have anecdotally heard more than once that a thoughtful but unknowing young boy would gift a girl in first or second grade this special box because she could do all kinds of amazing things with it, like ride horses or bikes, and do gymnastics.

By the 1960s, through skillful advertising campaigns, companies successfully associated bodily freedom and women’s liberation with the use of tampon technologies.6 Once women accepted tampons, they entered into a tacit agreement with the corporation, assuming that this commodity was safe. There were some complaints of abrasions, strings breaking, products leaking, and contact dermatitis related to deodorants and perfumes embedded in tampon materials. Other complaints regarded problems of disposal and clogged plumbing when they were flushed down the toilet. Yet, overall, cotton tampons enjoyed a solid reputation. They may not have worked well for all women, but they could be viewed similar to a bandage: a medical dressing to absorb blood.

Though we often think of tampons as static objects, designers, chemists, and inventors, working on behalf of large corporations, filed many patents to transform the plain old cotton tampon into something they thought would be significantly better and thus gain a larger share of the market. Though Tampax may have been the first cotton tampon to be successfully commercialized in 1936, others with different designs soon followed. Wix, a competitor of Tampax in the 1930s, incorporated a cellophane sheath, which, according to the inventor Frederick Richardson, was “to hold the body of the absorbent material in its proper desired shape, and in part, to enable the plug to be easily inserted into working position.”7 He suggested that deodorants such as phenol, peppermint, or wintergreen could be added easily to the cotton. At the Personal Products Corporation—a Johnson & Johnson subsidiary—George C. Graham developed a patent for a flexible tampon composed of “cotton, rayon, paper, hemp or wool” in 1957.8 Simultaneously, he applied for a patent for a tampon composed of absorptive salts, including sodium carboxyethylcellulose or sodium carboxymethylcellulose.9 He also received a patent in 1960 for a “tow tampon.” This tampon would have longer rather than shorter filaments for better absorption of fluids by creating capillaries. This patent made claim on a particular manufacturing process and design, but imagined a variety of materials to satisfy the end product of a tampon.

Patenting as broadly as possible was common practice, and materials included “Dacron” polymeric polyester, nylon, viscose rayon, vinyl fibers, acrylic fibers, “saran” polymeric vinyl chloride, polyethylene, glass fibers, protein fibers, and silk.10 Polyester emerged as a synthetic fiber in the 1950s, and the reference in the patent to Dacron reflected the proprietary name given to it by DuPont. Also by 1960, scientists at Kimberly-Clark Corporation, the maker of Kotex sanitary napkins, had received patents for tampons composed of 60 percent cotton and 40 percent “crimped viscose rayon staple fibers.”11 The variety of materials indicated that inventors were thinking beyond cotton grown on the farm, to fibers and substances easily created in the lab.

Viscose rayon emerged as a popular addition to tampons, proving to be both absorbent and cheap to procure. Derived from wood cellulose, it is processed with other chemicals, dried, and spun to form fibers. Unlike cotton or silk, which retain their properties and characteristics, chemical processes transform cellulose into a semi-synthetic fiber. Most of the popular brands of tampons—Tampax, Playtex, o.b., Kotex—have incorporated rayon, but because the labeling of ingredients is not mandated, that information is not readily available.12 By 1996, researchers felt that there were only two all-cotton tampons available to test; all the rest contained rayon.13 In part, Tambrands introduced “Tampax Naturals” that same year, calling the product line “the first U.S.-made all-cotton tampon”—despite that same composition of the original Tampax—in response to some women’s desires for a natural tampon. However, rayon continues to be used as a core component of tampons. Even the employees of the Good Shepherd Food-Bank in Maine, on a goodwill tour of the neighboring Tambrands manufacturing plant in 2012, waxed eloquent about the machinery as it produced Tampax Pearl tampons, made out of both cotton and rayon, the fibers “spun into a solid mat.”14

Inventors continued to develop new fibers and materials during the 1960s and 1970s. The scientists Billy Harper, Robert Bashaw, and Bobby Atkins developed sodium polyacrylate for Dow Chemical Company, filing a patent for the chemical in 1966.15 Due to its polymer structure containing sodium ions, sodium polyacrylate absorbs anywhere from 200 to 1,000 times its own weight in water. The material forms into a gel, which in essence holds fluids. In 1978, Russell L. Johnson for the Kimberly-Clark Corporation devised a digital tampon meant to be inserted with a finger. It used a cotton-rayon fiber base, and capitalized on the newly developed “super absorbent fibers,” including polyacrylate, cross-linked polyurethane, or polyester foam.16 Currently, sodium polyacrylate is a common absorbent in disposable baby diapers.17 Of course, bodily fluids from urine to menstrual fluid are not pure water, thus the polyacrylate is not as effective with salts and proteins, so it must be paired with other materials to produce an absorbent tampon or diaper less likely to leak.

By the mid-1970s, the leading tampon manufacturers landed patents for tampons that included some derivative of carboxymethylcellulose (CMC) as one of its absorbent components. CMC, derived from the more familiar plant material of cellulose, when synthesized by a reaction with chloroacetic acid, becomes a viscose thickening agent, shifting from powder to gel when introduced to liquids. It is used as a food additive to stabilize emulsions, such as ice cream, but also to help with gelling texture in toothpaste, detergents, or paints. It is considered nontoxic and hypoallergenic, and by all appearances, it is a dream material with which to work due to its relative stability. International Playtex, Inc., filed a patent for “preparation of water-insoluble carboxymethyl cellulose absorbents” in 1978, the purpose of which was for absorbency in a tampon.18 Kimberly-Clark filed a patent in 1976 for a compressed tampon composed of absorbent fibers, including carboxymethylcellulose.19

By 1974 Procter & Gamble (P&G) already test-marketed its synthetic Rely, composed of a polyester sheath, compressed polyurethane (and later polyester) foam cubes, and carboxymethylcellulose, but continued to hone its own version of a CMC tampon, as evidenced by its patent encompassing many “absorbent devices” filed in 1981.20 Incorporating CLD-2—the trade name for cross-linked CMC manufactured by Buckeye Cellulose Corporation, a subsidiary of P&G—this iteration of the tampon also included Pluronic L-92, a nonionic surfactant manufactured by BASF, helping the fibers to be more hydrophilic, and referred to as “mensesphilic” in the patent.21 The significance of this surfactant would not be discovered until the early 1990s, when researchers found that Pluronic L-92 increased production of the TSST-1 toxin.22 It is unfair to characterize this lack of oversight as purposeful, yet the zeal for superabsorbents overrode their downside.

Figure 1.1. Patent for Rely Tampons, 1974. This patent displays Rely’s novel features, including the shape, sheath, inserter, and polyurethane cells, later replaced with polyester foam. Source: Jean Schaefer, inventor; Procter & Gamble Company, assignee. Catamenial Aggregate Absorbent Body, US Patent 3,815,601, filed May 9, 1973 and assigned June 11, 1974.

Figure 1.2. Rely Tampon and applicator (side view). The plastic applicator houses and inserts the tampon. The unique composition of the tampon is quite light and airy compared to a compressed cotton tampon. Photo by Sharra Vostral.

Figure 1.3. Rely Tampon and applicator (front view). The polyester casing is visible here, showing the cuplike shape as it expands, referred to as a “rosette.” Within the case are small polyester foam cubes and the thickening agent carboxymethylcellulose. This tampon came from an unused sample box. Photo by Sharra Vostral.

In effect, the chemistry of absorbent materials had so flourished that the term “superabsorbents” defined this new category. A 1979 article title in Chemical Week proclaimed “Superabsorbents Seek Markets That Are Super,” indicating the turn from plain old cotton or rayon to highly processed and synthesized components in search of applications for customer purchase.23 The writer noted that personal care products and diapers were prime areas for applying these new polymers, since superabsorbents could soak up 50 to 1,500 times their weight in water. Yet the weekly urged that “consumer education must be undertaken to promote other uses for the materials and to dispel the notion that absorbent means bulky.” Because traditional materials required more volume rather than less to absorb an equivalent amount, this common wisdom needed to be dispelled to show that “new-and-improved” translated into a sleeker, smaller product.

Problematic Female-Specific Technologies

That tampons should be artifacts worth “modernizing” fits into the ideological scope of progressive science and technological determinism offered during the 1960s and 1970s. NASA experienced great success with the space program, inspiring a new generation of scientists to dream big in spite of the risks. Faster, nonhuman mainframe computers crunched mathematical formulas at blistering speeds. Insecticides and herbicides applied to crops yielded greater harvests, with abundance to share. And petrochemicals and plastics could be manufactured more efficiently and more cheaply than just about any material that they replaced. Scientists, it seemed, held the keys to nature itself and could not only solve the world...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Contents
• Abbreviations
• Introduction: Toxic Shock Syndrome
• 1. Unexpected Consequences
• 2. Mystery
• 3. The Media Sounds the Alarm
• 4. Grounds for Liability
• 5. Health Activism and the Limits of Labeling
• Conclusion: Managing Menstruation and Beyond
• Acknowledgments
• Appendix
• Notes
• Index
• About the Author