The Making of a Social Disease: Tuberculosis in Nineteenth-Century France [Reprint 2020 ed.] 9780520915176

Citation preview

The Making of a Social Disease

The Making of a Social Disease Tuberculosis in NineteenthCentury France

David S. Barnes

UNIVERSITY OF CALIFORNIA PRESS Berkeley • Los Angeles • London

University of California Press Berkeley and Los Angeles, California University of California Press London, England Copyright © 1995 by The Regents of the University of California

Library of Congress Cataloging-in-Publication Data Barnes, David S. The making of a social disease : tuberculosis in nineteenthcentury France / David S. Barnes p. cm. ® Includes bibliographical references and index. ISBN 0-520-08772-0 (cloth : alk. paper) 1. Tuberculosis—France—History—19th century. I. Title [DNLM: 1. Tuberculosis—history—France. 2. History of Medicine, 19th Cent.—France. 3. Disease Outbreaks—history—France. 4. Socioeconomic Factors. WF 11 GF7 B2m 1995] RC316.F8B37 1995 614.5'42'094409034—dc20 DNLM/DLC for Library of Congress

94-15230 CIP

Printed in the United States of America 1 2 3 4 5 6 7 8 9 The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials. ANSI Z39.48-1984 ®

To my parents, Richard and Helena Barnes, and to the memory of my grandmother, Helena Borcic, and my great-grandmother, Rose Stepanek

Contents

Acknowledgments Chronology: Tuberculosis in France, 1819-1919 Introduction 1. Social Anxiety, Social Disease, and the Question of Contagion 2. Redemptive Suffering and the Patron Saint of Tuberculosis 3. " Guerre au baciller Germ Theory and Fear of Contagion in the War on Tuberculosis 4. Interiors: Housing and the Casier sanitaire in the War on Tuberculosis 5. Morality and Mortality: Alcoholism, Syphilis, and the "Rural Exodus" in the War on Tuberculosis 6. Le Havre, Tuberculosis Capital of the Nineteenth Century 7. Dissenting Voices: Left-Wing Perspectives on Tuberculosis in the Belle Epoque Conclusion

ix xiii 1 23 48 74 112 138 174 215 247

viii

Contents

Notes

257

Selected Bibliography

289

Index

299

Acknowledgments

The research for this project was funded in part by the French government's Chateaubriand fellowship program and the Lurcy Charitable Trust. Dissertation writing support was provided by the Mellon Fellowships in the Humanities. In France, many people went out of their way to help me in my efforts to track down and make sense of my sources. Jean Legoy, Philippe Manneville, and Didier Nourrisson in Le Havre helped me understand what makes that city so fascinating for historical study and guided me in situating tuberculosis within a local social and political context. Colette Chambelland and Françoise Blum of the Musée social in Paris helped me find many elusive and invaluable materials. Jérôme Renaud of the Service des Archives, Assistance publique de Paris, graciously facilitated access to hospital records and other holdings. My research benefited from many helpful strategic discussions with, among others, Patrick Fridenson, Alain Corbin, Olivier Faure, Pierre Guillaume, Bernard-Pierre Lécuyer, Alain Cottereau, Lion Murard, and Patrick Zylberman. Allan Mitchell was generous with source material and drafts of his own work and cordially agreed to disagree with me on certain matters of interpretation. Annie Lenhart provided moral support and vital French newspaper clippings. Back in the Bay Area, a number of discussion groups and the cooperative atmosphere fostered by the History Department of the University of California, Berkeley, provided a friendly and comfortable academic environment in which to write and discuss the dissertation from which ix

X

Acknowledgments

this book developed. From the very earliest stages of this project, Catherine Kudlick has been an acute reader and supportive critic of countless drafts. She has also been my mentor in the history of disease and a trusted friend, and I owe her more than the devoted thanks I can express here. Denise Herd of the School of Public Health contributed her expertise to this project as a member of my dissertation committee, as did Thomas Laqueur, who cheerfully challenged me with his eclectic and imaginative sense of the history of the human body. Reggie Zelnik offered sage advice and gave freely of his time from the beginning. Tim Lennon and Lisa Schiff generously gave me thorough readings and helpful comments on the dissertation version of this study. I owe many thanks to Neil Leonard for his editorial and strategic advice over the years. Deirdre O'Reilly and Elizabeth Aife Murray gave immeasurable assistance during the preparation of the manuscript, and Stuart Kogod of RayKo Photo Center in San Francisco did yeoman's service on the illustrations. I am grateful to my sisters, Elizabeth Barnes and Ann Deschamps, and the Batistas, Roy, Kathy, Peggy, Matthew, and Marc, for their support. I would also like to thank Mary Jo Savage and the Rev. James Kolp for their insights concerning Saint Thérèse of Lisieux. Guenter Risse and Jack Pressman, my colleagues in the History of Health Sciences Department at the University of California, San Francisco, have greatly enlarged my view of the history of medicine and have never failed to engage me in fruitful discussion and debate. Jack also volunteered extensive advice on graphing and computing. The members of the Berkeley-San Francisco History, Medicine, and Culture group (affectionately and irreverently known as the "Med-Heads") were repeatedly exposed to tuberculosis; Lisa Cody, Caroline Acker, and Robert Martensen were particularly helpful. The meetings of the Northern California French History group also brought kindred spirits together for serious yet convivial historiographical discussion. In this latter group, I am especially grateful to Lou Roberts, Gabrielle Hecht, and Tyler Stovall for their insightful critiques and suggestions. For the participants in the illustrious French History dissertation group at Berkeley, the long and arduous process of dissertation writing is truly a collective enterprise. Countless evenings of fine food, drink, and scholarly exchange at the Barrows household—always'enlivened by the wise and stylish Alexandra Barrows—punctuated our hard work with critical- analysis, solidarity, and even occasional joy. I am grateful to Marjorie Beale,1 Joshua Cole, Sarah Farmer, Megan Koreman, Doug

Acknowledgments

xi

Mackaman, Jeff Ravel, Vanessa Schwartz, Matt Truesdell, Jeffrey Verhey, and Tami Whited. I owe special thanks to Ian Burney, Nicoletta Gullace, Regina Sweeney, and Sylvia Schafer, who helped me survive graduate school with their intellectual companionship and friendship. I first glimpsed the joys of studying history through the teaching of John Merriman. Bon vivant, raconteur, and archive connoisseur of world renown, he breathes life into the subject matter of French history as few other historians can. William Cronon's analytical rigor, mastery of style, and devotion to teaching taught me a great deal about the craft of history. The opportunity to work with these two historians as an undergraduate first instilled in me the desire to become one myself. In a profound way, my work bears the imprint of Susanna Barrows. I could not dream of a more inspiring and dedicated mentor. Her love of history and her ability to evoke its human dimension, both comic and tragic, serve as a model for all of her students. When she first suggested tuberculosis to me as a research topic, I recall thinking that with background in neither medicine nor opera, I was ill equipped for (and little interested in) the task. She knew better. Over the years, her advice has been demanding, surprising, constructive, counterintuitive, and unfailingly on target. My parents have encouraged me at every step of my academic career. Their love of France is more contagious than any disease, and I caught it at an early age; for that alone I am eternally grateful. They have lived the historian's life vicariously through me, housed me under their roof at various times on both sides of the Atlantic during my research, and provided critical readings of my chapter drafts along the way; they have been instrumental in seeing this project through to fruition. This book is dedicated to them and to the memory of my grandmother and my great-grandmother, who between them taught me to read and taught me to love learning. Finally, I owe a constant and profound debt of gratitude to Joan Batista, teacher, confidante, partner. She has put up with endless talk of germ theory and syndicalism, accompanied me—if not to the ends of the earth—as far as Lisieux and Le Havre, and made setbacks tolerable and good times better. It is both true and inadequate to say that my work and my life are richer because of her.

Chronology Tuberculosis

in France,

1819-1919

1819

First edition of René-Théophile-Hyacinthe Laënnec's Traité de l'auscultation médiate published

1829

Annales d'hygiène publique et de médecine légale, France's first journal of public health, founded

1830

Louis-René Villermé's study of differential mortality in Parisian neighborhoods published in Annales d'hygiène publique

1865

Jean-Antoine Villemin demonstrates transmissibility of tuberculosis in laboratory

1867-1868

Academy of Medicine debates contagiousness of tuberculosis

1870-1871

Franco-Prussian War, Prussian siege of Paris, Paris Commune

1879

Inauguration of municipal health department and easier sanitaire des maisons in Le Havre

1882

Robert Koch isolates and identifies tubercle bacillus, causal agent of tuberculosis

1894

Casier sanitaire des maisons begins operation in Paris

1894-1897

First major revolutionary syndicalist writings on tuberculosis published by Fernand Pelloutier and by the xiii

xiv

Chronology Groupe des étudiants socialistes révolutionnaires internationalistes

1898

Academy of Medicine report "On the Prophylaxis of Tuberculosis," first major manifesto of mainstream War on Tuberculosis, delivered by Joseph Grancher

1899

First government-appointed commission on tuberculosis convened

1901

Lionel Amodru reports to parliament on necessary measures to halt spread of tuberculosis "Permanent" commission on tuberculosis established under Ministry of Interior First antituberculosis dispensary opened in Lille under direction of Albert Calmette

1902

Public health law passed, mandating creation of municipal health departments in large cities

1904

Revolutionary syndicalist Marc Pierrot's lengthy series, "The War on Tuberculosis," published in Les Temps nouveaux

1905

International Tuberculosis Congress meets in Paris

1906

Revolutionary syndicalist campaign for eight-hour day culminates in strikes and protests beginning May 1

1914-1918

World War I

1916

Léon Bourgeois law passed, providing for widespread establishment of antituberculosis dispensaries

1919

André Honnorat law passed, providing for widespread establishment of sanatoriums

Introduction

Tuberculosis is back. In most developed nations, a steady decline throughout most of the twentieth century reversed itself beginning in the mid-1980s, and cases of the disease have increased ever since. New bacterial strains resistant to various antituberculosis drugs have caused considerable alarm in major cities, where tuberculosis is often associated with AIDS, drug abuse, homelessness, and poverty. Meanwhile, in less developed countries, where tuberculosis never left the scene, it continues apace. Experts offer dire warnings of "the greatest health disaster since the bubonic p l a g u e " W o r l d Health Organization officials estimate that three million people worldwide die of tuberculosis every year and that fully one-third of the world's population is infected with the tubercle bacillus.2 The increased incidence has been paralleled by increased public attention, as each week brings new press reports of epidemiological studies and antituberculosis strategies. France is no exception; recently, legislation has been introduced to revive that country's antituberculosis dispensaries. Recourse to such an old-fashioned institution, thought by most to be "outmoded," 3 suggests that the latest biomedical techniques can neither explain nor solve the problem of chronic illness in society. Indeed, the story of tuberculosis in France provides a revealing glimpse into the history of this problem. Or perhaps stories of tuberculosis would be more accurate. Cauldron of wealth and poverty, reform and revolution, social anxiety and scientific hubris, nineteenth-century France was the stage for several 1

2

Introduction

parallel dramas in which tuberculosis played key roles. French medicine, struggling to maintain its international preeminence, contributed crucial discoveries regarding the nature of the disease and oversaw the birth of germ theory. Intensifying worry over France's low birthrate and stagnating population contributed to increased concern over the nation's leading cause of death. Industrialization and urbanization radically altered the rhythms and material conditions of life. An ambitious, nationalistic bourgeoisie largely committed to economic liberalism finally assumed political power and debated how best to hold onto it. Meanwhile, a disastrous war with Prussia and the threat of class warfare made all of these issues more pressing during the early decades of the Third Republic. These and other stories will serve as the backdrop for this examination of tuberculosis as a social problem. The comeback of tuberculosis confounds the familiar history of medicine's incremental advances and triumphs. More than a century after the bacterial agent of tuberculosis was discovered and nearly half a century after the advent of effective antibiotic treatments, some very old questions are being asked about the disease, including, what is it about society that facilitates the spread of tuberculosis, and what can be done about it? These same questions were being asked with great urgency a century ago, and despite the vast technological and scientific changes of the intervening years, the answers most commonly proposed today bear a striking resemblance to the answers of the past. They range from a reliance on greater governmental intervention in public health matters (such as heightened surveillance by local authorities of those infected or "at risk") to forced isolation of active cases.4 A few scattered voices target poverty as the chief cause of tuberculosis and call for improvements in standards of living as the only means of effectively combating the disease.5 The questions and the answers seem to be preserved intact from the first time tuberculosis emerged as a major social problem in many countries in the nineteenth century. Meanwhile, since the mid-1980s, the AIDS crisis has forced increasingly technocratic, medicalized, welfare-state societies to confront the basic question of how and why a culture assigns particular meanings— especially moral meanings—to disease. Scientific knowledge, it has become clear, does not provide a single and exclusive "truth" about health and disease, and the clash of conflicting truths can be as traumatic (in a cultural sense) as any epidemic.6 Although they certainly do not impose a definitive reading on the past, present-day struggles to address the social meaning of AIDS and tuberculosis add relevance and urgency to

Introduction

3

an examination of the history of such efforts. Before considering the factors that came to bear on the understanding of tuberculosis in the unique circumstances of nineteenth-century France, it is worth briefly discussing the basic characteristics of that elusive pathological entity— characteristics that, if not timeless or absolute, at least correspond to the current consensus in medical science. Tuberculosis is a contagious disease. That simple fact is both indisputable and misleading. The causal agent of tuberculosis—variously known as the Koch bacillus (after Robert Koch, the German bacteriologist who first identified it in 1882), the tubercle bacillus, and Mycobacterium tuberculosis—is a bacterium transmitted from person to person most often through inhalation of "aerosolized" sputum droplets expelled through coughing. In the majority of cases, the infection is localized as a lesion in the respiratory tract and contained by immune reactions, never producing symptoms of illness (although it does, for example, cause a positive reaction to a skin test). When resistance is compromised for any reason, at the time of infection or at any subsequent time, the bacilli can spread and attack the body's tissue. This "active" or "open" tuberculosis occurs most often in the lungs but can also affect the lymphatic glands (scrofula), bones, intestines, brain, liver, kidneys, and other organs. Nonpulmonary forms of tuberculosis can also be acquired by ingesting milk or meat from infected cows. This form of transmission was the object of a certain amount of concern in the nineteenth century, before widespread pasteurization of milk and regulation of meat supplies, but it was always perceived as a minor danger compared to inhalation. 7 (Pulmonary tuberculosis is by far the most common form of the disease. Both in the nineteenth-century sources and in these pages, the word "tuberculosis" indicates primarily the pulmonary localization, although in prophylaxis, as opposed to diagnosis or treatment, there was often little practical distinction to be made among the various forms.) The recent resurgence of tuberculosis in the United States and other industrialized countries has taken place among certain clearly identifiable communities and "risk groups": homeless people, drug addicts, prison inmates, poor immigrants, migrant farm workers, the elderly, and people with HIV infection and AIDS.8 All of these groups share one common trait: immunodeficiency, the central element in the acronyms "HIV" and "AIDS." Most of them share another closely related trait: poverty, with all of its concomitant physical effects. This present-day epidemiology, so divergent at first glance from the observed and re-

4

Introduction

ported incidence of tuberculosis in nineteenth-century societies, may at least provide some questions (if not answers) with which to address the historical dimension of tuberculosis. In both present and past societies in which tuberculosis is prevalent, far more people are infected with (that is, exposed to) the bacillus than ever experience symptoms. A still smaller subset of the population dies of the disease. Even at the historical peaks of the disease's incidence, the seemingly vast numbers of deaths from tuberculosis each year represented just a fraction of those infected. Indeed, it is possible that a neartotality of the population of many large European cities in the nineteenth century technically " h a d " tuberculosis—that is, would have tested positive for exposure to the tubercle bacillus. 9 It is widely believed today that in the United States, only 10 percent of those infected with the disease ever develop active or "symptomatic" tuberculosis; in other words, even those who test positive for exposure (and therefore have Mycobacterium tuberculosis in their bodies) have only a one-inten chance of ever "getting" tuberculosis (becoming ill). This ratio is a widely quoted rule of thumb, 1 0 although there is evidence that this "risk of disease" (as opposed to "risk of infection") varies considerably and is often much lower than 10 percent. Detailed long-term studies of certain populations have shown (1) that the risk of disease among those infected with tuberculosis drops off considerably after the first one to two years, and (2) that even as long as ten years following infection, the risk of developing active disease is often considerably less than one in ten, with rates varying between 0.6 and 3.7 percent in U.S. studies and reaching as high as 9.4 percent in others. 1 1 It is impossible to know whether these proportions hold true for other geographic and historical contexts; yet even if the precise figures differ, there is reason to suppose that in many industrial cities a century ago, nearly the entire population was infected with tuberculosis. 12 In late-nineteenth-century Le Havre and Paris, when the disease was at its deadliest and accounted for one-fifth to one-fourth of all deaths, it killed only a fraction of those infected. It follows, therefore, that all or nearly all of those cities' residents were infected with the tubercle bacillus by the time they reached adulthood. Most people lived their entire lives without any inkling of their infection. Exposure does not equal illness. However, any circumstance that compromises the body's resistance by depressing immune reaction can cause latent tuberculosis infections to reactivate, no matter how long ago the original exposure took place. Today, such circumstances range from malnutrition, drug

Introduction

5

abuse, and alcoholism to cancer (especially following chemotherapy) and AIDS. 13 It is certain that similar immunosuppressive factors were at work in nineteenth-century France. Particularly among the working classes, where tuberculosis claimed most of its victims, the obstacles to maintaining a decent standard of living were formidable. The influence of any individual factor on the incidence of tuberculosis at the time is impossible to determine. It is not the aim of this book to develop a retrospective epidemiology of tuberculosis in nineteenth-century France, even if such a project were feasible. The primary sources for such an endeavor—even statistical reports and surveys—are so thoroughly imbued with the categories, preconceptions, and concerns of the time that to wrench them from this context would rob them of all meaning. Even to condemn them as "biased" would be to suggest misleadingly that they could have been otherwise. Juxtaposing the medical and public health texts of the nineteenth century with present-day judgments regarding the true causes or incidence of disease borders on reproaching the doctors and authorities of the time for not knowing then what is known now, an enterprise of little historiographical value. It is quite another matter, however, to examine orthodox or mainstream knowledge in light of conflicting views that were being expressed on the same issues at the same time. This book undertakes to trace what was known about tuberculosis in the nineteenth century, the conditions under which that knowledge was produced, and how it was used. A recent historiographical controversy has resuscitated the question of the "true" causes of tuberculosis in the nineteenth century. This debate illustrates the difficulties and uncertainties inherent in historical epidemiology as well as the implications of such scholarly questions for present-day tuberculosis control efforts. The exhaustive and pioneering work of Thomas McKeown in Britain had over several decades—in the view of most historians—established that the decline of tuberculosis and other infectious diseases in the industrial world was largely a result of rising standards of living rather than medical advances or state intervention in matters of public health. 14 This revisionist thesis opened up new horizons of scholarly inquiry, but it also stepped on some toes. In the past few years, a strong backlash against McKeown has emerged. A series of articles has attacked the standard-of-living thesis and argued that the real reasons for the decline of tuberculosis in France, Britain, and the United States can be found in government sanitary reforms and in the isolation of those suffering from the disease. 15

6

Introduction

Allan Mitchell, an expert in the history of France's relations with and attitudes toward Germany, has contended that the public powers' inaction in the face of tuberculosis explains France's relatively high death rate from the disease around the turn of the century. France lagged behind, the argument goes, while its neighbors in Britain and Germany pursued concerted campaigns to improve public health. Therefore, tuberculosis rates declined in both of the latter countries— but not in France—during the decades leading up to World War I. 1 6 Actually, the experience of the three major western European powers at the close of the nineteenth century can be read quite differently. The available evidence, in fact, clearly indicates (1) that tuberculosis mortality was declining in France, albeit more slowly than in Britain and Germany, and (2) that France's higher death rate and slower decline in tuberculosis corresponded to a standard of living that was lower and improving more slowly than that of the other two countries. 17 It is difficult to establish with any certainty the curve of tuberculosis mortality over the course of the nineteenth century in France. Nationwide statistics were not kept on such matters until after the First World

Introduction

1865

2.

7

1866

1867

1868

1869

1870

1871

1872

1873

1874

1875

Tuberculosis mortality in Paris, 1865-1875.

War; even for large cities, the figures date back only as far as 1887. However, Paris was under a microscope for most of the century, and the occasional publication of tuberculosis death rates for the capital begins in 1816. Calculating per capita and combining the early Paris numbers with the later figures for all of urban France, it is possible to approximate the direction, if not the overall magnitude, of the disease's incidence. According to this method, tuberculosis increased gradually in France until its peak in the late 1880s and early 1890s, whereupon it decreased, also gradually, through most of the twentieth century. Figure 1 depicts tuberculosis mortality for Paris over the entire nineteenth century, alongside Le Havre (France's tuberculosis leader) and an aggregate of the twenty-six largest French cities for the Belle Epoque, averaged out over census periods to give a more reliable long-term picture. 18 Figures 2 and 3 focus on periods of particular interest. One apparent anomaly is a dramatic increase in Paris in 1870 and 1871, during the FrancoPrussian War and the subsequent siege of Paris; figure 2, with annual figures not averaged out over census intervals, shows its magnitude and suddenness. Figure 3, also showing year-by-year changes, suggests that although statistics for cities other than Paris were kept only beginning

Introduction

8

a

£

•s