1. Social Anxiety, Social Disease, and the Question of Contagion

During the first half of the nineteenth century, France watched in fascination and horror as its capital showed every sign of imminent implosion. A city whose physical facilities had changed little in centuries saw its population double in less than thirty years. “In these years Paris looked around and was unable to recognize itself,” the historian Louis Chevalier wrote.

Another, larger city had overflowed into the unaltered framework of streets, mansions, houses and passageways…filling every nook and corner, making over the older dwellings of the nobility and gentry into workshops and lodging houses, erecting factories and stockpiles in gardens and courts where carriages had been moldering quietly away, packing the suddenly shrunken streets,…overloading the forgotten sewers, spreading litter and stench even into the adjacent countryside and besmirching the lovely sky of the Ile-de-France with [its] vast and universal exhalation.^[1]

Already a cauldron of volatile social and political forces, Paris suddenly had to accommodate hundreds of thousands of mostly poor migrants from the countryside and provincial cities who had come to the capital seeking a better life. Even before this massive influx, discontent and unruliness among the city’s population had been known to trigger political crises, including the events leading up to the great revolution of 1789. Occasional uprisings in the densely populated central quarters of Paris and two more full-scale revolutions—in 1830 and 1848—accompanied the city’s growth in this period. An emergent bourgeoisie assumed greater economic and political power under the July Monarchy (1830–1848) and began to perceive the swelling ranks of the urban poor as filthy, criminal, and politically dangerous. In an atmosphere of such political instability and class antagonism, the cataclysmic growth of Paris was regarded with extreme apprehension. When Asiatic cholera devastated the capital in 1832 and again in 1849—in both cases coinciding with civil unrest in the aftermath of revolutions—the worst fears of many seemed confirmed.^[2] Paris was headed for material and social catastrophe.

This dread expressed itself in a sizable literature of concern over the transformation Paris was undergoing. In the picturesque literature of crime and poverty as well as in public health investigations, a tone of fascinated disgust infused all descriptions of the pathological city. Honoré de Balzac, for one, was well known for his “filthy descriptions” of the capital’s poor neighborhoods. “Nothing escapes him,” wrote Jules Janin of Balzac, “not a wrinkle, not a sticky scab of this foul tetter.”^[3] In his own novel, Un Hiver à Paris, published in 1845, Janin also refused to shrink from the unpleasant details of life in Paris. Here is his description of the city at night.

Bespattered carts draw up to the door of the sleeping houses to carry off every kind of filth.…In the hideous lairs which Paris hides away behind its palaces and museums…there lurks a swarming and oozing population that beggars comparison.…A vile bohemian world, a frightful world, a purulent wart on the face of this great city.^[4]

Others lamented the disappearance of the great and proud city of recent memory, drowned in a sea of overcrowded buildings and people.

If you contemplate from the summit of Montmartre the congestion of houses piled up at every point of a vast horizon, what do you observe?.…One is tempted to wonder whether this is Paris; and, seized with a sudden fear, one is reluctant to venture into this vast maze, in which a million beings jostle one another, where the air, vitiated by unhealthy effluvia, rising in a poisonous cloud, almost obscures the sun.^[5]

Common to nearly all of the literature—fictional, political, and hygienic—on the growth of Paris in the early nineteenth century was a profound and fearful disgust at the city’s filth, smells, and overcrowding. Vivid descriptions of “purulent warts,” “sticky scabs,” “unhealthy effluvia,” and “a million beings jostl[ing] one another” fill many such accounts, in which few aspects of Parisian life could be depicted in any tone other than that of sheer physical revulsion.

In the historiography of medicine, the rise of germ theory is the great divide of the nineteenth century, in light of which all preceding and subsequent developments are interpreted. Where tuberculosis in France is concerned, the decisive dates have been 1865 and 1882, when Villemin demonstrated the inoculability of the disease and when Koch identified the tubercle bacillus, respectively. However, several significant elements of the pre-germ theory etiology of tuberculosis survived intact through the late nineteenth century. Among these elements are filth, stench, and overcrowding, all symptomatic of the underlying pathology of the city. Furthermore, the history of early-nineteenth-century medicine and public health includes some pivotal debates and revealing preoccupations underlying the search for the incidence and causes of tuberculosis.

The first half of the nineteenth century was not a time of great innovation in the realm of etiology. “Among the intervening causes of pulmonary consumption, I know of none more certain than sorrowful passions [passions tristes],” wrote René-Théophile-Hyacinthe Laënnec in 1826. Forty years later, the opinion of Laënnec, the inventor of the stethoscope and one of the most revered figures in the history of French medicine, continued to enjoy the status of virtually unquestioned dogma among physicians concerned with tuberculosis. When Professor Michel Peter of the Paris Faculty of Medicine reviewed the latest medical thinking in his 1866 book on tuberculosis, he reproduced Laënnec’s analysis almost unchanged. Tuberculosis, Peter wrote, arose within the body itself, determined by inherited predisposition and often also by “intervening causes” (causes occasionnelles) such as “sorrowful passions.”^[6]

It would be rash, however, to conclude that those four decades had been a time of stasis or inertia in the development of French society’s understanding of tuberculosis. In fact, they had seen not only the beginnings of a systematically “social” perspective on health and disease but also the modification of some key tenets of Laënnec’s “morbid spontaneity” and even the first nineteenth-century expressions of germ theory and contagionism relating to tuberculosis.

Historians have long regarded the Bourbon Restoration and the July Monarchy (1815–1848) as a crucial era in the development of French medicine and public health. Erwin Ackerknecht called Paris “the center of world medicine” and its medical school “the first faculty of the universe” during this time. He identified “a quite specific and unique type of medicine” characteristic of the time and place—he called it “hospital medicine”—based on firsthand physical examination, pathological anatomy, and statistics.^[7] Other historians have emphasized developments outside medicine itself; one recently claimed that this period saw the French “creat[e]…the modern notion of public health and…the scientific discipline of public hygiene.”^[8] William Coleman and Bernard-Pierre Lécuyer in particular have reevaluated the social investigations of Villermé and the other early hygienists—those who for the first time attempted to prove that “it was society rather than nature that produced inequality before death.”^[9] On the heels of these changes, during the Second Empire, Pasteurian bacteriology boldly asserted the contagiousness of tuberculosis.

The two most salient developments in early-nineteenth-century French knowledge about tuberculosis were (1) the shift from hereditary essentialism to contagionism in the etiology of tuberculosis and (2) the rise of various social epidemiologies of the disease in the emergent field of public health. It should be emphasized that these two trends were not necessarily related to each other. Coleman’s history of yellow fever in early- and mid-nineteenth-century Europe has shown the mutual independence of epidemiology and etiology—that is, that the development of epidemiology as a method of social investigation bore no necessary relation to the status of knowledge regarding disease causation.^[10] In fact, the increasing awareness of social factors in tuberculosis—if it was related at all to the competing etiologies—was associated with the older “miasmatic,” anticontagionist point of view. This chapter reviews the shift from essentialism to contagionism and the rise of the “social” perspective in light of the intensifying fear and anxiety with which many French social critics viewed the urban environment and the urban poor during the middle third of the nineteenth century.

Laënnec and Essentialist Medicine

One cannot help but think of the label “romantic medicine” when contemplating Laënnec’s remarks concerning les passions tristes and seeing their echo in subsequent decades. Such comments seem to replicate in medicine a common theme in romantic literature and art: the tragic, fatalistic determination of illness and death by “psychogenic” factors. Some have called the early nineteenth century the heyday of romantic medicine for other reasons, referring to the search for transcendent explanations and the tendency to speculative, idealistic, universal system building (in opposition to rationalist empiricism).^[11]

In France, as far as the etiology of disease is concerned, a better term might be “essentialist medicine”: the belief that disease in general (and tuberculosis in particular) was part of a person’s essence. Illness, in this view, arose spontaneously from internal causes and constitutional predisposition rather than from external causes, although external factors could influence the outcome of internal tendencies and predispositions. (This last corollary would become quite significant when essentialist medicine confronted the unequal incidence of tuberculosis in French society.) Some doctors even attributed epidemic disease to an “epidemic constitution.” According to Ackerknecht, a strong political and philosophical aversion to contagion brought about this “regression to older, classic causal explanations.” After all, in his words, “things had to be explained somehow.” Heredity served as an especially popular explanation of many diseases, including tuberculosis. Through heredity, it was assumed, a constitutional predisposition to the disease—or “diathesis”—transmitted itself from generation to generation.^[12]

Laënnec, whose opinions on tuberculosis influenced medical teaching and practice throughout the first two-thirds of the nineteenth century, rejected contagion in favor of heredity in his landmark Traité de l’auscultation médiate.

If the question of contagion may be regarded as highly dubious relative to tubercles, the same cannot be said of hereditary predisposition. Experience proves to all physicians that the children of consumptives are more frequently attacked by this disease than are other subjects.^[13]

In Laënnec’s treatise, however, the entire question of etiology was tinged with uncertainty and equivocation. Even his denial of contagion was less than rock solid.

Tuberculous phthisis has long been thought contagious, and it is still thought to be so by the common people, by magistrates, and by some doctors in certain countries, especially in the southern parts of Europe. In France, at least, it does not seem to be [contagious].^[14]

He based this curiously qualified opinion on his experience with many patients whose spouses remained healthy despite sharing a bed even in the late stages of the illness and with poor families who slept crowded together in a small room, where the tuberculosis of one family member did not endanger the health of the others. Yet Laënnec admitted that, “fortunately,” many countervailing examples existed for heredity as well, cases in which only one of several children in a family contracted the disease; conversely, he added, tuberculosis occasionally wiped out entire families who showed no signs of it in previous generations.^[15]

It is possible that this uncertainty, which was by no means unique to Laënnec, can be traced to the relative neglect of etiology itself in early-nineteenth-century medicine. The star of pathological anatomy was ascendant in French medicine, and most of its innovations concerned semiology and nosology: the symptoms and diagnosis of various disorders. The history of Laënnec’s landmark book on diseases of the chest is itself instructive on this point. The first edition, published in 1819, contained none of this material on the causes of tuberculosis in its thousand-plus pages. He added the section “Intervening Causes of Pulmonary Consumption” to the book’s second edition, which came out in 1826, just before his own death from tuberculosis. In the ensuing years (as will be seen below), epidemiological investigations associated with the early public health movement brought etiology and the social determinants of health under closer scrutiny. Still, forty years later, Michel Peter stated confidently, “If there is a universally accepted proposition, it is that of the heredity of [tuberculosis].” He called it “the most considerable cause” of the disease’s development.^[16] Heredity reigned supreme among causal explanations until it was displaced by contagion through the work of Villemin in the 1860s and, finally, Koch in 1882.

Meanwhile, equivocation, uncertainty, and emphasis on heredity did not prevent Laënnec and others from pointing out the contribution of various causes occasionnelles to the onset of tuberculosis. Significantly, the two chief factors invoked by the hereditarians were sorrowful passions and unhealthy sexual activity (including masturbation and “venereal excesses”). Both of these factors reinforced the impression that disorders such as tuberculosis were part of an individual’s essence. Neither factor was innate, certainly, but both were widely portrayed (in romantic and postromantic literature, among other genres) as aspects of fate, intimately related to identity and individuality.

As noted above, Laënnec found sorrowful passions to be one of the few certain causes of tuberculosis. Among other things, it explained why the disease was so common in cities and so rare in the countryside.

It is perhaps to this reason alone that the frequency of pulmonary consumption in large cities must be attributed: there, men have more relations with each other, and so have cause for more frequent and profound sorrows; bad morals and poor conduct of all sorts are more common there and are often the cause of bitter regrets that cannot be consoled and that even time cannot soften.^[17]

Here the connection between sorrow and “bad morals” was made explicit. Implicit was the conclusion that medicine was therapeutically impotent in the matter (no consolation, not even time itself, could heal these emotional wounds). The passage also came closer than most such texts to explaining the epidemiology of tuberculosis, or at least its concentration in large cities.

“Chagrin,” “regrets,” and “poor conduct” were exceedingly vague, but there was a consensus that more specific moral weaknesses also contributed to tuberculosis; namely, masturbation and venereal excesses. Laënnec glossed over the matter, calling “very probable” the chance that “excesses [and]…syphilitic conditions” were “sometimes the intervening cause” in the onset of tuberculosis, although he cautioned that these factors would be unlikely in and of themselves to cause the disease “in subjects who were not naturally predisposed to it.” However, many others, writing both before and after Laënnec, stressed the twin dangers in both “onanism” and “the abuse of coitus.” Both involved what Peter called “a double loss”: the loss of vital bodily fluids, which was “costly to the organism,” and the loss of “nerve impulses” through the convulsions of the spasme cynique at climax. It was also suggested that the “shock” of orgasm could cause harmful congestion in the heart and lungs.^[18]

It would be a mistake to confuse references in medical texts, however frequent, with a concerted social and political campaign aimed at stigmatizing certain groups and practices (such as the one that arose later in the century through the association of alcoholism and syphilis with tuberculosis). Nevertheless, these references show that there was in the early nineteenth century a significant and established current of thought connecting perceived moral failings with physical illness. They also prefigure later etiological debates in another respect. Essentialist medicine implicated venereal excesses as a cause of tuberculosis because they represented uncompensated “organic losses.” Peter especially decried such losses; they were part of “physiological poverty” (la misère physiologique), a combination of “excessive [bodily] expenditure and insufficient restoration.” Rest and nourishment did not match physical exertion. The same phrases recurred in the later leftist critique of capitalism and official medicine, in which overwork and low wages were seen as the principal causes of tuberculosis. Peter cited such factors explicitly, though few of his contemporaries followed suit.^[19] For the most part, medicine left social investigation to the emerging science of public health.

The Early Hygienists’ Social Perspective

Death is a social disease, according to the title of Coleman’s study of Villermé and the early public health movement in France. But “social disease” can mean many different things, even when applied to a specific illness such as tuberculosis. Later polemics would revolve around whether the term meant a disease inherent in the lifestyle of the working classes or a disease determined by the dictates of industrial capitalism and wage labor. Moreover, the very notion of contagion added an inherently social dimension to the antituberculosis campaigns of the late nineteenth century. The singular achievement of Villermé and his fellow hygienists in the 1830s and 1840s was to establish that mortality in general and tuberculosis in particular were socially determined in that they were not randomly distributed throughout society. Simply put, social status conferred relative susceptibility to or immunity from disease. The particulars of the poverty–mortality relationship or the specific social factors that contributed to tuberculosis were not fully explored in this period. Nonetheless, the breakthrough was significant and had lasting repercussions for French society’s response to tuberculosis.

As Coleman and other historians have shown, Villermé was the leading figure of the “party of hygiene” during the July Monarchy. Two of his projects in particular broke new ground for public health research: a series of articles around 1830 on mortality in Paris (based on the Recherches statistiques published periodically beginning in 1821 by the prefecture of the Seine), and the two-volume monograph published in 1840 on conditions among textile workers.^[20] The exhaustively documented and statistically measured conclusion of Villermé’s work was inescapable: the poor were sicker and died earlier than the rich. Although the simplicity of the proposition may seem almost self-evident, it was neither proven nor widely accepted—in fact, it was not given much consideration one way or the other—before Villermé’s time. Little of the subsequent work of the nineteenth-century hygienists would have been possible or plausible if this basic social connection had not been established.

However, Coleman overstated his case when he wrote that the early hygienists “created a thoroughly social view of the process of industrialization,” going out of their way to expose themselves to “the harsh reality of the daily life of the laboring population.”^[21] Villermé and the other pioneers in the field of public health could hardly have been expected to transcend their intellectual environment, class, and culture. Their work inevitably reflected the preoccupations and prejudices of their milieu, and, viewed in retrospect, it contained numerous gaps and silences. Although it is risky to criticize any work on the basis of what it does not say, such blind spots are noteworthy in several respects. The early hygienists held themselves to a high standard by their explicit claim to have enlarged the study of health and disease to encompass all of society. Furthermore, they self-consciously sought to address the “social question” at a time when socialism was in its crucial early stages of development in France and to provide alternative, nonsocialist answers through their work. As Lécuyer has pointed out, many hygienists considered it their duty to absolve industry of responsibility for death and disease.^[22] This attitude obviously colored, for example, their investigations of occupational health and even in other matters closed off certain areas of inquiry and excluded certain conclusions. Instead of a “thoroughly social” perspective, theirs was an innovatively social one, which opened the door for later ways of understanding disease but did not point them in a single clear direction.

From this perspective, the crucial point at which the social epidemiology of tuberculosis was set in motion seems to have been Villermé’s studies of differential mortality in the arrondissements of Paris. Taken together, the works (published between 1826 and 1830) represent a manual in statistical interpretation as well as a methodical review of possible causes of insalubrity in the capital. (Coleman and Lécuyer have each separately established Villermé’s—and these articles’—pivotal place in the history of sociological and statistical inquiry.)^[23] One by one, Villermé considered and rejected factors that had been proposed by various observers to explain mortality differences: climate, soil drainage, water supply, miasmatic filth, altitude, wind patterns. None correlated with the city’s death rates by arrondissement. Population density received the most detailed attention, as it was widely believed to be a contributing cause of ill health. Still, on close inspection, no clear correlation emerged. In Villermé’s mind, only one possibility remained: poverty. Using a considerable array of tables and charts, he presented the data in various different ways. Estimating or excluding deaths in hospitals, calculating average rental costs or percentage of untaxed rental housing units by arrondissement, the results were the same: the rank of arrondissements by mortality matched the inverse rank by wealth nearly exactly. “So, wealth, affluence, and poverty are…for the residents of the various arrondissements of Paris—by the conditions in which they place them—the principal causes (I do not say the only causes) to which one must attribute the great differences…in mortality.”^[24]

Given Villermé’s aims and approach, this was a final conclusion rather than an intermediate one or a starting point, notwithstanding the suggestive reference to the unnamed “conditions” in which wealth and poverty place Parisians. This was as far as he wanted to go, and he readily admitted as much. “It is enough for me here to have established this truth; I do not want to follow all of its medical consequences, nor by any means address it in a moral or economic light.”^[25] Later in his career, Villermé did touch on the specific conditions of poverty, and he certainly did not shy away from adopting an economic or moral point of view on these issues. But he never took the next step—the basis for so much of the later campaigns concerning tuberculosis—of relating the constituent elements of poverty to specific causes of death. Nor could he bring himself, committed as he was to the principles of liberal political economy, to recommend remedial public action on the scale of the problems he described.^[26] Several of his contemporaries, however, did go so far as to investigate the role of certain social and environmental factors in the specific disease of tuberculosis, without Villermé’s focus on wealth and poverty as variables. The questions these hygienists asked—and did not ask—and their tentative answers shed some light on the attitudes of public health experts toward the rapidly changing social fabric in the early nineteenth century.

Work and Environment: The Diagnosis of Occupational Predisposition

Several studies focused on the occupational incidence of tuberculosis, most often seeking to determine if particular toxins or environmental influences could be shown to have deleterious health effects. Lécuyer has analyzed this preoccupation with occupational exposure in terms of two related tendencies unique to this period: first, the fact that this class of hygienic investigation originated as inquiries into specific industries reputed to be harmful (for example, mines and tobacco factories); and second, the philosophical and political background of the hygienists themselves, which led them to place as much emphasis on absolving industry of responsibility as on identifying harmful conditions. “As a result,” according to Lécuyer, “anything that has to do with physical strenuousness, or even with a lack of air or with cramped working quarters, seems negligible to them.”^[27]

Two reports in particular, which appeared in the Annales d’hygiène publique in the early 1830s, merit closer attention because they illustrate the loose connection between epidemiology and etiology in these years: even the most exhaustive epidemiological studies bore no necessary relation to any established theory of disease causation.^[28] Henri Lombard’s 1834 article, “The Influence of Professions on Pulmonary Consumption,” attempted to draw a direct correspondence between the professions of tuberculosis victims (as gleaned from municipal death registers) and occupational conditions. By reviewing many different types of occupations, this relentless hymn to the statistical method gives the impression of comprehensiveness while actually considering only the immediate impact of certain types of work on the chest and lungs.^[29]

Lombard began by assembling data from five sources covering four cities: Paris, Geneva, Hamburg, and Vienna. All the sources indicated to some extent the professions and causes of death for all patients who died in certain of the cities’ hospitals over certain periods of time. For each city, Lombard compiled a list of all professions specified for tuberculosis victims and ranked the professions by the number of tuberculosis victims belonging to each of them. He then did the same for all causes of death combined, and he compared the two rankings of professions.

If a profession ranked higher on the tuberculosis list than it did on the overall list in a majority of cities, it was classified as “positive” for correlation with tuberculosis, no matter how high or low the actual ranks were. Those that ranked lower on the tuberculosis list than on the overall list for most cities were considered to have negative correlations with the disease. For example, day laborers ranked very high on both the tuberculosis list and the general list for all cities, but because they ranked higher on the general list, they were classified as negative. In effect, the classification said nothing about the actual mortality of day laborers from tuberculosis (the ratio of tuberculosis deaths to the total number of those workers in the population) but suggested that they were more likely than workers in the positive category to die of causes other than tuberculosis. Lombard considered this evidence that the occupation did not contribute to the disease.

Lombard’s unstated assumption that there was something inherent in the nature of the work for the “positive” occupations that was conducive to tuberculosis (and conversely, that the negatively correlating professions were inherently salutary) led him to venture explanations for the correlations of nearly every profession on his lists. Differences in workers’ physical well-being derived from three factors, according to Lombard: degree of wealth or poverty, forced exercise or inaction of certain parts of the body, and “purity or impurity of the surrounding atmosphere.” Tuberculosis was no exception, and by analyzing the various professions according to these three categories, he felt he could determine which aspects of work predisposed workers to contract the disease.^[30]

The first category, wealth and poverty, was quickly disposed of. Because one-fourth of the professions (not workers) in the below-average group were professions aisées and only one-eighth of the above-average occupations were of that class, Lombard deduced confidently that the poor were twice as likely as the rich to die of tuberculosis.^[31] The method was somewhat more clear for the bodily exercise category. Grouping the professions according to whether they were “inactive” or “active,” Lombard found more inactive jobs correlating positively than negatively with tuberculosis and more active occupations negative than positive. Therefore, he concluded, muscular activity warded off tuberculosis and inactivity invited it. Lombard rejected the long-held belief that constant arm movement, vocal activity, and bent-over body position caused tuberculosis. Professions corresponding to these characteristics did not correlate uniformly in the positive category, so he deemed the effects of such activity negligible.^[32]

The most significant feature of all in professional life, though, was neither economic status nor muscular activity but air. “Of all the circumstances to which workers in the various professions are submitted, none is as important as the surrounding atmosphere, because it acts directly on the lungs, the seat [siège] of consumption.”^[33] Lombard was most concerned about the presence of “foreign bodies” in the air. These included not just dust particles but “aqueous vapors” and “emanations” of various sorts. Aqueous vapors were beneficial to workers, he determined, because professions exercised in humid environments showed negative tuberculosis correlations. Similarly, “animal emanations” exercised a “protective” influence (butchers, for example, showed a negative tuberculosis correlation), but certain “vegetable” and “mineral” emanations were extremely harmful.^[34]

Lombard found one of his strongest correlations to tuberculosis in the breakdown of professions by whether they were exercised indoors or outdoors. Seventy percent of outdoor professions correlated negatively with tuberculosis, and Lombard claimed that “consumption [was] twice as frequent among workers confined to workshops [renfermés dans des ateliers] than among those who work outdoors [en plein air].”^[35] Even within the category of indoor professions, however, space counted; “vast and open” workshops did not allow propagation of tuberculosis to the extent evident in more cramped working quarters. “Thus, one can consider the vitiated air of the workplace [l’air vicié des locaux] as the cause of the large number of consumption cases observed in certain professions, whereas pure and constantly renewed air is an excellent prevention against the disease.”^[36]

Here was Lombard’s key finding: “vitiated air” caused tuberculosis, and air purified by ventilation and sunlight protected one from it. The elaboration of this concept marked a crucial step in the development of attitudes toward tuberculosis. It manifested an attitude toward the physical environment that laid the groundwork for later etiological theories, including the linkage of unsanitary housing and other environmental factors to tuberculosis. Lombard’s fundamental conclusion—that occupations played a determinant role in the epidemiology of tuberculosis—was inherent in his method. A similar investigation in the same journal in 1831 took a slightly different approach to the same problem. Louis-François Benoiston de Châteauneuf’s “The Influence of Certain Professions on the Development of Pulmonary Consumption” drew in factors such as sex differentials and the broader culture of poverty to the mix of pathogenic influences, but it too was as remarkable for the narrowness of its conclusions as for the breadth of occupations it considered.^[37]

Benoiston had long felt that certain causes commonly linked with tuberculosis needed to be verified, so he compiled information from the entry registers of four Paris hospitals covering the period 1817–1827 and noted the occupations of 1,554 tuberculosis patients. Like Lombard, he grouped the occupations into categories—in this case, seven, based on the position of the body during work, the type of muscular activity involved, and particles or vapors to which workers were exposed. For example, category 5 consisted of “occupations which submit the body, and especially the lower body, to the effects of dampness.” Unlike Lombard, Benoiston then calculated the ratio of workers with tuberculosis in each category to the total number of workers in that category represented in the registers for other illnesses. He then compared these ratios to the mortality rate from tuberculosis in the general population, to determine the relative susceptibility of workers in each category.

The way in which Benoiston chose to divide professions into categories predetermined to some extent the results of his investigation. No occupational conditions other than posture, muscle use, and particle or vapor exposure were considered. If certain occupations involved particular age groups, wage scales, work hours, types of housing, or other differential factors that might affect workers’ health, such correlations would not appear in the study’s findings. From the range of factors considered, Benoiston concluded—unlike Lombard—that those involving a hunched or bent over forward position (category 7, a curious mix of professions, including writers, shoemakers, and seamstresses) were the most dangerous, followed by those exposed to mercury vapors and “animal” particles. Occupations involving other particles and vapors were declared “innocent.” Benoiston concluded by recommending that some kind of remedial action or regulation be undertaken to alleviate the hazards of occupations exercised while bent over forward.^[38]

Benoiston’s and Lombard’s studies in the Annales d’hygiène publique are classic examples of the environmentalist style of medical thinking. This characteristic of pre-germ theory miasmatism sought the causes of disease in spatial relations and the exposure of bodies to weather conditions, vapors, particles, and other environmental factors. In the case of tuberculosis, environmentalism and essentialism were by no means mutually exclusive. Investigators often looked for local, spatial, and environmental correlations in the incidence of tuberculosis without denying the contributory role of an individual’s heredity, temperament, or constitution in any given case.

In the course of his investigation, Benoiston noticed something that several other doctors and hygienists had pointed out but that none had truly analyzed: women died of tuberculosis at a significantly higher rate than men. His occupational categories caused him to comment on the different circumstances faced by women and men in various professions, and this discussion eventually led him into a full-fledged diagnosis of the fundamental pathology of women.

Sexual Inequality Before Death (The “Gentle and Unfortunate Birthright” of Women)

Benoiston had one simple and one complicated explanation for the over-representation of women among the victims of tuberculosis. The simple one was menstruation and pregnancy, or, as he put it, “phenomena particular to [their] makeup, which appear with puberty and whose periodic return ceases only with age.” “The precautions that [these phenomena] always demand, the troubles they often go through, the storms of pregnancy, [and] the complications that follow it are enough to show why consumption is more frequent among women from age 15 to 50.”^[39] In fact, at least one scholar has credited exactly these factors, which can diminish the body’s resistance to infection, for the greater female susceptibility to tuberculosis that was evident for the first two-thirds of the nineteenth century.^[40]

A slightly different point of view emerged, however, when Benoiston remarked that occupational category 7—occupations necessitating a forward-leaning or bent over position of the body—exhibited an especially marked sex differential in tuberculosis mortality.

This innate weakness of women, gentle and unfortunate birthright of their sex [triste et doux apanage de leur sexe], which when they work alongside men exposes them to more than their share of dangers, this same weakness has another harmful result: it also condemns them to lesser earnings, and thereby to a state of poverty.^[41]

In other words, being female—and therefore burdened with an “innate weakness”—intensified all the regular occupational hazards, including poverty. This intensified poverty, Benoiston continued, prevented women from properly nourishing themselves, which added to their “natural weakness as women, and render[ed] their constitution less capable of resisting harmful influence[s].” This diminished resistance argument was remarkable enough for its time—it would later be a staple of germ theory analysis—but what followed was even more of a departure from what had come before.

Thereafter…poverty extinguishes neither the taste nor the desire for life’s pleasures—and even intensifies these desires while it deprives one of their fulfillment.…[T]hese continual and ardent wishes for a better state soon become an urgent need [and] push those [women]…into a series of imprudences and lapses whose sad effects end up destroying [their] organs, which were already impaired by painful labor and by even more painful privations.^[42]

The reference to prostitution was barely veiled. This fate was the result, Benoiston implied, of the economic inability to satisfy one’s desires and the concomitant intensification of those desires. Moreover, its effects added to the strain on “already impaired organs” that labor and physical hardships had set in motion. This chain of circumstances, Benoiston concluded, pushed women to an early death. “Thus, on the one hand, a weaker constitution, meager wages and the resultant poverty, and on the other hand, active passions and…excesses of all sorts, lead rapidly to the grave for these weak beings, led astray by deceptive dreams.”^[43]

This arresting segment of Benoiston’s otherwise staid article oscillates without warning from the inherent pathology of women to a critique of economic and sexual disempowerment, from fatalism to moral condemnation. In the final analysis, fatalism and moral condemnation share center stage. Commenting on the fact that some occupational categories did not show such a high susceptibility for women, Benoiston invoked “a sort of fate, an inevitable destiny,” which explained why certain occupations accounted for more filles publiques than others. Because this “fate” did not apply to men, men were less susceptible to tuberculosis than were women.^[44]

Simply by means of this brief didactic narrative,^[45] Benoiston managed to equate biology with destiny and reduce the sexual differential in mortality to a moral question—prostitution. In this respect, he echoed Laënnec and other doctors who implicated “venereal excesses” in tuberculosis, and he also reflected the early hygienists’ preoccupation with prostitution.^[46] Although Benoiston attenuated the blame that went along with such moral questions by lamenting the social circumstances that set poor women on the path to depravity, he did not do away with it altogether. He referred to “immoral behavior” (l’inconduite) as one of the causes of high tuberculosis mortality and formulated a conclusion that could serve as one of the central credos of the hygienic movement: “Of all the enemies that threaten man’s existence, the most dangerous [and] the most inevitable will always be himself.”^[47] Like the widespread disgust at the filthy, overcrowded environment of the city, the moralistic attribution of blame to tuberculosis victims would survive to become a central tenet of the dominant etiology at the end of the century.

Immediately following Benoiston’s 1831 article in the Annales d’hygiène publique there appeareda brief contribution by Pierre-Charles-Alexandre Louis entitled “Note on the Relative Frequency of Phthisis in the Two Sexes.” Louis remarked on the paucity of literature on the subject and complained that previous authors “[had] not, as far as I know, resolve[d] the question,…at least not in a rigorous and comprehensive manner.”^[48] One of the most prominent clinicians of the so-called Paris school in the early nineteenth century, Louis was the pioneer of the “numerical method,” by which systematic observation and statistics were used to assess the accuracy of theories and the efficacy of therapies.^[49] True to his method, he approached statistically the question of women’s and men’s relative susceptibility to la phthisie. Among tuberculosis patients treated by him at the Hôpital de la Charité between 1822 and 1825, Louis found 23 percent more women than men (although his figures, 70 women and 57 men, do not add up to his total of 123 patients). In addition, he found tubercles in the lungs of two-thirds more women than men who had died of causes other than tuberculosis (out of a sample divided evenly between the sexes). These figures and data he collected subsequently led Louis to conclude that women were 37 percent more likely than men to get tuberculosis.^[50]

After establishing this differential (based though it was on a fairly small sample), Louis addressed two factors traditionally thought to predispose women to tuberculosis. The first culprit was tight clothing, particularly corsets, which were then in vogue among Parisian women. Corsets inhibited chest development, it was thought, and thus invited tuberculosis. Most of the consumptive women Louis treated, however, grew up in the countryside, working in the fields, and did not wear corsets until after their arrival in Paris, when their chests were already fully developed and corsets would have had little effect on the dimensions thereof. Moreover, tuberculosis was more common among females even during childhood, when corsets were not generally worn. Louis therefore rejected the idea that tight clothing contributed to the onset of the disease.^[51]

Louis seemed to be persuaded, however, by another characteristic traditionally thought to be associated with the incidence of tuberculosis. “Lymphatic temperament,” the humoral orientation that was thought to make certain people languid and sluggish, had long been considered “favorable to the development of consumption” and was “incontestably more frequent among women than among men,” even in childhood, according to Louis. While he did not explicitly endorse this view, he noted that the statistical evidence “supports” it. Furthermore, his discussion of lymphatic temperament is the last paragraph of his “note”; it therefore occupies the place of a conclusion, whatever the author’s intent.^[52]

This is a classic expression of essentialist medical thought: women died of consumption more often than men because of their lymphatic nature. In fact, all the various interpretations of the sexual differential in tuberculosis provide further evidence of the fundamental compatibility between medical essentialism and the hygienists’ social perspective. Neither contagionism nor any other particular etiology was a precondition for examining disease from a social viewpoint or for charting its ramifications through society. While the rise of germ theory changed the language in which tuberculosis was depicted and oriented preventive strategies toward a focus on microbes, many of the constituent elements of the early-century essentialist etiologies of tuberculosis (including heredity, overcrowding, filth, and vice) maintained their status in the heyday of contagionism decades later.

Pidoux Versus Villemin: The Contagion Debate

Around 1865, the terms of discussion surrounding tuberculosis began to change; the old debates were engaged in a new way as they began to take on a different tone, and doctors aligned themselves on one side or another of a new controversy concerning the disease: contagion. In that year, Jean-Antoine Villemin, a military physician, announced that he had succeeded in inoculating tuberculosis into laboratory rabbits. By injecting tuberculous matter from a human cadaver into the rabbits, Villemin had produced the disease in the animals. If true, inoculability implied, though it did not prove, contagiousness.

Skeptical reaction was quick to follow Villemin’s claims, particularly after he reported his findings to the Academy of Medicine, the nation’s most prestigious medical body. The academy’s members were not inclined to accept such a radical reversal of conventional wisdom without thorough proof and lively debate. For decades, the controversial doctrine of contagionism—with the quarantines and other restrictions on commerce that it implied—had been anathema in established European medical circles and among liberals in general, as Ackerknecht pointed out in a now-classic 1948 article.^[53] At the time, contagion was seen less as a revolutionary new idea than as a relic of the past, a vulgar superstition kept alive by the uninformed masses. Many doctors committed to the optimistic outlook of positivism viewed contagion as a prejudice that inspired fear among the populace, pitted citizen against citizen, and stigmatized the sick as enemies of the healthy.

Michel Peter, known to posterity as a fierce anticontagionist and Pasteur’s most dogged opponent,^[54] responded to Villemin’s experiments even before the issue reached the academy. “The idea of the contagiousness of tuberculosis is almost universally—and nearly without discussion—rejected by contemporary scholars.” After describing Villemin’s methods, Peter concluded that the rabbits’ illness resulted from the injection of “cadaverous matter” and from “purulent or putrid infection” rather than from the communication of tuberculosis per se; he suggested that the results would have been different if tuberculous matter from a live patient had been used instead. Peter defended the tenets of hereditarian essentialism in terms scarcely changed from the days of Laënnec. Yet there was perhaps a slight trace in Peter’s argument of the hygienists’ social investigations, as he briefly mentioned poverty, malnutrition, overwork, and overcrowding as causal factors in tuberculosis.^[55]

After Villemin presented his findings to the Academy of Medicine, Jules Guérin—the originator of the term “social medicine” and an active participant in the republican revolution of February 1848—rose to refute the new contagionist claims. Like other progressive liberals in the crucible of mid-nineteenth-century medicine, Guérin refused to subscribe to the fearful creed of contagion. “Let us posit as a fact,” he said in response to Villemin, “that in its essence, tuberculosis is not contagious.” It was enough to consider nonpulmonary forms of tuberculosis, he argued, for the very notion of contagion to “provoke a widespread smile of incredulity.” If tuberculosis in other parts of the body was not contagious, then it was impossible for what all parties agreed to be the same disease to be contagious in the lungs.^[56] Guérin suggested that Villemin’s results could be explained by the quasi-miasmatic “putrefaction” emanating from the lesions of late-stage tuberculosis, which was capable of reproducing the disease “by a sort of graft.” The ensuing “pure infection,” like Peter’s “putrid infection,” had nothing in common with contagion, he insisted.^[57]

Villemin’s fiercest critic of all, however, was the academy’s Hermann Pidoux. His intervention in the controversy over the contagion of tuberculosis (in the Academy of Medicine debate and in his contemporary writings) deserves detailed scrutiny, because its often intriguing perspective and rationale were lost to history when it went down in ignominious defeat. Like Peter, Pidoux came to be remembered for his opposition to germ theory, for expressing the “ardor…[and] indignation of the old medicine which, feeling itself overtaken by an irresistible progress, clings with bitter desperation to its traditional ideas.”^[58] Of course, at the time, Pidoux felt that he was defending progress against the assault of an archaic and fanciful theory. “It is truly far too simple to say that disease has as its cause disease—that is, its seeds[—]just as rabbits and cabbages have as their cause cabbage seeds and rabbit semen.” Pidoux could not hide his disdain for Villemin’s contention that the tubercle (the small nodular lesion that characterizes tuberculosis) was not the agent of the disease but contained the agent (later identified as the tubercle bacillus). “This concept is at once naive and vulgar. It comes straight out of the Middle Ages. It is an animist doctrine of viruses, in which the specific agent is conceived of as a soul existing by itself.…This is very pleasing to the imagination, but it is not serious.”^[59]

Today, more than a century after the triumph of germ theory, it may seem more than a little strange that an entrenched foe of one of the basic truths of modern medicine could pose as a fighter of medieval fantasy. Pidoux was not alone, however, in this perception; he simply went further than most in ridiculing the contagionists and burning all bridges behind him. He could not understand how “all acquired notions” of tuberculosis could be “overthrown”; or that suddenly, in the onset of the disease, “the subject, the constitution, hygienic conditions, heredity, and diatheses are nothing.” And if tuberculosis were contagious and each patient received it from another patient, Pidoux asked, how did the first patient get it? One ended up with such speculative questions when, like Villemin, one extrapolated unreasonably from animal experimentation “without consulting clinical experience, [which] every day bears witness” that the disease is not contagious.^[60]

The direction in which medicine should be moving, Pidoux argued, was neither toward the dead end of contagionism (which posited as the cause of disease an invisible being beyond the reach of medicine or public health) nor in Laënnec’s voluminous description and classification of the symptoms and manifestations of tuberculosis. Rather, he called for a “medicine of the species above and beyond the medicine of the individual.” This new medicine would have to come up with “more advanced and more social solutions” to the problem of tuberculosis.^[61] At the same time, he defended the traditional essentialist concept of “morbid spontaneity”—the spontaneous rise of disease conditions in the body itself—with a twist. Pidoux’s spontaneity did not exclude the action of intervening causes. He said, “When I speak of spontaneity…I am considering the organism in its milieu, that is…surrounded by agents of hygiene,…by stimuli that are sufficient or insufficient, regular or irregular, favorable or harmful, healthy or unhealthy.”^[62] He proceeded to identify the most important of these intervening causes. Few were actually new to the medical literature, but the way in which he set them forth in his impassioned speech to the academy was impressive in its comprehensiveness and its social perspective. In light of the debates that were to take place thirty to forty years later concerning the social causes of tuberculosis, Pidoux’s polemic was ahead of its time.

Consumptives, he said, fell into three categories: (1) those who contracted the disease upon the influence of “appreciable external causes”; (2) those who contracted it upon the influence of “appreciable internal or pathological causes”; and (3) those in whom neither external nor internal causes were apparent, who must have contracted it through a diathesis, or constitutional predisposition. The first two categories corresponded roughly to social position: the poor and the rich, respectively. In the phthisie des pauvres, the crucial role was played by “external poverty [or misery]” (la misère extérieure); in the phthisie des riches, it was “internal poverty [or misery]” (la misère intérieure).^[63] It should be noted that like many medical writers of his era, Pidoux operated within what now seems a disconcerting semantic minefield, one laced with vague terms for the most common and familiar conditions. In this case, however, the field becomes negotiable when the notions of internal and external misère are explained.

External misère, the contributory cause of tuberculosis among the poor, meant “ignorance, overwork, malnutrition, unsanitary housing, [and] deprivations of all sorts,” according to Pidoux. Internal misère, bane of the rich, consisted of various chronic diseases, “laziness,” “habits of luxury and flabbiness [mollesse], excesses at table, [and] the torments of ambition.” Both types of misère resulted in “organic depletion” within the body, and in both cases, the “most common mode of degeneration” was tuberculosis. In other words, the poor got tuberculosis from poverty itself—because of “work in factories,” because they were “malnourished,” because they were “redeemed from serfdom but not yet from wage labor.” In contrast, the rich got tuberculosis from overindulgence in their own wealth.^[64]

Pidoux bristled when contagionists claimed factors such as overcrowding among the poor as evidence for their case and when they recommended slum clearance to “extinguish the sources of tuberculosis.” This was actually prominent in his own antituberculosis program, he explained, because overcrowding and unsanitary housing contributed greatly to external misère. “Therefore, we have a better right to this argument than do the contagionists,” he asserted contemptuously. To pretend otherwise, and to invoke overcrowding in service of contagion, was to mistake “the effect for the cause” (that is, to attribute the frequency of tuberculosis in close quarters to the frequency of tuberculosis in close quarters).^[65]

Perhaps more significant than his willing engagement in medical polemics, however, was Pidoux’s call for concerted public action against tuberculosis. Existing associations devoted to “improving the lot of the masses” were fighting the right battle, but Pidoux felt that they were not enough. He called for new public–private “leagues” to be formed around the nation, specifically dedicated to combating “the causes and multiplication of tuberculosis.” “In every city [and] in every village, there should be a permanent and active association for the extinction of Consumption.…The wealthy should use all the means at their disposal to help in this effort.” All of the area’s physicians would be involved, as would the local clergy.^[66]

But Pidoux did not envision just another philanthropic project. In this case, the state would have to intervene. Encouraging the creation of local leagues, “protecting them,” contributing money, even heading them directly was the state’s responsibility. Government representatives would need to be actively involved in local efforts and report to departmental prefects and other authorities on the leagues’ progress. To those who thought his proposals unrealistic or utopian, Pidoux replied angrily, “What I am proposing is less chimerical and less utopian than the search for new remedies against Consumption, [whose products] we see advertised every day and which are a disgrace to Medicine.” Instead of mesmerizing the public by promising miracle cures for tuberculosis, he seemed to be saying, medicine should be mobilizing the public.^[67]

Pidoux’s plan was unusual in two respects. First of all, except for smallpox vaccination and temporary emergencies such as cholera epidemics, such associations involving state participation were not a commonly accepted public health strategy in the 1860s, as they would be several decades later. Pidoux was one of the first to call for a government-sponsored fight against tuberculosis. Furthermore, demanding public intervention on a collective scale was a peculiar stance for an anticontagionist dedicated to preserving medical essentialism and morbid spontaneity. As he took pains to point out, however, spontaneity was not incompatible with the influence of external causes, and it was these external causes that Pidoux sought to battle through collective action.

There was also a poignant moment in Pidoux’s speech before the Academy of Medicine. It reveals one of the most elemental reasons for many doctors’ opposition to contagionism. Emotionally, Pidoux simply could not bring himself to believe in contagion, even in the face of Villemin’s evidence: “What a calamity such a result would be!.…[P]oor consumptives sequestered like lepers; the tenderness of [their] families at war with fear and selfishness.” The possibility was too horrible for him to contemplate. “If consumption is contagious, we must not say it out loud” (Si la phthisie est contagieuse, il faut le dire tout bas), Pidoux concluded plaintively.

Let us believe, then, until there is proof to the contrary, that we are right…we partisans of the spontaneous degeneration of the organism under the influence of [various] causes that we are seeking out everywhere, in order to combat the disease at its roots.^[68]

In retrospect, this was a turning point in French society’s understanding of tuberculosis. Pidoux felt that contagionism entailed nihilism and helplessness in preventive efforts; later, in the heyday of Pasteurian medicine, the point was debatable. There was no shortage of plans to extinguish the tubercle bacillus, but they had little, if any, effect. He also felt that to admit the truth of contagion would unleash fear and prejudice against those who had or were suspected of having the disease; on this point, he would later be proven correct.^[69]

On the etiology of tuberculosis—bacteriologically speaking—Pidoux was wrong. He ventured so far out on the limb of anticontagionism that when Koch finally identified the tubercle bacillus in 1882, thereby convincing nearly all the remaining doubters that the disease was contagious, every aspect of Pidoux’s argument was discredited. Overwork, low wages, poor diet, fighting tuberculosis by fighting poverty—all fell by the wayside until resurrected much later by the political Left. There is no indication that Pidoux was any kind of political radical, and in fact much of his writing on tuberculosis (including his request that the clergy involve itself in the public campaign against the disease) exhibits the prevailing medical moralism of his age. Nevertheless, he prefigured in some ways the later leftist critique of tuberculosis, and his ultimate failure was by no means assured at the time of the contagion debate. Instead of overthrowing hereditarian essentialism, Pidoux attempted to modify it and expand on it, entering certain new variables into the etiological equation of tuberculosis. He seems to have been concerned with steering medicine into areas in which preventive strategies, public health, and the state could fruitfully intervene. That he failed—and that germ theory emerged triumphant— sured that his perspective would be forgotten.

The contagion debate at the Academy of Medicine did not settle the matter once and for all; uncertainty over the etiology of tuberculosis persisted even after Koch’s identification of the tubercle bacillus in 1882. Beginning in the 1880s, however, the terms of discussion changed dramatically. Some habits survived from the essentialist era, including the adoption by bourgeois investigators of a disgusted and moralizing tone in describing the urban poor. These observers continued to look at the working class as if it were another species, filthy and brutish. Hygienists carried on Villermé’s method, examining the differential effects of tuberculosis in society and zealously collecting information without any corresponding imperative for intervention. But filth was henceforth dangerous in a new way, and the living conditions of the working class now contained the deadly menace of contagion. Furthermore, tuberculosis became not just a social disease but a national problem. Old worries were expressed in a new vocabulary of microbes and degeneration.

There was another facet to essentialism, however, that proved more resistant than Laënnec’s or Pidoux’s ideas to the emergence of new perspectives. In fact, in the history of perceptions and meanings surrounding tuberculosis, the mid-nineteenth century is primarily remembered neither for debates about contagion nor for the early hygienists’ investigations. Rather, this period is remembered as the age of the consumptive literary heroine, whose illness and death were tragic yet beautiful, with both physical and spiritual dimensions. The significance of this phenomenon, which transcended medical knowledge and rendered it all but irrelevant, is the subject of the next chapter.

Notes