3. “Guerre au bacille!”
Germ Theory and Fear of Contagion in the War on Tuberculosis
Playwrights, novelists, and nuns were not the only ones in nineteenth-century France making sense of tuberculosis by telling stories. Indeed, the use of narrative as a strategy to give meaning to disease seems to have been one of the few traits common to all parties in the public discussion of the tuberculosis problem. Within the framework of the dominant etiology during the Belle Epoque, narrative played an important role in the production and communication of medical knowledge. Housing conditions and immoral behavior were prominent among the social causes of tuberculosis that were denounced in the War on Tuberculosis; yet one cannot understand any of the various social factors implicated in the spread of the disease without first examining the concept of contagion itself, with its various social and political ramifications.
For the first two-thirds of the nineteenth century, essentialist explanations of tuberculosis predominated in France, from Laënnec to Hugo and the Goncourts. After Koch’s 1882 identification of the tubercle bacillus, the rising tide of contagionist medical opinion in France gained considerable momentum. Debate over the transmissibility of tuberculosis continued sporadically throughout the 1880s, but the few remaining anticontagionists were on the defensive; in the ascendancy of the Pasteurian revolution, they were so isolated as to appear backward-looking and resistant to change rather than as serious contenders for scientific legitimacy. Yet while the basic notion of contagion as it applied to tuberculosis was widely accepted, not everybody in the medical community agreed on just what contagion meant or how it operated.
This chapter explores the implications of contagion as it became the cornerstone of the dominant etiology of tuberculosis around the turn of the century. Doctors and hygienists close to the government and affiliated with the leading medical schools and periodicals pursued the notion of contagion to remarkable lengths and targeted spitting as the principal vehicle of tuberculosis and a fearsome threat to public health. Some doctors—mainly outside the profession’s dominant institutions and publications—hesitated to follow the doctrine of contagion quite so far and denounced what they saw as its excesses.
Yet zealous campaigns to eliminate or neutralize the tubercle bacillus prevailed, at least in the theory and propaganda of the antituberculosis crusade. The extent to which they were put into practice is less clear, but the dispensary movement provides some clues. Although antituberculosis dispensaries, which sprang up around France in the years before World War I, were ostensibly aimed at bringing preventive health care to the needy in their neighborhoods, much of the dispensary literature displays a different impulse at work. Dépistage, or tracking down those infected with the bacillus to render them harmless to the community, seems to have been a major motivating factor behind the dispensary movement. Many hygienists and public officials militated for mandatory declaration of tuberculosis cases, a highly controversial issue among doctors; some prominent figures went so far as to propose the forcible isolation of all infected individuals in tuberculoseries, or modern leper colonies, for the protection of the rest of society. While such proposals were extreme and marginal relative to the medical mainstream, they arose out of the same contagionist impulse that led the crusade against tuberculosis to focus its energies on isolating and containing the spread of the bacillus rather than on the strengthening of bodily resistance or the improvement of overall standards of living.
The Spread of Tuberculosis: Soil and Seed
A fundamental tenet of the dominant etiology of tuberculosis around the turn of the century was the need to consider the importance of both “soil” (or terrain) and “seed” in the spread of tuberculosis. The body’s state of receptivity or resistance, in other words, deserved as much attention as did contagion or the tubercle bacillus itself. It eventually became obligatory and formulaic, in the parlance of the time, to invoke both soil and seed in any discussion of the disease’s causes or prevention. However, most texts gave far from equal treatment to exposure and resistance. In the mainstream of French medicine, the tubercle bacillus and how to avoid coming into contact with it preoccupied most of the antituberculosis crusaders. Typically, a speech, article, or other text would begin with the ritual invocation of both soil and seed and mention in passing the importance of moderation, rest, and nutrition in maintaining organic resistance to infection. The remainder of the argument or discussion would focus exclusively on the various means of transmitting or receiving bacilli, as would the concluding remarks and practical recommendations. In this manner, the formulaic references to the equal importance of soil and seed were belied by the disproportionate weight of argument on the side of seed.
An apparent exception to this pattern was the “moral etiology” of tuberculosis, in which immorality—via alcoholism and venereal disease—contributed to the spread of tuberculosis by diminishing the body’s ability to fight off infection. This moral theme obviously depended for its validity on the soil side of the etiological equation; in fact, it was not uncommon for the perfunctory nod toward bodily resistance to consist of a denunciation of alcoholism. However, because of its moral and political content, even this conspicuous exception to the rule of “bacillocentrism” tends to reinforce rather than contradict the defining trait of the dominant etiology: the central role of social and political anxieties in the development of medical knowledge in France concerning tuberculosis.
Even before Koch’s experiments succeeded in isolating the tubercle bacillus as the living microorganism responsible for tuberculosis, the groundwork was being laid in France for a contagionist, bacillocentric strategy against the disease. Although Villemin’s 1865 inoculation experiments on rabbits were not absolutely conclusive, they eventually convinced many French doctors that tuberculosis was transmissible; the identification of the bacteriological culprit, they felt, was only a matter of time. Among these doctors was Louis Landouzy, at one time dean of the Paris medical faculty and one of the leading authorities on tuberculosis during the Belle Epoque. Landouzy presented a series of clinical lectures to medical students at the Charité hospital in 1881 entitled “How and Why One Gets Tuberculosis.” The lectures carefully allow for a divergence of opinion on the question of contagion but finally come down on the contagionist side of the argument.
In the Charité lectures, Landouzy established the pattern for his later career, in which he insisted repeatedly and forcefully on the dual importance of soil and seed while subtly steering discussion (and especially policy considerations) toward bacillocentrism. To the medical students, he “insist[ed] at length on the question of soil” “because it dominates the entire tuberculosis question.” “To fight against the likelihood of the seed falling on soils that would allow it to germinate; [and] to modify [soils] so that…they become unsuitable for the development of tuberculosis—this must be the doctor’s ideal.” While this may have been Landouzy’s “ideal”—to concentrate on rendering contagion harmless by fortifying the soil—it was not reflected in the thrust of his work or the work of other mainstream hygienists.
Most of the lecture series consisted of an examination of various current theories and experiments concerning the possible transmission of tuberculosis. According to some German experiments, Landouzy noted, respiration “seem[ed] to play the preponderant role” in introducing the disease into the body; furthermore, the same experiments highlighted the spittle of tuberculosis patients as an “agent of transmission” by showing that dogs forced to breathe air containing such spittle contracted the illness. This attention to spittle was significant, as it would later occupy a privileged place in the dominant etiology of tuberculosis.
Landouzy left open, however, the possibility that tuberculosis could be transmitted via other avenues. In fact, he went out of his way to suggest the myriad ways in which the agent morbifique might enter the body.
This passage is curious in several respects. Its syntax, beginning “Who knows if.…,” appears to violate the scientific demand for testing and proof of hypotheses (and thus to undermine the authority of the hypotheses that follow). Moreover, it seems at least to counterbalance, if not actually to contradict, Landouzy’s insistence on soil and its “domination” of the tuberculosis question. Finally, the casual mention of tainted milk, meat, and even drinking water could not help but contribute to a quite unscientific reaction—possibly leading to panic or hysteria—along the general population concerning the possibility of contracting tuberculosis. Perhaps Landouzy himself sensed these peculiarities, for he immediately followed this sentence with the defensive assertion, “I do not underestimate the enormous gravity of the questions I am raising.” It was better, he maintained, to “agitate” such matters publicly and thereby “shed light” on them than it would be to “leave these questions in the shadows.”
Who knows if the contaminating agent does not enter, simultaneously or successively, by dust from tuberculous expectoration, by tuberculous meat, by milk from tuberculous cows, perhaps even by water that is considered potable but might have been polluted by contact with the waste of consumptives?
Another common feature of what later became the dominant etiology that is evident in Landouzy’s Charité lectures is the core narrative. To illustrate their arguments, doctors and hygienists (or indeed, politicians, labor organizers, and novelists) often made use of archetypal stories that explained in lay terms the origin and spread of tuberculosis in a given social context. Often, through a simple tale, they offer a glimpse of the ideology at the core of a scientific explanation. Typically, there is a before-and-after quality to the narratives, in which an idealized past or state of grace is followed by transgression and tragedy. Whether they were hypothetical stories or purported to be factual reportage or case histories, the core narratives served the same essential function: to make moral sense of a fearsome and seemingly random killer.
The nature and function of narrative have always been subject to various interpretations, and the relation between narrative and “historical reality” has recently become a contentious topic of debate among historians. At the same time, humanists in the world of medicine have been investigating related matters, including “the art of the case history” and “the narrative structure of medical knowledge.” One of these scholars, Kathryn Montgomery Hunter, sees a special connection between medicine and literature that sets these two endeavors apart from other studies of humankind. The medical case history resembles literary narrative, she argues, not just in form but also in that both genres “can be about only one set of circumstances at a time.” Through their use of narrative, in other words, medicine and literature are linked in their particularism and uniquely individual meanings. This may be true for the specific genre of the medical case history as it evolved in clinical settings, but it hardly applies to the cloudy mixture of fact and fiction that constitutes much medical narrative. Some of the nineteenth-century tuberculosis narratives purport to be factual case histories of real patients; others present themselves strictly as fictional parables or as generalizations from years of experience; still others amalgamate bits from each of these categories. What unites them all and gives them their representational power is precisely their transcendence of the particular—their universal applicability, or at least their social applicability in a given context. Through these stories, individuals become archetypes.
The historian and cultural critic Hayden White has distinguished three styles of recording sequential events, which he calls “annals,” “chronicle,” and “narrative.” Each befits a particular worldview and epistemology. Of the three, only narrative manages to represent reality in such a way as to impart moral significance, order, and causality to otherwise disconnected or meaningless facts and events. “Narrativity, certainly in factual storytelling and probably in fictional storytelling as well, is intimately related to, if not a function of, the impulse to moralize reality, that is, to identify it with the social system that is the source of any morality that we can imagine.” Modern readers, as White points out, find annals and chronicle frustrating and incomplete as historical representations precisely because they lack the “plot” and narrative closure that tie significant events together in a causal order and make moral sense of them. This explanation (the theoretical details of which White lays out with admirable clarity but are beyond the scope of the discussion here) fits the core narratives of tuberculosis quite well. The style of these stories contrasts sharply with the detached, empirical, neutrally observant tone of standard medical writing, which is couched in the universal scientific present tense. (For example, “HIV infection is a risk factor for tuberculosis,” or “The tubercle bacillus is transmitted from person to person by inhalation of dried sputum particles.”) Medical or sociomedical narrative, in contrast, was indispensable in giving tuberculosis a coherent social and moral meaning. The ostensible universality of the core narratives contributed vitally to the dominant etiology’s efforts to speak to all of society.
In the 1881 Charité lectures, Landouzy’s featured core narrative concerned spousal contagion: a wealthy young man, with a history of tuberculosis in his family, married a “magnificent young girl,” with no such family history. Eighteen months after giving birth to their first child, the wife died of pulmonary tuberculosis. Two years later, the widower remarried into a family whose robust health history promised to “compensate” (in the words of the husband) for his own fragile heredity. After the birth of two children, the second wife also died of tuberculosis. “As for the husband, he died only later, of a slowly developing tuberculosis.” Landouzy followed this with several more stories of household and/or spousal contagion, a theme that later became a leitmotiv within the dominant etiology. These narratives may have been chosen to respond to the legion of instances, often cited by anticontagionists, in which spouses or others continuously in close contact with tuberculosis patients remained perfectly healthy. Landouzy’s story certainly contained implicit moral lessons concerning contagion, marriage, and ethical responsibility; one always needed to be vigilant against the possibility of contagion. Even at this embryonic stage of organized antituberculosis efforts in France, such narratives added a vital dimension to the sciences of medicine and public health, which in these years aspired increasingly to treat the social body as well as the individual body.
Landouzy concluded that even if the contagiousness of tuberculosis could not be proven, “it is our…strict duty to conduct ourselves as if the matter were definitively established.” One reason for this was that “often families will anticipate certain preventive measures, which you will be able to institute tactfully, without revealing the theoretical preoccupations that dictate your conduct.” Once again, scientific caution was uncharacteristically thrown to the winds, and doctors were advised to follow an unproven doctrine in their everyday practice. Landouzy’s reasoning seemed to be that patients’ families would take certain “contagionist” measures regardless of what the doctor said; therefore, it behooved the responsible physician to guide the families and to use his “tact” to make sure that they did not go too far.
Landouzy was not moved by the anticontagionists’ ethical argument (espoused most notably by Pidoux) that even if tuberculosis were contagious, it would be necessary to keep that fact quiet (for fear of panic and ostracism). Citing the example of widespread tuberculosis in the army, he asked, “Is it really an affront to our nature to be afraid of a coughing bunkmate[?] [S]hould this cougher be removed from the barracks as soon as possible, and sent to the hospital?” What would be unethical, in his view, was to do nothing in the face of mounting contagionist evidence. He concluded the lecture series by calling for doctors to “preoccupy themselves” with the issue of contagion rather than avoid it.
By the end of the five-part lecture series, the insistence on equal consideration of soil and seed was gone (or at least momentarily forgotten). The burning issue of the moment was contagion; the seed was everything, or nearly so.
We must seek the truth and, if we sense it, we must not shout it from the rooftops but rather make it inspire our behavior, conform our practice to it, allow our patients to benefit from it, and make it filter into the thinking of the various officials who are responsible for the public health.
Contagionism enjoyed one of its finest hours the following year, in 1882, when Koch identified the tubercle bacillus. Germ theory was reaching triumphant maturity, and none in the medical profession could ignore its power any longer. By the late 1880s, even the cautious within the profession had been won over to some extent, and hygienist Jules Rochard was able to write in 1888, “Today, the contagiousness of phthisis is admitted by nearly all doctors.” Nevertheless, many elements of prior etiologies continued to survive in these years. Rochard himself, for example, wrote in his hefty and influential Traité d’hygiène sociale that heredity was responsible for roughly half of all cases of tuberculosis and that “instances of contagion [were] extremely rare.” Given that he allowed for only two modes of “transmission” for the disease, heredity and contagion, the two assertions seem to contradict each other. Later theorists would cast this relationship in terms of an inherited soil that the contagious seed would or would not find receptive to its implantation. Indeed, Rochard discussed the importance of soil in his book, though not in connection with heredity; until at least the mid-1890s, heredity remained a looming, independent disease-causing presence. In the matters of both contagion and heredity, Rochard advocated gently persuasive education rather than strict, repressive regulations to persuade the general public to avoid contagion and to discourage tuberculous patients from marrying and procreating.
The rise of germ theory profoundly altered discussion of tuberculosis in France, and it is significant that bacillocentrism carried the day. Yet the appearance of unanimity or consensus can sometimes hide a more nuanced reality in which dissent and uncertainty persist. Somewhat lost in the increasingly contagionist atmosphere of the eighties and nineties were the protests of a few isolated figures who did not share the belief that the discovery of the tubercle bacillus had irrevocably altered the outlook and tactics of the fight against the disease. Some of these doctors, including Michel Peter, were veterans of the Villemin debates of 1865–1868. Peter had compromised his prominent position in the French medical establishment by taking the lead in opposing Pasteur and germ theory, thereby securing for himself permanent obscurity and discredit. Nonetheless, Peter continued to speak out against contagionism for the rest of his life. The 1893 edition of his Leçons de clinique médicale revived the notion of “morbid spontaneity,” citing the body’s “spontaneous” ability to prevent germs or other contaminants—constantly absorbed into the body in various ways—from causing illness. The fact that most of these hundreds of thousands of germs never resulted in disease, Peter reasoned, rendered “contagion” all but irrelevant. The relative rarity of various illnesses among doctors and others who were constantly exposed to them proved the same point. Koch’s discovery, in Peter’s view, had little practical value.
Peter did not deny that microbes existed; rather, he believed that they became “noxious” only when the body underwent “internal or external modifications,” such as through fatigue, malnutrition, or other debility.
Koch’s discovery was a scientific conquest.…It is an interesting fact from the point of view of pathological anatomy and semiology; but there ends its importance and its scope.…[T]he Koch bacillus has expanded the limits of our anatomical knowledge without advancing therapeutics in the slightest.
Isidore Straus showed more caution in criticizing contagionism; in fact, he dedicated his 1895 masterwork, La Tuberculose et son bacille, to his former teacher, Louis Pasteur. Yet Straus too argued that in tuberculosis, “the intervention of the microbe is not everything.” Like Peter, Straus emphasized the “powerful” role of “predisposing and adjuvant causes,” including fatigue and privation as well as poverty, “sorrows,” alcoholism, and certain debilitating diseases. The absence of these factors, he held, explained the fact that autopsies of those who died of other causes routinely revealed the presence of “healed” tubercles or tuberculous lesions. References to this phenomenon were quite common in later medical literature on tuberculosis: some accounts reported this result in half of all corpses, others in 90 percent or more. Straus attributed such signs of “latent” tuberculosis to early childhood exposure to the bacillus; the infection would remain latent unless “awakened” later in life by the various “adjuvant causes.”
Straus and Peter were in a distinct minority in the 1880s and 1890s, when contagionism was on the rise. By the turn of the century, even equal attention to both soil and seed was more of a slogan than a practice. During the decade 1898–1908, when the War on Tuberculosis reached its peak, discussions of the disease were much less likely to include such qualms as Peter’s and Straus’s than the following sorts of injunctions: “the fear of contagion is the beginning of good health”; “it is…toward the destruction of the bacillus that our efforts should be directed.” In the words of Albert Calmette, the physician who later earned fame as one of the originators of the BCG tuberculosis vaccine, “The enemy is the tuberculeux who is spitting bacilli.” Indeed, the identification of the victim as “enemy” and a preoccupation with spitting were two of the most significant new features of the bacillocentric perspective on tuberculosis.
In 1903, the hygienist Edouard Fuster testified to the victory of contagionism when he summarized the War on Tuberculosis at a meeting of the Société de médecine publique.
The various means proposed to fight tuberculosis by searching out and isolating the dangerous “vectors of contagion” will be discussed below. Before doing so, however, it is worth exploring in more depth the denunciation of spitting and human contact as conducive to the transmission of tuberculosis as well as some misgivings that were expressed regarding the inevitable consequences of sounding the contagionist alarm.
The prevention of tuberculosis as a social disease includes…all measures destined to remove recognized vectors of contagion—the sick—from still healthy milieus; consequently, to search them out in all human communities, and then to isolate them as soon as they are a threat.
Spitting and the Danger of Contact
“Spitting, that is the enemy!” (Le crachat, voilà l’ennemi!) If medical literature is any indication, spitting was a common and disgusting habit in Belle Epoque France. Furthermore, it was known that pulmonary tuberculosis significantly increased expectoration; its victims could therefore be expected to account for more than their share of this everyday practice. Doctors and hygienists tirelessly preached the antispitting gospel to anyone and everyone. “Each crachat,” one periodical told its working-class readership, “is, alas! a veritable army of billions of vigorous microbes, that [one] sends to attack the health of [one’s] wife, children, friends, and neighbors.”
Although they were commonly blamed for careless spitting, workers were not the only intended audience for antispitting propaganda. Maurice Letulle, speaking to an employers’ association in 1902, insisted that “terror of the crachat is the beginning of hygienic wisdom” and repeatedly stressed the importance of keeping the workplace spittle-free.
The message was an urgent one, full of fear and loathing: no matter where one went, the “hideous homicidal crachat” would be waiting. Letulle’s unrestrained, almost frenzied tone suggests that sheer revulsion contributed as much as germ theory to medical concern about spitting.
A single sick worker can contaminate an incalculable number of his comrades, the foremen, and even the bosses; since bacillus-laden crachats are lying on the ground everywhere! woe to the shoe sole that picks them up. In the street, on stairways, at home…in all places, the hideous homicidal crachat will be there [le hideux crachat homicide trouvera place].
Letulle’s comments also point to a crucial class distinction; the spitter is a worker. Furthermore, the practice is all the more nefarious because, through contagion, “even the bosses” are at risk. When the antispitting crusaders told of even respectable bourgeois men indulging in the habit, their indignant and surprised tone suggested that, in fact, spitting was considered a vulgar working-class practice. The negligent worker coughing, spitting, and infecting innocent bystanders—even the wealthy—was a recurrent motif in the antituberculosis literature.
In his 1908 medical thesis, Roger Reveillaud went so far as to observe the spitting behavior of passersby on the Parisian grands boulevards. On just one sidewalk, between the Opera and the rue Montmartre, he counted 875 crachats of various sizes lying on the ground. “And this does not count,” he added,
Presumably, Reveillaud was referring to sputum globules the size of five-franc pieces; like Letulle’s, his tone conveys as much repugnance as concern for public health.
those that may have inundated the café terraces, where one quite often sees clean and polite people spitting up veritable lakes.…[O]n the terrace of the Théatre-Français café, we noticed a gentleman coughing continually and covering the ground, utterly shamelessly, with I don’t know how many five-franc pieces, which the waiter came over twice to cover with sand.
Is not a law necessary here?
It is not necessary to take issue with the scientific proposition of droplet infection to see that the antispitting forces were influenced to some extent by a kind of visceral revulsion. The history of disgust is still largely uncharted territory, but the pathbreaking work of historians such as Norbert Elias and Alain Corbin has revealed some turning points and zones of particular anxiety in the development of modern mores. In the late nineteenth century, three nodes of disgust assumed preeminence in the official antituberculosis campaign: unpleasant smells, the “promiscuous” crowding together of bodies, and bodily fluids and excreta. Corbin has described the process by which, beginning in the late eighteenth century, the smell of excrement and other types of refuse came to be considered intolerable and disgusting. The power of these particular objects of horror and concerns about disease helped constitute each other: disgust fueled the War on Tuberculosis, in a sense, while efforts to improve public health directed increased attention toward the living conditions of the poor and intensified bourgeois disgust at them.
Elias has shown that far from being frowned on, spitting was encouraged in etiquette manuals as late as the mid-eighteenth century, when it was thought “ill-mannered to swallow what should be spat…[as] [t]his can nauseate others.” One hundred years later, by 1859, manners had changed in polite society to the extent that spitting was viewed as “a disgusting habit.” As Elias has pointed out, this change was entirely unrelated to medicine and the rise of germ theory. “Rational understanding of the origins of certain diseases, of the danger of sputum as a carrier of illness, is neither the primary cause of fear and repugnance nor the motor of civilization, the driving force of the changes in behavior with regard to spitting.” Disgust preceded and eclipsed science, for even after spitting came to represent the transmission of disease, an underlying sense of revulsion often pervaded the medical outcry against the practice. It also provided the strategists of the War on Tuberculosis with a means of getting their message across. Fuster, for example, suggested that spitters could be shamed out of the practice and advocated an education campaign “insisting on the fact that the habit of spitting is repugnant.”
Spitting was most often depicted as spreading tuberculosis in the victim’s home and workplace, via dried-up particles dispersed through dry sweeping and other unhygienic practices. Yet many observers insisted that the danger was even more widespread than that. Any public space was a potential arena of contagion; as one doctor put it, “It is primarily in public meeting places that the…contagiousness of tuberculosis is exhaled to the highest degree.” These dangerous spaces included theaters, post offices, omnibuses, government or administrative offices, train stations, train cars, workshops, department stores, hotel rooms, military barracks, and schools. Several studies, finding high rates of tuberculosis among laundresses, sounded the alarm over contagion through laundry. Negligence was found at blanchisseries in the handling of both clean and dirty laundry (the two often came in contact with each other), and no effort was made to disinfect laundry coming from tuberculous households.
The medical column of the Parisian daily newspaper Le Matin called yet another contagion menace to its readers’ attention in December 1905: reading books. The columnist, “Doctor Ox,” claimed that an average book from a circulating collection or library could contain forty-three bacteria per square centimeter of printed surface, which, for a 300- or 400-page book, “represents a worrisome number of bacilli and micrococci.” Who could know, Doctor Ox wondered, how many book borrowers or library readers were ill or convalescing and handled pages after coughing or sneezing on their hands? “Have you ever thought,” he asked his readers, “about the number of volumes a consumptive can infect during the long months of his illness?” Many people, he suggested, probably never thought about such things until it was too late.
It would be difficult to imagine the lay readers of Le Matin not being panicked, or at least disturbed, by such alarmism.
Bacilli…are preserved quite well between the pages of a novel, just as plants are preserved in a botanist’s herbarium. And when this bacteriological herbarium comes into your hands, can you be surprised that you or a family member comes down with scarlet fever or diphtheria of unknown origin[?]
Doctor Ox went on to relate a recent case of “reading contagion” from the Ukrainian city of Kharkov. An outbreak of tuberculosis among city hall employees was found on investigation to be largely confined to those who worked in the city archives. Bacteriologists determined that the archival documents were “literally covered with tubercle bacilli.”
The infected employee had “tuberculized” his documents and posthumously contaminated his successors through the “archives bacillifères.” One peculiarity of this story concerned the fact that in scientific experiments, the tubercle bacillus had never been known to survive for very long, whereas the Kharkov archivists fell ill “several years” after the death of their careless predecessor. Doctor Ox even cited a maximum life span of 103 days for the bacillus under laboratory conditions; instead of casting doubt on the veracity of the story, however, the doctor concluded that the Kharkov incident proved the experiments wrong.
Where did these bacilli come from? The investigation…revealed that, some years before, an employee assigned to the archives died of consumption, and that this employee was in the habit (a quite common one) of moistening his fingers with saliva when turning the pages of documents.
As this column in Le Matin shows, sputum-related contagion was thought to involve more than mere spitting. The chain of contamination and the vicissitudes of the bacillus seemingly extended into every realm of daily life. One could not be too careful, hygienists warned. “You should not think that it is…the hideous crachat alone…that constitutes the great danger.” Spitting into handkerchiefs or napkins, for example, and letting them dry on beds, pillows, or nightstands was likely to coat those furnishings (as well as the room’s occupants) with bacilli. Similarly, even those patients who took care to use spittoons were warned not to leave them uncovered, lest unwelcome creatures bathe in them. “I must note in passing the open spittoon that the fly dips its legs in before wiping them off in the sugar bowl[,] for the fly is one of the great traveling salesmen of tuberculosis.” The same doctor went on to warn against intimate talking.
As will be seen below, such extreme prohibitions were not allowed to go unchallenged, even within the medical community. Yet the point remains that even the most apparently innocent activities in daily life at some point became charged with bacteriological significance.
In the same bed, on the same pillow, when we talk to each other mouth to mouth, so to speak, the column of air breathed out carries with it infinitesimal bits of bacillus-laden spittle and reaches the person to whom one is talking, or the child to whom one is telling a story—like a poison arrow that makes him smile.
Given the range and diversity of practices condemned as hazardous to public health, it is perhaps surprising that there were only two concrete preventive measures on which doctors widely agreed: a prohibition against spitting on the ground and distribution of hygienic crachoirs, or spittoons. Even spittoons caused some controversy and debate, however. Fixed spittoons installed in public buildings were the subject of an exchange at the 1905 International Tuberculosis Congress in Paris. Jules Héricourt argued that the sight of such spittoons constituted a “solicitation to spit.” Passersby then spit in the general direction and often missed the target, causing a greater mess than if there were no spittoon at all. As head doctor for the postal service, Héricourt consequently had spittoons removed from all post offices. Landouzy disagreed, contending that Héricourt’s objection applied only to old-fashioned spittoons situated at ground level. Landouzy argued that the absence of spittoons in public buildings was certainly no disincentive to spit, as the most cursory observation would show; nor was the “habitually filthy” condition of most post offices. Furthermore, he asked, how could hygienists prohibit or discourage spitting on the ground without providing spittoons as an alternative?
Hygienic spittoons also came in individual, portable models, though some patients considered them a nuisance. Even those who were very conscientious about using spittoons in the sanatorium, in the hospital, or at home would not think of doing so outside, according to one doctor. Some refused to spit into the apparatus to avoid revealing the nature of their illness in public; others complained that the spittoon was pointless, since they would have to use their handkerchiefs to wipe away the spittle that clung to their lips or beard anyway. The indignity of washing out one’s own spittoon was also used as an excuse, as were the revulsion of servants at performing that task and the inconvenience, when riding a bicycle or horse, of stopping, dismounting, and retrieving the spittoon from one’s pocket.
A flat prohibition against spitting in public may have seemed a simpler strategy, but it too encountered obstacles. Fuster complained that “liberty is understood in such a way that our democracies, even while claiming to be guided more and more by science, seem more and more incapable of imposing such restraints on themselves.” He advocated a tireless effort to educate people, to achieve piecemeal local restrictions, and eventually to approach as nearly as possible the complete suppression of spitting, which would “in theory, render unnecessary all other measures” in the War on Tuberculosis. More ambitious, the medical student Reveillaud called for parliament to pass a law against spitting on the ground. “The crachat being the primary vehicle of the bacillus, we would like to see it, and only it, be the main target of our energies.…No matter what they might say, tuberculosis will disappear with it [the crachat].” Reveillaud’s “No matter what they might say,” likely referred to the advocates of soil-related prevention, who often pointed to poverty, slum housing, and other general social ills as causal factors in tuberculosis and as arenas of possible intervention. Hard-line bacillophobes such as Reveillaud would have none of it.
Meanwhile, hygienists and national and local authorities covered walls in public places with placards and posters warning against spitting on the ground or floor. Many dispensaries and other organizations published and distributed antituberculosis instructions aimed at lay audiences. The “recommendations” published by the prefecture of the Seine were fairly typical in their focus on spitting. “It is expressly recommended that you not spit in public,” they read. After explaining in simple language how bacilli could be transmitted from person to person, the tract added, “Every crachat is suspect, because, at a glance, nothing proves that it does not contain bacilli.” Then, as if to defuse any panic that such a frightening concept might engender, it immediately added the reassurance that tuberculosis, “despite its gravity,” was curable at every stage of its development—a misleading yet apparently necessary addendum that became a commonplace in the War on Tuberculosis. (Although no effective medication or other treatment existed at the time, “cures” were claimed when, typically after a period of rest and abundant nourishment, a patient’s symptoms disappeared, whether temporarily or permanently.) Also like other examples of the genre, the Seine prefecture’s instructions went on to recommend practical measures against contagion such as the use of spittoons, disinfection, wet mopping instead of sweeping, boiling of milk, and “sufficient” cooking of meat.
Of all the possible objections to antispitting propaganda, there was one that rarely surfaced in public, although it may help explain the official insistence on curability. Sooner or later, even the least scientific-minded layperson would realize that in order for sputum to present a danger, the spitter must have tuberculosis. The acknowledgment of this condition would amount (in the minds of most people, according to contemporary observers, and in statistical probability) to a death sentence and was therefore something to be avoided. (And those who knew for certain that they had the disease could hardly be expected to keep the protection of others uppermost in their minds.) The conscious mental leap from “spitting spreads tuberculosis” to “my spittle might actually be dangerous to others” was almost literally unthinkable. After all, the nontuberculous person who spit was guilty of nothing, unless it was of setting a bad example.
It may have been in response to this unspoken objection that anti-tuberculosis crusaders repeatedly asserted that one could have tuberculosis without being aware of it, that a diagnosis of tuberculosis was not a death sentence, and that patients could harm themselves by spitting (through reinfection that could aggravate their illness). As Reveillaud put it, “We must convince him of the idea that he is not marked for death because he is consumptive, and that Tuberculosis does not necessarily equal Death.” One popularizing pamphlet imagined a healthy person interrogating a hygienist, “What? you want to prevent me from spitting as I wish, when I do not have tuberculosis?” The hygienist’s response was brutal in its simplicity: “I hope you are right, and that you do not have it, but you just don’t know.” The apostles of public health seemed to be caught between the need to fight complacency and to stress the ubiquity of tuberculosis, on the one hand, and the desire to reassure the sick, promote the powers of medicine and hygiene, and avoid panic, on the other. Each individual assertion seemed to err on one side or the other and had to be counterbalanced (without being contradicted) by another.
The perceived danger of exposure to contagion led some people outside of the medical community to reject the presence in their neighborhoods of certain facilities intended to diagnose, treat, or house tuberculosis patients. Henry Fleury-Ravarin, a deputy from the Rhône, even introduced a bill in parliament to outlaw such establishments “in the vicinity of residential areas.” In 1901, city employees in Nantes wrote a letter to the mayor protesting a proposal to temporarily install an antituberculosis dispensary in the city hall, where they worked. On the heels of recent reports of widespread contagion in public buildings, including the main post office in Nantes, the employees could not accept the implantation of a new foyer de contagion in their midst. Some of them, they wrote, had even seen “crachats streaked with blood” on the stairs and in the hallways of the city’s health department. The following year, the neighbors of the newly proposed site for the dispensary, on the rue Voltaire, petitioned the municipal authorities to prevent its installation. The city was forced to solicit a legal opinion on the applicability of laws against unsanitary establishments, as well as medical advice from Paul Brouardel, France’s preeminent hygienist who held the chair in legal medicine at the Paris medical school; all of the advice encouraged the city to go ahead with the dispensary, which opened as planned.
Brouardel was called on for an expert opinion again in 1906, this time in a dispute over the location of a facility outside of Tours. The Count de Lafont, a landowner whose property was situated across the road from the cure d’air, or fresh-air rest home, of the local antituberculosis league, sued the league, contending that the proximity of so many tuberculosis patients constituted a contagion menace and, moreover, depressed his property’s value. The league’s lawyer, Maître Henri Robert, argued that the presence of the home (which was not, he insisted, a sanatorium, contrary to the count’s contention), far from being a public health danger, probably represented an improvement in the overall hygiene of the area. Instead of catering to the fear and prejudice that would treat the victim of a contagious disease as the ancients had treated lepers, the Ligue contre la tuberculose en Touraine enforced strict rules on hygiene and distributed brochures discussing the true circumstances under which tuberculosis could be spread. Any spitting by a patient outside of a crachoir would result in immediate expulsion from the cure d’air, and other precautions kept the home in an exemplary hygienic state, providing a model for its neighbors.
“Tuberculosis is only contagious if there is direct contact or absorption of the Koch bacillus,” Robert maintained, and “as long as the spitting tuberculeux takes certain precautions, one can live with him without danger and without appreciable risk.” In pleading his case, he even called on the nation’s most eminent hygienists, through the government’s Permanent Commission for the Prevention of Tuberculosis, to bolster his argument. Brouardel sent a report in the committee’s name to the court supporting the local league’s position. Even a sanatorium, Brouardel wrote, was not “a danger for the surrounding area.” “The precautions taken in [such] an establishment to prevent the propagation of tuberculosis seem to be, on the contrary, a lesson [on prevention] for residents of the surrounding area.” While the “free” tuberculosis victim was indeed a “social danger,” according to Brouardel’s report, “the consumptive [who is] taken in, educated, treated, [and] kept in check…becomes totally harmless.” Under such strict discipline, there could be no danger of contagion at the rest home; without some sort of proof that the patients had ignored the rules against spitting outside the crachoirs, the Count de Lafont’s fears—and his lawsuit—were groundless. The court agreed. However, even if lawsuits and organized protests were exceptional and generally unsuccessful, they suggest the considerable extent to which the hygienists’ propaganda and educational efforts penetrated the public consciousness. Other types of evidence, including scattered accounts of ostracism and hysteria related to tuberculosis, point to the same conclusion.
Demurrals from Bacillophobia
Bacillocentric alarm occasionally became so widespread and reached such a paranoid pitch that it caused some doctors to caution against overreaction and panic. Often, this took the form of casual references in the “official” antituberculosis literature to the exclusion or rejection commonly experienced by victims of the disease. Yet even in such instances, the strategists of the War on Tuberculosis rarely shifted emphasis away from contagion as the key etiological issue at stake; they simply denounced superstitious or cruel tendencies “in certain circles composed of overly simplistic people.” Other doctors, most often from outside the powerful institutions of French medicine, took issue with what they saw as an overemphasis on contagion in the etiology of tuberculosis. These doctors blamed the instances of ostracism and rejection on constant warnings against the ubiquitous danger of germ transmission.
The “official” doctors and hygienists often recommended discretion in the implementation of certain measures against contagion because, in Fuster’s words, “it is essential that we not forget that the tuberculeux…is already considered a pariah [un pestiféré], denied work and shunned.” A sensitive bedside manner would be needed to confront popular prejudices, which manifested themselves in various ways. Brouardel himself, who insisted on the harmlessness of “disciplined” tuberculosis patients, reported several distressing incidents: a worker thrown out of his Paris boardinghouse after returning from the sanatorium at Angicourt; a domestic servant who stopped going to the dispensary for fear of his illness being found out by his masters; a chambermaid “brutally” dismissed and called a “plague infecting the house”; and a patient whose own family threw him out on the street after he was discharged from the hospital.
Residential disinfection, touted by many doctors as a practical means of combating contagion, had its drawbacks as well. When a program of systematic weekly disinfection was tested on a group of one hundred tuberculosis patients, their neighbors threatened to move out. The angry landlords finally evicted “those mangy, scabrous types who caused all the trouble.” The program had to be abandoned. Albert Robin, one of the leading medical proponents of solidarism, told of a day laborer in the early stages of tuberculosis, still vigorous and strong enough to work. No sooner did a disinfection team show up at his lodging house than the man found himself out on the street, homeless.
But the odyssey of a young maid, as reported by Dr. Jules Lancereaux, may be the most poignant and revealing story of contagion paranoia. When she came down with bronchitis and began to cough, she was fired by her masters and forced to rent a room in a boardinghouse. There, showing signs of tuberculosis, she was promptly asked to leave. Fleeing to the countryside, where her prospects for recovery might have been greater, she sought refuge with her sister. There were young children in the household, however, and the sister refused to have her. The young woman’s last resort was the hospital, but even there, the doors were closed to her, because all of the beds were full. Obviously, whether through posters and official propaganda or by more informal channels, a great deal of bacillocentric medical theory had filtered through to the general population.
There were some doctors who fought back, not just against popular prejudice but against the excesses of contagionism in medical and public health circles as well. While neither particularly numerous nor influential, these peripheral figures challenged official medicine by drawing a clear causal link between the mainstream etiology of tuberculosis and popular contagion paranoia. Perhaps the clearest example of this controversy surfaced in the pages of La Médication martiale, a minor medical journal, in 1904.
Paul Cuq, a doctor from the Hérault, wrote the journal to warn against the role of kissing in the spread of tuberculosis, particularly where infants were concerned.
The slightest abrasion or ulceration on the baby’s face, Cuq maintained, could be enough to allow the “perfidious microbe” to penetrate the delicate organism. On such “frail” terrain, the seed would multiply rapidly.
Physicians should undertake a veritable crusade against the common habit of kissing children. The nicer they are, the more we smother them with kisses, without noticing that in our affectionate folly we might kiss the corner of the [child’s] mouth or even the whole mouth, thereby inoculating the tuberculosis that we could be carrying without knowing it.
Cuq embellished his argument with the obligatory didactic narratives. One concerned a family in which both parents enjoyed superb health, yet saw two children die of tuberculous illnesses. Their search through the household and among the staff for clues turned up nothing, with the exception of an old servant woman in poor health who had been employed by the family for generations. A favorite of the parents, she spoiled the children and loved to kiss them while she played with them. The parents hated to part with her, but when a third child succumbed to tuberculosis, they relented and fired her after a doctor diagnosed a slowly evolving lesion in her lungs.
Even more remarkable was a case on which Cuq himself was consulted, involving the children of another robust and healthy family. When a relative arrived in the house for an extended convalescence from tuberculosis, the family took all proper precautions to prevent contagion, including housing the relative in a separate wing. Nevertheless, the two previously healthy children both eventually came down with tuberculosis and died. Cuq discovered the unexpected means of the disease’s transmission. “My research on the etiology of their illness led me to note that the vehicle of the bacillus was a lovable little dog who ran throughout the house, played with the children and kissed them in his own way, even licking them on the face and mouth.” The same dog, it seemed, had free access to the convalescing relative’s room, where it “licked and swallowed the bits of meat chewed and spit out by the patient, and doubtless sputum as well, particles of which it carried on its tongue back to the children.” The immediate moral of the story—limit pets’ intimate contacts with people, and keep a close watch on children’s apparently innocuous play—was not the only lesson Cuq drew from the incident.
Cuq’s final admonition, “Beware” (Méfiez-vous), could well have served as a motto for the bacillophobes who dominated the official campaign against tuberculosis.
I will finish my plea—or rather my indictment—against kissing by pointing out that there are legions of young married couples who inoculated each other with tuberculosis by kissing on the lips.…Conclusion: Beware of kissing in general and above all, try to protect your children from it.
The next issue of La Médication martiale carried a response to Cuq’s piece from another provincial physician, A. Mirabail of the Cher. In an exceedingly sarcastic tone, Mirabail ridiculed the lengths to which Cuq was willing to go in the effort to prevent contagion. “After forbidding us to spit on the ground or even in our handkerchiefs, after condemning us to breathe only at a distance of a meter and a half from each other, now my excellent colleague…takes kissing away from us.” Mirabail pleaded for his readers not to fall for the contagionist alarmism. “At the risk of Doctor Cucq [sic] casting lightning bolts full of millions of expectorated bacilli in my direction, I urge the public not to submit to such a draconian measure!” He complained that the “fears” so common in the population, as well as among doctors, were largely unfounded, because they “forgot only one thing: the notion of terrain.” Citing 90 percent as the proportion of cadavers who did not die of tuberculosis and showed healed or cretaceous tubercles on autopsy, Mirabail argued that exposure to the disease was nearly universal. Since only a small percentage of people ever actually developed symptoms or full-blown, “open” tuberculosis, exposure could not be a decisive factor in the disease’s incidence. “[I] do not deny contagion—quite the contrary, because I recognized that we are all exposed to contagion—but must we attach so much importance to this fact? I think not.”
Instead of hunting down microbes wherever they might lurk and attempting to prevent any of them from entering the body, Mirabail reasoned, it would make more sense and yield better results to try to fortify the body itself, making it inhospitable to infection. Preventing contagion, he wrote, was as “ridiculous” as covering a field with a net to combat weeds. “We start by proscribing the kiss; where then will we stop? Will we find a well-intentioned doctor to prohibit conjugal relations and replace them by fertilization without contact?” In fact, Cuq had warned against contagion among newlyweds through kissing on the mouth, and some doctors had suggested the possibility of genital transmission of tuberculosis. But Mirabail would not hear of it. “Let us continue to kiss each other: if kissing gives us a few extra microbes, we will forgive it, considering the sweet joys it brings.” Beneath the sarcasm, Mirabail’s quarrel was really with the dominant etiology of tuberculosis as a whole, to the extent that it was ignoring its often stated promise to deal equally with soil and seed.
There are some signs that disaffection with bacillocentrism may have extended beyond the occasional sarcastic letter writer in medical journals, although it never seems to have had a major impact on the official War on Tuberculosis. Another of the newspaper medical columnists, Lucien Descaves in the daily Le Journal, spoke out in 1906 against the danger that the battle against one scourge (tuberculosis) might lead to one even worse: fear. Descaves strongly opposed recent proposals for the mandatory declaration of tuberculosis cases, saying it would make the lives of patients and their families “intolerable.” He went on to ridicule what he saw as the excesses of contagionist hygiene. “We are seeing sources of contagion everywhere: in the kisses that children give or receive; on their fingertips that they put in their noses; in old books.…; in meat, milk, and I don’t know what else! We are positively terrifying the public.” Mandatory declaration, Descaves wrote, would cater to the “blind pretentions” of those who would treat people with tuberculosis like plague victims. Patients would be forcibly estranged from family and friends “on the pretext” that they pose a threat of contamination. Descaves finished with a bit of hyperbole: “These practices will soon return us to the leper colonies of the Middle Ages.” He was probably unaware of the degree of truth in his rhetorical flourish; as early as 1905, as will be seen below, at least one prominent Parisian doctor had begun to propose in all seriousness the revival of leper colonies for tuberculosis victims.
In 1908, the same year that Reveillaud’s ultracontagionist thesis was published, another medical thesis with quite a different message appeared. Xavier Jousset aligned himself with the partisans of soil and advocated fortifying the body instead of preventing the entry of the bacillus as the appropriate means of fighting tuberculosis. Unlike some of his fellow combatants in this debate, however, Jousset explicitly mentioned class as the key variable in society’s contagion paranoia. “Tuberculosis being principally a disease of the poor, those unfortunates who must struggle to earn their livelihood are becoming, for the rich, horrible sources of contagion, and…are doomed to the worst, most inhuman measures of ostracism.” Jousset also attempted to explain the bacillophobia of mainstream medicine in terms of overreaction to or misinterpretation of individual experiments or incidents. Doctors had too easily extrapolated, he claimed, from transmission of tuberculosis under laboratory conditions (including Villemin’s inoculation of rabbits) to “social” transmission under the conditions of everyday life. Furthermore, certain terrifying stories with little or no basis in fact—according to Jousset—were repeated so often that they became part of the medical lore of tuberculosis, and their veracity became immaterial. For example, he cited the case of the boarding school in Chartres which caused a commotion at the Academy of Medicine when it was first reported. Thirteen girls had died of tuberculosis at the boarding school in a two-year period, and their deaths were attributed to drinking milk from a diseased cow. At the academy’s next meeting, the member who had reported the case was forced to retract it; on investigation, it was found that not only was milk from the cow in question served only to the school’s staff but all of the milk at the school was boiled before being consumed. This retraction, Jousset complained, received little attention, and the original story continued to make the rounds among hygienists. As long as it was repeated and used to illustrate the perils of contagion, its accuracy no longer mattered.
Sparks flew when mainstream bacillophobia was confronted with an aggressive opponent in a series of meetings of the Société médicale du IXe arrondissement in late 1905 and early 1906. Dr. Adolphe Leray, head of the X-ray laboratory at the Saint-Antoine hospital in Paris, presented a paper attacking the doctrine of contagionism and its consequences. His arguments were not significantly new, but his coverage of the history and range of contributions to the debate was thorough and the force with which he delivered and defended his thesis in front of a largely hostile audience was remarkable. Poverty and poor hygiene, Leray contended, not only prepared the soil for tuberculosis; they were, in fact, its primary determinant causes. The very omnipresence of the bacillus that so worried many hygienists proved that contagion could not account for who got tuberculosis and who did not. He restated at length the favorite argument of the early anticontagionists, namely, that contagion violated common sense and everyday observation: with so many thousands of consumptives spreading germs everywhere they went, why was not the entire population of Paris, for example, struck down by the disease within a matter of a few years? Why did physicians so rarely contract the disease, when they spent much of their lives exposed to its victims and their crachats?
Neither did Leray spare his opponents their share of ridicule. He accused them of promoting “the most detestable of tyrannies,” worthy of “the little despots” of past centuries. He quoted Emile Duclaux, Pasteur’s close collaborator, as wondering what would happen if all those suffering from tuberculosis could be exiled to a desert island. “This measure would be as beneficial,” Duclaux was reported to have said, “as eliminating within a few days all rabid dogs.” After citing this comment, Leray could only exclaim incredulously, “Comparing poor tuberculosis victims to rabid dogs!!!” His reaction to the antispitting campaign was little different, as his comparison to Don Quixote shows.
The war on spitting takes us back to more heroic times, when a certain illustrious knight, clad entirely in iron and accompanied by his faithful squire, also went off to war. Spittoons and disinfecting equipment have replaced swords, armor, and shields, which are outmoded weapons today.
Alas! nothing new under the sun.
Not surprisingly, the response to Leray’s paper at the Société médicale du IXe arrondissement was vehement and defensive. Leading the charge was M. Francon, who denied that contagionists sought a “brutal sequestration” of tuberculosis victims, or any kind of “tyranny.” He insisted that they only wanted to make obligatory what Leray called “rules of hygiene,” a task that would be made easier the more doctors were able to “educate the masses.” Francon threw back at Leray the example of the Œvre Grancher, which temporarily placed children from at-risk urban backgrounds with families in the countryside to protect them from all of the influences that predisposed to tuberculosis. He asked sarcastically if this philanthropic venture was yet another “cruelty, a torture revived from the age of barbarism” because the children were taken away from their families. On the contrary, Francon said, such measures were in the best interests of all concerned.
However, not all the reaction to Leray’s polemic was negative. Several speakers rose to endorse his position and to reinforce one or another of his points. One supporter deplored the “exaggerations committed by overly absolute and authoritarian hygienists” and lampooned the obsessive attention paid to different varieties of spittoons at the recent International Tuberculosis Congress in Paris. “If the Koch bacillus has not yet been killed by sheer ridicule, this is certainly due to its great resistance!” Leray himself finished with a plea for compassion rather than isolation, and material aid rather than quixotic fantasies.
While few would have argued with such sentiments, the participants certainly believed that there was a fundamental disagreement involved. Two particular characteristics of the War on Tuberculosis stand out from this exchange: first, the representatives of the dominant etiology, who tenaciously held to the soil-seed duality and defended their humanitarian sensitivity, consistently confined their practical recommendations to the field of contagion prevention; second, the rough balance between Leray’s defenders and his opponents which prevailed among those who intervened at these meetings in no way reflected the distribution of power in the broader arenas of medicine and public health.
Pity for those who go hungry! Pity for those who are cold! Fresh air for those who lack it; [a]nd finally, sunlight, to chase away mites and myths at the same time.
In the antituberculosis literature as a whole, these demurrals from bacillophobia represent a small fraction of the opinions expressed. They are summarized and quoted at length here to illustrate that bacillocentrism was not the inescapable, automatic product of a given set of circumstances. Rather, it was a contingent phenomenon, predominant during a given period despite the efforts of a few dissenters to discredit it. To oppose this scientific dogma was not unthinkable.
Dispensaries and Dépistage
Notwithstanding these vociferous but marginal protests, the hypercontagionist influence prevailed in the official antituberculosis campaign. Several different strategies were contemplated—and, to various degrees, put into practice—to identify and isolate potential vectors of contagion. The antituberculosis dispensary was the first line of defense in the War on Tuberculosis; it was to be the state’s hygienic eyes and ears in France’s remotest urban neighborhoods as well as the crucial vehicle for distribution of primary health care and philanthropic assistance. Although the dispensaries themselves stressed their care-giving and charitable aspects, their strategic role in the national campaign against tuberculosis was first and foremost one of dépistage, tracking down those who might be infected.
Dispensaries, it should be emphasized, aimed their intervention at one specific clientele: the poor. After all, this was where tuberculosis found most of its victims. Between 1901 and 1905, adult residents of the poor twentieth arrondissement of Paris were over six times more likely to die of tuberculosis than those in the wealthy eighth arrondissement. Annual adult tuberculosis mortality rates in those districts, 78 per 10,000 population and 12 per 10,000, respectively, suggest the degree of inequality before death that prevailed in the capital. Even if one discards the city’s low and high extremes for 1901–1905, one still finds an annual tuberculosis mortality for adults of 60 per 10,000 in the thirteenth, fourteenth, and fifteenth arrondissements compared to 28 per 10,000 in the affluent sixteenth arrondissement—a ratio of more than two to one.
While tuberculosis showed a marked preference for those on the lower rungs of the social ladder, the bourgeoisie was certainly not immune from the disease. Even the comparatively low death rates cited above for the city’s wealthy neighborhoods amounted to approximately 120 and 260 tuberculosis deaths per year in the eighth and sixteenth arrondissements, respectively—not all of which can be accounted for by domestic servants. Patients of means, while not the population with which the War on Tuberculosis was primarily concerned, confronted their own dilemmas and uncertainties when they found themselves ill. Those who could afford to do so, of course, sought treatment from private physicians. But seeking medical treatment for tuberculosis at the turn of the century was not as straightforward as it would become after the advent of streptomycin, rifampin, and isoniazid.
Even after medical science knew increasingly minute details about the nature, behavior, and transmission of the tubercle bacillus, it could still do nothing to treat tuberculosis. Germ theory by itself did not end the era of therapeutic impotence. The treatment regimens recommended by physicians for their tuberculous patients changed little with the bacteriological revolution. Commonly used treatments included goat’s milk, cod liver oil, lichen (ingested in teas and jams and applied to the skin in pastes), antimony, tannic acid, creosote, arsenic, and the inhalation of tar vapors. Occasional innovations such as the administration of formaldehyde gas with currents of static electricity vied for attention in the pages of medical journals and popular newspapers with advertisements for myriad patent remedies claiming miraculous curative powers. A “cure” could be claimed, it seemed, with every sign of improvement in a patient’s condition, or whenever a patient regained strength over a period of several months. The symptoms of tuberculosis could disappear even for years at a time—for example, when the patient was removed from the milieu or circumstances in which the illness appeared—only to return with equal or greater severity in times of stress or weakness.
Medicine’s inability to find a specific, reliable cure for tuberculosis in the nineteenth century merely underscores the remarkable presumption on the part of physicians to “treat” the disease socially by pronouncing on the most intimate matters of personal conduct and the most complex issues of social organization. That they did so owes less to the accumulation of knowledge about tuberculosis than to the increasingly prominent social and political position of medical doctors in nineteenth-century France. The degree to which physicians participated in government on both the local and national levels—not to mention philanthropy and other areas of social influence—made France unique among industrialized and “medicalized” nations. The pathbreaking discoveries of the Pasteurian revolution in microbiology and the promise of science to cure not only the individual’s but society’s ills allowed French medicine to arrogate the authority to prescribe social reform as well as medication. Such authority, however, did not add to the doctor’s therapeutic arsenal. In the absence of a “magic bullet” for tuberculosis, the only systematically reliable treatment in the years before antibiotics was what doctors described as lacure d’air, de repos, et de suralimentation (the fresh air, rest, and overfeeding cure): a well-fed vacation. Only with ample nutrition and rest in a healthful environment, it was observed, could the body withstand the ravages of tuberculosis.
These were, above all, cures for the bourgeoisie, and they could not have been universally prescribed even if the medical profession had wished to do so. Whatever the therapeutic value of the various treatments for tuberculosis, the working-class clientele of the dispensaries did not have the luxury of trying them, and they certainly could not afford to leave work and family to seek a rest cure in the countryside. The dispensary, therefore, could not reasonably be expected to cure disease. It could only attempt to alleviate some of the effects of poverty and to prevent the spread of tuberculosis by observing and reforming the local population.
The annual reports of French dispensaries for the years before World War I are replete with statistics on the monetary value of linen, meat and milk coupons given away, laundry washed, home disinfections, and other aid offered to the poor and indigent. This real material assistance was an important part of dispensaries’ day-to-day functioning, and it should not be disdained simply because many of the theorists and strategists of the War on Tuberculosis were preoccupied with dépistage. Nevertheless, it would be naive to accept uncritically the dispensaries’ self-representation and not to distinguish between strategic raison d’être, on the one hand, and the noble intentions or deeds of individual participants, on the other.
The model for all antituberculosis dispensaries in France was the Préventorium Emile Roux in Lille, established by Calmette in 1901. The phrases “modeled on the Lille dispensary” and “of the Calmette type” recur frequently in annual reports and proposals for the creation of new dispensaries. Calmette himself conceived of the ideal “preventorium” as a combination “recruiting office and practical school of hygiene.” First among all of its duties, he wrote, had to be recruitment: “to seek out, to attract, and to retain…workers who have, or are suspected of having, tuberculosis [les ouvriers atteints ou suspects de tuberculose].” This was the function that Calmette and others came to refer to as “dépistage.” The second major role of the dispensary was educational, to instill in its target population the elementary notions of personal and domestic hygiene.
Auxiliary to these two primary functions were others that complemented them in various ways. Dispensaries could serve as “filters” or triage centers for sanatoriums (assuming that enough of the latter could be created and made accessible to the poor), referring only patients who were “almost surely curable.” For the majority of patients, who for whatever reason could not go to a sanatorium and were not ready for the hospital, the dispensary could attend to their material needs by distributing food, clothing, bedding, and medication. For hopeless cases, it could at least protect family members and others from contamination. “It will give them the means to finish their lives without harming those close to them, without spreading contagion and misery all around them.”
Still, despite this variety of goals and activities, dépistage seemed to remain foremost in the minds of hygienists and public officials, who promoted the dispensary as a practical and inexpensive alternative to the sanatorium in the War on Tuberculosis. It would be unsatisfactory for dispensaries simply to offer their services and material aid to the public, as Calmette apparently understood.
This may have been the crucial difference between medicine and public health or hygiene: medicine waited for patients to come to it, whereas hygiene went out to find patients—even when patients did not know they were ill. Camille Savoire, another early and outspoken advocate of dispensaries, agreed with Calmette that “we must not wait for the patients to come to the doctor” and felt that dépistage had to go beyond haphazard and piecemeal efforts. He called for a “permanent and periodical medical inspection of all public and private organizations and groups,” which would constitute “a very fine-meshed net that will in passing filter out tuberculeux from various social milieus in order to give them the care that their state demands, to render them incapable of harming the community, and to ensure an early diagnosis.” At the very least, the fine-meshed net was meant to prevent patients from harming others (by contagion) as much as it was meant to single out potential recipients of medical care.
I think that instead of waiting for the consumptive worker to go to the doctor.…, we should adhere in principle to the necessity of going to him and giving him assistance, even before he notices that he is gravely ill. I would like for us to be able to track down [dépister] tuberculosis in the patient at the very beginning of its development.
Governmental authorities were also quite receptive to the dépistage that dispensaries could offer in the struggle against tuberculosis. Paris city councilman Ambroise Rendu, for instance, reported in 1908 on signs that the disease might be on the decline in Paris: “Among the means employed effectively in the fight against this scourge, we must give special priority to dépistage through dispensaries, and to the cooperation that has been established between them and the casier sanitaire.” It is revealing that Rendu not only singled out dépistage in praising dispensaries but also linked them to the casier sanitaire, the municipal administration’s office that monitored the city’s housing stock from the point of view of tuberculosis mortality. (See chap. 4, below.) Both aimed at extending the eyes and ears of the state (or its partners in the medical profession) into the neighborhoods, homes, and daily lives of the working class. Both relied more on observation and administrative knowledge than on material improvement or intervention.
The importance of administrative knowledge—the official registration and integration of a person into a network of aid, surveillance, and obligations—is suggested in other discussions of dispensaries as well. For example, the director of a Paris dispensary explained to a correspondent in 1903 that patients had to undergo three types of examinations before being registered: “clinical” tests, involving observable symptoms; “bacteriological” tests of sputum, blood, and urine; and a “social” inquiry into their housing and work conditions. Finally, “the patient, known [connu] from this triple point of view—clinical, bacteriological, and social—is admitted into the dispensary.” Without these fundamental and far-reaching connaissances, in the medical and administrative context of France at the turn of the century, the dispensary strategy would have been unthinkable.
The second great aim of the dispensary movement was hygienic education. Along with pocket spittoons, every dispensary gave patients printed “catechisms,” or lessons for avoiding tuberculosis, which were reviewed in person during visits as well. They admonished patients to wash themselves every day, to boil their milk, to cook their meat thoroughly (except for horse meat, which could be eaten raw because horses were not susceptible to tuberculosis), to beware of dust and, of course, of spittle too. “Be sober,” the catechisms advised, disinfect new lodgings with bleach when moving in, and breathe through the nose rather than the mouth, as one such sheet recommended. “The nose is a microbe-killer. A closed mouth preserves health, says the English proverb.”
All of the measures commonly found in the dispensary catechisms, except for sobriety, involved avoiding contagion. This is strange, given the fact that the only patients likely to get to the catechism stage of dispensary treatment were already designated as infected. Yet the instructions were generally phrased as contributing to the patient’s own protection, rather than the protection of family and friends. Such instructions were presumably intended to shield the as yet uninfected from contagion, but dispensary officials apparently did not deem it acceptable to admit as much openly. Perhaps it was feared that only self-interest could motivate a patient to follow the recommended regimen, or that at least some hope needed to be held out to the suffering patient.
With education came surveillance. Once admitted to treatment at the dispensary, “the tuberculeux, along with everything that concerns him, is never lost from sight,” as one legislator put it. Even if the patient was referred by the dispensary to a sanatorium or hospital, “as soon as he returns…the dispensary again assumes certain powers over him [le dispensaire reprend certains pouvoirs sur lui], always in his own interest and in the interest of those around him.” Fuster also emphasized that “the improved patient remains a suspect, from the social point of view, and for his own sake has a pressing interest in staying under observation.” In other words, no matter what the circumstances that led patients to the dispensary in the first place, the treatment and charitable aid they received there was not strictly voluntary. The patient who had been dépisté was from that moment onward a “suspect,” a potential danger to all those around him or her. At that point, individual rights were subordinated to the right of others to be free from contagion. As far as dispensaries were concerned, such issues rarely arose in public debate; but they came out into the open when attention turned to the mandatory declaration of tuberculosis and to proposals for the isolation of consumptives.
Mandatory Declaration and Isolation
Mandatory declaration—the legal obligation of doctors to report cases of tuberculosis to the authorities—represented the ultimate form of dépistage. Like the dépistage of dispensaries, it was inherently a preparatory measure, one that would have made little sense if not followed up by other measures. It is possible that advocates of mandatory declaration and other ways of tracking down those afflicted with tuberculosis intended to follow up with basic health care, residential disinfection, and education. However, the theme of forced or semiforced isolation arose often enough in discussions surrounding the War on Tuberculosis to suggest that at least some authorities considered it a corollary to mandatory declaration.
The most enthusiastic champions of mandatory declaration tended to be the nondoctors among hygienists and public officials. The medical profession was deeply divided over the issue, since it violated the secret médical, the almost sacred obligation of doctor-patient confidentiality. Some observers such as Fuster (who was not a medical doctor) treated ethical considerations as more of an annoyance than anything else. He called mandatory declaration of tuberculosis “the only serious resource with which the public powers could arm hygienists.” He envisioned declaration as obligatory not only for doctors but also for parents, employers, public assistance offices, and heads of schools, hotels, and other establishments. However, Fuster complained, “certain habits of liberty will no doubt long prevent us from giving hygienists the satisfaction on this point that their logic demands.” On one level, it is noteworthy that Fuster thought of objections on moral grounds as bothersome obstacles to progress. Yet on another level, one must wonder why he referred to “certain habits of liberty,” rather than specifically to the secret médical, for example. The only reason for which anyone would have raised such an objection would be that the “hygienists’ logic” would undermine personal freedom in some way—for instance, isolation of a less than voluntary nature—once mandatory declaration had become law.
Official calls for the quarantine of consumptives dated back even to the time of the contagion debates before the discovery of the tubercle bacillus. In 1880, when Dr. Adolphe Lecadre of Le Havre went before the Conseil d’hygiène publique of the Seine-Inférieure to argue that tuberculosis was indeed contagious, he called for its victims to be isolated within hospitals to prevent them from infecting others. In reporting Lecadre’s proposal, along with another that would keep children with tuberculosis from attending school, the Revue d’hygiène et de police sanitaire called them “premature,” since the contagiousness of the disease had not yet been conclusively proven. “Mandatory isolation always implies a certain infringement on individual liberty; in this case, the infringement would not be justified in the general interest, because the contagiousness of phthisis has not been proven.” The journal implied, however, that isolation would be justified when the disease was proven to be contagious.
By the time the dominant etiology had been fully elaborated and had achieved hegemony within the French medical community around the turn of the century, a consensus had developed on the proper roles of various institutions in the War on Tuberculosis. Whereas dispensaries were needed for dépistage and acted as the first line of defense, sanatoriums—to the extent that enough money could actually be raised to create them in sufficient numbers—were to be reserved for patients in the early stages of illness, who were eminently “curable.” The more hopeless cases, many hygienists agreed, were to be isolated in “asylums,” where they could “die tranquilly” without contaminating others.
This last category of patients, “who can no longer render society any more than intermittent services, or who will be a permanent drain [on society’s resources] until their imminent end,” were of interest to the authorities only in their capacity as vectors of contagion. Only patients with the potential to be useful to society in the future could be allowed to occupy scarce beds in sanatoriums. With both sanatoriums and asylum hospitals, Calmette wrote, “We will achieve as much as possible the isolation of the bacillus-spitting tuberculeux.” During the solidarist era before World War I, when private philanthropy was expected to fund all such institutions, this strategy was never put into practice extensively. Yet some historians have in fact argued that when sanatoriums came into more widespread use in France during the interwar period, they served a carceral function and that this function took precedence in practice over therapeutic goals.
The hard-liner Fuster drew a sharp distinction between isolation and effective treatment: the latter was rarely a realistic expectation, yet the former was vital. To fulfill the hygienist’s objectives, that basic truth had to be hidden from patients. In calling for the institutionalization of contagious cases, Fuster made it clear that treatment was not the primary aim. “[It would be] fortunate if our therapeutic resources could enable us, in addition, to cure this individual socially, that is, to bring him to a state of health in which he would no longer be contagious!” Improvement in the patient’s condition would be an added bonus, from the hygienic point of view, because he or she would no longer pose a threat to society. This was as true of the sanatorium as it was of any other institution; although it offered mild cases of tuberculosis “a few chances of spontaneous cure,” it also offered “the immediate advantage of removing from the family or social milieu persons who would soon be contagious.” From Fuster’s point of view, the harsh truth was that the treatment of sick individuals was not the goal of the War on Tuberculosis. The hygienist’s responsibility was to the healthy majority of the citizenry, to protect it from contagion.
Fuster cautioned, however, that isolation would be difficult to put into practice without unforeseen help from legislators. The tuberculosis patient, he explained, often enjoyed prolonged periods of improvement in symptoms and rarely lapsed into the “resignation of the infirm.” These episodes of remission gave sick persons renewed hope and made them unlikely candidates for the role of “the good asylum patient, condemned but calm.” Under these circumstances, without a law enabling forced internment, convincing the patient to volunteer for isolation would be all but impossible:
It was up to the “dépisteurs,” then, to feed enough false hope to patients that they would be obedient and allow themselves to be “interned” under the pretext of medical care. Fuster’s views on these issues were almost certainly not typical of all those who aligned themselves with the War on Tuberculosis; after all, not being a physician, he did not have to deal with patients on a personal, everyday basis. Yet he was honest enough to state baldly what he probably saw as uncomfortable truths. Much of what he admitted may have underlain, unstated, the positions of others who elided the distinctions among such concepts as dépistage, isolation, and treatment.
It is essential to always speak to him of possible treatment, if we want him to allow himself to be isolated [and] interned. Because, ultimately, no law authorizes us to take him away from his lodgings and his habits.…To isolate them, we will therefore have to open small asylums where dispensaries and other dépisteurs can send them, leaving them the illusion that they are going there to recover.
One doctor who matched, and at times even exceeded, Fuster’s brutal candor was Jules Héricourt, who unabashedly championed forced isolation of tuberculosis patients throughout his career. Héricourt reasoned, just as Fuster did, in terms of the relative value and danger to society of sick and healthy individuals and concluded that one group had to be protected at the expense of the other. The cold logic of his argument merits a close reading, to explore a point of view that pushed at the outer limits of the acceptable even in the heyday of germ theory.
Héricourt advocated the creation of tuberculoseries, modern-day leper colonies, to eliminate tuberculosis by removing its victims from society. His premise was that the consumptive represented a reduced (if not null) social value:
For these reasons, the hygienist was obliged “to protect the healthy man.” To do so, Héricourt suggested that the twentieth century could learn something from the Middle Ages, when “our ancestors…had the genius to eliminate leprosy by eliminating lepers, that is, by confining them in leper colonies.” The medieval example was all the more admirable in that, “several centuries before Pasteur,” it succeeded in implementing “on a vast practical scale” what the great microbiologist achieved in the laboratory by separating diseased silkworms from their healthy counterparts.
From the social point of view, the sick man is obviously of less interest than the healthy man. His value is reduced, if not annulled, from the point of view of production, and he constitutes a danger to the community, whereas the healthy man retains all his present value and, through his family, represents the future.
Héricourt’s solution to the tuberculosis problem was a revival of léproseries as tuberculoseries, where the infected would be confined to prevent contagion. In 1905, he believed that the idea’s time might finally have come. “It has now been fifteen years since I first dared to speak of tuberculoseries. Since then, the idea has progressed, and the word now appears fairly frequently in speeches. Let us hope that some day it will be put into action.” His optimism seems to have been unjustified. In fact, the only speeches in which the word tuberculoserie occurred to any noticeable extent were Héricourt’s own. As shown above, even when doctors and hygienists spoke of “isolation” as a means of combating tuberculosis, they usually qualified their endorsement by acknowledging that such measures were unrealistic in the context of prevailing mores and concerns about “individual liberty.” More typical than Héricourt’s solution was his lament about what would happen if drastic action was not taken soon: “as long as tuberculeux continue to circulate, they will spread contagion in the streets and in public places, and through their coughing, they will continue to breathe contagion into the atmosphere.”
Héricourt’s extreme positions did not necessarily represent the mainstream of French medical opinion, and his plans were never fully realized. Some present-day readers may find his recommendations harsh and repressive. (Nevertheless, even in the 1990s, public health experts still consider incarceration a viable weapon in the fight against tuberculosis. In 1993, New York City reopened an old hospital ward on Roosevelt Island for the forcible detention of patients who had repeatedly failed to complete their full course of antituberculosis treatment.) Was this doctor articulating what his peers felt but were afraid to say, or was he simply a bizarre extremist? While there may be no clear answer to this question, it is certainly true that Héricourt was an influential and well-connected figure in the world of French science at the turn of the century. He served as editor of the prestigious Revue scientifique. He collaborated closely for many years with Charles Richet, the 1913 Nobel Prize winner in medicine and physiology, who wrote the preface to one of his books. The same book was dedicated to “my learned friend” Gustave Lebon, the famous crowd psychologist. Whatever else he may have been, Héricourt was no mere crackpot; whether his colleagues shared his views on tuberculosis prevention or not, he clearly enjoyed an influential and respected place in French medicine.
Héricourt’s tuberculoseries, along with the dépistage and surveillance functions of the dispensary, recall Foucault’s discussion of the “carceral archipelago” in Discipline and Punish. In the context of the history of prisons and penology, Foucault described the vast network of institutions and practices that contributed to the dual functions of discipline and normalization as follows:
It is not difficult to see Héricourt’s tuberculoseries and the strategies of some sanatorium proponents as fundamentally disciplinary and carceral in nature. But can the same be said of public health programs, such as the dispensary, that purport to be strictly philanthropic? Certain institutions and their advocates may have been preoccupied explicitly with punishment and incarceration, yet it is important to recognize the extent to which auxiliary, facilitative policies also contributed to a general environment of “the ‘carceral’ with its many diffuse or compact forms, its institutions of supervision or constraint, of discreet surveillance and insistent coercion.”
The judges of normality are present everywhere. We are in the society of the teacher-judge, the doctor-judge, the educator-judge, the social-worker-judge; it is on them that the universal reign of the normative is based; and each individual, wherever he may find himself, subjects to it his body, his gestures, his behaviour, his aptitudes, his achievements. The carceral network…with its systems of insertion, distribution, surveillance, observation, has been the greatest support, in modern society, of the normalizing power.
The disciplinary and carceral aspects of the War on Tuberculosis did not necessarily operate as conscious motivations for the medical men and politicians who participated in these debates. This would be a far too instrumental and conspiratorial reading of the actors and texts involved. Héricourt certainly must have known that his proposals bore a close relationship to the penality of the prison; but even if he had been less straightforward, and even though some of his colleagues may have been less self-conscious in their appeal to the carceral impulse, the power of that impulse should not be underestimated simply because it remained unacknowledged. During the nineteenth century, as Foucault took pains to point out, the various forms of discipline and surveillance became less easily identifiable and less distinguishable from one another as they became more sophisticated. The “great carceral continuum” also constituted “[a] subtle, graduated carceral net, with compact institutions, but also separate and diffused methods.” The judgments that resulted were subtle and continuous rather than sharp, conscious, and distinct. The principles of dépistage and isolation were triumphant precisely to the extent that they appeared both necessary and natural to nineteenth-century reformers. Once the key notions of hygienic urgency and social danger were accepted, the progression from assistance to surveillance to confinement was just a small logical step.
No single factor can explain the powerful and enduring appeal of bacillocentrism in the French response to tuberculosis. The dramatic success—and dramaturgical power—of Pasteur’s experiments with wine, silkworms, rabies, and anthrax no doubt encouraged in many observers first the hope and then the conviction that salvation from all manner of ills lay in controlling microbes. Yet there must have been more to it than that, particularly where tuberculosis was concerned. Germ theory explained the disease and in so doing conferred blame for it; rather than blaming the individual victim for his or her own illness, as other facets of the dominant etiology did, contagion blamed victims as a class for spreading the disease. On occasion, participants in the War on Tuberculosis attributed blame directly, as when one doctor urged patients not to spit on the ground. “What moral responsibility [would be yours] if, by your negligence, you contaminated a relative, a friend, [or] any one of your compatriots.” The patient who ignored this injunction was guilty of “sinning against his brothers [and] against society.”
Through spitting, the spread of tuberculosis was associated with a practice perceived as disgusting and uncivilized. Spitting also brought with it a class dimension. The warnings of Paul Juillerat, a hygienist and director of the Paris municipal casier sanitaire, highlight the perceived danger of interclass contagion. Juillerat went to great lengths to convince all Parisians of the need to fear the germs of tuberculosis. Millions of “murderous bacilli” were distributed every day in the streets, the offices, the workshops, and the lodgings of the city, he cautioned, by coughing and spitting consumptives.
Perhaps unintentionally, this statement expressed with unusual clarity the respective social ranks of the vehicle and victim in the archetypal transmission of tuberculosis. Even the bourgeois had something to fear, if only because he had daily contact with his servants.
One shudders at the permanent danger to which one is exposed. Who can pretend, whatever his social position, that he will never receive at his residence someone with tuberculosis, visitor or servant, who will deposit the fearsome germ in his home?
Even without considering the statistics (widely quoted at the time) that showed the working class to be far more susceptible to tuberculosis than the rest of the population, it is clear that tuberculosis was generally considered to be a disease of the poor, to which others also occasionally fell prey. Contagion allowed hygienists to sound the alarm among the wealthy and powerful that even they were not immune; it also served to embody the threat in a human (working-class) form. The resulting bacillophobia turned casual passersby into suspects, and patients into potentially murderous coughers and spitters.
1. See chap. 5, below. [BACK]
2. I use this neologism to indicate not a single tenet or argument in discussions of the causes and prevention of tuberculosis but rather a general preoccupation with “seed” over “soil,” with contagion over receptivity, and with the tracking down, isolation, and neutralization of the tubercle bacillus. [BACK]
3. Louis Landouzy, “Comment et pourquoi on devient tuberculeux” (lecture series, Hôpital de la Charité, 1881), Le Progrès médical (1882): 685. [BACK]
4. Ibid., 666–667. [BACK]
5. Ibid., 667. [BACK]
6. See, for example, the thematic issue of the journal Literature and Medicine (vol. 11, no. 1 [Spring 1992]) entitled “The Art of the Case History,” and Kathryn Montgomery Hunter, Doctors’ Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, 1991). [BACK]
7. Hunter, Doctors’ Stories, 152–153. [BACK]
8. These categories break down roughly as follows:
Ibid., 186 n. 5; Hayden White, “The Value of Narrativity in the Representation of Reality,” Critical Inquiry 7 (1980): 5–27. [BACK]
Annals typically list “events” without interpretation or conclusion: “Interval 1: The King died. Interval 2: Crops failed. Interval 3: the Queen died.” A chronicle introduces selectivity and sequence, the germ of a story, but still lacks closure: “The King died, then the Queen died.” Narrative implies causality or the operation of a moral principle: “The King died; then the Queen died of grief.”
9. White, The Content of the Form, 1–25, quotation at 14. [BACK]
10. Landouzy, “Comment et pourquoi on devient tuberculeux,” 701–702. [BACK]
11. Ibid., 701. [BACK]
12. See chap. 1, above. [BACK]
13. Landouzy, “Comment et pourquoi on devient tuberculeux,” 702–703. [BACK]
14. Jules Rochard, Traité d’hygiène sociale (Paris: Delahaye et Lecrosnier, 1888), 536–560. [BACK]
15. See, for example, Latour, Les Microbes. [BACK]
16. Michel Peter, Leçons de clinique médicale, vol. 3 (Paris: Asselin et Houzeau, 1893), 44–45, 57–58. [BACK]
17. Ibid., 171. [BACK]
18. See, for example, A. Mirabail, “Baiser et tuberculose,” La Médication martiale (1904): 552–553. [BACK]
19. Isidore Straus, La Tuberculose et son bacille, 466–468. [BACK]
20. Charles Fauchon, La Tuberculose, question sociale (Paris: Asselin et Houzeau, 1903), 70; Albert Calmette, “La Lutte contre la tuberculose,” Revue philanthropique 21 (1907): 570–571. (Emphasis in original.) [BACK]
21. Edouard Fuster, “La Tuberculose, maladie sociale,” Revue d’hygiène et de police sanitaire (1904): 27. (Emphasis in original.) [BACK]
22. This phrase recurred quite frequently in antituberculosis literature; see, among others, Ernest Fernbach, Deux conférences sur la tuberculose (Paris: Fernand Nathan, n.d.): 10. [BACK]
23. Allan Mitchell discusses spitting and the turn-of-the-century campaign against tuberculosis in “Obsessive Questions and Faint Answers: The French Response to Tuberculosis in the Belle Epoque,” Bulletin of the History of Medicine 62 (1988): 215–235, esp. 223–225. [BACK]
24. L.B., untitled article in Hygiène ouvrière (1912): 3–4. [BACK]
25. Maurice Letulle, “La Lutte contre la tuberculose en France: Prophylaxie et traitement hygiénique dans les milieux ouvriers,” Bulletin mensuel de l’Alliance syndicale du commerce et de l’industrie (January 1902): 11–14. [BACK]
26. The space occupied by a sick worker in a factory or workshop was seen as particularly dangerous:
Ouvriers, qui travaillez dans des ateliers, vous connaissez tous la place maudite: vous savez que vous ne pouvez vous asseoir à cette place sans risquer de contracter la phtisie. Pourquoi: Parce qu’un de vos camarades, malade[,] y a travaillé, parce qu’il a éternué, toussé à cette place, parce qu’il a répandu ses crachats tout autour. Ces crachats se sont desséchés, se sont réduits en poussières; à chaque pas que vous faites vous soulevez ces poussières et vous respirez des bacilles tuberculeux par milliers.
Fernbach, Deux conférences, 7–8
27. Roger Reveillaud, La Tuberculose au point de vue social, thesis, Faculté de médecine, Paris, 1908 (Paris: A. Maloine, 1908), 80. [BACK]
28. Alain Corbin, Le Miasme et la jonquille: L’odorat et l’imaginaire social, XVIIIe–XIXe siècles (Paris: Flammarion, 1986); on attitudes toward crowding and filth in working-class housing, see chap. 4, below. [BACK]
29. Norbert Elias, The History of Manners, trans. Edmund Jephcott (New York: Pantheon, 1978), 153–160. [BACK]
30. Fuster, “La Tuberculose,” 28. [BACK]
31. Fauchon, La Tuberculose, 67–80. [BACK]
32. See, for example, Samuel Bernheim and André Roblot, “Tuberculose et blanchisseries,” L’Hygiène familiale (February 1906): 54–57. [BACK]
33. Doctor Ox, “Livres et microbes,” Le Matin, December 28, 1905. [BACK]
34. Ibid. [BACK]
35. Paul Cuq, “Le Baiser et ses dangers au point de vue de la tuberculose,” La Médication martiale (1904): 481. [BACK]
36. “Hygiène des bureaux de poste,” Revue médicale, November 15, 1905, 912. [BACK]
37. Fauchon, La Tuberculose, 62–64. [BACK]
38. Fuster, “La Tuberculose,” 28. [BACK]
39. Reveillaud, La Tuberculose au point de vue social, 18–19. [BACK]
40. “Recommandations publiées sur l’avis du Comité permanent de défense contre les épidémies et de la Société de préservation contre la tuberculose,” Bulletin municipal officiel, Paris, September 23, 1905, 3293. [BACK]
41. Reveillaud, La Tuberculose au point de vue social, 85; Fernbach, Deux conférences, 10. [BACK]
42. Archives nationales [A.N.], C 7324, dossier 1496. [BACK]
44. La Ligue contre la tuberculose en Touraine contre M. le Comte de Lafont (Tours: Paul Salmon, 1906), 8–12. [BACK]
45. Ibid., 10, 20–22. [BACK]
46. By this imprecise term, I mean the speeches, writings, and other works of the governmental officials, hygienists, professors, and doctors affiliated with the most prominent (usually Parisian) institutions prosecuting the War on Tuberculosis, including the Academy of Medicine, the Paris medical faculty, prestigious medical journals, and committees such as the Commission permanente de préservation contre la tuberculose. [BACK]
47. Fuster, “La Tuberculose,” 30. [BACK]
48. Paul Brouardel, cited in Xavier Jousset, Transmission de la tuberculose dans les rapports sociaux, thesis, Faculté de médecine, Paris, 1908 (Paris: Imprimerie de la Faculté de médecine, 1908), 7. [BACK]
49. See, for example, his contribution to P. Budin et al., Les Applications sociales de la solidarité (Paris: Félix Alcan, 1904); the ramifications of solidarism on the War on Tuberculosis are discussed in chap. 4, below. [BACK]
50. All cited in Doctor Ox, “Théorie et pratique,” Le Matin, September 14, 1913. [BACK]
51. Cited ibid. [BACK]
52. Paul Cuq, “Le Baiser et ses dangers au point de vue de la tuberculose,” La Médication martiale (1904): 479. [BACK]
53. Ibid., 479–480. [BACK]
54. Ibid., 480–481. [BACK]
55. Mirabail, “Baiser et tuberculose,” 552–553. [BACK]
56. Ibid., 553. [BACK]
57. Lucien Descaves, “Les Pestiférés,” Le Journal, February 14, 1906. [BACK]
58. Jousset, Transmission de la tuberculose. See chap. 7 on left-wing perspectives, below, for the full elaboration of class analysis as applied to tuberculosis at the time; the syndicalist and socialist “dissenters” were different in many respects from the likes of Cuq, Descaves, and Jousset, but they shared an emphasis on terrain and a deemphasis on contagion in the spread of tuberculosis. [BACK]
59. Adolphe Leray, Genèse de la tuberculose dans l’espèce humaine: Contagion ou auto-infection? (Paris: Vigot Frères, 1906), 14–19. [BACK]
60. Ibid., 18, 67–68. [BACK]
61. Ibid., 32. [BACK]
62. Ibid., 39. [BACK]
63. Ibid., 74. (Paragraph separations omitted.) [BACK]
64. Marcel Moine, Recherches et considérations générales sur la mortalité à Paris depuis la Restauration (Paris: Union des Caisses d’Assurances Sociales de la Région Parisienne, 1941), 25. [BACK]
65. Georges Bourgeois, Exode rural et tuberculose, thesis, Faculté de médecine, Paris, 1904 (Paris: Félix Alcan, 1904), Table X. [BACK]
66. Grellet and Kruse, Histoires de la tuberculose, 36–47, 95–107; Guillaume, Du désespoir au salut, 43–80. On the waxing and waning of symptoms with alternating periods of work and rest, see, for example, Marc Pierrot, “La Lutte contre la tuberculose et la question des sanatoriums,” Les Temps nouveaux, nineteen installments between July 23–29 and December 10–16, 1904. [BACK]
67. The best analysis of this aspect of “medicalization” in nineteenth-century France is Léonard, La Médecine entre les pouvoirs et les savoirs; see also Jack D. Ellis, The Physician-Legislators of France: Medicine and Politics in the Early Third Republic, 1870–1914 (Cambridge: Cambridge University Press, 1990). [BACK]
68. Grellet and Kruse, Histoires de la tuberculose, 36–47, 95–107; Guillaume, Du désespoir au salut, 43–80. [BACK]
69. This imitation apparently began quite soon after the “preventorium” began operations in Lille. For example, it was evident in the announcement of the opening of a dispensary in Poitiers in February 1903. “Echos et nouvelles,” Revue internationale de la tuberculose (February 1903): 150. [BACK]
70. Albert Calmette, Désiré Verhæghe, and Th. Wœhrel, Les Préventoriums, ou dispensaires de prophylaxie sociale antituberculeuse: Le Préventorium “Emile Roux” de Lille (Lille: L. Danel, 1905), 5–6, 21. [BACK]
71. Ibid., p. 22. [BACK]
72. Calmette, “Nécessité du dispensaire,” L’Idéal du foyer, May 1, 1903, 1. [BACK]
73. Camille Savoire, discussion of Fuster’s “La Tuberculose, maladie sociale,” Société de médecine publique, meeting of December 23, 1903, Revue d’hygiène et de police sanitaire (1904): 158. [BACK]
74. Alfred Fillassier, review of Ambroise Rendu, “Du rôle du dispensaire dans la lutte contre la tuberculose” [no further attribution given], in L’Hygiène générale et appliquée 3 (1908): 244–245. [BACK]
77. Since this question was never explicitly addressed, it is a murky area. But such phrases as “Si vous le voulez, vous supprimez les causes prédisposantes” and “Défiez-vous de la salive d’un tuberculeux” certainly imply that the intended reader would be avoiding tuberculosis for himself or herself. Ibid. See also, for the context in which the “catechisms” were given out, “Dispensaire de l’OEuvre Antituberculeuse de la Loire-Inférieure: Son fonctionnement depuis le 1er novembre 1904 au 30 avril 1905,” A.M. Nantes, series Q, carton 12. [BACK]
78. Marius Devèze, “Proposition de loi tendant à la création de dispensaires antituberculeux dans les principaux centres,” in A.N., C 7470: 1810, 7–8; Fuster, “La Tuberculose,” 37. [BACK]
79. Fuster, “La Tuberculose,” 28. [BACK]
80. Emile Vallin, “Compte-rendu des travaux des conseils d’hygiène,” Revue d’hygiène et de police sanitaire 2 (1880): 780–782. [BACK]
81. See, for example, Fauchon, La Tuberculose, 90–97. [BACK]
82. Calmette, Verhæghe, and Wœhrel, Les Préventoriums, 3–4. (Emphasis in original.) [BACK]
83. Dessertine and Faure, “Malades et sanatoriums dans l’entre-deux-guerres.” [BACK]
84. Fuster, “La Tuberculose,” 28, 33. [BACK]
85. Ibid., 32. (Emphasis in original.) [BACK]
86. Jules Héricourt, “La Lutte contre la tuberculose,” La Revue, October 1, 1905, 296–297. [BACK]
87. Ibid. [BACK]
88. Mireya Navarro, “Confinement for TB: Weighing Rights vs. Health, ” New York Times, November 21, 1993. See also Michael Specter, “TB Carriers See Clash of Liberty and Health,” New York Times, October 14, 1992; “Tuberculosis: A Deadly Return,” Newsweek, March 16, 1992, 57. [BACK]
89. Jules Héricourt, Le Terrain dans les maladies (Paris: E. Flammarion, 1927); Léonard, La Médecine entre les pouvoirs et les savoirs. [BACK]
90. Michel Foucault, Discipline and Punish: The Birth of the Prison, trans. Alan Sheridan (New York: Pantheon, 1977), 304. [BACK]
91. Ibid., 299. [BACK]
92. Ibid., 297, 299, 302–303. [BACK]
93. Recently, increased attention has been paid to the careful and effective orchestration of Pasteur’s most famous experiments. See especially Bruno Latour, “Give Me a Laboratory and I Will Raise the World,” in Karin D. Knorr-Cetina and Michael Mulkay, eds., Science Observed: Perspectives on the Social Study of Science (London: Sage, 1983), 141–170; see also Latour, Les Microbes, and Gerald Geison, “Pasteur, Roux and Rabies: Scientific versus Clinical Mentalities,” Journal of the History of Medicine and Allied Sciences 45 (1990): 341–365. [BACK]
94. Fauchon, La Tuberculose, 65–67, 81–82. [BACK]
95. Paul Juillerat, “Le Choix d’un logement,” Annuaire de la tuberculose, 1907, 166. (Emphasis added.) [BACK]
96. See, for example, the numerous statistical tables in Bourgeois, Exode rural et tuberculose. [BACK]