Disease and Civilization: The Cholera in Paris, 1832 9780262040846, 0262040840

Table of contents :
Disease and Civilization
Foreword
Translator s Note
A ck nowledgments
Introduction
Management
Fear
Investigation
Apology
Medicine
Epidemic
Conclusion
Notes
Biographical Glossary
Index

Citation preview

Disease and Civilization The Cholera in Paris, 1832

François Delaporte translated by Arthur Goldhammer foreword by Paul Rabinow

The MIT Press Cambridge, Massachusetts London, England

English translation © 1986 by The Massachusetts Institute of Technology. This English-language version represents the first publi­ cation of the work. All rights reserved. No part of this book may be reproduced in any form or by any means (including photocopying, recording, or information storage and retrieval) without permission in writing from the publisher. This book was set in Sabon by Village Typographers, Inc., and printed and bound by The Murray Printing Co. in the United States of America. Library of Congress Cataloging-in-Publication Data Delaporte, François, 1941Disease and civilization. Bibliography: p. Includes index. i . Cholera, Asiatic— France— Paris— History— 19th century. I. Title. [DNLM: 1. Cholera— history— Paris. 2. Civilization— history— Paris. WC 264 D338dl RC133.F9P33 1986 944'.36*063 85-18232 ISBN 0-262-04084-0

In memory of Edouard Delaporte, architect and painter

Contents

F o r e w o r d b y P a u l R a b in o w T ra n sla to r's N o t e A c k n o w le d g m e n ts

ix XV

xvii

I n tr o d u c tio n

r

M anagem ent

>5

A Privileged Nation Anticipation and Planning Administering the Epidemic

22

Fear

The Purge Changing the City Conflicts I n v e stig a tio n

Method Living Conditions

15 33 47 47 58

65 73 73 78

viii

The End of “Constitutions” Political Truths

83 91

5

Apology Civilization and Barbarism The Juste-Milieu

97 97 107

6

Medicine Medical Theories A Specific Malady

115 115 130

7

Epidemic Eminent Reasons Theories and Concepts Models Objects Problems A Political Hygiene

139 139 149 163 170 177 189

8

Conclusion

197

Notes

201

B iographical G lossary

235

Index

245

CONTENTS

Foreword François Delaporte is remarkably lucid about his object of study: “Disease does not exist. What does exist is not disease but practices.” This is a simple and yet endlessly misunderstood point. It does not assert the nonexistence of bacilli, but rather that we can know the world only through our elaboration of concepts. As François Jacob has brilliandy shown in The Logic o f Life [i], biology is no exception to this rule. Disease and Civilization is about practices, medical practices to be precise, and predominantly discursive med­ ical practices to be even more precise. It is both rigorous and disciplined. I say this because the temptation must have been great to rehearse once again the rich and complex opera of literature, journalism, popular emotions, and class politics that Louis Chevalier narrated to us almost thirty years ago in his sprawling classic Laboring Classes and Dangerous Classes in Paris During the First Half o f the Nineteenth Century [2]. Delaporte’s book resists the temp­ tation to claim coherence and historical unity by piling metaphor upon citation. It is ironic that Delaporte, by stoutly refusing a dis­ tinction between disease and cultural practices, is refuting an argument drawn from a medical anthropologist who proposes a sharp and easily identifiable break between na­ ture and culture, disease and its interpretation. As Clifford

Geertz has eloquently argued, this layer-cake view of homo sapiens—that there are cultural, social, psychological, and biological levels—just does not stand up to scrutiny. The great strength of modern anthropology, after all, has been to introduce a decentering into Western self-understand­ ing. Cultural and historical differences exist and matter. The Other is not a poorer, or more pristine, version of Us. This simple but shattering insight has had far-reaching ethical, political, and scientific consequences, but resistance to it remains strong. Western triumphalism in culture, soci­ ety, and science remains. What anthropology has not been successful in doing, in part because it has not yet tried, is to include two central dimensions of our own Western practices into this decen­ tering, relativizing turn. From at least Nietzsche forward, the radical breaks within our own traditions and the rigor­ ous contingency of our sciences have been both heralded and denied. It is only recently that, in a strict sense, these decenterings have been thought. In the history of the bio­ logical sciences, the names of Georges Canguilhem and Michel Foucault stand out in this regard. Georges Canguilhem is responsible for the rejuvena­ tion of the history of biology in France. In a series of tech­ nical articles with broad implications published over the last four decades, Canguilhem has shown us how analyti­ cally to place a number of concepts from the reflex arc to evolution within the scientific fields from which they emerged and which they, in turn, altered [3]. In Canguilhem’s hands, the history of biology moved from a pane­ gyric to progress to a precise laying out of the movement of concepts. Although hinted at throughout his work, the immense social and political implications of much of Canguilhem’s research was systematically developed by his most famous student, Michel Foucault. Lest it be forgotten, Foucault’s work in the 1960s was to an important extent centered on the history of what we FOREWORD

XI

now call biology. In The Birth o f the Clinic he detailed not only the rise and architectural instauration of the medical gaze, but also the rise of the concept of life in all of its modernity, its ability to be rigorously thought once it was coupled with death. In The Order o f Things he recounted the ruptures and epistemic changes surrounding the emer­ gence of our modern conceptual fields of life, labor, and language—Foucault’s much heralded and little understood announcement of the birth of Man—out of the classical epistemic fields in which none of these concepts had a space. Finally, in the Archaeology o f Knowledge he pre­ sented a comprehensive program for the study of concep­ tual objects, subjects, and strategies. Whatever its limita­ tions, the Archaeology is a gold mine of insights and suggestions for the study of the history of scientific objects. François Delaporte uses this methodology to illuminate the cholera epidemic that swept through Europe in 1832. This epidemic was extremely important. It turned out to be a major threshold between older conceptions and practices of disease, society, and administration—public health— and many of the modern ones we still live with. Delaporte succeeds in keeping these different strands clearly separate; he does not reduce medical changes to political changes. But this does not mean that biology, society, and history were not interrelated. Disease and Civilization demon­ strates the intricacies and importance of analyzing those links. It is in this sense that the book is methodologically exemplary. In 1832, Europe’s doctors and politicians watched anxiously as the cholera epidemic spread through the ports of call along the trade routes from* India to Russia and Po­ land, Germany, and Austria, and finally into Paris itself. This is the year in which Europe’s older medicine met its conceptual and practical Waterloo. The Enlightenment and particularly French optimism about its ability to compre­ hend and thereby order—the word is “police” —its terriFOREWORD

tory and citizens was dealt a severe setback. As soon be­ came apparent, cholera could not be explained by the es­ sentially still Galenic theories of climate, topography, and circulation of fluids; its spread was not halted by the tech­ niques of quarantine and segregation developed against the plague and leprosy. As Delaporte reminds us, this led to massive fear; fear on the part of the lower classes that they were being poisoned, fear on the part of the upper classes that the way of life of the poorer and miserable classes of the capital provided a lethal breeding ground. Although Delaporte de­ scribes this fear, it provides the background but not the· object of his analysis. He shows us that this impasse also led to a major crisis of scientific understanding. Whatever the Parisian authorities did not do— and this included thoroughly implementing sweeping cleanups of water and waste (because of their reluctance to pay for it, their lack of sufficient political power to carry it through, and the climate of fear and distrust of all such government measures, medical and otherwise)—they did study in detail cholera’s progression through bodies, houses, neighborhoods, arrondissements, cities, regions, countries, and continents. The findings were clear if disturbing: The older theories just did not account for the spread of the disease. Cholera, it soon became clear, was related not only to topographic and climatic conditions, but to social con­ ditions as well. Medicine and society were joined. The impact of this discovery was to be profound. In an important sense, not only modern medicine but also the modern social sciences were born at this conjuncture. So, too, was a whole range of administrative practices. Al­ though neatly summarized, these practices do not form, however, the true object of Delaporte’s analysis. He shows us that new knowledge—a new field of objects, methods; and practices in which debate, disagreement, and contro­ versy could productively flourish—also emerged from the FOREWORD

shattering impact of cholera. In the end, it is the analysis of these practices that forms the heart of his book and its major contribution. References 1

François Jacob, La Logique du vivant, One histoire de l’hérédité, Editions Gallimard, Paris, 1970, English translation, Pantheon Books, New York, 1974. 2 Louis Chevalier, Classes Laborieuses et classes dangereuses, Plon, Paris, 1958, English translation, Fertig, N ew York, 1974.

3

Georges Canguilhem, La Connaissance de la vie, Paris, Vrin, 1965; Le Normal et le pathologique, Presses Universitaires de France, Paris, 4th edition, 1979.

Paul Rabinow

FOREWORD

Translator s Note Citations from the work of Michel Foucault have been translated by me from the French text. English versions do exist: LHistoire de la sexualité has been translated by Robert Hurley as The History o f Sexuality (New York: Random House, 1978), and La Naissance de la clinique has been translated by A. M. Sheridan Smith as The Birth o f the Clinic (London: Tavistock, 1973). I would like to thank Harry Marks of Harvard Medi­ cal School’s Department of Social Medicine, and the au­ thor, François Delaporte, for their considerable help in the preparation of this translation. Both read and made nu­ merous detailed comments on the manuscript. I also wish to thank my wife, Dr. Stephanie Engel, for help with many questions of medicine.

A ck nowledgments Everyone who helped me to write this book deserves thanks. Michel Foucault some years ago suggested that I work on this subject and was kind enough to read the manuscript in draft. Georges Canguilhem gave me invalu­ able advice. I have used Louis Chevalier’s book, Classes laborieuses et classes dangereuses à Paris pendant la pre­ mière moitié du XIXe siècle (Paris: Plon, 1969) and the re­ markable study by Jacques Piquemal, Le Choléra de 1832 en France et la pensée médicale (Paris: Thalès, 1959), pp. 27 73 I want to thank Geneviève Seznec and the Arthur Sachs Foundation for helping me to continue work on the book in Cambridge, Massachusetts. I shall not forget the welcome extended to me there by Barbara G. Rosenkrantz and Everett Mendelsohn of the Department of the History of Science at Harvard University. And I am equally grateful for the welcome afforded by Roberto Moreno de los Areos at the Universidad Nacional Autonoma of Mexico. Cecilia Mora, Arthur Goldhammer, and Jürgen Mahnert-Lueg know that there is something of their presence in these pages. -

·

François Delaporte Mexico City January 1984

Disease and Civilization

I

Introduction In 1831 Larrey envisioned the impending invasion of chol­ era in these terms: The topographical situation of France is so advantageous that there is little to fear in this country from cholera morbus or any other pestilential epidemic. . . . As for the plague’s entering by way of our seaports, I find little probability of such an occurrence, particularly in the Atlantic ports, where sanitary measures have been so carefully observed that it would seem to me quite difficult for the disease to infiltrate our borders. And in any event, the disease would quickly be confined to the ports and treated with such success by rational medicine, known to all French physicians, that there need be no fear of its spreading to the interior.. . . Throughout France, the felicitous application that has been made since the Revolution of 1789 of rules of hygiene and health measures has redounded to the benefit of the country’s inhabitants. . . . All things consid­ ered, then, we may feel perfectly secure as to the danger of the invasion and spread of cholera morbus in France. By contrast, recall that, so far as we know, the disease has proved devastating only in fetid, marshy areas in certain parts of Asia Minor, Russia, and Poland.. . . Today in no other country of the globe have civili­ zation, industry, and commerce achieved a higher degree of perfection [than in France] and in no country but England are the rules of hygiene more faithfully observed. Cleanliness and above all sobriety, prophylactics against

every sort of disease, are the leading traits of the French citizenry. . . . Enlightenment has spread so widely through all classes of society that everyone is well aware of the pre­ cautions to be taken against the causes of disease: We are blessed with a superb and healthy population. . . . What country, moreover, is richer than ours in enlightened physicians who contribute so powerfully to the maintenance of public health?1 A few months later Michel Chevalier offered this ac­ count of a country in the grip of epidemic: Should poisoning, pestilence, and death be the watch­ words of the government of France, the world’s premier nation? . . . The admirable people of Paris, who are so heroically confronting the cholera of poverty, which in eighteen months has tripled the death rolls—the people of Paris were not made to serve as fodder for the cholera of Asia and to die like slaves in pain and terror. There is one true protection against cholera; it is to remain, in the presence of this new and ubiquitous enemy, courageous and invincible. There is, as I have suggested, an important lesson to be learned in the midst of public calamity: namely, that man is in part the author of his own destiny. For in the external world man may not always be master, capable of preventing nature from encroaching in ways often destructive to his own work; but he is almost always ca­ pable of stopping, and energetically repelling, these invasions of evil, by means of a moral reaction that stems from within. . . . One more step for France, and Europe will be in a position to teach the East that the sun has changed course and that henceforth day is dawning for the nations in the West of the old world. . . . Paris—that center of civilization and progress, a city where such vast resources are sacrificed on the altar of public welfare— should have demonstrated the power of the social state (l’état social) by triumphing over the most terrible scourge to afflict the human race.

CHAPTER

Instead, Paris has succumbed to this new invasion; the disease has proved more lethal here than elsewhere; and no quarter of this great city is nowadays so populous as its cemeteries. What good, then, are all its hospitals, its doctors, its science, and its public administration? Are all the re­ sources of civilization worthless? Is civilization incapable of compensating mankind for all the harm it has done through its laws, its institutions, its errors, and its injustices? No: the blame should not be laid at the door of the social state itself. Instead, the finger of accusation should point at those who exploit the state and corrupt it, at those who see civilization merely as a more sophisticated servant of their luxury and pleasure, at those who view a great city as a factory in which all hands labor for their benefit and all space is arranged for their convenience. The city is a city of palaces and hovels: a few splen­ did quarters with colonnades and huge gardens closed to the man in work clothes and, in the center of this sumptuous enclosure, a sewer of narrow streets and dark, unhealthy buildings, as dank as dungeons, where those who toil come to catch their breath in fetid air. So, an epidemic arrives, preceded by cries of terror from two continents, and finds its prey ready-made, its victims huddled together and weak. It opens its charnel house in the artisans’ district, whereupon the philanthrophists say that the public should take heart, for the scourge seems willing to claim as its victims only the ill-clad, ill-housed, and ill-fed, which is to say, the work­ ing people of Paris.2 Here, then, we have a utopian vision and an eyewitness account, separated by only a few months in time. Though both refer to the same event, the scenes they describe are quite different. One is serene and confident, the other a somber picture in words of what another contemporary, Daumier, captured in unforgettable pictorial images. At first sight these two texts are diametrically opposed. They speak of cholera, of the population, of public administra­ tion, of medicine, of science, and of policy. But their reINTRODUCTION

4

spective attitudes toward the plague are very different. Lar­ rey describes a people well informed about health issues, educated and cooperative. He holds the French system of public health to be such a paragon that the possibility of disaster does not even occur to him. For the nation is pro­ tected not only by a medical “police” but also by “rational medicine,” whose forces can if necessary be swiftly mobil­ ized to snuff out any disease. In the France of the JusteMilieu [literally “happy medium,” used to characterize the middle-of-the-road politics of the liberal monarchy of Louis-Philippe—Trans.] the standard of living is so satis­ factory that Larrey feels justified in describing the populace as “superb and healthy.” Hence the plague, he imagines, will simply pass over France without causing the slightest harm, without revealing the least flaw in the well-being of the public. By contrast, Michel Chevalier describes a soci­ ety tormented and racked by harsh privations, a wretched populace oppressed by an exploitative ruling class, an im­ potent government, an ineffective public health system, and a medicine powerless to deal with the disease. Before the epidemic arrived Larrey believed that it would demon­ strate that French society was secure and sound; afterward Michel Chevalier is equally certain that the epidemic has inflicted a hard lesson. My point, however, is not to draw a contrast between the dreams of the liberal social imagination and the disas­ trous consequences of liberal social policies. Nor is it to call attention to the distance between Larrey’s illusion of readi­ ness and the actual incompetence of the government. Rather, my intention in juxtaposing these two passages is to make clear how similar they really are. For Larrey is after all merely describing a situation that Chevalier be­ lieves to be entirely within the realm of possibility. The difference is that Larrey believes what he is describing to be a state of affairs that actually exists, whereas Chevalier merely says that it ought to exist: “Paris . . . should have CHAPTER

demonstrated the power of the social state by triumphing over the most terrible scourge to afflict the human race.” Larrey’s main point, that French society has achieved such a degree of perfection as to be able to withstand the plague, brands him as a utopian of the same stripe as Chevalier, who insists that “one more step for France, and Europe will be in a position to teach the East that the sun has changed course and that henceforth day is dawning for the nations in the West of the old world.” And finally, for us, there is an even deeper kinship between the two statements, in that Larrey’s sets forth, before the fact, the normative lessons to be drawn from the catastrophe that Chevalier describes. There can be no doubt that disasters like the epi­ demic of 1832 had to occur before the countries of the West could make Larrey’s visionary ideal an actual goal of policy. We are concerned, then, with the period during which France, like so many other nations before it, confronted that great modern plague, cholera. We know what course the disease followed before reaching French frontiers. The initial outbreak occurred in India in 1826. From there the disease moved to Persia in 1829 and to Russia in 1830. It then continued its westward push, attacking Poland, Hun­ gary, Prussia, Germany, Austria, and England in 1831. By the spring of 1832 it had reached Paris, where it killed 18,000 people in a population of 785,000. It is tempting to assert right at the outset that cholera cannot be studied solely as a medical question. For is it not self-evident that questions of sociology, mentalities, and ideology must also be taken into account? Any society confronted with an epidemic will exhibit certain defensive reactions. Deadly disease evokes widespread fears, shaped in part by popular beliefs. In the case of cholera, faith in the superiority of Western values was shaken to such a degree that some people felt the need to defend the Western, INTRODUCTION

6

which is to say, the modern industrial, world, whence the involvement of ideology. These remarks, if true, suggest that any study of the cholera epidemic of 1832 ought to proceed along two parallel lines. First, find out what was known about the disease: What were the predisposing causes? What was known about pathogenesis? And above all, where did the disease come from and how did it spread? Pursuing this line of inquiry would lead us to con­ sider three related topics: public health, medical theory in the strict sense, and epidemiology. At the same time we would also have to study the social response to the dis­ ease. Again, three major headings: the preventive measures adopted by more or less enlightened authorities; the violent reactions of the poor, which were quickly put down by the government; and the shrewd responses of administrators who, without denying the high mortality rate, managed to exculpate the government as well as “civilization” in gen­ eral. To write the history of the 1832 epidemic in the man­ ner just outlined would in fact be to ratify what one recent writer has proposed as the three principles of medical anthropology: 1. Disease in some form is a universal fact of human life. 2. All known human groups develop some set of beliefs, cognitions, and perceptions . . . for defining or cognizing disease. 3. All known human groups develop methods and allo­ cate roles . . . for coping with or responding to disease.3 I see no useful purpose to be served by undertaking here to criticize these methodological presuppositions and to draw out their consequences. Let me simply put my own view as starkly as possible, to emphasize the contrast. I as­ sert, to begin with, that “disease” does not exist. It is therefore illusory to think that one can “develop beliefs” about it or “respond” to it. What does exist is not disease but practices.

CHAPTER I

In denying that “human groups develop some set of beliefs, cognitions, and perceptions . . . for defining or cog­ nizing disease,” I do not mean to deny that people did in fact attempt to determine the predisposing causes of chol­ era, to establish the pathology of the disease, and to ex­ plain its origin and propagation. I would simply make the following points: 1. Living conditions and other social factors were not seen as predisposing causes except in the context of a study that defined the specific living conditions of the working classes in terms of urban overcrowding and common habits of the poor. 2. Different schools of medicine classified cholera in different ways. Physiological medicine saw it as an acute form of gastroenteritis and hence as a consequence of inflammation. Experimental medicine—another form, if you will, of medical practice— saw the same set of symptoms as evidence of an affliction of the heart. And there were still other forms of medical practice: nervous pathology, for example, which classified cholera as a form of “neurosis,” and humoral pathology, which defined it as an “alteration of the blood” or “general poisoning” (psorentery). 3. As a disease affecting large numbers of people, cholera was defined by some as “epidemic” (or “infectious”) disease caused by a morbid agent acting on the respiratory or digestive membranes, while others believed that it was a “contagious” disease caused by a germ or virus that acted primarily on the skin. Furthermore, in denying that “human groups develop methods and allocate roles . . . for coping with or respond­ ing to disease,” I do not mean to deny that the government adopted various tactics for dealing with the plague, that the various social classes appointed officials to take charge of the situation, or that government administrators attempted INTRODUCTION

to justify the devastation caused by the epidemic. I would simply make the following points: 1. The tactics employed to counter the epidemic or to reduce its virulence were adopted in response to issues that the government itself raised. It is banal to say that men attempted to cope with death by taking steps to prevent it. Rather than repeat such a banality, what we must do is to show how, in 1832, one class sought to control another, which it saw as powerless but potentially dangerous. How were traditional defensive measures against disease modified and implemented? 2. The violence of the population and the even more insidious violence of the authorities were merely continua­ tions, or perceptible effects, of other responses to issues raised by both sides in the conflict. Not all of these issues were associated with the outbreak of the epidemic. Rather than make the hackneyed claim that in time of epidemic class hatreds are exacerbated, we must try to understand how violent attacks on physicians resulted from the widespread belief that the government was seeking to resolve the issue of unemployment by poisoning the unemployed. Medical personnel were simply viewed as the agents of the enemy. Conversely, the ruling class cast the working class as a threat to public welfare, as both carriers of disease and fomenters of riot. Accordingly, a system of vigilance was proposed that would protect soci­ ety against both sedition and disease. 3. What was the purpose of the apologia that was made in behalf of Western civilization and the values of the Juste-Milieu? Let me say at once that it was not to respond to the political challenge posed by the (undeni­ ably) high mortality rate. It is commonplace to say that the function of an ideology is to compensate a social class for what it does not have, or to portray what is in the interest of one social class as being in the interest of CHAPTER I

9

society in general. My point is different. What I want to show is that some people felt the need to justify the extremely high mortality rate among the poor of Paris by arguing that poverty is the consequence of barbarousness, while others claimed that it was the moral weakness, the irresponsibility, of the poor that contributed to the spread of cholera in impoverished areas. In 1831 Larrey believed that cholera would not invade France. The reasons for his belief were clearly stated; they had to do with geography, geopolitics, and history. France enjoyed a unique topography and a healthy population and had eliminated the causes of disease from its cities. In spite of this belief, however, Larrey was not inclined to stand by idly. He discussed what health measures should be taken in the port cities and in Paris if a threat did arise. To establish quarantines and to clean up filthy areas was to diminish the risk of disease. Taken together, such measures constituted a policy of prevention, the result of recommendations by panels of leading experts from the Royal Academy of Medicine, for example, as well as commissions that had been sent abroad to investigate the epidemic in other countries. Two points are worth noting: cholera seemed to be a contagious disease because it followed major trade routes, and it had struck chiefly the poorest classes living in the filthiest sections of the city. The government therefore imposed quarantines in the ports, established “sanitary cordons” on the borders, and set up health committees in each district of the capital. When these preventive measures failed, it became necessary to manage the disease. The gov­ ernment sought to clean up filthy areas, assist the poor, and care for the sick, naturally at the lowest possible cost. It was also forced to deal with the panic triggered by disease and death. Michel Chevalier protested that “poisoning, pestilence, and death” were the watchwords of the French govemINTRODUCTION

ment. It is true that the malady was exploited politically by the government and by reactionary political factions. My purpose here, however, is not to try (or retry) the ruling class for its alleged crimes or to justify the behavior of the populace. I hope, rather, to describe the various meanings that different social classes attached to the epidemic and to show that these contrasting interpretations were actually variant forms of a single fear. At the level of fantasy, the epidemic was conceived as an instrument for settling social scores. The working class feared that it was being poi­ soned, while the privileged were afraid that they were being contaminated by lethal germs. One group feared the sub­ versive activities of revolutionaries, the other ruthless mur­ der by the ruling elite. Signs of this class antagonism in­ cluded widespread suspicions on the part of the proletariat that food and beverages were tainted, that the government had sent agitators to stir up trouble, and ultimately that doctors were involved in the plot against the poor. The wealthy, on the other hand, believed that poor quarters of the city were tainted and that poor workers and even their own downstairs tenants and servants were spreading the disease. The doctors who attended at the bedside of Casi­ mir Périer were seen as allies of power; the poor, who rioted at the funeral of General Lamarque, were seen as agents of subversion. The two names just mentioned clearly show what forces were in contention: Casimir Périer, the Resto­ ration financier, champion of the banks and the JusteMilieu, and General Lamarque, who embodied republican hopes. Périer’s funeral procession passed with great pomp before the Stock Market and through the wealthy quarters, whereas Lamarque’s was followed by a mob of political refugees, proletarians, and anarchists. It is simply a fact that issues of public health and disease prevention were in­ extricably associated with issues of wealth, public order, and the survival of the poorest.

CHAPTER

Michel Chevalier was a good observer: “A city of palaces and hovels: a few splendid quarters with colonnades and huge gardens . . . and a sewer of narrow streets and dark, unhealthy buildings, as dank as dungeons, where those who toil come to catch their breath in fetid air. So, an epi­ demic arrives . . . and finds its prey ready-made, its victims huddled together and weak.” Cholera’s first victim was the pauper. But to see that this was so required a careful inves­ tigation. The Report on the Progress and Effects of Chol­ era Morbus in Paris (1834) clearly established that inequal­ ity with respect to death coincided with inequality with respect to life. This report was the first systematic and exhaustive study to focus on the theme of “living condi­ tions,” which was to become the central focus of public health discourse. The ravages of the epidemic pointed up shortcomings in urban design and demonstrated the urgent need for a new code of public health. The other salient fact about the cholera inquiry was its neglect of traditional Hippocratic theories. Climate and topography played vir­ tually no role in the report, which delved into social factors in great detail. From this investigation emerged the idea that no fate is fixed for the masses. If many died as a result of calamities like the cholera epidemic, the fault lay pri­ marily with defective institutions. Thus investigation of the epidemic led to political conclusions. We must be careful, though. The apparent politicization of medical discourse is in fact paradoxical. The revival of certain presumably out­ dated etiologies had the effect of imposing a new require­ ment on medical theory: to explain how social factors might contribute to disease. Many hygienists moved from the analysis of living condi­ tions to a philosophical critique of Western civilization. How did this happen? Before the epidemic had reached French borders Larrey drew a distinction between coun­ tries like France where “civilization” had attained “a highINTRODUCTION

er degree of perfection” and “fetid, marshy areas in certain parts of Asia Minor.” He obviously believed that the vir­ tues of civilization repel the plague while the vices of bar­ barism afford it free passage. Oddly enough, the same dis­ tinction was invoked by the hygienists at the very moment when cholera was ravaging the people of Paris. Why? So that they could use the observed mortality rate as a justifi­ cation of civilization. If cholera had proved less deadly than past plagues, one had the benefits of progress to thank. The claim, in other words, was that the death toll among the poor was not as bad as it might have been. But that toll was acknowledged, for example, by Michel Che­ valier, who observed that the people of Paris had become “fodder for the cholera of Asia” and died “like slaves in pain and terror.” Not only was the mortality of the poor acknowledged, it was also justified by an analogy: the working classes were to the privileged classes as India was to France. Within the bosom of French society the pro­ letariat constituted another race—a singularly vulnerable race. Proof that this belief was indeed prevalent is con­ tained, in part, in Chevalier’s recommendations. To a ner­ vous populace he suggests two preventive measures: “to remain, in the presence of this new and ubiquitous enemy, courageous and invincible” and to repel the evil by means of a “moral reaction.” If the poor were decimated, it was because they failed to bring sufficient moral strength and force of character to the battle against the plague. The poor were not just poor, they were also pusillanimous and de­ bauched. For hygienists this was reason enough for the high mortality rates in impoverished sections. If cholera did come to France, Larrey believed that “the disease would quickly be confined to the ports and treated with such success by rational medicine .. . that there need be no fear of its spreading.” In the moment of truth Michel Chevalier asked himself what was the good of medicine: CHAPTER I

13

“No quarter of this great city is nowadays so populous as its cemeteries.” There is no point in repeating what con­ temporaries and historians have already said, that medicine failed utterly to stem the tide of cholera in 1832. Does it follow that, because treatment of the disease was unsuc­ cessful, the underlying medical theories were false or ab­ surd? It. is better, I think, to see what powerful ideas these theories contained along with much that was undoubtedly conjectural or adventitious. And there is another reason for looking at the way in which the medical profession con­ fronted cholera in 1832: the epidemic mobilized medical thought. It offers what Jacques Piquemal has called a “snapshot” of medical practice, a glimpse of the physician at work. What is more, as Cruveilhier noted at the time, “Each physician seeks to explain this disease in terms of the doctrine that he himself has developed or adopted, and even to present it, on account of its seriousness, as proof of that doctrine.”4 Thus the attempt to elaborate a theory of cholera brought into play several of the dominant themes of early nineteenth-century medicine. As we shall see in what follows, the cholera epidemic highlights a nec­ essary stage in the epistemological development of scien­ tific knowledge. When Larrey distinguishes between “sanitary measures” (;mesures sanitaires) and “health measures” (mesures de sa­ lubrité) he is alluding to the two distinct medical theories that were used to justify these two distinct tactics of de­ fense. His mention of the “sanitary measures . . . so care­ fully observed” in the seaports reminds us that 1832 was a landmark year for quarantines. By the “enlightened physi­ cians who contribute so powerfully to the maintenance of public health,” Larrey means the physiologists. “Sanitary measures” were directed against contagion (i.e., the princi­ ple that disease is spread by direct contact with the body of an affected person) and “health measures” against infecINTRODUCTION

tion (i.e., the principle that disease is spread through the air or by other distant means). There can be no doubt that the epidemic of 1832 seemed to lend credence to the theory of infection and to contradict the theory of contagion. For cholera was able to leap over “sanitary cordons” and thereby to demonstrate its infectious nature, or so it was felt. It is significant, for example, that the anticontagionist Chervin was unanimously elected to the Royal Academy of Medicine. At the same time the Society for the Propagation of the Idea that Cholera Morbus Is a Contagious Disease, proposed by Pariset, was dissolved before it could hold a single meeting. Every textbook of the history of medicine repeats the assertion that the conflict between infectionists and contagionists was one of the most vehement disputes in medical annals. But in this conflict most historians see only the transfer to the medical arena of preexisting politi­ cal differences. The contagion theory, we are told, was the tool of a conservative and despotic government, whereas the infection theory appealed to liberals and progressives. In reality, “high politics” had very little bearing on the de­ bate as to the nature of epidemics and the proposed revi­ sion of the public health code. But the cholera epidemic of 1832 did have an important impact on these matters.

CHAPTER

I

2

Management A PRIVILEGED NATION

“Rich by virtue of its most advantageous geographical po­ sition, its gentle sky, its temperate climate, its fertile soil, its fortunate distribution of property in land, its universal in­ dustry, and its widely shared instruction, and on that ac­ count blessed also with a hygienic situation that leaves little to be desired in either the public or the private sphere, France hopes to be protected from this scourge.”1 The Royal Academy of Medicine believed that France possessed all the advantages accruing to a highly civilized nation. Its inhabitants would be spared by the epidemic. In any case the malady was not without a precedent. The members of the Academy felt called upon to remind the nation what had occurred in 1814-1815, when typhus had devastated the Rhine valley. It even reached Paris, where many sol­ diers had to be hospitalized. From the hospitals the malady was carried into various quarters of the city. The epidemic spread south as far as the Loire. But the typhus epidemic had not been a great killer: “It succumbed to the wealth and prosperity enjoyed by the residents of the capital and the central provinces.”2 The new threat of cholera gave point to the memory of this earlier episode, especially since many doctors believed that cholera, or at least one of its forms, led to typhus fever. Cholera was an exotic disease.

of uncertain etiology. But people wanted to see a connec­ tion between it and typhus, for it would then be reasonable to think that if cholera came to France it would claim no more victims than typhus had claimed two decades earlier. The idea was reassuring. The thought that civilization was somehow a protec­ tion against the disease was further reinforced by the fact that cholera had first developed in India. For was not India deprived of the benefits of civilization? The valley of the Ganges was an unhealthy region inhabited by an unedu­ cated and wretched people. As cholera moved into the civilized countries its severity should decrease, or so it was believed: “The torrent seems to be digging a bed less wide and less deep as it proceeds to attack wealthier, more en­ lightened populations, where the requirements of cleanli­ ness are less neglected.”3 It might seem surprising that Double should have been so convinced of the superiority of the West at a time of social unrest and economic crisis. But in fact his comments were widely reported, indeed re­ printed in the Avis au peuple and Instructions populaires. Of course such remarks may have been uttered for purely defensive and psychological reasons. It was common, when a deadly epidemic broke out, to seek to calm a worried population. Why add to people’s daily burden anxiety about disease? This may have been part of the reason for invoking the argument of Western superiority, but it was not the decisive factor. The idea that civilization has the power to ward off disease was not just a useful lie fobbed off on an unsuspecting population, nor was it a rational­ ized version of the ancient belief in protective deities. The belief that France was invincible in fact emerged from two separate but convergent dialectical processes. First, France was seen as the antithesis of India, in both a geographical and a geopolitical sense. Further, postrevolutionary France was regarded as the antithesis of the Ancien Régime. Invin-

CHAPTER 2

cibility was a “sign” whose “referents” were foreignness and the history of France. Foreignness and progress were the “signifieds” on which the feeling of invulnerability and the dream of immunity were based. In what sense were France and India held to be geographi­ cally antithetical? The contrast that was drawn between the two countries was not subtle. Rather, the meteorologi­ cal and hydrographical data were simply arranged in such a way as to thicken the miasmata in the East and dispel them in the West. In fact the hygienists were really inter­ preting geography in the light of one of their primary preoccupations: hospital architecture. One of their goals was to replace the small, poorly ventilated rooms of the old hospitals with newer hospitals expressly designed to min­ imize the risks of contamination. Great stress was placed on the importance of evacuating polluted air and ensuring cleanliness by means of proper plumbing and ventilation. In other words, space could be arranged in such a way as to encourage the spread of disease or to oppose it. In the imagination of the hygienists these questions of hospital architecture were simply projected onto the two countries France and India. The same contrast that could be seen in actual hospital buildings was found to exist in the geog­ raphy of the two countries. The hygienists drew analogies between certain natural geographical features and various man-made methods for reducing the danger of hospital fever. The East was associated with pestilential diseases: “Cholera . . . is an exotic production; its yeast was born or developed in the uncultivated, arid plains of Asia and in the rotting algae deposited by the flooding Nile; it ferments and warms itself amidst the residue of poisonous plants burned by the sun.”4 France, by contrast, possesses an effi­ cient system for the destruction of morbid agents, with breezes to provide good ventilation and streams to carry off noxious matter. Travel routes in border areas of France MANAGEMENT

follow mountain valleys where “the air is especially puri­ fying, being almost everywhere saturated with sulfurous and nitrous vapors emitted by the hot springs, so that the pernicious miasmata that nourish epidemic in certain ori­ ental countries are neutralized and cannot survive.”5 Thus France and India symbolize opposing values: the former embodies the latest in antiepidemic techniques, whereas the latter is so constructed as to encourage proliferation of the noxious agents. The two countries are next compared in geopolitical terms, and the same contrast is found to exist. The hy­ gienists revived the old Hippocratic notion that the tem­ perament of a people depends on climate and government. In warm countries ruled by tyrants people are cowardly and lazy. Europeans, on the other hand, are bellicose, ac­ tive, and enterprising, owing to the tranquil rule of monar­ chy and the regular cycle of the seasons. In other words, climate and government are external signs that reveal the internal constitution of the individual. The ravages caused by cholera among the people of India can then be explained as follows: “The miasmata . . . enter into and boil in blood already partially putrid and therefore disposed to receive them. . . . Half-paralyzed organs are not strong enough to reject the noxious corpuscles. They continue to function in the usual manner.”6 The French, on the other hand, have just fought hard to establish a liberal form of government. Just let the epidemic come: “Its cause, the subject of so much alarm, will have difficulty gaining a hold over people animated by such great emotions. . . . Hence throughout France the choleraic humor will naturally be eliminated by all the emunctories without endangering life.”7 In addition to the geographical and geopolitical fac­ tors contributing to neutralization of the miasmata and to strengthening the body’s resistance, a flourishing system of public health made it even more unlikely that the epidemic would spread to France. To see this one had only to comCHAPTER 2

19

pare the France of 1830 with the France of the Ancien Ré­ gime. Before the Revolution Paris was a city of poorly lighted, poorly paved streets, strewn with filth; buildings were tall, narrow, and dark and pressed close to bridges and quays; industries producing noxious odors and fumes were located within the city, limits; and death, too, had its repositories. Compare to this the much more sanitary Paris of 1830. Streets, bridges, and quays were all more open to sunlight and healthful breezes. The La Villette reservoir, fed by the Ourcq Canal, supplied water to new fountains in every quarter of the city. Certain closed-in and unhealthy areas had been razed (the Châtelet, the Carrousel, the paddock in the Tuileries, and the neighborhood of SaintAndré-des-Arts). Other areas had been enlarged and re­ freshed by broad streets and huge open squares. Industries were banished from the city’s center. Cemeteries were moved outside the city walls. Last but not least, hospitals were more numerous and better run, and there were facili­ ties for people of all ages and for every kind of disease. The contrast was stark between Louis-Sébastien Mercier’s pre­ revolutionary Tableau de Paris and what Benoiston de Châteauneuf called “a glance at the sanitary status of the capital at the moment of the invasion.”8 To be sure, much could be said about this flattering portrait of Paris before the epidemic. It was easy enough to draw a quite different picture: “It must be admitted, to the shame of this great city, which nevertheless aspires to pass for the capital of the arts, the sciences, and civilization, that it remains to this day subject, in its streets, its buildings, and its homes, to the most dangerous and degrading in­ salubrity.”9 Blame was placed on the age of the city, which had grown haphazardly over a long period. The authori­ ties, too, came in for their share of reproach, owing to their failure to establish any general system of organiza­ tion. The Municipal Assembly, moreover, was not really autonomous. MANAGEMENT

2 0

These opposing pictures of Paris, one idyllic, the other derogatory, seem profoundly at odds. In reality all hygien­ ists knew that if Paris was not exactly a model city, neither was it a sewer. Whether they chose to stress the good that had been done or to point out the ills that had yet to be dealt with, all believed that a flourishing system of public health—the correlative of a high civilization—would pro­ vide the best possible defense against the plague. Once such a system had been established, the population would be rendered invulnerable to epidemic; the disease would feed on and destroy itself: “It has even been said that a country whose citizens make a religion of hygiene will never come into contact with an epidemic agent.”10 France, it was be­ lieved, was on its way to such a state. Those who asso­ ciated public health with the dynamic of progress believed that the country was indeed perfectible. Before the cholera outbreak, then, all hygienists were convinced of two by no means incompatible truths: first, that as a civilization the France of the July Monarchy enjoyed superiority over both India and prerevolutionary France, and second, that per­ fection had not yet been achieved. While nearly everyone was pleased with the progress that had been made, some were more cautious in their judgment. There were specific areas of concern, concrete improvements needed in the area of public health. Still, the changes that had already been made were important and numerous: “They attest to a less harsh way of life and to more liberal ideas; but they are far from complete, and when it comes to the welfare of the public the job is done only when there is nothing more to do.”11 A rather abrupt shift occurred. Where the dominant subject of discussion had been the indubitable natural secu­ rity from the plague that France enjoyed, hygienists now began to talk about the need to provide additional security. It was no longer the country’s remarkable topography and the tranquil strength of its inhabitants that would save CHAPTER 2

France from cholera, but a concrete set of regulations, pre­ scriptions, and prohibitions designed to provide protection against the disease— a “medical police.” These regulations would be enforced if there were a threat of cholera’s en­ tering via the seaports or across land borders. Notwith­ standing all the advantages that France might possess, “I shall nevertheless urge the French government,” said Fodéré, “not to hesitate to enforce, against the invasion of this new plague, the sanitary regulations set forth in the law of 3 March 1822 and the royal ordinance of 7 August following.”12 From the standpoint of public health Paris had undergone considerable change. But much that was unhealthy remained. Many streets were still without public fountains and latrines. Mud and garbage removal was neither prompt nor convenient. Something had to be done about the flooding of the Seine: from the Arsenal to the Iena Bridge houses were vulnerable to flood waters, which left behind a thick layer of silt when they receded. Rains often made bogs of the Peuple and Popincourt sections. To improve rainwater drainage, additional sluices had to be built and existing ones cleaned more frequently. A more extensive system of drains would help to dry out streets whose dampness was chiefly responsible for the unhealthi­ ness of some neighborhoods. “If the authorities continue to make the requested improvements, we can rest assured that if the epidemic reaches us, it will not be a killer and will not last long.”13 After France’s advantages had been examined with respect to geography, institutions, and public health, discussion turned to the question of active resistance. Traditional de­ fensive measures were to be employed along the borders, while noxious influences were to be eliminated in the interior. These defensive measures were based on two sim­ ple principles: to repel causes of morbidity and remove causes of insalubrity. Each principle had its associated MANAGEMENT

medical theory: quarantines were based on the contagion theory, hygienic measures on the infection theory. The two theories may have been in conflict, but before the arrival of the epidemic the defensive measures derived from them were seen as complementary. Why? Because no one was sure what kind of disease cholera was, whether contagious or infectious, while everyone was sure about the causes of insalubrity. It was this same mixture of doubt and certainty that prevented open conflict from erupting between the supporters of the contagion and infection theories. Since physicians were in doubt as to the nature of cholera, all agreed that there was nothing to be lost by imposing quarantines and other sanitary measures in the ports and along the borders, “even if the only purpose is to calm a frightened population.”14 On the other hand, they were certain about the sources of insalubrity; eliminating these might not stop the epidemic but would at least reduce its severity. Doubt as to the nature of the disease coupled with certainty about what could be done to improve public health encouraged planning to meet the onslaught. ANTICIPATION AND PLANNING

The government was faced with two sets of issues. The first had to do with defending the country against disease. If cholera threatened to invade France, what was to be done? Should protective measures be taken in the ports and along the borders? If the threat of epidemic came from the di­ rection of the sea, for what period should quarantines be imposed? If cholera was a transmissible disease, was it transmitted by contact with persons or with things? If by contact with persons, it was important to know the period of incubation and hence the critical moment at which the disease could be transmitted to others. If by contact with things, which commodities should be suspected of carrying CHAPTER 2

the germs? It was not known whether the possessions of cholera victims could carry the disease. Which precautions were appropriate depended on knowledge of how the dis­ ease was propagated. But there was much uncertainty about the circumstances of transmission. Yet in spite of this ignorance it was still necessary to organize teams of health inspectors and assign powers to various health agencies. The second set of issues had to do with the effort to eliminate sources of infection. There was general agree­ ment that such notoriously unhealthy locations as the Montfaucon dump should be cleaned up. But people knew that the sources of infection were numerous and for the most part invisible. They lurked in farmyards, workshops, and homes, out of the public view. How were they to be found out? Was it possible to clean up an entire city? It was to deal with the first set of issues that the govern­ ment issued a request to the Royal Academy of Medicine. On 4 March 1831 the minister of the interior wrote to ad­ vise Academy members of the fears of health inspectors in Marseilles, whose port was used by large numbers of ships carrying cargoes from the Baltic and Black seas. The min­ ister requested that the Academy draw up a set of instruc­ tions to guide health inspectors throughout the kingdom. A committee was established at once, composed of Messrs. Keraudren, Chomel, Coutanceau, Boisseau, Desportes, Marc, Dupuytren, Pelletier, Louis, Desgenettes, Emery, and Double. Three reports were prepared. The first was read on 20 and 26 July 1831, the second on 13 September 1831. The third, which was issued in December of the same year, was the report of the commission sent to Poland that May. At the same time the army’s Supreme Health Council also sent investigators to Poland (a commission consisting of Chamberet and Trachez, Jacques and Guyon), while Gaimard and Gérard went to observe the epidemic in Rus­ sia. Such missions were not unprecedented. Pariset and MANAGEMENT

Mazet had earlier been sent to Spain by the Decazes minis­ try to investigate reports of yellow fever in Cadiz and Bar­ celona. Thus the government had previously turned to the medical authorities for advice and had been satisfied with the results. The Royal Academy of Medicine advised the govern­ ment that it would be wise to keep a close watch on the progress of the disease in neighboring countries. To do this it proposed dispatching physicians to serve at embassies and legations in countries where cholera had been detected or was suspected. Only by maintaining constant vigilance and obtaining reliable information could the government hope to cope with the sometimes exaggerated, sometimes fantastic rumors that it was regularly called upon to deny. In addition, the Academy also proposed establishing health councils on the borders of suspect countries. The councils would set up observation posts, which, if the danger turned out to be real, could immediately be turned into quarantine stations. As for measures to be taken in the seaports, no definitive recommendations could be made because noth­ ing was known about the way in which the “virus” was transmitted. It was doubtful that the malady was conta­ gious. Nevertheless, the Academy recommended that ships’ cargo be exposed to the open air but advised against washing and fumigation. Academy members did not ques­ tion the usefulness of quarantines and sanitary cordons along France’s borders. They did, however, oppose the im­ position of internal quarantines (séquestration) on cities, neighborhoods, or homes, for the simple reason that if cholera did breach the frontier at all, it would then be clear that the disease was not contagious. On io June 1831 the government issued orders that steps be taken to protect the health of the public. Instruc­ tions were issued to health authorities in the ports that car­ goes arriving from the Baltic should be accompanied by a certificate of health and subjected to strict quarantine. chapter

2

Health agencies all along the coast were advised to bring their personnel up to full strength, to set up quarantine sta­ tions, and to secure improved roadsteads for ships. These orders were accompanied by a note drafted by Moreau de Jonnès concerning the nature of cholera morbus. The gov­ ernment also applied to the Chamber of Deputies for a supplementary allocation of i million francs to defray the costs of these precautionary measures. Throughout the summer of 1831 orders continued to flow from the ministry of the interior, as information about the progress of the disease continued to pour in. On 15 July an order was is­ sued listing the roadsteads where goods held in quarantine were to be cleared. In the meantime Casimir Périer issued a stronger warning: “In England and Prussia prudent pre­ cautions have already been adopted in regard to shipments from Russia. At a time when the heat of the season as well as free navigation on the Sound and the Niva are increasing the danger, the French government does not want to ap­ pear less prudent than the governments of these two coun­ tries. I therefore have no doubt that you will be especially diligent in enforcing the rules that I have just estab­ lished.” 15 A royal ordinance of 16 August prohibited the entry of items considered capable of carrying the disease. Another ordinance issued on the same day ordered the es­ tablishment of health inspection offices in 20 départements close to the country’s northern and eastern borders. An or­ dinance of 26 August specified measures to be taken in dealing with cargoes from Spain and Frankfurt. Restric­ tions also applied to shipments from the principality of Nassau and the grand duchies of Hesse-Darmstadt and Ba­ den: six customs stations were designated to inspect sus­ pect cargoes. An ordinance of 23 September established health commissions in 15 additional departments contigu­ ous with those listed in the ordinance of 16 August. Sani­ tary cordons were established in all military districts.

MANAGEMENT

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But it was impossible to close off the country at a time when many nations were massing troops along their bor­ ders, troops that carried with them the unsanitary condi­ tions so favorable to the spread of disease. And there were other reasons to doubt the effectiveness of the govern­ ment’s precautionary measures. For one thing, the regula­ tions varied from place to place and were haphazardly en­ forced. For example, passengers arriving in the ports of Boulogne and Calais were subject to strict inspection. As a result, passengers shunned those ports, traveling instead by way of Le Havre: “The number of travelers from England to Le Havre grew tenfold. The inconvenience of the long sea journey was more than compensated by the exemption one obtained from quarantine.”16 In addition, it was easy for the rich to get around the restrictions and for the poor to flout them: “In industrial countries like England and France, where commerce is the soul of social life, it is im­ possible to establish an effective system of regulations, be­ cause it is so easy to evade the rules.”17 By the end of March cholera had reached Paris. On the first of May a royal ordinance abolished the health com­ missions and inspection agencies established the previous year. As for measures to be taken within the capital, the prefect of police turned first to the General Council of Hospices. On 26 July 1831 that council set up two committees: an administrative committee composed of Count Chaptal, Baron Carnet de la Bonardière, and Dr. Cochin, along with the hospital administrators Desportes and Jourdan, and a health committee composed of Baron Portal, Antoine Du­ bois, and Messrs. Lisfranc, Chomel, Cruveilhier, ParentDuchâtelet, and Guéneau de Mussy. The health commis­ sion decided on three steps. First, treatment was to be decentralized: the hospitals of Beaujon, Saint-Louis, SaintAntoine, and Cochin were to be used exclusively for the ch apter

2

treatment of cholera victims, and hospices were to be es­ tablished outside Paris, in Montmartre and Mont-Valérien, for convalescents. Second, public gatherings were out­ lawed, and it was ordered that all markets be removed to the city’s outskirts. Finally, homes of cholera victims were to be marked with signs that were to remain in place for one week following the recovery or death of the victim. But these measures, based as they were on the assumption that the disease is contagious, did not satisfy the government, because segregation was a “sanitary” rather than a “hy­ gienic” response to the threat. Furthermore, the proposed measures could not be adopted until the disease had al­ ready broken out. The government was more interested in preventing the epidemic from reaching the city. It therefore issued a decree on 20 August 1831 establishing a central health commission with 43 members. This central commission supervised the work of 12 subordinate commissions in each arrondisse­ ment of the city, which in turn supervised commissions in each quartier [Paris was then divided into twelve arron­ dissements, each containing four quartiers—Trans.]. Thus the city of Paris was equipped with its own highly strati­ fied municipal health department, with the arrondissement commissions playing an essentially passive intermediary role. Before long it was found that the latter were redun­ dant, since the neighborhood commissions (in each quar­ tier) were more closely in touch with the population and could communicate directly with the central commission and the prefect of police. It seems appropriate, therefore, to concentrate our at­ tention on the neighborhood commissions. Who served on them? Most members were professionals, whose standing in the community inspired confidence. As men of learning they tended to be temperate and conciliatory, as befitted their role. Because commission members were educated it was assumed that ordinary people would listen to them. MANAGEMENT

28

The work load was considerable, so neighborhood com­ missions tended to be fairly large groups. Police constables and inspectors were assigned to help. The commissions were specifically authorized to call on the authorities for additional help should they need it. Their mission was one of investigation and observation; in addition they were empowered to take action where necessary to protect the health of the public. They were also to educate people by informing them that their safety was at stake and letting them know what they could do to help themselves. It was not at all unusual for the government to establish this sort of administrative machinery for the purpose of public sur­ veillance and social control. The forerunner of the commis­ sions of 1832 was the Seine Health Council, established early in the century at the behest of Cadet de Gassincourt. On 6 July 1802 the prefect of police, Count Dubois, estab­ lished the first health council in Paris. Its membership was increased from four to seven on 26 October 1807, and its powers were expanded to include inspection of food qual­ ity, elimination of unhealthy conditions in factories and shops, and inspection of public places. Prior to the cholera epidemic these were the major areas of concern of the health authorities—matters of public health and “medical police.” The arrondissement and neighborhood commissions inspected all public gathering places, both temporary and permanent. They were responsible for regulating noxious or dangerous industries and for inspecting warehouses and storage yards used by refuse collectors. They also inspected private residences, checking sewage connections, wells, cesspools, latrines, and outhouses. Consider, by way of ex­ ample, the work of the commission for the fifth arron­ dissement, one of the largest and most populous districts in the city. Homes were inspected by two adjoint commis­ sioners: one, a physician, noted unhealthy conditions, while the other, an architect, master mason, or carpenter, chapter

2

indicated the necessary repairs. A letter bearing the ma­ yor’s seal and signed by the commission chairman was then sent to the property owner. If nothing was done, further attempts would be made to obtain action, failing which legal proceedings would be instituted. Among the condi­ tions noted by the commission as requiring attention were the following: the storage of mud and waste matter near certain furnaces; the lack of paving on a number of streets around the Luxembourg Gardens; and unhealthy factories. The commission suggested the construction of fountains, gutters, public latrines, and new streets and the removal of garbage from various sites. Over a two-month period some 900 locations, both public and private, were visited. Half were declared unhealthy: “These inspections resulted in four hundred letters being written to various property owners and in more than two hundred reports to the au­ thorities, but most important of all they revealed how many sources of infection and insalubrity remain in the city of Paris. The commission regrets that this report all too often provides proof of this unhappy assertion.”18 Investigations were made and information gathered, but nothing was done with that information. Unhealthy conditions were known, but action to get rid of them was not taken. The problem was that the government had no interest in undertaking a full-scale urban redevelopment project. And this is what would have been required, since the unhealthy conditions cited had to do with the unfortu­ nate way in which the city’s population concentrations had developed in relation to its topography. Problems of loca­ tion and drainage made for noxious conditions. In the neighborhood of the Hôtel-de-Ville, for example, homes were built on low-lying land along the Seine. In the fau­ bourg Saint-Denis houses were improperly situated on the uneven terrain: “The land on which homes were built lay below the level of the surrounding terrain.. . . In general, courtyards lie below street level, so that rain water and MANAGEMENT

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household waste water do not flow into the public chan­ nels. It has become necessary to dig sump holes in the courtyards, thus posing a major health risk to many resi­ dents.”19 The neighborhood commissions suggested more modest projects that would not require the investment of large sums. But their proposals encountered serious obsta­ cles. Bureaucratic procedures did not simply slow efforts to deal with the problems turned up by the investigators; they actually thwarted those efforts. The government did not use its powers and did not appropriate the required funds. The commission in the Hôtel-de-Ville neighborhood, for example, had proposed setting up public fountains and la­ trines, but the government responded that it “found itself ' unable to comply with the Commission’s request; never­ theless, one fountain has been placed on the rue Greniersur-Peau, and the placement of such other fountains as might be useful has been postponed until later.” As for la­ trines, “sites for placement have been designated, but this measure, urgent as it is, has yet to begin execution.”20 It was not just the government, however, that opposed the carrying out of health measures. The resistance of the governed was far more visible. The authorities regained some of their prestige: they dictated the laws, and if the laws were not respected, the fault lay with the people. The careless attitude, and indeed malevolence, of the popula­ tion discouraged the solicitude of the government. What is the good of cleaning up the environment, officials argued, if people don’t know how to respect it? The problem, of course, was that segment of the population that escaped from the control of the authorities; in time of trouble it promptly turned against the government. By nature hostile and ignorant (or so it was maintained), this group was scornful of the regulations designed to protect the health of the public: “What can the authorities, for all their vigilance and zeal, and philanthropists, for all their enlightened good will, do without the cooperation of the very population CHAPTER 2

whose well-being is the aim of all concerned? What can the government, with all its regulations, do if instead of finding citizens ready and willing to abide by the rules, it all too often encounters nothing but indifference, hostility, or re­ sistance?”21 Was the problem, then, that the government was incompetent, or was it rather that the people were un­ disciplined? Sandras refuses to say: “What is certain, in any case, is that when I left Paris to go to Poland, I left it no filthier than I find it today.”22 What is also certain is that the conclusions drawn by investigative commissions abroad foreshadowed those of the neighborhood commissions looking into conditions at home in Paris: there was no doubt that the epidemic showed a marked affinity for the underprivileged classes. Now, it seemed obvious that if cholera was due only to some specific germ or agent, living conditions would have no impact on the disease, and people would be equally likely to succumb whether they were rich or poor. This was not the case. Hence whatever the primary cause of the dis­ ease might be, it was necessary to consider other, “predis­ posing” causes, such as poverty and sanitation. These must somehow explain the high mortality rates observed in poor areas. Nothing could be done about the primary cause of the disease, but something could be done about the predis­ posing causes associated with certain classes of individuals and certain places within the city. Among the predisposing causes associated with individuals were violent emotions, dietary irregularities, malnutrition, and unclean habits. As for places, the disease was associated with damp, filthy dwellings in which large families huddled together, breath­ ing foul, polluted air: “Is it not obvious that our conduct must be based on these well-established facts?”23 Once the spatial and social roots of morbidity had been identified, the next move was to determine what steps might be taken to protect the public health. What was needed was clear: MANAGEMENT

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orderly habits, bodily cleanliness, good diet, and spacious, well-ventilated rooms. But these depended on a certain level of wealth. Hence to protect the public health the liv­ ing conditions of the underprivileged had to be brought up to par with those of the privileged. This was clearly impos­ sible. So when the epidemic underscored the influence of social factors on mortality, discussion of public hygiene was simply adapted to conform to the traditional terms of poor relief: clean up unhealthy conditions, aid the poor, care for the sick. But before settling finally on these traditional reme­ dies—disinfection, relief, and hospitalization—the author­ ities briefly considered the use of a technique recommended by military doctors: removing the sick from infected areas. The population was divided into two groups: those who could move and those who could not. The first included all who could be moved because they were subject to the au­ thority of the interior, army, or justice ministries; the sec­ ond included all who could not be moved— ordinary citi­ zens and civilians. It was easy for the police to send back to the provinces the floating population of vagabonds and seasonal workers that lived in the city’s hovels and board­ ing houses. The army and justice ministries could empty out the barracks and prisons. Soldiers and prisoners could be temporarily housed in makeshift quarters, in tents or barracks located on safe, high ground. But what about the rest of the city’s residents? They, too, would have to be dispersed and settled in suitably chosen locations. Such an evacuation might be feasible, say, on the scale of a hospital, but it was impossible to imagine for an entire city: “Evacu­ ation of the entire population of a city or of several quar­ tiers . . . cannot be carried out without great difficulty, especially in a large city.”24 It was impossible to define public hygiene simply as private hygiene applied to the masses. And it was also im­ possible to contemplate dispersal of the entire population chapter

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of a large city. Hence the work of the public health com­ missions was essentially a matter of planning. Cayol ex­ plained why: “It was not within the power of the physi­ cians who had assumed responsibility to inspect and sanitize every household, to change the habits of the resi­ dents, to provide large numbers of people with good cloth­ ing, to prevent the poor class from eating poor-quality foods, to stop penniless workers from drinking too much or from remaining crowded together in damp, low-lying places never warmed by the rays of the sun—in short, it was simply impossible to remove these people, who lead such desperate lives, from the conditions necessary to the spread of the epidemic. Hence the cholera was especially severe among the most wretched of the men and women living in cramped rooms on crowded streets, among those most weakened by toil and privation.”25 When cholera finally did break out in Paris, the govern­ ment had to deal with a whole new set of issues, having to do with the management of the disease. ADMINISTERING THE EPIDEMIC

After the outbreak of cholera the public health commission met regularly under the chairmanship of the Count de Tascher. Casimir Périer appointed two prosecutors, six in­ vestigators, and two chief inspectors to gather information about health conditions in the capital. The government began to enforce the regulations drafted prior to the out­ break of the disease. Essentially these were just the regula­ tions proposed by Boisseau, namely, “to complete public health projects, to expand public assistance to the ill and facilitate their admission to hospitals, and to provide food to the indigent classes and supply them with clothing and fuel for heating.”26

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In the area of public health, the projects undertaken included improvements to the sewers. Funds were allocated to the sewer department, which began repairs on hundreds of existing drains and undertook to build several new ones. Some open sewers were eliminated: a drainage ditch on Louviers Island was filled with water from the SaintMartin Canal. As always in time of epidemic, charity was provided to the sick. The royal family displayed its gen­ erosity with a donation from the king to the City of Paris of 584,000 francs. Government ministers and secretariesgeneral followed the king’s example: the former contrib­ uted 1,000 francs each and the latter 300. Over a threemonth period the Duke of Orléans provided several thou-' sand portions of rice to be dispensed to the indigent. Such handouts continued throughout the epidemic. Wealthy women sewed warm clothing for the poor. The Church as well as the state was a leading source of charity: “Religion, which has covered the world and especially France with a host of asylums against misfortune, must once again show, in these circumstances, what it is capable of.”27 The Church’s aid was spiritual as well as material. It was with an eye to the future that the “Charity of the Orphans of Saint-Vincent de Paul due to the Cholera” was created. As for hospital treatment of the ill, two wards in each hospital were set aside for cholera victims, one for men, the other for women. It was also decided that the cholera service should not be managed by a single physician; rather, the work was to be shared equally by all physicians on the hospital staff. But the steps taken by the government in each of the three areas mentioned—public hygiene, poor relief, and hospitalization—actually impeded achievement of the de­ sired goal. Attempting to clean up unhealthy sites in the midst of an epidemic exposed residents to noxious materi­ als. Stirring up the muck increased the risk of infection. Lime water could be introduced, if needed, into drainage CHAPTER 2

ditches on the boulevards, but dredging the ditches was to be avoided at all costs. Charity efforts only offended the population. The visit of the Duke of Orléans to the Hôtel-Dieu was supposed to symbolize the king’s concern for the health of his subjects, but in fact the gesture back­ fired. People said that the king was sending the duke to the hospital as he had sent him earlier to Lyons, to see poverty at close range. As for the Church’s efforts, the pious were quite satisfied, because good works were rewarded with indulgences granted by Pope Gregory XVI. Finally, it was hoped that the poor would enter the hospitals. But the rules and regulations discouraged them from doing so. Most physicians later denounced the rules promulgated by the General Council on Hospices, which were based on the as­ sumption that the disease was contagious. In addition, the fact that wards were administered by many different doc­ tors only added to the confusion and disorder. Patients treated by different doctors in radically different ways lay cheek by jowl and watched one another die. Contemporary views of private charity and state ef­ forts to improve sanitation and hospitalization differed sharply, depending on the observer’s attitude toward the government. The events of 1832 formed the basis of argu­ ments for or against the regime. Those who approved of the liberal monarchy pointed with pride to the cleanup of noxious sites, the generosity of the wealthy, and the smooth operation of the hospitals. Those who disapproved emphasized the inadequacy of the cleanup efforts, criti­ cized the rich for humiliating the poor with their charity, and deplored the chaos in the hospitals. Political beliefs thus dictated the response to efforts to deal with the situa­ tion. Rather than focus on contemporary responses, how­ ever, it is more important for us to try to understand the problems with which the government had to cope. In other words, what went wrong with efforts to manage the dis­ ease? With society and its machinery on trial, the governMANAGEMENT

ment was not without resources at its disposal. But how are we to understand its first actions as the epidemic ap­ proached? These may be grouped under three heads: cleanup, relief, and hospitalization. These three kinds of activity seemed to respond to three obvious needs: to eliminate dangerous sources of infection, to help the poor survive the epidemic, and to treat the sick. The activist gov­ ernment, generous almsgiving by the wealthy, and the sys­ tem of hospitals for the poor were all seen as signs of French philanthropy. But that philanthropy was neither benevolent nor disinterested. What was done was no more than what privileged classes had always done to protect themselves against threats to their own well-being. While the sewer cleanup may have benefited all, charity and hos­ pitals, ostensibly intended for the poor, were actually of benefit mainly to the wealthy. With their charity the wellheeled bought calm and reduced their own risk of falling ill: “It is in such moments that all generous hearts must unite to help the unfortunate. By reducing the ills of the afflicted, the wealthy reduce their own chance of catch­ ing the disease. Humanity is the obvious antidote to the scourge.”28 The hospitalization of the sick isolated them and kept them at a reassuring distance from the healthy. The objective in 1832 was no different from what it had been in earlier epidemics, namely, to secure protection from the disease. But given the circumstances and the se­ verity of the epidemic, new forms of action were called for. The tactics changed, but not the objective. There is no point in dwelling on the inadequacy of the tra­ ditional means of coping with epidemic disease. Cleanup efforts proved insufficient. Even though the government reluctantly agreed to assume responsibility for the most ur­ gently required projects, less glaring but no less dangerous sources of infection remained untouched. What is more, some of the traditional means of aiding the poor were no CHAPTER 2

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longer available. In Russia, England, and Belgium the suf­ fering poor made the cities resound with their prayers, that God might spare them; but the people of Paris not only did not pray, they cursed the Church. The poor of Russia blessed the emperor for giving them food, shelter, and money, while Parisian paupers reviled the royal family, the nobles, and the rich. In Paris the old ties, which in calami­ tous times could still bind the people of other cities to­ gether, had been severed for good. The people of Paris scorned repentance and refused to participate in ritual pro­ cessions and offerings. They wanted no part of divine help. Nor did they want “free will” charity, which they saw as much too capricious and unjust, for charity had its own rules, its own requirements, and its own clientele. Last but not least, the hospitalization of cholera victims proved to be dangerous. During epidemics hospitals are nothing but death traps in which disease can proliferate, “vast centers of infection, as lethal for the patients as they are dangerous for the population at large.”29 Related to the question of hospitalization were two other issues: one concerning the transport of patients, the other hostility to hospitals. Vic­ tims of epidemics must be swiftly transported to treatment facilities. Cholera in particular demands prompt treatment. But moving the sick to hospitals meant delaying treatment and risked spreading the disease. Furthermore, the thought of passing away while in a hospital was demoralizing; peo­ ple were afraid of dying in anonymity, without the support of their families. Hence in 1832 it was felt for related reasons of poli­ tics, hygiene, and medicine that the old defensive strategy against disease should be scrapped and replaced by a new approach: the strategy of management. Remusat seems al­ most to regret the change: “I believe that at no other time have such ills been treated better or with greater devotion, but the devotion is so professional, so bureaucratic that it barely touches the persons affected. . . . It is as though one MANAGEMENT

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were dealing with an epizooty rather than an epidemic.”30 There is no doubt that the masses of the poor were looked upon as dangerous carriers. They were believed to be re­ sponsible for spreading the disease, which in the tragic spring of 1832 was their principal possession. Hence pro­ tection was required against an “affection” carried pri­ marily by the underprivileged. No doubt the same dream colored the imaginations of all the administrators respon­ sible for developing an effective system of defenses against the plague: the dream of a perfect germ-free city, where people could live without hospitals and safe from priva­ tion. Normally people were indifferent to the lot of the. working class, but the best way to combat the disease, it was thought, was briefly to make the working class a ward of the state and beneficiary of official protections: “During a cholera epidemic we all return to the bosom of a single family, in which the poor are children and the opulent the elders (patrons). Let the latter tend to the needs of the flock.”31 But it was impossible to do everything that was needed, to deal with all of society’s needs, for the obvious reason that the imperatives of defense against disease had to be reconciled with the imperatives of the economy. Dwellings, inhabitants, and hospitals were all sources of danger to be eliminated— at the source: clean up unsani­ tary conditions in the home, meet the needs of the poor, and relieve crowding in the hospitals. All this required funds. The guiding principle of the government’s efforts was to mount an effective defense against the disease at mini­ mum cost. The bureaucracy had worked out the least ex­ pensive means of achieving various ends. To obtain the broadest possible protection required the minutest inspec­ tion of the city’s smallest nooks and crannies. Eliminating relatively minor sources of infection was precisely the task assigned to the neighborhood commissions. Before cholera struck, well-meaning inspectors were supposed to prod CHAPTER 2

neighborhood residents into performing necessary work and repairs. With the epidemic in full force the work of the commissions did not come to an end. For after all they con­ stituted an “admirable institution,” well suited to the dis­ tribution of funds collected through charitable organiza­ tions and public solicitations. Equity was guaranteed by accurate evaluation of the needs of each recipient: “It is possible, without undue difficulty, for the wealthy to en­ dure an unequal distribution of their pleasures; but an un­ equal distribution of the bread of the poor is cruel, for what one enjoys to excess may well mean the death of an­ other.”32 Money was accepted from the wealthy, but be­ fore going to the poor it had first to pass through a system of distribution run by men well versed in the principles of good management. They would know how to parcel it out wisely. Finally, the sanitary councils had set forth what needed to be done to deal with the problems of the hospi­ tals. The goals were to calm patient fears, provide rapid treatment, and minimize the risks of infection owing to the concentration of many cholera victims in a confined space. Decentralization was the answer. Treatment facilities were to be dispersed throughout the capital. Medical aid stations were set up in every neighborhood.33 The treatment dis­ pensed by these stations might not be family care but it was at least familiar. These stations inspired confidence, offer­ ing neighborhood residents places to go if they needed help. Because the aid stations were grass-roots facilities, the physicians who manned them were in the front lines of the battle against a disease whose cause they did not know. What they did know, however, was that this unknown cause affected primarily indigent people living in unhealthy sections of the city. This rather superficial etiology was used to justify intervention of two kinds. First, teams of constable-observers were assigned to the task of “sanitary surveillance,” intended to combat unhealthy conditions. MANAGEMENT

The team operating in the neighborhood of the Luxem­ bourg Gardens served as the model. Casimir Périer ordered the prefect of police to set up similar teams in all twelve arrondissements. Second, so-called charity offices worked to distribute alms to the poor in an equitable manner. Of greatest importance of all, however, was the role of the physician. It was he who gathered information about sani­ tary conditions in the homes he visited. In addition, he was empowered to issue ration coupons for food. To sum up, then, the privileged exercised control over the underprivi­ leged (who were seen as a dangerous source of infection) through a system consisting of charity offices, teams of constable-observers, and aid stations staffed by physicians. But it must be admitted that the outcome of the epidemic was foreordained even before this system of aid/social control was put in place. At the beginning of April the dead numbered in the hundreds. By the fourteenth of that month twelve to thirteen thousand people were sick and more than seven thousand lay dead. But it was not until the last two weeks of April that the aid stations were opened. In the fifteenth arrondissement an aid station opened on the eighteenth, with just two rooms and thirty beds to a room. It was not until the twelfth that the prefect dispatched doctors and medical students to the neighborhood stations. In other words, the medical assistance intended to cope with the epidemic was not available until after many peo­ ple had already fallen ill, by which time the disease was in full force. The same delays were experienced in setting up temporary hospitals: the hospital at Grenier dAbondance did not open its doors until 15 April and that at SaintSulpice was not ready until the eighteenth. Oddly enough, contemporaries did not hold poor government planning re­ sponsible for the disaster. Instead they blamed cholera’s surprise tactics: “The rapid progress of the disease, which leapt from London to Paris at a single bound, its sudden CHAPTER 2

and unexpected appearance in our midst, and its extreme virulence hitherto unparalleled in Europe made a mockery of all calculations and rendered inadequate all our precau­ tions.”34 It is clear that the “ambulances,” as the aid sta­ tions were also called, served patients who were too poor to pay for home care and who lived too far away to be taken to hospitals. But the ambulances also performed an­ other function, which served the interest of the govern­ ment. At the height of the epidemic cholera was seen as an invisible enemy and the city as a battlefield. The am­ bulances symbolized an alert government, ever vigilant against the enemy. They met the emotional needs of a pan­ icky population and thus helped to reinforce the authority of a government that had come close to losing the confi­ dence of its people. The ambulances were particularly use­ ful from a political standpoint, because they brought “the population close to the government.”35 They were witness to the most distressing and painful scenes. They also col­ lected the bodies of the dead. People saw that the government was incapable of coping with the epidemic, but they refused to admit that it did not know how to manage mass death. Death registration, fu­ neral ceremonies, and burials all became issues; what is more, certain fears were associated with all three activities, fears related to governmental practices that compounded the effects of clumsiness and negligence. Consider first the registration of the dead. It was re­ quired that a declaration be made at the mayor’s office in each arrondissement. A physician equipped with a search warrant was then assigned to verify that a death had taken place and to determine its cause. The results of this investi­ gation were recorded in two affidavits, one to be kept at the mayor’s office and the other to be sent to the prefect of the département. On the basis of this affidavit, confirmed by two witnesses, a death certificate was issued and recorded. MANAGEMENT

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Only then could a burial permit be issued. There was a deliberate delay built into the procedure: burial could not take place less than twenty-four hours after verification of death. The delay was designed to protect against the risk of overhasty burial. Such procedural guarantees are revealing of the attitudes of the men who framed article 77 of the civil code: the slowness of the bureaucracy was intended to compensate for the fact that medical science was unsure about what precisely the signs of death were. Cholera complicated matters. People suspected that the disease might be contagious. Burials were delayed not only because the law required it but also because the bu­ reaucracy was overwhelmed by the large number of deaths; but undue delay in burial meant increasing the risk of con­ tamination. Double had called attention to the danger early on: “Too much delay in burial. . . could prove harmful to the population during an epidemic, for experience has shown that in certain circumstances every patient may be­ come a source of choleraic emanations.”36 Hence prompt burial of the dead was called for. But in this, too, there was danger: by trying to avoid the risk of contamination one ran the risk of burying people alive. A lethargic patient, a person showing no signs of life, could easily be mistaken for a true cadaver. The result was panic about the possibil­ ity of precipitate burial, a panic that stemmed from a deeply rooted fear, what Philippe Ariès has called an “un­ articulated fear.” This fear surfaces in every epidemic. It was in connection with a plague epidemic in Barcelona that Chervin remarked, “The fear of being contaminated by cadavers led to men who were still drawing breath being thrown into the common grave.”37 A rumor spread through Paris: cries and sobs had been heard to come from wagons carrying bodies to the cemeteries. The fear of being buried alive had been considerably accentuated in 1832 by the phenomenon of “cadaverization,” as Magendie called it, which resulted from suspenCHAPTER 2

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sion of circulation. Many doctors were struck by the ca­ daverlike appearance of their patients, which was some­ times more pronounced in living patients than in actual cadavers: among the signs were dryness or slackness of the skin due to lack of blood in the capillaries; facial changes, especially hollowness of the cheeks; eyes that appeared sunken and bluish; and a loss of transparency in the cornea, which appeared to be folded or collapsed back on itself and opaline in color. Now, all of these were signs observed in cadavers and regarded as sure indications of death, but they were also found in living cholera victims. What a strange disease cholera was, that literally mas­ queraded as death. This singular pathology took on what had hitherto been death’s surest and most stable features. Life was mimicking its opposite. And death restored the form of life, but only after its substance had been extin­ guished. It was said, therefore, that this was a disease in which the living look dead and the dead look alive: “It is so easy to be completely mistaken that I once marked down as dead an individual who in fact died only several hours later.”38 It was impossible to record in the normal manner at the bureau of vital statistics all the deaths due to cholera. Hence chaos reigned during the first few weeks of the epi­ demic. Finally, the government reluctantly acceded to the advice of physicians. Boisseau, for example, recommended against publishing death tolls, “for it is difficult to appreci­ ate the true meaning [of the figures], which only spread fear in the public mind.”39 So the government, which had begun publishing death figures at the end of March, sud­ denly stopped doing so, further exacerbating the fears of the population. At the same time the government took steps to conduct all burials at night. The public immedi­ ately interpreted these actions by the government as bad signs: “The disease must be really serious if the dead can­ not be counted and night is used to conceal both burials MANAGEMENT

44

and tears.”40 A second bureau of vital statistics was estab­ lished in each mayor’s office and an auditor assigned to straighten out death rolls. Even more serious problems developed in connection with the transport of bodies. Doubling the number of workers assigned to this task did no good, because there were not enough wagons to carry all the corpses. An order was issued for fifty additional wagons. But the workers as­ signed to building them refused to work at night. The gov­ ernment then asked the war ministry to provide iron smiths. But this solution turned out to be unworkable: “The heavy battering sustained by the coffins caused the planks to come unnailed and the bodies to fall out, which caused the flaccid tissue of the viscera to break and allowed an infected liquid to spread over the insides of the wagons and to escape onto the pavement. This method had to be abandoned the very next day.”41 As a second alternative, wagons were requisitioned from carpet dealers. At first sight this seemed to be a wise move: these wagons had good suspensions and could hold a large number of coffins. But the government had failed to reckon with the fear that these “omnibuses of death,” as Heinrich Heine called them, aroused in passersby. Here we encounter fear of the dead, as distinct from fear of the disease. At first cholera victims were buried with full civilian, military, and reli­ gious honors. Very quickly, however, the ravages of the disease affected these rituals, which had helped to mask the hideousness of death and to moderate the suffering and re­ store the strength of survivors. Now the dead were trans­ ported like freight, which caused a scandal, as did the use of makeshift coffins that sometimes came apart. The public felt outrage at the impiety and at what it regarded as the profanation of the dead. There were also problems with burial. Gravediggers refused to work, not so much because of the large number of graves to be dug as because of their fear of catching the CHAPTER 2

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disease. The regulations (as set forth in the Imperial Decree of 33 prairial in the year 4) specified that individual graves should be 80 centimeters wide by 1.50 meters in depth and that common graves should be 20 meters long with no more than one layer of bodies, a layer of quicklime on top, and at least 1.50 meters of earth on top of that. Because of the large number of bodies, the General Council of Hospi­ tals found it impossible to abide by these regulations. It therefore stipulated that up to three layers of corpses, stacked one above the other, be placed in each mass grave. This practice gave rise to noxious odors and posed a threat of contamination. Here we come to yet a third type of fear, the fear of contamination. This was nothing new: in the late eighteenth century there had been panics as a result of the popular obsession with infection from the air emanat­ ing from cemeteries. This old fear resurfaced in 1832: “Soon the cemeteries would become appalling sources of infection that no one would be willing to go near; and what would become of the capital itself, devoured by epidemic and death?”42 Great was the embarrassment and desperate the situation. The inspector general of cemeteries was or­ dered to enforce the burial regulations to the letter. He also replaced gravediggers who refused to work with others drawn from the ranks of the unemployed. Finally, to al­ leviate the fear of contagion, a medical station was set up near each cemetery. The 1832 cholera epidemic pointed up weaknesses in the medical system, as the failure of preventive measures against the disease illustrates. It also pointed up problems in areas where it had been thought that decisive progress had been made, such as hospitals and cemeteries. But besides the usual fears that are always associated with disease and death, this epidemic provoked panic of another kind, a panic that led to violence because it came to be linked with the class struggle. MANAGEMENT

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F ear

THE PURGE

In the eyes of contemporaries, the incredulity of the work­ ing class had something extraordinary about it. The people refused to believe in the existence of the epidemic. This was because news of it had been kept from them. For a good reason: “For more than three months now we have had on our hands several indubitable cases of cholera morbus . . . but for fear of alarming an already nervous population we shall say nothing until such time as the disease has devel­ oped to a greater degree than is now the case.”1 People therefore spoke of cholera as of a creature of the imagi­ nation. Fear led irresistibly to fantasy and, at times, to remarkable bluster and bravado. Heinrich Heine, who was fond of strolling about Paris, has left the following account: Since it was mid-Lent Sunday and the sun was shining and the weather fair, Parisians danced with even more gaiety than usual on the boulevards, where one saw masks whose sickly pallor and deformed features mocked the fear of cholera and the disease itself. That same night the dance halls were more crowded than ever: brash laughter almost drowned out the blaring music. People worked up quite a lather in the chahut, a rather suggestive dance. The revelers were eagerly consuming ice cream and

various cold drinks when suddenly the sprightliest of the harlequins felt cold in his legs, ripped off his mask, and to everyone’s astonishment revealed a face that had turned bluish-purple in color. . . . It is said that the corpses were buried so quickly that no one bothered to remove the gaudy liveries they wore to frolic, and that they lie in their graves as they lived, gaily.2 There had been some rumors of the disease, but they quickly died out. For a while it was believed that the re­ ports of cholera had been planted by the government: “Many people in France saw the disease as nothing more than a suggestion planted in people’s minds by the gov­ ernment in order to distract attention from public affairs.”3 This belief was false. Political leaders did not raise the specter of disease to cover up the problems of unemploy­ ment and poverty. Cholera was not something dreamed up by the government to hide its own incompetence. But even this allegation paled before a far more radical charge: that the government was using cholera as a weapon. Some held that the so-called epidemic was in fact a program of exter­ mination concocted by the authorities. The belief that mass poisonings were being conducted by government agents spread quickly. This idea presumably had as little basis in reality as the previous one. Could the ruling class have har­ bored such criminal designs? Such a fantastic allegation must have been the work of overheated imaginations. Yet in retrospect, perhaps, the popular belief seems somewhat less fantastic. The people who believed these rumors of course cared little about matters of etiology and epidemi­ ology. The popular belief in poisoning of course had noth­ ing to do with the fact that medical science now holds that the cause of cholera is a toxin. The fantasy of poisoning simply reflected the way ordinary people saw the disease and expressed their fears. How could this fantasy have be­ come so widespread? To answer this question we must look at class antagonism in early nineteenth-century France. The

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working class believed that the ruling class had chosen to use poison as a weapon in the class war—a weapon in a death struggle that would end only with the extermination of the bottom layers of the social hierarchy. Suspicion fo­ cused on both the current government [the liberal monar­ chy under the Orleanist branch of the royal family— Trans.] and the [legitimist Bourbon] dynasty that had only recently been driven from power. What was surprising was that an affliction like chol­ era, which reminded people of the great medieval epidem­ ics, should have appeared in an age of progress. Hence the devastation caused by the disease came as a shock, espe­ cially to members of the bourgeoisie, who with all the re­ sources of civilization at their disposal never dreamed that they would have to contend with such a frightful calamity. Littré is clear on this point: “Paris, to which heaven had long been so kind, had forgotten those sad times when plague sowed devastation within its walls. Proud of our civ­ ilization, we Parisians gave little thought to the ferocious attacks that nature occasionally unleashes on the races of mankind.”4 In other words, the epidemic was an anach­ ronism. It is hardly surprising, then, that it should have aroused old reflexes in an ignorant, uneducated populace, not altogether unlike the medieval mob. In the darkest days of the crisis the government had to respond, in the words of Casimir Périer, to the cry of a savage people. Strange tales were told in the streets. People said that with the help of satanic magic an invisible poison powder was being thrown into the air, a powder that caused the bowels of its victims to burn, dry out, and turn black. Ancient obses­ sions seemed to well up from the depths of the Middle Ages. In fact, however, the popular reaction to the 1832 epidemic was quite unlike reactions to earlier plagues. But it was in many ways similar to the reaction to cholera in other countries. In Russia, for example, “when the disease appeared, the people of Revel, like the people of other RusFEAR

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sian cities, were convinced that they had been poisoned. They became extremely hostile, rejected medical help, re­ fused to accept gifts of food, could not overcome their aversion to the hospitals, and began to disregard the orders of the authorities.”5 The poor all over Europe shared the same fears and identified the same enemy, for the simple reason that cholera struck the poor first. People could not understand how a disease that attacked only the lower classes could be anything but intentional. Priority meant deliberate choice, indeed premeditation— a plot, in other words. In France the plot was laid by some at the door of the resistance [to the July Monarchy], the Carlists and as­ sassins of the south and west, while others blamed con­ spirators within the Juste-Milieu itself. It is worth delving a little more deeply into this fear of poisoning. Why was it so prevalent? Why poisoning rather than some other possible explanation? Let me set the stage for the subsequent dis­ cussion by saying that the arguments for poisoning were drawn, in increasing order of importance, from medicine, history, and economics. Let us begin with the medical argument. Cholera struck its victims in the most diverse and unusual settings. Not all died at home or in the hospital. Some succumbed in public places, on the streets, or along the quays. Others collapsed suddenly in places frequented by the down-and-out, the unemployed, and the homeless. Still others died in taverns after eating or drinking (which lent credence to the belief that food and drinks were poisoned). Most important of all, to inexperienced observers the symptoms of cholera re­ sembled the symptoms of severe intoxication: vomiting, spasms, convulsions. Dalmas lent the weight of medical authority to the popular belief: “The meaning of the word ‘poisoning’ is not so restricted that one cannot apply it, with apparent justice, to a disease in which the victim passes suddenly from a state of health to the most immiCHAPTER 3

nent danger; so prompt a change suggests poisoning and the effects of the most venomous substances.”6 The doctors did not stop at appearances, however. Most of them recog­ nized the difference between cholera and poisoning: the latter was accompanied by vomiting, hard stools, and gas­ trointestinal pain, whereas the former was accompanied by characteristic “rice-water stools,” cramps, and coldness due to circulatory collapse. As for history, the series of revolutions and counter­ revolutions that France had endured since 1789 had made its people suspicious and fearful. The memory of the July Days was still fresh. For twenty months a revolutionary climate had dominated France, heightening suspicion still further. Many people felt that murder and execution had been made familiar by popular literature. This was to re­ verse cause and effect, since writers drew their material from daily scenes of violence (and even from the works of the hygienists). It was not as though popular anger needed to be pricked in the theater. But this false assumption was nevertheless common: “Cholera exhibited all the symp­ toms of a poisoning that everyone knew from the theater, which corrupted taste allowed to pervert the public mor­ als.”7 Reports circulated through the city, all the more alarming because of their remarkably detailed nature. Louis-Philippe was rumored to have written the Queen of Saxony that cholera had struck Paris, but that really it was the result of poisoning. It was also said that the govern­ ment, in league with the Carlists, had decided to sow dev­ astation and restore the monarchy. July’s victors were the designated targets of the poisoners. We come, finally, to the economic argument for poi­ soning. Poisoning the people, it was said, was the means by which the government hoped to avert an imminent famine. By this expeditious and effective tactic the government hoped to conceal its responsibility better than it could have done had food been allowed to run short. Such was the FEAR

popular belief. But sophisticated theorists were not far from sharing it. The hygienists, absorbed in their statistics and their principles of management, made much the same point. The epidemic, they argued, was consuming the surplus population. It was one of the regulatory mecha­ nisms for maintaining demographic equilibrium: “As the population continues to grow, will it not exceed the avail­ able resources? If so, one would almost be tempted to be­ lieve that the Asiatic cholera morbus, which has invaded so vast a portion of the globe, is a necessary evil.”8 Thus it was not just the working class that believed the disease served a clear economic function. Many hygienists, con­ vinced that the population was too large for the available resources, reverted to the old Linnaean idea of a “natural police.” But where the hygienists saw an epidemic whose purpose was to maintain the equilibrium of the population, the people saw a dark plot hatched by the government. The hygienists saw the disease as a sign of divine providence; the people saw it as a sign of official skullduggery. Some­ one may object that the Malthusian idea of a natural economy was not something with which the people of Paris would likely have been familiar. But poverty taught them all they needed to know about how the ruling elite viewed their growing numbers. The lower orders were under no illusion as to the gov­ ernment’s methods of dealing with economic problems. The people believed that they were the target of a purge. According to Littré, the word “purge” (épuration) was first used in 1835 to mean “elimination by a society of members deemed undesirable.” But in fact the word appears in the medical literature as early as 1832 in connection with chol­ era: “In our view this is the way [the cholera] may go, choosing its customary prey among those who have long lived physically sickly or morally squalid lives or who have worn themselves out through abuse and who, therefore, could only cause deterioration in the species . . . in short, chapter

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as though it were charged with inflicting upon mankind I know not what frightful purge.”9 Clearly, the outcome of the epidemic was “overdetermined.” The existence of indi­ viduals too weak to be productive and too dangerous to be tolerated posed a threat to society. Writers accentuated the physical and moral flaws of the groups hardest hit by the epidemic, suggesting that the victims were somehow de­ generate and that the “purge” was therefore a eugenic so­ lution to a pressing social problem. But to cast cholera as a purge was to lend credence to popular fears. For what was a purge but a natural (or technically sophisticated) version of the tried and true method of poisoning? Purge or poison, the end result was the same. To those who were singled out as a useless surplus to be eliminated, the operation ap­ peared monstrous in either case. But to those who saw the epidemic as a device for eliminating unproductive members of society, it seemed a boon. Cholera would in fact improve the economy by liquidating exhausted workers no longer able to carry out their assigned functions. Jobs left vacant could then be filled by healthier, more robust individuals. Vigorous workers would replace worn-out workers. Fi­ nally, cholera would have an overall health benefit: “Great epidemics are followed by periods of great health. . . . The disease has claimed mainly sickly individuals of delicate constitution, worn out by suffering and early privation.”10 According to the hygienists, deadly plagues were indices of poverty: “The frequent recurrence of epidemics is a sign of poverty, or, what comes to the same thing, of an excess of population with respect to the means of subsistence.”11 The hygienists borrowed this definition of poverty from Malthus. The devastation of the 1832 epidemic was mani­ fest. Workers were reduced to beggars: in the twelfth ar­ rondissement 24,000 paupers required charity, and in the neighborhood of the Hôtel de Ville 950 households and approximately 2,500 individuals were inscribed on the re­ lief office registers. As Louis Chevalier has observed, conFEAR

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temporary accounts “suffice to show that the cholera or­ deal was not an exceptional catastrophe due to unusual circumstances that unleashed a monstrous nightmare in the city but rather the culmination of a long series of devel­ opments; the epidemic revealed physical, economic, and social conditions that had grown steadily worse since the last years of the Restoration.” 12 People did not have to read the hygienists in order to understand their message: desti­ tution and distress told them all they needed to know. If the people did not read the hygienists, they still could not fail to read the official circular drafted on behalf of the prefect of police and posted on walls all over Paris on 2 April: “The appearance of cholera morbus in the capital has provided the eternal enemies o f order with a fresh op­ portunity to spread infamous calumnies against the gov­ ernment. They have had the impudence to say that cholera was merely poisoning carried out by official agents in order to reduce the size of the population and distract attention from political affairs. I am informed that certain scoundrels intend to support these outrageous charges by introducing vials and packets of poison into cabarets and butchers’ stalls, perhaps only pretending to spread poison, where­ upon they plan to have themselves arrested by accomplices who will indicate that the parties thus apprehended are employees of the police and then allow them to escape.”13 The prefect of police hoped to protect the government against any possible suspicion. By announcing that he was on the track of those responsible for the poisoning, how­ ever, he lent official credence to the widespread rumors. Was he attempting to manipulate public opinion or simply acting maladroitly? Since people temporarily forgot the government and turned their suspicions toward alleged agitators and criminal physicians, perhaps the prefect was merely trying to influence opinion. People who read the circular became wary of food and drink, of one another, CHAPTER 3

and especially of anyone administering treatment. But the whole maneuver was so clumsy that it triggered a violent reaction and even riots, whereupon it became necessary to deny the earlier reports and insist that there were no provocateurs. Suspect items of food and drink were brought to the authorities. Numerous reports were prepared by police officials and transmitted to the prosecutors, who ordered further investigation if warranted. Physicians and chemists analyzed suspected materials.14 The declaration of the pre­ fect of police, which confirmed the popular beliefs, had dramatic consequences, heightening the climate of suspi­ cion and provoking scenes of unprecedented violence. Indi­ viduals wrongly suspected of being poisoners were beaten and killed.15 Suspicion turned from government agents to antigovernment agitators. But the latter were hard to iden­ tify, so popular mistrust focused instead on the physicians, who were charged with being agents of the government. A scapegoat was needed. As in all epidemics, the doctors were palpable enemies, while the disease itself was invul­ nerable. It may be worth mentioning in passing that the doctors who first identified the symptoms of the plague in 1720 narrowly escaped being murdered. But something more was needed to transform the doctors into assassins hired by the government. Reasons for resentment accumulated. For one thing, doctors were suspected of studying the diseases of the poor in order to save the rich. The poor, Louis Blanc said, were being used as “experimental subjects.” Somewhat earlier Magendie had been accused of practicing human vivisection. Other factors were also at work in 1832. Because of the fear of contagion measures of segregation had been instituted: “Thus families were prohibited from visiting hospitalized relatives, and the common people believed firmly that the first cholera victims to enter the hospitals had been poi­ soned.”16 To be sure, the treatments used amply justified FEAR

what some historians have rather hastily dubbed “resis­ tance to medicalization.” “Expectant medicine” was a meditation on death; “active medicine,” on the other hand, hastened death’s coming. Many different treatment plans were employed in one hospital, the Hôtel-Dieu of Paris. Some patients were forced to swallow violent stimulants. Some were treated by affusion [the pouring of water over parts of the body—Trans.]. Still others were subjected to electric shocks or cauterization: “But the stimulating po­ tions were vomited up or caused horrible pains; the pa­ tients treated by affusion were brought back dying to their beds; those treated with electricity derived only a few hours’ torture from the experience. Fresh experiments were begun the next day in the same beds but not on the same patients.”17 The physician therefore ceased to be seen as the pro­ tector of the public health and became instead the agent of the “authorities,” either an accomplice of those to whom the people had given power or a hireling of the dynasty that they had overthrown. Popular hostility shifted to the medi­ cal profession: “Georges Lefebvre has called attention to the ‘leveling’ that occurred in 1789 and that gave rise to the concept of a ‘typical lord,’ an ‘abstraction’ that proved fatal to good and bad lords alike, many of them noble but including, too, some bourgeois purchasers of feudal rights. During the epidemic a similar syncretism led to a con­ founding of all those who practiced the healing arts; they became agents of the enemy.”18 Doctors were forced to disguise themselves while making calls so as not to be rec­ ognized by the mobs, and when, in spite of such precau­ tions, people identified them as doctors “they stirred up their neighbors against us, so imbued were they with the prejudice that cholera was a made-up disease designed to purge Paris of what was called ‘riot material’ and that the hospital was the laboratory in which this infernal program of political persecution was being carried out.” 19 We are chapter

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not dealing here with a persecution mania confined to just a few physicians. Listen to Magendie: “I shall never forget the impression that I felt when, after doing all that I could to try to alleviate the suffering and if possible to save the lives of the unfortunate victims entrusted to me, I read in their worried faces, their taciturn manner, and their un­ spoken fears that they suspected me of poisoning them.”20 The government was hoisted by its own petard. The prefect acted quickly, ordering an immediate investigation. Julia de Fontenelle examined various brands of wine and samples of delicatessen and bread taken from different parts of Paris. Her analyses proved that the poisoning charges were false.21 But the proof was apparently deemed insufficient, for the medical profession was also consulted. The doctors of the Hôtel-Dieu drew up and signed a decla­ ration, which was posted on the walls of Paris on 5 April: Monsieur the Prefect of the Seine, in response to the false rumors spread by malevolent individuals, believes it his duty to make known to the inhabitants of Paris the following declaration: The physicians and surgeons of the Hôtel-Dieu declare that since the beginning of the current epidemic they have found no symptoms other than those of cholera in the numerous patients they have treated, the same symptoms that have been observed wherever the disease has been prevalent; They declare that in the autopsies they have per­ formed they have found not one atom of venomous substance; Finally, they declare that they have not found in either the stomach or intestines any of the lesions pro­ duced by various poisons. Done at the Hôtel-Dieu, 5 April 1832. Signed, Petit, Dupuytren, Récamier, Bailly, Caillard, Gendrin, Magendie, Husson, Guénaud de Mussy, Sanson, Breschet.22 Did this declaration reassure the populace? It seems doubtful, since the doctors who signed it were the same FEAR

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ones who stood accused of administering poison. In any case, the declaration provided a categorical denial of the rumors. CHANGING THE CITY

Unlike the working classes, the privileged classes had no doubt that the epidemic was real. Better informed than the common people, the wealthy had been following the prog­ ress of the disease for some time. They had read frightening articles about the destructive effects of cholera in Calcutta, the Levant, Russia, and various countries in Europe. Pro- phylactics were stockpiled and people filled their homes with chlorine and camphor. The first reflex of the wealthy was to flee. The first signs of cholera in Paris were accom­ panied by a mass exodus of bourgeois, deputies, peers, and foreigners: “At the news that cholera morbus had invaded Paris and at the sight of coffins being moved about the city fear seized hold of people’s minds, and multitudes fled in early March and throughout the month of April.”23 Some of those who fled later returned, but on business. Those who remained, moreover, had carefully weighed the dangers of going against the advantages of waiting: those who fled risked falling ill en route and being unable to find help, while those who stayed hoped either to benefit from acclimatization or, if they did get sick, to be sure of finding a doctor. One did not have to be a hygienist to notice that the disease struck poor neighborhoods first. In the heart of the city the epidemic found its natural terrain. Its virulence per­ sisted in central Paris well after it had spread to other areas, and it was not in the wealthy districts around the Chaussée d’Antin, the Bourse, and the Tuileries that the earliest vic­ tims lived. The wealthy were not the first to succumb: this fact was so obvious that people asked how the disease CHAPTER 3

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could have come to France by way of England, since the poor of Paris were unlikely to have paid recent visits to London merchants or the House of Lords. The full fury of the disease was vented first on working-class areas, on the poor wretches who inhabited filthy hovels on the Ile de la Cité and in the area around Notre Dame. Significantly, the first victims came from the rue de La Mortellerie (Stonemill Street). For those whose lives were safe from need, fear of the disease was tightly bound up with fear of those who carried and probably also spread the disease. Anything that came from the lower orders was perceived as threatening. Cholera had struck the common folk first, and soon it would spread to others, from garrets to apartments, from hovels to palaces, from alleyways to boulevards. The dis­ ease was following in the footsteps of insurrection and re­ bellion. Hence the wealthy felt a generalized fear, felt the need to protect themselves not only against epidemic but also against possible riot. As Bernardin de Saint-Pierre had said, it is from the common people that “epidemic, theft, sedition all come.”24 To reactionaries it was of course self-evident that the people were responsible for all society’s ills. Carlist prop­ aganda tried to show that cholera had followed the same route as subversive political ideas. Broussais, in his lectures at Val-de-Grâce, argued that the disease had come to Rus­ sia via overland trade with Persia and India and that the Russian armies had then carried it to Poland. He did not say, however, that it was the Poles who had brought the disease to France. But for the Carlists this extension of the argument was obvious. Poland had risen on 29 November 1830 in a rebellion intended to secure independence from Russia. In the spring of 1831 the Russian troops occupying the country received reinforcements, as well as cholera, from home. After the battle of Iganie the first cases turned up among the Polish ranks. From Germany the epidemic spread to England. Polish refugees and the July Revolution FEAR

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had brought it to Paris: of this the Carlists had no doubt. Was it “substantial infection” that had caused the cholera to spread? “No, [it spread] rather by revolutionary infec­ tion, which progresses in the same way, which erupts with­ out good reason. . . . Cholera, like revolution, must be eradicated at the source.”25 The clergy were quick to dispatch pastoral letters of a seditious tenor. The Church saw the epidemic as an op­ portunity to renew its ties with a population that had shown itself unfaithful to the Catholic religion and the Bourbon dynasty. An angry God had sent the plague to punish France for its religious and political vacillation. Listen to the Bishop of Bayonne: “Impiety had erected its fortress in that city [Paris], the object of universal admira­ tion; it seemed to have risen as one person against the Lord. From here blasphemous and impious doctrines were car­ ried forth to all the nations of the earth and like a wind of fire shriveled the seeds of faith in countless hearts.”26 Was there an audience for this kind of preaching? It seems likely that there was, since the republicans took the trouble to refute the medieval etiology on which it relied. They pointed out, for instance, that the epidemic had not spared cities where monarchy still reigned: “Everyone knows that Moscow, Saint Petersburg, Vienna, Berlin, and London have yielded many victims to this epidemic, and yet none of these cities has toppled a tyrant from his throne. A bishop should show sympathy but be wary of political pas­ sions.”27 Besides, the avenging arm of the Lord had been extremely poor in its aim: “If there were anything to this mumbo jumbo, the proof would be that cholera carried off only those who had profaned churches and smashed icons. But then it would hardly have spared the Juste-Milieu of Monsieur Casimir-Périer.”28 We come now to the essential point. The 1832 epidemic fostered two myths that demonstrate the highly ambivalent CHAPTER 3

nature of the kind of fear we have been discussing—am­ bivalent in the sense that fear of disease alternated with fear of riot. One of these myths recounts how the epidemic spread through society; the other tells how the disease gradually disappeared from a city inhabited by a hard­ working and obedient population. Countless writers from Eugène Sue to Victor Hugo attest to the power of the metaphor of the city as a sick, and dangerous, organism. The hygienists, for their part, formed a quite different image of the city: a healthy, tranquil place in which all men lived in harmony. Urbanists accepted neither the black nor the white image and proposed instead a meticulously de­ tailed picture of their own: they saw a country that had sufficient resources to stop cholera in its tracks, a country where “poverty will have given way to plenty, excess to moderation, weariness to rest, where there will be no large numbers of people ill clad, ill nourished, and ill housed, where surely there will be few if any cholera victims.”29 In such a country citizens would be encouraged to participate in governmental decisions. They would also be urged to assist magistrates and physicians in carrying out their as­ signed tasks. There was no doubt that this was what the future held: “Education, when it comes to that segment of the populace whose vice and poverty are due in part to ignorance, will foster not only higher moral standards but also more regular habits, habits more in conformity with the requirements of public health.”30 Here we have, com­ bined in a single statement, the fantasy of a city gnawed by leprosy and the dream of another city, healthy and docile, which together symbolize an unarticulated fear and its triumphal negation. The fear was directed not only against a disease but also against a class—the dangerous class— whose hostility might at any moment be unleashed. The hope was that by active intervention all the social evils could somehow be nipped in the bud, that society could be mastered and controlled. Underlying this reformist vision FEAR

of utopia was a dualism of the healthy and the unhealthy, of security and danger. In answer to the degradation of urban living condi­ tions and social unrest some raised as an ideal the “society of surveillance.” It is worth dwelling for a moment on the opposition degradation/surveillance. The metaphor of a de­ caying city carried with it the implication that the disease had spread through the city starting from the unhealthiest streets and dwellings: “This deplorable devastation of hu­ man beings occurred only in these [unhealthy] districts, be­ cause nowhere else is space so cramped, are people more pressed together, is the air unhealthier, or is living so dangerous.”31 Sinks of pestilence, emanations of evil, filled the city. Landmarks such as the Saint-Laurent fair, once the meeting place of high society, were now seen as a chamber of horrors: “Is not the area whose extraordinarily filthy condition has just been indicated a place of extreme danger to the public health?”32 Thus places as well as corpses were viewed as threats. The hygienists made plans to deal with both. They proposed first buying up dilapidated housing, demolishing it, and building new and safer dwellings on the same sites. Little by little the face of the city would change, thanks to the example of virtue set by the government. There would be a progressive and carefully orchestrated replacement of run-down areas by healthy new quarters. What was left out of this equation was the greed of devel­ opers and the complicity of architects. But perhaps these too could be dealt with, simply by adopting strict regula­ tions that would reduce the opportunity for greedy prop­ erty owners to take advantage of the renovation plans. The hygienists’ second proposal, no shrewder than the first, was to move the poor into large warehouses and unused old buildings leased by the government. This plan was quickly abandoned as unrealistic. But it does show that old ideas of confinement were revived as a way of dealing with the danger inherent in the lower classes. chapter

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Various public health ordinances were already on the books in the early nineteenth century. The authorities did not hesitate to invoke these as needed, though not without making changes they deemed necessary. A 1788 ordinance set the minimum street width at thirty feet; in 1820 this was increased to thirty-six feet; by 1832 this was no longer deemed adequate, and the minimum was raised to forty feet or more in some cases. In 1827 the Public Health Council had drafted a health code for new construction that re­ flected recent findings concerning the effects of housing on public health. It was proposed, for instance, that the heights of buildings be no greater than the width of the streets on which they were built, so as to allow for ade­ quate sunlight and ventilation. Public sanitation was to be improved. It was widely believed at this point in time that every square inch of the city was a potential source of danger, for the atmosphere could easily be contaminated by noxious vapors emitted from anywhere. But dealing with buildings was not enough by itself; something also had to be done about the people. Cholera was a disease of the poor, and particularly of “tramps” and “vagabonds.” It was not only a physical but also a moral and social affliction. The epidemic zeroed in on the jobless and homeless, who were also people likely to become in­ volved in criminal activity or even riots. There were first of all the ragpickers, five or six thousand of them, who pros­ pected for treasure in the garbage of the capital: “They rec­ ognize no law, no homeland, and no magistrate; a sort of hermaphroditic race, they belong neither to nature, since they are nothing like savages, nor to society, since they are not civilized.”33 They were joined by various sorts of vaga­ bonds, beggars, and day laborers without regular employ­ ment. This was a roving population, composed of people who moved from house to house and neighborhood to neighborhood in order to avoid the watchful eye of the police. This partly invisible underclass worried the forces of FEAR

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law and order, whose job it was to keep track of peo­ ple’s movements, regulate behavior, and punish those who broke the law. As Louis Chevalier has observed, “This group in particular was held responsible for all the ills, be­ cause by its very nature it transmitted to other segments of the population and to the city as a whole the noxious ef­ fects of its harsh and primitive living conditions, its vices, and even its bad breath and foul odor.”34 This was a group refractory to the laws of public health and untouched by the amenities of civilization. For reasons of public health and public safety, therefore, the government felt bound to take action: “The government must be constantly on the alert to protect the population against any threat.”35 And the government’s vigilance must extend to any place where a threat might lurk: the authorities were urged “to monitor the number of tenants in every building, every apartment, and every room.”36 Fear of the disease and fear of riot were closely related. Unhealthy areas of the city, and the people who lived in them, threatened residents of well-to-do neighborhoods in two ways. First, they emitted noxious vapors that in some intangible way were a cause of corruption. People were afraid of being contaminated by “miasmata,” “putrid ema­ nations,” and “pestilential germs.” Métrai called attention to this danger: “The poverty in which they allow the people to languish attracts, engenders, and nourishes the deadly disease that causes them to perish. . . . Despite the per­ fumes they spray into their throats, they are infected by the filthy dwelling places of poverty.”37 At the behest of Ma­ gendie the Academy of Sciences on i April appointed a commission to analyze the city’s air. Once again it was Julia de Fontenelle who examined samples of air collected from different parts of Paris. It was found, however, that the samples from infected and healthy districts were equally pure. “Based on these facts, I feel sure that, so far as the present state of our knowledge allows us to determine, it is chapter

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impossible to detect anything in the atmospheric air of Paris that is not contained in pure air.”38 CONFLICTS

Rich and poor suspected one another. The rich feared le­ thal contamination by noxious air emanating from poor districts of the city. The poor feared that the rich were poi­ soning them. The authorities, as we have seen, called upon the doctors to put an end to wild fantasies about contami­ nated air, food, and drink. Knowledge was supposed to dispel such fears. The belief in poisoning shows clearly that the working classes saw the medical profession as a tool of both the authorities and the wealthy. Doctors, the people believed, were employed by the government to get rid of dissidents. This benefited the wealthy by removing wornout workers from the productive apparatus, or so it was claimed. Now, as we saw earlier, this popular interpreta­ tion was in some sense shared by the hygienists, who saw the cholera epidemic as a purge whose effect would be to eliminate undesirable and unproductive elements of the population. As the idea of the city as a dangerous place took hold, the need was felt to make urban areas not only safer but also more “recreational,” that is, better able to conserve the strength of workers so vital to production. The city had to be made both safe and sound “by roundthe-clock vigilance to ensure that calm and order are not disturbed and by enforcement of health regulations in re­ pairs and new construction.”39 The proposed reforms reflected both the law-andorder and health concerns. Proposals included the estab­ lishment of a comprehensive system of surveillance as well as improvement in living conditions—in other words, im­ provement in the means of exploiting and monitoring the activities of the working class. Public health measures alFEAR

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ways had two aspects: to maintain law and order and to promote the accumulation of wealth. Health, law and order, accumulation: all three came under the aegis of a series of regulations and institutions referred to from the late seventeenth century onward as “police”: “Down to the end of the Ancien Régime the word ‘police’ referred to more than just the police force; it included all the various means of securing law and order, funneling the accumula­ tion of wealth, and establishing ‘the general conditions’ of health.”40 Had nothing changed, then, since the seventeenth cen­ tury? In 1832 the three functions of health, law and order, and economic accumulation were so closely related that all three influenced the framing of every piece of public health legislation. In other words, health legislation had objectives that extended beyond health per se. Both the government and the governed viewed health legislation in terms of its broader effects, which included economic growth and law and order. This led to conflict of two kinds, one centered on questions of profit, in which the government was pitted against various occupational groups such as ragpickers, merchants, and physicians, and the other centered on law and order, in which the government was pitted against the “dangerous classes” of society. Consider first the conflict between the government and the ragpickers. In early April the prefect of police precipitated a disturbance that quickly degenerated into a riot. What he had done was simply to order that all garbage be placed in containers for removal by a company that had just been granted an exclusive franchise to conduct all city sanitation services. In issuing this order the prefect believed he was taking a step beneficial to the health of the public. But the additional evening garbage collection dealt a severe blow to the ragpickers’ livelihood. The order proved unpopular, because it deprived the poorest segment of the population chapter

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of its daily booty. The ragpickers and various of their associates— resellers, second-hand dealers, and rag mer­ chants—took violent action: wagons were burned and thrown into the Seine, barricades were erected in the center of Paris, and the poor of the Ile de la Cité demonstrated on the place de Grève and the boulevards. Police reports sug­ gest that there were several centers of unrest. On 4 April the police staged a show of force and put down the riot. Later, the prefect of police wrote, “I was briefly fearful for the security of Paris. I could not help thinking that the lives and property of the decent citizens of Paris were in danger.”41 A second, somewhat more obscure conflict affected certain groups of workers and farmers. It, too, arose out of public health concerns. Doctors, consulted about what diet was best for warding off the disease, had warned against drinking alcoholic beverages, especially to excess. They had also advised against a diet composed mainly of fruits, veg­ etables, and pork products. These were preventive recom­ mendations, aimed at avoiding digestive problems that might lead to diarrhea. The advice of the physicians was delivered to the authorities in a document entitled “Con­ sultation signed by the physicians of Paris and the Prefect of Police concerning the treatment to protect oneself against cholera,” as well as in the Memoir Concerning Cholera Morbus, Followed by Instruction for the Layman Pertain­ ing to This Disease, which was published by Portal. But the advice not to drink poor-quality beer met with the follow­ ing response: “Consumers have unfortunately concluded that the use of this beverage was [sic] harmful. This false interpretation has reduced the breweries to the most dis­ tressing idleness. Many are faced with certain ruin, and all have been forced to deprive numbers of employees of work and bread.”42 And the recommendation not to eat fruits, vegetables, and pork products drew this comment: “The fruitsellers, vegetable sellers, and pork butchers curse the doctors. . . . Hundreds of small holders in the Paris area FEAR

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who live by selling fruits and vegetables now find that the market is closed. And these fruits and vegetables, their only resource for the entire year, are meanwhile rotting; hunger and misery lie in the offing, and plague is not far behind.”43 A third conflict involved the government and the medical profession. Doctors felt exploited and complained that their profession was not protected. They felt exploited because the government had sought to impose generosity on them as a duty: doctors were giving freely of their own time, without compensation, but the government, forget­ ting this act of generosity, tried to compel them to treat cholera victims. The doctors were also unhappy that they had to pay a license fee known as the patente, which they felt reduced their profession to the level of the most vulgar tradesman. Further discontent stemmed from the fact that the medical profession was not protected from competi­ tion. Foreign doctors were not excluded from the practice of medicine, and the law afforded inadequate protection to practitioners. Now that calamity had struck, healers and other self-taught physicians were suddenly plentiful. Ma­ gendie fulminated against this “horde of charlatans from the garrets and cellars who derive their inspiration from either ignoble greed or an insatiable lust for publicity, peo­ ple who are always distasteful but who are even more so now that they are practicing in the midst of general calam­ ity and at the public’s expense.”44 The vogue for “empirical medicine” in the midst of an epidemic was no doubt due in part to ignorance and fear. But surely it also had something to do with the state of disarray in which official medicine found itself: “When art is deficient and theory powerless it is surely permissible to resort to empiricism, and even if the remedies suggested do not all produce the miracles ascribed to them, they calm the public mind and reassure people in despair.”45 A distinction had to be made: those who spec­ ulated on the disaster and sold drugs at inflated prices had to be denounced, while those who praised the purifying chapter

3

virtues of fresh water, which was said to “cleanse the hu­ mors” and eliminate “corrupt matter,” were deserving of tolerance. Turning now to the question of law and order, it was shortly after the riot on the occasion of General Lamarque’s fu­ neral that an increase in the number of cholera victims was noted. Some physicians saw a correlation between the two events: the rise in mortality, they said, had been caused by the June insurrection. Violent emotions due to tumult and disorder were held to favor the spread of the epidemic: “As for the new cholera victims, it is correct to attribute their increased number to the political disaster that we suffered a few days ago. Many of those who became ill were people upset by violent emotions who succumbed to the epidemic influence. Without this unforeseen shock it is probable that a certain number would have escaped, and that those who lacked the strength to resist would not have been stricken so suddenly.”46 The idea that intense emotions were a pre­ disposing cause of cholera was a commonplace of the time. But only a few doctors associated with the Juste-Milieu went so far as to maintain that the reason why the patient had experienced such strong emotions might itself be a contributing factor. If social unrest caused emotions that contributed to the spread of the epidemic, the argument ran, then repression was justified. Indeed, if political re­ pression were aimed not merely at putting down rebellion but also at preventing it, then it might help to prevent the disease. Security measures were prophylactic. Delpech de Frayssinet observed the events in Paris and drew the inevi­ table conclusions: “Magistrates shall above all see to it that the agitators do not foment sedition or riot, there being nothing more favorable to the spread and development of the epidemic than the state of erethism and exaltation prev­ alent in populations subject to political excess. . . .The re-

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surgence of cholera in the population of Paris after the events of June is a somber example of this sad truth.”47 To be sure, not all physicians shared the idea that the emotions aroused by the June disturbances had contributed to the resurgence of cholera. Those who actually watched the progress of the disease in the Saint-Mery cloister where the disturbances took place noted no increase in the num­ ber of victims or deaths. There is no doubt that the number of deaths from cholera did increase, but only somewhat later: according to information supplied by the commis­ sion, after 18 June. The commission itself did not link the increase in mortality to the riots; but it did little to clarify matters when it blamed emotions aroused by the epidemic itself: “Political commotions, generally of short duration, are less terrifying than the presence of a terrible scourge.”48 At bottom it scarcely mattered whether fear was the result of the rioting or of cholera itself: it was still seen as a con­ tributing factor in the epidemic. Some republicans believed that the government should exploit this fear. On the pre­ text of adopting new health measures, it should take steps to guarantee calm in the streets: “Let us declare in the face of common sense and reason that it [the disease] is conta­ gious, indeed highly contagious, and that we all, in our own interest, should remain in the juste-milieu, i.e., at home; and to make sure that this happens, let us quickly enforce the health laws.”49 Thus there were two possibili­ ties: repression could be justified as necessary to dispel fear, or fear could be used as an instrument of repression. And that is not all: when the events of June made it necessary to restore order, an old sanitary law was invoked. The police ordinance of 9 June 1832 stipulated that all phy­ sicians, surgeons, health officers, and pharmacists in Paris who had administered treatment to wounded individuals since the fourth of the month were required to declare that fact to police officials or pay a fine of 300 francs. The sec­ ond article of the ordinance specified that this declaration chapter

3

should contain the first and last names, addresses, and oc­ cupations of the individuals treated, the nature and seri­ ousness of their wounds, and the circumstances under which the wounds were received. The first article invoked an edict of December 1666, which provided for a fine of 300 livres for contravention of any police ordinance, as well as another police ordinance of 4 November 1788 requiring every physician to denounce to the authorities any indi­ vidual seeking treatment for any disease considered to be contagious. Since the June riot occurred at the height of an epidemic, the government saw fit to dredge up this old or­ dinance concerning contagious diseases. It thus converted a public health measure into a public safety measure. Now it was the rioter, and not the possible carrier of a contagious disease, who was to be denounced to the police. In fact, the government treated the rioting as though it were a kind of epidemic. Insurrection was regarded as a social malady. The debate surrounding this ordinance quickly bogged down in legal technicalities. The opposition claimed that the government was exhuming old laws tacitly nullified by article 378 of the penal code, which permitted doctors to keep details of treatment secret except in cases where “the law obliges them to furnish information.” So the debate revolved around the issue of whether the current circum­ stances were or were not “exceptional” under the terms of article 378. It was pointed out that the victorious rebels of 1830 had treated government soldiers with respect. Some protested the government ordinance on principle, on the grounds that the confidentiality of the doctor-patient rela­ tionship should not be violated; others protested for oppor­ tunistic reasons, in order to make a name for themselves. The Royal Academy of Medicine, for its part, declared that it was not competent to judge questions of law. In the end the government backed down and chose not to enforce the ordinance.

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The 1832 epidemic exacerbated class antagonism. In this confrontation, the relationship of the medical profession to the populace was analogous to that of the working people to the well-off: both the doctors, as agents of the govern­ ment, and the lower orders, as agents of revolution, were seen as spreading death. But it quickly became clear that the poor were dying more quickly than the wealthy, and in greater numbers. When doctors were not charged with being enemies of the people, they were seen as little more than bookkeepers: “The government prepared its cholera tables, which as everyone knows are remarkably accurate; and during the epidemic its agents did nothing else.”50 The judgment is harsh. The government actually did more than just prepare its tables: it also pondered them. From this came the conclusion that cholera, far from being the conse­ quence of some dark plot, had deep-seated roots in French society. These suspicions were gradually to be confirmed in minute detail, with cold and calculating method.

chapter

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4

Investigation METHOD

In the commission report we read the following: “Having gathered a large number of facts concerning every part of the capital and the département, [the commission] hoped that by organizing the data and comparing one item with another science might produce some unexpected glimmer of light that would suddenly dispel the deep darkness that has hitherto resisted all attempts at illumination.”1 Thus it was hoped that the Report would establish which factors had contributed to the disease. To us it is clear that poverty facilitates the spread of epidemic disease. To the men of 1832 things were not so clear. The commission played an important part in bringing these matters into focus. Its work yielded one incontestable result: inequality in life is correlated with inequality in the face of death. The Report is a work of synthesis. The problem was to correlate information gathered by the various local com­ missions in order to determine what factors had affected mortality from the disease. Before this could be done, an analytic framework had to be established; for this purpose the city was subdivided into districts. There were four per­ tinent analytic variables: the number of districts or quar­ tiers, the relative size of each, their nature, and their relative location. “A map of Paris was first cut up into forty-eight

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quartiers, each of which was copied onto a separate sheet of paper to form a new map of each individual neigh­ borhood, so that it became possible to see at a glance the widely varying size of the neighborhoods, their sometimes bizarre shapes, and the way in which these various sections of the capital were situated.”2 The resemblance between this method and that of Linnaeus stops here, however. For the neighborhoods could easily disappear into the fabric of the city, woven of a crisscrossing network of streets and houses. They could also be grouped together to form larger districts, the arrondissements. So the analysis could pro­ ceed on various levels, ranging from fairly large-scale ad­ ministrative units to individual dwellings. The question then becomes: How were the data inter­ preted at each level of analysis? One possibility was to cor­ relate mortality rates with climatological and topographical data or with population densities. Another was to compare mortality rates in different areas in the hope of turning up the decisive factor. Studies of temperature, climate, and ex­ posure showed that none of these factors influenced the death rate. Nor did comparative studies of the population density in each neighborhood turn up any interesting re­ sults. Only when the investigators began to look at the den­ sity of population in each dwelling did the results begin to look interesting. This suggested that the analysts should look first at housing and then at inhabitants: crowded buildings inhabited by people who lived in a certain man­ ner turned out to be the primary contributing factor in the development of cholera. The first study to be carried out involved the relationship between death from cholera and the weather. The year 1832 was notable for a very cold spring followed by a dry summer. But these weather conditions could not be shown to be decisive causes of the disease. There had been noth-

CHAPTER 4

ing remarkable about the weather of preceding years and nothing really unusual about the conditions under which the epidemic broke out. Research carried out at the Paris Observatory into changes in temperature, humidity, and barometric pressure turned up nothing significant: “In the Paris climate, the temperature and wind direction do not seem to have moderated or exacerbated the cholera. . . . Its mode of action seems to have been completely independent of variations in the atmosphere.”3 Once the weather was ruled out as a cause, it seemed logical to look to more permanent features, such as the de­ gree of exposure of various dwellings, elevation of the land, and degree of dampness or dryness. It was believed that such circumstances affected susceptibility to disease. But cholera proved to have been equally virulent in areas that differed sharply in these respects. Consider degree of expo­ sure, for example: “Mortality rates seem to vary widely for places with the same relative exposure, with rates two or even three times as high observed as we move from one neighborhood, quay, or even house to another, so that the commission will refrain from drawing any conclusion.”4 Or again, consider the report concerning the relationship of mortality to dampness: “The mortality rate along the banks of the Seine, the Bièvre, and the Saint-Martin Canal was 26 per 1,000. As we have already seen, the average for all neighborhoods was 24 per 1,000. The effect of flowing water on the development of cholera in Paris was to in­ crease deaths by 3 per 1,000, or 1.5 per 500. One can therefore regard this effect as insignificant for the capital.”5 Similarly, topographic differences were also discarded as a possible influence. Turning now to the study of mortality rates in relation to population densities, it is useful to distinguish between two levels of analysis. One approach, which might be called “macrogeographic,” was to compare mortality to popula­ tion density by arrondissement or quartier. It quickly beINVESTIGATION

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came apparent that when “living space” was measured in terms of square meters per inhabitant, no significant results were obtained: districts with comparable population den­ sities had different mortality rates, while other districts with sharply different densities had almost identical death rates: “One neighborhood with only seven square meters per inhabitant (Les Arcis) had 42 deaths per 1,000 popula­ tion, and another (Les Marchés) had 21 per 1,000. SaintThomas-d’Aquin, with 55 square meters per individual, had 38 deaths per 1,000, while Invalides had 34 per 1,000 with 147 square meters. . . . In the arrondissements as in the quartiers the disease retains what appears to be its own peculiar character, causing similar mortality rates in local­ ities that have nothing else in common.”6 In other words, simply dividing the area of the arrondissement or quartier by the number of inhabitants to obtain an average “living space per inhabitant” yielded illusory results, because the scale chosen for the analysis was not appropriate to the problem at hand. The second, or “microgeographic,” approach to the problem produced a sharply different picture. Here the emphasis was on the number of square meters of dwelling space available to each inhabitant, and this proved to be a truly significant figure. “Crowded together, piled one on top of another in tiny rooms, people live as at numbers 62, 38, 20, and 114 rue de la Mortellerie, with scarcely three [square] meters per person; at numbers 24 and 26 rue des Marmousets they have only two; and at number 126 rue Saint-Lazare 192 individuals live with less than one [square] meter per person. . . . In places where a wretched popula­ tion lived crowded together in cramped, filthy buildings, the epidemic claimed large numbers of victims.”7 The re­ port of these high densities, a sign of destitution and mis­ ery, includes a description of the hovels occupied by the poor. Thus the study of dwelling space is of interest not only because its results proved significant but also because CHAPTER 4

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it focused the investigators’ attention on people rather than on the “objective” situation. The commission felt the need to find out something about the type of individual affected by the disease: “Hence in order to study the effects [of cholera] and to appreciate its influence, it was necessary for the commission to bring its investigations down to the level of individuals, to know something about their condition, their mores, and their habits.”8 The idea was to study the population mainly in terms of occupational groups. But in addition to information about the way in which various trades were practiced, the commission also included data about income and associ­ ated living conditions. Rentiers and property owners were largely exempt from the disease. Cholera also seemed to spare those whose work secured them shelter from bad weather, such as (indoor) merchants and craftsmen. But second-hand clothing and furniture dealers and others who worked out of doors succumbed in large numbers. The highest mortality rates were noted among charcoal dealers, ragpickers, day laborers, janitors, knife grinders, ditchdiggers, masons, and mattress makers. Of 18,402 deaths, 2,776 were either children or of unknown occupation; 10,703 were artisans or wage workers; the remaining 4,923 were professionals, merchants, and members of the military. The conclusion of the Report reads as follows: “It emerges from examination of these occupations, both in themselves and in regard to their different modes of activity, that chol­ era appears to have been less severe among individuals whose work permitted them shelter from bad weather or whose social position was not without certain amenities or who earned from their craft or trade a sufficient living to maintain an adequate standard of living.”9 Once attention was focused on work activities and standards of living, it became clear that wealth diminished mortality and poverty increased it.

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To sum up, then, the study of physical factors such as weather and topography and of large-scale population den­ sities proved disappointing: the expected correlations were not verified by the facts. By contrast, the study of dwelling space per occupant met with success: overcrowded housing could explain the variations in the mortality rate. Poverty could also explain these variations, as was made clear by studying mortality in relation to occupation and living conditions. All of these results deserve further attention. For one thing, what was meant by the notion of “living conditions” needs to be clarified. For another, it is interesting to ask why the “macrogeographic” studies turned up such anom: alous results. How did the distribution of the poor around the city affect the outcome? It is also worth looking at the way in which the study of the unhealthy neighborhoods helped to refute arguments derived from the Hippocratic tradition within medicine. Finally, I want to investigate the paradoxical way in which certain political affirmations were linked to the reactivation of ancient etiologies. LIVING CONDITIONS

Even before the epidemic hit, much was known about the living conditions of the working classes. For example, it had been ascertained that the mortality rate in the various arrondissements of Paris bore a significant relation to the poverty of the population. Still, the investigation of the 1832 epidemic had profound repercussions. Not only did it confirm the results obtained by Villermé, but it also led to refinements in the methods for analyzing living conditions. Villermé had stressed income above all other factors. The Report took account of other variables, such as working conditions and life style. It also collated vast amounts of data. Cholera came as a revelation. In the eyes of contemCHAPTER 4

poraries the epidemic underscored the influence of socio­ economic conditions on mortality. As Littré said, “Chol­ era, by necessitating home visits, led to cruel discoveries.”10 What was new about the Report was its focus on the living conditions of the working class. In order to understand the idea of “living conditions” (conditions d'existence) we must know something of its origins. Michel Foucault has shown how the methods of botany provided the model on which eighteenth-century physicians based their nosography. The identification of plant species and the classifica­ tion of diseases are both aspects of a single episteme: “The rationality of life is identical to the rationality of that which threatens life.”11 If there is a logic immanent to life, and if life has within itself some central coherence, then knowl­ edge of life—in both its normal and pathological manifes­ tations— must strive to reproduce that coherence. It may be that, in the first half of the nineteenth century, physi­ cians still modeled their research on natural history: “Nat­ ural history,” Cuvier tells us, “has its own unique principle, the principle of ‘living conditions.’ ”12 But in order for the cultural history of disease to be based on an analogy with natural history, this principle had to be modified slightly and applied not to the disease itself but to its predisposing causes. In other words, poor living conditions produce failing health, which in turn increases a person’s chance of falling ill or dying. If many members of the working class died from cholera, this was “because [all workers] share similar living conditions.”13 The comment may seem un­ remarkable. But it was only a short while earlier that epi­ demics had first been studied as a form of epizooty. By liv­ ing in hovels men hastened their own deaths. What had been discovered was nothing less than a historicity inherent in human life: how survival and extinction were regulated in and through living conditions. The Report on the Prog­ ress and Effects o f Cholera Morbus in Paris belongs to the INVESTIGATION

same period as Georges Cuvier’s Lessons o f Comparative Anatomy. Living conditions affect two distinct areas, one within the body, the other outside it: organic space and social space. Social space is the space within which the organism lives and labors, and the conditions of existence within that space—living conditions— determine the probability of life and death. The idea of “predisposition” to disease merely translates the influence of the environment into bio­ logical terms. Predisposition is the effect of living condi­ tions on organic space. An organism predisposed to a par­ ticular disease is merely an organism that has internalized the effects of the environment. The link between the weak constitution that is vulnerable to disease and the social space is created by the life functions: alimentation, respira­ tion, habitation. It is not enough, however, simply to com­ pile a list of predisposing factors to understand why a given organism is susceptible to a particular disease. For there is a logic to the endless struggle for survival. Consider, first, the coexistence of different predisposing factors; one cannot be present without the others. As soon as one looks at mal­ nutrition, for example, it becomes clear that the same peo­ ple who suffer from a poor diet are also low-income work­ ers living in wretched slums. There is also a hierarchy of factors: income determines living conditions. Income is the invariant cause, always producing the same effects and al­ ways entailing other, secondary causes: “This last reason [i.e., low income] is not the least powerful, for it necessarily entails a bad diet, want of personal hygiene, lack of cloth­ ing, and all the other ills engendered by poverty.”14 The variability of individual responses to living conditions sug­ gested a comparative anatomy of poverty and wealth and highlighted the class differences that existed in French so­ ciety. Further study of the geographical distribution of classes confirmed the validity of these results.

CHAPTER 4

Analysis of population densities on the scale of arron­ dissements and quartiers proved inappropriate. This was because the heavy losses in the slums did not emerge clearly at this level of analysis. By looking at each individual dwell­ ing, researchers found what seemed to be more promising results, showing how the fabric of the city had been eaten away in certain specific locales. When the hard-hit slum areas were combined to form an overall picture, the pattern that emerged was actually familiar. Of the dwellings with the highest mortality rates, “all without exception are lo­ cated in the worst neighborhoods, including the* quartiers of La Cité and Hôtel de Ville and some of the worst streets in the better quartiers”15 Thus two compatible “maps of mortality” emerged: one highlighting unhealthy housing and the other, somewhat less precise, indicating vast areas of working-class poverty. The two “maps” were in a sense complementary and quite revealing about the history of Parisian demographics and construction. Each house was a part of a larger structure, a microcosm of society: “A single building might contain an aristocatic hotel at the end of a tranquil, provincial courtyard, in which one family lived nobly, while on the noisy and dirty street side one might find dark shops and separate flats, some rented to bour­ geois families, others to poor and sometimes wretched families who lived under the roofs, in the attics. Thus each block of houses . . . represents a comprehensive sample of urban society, with all its possibilities of birth and for­ tune.”16 The areas with high mortality rates were those in the center of the city, where the population had continued to increase over a long period. Sixteenth- and seventeenthcentury buildings in these sections were renovated to ac­ commodate the growing population: new floors were add­ ed, existing floors were subdivided to form smaller apart­ ments, and garrets were rented out without authorization. In eastern and southeastern sections of the city there were working-class neighborhoods associated with new shops INVESTIGATION

and factories. Meanwhile, wealthy sections expanded to­ ward the southwest. Thus people from different classes lived close together in some parts of the city but not in others. And there was a growing separation between “bourgeois” and “working-class” areas. The deterioration of urban housing must be seen in relation to the concentration of population that normally occurs in highly urbanized industrial societies. If wellplanned, well-ventilated new housing was to be built, old buildings had to be torn down, for they stood in the way. But the residents of those demolished buildings were forced to seek refuge in the quartiers of Les Arcis, La Grève, and La Cité. The newcomers crowded in alongside the already numerous inhabitants of these unhealthy sections. On top of this came a further influx of seasonal laborers: masons and construction laborers flocked to Paris every spring from the départements of La Creuse and Haute-Vienne. The center of Paris simply could not accommodate such large numbers of poor people. The cholera disaster pointed up the urgent need for what was called “political medicine.” Political medicine was part economics and part biology. It was related to economics because hygienists envisioned the population as wealth or “human capital.” And it was related to biology because they also looked at society as a collective organism. The task of political medicine was supposed to involve study of how the population—viewed both as human capital and as organism—is shaped, organized, reproduced, maintained, and consumed. Health objectives were closely related to is­ sues involving the conservation and upkeep of the work force. The following observation is worth noting: “There is one section of Paris (Les Arcis) where more than 1,500 peo­ ple live in an area of a single hectare. One would hardly think of growing a thousand trees in so small a space if one hoped to see them strong and healthy.” 17 Knowledge of CHAPTER 4

living conditions was thought to be essential for good gov­ ernment, for with such information the government could determine to what extent it might hope to change the be­ havior patterns of various social groups. Social life could be managed, in other words, with the help of knowledge of the circumstances in which people lived. Armed with the right data, the government could exert the appropriate pressures and establish the regulations necessary to keep society running smoothly. THE END OF “CONSTITUTIONS”

The investigation of the 1832 epidemic had ruled out weather and topography as causes of the disease. In fact, a whole mode of inquiry had suddenly been rendered obso­ lete. The facts so painstakingly accumulated over the years proved to be of no importance at all in understanding the havoc wrought by the new epidemic. The sweeping plans set forth by the Royal Academy of Medicine (in the ordi­ nance of 20 December 1820) now appeared to be hopelessly outmoded, in substance if not in ultimate goals. In the 1828 Report o f the Commission Charged with Drawing Up Plans for Instructing the Public About Epi­ demics “observation” was still the watchword that was supposed to guide the work of physicians in dealing with epidemic disease. This report belonged to the tradition of Hippocrates and Sydenham, of Stoll and Baglivi. It recom­ mended tabulating in parallel columns information per­ taining to atmospheric conditions, topography, and public hygiene. From such a tabulation it was supposed that ideas about the causes of any epidemic would emerge. In 1831 Double could still make the following proposal: “We shall make a comparative study of the topography of those areas into which the epidemic penetrated with ease as opposed to those nearby regions that did not succumb.”18 This was INVESTIGATION

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in conformity with the program set forth by the Royal Academy of Medicine. The latter, as is well known, revived the memory and assumed some of the functions of the ear­ lier Royal Society of Medicine, whose creation in 1776 marked a new awareness of the collective character of pathological phenomena. The cholera investigation demon­ strated the failure of these traditional approaches. It also pointed the way to a new line of inquiry: instead of tab­ ulating data in the old way, hygienists should concentrate on describing a “living space.” By thus emphasizing the cir­ cumstances surrounding an epidemic disease, the new ap­ proach signals a developing awareness of the historical character of pathological phenomena. It is a mistake, however, to think that the 1832 investiga­ tion was associated with the development of a new urban policy (politique de l'habitat). On the one hand, the in­ vestigation helped to discredit the Hippocratic tradition, whose fanciful topographies had justified the absence of an environmental policy. On the other hand, the investigation placed stress on the conditions in which men were forced to live. These conditions were said to help foster disease, an idea that ran counter to the Hippocratic notion that man and his environment were always in harmony. The word “environment” (habitat) does not seem to have been used in the hygienist literature of the time. This is a sign of both the rejection of the Hippocratic tradition and the absence of any environmental policy. In botany the word “habitat” refers to the area inhab­ ited by a particular plant species. Botanical geographers used it to describe the distribution of the various species of plants. It occurs in studies of the relation among climate, soil, and plant structure. In zoology it is used in speaking of the relations between an animal’s environment and way of life and its anatomical structure. In botanical geography the connotations of the term “habitat” are essentially physical. C H A PT E R 4

In Linnaeus’s Oeconomia naturae it has both a theological and a teleological meaning. We find, however, that in the reports stemming from the investigation into the cholera epidemic of 1832, the idea of “habitat” was replaced by the notion of “living conditions.” For “habitat” suggested both the traditional Hippocratic categories of explanation and the idea that every species is perfectly adapted to its environment. But since the problem now was to describe man’s failure to adapt to the artificial environment that he himself had constructed, it was felt that these connotations of the term “habitat” made it inappropriate. A better choice was “living conditions,” which excluded both nat­ ural features of the environment and theological consid­ erations relating to a “final cause” of some sort. It had been supposed that every species occupies a habitat in harmony with its essential nature; by contrast, “living conditions” were just those features of the environment that tended to hinder rather than promote a species’ development. The idea of living conditions thus correlates with the social and historical dimension of epidemic disease rather than with the natural or theological dimension. But is it really so easy to distinguish between the tradi­ tional Hippocratic approach and the modern approach pursued in the 1832 study, which singled out such factors as lack of air, sunlight, and dwelling space? Wasn’t the new approach just a microscopic version of the Hippocratic one? The answer is no, because the change of scale actually gave rise to a new object of study: the relation of man to the elements, as refracted through his environment. It had long been held that air, light, and housing came in two kinds: healthy and unhealthy. This had been one of the major preoccupations of public health officials throughout the seventeenth and eighteenth centuries. The healthy/unhealthy dichotomy was associated, moreover, with pro­ grams of urban improvement. Now, public health concerns were of course still prominent issues in nineteenth-century INVESTIGATION

urban development, as the strength of the hygienist move­ ment attests. But the old dichotomy had by this time been supplanted by what was called “analysis of the pathogenic ensemble.” Such conditions as the quality of air, light, and housing were now associated with something of a more functional nature—the function of “inhabiting.” Men con­ struct an envelope that stands between them and the exter­ nal elements of which they make use: the light that strikes their retinas, the air that they breathe. Before contacting individuals, the elements must first pass through the man­ made envelope; the elements are incorporated into artifi­ cial dwellings and thus contribute to the formation of the “morbid environment,” as it was called. Living space, in other words, is a causal space. Every dwelling place creates certain living conditions. Thus in order to understand the factors that contribute to epidemic disease, one must in­ vestigate dwellings and the living conditions that they es­ tablish. Weather, seasonal changes, and air quality are no longer the factors that matter. What does matter is living conditions, which, according to Fodéré, are “very different from those miraculous medical constitutions of which it can be said that the time has come for critical minds to restore a proper perspective as to their importance.”19 Cholera followed the lines of poverty, and death cut a swath through the slums. Still, a substantial number of contemporary observers attempted to interpret the course of the epidemic in outmoded Hippocratic terms. The re­ sults of the Paris investigation were challenged and the motives of the investigators impugned. For Petit de Mauri­ enne, the studies of the influence of weather and topog­ raphy on cholera in Paris “do not bear the stamp of truth that marks all research by unprejudiced minds. . . . The reason is that the investigators wished to arrive at the promised and announced explanations and, in the final analysis, the accumulation o f misery had to be responsible C H A PTER 4

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for all the difference in the number of deaths from one neighborhood of Paris to the next.”20 Medical conservativism was no doubt partly responsible for this critique. But attachment to the Hippocratic tradition cannot by itself explain why the old idea of “epidemic constitutions” was revived. In order to refute the conclusions of the Report and revive certain traditional explanations, stress was placed on the fact that the epidemic seemed to show a pre­ dilection for certain locations. It was particularly severe in damp and low-lying areas. It seemed to select neighbor­ hoods located near water, along rivers, streams, or canals. In Moscow, for example, the epidemic had been most sav­ age in sections along the right bank of the Moskva; in War­ saw, along both banks of the Vistula; in London, along the banks of the Thames. Many observers had reported these singular circumstances, and their reports were enough to justify reactivating the old “combinatorics of qualities.” Water, rain, fog, and wind were accordingly seen as sub­ strates of such qualities as cold and dampness. It was also pointed out that water has an affinity for either electricity or certain types of terrain. This led to the development of various etiologies, all of which were sanctioned by tradi­ tional Hippocratic categories of explanation: i . A Hydraulic Etiology: Petit de Maurienne proposed an explanation involving rain, fog, and wind as causes of the disease. It was claimed that the onset of cholera could be related to these climatological and meteorological factors. In India the rainy season heralded the coming of cholera. In Marseilles it was observed that cholera broke out after a hurricane accompanied by heavy wind and a sharp drop in temperature. In Troyes the disease followed a period of fog and stormy weather apt to pro­ duce an “epidemic constitution.” And finally, in Paris, the epidemic began in a period of dampness coupled with northerly winds; the winds “acted as the efficient cause;

INVESTIGATION

the dampness, by favoring the development of fogs, acted as a predisposing cause.”21 Since the disease struck damp, low, windy places, it was important to show that dry, high, sheltered places were spared. Examples were not lacking. Audouard reported that elevated sections of Algiers had very few cases of the disease compared with lower-lying sections. As for Paris, there was a “total absence of cholera deaths in the dry, high communes far from evaporable surfaces, and in those more or less protected against northerly winds.”22 This etiology ac­ corded quite well with a very simple pathological hypoth­ esis: the dampness of the atmosphere, it was supposed, halted invisible perspiration, whereupon the body’s vital heat, unable to dissipate itself, caused the symptoms associated with cholera. 2. An Electrical Etiology: It was observed first that cholera spread rapidly along canals and rivers and second that electricity has an affinity for water. This led to the hypothesis that electricity might be the cause of cholera: “Cholera, like stormy weather, originates in the electric fluid; and like stormy weather cholera is carried by that fluid to different areas. It has followed, as though by force of attraction, the channels of rivers, because water is always wet and wetness is one of the most powerful conductors of electricity.”23 Further support for this hypothesis was provided by the observation that the cramps suffered by cholera victims were vaguely similar to the “voltaic spasms” caused by electrical currents. Another suggestion was that individuals dissipate large amounts of negative electricity but cannot soak up posi­ tive electricity. This was supposed to result in either a slowing of the vital functions or a perversion of the electricity in the blood, whose globules coagulated for want of an appropriate source of repulsive force.

CHAPTER 4

3· A Geological Etiology: Some writers spoke of the “geological course of cholera.”24 They believed, as Boubée explained, that there was an affinity between water and so-called ternary or alluvial soils. These happened also to be the areas hardest hit by cholera. Comparison of the geological data with what was known of the progress of the disease thus produced a geological etiology. In India there was the Ganges, while Hungary, Poland, and Prussia all occupied alluvial terrain, composed of gravel, sand, or porous limestone. By contrast, cholera seemed to have a much harder time spreading in older terrains, where it lost intensity and in some cases even died out. Specifically, this observation applied to primordial and plutonic formations in Norway, Sweden, and the Tyrol. Using the same prin­ ciple, Boubée explained the neighborhood-to-neighborhood variations in mortality rate observed in Paris. High mortality rates occurred in sections that were paved poorly or not at all. In such areas large amounts of rain were absorbed during rainy periods, and correspondingly large amounts of moisture were evaporated during warm spells. Low mortality rates occurred in wealthy sections, where paved streets formed an artificial geological stratum impermeable to water. Finally, it was possible to relate the unhealthiness of alluvial terrain to the unhealthiness of marshland. B. de Beaumont, for example, saw the cause of cholera in “emanations from alluvial lands. . . . It is remarkable that since time immemorial the Seine has never been as low as it was this spring.”25 Observers who considered not isolated facts but the actual path followed by the disease quickly came to the conclusion that the explanation of cholera could not be ade­ quately framed in Hippocratic terms, even when suitably modernized as in the list just given. For it was claimed that cholera depended on dampness and rain, yet it was known that the disease had claimed many victims during dry peri-

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ods. It was claimed that cholera struck low-lying areas, yet the disease had been observed in the plateaus of Nepal and Tartary. It was claimed that cholera clung to alluvial ter­ rain, yet it had shown itself to be just as virulent in areas underlain by volcanic soil and on the limestone plateaus of Persia. Deville therefore concluded that “cholera, in tra­ versing Asia and Europe, was to confirm this truth, that there is almost nothing certain in the study of epidemics.”26 Nevertheless, the affinity between cholera and water was so disturbing that some physicians suspected water of being the vehicle of the cholera germ. Some twenty years before Snow was able to point out on a map of London the corre­ lation between the appearance of new cases of cholera and the layout of that city’s water distribution system, Delpech had this to say: “A large number of other diseases occurred in the same neighborhood: the disease there spread, as I have just shown, from a central point toward the periph­ ery, and that central point was the bank of the river.”27 Lauret made a similar point: “It seems highly probable that the water that flowed from this fountain, obviously full of putrid matter, was the cause of the sad accidents that oc­ curred. . . . Once the fountain was abandoned, there were no further cases of cholera.”28 To be sure, these observa­ tions are little more than reports of coincidences. But they accounted for the affinity between the “choleraic principle” and water without going so far as to revive the old Hippo­ cratic ideas. After 1832 people gradually stopped talking about “medi­ cal constitutions” and started talking about the “ambient environment.” The latter phrase referred to the physical conditions in which people lived and to their state of hy­ giene. Thus the notion of the ambient environment em­ braced two other notions, once part of the Hippocratic tra­ dition but now freed of associations with it: namely, the idea that physicochemical agents affect human life and the C H A PT E R 4

idea that social conditions influence health. Gavarret was well aware that the study of these various influences marked a break with the Hippocratic tradition: “No one is more willing than I to admire the great achievement of the Hippocratic school in affirming that there is an intimate connection between conditions in the ambient environment and human health. . . . But we must not expect to find in the work of the sage of Cos a clear and precise statement of the laws that govern those influences.”29 Enough, then, of generalities about winds, storms, and numbers of rainy days. Other objectives loomed on the horizon. What, for instance, was the relationship between external physical conditions and biological phenomena? Gavarret cited as exemplary the work of Milne-Edward, Concerning the In­ fluence o f Physical Agents on Life. In the past men had described the relations between the cycle of the seasons and disease. The new objective was to substitute for the tran­ quil cyclicality of the seasons the violence of real life. Rather than a natural history of disease, men now wanted a cultural history: “The nosological frameworks should as a general rule form vast mirrors reflecting the prosperity and misery of the people subject to observation.”30 These were the two components of what would later be called mesology: the influence of the environment on living things (mesobiology) and on social groups (mesosociology). POLITICAL TRUTHS

The difficulty of identifying a medical constitution capable of explaining the development of cholera may have been the reason why some doctors reverted to outmoded theo­ ries. But didn’t something in the appearance of the disease itself suggest an accident of a cosmic order? As Gérardin said, “It falls like a thunderbolt on a city or a few neigh­ borhoods of a metropolis and then spreads rapidly in irINVESTIGATION

9 2

regular flashes to other neighborhoods and surrounding areas. It has been compared to a volcanic explosion, debris from which is hurled in a hundred different directions to hit or miss at random.”31 In the seventeenth and eighteenth centuries, too, medical constitutions were not always per­ ceptible. Franck, for example, was following the example of Sydenham when he said that the cause of cholera was a hidden alteration in the bowels of the earth. In 1832 Méray blamed a geological disaster. But the resemblance between his argument and Franck’s is only superficial: whereas Sydenham and Franck invoked natural phenomena whose nature remained enigmatic and all but impenetrable, Méray explained the mechanism of the cause. The fact that he situates that mechanism deep inside the earth only accen­ tuates the importance of the causal factor he singles out, a factor that becomes an aspect of the history of the earth. Paradoxically, the revival of old etiologies made it possible to take some of the power previously ascribed to physical elements and transfer it to the social realm. The revival of such old speculations actually lent credence to a new idea: that if men endure calamities like cholera, it is primarily human institutions that are at fault. For Méray, the primary cause of cholera is a subterranean change. This change is signaled by a reduction in tempera­ ture, which proceeds from the circumference of the earth toward the center. This global cooling leads to a sudden concentration of the caloric fluid. In appearance this theory is obviously the result of transferring results from geology into the domain of medicine. For the cooling of the earth and the igneous nature of its core were hypotheses current in Méray’s time and confirmed by the work of Cordier. In fact, however, Méray’s account of the ultimate cause of cholera is nothing but a paraphrase, in geological terms, of the most visible manifestations of the disease. The shivering and freezing sensations reported by cholera victims have C H A PT E R 4

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simply been transferred from the bodies of sufferers to the body of the world and dressed up as the ultimate cause of the disease. From the realm of perception we have moved to the realm of explanation. But the perception of the dis­ ease is superficial at best, focusing exclusively on cholera’s most prominent symptoms. Still, it was impressive enough for Prost to carry it over, in his analysis of the proximate cause of cholera, from the exterior to the interior of the body: “A fire is lighted in the stomach, while the skin is icy and the blood increasingly moves away from it in order to feed the ventral flames. . . . It rushes toward the hot cen­ ter. . . . It has become a volcanic core.”32 But where Prost sees only images, Méray sees the reproduction, within the organism, of a geological event, from which he derives the following idiosyncratic view of the disease: “The decalorization of all natural bodies, including the bodies of the human species, is therefore nothing other than an exact repetition of what takes place in the center of our planet. It is an imitation whose impulsive type originates in the mode of destruction of that planet.”33 For Méray, man is still the world’s other half, for man shares all the vicissitudes to which the earth is subject. This dependence relation is enough to explain how the cooling effect is propagated: it is a morbid principle that first affects the earth, then man. Another possibility was the zoological etiology devel­ oped, for example, by Le Maout, according to which the morbid principle stems from an alteration of the humors. Le Maout devoted considerable space to a description of his experiments, which had more in common with the practices of alchemy than with the science of his time. Thanks to these experiments he was able to discover what his contemporaries held to be unknowable: the first cause of cholera. After condensing the “deleterious principle” and subjecting it to chemical and microscopic examination, he succeeded in discovering “very curious corpuscles, ani-

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mal in nature, drawing their origin from the blood, and of which air appears to be the vehicle.”34 At first sight both Méray’s and Le Maout’s accounts suggest a return to a form of knowledge that was familiar in the Renaissance. Méray is appealing to old notions of similitude, and Le Maout has rediscovered a very old the­ ory of the generation of germs. These lithological and zoological etiologies would seem to belong to the history of aberration rather than to the history of science. Indeed, Méray’s reflections seem much of a piece with other forms of teleological speculation. The great plagues evoke the Apocalypse: “All signs indicate that the disease known as cholera will be the last disease of mankind; all living things will cool to the point of extinction, along with the universal cause; so for us, eternity is nothingness.”35 We must be careful, however. The geological catastrophe painted by Méray has a different status from apocalyptical events in earlier accounts. This remains true even though, like past apocalypses, Méray’s is both a sign and a cause. In the Re­ naissance every calamity was the sign of the first cause, i.e., the wrath of God. For Méray, however, it is the sign of secondary causes: the cooling of the earth, transmitted to the human body, “should warn us of the deficiencies and nocuousness of our hygiene and dietary practices.” Fur­ thermore, in the Renaissance, the elements, unleashed by the will of God, were always secondary causes, instruments used by God to inflict punishment. For Méray, however, the elements are the first cause—necessary but not suffi­ cient, because it is a cause that becomes operative only if there has been a prior weakening of the organism due to secondary causes. Then and only then can the first cause work its destructive effects: “It is indeed probable that without the prejudicial conditions of our way of life, our constitutions would not immediately have felt so terrible a shock from this terrestrial phenomenon. . . . This periodic catastrophe would have been postponed for several cenCHAPTER 4

turies.”36 Similarly, Le Maout believes that the morbid germs act mainly on organisms weakened by predisposing causes: “One of the causes that has contributed most to the ravages of cholera in the working class is the fatigue to which they are continually exposed in their muscular labor. The cholera has hit hardest those classes of society whose lives are least comfortable.”37 But there is much that is surprising in this disparity between primary and secondary causes. Why make the epi­ demic a part of the great Heraclitean cycle of cosmic catas­ trophes just as increasing stress was beginning to be placed on the social factors that contributed to the disease? Is a resistance of some sort to be read in the unexpected linkage of archaic etiologies to modern predisposing causes? Is it because, having discovered the importance of the most proximate causes, these authors hoped to neutralize that discovery by emphasizing remote causes instead? No; in fact their reasoning ran in the opposite direction. The key issue was the peculiar susceptibility of certain people to the disease. The susceptibility of these people was a conse­ quence of their living conditions, which made them vulner­ able to either telluric influence or morbid germs, as the case may be. In both theories, the secondary causes are really more important than the primary cause, because the latter only becomes a cause given the proper circumstances. In other words, disease strikes at the point where a specific moment in geological history coincides with a specific mo­ ment in human history. Now, characteristic of human his­ tory is a degradation in man’s way of life. The old etiologies were revived in order to underscore the importance of the conditions of human existence: poor diet, overcrowding, fatigue, and poverty—in a word, civilization. Pinel, as is well known, believed that corrupting civili­ zation was an important cause of malignant diseases and serious fevers. Thus the idea was not new. In fact, it ap­ peared as early as the eighteenth century. But it was then INVESTIGATION

mainly a matter of diseases affecting people of leisure, as a result of the heightening of the passions by luxury and idle­ ness. In the nineteenth century it was a question of diseases affecting working people, epidemics rather than diseases of the mind. The finger of blame was pointed at the increased number of unhealthy occupations, the decline of morals, and the expansion of human needs. Sickness found its course smoothed by these external changes: “Our economy trembles uniformly before a physical or moral impetus.. . . This explains why our species is more suceptible than oth­ ers to epidemic, to deleterious miasmata.” From this was derived the following positive image of animal existence: “The way to restore a healthy equilibrium is to return to the brutal life of animals, to digest better so as to think less and feel less.”38 This also explained the attraction of prim­ itive life: “One can say in general that diseases are engen­ dered by society; they are hardly known among savages.”39 As for cholera and the lesson to be drawn from the epidemic of 1832, it was said that “it came to teach the world political truths. . . . It came to demand the social in­ stitutions without which this world can no longer exist.”40 But hygienists for the most part heeded other truths, truths of a rather different nature. For they were concerned with the advantages that French society had to offer from a pub­ lic health standpoint, advantages that they ascribed to the progress of civilization and the virtues of the Juste-Milieu.

CHAPTER 4

5

Apology CIVILIZATION AND BARBARISM

That civilization was at the root of the high mortality rates observed in the epidemic was, of course, not an idea shared by everyone: “This opinion is merely a prejudice; it is false from almost every point of view, and civilization contrib­ utes far more to public health than, in certain respects, it costs.”1 Man’s sociability doubtless made him more fragile, more likely to contract diseases. But suppose that man were to live in a state of nature: “There we find him healthy, physically strong, but irresponsible, insensitive, stupid, or rather vegetating, eating, drinking, and sleeping like a fool, as in a true Eden where he can grow fat in carefree lei­ sure.”2 In other words, the price of health is a mediocre life and, more than that, a life limited by man’s animal in­ stincts—the image of animality was not intended to be at­ tractive. Nor was the savage state, however much it might be vaunted by a few philosophers, for in that state indi­ viduals were subject to all sorts of woes. Among these were several indirect causes of epidemic: a hostile climate, inade­ quate cultivation of the land, and frequent, deadly famines. The weaker and poorer the population, the more it is sub­ ject to disease. By contrast, social life brings many boons: improved crops, new industries, comfortable, healthy hous-

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ing, and public health measures designed to protect the population. Consequently, disease is rarer and less deadly. This is why Pariset said that “if public health is the result of a more perfect civilization, it is also the infallible, and perhaps the only, sign of such perfection.”3 Most hygien­ ists wrote with the West in mind. But it became increasingly difficult to defend this idea of civilization as cholera laid waste to Europe. The progress of the disease seemed to contradict the idea that progress ac­ companies civilization. If civilization implied personal se­ curity, the epidemic should have died out as it approached the West. But not only had it invaded the Western nations, it had devastated their populations: “One is no less sad­ dened to see the populace as cruelly decimated by this hor­ rible scourge in Berlin, London, and Paris, which stand at the head of modern civilization, as in the backward nations of the Orient and Northern Europe.”4 Would it be neces­ sary to give up the myth that the civilized nations are supe­ rior? Would Frenchmen have to acknowledge that in their country, too, mass poverty was responsible for the high mortality rate? The idea that the ravages of the plague could somehow reduce the West to the level of the East was unacceptable. Hence it was assumed that the course fol­ lowed by the disease had nothing to do with the social fac­ tors at work in its genesis. The epidemic had to be like a natural disaster, a violent earthquake or hurricane: “This new typhoon . . . circulates through the world as poison circulates through an artery, taking no notice of the place to which its driving force impels it to go. In a word, cholera follows the earth”5 This was a fact. The course of the epi­ demic provided the basis for a purely natural explanation: “The generally westward direction that the cholera has followed in its advance has greatly concerned physicians. It has been seen as a peculiarity of this disease and has served

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as one of the principal arguments advanced by those who sought to propose a telluric or atmospheric cause.”6 Consider, for a moment, the idea of a telluric cause. The epidemic could be treated as a natural phenomenon if its occurrence could be associated with a related phenom­ enon from which an explanatory principle could be de­ rived. For example, the absence, resurgence, or remission of an epidemic could be related to the absence, frequency, and intensity of volcanic eruptions. And in fact the appear­ ance of cholera had almost everywhere been associated with underground disturbances: in Java in 1817, in south­ ern Hindustan from June until November 1819, in the Himalayas in 1820, on the Syrian coast in 1822 and, later, in Persia. Rudolphi therefore made the following statement in 1826: “There is no doubt that exhalations stemming from numerous volcanoes in India are the cause of cholera. It is also worth noting that, in its progress across the various countries that it has visited, cholera appears to be related to volcanic activity that has been observed in each place.”7 In 1832 Hufeland and Schnurrer revived this explanation, ad­ ducing not only telluric factors but also mysterious mete­ orological and magnetic influences. In France Voisin said that “the germ, whatever it may be, comes from the earth. . . . Upon fresh terrestrial upheaval, and in conse­ quence thereof, there occur further emanations of the same kind that have already sowed death along the path fol­ lowed by the epidemic.”8 Let us turn now to the question of an “atmospheric” cause of cholera. Every twenty-four hours the earth makes one full rotation from west to east. Physicians and as­ tronomers agreed that, in planetary rotation, the atmo­ sphere rotates with the body of the planet. Now, when a solid body immersed in a fluid is rotated, the fluid lags slightly behind the solid. By analogy, therefore, it was sup­ posed that after one rotation of the earth each point in the atmosphere would end up slightly behind where it had been APOLOGY

ioo

twenty-four hours earlier. Accordingly, if cholera were to find its way into the atmosphere in India, it would ulti­ mately make its way around the globe: “The rotation of our planet. . . seems to explain . . . the east-to-west prog­ ress of the cholera epidemic. . . . Our climates will also be affected by the Russian cholera epidemic when the mass of atmospheric air that surrounds us has been penetrated by the deleterious principle of which we have spoken.”9 Besides these two revolutions—within the earth and of the earth—there was of course also political revolution: “Great epidemics require the simultaneous occurrence of both moral disturbances that violently alter the social con­ dition of nations and cosmic disturbances that have no less substantial an impact on their physical condition; we do not lack for proof of the combination of these influences before and during the cholera.”10 The progress of the dis­ ease from east to west was no accident. The West was like a magnet that drew the disease toward itself. It was not the poverty of the large cities that attracted cholera, but rather their size. The idea of a coincidence of cosmic and political upheaval accorded well with the feeling that there was something transcendent about an epidemic of such sober­ ing magnitude. People believed that society as it was then constituted was on the verge of disintegration. It surprised no one that the price to be paid for the emancipation of nations was heightened susceptibility to disease. High mortality rates were seen as an inevitable consequence of social change. The ravages of cholera would help to estab­ lish a new order by purifying the old: “In some respects major epidemics are comparable to thunderbolts: they de­ stroy the impurities of civilization in moments of hesitation and doubt, when humanity, suspended, as it were, between the expiring institutions and the expansion of a new order, needs to draw on all the combined forces of nature for help in surmounting the crisis and launching itself upon a new life.”11 CHAPTER 5

ιοί

It was possible to use the destination of the disease to justify its spread, because Europeans believed that they were living through a period of great importance to all mankind, an era of remarkable intellectual and political progress. The past fifty years had seen an endless succession of revolutions and wars. People everywhere had been roused by the ideas of independence and freedom. Now, as it happened, this remarkable era was also a time in which new diseases had appeared on the scene. More than that, the coming of cholera was a necessary consequence of the preceding upheaval. People were quick to compare this pe­ riod with the era of the crusades or the discovery of the New World—all were illustrious times marred by the out­ break of new diseases. The rebirth of the West had set in motion evolutionary changes. Immigrants came from the East seeking civilization, for human progress had always moved from east to west. “Similarly, epidemics, including cholera, have shown themselves to be organisms existing by themselves, which share in the general tendency of life to move from east to west.”12 Less philosophical minds, unable to regard the new disease as an example of palingenesis, held that its progress enacted a kind of punishment. Consider, for instance, the republi­ can mysticism of Prost and Giraudeau de Saint-Gervais, who saw a divine punishment inflicted upon the powerful and upon the French people in general. The powerful de­ served punishment: “This is a scourge from on high, which is humbling the great by reducing the number of their slaves while not exempting the masters themselves.”13 And the French people, too, deserved punishment, because they had stood by while the Austrian army subjugated Italy and the Russian army invaded Poland: “In order to punish us for our apathy and darken the horizon with our woes, a scourge more terrible than the most disastrous of wars and more deadly than the plague is already threatening the APOLOGY

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existence of each and every one of us.”14 The scourge was even referred to as God’s War. Contemplation of its prog­ ress reawakened ancient fears: “It is to be feared that this scourge, similar to the barbarian invasion of the Middle Ages, will decimate nations, disrupt society, destroy com­ merce, and set back civilization.”15 Thus the notion of God’s War gave way to the idea of a war against the bar­ barians, with a consequent shift in values. The armies of disease, dispatched by God, had marched in service of the faith, for their aim was to conquer in order to pacify. By contrast, the armies of cholera were the armies of evil and aimed to conquer in order to destroy: “It [evil] will slowly but surely march into Europe from east to west; it will sur­ round us, spreading desolation and death.”16 But there was more to the comparison of the disease with a barbarian invasion than is suggested by this idea of a blind and malevolent force. For in 1832 the triumph of bar­ barism also meant the triumph of tyranny: “Cholera would not be present among us had despotism not introduced it together with its ball and chain.”17 Cholera also stood for the primitive: “The epidemics, some rare, some more fre­ quent, that mow down human beings—those epidemics represent the triumph of ignorance.”18 The year 1832 was thus a year of confrontation between barbarism and civili­ zation, between despotism and liberalism, between igno­ rance and knowledge. This myth, the product of philosoph­ ical speculation pushed to the limit, played an important role: not only did it justify colonization by linking the dis­ ease to the alleged political and cultural inferiority of the oriental nations, but it also proved, to the satisfaction of Europeans, that the poverty of those nations stemmed from the temperament of their people. We saw earlier how in 1831 the projection of a few typological observations onto the domain of “organic economy” resulted in a theory that explained the high mortality rates in India and predicted that the French people would be able to withstand the disCHAPTER 5

ease. Oriental peoples were said to be fearful and lazy, from which it followed that their humors had been corrupted and their excretory systems paralyzed. By contrast, the courage and strength of the French had prepared their blood and other defense mechanisms for the onslaught of the disease. But these metaphors also played another role, that of justifying the “civilizing mission” of European col­ onizers: the purpose of courage in this context was not to conquer but to gain freedom (or to liberate), and the pur­ pose of strength was not to exploit but to master knowl­ edge (or to educate). This reformulation of the goals of col­ onization had immediate consequences: the fear imputed to foreigners explained not their subjection to the European oppression but rather their submission to their own ty­ rants; similarly, their alleged laziness implied ignorance rather than unfitness for work. Colonization therefore brought freedom and enlightenment and gave rise to a new representation of the poverty from which disease was sup­ posed to stem: namely, that poverty is a consequence of despotism and ignorance, which are in turn expressions of a nation’s essential nature, that is, of its native cowardice and apathy. Poverty is therefore the most immediate and visible consequence of a nation’s living in a state of slavery and ignorance. In essence, poverty was identified not only with the vestiges of slavery but also with what remained un­ tamed in nature. As such it was seen as the destiny of bar­ barous peoples rather than as a result of European oppres­ sion, which burdened native peoples with crushing taxes, swelled the coffers of trading companies, and expanded the territory of the countries of Europe. This representation of poverty cannot be understood in isolation from the dream of progress, held to be the fruit of civilization. Only a free country with knowledge of how to improve human welfare could possibly create the conditions propitious to health. A convincing explanation of epidemics was therefore readily APOLOGY

available: “Most contagious diseases—the great scourges of the human race— originated among and were spread by the barbarous peoples.”19 When Bérard speaks of barba­ rous peoples he has in mind the subjugated, ignorant, and impoverished nations of the east, India first and foremost. But it was still necessary to explain why the disease had spread through Europe and to dispel what might seem paradoxical in the fact that civilization’s boons were ex­ tolled at a time when cholera seemed to have revealed its failures. In truth, however, most people concentrated on the success of Western civilization and held that the failure, if there was one, was only by comparison with the even greater success that might have been achieved. It was be­ lieved that if the mortality rate in this epidemic could be shown to be less than in previous epidemics, this would provide conclusive proof of the superiority of Western civilization. Hence the cholera epidemic was compared to the great plagues of the Middle Ages. And the evidence was clear. The Black Plague of 1348 had claimed 80,000 lives in eight months, and the plague of 1366 40,000 lives in two months, whereas the cholera of 1832 claimed only 25,000 in six months: “We are certainly indebted to the progress of civilization for the fact that the extremely high mortality rates of yesteryear were not repeated; for we see every­ where that as barbarism declines, epidemics occur less often and with less intensity than in the past.”20 Barbarism might be on the decline, but it had not yet vanished even from the civilized countries. Philosophy, with its barbarism/civilization antithesis, could explain just why this was so. Poverty was a sign of the fact that the people most vul­ nerable to the disease lived lives of indolence and fear; it was also the sign of the toiling masses. Within French soci­ ety it was the proletariat that was analogous to the popula­ tion of India. The analogy was not quite perfect; hence the fear of the lower orders was somewhat attenuated com­ pared with the fear of the barbarian: it was expressed by chapter

5

references to the alleged “nomadism” and “debasement” of the working class (as opposed to the subjugation and incompetence of the Indians). The reason for this was that subjugation and incompetence were qualities that it would have been dangerous for the ruling class to ascribe to those whom it ruled. For these terms implied that the rulers were somehow responsible for the condition of the people. Had they been applied to workers they would have established an equation between the owners of property and the ty­ rants who ruled the downtrodden natives, tyrants de­ nounced by imperialism as a way of demonstrating that its motives were of the noblest sort. To emphasize the exis­ tence of an enslaved and ignorant proletariat was to spell out, in part, the nature of exploitation at home. Nomadism and debasement were far less compromising images. They suggested that the lower orders did not quite measure up to the standards of the civilized world, that they still lived to some degree in a state of nature: roaming the world in ig­ norance, workers lived if not like animals then at any rate like primitive peoples. The working class was a savage sur­ vival in the heart of the city. Hence this line of argument represents a repudiation of the philosophical critique discussed earlier, according to which disease is a product of living conditions and there­ fore dependent on history. According to this new line of argument, that contention is false, for disease is dependent not on history but on nature. Progress can have no effect on the working class: “Is it not the case that civilization halts, as it were, on the thresholds of the poor, in whose homes all needs go unmet, every sort of physical and moral debil­ ity is to be found, and disease and death ineluctably take possession?”21 If the proletariat had been decimated, its poverty was to blame. And its poverty was a consequence of its nomadism and degradation, the distinguishing char­ acteristics of this social group. Nomadism was the sign of the proletarian’s fear of tomorrow and degradation the sign APOLOGY

o6

of his day-to-day existence. This characterization of the proletariat is the best-known feature of the bourgeois per­ ception of that class. But in fact it is only the negative counterpart of a positive—and far more subtle— feature of the analysis: namely, that the bourgeoisie, in creating the concept of a “social class,” envisioned class in terms of race. But when it came to concerns about the physical con­ dition associated with class—concerns about the body, in other words—the bourgeoisie, determined to affirm its own independence, did more than simply appropriate the old idea of the aristocracy as a distinct race. Another pur­ pose was involved, as Michel Foucault has shown: “An in­ tensification of the body, a problematization of health and of its operational terms. . . . It was primarily a matter of the body, of physical vigor, of longevity, of progeniture, and of the descendants of the class that ‘ruled.’ ”22 Those who pointed to the ravages of cholera in Paris in order to argue that the advances supposedly due to civilization were in fact illusory did not see that “civilization” referred to the attainments of a privileged class. Finally, the connection was made: “The wealthy classes are to the inferior classes what Europe is to the Orient, i.e., proportionally they suf­ fer far less.”23 In the mode of analysis based on living conditions, the high mortality rate among the working class was linked to the way in which that class lived. But in this new mode of analysis the same high mortality rate was associated with traits said to be characteristic of a group deemed inferior by its very nature. We have moved from the plane of physical and historical analysis to the realm of the spirit, and what we see is no longer the consequence of historical evolution but the manifestation of immutable moral essence.

chapter

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THE JUSTE-MILIEU

Prior to the cholera outbreak Bressy had overlooked bar­ barism in his haste to blame all disease on inner or moral flaws. In 1802, in fact, he spoke of all those epidemics that “intemperance, debauchery, and immorality have created in the dregs of the most abject peoples.”24 In 1832 the soci­ ety of the Juste-Milieu extolled its own virtues and claimed to have defeated cholera. In accentuating the values of tem­ perance and moderation it appealed to prevailing medical theories for justification. The theories lent an air of scien­ tific authority to the claim that bourgeois morality yielded concrete benefits. This was particularly true of “physio­ logical medicine,” which held that disease is nothing but the consequence of changes in the intensity of response to various stimuli. It claimed that most ailments, as well as the susceptibility to them, are due to an excess of irritating powers (puissances irritantes) and defined health, con­ versely, as a suitable equilibrium thereof. Now, excessive irritation, it was further maintained, is the result of so­ cially reprehensible behavior, whereas self-control leads to healthy equilibrium: moderation keeps excitement within bounds, whereas overindulgence in food, drink, and other pleasures leads to hyperirritability of the gastric tract and nerve centers. Hence the difference between health and sickness, which was said to be quantitative in nature, ap­ parently derived from a qualitative opposition based on the contrast between virtue and vice. This pathology had as its natural complement a “moral hygiene,” or science of the effects of vicious or virtuous tendencies. Here, with the “natural inclinations” of the patient, lay scientific terra firma, from which vantage point such considerations as living conditions seemed to have no more than secondary importance. Vice was responsible for every ill. Substituting moral causes for social causes made it possible to show that

APOLOGY

rich and poor sometimes faced disease on an equal footing and, further, that the high mortality rate among the work­ ing class could in every instance be explained as the result of debauchery. Freed of all association with the theme of living conditions, the dialectics of morality and immorality served to unify a set of analyses in which class antagonisms no longer played a part. For even though the social condition of the opulent rich and the destitute poor might differ, that difference was nullified by similarity of behavior. If both rich and poor plunge headlong into the pursuit of boundless pleasure, then both must be condemned on the ground of immoral­ ity. Thus wealth or poverty can no longer explain why dif­ ferent people show different susceptibility to disease. The “predisposing causes” of morbidity, thought by some to be historical in nature, must, if this view is correct, have a moral basis instead: “An incontestable truth is that intem­ perance and irregularities of all sorts in the diet of both the working class and the wealthy have been the two main causes of fatalities.”25 By thus treating values as “charac­ ters” (in the taxonomic sense of the word) applicable to people at every level of society, one is sure to discover equality where the study of living conditions had turned up surprising disparities. In this kind of research, little atten­ tion need be paid to the different ways in which individuals satisfy their inclinations. All that matters is the nature of the vice, and its consequences: “It was in the wake not of some vulgar quarrel, tavern orgy, or entanglement with prostitution that an important personage would die, but of what amounts to much the same thing, a stifled rage, a sumptuous meal, or an evening of lascivious pleasure art­ fully prepared by a courtesan. . . . The contagion struck misery and greatness for the same reason and with the same force.”26 The argument was coherent: just as vice was to be found at both extremes of the social ladder, so, too, was chapter

5

virtue. Here I cannot resist departing from my usual cus­ tom to cite a novel set in the Paris of the 1830s: “A noble spectacle, a touching symbol. . . . The two ends of the so­ cial ladder touched and mingled in a moving display of equality. . . . For the working-class girl and the patrician woman were equals in intelligence, heart, and soul. . . . They were also equals in another respect: the one was a paragon of wealth, grace, and beauty. . . the other a para­ gon of resignation and undeserved misfortune.”27 With dissipation the rule at both extremes, it was those in the middle, the Juste-Milieu, that reaped the bene­ fits. Not only did the Juste-Milieu present itself, with its predilection for simplicity and temperance, as a model so­ ciety, but it claimed to be a unique community whose mo­ rality was somehow a gift of nature. If the Juste-Milieu lay, as the name implies, in the middle, then the two extremes of society were excluded from this model community: “Everywhere the cholera hurled the majority of its shafts at the two extremes of society, which stand farthest removed from nature.”28 Intemperance deprived both the rich and the poor of the virtues of nature. But for the rich it scarcely mattered: though excluded from nature, they remained in society. The poor, however, were excluded from both na­ ture and society. What might seem a minor difference was in fact fraught with consequences. To stand outside society was to stand against society—where cholera preferred to strike. If the epidemic was a purge that eliminated the dis­ solute from society, it eliminated only those at the bottom of the social scale, those who were not just dissolute but also impoverished: “The cholera, by choosing its victims mainly among those whom immorality as well as poverty causes to commit frequent crimes against society, inevita­ bly led to social purification.”29 Cholera was thus an aux­ iliary of the police, providing protection for persons and property.

APOLOGY

I IO

Singling out vice as the major cause of disease made it pos­ sible to explain the high working-class death toll without alluding to living conditions: “For individuals of the work­ ing class, the cholera epidemic in Paris confirmed all too well the judgment of the English Hippocrates concerning the influence of certain vices of diet [Sydenham had alluded to crapula et ingluvies]”30 There would have been no rea­ son to study the influence of excessive drinking on cholera fatalities had it not been for the belief that the vice was characteristic of the working class. Rather than seek neces­ sary rest, did not workers spend their wages on debauch? Specific forms of behavior were singled out as deviant with respect to bourgeois norms of virtue and temperance. Then' statistical studies were carried out to ascertain the exact extent of such deviant behavior. Tâcheron reported the following findings: “Our researches prove that the number of new cases and deaths increased mainly on Mondays, Tuesdays, and Wednesdays, because of the excesses in­ dulged in by the working population on Sundays and Mon­ days.”31 In 1840, however, Gavarret clearly showed that the daily variation in numbers of new cases was not enough to justify such an assertion. Instead of overestimating the significance of certain events, their frequency should have been determined before identifying them as causes.32 But in 1844 Valleix would again maintain that “bearing in mind that excessive consumption of wine is most common, the effort should concentrate mainly on relating the spread of the disease to this type of excess.”33 Alcohol abuse was the most glaring form of intemper­ ance, but there were many other excesses that deranged the senses and made people susceptible to disease. Overindul­ gence in sensual pleasures, for example, led to a weakening of the constitution and broke down resistance to the epi­ demic influence. Such shocks to the nervous system left people in a state of prostration, hence vulnerable to illness: “It is known that in Berlin cholera was especially severe chapter

5

among prostitutes; in Paris several individuals were found to have been struck by the disease shortly after engaging in the act of reproduction.”34 Another cause of derangement of the senses and hence of cholera was a predilection for serialized fiction, which excited the imagination and sug­ gested deviant forms of behavior. “We are awash in blood, muck, and physical and moral filth of every kind. . . . This aberration is a veritable moral epidemic.”35 Once the predisposing causes of cholera were known, it was natural to think of protective hygienic measures. To avoid the disease it was enough to lead a sober life and shun all excess. This advice, offered by physicians, hygienists, and philanthropists associated with the Juste-Milieu, de­ rived directly from the material of Sunday sermons: “Prov­ idence, in its wisdom and mercy, has given its faithless chil­ dren sure and obvious ways to prevent or halt the malady. All that is necessary is strict temperance, which in any case is one of the fundamental precepts of Christian morality, so as to avoid anything that might disrupt the digestive func­ tions.”36 There is room to doubt that temperance was in fact an effective protection against cholera, but it seems likely that this recommendation helped to reassure the wealthy. All physicians, from the best known to the most obscure, counseled moderation. Among the things to be avoided were fatiguing labor, late hours, inappropriate fasting, and overindulgence in food, alcohol, or coitus. And, Moulin added, if in addition to abiding by these pre­ cepts one could “muster sufficient moral force, if not to brave the danger then at least not to fear it, then I believe that it is impossible to be afflicted by this disease.”37 In­ stitutions governed by established disciplinary rules were held up as an example: “The degree to which an ordered, regular, busy, and sober life can contribute to the preven­ tion of cholera cannot be overstated. In our innumerable

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colleges, special schools, cloisters, and boarding establish­ ments only a few cases have been noted.”38 Health was seen as the reward of living in accordance with bourgeois ethical principles: “The intermediate class in which one finds greater frugality and calm, greater vir­ tue, and money enough to live comfortably, was less af­ flicted.”39 By contrast, sickness was a punishment: “By preferentially attacking individuals debilitated by excess, this calamity teaches us that we must use the good things of life and not abuse them. . . . It shows that neglect of this rule is not merely a minor failing but a grave fault, which brings its own punishment.”40 The likelihood of falling ill depended on the extent to which one violated the rules of bourgeois morality. Disease struck those who lacked proper concern for their behavior. Thus people were the cause of their own misfortune. They failed to heed the ad­ vice that was constantly offered. The high death toll among the working class clearly demonstrated the irresponsibility of workers. Cholera, it was said, afflicts “individuals sub­ ject to bad habits or ways of living, who cannot or will not take advantage of the sound advice being offered to them.”41 But the simplicity of the preventive recommendations that were offered— recommendations shaped by ancient medi­ cal and moral traditions—cannot justify a negative judg­ ment of the medicine of the time. Nor can the inadequacy of the various kinds of treatment proposed by physicians justify such a judgment. Broussais’s antistimulant treat­ ment was without; an object. What good are lancets and leeches when the flow of thick and viscous blood is im­ peded? Bleeding was impracticable. Magendie, for his part, rediscovered an old biological insight according to which the therapeutic need must be a vital need. Doctors must attend to the instincts of their patients: if they were cold, for example, the proper treatment was warm punch and CHAPTER 5

body rubs. Those physicians who believed that cholera was a disease of the nervous system dreamed of repairing that regulator of organic life much as one might repair a watch: they lay vesicatories along the spinal column, in the hope that these would act by evulsion on the spinal cord and the nerve roots. Humoral pathology incorporated a number of therapeutic ideas of seventeenth-century medicine: restor­ ing the corrupted blood of cholera victims with new blood (by transfusion) or, if that was impossible, replacing lost water and salts (by intravenous injection).42 These preven­ tive and therapeutic measures were all in line with old medical practices. Yet this clear continuity did not prevent a major change: the old, unified nosographie model of medicine had been replaced by a number of new models. The year of the cholera epidemic was the year in which these new models were put to the test. But what was the significance of the various new models? What was the scope of each, and what were their limitations?

APOLOGY

6

Medicine MEDICAL THEORIES

The confrontation between French medicine and the Asi­ atic plague was eagerly anticipated. Paris was considered the center of enlightenment. The physicians of the capital had no doubt that they could do more, and better, than their Russian, German, and English colleagues had done in treating the disease. In short, the French medical profession believed that it had both a scientific mission and the means to accomplish that mission: “What medical Europe had been unable to do in four years and in twenty different theaters French medicine did in a few months and in a sin­ gle city.”1 The symptoms of the malady had been described fairly accurately. But there was no good information about where the disease first attacked the body and no comprehensive theory of how the symptoms were related to one another or what they meant. A little was known about cholera’s early signs. Although some doctors asserted that quick treatment could guarantee a cure, this was far from the truth of the matter. There was much uncertainty about the pathologi­ cal changes produced by cholera. Little was known about how specific lesions corresponded to various phases in the course of the disease. Symptoms observed in living patients had not been correlated with the alterations found upon

postmortem examination. There were lacunae in reports on the disease prepared by foreign doctors. It was necessary to begin again, from the beginning. In fact, careful rigorous observation of the sort for which Paris was famous was just what was needed to further medical knowledge of the new disease. Why was this task left to French medicine? To begin with, there were the institutional and cultural factors de­ scribed by Michel Foucault in his book The Birth o f the Clinic. Among these were the combination of hospital re­ form with advances in clinical technique, including percus­ sion and the use of the stethoscope. The French had been pioneers in relating anatomical and pathological discover­ ies to clinical observation. As a result of these develop­ ments, French medicine led the world, as contemporaries were well aware. New knowledge had helped to refute ageold notions of epidemic disease. More than that, it pro­ vided the basis for further discovery: “The epidemic that we are now witnessing will hold a particularly important place in history, because it has come in a century when progress in the physical sciences, pathological anatomy, and observational techniques has made it possible to study all aspects of the disease far more thoroughly than ever before.”2 The study of cholera by clinical science led immedi­ ately to the elimination of extraneous symptomatology (previously the disease had been confused with intermittent pernicious fever, intense algidity, typhus, peritonitis, and tetanus). But the seat and nature of the affliction remained a matter of controversy. Clinical medicine provided a tech­ nical and conceptual heuristic that enabled doctors to go beyond the surface manifestations of the disease and to dis­ cover the lesions associated with its various signs. But use of this tool actually led to conflicting accounts of the course of the disease, because different doctors focused on dif-

CHAPTER 6

ferent signs and different lesions. As a result, the medical theories that guided investigation assumed a particular im­ portance: on the one side was “physiological medicine” and on the other “experimental medicine” [or experimental physiology, as it is perhaps better known in English— Trans.], with the theory of nervous and humoral patholo­ gies located midway between the two. If French doctors accomplished more than scientists elsewhere in Europe, it was in part thanks to these theories. Thus it was the birth of the clinic coupled with the emergence of new medical theories that changed the face of medicine. These were the epistemological factors that contributed to the strength of French medicine in its confrontation with cholera. Consider, first, the way in which physicians deciphered the disease. Using new techniques of examination they were able to pinpoint the indubitable signs of cholera. It was not simply a matter of combining clinical signs in such a way as to define a “morbid species.” Nor was it a matter of iden­ tifying symptoms that could help to establish an analogy between cholera and other, more familiar diseases. Prost has left an apt description of the new attitude: “I always like to judge a disease in terms of its anatomical lesions. I never proceed in any other way at the bedside of a patient. With my mind I travel through the patient’s body.”3 In other words, clinical examination is intended to anticipate the results of autopsy. Attention is focused on signs indi­ cating specific anatomical lesions: touch, for instance, may disclose a flaccid abdominal wall and percussion may indi­ cate serious intestinal congestion. The characteristic flow of liquid from the cholera victim (which has been compared to water used for cooking rice) was described by Bouillaud as one of the most constant “anatomical characters” (ca­ ractères anatomiques) of the disease. Magendie examined various parts of the body with thermometer and stetho­ scope and found heat and a strong pulse in the central secMEDICINE

tions and cold and absence of pulse in the extremities. These were incontestable signs of circulatory collapse. Louis-Charles Roche and Larroque focused attention on the state of the muscles, in the belief that muscular rigidity was the “pathognomonic” sign of irritation of the cerebro­ spinal system [a pathognomonic sign is one that is specially characteristic of a disease, and on the presence or absence of which the diagnosis depends—Trans.]. As far as the “humoralists” were concerned, the most salient features of the disease were of course the thickening and increased vis­ cosity of the blood. Thus everyone agreed that the symptoms of cholera stemmed from the digestive, circulatory, and nervous sys­ tems as well as from the blood. Vomiting and diarrhea were related to digestive problems; algidity (i.e., coldness from the collapse of a vital function) was related to the circula­ tory system; cramps were related to the nervous system; and cyanosis was due to thickening of the blood. Now, each of these four observations suggested a possible source of the disease. All four signs were uncertain, however. Any contemporary observer willing to take a step back to sur­ vey the scene would quickly have reached the same conclu­ sion as Dalmas, namely, that it “is impossible to say that this or that symptom is constant, necessary, and pathogno­ monic; every symptom that one might have believed to be essential has been found in certain circumstances to be missing.”4 From these various observations it seemed likely that none of the elements considered essential really was. At first sign it might appear that a clinical science that could have allowed such diverse systems to be identified as possi­ ble causes of the disease must not have been very rigorous. But in fact there was nothing wrong with clinical science as such; rather, the diversity of the results just cited reflected the divergence of the underlying medical theories. The lim­ its of the anatomoclinical method as applied to cholera were only part of the issue; the larger question was to deCHAPTER 6

termine the limits of the contending medical theories by using cholera as a test case. Singling out a particular sign as preeminent was really tantamount to affirming the truth of a particular theory. Each theory had also to satisfy a further requirement: to link the disorder that it held to be essential and primordial to the whole range of other symptoms of the disease. Think of the elements of cholera as forming a pyramid, whose four vertices are labeled intestinal disorders, paralysis of the heart, nervous disorders, and alteration of the blood; the edges of the pyramid represent relations among these four conditions. Each theory singled out one vertex as pri­ mary and established a particular hierarchy among the subordinate relations. Physiological medicine proposed a theory of cholera based on inflammation of the digestive tract. Experimental medi­ cine gave priority to circulatory collapse. Still another the­ ory emphasized a nervous pathology, focusing on changes in the nerves. And finally, humoralist pathology attached primary importance to changes in the blood. Each theory held its associated sign to be primary and made the three others subordinate to it. It is worth exploring each of these positions in detail. i. Physiological Medicine: The physiologists regarded cholera as a form of acute phlegmasia. Following Bichat they believed that inflammation affects the body’s tissues. The reasoning that Broussais had used to establish that phlegmasias are due to lesions of the digestive tract (stom­ ach, small intestine, colon) also held good for cholera: “All inflammations of the digestive tract have this peculiar fea­ ture in common, namely, that they can be located pre­ dominantly in any of these sections. . . . Cholera is not exempt from this law. We have observed the beginnings of the disease in all three sections of the alimentary canal.”5 Subsequently such characteristic signs as a weak pulse and MEDICINE

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cyanosis appeared. Broussais linked these disorders to a general inflammation of the mucosa of the digestive tract. What Broussais seemed to be doing, then, was putting to­ gether an explanation of cholera in terms of a well-known model. But in fact he was deducing from the symptoms of the disease that its cause must be an inflammation of the digestive tract. Physiologists treated symptoms as signs of morbid functional changes of varying degrees of impor­ tance. They distinguished primary from secondary func­ tional lesions, the latter being lesions that develop in a later stage of the disease, either as a result of sympathetic affec­ tion (as Broussais argued) or as a consequence of physio­ logical laws modeled on the laws of mechanics (as Bouillaud maintained). For Broussais, diarrhea, nausea, and gastric distress all pointed to sanguinary congestion affecting the entire di­ gestive tract. The irritation then affected the spinal column, producing muscular symptoms (cramps and convulsions) and paralysis of the heart, leading to circulatory disorders (and hence to cyanosis and algidity). For Bouillaud, con­ gestion was also the primary factor. But unlike Broussias he maintained that circulatory failure was subordinate to hyperactivity of the digestive apparatus. The large volume of stool affected the blood, which became thick and vis­ cous. This in turn led to stasis and slowing of the circula­ tion and weakening of the pulse. Finally, these conditions produced the blue color and cooling of the skin. Thus the sequence of symptoms indicated the regular progress of an idiopathic disorder. Autopsy confirmed the symptomatological deduction of functional lesions. Postmortem ex­ amination of cholera victims revealed varying degrees of redness in the intestinal mucosa. Physiological medicine emphasized the constancy of digestive tract lesions among cholera victims. But it also showed that there was not the slightest trace of alteration in the spinal column, nerves, or heart. Secondary symptoms and functional lesions were CHAPTER 6

12i

therefore the sign of a generalization of the local distur­ bance to other parts of the body. The only diagnostic imperative was to pinpoint the source of the local distur­ bance. Autopsy confirmed the distinction between sympa­ thetic and idiopathic lesions. Combining the physiological explanation of the symptoms with the results of pathologi­ cal anatomy produced an adequate description of the dis­ ease: “We have proved that the symptoms and anatomical lesions revealed by study of the digestive process are com­ mensurate only with the symptoms and anatomical le­ sions characteristic of certain irritations of the gastrointes­ tinal tract. Cholera is therefore a kind o f gastrointestinal irritation.”6 Thus physiological medicine shifted the emphasis from the relationship between symptoms and organic lesions to the relationship between symptoms and functional le­ sions. Broussais saw this shift as the characteristic feature that distinguished his work from that of the “anatomical school.” He believed that he could describe the processes that underlie structural change: “The great Corvisart, so admirable for his skill in pursuing the functional aspects of his investigations, lacked an adequate idea of what physio­ logical functions are. He knew how to locate a tumor hid­ den in the depths of the viscera, but he did not indicate the nature of that tumor.”7 For the physiologists, the role of autopsy was simply to reveal inflammation. That inflam­ mation was the systemic counterpart of a physiological process, whose effects were far-reaching. By combining Bichat’s notion of tissue with Haller’s concept of irritabil­ ity, Broussais was able to describe physiological properties of tissue that bore no obvious relation to their manifest anatomical structures. Three-dimensional space assumed paramount importance, whereas in pathological anatomy it had been only the surface that mattered, that which could be seen with the naked eye. Broussais was able to transcend the limits of anatomopathology and thus to make a cruMEDICINE

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dal advance. The “spatialization of medical experience” owed everything to the physiological exploration of mor­ bid phenomena. 2. Experimental Medicine: Magendie believed that the fundamental disorder responsible for cholera was “car­ diac adynamia.” Cramps, vomiting, diarrhea, and altera­ tion of the blood were, in this view, secondary symptoms. Magendie believed that pathology could be related to phys­ iology only if one had a clear notion of what one was up to, and only if one were willing to settle for incomplete rather than total explanations of the disease. His was a strictly naturalistic approach, based on the search for a principle of correspondence between observed facts and effects that could be produced by an experimenter in the labora­ tory—in other words, between the spontaneous and the artificial. What he sought to demonstrate was how patho­ logical functional changes could be closely duplicated in the laboratory; laboratory experiment might then shed light on the disease process. In extreme cases, it might not even be necessary to perform the experiment: the pathol­ ogy itself would act as a kind of experimental test. For dis­ ease was like an experimental scientist, probing the work­ ings of the affected organism: “This disease . . . produces a host of physiological effects that bear a marvelous resem­ blance to known effects of experimental physiology. . . . The pathological effects that I shall describe are in one sense the effects of experiments deliberately designed to demonstrate the mechanisms of various functions.”8 For example, Magendie began by showing how the effects of circulatory disorders could be related to the re­ sults of an experiment described in his Précis élémentaire de physiologie (1816-1817). Compression of the crural ar­ tery by ligature of the thigh caused the artery to empty and blood to stagnate in the veins. The result of this experiment was to weaken the contractions of the ventricles of the heart, causing the subject animal to experience the pathoCHAPTER 6

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logical effects of circulatory failure. Circulation in fact ceased at the body’s extremities but continued in the center. Measurements with a thermometer confirmed this hypoth­ esis: the cooling of the peripheral blood was due to lack of “calorification” derived from arterial blood owing to this irregular state of hematosis: “Thus you see that the blue coloration [and the cold]. . . are direct, obvious, and in­ evitable consequences of the diminution of the contraction of the ventricles of the heart.”9 As for the abdominal secretions associated with chol­ era, there were two possible sources: either the mesenteric arteries that carry blood to the intestines or the mesenteric veins that carry blood back to the heart. The first hypothe­ sis is obviously incorrect, because the circulation is sus­ pended. This leaves the veins ramified in the surface of the mucosa. With the aid of experiment the mode of secretion of the choleraic liquid could be demonstrated. Injecting mercury into the vein stem showed that the metal flowed into the villi of the intestine and appeared as droplets on the intestinal wall. Magendie also injected both choleraic blood and water into a loop of intestine. These liquids car­ ried away a small quantity of mucus, producing a fluid quite similar to the intestinal evacuations of cholera vic­ tims. Hence the mechanisms must also be similar: “If, after death, this fluid forms in the intestine, carries away the in­ testinal mucus, and yields a liquid that is exactly the same as that which flows from the intestines, then there is noth­ ing to prevent us from supposing that something analogous occurs in life.”10 The same experiment also explains the increase in the viscosity of the blood: the serosity of the blood is partially absorbed through the intestinal wall. For Magendie, then, physiological experimentation should reproduce some phase of the pathological process. That process is too complex to permit a comprehensive a priori explanation. Induction is permissible, however, if every hypothesis is controlled by experiment: “Following MEDICINE

the experimental procedure one arrives at certain conclu­ sions, certain facts, some of them isolated, others suscepti­ ble of being fitted into a more general scheme. But beyond a certain point one cannot go.”11 Magendie was particularly interested in the circulatory failure associated with cholera: here was an important pathological fact that called for ex­ perimental analysis of the kind he had always employed in his work. It was responsible, moreover, for other morbid phenomena, indeed for precisely those phenomena that were held to be characteristic of cholera: cyanosis, algidity, intestinal disorders, and changes in the blood. But Magen­ die ran up against the limits of his methodology when it came to explaining the muscular symptoms of the disease: “How is it that with the onset of cholera patients experi­ ence cramps? I do not know. I cannot say what takes place in the nerves and muscles.”12 Despite its inadequacies and limitations, Magendie’s brand of experimental medicine was the first to establish a crucial link between the clinic and the laboratory. 3. A Nervous Pathology: Some held that the cause of the symptoms of cholera was a nervous disorder. They rea­ soned, first, that the vital functions are under the control of the nervous system. Second, autopsy disclosed no obvious inflammation or other significant disorder. To make the nervous system the central focus of a theory of cholera was to rely on theories of brain disease. One such theory was British in origin; another was associated with Pinel’s nosography. British physicians classified cholera as a “ner­ vous catarrh”: an alteration of the mucous secretions but without inflammation, since the intestinal membrane is white and shows no sign of tumefaction. In other words, a distinction was drawn between catarrh and inflammation; inflammation was caused by irritation, catarrh by varia­ tions in climate. The insular position of Britain allegedly magnified the presumed pernicious effects of wind, weath­ er, and dampness on the nervous system. A theory of cholCHAPTER 6

era was based on this climatic theory of brain disease. Prior to the outbreak of cholera in France, some French doctors imported this British theory: “Cholera morbus is a catar­ rhal disease that has penetrated to the innermost parts of the body’s organization, as far as the ganglionary nervous system, which controls the organs of digestion, reproduc­ tion, and secretion, as well as the muscular tissue of the heart and above all the movement of the arteries of those organs.”13 The theory of cholera as a form of neurosis de­ pended on two aspects of Bichat’s work. First, Bichat rec­ ognized the existence of diseases without apparent lesions, namely, the nervous diseases. Second, he distinguished two parts of the nervous system: one that controls the animal functions (the brain and its subordinate components) and another that controls the vegetative functions (the sym­ pathetic nerve). Auzoux used this distinction of Bichat’s as the basis for a nosographie classification: “Cholera morbus is to the sympathetic nerve what epilepsy is to the brain. Epilepsy causes functional disturbances in all the organs of animal life. Cholera morbus causes functional disturbances in all the organs of organic life.”14 These attempts to explain cholera as a nervous disease may seem rather backward compared with the innovations of physiological and experimental medicine. The fact that Bichat accepted the idea of diseases without organic lesion only showed that he had not broken entirely with Pinel. Those who followed this line of reasoning rejected the principle of localization with which Broussais had swept away the old nosographie distinction between vital lesions and organic alterations. Foy reacted to this with a polemi­ cal tone reminiscent of Broussais himself: “Simply because certain pathological alterations, particularly those asso­ ciated with the neuroses, escape detection by our senses, shall we deny their existence? No . . . so far as I am aware people do not die of nothing.” 15 Accepting the idea of dis­ eases without organic lesions also meant giving up the MEDICINE

promising path of experimentation. In the case of cholera, which was held to be an essential affliction, this seemed nonsensical. Neither Broussais nor Magendie believed in a nervous pathogenesis of cholera. Or did they? Two remarks. First, although Broussais acknowledged that the disease might have a nervous origin, his theory provided a ready-made in­ terpretation: the patient had simply failed to notice a prior irritation of the digestive system, which had provoked a reaction in the nervous system. Second, Magendie showed considerable restraint and caution in refusing to offer any explanation of muscular disorders and, in particular, of cardiac problems. Yet it is somewhat misleading to leave the matter at that. Broussais actually recognized the possi­ bility of cholera without evacuation and with pronounced nervous irritation: “The danger does not come from the abundance of secretions and the exhaustion of fluids but in fact from the excessive irritation of the nervous centers, which hinders their regular innervation of the heart.”16 Magendie, for his part, recognized that the physiological data left room for various conjectures: “There are certain physiological experiments that are, in a sense, deliberately designed to produce a choleraic state. Legallois, for exam­ ple, in attempting to demonstrate the influence of the spinal cord on the flow of blood, noted that if a portion of the spinal cord is destroyed, the intensity of the contractions of the heart is reduced by a certain amount.”17 Some investigators, who combined the approaches of Broussais and Magendie, did therefore pursue the possibil­ ity that cholera was a nervous disease. If disease is space, they reasoned, experimental physiology might be able to reproduce its symptoms by artificial means and thus deter­ mine the nature of the lesion by analogical reasoning. In the case of cholera, the observed similarity between the symp­ toms of the disease and the results of certain vivisectional experiments seemed to allow the application of the prinCHAPTER 6

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ciple of localization. Louis-Charles Roche, for example, stressed the fact that partial destruction of the upper sec­ tion of the spinal cord resulted in a slowing of the circula­ tion, cyanosis, and algidity. This artificial production of morbid phenomena similar to those observed in cholera victims proved intriguing; doctors were so impressed that the results of the experiment colored their interpretation of autopsy findings: “Finally, investigate the cadavers of indi­ viduals who succumb to cholera morbus, and in every in­ stance you will find traces of blood injected into the spinal cord and its envelopes. . . . From this it follows that the nonabdominal phenomena of cholera morbus result from a complex lesion of the nervous system, and primarily of the spinal cord.”18 When, much later, in 1865, Marey finally published his Essay on a Physiological Theory o f Cholera he of course proposed a theory inspired by the work of Claude Bernard. But he also mentioned the names of those who, before him, ascribed a role of primary importance to alterations in the nervous system, including Auzoux, Scipion Pinel, Delpech, and Louis-Charles Roche. 4. A Humoral Pathology: The fourth and final focus of inquiry was the blood. Disorders in the digestive, cir­ culatory, and nervous systems all appeared consecutively. Hence it was logical to think that the role of the blood, a fluid in contact with all these systems, might be important. Researchers therefore looked for an idiopathic lesion in the blood. Those who believed that the primary cause of the disease was a fluid immediately conceived of their results in polemical terms, pitting humoralism against solidism. Bonnet deplored the fact that “the scorn heaped on humoralist theories of the sort proposed by Galen and his imi­ tators has been extended to any theory based on an altera­ tion of the blood or its parts.” 19 In fact there was no scorn but, as Michel Foucault has shown, a blindness necessary to the development of clinical science: “The gaze alone dominated the whole range of possible knowledge. The use MEDICINE

of techniques that would have raised questions of mea­ surement, questions of the substances and compounds as­ sociated with invisible structures, was ruled out.”20 Now, to refer to “solidism” in 1832 was to attack the anatomical school. Indeed, the “failure” of solidism seemed to justify the revival of humoralism. Some spoke of “certain diseases that pathological anatomy is powerless to explain . . . such as cholera. What suggests that this is the case is the extreme divergence of opinions as to its nature and situs.”21 What we see here is a return to a type of analysis familiar in eighteenth-century medicine: the analysis of fluids. Still, doctors did not abandon the guiding precepts of clinical science: the problem was to make the interpretation of the symptoms fit the hypothesis of an alteration of the blood and to link the consecutive disorders of the various systems to the primary fluid cause. Alteration of the blood was brought to light by chemi­ cal analysis. The key results pertained to the proportions of the various blood components. French chemists confirmed results obtained earlier by the English: the blood of cholera victims contained less water and salts than normal blood.22 Bonnet believed that the symptoms of the disease could be explained by this alteration of the blood. The blue color of tissues was due to the large amount of coloring substance in choleraic blood (known to be four times the amount in normal blood). The increased viscosity of the blood ac­ counted for the slowing of the circulation, which was the cause of algidity. And the fact that the nervous system was irrigated by black blood was sufficient to explain the vic­ tim’s cramps. All the disorders associated with cholera could therefore be explained as consequences of the blood lesion. What is more, chemical analysis showed that the components missing from the blood of a cholera victim were found in his excretory products. Bonnet therefore concluded that “the intestinal secretion, which contains all the elements that the blood has lost, is the primary cause CHAPTER 6

I29

of the lost water, fibrin, albumin, and salts that one finds in this liquid.”23 Paradoxically, analysis of the blood gave new force to the arguments of physiological medicine, which the humoralists did not accept. If the abdominal disorders were truly secondary (i.e., if their purpose was to eliminate the choleraic toxin), then there had to be something more in the blood than the chemists had discovered. As Rochoux argued, “Cholera belongs to that class of poisoning whose symptoms result from the alteration of the blood by addi­ tion of a deleterious agent.”24 Those who saw the altera­ tion of the blood as the primary cause of cholera therefore turned from hematological analysis to another avenue of research: by injecting toxic substances into animals they attempted to produce artificial choleras. This kind of re­ search should therefore be classed with the experimental study of poisons. Similarity of symptoms was assumed to mean similarity of causes. And these experimental ideas seemed to meet with success. In any case, Ledeschault made them the basis of his theory of cholera, according to which the disease causes spontaneously in man the same effects that could be produced experimentally in animals: “Every­ thing suggests that liquids are here the primary seat of the disease. It seems that blood contains a deleterious principle that originates spontaneously, invades the nervous system, and hinders the movements of circulation.”25 Despite the dogmatic aspects of this humoralist pathology, it helped to lay the foundations of clinical chemistry. To sum up, then: We have reviewed four proposed theories of the disease. As medical science confronted the epidemic, theory soon confronted theory. There was deep disagree­ ment over pathophysiology. Magendie believed that the physiologists had been led astray by mistaking mere red­ ness for inflammation, since the alleged inflammation could be eliminated by injection. Bouillaud believed that the exMEDICINE

perimentalists erred in thinking that the cardiac disorder was the main phenomenon; they also erred in relating mucous secretions to circulatory stasis. On the other hand, Magendie and Bouillaud agreed that the humoralists were wrong to think of the alteration of the blood as primary: intestinal disorders sufficed to explain the observed changes in the blood. In addition, both doubted the results of au­ topsies that claimed to show lesions in the nervous system. There is no need to pursue the debates that were carried on among partisans of the various schools. It is more impor­ tant to bring out one point on which all agreed, and which concerns the etiology of cholera: namely, that the cause of the disease belonged to the same family as the most dan­ gerous irritants and the most violent poisons. A SPECIFIC MALADY

At first glance, Serres’s work on cholera, which he pre­ ferred to call psorentery, appears to have been based on pathological anatomy. According to the cholera-psorentery theory, inflammation of the granular crypts known as Brunner’s glandules was the distinguishing feature of “Pa­ risian” cholera: “It will probably turn out that psorentery, like enteromesenteric fever, can be called by a variety of names; but the granular eruption that we have reported and described will remain the principal and distinctive le­ sion of the cholera epidemic.”26 This statement seems to break no new ground, for Serres and M.-A. Petit had earlier reported a similar inflammation of the pustules of Peyer as the distinctive and fundamental character of enteromes­ enteric fever (which Bretonneau called dothinentery and Louis called typhoid fever). In reality, however, the psor­ entery theory was more novel than this analogy would sug­ gest, because the problem was no longer simply to identify a characteristic lesion. This was well understood at the chapter

6

time: “If one holds that the development of the mucous follicules is the character of cholera, then one must argue that cholera and dothinentery are diseases of the same na­ ture,”27 i.e., both are specific diseases produced by specific causes. For the psorentery theory was based on the notion of “special inflammations,” and what was new about this notion was that each disease species has its own specific cause. Diseases due to different causes follow different courses and have different final forms. Serious diseases, moreover, affect the whole organism. A single, limited le­ sion could not possibly account for a wide range of symp­ toms. The fact that some doctors linked psorentery and dothinentery in 1832 suggests that a change in medical thinking was under way, which exempted the cholerapsorentery theory from the criticisms that Broussais had rightly leveled at the Serres-Petit theory of enteromesenteric fever. What made the difference between the Treatise on Enteromesenteric Fever (1813) and the Memoir on Psorentery, or Cholera o f Paris (published some twenty years later) was that in the meantime Bretonneau had pro­ duced his work on dothinentery. Let us briefly retrace this history. Broussais’s principle of absolute localization overthrew the doctrine of “essential fevers” (essentialités fébriles). But the irritation that was held to be responsible for all fevers still had an abstract structure: “The universality that enabled him to explain everything imposed a final screen of ab­ straction upon the gaze fixed on the organism.”28 Irritation always produced the same fixed change in texture, its visi­ ble correlate. In his study of the modality of inflammation Bretonneau discovered what he called the “special inflam­ mations.” Rather than speak of inflammation in the ab­ stract, as Broussais had done, Bretonneau referred to inflammations in the plural. Instead of Broussais’s patho­ logical monism Bretonneau preferred a pluralistic nosolMEDICINE

ogy. This did not prevent him from reducing, as Broussais had done, supposedly different morbid species to different forms of a single affection. This is demonstrated by his work on diphtheria. What irked Bretonneau about Broussais’s critique of ontology was its extravagance. Inflamma­ tion is only a generic character; specific inflammations ap­ pear as soon as one begins to look for them: for example, dothinenteric inflammation is different from aphtous in­ flammation, catarrhal inflammation, dysenteric inflamma­ tion, and tuberculous inflammation. Furthermore, the erup­ tion of the closed follicles that accompanies changes in the mesenteric glands can be distinguished from postmortem changes. Bretonneau also showed that diphtheric inflamma­ tion can be differentiated from lesions of the same intensity but due to irritants of a different nature. Though identical at first, these lesions soon exhibit differences of texture, color, extent, density, and duration: “There the analogy ceases; and the more complete it was to that point, the more the specificity of the two inflammations is estab­ lished.”29 Thus it was by applying the rules of classification to changes in tissue, and with the help of experimen­ tation, that Bretonneau came to reshape the concept of inflammation. The doctor from Tours did not repudiate the concept of inflammation, but subjected it to critical scrutiny; he re­ worked it so as to exploit its potentialities to the full. In­ flammations differ, he argued, qualitatively rather than quantitatively. He replaced a unitary concept, that of in­ flammation, by a differential concept, that of specific in­ flammations. This was important to the history of medicine in two ways. First, it led to the hypothesis that the specific character of an inflammation is determined by the cause of the disease. Second, it suggested that the character of the inflammation might be a sign of the character of the dis­ ease. In other words, an inflammation bears the stamp of some external agent or virus, and, further, its nature (evoCHAPTER 6

33

lution, etc.) can be used as the basis of a new nosological order. We must be careful, however. When Bretonneau suggested that a benign lesion—one that did not violate the integrity of the mucous membrane—could not account for a severe fever, he was not regressing to the views of Pinel. Disease can be space without necessarily being the generali­ zation of a local affection. Broussais related the sequence of symptoms to the “lesional space” by asserting that second­ ary symptoms must depend on primary ones; this was pre­ cisely the assertion that Bretonneau called into question. Broussais regarded the local point of attack as the “cause” of the disease; for Bretonneau this was merely an effect of the same order as other effects. In other words, intestinal lesions and serious symptoms are the result of a poisoning. Magendie indicated his agreement with Bretonneau when he wrote, “One must be quite circumspect in explaining general morbid phenomena in terms of a local pathological alteration.”30 In any case, it is wrong to think that research based on pathological anatomy (which has been disparaged as “ana­ tomical nosologism”) was somehow foreordained to pro­ duce a theory of the cholera-is-psorentery variety, on account of the kinds of questions habitually asked by members of that school. In fact, the view embodied in the psorentery theory of cholera was quite unlike anything a pure pathological anatomist would have come up with, be­ cause it was based, as I suggested earlier, on a very different model: the theory of dothinentery. Bretonneau believed that the relation between lesions and morbid phenomena was one of “concomitance”: a given set of symptoms is generally found in the company of a given set of lesions. The various features of the clinical course of dothinentery correspond to a precise series of internal organic changes. Similarly, Foville reported that the symptoms of cholera parallel changes in the developMEDICINE

1 34

ment of the follicles. And Serres, for his part, reported that “there is an exact correspondence between the extent of the eruption and the gravity of the symptoms; the intestinal granulations followed the same course as the disease.”31 Bretonneau related the major lesions of the intestine to the symptoms corresponding to the final phase of the dis­ ease. Only in the final stage do those lesions account for the morbid phenomena. Similarly, in the case of cholera, Serres noted that “the typhoid phenomena coincide with the in­ flammatory state of this granular eruption.” Furthermore, in both dothinentery and cholera there is initially the same contrast between the gravity of the symptoms and the be­ nignness of the intestinal lesion. Bretonneau believed that the initial manifestations of illness, the fever symptoms, did not reflect organic disorders. Similarly, Serres maintained that “the inflammation of these granulations is not enough to explain the functional disorders.”32 Bretonneau be­ lieved, moreover, that dothinentery was a disease of the entire organism and that both the major symptoms and the distinctive intestinal lesions were effects of a general poi­ soning. In the case of cholera, Cruveilhier aptly summarizes an idea shared by believers in morbid specificity: “These general phenomena are simultaneous rather than sequential effects of a single cause that presumably acts on the entire organism, and in particular on the fundamental functions of innervation and circulation, in such a way that the as­ phyxie, algid, syncopal condition appears to develop at the same time as the intestinal flux.”33 Finally, Bretonneau stressed the similarities he had ob­ served between phlegmasias and diseases of the skin. Simi­ larly, in 1832, doctors reported analogies between the granulations in the intestines of cholera victims and scabies, smallpox, and so-called millet-seed rash.34 Just as the name “dothinentery” indicated an analogy with exanthematic pyrexias, so did the term “psorentery” (from psora, pim-

CHAPTER 6

1 35

ple, and enteron, intestine) suggest an analogy both with dothinentery and with the associated idea of specificity. According to the doctrine of morbid specificity, cholera was a kind of poisoning. All other medical theories arrived at the same conclusion. But if all doctors agreed that chol­ era was the work of a toxic agent, why was there such vio­ lent controversy over the nature of the scourge? The con­ tagion theory was supported only by those who believed in morbid specificity, while the infection theory was sup­ ported by all other physicians, who played down their other differences so far as this particular controversy was concerned. Magendie, Louis-Charles Roche, and Rochoux actually adopted Broussais’s ideas about infection. But why did experimental physiologists, nervous pathologists, and humoralists make common cause with the proponents of physiological medicine? The answer is that the issue was one of epidemiology and not physiopathology. In the latter domain the conflicts were numerous, major, and irreduci­ ble. By contrast, agreement was quickly reached on the subject of the origin and mode of propagation of epidemic disease. The only issue in dispute was the question of con­ tagion versus infection. There were two possible sources of epidemic disease: either a miasma mixed with the air or a virus carried by persons or things. It is clear why the doctrine of morbid specificity was associated with the contagion theory. For one thing, the specificity of the lesions associated with a disease suggested that the agent, too, was specific. For another, diseases that were believed to be transmissible exhibited skin rashes among their symptoms. Therefore the idea took hold that the skin was the primary point of attack for the virus. Dis­ ease was transmitted by contact with a victim’s body or clothing: “One always comes back to the older, better es­ tablished view that the cutaneous system is the essential organ of contagion, as is proved by the analogy between MEDICINE

local and artificial contagions.”35 By contrast, it is much less clear why all other physicians agreed that the deleteri­ ous principle was carried by the atmosphere, especially given the different localizations and incompatible patho­ genetic explanations they proposed for the disease. Yet it was precisely the differences at the level of physiopathology that explained the convergence at the level of epidemiol­ ogy. Let me explain what I mean by this rather cryptic as­ sertion. In the first place, whether one viewed cholera as a nervous disease, a heart disease, or an alteration of the blood, the primary role was in each case assigned to the circulatory system. The toxic agent might act on the ner­ vous system, the heart, or the blood, but it was always car­ ried by the blood. On the other hand, if one saw cholera as an acute form of gastroenteritis, it was the digestive system that was attacked and inflamed by the toxic agent and that played the primary role. Now, what is it that mixes with blood as a result of breathing and that is swallowed along with the saliva, food, and drink? The answer is air—air whose composition may have been corrupted by unseen miasmata. Remember that this was a time when Nysten, Magendie, and Milne-Edwards were demonstrating the importance of pulmonary absorption. And remember, too, that Broussais had recently made phlegmasias the centerpiece of his system. Hence the mucous membranes of the respiratory and digestive systems were regarded as the most likely areas for deleterious agents to penetrate: “It is surely to the air that one must generally look for epidemic ele­ ments. . . . A proof of this assertion is that almost all purely epidemic diseases attack the mucous membranes, as do the catarrhs and dysenteries.”36 Clearly, then, the dispute between the infection and contagion theories centered on a particular element of anatomy. The differences between the two theories actually coincide with two different manifestations of the same kind of tissue, the one external and enveloping, the other interCHAPTER 6

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nal and lining— i.e., the skin and the mucous membranes. Everything else follows from this primary difference. If the toxic agent acts or enters the body internally, then it must reside in the atmosphere. Conversely, if the toxic agent en­ ters via the skin, then it must be associated with bodies and things. If the agent resides in the atmosphere, anyone who lives in the affected area can become ill: this is infection. On the other hand, if the agent is associated with individu­ als, then the disease must attack each person in succession: this is contagion. In highly schematic fashion, then, these are the principal differences between the two systems. In regard to the origin of the epidemic and its mode of propa­ gation, we can now see why the differences between the disciplines tended to fade away and why a new alliance came into being, in opposition to contagionism. One final remark: Magendie, Louis-Charles Roche, and Rochoux all became supporters of physiological medicine because it alone had treated the question of infection in a systematic way—for doctrinal reasons having to do with the great de­ bate between infectionists and contagionists, which is the subject of the next chapter.

MEDICINE

7

Epidemic EMINENT REASONS

Let me begin by citing Rochoux: The history of cholera morbus, if I may be permitted to make the comparison, offers us something analogous to what occurred a few years ago in politics in our France. With the restoration of the Bourbons some people wished to revive the ideas of divine rights, religious monarchy, hereditary privileges, and so forth, and what happened was that all of this superstructure, having been weakened over many years by sound philosophy, collapsed for good under the blows of a people only too content with its victory. Similarly, the cholera, which was heralded as ushering in a medical restoration, a restoration of old medical doctrine concerning the contagiousness of epi­ demic diseases, seems destined to complete the ruin of the etiological system whose triumph it was supposedly sure to bring about.1 If it were solely a question of medical science, this state­ ment would surely be exaggerated. But in fact, since the real issues in the contagion-infection controversy were leg­ islative and bureaucratic, Rochoux’s comparison is re­ markably apt. Very quickly the opposition between the contagion theory and the infection theory began to look like a battle. The proponents of the infection theory, who believed that

they represented the forces of liberalism, confronted the reactionary supporters of contagionism. The battle had to be waged on two fronts, one scientific, the other political, since the issue was freedom of commerce and of persons. Ostensibly, the first blow was struck by physiological medicine against an outmoded medical system. To declare oneself in favor of the infection theory at this point in his­ tory was to champion advanced ideas in medicine. At a time when Broussais was making his medical revolution, contagionism was seen as a legacy of the past that would have to be discarded. As Bouillaud put it, “Among the rare partisans of this system [i.e., contagionism], everything comes down to opinions without proof, to allegations that: conform neither to the laws of sound reasoning nor to the facts revealed by the most careful observation. This is, if I may say so, one of those scientific superstitions with which it is to be hoped that we shall soon be finished.”2 To trace the origins of the contagionist doctrine was to indict it. For did not its earliest formulations date from the time of Fracastoro, Cardano, and Paracelsus? It gained renewed vigor at the end of the seventeenth century, with the dis­ covery of animalcules. In the eighteenth century Linnaeus and Réaumur were among its defenders. But by the early nineteenth century contagionism had fallen out of favor. The only reason to bother refuting such an outmoded doc­ trine was that it was used to support segregation and quarantine. More than that, it involved an idea of disease that seemed as fantastic as it was old-fashioned: namely, that disease is a kind of demon that takes control of the body. This image of disease Broussais, for one, constantly combated. This Manichaean, and simplistic, version of contagionism was directed against Broussais’s bête noire, medical ontology. Contagionists saw disease as a legitimate part of nature, a natural being. Physiologists like Broussais pointed out that the contagion theory was part of a coher­ ent doctrine; belief in it entailed belief in other irrational c h a p te r 7

fancies: “Sanitary cordons are products of ontologism; sound reason condemns them.”3 Identifying itself with sound reason, physiological medicine denounced both a conception of disease and a mode of prevention; according to the physiologists, belief in ontology entailed mistaken, indeed chimerical, views of both the threats to life and the way to counter those threats. But the battle between infectionism and contagionism was not simply a struggle between knowledge and igno­ rance. The usual view is that the conflict symbolized the antagonism between two systems of thought, the one lib­ eral and progressive, the other conservative and regressive. We are told that those who argued in favor of quarantine were bureaucrats with their eyes fixed firmly on the past. Their behavior was allegedly dictated by routine and selfinterest. Routine, because benighted bureaucrats supposed­ ly hid behind old regulations: indolent Provence, more interested in security than in business and jealous of its pre­ rogatives, was allegedly suspicious of the industrial north. And self-interest, because these same bureaucrats were de­ termined to protect their sinecures: “What is the purpose of these antiscientific, antisocial maneuvers? Nothing other than to secure emoluments of a few thousand francs and to enable the recipients of those emoluments to cut what they call an ‘honorable figure’ in society.”4 Another standard accusation is that contagionism served the interests of the protectionists, who failed to comprehend the needs of an era of economic growth. Liberalization of trade was crucial to new industries whose growth was hampered by short­ ages of raw materials. Freedom of travel and freedom of trade went hand in hand; both were important to business interests. Industrialists and bankers had a great deal of influence in the government, in part through the SaintSimonians, who favored free circulation of goods and cap­ ital. Such liberal theorists as Louis Chevalier and Bastiat, the mayor of Bordeaux and founder of the Association for EPIDEMIC

I4 2

the Freedom of Trade, conducted energetic campaigns in the press. The government’s own interests were also at stake. For it had been obliged to build expensive quaran­ tine stations on the Atlantic coast and to absorb losses stemming from the ban on sailing imposed on the merchant fleet. All of this accounts for the prestige afforded to Chervin, who was the symbol of this ephemeral alliance be­ tween scientific and economic progress. His battle cry was to oppose those whose aim was to halt the growth of com­ merce and dry up the source of government revenue. Chervin was not alone in this fight. Most physicians expressed outrage at the impediments to trade in more or less the same terms as Magendie: “The doctrine of contagion is prevalent in Europe, where it is producing the most unfor­ tunate results by placing costly obstacles in the way of trade while increasing government expenditures for no motive that reason can avow.”5 In the realm of politics the battle lines, we are told, were no less clearly drawn. The segregation measures were allegedly the work of a despotic government. Some Machi­ avellian scheme lay behind the contagionist theory. If this was true, then nothing had changed since the time when Pope Paul III, determined to move the Council of Trent to Bologna, gained his wish by allegedly forging the signature of the city physician of Verona (who had accredited the notion that a then prevalent disease was contagious). If the government envisioned strict enforcement of the sanitary laws, the reason was not so much fear of disease as oppor­ tunity to reap political benefit. Part of the calculation in­ volved in the government’s strategy was said to be of such a nature that it could not be publicly avowed. Noninterven­ tion in Poland was a case in point: “You are allowing our Polish brothers to be massacred by barbarian swords under the orders of a despot. Your pretext for behaving so falsely is, or so you say, to save your own people and to protect them against cholera.”6 This argument seemed rather tenCHAPTER 7

uous, given the fact that ten years earlier the government of the Restoration was criticized for using the contagion the­ ory as an argument in favor o f intervention: “At that time Spain was in the throes of revolution. The French govern­ ment, whose ulterior motive was to halt the spread of that revolution, looked for a pretext to mass an army on the frontiers of the Iberian Peninsula. And that army was in fact referred to as a ‘sanitary cordon.’ ”7 In that time of yellow fever, it was said that the French liberals had urged Devèze to propagandize in favor of the infection theory. In 1832 the ties between infectionism and liberalism were so close that Broussais could argue that if only bureaucrats and legislators would adopt his system, there would be an end to “these panic frights that give rise to sanitary cordons and provide pretexts for actions that the cabinet could not otherwise justify.”8 Thus the usual view is that the quaran­ tines were opposed by liberals eager to embody the ethical principles of the middle class in legislative form. Quarantines were tainted by their origins in the age of leprosy and plague. Regulations first imposed on lepers formed the basis of the quarantine regulations used during periods of plague in the seventeenth and eighteenth cen­ turies. Now, in the first half of the nineteenth century, some people wanted to apply these same regulations to still other diseases, such as yellow fever and cholera. In the midst of industrial civilization this was a heresy. It was not at all difficult to show that the regulations were ambiva­ lent: as well as being preventive measures they were also measures of confinement, procedures for control and sur­ veillance of the population, a focal point of fear and confu­ sion. The old idea of casting out the leper and isolating the victim of plague was incompatible with the dream of a so­ ciety in which all men were at last free and equal. Thus the ideas of the opponents of segregation were seen as liberal ideas par excellence. If put into practice these ideas would abolish the fetters on human freedom. EPIDEMIC

Against contagionist dogma, then, proponents of the infection theory advanced reasons of high politics and superior rationality. They believed themselves to be su­ premely rational in that they wished to overthrow ontologism in medicine once and for all. Politically, liberalism and progress were held to be incompatible with segrega­ tion. Both lines of argument converged toward a single ob­ jective: that of demonstrating the anachronistic nature of a defense against disease that allegedly represented the height of obscurantism, despotism, and barbarism. It is clear, then, how the proponents of infectionism wished us to in­ terpret the behavior of the experts who tried to remove the sanitary cordons from French borders: namely, as an at­ tempt to abolish ancient constraints on human freedom in the name of benevolence, enlightenment, and liberalism. As Chervin put it, “The interests of humanity, science, and commerce will not be sacrificed to the systematic views of the government’s advisers on sanitary matters.”9 These positive arguments responded to the negative arguments that were advanced in favor of segregation. But in all of this there is a glaring methodological prejudice: the presump­ tion is that the meaning of the health code, the opposition it aroused, and the reforms that it called forth can all be ex­ plained in terms of the conflict of opposing interests. No doubt the measures of segregation adopted in 1832 did re­ semble those employed in the past, and they surely did hin­ der commerce and personal travel. But to argue that the sanitary code of 18S2 was the result of ignorance and that its enforcement was due solely to a desire to hamper busi­ ness, or to a conspiracy by the enemies of liberty, is pre­ posterous. It amounts to the claim that the defenses against cholera were really a machination of conservatives bent on promoting obscurantism, protectionism, and repression above all else. The passage cited above from Rochoux at­ tests to what was a common illusion in this first half of the nineteenth century, that of mistaking the opposition to c h a p te r 7

one’s own position as a survival of the Ancien Régime: in this case medicine saw the contagionist doctrine as a mani­ festation of the Ancien Régime spirit. The analysis that I shall give will not be much concerned with the subjective intentions of the actors. I shall describe practices. But why, then, have I placed so much stress on the motives that, in the eyes of contemporaries, guided the actors in their combats? The reason is that historians of medicine have for the most part been content to revive these contemporary accounts. To explain the strength of the anticontagionist movement, for example, Ackerknecht has pointed mainly to the development of political lib­ eralism and to the progress of humanism as weighty, exter­ nal, and primary factors: “Still, the vigor of our movement would remain largely unexplained, did we not realize the powerful social and political factors that animated this seemingly scientific discussion. . . . Anticontagionists were thus not simply scientists, they were reformers, fighting for the freedom of the individual and commerce against the shackles of despotism and reaction.”10 It seems fair to say, moreover, that Ackerknecht focuses exclusively on these factors, since he argues that reasons of a scientific order played no role in the decision in favor of one theory over the other. This assertion warrants a brief discussion. In the first half of the nineteenth century, it was if not justifiable then at least possible to confound medical progress with political progress. As we have seen, physicians saw a con­ nection between Broussais’s medical revolution on the one hand and liberalism and humanism on the other. The twentieth-century historian has less latitude than did the early nineteenth-century physician, however. Once it was understood that mass afflictions are communicable and caused by a microbe, it became necessary to develop a his­ torical account of the contagionist-anticontagionist con­ troversy in which contagion theory was not depicted as an EPIDEMIC

altogether medieval and outdated theory: “As a matter of fact, contagion and the contagium animatum were rather old theories around 1800. The youthful appearance they enjoy in our mind today is exclusively due to the very thor­ ough rejuvenation they underwent in the 1870s and ’80s.”11 Correspondingly, anticontagionism, which stood for pro­ gressive medical thinking at the time, appears to the histo­ rian as a rather retrograde movement: “The emphasis on anticontagionism and the disregard for contagion as a cause of the disease inevitably brought about a regression to older, classic causal explanations.. . .We have already mentioned the sporadic reappearance of the ‘epidemic con­ stitution.’ ”12 Ackerknecht has no doubt fully appreciated the implications of this “sporadic reappearance.” In this retrospective account, bacteriology, whose chief effect is here to demonstrate the irrelevance of economic, ethical, and political factors, plays an organizing role. In­ deed, the vindication of contagionism was also the vindica­ tion of its practical corollaries, the quarantines and sanitary cordons. Such measures therefore ceased to seem the in­ struments of reactionary political forces. At the same time, opposition to these measures, which can now be seen to have been based on scientifically backward principles, ceased to seem the expression of political liberalism. The foregoing analysis seems to cast doubt on extemalism, i.e., “a way of writing history in which certain events, which one continues to call scientific more by tradition than as a result of critical analysis, are said to be conditioned by their relations to economic and social interests. . . . In sum, this is an attenuated, or rather, impoverished, form of Marx­ ism, currently practiced in wealthy societies.” 13 How is one to escape from this impasse while main­ taining the belief that socioeconomic factors were para­ mount? There is only one solution: to show that reasons of a scientific order could not have been decisive because the two contending medical theories were strictly equivalent. CHAPTER 7

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Then and only then can the two doctrines be said to have weighed equally in the balance of scientific judgment, which is the same as saying that scientific judgment carried no weight in the debate. With subsequent bacteriological discoveries in mind, one can upgrade contagionism and downgrade anticontagionism as belonging to the Hippo­ cratic past. Then, to reestablish equilibrium, one has only to take the opposite tack. In the light of another subsequent development in medical science, the theory of environ­ ments (théorie des milieux), it is just as easy to upgrade anticontagionism (“The ‘filth-miasma’ theory of disease fitted much better into a social theory of epidemics”14) and to downgrade contagionism (that “old medieval theory,” which belongs to the past). In short, Ackerknecht divides knowledge into two distinct but interwoven strands: one defined by what was already known (the legacy of Hippocratism, the doctrines of contagion and the contagium ani­ matum), the other by what was not yet known (the theory of environments, bacteriology). I shall not dwell on the pre­ suppositions implicit in such a method. It is enough for present purposes to indicate its function: namely, to show that the two contending medical theories were equally valid and therefore played no role in the controversy: “Intellec­ tually and rationally the two theories balanced each other too evenly.”15 What does this leave? Economic, ethical, and political factors. On one side, quarantines and sanitary cordons, supported by protectionist, repressive conserva­ tism. On the other side, opposition to these measures, ex­ pressing the interests of political liberalism and its asso­ ciated values. Accordingly, “under such conditions the accident of personal experience and temperament, and es­ pecially economic outlook and political loyalties will de­ termine the decision. These, being liberal and bourgeois in the majority of the physicians of the time, brought about the victory of anticontagionism.”16 What we end up with, then, is a rather naive mixture of psychologism and s o c i o e p id e m ic

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logism, which it would be wrong to mistake for a rudi­ mentary materialist theory of power and knowledge. In order to avoid these methodological errors and the kinds of interpretations they are likely to produce, we must first free ourselves from the idea that the measures of segrega­ tion were dictated by conservatism and the opposition to such measures by liberalism. And we must abandon the notion that the reform of the health code marked the vic­ tory of the liberals over the conservatives. Medical theories do not rise and fall with political factions. It is an error to believe that the prestige of infectionism rose after the July Revolution and that the later success of contagionism coin­ cided with the triumph of reaction. These strict correlations are historically inaccurate. Contemporary interpretations (as well as Ackerknecht’s interpretation, which is based on them) tell us nothing about actual practices. To describe the latter, we must follow certain methodological rules: 1. Rather than view preventive measures exclusively in terms of liberal or repressive consequences, we must see them in terms of likely positive outcomes, as strategies aimed at producing definite results. In other words, we must relate preventive measures not to the dogma of medicine but to its practice. This leads to the following question: What were the tactical results of various medical theories and concepts? 2. What criteria were used to distinguish between epi­ demic and contagious diseases? What disease types served as frames of reference for research into a new disease like cholera? 3. We must avoid analyzing opposing health measures as stemming from antagonistic principles— one conservative, protectionist, and despotic, the other liberal, free-trade, and humanistic—and look instead for differences in practical effect. What “objects” had to be defined before CHAPTER 7

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quarantines could be imposed or, conversely, superseded by other measures? 4. We must not mistake the following for hard facts: different interpretations of immunity or predisposition; different interpretations of the origin and mode of propa­ gation of disease; arguments in favor of infection or contagion. It is better to ask how different proposals for health code reform depended on the types of objects defined by experience, types of models chosen, and theo­ ries and concepts employed. 5. We must not attempt to link the reform of the health code to changes in the medical profession or the economy, as if these could have had a simple or straightforward effect on the law. Instead, we should look for a common matrix or, to borrow Michel Foucault’s term, a common “epistemological-juridical process.” What economic practices, connected with what problems of preventive hygiene, forced revision of the health code? We should at­ tempt, further, to show how legislative reform responded to a series of problems, initially distinct but ultimately intertwined in such a way as to reveal a common pre­ occupation: “To establish the foundations of a political hygiene that might guide people in their undertakings.”17 What we shall find is that, in spite of appearances, the contributions of infectionism and contagionism were not unequal. Rather than focus on conflicts that were merely superficial, the important thing is to decipher what it meant for a medical-political structure of this kind to be established. THEORIES AND CONCEPTS

The theories of infection and contagion led to the imple­ mentation of opposing practices: one whose purpose was to open up, the other whose purpose was to close down. EPIDEMIC

Physiological medicine argued for dispersal of the pop­ ulation, while germ theory bolstered the principle of segre­ gation. But physiological medicine was not Hippocratism in disguise, nor was nineteenth-century germ theory a warmed-over theory of contagia. The former did not redis­ cover traditional hygienic practices, nor did the latter re­ vive old rituals of confinement. By the first half of the nineteenth century the terms infection and contagion no longer referred to the same concepts, and their associated practices no longer had the same objectives, as in the past. It may be that for a short time the old doctrines were used as points of reference. But it would be quite misleading to suggest that there was any genuine regression. What has to be recognized is that behind these apparent returns to the past a rather complex process of transformation was in fact under way. At work was a new imperative: to separate the ideas of infection and contagion, which at the turn of the nineteenth century were still closely related. It was only after this separation had been accomplished that the two ideas became incompatible. The important questions are the following. How did physiological medicine come to separate the ideas of infection and contagion? Having sepa­ rated them, why did it reject the latter in order to make the idea of infection the basis of a new system of etiology? And how did germ theory come to take the opposite course? This divergence at the theoretical level resulted, in practice, in apparently irreconcilable sanitary measures. The disci­ pline of political hygiene that developed soon thereafter concealed the fact that these measures were actually com­ plementary. But we must not get ahead of ourselves. In physiological medicine the idea of epidemic disease was a secondary notion. Acute illnesses were only continuations or complications of phlegmasias, a term applied to the various possible forms of gastroenteritis. As with gastro­ enteritis, the key problem was to determine the fundamenCHAPTER 7

tal disorder from the symptoms, that is, to show that irri­ tation was the cause of the congestion of the blood. Not the least important consequence of regarding acute disease as belonging to this disease type was that a sharp distinction was made between the proximate cause, namely, irritation, and more remote (“irritating”) causes. Cholera, viewed as an acute form of gastroenteritis, was not unlike various ailments caused by the ingestion of poison. It was also compared to a bilious attack. Pinel, in fact, had described cholera as a “catarrh of the stomach.” Thus the etiology of cholera might have something in common with violent poisoning, or it might have something in common with dis­ eases due to simple failure to observe the laws of hygiene. But since the effects of all these agents were identical (save for their intensity), the distinctions among them quickly lost their importance. The identical outcome—inflamma­ tion—was all that mattered. The remote cause was a trauma of some kind and of no interest to medicine: “The symptoms of the essential fevers, regardless of their remote cause, are always the result of a single proximate cause, inflammation of the internal membrane of the digestive tract.”18 Thus physiological medicine could adduce any number of different causal agents without contradiction. Such causes could range from unknown irritants or conta­ gious agents to climatological factors in unhealthy living conditions to a bad diet. Disease could be the result of momentary contact with any of a broad variety of external agents, but the specific nature of the agent was of no real significance. In physiological medicine, discussion of causality be­ gan with remote causes, but it was deemed epistemologi­ cally prudent to abstract from those causes as soon as pos­ sible. Physiologists proceeded to revive the old Hippocratic idea of “medical constitutions.” The whole discussion harked back to Sydenham’s views on epidemic diseases (as distinct from the “medicine of species”) for which causes of EPIDEMIC

the pathology could be determined. Among the possible factors contributing to epidemic diseases were climate, sea­ sons, rainfall, wind, and quality of the soil. For both Brous­ sais and Sydenham, epidemics and epizooties were appro­ priately treated within the context of theories of nature and the world order. Broussais acknowledged that epizooties, like cholera, break out in the spring. He also admitted that cholera depends on the climate: “We note the prolonged prevalence of dry east winds, contrasting with the heat of the sun.”19 Hadn’t various precursors of the cholera epi­ demic been observed? In Germany, for example, cholera was supposed to have been preceded by a “kind of convul­ sive catarrh” that was given the name “grippe.” Broussais claims that five weeks before the outbreak of cholera he had observed a marked increase in the irritability of the digestive system. This observation was confirmed by Bouillaud. Lemasson, for his part, had observed an increase in diseases of the digestive tract in the fall of 1831. These were sufficiently similar to cholera that he gave them the name cholerine.20 It was even believed that there had been a tran­ sition from the preceding “medical constitution” to the “epidemic constitution” now in force: as we have seen, gastric conditions were more numerous, diarrheas and dys­ entery more frequent. In short, abdominal diseases domi­ nated the scene. But the rediscovery of Hippocratism had not occurred without a major change. Doctors had to con­ sider not only atmospheric factors but also unsanitary con­ ditions and the physical debilitation that these entailed. Therein, too, lay causes of the epidemic. In the end, all these factors contributed to the development of cholera. A strange amalgam of climatological and social factors had resulted in the corruption of a place fashioned not by na­ ture but by the hand of man: some of these factors be­ longed to the medicine of yesteryear, some to the newly emerging discipline of public hygiene. The names of Syden-

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ham and Villermé may be taken as representative of the two possibilities. Yet somehow all these disparate threads had to be knitted into a single fabric. Medical constitutions and liv­ ing conditions are not merely the background [fond) but rather the source {foyer) of epidemic disease. Broussais distinguished three kinds of disease sources: miasmata gen­ erated by the decomposition of dead organic matter (from swamps, beaches, cemeteries, sewers); congregations of individuals (such as prisons, hospitals, besieged cities, ves­ sels); and diseased individuals. This scheme finally elimi­ nated the disparity between natural and social causes of illness. Physiological medicine treated all causes alike, amal­ gamating the legacy of the past with the discoveries of recent years. The disease source was a medical constitution of which Broussais determined the species. The notion of a disease source also played a key role in the infection theory. Its importance was twofold. First, ac­ cording to that theory the source is to the epidemic what the irritating cause is to the individual disease. Treatment therefore requires neutralizing the source of disease: in the case of pneumonia, for example, the patient must be pro­ tected against cold, and in the case of an epidemic the af­ fected population must be protected against the influence of the source, by “encouraging emigration to healthy lo­ cales.” Thus the appropriate tactic was one of avoidance. Second, it was known that the effects of an irritating cause did not cease immediately when the cause ceased to act. In an individual disease congestion of the blood caused irrita­ bility to persist in particular parts of the body. Accordingly, an antiphlogistic treatment was used to reduce inflamma­ tion. Now, the “source of infection” is to the epidemic disease what the “source of irritation” is to the individual disease. The causal role of the source of infection is struc­ turally analogous to that of inflammation: it is a local phe­ nomenon with a radiating structure. The source not only EPIDEMIC

! 54

generates the infection but perpetuates and propagates it. Hence the source, like the inflammation, must be localized and then treated and cured: “What one must do . . . [is] to disinfect the primary source by improving drainage, main­ taining the cleanliness of streets, public places, and docks, and carefully supervising the burial of the dead. If these precautions are taken the spread of the disease is no longer to be feared.”21 What propagates outward from the source is therefore the “infection.” But what propagates into the body under the name “infection” is actually irritation. Irritation is therefore an effect of infection and not of contagion. At first sight this formulation may seem surprising, since it as­ sumes that infection results from contact with one or more infectious agents. Broussais himself said that individuals exposed to an infected atmosphere have their systems “im­ pregnated” by miasmata. He cites the classic examples, the gut-dressers and cesspool drainers, who spend their lives in the midst of putrid emanations. If it is true that there can be no irritation without prior contact, why is it that infection excludes contagion rather than implying it? In order to an­ swer this question we must first examine the notion of in­ fection a little more closely. The word infection was syn­ onymous with stench; it was applied to the odors released by the corruption of organic matter. The term evokes im­ ages of putrefaction and pestilence. It connotes that which is repugnant to the olfactory sense. Etymologically the word is associated with dyeing (from the Latin inficere, to dip into, to stain); the smell of a dyed fabric bore a direct relation to its color. When the word infection was bor­ rowed by physiological medicine, it was this image of the technique of dyeing that ultimately displaced the idea of contagion. The meaning shifted from mere impregnation to something more like impression. Mere contact does not imply pressure and consequent inflammation and hence disease. In other words, noxious miasmata can impregnate chapter

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or touch the living system without inducing disease in the tissue. But when a tissue becomes inflamed, that is, tinted red, it has been “tainted,” impressed rather than merely touched, by the infection. The fever is determined not by the quantity of miasma absorbed but by the intensity of the inflammation. Physiological medicine could therefore in­ corporate the notion of infection provided that it separated it from the closely related notion of contagion. Further­ more, ontologism, the correlative of contagion in medical theory, also had to be rejected: where some saw bodies subject to the influence of harmful miasmata, Broussais saw only tissue from which the “taint” had to be removed. With respect to the tactics of treatment, it is clear that the analogy between infection and the technical procedure of dyeing suggested the possibility of reversing the process. Just as it was imperative to extinguish inflammation within the body, so too was it urgent to eliminate the sources of infection, to disinfect or neutralize the noxious emana­ tions, to drain the swamps, and to prevent waste matter from accumulating in stagnant pools. Those who believed in morbid specificity believed that the epidemic must spread from individual to individual by transmission of a particular germ. Thus the idea of con­ tagion was an extension of the doctrine of morbid specific­ ity. By carrying anatomical-pathological analysis to its highest perfection, Bretonneau was also able to test its lim­ its. This led him to renounce, in part, its interpretive pro­ tocols. In granting the principle of morbid specificity precedence over the principle of localization, Bretonneau affirmed the priority of disease type over physiology. This enabled him to sidestep two of the reigning doctrines of physiological medicine: if “special inflammations” indi­ cated species of disease and specific causes, then focusing attention on inflammations would force doctors to revert to nosography, which Broussais had repudiated, and to EPIDEMIC

treat remote causes, which Broussais did almost entirely by neglect. Emphasizing the action of a specific agent relegated the influence of atmospheric and living conditions to the second rank. To be sure, the notion of specificity was not new. The epithet “specific” had been applied originally, of course, to certain “morbific” causes as well as to certain diseases. “Specific” as applied to causes referred to a hid­ den or occult agent of disease; as applied to diseases it re­ ferred to the existence of distinctive disease characters. But there was no relation between the occult causes of disease and the clear nosographie ordering of the disease species: the specific cause of a disease was not only mysterious but also distinct from the disease itself. With the notion of “special inflammation” Bretonneau established a bridge between the specificity of causes and the specificity of dis­ eases. The notion of morbid specificity was a step toward unifying cause and effect. When proponents of morbid specificity treated the question of disease agents, they seemed to hark back to the old theory of contagia. Fracastoro, in his De contagione et contagiosis morbis et curatione (1546), discussed germs that emanated from diseased bodies and spread through the air to other persons and things. By the nineteenth century, however, the old theory of contagia had been profoundly altered in many ways. For Fracastoro the phenomenon of contagion was one aspect of a general theory of sym­ pathies; he assumed that contagia have selective properties; and he believed in a hermeneutics of premonitory signs, including the conjunction of the planets, the aspect of the heavens, and the character of the winds. The Tours school was a long way from these preoccupations of the Renais­ sance. Contagion was not merely asserted but demon­ strated by careful observation of actual cases. In France and elsewhere it was established that cholera could be com­ municated by contact with, or proximity to, persons suf­ fering from the disease. Curiously, however, the abundant chapter

7

medical literature of the period contains relatively few re­ ports of this kind. Apart from those of Delpech, Moreau de Jonnès, and Littré, which are based on case reports by ob­ scure Prussian health officials, we have the accounts of sev­ eral members of the Tours school: Esprit Gendron, Bre­ tonneau, and Velpeau. The term “contagion” referred in general to all the ways in which disease could be transmitted, but in this pe­ riod attention was focused exclusively on those phenomena that were susceptible of analysis. It is worth pointing out that an analogy was drawn between contagion and genera­ tion. In this there was nothing preposterous: both phenom­ ena involved effects that manifested themselves subsequent to contact of one sort or another and that seemed to be caused by agents whose essential nature remained puzzling. Rather than speculate about something so enigmatic, it was thought more appropriate to proceed by attempting to un­ ravel the workings of these mysterious agents. Naturalists had, ever since the late eighteenth century, distinguished various means of fertilization; similarly, Esprit Gendron, Hildebrand, and Bretonneau worked out the modalities of contagion. And it turned out that these were remarkably similar to the modalities of generation in plants and ani­ mals. In generation there were two kinds of fertilization: direct and indirect. Among animals direct fertilization was the rule. Among plants indirect fertilization was more common, sometimes aided by animate beings such as in­ sects, sometimes by inanimate phenomena such as the wind. Similarly, diseases could be transmitted either by direct contact (from patient to nurse) or by indirect contact (from patient to neighbors via the air, clothing, or a healthy car­ rier). There was a troubling disparity, however, between the simplicity of these modes of transmission and the ob­ scurity that shrouded the nature of the agent. This obscurity called for analytic attack. That attack was mounted in the “metaphorical space” associated with EPIDEMIC

the imagery of growth. Bretonneau likened diseased bodies to sowers of seed. And Hildebrand described the conta­ gious agent thus: “This contagious material must be re­ ceived and take root in the human body or in an animal soil.”22 It is a mistake to think, however, that these morbid “vegetations” were like the species described in the nosog­ raphies. On the contrary, germ medicine was opposed to the medicine of species, just as the study of living plant morphology was opposed to the study of vegetal essences, i.e., as “the order of life” was opposed to taxonomy [to borrow the distinction first made by Michel Foucault— Trans.]. Pathological anatomy disclosed the phenomena of germination and arborescence. Disease vegetates; it is force, growth, and ramification within the body’s organic space. Here the question is the specific effect of germs upon organisms. When Foucault analyzed this decisive moment in the history of clinical medicine, images of vegetality flowed naturally from his pen: “Disease is like an organic system of vegetation, with its own form, root system, and favorite habitat. Pathological phenomena, spatially em­ bodied within the organism along lines and within regions peculiar to their own intrinsic nature, assume the aspect of living processes.”23 Corvisart, G.-L. Bayle, and Laënnec re­ garded this living pathology as a form of degeneration; others, like Bretonneau, treated it as a form of generation. In so doing they were not reverting to earlier ideas of dis­ ease as the enemy of life. Rather, they saw the causes of disease as part of the order of life and of such a nature as to produce specific signs of illness upon contact with living things. Only with such an assumption was it possible to argue that specific lesions must be caused by specific germs. Germs that determine disease forms belong to the bodies they invade: they are prisoners. But in certain circum­ stances the invaded organisms can liberate their germs. Given this concept of disease it was natural to think of pre­ vention in terms of tactics of avoidance, concretely embodCHAPTER 7

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ied in the practice of segregation, i.e., confinement of af­ fected individuals within isolated, supervised areas, where the disease could “vegetate” without disseminating its germs. Isolate the ill—this was what Esprit Gendron thought should be done with the victims of typhoid fever (dothinentery): “The emigration of dothinenterics has all too often multiplied the number of sources of infection. Enlightened administrators and prudent physicians will, through their counsel, oppose emigration, unless it be to hospitals, which are in effect lazarets where the number of people subject to contagion is usually limited.”24 What is propagated by the body’s agency, then, is contagion. But what propagates through the body, though referred to as contagious disease, is actually a “specific dis­ ease,” which is the product of contagion and not infection. This may seem surprising, for contagion presupposes the existence of a cause that produces the illness, a source of infection. Whence the following question: If there can be no contagion without a source of infection, why was it that in the end contagion and infection were held to be mutually exclusive? In order to answer this question we must first delve a little more deeply into the concept of contagion. Contagion and contamination are words derived from the Latin for “contact with filth.” Miasma, a term employed by Esprit Gendron, was borrowed from the Greek for “defile­ ment.” All three words suggest active touching. Attached to them are values and images associated with leprosy. Now, we know that one of the legacies of the age of leprosy was the idea that man is not without responsibility for his own suffering. When physicians began to look for the ori­ gin of disease in a chemistry of the humors, they simply translated the old divine etiology into the language of medicine. The danger of touching was part of the imagery of leprosy, a disease viewed as a moral as well as a physical debility. Hence contagion came to imply infection: the

EPIDEMIC

cause that produces the disease and the cause that propa­ gates it were both inherent in the diseased individual. When contagion was later incorporated into the the­ ory of germs, the mechanical aspect of touching gained prominence and ultimately eclipsed the idea of infection. The reason for this was that a sharp distinction was made between the germ, or cause of the disease, and its vehicle, or cause of transmission. Disease, it was believed, occurred at the point where a healthy individual came into contact with the vehicle o f the germ. Thus disease is first touching. The total separation of the agent of transmission from the morbid cause meant that the diseased person ceased to be responsible for the disease. The infectious agent was at­ tached to the germ, hence the status of the patient changed: the diseased person was now a carrier of the virus, just as a healthy person or inanimate object might be carriers. Re­ jecting the idea of infection also meant abandoning a set of ideas foreign to the principles of germ theory, such as the idea of contact, together with its concomitant imagery of impurity, vice, or degeneracy of the humors. The patient was now seen as a mere temporary host to the disease germ, one host among many others. This is what Esprit Gendron had in mind when he spoke of diseased individuals as “sources of infection.” To return to the notion of conta­ gion and its associated tactics of prevention, it is clear that belief in contagion suggested basing prevention on the avoidance of contact: isolation of germ carriers could break the chain of transmission. By this point it will be clear, I hope, not only how the sys­ tem of infection differed from the system of contagion but also how the former was differentiated from Hippocratism and the latter from the old theory of contagia. From the infectionist point of view, antistimulant and antiputrid (or hygienic) methods were merely different forms of active intervention to prevent infection. If mass diseases spring c h a p te r 7

from and are propagated by sources of infection, then those sources must be eliminated. The air could be vitiated by respiration as well as putrid emanation. No clear distinc­ tion was made between the two. But medical technology could combat infection in either case. Lavoisier lent scien­ tific credibility to the myth that pestilential diseases could be eradicated by adherence to the rules of hygiene. Relief of crowding, aeration, ventilation, and public health regula­ tions all converged toward a single goal: the prevention of epidemics. The meaning of “contagion” was narrowed to encompass only the phenomenon of transmission itself. This change in meaning had repercussions on the signifi­ cance of sequestration. For as everyone knows the separa­ tion of lepers from the rest of society had motives other than belief in the transmissibility of the disease. Isolation was temporary and individual, but sequestration meant permanent removal from the community. In his Histoire de la folie Michel Foucault has shown how social exclusion was interpreted as spiritual reintegration. The response to the cholera epidemic broke not with these old procedures of segregation but with the obsessive images that those procedures had always aroused: in 1832 segregation meant protection against contagion and nothing more. Where in­ fection festered, where the signs of the disease indicated the presence of a taint, people now saw nothing more than a link in a possible causal chain; where they used to see the martyr, the divinely chosen victim, now they saw only the individual who played temporary host to the germ. Thus the arbitrariness of quarantine was gradually eliminated, the arbitrariness that had extended from the docks and borders to the interior of the country, to individual neigh­ borhoods and even homes. Now quarantine meant nothing more than a period (which varied with the disease) of iso­ lation intended to prevent contamination. While these changes were under way, those who were making them failed to see that they were complementary EPIDEMIC

and not exclusive. To the infectionists segregation seemed only to create sources of infection. Sooner or later sanitary cordons always did more harm than good. Sequestration perpetuated and multiplied the sources of infection rather than reducing their number. Such tactics, it was argued, were lethal, because they forced people to live in infected areas, in proximity to death. To confine people was to press them together, to concentrate the disease, and therefore to heighten fear and misery. It was further argued that such measures did no good for neighboring populations, be­ cause the epidemic spread only where there was an active source of infection. By contrast, proponents of the system of contagion believed that opening up diseased areas only allowed residents to disperse. By increasing the number of disease carriers, this subjected even more people to the risk of illness. Not to establish sanitary cordons was to increase the number of possible routes of transmission. Freedom of travel led to reckless dissemination of persons and things, dangerously exposing neighboring populations. On the one hand, supporters of the infection theory denounced the violence, and indeed the cruelty, of segrega­ tion. Diseased cities resembled places under siege: com­ munications were intercepted, prices rose, food ran short. Fear of contagion led to a general breakdown of discipline. Experience had shown such measures to be inhumane. On the other hand, proponents of the contagion theory de­ nounced the cynical collusion of mercantilism and infectionism: goods could flow, and disease followed. Business was satisfied, but populations were decimated. But the re­ course by both sides to humanitarian arguments must not be allowed to mask the essential point. Assuming that the agent of infection remains bound to so-called sources of infection, then it follows that these should be shunned, and hence that the contagion theory is seriously misleading. But if the agent clings instead to individuals, then every dis-

CHAPTER 7

eased person should be kept in isolation, and the pursuit of uninhibited trade involves serious risks. MODELS

If I may anticipate the reader’s objection, perhaps the op­ position between the system of infection and the system of contagion was not as sharp as I have made it out. Perhaps a more subtle account is required. Let me begin by conceding that infectionists did not reject the idea of contagion out of hand, nor did contagionists rule out the possibility of in­ fection. But the infectionists did reject the idea of using contagion to explain diseases like the plague, typhoid fever, and cholera, even if they accepted it without hesitation in the case of smallpox. Broussais, for instance, acknowledged that a sick individual could transmit his disease to a healthy individual (patients constituted an “infection source of the third kind”). Before the outbreak of cholera in France he wrote, “We do not know for certain that what has come out of India is not a contagious principle, susceptible, like variola and vaccinia, of being carried from one climate to another without losing any of its specificity.”25 In other words, if a disease is contagious, it is in the sense that smallpox is contagious. The contagionists, on the other hand, rejected the idea of using infection to explain diseases like measles, scarlet fever, typhoid fever, plague, and chol­ era, but they readily accepted infection as an explanation of fevers due to “atmospheric constitutions” or local condi­ tions. Esprit Gendron and Velpeau conceded that a “source of infection” was responsible for those endemic diseases that for a few weeks each year laid low entire rural villages. This was the attractive aspect of infection theory, its strong point, as many contagionists admitted. Velpeau, for in­ stance, never overcame his anxieties about the yellow fever he had witnessed in Gibraltar, which prompted this quesEPIDEMIC

I 64

tion to Bretonneau: “Do you think that there is a conta­ gious disease . . . that, in the space of four months, can in­ vade a city and spare only twenty-eight of its inhabitants, as occurred in 1804 in Gibraltar?”26 But these remarks, far from justifying the hypothetical objection raised at the beginning of this section, actually tell against it. If this seems paradoxical, perhaps the further discussion to follow will help to clear things up. All physicians agreed that collective diseases were either contagious or infectious. This unanimity was related to a question of methodology. Both the infection and contagion systems incorporated two complimentary principles: the principle of the uniformity of nature (which eschews ex­ treme variety) and the principle of the diversity of nature’s ways and means (which eschews extreme similarity). The only difference between the two systems involved the points at which these principles were applied: the infectionists stressed the principle of uniformity with respect to the propagation of contagious diseases and the principle of diversity or variability for the propagation of infectious diseases, whereas the contagionists did precisely the re­ verse. The contrast between the systems of contagion and infection was heightened by this dissimilar use of identical principles. Applying the principle of uniformity meant first of all choosing a “typical disease” as a point of reference. For the system of infection this was smallpox. The significance of the development of a smallpox vaccine cannot be over­ emphasized. Smallpox became the model transmissible dis­ ease; epistemologically, the model consisted of a mode of contamination coupled with a technique of prevention.27 It was found that smallpox forms an organic substance that serves as the vehicle of the virus. Mixing this substance with the blood of a healthy subject produces a benign form of the disease, resulting in immunity for the individual so c h a p te r 7

treated. This immunization could be repeated as often as one wished. Smallpox was therefore the contagious disease par excellence. Now, the system of contagion allowed room for some fevers caused by infection. These were fe­ vers that attacked many people at once and that could be blamed on some general cause or on local conditions. Gen­ eral causes of so-called constitutional diseases included at­ mospheric changes and deleterious substances carried by the air. Local causes were invoked to explain such diseases as “swamp fever” (observed in marshy locales) and “prison fever” (due to overcrowding). Applying the principle of uniformity also meant com­ paring the propagation of cholera with the propagation of better-understood infectious and contagious diseases. It was hoped that the nature of cholera could be determined by noting any similarities, analogies, or identities between its development and spread and the development and spread of other diseases. Now, according to the infection theory, a disease could be regarded as contagious if it was analogous in cer­ tain ways to smallpox: it had to be a simple disease for which immunity could be acquired and that could be transmitted by inoculation. Cholera, however, was not sim­ ple: it came in a great many different forms. There was no acquired immunity against it: a first attack of cholera did not guarantee immunity from further attacks, and indi­ viduals were known who had contracted the disease more than once. The most important criterion of all was inoculability: all attempts to induce artificial contamination with cholera germs failed, despite the eagerness of many physi­ cians to perform experiments. In these experiments they naturally used the substances presumed to carry the chol­ eraic germs: the blood, secretions, excretions, and property of cholera victims. Foy’s experiments are the best known: “In inoculating myself with blood taken from the veins of cholera victims, in breathing their exhalations, and in tastEPIDEMIC

ing—and not, as has been said, swallowing—vomited liquids, I believe that I have performed useful experi­ ments.”28 Doubtless these were valuable and profitable ex­ periments, but to Chervin they seemed haphazard and unorganized. He therefore proposed the establishment of “experimental lazarets.” This was a dangerous, unrealistic, and illegal proposal, prohibited by the law of 3 March 1822, which decreed the death penalty for anyone estab­ lishing contact with suspect persons or objects. Such, at any rate, was the response to Chervin delivered by the Count d’Argoult upon advice of the Superior Health Council. In any case, the experiments proposed by Chervin would not have proved any more conclusive than those carried out by Foy. The failures did not prove that the contagia could not be transmitted but only that the conditions of transmission had yet to be discovered. According to the contagion theory, on the other hand, a disease could be considered epidemic if the existence of a “local or general influence” could be demonstrated. A dis­ ease that attacks many people at once suggests a cause of this kind. General influences included miasmata carried by the air and “atmospheric constitutions.” Cholera, for in­ stance, was thought to have attacked areas swept by certain winds. The epidemic was said to have moved in a direction opposite to the prevailing winds, propelled by contrary air currents. As for atmospheric constitutions, research was to focus, for example, on atmospheric changes induced by the alternation of heat and cold. Cholera could be devastating in any season and not just in the spring and fall like most other fevers. Local influences were to be found both in na­ ture and in the cities. If cholera had depended on locale, it would have remained limited to certain regions. But it was known that the disease had been equally virulent in places of widely different topography. Emanations from marshes and rivers could not have been necessary to cholera, which was known to have spread to deserts and other arid regions chapter

7

south of the equator. If cholera required unhygienic or crowded conditions, it should have spared clean places and individuals respectful of the laws of hygiene. But this was not the case, and, what is worse, some filthy areas had es­ caped unscathed. Unhygienic conditions were frequently chronic, moreover, whereas cholera was a temporary phe­ nomenon. From this Moreau de Jonnès concluded that “the negative propositions, established by these facts, prove beyond a shadow of a doubt that cholera obeys none of the laws of epidemic disease.”29 So the adversaries of contagionism had their experi­ ments, and the adversaries of infectionism had their obser­ vations. But the significance of these observations and ex­ periments was not simply epistemological. Both served to calm the population. In Warsaw Foy behaved much as Desgenettes had with the soldiers of the Army of the East, when in order to bolster the courage of the hospitalized troops he had plunged a lancet into the pus of a bubo and then pricked himself in the groin and armpit. When Foy inoculated himself with the blood of a cholera victim his experimental gesture was intended not as proof (démon­ stration) but as illustration (monstration). It was a spec­ tacular gesture of defiance, intended to ridicule and silence the people’s fear of the disease. Similarly, the contagionists’ observations also had a defensive psychological purpose. By showing that the cause of cholera did not lie in the envi­ ronment, these observations proved that there was no dan­ gerous miasma lurking in the atmosphere. For what could be done to ward off such a danger? “If one were forced to admit that this disease is purely epidemic, which is to say caused by miasmata swimming in the atmosphere . . . then surely no human power could halt its dissemination . . . [and] mankind would then have to submit to its sad des­ tiny.”30 Thus to see each cholera victim as a germ carrier was to some extent reassuring. The infectionists, who saw contagionism as a fatalistic doctrine that sowed fear EPIDEMIC

16 8

among the population, were themselves subject to the same reproach. To return to the question of the nature of cholera, re­ search by members of the two schools produced diametri­ cally opposed results: the infectionists believed they had ruled out the possibility that cholera was contagious, while the contagionists believed that they had shown that cholera could not possibly be infectious. These negative results had positive counterparts: infectionists believed that cholera was an epidemic disease, while contagionists believed that it was transmitted by contact. Both sides invoked the prin­ ciple of variability. The infectionists were well aware that none of the usual causes of epidemics satisfactorily ex­ plained the propagation of cholera. But for them this sim­ ply meant that the true cause had yet to be discovered; invisible was not the same as nonexistent. A choleraic “emanation” or “atmosphere” must exist, but for the time being its nature remained unknown. Rochoux therefore fastened eagerly on every new report or discovery: “Ac­ cording to the German newspapers, thick green vapors were seen to cloud the atmosphere shortly before the out­ break of cholera morbus in Riga, and similar observations appear to have been made in several places struck by this disease.”31 Similarly, the contagionists were well aware that cholera is not transmitted in the same way as small­ pox. Still, was it not reasonable to assume that every con­ tagious disease has its own particular mode of action? Scabies was known to be transmitted by contact, rabies by puncture, venereal disease by friction, and typhus, measles, and scarlet fever by the air. And germs could be carried by many different vehicles, such as the pulverulent substance of smallpox pustules, the pus of plague buboes, and the saliva of rabid animals. Thus contagious diseases were transmitted in many different ways. “Why should it be any different with cholera morbus? Why should it not

CHAPTER 7

have its own special mode, its own special conditions of contagion?”32 Confronted with a problematic disease, medical thinking clearly vacillated between two possible responses: physi­ cians first attempted to interpret the unknown in terms of familiar models and, when that failed, invoked the variety of nature’s ways and means, postponing proof of their hy­ potheses indefinitely. The essential points are these: For infectionists smallpox was the type of all contagious dis­ eases. Failure of attempts to demonstrate that new diseases were transmitted in the same way as smallpox led to the assumption that smallpox was the exception to the rule and that the new diseases must be infectious. For contagionists the impossibility of modeling the propagation of the new diseases on that of certain known fevers supported the hy­ pothesis that those fevers were the exceptions to the rule that most diseases are contagious. The difference between the system of infection and the system of contagion was at once infinitesimal and irreconcilable. Infinitesimal because both systems accepted the distinction between an infectious mode and a contagious mode of transmission. Irreconcil­ able, not because the contagionists saw a rule where the infectionists saw an exception and vice versa, but because rule and exception were both interpreted as indices of the differences between the objects treated by the two theories. It is when we examine the empirical objects on which each theory focused that we understand why the differ­ ences between the two systems were truly irreconcilable. For the infection theory treated populations, whereas the contagion theory dealt with individuals. The battle lines actually coincided with the objects of study: city doctors saw infection whereas rural doctors saw contagion. The infection/contagion opposition overlapped the city/country opposition. To unravel this conflict fully we must pause a moment to examine these related matters, which heavEPIDEMIC

ily influenced the study of the propagation of pandemic diseases. OBJECTS

During the first half of the nineteenth century both the cities and the countryside experienced epidemic disease. Various social factors made it simpler to demonstrate the process of contagion in rural areas while complicating the picture in the cities. Contagionists used the comparative data to provide experimental proof of their theory, inde­ pendent of the environment, whereas infectionists used these same data to demonstrate the influence of the envi­ ronment and living conditions. But one’s choice of one system or the other did not depend exclusively on where one lived. Social factors were necessary but not sufficient. Rural observers focused on how disease was transmitted, while urban observers focused on the spread of slums. Urban theorists centered attention on the masses, rural ob­ servers on individuals. Parisian physicians elaborated the theme of epidemic disease because it was associated with the system of infection. Provincial physicians who sup­ ported the germ theory also believed in contagion; it was as a direct consequence of the doctrine of specificity that they noticed the role of migration in spreading the disease. Thus two incompatible approaches to cholera took shape, each with its own specific object of inquiry. I shall here be concerned with how these two distinctive ways of seeing came to be. The two approaches were so different that some writers have believed that their opposition must have stemmed from the long-standing rivalry between Paris and the provinces, between power and knowledge: the country doctor with his plain truths versus the arrogant physicians of the faculties, blinded by prejudice and swol-

CHAPTER 7

l 7l

len with authority. This picture is arresting but naive. I be­ lieve that the following account comes closer to the truth. No one could fail to see the difference between the great scourge of cholera, a disease that descended upon a large city and wiped out thousands of people in a few weeks’ time, and the relatively limited epidemics that had long been familiar in the provinces. It was the difference be­ tween “macrocontagion” and “microcontagion,” or, as Esprit Gendron put it, between the grand epidemics and the “epidemics in miniature.” Thanks to the reduced scale of the latter, physicians were able to follow the precise course of the disease: details that were invisible in the city stood out with clarity in the countryside. The more circumscribed the epidemic, the easier it was to follow the path of con­ tagion. It was therefore the role of rural medicine to map epidemic disease. From farm to hamlet to burg to village the progress of illness could be traced. Lines of develop­ ment could be drawn and the source of the disease located; when and in what circumstances each individual had fallen ill could be determined with precision. Such research was inconceivable in the city: by the time the authorities be­ came aware of what was happening the disease had already claimed large numbers of victims. The physicians of the capital were so little attuned to the early progress of cholera that they pointed to its rapid spread as certain proof of its infectious nature. Dark, labyrinthine, and overpopulated, the city contrived to hide the epidemic’s tracks. By contrast, rural epidemiologists had the keen eyes of expert scouts. Littré explains why: “It is above all in the country, where dwellings are isolated, that such observations can be made. They are impossible in the cities, where people live crowded together and in frequent contact with one an­ other.”33 This constant mingling had two seemingly contraditory consequences: a decrease in the number of new cases, which suggested that the disease was on the wane, EPIDEMIC

coupled with a stubborn persistence of the epidemic, which resisted final eradication. This stability of the disease was due to the large number of possible paths of contagion. Hence the likelihood of transmission increased and the probability of prevention decreased: “The influence of a more mobile population and of more numerous indirect contacts is making itself felt. Once the number of cases reaches a certain point, the epidemic seems to stop obeying the rules that it had previously followed.”34 A second difference between urban and rural popula­ tions had to do with the nature of personal relationships. Family ties in the city were relatively loose. In Paris, for example, family members were frequently scattered around the city in various rooming houses, schools, and work­ shops. People who lived on the same floor in the same building often did not know one another. In extreme cases individuals were simply abandoned to their own devices. This was common among hospital patients, where the staff had many concerns other than the patients’ welfare. Here is Magendie’s edifying account: “More than once, upon ar­ riving unexpectedly, I was chagrined to find all my male nurses huddled around the fire and ignoring the cries of the dying, and more than once I was forced to fire them all on the spot, even before I could be sure of finding others to replace them.”35 Oddly enough, it was to this unstable group of hospital workers that Parisian physicians referred when they argued, in opposition to the contagionists, that, compared to other occupational groups, relatively fewer hospital personnel had succumbed to the disease. In the countryside the picture was remarkably differ­ ent. To begin with, most families slept together in a single room. In large families beds were shared by several indi­ viduals. Family ties were closer: peasant families stayed to­ gether. And there was solidarity among families. Relatives and neighbors helped one another. If a servant fell ill, for example, a relative would come to offer care and perhaps CHAPTER 7

1 73

to take the person away to live with his or her own family, even if that meant traveling a distance of several leagues. Patients in the country received constant and attentive care: “The rural practitioner finds a host of important facts to observe in such habits and relationships, and no deliberate experiment could possibly yield more significant results.”36 Contagionists were particularly interested in those who nursed the sick, for they were thought to be disseminators of the disease. Finally, an observer who hoped to follow the course of a spreading disease had to be in a position to follow peo­ ple’s movements. This was rarely possible in the city: such information was at worst unavailable, at best incomplete. Most of the sick lived in furnished rooms. Boarding-house keepers were reluctant to damage their reputation by re­ porting cases of illness. The sick themselves knew nothing about previous occupants of their rooms. Hospitalized vic­ tims could say little about the circumstances in which they had contracted the disease. Most were people who ne­ glected their health and who proved unhelpful to those who questioned them: “Poverty casts them out; their rela­ tives ordinarily know no more than they do, if they so much as show up to offer information.”37 In large cities investigations were hampered by other factors as well. Many of the sick hid their illness so as not to lose their jobs. Thus the doctor was called in too late. In some cases the cause of death was challenged. For all these reasons it was difficult to know where the earliest cases occurred and hence how the disease entered and spread through the city. Finally, an investigation could only be carried out if a single doctor saw and treated all the victims in a given neigh­ borhood or house or hospital. This was rarely the case. By contrast, the rural doctor was informed about all aspects of the problem. He knew the state of health of everyone in the village, and knew which people came and went. In communication with nearby colleagues, he could EPIDEMIC

gather additional information when necessary. Villagers knew one another well and could provide an exact account of the circumstances preceding and following the outbreak of disease. Bretonneau, known for his plain speaking, had this to say to Velpeau: “The peasants will go against you once again. In the fields the contagion can be tracked, and there people say what they think.”38 Thus it was up to the rural physician to follow the contagion and establish the paths of transmission. Someone may object that there were contagionists in the cities as well.39 But that meant simply that they held cholera to be a transmissible disease. Contagionism was a hypothesis that guided observation. The isolation of rural villages was of course not total. Strangers to the community were quickly spotted. Migrant workers returned home after the harvest, villagers returned from lengthy journeys, people came from places struck by the epidemic.40 The contagious character of disease was often obvious to villagers, who named diseases for the places in which they first appeared, the places where they had been “imported” into the village. Esprit Gendron noted that it was generally the person who took care of the first victim who was the next to succumb. From there the disease spread in ever widening circles—but still, circles with a discernible perimeter. Villagers and family members succumbed in the order in which they contacted the initial victim. In small communities the disease spread from fam­ ily to family; examples were known in which related fami­ lies had been struck but neighbors spared. In interclass contaminations domestic servants played a role analogous to that of family members who nursed victims: “When it [contamination] affects the more fortunate classes, it is gen­ erally by way of the domestics, intermediary agents of communication between one class and another.”41 Some boarding schools and garrisons were spared, apparently because of their isolation from the rest of the population.

c h a p te r 7

175

But again, this isolation was not complete. If a student or soldier who had contact with the outside returned to his dormitory or barracks, the whole group could come down with the disease. Finally, on a broader scale, the progress and chronology of the disease seemed to confirm what had been established in rural areas, that it was contagious in nature. Bouillaud, who denied that cholera was contagious, could not overcome his anxiety on this score: “Nations can be thought of as enormous individuals, and it may be that the first to succumb spread the disease to others, if, con­ trary to the opinion we have stated, this disease is trans­ mitted via what is properly called the contagious route.”42 With such strikingly convincing proof that cholera is a contagious disease, why did a large segment of the medical profession refuse to accept the idea? Does the blame lie with the rivalry between the capital and the provinces? The members of the Royal Academy of Medicine greeted the observations of Esprit Gendron with astonishment and de­ rision. And Broussais condescendingly observed of Breton­ neau that he was a “provincial practitioner, famous, it is true, in his own département”*3 Doubtless it was evidence of this kind that led Brochard to point out that most of the physicians who based their belief in a contagious form of cholera on empirical observation lived in small communi­ ties. To which he added that “nothing was missing from their research, but their pronouncements lacked author­ ity.”44 In fact, however, what their pronouncements lacked was not so much authority as response. And response was precisely what the pronouncements of the Parisian doctors did not lack: what they said was heard loud and clear. This was because the idea of infection, which they championed, resonated with the concerns of government administrators. The needs of medical technology converged with the needs of political reform. Hygienists, philanthropists, adminis-

EPIDEMIC

trators, and property owners all demanded the elimination of sources of infection. The battle against filth and poverty, the most visible causes of the epidemic, was not only a medical but also a political and moral necessity. Everyone saw the eradication of sources of infections as the way to alleviate a public calamity. The government and the wealthy felt that it was incumbent upon them to eliminate poverty by creating jobs, taking care of diseased paupers, and making hygiene a part of public education. These generous endeavors left country doctors indif­ ferent. To them, class division was more a geographical fact than a cause of inequality in the face of death. They saw no substance to the idea of a “morbid influence” associated with filth and impoverished living conditions: “The con­ tagion acts in proportion to the frequency of contact and the number of cases of disease, independent of the filth of the locale, the poverty of the inhabitants, or the neigh­ borhood of the dwelling.”45 But contagionists did not deny that the disease generally afflicted the poor. This was be­ cause it followed certain “lines of transmission.” As for filth, it was suspect as a receptacle of germs and not as a “source of infection.” Infectionists saw the system of contagion as pro­ foundly reactionary, as the following remark of Rochoux’s suggests: “One revolting absurdity of this system is that in explaining the propagation of the disease it takes no ac­ count of the scarcity of food, of overcrowding, of filthy drains and sewers, of the accumulation of decaying gar­ bage, of pollution of the air, etc.”46 To these vehement and unjust accusations Hildebrand had responded before the fact with his recommendation that the authorities con­ cern themselves with individuals rather than large groups: “Governments should still devote their most strenuous at­ tention to the individual, because it is often upon the indi­ vidual that preservation of the public health depends.”47

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PROBLEM S

Both the system of infection and the system of contagion were a long way from finding empirical confirmation, al­ though both sought to bring their theoretical principles into line with observed fact. Each doctrine was confronted with three problems. First, no epidemic attacks every indi­ vidual in its “area of influence.” It is hard to account for this in terms of pure pathology. Similarly, no contagion affects every person who is exposed. How is it that causes supposed to produce constant effects are so easily deterred? The second problem has to do with the origin and spread of epidemic disease. When one looked at where epi­ demics initially appeared, the evidence seemed to favor the infection theory over the contagion theory. But if one looked instead at how disease was transmitted, the con­ tagion theory seemed to gain and the infection theory to lose support. Thus the difficulties faced by the two theories were symmetric and inverse: one side had to account for the progress of the epidemic without bringing in the ideas of contagion or importation, while the other side had to explain the origin of the disease without using the notion of infection or source of infection. The third problem has to do with the proofs adduced to show that the pathogenic agent was, in the one theory a miasma or atmospheric pollution of some sort, in the other theory a germ or virus. I shall attempt to show that even though the causal hypotheses being tested were irreconcil­ able, the proposed methods for testing them drew upon the same empirical domain (champ d'expérience). Let us begin with the first of the problems posed above: When an epidemic strikes a city or rural area, why are some afflicted and others spared? In the system of infection, the epidemic cause, whether local or general, acts on all who

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happen to be within its zone of influence. But this influence is not uniform. According to Magendie, the entire popula­ tion of Paris experienced the epidemic influence, but to varying degrees. Why were different people affected in dif­ ferent ways? Broussais and Bouillaud, parting company on this point with Magendie, argued that some residents of the city had not been touched by the influence: “If anything ought to astonish us, it is not that several people in the same house or apartment were struck when an entire pop­ ulation was subjected to a general epidemic influence; it is rather that a large number of people in this population were fortunate enough to escape the effects of that influ­ ence.”48 As for the system of contagion, a single contact was presumably enough to ensure transmission of the dis­ ease. How, then, could it be explained that some people who had frequent contact with cholera victims did not con­ tract cholera? In short, then, no matter whether the cause acts on everyone simultaneously or on each person indi­ vidually, it does not always produce the expected effect. Obviously there must be some perturbing element, some factor capable of nullifying the effects of a cause that is supposed to affect everyone in the same way. The solu­ tions to this problem proposed by contagionists and infectionists seem rather similar at first sight. The infectionists alluded to “predisposition” and “resistance,” whereas the contagionists spoke of “aptitude” and “immunity.” The meanings of these pairs of terms are obviously quite similar and refer to the two possible states of an organism with respect to disease. In fact they are merely a way of re­ phrasing the observed fact that some people become ill and others do not. It had long been known that some people did not succumb during epidemics, either because they had had the disease before or because they had robust constitutions. Upon closer examination, however, it becomes clear that the pairs predisposition-resistance and aptitude-immunity are not entirely identical in meaning. Both suggest that cirCHAPTER 7

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cumstantial factors can either favor or retard the causes of disease. But for the system of infection those circumstantial factors were closely related to living conditions and the en­ vironment, whereas for the system of contagion they were related to the “organic economy” of the individual. At first sight, it is surprising that the epidemic worked in favor of the system of infection. To understand why this was so, we must look at another aspect of the notion of infection, its astrological component. It was this that Ma­ gendie had in mind when he alluded to an “epidemic influ­ ence” and that Broussais had in mind when he spoke of “unknown atmospheric influences.” And it was this that many other physicians had in mind when they insisted on the existence of a “choleraic atmosphere” affecting man­ kind. Somewhat earlier, Buffon, in his Dégénération des animaux, mentioned the “tinge (teinture) of the heavens,” a term he borrowed from Paracelsus to explain certain peculiarities of living things. Like climate, infection re­ ferred to the influence of heaven on earth. When Magendie said that the entire population of Paris had been afflicted with cholerine, a benign form of cholera, he was surely thinking of a general cause from which no one was exempt. The meanings of the words “epidemic” and “infection” were in fact identical, as Nysten demonstrated by etymol­ ogy: “From the Greek epi-, upon, and demos, people. A disease that simultaneously attacks large numbers of people in the same place, and which depends on a common and general cause that comes about accidentally, such as an al­ teration of the air.”49 The term “epidemic” denoted not only the magnitude of disease, the quantity of patients, but also the cause, or quality; epidemics were remarkable both for the number of their victims and for the nature of their cause, which, as Nysten noted in his definition, was acci­ dental, unexpected. In 1832, however, the high death toll in a short period of time was the sign not so much of a cosmic force as of the heightened susceptibility of the human orEPIDEMIC

ganism. Even as physicians invoked remote and occult in­ fluences, they linked the lethal consequences to a quite proximate cause: the conditions in which people lived. Dalmas avoided mentioning the reason for the deadliness of the disease to which he nevertheless clearly alluded: “In Paris as well as in northern and eastern France, the cholera has shown itself to be as grave and as virulent as in the heart of Russia or India. This deplorable fact has to do with a host of considerations that would be tedious to explore here and which, having to do with the state of French soci­ ety, fall within the purview not so much of medicine as of politics.”50 Living conditions explained why the poor were dispro­ portionately likely to fall ill. Indeed, living conditions im­ pressed a predisposition to the disease upon the organism. This idea accorded well with the idea of sources of infec­ tion. It explained the affinity between the cause of the dis­ ease and the bodies of its victims. Just as a spark will “take” only where there is inflammable material, so the cholera will attack only those who are “susceptible”: “One might say that there is a sympathy between this scourge and human misery.”51 When Brière de Boismont spoke of the “raw material” of the epidemic, he was describing the poor classes, a segment of the population “given” to disease. Thus the survey of infection sources can be related to the map of poverty and its companion, death. In every major European city the boundaries of poverty and the bound­ aries of disease were found to coincide. Weakened individ­ ual constitutions were related to living conditions, which at this stage were held to be the decisive factor. Wasted bodies due to poor living conditions were particularly receptive to epidemics. The system of infection, which emphasized the pathogenic character of the social environment, came close to denunciation of society as then constituted. The 1832 epidemic pointed up the similarity between the provinces of France and rural India. Dalmas alluded to politics; CHAPTER 7

Emangard described its effects: emaciation, suffering, and undernourishment, and if, in addition to these, one took account of “the influence of small and poorly ventilated houses in which several families sleep crowded together on cots and rags, one can see the horrible and true counterpart of the hideous picture we discover in India, where miser­ able pariahs deprived of nourishing and healthy food are forced to sleep on damp mats.”52 The dividing line between resistance and predisposition was therefore an internal divi­ sion within French society. The difference between consti­ tutions susceptible to cholera and those not so susceptible stemmed from the opposition between the classes. Cholera affected the poor and spared the rich: “This special predis­ position . . . is lacking in many individuals. It is more and more absent with each passing day, as the epidemic moves toward more enlightened, more comfortable populations.”53 The system of contagion worked out the ultimate im­ plication of the analogy between the morbid principle and the seeds of plants. If the virus takes root in some people and not in others, the reason is that viruses are like seeds. Certain soils are not suited to certain seeds. A given species of plant is compatible with some soils, for which that species has an affinity, and incompatible with others. The same is true of the virus of a disease and individuals. These comparisons were based, in general, on parasitic diseases. The earth has its flora and fauna, man has his parasites. Listen to Prost: “With this we come to the great question of contagion, and we can treat it, in regard to all life, by re­ ducing it to the question of what happens in nature when it comes to the multiplication of species that live at the ex­ pense of other species.”54 The “human economy” is the prize in a great battle, the target of invasion by inferior organisms, some perceptible, others not. From this combat the individual emerges as either victor or vanquished: vic­ tor if he has immunity, vanquished if he shows an “ap­ titude” for the disease in question. EPIDEMIC

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The notion of “terrain” was carried over from geog­ raphy to medicine. It is curious to note that in the process it came to be associated with the juridical notions of aptitude and immunity. No doubt this was because “aptitude” (in the sense of fitness to receive an inheritance or gift) and “immunity” (in the sense of exemption from some tax or obligation) were based on social rank, on family ties or blood. These were viewed as natural prerogatives. The es­ sential point is that the analogy that was established be­ tween individuals and types of terrain obscured the re­ lationship between the individual and his environment. As a microcosm, the individual was presumed to have, from birth, either an aptitude for or an immunity against disease. Hence the contagion system limited its view of man’s re­ lationship to the causes of disease to one of acceptance or rejection: “There must be a prior disposition of the body, which favors the elective attraction existing between this organ and the contagious virus, and in like measure the development of the initial roots of the disease.”55 In the system of contagion the environment exerts no influence, since the organism is said to be like a soil that accepts (or rejects) the invasion of the germ. The organism is a plot of land that is either hospitable or inhospitable to the disease, whose germs can either take root or fail to take root. Once the disease takes root, the organism is powerless to alter its preordained proliferation, its evolutionary course. The second problem confronted by both the system of in­ fection and the system of contagion concerned the origin and spread of epidemic disease. Both systems agreed that every disease has its native region. The plague originated in the Nile delta and in western Asia. Smallpox came from Arabia. Yellow fever began in the New World and was prevalent in the Mississippi and Orinoco deltas. Cholera first developed along the banks of the Ganges. Thus the sources of epidemics lay in the mouths of great rivers, in c h a p te r 7

stagnant bodies of water, and in hot regions. Both systems also agreed that epidemics traveled along the major inter­ national trade routes. Yellow fever had crossed the ocean by ship. Cholera followed in the wake of armies, caravans, and ships. Two things seemed certain: epidemics were born abroad and followed the same routes as men. These facts both supported and contradicted the two reigning systems. The infection theory was bolstered by the idea that epi­ demics were born abroad, which seemed to argue for the existence of sources of infection and spontaneous morbid­ ity. But the course traveled by these diseases seemed to confirm the idea of importation and the associated notion of transmissibility and hence worked in favor of the con­ tagion theory. Conversely, the itineraries weakened the in­ fection theory and the foreign origins weakened the con­ tagion theory. It behooves us to examine, therefore, how each system handled these difficulties. The infection theory, with its notions of general influ­ ences and local sources of infection, seemed hard put to explain the itineraries followed by the major epidemics. How could such well-defined routes of travel be reconciled with the idea of an atmospheric influence? “It may be that causes whose nature is unknown to us introduced into each of these countries in succession a medical constitution similar to that which caused the disease to break out in Jessore.”56 This hypothesis seemed quite tenuous to Bouillaud and Magendie, who preferred to leave the question in suspense. Quid divinum? Broussais, on the other hand, be­ lieved he had a way around the difficulty. This was because he favored the idea of a sharply circumscribed local influ­ ence, and one that was mobile besides. There was no reason why sources of the first kind could not generate sources of the second kind. The spread of yellow fever was a good example of the process: born in hot, damp countries, it traveled with ships, just as typhus traveled with armies. This was possible because on board ship and among troops EPIDEMIC

on the march there existed local causes similar to those that originally produced these diseases. Broussais had no doubt that cholera had followed a similar course: “No matter what anyone says, a gastroenteritis can never travel in this fashion or transmigrate from one latitude to another. It can proceed in this way only in the wake of war, famine, or other major calamity. We believe this to be the case with the cholera morbus in the Russian and Polish armies.”57 Thus the transport of cholera was in no way incompatible with the idea that the disease was the product of a cir­ cumscribed and spontaneous local cause. This cause was continuously active and constantly renewed. It was regu­ larly produced and carried by such microsources as armies, ships, caravans, and groups of pilgrims—ambulatory epi­ demic material, as Foy called them. If the sources of infec­ tion in Europe were the dark sewers of the big cities, they had their exotic counterparts in the warm, humid, swampy countries of the east. Sources of infection—seemingly no­ madic—could be carried far from their native lands and transferred from the banks of the Ganges to the banks of the Seine with never a mention of contagion or importation. The system of contagion, for its part, could easily ac­ commodate the idea that epidemics were bom in exotic places. All that was necessary was to designate those places as “zones of origin.” If a particular disease developed in one region rather than another, that simply proved that the distribution of such zones was like the distribution of ani­ mal or plant species. Viruses obeyed the same laws of geo­ graphical distribution as living organisms. With morbid germs it was simply the case that, as Moreau de Jonnès put it, “their distribution is analogous to the distribution of species of the organic kingdom; and each one is born, like plants and insects, in a particular region from which all others are excluded.”58 To ask about the origin of morbid germs therefore makes no more sense than to ask about the origin of the horse or the rosebush. The idea of an imported CHAPTER 7

virus contrasted radically with the notion of a source of infection. The route of contagion correlated well with the idea of a foreign origin. Like any plant or animal species, germs are born in one place or another; but they follow regular lines of communication and eventually become ac­ climated in other regions. The third problem was that regardless of whether the de­ leterious principle was a miasma emitted by some source of infection or a germ, it remained a mystery. What Dupuy­ tren had said about yellow fever applied also to cholera: “In this respect at least, the two theories are entirely equal. The first to give a body to its hypothetical agent will thereby acquire a marked and incontestable superiority over the other and a great claim upon the gratitude of the public.”59 Infectionists, who believed that some kind of deterioration of the atmosphere was responsible for the disease, based their research on chemical analysis. Investi­ gation showed that the quality of the air in a confined space did undergo change. Many experiments were subsequently carried out on the air of rice paddies (Moscati) and the emanations of marshes (Brachet). As we saw earlier, Julia de Fontenelle analyzed the air from different sections of Paris. But the results were nil. Sérulas believed that the choleraic principle was connected somehow with the water vapor in the air. Using a freezing technique on samples of air from cholera wards, he collected water that had been held in suspension in the air. But analysis of this water turned up nothing but its primary constituents. The contagionists met with similar failure. Analyses of pus from the buboes of the plague or from abscesses as well as examina­ tion of other materials supposed to contain the germs of various diseases always yielded the same results: gelatin, albumin, fibrin, and various salts. The virus eluded every attempt to identify it. Physical measurements using eudi-

EPIDEMIC

ometers and chemical analysis also failed to disclose the cause of the disease. Scientists therefore gave up hope of discovering the epidemic or contagious agent but continued to look for proof that one or the other existed. If the agent itself could not be pinpointed, perhaps the vessel or vehicle could: one could study not the miasma but the atmosphere with which it was mixed, and not the virus but the vehicle that carried it. These objects could be studied by means of the senses: smell and sight. Infectionists believed that the sense of smell was an infallible detector of atmospheric changes: “The sense of smell frequently warns us, through unpleasant im­ pressions, of this aerial adulteration. . . .Vitiations of the air and their effects on us are thus undeniable.”60 Was there, for instance, a connection between the stench of the hospital and the cause of the disease? “In 1813, when typhus devastated Mainz following the rout of Leipzig, a peculiar odor could be detected ten paces from the hospital entrance. Was this the principle of typhus?”61 As for con­ tagion, since it was concentrated in the body, the sense of sight was particularly important. The envelope or matrix of the germs could be detected at a glance. This was because each virus contained both an active principle inaccessible to the senses and “a visible material component visible to the eye or detectible by the other senses.”62 It was believed that nature did with viruses what art did with various aromatic essences. Although it was impossible to give body to those essences, they could be combined with a liquid. It was known that the variola virus was carried by a visible fluid and the typhoid virus by the nasal mucus. But this knowl­ edge derived from the senses was of no use in the investiga­ tion of cholera. Just as the sense of smell failed to reveal the existence of a choleraic atmosphere, so did the sense of sight fail to disclose the substrate of the choleraic germs. Contagionists and infectionists therefore both looked to other empirical data. Infectionists believed that a noxCHAPTER 7

ious principle in the air could affect large numbers of peo­ ple in a very short period of time, whereas contagionists believed that the cause of the disease was transmitted from individual to individual, as had been observed in the prov­ inces. Therefore infectionists looked for simultaneity in the hope that this would prove that cholera was an infectious epidemic, while contagionists looked for sequences in the hope that this would settle the matter in favor of contagion. Both sides found what they were looking for. Forced into Procrustean beds prepared by both theories, unsophisti­ cated and careless observation soon turned up positive proof that each was correct. Infectionists held that the si­ multaneous outbreak of cholera among the residents of a single house or neighborhood or city provided a strong ar­ gument in favor of their view. Contagionists pointed to the well-documented cases of transmission as an irrefutable ar­ gument. We may safely neglect the interminable and tedi­ ous arguments to which these observations and subsequent embellishments gave rise. They were the product of nar­ rowly partisan views. The facts seemed contradictory be­ cause they were arranged in highly dogmatic ways. Yet some physicians conceded that the disease might spread in more than one way. For example, Littré said that “these modes of propagation mix and combine with one another, but in highly unequal proportions, and it is by considering them all that one can best arrive at an adequate idea of the progress of the epidemic.”63 Significantly, Chamberet de­ plored “the absence of a term capable of expressing the subtlety of the transmission from one place to another, which overwhelms and obscures the transmission from in­ dividual to individual and yet which cannot be regarded as an epidemic or purely atmospheric influence.”64 The shift in meaning that is so obvious to us, between the lack of an epidemiological theory of cholera and the lack of a term, went unnoticed by contemporaries. This was because med­ icine at this point could only interpret the mechanism of EPIDEMIC

propagation in terms of the opposition between epidemic and contagion; its only criteria were simultaneity and succession. In the system of contagion the terms “aptitude” and “im­ munity” referred to natural dispositions. This “naturist” version of the exemption and receptivity phenomena was not opposed to disinfection per se, provided it was strictly limited to the neighborhood of the contaminated: “Isolate the sick, cleanse dwellings, disinfect clothing and linen; chemically destroy the deleterious principles that the intes­ tinal evacuations produce or carry with them. . . . These are the means to use.. . . They are infallible.”65 These rec­ ommendations were useful and judicious but limited in scope. As for prevention, cholera still awaited its Jenner. The system of infection, for its part, stressed the inter­ dependence of living conditions and predisposition. This led to the idea that if predisposition to cholera were to be eliminated, living conditions would have to be improved. Ultimately this extended even to medical guidance of city planning: Dupuytren argued that physicians ought to select healthy sites for construction, and Dalmas dreamed of re­ building and improving those eastern breeding grounds of the plague, Constantinople, Smyrna, and Cairo. It was further believed that public hygiene was to the population at large what vaccine was to individuals: “It is in the exe­ cution of administrative and hygienic measures designed to calm the public mind and to improve social conditions that we shall discover the true means o f protecting against cholera.”66 The system of infection derived prestige from its ap­ parent advantages in the battle against epidemics. General disinfection seemed more promising than local disinfection. Cleaning up sources of infection suggested a sweeping at­ tack on the roots of the disease, compared with which the neutralization of germ carriers after the disease had struck CHAPTER 7

seemed risible. Indeed, to attack the breeding grounds of cholera was to strike at both the cause of the disease and the cause of its spread, while offering the further advantage of appearing to be a preventive measure. But the sanitary code was based on contagionist principles: disinfection, isolation, quarantine. Hence the attacks of the infectionists all converged on the French health code. A POLITICAL HYGIENE

In the history of the revision of the sanitary code, two dates stand out. It was in 1822 that a new code was promulgated in France, confirming and strengthening steps already taken along the Mediterranean coast. This code embodied all the severity of the health regulations of centuries past. It gave local authorities exorbitant discretion and provided very heavy penalties for various infractions. In 1853, however, a flexible and open international health code was adopted that would ultimately serve as the model for later treaties. This new code was forged by physicians in concert with consuls representing the commercial interests of a number of countries. Thus in the short space of thirty years a health code that had been thought to embody the traditional wis­ dom of centuries was overturned. In this transformation of the law the cholera epidemic of 1832 played a major role. The cholera that swept across Europe demonstrated the vulnerability of an ancient system of defense. Moreau de Jonnès reported cases in which the disease appeared to follow trade, particularly maritime trade. Many govern­ ments used their armies and their treasuries to combat the scourge—in vain. Despite all the preventive measures the progress of cholera was not slowed. The number of victims was not reduced. Protected areas were just as hard hit as unprotected ones. In Russia sanitary cordons failed to protect Moscow and Saint Petersburg. Stringent measures EPIDEMIC

in Austria failed to halt the progress of the disease. The same was true of Prussia, where the government had not stinted in its efforts to establish an impregnable cordon of troops (stationing more than 60,000 men along the Russian and Polish frontiers). Berlin, though defended by a triple cordon, was not spared. Cholera invaded England and France. It was at this very juncture that the French ambas­ sador in Vienna raised the economic issue, asking that quarantine be abandoned and an international law estab­ lished to deal with the situation. To which Metternich re­ sponded, “Indeed, the needs of commerce and industry, the immense recent progress in the sphere of transport and communication, the rapidity of navigation and interna­ tional relations made possible by the steamship, all cry out for revision, and in many areas for reform, of current prac­ tices in regard to quarantine.”67 But it would be a mistake to think that free-traders skillfully exploited the failure of the old system of defense to promote liberalization of trade. And it is equally wrong to assume that the reform of the health code was a conse­ quence of the triumph of liberal policy (or, if you will, of the willingness of liberals to put profit ahead of public health). The cholera years do not represent the victory of economic imperatives over the requirements of public health. Indeed, the real point is that the contradiction be­ tween the two was on the wane and soon to disappear. The new watchword was trade along with health safeguards. The emerging preoccupation was to bring the goals of commerce into line with the goals of public health, to per­ mit the free circulation of people and goods while main­ taining vigilance against disease. Aubert-Roche expressed the new outlook clearly in a discussion of the plague: “Re­ move the fetters that are hindering commerce and com­ munication; prevent the plague from entering Europe, as­ suming that it is contagious.”68

c h a p te r 7

There was, to be sure, conflict between the proponents of quarantine and those who favored a system better suited to the needs of a free-trade economy. Resistance to reform was due, apparently, to the conservatism of certain institu­ tions: “A single city in France seems to have taken it upon itself to halt the progress of sound reason. That city is Mar­ seilles. Every individual there seems to have made it a per­ sonal mission to champion the old doctrines by inventing new ways to confront the contagion. Whereas people ev­ erywhere else have tended to relax the severity of sanitary measures, in Marseilles they are busy trying to make the rules stricter still.”69 The truth is that the refusal of health inspectors in Marseilles to relax the rules was due to fear of the disease. The example chosen by Rochoux is significant. Attachment to quarantine was common in cities that had long had to face the danger of contagious disease. It is not at all surprising that resistance to reform should have been centered in major seaports. Marseilles had often been ex­ posed to disease and on one occasion had suffered heavy losses. The plague of 1720 was still a living memory in 1851: ‘A royal ordinance recently issued on the subject of quarantines caused a considerable stir in Marseilles, which has just celebrated the anniversary of the end of the plague o f i 72o.”70 What was the nature of this system of defense that the seaport cities were being asked to give up? It all revolved around the complex ritual of sequestration: constant sur­ veillance and inspection carried out by a centralized and hierarchical bureaucracy. Also involved were various disin­ fection procedures, including exposure and washing of car­ go. This centuries-old system was well established and op­ erated in many southern ports: Marseilles, Toulon, Genoa, Trieste, and Leghorn (Livorno) all had major quarantine stations. Ships had to anchor in these stations before being admitted to the port. Since cargoes from the East were al­ ways suspect, these ports functioned as safety valves. Had EPIDEMIC

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they relaxed their sanitary regulations even slightly, they would have lost prestige. Not the least important conse­ quence of these strict quarantines was that they helped to create a valuable trade monopoly. Quarantine stations, health inspections, and strict regulations created a clear boundary between the ships and the city. Now it was pro­ posed that this whole system of prescriptions, regulations, and customary practice be eliminated. No one doubts that this system had helped to alleviate the anxiety of the pop­ ulace. It may also have done more; it may have provided an effective defense against disease. To cite Pierre Chaunu: “The confinement of the plague was one of the greatest victories of baroque Europe. . . . In 1720 the primacy of public health extended beyond the state and imposed itself upon international relations.”71 Until the disaster of 1832, the need for defense against disease, reinforced by fears aroused by the yellow fever epidemic, took precedence over the requirements of trade. Public safety was guaranteed at the expense of free circulation of people and goods. Health inspectors did not hesitate to throw themselves into the breach to halt disease, whatever the cost. Slightly more than a century after the great plague of Marseilles, the nature of the issues had changed entirely. The expansion of trade coupled with the failure of quaran­ tines to check cholera led governments to think again about the usefulness of these measures. Officials began to cast about for new procedures that might be more effective against disease and yet less of a hindrance to trade. For one thing, by the early nineteenth century the map of disease had changed considerably. Diseases spread along trade routes. Broadly speaking, the major breeding grounds lay in the Americas, from which yellow fever had come, in India, the birthplace of cholera and the plague, and in the Mediterranean, which maintained close relations with Af­ rica and which was vulnerable to diseases from all over the world. Seaports constituted secondary sources of infection; chapter

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they were like revolving turntables that received incoming disease from one part of the world and rerouted it to an­ other. Hence the goal of reform was not to eliminate quarantines but to reorganize them on a more rational basis. If, for example, one knew the contagious period of each disease, one could then determine how long to keep possibly contaminated individuals under observation. It seemed reasonable that the length of quarantine should de­ pend on the nature of the disease and its mode of propaga­ tion. Esprit Gendron believed that cholera was contagious only in its early stages and that it could be transmitted via clothing: “From the latter two propositions it follows that there is no point quarantining individuals for more than a few days’ time and that the existing quarantine of contami­ nated belongings may not be long enough.”72 Measuring the incubation period of various diseases was another way of rationalizing the quarantine regulations. By counting the duration of the voyage as part of the quarantine period, ma­ jor reductions of quarantine time could be realized. AubertRoche seems to have been largely in agreement with Esprit Gendron in his recommendation that the quarantine for plague could be reduced from thirty days to nine: “Any ship arriving from Levantine ports that has had no cases at sea will be admitted into the port on the ninth day after its departure.”73 Turning now to the economic aspect of the question, seaports were strategic trade centers. With the increased volume of trade it was no longer possible to put up with a system designed around slowness, isolation, and discrimi­ nation. The disadvantages associated with enforcement of the old health regulations were numerous. The practice of destroying cargoes for health reasons was ruinously expen­ sive. The extra handling of cargo adversely affected the quality of goods and increased prices. This put merchants at a disadvantage on foreign markets. Ships themselves suffered from being kept in poor anchorages and prevented EPIDEMIC

from obtaining necessary repairs. Another problem was that the disparity of health regulations from country to country gave unfair advantages to foreign traders. England and Austria, for example, abolished quarantines on freight­ ers from Alexandria and Constantinople. France therefore lost the advantage of her location, because it actually took half as long to ship goods from the Orient to Paris via Lon­ don as it took to ship the same goods through the port of Marseilles: “The commercial and political interests of France are under heavy attack; it is these measures that must bear the brunt of the blame for the losses sustained by our shipping lines in the Mediterranean.”74 The old system was incompatible with the requirements of industry and commerce. Isolation, separation, and defense were no longer the order of the day; ships now had to be enticed into port, and trade was a matter of national survival. This meant knocking down the barriers between countries sup­ plying raw materials and seaports; it meant facilitating rather than impeding the flow of traffic. The ports, as places of transit, brokerage, and business, must be open. A comparison of the sanitary code of 1822 with that of 1853 shows that all the changes served to facilitate the circula­ tion of people and wealth. This did not mean throwing all caution to the winds, however. In the first half of the nineteenth century, thinking about epidemics and their spread was greatly influenced by the increase in intercontinental trade. One conclusion was ob­ vious: The expansion of commerce is increasingly spread­ ing diseases that had seemed confined by nature to certain climates. In this regard, 1832 was a remarkable year on two counts: it was the year that cholera came to France and it was also the year that Algeria was conquered. The issue of public health was an important aspect of the colonial ad­ venture. This is why political hygiene—the new discipline whose development Gérardin so eagerly desired—was so c h a p te r 7

urgently needed. In the eyes of Gérardin’s contemporaries, the need to clean up other countries could even justify the establishment of colonies in them. As we now know, the transmission of health (via vaccination) later became the centerpiece of a prevention-oriented policy of public health. From a strictly medical point of view, infectionism could pay no greater homage than this to the system of contagion.

EPIDEMIC

8

Conclusion In the medical literature of the 1830s one finds few medi­ cally correct statements and many errors. Some historians of medicine may object to my having said nothing about the confusion of Broussais and Magendie on the subject of contagious disease or about the theoretical aberrations of nervous and humoralist pathology or about the mistakes of Serres. For their benefit I include the following statement by a physician: “I should be upset if you took what is called the vagueness of medicine as a reason to condemn or to accept it—upset about your judgment. Medicine is a sci­ ence of relations, of analogy, of judgment, and of experi­ ence; it is not on that account any less positive or less use­ ful. . . . A science need not blush because it is subject to conjecture and error.”1 The year of cholera was a year of testing for a variety of models, hypotheses, and tactics, all of which played their part in the elaboration of a scientific medicine. I, and others before me, have chosen to focus on what was positive in these models, hypotheses, and tactics. The cholera debate supplanted the great debate over the question of “essential fevers” and consolidated the break with the old nosographie medicine (la médecine des maladies). Through these debates we can trace some of the lines of research that were pursued, albeit not without crit­ icism, schism, and reorientation, throughout the nineteenth

198

century. Physiological medicine inaugurated the study of pathological reactions. Experimental medicine began the changes that would lead to the medicine of the laboratory. Nervous and humoralist pathology, which identified dis­ ease with poisoning, prefigured some of the themes of Claude Bernard’s work. The idea of cholera as psorentery reinforced the notion of morbid specificity. From the sys­ tems of infection and contagion derived etiological hypoth­ eses and offensive and defensive measures against disease. The fact that later epidemiology would have to rework some of these hypotheses and revise and in part discard some of these tactics shows that they were indeed useful. What is modified or rejected is no less valuable than what temporarily takes its place. The cholera epidemic also raised the question of what conditions favored the disease. Some predisposing factors were extrinsic: the entire environment of the working class, its way of life, its diet, its clothing, its housing. Others were believed to be intrinsic, revealed by such character traits as congenital laziness and fearfulness and by such moral qualities as dissolution and irresponsibility. The wretchedness of the proletariat was thus seen as the consequence of an underdevelopment that was at once material, biological, and intellectual. To society’s managers this underdevelopment seemed irrational, and the prole­ tarians were likened to barbarians and savages. In conse­ quence, the cholera was seen as a purge that could rid society of what Boulay de la Meurthe called “creatures whose physical and moral existence, always feeble and wretched . . . could not but cause the species to deterio­ rate.” But this “useful” consequence of cholera merely evokes rather than dispels the great threat of degeneracy. This, as we know, was one of the obsessions of the nineteenth century. In The History o f Sexuality Michel Fou­ cault has shown how it led to displacement: “The ‘blood’ of the bourgeoisie was its sex. . . . Many themes characCHAPTER 8

teristic of the caste manners of the nobility reappeared in the nineteenth-century bourgeoisie, but as biological, med­ ical, and eugenic precepts; the concern with genealogy be­ came a preoccupation with heredity.”2 We also know that around the turn of the nineteenth century new value was attached to the body in a variety of ways, as reflected in concerns about public cleanliness, personal hygiene, cloth­ ing, and even gymnastics, which helped to create “a more ‘independent’ posture. . . . The erect position . . . was no longer a mark of distinction but a labor.”3 In this rational­ ized physical training “there was more than just a trans­ position by the bourgeoisie of themes of the nobility into the key of self-fulfillment. Also involved was another project, that of the “endless extension of strength, vigor, health, and life . . . made possible by the political, eco­ nomic, and historical objectives that the bourgeoisie hoped to achieve, both in the present and in the future, through the ‘cultivation’ of its own body.”4 In 1832 Michel Chevalier wrote that “the cholera. . . meant [that] public hygiene was detestable. The human species was withering away, in atrophy. The time has come when nations must either accept a hideous death or else care for their bodies as they care for their minds, when governments must embrace the material as well as the ra­ tional development of the human race and concern them­ selves as much with the clothing, diet, gymnastics, and in­ deed the flesh of the governed, in all its forms, as they do, or are supposed to do, with the people’s intelligence.”5 I shall end with the foregoing citation. It shows that in 1832 one was still a long way from worrying about the body, i.e., the physical well-being, of the proletariat—its hygiene and its progeny. Before the health of the masses could become a political issue conflict was necessary, con­ flict and deadly surprises like the cholera epidemic. It shows, too, that the epidemic of 1832 surely marks a his-

CONCLUSION

200

torical watershed: the moment when the need to import into the exploited class a health apparatus forged by and for the bourgeoisie became evident—an apparatus, more­ over, that remained the instrument of the bourgeoisie’s hegemony.

CHAPTER 8

Notes i Introduction 1 J.-D. Larrey, Mémoire sur le choléra-morbus, Paris 1831, pp.

27 33* 2 M. Chevalier, Société des amis du peuple. De la civilisation, Paris 1832, pp. 2 -6 . 3

E. Wellin, “Theoretical orientations in medical anthropology: Continuity and change over the past century,” in D. Landy, ed., Culture, Disease, and Healing. Studies in Medical Anthropology, New York 1977, p. 48. 4

J. Cruveilhier, Anatomie pathologique du corps humain, Paris 1829—1835» vol· I» Ρ· 4 2· 2 Management F. -J. Double, Rapport sur le choléra-morbus, /« d VAcadémie royale de Médecine le ij septembre i $j i f Paris 1831, pp. 156-157. 2 Ibid., pp. 157-158. 3

Ibid., p. 157. In the same vein is the following passage from E Leuret: “To the degree that Europe differs from Asia in civiliza­ tion so, too, must it differ in mortality, as a result of the failure to observe the rules of hygiene” (Mémoire sur Vépidémie actuelle désignée sous le nom de choléra-morbus de lin de , Paris 1831, p. 117).

202

4

J. Sarazin, Le Choléra pestilentiel, Paris 1831, pp. 19—20. 5

J.-D. Larrey, Mémoire sur le choléra-morbus, Paris 1831, p. 28. Concerning the design of hospitals as anticontagion “devices,” see F. Béguin, “La machine à Guérir,” in Les Machines à guérir; Paris 1976, pp. 55-69. 6 J. Sarazin, Le Choléra pestilentiel, Paris 1831, pp. 13-14. This theme also figures in J.-M. Audin-Rouvière, Hygiène abrégée, Paris 1827, pp. 21-22, and in P. Boriès, Du choléra-morbus asi­ atique et des moyens de s'en préserver; Paris 1832, p. 16. 7

Ibid., p. 16. 8 As one can read in Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, pp. 20—38. 9

H. Boulay de la Meurthe, Histoire du choléra-morbus dans le quartier du Luxembourg, Paris 1832, pp. 1-2; cf. on this subject F. Hatin, Essai médico-philosophique, Paris 1832, p. iff. 10 M. Lauvergne, Choléra-morbus en Provence, Toulon 1836, p. 265; similarly J. Guichard writes, “The highest degree of civiliza­ tion to which man can lay claim: the complete destruction of epi­ demic disease” (Relation statistique et pathogénique du choléramorbus dans le quartier des Invalides, Paris 1832, p. 36). 11 Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 33. F.-G. Boisseau, too, said, “We have made progress in this area, but here as in so many others we are a long way from perfection” (Traité du choléramorbus considéré sous le rapport médical et administratif Paris 1832, pp. 280-281). i2 F.-E. Fodéré, Recherches historiques et critiques sur la nature, les causes et le traitement du choléra-morbus, Paris 1831, p. 315.

13

F. Leuret, Mémoire sur l'épidémie actuelle désignée sous le nom de choléra-morbus de l'Inde, Paris 1831, introduction (unpaginated). !4

G. Prunelle, “Rapport sur le choléra-morbus, fait par le docteur Prunelle, à la Chambre des Députés dans la séance du 14 sep-

NOTESTO PAGES

17-22

203

tembre 1831,” in F.-G. Boisseau, Traité du choléra-morbus con­ sidéré sous le rapport médical et administratif Paris 1832, p. 400. The same recommendation is found in P.-F. Kéraudren, Mémoire sur le choléra-morbus de l’Inde, Paris 1831, p. 32. For L.-J. Robert the efficacy is real: “It was sequestration, and the cordon estab­ lished around the city of Saint-Denis, that so quickly halted the progress of cholera morbus in the lie Bourbon” (Lettre à M. de Tourguenef sur le choléra-morbus de l’Inde, Marseille 1831, p. 6).

!5

M.-V. de Moléon, Du choléra-morbus. Notice générale sur cette maladie, Paris 1831, p. 96. 16 Gazette des hôpitaux civils et militaires, VI, 1832, no. 4, p. 16.

17

Godelle, “Sur le choléra qui a régné dans l’arrondissement de Soissons pendant l’été de 1832,” Revue médicale, IV, 1832, p. 369. 18 Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 17. *9

F. Moreau, Histoire statistique du choléra-morbus dans le quar­ tier du faubourg Saint-Denis, Paris 1833, p. 3. 20 J.-J. Deville, Compte rendu des travaux de la commission sani­ taire du quartier de l’Hôtel-de-Ville, Paris 1832, pp. 10-11. J. Guichard justified the government’s actions: “It must be that the immense burdens that overwhelmed the city made it impossible for the authorities to act on the commission’s complaints and just demands” (Relation statistique et pathologique du choléramorbus dans le quartier des Invalides, Paris 1832, p. 6).

21 Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, P· 2° 3 22 S. Sandras, Du choléra-morbus observé en Pologne, en Allemagne et en France, Paris 1832, pp. 9 0 -9 1 . 2 3 F.-J. Double, Rapport sur le choléra-morbus, lu à l’Académie royale de Médecine le 13 septembre 1831, Paris 1831, p. 155. 24

A.-N. Gendrin, Monographie du choléra-morbus épidémique de Paris, Paris 1832, p. 308.

NOTES TO PAGES

25-32

204

25

J.-B. Cayol, “Considérations pratiques sur le choléra-morbus de Paris,” Journal de médecine et de chirurgie pratiques, 3, 1832, p. 129. 26 F.-G. Boisseau, Traité du choléra-morbus considéré sous le rap­ port médical et administratif, Paris 1832, pp. 287-288. 27

Oeuvre des orphelins de Saint-Vincent de Paul par suite du choléra-morbus de Paris, Paris 1832, p. 1. 28 A. Brière de Boismont, Relation historique et médicale du cho­ léra-morbus de Pologne, Paris 1832, p. 201; cf. on this subject C. Allibert: “Gifts to the poor are the perfect specific for a cholera epidemic; here is a prescription that men and women of good society can dispense on their own” (Rapport lu à VAcadémie

royale de Médecine, et remis à M. le Ministre du commerce et des travaux publics en décembre 1831, Paris 1832, p. 84). 29 J.-B. Cayol, “Choléra-morbus,” Revue médicale, I, 1832, p. 491. 30 Ch. de Rémusat, “Lettre du 25 avril 1832,” in Souvenirs du Baron de Barante de VAcadémie française, 1782-1866, published by Cl. Barante, Paris 1894, v°l· ^V, 1830-1832, pp. 509-510. On the analogies between epidemics and épizooties, see L.-M. Rigaud de l’Isle, Recherches sur le mauvais air et ses effets, Paris 1832, p. 17 2ff.

31

A. Fabre and F. Chailan, Histoire du choléra-morbus, depuis son

départ des bords du Gange, en 1817, jusquà l'invasion du midi de la France en 1833, Marseille 1835, p. 282.

32 H. Boulay de la Meurthe, Histoire du choléra-morbus dans le quartier du Luxembourg, Paris 1832, p. 47; cf. C.-A. Durande: “Distribute alms equitably without favoritism or double por­ tions” (Quelques idées sur la maladie dite choléra, Dijon 1832, p. 21). Concerning the problems raised by charitable assistance, see L.-R. Villermé, “Quelques réflexions sur les établissements de charité publique,” Annales d'hygiène publique et de médecine lé­ gale, III, 1830, pp. 92-1 h . 33

“One physician, one pharmacist, a few medical students, two spa­ cious rooms, a few medicines, some beds and some stretch-

NOTES TO PAGES 3 3 - 3 9

2 0 5

ers. . . .Your commission, in fulfilling the first of its assigned du­ ties, has striven to do as much as possible at the lowest possible cost” (Rapport de la commission chargée d'organiser et d'indi­

quer le personnel des bureaux de secours, Préfecture de police, Commission centrale de salubrité, 13 et 2y novembre, Paris 1831, P- O34

Benoiston'de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 41. Concerning the ad­ ministration of treatment at the beginning of the epidemic, see L. Blanc, Histoire de dix ans, 1830—1840, Paris 1843, vol. III, p. 2 2off., and A. Bompart, Première lettre à un magistrat sur l'épi­ démie régnante, Paris 1832. 35

L.-F. Trolliet, Polinière, and Bottex, Rapport sur choléra-morbus de Paris, Lyon 1832, p. 48. Cf., on this topic, A.-N. Gendrin: “These establishments have been quite useful, and have made the residents of Paris feel very safe” (Monographie du choléramorbus épidémique de Paris, Paris 1832, p. 318).

36 F.-J. Double, Rapport sur le choléra-morbus, lu à l'Académie royale de Médecine le 13 septembre 1831, Paris 1831, p. 172. 37

N. Chervin, Pétition adressée à la Chambre des députés, Paris 1833, pp. 62-63. On these questions, see Ph. Ariès, L'Homme devant la mort, Paris 1977, pp. 368-373 and 389-399.

38 H. Scoutetten, Relation historique et médicale de l'épidémie de choléra qui a régné à Berlin en 1831, Paris 1832, p. 106. Cf. on this subject “Des signes certains de la mort chez les cholériques,” Gazette médicale de Paris, 3, 1832, p. 442a,b. 39

F.-G. Boisseau, Traité du choléra-morbus considéré sous le rap­ port médical et administratif, Paris 1832, p. 291. 40 A. Métrai, Description naturelle, morale et politique du choléramorbus à Paris, Paris 1833, p. 88.

41

Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 45.

42 Ibid., p. 48.

NOTES TO PAGES 4 1 - 4 5

2o6

3

Fear

1 “Sur l’invasion du choléra-morbus à Paris,” Gazette médicale de Paris, 3, 1832, no. 13, p. 137b. 2 H. Heine, De la France, Paris i960; cited by L. Chevalier, Le Choléra à Paris, Paris 1958, p. 5. 3

Alexandre B., Du choléra-morbus, ou de Pasthénie des organes gastriques, Rouen 1832, p. 6. 4

E. Littré, “Le choléra à Paris en 1832,” in Médecine et médecins, 3rd ed., Paris 1875, p. 184. 5

A. Gérardin and P. Gaimard, Du choléra-morbus en Russie, en Prusse et en Autriche pendant les années 1831 et 1832, Paris 1832, p. 6. For Hungary see the account of P.-A. Piorry, Mémoire sur les

causes occasionnelles qui ont spécialement agi dans Vépidémie de choléra observée à Paris en 1832, Paris 1832, p. 223. 6 A. Dalmas, “Choléra,” in Dictionnaire de médecine, Paris 1834, p. 509. 7

A. Métrai, Description naturelle, morale et politique du choléramorbus de Paris, Paris 1833, p. 21. 8 J.-R. de Kerckhove, Considérations sur la nature et le traitement du choléra-morbusy Anvers 1833, pp. VI-VII. On this topic cf. D. Thibaut: “If low-lying and damp areas are affected first, the rea­ son is that these are generally more densely populated, more plethoric, than other areas, and because for them the law of Maithus is a primary necessity” (Considérations sur les épidé­

mies, les endémies, les épizooties et les enzooties, sur la contagion et Pinfection, Metz 1849, p. 32), and J.-J. Virey, Hygiène philo­ sophique, Paris 1828, vol. II, pp. 370-371. 9

H. Boulay de la Meurthe, Histoire du choléra-morbus dans le quartier du Luxembourg, Paris 1832, p. 116. 10 L.-R. Villermé, “Des épidémies sous les rapports de l’hygiène publique, de la statistique médicale et de l’économie politique,” Annales d ’hygiène publique et de médecine légale, IX, 1833, pp. 45-46; the population was quickly reduced to its proper level (p. 52): “Population losses due to epidemics are not completely made

NOTES TO PAGES 4 7 - 5 3

2 0 7

up by births alone. The very scene of the disease receives immi­ grants from neighboring areas once the disease has abated.” F. Bérard also speaks of a “principle of reparation that is always read to come into play. . . and that tends promptly to make up for any losses” (Discours sur les améliorations progressives de la santé publique, Paris 1826, p. 113).

11 Ibid., p. 14.

12 L. Chevalier, Le Choléra à Paris, Paris 1958, p. 8. On the living conditions of the proletariat see P. Caffe, Considérations sur Phistoire médicale et statistique du choléra-morbus de Paris, Paris 1832, p. 13. 13 “Circulaire du 2 avril 1832,” Revue médicale, III, 1832, p. 160.

14

For this subject see “Cas de choléra pris pour un empoisonne­ ment,” Annales d yhygiène publique et de médecine légale, IX, 1833, pp. 405-410, and A. Chevallier, “Examen de divers produits empoisonnés ou pouvant causer des empoisonnements,” Annales d yhygiène publique et de médecine légale, VIII, 1832, pp. 311-324.

15

Cf. Anonymous, La Vérité toute entière sur les empoisonnements, Paris 1832. Another eyewitness account: “On the Quai de la Féraille one unfortunate victim was knocked to the ground and then ripped to shreds by dogs that were told to attack. Finally they tied him to a fir plank and threw him into the river, so that everybody on the bridges and quays could see what punishment was inflicted on poisoners” (Gazette médicale de Paris, 3, no. 28, 1832, p. 215). 16 F. Magendie, Leçons sur le choléra-morbus, faites au Collège de France, Paris 1832, p. 223.

17

A. Carteaux, Compte rendu de Vambulance établie dans les bâti­ ments de Landen trésor, Paris 1832, p. 2. 18 G. Lefebvre, Foules historiques, les Foules révolutionnaires, Paris 1934, cited and commented on by R. Baerhel, “La haine de classe en temps d’épidémie,” Annales (Economies, Sociétés, Civilisa­ tions), VI, no. 3, 1952, p. 358.

19

Choléra. Moyens préservateurs et remèdes employés avec le plus de succès à Paris en 1832, Lyon 1835, p. 22. The reaction abroad

NOTES TO PAGES 5 3 - 5 6

2o8

was the same: see J. Delpech, Etude du choléra-morbus en Angle­ terre et en Ecosse pendant les mois de janvier et février 1832, Paris 1832, pp. 149-150, and Dr. Sophianopoulo, Relation des épidé­ mies du choléra-morbus observées en Hongrie, Moldavie, Gallicie et à Vienne en Autriche, Paris 1832, p. 30. For the provinces, see F.-P. Emangard: “The word was put about that I was paid by the Government to kill the poor” (“Relation de l’épidémie de choléra-morbus qui a régné à Laigle (Orne),” Annales de la médecine physiologique, 22, 1832, p. 569). 20 F. Magendie, Leçons sur le choléra-morbus, faites au Collège de France, Paris 1832, p. 223. 21 “Futilité des bruits d’empoisonnement, lettre de Julia de Fontenelle du 4 avril 1832 à M. le préfet de police,” Gazette des hôpitaux civils et militaires, 1832, p. 68. 22 Anonymous, La Vérité toute entière sur les empoisonnements, Paris 1832, p. 8. 2 3 L.-R. Villermé, “Note sur les ravages du choléra-morbus,” An­ nales d'hygiène publique et de médecine légale, XI, 1834, p. 389. Benoiston de Châteauneuf adds further detail: “The number of post horses used on April 5, 6, and 7 was 618 and the number of passports issued rose by 500 per day. The number of those checking out of hotels and rooming houses during the month of April was 900-1,000, compared with fewer than 500 checking in”

(Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 49, note 2).

24

J.-H. Bernardin de Saint Pierre, Etudes de la nature, Paris 1825, vol. V, p. 167. 25

D. Thibaut, Considérations sur les épidémies, les endémies, les épizooties et les enzooties, sur la contagion et l'infection, Metz 1849, p. 27. Cf. on this subject A. Siegfried, Itinéraires de conta­ gion. Epidémies et idéologies, Paris 1960. 26 Cited in A. Métrai, Description naturelle, morale et politique du choléra-morbus à Paris, Paris 1833, p. 112. The legitimist press of course published these homilies. 27

N. Henry, Le Choléra-morbus, 2nd ed., Paris 1832, p. 30. Cf. also F.-E. Fodéré: “According to other visionaries, we should be all the more resigned because this is a divine scourge sent as punishment

NOTES TO PAGES 5 7 - 6 0

20Ç

for our crimes; a providential scourge whose mission for the past fifteen years has been to ravage and punish this wretched earth. . . . B u t. . . are the crimes of our age greater than those of the fright­ ful centuries of Charles VI, Charles VII, Louis XI, Charles VIII, and various of their successors?” (Recherches historiques et cri­ tiques sur la nature, les causes et le traitement du choléra-morbus, Paris 1831, p. 419). 28 P. Dufay, Avis au peuple sur le choléra-morbus, Paris 1833, p. 16. 29 F. Foy, Le Choléra-morbus de Pologne, Paris 1832, pp. 39-40. 30 Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 204.

31

Ibid., p. 196. 32 M.-F. Moreau, Histoire statistique du choléra-morbus dans le quartier du faubourg Saint-Denis, Paris 1833, pp. 40-41. Cf. also J.-J. Deville, Compte rendu des travaux de la commission sani­ taire du quartier de Phôtel-de-Ville, Paris 1832, p. 1, note 10. 33

A. Métrai, Description naturelle, morale et politique du choléramorbus à Paris, Paris 1833, p. 24. Michel Foucault adds, “For a long time hermaphrodites were criminals, or the progeny of criminals, because their anatomical configuration, their very be­ ing, muddled the law that distinguished the sexes and prescribed their conjunction” (Histoire de la sexualité, Paris 1976, p. 53). 34

L. Chevalier, Classes laborieuses et Classes dangereuses, Paris 1978, p. 277. 35

Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, P· I9 1· 36 C. Allibert, Rapport de la commission envoyée en Pologne, par

M. le ministre des travaux publics, pour étudier le choléramorbus, Paris 1832, p. 83. 37

A. Métrai, Description naturelle, morale et politique du choléramorbus à Paris, Paris 1833, p. 160. On this theme see P.-A. Piorry,

Mémoire sur les causes occasionnelles qui ont spécialement agi dans Vépidémie de choléra à Paris en 1832, Paris 1832, p. 198ff.

NOTES TO PAGES 6 0 - 6 4

2 10

38 Julia de Fontenelle, “Analyse de l’air atmosphérique de Paris,” Gazette médicale de Paris, 3, no. 19, 1832, p. 174b. 39

Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, pp. 199—200. 40 M. Foucault, “Préface,” in Les Machines à guérir; Paris 1976, p. 14.

41

H. Gisquet, Mémoires, Paris 1840, vol. I, pp. 464-465. 2 Chappelet, “Extrait d’une réclamation des Brasseurs de Paris à la Commission centrale de salubrité,” Gazette médicale de Paris, 3, no. 22, 1832, p. 187b.

4

43

Ch. Robinson, Considération sur le choléra-morbus observé à Paris et à Crécy, Paris 1833, pp. 59-60. Conversely, disinfectants such as camphor, aromatics, chlorine, and perfumes were sold at high prices. 44

F. Magendie, Leçons sur le choléra-morbus, faites au Collège de France, Paris 1832, p. 2. 45

J.-A. Duboc, Recherches sur le choléra, Paris 1833, p. 15; cf. on this subject M. Oertel, LEau fraîche, spécifique infaillible contre le choléra, Paris 1831. 46 Gazette médicale de Paris, 3, no. 48, 1832, p. 345. A.-N. Gendrin was convinced of it: “The riots that took place in the first few days of April, when the people were convinced that the deaths were due to poisoning, also contributed greatly to the increase in the number of cases of the disease” {Monographie du choléramorbus épidémique de Paris, Paris 1832, p. 10). But the argument could also be stood on its head, and terror could be made to play the role of impeding the progress of the disease: “At the time of the Warsaw massacres that occurred during the night of 15-16 August, the terror of city residents was so great, their minds were so agitated and worried, that for seven or eight days thereafter few cholera cases were admitted to the hospitals. Thus if, as I believe, fear is in the first rank of propagating causes of epidemic disease, terror can sometimes suspend its course” (F. Foy, Le Choléra-morbus de Pologne, Paris 1832, p. 21).

NOTES TO PAGES 6 5 - 6 9

2II

47

Delpech de Frayssinet, Mémoire sur le choléra-morbus, pour ser­ vir à Vhistoire de cette maladie sur le territoire français, Lyon 1833, pp. 167-169. 48 Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 141. On this subject, cf. Broussais: “The sad affections of the soul, fear in particular, are rightly considered to be conditions that predispose to cholera, and what is no less true is that once cholera has developed, fear sin­ gularly aggravates what is in itself so grave a malady” {Le

Choléra-morbus épidémique observé et traité selon la méthode physiologique, 2nd ed., Paris 1832, p. 188). B. de Beaumont went so far as to say this: “The ravages of fear and those of cholera of material origin possess a great similarity; moral ills, like physical ones, first attack the entrails. It follows from the virtual identity of their modes of action that the two scourges prepare the way for one another” (Mémoire sur la formation et la contagion appa­ rente des atmosphères cholériques, Paris 1833, p. 64). 49

F. Delarue, De la peur et de la folie des gouvernements au sujet du choléra, Paris 1831, p. 10; and on pp. 8-9 : “But is it really fear of contagion that induces governments to use the full rigor of the sanitary laws in the present circumstances? . . .What if there were other, hidden motives, political motives whose purpose might be to fetter the liberty that rose as if by miracle from the barricades in that brilliant dawn of July 27, 28, and 29?” 50 F.-P. Emangard, Dissertation sur le choléra-morbus, L’Aigle 1832, p. 16. 4 Investigation 1 Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 13. 2 Ibid., p. 76. 3

Ibid., p. 74. . Ibid., p. 90.

4

5.

Ibid., p. 110; and on p. 107: “It is a long way from being the case that the severity of the disease was directly proportional to the

NOTES TO PAGES 7 0 - 7 2

2 12

amount of water contained within the boundaries of each arron­

dissement.” 6 Ibid., pp. 117-118; and on p. 114: “In the first and the eighth, where each resident has 84 and 83 square meters of land, respec­ tively, losses of twelve and in some cases twenty-six per thousand were sustained.” 7

Ibid., p. 120. On this subject, see L.-R. Villermé: “The ravages of the disease were in proportion to the flagrant causes of insalubrity that these areas contained, and to their poverty, to the misery of their inhabitants” (“Note sur les ravages du choléra-morbus,” Annales d'hygiène publique et de médecine légale, XI, 1834, p. 403). 8 Ibid., p. 126. 9

Ibid., p. 137. On this subject, see H. Boulay de la Meurthe: “In rural districts as in the capital the cholera seems to have at­ tacked especially those occupations that indicate less comfortable means” (Histoire du choléra-morbus dans le quartier du Luxem­ bourg, Paris 1833, pp. 188-189). 10 E. Littré, “Le choléra à Paris en 1832,” in Médecine et médecins, 3rd ed., Paris 1875, p. 194. On the work done prior to 1832, see especially L.-R. Villermé, “Mémoire sur la mortalité en France, dans la classe aisée et dans la classe indigente,” Mémoire de l'Académie royale de Médecine, I, 1828, p. 5 iff., and “De la mor­ talité dans les divers quartiers de la ville de Paris,” Annales d'hygiène publique et de médecine légale, III, 1830, p. 294ff.; cf. also Benoiston de Châteauneuf, “De la durée de la vie chez le riche et chez le pauvre,” Annales d'hygiène publique et de mé­ decine légale, III, 1830, p. 5ff. On the hygienist movement in France see William Coleman, Death Is a Social Disease: Public Health and Political Economy in Early Industrial France, Madi­ son (Wisconsin) 1982. For England see M. Pelling, Cholera, Fever and English Medicine 1825—1865, London 1978. I I

M. Foucault, Naissance de la clinique, Paris 1963, p. 6. i2 Cited by J.-M. Flourens, in Cuvier; histoire de ses travaux, 2nd ed., Paris 1845, p. 302. 13 Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 123. Compare the fol-

NOTES TO PAGES 7 6 - 7 9

lowing: “The state of disease . . . a necessary consequence of the living conditions to which we are subjected” (Encyclopédie por­

tative ou Résumé universel des sciences, des lettres et des arts, Hygiène publique et médecine légale, Paris 1830, p. 17).

14

J.-J. Deville, Compte rendu des travaux de la Commission sani­ taire due quartier de VHôtel-de-Ville, Paris 1832, p. 12; cf. also C.-F. Tâcheron: “Indigence and filth generally go together; the presence of one suggests the presence of the other” (Histoire du choléra-morbus dans le quartier du Luxembourg, Paris 1832, p. 10). !5

Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, P· 119; and on p. 125: “The same reasons, crowding and poverty, also explain the differ­ ence in mortality between the first six arrondissements of Paris and the last six.” 16 Ph. Ariès, Histoire des populations françaises, Paris 1971, p. 129. 17

Benoiston de Châteauneuf, Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 112. 18 F.-J. Double, Rapport sur le choléra-morbus, lu à ΓAcadémie royale de Médecine le 13 septembre 1831, Paris 1831, p. 179. 19

F.-E. Fodéré, Recherches historiques et critiques sur la nature, les causes et le traitement du choléra-morbus, Paris 1831, p. 416. 20 A. Petit de Maurienne, Recherches sur les causes, la nature et le traitement du choléra, Paris 1837, pp. 106-107. 2 I

Ibid., p. 109. 22 Ibid., p. 108. 23 M. Dudon, Recherches sur le siège, les causes et le traitement du choléra-morbus épidémique, Paris 1832, pp. 20-21. This etiology is also proposed by A.-F. Bulard, Nouvelles recherches sur la

cause, la nature, les moyens préservatifs et le traitement du cho­ léra, Paris 1833, p. 20; and P. Sellier, “L’électricité considérée comme cause possible du choléra-morbus,” Gazette médicale de Paris, 3, 1832, p. 127.

NOTES TO PAGES 8 0 - 8 8

2i4

24

N. Boubée, “Sur la marche géologique du choléra,” Gazette médicale de Paris, 3, 1832, p. 474. N. Boubée developed this the­ ory in La Géologie dans ses rapports avec la médecine et Vhygiène

publique. Conditions géologiques des maladies épidémiques et endémique en général et du choléra en particulier,; Paris 1849. 25

B. de Beaumont, Mémoire sur la formation et la contagion appa­ rente des atmosphères cholériques, Paris 1833, P* io ^· 26 J.-J. Deville, Histoire médicale du choléra-morbus dans le quar­ tier de PHôtel de Ville, Paris 1833, p. 16. On this subject cf. J. Gavarret: “When one sees cholera start from the banks of the Ganges and in the space of a few years devastate the greater part of the globe, following no rules in its unsteady and capricious march, crossing oceans and attacking pell-mell the various conti­ nents . . . one wonders what causes can account for such phe­ nomena” (Principes généraux de statistique médicale, Paris 1840, pp. 185-186). 27

J. Delpech, Etude du choléra-morbus en Angleterre et en Ecosse pendant les mois de janvier et février 1832, Paris 1832, p. 128. 28 F. Leuret, Mémoire sur Vépidémie actuelle désignée sous le nom de choléra-morbus de Vïnde, Paris 1831, p. 58. On this subject cf. A. Brière de Boismont: “We have seen the appearance of cholera coincide with the ingestion of unclean, muddy drinks” (Des

premiers secours à donner aux personnes atteintes du choléramorbus, et des moyens préservatifs, Paris 1832, p. 11). 29

J. Gavarret, Principes généraux de statistique médicale, Paris 1840, p. 165. Recently, too, Georges Canguilhem wrote, “It would therefore be a mistake to look upon the old theory of epidemic constitutions as a sort of anticipation of the theory of milieus” (“Guérison,” Nouvelle Revue de psychanalyse, XVII, 1978, p. 16). 30 Ibid., p. 178. A. Dodin and J. Brossollet have noted this: “For the first time, the Gazette médicale of 28 June 1832 called for the creation of a chair in Epidemiology, so that the study of that sub­ ject, which had previously been combined with Hygiene, could progress and develop” (“Thérapeutiques au cours de l’épidémie de choléra de 1832,” Bulletin de la Société de Pathologie exotique, vol. 64, no. 5, September-October 1971, p. 623).

NOTES TO PAGES 8 9 - 9

215

31

A. Gérardin and P. Gaimard, Du choléra-morbus en Russie, en Prusse et en Autriche pendant les années i8 ji et 1832, Paris 1832, p. 115. 32 P.-A. Prost, Traité du choléra-morbus considéré sous les rapports physiologiquey anatomico-pathologique, thérapeutique et hygié­ niquey Paris 1832, pp. 496-497. 33

R.-F. Méray, Recherches géologiques et philosophiques sur le re­ froidissement animal improprement appelé choléra-morbus, Paris 1833, p. 65. 34

Ch. Le Maout, Expériences chimico-microscopiques sur le mi­ asme du choléray Paris 1833, p. 3. 35

R.-F. Méray, Recherches géologiques et philosophiques sur le re­ froidissement animal improprement appelé choléra-morbus, Paris 1833, p. 26. 3 4

J. Giraudeau de Saint-Gervais, Choléra-morbus, Paris 1831, p. 2. !5

A. Moreau de Jonnès, Rapport au conseil supérieur de santé sur le choléra-morbus pestilentiel, Paris 1831, p. 34. Concerning the comparison of cholera with a barbarian horde, see M.-J. Desruelles, Précis physiologique du choléra-morbus, Paris 1831, p. 9, and M. de la Boutraye, Documents sur le choléra-morbus envoyés à Pintendance sanitaire de la Gironde, Bordeaux 1832, p. ηή. i6 M.-G. Weland, Traité sur le choléra-morbus asiatique, Paris 1831, p. 15; cf. also H. Lauvergne: “In its march it unmasked itself to kings and peoples and revealed to them its mission, which is to decimate us” (Choléra-morbus en Provence, Toulon 1836, p. 212).

Π

P.-A. Prost, Traité du choléra-morbus considéré sous les rapports

physiologique, anatomico-pathologique, thérapeutique et hygié­ nique, Paris 1832, p. 214; Cf. A. Métrai: “There is reason to think that if the peoples of the banks of the Ganges had the good for­ tune to live under free governments . . . they would tame the plague that their river is vomiting forth to poison other parts of the earth. The arm of liberty would snuff out the impure monster at its source” (Description naturelle, morale et politique du choléra-morbus à Paris, Paris 1833, p. V). 18 H. Lauvergne, Choléra-morbus de Provence, Toulon 1836, p. 216; cf. J. Guichard: “Scourges that seem to be reserved for races mired in ignorance” (Relation statistique et pathologique du choléra-morbus dans le quartier des Invalides, Paris 1832, p. 36). 19

F. Bérard, Discours sur les améliorations progressives de la santé publique, Paris 1826, p. 107. A Métrai also said: “This disease was particularly bent on destroying nations sunk in barbarism” (Des­

cription naturelle, morale et politique du choléra-morbus à Paris, Paris 1833, p. 5). 20 L. -R. Villermé, “Des épidémies sous les rapports d l’hygiène pu­ blique, de la statistique médicale et de l’économie politique,” An­ nales d ’hygiène publique et de médecine légale, IX, 1833, p. 7. 21 Ch. Anglada, De l’heureuse influence de la civilisation sur la fré­ quence des maladies populaires, Montpellier 1854, p. 56. 22 M. Foucault, Histoire de la sexualité, Paris 1976, p. 162.

NOTES TO PAGES 1 0 2 - 1 0 6

2I8

23

E. Littré, Du choléra oriental, Paris 1832, p. 115. 24

J. Bressy, Théorie de la contagion et son application à la petite vérole, à la vaccine, à leurs inoculations, et à Γhygiène, Paris 1802, pp. 205-206. 25

C.-F. Tâcheron, Statistique médicale de la mortalité du choléramorbus dans le XI arrondissement, Paris 1832, p. 59. 26 A. Métrai, Description naturelle, morale et politique du choléramorbus à Paris, Paris 1833, p. 54. 27

E. Sue, Le Juif errant, p. 168. 28 A. Métrai, Description naturelle, morale et politique du choléramorbus à Paris, Paris 1833, P· 56; and on P· II($: “Poverty and opulence are the two extremes of society most outside the holy laws of nature.” 29

L.-R. Villermé, “Note sur les ravages du choléra-morbus à Paris,” Annales d yhygiène publique et de médecine légale, IX, 1834, p. 404.

30 Benoiston de Châteauneuf also speaks of “this class that has nothing of its own except poverty and vice” ( Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, P· 191). 31

J. Bouillaud, Traité pratique, théorique et statistique du choléramorbus de Paris, Paris 1832, p. 183. 32 C.-F. Tâcheron, Statistique médicale de la mortalité du choléramorbus dans le XI arrondissement, Paris 1832, p. 53. On this subject see Benoiston de Châteauneuf: “The excesses in which the working population of Paris indulges all too frequently on Sun­ days seem to have produced an increase of Ve in the number of hospital admissions on Mondays” (Rapport sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 189), and H. Boulay de la Meurthe: “O f 308 deceased whose hygienic habits have been checked, 111 were intemperate and frequently indulged in debauchery, overeating, and especially excess drinking” (His­ toire du choléra-morbus dans le quartier du Luxembourg, Paris 1832, p. 79).

NOTES TO PAGES 1 0 6 - 1 10

2I9

j. Gavarret, Principes généraux de statistique médicale, Paris 1840, p. 223. For a study of the numerist school (école numériste ) see J. Piquemal, “Le choléra de 1832 en France et la pensée médicale,” Thalès, 1959, pp. 59-6 1 . 34

F.-L. Valleix, Guide du médecin praticien, Paris 1844, vol. V, pp. 426-427. 35

A. Dauvergne, Recueil d'observations sur le choléra-morbus faites à l'hôpital Saint-Louis de Paris, Marseille 1832, pp. 71-72; cf. on this subject H. Ripault, Quelques réflexions sur le choléramorbus observé à Hôtel-Dieu de Paris, Paris 1832, p. 26, and Carteaux, Compte rendu de l'ambulance établie dans les bâti­ ments de l'ancien trésor; Paris 1832, p. 7. 36 “De l’influence hygiénique du fantastique en littérature,” Gazette médicale de Paris, 3, no. 103, 1832, p. 707a. 37

Alosius de Mey, Quelques lettres sur le choléra-morbus, Paris 1832, p. 68. As for peace of mind: “The physicians recommend it, everybody preaches it, but in vain unless one seeks it with God, who alone can grant it” (Instruction à la portée de tout le monde sur le choléra-morbus y Paris 1844, p. 3). 38 E. Moulin, Hygiène et traitement du choléra-morbus, coup d'oeil historique sur l'épidémie de Paris de 1832, Paris 1832, pp. 15-16. 39

F. -J. Double, “Rapport et instructions pratiques sur le choléramorbus,” Archives générales de médecine, 34, 1832, p. 25; see also Dr. Sophianopoulo: “Is it not to sobriety and to a uniform and regular life that convents, boarding establishments, and so forth have in general been indebted for their protection against the choleraic epidemic?” (Relation des épidémies de choléra-morbus observées en Hongriet Moldavie, Gallicie et à Vienne en Autrichet Paris 1832, p. 2 1). 40 A. Métrai, Description naturelle, morale et politique du choléramorbus à Paris, Paris 1833, p. 55. 1 H. Boulay de la Meurthe, Histoire du choléra-morbus dans le quartier du Luxembourg, Paris 1832, p. 116; see also A. Métrai: “He thunders at all that is most shameful in vice, drunkenness, intemperance, and prostitution” (Description naturelle, morale et politique du choléra-morbus à Paris, Paris 1833, p. 5). 4

NOTES TO PAGES 1 1 0 - 1 1 2

220

42

F. Foy, Histoire médicale du choléra-morbus à Paris, Paris 1832, P· 4 3 ·

6

Medicine

L.-Ch. Roche, “Mémoire sur le choléra-morbus épidémique ob­ servé à Paris,” Journal universel et hebdomadaire de médecine, VII, 1832, p. 438. 2 “Du choléra-morbus épidémique,” Archives générales de méde­ cine, 28, 1832, p. 527. 3

P.-A. Prost, Traité du choléra-morbus considéré sous les rapports

physiologique, anatomico-pathologique, thérapeutique et hygié­ niquey Paris 1832, p. 494. On this subject see M. Foucault, Nais­ sance de la clinique, Paris 1963, chap. IX, “L’invisible visible.” 4

A. Dalmas, “Choléra,” in Dictionnaire de médecine, Paris 1834, p. 47. 5

F.-J.-V. Broussais, Le choléra-morbus épidémique, observé et traité selon la méthode physiologique, Paris 1832, p. 22. He had previously said, “Acute gastritis sometimes begins with the most terrible symptoms of cholera morbus, which all too often is not differentiated from it” (Histoire des phlegmasies chroniques, 4th ed., Paris 1826, vol. Ill, p. 34). 6 J. Bouillaud, Traité pratique, théorique et statistique du choléramorbus de Paris, Paris 1832, p. 284. 7

F.-J.-V. Broussais, “Mémoire sur l’influence que les travaux des médecins physiologistes ont exercés sur l’état de la médecine en France,” Annales de la médecine physiologique, XXI, 1832, p. 653. 8 F. Magendie, Leçons sur le choléra-morbus, faites au Collège de France, Paris 1832, p. 12. 9

Ibid., pp. 50-51. 10 Ibid., p. 81. 11 Ibid., p. 3.

NOTES TO PAGES 11 3 -1 24

221

I 2

Ibid., p. 59. 1 3 L. de Haynau, Le choléra-morbus, cause de cette maladie, Paris 1831, p. 1; cf. also Poumiev: “Profound alteration of the vital properties of the nervous system. Catarrhal state without trace of inflammation” (Essais sur le choléra asiatique, Fontainebleau 1832, p. 11), and F.-J. Double, Rapport sur le choléra-morbus, lu en séance générale les 26 et 30 juillet, Paris 1831, p. 45. !4

L. Auzoux, Du choléra-morbus, son siège, sa nature et son traitement, Paris 1832, p. 12. See Scipion Pinel: “It is in the ner­ vous system that governs its functions that I shall look for the primitive site of the disease. . . . In my opinion the disease should be called trisplanchnia, both to indicate its presumed site and to make clear that it is a wholly new affection” (“Observations sur le choléra-morbus de Pologne,” Gazette médicale de Paris, 3, no. 10, 1832, p. 103b); before him, P.-F. Kéraudren had said, “Who can doubt that the pneumogastric and the trisplanchnic that gov­ ern the functions of the organs involved in the disease that con­ cerns us do not participate in some way in the disorder that affects them?” ( Mémoire sur le choléra-morbus de l’Inde, Paris 1831, p. 22). On cholera as neurosis see J. le Coeur, Précis sommaire sur le choléra-morbus épidémique, Caen 1832, pp. 14-15, and A. Olinet, Considérations sur le choléra-morbus spasmodique, Paris 1832, p. 13. *5

F. Foy, Histoire médicale du choléra-morbus à Paris, Paris 1832, p. 22. 16 F.-J.-V. Broussais, Le choléra-morbus épidémique, observé et traité selon la méthode physiologique, Paris 1832, p. 156. Brous­ sais took this idea from his student Gravier, who had studied the Indian cholera in which nervous symptoms are more important than secretory symptoms: “In general the traces of inflammation are less apparent in the cadavers of individuals who died suddenly and succumbed to pain and the intensity of convulsive spasms rather than to the disorganization of the viscera” (“Document sur le choléra-morbus de l’Inde,” Annales de la médecine physio­ logique, II, 1827, p. 273). See also F.-G. Boisseau, a disciple of Broussais and author of the Pyrétologie physiologique (1823): “In saying that the lesion depends on the nervous system of the diges­ tive tract, we do not wish to diminish its importance or deny that it can sometimes be primary. It is even probable that in the course of cholera morbus epidemics, in certain patients who succumb

NOTES TO PAGES 1 2 4 - 1 26

222

almost suddenly, there are no lesions except in the nervous sys­ tem” ( Traité du choléra-morbus considéré sous le rapport médi­ cal et administratif Paris 1832, p. 147).

Π

F. Magendie, Leçons sur le choléra-morbus y faites au Collège de France, Paris 1832, p. 37. 18 L. -Ch. Roche, “Mémoire sur le choléra-morbus observé à Paris,” Journal universel et hebdomadaire de medécine, VII, 1832, p. 443-444; J.-B. Delarroque writes: “The spinal cord, the medulla oblongata, and their membranes are the site of a congestion proved by anatomical inspection” (“Remarques sur la physiologie pathologique du choléra-morbus,” Archives générales de méde­ cine, 29, 1832, p. 203). Other physicians, like J. Delpech, believed instead that it was the solar plexus that was affected: “A morbid state, usually inflammatory, of the main part, and what is re­ garded as the central part, of the ganglionary nervous apparatus”

(Etude du choléra-morbus en Angleterre et en Ecosse pendant les mois de janvier et février 1832, Paris 1832, p. 212). Finally, still others opted for a trisplanchnic and myelic cholera; cf. J.-A. Ozanam: “Organic and vital lesions of the cerebrospinal and trisplanchnic nervous system” (Histoire médicale, générale et par­ ticulière des maladies épidémiques, 2nd ed., Lyon 1835, vol. I, p. 94); M. Magistel, Notice sur le choléra-morbus sporadique et pestilentiel, Paris 1831, pp. 11-12; P. Jolly, Lettre sur le choléramorbus, Paris 1832, p. 23. 19 A. Bonnet, “Recherches sur le choléra-morbus,” Archives géné­ rales de médecine, 28, 1832, p. 545. 20 M. Foucault, Naissance de la clinique, Paris 1963, p. 170; and on p. 169: “Still more significant was the rejection of chemistry. Analysis in the manner of Lavoisier served the new anatomy as an epistemological model but did not operate as a technological ex­ tension of its gaze.” 21 P. Ledeschault, Recherches sur la nature et la cause du choléramorbus, Paris 1832, pp. 6 -7 . Cf. also M. Lauvergne: “Vain at­ tempts have been made to localize this disease, and the anatomi­ cal school must at least this once acknowledge its impotence” (Choléra-morbus en Provence, Toulon 1836, p. 204). 22 Concerning analyses of the blood, see the summaries in J. Bouillaud, Traité pratique, théorique et statistique du choléra-morbus de Paris, Paris 1832, pp. 216-226, and A. Bonnet, “Recherches sur

NOTES TO PAGES i 2 6 - 1 2 8

le choléra-morbus ,” Archives générales de médecine, 28, 1832, pp. 560-567. Concerning the results obtained by O’Shaughnessy, see “Analyse du sang cholérique,” Gazette médicale de Paris, 3, 1832, p. 109b.

2

3

A. Bonnet, “Recherches sur le choléra-morbus,” Archives géné­ rales de médecine, 28, 1832, pp. 573-574. P. Rayer arrived at the same conclusion: “The series of abdominal symptoms . . . appears to be independent of these modifications of the blood and seems to originate in a much more obscure source, in the cause o f chol­ era itself” (“De l’altération du sang dans le choléra, et de ses prin­ cipaux effets— expériences comparatives sur des animaux, avec le sang cholérique et non cholérique,” Gazette médicale de Paris, 3, no. 61, 1832, p. 430b. And A.-N. Gendrin: “I believe that in chol­ era the intestinal phlegmorrhagia is primitive and is the cause of the alteration that has been noted in the blood” (Monographie du choléra-morbus épidémique de Paris, Paris 1832, p. 133). 24

J.-A. Rochoux, “Notice sur le choléra-morbus, et en particulier sur celui de Bicêtre,” Archives générales de médecine, 30, 1832, p. 467. 25

P. Ledeschault, Recherches sur la nature et la cause du choléramorbus, Paris 1832, p. 7; similarly, Levicaire says, “Cholera re­ sults from the presence and action of hydrocyanic acid, which develops spontaneously in the animal economy” (“Choléramorbus,” Archives générales de médecine, 30, 1832, p. 273). 26 E.-R. A. Serres and A. Nonat, Mémoire sur la psorentérie, ou choléra de Paris, Paris 1832. It was in early April of 1832 that Serres announced his discovery; see “Observations sur le choléramorbus de Paris. Psorentérie, lues à l’Académie des Sciences,” Gazette médicale de Paris, 3, no. 26, 1832, pp. 206-207. Other doctors shared Serres’s views; A.-L. Foville wrote, “This altera­ tion consists in a sort of eruption, a morbid development of the follicules known as Peyer’s and Brunner’s” (De la nature, du siège et du traitement du choléra-morbus, Rouen 1832, p. 28). 27

“Commentaire sur la lettre de M. Dupuytren à M. le baron de Rothschild sur le choléra-morbus,” Revue médicale, I, 1832, p. 259. Fodéré, too, was not mistaken when he criticized Ranque who even before looking at cholera had voiced an idea similar to that of Serres: “Anatomical lesion entirely imagined by the au­ thor, and no doubt solely to show himself equal to the dothinentery theory” (Recherches historiques et critiques sur la nature, les causes et le traitement du choléra-morbus, Paris 1831, p. 444). NOTES TO PAGES 1 2 9 - 1 3

224

28 M. Foucault, Naissance de la clinique, Paris 1963, p. 194.

29

E-E Bretonneau, Des inflammations spéciales du tissu mu­

queux, et en particulier de la diphtérie ou inflammation pelliculaire, Paris 1826, p. 368. 3° E Magendie, Phénomènes physiques de la vie, Paris 1832, vol. II, p. 173.

31

E.-R.-A. Serres, Mémoire sur la psorentérie, ou choléra de Paris, Paris 1832, p. 6.

32 Ibid., p. 74. 33

J. Cruveilhier, Anatomie pathologique du corps humain, Paris 1829-1835, vol. I, pp. 41-42. 34

For scabies, see Serres, “Observations sur le choléra-morbus de Paris. Psorentérie, lues à l’Académie des Sciences,” Gazette médi­ cale de Paris, 3, no. 26, 1832, p. 206. For smallpox, see A.-L. Foville and J.-B. Parchappe, De la nature, du siège et du traite­ ment du choléra-morbus, Rouen 1832, p. 31. For millet-seed rash, see L. Dueros, Relation médicale de la commission envoyée à

Paris par la chambre de commerce et par Vintendance sanitaire de Marseille pour observer le choléra-morbus, Marseille 1832, p. 94. 35

J. Hildebrand, Du typhus contagieux, Paris 1811, p. 133. On this subject, see Nacquart: “The more one reflects on the importance of the role played by the skin in the development, transmission, and absorption of contagious viruses, the more one is tempted to set forth the principle that contagions are associated with diseases that are essentially cutaneous in nature” (“Contagion,” in Dic­ tionnaire des sciences médicales, Paris 1813, vol. VI, p. 52).

36

J.-A. Ozanam, Histoire médicale, générale et particulière des maladies épidémiques, Lyon 1835, vol. I, p. 31.

7 Epidemic J.-A. Rochoux, “Quelques réflexions sur le typhus, la dothinentérie, le choléra-morbus et leur contagion,” Journal universel et hebdomadaire de médecine, VII, 1832, p. 507.

NOTES TO PAGES i 3 1-1 39

J. Bouillaud, Traité pratique, théorique et statistique du choléramorbus de Paris, Paris 1832, p. 203. 3

M. Treille, Choléra-morbus. Observations adressées à M. le ré­ dacteur des Annales de la médecine physiologique, Paris 1832, p. 16. 4

J.-A. Rochoux, “Quelques réflexions sur le typhus, la dothinentérie, le choléra-morbus et leur contagion,” Journal universel et hebdomadaire de médecine, VII, 1832, p. 515. This is no doubt an allusion to the pension of 3,000 francs awarded to the physicians Pariset, Bailly, and François following the submission o f their contagionist report on yellow fever, which they observed in Gi­ braltar in 1821. 5

F. Magendie, Leçons sur le choléra-morbus, faites au Collège de France, Paris 1832, p. 272. 6 F. Delarue, De la peur et de la folie des gouvernements de VEurope au sujet du choléra, Paris 1831, p. 10. 7

M. Delpech de Frayssinet, Mémoire sur le choléra-morbus, pour servir à Phistoire de cette maladie sur le territoire français, Lyon 1833, p. 7; F.-E. Fodéré, too, said, “Several sanitary cordons have been established, as much for political reasons as for fear of a physical disease” (Recherches historiques et critiques sur la na­ ture, les causes et le traitement du choléra-morbus, Paris 1831, p. 42). 8 F.-J.-V. Broussais, Annales de la médecine physiologique, XIX, 1831, p. 417. 9

N. Chervin, Pétition adressée à la Chambre des députés, Paris 1833, p. I. 10 E. H. Ackerknecht, “Anticontagionism between 1821 and 1867,” in Bulletin o f the History o f Medicine, XXII, no. 5, 1948, p. 567. The portrait of the contagionist as bureaucratic and conservative, to which Ackerknecht has given the dimensions of a myth, could use some touching up. Fodéré, for instance, speaks of Moreau de Jonnès as an “author, moreover, with so little animosity toward commerce and industry that he has several times shared all the present day’s tender solicitude for them in various memoirs read to the Academy of Sciences” (Recherches historiques et critiques

NOTES TO

PAGES 1 4 0 - 1 4 5

22 0

sur la naturey les causes et le traitement du choléra-morbust Paris 1831, p. 293). On Moreau de Jonnès see A. Dodin and J. Brossollet, “L’épidémie de choléra de 1832, ou la naissance de l’épidé­ miologie moderne,” in Hommage à Marcel Baltazardy Institut Pasteur, pp. 97-118. And this portrait of Pariset by Triaire: “Very literate and very erudite, in the once classic sense of the word . . . a profound and gentle thinker. . . . In the Academy of Medicine Pariset exemplified that breed of physician that was steeped in broad literary studies, a breed that advanced us so far in the art and science of speaking well and that added luster to the Royal Society of Medicine and Surgery” (Bretonneau et ses corres­ pondantsy Paris 1892, vol. II, p. 254, note 1). I I

Ackerknecht, “Anticontagionism,” p. 564.

12 E. H. Ackerknecht, Medicine at the Paris Hospital, 1794-1798, Baltimore 1967, p. 160. !3

G. Canguilhem, “L’objet de l’histoire des sciences,” Etudes d'his­ toire et de philosophie des sciences, Paris 1968, p. 15. !4

Ackerknecht, Medicine at the Paris Hospital, p. 157.

15

Ackerknecht, “Anticontagionism,” p. 589. 16 Ibid. This analysis has been widely repeated, to say the least. See, for example, R. J. Morris, Cholera 1832: The Social Response to an Epidemic, New York 1976: “Because the choice between the two paradigms could not be made by scientific rules, the choice was directed by social pressures from outside the medical com­ munity.” For a tribute to Ackerknecht see R. Cooter, “Anticon­ tagionism and History’s Medical Record,” in The Problem of Medical Knowledge, Edinburgh 1982, pp. 87-108.

17

N.-V. Gérardin, Mémoire sur la fièvre jaune, considérée dans sa nature et dans ses rapports avec les gouvernements, Paris 1820, p. 83. 18 F. -J.-V. Broussais, Examen des doctrines médicales, Paris 18291834, vol. IV, p. 467. *9

F.-J.-V. Broussais, Le choléra-morbus épidémique, observé et traité selon la méthode physiologique, Paris 1832, p. 42. Gravier, too, said, “The necessary conditions for cholera morbus are

NOTES TO PAGES 14 6 - 1 5 2

ni

therefore the cold and dampness of night, alternating with the heat of the day, during the northeasterly monsoon” (“Documents sur le choléra-morbus de l’Inde,” Annales de la médecine physio­ logique, XI, 1827, pp. 273-274). 20 Th. Lemasson, Aperçu historique et médical sur le choléramorbus, Paris 1831.

21 F.-J.-V. Broussais, Catéchisme de médecine physiologique, Paris 1824, p. 62. 22 J. Hildebrand, Du typhus contagieux, translated from German by J.-Ch. Gase, Paris 1811, p. 132. 23

M. Foucault, La Naissance de la clinique, Paris 1963, p. 155. 24 E. Gendron, “Recherches sur les épidémies des petites localités,” Journal des connaissances médico-chirurgicales, VIII, 1834, article 4, p. 19b; and in article 2, p. 232b: “In regiments, colleges, and boarding houses convalescents from dothinentery will have to be placed for several weeks in a special infirmary.”

25

F. -J.-V. Broussais, Annales de la médecine physiologique, XIX, 1831, pp. 414-415· 26 L.-M. Velpeau, “Lettre CCVI du 16 mars 1829,” in P.-F. Breton­ neau, Correspondance avec Trousseau et Velpeau, published by P. Triaire, Paris 1892, vol. II, p. 257.

27

Concerning the history of this practice, see the interesting study by Anne-Marie Moulin and Pierre Juvin, Lady Mary Montagu: LIslam au péril des femmes, Paris 1981, pp. 65-87. Concerning smallpox as a disease-type, see A. Bonnet, Mémoire sur les virus, Bordeaux 1825. 28 F. Foy, Du choléra-morbus de Pologne, Paris 1832, p. 3. For the infectionists, a contagious disease was first of all an inoculable disease; cf. Broussais, “As for contagion, it is out of the question, if one means a contagion similar to that of smallpox; for cholera cannot be inoculated like smallpox” (Le choléra-morbus épidé­ mique, observé et traité selon la méthode physiologique, Paris 1832, p. i 2), and A. Dauvergne: “I shall be ready to accept con­ tagion only when it has been demonstrated that the disease can be transmitted by inoculation” (Recueil d'observations sur le

NOTES TO PAGES 1 5 2 - 1 6 6

228

choléra-morbus faite à l'hôpital Saint-Louis, Marseille 1832, p. 19). 29 A. Moreau de Jonnès, Rapport au conseil supérieur de santé sur le choléra-morbus pestilentiel, Paris 1831, p. 121. 3° L -Μ. Robert, Lettre à M. de Tourguenef sur le choléra-morbus de l’Inde, Marseille 1831, p. 17.

31

J.-A. Rochoux, “Quelques réflexions sur le typhus, la dothinentérie, le choléra-morbus, et leur contagion,” Journal universel et hebdomadaire de médecine, VII, 1832, p. 515, note 1.

32 H. Gouraud, Réflexions sur la nature du choléra-morbus, Paris 1831, p. 15. Bretonneau had already said, “A disease can be transmissible and yet not to the same degree or in the same man­ ner as smallpox” (Traité de la dothinentérie et de la spécificité, published by Dr. Dubreuil-Chambardel, Paris 1922, p. 249). 33

E. Littré, Du choléra oriental, Paris 1832, p. 53. Cf. P.-F. Breton­ neau: “In the midst of this populace inflamed by riot, packed in hotels, crowded into churches, theaters, courts, etc., how can one hope to follow the tracks of the contagion” (Bretonneau et ses correspondants, Paris 1892, vol. II, p. 314). 34

E. Gendron, “Recherches sur les épidémies des petites localités,” Journal des connaissances médico-chirurgicales, VIII, 1834, article 2, p. 230a. 35

E Magendie, Leçons sur le choléra-morbus, faites au Collège de France, Paris 1832, p. 235; and on p. 233: “Fear among the staff, ill will, lack of zeal, and on more than one occasion, mischief.” Cf. also the report of Broussais: “The motto of these women is of course to eat and drink as much as possible at the expense of the people who employ them” {Le choléra-morbus épidémique, ob­ servé et traité selon la méthode physiologique, Paris 1832, p. 13). On problems with hospital staff, see A.-N. Gendrin, Mono­ graphie du choléra-morbus épidémique de Paris, Paris 1832, p. 321. 36

E. Gendron, “Recherches sur les épidémies des petites localités,” Journal des connaissances médico-chirurgicales, article 1, VII, 1834, p. 195a; and on p. 194a: “The country doctor is well placed to follow the migration of so-called epidemic diseases and to de­ termine with the least possible doubt when they broke out.” NOTES TO PAGES 1 6 7 - 1 7 3

229

37

J. Delpech, Etude du choléra-morbus en Angleterre et en Ecosse pendant les mois de janvier et février 1832, Paris 1832, p. 188. 38

R-F. Bretonneau, Bretonneau et ses correspondants, Paris 1892, vol. II, pp. 312 - 3 13. On this subject, cf. E. Gendron: “As a saying common among simple country folk has it, it is not the air of the country but the air of the patient that is unhealthy” (“Recherches sur les épidémies des petites localités,” Journal des connaissances médico-chirurgicales, VIII, 1834, article 2, p. 231b).

39

For example, A.-L. Foville and J.-B. Parchappe, De la nature, du siège et du traitement du choléra-morbus, Rouen 1832; and Vel­ peau identified paths of transmission both in the city and in the hospital: see “Du choléra-morbus épidémique de Paris,” Archives générales de médecine, 1832, pp. 222-224.

40

Cf. on this subject the reports of Arsène Gendron, “Sur la con­ tagion du choléra, Vendôme le 10 novembre 1832,” Gazette mé­ dicale de Paris, 3, 1832, p. 804; E. Littré, Du choléra oriental, Paris 1832, pp. 50-55; J. Delpech, Etude du choléra-morbus en

Angleterre et en Ecosse pendant les mois de janvier et février 1832, Paris 1832, p. 220; Dubreuil and Reich, Rapport sur le choléra asiatique qui a régné dans le midi de la France en 1832, Montpel­ lier 1836, p. 253. E. Gendron reports a typical case of a country woman returning home: “On 25 April 1832 the Vasseur woman was stricken with cholera on the day after returning from Paris. The first case in the village, she succumbed in less than 48 hours. The second case was a neighbor woman by the name of Bigot. . . . The third case was the Gaudefroy woman; she had helped care for the previous victim. Bigot fell ill on the 27th, Gaudefroy on the 28th. The fourth case was the Gaudefroy daughter, who had nursed her mother. . . .The fifth, Mme Forestier, her neigh­ bor. . . . The used linen was taken to a neighboring laundry run by one Pourpi. Twenty-four hours later he was stricken; fortyeight hours after that he and his wife were dead of cholera. . . . It was necessary to find out why the second case, the Bigot woman, was stricken in preference to the husband of the first victim. . . . The Vasseur woman, on the night of her arrival from Paris, left her home following a quarrel and went to the home of her friend, the Bigot woman. Her change of domicile occurred on the 24th. On the 25th she came down with cholera, and the Bigot woman fell ill on the 25th” (“Maladies épidémiques,” Journal des con­ naissances médico-chirurgicales, V, 1835^ Ρ· 3 4 a>b)·

NOTES TO PAGES 1 7 3 - 1 7 4

2 30

4 1

E. Gendron, “Maladies épidémiques,” Journal des connaissances médico-chirurgicales, V, 1835, p. 37b; observations confirmed by M. de la Boutraye: “Initially cholera struck only the poor class in Danzig, the working class and the soldier. . . . But subsequently the disease spread to other classes, and it struck several families of unimpeachable morals” (Documents sur le choléra-morbus en­ voyés à Pintendance sanitaire de la Gironde, Bordeaux 1832, p.

i?)· 42

J. Bouillaud, Traité pratique, théorique et statistique du choléramorbus de Paris, Paris 1832, p. 289. For E. Littré this was a cer­ tainty: “In this progress one can follow the continuity of the dis­ ease; it is an uninterrupted chain, one end of which is in India; nowhere is there a complete break; only after India did cholera invade Persia; only on leaving Persia did it gain Russia; Poland and Turkey came only after Russia. . . . Paris will be invaded only after the disease has neared the Rhine or the English Channel” (Du choléra oriental, Paris 1832, p. 59). See also A. Moreau de Jonnès, Rapport au conseil supérieur de santé sur le choléramorbus, Paris 1831. 43

F. -J.-V. Broussais, Examen des doctrines médicales, Paris 18291834, vol. IV, p. 409. 44

A. Brochard, “De la contagion du choléra-morbus,” Archives générales de médecine, 4 s., 23, 1851, p. 123. Concerning the re­ sistance of Parisian physicians to the notion that dothintery is contagious, cf. Bretonneau, “Notices sur la contagion de la dothinentérie,” Archives générales de médecine, XXI, 1829, pp. 57- 58. 45

E. Gendron, “Recherches sur les épidémies des petites localités,”

Journal des connaissances médico-chirurgicales, article 4, VIII, 1834, p. 19. It must be said that Parisian physicians were discon­ certed when they observed in Paris what Gendron had reported from the provinces; on this subject cf. Benoiston de Châteauneuf: “Frequently it was in the cleanest and best-kept villages that it [the disease] was pleased to do the most damage, whereas it left hardly any trace in localities that were reported to be sources of infection and breeding grounds for every kind of disease” (Rap­

port sur la marche et les effets du choléra-morbus dans Paris, Paris 1834, p. 175), and F.-J. Double, “De l’influence des émana­ tions animales ou végétales dans l’épidémie cholérique,” Gazette médicale de Paris, 3, 1832, p. 580a,b.

NOTES TO PAGES 17 4 - 1 7 6

231

46

J.-A. Rochoux, “Quelques réflexions sur le typhus, la dothinentérie, le choléra-morbus et leur contagion,” Journal universel et hebdomadaire de médecine, VII, 1832, p. 485. 47

J. Hildebrand, Du typhus contagieux, Paris 1811, p. 281. 48 J. Bouillaud, Traité pratique, théorique et statistique du choléramorbus, Paris 1832, p. 207. 49

P.-H. Nysten, Dictionnaire de médecine, Paris 1841, pp. 382-383. On Hippocrates and the notion that earth is subordinate to the heavens, cf. Georges Canguilhem, La Connaissance de la vie, 2nd ed., Paris 1967, pp. 132-150. 50 A. Dalmas, “Choléra,” in p. 521.

Dictionnaire de médecine, Paris 1834,

51

A. Bardet, Notice sur le choléra-morbus, Bernay 1832. 52 F.-P. Emangard, “Relation de l’épidémie de choléra-morbus qui a régné à Laigle (Orne),” Annales de la médecine physiologique, XXII, 1832, p. 571. 53

F.-J. Double, Rapport sur le choléra-morbus, lu à VAcadémie royale de Médecine le 13 septembre 1831, Paris 1831, p. 196. 54

R-A. Prost, Traité du choléra-morbus considéré sous les rapports

physiologique, anatomico-pathologique, thérapeutique et hygié­ nique, Paris 1832, p. 111. 55

J. Hildebrand, Du typhus contagieux, Paris 1811, p. 135. See also M. Gérard: “These miasmata, similar to several others, are living beings of animal or vegetal species. . . .They must find a favor­ able terrain in which to reproduce” (“Lettre au rédacteur des Transactions médicale, sur les causes le mode de propagation et le traitement du choléra-morbus épidémique,” Paris 1832, p. 4). 56 J.-A. Buet, Histoire générale du choléra-morbus depuis ι8 ιγ jusqu*en août 1831, Paris 1831, p. 67. Fodéré comments thus: “This successive repetition of new sources of infection: it is par­ ticularly unthinkable, as one would have to imagine, for the cause of a disease to traverse several hundred leagues in this manner”

(Recherches historiques et critiques sur la nature, les causes et le traitement du choléra-morbus, Paris 1831, p. 174). NOTES TO PAGES 17 6 - 1 8 3

232

57

F. -J.-V. Broussais, Annales de la médecine physiologique, XIX, 1831, pp. 414—415. The theme of migrating sources of disease is a persistent one in physiological medicine; see Gravier: “He recog­ nizes only sources of infection that can originate in the midst of large groups of people and that are subsequently transported from one place to another” (“Documents sur le choléra-morbus de l’Inde,” Annales de la médecine physiologique, II, 1827, p. 274)· 58 A. Moreau de Jonnès, Rapport au conseil supérieur de santé sur le choléra-morbus pestilentiel, Paris 1831, p. 90. 59

G. Dupuytren, Rapport fait dans les séances du 26 septembre, 7 et 21 novembre 1823, Paris 1826, pp. 11-12. 60 A. Alquié, Précis de la doctrine médicale de Pécole de Montpel­ lier, Montpellier 1846, pp. 123-124. 61 M.-A. Duchassin, Du choléra pestilentiel, méthode préservative et curative de cette maladie, Saint-Quentin 1831, p. 19. 62 J. Hildebrand, Du typhus contagieux, Paris 1811, p. 116.

63

E. Littré, Du choléra oriental, Paris 1832, p. 58; the same idea was proposed by E. Dubuc, Rapport adressé à Pintendance sanitaire

de Rouen sur le choléra-morbus observé à Sunderland, Newcastle et les environs, Rouen 1832, p. 36. 64

Observations sur le choléra-morbus, recueillies et publiées par Pambassade de France en Russie, Paris 1831, p. 15.

65

Godelle, “Sur le choléra qui a régné dans l’arrondissement de Soissons pendant l’été de 1832,” Revue médicale, IV, 1832, p. 367. A shrewd remark: “The invasion and various terminal modes of cholera allow no doubt that its generative principle is a virulent substance whose form remains indeterminate but whose seat is in the diarrheic substance” (ibid.). 66 A. Gérardin and P. Gaimard, Du choléra-morbus en Russie, en Prusse et en Autriche pendant les années 1831 et 1832, Paris 1832, p. 264.

67

Correspondance relative to the contagion of Plague and the quarantine regulations o f foreign countries 1836—1842, presented NOTES TO PAGES 1 8 4 - 1 9 0

to the House o f Commons, by command o f the Majesty, pp. 17-18, cited in J. Girette, La Civilisation et le choléra, Paris 1867, p. 38 (Letter, Vienna, 13 July 1838). 68 L. Aubert-Roche, De la réforme des quarantaines et des lois sanitaires de la peste, Paris 1843, p. 85. 69 J.-A. Rochoux, “Quelques réflexions sur le typhus, la dothinentérie, le choléra-morbus et leur contagion,” Journal universel et hebdomadaire de médecine, VII, 1832, p. 488.

70

A. Gontard, De la réorganisation de l’intendance sanitaire au point de vue du droit communal et de Vintérêt marseillais, Mar­ seille 1851, p. 35. At issue was the ordinance of 1845, according to which ships arriving from Africa and America would be admitted into port if there had been no case of or death from yellow fever on board in the eight days prior to arrival.

71

P. Chaunu, La civilisation de VEurope classique, Paris 1966, pp. 221-223. Concerning the question of the actual efficacy of the quarantine and, more generally, of the work of the Marseilles health bureau, see the interesting study by Françoise Hildeshei­ mer, Le Bureau de la santé de Marseille, Marseille 1980. 72

E. Gendron, “Maladies épidémiques,” Journal des connaissances

médico-chirurgicales, V, 1835, p. 38b. 73

L. Aubert-Roche, Réforme des quarantaines françaises, par suite de l’abolition des quarantaines en Angleterre et en Autriche, Paris 1843, p. I. 74

L. Aubert-Roche, De la réforme des quarantaines et des lois sanitaires de la peste, Paris 1843, p. 85.

8

Conclusion

1 H. Gouraud, “Du choléra-morbus et de la médecine à Paris. Lettre à un ami de Province, Paris, le 12 mai 1832,” Revue médicale, II, 1832, pp. 217-318. 2 M. Foucault, Histoire de la sexualité, Paris 1976, pp. 164—165. 3

G. Vigarello, “Posture, espace et pédagogie,” Dix-huitième siècle, special issue: “Le Sain et le malsain,” Paris 1977, p. 48.

NOTES TO PAGES 1 9 0 - 1 9 9

234

4

M. Foucault, Histoire de la sexualité, Paris 1976, p. 165.

5

M. Chevalier, Religion Saint-Simonienne, Paris 1832, p. 2.

NOTES TO PAGE 199

Biographical Glossary Allibert, Pierre-Casimir: French physician, studied cholera in Po­ land and Russia and wrote the Report read to the academy of medicine in December 1832. Alquié, Alexis (1812-1865): professor of clinical surgery at the Faculty of Medicine of Montpellier and representative of the old medical school of Montpellier. Anglada, Charles: professor at the faculty of medicine of Mont­ pellier, his primary interest was in epidemic medicine. Aubert-Roche, Louis-Rémy (1810—1874): French physician in Alexandria in 1831, later physician of the Suez Canal Corpora­ tion. Audin-Rouvière, Joseph-Marie (1764-1832): French physician who served as military doctor during the Italian campaign, pri­ marily interested in urbanism and hygiene. Auzoux, Louis-Thomas (1797-1880): pioneer in the use of models for anatomical study, author of numerous works in skeletal anatomy. Baglivi, Giorgio (1668—1707): Italian clinician and forerunner of experimental physiology. Bailly, Victor (1775-1866): member of the Academy of Medicine, participated in the Santo Domingo expedition as chief of the medical service, studied yellow fever at Barcelona in 1821. Bastiat, Frédéric (1801-1850): French economist, champion of free trade, known for his works against the “prohibitive system.” Bayle, Gaspard-Laurent (1774-1816): anatomopathologist and clinician, he established the specificity of tuberculosis, laying the groundwork for Läennec.

2 36

Benoiston de Châteauneuf, Louis-François (1776-1856): physi­ cian and statistician, collaborator of Villermé and specialist in matters of public hygiene. Bérard, Frédéric (1789-1828): professor of hygiene at the Faculty of Montpellier and representative of the Montpellier school. Bichat, Xavier (1771-1802): anatomist and physiologist. Blanc, Louis (1811-1882): writer and political reformer interested in the organization of labor, he established the Revue du Progrès in 1839. Boisseau, François-Gabriel (1791-1836): French physician, disci­ ple of Broussais, was named adjoint professor of medicine at the military teaching hospital in Metz. Bompart, Alexis (1782-?): French physician and historian of medicine. Bonnet, Auguste-Ferdinand (1791-1873): French physician and hygienist, taught pathology and therapeutics at the Bordeaux pre­ paratory school. Boriès, Pierre, (1785-?): pharmacist and physician, discovered the disinfecting properties of lime and the usefulness of quinine root in treating fevers. Boubée, Nérée Théodore (1806-1863): taught natural history in Paris, directed several newspapers such as LEcho du monde sa­ vant (1834—1838). Bouillaud, Jean-Baptiste (1796-1881): disciple of Broussais, did research on the functions of the cerebellum and brain and discov­ ered the rheumatic source of most forms of endocarditis. Boulay de la Meurthe, Henri-Georges, count (1797—1858): philan­ thropist who became director of public education in 1848 and was named senator by decree in 1852. Breschet, Gilbert (1784—1845): interested mainly in comparative and human anatomy. Bretonneau, Pierre-Fidèle (1778-1862): officier de santé and later physician at the hospital of Tours, promoter of the doctrine of morbid specificity. Brière de Boismont, Alexandre (1797-1881): alienist interested particularly in mania and suicide. Brochard, André-Théodore (1810-1883): physician at the HôtelDieu of Nogent-le-Rotrou, taught hygiene at the practical school of the Faculty of Medicine.

B IO G R A P H IC A L G L O SSA R Y

Broussais, François-Joseph-Victor (1772-1838): army physician, founder of physiological medicine and adversary of Pinel. Brunner, Conrad (1653-1727): at Heidelberg, discovered the duo­ denal glands. Buffon, Georges-Louis Leclerc, count of (1707-1788): naturalist and director of the Royal Gardens and Museum. Bulard, Arsène-François (1805-1843): as doctoral thesis in medi­ cine wrote Etudes sur la choléra. He studied the disease in the Orient, and in 1839 he presented a “project for health reform.” Cadet de Cassincourt, Charles-Louis (1769-1821): pharmacist named in 1806 secretary general of the Paris Health Council. Caffe, Pierre (1778-1821): French physician brought before the court of Poitiers in connection with the Berton affair. Carnet de la Bonardière, Philippe-Gaspard (1769-1842): politi­ cian, in 1803 became member and later administrator of the Bureau of Hospices and Mont-de-Piété, was also mayor of the Xle

arrondissement. Cardan, Jerome (1501-1576): astronomer born in Pavia, also taught and practiced medicine in Rome. Chamberet, Jean Baptiste Tyrbas de (1779-1843): French physi­ cian, named professor of hygiene and physiology at the military teaching hospital in Lille in 1815 and in 1840 became chief physi­ cian at the military hospital of Val-de-Grace. Chaptal, Jean-Antoine (1756-1832): French chemist, minister of the interior of the first consul, founder of the Vaccine Society. Charles X (1757-1836): Comte d’Artois until his accession to the throne in 1824, succeeding Louis XVIII. Chervin, Nicolas (1783-1843): French physician, believed that yellow fever was noncontagious, elected member of the Royal Academy of Medicine in 1832. Chevalier, Michel (1806-1879): French economist, Saint-Simonian, and liberal theorist, succeeded Jean-Baptiste Say at the Col­ lège de France. Chevallier, Jean-Baptiste (1793-1879): pharmacist, published a Traité des réactifs (1822) and a Dictionnaire des drogues (1831). Chomel, Auguste (1788-1858): held Laennec’s chair until 1851, author of several treatises on pestilential fevers. Cordier, Louis-Antoine (1777-1861): French geologist, member of the Academy of Sciences, professor and administrator at the Museum of Natural History, also peer of France and councilor of state. B IO G R A P H IC A L G L O SSA R Y

Corvisart, Jean-Nicolas (1755-1821): clinician, professor at the Ecole de Santé, his teaching was inspired by the doctrines of Boerhaave and Auenbrügger. Coutenceau, Godefroy Barthélémy (1775—1837): French physician and surgeon. Cruveilheir, Jean (1791-1874): anatomopathologist, his Atlas re­ mains one of the finest iconographie monuments of the century. Cuvier, Georges Leopold Baron (1769-1832): naturalist. Dalmas, Antoine: named royal physician after the return of the Bourbons, he was an honorary member of the Academy of Medi­ cine. Decazes, Elie due (1780-1860): French statesman, deputy for the Seine and prefect of police in 1815. Delpech, Jacques Mathieu (1777-1832): one of the first physicians to practice orthopedics in France (under the name of “orthomorphie”), he was a surgeon who studied at Montpellier. Desgenettes, Nicolas-René, baron (1762—1837): chief physician of the Army of the East, named chief physician of the Invalides in 1832. Desportes, Eugène-Henri (1782-1875): French physician, member of the Academy of Medicine from its inception in 1820. Devèze, Jean (1753—1829): believed that yellow fever was noncontagious and founded the Maison de Santé in Santo Domingo. Deville, Jean-Joseph (1797-1872): observed cholera in Bengal and defended his thesis on this subject in 1828, was named secretary of the health commission for the Hôtel-de-Ville district in 1832. Double, François-Joseph (1776-1842): doctor on the Faculty of Montpellier, one of the founders of the Academy of Medicine, along with Portal. Dubois, Antoine (1756-1837): professor of clinical surgery and obstetrics, he succeeded Baudelocque in 1810 at the Maison d Accouchement. Dubois, Edmond (1747-1814): prefect of police in Paris in 1802. Ducros, Antoine (1791-1858): studied at the military hospital in Toulon in 1810, professor at the school of medicine in Marseilles. Dufay, Charles (1815-1898): physician at the penitentiary of Blois. Dupuytren, Guillaume (1777-1835): member of the Société d’Emulation, surgeon and professor at the Hôtel-Dieu, member of the Royal Academy of Medicine and the Institute.

B IO G R A P H IC A L G L O SSA R Y

Durande, Claude-Auguste (1764-1835): French physician, mayor of Dijon in 1806 and member of the Academy of Dijon. Elie de Beaumont, Jean-Baptiste (1798-1874): geologist, member of the Academy of Sciences. Emangard, François-Pierre (1778-1859): served in the army as surgeon-major under Napoleon, defended his doctoral thesis in Paris in 1815. Emery, Edouard-Félix (1788-1856): French physician, in 1830 obtained the chair of anatomy at the Ecole des Beaux-Arts and in 1835 became titular member of the Academy of Medicine. Fabre, Antoine-François (1797-1853): French physician, in 1828 founded the Lancette française and in 1833 received a medal from the Institute for his work on cholera. Fodéré, François-Emmanuel (1764-1835): army doctor, author of the great Traité de médecine légale. Foville, Achille-Louis de (1799—1878): received his medical degree in 1824, disciple of Esquirol, physician at the Maison Royale de Charenton. Foy, François (1793-1867): obtained master of pharmacy in 1817, on his return from Poland named pharmacist-in-chief of the H ô­ pital Saint-Louis. Fracastoro, Girolamo (1483-1553): Italian physician, originator of the germ theory. François, André (1769-1841): in Paris in 1804 defended his doc­ toral thesis on yellow fever, which he had observed in Santo Domingo, and in 1822 served on the Pariset-Bailly commission. Frank, Johann Peter (1745-1821): physician and epidemiologist, professor of practical medicine at the University of Vienna. Fuster, Joseph-Jean (1801-1876): appointed physician of the Paris city dispensaries in 1831, professor of clinical medicine at Mont­ pellier from 1848 to 1873. Gaimard, Joseph Paul (1790—1858): physician, naturalist, and ex­ plorer. Gavarret, Dominique-Jules (1809-1890): researcher admitted to L’Ecole polytechnique in 1829, he applied statistics to medicine. Gendrin, Auguste-Nicolas (1796-1890): French physician, won a prize from the Academy of Sciences for his work on cholera, practiced at Hôpital Cochin, La Pitié, and Hôtel-Dieu. Gendron, Esprit (1794-1860): rural physician, disciple of Breton­ neau, supporter of the doctrines of contagion and morbid speci­ ficity. B IO G R A P H I C A L G L O S S A R Y

240

Gérardin, Vincent-Auguste (1790-1808): physician, wrote on plague, cholera, and chronic rheumatism. Giraudeau de Saint Gervais, Jean (1802-1861): physician, spe­ cialized from 1828 in the treatment of syphilis. Gisquet, Henri (1792-1866): administrator, took part in the rev­ olution of 1830. Prefect of police in October 1831, he prosecuted the republicans and was forced to resign in 1836. Haller, Albrecht von (1708-1777): Swiss by birth, physician, nat­ uralist, and physiologist. Haynau, Julius von, baron (1786-1853): Austrian general. Heine, Heinrich (1797-1856): German poet and writer. Hildebrandt, Georg Friedrich (1764-1816): physician and nat­ uralist, professor of medicine at Erlangen. Hippocrates of Cos (c. 4 6 9 -c . 399 bc): the most famous Greek physician. Hufeland, Christophe-Guillaume (1762-1836): private physician to the king of Prussia and member of the Academy of Sciences. Hugo, Victor (1802-1885): politician, poet, and novelist. Jourdan, Jacques Louis (1788-1848): French physician attached to the military hospitals of Val-de-Grâce and Gros-Caillou. Julia de Fontenelle, Jean-Sebastien (1790-1842): French chemist, student of Fourcroy and Berthollet, founder of the Société des Sciences physiques et chimiques. Keraudren, Pierre-François (1769): naval medical inspector, au­ thor of works on diseases among sailors. Kerckove, Jean-Baptiste de (1790-1832): Belgian politician. Läennec, René Théophile Hyacinthe (1781-1826): physician, in­ vented the stethoscope. Lamarque, Maximilien (1770-1832): French general and politi­ cian. Lancisi, Giovanni-Maria (1654-1720): physician to popes Inno­ cent XI and Clement XI, his works concerned epidemiology and hygiene. Larrey, Dominique Jean, baron (1766-1842): French surgeon and inspector of the army health service, member of the supreme health council after the July events. Legallois, César (1770-1814): French physiologist, the first to lo­ cate the respiratory center in the spinal cord. Leuret, François (1797-1851): French alienist and physician.

B IO G R A P H IC A L G L O SSA R Y

24 ï

Linnaeus, Carolus (1707-1778): Swedish botanist, founder of systematic botany. Lisfranc, Jacques (1790-1847): French surgeon, student of Du­ puytren and member of the Academy of Medicine. Littré, Emile (1801-1881): French philologist, philosopher, and physician. Louis-Philippe (1773-1850): king of France from 1830 to 1848. Magendie, François (1783-1855): founder of experimental physi­ ology. Malthus, Thomas Robert (1766-1834): English economist. Marc, Charles-Chrétien (1771-1841): French physician, helped to found the Société Médicale d’Emulation and the review Annales

d ’hygiène publique et de médecine légale. Marey, Etienne Jules (1830-1904): pioneer of the analysis of movement. Mazet, André (1793-1821): French physician, observed yellow fever at Cadiz and Barcelona in 1820. Métrai, Antoine (1778-1839): trained as a lawyer, also worked as a journalist. Mercier, Louis-Sébastien (1740-1814): French writer. Metternich, prince (1773-1859): Austrian statesman. Milne-Edwards, Henri (1800-1885): French naturalist, held the chair in entomology at the Jardin des Plantes in 1841, member of the Academy of Sciences. Moléon, Gabriel-Victor de (1784-1856): French writer, graduate of the Ecole Polytechnique. Moreau, François-Joseph (1789-?): French physician. Moreau de Jonnès, Alexandre (1778-1870): French statistician and economist. Moscati, Piétro, count (1740-1824): Italian physician, held a chair at the University of Pavia. Nysten, Pierre (1771-1818): of Belgian origin, his name is asso­ ciated with the Dictionnaire de médecine (1810), which went through several editions. Ozanam, J. (1772-1836): French physician and epidemiologist, practiced at the Hôtel-Dieu in the city of Lyons. Paracelsus, Theophrast von Hohenheim (1493-1541): alchemist and physician, believer in contagion.

B IO G R A P H IC A L G L O SSA R Y

Parent-Duchâtelet, Alexandre (1790-1836): French physician and hygienist. Pariset, Etienne (1770-1847): physician and writer, author of a

History o f the Members o f the Royal Academy o f Medicine (1845), 2 vols. Pelletier, Pierre-Joseph (1788-1842): French chemist, author of treatises on ipecac and quinine, contributor to the Dictionnaire de médecine, member of the Academy of Medicine. Périer, Casimir (1777-1832): French statesman, president of the Council, victim of cholera in 1832. Petit, Marc Antoine (1766-1811): French physician. Peyer, Johann (1653-1712): from Schaffhouse, he described the follicles that have since been known as Peyer’s patches. Pinel, Philippe (1745-1826): French physician and alienist, author of nosologies. Piorry, Pierre (1794—1870): clinician, author of a method of per­ cussion that he called “dactyloplessimétrie.” Prost, Pierre Antoine ( ? - i 832): French physician, anatomopathologist known for his works on inflammation. Prunelle, Gabriel (1777-1853): physician and mayor of Lyons in 1830, historian of medicine. Rayer, Pierre (1793—1867): French physician, one of the founders of the Société de Biologie. Réaumur, René Antoine Ferchault de (1683-1757): French physi­ cian and naturalist. Récamier, Joseph-Claude (1774-1852): French physician, member of the Academy of Medicine from 1820, succeeded Läennec as professor at the Collège de France in 1827. Remusat, Charles, count (1797-1861): French philosopher and statesman. Rigaud de l’Isle, Louis Michel (1761-1826): French agronomist who studied in Rome in 1810 the question of the drying up öf the Pontine Marshes. Rudolphi, Charles-Asmund (1771-1832): Swedish naturalist and physician, member of the Academy of Sciences in Berlin. Serres, Antoine Etienne R. A. (1786-1868): French physiologist and physician, chief physician at La Pitié, succeeded Flourens in the chair of comparative anatomy.

B IO G R A P H I C A L G L O S S A R Y

Serullas, Georges-Simon (1774-1832): French pharmacist, profes­ sor of chemistry at the Jardin des Plantes, succeeded Vauquelin in the Academy of Sciences in 1829. Snow, John (1813-1858): English physician, studied the mode of transmission of cholera via contaminated water. Stoll, Maximilien (1742-1788): German physician, studied medi­ cal constitutions and practiced in Vienna, where he succeeded Van Haen in the chair of practical medicine. Sue, Eugène (1804-1857): trained as a physician, best known as novelist and author of Les Mystères de Paris. Sydenham, Thomas (1624-1689): English physician and epidemi­ ologist, his Complete Works were published in London in 1685. Tascher, Ferdinand-Jean-Samuel, count (1779-1858): graduate of the Ecole Polytechnique, auditor of the Conseil d’Etat in 1805, joined the July monarchy. Valleix, François (1807-1855): clinician who discovered the laws that govern the location of the painful pressure points in neu­ ralgias. Velpeau, Alfred (1795-1867): French surgeon whose Traité d ’anatomie chirurgicale (1823) was long considered a classic. Villermé, Louis-René (1782-1863): economist, statistician, foun­ der of labor medicine.

B IO G R A P H I C A L G L O S S A R Y

Index Ackerknecht, E. H., 144, 146-147 Aid stations, 39-41 Air quality, 17-19, 64-65, 85-86, 136, 161, 185-187. See also Atmospheric etiology of disease Ambient environment theory, 90-91 Ambulances, 39-41 Aptitude for disease, 178-179, 181—182, 188 Ariès, Philippe, 42 Arrondissement commissions, 27-29 Astrology, 179 Atmospheric etiology of disease, 99-100, 135—137, 154-156, 165-166, 179, 183, 185-186 Aubert-Roche, Louis-Rémy, 190, 193 Austria, spread of cholera to, 5, 190

Bichat, Xavier, 121, 125 Boisseau, François-Gabriel, 43 Bonnet, Auguste-Ferdinand, 127, 128, 129 Bouillaud, Jean-Baptiste, 117, 120, 129-1 30, 140, 175, 178 Boulay de la Meurthe, Henri-Georges, 198 Bourgeoisie, 49-50, 58-59, 96, 106, 200 charity efforts by, 34-36 control over underprivileged, 40, 200 moral qualities of, 108-110 response to disease, 8, 1o, 175-'7 6

Barbarism, and susceptibility to disease, 97, 102-105 Bastiat, Frédéric, 141 Belgium, spread of cholera to,

I78, 183-184 Burial, delay and difficulties in, 42-45

37 Bérard, Frédéric, 104 Bernard, Claude, 127

Bressy, J., 107 Bretonneau, Pierre-Fidèle, ' 3 1— 134»«55»157— «58, ' 7 4 ~ '75

Broussais, François-JosephVictor, 59, 112, 119—121, 125-126, 131-133, 140,

' 52— ' 53»' 55— ' 56»' 63»' 75.

Cadaverization, 42—43 Cayol, J.-B., 32

Chamberet, Jean Baptiste Tyrbas de, 187 Character traits, and disease, 12, 18, 30-31, 103, 106-107, *98 Charity efforts, 34-37, 39-40 Chervin, Nicolas, 14, 42, 142, 166 Chevalier, Louis, 53-54, 64,

141

Chevalier, Michel, 2, 4—5, 9, 11-13, 199 Church (Catholic), 34, 37, 60 Civilization as protection against disease, 1-2, 11-12, 15-17, 20, 97-98, 102, 104 Climate and topography, 11, 18, 74-75, 83, 86-90, 152, 166 Contagionism, 7, 9, 13-14, 22, 71, i 35-136, 139-147, 149-150, 154-158, 160—164, 166—170, 174, 176—178, 182—183, 186, 198 Cruveilhier, Jean, 13, 134 Dalmas, Antoine, 50-51, 118, 180 Death registration, 41-44 Decentralization of treatment facilities, 27-28, 39-41 Delpech, Jacques Matthieu, 69-70, 90 Diet, 67-68. See also Poisoning theory Disease, existence of, 6 Divine punishment, disease as, 101-102 Dothinentery theory, 131-135, 158 Double, François-Joseph, 42, 83-84 Drainage systems, 21, 28-29, 3 4 - 3 5 , I 5 4 “ I 55

IN D EX

Drugs, 68 Dupuytren, Guillaume, 185, 188 Electrical etiology of disease, 88 Empirical medicine, 68 England, spread of cholera to, 5 , 3 7 , 9 °, I2 4 , l 9 ° Epidemic disease. See Infectionism Epidemiology, 6, 170-175, 187—188, 198 Eugenics, 53 Experimental medicine, 7, 117, 119, 122-124, 198 Fodéré, François-Emmanuel, 21, 86 Fontenelle, Julia de, 57, 64-65, 185 Foucault, Michel, 79, 106, 116, 127—128, 158, 161, 198-199 Foville, Achille-Louis de, 13 3 “ 1 3 4 Foy, François, 165-167 Fracastoro, Girolamo, 156 Gavarret, Dominique-Jules, 91, 110 Gendron, Esprit, 15 7 15 ®, 160, 163, 171, 174, 193 General Council of Hospices, z6, 3 5 , 4 5 Geographic etiology of disease, 182-185 Geological etiology of disease, 89, 9 2 -9 3 , 95 Gérardin, Vincent-Auguste, 91-92 Germ theory, 156, 158, 160, 167 Germany, spread of cholera to, 5

247

Giraudeau de Saint-Gervais, Jean, ιοί Government mistrust of, 8, io, 48, 50-57,

65

and national temperament, 18 response to disease, 6 -8 , 10, 22-45, *75“ 176 Habitat, 84-85 Haller, Albrecht von, 121 Health inspectors, 23, 25-26, 38-39, 192 Heine, Heinrich, 47-48 Hildebrandt, Georg Friedrich, 157 15®* 176 Hippocratic tradition, 11, 18, 8487, 90-91 Hospital architecture, 17 Hospitalization, 26-28, 32, 34- 37» 39-40 Housing, 75-76, 78, 81-83, 8 5 - 86 Humoral pathology, 7, 113, 117—119, 127—129, 198 Hungary, spread of cholera to, 5 Hydraulic etiology of disease, 87, 88, 90, 182—183 Hygienic measures. See Public health Immunity to disease, 178-179, 181— 182, 188 India, spread of cholera to, 5, 16-18 Infectionism, 7, 13-14, 22, 135» 139- 141 » * 44“ * 5° » 154—155» 160-170, 176-178, 18 2 183, 185—187, 198 Inflammations, special,

131 133» 155

Inoculation against disease, 165—166

IND EX

Juste-Milieu, 4, 8, 71, 109—112 Larrey, J.-D., 1-2, 4 -5 , 9,

11—12 Latrines and outhouses, inspection of, 28-29 Ledeschault, P., 129 Le Maout, C., 93, 95 Lemasson, T., 152 Leprosy, 143, 158, 161 Leuret, François, 90 Literature, hygienic influence of, i n Littré, Emile, 49, 52, 187 Living conditions, 7, 11, 31-32, 77-86, 156, 176, 180-181, 188, 198

Louis-Philippe, 34-35, 51 Magendie, François, 57» 68, I I 2, I 17, I 22 —I 24, I 26, i 29-1 30, 133, 172, 178-179 Malthusian theory, 52-53 Marey, Etienne Jules, 127 Medical constitutions, 87, 91-92, 151-153» i 8 3 “Medical police,” 4, 28 Medical theories, 6, 13, 22, 56, 148, 197-198 experimental theories, 7, 117, 119, 122—124, 198 humoral pathology theory, 7, 113, 117-119, 127-129, 198 nervous pathology theory, 7, 69, 71, 117, 119, 124-127, 198 physiological theories, 7, 107, 117, 119-122, 126, 137, 140—141, 150—15 1, I5 3 “ I5 5 » ! 9 8 Meray, R.-E, 9 2 -9 4 Mesology, 91 Metral, A., 64 Moral qualities, 12, 31, 53, 63, 107—112, 198. See also Juste-Milieu

Morbid specificity theory, i 33,

i35> ι 55~ι 56* l8l> !98

Moreau de Jonnès, Alexandre, 25, 167, 184, 189 Mortality rates, 5, 12, 31, 40, 69» 7 3 “ 9 8» 104 Moulin, E., h i , 112 National temperament, 18, 103 Natural phenomenon, cholera as, 98-100, 105 Neighborhood commissions, 27-30, 38-39 Nervous pathology, 7, 69, 71, 117, 119, 124-127, 198 Neurosis, 7 Nysten, Pierre, 179 Occupational groups, 77-78 Organic space, 80 Orléans, Duke of, 34-35 Paracelsus, Theophrast von Hohenheim, 179 Paris, 172, 178 evacuation of, 32, 58 health commissions in, 27-30, 38-40 investigation of cholera in, 73-98 and mortality rates, 5 riots in, 66-67 Pariset, Etienne, 14, 98 Périer, Casimir, 25, 32, 40 Persia, spread of cholera to, 5 Petit, Marc Antoine, 130 Petit de Maurienne, A., 86-87 Physicians, 8, 10, 40, 55-57, 65, 68—69, 72 Physiological medicine, 7, 107, 117, 119—122, 126, 137, 140-141, 150-151,

l 53~l 55> 198

Pinel, Philippe, 95, 124-125,15 151

IN D EX

Piquemal, J., 13 Plague, 104, 143 Poisoning theory, 7 -8 , 10, 48-55» 57-58, 65, 134-136 Poland, spread of cholera to, 5» 2 3 Police, role of, 26-28, 40, 54, 66—67, io9 Politics, cholera and, 141-148, 190 Population densities, 75-76, 78,81 Predisposition to disease, 7, 79-80, 95, 108, 178-179, 18 1, 188, 198 Preventive measures, 6. See also Health inspectors; Public health; Quarantines and sanitary cordons; Sanitary measures; Segregation of cholera victims Proletariat, 37, 47-50, 58-59, 198-199 attitudes toward, 8—10, 12, 31, 38, 52-53, 59, 61, 63-65 living conditions of, 7,11, 31» 32» 77-83 moral qualities of, 108—n o and mortality rates, 12, 31,

78 response to disease, 6, 8, 10, 103-106 Prost, Pierre Antoine, 93, 101,

117, lgi Prussia, spread of cholera to, 5» 190 Psorentery theory, 130-1 35, 198 Public health, 6, 11, 13-14, 20-22, 32, 34, 63, 65-66, 85, 188—189 during Ancien Regime, 18—19, 66 and Juste-Milieu, 111—112

Public surveillance, 28-30, 38—40, 62, 65—66. See also Social control Quarantines and sanitary cordons, 9, 13-14, 22, 141, 143, 161, 189 of seaport cities, 24-26, 142, 191-194

Social control, 28, 32-45, 66. See also Public surveillance Social response to disease, 6 -1 1 Social space, 80 Sources of infection theory, 15 3 — 15 4 » l 6 ° » i 6 3 » 176 » 180 , 182-183, 188 Special inflammations,

131“ 133» *55 Remusat, Charles de, 37-38 Report, 73-98 Resistance to disease, 178-179, 181 Riots, 59—62, 64, 66—67, 69-72 Roche, L.-C., 118, 127 Rochoux, J.-A., 129, i 39, 168, 176 Royal Academy of Medicine, *5» 23-24, 71, 83-84, 175 Rudolphi, Charles-Asmund,

99 Rural and urban populations, 170—178 Russia, spread of cholera to, 5, 23, 25, 37, 49-50, 189 Sanitary cordons. See Quarantines and sanitary cordons Sanitary measures, 9, 13, 17,

*9» 31» 34~36» 4°, 63 Segregation of cholera victims, 26-27, 32, 36» 55» I43“ I44» 158, 161—162 Seine Health Council, 28 Serres, Antoine, Etienne R. A.,

13°» 134 Serullas, Georges-Simon, 185 Sewage disposal, 17, 28-29,

34»

1 5 4 —1 5 5

Smallpox, 164-165 Social change, and disease,

100—IOI

IN D EX

Statistics, medical use of, 43-44, 83, n o Sydenham, Thomas,

151 15 3 Symptomatology, 50—51, 93, 115-129 Tâcheron, C.-E, 110 Telluric etiology of disease,

99 Temperance, and disease, 109—112 Typhus, 15-16, 186 Uniformity of nature principle, 164-165 Urban and rural populations, 170-178 Urban redevelopment, 29—30, 62 Valleix, François, 110 Velpeau, Alfred, 163—164 Villermé, Louis-René, 78,

15 3 Voisin, J.-C., 99 Waste disposal, 21, 28-29,

I54“ I55 Water supply, 19, 21, 29-30, 69 Working classes. See Proletariat Working conditions,

77-78

250

Yellow fever, 143, 163-164, 183-185 Zones of disease origin, 184 Zoological etiology of disease, 9 3 -9 4

INDEX