Health Care in the Parisian Countryside: 1800-1914.

Although it is surely one of the central questions in the social history of medicine and health care, we still know surprisingly little about how the transformation of medical science and institutions in the nineteenth and early twentieth centuries affected beliefs and practices in the general population; we are only beginning to construct a reception history of modern medicine. This process is best studied on a limited scale, as Ackerman shows in her welcome monograph on the former French department of Seine-et-Oise. She has a long and thorough acquaintance with this region, having devoted an earlier study to the village of Bonnieres-sur-Seine, in the northwestern corner of the department.(1) A fixture of French political geography from the Revolution until a law of 1964 rearranged the administrative divisions of the Parisian basin, the mainly rural department of Seine-et-Oise, with its seat at Versailles, entirely surrounded the department of the Seine (the capital and its immediate suburbs), which was situated a little north of the median line and close to the eastern boundary of the larger department; hence the "Parisian countryside" of the book's title. As Ackerman notes, her choice of the Seine-et-Oise, which enjoyed regular contacts with the metropolis and lacked a distinctive local culture or patois, provides a case study of a district relatively open to new influences emanating from the center, in contrast to the more remote provinces described in earlier studies of medicalization in France.(2) (Its population was also a highly mobile one--so much so, Ackerman suggests, as to preclude a meaningful analysis of changes in mortality, which one might otherwise have hoped to see in a work that deals in part with the effects of public health measures.)

Ackerman offers an account of "a community of the sick and their healers", in which traditional medical ideas and their practices coexisted with modern scientific medicine; she rightly avoids treating their interaction as an encounter between two entirely separate antagonistic forces. She does, however, note the conflict between incompatible assumptions (about the wholesome or noxious properties of dirt, for example), as well as the medical profession's largely unsuccessful efforts to restrict the dispensaries maintained by religious communities and suppress the activities of unlicensed practitioners, such as the successive generations of the Mouffle dynasty, long celebrated among their grateful fellow citizens--and defended by local officials--for treating victims of the bites of rabid animals. Given the relative weight of the available sources, the bulk of the discussion inevitably focuses on the medical profession, official therapeutics, and public health measures and institutions. As is often the case, popular attitudes prove an elusive subject, on which intelligent speculation must sometimes substitute for documentation. The history of medicine from the patient's point of view, so attractive as a program, can present almost insuperable difficulties in practice; Ackerman reveals that the one peasant diary she was able to locate, kept by a member of a family very active in local politics, turned out to consist of three decades' worth of notations on weather conditions.

As in many other parts of France, the ratio of medical personnel to population in the Seine-et-Oise increased in the first decades of the 1800s, peaked and then declined at mid-century, and then rose once more; Ackerman displays these changes, together with the shifting distribution of practitioners within the department, in a series of well-executed maps. Perhaps the most significant trend, however, was the steady growth in the percentage of the population living in communes that had at least one first-order practitioner (an Old Regime physician or higher-level surgeon or a new-style doctor of medicine or surgery, as opposed to a lower-level surgeon or health officer). The changes in the medical network, together with the expansion of mutual aid societies and public programs of medical assistance, greatly facilitated access to modern medical services in the latter part of the century. On the other hand, although reliable statistical evidence is hard to come by, it is clear that popular healers also continued to flourish into the twentieth century, as the field work by the folklorists Claude and Jacques Seignolle confirmed in the 1930s.(3) Regrettably, we learn little about who actually consulted whom; Ackerman seems not to have had access to physicians' private papers, a type of source that she has very ably exploited in another context,(4) and which might have shed some light on the changing composition of the profession's clientele.

In the realm of public health, Ackerman charts the increasing involvement of the state and the development of independent initiatives at the department level. Institutions and services included a system of epidemic doctors, an Old Regime institution revived by a ministerial circular of 1805; a very active departmental health commission established in 1849, as mandated by a national law of 1848; a program of medical assistance, urged on the departments by the government of Napoleon III and inaugurated in the Seine-et-Oise in 1854; and a departmental maternity service for the poor set up in 1901, anticipating a national law of 1913, to name only some of the most important. A separate chapter is devoted to a case study of the Hotel-Dieu (hospital) of Mantes-la-Jolie and its inmate population. (One might have wished for a fuller discussion of the implementation of the 1893 law on rural medical assistance, which, for reasons not entirely clear from this account, was followed in the Seine-et-Oise by a decline in the level of services provided to the indigent population of the department; since medical syndicalism was strong there, and the profession successfully exploited the program elsewhere as a source of generous subsidies for private medical practice, one would have expected a different result.)(5) The emphasis is on government intervention in the second half of the century; although it is perhaps misleading to characterize the public health policies of both the Restoration and July Monarchy as laissez-faire (the anti-epidemic legislation of 1822, for example, was thoroughly authoritarian in spirit and horrified liberals), it is undoubtedly true that the Second Empire and, even more, the Third Republic saw a steady rise in the level of routine intervention and assistance, as opposed to emergency measures invoked in times of crisis. In the earlier period, the work of the epidemic doctors seems to have had made only a limited impression on the population, while the response to the first irruption of cholera--which some in the Seine-et Oise, as elsewhere in France, blamed on poisoning by government agents, including the physicians--may actually have reinforced fatalism and distrust of the profession among the peasantry. Later in the century, Ackerman suggests, increasing contacts and growing popular acceptance proved mutually reinforcing.

Ackerman finds both continuity and change, stressing that the latter, which entailed a willingness to embrace new ideas, adopt unfamiliar practices, and consult different practitioners, involved "not a process of replacement, but one of addition". Resistance to vaccination was widespread in the early 1800s but less so later in the century, particularly after the smallpox epidemic associated with the Franco-Prussian war, which took a terrible toll among the civilian population but not among the Prussian troops, who had been regularly revaccinated. Cinchona (and then purified quinine) won ready acceptance, as did the diphtheria antitoxin developed by Emile Roux in the 1890s, because, Ackerman argues, they demonstrably worked; there was even some popular demand in the later decades for disinfection services, in part, she suggests, because the treatment of infected bedding killed vermin. The hospital, however, remained an object of distrust among the rural population, even though it was less clearly a shelter for unfortunates at the century's end than at its beginning. On the whole, Ackerman submits, peasants were not simply fatalists; just as they learned to limit family size and use new agricultural techniques that improved crop yields, so they were willing and even eager to profit from practical innovations in medicine. In addition, the handbooks of hygiene turned out by physicians of the Seine-et-Oise and used in the schools in the second half of the century may have helped inculcate views on health and disease more compatible with those of the medical profession; and starting in the 1880s, the successes of Pasteurism enhanced the popular prestige of medicine as a whole.

These measured conclusions allow Ackerman to take the middle ground in the long-standing and by now rather sterile controversies over medicalization, professional power, and modernization. She sees a somewhat less profound transformation of the peasantry in the first decades of the Third Republic, and perhaps a less clear convergence of elite and popular culture, than Eugen Weber has described, though she accepts his basic framework and his high regard for Roger Thabault's observations on the transformative powers of schools, roads, and military service.(6) On the other hand, while noting the tenacity of traditional practices and beliefs, she stops well short of Judith Devlin's almost ahistorical conception of the persistence of superstition.(7) Similarly, she manages to avoid both the whig triumphalism of older histories of medicine, in which doctors brought the gift of health to the grateful masses, and its near mirror image in some of the scholarship inspired by Michel Foucault, which presents physicians as the repressive agents of Enlightenment discipline and medical power, and the masses as their victims. Taking note of the theoretical debates without entering them, Ackerman sensibly treats all the human subjects in her story as complex actors, motivated in large part by the never-ending struggle against suffering and death. Along the way she reminds us that peasants were not merely passive beneficiaries or victims; they made active choices and helped shape the pattern of health care in their community. In the end, like Weber, she has limited nostalgia for the good old days; modern medicine, she suggests, won converts because it worked better than the alternatives, and we should not allow either the pessimism of late-nineteenth-century elites, obsessed by decadence, or the self-doubts of their late-twentieth-century counterparts, to obscure the real benefits that progress (Ackerman does not use the word, but no other term will do) conferred on the masses. But she never condescends, and the even-handed respect she demonstrates both for the people of the Seine-et-Oise and for the evidence makes this study a useful corrective to some of the more extravagant metahistories concocted by the Foucauldians and adepts of fin-de-siecle post-modernism.

ENDNOTES

1. Village on the Seine: Tradition and Change in Bonnieres, 1815-1914 (Ithaca, NY, 1978).

2. These include the publications of Jean-Pierre Goubert and Jacques Leonard on Brittany, too numerous to list here, and John Spears, "Peasants, Doctors, and Typhoid Fever: The French Department of the High Alps, 1780-1870," Ph.D. dissertation, Johns Hopkins University, 1979--still the only monograph in English comparable to Ackerman's. Olivier Faure's French state doctoral thesis, "La Medicalisation de la societe de la region lyonnaise au XIX(e) siecle, 1800-1914" (Universite de Lyon II, 1989) would have furnished an interesting comparison but was not completed in time for Ackerman to consult it.

3. Le Folklore du Hurepoix (Seine, Seine-et-Oise, Seine-et-Marne) (Paris, 1937).

4. Ackerman, "The Activities of a Country Doctor in New York State: Dr. Elias Cornelius of Somers, 1974-1803," Historical Reflections/Reflexions historiques, 9 (1982): 181-93.

5. This point is well developed in Martha L. Hildreth, Doctors, Bureaucrats, and Public Health in France, 1888-1902 (New York, 1987).

6. Weber, Peasants into Frenchmen: The Modernization of Rural France, 1870-1914 (Stanford, 1976); Roger Thabault, Mon village: ses hommes, ses routes, son ecole (Paris, 1945).

7. Devlin, The Superstitious Mind: French Peasants and the Supernatural in the Nineteenth Century (New Haven, 1987).