The Making of a Social Disease: Tuberculosis in Nineteenth-Century France.

In a certain sense, all diseases are social in definition: elaborate and often elusive culture-based constructions that incorporate a wide range of elements from the biomedical to the symbolic. In this first study in English of tuberculosis in nineteenth-century France, David S. Barnes, an assistant professor at Emory University, has chosen to study the construction or "making" of tuberculosis by bourgeois male doctors and hygienists during the so-called War on Tuberculosis from the 1890s to the eve of the First World War. In this period, with its well-documented "anxiety crisis" that was often expressed in terms of a biological degeneration of the French "race," the campaign against tuberculosis developed a threefold "dominant etiology" that, Barnes argues, was specifically French. First, the War on Tuberculosis was characterized by a "bacillophobia," an obsession with preventing the spread of the Koch bacillus rather than by a concern with fortifying physical resistance to infection or eliminating the poverty that facilitated its spread. Second, doctors and hygienists emphasized the dangers of slum housing and, by extension, the unsanitary habits of the poor. Third, the campaign was characterized by a "moral etiology" that linked tuberculosis with alcoholism and syphilis in a manner that blamed the disease on the bad habits of its victims.

Barnes's approach is characterized by a detailed analysis of the writings of the doctors and hygienists who advocated action against tuberculosis. Drawing on selected reading in a variety of fields and armed with a sustained scepticism, a good eye for the ridiculous, and a crisp, clear style, Barnes reveals the inconsistencies, biases, and exaggerations of medical theory. For example, his discussion of the campaign against spitting - a section not recommended for the squeamish - uses recent studies in the history of disgust to demonstrate that this centerpiece of antituberculosis efforts was less the product of the recent discovery, of the Koch bacillus than of bourgeois revulsion against unpleasant smells and bodily fluids. The war against the "hideous homicidal crachat" (p. 83) transformed ordinary activities, such as sweeping, kissing, or even talking, into bacteriological menaces. Not surprisingly, it also provoked exaggerated responses, such as the report that workers in one city archive contracted tuberculosis because a consumptive employee licked his fingers to turn the pages of documents. Barnes is also effective in using the arguments of the rare and long-forgotten critics of contagion theory to convey the fallacies and dangers of French medicine's "bacillophobia."

The War on Tuberculosis, like a similar campaign against alcoholism, produced more words than results. But this study provides an extensive account of the exceptional efforts of one French city to fight tuberculosis. In Le Havre, a port city with the highest rate of tuberculosis in France and perhaps in Europe, reforming politicians and philanthropists such as Jules Siegfried developed worker housing and the first municipal health department in France. Barnes underscores the inadequacy of these efforts, thereby reinforcing the arguments of scholars such as Allan Mitchell who stress the failure of social reform in the Third Republic. But, contrary to Mitchell and in line with Thomas McKeown's theories about the importance of economic and social progress in reducing rates of mortality, Barnes questions the impact of public health measures. Le Havre, he notes, did experience a decline in deaths from tuberculosis but so did other French cities with less extensive public health programs.

The general theses of this work will be familiar to researchers in the fields of social history and the social history of medicine. The development of French medical knowledge was shaped, Barnes asserts, by longstanding but recently heightened bourgeois anxieties about the alien and dangerous working classes that had invaded French cities. The War on Tuberculosis not only blamed the poverty-stricken (male) victims of the disease but provided a seemingly scientific rationale for more extensive surveillance and control of the working classes, particularly through the collection of statistics on unsanitary housing and through the establishment of dispensaries in poorer districts. Although Barnes acknowledges that disciplinary and carceral motivations may not have consciously driven reformers, they were, he maintains, fundamental. Even when doctors were correct by today's standards of medical research, as in their arguments that alcoholism was a risk factor in the development of tuberculosis, Barnes argues that "[t]he perception of a connection, rather than the medical 'truth' of the connection, is the relevant fact here." (p. 140) Only revolutionary syndicalism, the radical wing of French labor, was able, he suggests, to establish an alternative etiology of tuberculosis that emphasized the effects of poverty and overwork rather than contagion.

It would, however, be worth knowing more about those doctors and hygienists whose words Barnes has carefully examined. Many, such as Louis Landouzy, were respected clinicians with long experience in the diagnosis and treatment of tuberculosis. What role did their daily medical practice play in their definitions of tuberculosis and in reinforcing or attenuating their social and moral anxieties? As well, the medical world was not as united in its definitions of tuberculosis as Barnes suggests. The "dominant etiology" of the anti-tuberculosis campaign may have met little contradiction at the theoretical level but, as Martha Hildreth has shown, general practitioners were strongly opposed to the development of tuberculosis dispensaries, both for medical and professional reasons. Finally, although certain anxieties were specific to the French bourgeoisie, fear of infectious disease and a consequent tendency to blame its victims have never been restricted to one class. Barnes reports strong opposition from both wealthy and working-class neighbourhoods in Le Havre to a proposed dispensary in their areas. Such working-class fears may, as he suggests, represent the success of bourgeois anti-tuberculosis campaigns, but equally, they may have originated in the medical experience and the social anxieties of workers themselves.

Today, when the World Health Organization warns of the resurgence of tuberculosis, augmented by the AIDS epidemic, this study of nineteenth-century views of the disease is an important reminder of the terror that infectious diseases can evoke and of the ambiguities of medical knowledge.

Patricia E. Prestwich University of Alberta Edmonton