Gérard TILLES M.D., Ph. D., Daniel WALLACH M.D.
Musée-bibliothèque de l'hôpital Saint-Louis, Paris, France.
The relationship between diseases and society are a great matter of interest for the physicians. In this respect, sexually transmitted diseases are particularly involved in the connections between medicine and society and today AIDS emphasizes how essential are the social and cultural environment. Historical works may thus be of some value in providing us with models that can improve our understanding of present days situations.
Describing and analyzing the complete scope of the social implications of syphilis in the nineteenth century in a short overview sounds a impossible challenge. I will thus limit my talk to few of the main questions in which physicians took part.
The social implications of syphilis in the nineteenth century are first characterized by the time they occured. In effect, the last third of the century was clearly the period. Prior to this period, nothing in the medical writings indicates that syphilis could have any social consequence in its own. In the beginning of the nineteenth century, no physician worried about syphilis as being a possible social or racial danger. Syphilis seemed to be better known; cutaneous and extracutaneous signs, the three stages were better described. Thanks to the works of Ricord and Bassereau, physicians could identify syphilitic chancre and soft chancre. Mercury was regarded by almost all physicians an efficient therapy. In short, syphilis seemed to cause only medical problems like another infectious disease ans no physician social worriness.
Contrasting with the quiet appearance that syphilis offered until the end of the 1860's, the situation changed drastically from the 1870's when the moral and social implications produced a strong breaking.
The syphilitic contagion became a matter of strong social considerations. The transmission of syphilis was no more described only as an infectious disease - as it previously was- but as the matter of social conflicts. As a general rule, medical writings considered only the husbands as capable to bring syphilis into the families. Transmitted by prostitutes to the honest wives and killing the children of the upper classes, syphilic patients became the symbol of the destruction of the bourgeoisie by the working classes.
In fact, the main driving force of the connexion between syphilis and society was the creation by the physicians of theories on syphilis heredity, . Thanks to these theories, despite the absence of any scientific evidence, syphilis, previously considered as an ordinary disease which consequences may those of a normal sexual activity, became regarded as a serial killer. The struggle against it was described by physicians as a top priority because of the contagiousness that inflicted dame on the family but first of all because of the hereditary consequences notably the frightening mortality threatening future generations and in part because of the degeneration that syphilis could bring upon the human race. The role of syphilis heredity became stronger and stronger to such a point that it was considered as capable to encompass all the manifestations of morbid heredity in general. The obsessive fear of syphilis heredity was such that few physicians created anthropometric list that allowed to identify syphilitic patients -or supposed so- at a glance. Besides certain features considered as characteristics of the patient bearing syphilis heredity as the shape of ears or the toothline, the stammering, the somnambulism, the nervous tics and even the ginger hair were supposed to be of syphilitic origin.
So in the last thirty years of the nineteenth century appeared quite elaborated medical writings to which the majority of the physicians supported. These writings allowed to emphasize the fact that syphilis could concern not only everyone in itself and its close family but could also result in the extinction of the mankind.
Facing to this venereal peril that could transform civilized nations into deserts or into countries peopled with sick people only, physicians pointed out prophylactic policies considered as a national emergency. In fact, they defined therapeutic and teaching actions : to attack syphilis by treating the disease and to fight syphilis by educating the younger generation of physicians of all aspects of the disease. But, in addition to these medico-scientific measures, they insisted
Condoms and sexuality being condamned, marriage was regarded as the ideal solution. Marriage is a condom, wrote Diday. "Marriage prevents rapid consumption produced by the venereal excess by excluding the attraction of novelty and subjecting physical instinct to a more sublime moral goal". "For marriage plentyfully fulfill its role, it must encourage men and women to marry as virgin" recommends Fournier, fisrt professeur of dermatology in Paris.
Finally, to apply the incitement of prophylaxis to marriage appeared to be one of the essential motivation of the antisyphilitic crusade : the control of sexuality. It was from this derivation that a strategy of prevention emerged (encouragement for marriage) without direct relationship to the cause of syphilis.
Using marriage as a weapon in their strategy of the struggle against syphilis, physicians set a message of exclusion and stimatization. In fact, the incitement to marriage produced two main consequences : first the exclusion syphilitic patients from a so called honest life and secondly the stigmatization of a social group: the protitutes.
Marriage was defined as an association where all married persons bring not only financial capital but a "capital of health and physical values". Thus, theoretically accessible to all, marriage was foreseen only on condition of good health, that is, not available to those with "depreciated capital". "Marriage is not an infirmary, to enter into marriage, it is necessary to be healthy, beautiful in body, spirit and conscience". The idea of marriage was so much connected with an intact physique that Fournier did not hesitate to compare the health of syphilitics with "altered capital with suspect values signaling the depreciation of the future". The finality of marriage was birth : ultimate goal and sacrosanct in all unions. Without this objective, encouring an increase in the birth rate, " adignified life is not possible; marriage without children is an abnormal state. "Husband and wife without children is biologically abnormal".
In this medical discourse, marriage was reserved for honest, beautiful couples of helathy mind and body who would produce beautiful and healthy children. The prohibition of marriage according to the criteria defined by physicians posed the basis of a social exclusion by motives of nonconformity to the mental or physical ideal. Those excluded from marriage formed a miserable people "banished from honest life thrown into the irregular life replete with many miseries". Syphilitic patients "who border the system of the bourgeois order of supor and fear are debitors responsible for the bankruptcy of society". Marriage held apart all those who did not conform to the normal and represented for the ideal society of married men and women, a physical threat due to the nature of the contagious disease and a blow to the social order. Because the relationship between syphilis and marriage was essentially defined as a social conflict, the system of prophylaxis was designed to construct obstacles preventing contamination of the bourgeois and aristocratic classes.
The second main consequence of the incitement to marriage was the stigmatization of a group judged to be socially dangerous : the protitutes. Prostitutes could introduce syphilis into marriage and violate the physical integrity of the wife and future mother. By inciting the husband to commit adultery, they attacked the integrity of the social order and by transmitting syphilis, considered as hereditary, to honest families, prostitutes played an essential role in the degeneration of the race. It was not so much the syphilitic prostitutes who justify the prophylaxis, but the 20% of so called innocent married women. In effect, wrote Fournier, "if it concerned only those who have sought the disease, those who have contracted it under irregular moral and social circumstances, the purpose of this prophylaxis would be debatable. What is important is to protect those who do not have the means to protect themselves, most importantly all honest women and children".
The biologic and epidemiologic discourse of the contamination was superceded, through marriage, by that of a conflict of classes. Thus, venereal disease symbolized the risk of contagion by dangerous classes, prostitutes, which constituted a terrible threat for the future of the race.
The incitement to marriage enhanced the role of physicians who defined themselves as "protectors of society" and by denying or authorizing marriage (on clinical criteria before the discovery of the Wasserman reaction and the Treponema pallidum in 1905 and 1906 respectively), physicians became the guardians of the social order. Physicians extended thus their influence beyond the individual life of men and women and by promoting this incitement they finally developped a message of collective fear of prostitutes, a marginal social category and in a general manner of the working classes who allowed physicians to describe syphilis as rupturing social order.
In conclusion of this quick overview of the social implications of syphilis at the turn of the century, it is essential to underline that, despite their influence, it would be simplistic to attribute the physicians the entire responsabilty of the desastrous consequences of their theories notably on heredity. It seems more accurate to understand the anxiety of syphilis expressed by physicians as the scientific translation of the upper classes anxiety of syphilis, alcoohol and tuberculosis the main social plagues of that time. However, in translating into scientific words the fantasms of the social class they belonged to, the physicians gave the guarantee of science and enhancing the sanitary danger, they reinforced their authority.