Gérard TILLES M.D
Syphilis was in the foreground position of the dermatologic litterature of the 19th century. Hundreds books and thousands articles dealt with it.
In the non medical litterature, many novels and plays of theater presented syphilis as an essential part of the action1 . In these reflects of the culture, disgrace attached to syphilitic patients surrounded their social and personnal life with a climate of stigmatisation. Involving social, moral, political and religious aspects, these stigma are obviously very intricated and any attempt to clarify them may be regarded as artificial and oversimplistic. Despite this risk, I would propose a schematic and hopefully understandable approach that will summarize the stigma according to three levels : stigma in the nation, stigma in the city and stigma in the private life. But prior to this presentation, a brief remind of the medical knowledge about syphilis in the 19th century 2 will place the syphiligraphic atmosphere of the time.
Syphilis was clearly isolated from gonorrhoea, physicians could identify soft chancre from hard chancre previously confused under a common syphilitic origin. The circumstances of the contagion, the three stages of the disease, the major symptoms of secondary syphilis, the symptoms of late syphilis were widely described. Thanks to the works of Alfred Fournier syphilitic origin of tabes and general paralysis was admitted.
The cutaneous symptoms of early congenital syphilis were described by Paul Diday as the teeth in late congenital syphilis by Hutchinson the bones abnormalities by Parrot. However, for the majority of the physicians, misconceptions remained about contagion and heredity and syphilis was still regarded as an hereditary disease.
Few essential questions remained unanswered : the causative agent (T. pallidum) discovered in 1905, the first blood test (Bordet-Wasserman test) invented in 1906 and despite the religious believing in the efficiency of mercury3, 4, the definite treatment, penicillin, first used in this indication in 1943, was still an expectation.
STIGMA IN THE NATION
Physicians elaborated from the 1880’s a system of thinking that made hereditary syphilis the center of moral concern and anguish of their time.
In fact, still confusing contagion and heredity, they created a series of theories expressed by scientific laws that reinforced the importance of the presumed morals. The anxiety about syphilis became stronger and stronger to such an extent that it was considered to encompass all the morbid manifestations of the morbid heredity in general. Despite the absence of any real evidence, syphilis became regarded as capable to produce a race of degenerate children or as a serial killer5.
In fact, the preoccupation with the effect on birth rate came from an actual depopulation of France6 at the end of the 19th century and from the bordering nations, especially Germany, victorious of the prussian french war in 1870. Affecting the physical integrity, syphilis deprived the Nation of the future soldiers indispensable for the revengful projects. Xenophobic considerations completed the military preoccupations. Considering the decrease of population supposed to be a consequence of syphilis, the most active people in the struggle against syphilis pointed out the constrasting increase of foreign workers, indispensable to replace the missing french people and regarde as ennemies of the Nation.
In summary, the struggle against syphilis became thus a top priority not only because of the individual damages but also because of the collective damages inflicted on the family, because of the frightening mortality threatening future generations and finally because of the degeneration and deterioration thaht syphilis could bring upon the human race.
STIGMA IN THE CITY
WHAT KIND OF HOSPITAL FOR THE SYPHILITIC PATIENTS?
The type of hospital for syphilitic patients was still a questionnable problem and there were actually two opposite theories on the question: some physicians like Fournier insisted on the necessity of creating special hospitals and special dispensaries, that will give all the facilities to cure the syphilitic patients apart from the the non syphilitics ones 7. Other physicians such as Brocq 8 favoured the cure of syphilitics in general hospitals or at least in dermatovenerologic departments and non in departments exclusively devoted to syphilis so that the syphilitics were not frightened by the hospital and their moral level be raised.
In Paris, 3 hospitals accomodated syphilitics : Lourcine devoted to women, Hôpital du Midi for men (then called Riocord after the name of the founder of the french venereology) and Saint-Louis, specialized in dermatology and venerology and place of the chair of teachnig of the specialty.
THE CURE BY PRISON FOR THE PROSTITUTES
As a general rule, the syphilis contagion was considered as being transported into the families from the prostitutes or women of the working classes 9. 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 were regarded as playing an essential role in the degeneration of the race10 . So, the biologic discourse of the contamination was superceded by that of a conflict of classes, prostitutes symbolizing more the de-moralisation of the society by sex than only the transmission of a contagious disease.
In this context, the policy with regard to prostitution was
- either to consider the prostitutes as ordinary people suffering of a contagious and possibly severe disease thus deserving to be treated as any other sick person in general hospitals.
- or to consider prostitution « as a moral and fateful disease 11 » and syphilis as an unavoidable stage in the life of the prostitutes. Demoralizing the society thus they deserved imprisonment as the only efficient treatment.
According to this last attitude, the more remanent in the 19th century France, the regulation of prostitution was based upon two principles:
- to know the prostitutes thanks to mandatory regulation
- and to subdue them to medical controls the consequences being, in case of venereal disease, the imprisonment until they recovered a healthy state 12.
In fact, these administratives measures controlled by the police went beyond their public health objectives and allowed to control the behaviour of the prostitutes and to arrest them for any motif whatever their health state.
The sanitary control of the prostitutes took place in awfull conditions. The prostitutes identified by the police by individual cards were subjected to weekly medical examination. Once syphilis was suspected, the patients were called in at a special infirmary, created in 1843 and located in the Headquarters of the Paris Police (Préfecture de Police) 13. Then, after being controlled by the police, a physician appointed by the Police department conducted a physical examination strictly scheduled, each practitionner having about 1 minute per women at his disposal14.
After this very short examination, the patients regarded as ill, were driven in a police van used for murderers or thieves15 » to special departments of general hospitals and after february 1836 to the newly created infirmary of the Prison-Hospital Saint-Lazare. In that way, from 1871 to 1903, 725 000 women being of age or not were arrested. In fact some physicians considered prison as the only way to maintiain the prostitutes in the line of duty 16.
In this hospital, the prostitutes officially imprisonned to be treated were submitted to the wearing of the prison suit, to the absolute silence during the working hours and to various penalties. The diet was dreadful, the hygiene disastrous, the dormitories never warmed, the visitor’s rooms forbidden. As for the nuns responsible of the supervision, it seems they rarely fulfilled their duty of charity but despite this attitude, the attendance at the sunday’s masses was compulsory. Moreover, some physicians such Parent Duchatelet proposed the prostitutes be subjected to a military regim17 and even advised the use of the tread-mills like in the english jails emphasizing the physical advantages of such a method for oxen that fattened in these walking machines18.
STIGMA IN THE PERSONAL LIFE
A LONG – LIFE TREATMENT
Employed since the end of the 15th century, mercury envaded the field of the therapeutics and despite few sporadic oppositions, such as potassium iodide, for the majority of physicians mercury, despite a tremendous toxicity and a questionnable efficiency, was still regarded as the real and only specific. Mercury became synonymous of syphilis and only the word was sufficient to denounce the patient to the social stigmatisation so much that physicians endeavoured to hide mercury behind trivial appearances that allowed the patient to be treated without arousing suspicions.
CONTROL OF SEXUALITY
In the 19th century, the fight against venereal peril appeared in various ways, the principal offshoot being the Société française de prophylaxie sanitaire et morale (SFPSM) founded by Fournier in 1901 20. It became the center of a lobby which role was of a tremendous importance in the regulation of the prostitution and in the thought about sexuality lead by physicians, military people and the families of the upper classes.
The action of the Société has essentially consisted in partly successful campaigns towards the sexuality of the teenagers. Many leaflets about the supposed dangers of sexuality and published by physicians for young men and women stressed the diseases that were lying in wait for them and enough serious to discourage them from having sexual intercourse before marriage. In fact because of the necessity of births, reproduction was considered the first factor of sexuality: « the genital organs are made to procreate. They have a single function 21« . Sexual abstinence was even sometimes suggested as a natural way to fight syphilis and even considered by few authors as easier to complete by women whose sexual needs would be limited to the only wish of motherhood.
In summary, the members of the SFPSM extended their influence beyond the individual life of men and women finally developped a message of collective fear:
- fear of prostitutes, a marginal social category and in a general manner of the working classes considered as aggressors of the aristocratic society and bourgeoisie
- fear of sexuality regarded as an element of degeneration followed by diseappearance of the race by reason of deleterious consequences of syphilis on birth rate,
- and finally fear of the decay of the social order.
Despite the contagiousness of the genital lesions of syphilis, only a few physicians considered condoms as an efficacious prophylactic method. In fact, for the majority of physicians, the condom by its antibirth function represented a social and political controversy, the use of condoms joining the nationalistic and xenophobic considerations above described and was sometimes considered as capable of causin diseases especially in women whose genital organs were supposed to be « affected by a useless orgasm » 24.
Besides the prophylaxis by treatment and administratives measures, to create a purified society cleared of debauchery seemed to many people the best prophylactic method. In this ideal perspective, precocious marriage between was the essential symbol of this rewed society 25.
Thanks to marriage and supervised sexuality, the question of the condoms could be easily solved. In fact, for the majority of physicians, the condom by its antibirth function represented a social and political controversy.
The incitement to marriage promoted as a prophylactic method against syphilis posed the basis of a social exclusion by motives of non conformity to a mental and physical ideal. In fact, the idea of marriage was so much connected with intact physical condition that the health of syphilitics was compared with « altered capital, with suspect values signaling depreciation in the future »26. The prohibition of marriage according to the criteria defined by physicians posed the basis of a social exclusion by motives of non conformity to a mental or physical ideal. In this respect, those excluded from marriage such as the syphilitics formed a miserable people « bannished from a honest life thrown into the irregular life replete with many miseries » bordering the system of the bourgeois order of stupor and fear and debitors responsible for the bankruptcy of society »27 . These people 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.
In summary, it is necessary to insist on the reality of a certain type of medical discourse according to which marriage was reserved for honest, beautiful men and women and which goal was to give birth to children in their images, thereby leaving syphilitic and other sick people as beings without a social function.
Sexual contamination as a crime
Considering sexual contamination as an offence was many times on the agenda of the meetings of the Société française de prophylaxie sanitaire et morale. Every member agreed with that proposition, the question being to find the best sanction between the imprisonning for few days and the sentence to life.28
In conclusion of this overview, the 19th century was an impressionnable period during which multiple interactions were exerted on the syphilitic patients to exclude them from the life of the so-called honest people. At any stage of his life, the patient represented a danger for the glorified values, Nation, marriage, army, work, family. These factors have affected the understanding of the disease and defined the social construction of the sexually transmitted diseases (STD), the moral interpretation of the sexual activity being in the heart of the variations of the collective conscience with respect to STD.