Completing the Triangle: Immoral
Places, Immoral Behavior
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The confluence of alcoholism, syphilis, and tuberculosis––the
complete triangular association––operated in a subtler way than
did the two-part connections discussed above. Above all, the
triangular link demonstrated the force and frequency of the
specter of the cabaret (and, to a lesser extent, the prostitute)
in turn-of-the-century fears of French decline and degeneration.
Before considering the triangular link in its full three-part
form, it is worth mentioning that on occasion during this same
period, medical literature explicitly linked alcoholism and
venereal disease without the nexus of tuberculosis. For example,
the 1901 International Congress on Alcoholism heard a paper in
which it was argued that while alcohol had an undeniable
influence on venereal disease by encouraging sexual excesses, it
was “tipsiness” rather than drunkenness or chronic alcoholism
that correlated most closely to the contraction of venereal
infection.[87]
Another of the rare medical expositions of the
alcoholism–syphilis connection was more provocative in its
social implications. This study, by Dr. Barthélemy of the
clinical staff of the Paris medical faculty, appeared in the
Annales d’hygiène publique in 1883 (before the other links
described above had coalesced). As a follow-up to one of his
earlier studies, which had posited an aggravating effect of
alcoholism on syphilitic chancres, Barthélemy looked into the
surprising frequency in the initial study of serious cutaneous
infection among women. He found that all of the women so
affected were “femmes de brasserie,” pub waitresses known
to offer additional services to their customers, and that all of
them were forced by their employers to drink excessively.[88]
On further study of the situation of femmes de brasserie in
general, Barthélemy found that most were syphilitic; indeed,
they were the principal source of venereal disease among “the
young men of the Ecoles.” In the interest of public
health and better surveillance of “clandestine prostitution,”
the doctor recommended that these “establishments served by
women” be suppressed in their current form as “insalubrious
establishments of the first degree.” Barthélemy justified such a
regulatory measure (at first sight incongruous in an article
entitled “Influence of Alcoholism on Syphilis”) by “the
frightening proportion in which [syphilis] contributes to the
depopulation of the species…and at the very least to the
degeneration of the race.”[89]
This is one of the first instances of the cabaret and the
prostitute being medically implicated in depopulation and
degeneration. It would not be the last.
It is impossible to pin down chronologically the origins of the
three-way alcoholism–syphilis–tuberculosis connection. In a
paper presented at a 1891 tuberculosis conference that may
represent the first explicit reference, Dr. E. Tison included a
case study of an alcoholic and syphilitic patient who died of
tuberculosis. Tison concluded that the progress of the
tuberculosis was more rapid than normal in this case (not
sclérosant) and that “pulmonary [tuberculosis] followed
organic weakening by syphilis and alcoholism.”[90]
Somewhat indirect references to this triangular connection can
be found in writings on tuberculosis around the turn of the
century as well. For example, Romme maintained in 1901 that the
“seed” of tuberculosis found “a particularly propitious soil” in
unsanitary lodgings, whose inhabitants were “ravaged by syphilis
and alcohol.”[91]
In most cases, references to the three-way connection were
oblique, or remained at the level of allusion.
Rénon went beyond allusion in 1905 when he confronted the
triangular link explicitly and in detail. Both in his lecture at
the international tuberculosis congress of that year and in his
book Les Maladies populaires, Rénon clearly targeted
alcoholism, syphilis, and tuberculosis—and the behavior they
represented—as dangerous threats to French society. First, he
laid the medical groundwork for the connections: both alcoholism
and syphilis seem to favor the development of tuberculosis; in
addition, the déchéance that predisposes to tuberculosis can be
inherited, and the children of alcoholics and syphilitics (as
well as the children of tuberculous parents) are likely future
victims of tuberculosis.[92]
Rénon then proceeded, in his lecture, to sketch the outlines of
the “social defense against tuberculosis” that he had in mind.
In this fight, the cabaret was a formidable adversary. “I regret
that we cannot diminish the strength of this enemy of the
people, the cabaret.” However, action against the threat was
both possible and necessary. “The fight against syphilis and
other intoxications, in solidarity with the fight against
tuberculosis, will find serious support in…[a] union of all
efforts to defend the physical and moral interests of the
community.”[93]
Rénon not only turned the language of revolution on its head
with the epithet “enemy of the people” but also demonstrated how
inseparable were the physical health and the moral health of
France in the diagnosis of social pathology.
The crucial role of the cabaret in uniting all three scourges
was never more succinctly expressed, however, than in Les
Maladies populaires.
Alcoholism is the great purveyor of tuberculosis. “La phtisie
se prend sur le zinc,” said M. Hayem, and this is true. It
is the associate of syphilis, in those shady cabarets [cabarets
interlopes] found in abundance around barracks [and]
factories, bars where one gets alcoholism on one side of the
counter and syphilis on the other [débits où l’on s’alcoolise
d’un côté du comptoir et où l’on se syphilise de l’autre].[94]
Once again, the word associate was used to define the
connection among the scourges. The cabarets (and, by adroit
implication, prostitution) were all the more dangerous in that
they were “spread out” around factories and garrisons, where
they turned vital workers and soldiers into degenerates and
sapped France’s economic and military strength. The triangle was
completed not through tuberculosis this time but rather via the
nexus of the cabaret’s zinc countertop: “You get phthisis at the
zinc”; on one side of it, you get alcoholism and, on the
other side, syphilis.
Mortality in general (and its leading cause, tuberculosis, in
particular) posed a vexing problem to a demographically stagnant
nation that perceived itself as in danger of decline. The
problem was even more worrisome, however, when it appeared that
physical or numerical decline was inextricable from––indeed,
both evidence and a result of––vice, political subversion,
productive incapacity, moral “déchéance.” Through vice and
heredity, it was feared, a kind of subspecies was being
propagated in France, a lower race of “candidates” for
tuberculosis and other afflictions, morally and physically
degenerate. Resulting mortality kept population from increasing,
so lower quality was matched by lower quantity.
General fears of national decline, combined with a specific and
acute Germanophobia in the aftermath of the Franco-Prussian War
of 1870, allowed the appropriation of ostensibly medical issues
for the expression of political concerns, or at least the
evocation of such concerns in medical discourse. For
example, at the Toulouse conference on alcoholism and
tuberculosis in 1903, one speaker recalled the words of Gambetta
after the Prussian capture of Metz in 1870.
In the presence of so many evils and the prodigious effort they
require, the country should once again hear the great voice
which rose up in the somber days of 1870, after the capitulation
of Metz, and which kindled hope in our hearts: “Frenchmen, lift
up your souls and your resolution to the level of the terrible
perils which weigh on the Patrie.”
“It still depends on us to leave behind ill fortune and to show
the universe what a great people is made of, [a people] which
does not wish to perish and whose courage is aroused even in the
midst of catastrophe.”[95]
In this instance, alcoholism and tuberculosis not only were
compared metaphorically to national military defeat and la
patrie en danger but also served as a reminder of the need
to preserve the greatness of the French nation and to prove that
greatness in response to the threat of decline.
Furthermore, perceived moral and physical degeneration fed
political fears of domestic as well as foreign threats. In
addition to Triboulet’s diatribe against the politics of the
cabaret, the characterization of the Paris Commune of 1871 as
the work of alcoholics was quite common. Barrows has shown that
“the terrible year of 1870–71 triggered an immediate and
dramatic shift in the perception of drink.”[96]
The entire experience of that year, the “année terrible,”
had ingrained a lasting fear of French decline that could take
(and in many minds had taken) biological as well as political
form. Nevertheless, the medical form of this fear seems to have
intensified during and after the 1890s, particularly during the
decade 1895–1905. Other historians of France have also
pinpointed this period as one of heightened medical attention to
preventive social and hygienic policy and have attributed this
attention in part to the demographic anxiety of the time.[97]
Degeneration symbolized many perceived trends and threats, from
loss of productive economic capacity (through lost man-hours due
to illness and an unreliable workforce) to declining national
vitality and virility (through a declining birthrate) and loss
of national stature in the world arena.
The structure and evolution of the three-way association
exemplify the peculiar interactions of scientific medicine with
society as a whole. In the case of the alcoholism–tuberculosis
connection, debate among doctors and scientists gave way in the
last decade of the nineteenth century to near-unanimity and an
abundance of physiological evidence supporting the etiology. In
contrast, the syphilis–tuberculosis “association” was never
actually a debate, even though ambiguous and seemingly
conflicting data were presented in connection with it. Moreover,
the type of scientific proof of a causal or predisposing
relation common in the literature on alcoholism was
comparatively meager in the work on syphilis, apart from
statements concerning the effects of debilitating diseases in
general. Yet overriding social and moral factors seem to have
imposed a strong triangular association, regardless of the
clinical evidence.
The concept of heredity clearly played a major role in the
diagnosis of degeneration, and its use marked a significant
change in medical thought in France.[98]
As was the case with overcrowding and filth, an element of
pre-germ theory etiologies persisted into the time of the War on
Tuberculosis but in somewhat altered form. In the essentialist
era of the early and mid-nineteenth century, before Villemin and
Koch, tuberculosis had been understood as an inherited
disease—that is, acquired principally and directly by heredity.
Heredity was thus essentially a backward-looking concept,
used to explain why people were afflicted with tuberculosis at
that time. By the turn of the century, heredity had given way to
contagion and behavior as a direct cause of tuberculosis;
however, it remained an indirect cause through the concept of
inherited predisposition. In this usage, amid concerns over
national demographic decline, heredity was a largely
forward-looking concept that explained why the future
consequences of all three scourges were so grave.
Both alcoholism and syphilis served to bring a moral and
behavioral element into the etiology of tuberculosis, a
rampant—and for years inexplicable—killer. Moral judgments have
often characterized societies’ responses to disease throughout
history—the example of AIDS, among others, shows this to be no
less true in the late twentieth century—and have rendered
mysterious threats comprehensible and less threatening to many
members of those societies. In this respect, the role of
syphilis in France at the turn of the century is crucial, for it
did not enter the dominant etiology with as much accumulated
“science” behind it as did alcoholism. Judged by the standards
of the time, that is, fewer studies and more tenuous types of
evidence linked syphilis to tuberculosis than linked alcoholism
to tuberculosis.
If syphilis was thought to affect the body’s resistance to
tuberculosis only in the same manner as many other diseases, why
did it become closely connected to tuberculosis? Several answers
can be conjectured. First, syphilis was closely associated with
infertility and birth defects, and the connection thus spoke to
fears of depopulation. Second, it reinforced the
moral/behavioral etiology of tuberculosis; in so doing, it may
also have strengthened the repressive power of the reigning
bourgeois ethos of family and monogamy. Third, syphilis
introduced the prostitute as a mortal danger; she was already
the consummate symbol of degeneracy and social pathology in
France. In the words of Alain Corbin, “the prostitute figures at
the center of the tragedy of this time because she contains and
symbolizes at once the venereal evil, alcoholism, tuberculosis
and dégénérescence.”[99]
Alcoholism, syphilis, and prostitution all focused attention on
that other potent symbol of social fear, the cabaret. The
continual intrusion of the cabaret into medical investigations
and explanations is one of the most salient and striking
features of the alcoholism–syphilis–tuberculosis connection.
Inherently “shady,” the cabaret lay at the confluence of several
social pathologies: economic unproductiveness, immoderation,
sexual promiscuity, prostitution, and left-wing politics. The
central role of the cabaret in the moral etiology of
tuberculosis also allowed it to fit relatively seamlessly with
the other two strands of the dominant etiology as a whole, those
involving contagion and housing. For example, the cabaret became
a breeding ground for bacilli and a locus of contagion;
meanwhile, the lamentable conditions of the worker’s slum
lodgings further encouraged him to spend his time at the
cabaret.
The doctors who were in the forefront of the evolving triangular
association did not simply use the problems of tuberculosis,
syphilis, and alcoholism as a front or a sham hiding their true
social and political agenda. Neither, however, was the
connection a straightforward, ideologically neutral medical
attempt to improve public health. Rather, there was a subtle
slide from the ostensibly empirical scientific observation of
pathological correlations to a broader social diagnosis. This
diagnosis captured, channeled, and expressed a wide range of
anxieties, which included but were not limited to concern over
the health of Frenchmen. It did so in a manner that seems to
have been compelling, and it was also politically expedient.
The connection of alcoholism and of syphilis with
tuberculosis—and, later, the mutual association of all three
scourges—indicted certain social pathologies in the
biological decline of France (and, by extension, its
political and economic downfall) at the turn of the century. The
focus on the cabaret and on prostitution added potency to the
moral etiology of disease, and embodied in familiar targets
manifold threats to the nation.
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