'The Great Scourge': Syphilis as a medical problem and moral metaphor, 1880-1916

Lesley A. Hall

Wellcome Institute for the History of Medicine, London

NB: Not to be quoted without the author's permission.
This paper was written for the Courtauld Institute Symposium, 23 May 1998, on 'Le Grand Mort. Twentieth Century Bodies, Sexuality, Death and Degeneracy'. Some of the material also appears in my chapter on VD in the UK from the Contagious Diseases Acts to the National Health Service, and in the Introduction, in Roger Davidson and Lesley A. Hall (eds), Sex, Sin and Suffering: Venereal Disease and European Society Since 1870 (Routledge, 2001). However, the approach is sufficiently different (and there is material here which does not appear in SSS), that I am leaving this paper available on-line.

Why did syphilis become such a reverberating topic around the turn of the nineteenth and twentieth centuries? Was this simply because it clearly encoded several resonant anxieties around sex and gender at a time of ever-accelerating social change and increasing threats to the self-confidence of the 'advanced' Western nations which throughout the nineteenth century had regarded themselves as at the pinnacle of evolution?

Syphilis certainly provided a potent metaphor for a plethora of moral concerns, but at the end of the nineteenth century also stood as a ghastly reminder of the inadequacies of medical and sanitary science. The nineteenth century had seen many successes in the war against disease: improved sanitation and water supplies had largely eradicated the epidemics of typhoid and cholera which had seemed so devastating in the earlier decades of the century. Isolation hospitals further prevented the wildfire spread of infectious diseases, while vaccination (albeit a contested practice) had made significant inroads towards eradicating this dangerous and disfiguring ailment.

However, the failures of the sanitarian project for the control and eradication of disease were the more glaring for these obvious successes. The sufferers from chronic causes of debilitation, who might once have been the first to be carried off by epidemics, were now surviving and perhaps more obvious. While the new science of bacteriology was at least identifying the causative organisms of many illnesses, the origin of syphilis was still unknown. If Darwin's doctrines of the struggle for existence and the survival of the fittest had at first seemed to confer a scientific and evolutionary basis for the superiority of the industrialised West, they also held the threat that more robust and fitter organisms might eventually supersede the present fittest; and, once at the pinnacle of evolution, where was there to go but down? Did the persistence of tuberculosis, cancer, and syphilis, indicate that the current lords of creation were ultimately betrayed by what was false within?

In particular, the state of knowledge about syphilis in the ultimate decades of the nineteenth century was conducive to pessimism, if not medical nihilism. In the mid-century the great French syphilologist Philippe Ricord had promoted a basically optimistic model of syphilis as limited, treatable and controllable. This was a view which ever-developing standards of clinical observation which made increasing efforts to determine patient's full medical histories, and the rise of morbid pathology, no longer made tenable. Ricord's pupil and heir to his mantle, Alfred Fournier, was accused of seeing syphilis everywhere and took a very gloomy view as to its wide prevalence and lack of curability. Preventive measures, he felt, were probably the only solution.

Syphilis had long been known to have two obvious stages, although the idea that syphilis and gonorrhoea were simply two manifestations of the same underlying disease had been argued well into the nineteenth century. The earliest manifestation of syphilis is the appearance of a chancre (or possibly more than one) at the site where the microbial organism had penetrated the skin, through some existing lesion, after an incubation period of between ten days and three months, but usually three to four weeks. This initial sore was often confused with another, milder, disease soft chancre or chancroid which produced a genital sore but did not proceed to the later and more malign effects of syphilis (although in situations of poor hygiene it could produce very horrible local effects). The primary chancre of syphilis is not usually painful, unless it becomes ulcerated through pressure. There is some swelling of adjacent glands. These primary sores normally appear on the genitals or in the groin area but can occur anywhere on the body.

Further confusion about syphilis and its aetiology was caused by the fact that many women seemed to become syphilitic without ever having had this primary sore; this of course was because it had developed in the interior of the vagina or on the cervix and thus was not noticed. Also many women in apparent good health with no signs of the disease bore children with the stigmata of congenital syphilis. It was argued that the child was directly infected by the paternal semen (rather than by the latent infection of the mother) and might indeed give the disease to a previously healthy mother. In fact syphilis which had been latent in the woman because of the immunological side-effects of pregnancy might manifest itself following the birth.

The second stage of the disease, which follows some weeks after the first, demonstrates its growing generalisation throughout the system. There is an outbreak of rashes, which may take a variety of different forms, on the skin, and lesions of mucous membranes of the mouth, throat, and anus. Glands throughout the body become enlarged and there can be feverishness. Aches, pains and headaches are also noticed. Irregular hair loss may be experienced. This is a disease, therefore, which is literally stigmatising in that it produces a variety of visible effects which are not easy to conceal.

It had always been known that besides the initial chancre and this more virulent systemic secondary stage of infection, syphilis could cause longer term effects, most vividly with the spread of lesions and ulcers of the skin and mucous membranes, often extremely disfiguring. The formation of gummata, or rubbery tumours, in muscles and bones, were also recognised as a result of syphilis. These manifestations were described, somewhat ironically as 'late benign syphilis': while not malignant in the ways that cancerous tumours are these gummata had effects that were very far from benign. If they affected the bones and muscles of the limbs they caused characteristic changes in the way of walking and moving. Gummatous infiltration of the bones of the nose was responsible for one of the most horrible deformities caused by syphilis as the nose itself eroded and sometimes collapsed and ulceration spread to the face. As a private in the Volunteer Medical Staff Corps L W Harrison, who later became a leader in the effective treatment and control of venereal diseases in Britain, was once shown a ward of soldiers with faces 'literally rotting away with tertiary syphilis'. One occasionally reads anecdotes of young men in the late nineteenth and early twentieth centuries being taken by their fathers or other concerned older men to wards of late syphilitics suffering these horrible consequences as a dreadful warning about the penalties of immorality.

The extraordinary diversity of tertiary syphilis was greatly illuminated by clinical and pathological observations during the nineteenth century, until it seemed that no organ could escape from infiltration. However, most people who died of syphilis did not die of the obvious long-term effects of the disease.

The vast majority of syphilis-related deaths were those caused by its effects on the cardiovascular and nervous systems, but it was a long time before this outcome was recognised. While some association was made between a history of syphilis and cardiac disorders, especially aneurysm of the aorta--the weakening of the wall of the main artery leading from the heart so that it ballooned into a sac--was made, no systematic investigation took place until the later nineteenth century. The initial subjects of detailed clinical study were soldiers, but even though it was easier to establish a syphilitic history in such cases, since this information would be in their military medical records, it was argued that their aneurysm was at least partially due to the other concomitants of the military life. Following the identification of the micro-organism responsible for syphilis, spirochaeta pallida or treponema pallidum in 1905, this was demonstrated to exist in aortic lesions and the connection was definitively established, even prior to the advent of the Wasserman test.

The development of syphilitic gummatous tumours in the brain had been known about but the relationship of syphilis to far more insidious nervous disease was not assumed. This could take the form of locomotor ataxia or tabes dorsalis, a wasting disease of the spinal cord characterised by 'lightning pains' and effects on walking, or paresis or general paralysis of the insane, a organic disorder of the brain which accounted for many of the patients in nineteenth century lunatic asylums. While those who succumbed to these long-term consequences might have had an episode of syphilis in youth, medical thinking tended to identify related lifestyle factors with the development of manifest mental and nervous disorder. Even when, following the increasing sophistication of neurological diagnosis and differentiation of types of paralysis, it was accepted that syphilis was implicated it was seen as predisposing rather than a unique cause. Unlike other late syphilitic disorders, tabes dorsalis and gpi did not respond to mercurial treatment, and often followed a long period of apparent good health since the initial infection.

The characteristic long periods of latency, during which the infected person not only had no obvious symptoms but might seem to be in perfect health, contributed to the state of confusion which existed about syphilis as a disease. Not all who underwent the first two stages succumbed to tertiary disorders, which only became obviously manifest in about one-third of all those who contracted syphilis. Some authorities believed these to be an aftermath of the disease rather than actual syphilis. There was a good deal of controversy about how contagious the disease was and at what stage, which had implications for its treatment and management.

The picture was made even gloomier by the relationship that was increasingly demonstrated between syphilis in the father and its effects on his children. Not only did it cause an incalculable number of miscarriages, still-births and deaths in early infancy, it caused the birth of babies looking like 'little old men', ill-developed, miserable, puny, and wizened. The longer term effects of this pre-natal infection were however being identified in greater and greater numbers, in particular by the work of Sir Jonathan Hutchinson, who gave his name to the characteristic 'Hutchinson's triad' of pegged and notched teeth, the optical disorder chronic interstitial keratitis,and nerve deafness. Other manifestations were cranio-facial abnormalities, defects of the soft palate, enlargement of the spleen, bone lesions (vividly revealed by new X-ray technology in the 1890s) and retardation generally in development. To allude to my previous comments on the successes of public health during the nineteenth century, it is possible that congenital syphilis become more apparent as health standards improved, and it was thus responsible for a proportionately great percentage of childhood disease and deformity rather than being only one among many factors.

By the end of the nineteenth century, therefore, syphilis was already perceived as 'an imitator' which could mimic the effects of many other diseases, and the great physician Sir William Osler claimed, 'Know syphilis and all its manifestations and all things clinical will be added unto you'. This sense of the pervasiveness and insidiousness of syphilis was only confirmed and extended when the guilty micro-organism was finally identified in 1905 by Schaudinn and Hoffman and could be shown to be definitely present in the late manifestations. In the following year the 'Wasserman test' for serum diagnosis of syphilis was evolved and revealed the extent to which latent asymptomatic syphilis was present among the population.

Syphilis was therefore something which in its own right as a disease entity with horrible implications for both the sufferer and his or her offspring was greatly to be feared. Because it was largely caught through sexual activity, in particular illicit sexual activity, it carried an enormous moral stigma which was seriously counter-productive in medical terms as regarded treatment and control. It was strongly associated with prostitutes: even in the nineteenth century many theories of the disease conceived of it as somehow generated within the sexual organs of this stigmatised group of women, created somehow by their promiscuity. Drawing on very ancient traditions of women as tainted and pathological, nineteenth century thought separated the prostitute from the virtuous woman not only as moral categories but as diseased and dangerous versus healthy and pure bodies. It was assumed that any genital disorder in a woman identified as a prostitute was a venereal disease.

But as a group both men and women with venereal disease were discriminated against. Many medical institutions refused to admit patients with venereal diseases. In Britain, the voluntary hospitals which were set up from the mid-eighteenth century to provide treatment for the deserving sick poor usually explicitly excluded VD patients unless there were extenuating circumstances - innocent wives infected by husbands, for example. The few Lock Hospitals which were established specifically to treat this unfortunate group of patients always had difficulty in attracting subscribers for the benefit of those who were felt to have brought about their own ill-health through immoral behaviour. It does not appear that there was any consistent policy about provisions for the very poor who were eligible for treatment under the Poor Law in workhouse infirmaries, although significant numbers of paupers died of syphilis-related conditions.

The treatments available savoured of the punitive. Some authorities argued for the radical excision of the primary chancre on its first appearance (which would have been far too late to prevent the spirochaete penetrating the system). The main treatment, however, relied on mercury. There was controversy over how it should be administered - by mouth, by rubbing into the skin, by injection - and at what stage it should be introduced. Mercury, although it did have some effect on ameliorating the symptoms of syphilis, and may have lessened the severity of attacks, does not seem to have actually cured the disease (LW Harrison suggested that although it slowed down the spirochaete, it did not destroy it), It was also highly toxic and had a number of undesirable side-effects: it caused massive amounts of salivation (some authorities believed this was a good thing and encouraged doses which would promote it in great quantity), gastero-enteritis, rashes, liver and kidney damage, and it also had discolouring effects on the teeth. Mercury, therefore, as much as the disease itself, produced physical stigmata in its train.

If a man consulted his doctor, he would find that he was expected to undergo a lengthy and unpleasant course of treatment.Men were often reluctant to consult their regular practitioner at all when it came to such a shameful ailment. Few doctors were even particularly well-informed about the disease: in Britain, at least, venereology did not form part of the standard medical curriculum at the undergraduate level and any expertise had to be gained by private enterprise post-qualification. It was not an attractive speciality: because of the stigma surrounding the disease, and because of the continuing strong associations between quackery and the treatment of sexual disorders, this was not one of the high status branches of the profession. Nevertheless, this sordid specialism could lead to financial rewards in private practice, and even honours; Sir Alfred Cooper, a distinguished practitioner in the field of the late nineteenth century, received his knighthood, it was alleged, for his services to a royal personage with a very unregal complaint. He also made enough money to run a very posh carriage, which was, however, known among his professional colleagues as 'the clap trap'. Professional honours eluded him and this aspect of his practice was barely alluded to in his obituaries. Even in other European nations sometimes assumed to be less prudish than Britain, a career in venereology was not the obvious route for an ambitious young medic: even Ricord had to wait a lengthy twenty years before being admitted to the French Academy of Medicine and it took twenty-five years for the leading German venereologist Neisser, who identified the organism responsible for gonorrhoea, to achieve a full professorship at Breslau.

Thus, for various reasons, those who had a choice over treatment, that is, those who could afford to consult a private practitioner rather than those who had to accept what was handed out to them, either because they could not afford choice or they were members of Her Majesty's Forces, were attracted by the lures of those who promised to deal with syphilis discreetly, in a short space of time without interruption of the normal routine of life, and without the use of mercury. As has been indicated, both the primary and secondary stages of syphilis are self-limiting and the symptoms disappear in any case after some while. This would naturally give the false appearance of cure.

While there was a subterranean trade in condoms for the prevention of disease, this was all very surreptitious and very definitely not what the medical profession were advocating, either in the case of promiscuous intercourse or within marriage when one partner was infected. When the prevention of venereal disease was debated as an issue of public health policy, the remedy that was normally suggested was the control of prostitutes. Given that it seemed very little could be done about this insidious and prevalent disease, and that there was an enormous 'Gawdsake' factor--what HG Wells described in a more general context as the syndrome of rushing around crying 'For Gawd's sake, DO something'--policing prostitutes was at least taking some kind of action, rather than remaining passive in the face of the spread of the disease.

In most European countries some form of regulated prostitution was in existence. Prostitutes were entered on a register, expected to reside in certain parts of town and not others, and to undergo regular medical examination. This latter requirement was not the point of the whole system but was tacked on at a fairly late stage to administrative machinery primarily intended to police and control prostitute women in the interests of good public order. This system, though it had many champions in nineteenth century Europe and America, and was often held up in the United Kingdom as a model that should be followed, had very major weaknesses. As I think it has been made clear, the state of medical knowledge did not necessarily enable the easy diagnosis of syphilis even with careful examination. Given the time pressures examining surgeons were under and the fact that this was not a high-status job recommending it to the ambitious young medic, it was very unlikely that they were able to make accurate diagnoses except in the presence of the most florid symptoms. Brothel-keepers, who obviously did not want the women in their establishments removed from the work-force for treatment, had many means to disguise sinister symptoms. The lack of what would now be considered elementary hygienic measures meant a constant possibility of cross-infection through the instruments employed. The rigours of this system also encouraged many women to engage in clandestine prostitution to avoid being inscribed on the register and thus they completely evaded any medical examination.

Also, of course, one important element in the transmission of the disease was entirely ignored: the prostitute's customers. While sometimes in military brothels soldiers were inspected for any signs of disease, this was hardly something that could be demanded of the patrons of the better class of houses, even though one of the theories of the transmission of syphilis was that of 'mediate contagion', whereby a man could be infected by having intercourse with a prostitute who had recently had connection with a man suffering from syphilis.

What then was to be done, given the increasing understanding of the long-term, generational dangers of syphilis? Concerned medical men, though anxious to do something about the problem, did not want to disrupt conventional gender and family relations. Even if the system of regulation and licensing was agreed to have substantial defects in practice, the necessity of prostitution as an institution was assumed. Men had certain needs which had to be catered for. While, in particular in the United Kingdom, there was some endeavour to create an ideology of male purity and self-restraint which had some effect, the organisations engaged in this activity were at least if not more concerned about the perils of masturbation as of fornication. All impurity had to be stamped out, there was no discourse about replacing a highly dangerous practice leading to contagion with a safer one, since self-abuse was believed to be itself dangerous and to lead to debilitating illness.

So dealing with syphilis was for the medical profession an issue of damage control and limitation. If it was not possible to prevent men from becoming infected, it might at least be possible to prevent them from communicating their infection to the next generation. Men were to be encouraged to have premarital medical examinations: however, doctors differed as to how long the prospective bridegroom was to be advised to wait if he was found to be syphilitic. Fournier suggested as much as four years, many British doctors thought a year was ample. This was an expedient which could prove socially problematic if the marriage arrangements were already in hand. It was not suggested that the bride should be informed. In their commitment to a patriarchal family system, doctors suggested that the intended father-in-law should be the one to demand a clean bill of health from his prospective son-in-law. One can see that however desirable this state of affairs, it was highly unlikely that the degree of openness and honesty this course of action required would have been universal: and only universality would have made it an entirely efficacious solution, rather than a means by which a particular family could prevent disease from being imported into it.

The law certainly took cognisance of the injury inflicted upon a woman whose husband gave her syphilis. In some countries this was in fact grounds for divorce, and in England it was increasingly being defined within the matrimonial courts as cruelty to knowingly infect a wife in this way. A woman who was infected by her husband with syphilis contracted before the marriage could obtain a separation; if he had caught the disease afterwards she could obtain a divorce, since this presumed adultery had also taken place. But the idea that women should be informed of the risks before marriage was still abhorrent to most men in positions of medical or legal power, and indeed it was often deemed advisable for doctors not to be too explicit with married women suffering from mysterious maladies, in the interests of preserving domestic harmony.

So, by the 1890s, doctors, lawyers and many other men were aware of syphilis as a looming problem. But they did not have any solutions to the problem which seemed likely to be particularly efficacious, falling down as they did over simple questions of human nature. Some writers at least were articulating the problem to a wider public: Ibsen's Ghosts (1881) which dealt with hereditary syphilis was considered dreadfully shocking when it was first produced in London in 1891, although Ibsen was deploying the disease as a metaphor rather than writing a thesis-drama against it.

The French dramatist Brieux however wrote Les Avariés (1905) (known in English translation as Damaged Goods) specifically to attack the conspiracy of silence around venereal disease. It was widely translated and produced throughout Europe, although in England it experienced considerable problems with the theatrical censorship. The English translation was published in 1911 with a laudatory foreword by George Bernard Shaw but in spite of Shaw's praise for Brieux's dramatic powers the play has now sunk into oblivion apart from its historical significance in stimulating discussion of the syphilis problem. It is particular notable as it deals with the problem of syphilis in the respectable bourgeoisie, rather than in the demi-monde, as in the notorious novel Bubu of Montparnasse, about a pimp who contracts syphilis from the prostitute he manages, or among bohemians

Act One starts with George Dupont, a young man shortly to marry, consulting a doctor. Dupont is presented as having been extremely cautious in his premarital sex life--to a degree which strikes the modern reader as unsympathetic and calculating in the extreme--but has nonetheless contracted syphilis. The doctor warns him that by marrying without a lengthy delay he is risking his wife's and children's health. He advocates telling the potential father-in-law 'the unvarnished truth' in order to get the wedding postponed. Dupont presents various cavils--for example, in expectation of his wife's dowry he has already committed himself to buying into a legal partnership---but eventually seems convinced. However in Act Two he has been married a year and the couple have a daughter. It emerges that the marriage was delayed for a few months under the pretext of a touch of suspected consumption, and we are given to understand that Dupont went to a quack who falsely assured him that all would be well after three months. Dupont's mother returns from the country with the child and its wet-nurse. It soon transpires that the child has congenital syphilis and that the nurse is in danger of infection. While Dupont's mother tries to conceal what is the matter, the nurse, alerted by the doctor (the same one consulted by George in Act One) leaves, not before attacking George for having contracted 'a beastly disease from some woman of the streets' in front of his wife, who faints. In Act Three her father, a member of the Chamber of Deputies and thus with some degree of political power, confronts the doctor with a request for a certificate of evidence of George's infection so that his wife can divorce him. The doctor refuses and gives him a lengthy demonstration of the evils of the system of ignorance.

But Brieux did not mount a really radical attack the system whereby young men 'sowed their wild oats' and then married 'good women'. It is symptomatic that it is the husband and the father-in-law who are the objects of the doctor's propaganda. George's wife Henriette is not much better than a cipher, a symbol of pure innocent womanhood tainted by her cowardly husband. And what did Brieux recommend: in the persona of the doctor, to the young man, he suggests 'love only one woman, be her first, and love her so well she will never be false'. The other alternative was to go to the 'licensed dealers' and choose one who was 'a little stale' because 'at a certain age they have paid their toll', alluding to the assumption that a woman who had been a prostitute long enough was likely to have reached the non-infective stage. To the father-in-law he advocates making the same searching enquiries into a prospective son-in-law's health as he would into his financial prospects. And in general he speaks of doing away with ignorance, but again, this need to eradicate ignorance was directed towards males. Brieux was not entirely lacking in sympathy for women, in his depiction of the callousness of the Duponts towards the possible infection of the child's nurse, and in the last act in a 'case-study' of a young woman sexually exploited as a domestic servant by her master, turned out on becoming pregnant, forced into a life of shame, who claims 'These beastly men, they give you their foul diseases' but also adds 'I had my tit for tat'. But it is men on whom he turns his zeal to convert. However, as we can see, he has no radical solutions to offer, only some suggestions for individual preservation, although it was perhaps sufficiently radical to name the disease and to speak out against the prevalent ignorance of its dangers and means of possible amelioration, and to suggest the need for health certificates on marriage. But these were not structural solutions.

An International Medical Conference was held in Brussels in 1899. Strongly influenced by the Abolitionist movement (which endeavoured to abolish the regulation and licensing of prostitutes) it did not advocate any kind of regulation: Professor Fournier, indeed, presented a paper on the highly unsatisfactory state of Paris after a hundred years of the licensing of prostitutes. Instead, it argued for long-term solutions such as the improvement of medical education in venereology, the protection of the young by knowledge, legislation to protect underage girls and to penalise the procurer and pimp, investigation into the prevalence of the diseases and the drawing up of statistics on a common basis. However, there was a chasm between the solutions propounded by the International Conference, and any positive action undertaken at the national level, governments being reluctant to meddle with a topic which was politically highly sensitive.

The idea of syphilis, however, provided a potent metaphor and a quest for more active solutions among late-nineteenth century proponents of women's emancipation. In spite of the rhetoric of the good women who was completely innocent of sexual knowledge and any understanding of the darker side of male desires, the second half of Victoria's reign had seen, in Britain at least, a forceful speaking out against male standards of morality. These had focussed on the Contagious Diseases Acts of 1864, 1866 and 1869, which were aimed at reducing the extremely high rate of venereal infection in the Army and Navy by the medical policing of prostitutes in designated port and garrison towns. Women in these areas known or suspected to be prostitutes could be apprehended by the police, forced to undergo medical inspection, and if found to be infected, incarcerated in Lock wards until 'cured'. These Acts were opposed on a variety of grounds from moral outrage at making vice 'safe' and giving it a kind of government seal of approval, working class objections to a measure which bore most heavily on women of that class, medical criticisms of the assumptions of the Acts concerning the ease of diagnosis and cure, and a proto-feminist fury at legislation which punished women under the rubric of 'medical necessity' while ignoring the male half of the disease equation (soldiers were not even routinely inspected for venereal diseases in the 1860s).

Under the charismatic leadership of Josephine Butler, the Ladies's National Association for the Repeal of the Contagious Diseases Acts mounted a forceful critique of the assumptions about male sexuality and female culpability which underlay the Acts. This developed into a broader concern about questions of sexual morality, the state, and society, evolving into a wider social purity movement by the time the Acts were finally suspended, and then repealed, in the 1880s. While the social purity movement was a somewhat ambiguous heir to Butler's original Association, incorporating many points of view not always far removed from concepts of regulation, the campaign against the CD Acts had accustomed women, or at least some women, to engaging with the very subjects ladies were supposed to know nothing about, linking on to a longer tradition of the prostitute rescue movement.

The first uses of syphilis by feminists were in fictional form in the 'New Woman' novels of the 1890s. These novels, considered extremely daring and even revolutionary in their day, dealt with various burning issues of the women's movement, in particular sexual matters, marriage and motherhood. In Sarah Grand's The Heavenly Twins 1893, and Emma Brooke's A Superfluous Woman 1894, syphilis appears as part of a critique of conventional marriage and class attitudes. n Grand's long and complex novel one sub-plot concerns the contrasted fates of two young women, Edith and Evadne. Edith marries Sir Moseley Monteith, a syphilitic naval officer, who also embodies the degenerate aristocrat. She gives birth to a syphilitic child, goes mad and dies in agony. Evadne, who has acquired knowledge through her reading of medical and sociological texts, discovers a few hours after her marriage to Major Colquhoun that he is a 'moral leper', 'a vice-worn man', i.e. he has had a mistress. She refuses to consummate the marriage. Surprisingly, her husband agrees to this and they live like brother and sister: the real-life case of Lord Colin Campbell, who had been advised by his doctors not to consummate his marriage with a Miss Gertrude Blood while he was undergoing treatment for syphilis and in a state of considerable invalidity, was very different. His infection of her was at the heart of a notorious divorce case of 1886. In Grand's autobiographical novel, The Beth Book, 1898 the moral degeneracy of Beth's doctor husband is established when it is revealed that he holds a post at the local Lock Hospital (his hobby is vivisection). Emma Brooke's A superfluous woman takes up similar themes. Jessamine, the heroine, is courted by Lord Heriot. She rejects a strong healthy Scottish farmer and succumbs to the glamorous lure of society represented by Heriot, a syphilitic aristocrat who passes on the degeneracy of his line.

The corruption at the heart of conventionally highly desirable marriages was central to these novelists' messages. Syphilis in these novels, and in the short stories of 'George Egerton', another New Woman writer, operates as a powerful metaphor for the dangers to which unknowing women were exposed when pursuing what they were told should be their prime aim, a good marriage. It symbolises the moral difference between knowing, even corrupt and tainted men, and the 'innocent' women they married, and also all the perils of adult life from which young girls were shielded through a policy of keeping them deliberately ignorant. It blights not only their lives but those of their children.

The 'New Women' writers tended to imply that if a woman was informed what to look for she could identify the degenerate male: the debauched Sir Moseley Monteith, for example, has eyes which are 'small, peery, and too close together' and his head resembles an ape's. We may compare this to the possible syphilitic subtext in Oscar Wilde's The Picture of Dorian Gray, in which the festering corruption which steals over the portrait of Dorian is not mirrored in his own unchanging youthful beauty. The way the increasing horror of the portrait develops, and the description of the unrecognisably loathsome corpse of Dorian at the end strongly resemble depictions of syphilis. Dorian himself brings destruction to his friends and lovers. While this is not the only, or a full reading of the meanings of The Portrait, it seems quite probable that Wilde was drawing on the images of internal and invisible corruption associated with syphilis. Emile Zola's Nana, however, in the novel of that name, dies a symbolically necessary rapid death from smallpox rather than the lingering death from syphilis which her reckless and promiscuous life-style, and the hereditary degeneracy Zola ascribes to her, would have predicated.

In the new century, however, syphilis became increasingly part of anxieties not just about individual health but national well-being. The later nineteenth century had already encountered threats to the existing social and political system with the rise of working-class movements, demands for female emancipation, and nationalism among submerged and colonised ethnic groups, within Europe itself as well as in the colonial Empires, as well as from the economic effects of trade-cycles. The major Western powers were in rivalry with one another and concerned about their ability to maintain their position in the face of increasing competition. France had suffered defeat and invasion by the Prussians within living memory; the British had suffering humiliation at the hands of the Boers in South Africa; and European ethnocentric assumptions of superiority were even more severely shaken when the Japanese emerged victorious from the Russo-Japanese War of 1904. Several of the nations which considered themselves the most advanced were undergoing a noticeable population decline, while rates of infant mortality still stood unacceptably high.

Evolutionary theory also undermined complacency. Perhaps the white European ruling classes, like the mastodon, had had their day. Perhaps the struggle for existence was already throwing up competitors more likely to gain the pinnacle on which this class had assumed it was permanently set. In Britain Darwin's cousin, the polymath scientist Francis Galton, developed the concept of eugenics, by which humanity would take charge of its own evolution by encouraging the best to breed and discouraging the less desirable from reproducing. It was already feared that the reverse was happening, with the middle classes marrying late and having small families while the underclasses recklessly pullulated in the slums. This was closely tied in with anxieties around syphilis, and other diseases which were believed at the time to have a hereditary component, such as tuberculosis, there was no strict division between inherited defects and congenital illnesses.

The male establishment could not see any particular way forward through this problem, apart from endlessly pointing out that it existed, since one expedient which might have seemed the obvious solution to at least part of the difficulty, birth control, was pretty well unmentionable. Women, however, could take a more positive stance.

Syphilis had in the 1890s had symbolised the dangers of marriage for the individual woman under the existing oppressive conventions of society and her carefully inculcated state of ignorance. In the new century, women's arguments against the Double Moral Standard which allowed men their sexual peccadillos but insisted that a woman's virtue and honour was defined by sexual chastity could be presented as not just a private issue but one with repercussions for the nation and the 'race'. Given the increasing emphasis on the importance of motherhood to the nation, women could and did point out that women were rendered infertile or bore sickly children as a result of diseases which were the consequence of male vice.

Women active in the suffrage movement no longer simply deployed syphilis as a literary metaphor for male corruption. They spoke out with the facts of medicine, science, and sociology to show how men's insistence on their need for extra-marital sex was ruining the nation. The name which is most often associated with an attack on men as sexually-driven predators festering with disease is Christabel Pankhurst, who in her volume The Great Scourge promoted 'Votes for women, and chastity for men' as the panacea for the disease which was vitiating the nation's fitness. She defended the militant suffrage campaign against 'vigorous criticism of the policy of destroying property for the sake of Votes for Women. That criticism is silenced by the retort that men have destroyed, and are destroying, the health and life of women in the pursuit of vice'. However, she was not the first nor the only woman to put the feminist case against the existing sexual system as a promoter of syphilis. Women across the whole range of the suffrage movement perceived this as a central issue on which they were fighting.

Louisa Martindale, of the non-militant London Women's Suffrage Society led by Millicent Garrett Fawcett, brought the authority of a doctor as well as a suffragist to her work, Under the Surface, 1908. She argued that Women's Suffrage movement signified 'the uprising of women, to a recognition of their civic and political duties; a desire to purify, by means of good laws, the social life of the people; a determination to disseminate only accurate, true, and therefore good knowledge amongst young men and women'. Venereal diseases were the outcome of prostitution, which was the result of the existing male-dominated social system. The solution was 'THE EMANCIPATION OF WOMEN'. If women could earn a decent living wage, if women were given a sense of self-worth, and the knowledge to protect themselves, society itself would be benefited by the eradication of prostitution (since women would have other economic alternatives, and be better able to resist male entrapment) and the improvement of public standards of morality.

Cicely Hamilton, actress, writer, and member of the Women's Freedom League, in her polemic Marriage as a Trade 1909, described her own accidental encounter with the 'simple matter of bald statement and statistics' about syphilis. She still recalled thinking 'we are told we have got to be married, but we are never told that!'. She argued that 'Women, like men, when they enter upon a calling, have a perfect right to know exactly what are the dangers and drawbacks', pointing out that 'certain risks attaching to the state of marriage are... sedulously concealed from them as things which it is unfit for them to know'. She had personal evidence of 'the number of women... who seem to have hardly more than a vague inkling - and some not even that - of the tangible, physical consequence of loose living'. While not claiming to be dealing with questions of masculine morals, Hamilton nonetheless suggested that 'If marriage is a trade we ought to know its risks': whereas syphilis was never mentioned, 'except in technical publications, in connection with the infant death-rate'. The subject was also alluded to in the various women's suffrage journals.

Not all women were happy with the simple version Pankhurst posited of inverting the existing meanings of syphilis. Was it really any advance in getting a grasp on the problems of this dreadful disease simply to change the conventional ascription of the disease to immoral women to ascribing it to immoral men? The youthful Rebecca West, already a noted and outspoken journalist aged barely twenty, suggested that 'the fallen man... is as much a victim of social conditions as the fallen woman'. Most victims of syphilis were 'mere youths, sometimes perilously ignorant'. She argued that Pankhurst's stigmatising approach was ultimately counter-productive, if 'sufferers are intimidated by a hostile social atmosphere into being afraid to acknowledge the nature of their illness and thus to seek advice as to the best method of treatment'. Given Pankhurst's claim that most nerve disorders were the result of syphilis, West remarked with mordant wit 'Perhaps [she] is now puzzled at a certain coldness noticeable in those of her friends who have had nervous breakdowns.' Similar views on syphilis as a general symptom of imbalances and disorders in the social and sexual economy were put forward by both men and women involved with the sex reform movement which grew up in the early twentieth century stimulated by the writings of sexologists, British and Continental, who were trying to achieve the difficult task of turning a rational and scientific gazw upon sexual phenomena,

The subject of syphilis was, therefore, gradually being more talked about: as we can see, Christabel Pankhurst did not single-handedly breach a monolithic conspiracy of silence. The subject was of increasing concern to doctors, public health workers (including the growing numbers of women employed in this area), welfare workers, philanthropists, reformers etc. There were, in Britain, various attempts to engender government action, if only the appointment of a commission to investigate the extent of the problem. Writings on the subject emphasised that anyone might contract syphilis, and the perils of innocent infection were continually rehearsed. The innocently infected were not only the unwitting wife and her syphilitic children, the doctor or nurse who contracted extra-genital syphilis from a patient, but those who caught it through careless hygiene in operations such as vaccination, from barbers' implements, from shared cutlery and cups, and even from social kissing. The significance given to the fact that anyone might catch syphilis was perhaps a strategic move to dissociate the disease from its inevitable association with sexual immorality, but it caused it to seem even more pervasive and inescapable than it was. And of course provided a set of accepted excuses for having the disease at all: the myth of lavatory seat transmission goes back at least this far. But still, the root of the matter, however apparently innocuous the means of transmission was, went back to someone's sexual activities, with repercussions like spreading ripples in a pond.

But in spite of this gloom, and the apparent failure of traditional sanitarian public health measures, the beginning of the twentieth century also saw the glimmerings of hope. If the discovery of the spirochaete and the implementation of the Wasserman test confirmed beyond doubt and conjecture how terribly pervasive syphilis, was, these discoveries also enabled major advances to be made towards adequate treatment. In 1909 the German bacteriologist Paul Ehrlich finally discovered the 'magic bullet', '606' of the substances he had tested, the arsenical compound Salvarsan. This literally seemed like magic to those who first used it and saw the spirochaetes, which mercury had only slowed down, vanish completely. However, it was not exactly a simple solution: it took a good deal of work to get the exact means of administration worked out, and the early trials of the drug indicated some dangerous side-effects, as might be expected when dealing with a toxic substance. Even when this had been better ascertained, salvarsan required some degree of expertise to administer, and the course had to be kept up until the patient finally manifested a negative response to the Wasserman test. This usually took around two years, involving regular visits to the doctor for intramuscular injections. While, unlike mercury, treatment did not require sequestering the patient, who could thus carry on with the ordinary pursuits of his or her life, it was a prolonged and inconvenient process, and not everyone responded to this miracle drug. Nor did it provide a solution to the worst aspects of late syphilis, tabes dorsalis and general paralysis. But it did give cause for optimism.

It was, at last, something that could be done. The problem now was how to get this new treatment and the appropriate patients together. After over a decade of attempts in Britain to get a government commission on the subject of venereal diseases, a Royal Commission was finally appointed in 1913, with a remit to enquire into the prevalence of the diseases, and to make suggestions for prevention and treatment. There was a new openness about the topic: for the very first time, The Times printed an article using the word 'syphilis' instead of the euphemisms formerly employed whenever it was alluded to.

And then, a year later, the First World War broke out. War had historically been a breeding ground for venereal diseases, which had got much of the medical attention they had benefited from in the military context. They were a problem to all the combatant nations. In Britain, partly as a result of the debates which had been seething in the previous years, the issue of sexually-transmitted diseases was a major policy problem, while the means of control which had been appropriate for a small professional army were unsuitable for an army whose ranks were being swelled by large numbers of recruits from social classes which would normally never have considered enlistment an option. Venereal diseases also came to be embodied in a new group of disorderly women: by an ironic twist, the formerly demonised prostitute was reconfigured as a professional woman who 'knew how to take care of herself', a known quantity, while the health of the nation's forces was allegedly endangered by hysterical girls, mad with 'khaki fever', throwing themselves in erotic abandon at anything in uniform. A new version of an old metaphor, in the association of sexual diseases and women who failed to fit in to acceptable social categories, who crossed boundaries, who were uncontrolled.

In 1916 the Royal Commission finally reported. It took the radical but realistic line, congruent with existing public health policy, that it would be counter-productive to differentiate between innocent and guilty, between men and women, that any policy would have to apply even-handedly and without bias to all. It recommended, a policy which was shortly carried out, the introduction of specialist venereal disease clinics, at which treatment would be expert, free, confidential, and conveniently accessible, for example by arranging clinic hours that would not impinge upon working time. Salvarsan was only to be administered by trained doctors, and a law was passed making it illegal for anyone to purvey other alleged remedies. The Commission also indicated the importance of propaganda and educational work in eradicating these diseases - while syphilis was now curable, there was still no equivalent of salvarsan for gonorrhoea, which was becoming recognised as a more significant danger to personal and national health than had once been thought.

So, happy ending to a long and dark story, as Dr Ehrlich's magic bullet zaps the spirochaete? Not quite. Because there was something that could effectively be done, public health campaigns were put in motion to make sure that it would be done. People had to be persuaded to go to clinics and undertake testing and treatment. It can sometimes seem that the great age of syphilophobia was the period between salvarsan and penicillin, when public consciousness of the disease reached a heightened state. In visual propaganda, including the growing use of the new technology of the cinema for particularly dramatic effect, there was a persistent recursion to the image of the 'dangerous woman', who, if not a prostitute, was 'easy' or 'loose', seductive and threatening. The early twentieth century feminist use of syphilis as a potent metaphor for male oppression and corruption, literalising what was false within the existing patriarchal social system, largely disappeared.

Furthermore, the very success of Ehrlich's quest for a 'magic bullet' may have increased popular belief in the capacity of science to come up with solutions for long-standing social problems. Those who believed that, just as the congenital disorder of syphilis could be eradicated by the interventions of testing and medication, other hereditary ailments might also be eliminated through eugenic programmes, did not pause to consider that, difficult as it had been, the identification of the spirochaete and the development of a chemotherapeutic agent were as child's play to the intricacies of human heredity and its control.

The continuing significance of social factors to the spread of syphilis was manifested once more at the outbreak of the Second World War. While its incidence had declined to record-breakingly low levels by the late 1930s, the graph took a steep upturn once war broke out, even, surprisingly, in neutral countries such as Sweden.

Useful link on history of syphilis

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