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.