Late one evening an anxious Sir Francis Norton knocked at the door of Dr Horace Selby, a specialist with a âEuropean reputationâ. Selby had a large practice on Scudamore Lane. It was a secluded location for so prominent a medical man but in his particular field patients did not always see this as a disadvantage. Norton was shown into a spacious and well-appointed consulting room. On a table lay copies of the five books that Selby had written on the subject with which his name had become particularly associated.
Selby was a large man with an imposing presence but he had sympathetic eyes that could elicit his patientsâ most shameful secrets. Those same patients found his bulk and dignity reassuring as if somehow hinting at past victories over disease and promising equal success in future cases. Before proceeding far with his examination, Selby enquired of his patient whether he could account for his current ill health. After much earnest protest from Norton, Selby continued his examination, starting with the serpiginous on the shin and moving up to the eyes and teeth. Selby became increasingly fascinated by his patientâs characteristic symptoms. He was writing a monograph on the subject and found it gratifyingly singular that Norton presented so well-marked a case. Selby had become so absorbed by the singularity of the case that he had all but forgotten the person standing before him. He soon collected himself when Norton asked for his medical opinion. However, Selby deemed it unnecessary to go into great clinical detail because he believed Norton would be none the wiser if told that he had interstitial keratitis or showed signs of strumous diathesis. Selby would say only that Norton had âa constitutional and hereditary taintâ. 1 Faced with social disgrace, Norton threw himself under the wheels of a dray shortly after leaving Selbyâs consulting room.
Arthur Conan Doyleâs short story Third Generation is one of the few pieces of English fiction that drew upon the provocative subject of venereal diseases. Moreover, it is unique in its attention to the role of doctors in treating venereally diseased patients. Nortonâs predicament and Selbyâs clinical examination may have been fictional, but they were nonetheless grounded in real medical practices, ideas, debates and uncertainties that characterised English venereology around the turn of the twentieth century. The âhereditary taintâ to which Selby referred was the congenital transmission of syphilis. Norton demonstrated the interstitial keratitis, notched teeth and visual impairment that was characteristic of inherited syphilis. However, his case was unusual because, for Selby, it seemingly confirmed the contested theory of third-generation congenital infection. This was just one of many questions that surrounded the aetiology, diagnosis and treatment of venereal diseases around the turn of the twentieth century. As a doctor with a special interest in venereal diseases, Selby was professionally and intellectually intrigued by a unique example of a disease to which he had devoted his medical career.
The subject of venereal diseases in England, especially in the nineteenth and early twentieth centuries, is one that has preoccupied historians for many decades. 2 It encompasses important questions regarding medical knowledge and practice, public health policy, morality, eugenics, gender and sexuality. Historians have examined developments in venereological knowledge, 3 critiqued cultural and moral reactions to venereal diseases, 4 and assessed the effects of state and medical intervention upon the health and sexual practices of men and women of different social classes. 5 The breadth and richness of existing scholarship makes attempting any fresh contribution particularly challenging. Yet there is one area that has received little attention and it is this area with which Medicine, Knowledge and Venereal Diseases is concerned: the development and circulation of knowledge claims, clinical practices and technologies among different groups of medical professionals.
Historians have offered increasingly sophisticated interpretations of venereal diseases as a social, as well as an epidemiological, problem. 6 This approach allows us to appreciate the porous boundaries between science, medicine and society. However, it has sometimes contributed to a reductive and arbitrary view of scientific, biological and clinical influences upon the development of venereological knowledge and its application in clinical practice. Doctors were unquestionably products of their social, moral and ideological milieu but a more judicious focus is needed. We must consider the combined professional and scientific forces that also influenced the development, circulation and application of venereological knowledge. Such an approach can best contextualise the study and clinical practice of medical professionals within a variety of interconnected professional and institutional frameworks to show how knowledge of venereal diseases was built up and how that knowledge was circulated.
Medicine, Knowledge and Venereal Diseases is bookended by two of the most significant moments in English venereology: the repeal of the Contagious Diseases (CD) Acts in 1886 and the conclusion of the Royal Commission on Venereal Diseases (RCVD) in 1916. These events represented important shifts in government policy and in the trajectory of English venereology. The intervening decades may well have been marked by an absence of government intervention but doctors, nurses and midwives continued to develop their venereological knowledge. This included the aetiological links between venereal diseases and a range of associated conditions, the development and adoption of new diagnostic and therapeutic technologies and the growing centrality of laboratory-based medicine. Investigatory committees and medical congresses also gave health officials and doctors opportunities to raise concerns over infection rates, inadequate sanitary and hospital provisions and the exclusion of venereal diseases from statutory notification. Despite an apparent ubiquity of references by historians to venereological knowledge among medical professionals, the precise content and modes of circulating this knowledge have been addressed neither systematically nor in detail. Rather, the contemporary historiography rests on a great deal of assumption.
This book offers a far more nuanced account of how medical professionals acquired, developed and applied their knowledge of venereal diseases. It is a study based upon surviving collections taken from royal commissions and departmental inquiries, medical texts and periodicals, hospital administrative records, teaching materials, examination papers and patient case notes. These sources represent only the tip of an indeterminately large iceberg of clinical work, research and professional debate surrounding venereal diseases in England between 1886 and 1916, the records for which have not survived. The sources used are those that best represent the development and circulation of venereological knowledge among different groups of medical professionals and the application of this knowledge in their professional practice. It is a selective study, examining key channels through which they were able to develop their knowledge and skill. These were not the only educational and professional channels but they are the ones for which archival material has survived in the greatest quantity.
Venereological Knowledge
Although Medicine, Knowledge and Venereal Diseases focuses on the work of medical professionals following the repeal of the CD Acts, it does acknowledge the ongoing influence of this legislation, especially in the attitudes of doctors towards clinical examinations and the aetiology and epidemiology of venereal diseases. By the time that the CD Acts were repealed, the English medical profession had answered a number of important questions regarding the pathology of syphilis and gonorrhoea. Gonorrhoea was increasingly acknowledged as a serious threat to the health and fertility of both men and women. Syphilis increasingly represented a serious threat to national efficiency and, through congenital transmission, the health of future generations. However, there was still much uncertainty, especially regarding modes of transmission, effective diagnostic and therapeutic practices and the aetiology of conditions such as tabes dorsalis and ophthalmia neonatorum. 7 A growing awareness of the serious implications of gonorrhoea for women generated concern over the limitations of available treatments. 8 By the 1880s and 1890s doctors also understood that mercurial treatments were limited in their efficacy against syphilis and even dangerous if given too frequently or in too high a concentration. 9
Throughout the latter half of the nineteenth century, medical professionals relied upon the presence of well-defined and characteristic symptoms to diagnose cases of syphilis and gonorrhoea. In cases of gonorrhoea, doctors looked for discharge, urethritis and painful urination. Chancres, rashes, stricture, discharges, genital sores and the Hutchinsonian triad of interstitial keratitis, notched teeth and middle-ear deafness were among the common symptoms of acquired and congenital syphilis. Reliance upon such observable collections of symptoms was problematic, especially in asymptomatic or latent cases. The more ambiguous manifestations of syphilis, such as tertiary-stage neurological dysfunction, were difficult to accurately diagnose and aetiologically link to an underlying syphilitic infection. The asymptomatic presence of gonorrhoea, especially among women, also meant that infection frequently went unregarded or was misdiagnosed until it became acute, potentially resulting in infertility and necessitating surgical intervention.
Medical professionals found themselves in a difficult ideological and legislative predicament. Changing knowledge of the transmissibility, aetiology and pathology of venereal diseases made them increasingly aware that, although regulationism had proven ineffective, some form of centralised medical intervention was necessary. Yet the measures implemented under the CD Acts had been stigmatising in their identification of venereally diseased persons as socially and morally deviant. Medicine, Knowledge and Venereal Diseases charts how a growing class of public health officials and medical professionals negotiated competing concerns for placating liberal sensibilities while implementing and consolidating more effective methods of diagnosis, treatment and prevention.
With developing epidemiological knowledge of syphilis and gonorrhoea, doctors became increasingly critical of what they saw as the cursory clinical practices employed under the auspices of the CD Acts. James Ernest Lane, surgeon to the London Lock Hospital, was among a growing number to concede that the process of compulsory inspection and treatment had been fundamentally flawed. 10 These earlier empirical practices had not taken adequate account of the possibility that the patient had entered a latent stage of infection or that their symptoms were so obscure as to be overlooked. Complete reliance upon empirical diagnoses in the absence of serological or bacteriological testing risked periods of latency being misinterpreted as progress towards recovery. Sections of the medical profession therefore attempted to avoid what they viewed as an unscientific process by placing increasing emphasis on laboratory-based diagnostic and therapeutic practices.
The broad clinical and bacteriological developments that marked the final decades of the nineteenth century and the first decade of the twentieth century are well documented. 11 Historians have privileged continental developments, focusing on what J.E.R. McDonagh, surgeon to the London Lock Hospital, described as the âGerman syphilitic trinityâ. 12 Albert Neisser had identified the gonococcus as the causative microorganism of gonorrhoea in 1879, while Fritz Schaudinn and Erich Hoffmann identified the spirochĂŠate pallida as the causative microorganism of syphilis in 1905. In 1906 August Paul von Wassermann developed a complement-fixation test that would be widely adopted as a diagnostic test for syphilis. Between 1909 and 1912, Paul Ehrlich and Hideyo Noguchi developed the arsphenamine compounds, salvarsan and neo-salvarsan (606 and 914, respectively), which were quickly adopted, first in combination with mercury and then as replacements for mercurial treatments. 13 Considerable attention has been given to the place of the laboratory within a wider context of scientific medicine. 14 However, only a handful of historians have considered how technologies like vaccine therapy, salvarsan and the serodiagnostic Wassermann reaction were integrated (or not integrated) into English medical education and clinical practice among wider circles of doctors, or how these technologies helped to augment their knowledge of venereal diseases. 15
Historians have implicitly looked upon such continental developments as examples of a universal venereological knowledge, within which the nuances of study and treatment among English medical professionals have been unhelpfully subsumed. In order fully to appreciate the complex state of knowledge and clinical practice in England, we must focus instead on ongoing processes ...