Syphilis in the Fergana Valley - Valerian Kushelevsky, 1891

Translation of a medical report detailing the spread of syphilis in the Fergana Oblast in Russian Central Asia

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Bazaar in Old Margelan, Fergana Valley

Translator’s Introduction

Below is a translation of excerpts from the Russian text “Материалы для Медицинской Географии и Санитарного Описания Ферганской Области том III” (“Materials for Medical Geography and Sanitary Description of the Fergana region volume III”), published by the State Committee of the Fergana Oblast, 1891. The first volume can be found here, on the website of the State Historical Public Library of Russia. Volume III in its entirety, can be found here, on Academia.edu. Volume II is also on Academia.edu. This translation is from an abridged text, written in the modernized, post-1917 reform script. This source can be found here.

Valerian Iustinovich Kushelevsky’s report on syphilis in the Fergana Valley in Russian Central Asia is interesting for two reasons. First, it sheds light on a lesser known, but very significant issue, in addition to providing fascinating anthropological information about the residents of the Fergana Valley in the 19th century. From Kushelevsky’s report we learn not only about the complete lack of hygiene among the locals, but also Fergana’s rampant prostitution at the time. It really must be noted that different peoples, both individuals and cultures, have radically different hygienic standards. Anyone who has extensive personal experience either through traveling or from somewhere else, or has read enough 19th century/early 20th century anthropological texts and travelogues will already understand this.

Secondly, the text depicts how the modern, European state administration apparatus came into contact with pre-modern societies that were colonized in the 19th century. For the first time, these populations were analyzed and examined by objective observers. Prior, indigenous state apparatuses were fairly limited in their scope and reach. Their ability to penetrate society, to see and understand what was happening, was extremely limited. Maybe only the Chinese dynasties, the Roman Republic and few others could do this is a manner comparable to modern states. A good book on this subject is James C. Scott’s “Seeing Like a State.”

I would also like to note that Kushelevsky’s claim in the text that it was the natives of Fergana who spread syphilis to Russian soldiers, and the not reverse, should not be accepted at face value. It might be true, I suspect it is true, but Kushelevsky does have an interest in pinning the blame on people other than his fellow Russians. Claims like this should always be treated with a high degree of skepticism.

I have little medical knowledge, and practically nothing on the treatment of syphilis, so I cannot comment on any medical affairs discussed in this text. I have heard though, anecdotally, that the Fergana Valley still has a rampant prostitution today.

Lastly, I initially planned to include pictures that depict the symptoms of syphilis, such as: sunken nose, missing roof of the mouth, general rotting of fresh, etc. Upon further consideration I thought it best not to include them. That being said, I do encourage readers unfamiliar with such things to look it up for themselves.

Map of Fergana Valley

Syphilis in the Fergana Valley

Syphilis, or venereal disease, as it is listed on the nosological table,¹ has developed among the natives of Fergana to a very powerful degree and in the most serious form, and especially among the settled population.² Being one of the very sad factors of public life, undermining the best of the people's strength by way of both hereditary and direct transmission - this requires very serious attention. Syphilis here is encountered among all ages, beginning with the first days of a child, up to the depths of old age. The Kokand district doctor Birkin correctly noted, that syphilis is one of the most dominated illnesses among the natives. Among those who come for medical advice, one half of them have syphilis in one form or another. Of course, they are for the most part residents of Kokand, because very few people from outlying kishlaks³ visit medical offices. The manifestations and consequences of syphilis vary greatly. Damaged joints, ulcerative laryngitis,⁴ destruction in the pharynx,⁵ and sunken nose are not only common, they almost always present.

Main street in old Kokand

Despite such visible and sorrowful consequences, the natives are much too indifferent to this illness. Only severe pain and symptoms, the secondary and tertiary consequences of the disease, compel them to seek treatment; only in rare cases do they seek treatment at the first signs of being ill, and this is only among the more intelligent people who pay attention to themselves. The sick come for advice about the secondary and tertiary phenomenon in those cases only, when papules⁶ start to become wet or when pains in their bones deprive them of sleep. Destruction in parts of their face, mouth, pharynx - also serve as stimulus to seek the help of a doctor. It does happen, however, that a doctor will examine the oral cavity due to a cough, and will see that it is not only if the roof of the mouth is soft, but has lost its firmness long ago and ulceration is fully underway. It is not the illness itself that sends patients to the hospital, but it is the disease’s more exquisite and disfiguring manifestations. All this indicates the complete ignorance the masses have about their actual situation, in terms of what illnesses they have, and about what harm they have, what they can do with their health, what influence they can have on their health, and what impact such an illness has on their offspring.

Women are often seen to have the primary and secondary manifestations of syphilis, but they rarely seem to have the more pronounced forms that can cause such major physical destruction as seen among men. This, in all probability, is a result of a lower number of female visitors, as their husbands often do not allow them to visit male doctors, as a result of the rules of Sharia.⁷ Since 1887, women's clinics have been opened in Kokand, Andijan, Namangan and Old Margelan, in which patients will be accepted and be treated by female doctors and nurses. Therefore, Sart⁸ women will become less shy, and mainly - husbands will not oppose them visiting the clinics, and then we will receive more detailed data about the various diseases among native women. Besides, if female doctors will have a stronger degree of informed observations, then, when visiting the sick in their apartments they will be able to explain many etiological⁹ points, which currently, due to isolation of women, we know very little about.

Women from Kokand

From where and in what time syphilis first appeared in Fergana - we know nothing, just as the natives themselves. But following the occupation of the Kokand Khanate¹⁰ our Russian doctors noticed that this disease had spread widely among the Khanate's residents. Therefore it is completely useless to slander the Russians by saying they contributed to the development and spread of syphilis among the population. To contrary, one of the diseased, who was a native women, had earlier given the disease to our soldiers and officers.¹¹ Already in 1877, accordingly, in the second year after the unification¹² with the Kokand Khanate, from 5405 natives who applied to our doctors for allowance, 666 people had venereal disease, which consisted of 123.2 out of 1000 of the total number of patients. Naturally of course, that all of these sick were with an older form of syphilis, because Sarts very rarely address the primary symptoms. The 1883 report by the doctor from the Namangan District showed that among 284 cases of syphilis, there were 7 with primary symptoms, 66 with secondary symptoms, and 143 with tertiary symptoms. In addition, there were 68 cases that were not in any category, but as according to prescribed treatments, it must be assumed that the majority of these cases manifested tertiary symptoms.

For the past 6 years, out of 1000 patients who visited our doctors, the annual average number of cases of venereal disease was 78.2. Compared to the same figures throughout all of the empire, we have, apparently less: for every 1000 patients, those who visited hospitals and clinics for venereal disease was:1881 – 93.2, 1882 – 94.9, 1883 – 93.7.

But here in Fergana, gonorrhea was not included, because they usually include it in the rubric of inflammation of the urinary organs. Out of 1000 annual patients, there are on average 56.3 with gonorrhea. If we combine both rubrics, i. e., those who became ill with venereal disease and inflammation of the urinary organ, then out of 1000 patients there will be 134 - a number significantly exceeding anywhere else in the empire. It is also true that gonorrhea is occasionally ignored within both of these rubrics, and classified as something else.

From reports of district doctors it is seen that among the urban population venereal disease is significantly more developed than among rural villagers. Although this fact is very plausible, as because everywhere in cities depravity is much more widespread, but precise data on this issue does not exist. Currently hospitals and emergency rooms only exist in cities, and that is why it is not surprising that only urban residents and residents of nearby villages have the possibility to freely use our doctors. While villagers from outlaying kishlaks consider it completely unnecessary to travel to seek advice from a doctor, and that much more so send their wife to one, who in the majority of cases has never been to a distant city before.

Andijan

The reason for this, is that syphilis has such deep roots among the native population, caused mainly by the low level of native medicine, especially with regards to medical diagnostics and therapy. There is also an abundance of prejudice, with which is tied to the native's view about diseases of the genital organs, which they believe should remain a secret. Because of this, syphilis is either not treated at all, or is handled extremely irrationally, with treatment limited to the destruction of external symptoms, and without worries about further developments. Syphilis, in a hidden state, is usually left to itself and the native will look at subsequent manifestations of the disease as an independent disease onto itself, not having any connection with syphilis, which is ignored and left completely untreated, or treats it extremely incorrectly. This situation is inherent to all eastern and little-civilized peoples, and according to observations by some doctors, pure forms of syphilis is very rarely encounter and for the most part it is masked and altered by incorrect treatments and local conditions.

It cannot be said that the local tabibs¹³ never use any treatments against syphilis; to the contrary, they very often abuse mercury drugs, as in the form of internal use of sublimate,¹⁴ and as an form of fumigation with cinnabar. But being unable to exactly define the disease, they use these means empirically, often incorrectly, without any need, and in such cases, when they really should use energetic mercury, - they are limited to using only a few herbs and roots.

Concerning the sources, where and how syphilis is transmitted, secret prostitution is ranked before all others, which has existed and currently exists among the native population at a large scale. Depravity among the natives has developed to a wide extent. Sometimes boys 10 years old appear in a hospital, proudly declaring, that his gonorrhea or shanker¹⁵ was acquired through copulation.

The role explicit prostitution plays on spreading syphilis is less noteworthy, because they are monitored and inspected, and at the first signs of sickness they are sent to the hospital. A supervisor was also established for visitors to the brothels in New Margelan, which, although it did not fully achieve its goal, the prostitutes there probably do not contain one infection contracted from a visitor. The Sarts in particular are careless in these affairs, and syphilis usually does not serve as an obstacle to copulation for them.

Sarts at a chai-khana with a kalyan, Kokand

Transmission of syphilis from one person to another, it seems to me, is often also due to the sharing of tableware, as well as a copulation (syphilis insontium). The native's chai-khana (this is a kind of tavern) play a noteworthy role on this relationship, in which visitors are served the same kalyan¹⁶ to all of the visitors, and very rarely do they even think of wiping the mouthpiece before they take it up to their mouth. In these same chai-khanas the same bowl (used as a tea cup) are passed from one to another, and it almost never gets washed and wiped clean. Clearly, it is such negligence that makes the transmission of syphilis possible, and our doctors have more than once seen the early manifestations of syphilis on the lips and mouths. In private homes tea utensils are handled the same, and, thus, one syphilitic can easily infect their entire family, and that is very often the case.

Chai-khana in Kokand

The native's baths are very convenient for the transmission of syphilis, scabies¹⁷ and various other skin diseases. They are kept very dirty, never drained, because they are open every day of the week. None of the servants working at the baths think about cleaning the floors and benches more regularly either. But what is all the more outrageous in the native's baths is that rags, with which they wrap the visitors' bodies in their navel to their knees, in order to conceal the parts that according to the Sharia must not be seen by others. These rags are only rinsed in one of the public korchaga,[17] with water that is rarely ever changed, causing it to have a thick layer of dirt at the top that is collected from all the visitors. When these rags are still only a little bit dried they are offered to another visitor, and so it is easy to assume that this contributes to many cases of where syphilis and other skin diseases are transmitted from one to another. Amazingly, it does not arrive to the Sarts' mind to bring a rag from home, nor a desire to wash the place on which he intends to clean. Of course, there is not only a habit of filthiness, but also an entire absence of thought about the possibility of getting a disease through transmission from one another by way of dirty items.

The yard of a brothel in Fergana, view for the guest - S. M. Dudin

By the way, I will mention that the hygienic situation of local brothels has an undeniable influence upon on the prostitutes living in them, and equally upon the visitors. These houses here are usually set up in such a way that a certain area of land is surrounded by short clay walls, and located there are shacks and huts without any order and consideration to the basic rules of hygiene. In every detached room, or more correctly called the prostitute's kennel, she lives and receives visitors. The situation of this is so pathetic that is produces a depressing impression on an unaccustomed person. The absence of light, the dirt, dust, stink, cold, mass of insects - make it resemble a lair more so than a person's home. This awful environment sometimes brightened up by a bed, a clothing box, with a few towels hung out, a dutara (a type of guitar) and a few trinkets placed on niches on the wall. But in the majority of cases the only item serving as decoration is felt bedding on an earthen floor, a blanket and pillow. There is no bed linen to speak about.  The inhabitant sleeps on the same bedding and receives visitors on it, until it is worn out and comes into a state of utter disrepair, and then it is replaced.

The same yard has a small pond or, rather, a puddle of dirty water, in which the prostitutes wash themselves. Good baths, where they could swim, - are nowhere to be found. Food for the prostitutes is very meager; for the most part they get by on cakes and tea. Only during celebrations, if someone will treat them, will they enjoy plov, fruits, sweets, pistachios and other delicacies that the Sarts enjoy. Generally, the living conditions of prostitutes are extremely unpleasant to see.

It goes without saying, that these brothels, in such a state, would become the most horrible breeding grounds for syphilis, if it was not for the vigilant supervision of these prostitutes by the medical-police. But despite this, they often encounter infections in brothels, and the sick person is often unable to identify who they contracted it from. In every one of these brothels there are many entrances and exits, and those engaged in secret debauchery come under the cover of mingling with others, where they come and spread the infection. Prostitutes living in brothels, where their "friends" come to visit, carefully hide and do not reveal who is responsible for spreading the disease. Therefore, very often infected soldiers will say they were infected at these brothels, but will be unable to say who gave it to him, because the girl is no longer there. Sometimes he will name just any prostitute, which appears similar to him as the one he had intercourse with. But upon examination she will be healthy, and they suspect the soldier in such cases of deliberately concealing who he slept with, although he is sometimes innocent of this. In general, a huge majority of soldiers, and also officers, are infected from visits to secret prostitutes, which is hidden from the medical-police supervisor, and not inspected by doctors, and as a result they spread syphilis with impunity. Besides Sart women who constitute the main contingent of secret prostitutes, our soldiers here in this locality are also distinguished by an inclination to debauchery, and regularly partake in this trade.

Kokand

In view of these circumstances, venereal disease among the military ranks is fairly well developed. During the past 6 years, out of the total number of those who used the services at out infirmaries, 9% did so because of venereal disease. If the same these figures are added to those of gonorrhea, which is usually under the rubric of inflammation of the urinary organ, then the total figure is 15.6%.

But compared to the entire Russian Army, the forces stationed in Fergana that are sick with venereal disease are less than the force-wide average. As according the information for the years 1872, 1873, and 1874, across the entire army, there were on average annually 46.22 cases out of 1000, but among the forces in Fergana for the past 6 years there was only 35.85.

In the Russian Army in 1875, out of 1000 people expelled due to incapacitation from illness, 2.4 were due to syphilis, but in the Fergana Oblast during the past 6 years, not one was expelled for this reason.

For the same year of 1875, in the Russian Army, for every 1000 who die, 1 is due to syphilis, but among the forces in Fergana Oblast the average annual rate in the past 6 years is 10. Strictly speaking, they die not from syphilis, but other diseases. What happens is that they are admitted to the infirmary with syphilis, and there they contract a new disease which in the end results in their death. Yet, the previous diagnostics remains unchanged, and thus according to the report they died of syphilis.

It should be noted, that syphilis in the local area heals much better than in European Russia or in Siberia, as mercury treatments are carried out without impunity.

For older forms of syphilis, the Kazert-Ayub springs work successfully together with the use of mercury and iodine drugs. According to reports by doctors who were in charge of the sanitary department and supervised those who used the springs, during the summers of 1884, 1885, and 1886, of the 41 members of the lower ranks with various older forms of syphilis who used these spring, 28 were completely cured, 8 received relief, 5 remained unchanged. All of the patients had been long treated in infirmaries, without success. The waters alone, without mercury treatments, in such cases bring little benefits.

Baazar in Osh

1. Nosology is the study of the classification of disease. From the ancient Greek words of  νόσος (nosos) “disease” and -λογία (-logia) “study of'”

2. Historically the Fergana Valley was home to both sedentary and nomadic populations. Today almost everyone is nominally settled

3. Kishlak is a Turkic word for homes in a village, or other rural forms of settlement

4. Ulcerative Laryngitis is when ulcers and erythema develop on the larynx (voice box). This caused hoarseness and even loss of voice

5. Pharynx is a part of the respiratory system and digestive system

6. A papule is a raised area of skin tissue that's less than 1 centimeter around, usually called acne today

7. Islamic law

8. Sart is an old, 19^th century term local to Central Asia referring to the sedentary population

9. The cause or contributing factors in the development of a disease or condition

10. The Kokand Khanate was original made into a Russian vassal state after 1866, but after the pro-Russian regime was overthrown in a mass uprising, the Russians occupied Kokand in 1875

11. Presumably through prostitution, if Kushelevsky is to be believed

12. Присоединения – usually translates as “joining”, “uniting”. Common Russian/Soviet euphemism for “conquest”

13. Uzbek term for traditional doctors

14. “как в форме внутреннего употребления сулемы”. I am not sure what is meant here

15. Russian word for hookah

16. An infestation of the skin by the human itch mite

17. A very large pot