hist-234: Epidemics in Western Society Since 1600
Lecture 12 - Syphilis: From the "Great Pox" to the Modern Version [February 22, 2010]
Chapter 1. Comparative Questions about Diseases [00:00:00]
Professor Frank Snowden: Welcome back. And what I want to do this morning is to be cognizant of the fact that you have, as you all know, the hour exam later this week. It's in a different format, and I've written to you about that. Because of that, what I thought would be useful to do this morning would be to have something of a review session, in which we make explicit some of the ways in which it's useful to think about epidemic diseases, and in which we go over some of the terrain that we've covered thus far in the semester.
At the same time, I want to talk about — introduce a new and important disease, which is syphilis, and provide a bit of background for the book that you're reading this week, which is Allan Brandt's No Magic Bullet. And you'll be wanting to know, well where did syphilis come from, what's the historical background? So, I'm going to try to introduce that, while going over some of the issues that we've already presented. You'll find a lot that's already familiar this morning, as we go back in time, covering major issues that we've dealt with. And I hope, at the same time, to be introducing something new, which is syphilis. So, we'll look at the period we've covered in the course, through the lens of syphilis.
That's the direction in which we're headed. Now, in order to talk about a variety of epidemic diseases and their impact, we ought to have some comparative questions that we make explicit. That is, what is it that we need to know about each of the diseases that we're talking about? What are the crucial aspects that make it a transformative force or not? What are the historical variables? I have a sort of suggestion of maybe ten major questions that we ought to be thinking about with regard to each of the diseases that we examine throughout the semester. A first one is — these questions, by the way, are not canonical. I don't mean that you shouldn't be asking other questions as well, and indeed I hope you will. But I think we should know at least the answers to these ten questions and then build on that as a foundation.
The first major question, for any of the diseases we're talking about, was what's the total mortality and morbidity that's caused by the epidemic in question? The mortality, the total numbers of deaths. Morbidity, the total number of cases. That's an important factor that needs to be taken into account in assessing the impact of the epidemic. A second question has to do with a term we introduced long ago, a phrase, which was the case fatality rate. And a related question with that is, is there an effective therapy or means of prevention, or instead does a society experience the disease in feeling itself to be helpless, and physicians feeling the same?
The case fatality rate is — we could call it the kill rate of a disease, the percentage of cases that terminate in death. And we know that, for example, in dealing with plague, one of the features of it — and Asiatic cholera as well — was a very high case fatality rate, of plague, fifty to eighty percent, cholera, something like fifty percent. At the other extreme, when we come to it, we'll see that influenza has a very high morbidity, but quite a low case fatality rate, and that's related, I think, to the impact that that disease, influenza, has on society, which isn't associated with such terror as say plague or cholera. That's an important variable, the kill rate of the disease.
Another factor, a third question we need to ask, is what's the nature of the symptoms of the infectious disease in question? Are they particularly painful? Are they degrading, according to the norms of the time? And we've seen, for example, in dealing with plague and cholera that a major feature about them was that their symptoms were agonizing and dehumanizing. Clearly, as we turn to syphilis, its symptoms also were extremely important in the way that the disease was experienced. Tuberculosis, on the other hand — and we'll be looking at that — was seen, at the time, to make its sufferers more intelligent, more romantic, more beautiful in some sense, at least in the first half of the nineteenth century. So, that — what is the nature of the symptoms, is a crucially important question.
Another, fourth question, that I hope you'll bear in mind throughout the course, and in your review for the exercise this week, is the question, is this disease new, or is it familiar to the population? Familiar diseases tend not to be so terrifying. The population is also likely to have some degree of immunity to the disease, and the disease is likely, or may have, already mutated to become less deadly. Examples are the so-called diseases of childhood, like chickenpox, mumps and measles; normally relatively mild, but in populations to which they're newly introduced, they can be devastating.
A fifth question has to do with, what's the profile of the victims of the disease? Is this a disease that's an affliction of the young and the elderly; that is, experienced as a more normal course of a disease, in accord with society's expectations and past experience? Or does it instead strike down particularly those who are in the prime of life, thereby no longer seeming natural but as something extraordinary in the experience of the population? And it also means that the disease is likely to maximize its economic and financial impact, to be particularly destabilizing to a community. Cholera, in this regard, for example, was terrifying because of the way in which it seemed to afflict those who were the bulwarks of families and of communities.
A sixth question that's important: what's the class profile of the sufferers? What sorts of people in society are stricken with the affliction? Is this a disease of poverty, such as cholera is usually thought of? Or is it an affliction that strikes everyone, without particular reference to class or social and economic status, like influenza or syphilis, indeed?
A seventh important question is what is the mode of transmission of the disease? Is it transmitted person to person? Is it transmitted by contaminated food and water? Are vectors involved? Is it spread through the air by droplets? Is it spread by sexual contact? And clearly, I think we'll be arguing that the mode of transmission is really crucial, and in sexually transmitted diseases I think that that is fairly self-evident and a very important factor in the social impact of those diseases.
An eighth important question is whether the disease is fulminant in its course, or is it slow acting and a wasting disease? If we look, for example, at cholera, one of the features, and a striking one, is that it was one of the most fulminant of diseases. It would strike down a sufferer, and you could board a train and die before you reached your destination, as the disease ran its course that quickly through the human body. Or, on the other hand, is the disease one that takes years, perhaps even decades, to run its course? And an example of that, of course, would be tuberculosis or HIV-AIDS, in our own time.
A ninth important question we need always to bear in mind is how is the disease understood by the population that it's infecting? Is it seen as a punishment of God? Is it later on thought to be something that comes from the dangerous classes? Or later on, is it understood to be a microbial infection? And those ways in which the disease is understood have enormous impact on how the population reacts to the disease. A tenth variable is what's the duration of the epidemic? Influenza, for example, passes through a locality in a matter of weeks, normally. Cholera or plague tend to have epidemics that last for months. And tuberculosis, one might describe as an epidemic in slow motion that afflicts a community for a whole century or more.
So, those are ten major questions that I hope that you'll be bearing in mind throughout the course. I think they'll help you in dealing with the diseases in a comparative manner, and finding out and teasing out why some diseases have an impact of one kind, and others are very different. Well, this morning I'd like to go through some of this material again, in a review manner, by looking at syphilis. Why syphilis at this stage of the course? I think that it provides background for No Magic Bullet, and it also helps us to look at some of the material that we've already covered, and that you'll be writing about in the next few days.
Chapter 2. Syphilis: Background [00:12:37]
Well, first let's deal then with the chronology, and this helps us to step back in time from the nineteenth century; to go back, indeed, to the plague years. Syphilis, in fact, was contemporary in its onset with plague, and like plague, at the time it was a new disease that first struck Europe, in this case, in the late 1490s. And we'll see that there's an important Darwinian evolution that takes place, which is to say that the syphilis of the fifteenth and sixteenth centuries is quite different from syphilis thereafter.
Syphilis in its first century or so was what we might call the "Great Pox," a disease that was much more severe than modern syphilis. So, syphilis clearly begins as a dreadful epidemic that swept Europe and then the world. After the sixteenth century, it's still a very serious illness, but it's much milder, less fatal and less agonizing. Today we're going to deal primarily with the early syphilis, the syphilis of the Great Pox. Now, the mode of transmission is clearly important, and we need to examine what are the particular features of STDs, of sexually transmitted diseases.
Among the venereal diseases — to use an older term — syphilis was king from the fifteenth century until the late twentieth, when there was the appearance of a much more threatening competitor, HIV/AIDS. And in more recent times, after World War II and the introduction of the era of antibiotics — particularly penicillin — and sex education, there's been a radical decline in the incidence of syphilis. And for a time there were even heady hopes that it could be eradicated altogether. But most recently, unfortunately, it's made something of a comeback.
Now, keep in mind, too, that historically the STDs weren't carefully distinguished, one from another. Until late in the nineteenth century, other significant STDs — gonorrhea and chancre, in particular — weren't known to be separate diseases. They were thought to be simply milder manifestations of syphilis. So, there was, we might say, a unicity theory of the venereal diseases; there was thought to be one disease. A reason for dealing with syphilis now, at this point in the course, is that it had a significant impact on medical science, in ways that we've already touched upon with regard to bubonic plague. That is to say, like plague, syphilis seemed clearly to be contagious, and it was understood, from the beginning, to be spread somehow — no one quite knew how — through sexual contact.
And, so, like plague, syphilis challenged the reigning orthodoxy of humoralism, and gave rise through someone we've already met, and we can look at again in a moment, through Girolamo Fracastoro, in particular, to the doctrine of contagion. And it generated also the idea that disease might be a specific entity. Syphilis was clearly something distinctive, and many people regarded it as a disease on its own, rather than an example of humoral imbalance. So, syphilis had an impact on medical science and influenced, along with plague the — if we like, began to make humoral doctrine less stable at its foundations.
Chapter 3. Origins [00:17:30]
Well, where does syphilis come from? What are its origins? And here there's a major debate, that has not been resolved, and it continues down to this day. I'll put forward a couple of candidates. And I think it's more important to note these different origins, theories of the origins of syphilis, because they have a big impact on how the disease is experienced. Rather than expecting us to resolve the issue of where the disease came from in fact, let's note how people thought the disease appeared.
A first theory was the one associated with Christopher Columbus. This is the Americanist idea of the origins of syphilis. And we've talked already about the Columbian Exchange. So, I just wanted to review that again. That's Columbus's first trip, and this is the idea of the Columbian Exchange, of what was transmitted from the Old World to the New, the Old World contributing various foodstuffs, like coffee beans and rice, livestock — cows — and various diseases; as you already know, smallpox, measles and so on, and the New World being the source for Europeans of corn, potatoes and so on, certain precious metals, tobacco. And there is the idea that the Americanists — so called — argued that it was Columbus and his crew who brought back syphilis from the New World. This idea held that syphilis was endemic in the New World, spread to Columbus's sailors, and was reported to Europe on their return.
The problem, of course, for the theory, is that there isn't, in fact, any definitive evidence that syphilis did exist in the New World at the time, or that Columbus's sailors were actually infected in the manner required by the theory. So, the evidence in support of this is entirely circumstantial. The chronology works. That's one factor. And another is that there isn't, in fact, in the medical literature, before this time a disease like syphilis anywhere in Europe. And more recently, paleopathologists haven't unearthed evidence of syphilis in European cemeteries. It clearly seems to be a disease that was a new — or let us use an anachronistic term — an emerging disease in the 1490s. And because of Eurocentrism, and perhaps xenophobia, there was a preference to blame the other.
A second idea that was very popular was that syphilis, instead of being of American or New World origins, was of Spanish or African origin. This theory held that perhaps the disease was present in Europe for a long time, but had been confined to a small corner of the continent, perhaps — and one can see certain sinister views here — confined perhaps to Jews, or Moors in Spain, and unnoticed by outsiders. Then with the expulsion of the Jews in the 1490s, the disease was disseminated across Europe. Now, among those who propounded this view, there was clearly a current of racism, anti-Semitism and xenophobia.
Syphilis was supposed to have been endemic among the Jews, having come perhaps earlier from Africa, and was prevalent in those populations because their sex in some way was unnatural and out of control. So, syphilis was confined in Europe to Spain, this theory argues, until the expulsion of the Jews in 1492, when they unleashed their contagion on the rest of Europe. In any case, what's really clear is that absolutely no one wanted to acknowledge syphilis as his or her own. For Italians, syphilis was somebody else's, it was the French disease. For the French, it was the Neapolitan disease. For Russians, it was the Polish disease. And for everyone, it was the Great Pox, or the clap.
Now, how do we get the term syphilis, where does that come from? The word itself was coined by the Italian physician, whom you've already met, Fracastoro, who did something extraordinary in 1531, which was that he wrote a work calledSyphilis. And here was Fracastoro, whose face you've seen again. Now, this work was odd, or unusual, in a number of respects. It was a poem, written in Latin, and modeled on Virgil. And, as I think about it, I can't think at the moment of another poem about an epidemic disease. It was also an instant success. It rapidly went through lots of editions, and established Fracastoro's fame, even more than his more scientific works. It also offered what I think we could say was a clearly moralizing, judgmental analysis of this disease as a scourge of God. You know the drill by now.
In the poem, the first victim of the disease was a shepherd whose name was Syphilis. And the shepherd had offended the gods by turning against them and worshipping a king as a deity. So, in their anger, the gods afflicted Syphilis with this terrible pox. We can see that built into it, from the beginning, was the idea that syphilis was best understood as the wages of sin. And there's a further polemical thrust that's not made explicit but is a subtle undertow in the poem. Remember, the poem was written in the 1530s, in the midst of a religious schism with Martin Luther, a devout adherent of orthodoxy — that is, Fracastoro was — and of the Catholic Church. He was a physician to bishops, archbishops and cardinals. And Syphilis, as I've said, was a shepherd, and in Latin the word for shepherd is pastor. The man who was punished was a pastor, not a priest; that is, possibly a Protestant leader. So, there's a sly hint here that syphilis, the disease, is a divine punishment for the Reformation. So, Fracastoro didn't adhere to the Americanist position.
Then there's perhaps a third more modern idea, or hypothesis, is that perhaps the causative agent of syphilis emerged in a Darwinian manner; the spirochete or treponema pallidum, arose perhaps as a mutation of some pre-existing treponemes that are morphologically very similar under the microscope, and perhaps it was — it emerged as an evolution from the treponeme that causes yaws. In any case, it was clear that whatever the site of its origin, it spread across Europe with terrifying rapidity.
One can see the role of warfare, in particular, in promoting the movement of syphilis. And its spread across Europe was closely associated with Charles VIII of France, known as Charles the Affable, who lived from 1470 to '98, and launched a series of wars with Italy, which he invaded in 1494, at the head of a large, large army. The army marched across the Italian Peninsula and reached Naples, that Charles besieged and captured. He then found himself facing a powerful coalition of powers that have ultimately defeated him. And after his forced withdrawal — the point is that his army disbanded. And this was a large army, a mercenary force of tens of thousands of men from various nationalities.
A feature of war is that it's always a providential time for epidemic disease, and sexually transmitted diseases in particular. The army of Charles VIII was poorly disciplined. It indulged in pillage, plunder and rape, and it had its numerous camp followers of beggars and prostitutes. So, among the troops, and those who consorted with them, the disease flared up. And after their disbanding and demobilization, it was disseminated across the continent. Between 1495 and 1520, something frightful happened as the epidemic swept Europe from Naples to Moscow; to Oslo, Madrid, London, and every place in between. So, this is the origin of syphilis. However it arose — whether it was imported, whether it was a newly emerging disease, perhaps a mutation from yaws, from a disease already present in Europe — it was clearly spread by this favorable opportunity of warfare and the army of Charles VIII.
Chapter 4. Etiology and Symptomatology [00:29:16]
Well, what's the etiology and symptomatology of syphilis? And here, this is the causative agent, the treponema pallidum, or spirochete. This, the treponema pallidum, has a special feature, in that it's exquisitely fastidious and fragile, and re quires very precise conditions in order to live. It cannot survive outside of bodily fluids and the warmth of the human body, and therefore it can only be transmitted by intimate contact. Indeed, the spirochete is so delicate that it can hardly be cultivated in vitro, and that's one of the reasons that the development of a vaccine has proved so difficult. Well, there's an initial incubation period with syphilis, and we'll talk about three stages in its impact on the individual human body.
The first stage — and we're talking now about the Great Pox, this early stage in the history of syphilis — the first stage lasted a month or two, and was marked by a painful and alarming chancre at the site of entry of the spirochete into the body. But this chancre heals spontaneously, just like lesions in chickenpox or herpes. But that doesn't mean that the patient is cured. The disease in fact persists, but for a time without generating symptoms. Then there's the onset of the second stage of syphilis, between forty-five days after the disappearance of the chancre and a year. There are numerous symptoms, but in the second stage of syphilis only the superficial tissues of the skin are affected, with rash and boils.
Now, it was this second stage of syphilis that was of extraordinary severity during the era of the Great Pox. It was painful, disfiguring, incapacitating and often fatal. There were sores and swellings all over the body, from the soles of the foot to the crown of the head, leaving disfiguring scabs and pockmarks. Worse, the disease was described as attacking the whole of the body. It was said to eat it away and consume it. The body stank, and the sufferers were afflicted, in addition, with fever and pain in their joints, so intense, one contemporary wrote, that the victims screamed day and night, envying the very dead.
Let's listen to Fracastoro himself, who described the Great Pox like this. He wrote — remember, he was a physician as well as a poet — "In the majority of cases, small ulcers began to appear on the sexual organs. They were intractable and would not depart. Next, the skin broke out with encrusted pustules. They soon grew, little by little, until they were the size of an acorn; which they in fact resembled. Then these ulcerated pustules ate away the skin and sometimes infected not only the fleshy parts, but the very bones as well. In cases where the malady was firmly established, in the upper parts of the body, the patient suffered from pernicious catarrh that eroded the palate, or the pharynx and tonsils. In some cases the lips, the nose and eyes were eaten away, or in others, the whole of the sexual organs. Moreover, many patients suffered from the great deformity, or gummata that developed. Besides all of the above symptoms, as if they were not bad enough, violent pains attacked the muscles. These pains were persistent, tormented the sufferer chiefly at night, and were the most cruel of all the symptoms."
There is a theory that maybe even the disease was too virulent for its own good, that its symptoms were so debilitating as to prevent sufferers from transmitting it, and so the modern disease evolved during the sixteenth and seventeenth centuries as a milder form of the Great Pox. I'll show you a couple of images of extreme forms of modern syphilis, that's said to give us some idea of what the Great Pox was like. They're rather, of course, unpleasant slides. So, I would tell you that in advance. But this will give you some idea of how terrible the Great Pox was. It looked like that, or indeed like that. We'll move on.
Then there's third-stage syphilis, tertiary syphilis, and in this phase you have involvement of the deep tissues. And its symptoms are things such as what's called tabes dorsalis, which is a degeneration of the neurons in the spinal cord, and leads therefore to lack of coordination, to a stumbling gait, and symptoms of that kind; to ataxia, which means the stumbling gait. It also leads, in this phase, to cardiovascular disease, often to insanity and dementia, to general paralysis, and to death. So, tertiary syphilis can be the cause of death.
Chapter 5. Societal Effects [00:36:15]
What were — if that's what the disease looked like — what were some of its effects on society? Well, because of its mode of transmission, syphilis was associated with terrible social effects, with anxiety, guilt, pain, broken relationships, breakdowns in trust within families, infertility among women. And like the plague, and unlike some of the diseases that we'll be studying, syphilis was no respecter of persons, of social class or status. We might perhaps ironically call it a democratic disease, in that it afflicted everyone, from the bottom of the social scale, to aristocrats, learned professionals, kings, cardinals, bishops, occasionally even popes, such as Julius II, who was also a syphilitic.
So, accordingly, one might argue, syphilis caused a great strain on society, but not along the fissures running between classes, as did, for example, Asiatic cholera. It was also unlike plague in that it was not terrifyingly swift, and its obvious association with sex meant that the means to avoid it were clear. And so there was no generalized terror, of the kind that accompanied say bubonic plague or Asiatic cholera. Everyone knew how syphilis could be avoided.
What were the effects on then? One was a new asceticism. There was a suspicion of pleasures. In the Protestant world, an epidemic of syphilis was perfectly timed not to create — and here I don't want to be saying that epidemic diseases created Puritanism; I would argue instead simply that this is a disease that reinforced it. Asceticism indeed had long been present in European culture, but syphilis helped make it more popular and a widely held sentiment. In the Catholic world, one can see a new piety as well, in the Catholic Reformation, in Jansenism, for example. Another impact clearly was in terms of tensions between the sexes.
Now, this is familiar to you; we're going back over old ground in our course. Remember paintings that we saw earlier of the Garden of Eden and Origin Sin, Adam drawn into evil by his helpmate Eve, the original temptress. Well, the passage of syphilis was marked by a sinister undertow of misogyny. In a patriarchal society, male fears, anxieties, and indeed guilt, were projected onto women, who were seen as the crucial agents in the spread of this disease to men. And two groups of women were particularly suspect, prostitutes first. And here was a prime example of a new male double standard.
The passage of syphilis was marked by harsh police measures against prostitutes, including the closing of brothels and the rounding up and exile of people from communities. There was also a hunt for scapegoats, and witch hunts were part of that. Another feature was a new religious cult; the cult, in particular, of a new saint. And this is rather unique, which is there's only, as far as I know, one saint who wasn't a Christian, and this is Job, from the Book of Job in the Old Testament. Job, however, was actually said — in the Book of Job, he had an especially convincing defense attorney, and that was God himself. Because God says in the Book of Job that this is the most just of all men, he's the best and most innocent. And yet to try his faith, he was scourged by Satan.
This is a painting by William Blake of this scourging of Job by Satan, who's pouring out boils that will soon torment him from head to foot. And the description of the disease that afflicted Job, in the Book of Job, is highly suggestive of what we might call a venereal disease or STD. He was covered from head to foot in boils. And yet Job was reassuringly free from sin. We know that because God tells us so. And, so, Job became the patron saint of syphilitics. There was also a public health response; that is to say, the building of hospitals for the incurables, who were the syphilitics. And there was a new philanthropy, and religious orders that took over their care.
Let's look for a moment at some of the treatment regimens that were also important in this disease. One was the beginning — it began, the most common treatment regimen, with a forty-day period, beginning with fasting, and then the administration of mercury, which had been used in the treatment of skin disorders over the centuries, diseases such as scabies. So, mercury was sometimes applied — it was applied in lots of different ways. Disparate remedies for a desperate disease. Ointments were applied to the skin lesions.
There was a so-called general friction in which applications of mercury were made to the whole body. Sometimes it was administered internally. But as you know, mercury is extremely toxic. It causes great salivation, the falling out of the teeth, and then serious and often life-threatening symptoms. But salivation seemed to be the right approach. According to humoralist principles, it would lead to an evacuation of the peccant humor. And it also — and here was a factor — it seemed to work when applied to second-stage syphilis, perhaps simply because, as we've already seen, second-stage syphilis goes into spontaneous and often lengthy remission. And it was possible to argue that it was the therapy, the treatment, that had been effective. And perhaps the suffering that accompanied this particular treatment provided some moral satisfaction to those who administered it.
Another remedy that was tried was guaiac, which is a hardwood from a tree in the New World. It was ground into sawdust and made into a decoction that patients drank twice a day for forty days. We see these forty days appearing over and over: in quarantine; the forty day fasting; the regimen for mercury; the regimen for guaiac. Well, all of this, of course, had a religious background. And, so, the guaiac was administered for forty days, during which there was fasting. At the same time then — so guaiac and mercury were, so we might say, the miracle drugs, the wonder drugs of their era.
There were other indications also recommended for syphilis: bloodletting, baths, purgation, cauterization of the boils. An important impact, then — the next thing I want to point out — is the impact of syphilis on medical science. We already — and this gives us a moment of review — we know already the traditional approach to these and other diseases; that they were an imbalance of humors. There had been no idea of discrete entities that were diseases. Diseases were an individual matter, depending on the constitution of the patient and the environmental influences that acted on him or her. In the nineteenth century, however, we've seen already that diseases fully crystallized into forms of specific entities, that were actually biological entities that existed apart from the body of the individual sufferer.
The period from the 1490s to the nineteenth century, the period that emplaced both plague and the Great Pox, and then modern syphilis, marked an era of transition. And I would argue that syphilis was something that propelled this transition forward. Remember how traditional medicine, as taught at universities and practiced by the elite physicians, was that the truth about disease was to read the classics: Hippocrates and Galen, supplemented later, in the Middle Ages, by astrology. So, for humoralist physicians, then, that was the way it was preceded, and when syphilis first struck, there were disputations in which people sought the truth of the disease by looking through into Hippocrates, or what Galen had written. And so there were disputes, disputations that were formally held through library medicine.
The challenge of syphilis was that it was a pandemic that was difficult to explain within the traditional framework of humoralism. At the same time, the disease had no real place in the Classics. Humoralism was static, and had no way of accommodating emerging diseases. So, what do you do with a disease that was unknown to the Ancients? Syphilis was also clearly contagious, everyone could see that, and so there was obviously some morbific substance that passed from one body to another. The disease, in other words, seemed to be something specific; and this helped to promote also the idea of a new concept of disease. And syphilis tried physicians because it really was an incurable disease at the time, and until the late twentieth century didn't respond to the classical recommendations for therapy.
All of this made it a major challenge to humoralist orthodoxy. And with that, I would say we've reviewed this period of syphilis and plague that presented a major impact on society, and a major impact on medical science. And we've run out of time this morning. Next time, having had our review session, we'll come back to the nineteenth century and deal with the debate, the huge medical debate, between contagionists and anti-contagionists.
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