WEBVTT

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Prof: Welcome back.

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And what I want to do this
morning is to be cognizant of

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the fact that you have,
as you all know,

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the hour exam later this week.

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It's in a different format,
and I've written to you about

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that.

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Because of that,
what I thought would be useful

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to do this morning would be to
have something of a review

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session,
in which we make explicit some

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of the ways in which it's useful
to think about epidemic

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diseases,
and in which we go over some of

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the terrain that we've covered
thus far in the semester.

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At the same time,
I want to talk about--

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introduce a new and important
disease,

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which is syphilis,
and provide a bit of background

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for the book that you're reading
this week,

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which is Allan Brandt's No
Magic Bullet.

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And you'll be wanting to know,
well where did syphilis come

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from, what's the historical
background?

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So, I'm going to try to
introduce that,

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while going over some of the
issues that we've already

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presented.

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You'll find a lot that's
already familiar this morning,

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as we go back in time,
covering major issues that

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we've dealt with.

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And I hope, at the same time,
to be introducing something

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new, which is syphilis.

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So, we'll look at the period
we've covered in the course,

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through the lens of syphilis.

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That's the direction in which
we're headed.

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Now, in order to talk about a
variety of epidemic diseases and

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their impact,
we ought to have some

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comparative questions that we
make explicit.

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That is, what is it that we
need to know about each of the

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diseases that we're talking
about?

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What are the crucial aspects
that make it a transformative

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force or not?

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What are the historical
variables?

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I have a sort of suggestion of
maybe ten major questions that

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we ought to be thinking about
with regard to each of the

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diseases that we examine
throughout the semester.

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A first one is--these
questions, by the way,

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are not canonical.

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I don't mean that you shouldn't
be asking other questions as

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well, and indeed I hope you
will.

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But I think we should know at
least the answers to these ten

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questions and then build on that
as a foundation.

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The first major question,
for any of the diseases we're

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talking about,
was what's the total mortality

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and morbidity that's caused by
the epidemic in question?

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The mortality,
the total numbers of deaths.

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Morbidity, the total number of
cases.

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That's an important factor that
needs to be taken into account

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in assessing the impact of the
epidemic.

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A second question has to do
with a term we introduced long

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ago, a phrase,
which was the case fatality

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rate.

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And a related question with
that is,

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is there an effective therapy
or means of prevention,

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or instead does a society
experience the disease in

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feeling itself to be helpless,
and physicians feeling the same?

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The case fatality rate is--we
could call it the kill rate of a

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disease, the percentage of cases
that terminate in death.

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And we know that,
for example,

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in dealing with plague,
one of the features of it--and

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Asiatic cholera as well--
was a very high case fatality

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rate,
of plague, fifty to eighty

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percent,
cholera, something like fifty

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percent.

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At the other extreme,
when we come to it,

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we'll see that influenza has a
very high morbidity,

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but quite a low case fatality
rate,

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and that's related,
I think, to the impact that

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that disease,
influenza, has on society,

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which isn't associated with
such terror as say plague or

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cholera.

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That's an important variable,
the kill rate of the disease.

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Another factor,
a third question we need to

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ask, is what's the nature of the
symptoms of the infectious

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disease in question?

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Are they particularly painful?

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Are they degrading,
according to the norms of the

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time?

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And we've seen,
for example,

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in dealing with plague and
cholera that a major feature

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about them was that their
symptoms were agonizing and

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dehumanizing.

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Clearly, as we turn to
syphilis, its symptoms also were

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extremely important in the way
that the disease was

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experienced.

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Tuberculosis,
on the other hand--and we'll be

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looking at that--
was seen, at the time,

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to make its sufferers more
intelligent,

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more romantic,
more beautiful in some sense,

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at least in the first half of
the nineteenth century.

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So, that--what is the nature of
the symptoms,

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is a crucially important
question.

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Another, fourth question,
that I hope you'll bear in mind

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throughout the course,
and in your review for the

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exercise this week,
is the question,

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is this disease new,
or is it familiar to the

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population?

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Familiar diseases tend not to
be so terrifying.

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The population is also likely
to have some degree of immunity

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to the disease,
and the disease is likely,

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or may have,
already mutated to become less

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deadly.

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Examples are the so-called
diseases of childhood,

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like chickenpox,
mumps and measles;

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normally relatively mild,
but in populations to which

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they're newly introduced,
they can be devastating.

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A fifth question has to do
with, what's the profile of the

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victims of the disease?

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Is this a disease that's an
affliction of the young and the

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elderly;
that is, experienced as a more

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normal course of a disease,
in accord with society's

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expectations and past
experience?

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Or does it instead strike down
particularly those who are in

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the prime of life,
thereby no longer seeming

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natural but as something
extraordinary in the experience

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of the population?

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And it also means that the
disease is likely to maximize

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its economic and financial
impact, to be particularly

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destabilizing to a community.

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Cholera, in this regard,
for example,

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was terrifying because of the
way in which it seemed to

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afflict those who were the
bulwarks of families and of

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communities.

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A sixth question that's
important: what's the class

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profile of the sufferers?

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What sorts of people in society
are stricken with the

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affliction?

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Is this a disease of poverty,
such as cholera is usually

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thought of?

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Or is it an affliction that
strikes everyone,

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without particular reference to
class or social and economic

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status, like influenza or
syphilis, indeed?

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A seventh important question is
what is the mode of transmission

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of the disease?

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Is it transmitted person to
person?

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Is it transmitted by
contaminated food and water?

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Are vectors involved?

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Is it spread through the air by
droplets?

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Is it spread by sexual contact?

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And clearly,
I think we'll be arguing that

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the mode of transmission is
really crucial,

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and in sexually transmitted
diseases I think that that is

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fairly self-evident and a very
important factor in the social

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impact of those diseases.

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An eighth important question is
whether the disease is fulminant

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in its course,
or is it slow acting and a

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wasting disease?

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If we look, for example,
at cholera, one of the

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features, and a striking one,
is that it was one of the most

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fulminant of diseases.

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It would strike down a
sufferer, and you could board a

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train and die before you reached
your destination,

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as the disease ran its course
that quickly through the human

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body.

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Or, on the other hand,
is the disease one that takes

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years, perhaps even decades,
to run its course?

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And an example of that,
of course, would be

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tuberculosis or HIV-AIDS,
in our own time.

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A ninth important question we
need always to bear in mind is

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how is the disease understood by
the population that it's

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infecting?

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Is it seen as a punishment of
God?

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Is it later on thought to be
something that comes from the

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dangerous classes?

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Or later on,
is it understood to be a

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microbial infection?

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And those ways in which the
disease is understood have

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enormous impact on how the
population reacts to the

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disease.

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A tenth variable is what's the
duration of the epidemic?

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Influenza, for example,
passes through a locality in a

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matter of weeks,
normally.

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Cholera or plague tend to have
epidemics that last for months.

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And tuberculosis,
one might describe as an

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epidemic in slow motion that
afflicts a community for a whole

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century or more.

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So, those are ten major
questions that I hope that

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you'll be bearing in mind
throughout the course.

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I think they'll help you in
dealing with the diseases in a

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comparative manner,
and finding out and teasing out

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why some diseases have an impact
of one kind,

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and others are very different.

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Well, this morning I'd like to
go through some of this material

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again, in a review manner,
by looking at syphilis.

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Why syphilis at this stage of
the course?

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I think that it provides
background for No Magic

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Bullet,
and it also helps us to look at

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some of the material that we've
already covered,

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and that you'll be writing
about in the next few days.

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Well, first let's deal then
with the chronology,

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and this helps us to step back
in time from the nineteenth

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century;
to go back, indeed,

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to the plague years.

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Syphilis, in fact,
was contemporary in its onset

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with plague,
and like plague,

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at the time it was a new
disease that first struck

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Europe,
in this case, in the late 1490s.

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And we'll see that there's an
important Darwinian evolution

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that takes place,
which is to say that the

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syphilis of the fifteenth and
sixteenth centuries is quite

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different from syphilis
thereafter.

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Syphilis in its first century
or so was what we might call the

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"Great Pox,"
a disease that was much more

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severe than modern syphilis.

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So, syphilis clearly begins as
a dreadful epidemic that swept

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Europe and then the world.

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After the sixteenth century,
it's still a very serious

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illness, but it's much milder,
less fatal and less agonizing.

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Today we're going to deal
primarily with the early

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syphilis, the syphilis of the
Great Pox.

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Now, the mode of transmission
is clearly important,

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and we need to examine what are
the particular features of STDs,

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of sexually transmitted
diseases.

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Among the venereal diseases--to
use an older term--

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syphilis was king from the
fifteenth century until the late

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twentieth,
when there was the appearance

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of a much more threatening
competitor,

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HIV/AIDS.

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And in more recent times,
after World War II and the

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introduction of the era of
antibiotics--

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particularly penicillin--and
sex education,

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there's been a radical decline
in the incidence of syphilis.

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And for a time there were even
heady hopes that it could be

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eradicated altogether.

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But most recently,
unfortunately,

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it's made something of a
comeback.

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Now, keep in mind,
too, that historically the STDs

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weren't carefully distinguished,
one from another.

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Until late in the nineteenth
century, other significant

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STDs--gonorrhea and chancre,
in particular--weren't known to

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be separate diseases.

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They were thought to be simply
milder manifestations of

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syphilis.

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So, there was,
we might say,

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a unicity theory of the
venereal diseases;

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there was thought to be one
disease.

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A reason for dealing with
syphilis now,

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at this point in the course,
is that it had a significant

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impact on medical science,
in ways that we've already

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touched upon with regard to
bubonic plague.

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That is to say,
like plague,

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syphilis seemed clearly to be
contagious,

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and it was understood,
from the beginning,

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to be spread somehow--no one
quite knew how--

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through sexual contact.

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And, so, like plague,
syphilis challenged the

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reigning orthodoxy of
humoralism,

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and gave rise through someone
we've already met,

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and we can look at again in a
moment,

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through Girolamo Fracastoro,
in particular,

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to the doctrine of contagion.

16:50.149 --> 16:56.419
And it generated also the idea
that disease might be a specific

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entity.

16:57.330 --> 17:03.320
Syphilis was clearly something
distinctive, and many people

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regarded it as a disease on its
own, rather than an example of

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humoral imbalance.

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So, syphilis had an impact on
medical science and influenced,

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along with plague the--if we
like, began to make humoral

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doctrine less stable at its
foundations.

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Well, where does syphilis come
from?

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What are its origins?

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And here there's a major
debate, that has not been

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resolved, and it continues down
to this day.

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I'll put forward a couple of
candidates.

17:46.858 --> 17:51.888
And I think it's more important
to note these different origins,

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theories of the origins of
syphilis,

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because they have a big impact
on how the disease is

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experienced.

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Rather than expecting us to
resolve the issue of where the

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disease came from in fact,
let's note how people thought

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the disease appeared.

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A first theory was the one
associated with Christopher

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Columbus.

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This is the Americanist idea of
the origins of syphilis.

18:23.868 --> 18:29.938
And we've talked already about
the Columbian Exchange.

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So, I just wanted to review
that again.

18:31.960 --> 18:38.640
That's Columbus's first trip,
and this is the idea of the

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Columbian Exchange,
of what was transmitted from

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the Old World to the New,
the Old World contributing

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various foodstuffs,
like coffee beans and rice,

18:52.527 --> 18:55.567
livestock--
cows--and various diseases;

18:55.568 --> 18:59.588
as you already know,
smallpox, measles and so on,

18:59.588 --> 19:04.888
and the New World being the
source for Europeans of corn,

19:04.890 --> 19:09.480
potatoes and so on,
certain precious metals,

19:09.480 --> 19:10.500
tobacco.

19:10.500 --> 19:16.530
And there is the idea that the
Americanists--so called--argued

19:16.526 --> 19:22.256
that it was Columbus and his
crew who brought back syphilis

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from the New World.

19:24.528 --> 19:29.398
This idea held that syphilis
was endemic in the New World,

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spread to Columbus's sailors,
and was reported to Europe on

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their return.

19:35.818 --> 19:37.868
The problem,
of course, for the theory,

19:37.868 --> 19:40.938
is that there isn't,
in fact, any definitive

19:40.939 --> 19:45.579
evidence that syphilis did exist
in the New World at the time,

19:45.578 --> 19:51.528
or that Columbus's sailors were
actually infected in the manner

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required by the theory.

19:53.930 --> 19:59.780
So, the evidence in support of
this is entirely circumstantial.

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The chronology works.

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That's one factor.

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And another is that there
isn't, in fact,

20:07.593 --> 20:12.793
in the medical literature,
before this time a disease like

20:12.785 --> 20:15.695
syphilis anywhere in Europe.

20:15.700 --> 20:19.620
And more recently,
paleopathologists haven't

20:19.616 --> 20:24.716
unearthed evidence of syphilis
in European cemeteries.

20:24.720 --> 20:29.470
It clearly seems to be a
disease that was a new--or let

20:29.471 --> 20:35.191
us use an anachronistic term--an
emerging disease in the 1490s.

20:35.190 --> 20:41.570
And because of Eurocentrism,
and perhaps xenophobia,

20:41.573 --> 20:47.083
there was a preference to blame
the other.

20:47.078 --> 20:53.508
A second idea that was very
popular was that syphilis,

20:53.511 --> 20:59.461
instead of being of American or
New World origins,

20:59.459 --> 21:03.949
was of Spanish or African
origin.

21:03.950 --> 21:08.120
This theory held that perhaps
the disease was present in

21:08.118 --> 21:12.038
Europe for a long time,
but had been confined to a

21:12.038 --> 21:17.368
small corner of the continent,
perhaps--and one can see

21:17.367 --> 21:23.497
certain sinister views here--
confined perhaps to Jews,

21:23.496 --> 21:28.546
or Moors in Spain,
and unnoticed by outsiders.

21:28.548 --> 21:33.428
Then with the expulsion of the
Jews in the 1490s,

21:33.426 --> 21:37.996
the disease was disseminated
across Europe.

21:38.000 --> 21:43.640
Now, among those who propounded
this view, there was clearly a

21:43.643 --> 21:48.273
current of racism,
anti-Semitism and xenophobia.

21:48.269 --> 21:52.229
Syphilis was supposed to have
been endemic among the Jews,

21:52.230 --> 21:56.550
having come perhaps earlier
from Africa,

21:56.548 --> 22:02.768
and was prevalent in those
populations because their sex in

22:02.765 --> 22:07.475
some way was unnatural and out
of control.

22:07.480 --> 22:10.930
So, syphilis was confined in
Europe to Spain,

22:10.930 --> 22:15.380
this theory argues,
until the expulsion of the Jews

22:15.380 --> 22:17.920
in 1492,
when they unleashed their

22:17.915 --> 22:19.965
contagion on the rest of Europe.

22:19.970 --> 22:23.440
In any case,
what's really clear is that

22:23.440 --> 22:28.510
absolutely no one wanted to
acknowledge syphilis as his or

22:28.511 --> 22:29.581
her own.

22:29.578 --> 22:33.738
For Italians,
syphilis was somebody else's,

22:33.742 --> 22:36.522
it was the French disease.

22:36.519 --> 22:41.319
For the French,
it was the Neapolitan disease.

22:41.318 --> 22:45.268
For Russians,
it was the Polish disease.

22:45.269 --> 22:48.899
And for everyone,
it was the Great Pox,

22:48.901 --> 22:50.241
or the clap.

22:50.240 --> 22:55.180
Now, how do we get the term
syphilis, where does that come

22:55.182 --> 22:55.792
from?

22:55.788 --> 23:00.258
The word itself was coined by
the Italian physician,

23:00.259 --> 23:03.989
whom you've already met,
Fracastoro,

23:03.990 --> 23:07.550
who did something extraordinary
in 1531,

23:07.548 --> 23:13.648
which was that he wrote a work
called Syphilis.

23:13.650 --> 23:19.550
And here was Fracastoro,
whose face you've seen again.

23:19.548 --> 23:23.788
Now, this work was odd,
or unusual, in a number of

23:23.788 --> 23:24.738
respects.

23:24.740 --> 23:27.900
It was a poem,
written in Latin,

23:27.902 --> 23:30.352
and modeled on Virgil.

23:30.348 --> 23:35.858
And, as I think about it,
I can't think at the moment of

23:35.861 --> 23:39.971
another poem about an epidemic
disease.

23:39.970 --> 23:42.980
It was also an instant success.

23:42.980 --> 23:47.680
It rapidly went through lots of
editions, and established

23:47.682 --> 23:51.132
Fracastoro's fame,
even more than his more

23:51.125 --> 23:52.885
scientific works.

23:52.890 --> 23:59.220
It also offered what I think we
could say was a clearly

23:59.221 --> 24:06.491
moralizing, judgmental analysis
of this disease as a scourge of

24:06.490 --> 24:07.430
God.

24:07.430 --> 24:10.480
You know the drill by now.

24:10.480 --> 24:14.900
In the poem,
the first victim of the disease

24:14.896 --> 24:19.106
was a shepherd whose name was
Syphilis.

24:19.108 --> 24:24.648
And the shepherd had offended
the gods by turning against them

24:24.650 --> 24:27.920
and worshipping a king as a
deity.

24:27.920 --> 24:32.420
So, in their anger,
the gods afflicted Syphilis

24:32.422 --> 24:34.872
with this terrible pox.

24:34.868 --> 24:39.298
We can see that built into it,
from the beginning,

24:39.304 --> 24:44.834
was the idea that syphilis was
best understood as the wages of

24:44.825 --> 24:45.545
sin.

24:45.548 --> 24:50.748
And there's a further polemical
thrust that's not made explicit

24:50.749 --> 24:54.019
but is a subtle undertow in the
poem.

24:54.019 --> 24:57.649
Remember, the poem was written
in the 1530s,

24:57.650 --> 25:02.190
in the midst of a religious
schism with Martin Luther,

25:02.190 --> 25:06.770
a devout adherent of
orthodoxy--that is,

25:06.769 --> 25:11.089
Fracastoro was--and of the
Catholic Church.

25:11.088 --> 25:16.518
He was a physician to bishops,
archbishops and cardinals.

25:16.519 --> 25:18.569
And Syphilis,
as I've said,

25:18.571 --> 25:21.731
was a shepherd,
and in Latin the word for

25:21.729 --> 25:24.649
shepherd is
pastor.

25:24.650 --> 25:29.380
The man who was punished was a
pastor, not a priest;

25:29.380 --> 25:32.280
that is, possibly a Protestant
leader.

25:32.278 --> 25:35.998
So, there's a sly hint here
that syphilis,

25:35.998 --> 25:39.808
the disease,
is a divine punishment for the

25:39.807 --> 25:41.257
Reformation.

25:41.259 --> 25:47.699
So, Fracastoro didn't adhere to
the Americanist position.

25:47.700 --> 25:52.840
Then there's perhaps a third
more modern idea,

25:52.836 --> 25:57.736
or hypothesis,
is that perhaps the causative

25:57.743 --> 26:03.683
agent of syphilis emerged in a
Darwinian manner;

26:03.680 --> 26:07.830
the spirochete or treponema
pallidum,

26:07.828 --> 26:12.988
arose perhaps as a mutation of
some pre-existing treponemes

26:12.987 --> 26:18.497
that are morphologically very
similar under the microscope,

26:18.500 --> 26:25.090
and perhaps it was--it emerged
as an evolution from the

26:25.089 --> 26:28.629
treponeme that causes yaws.

26:28.630 --> 26:32.540
In any case,
it was clear that whatever the

26:32.539 --> 26:36.909
site of its origin,
it spread across Europe with

26:36.914 --> 26:39.154
terrifying rapidity.

26:39.150 --> 26:43.530
One can see the role of
warfare, in particular,

26:43.525 --> 26:47.325
in promoting the movement of
syphilis.

26:47.328 --> 26:52.508
And its spread across Europe
was closely associated with

26:52.509 --> 26:58.129
Charles VIII of France,
known as Charles the Affable,

26:58.130 --> 27:03.890
who lived from 1470 to '98,
and launched a series of wars

27:03.888 --> 27:07.748
with Italy,
which he invaded in 1494,

27:07.750 --> 27:13.090
at the head of a large,
large army.

27:13.088 --> 27:18.718
The army marched across the
Italian Peninsula and reached

27:18.717 --> 27:23.237
Naples, that Charles besieged
and captured.

27:23.240 --> 27:28.440
He then found himself facing a
powerful coalition of powers

27:28.441 --> 27:31.671
that have ultimately defeated
him.

27:31.670 --> 27:35.920
And after his forced
withdrawal--the point is that

27:35.924 --> 27:37.754
his army disbanded.

27:37.750 --> 27:42.800
And this was a large army,
a mercenary force of tens of

27:42.798 --> 27:47.098
thousands of men from various
nationalities.

27:47.098 --> 27:54.028
A feature of war is that it's
always a providential time for

27:54.026 --> 27:58.836
epidemic disease,
and sexually transmitted

27:58.839 --> 28:02.009
diseases in particular.

28:02.009 --> 28:06.549
The army of Charles VIII was
poorly disciplined.

28:06.548 --> 28:11.058
It indulged in pillage,
plunder and rape,

28:11.057 --> 28:16.917
and it had its numerous camp
followers of beggars and

28:16.916 --> 28:18.716
prostitutes.

28:18.720 --> 28:22.860
So, among the troops,
and those who consorted with

28:22.863 --> 28:25.403
them, the disease flared up.

28:25.400 --> 28:28.730
And after their disbanding and
demobilization,

28:28.728 --> 28:31.908
it was disseminated across the
continent.

28:31.910 --> 28:38.040
Between 1495 and 1520,
something frightful happened as

28:38.042 --> 28:43.832
the epidemic swept Europe from
Naples to Moscow;

28:43.828 --> 28:48.968
to Oslo, Madrid,
London, and every place in

28:48.965 --> 28:50.185
between.

28:50.190 --> 28:54.930
So, this is the origin of
syphilis.

28:54.930 --> 28:58.680
However it arose--whether it
was imported,

28:58.680 --> 29:02.670
whether it was a newly emerging
disease,

29:02.670 --> 29:06.770
perhaps a mutation from yaws,
from a disease already present

29:06.767 --> 29:10.517
in Europe--
it was clearly spread by this

29:10.516 --> 29:16.696
favorable opportunity of warfare
and the army of Charles VIII.

29:16.700 --> 29:22.090
Well, what's the etiology and
symptomatology of syphilis?

29:22.088 --> 29:29.398
And here, this is the causative
agent, the treponema

29:29.398 --> 29:33.458
pallidum,
or spirochete.

29:33.460 --> 29:36.480
This, the treponema
pallidum,

29:36.480 --> 29:42.120
has a special feature,
in that it's exquisitely

29:42.121 --> 29:48.381
fastidious and fragile,
and re quires very precise

29:48.382 --> 29:51.812
conditions in order to live.

29:51.808 --> 29:57.998
It cannot survive outside of
bodily fluids and the warmth of

29:58.000 --> 30:02.510
the human body,
and therefore it can only be

30:02.511 --> 30:06.291
transmitted by intimate contact.

30:06.288 --> 30:11.528
Indeed, the spirochete is so
delicate that it can hardly be

30:11.530 --> 30:15.910
cultivated in vitro,
and that's one of the reasons

30:15.905 --> 30:20.575
that the development of a
vaccine has proved so difficult.

30:20.578 --> 30:26.358
Well, there's an initial
incubation period with syphilis,

30:26.362 --> 30:31.842
and we'll talk about three
stages in its impact on the

30:31.835 --> 30:34.515
individual human body.

30:34.519 --> 30:39.159
The first stage--and we're
talking now about the Great Pox,

30:39.160 --> 30:43.090
this early stage in the history
of syphilis--

30:43.088 --> 30:48.498
the first stage lasted a month
or two,

30:48.500 --> 30:55.280
and was marked by a painful and
alarming chancre at the site of

30:55.277 --> 30:59.647
entry of the spirochete into the
body.

30:59.650 --> 31:03.430
But this chancre heals
spontaneously,

31:03.433 --> 31:08.063
just like lesions in chickenpox
or herpes.

31:08.058 --> 31:13.508
But that doesn't mean that the
patient is cured.

31:13.509 --> 31:19.239
The disease in fact persists,
but for a time without

31:19.238 --> 31:21.708
generating symptoms.

31:21.710 --> 31:27.350
Then there's the onset of the
second stage of syphilis,

31:27.346 --> 31:33.706
between forty-five days after
the disappearance of the chancre

31:33.713 --> 31:35.283
and a year.

31:35.279 --> 31:40.179
There are numerous symptoms,
but in the second stage of

31:40.182 --> 31:44.902
syphilis only the superficial
tissues of the skin are

31:44.903 --> 31:47.993
affected, with rash and boils.

31:47.990 --> 31:52.390
Now, it was this second stage
of syphilis that was of

31:52.393 --> 31:57.223
extraordinary severity during
the era of the Great Pox.

31:57.220 --> 32:00.670
It was painful,
disfiguring,

32:00.665 --> 32:04.875
incapacitating and often fatal.

32:04.880 --> 32:08.800
There were sores and swellings
all over the body,

32:08.799 --> 32:12.969
from the soles of the foot to
the crown of the head,

32:12.965 --> 32:16.555
leaving disfiguring scabs and
pockmarks.

32:16.558 --> 32:20.128
Worse, the disease was
described as attacking the whole

32:20.125 --> 32:21.045
of the body.

32:21.048 --> 32:25.008
It was said to eat it away and
consume it.

32:25.009 --> 32:28.029
The body stank,
and the sufferers were

32:28.028 --> 32:30.098
afflicted,
in addition,

32:30.096 --> 32:33.286
with fever and pain in their
joints,

32:33.288 --> 32:36.488
so intense, one contemporary
wrote,

32:36.490 --> 32:39.730
that the victims screamed day
and night,

32:39.730 --> 32:43.400
envying the very dead.

32:43.400 --> 32:49.030
Let's listen to Fracastoro
himself, who described the Great

32:49.027 --> 32:50.577
Pox like this.

32:50.578 --> 32:55.498
He wrote--remember,
he was a physician as well as a

32:55.497 --> 33:01.197
poet--"In the majority of
cases, small ulcers began to

33:01.201 --> 33:04.351
appear on the sexual organs.

33:04.348 --> 33:08.528
They were intractable and would
not depart.

33:08.528 --> 33:13.508
Next, the skin broke out with
encrusted pustules.

33:13.509 --> 33:16.059
They soon grew,
little by little,

33:16.059 --> 33:19.169
until they were the size of an
acorn;

33:19.170 --> 33:22.080
which they in fact resembled.

33:22.078 --> 33:27.198
Then these ulcerated pustules
ate away the skin and sometimes

33:27.201 --> 33:31.981
infected not only the fleshy
parts, but the very bones as

33:31.980 --> 33:32.750
well.

33:32.750 --> 33:35.800
In cases where the malady was
firmly established,

33:35.798 --> 33:40.358
in the upper parts of the body,
the patient suffered from

33:40.356 --> 33:44.016
pernicious catarrh that eroded
the palate,

33:44.019 --> 33:46.879
or the pharynx and tonsils.

33:46.880 --> 33:51.140
In some cases the lips,
the nose and eyes were eaten

33:51.135 --> 33:55.555
away, or in others,
the whole of the sexual organs.

33:55.558 --> 33:59.168
Moreover, many patients
suffered from the great

33:59.173 --> 34:02.793
deformity, or gummata
that developed.

34:02.788 --> 34:06.648
Besides all of the above
symptoms, as if they were not

34:06.650 --> 34:10.220
bad enough, violent pains
attacked the muscles.

34:10.219 --> 34:15.569
These pains were persistent,
tormented the sufferer chiefly

34:15.574 --> 34:21.304
at night, and were the most
cruel of all the symptoms."

34:21.300 --> 34:24.750
There is a theory that maybe
even the disease was too

34:24.746 --> 34:28.596
virulent for its own good,
that its symptoms were so

34:28.596 --> 34:33.216
debilitating as to prevent
sufferers from transmitting it,

34:33.219 --> 34:38.079
and so the modern disease
evolved during the sixteenth and

34:38.081 --> 34:43.031
seventeenth centuries as a
milder form of the Great Pox.

34:43.030 --> 34:48.740
I'll show you a couple of
images of extreme forms of

34:48.735 --> 34:53.545
modern syphilis,
that's said to give us some

34:53.545 --> 34:58.015
idea of what the Great Pox was
like.

34:58.018 --> 35:00.668
They're rather,
of course, unpleasant slides.

35:00.670 --> 35:02.810
So, I would tell you that in
advance.

35:02.809 --> 35:07.809
But this will give you some
idea of how terrible the Great

35:07.811 --> 35:08.691
Pox was.

35:08.690 --> 35:15.940
It looked like that,
or indeed like that.

35:15.940 --> 35:18.670
We'll move on.

35:18.670 --> 35:24.650
Then there's third-stage
syphilis, tertiary syphilis,

35:24.652 --> 35:31.672
and in this phase you have
involvement of the deep tissues.

35:31.670 --> 35:36.260
And its symptoms are things
such as what's called tabes

35:36.260 --> 35:40.310
dorsalis,
which is a degeneration of the

35:40.311 --> 35:45.371
neurons in the spinal cord,
and leads therefore to lack of

35:45.365 --> 35:48.825
coordination,
to a stumbling gait,

35:48.827 --> 35:54.607
and symptoms of that kind;
to ataxia, which means the

35:54.606 --> 35:56.276
stumbling gait.

35:56.280 --> 35:59.340
It also leads,
in this phase,

35:59.336 --> 36:05.556
to cardiovascular disease,
often to insanity and dementia,

36:05.561 --> 36:09.821
to general paralysis,
and to death.

36:09.820 --> 36:15.780
So, tertiary syphilis can be
the cause of death.

36:15.780 --> 36:20.800
What were--if that's what the
disease looked like--what were

36:20.800 --> 36:23.610
some of its effects on society?

36:23.610 --> 36:27.140
Well, because of its mode of
transmission,

36:27.139 --> 36:33.359
syphilis was associated with
terrible social effects,

36:33.360 --> 36:38.070
with anxiety,
guilt, pain,

36:38.068 --> 36:44.798
broken relationships,
breakdowns in trust within

36:44.802 --> 36:49.142
families,
infertility among women.

36:49.139 --> 36:53.799
And like the plague,
and unlike some of the diseases

36:53.795 --> 36:58.445
that we'll be studying,
syphilis was no respecter of

36:58.449 --> 37:02.009
persons, of social class or
status.

37:02.010 --> 37:08.170
We might perhaps ironically
call it a democratic disease,

37:08.170 --> 37:11.860
in that it afflicted everyone,
from the bottom of the social

37:11.856 --> 37:13.816
scale,
to aristocrats,

37:13.815 --> 37:17.605
learned professionals,
kings, cardinals,

37:17.608 --> 37:20.818
bishops, occasionally even
popes,

37:20.820 --> 37:27.270
such as Julius II,
who was also a syphilitic.

37:27.268 --> 37:30.038
So, accordingly,
one might argue,

37:30.041 --> 37:33.941
syphilis caused a great strain
on society,

37:33.940 --> 37:40.880
but not along the fissures
running between classes,

37:40.880 --> 37:46.220
as did, for example,
Asiatic cholera.

37:46.219 --> 37:50.819
It was also unlike plague in
that it was not terrifyingly

37:50.818 --> 37:55.168
swift, and its obvious
association with sex meant that

37:55.170 --> 37:58.210
the means to avoid it were
clear.

37:58.210 --> 38:03.590
And so there was no generalized
terror, of the kind that

38:03.590 --> 38:08.680
accompanied say bubonic plague
or Asiatic cholera.

38:08.679 --> 38:14.659
Everyone knew how syphilis
could be avoided.

38:14.659 --> 38:18.169
What were the effects on then?

38:18.170 --> 38:21.640
One was a new asceticism.

38:21.639 --> 38:26.029
There was a suspicion of
pleasures.

38:26.030 --> 38:30.220
In the Protestant world,
an epidemic of syphilis was

38:30.224 --> 38:35.354
perfectly timed not to create--
and here I don't want to be

38:35.351 --> 38:39.821
saying that epidemic diseases
created Puritanism;

38:39.820 --> 38:44.750
I would argue instead simply
that this is a disease that

38:44.746 --> 38:46.176
reinforced it.

38:46.179 --> 38:51.079
Asceticism indeed had long been
present in European culture,

38:51.081 --> 38:55.821
but syphilis helped make it
more popular and a widely held

38:55.815 --> 38:56.975
sentiment.

38:56.980 --> 39:01.050
In the Catholic world,
one can see a new piety as

39:01.048 --> 39:05.028
well, in the Catholic
Reformation, in Jansenism,

39:05.032 --> 39:06.392
for example.

39:06.389 --> 39:11.769
Another impact clearly was in
terms of tensions between the

39:11.768 --> 39:12.508
sexes.

39:12.510 --> 39:16.580
Now, this is familiar to you;
we're going back over old

39:16.583 --> 39:18.323
ground in our course.

39:18.320 --> 39:23.460
Remember paintings that we saw
earlier of the Garden of Eden

39:23.463 --> 39:27.133
and Origin Sin,
Adam drawn into evil by his

39:27.125 --> 39:30.695
helpmate Eve,
the original temptress.

39:30.699 --> 39:36.439
Well, the passage of syphilis
was marked by a sinister

39:36.438 --> 39:38.928
undertow of misogyny.

39:38.929 --> 39:42.789
In a patriarchal society,
male fears,

39:42.789 --> 39:48.409
anxieties, and indeed guilt,
were projected onto women,

39:48.409 --> 39:53.529
who were seen as the crucial
agents in the spread of this

39:53.525 --> 39:55.075
disease to men.

39:55.079 --> 39:59.529
And two groups of women were
particularly suspect,

39:59.525 --> 40:01.335
prostitutes first.

40:01.340 --> 40:06.590
And here was a prime example of
a new male double standard.

40:06.590 --> 40:11.100
The passage of syphilis was
marked by harsh police measures

40:11.101 --> 40:14.891
against prostitutes,
including the closing of

40:14.885 --> 40:19.205
brothels and the rounding up and
exile of people from

40:19.211 --> 40:20.461
communities.

40:20.460 --> 40:26.330
There was also a hunt for
scapegoats, and witch hunts were

40:26.333 --> 40:27.883
part of that.

40:27.880 --> 40:31.840
Another feature was a new
religious cult;

40:31.840 --> 40:35.490
the cult, in particular,
of a new saint.

40:35.489 --> 40:40.159
And this is rather unique,
which is there's only,

40:40.159 --> 40:44.969
as far as I know,
one saint who wasn't a

40:44.974 --> 40:48.434
Christian,
and this is Job,

40:48.431 --> 40:53.411
from the Book of Job in the Old
Testament.

40:53.409 --> 40:58.709
Job, however,
was actually said--in the Book

40:58.706 --> 41:05.606
of Job, he had an especially
convincing defense attorney,

41:05.606 --> 41:09.176
and that was God himself.

41:09.179 --> 41:14.749
Because God says in the Book of
Job that this is the most just

41:14.748 --> 41:18.948
of all men, he's the best and
most innocent.

41:18.949 --> 41:23.079
And yet to try his faith,
he was scourged by Satan.

41:23.079 --> 41:30.319
This is a painting by William
Blake of this scourging of Job

41:30.315 --> 41:37.545
by Satan, who's pouring out
boils that will soon torment him

41:37.550 --> 41:40.250
from head to foot.

41:40.250 --> 41:44.660
And the description of the
disease that afflicted Job,

41:44.655 --> 41:48.805
in the Book of Job,
is highly suggestive of what we

41:48.811 --> 41:52.221
might call a venereal disease or
STD.

41:52.219 --> 41:55.319
He was covered from head to
foot in boils.

41:55.320 --> 41:59.010
And yet Job was reassuringly
free from sin.

41:59.010 --> 42:02.720
We know that because God tells
us so.

42:02.719 --> 42:08.419
And, so, Job became the patron
saint of syphilitics.

42:08.420 --> 42:12.360
There was also a public health
response;

42:12.360 --> 42:15.590
that is to say,
the building of hospitals for

42:15.585 --> 42:18.735
the incurables,
who were the syphilitics.

42:18.739 --> 42:21.179
And there was a new
philanthropy,

42:21.184 --> 42:24.934
and religious orders that took
over their care.

42:24.929 --> 42:28.949
Let's look for a moment at some
of the treatment regimens that

42:28.952 --> 42:31.462
were also important in this
disease.

42:31.460 --> 42:37.410
One was the beginning--it
began, the most common treatment

42:37.411 --> 42:40.731
regimen,
with a forty-day period,

42:40.733 --> 42:45.503
beginning with fasting,
and then the administration of

42:45.496 --> 42:47.856
mercury,
which had been used in the

42:47.862 --> 42:50.752
treatment of skin disorders over
the centuries,

42:50.750 --> 42:53.450
diseases such as scabies.

42:53.449 --> 42:57.419
So, mercury was sometimes
applied--it was applied in lots

42:57.420 --> 42:58.840
of different ways.

42:58.840 --> 43:03.490
Disparate remedies for a
desperate disease.

43:03.489 --> 43:07.569
Ointments were applied to the
skin lesions.

43:07.570 --> 43:12.220
There was a so-called general
friction in which applications

43:12.224 --> 43:15.464
of mercury were made to the
whole body.

43:15.460 --> 43:19.720
Sometimes it was administered
internally.

43:19.719 --> 43:24.119
But as you know,
mercury is extremely toxic.

43:24.119 --> 43:28.889
It causes great salivation,
the falling out of the teeth,

43:28.891 --> 43:33.581
and then serious and often
life-threatening symptoms.

43:33.579 --> 43:37.029
But salivation seemed to be the
right approach.

43:37.030 --> 43:41.640
According to humoralist
principles, it would lead to an

43:41.643 --> 43:44.553
evacuation of the peccant humor.

43:44.550 --> 43:47.450
And it also--and here was a
factor--

43:47.449 --> 43:53.159
it seemed to work when applied
to second-stage syphilis,

43:53.159 --> 43:56.379
perhaps simply because,
as we've already seen,

43:56.380 --> 44:01.660
second-stage syphilis goes into
spontaneous and often lengthy

44:01.663 --> 44:02.723
remission.

44:02.719 --> 44:06.509
And it was possible to argue
that it was the therapy,

44:06.510 --> 44:09.500
the treatment,
that had been effective.

44:09.500 --> 44:14.530
And perhaps the suffering that
accompanied this particular

44:14.528 --> 44:19.298
treatment provided some moral
satisfaction to those who

44:19.295 --> 44:21.055
administered it.

44:21.059 --> 44:27.759
Another remedy that was tried
was guaiac, which is a hardwood

44:27.764 --> 44:31.234
from a tree in the New World.

44:31.230 --> 44:35.550
It was ground into sawdust and
made into a decoction that

44:35.547 --> 44:38.937
patients drank twice a day for
forty days.

44:38.940 --> 44:42.850
We see these forty days
appearing over and over:

44:42.849 --> 44:45.809
in quarantine;
the forty day fasting;

44:45.809 --> 44:49.609
the regimen for mercury;
the regimen for guaiac.

44:49.610 --> 44:53.590
Well, all of this,
of course, had a religious

44:53.585 --> 44:54.755
background.

44:54.760 --> 44:59.200
And, so, the guaiac was
administered for forty days,

44:59.204 --> 45:02.084
during which there was fasting.

45:02.079 --> 45:07.149
At the same time then--so
guaiac and mercury were,

45:07.146 --> 45:10.656
so we might say,
the miracle drugs,

45:10.663 --> 45:14.183
the wonder drugs of their era.

45:14.179 --> 45:19.799
There were other indications
also recommended for syphilis:

45:19.804 --> 45:22.714
bloodletting,
baths, purgation,

45:22.713 --> 45:25.723
cauterization of the boils.

45:25.719 --> 45:30.519
An important impact,
then--the next thing I want to

45:30.519 --> 45:36.089
point out--is the impact of
syphilis on medical science.

45:36.090 --> 45:40.520
We already--and this gives us a
moment of review--we know

45:40.518 --> 45:45.498
already the traditional approach
to these and other diseases;

45:45.500 --> 45:48.970
that they were an imbalance of
humors.

45:48.969 --> 45:52.959
There had been no idea of
discrete entities that were

45:52.956 --> 45:53.796
diseases.

45:53.800 --> 45:58.050
Diseases were an individual
matter, depending on the

45:58.052 --> 46:02.972
constitution of the patient and
the environmental influences

46:02.971 --> 46:05.391
that acted on him or her.

46:05.389 --> 46:07.209
In the nineteenth century,
however,

46:07.210 --> 46:11.720
we've seen already that
diseases fully crystallized into

46:11.719 --> 46:16.399
forms of specific entities,
that were actually biological

46:16.400 --> 46:20.840
entities that existed apart from
the body of the individual

46:20.840 --> 46:21.760
sufferer.

46:21.760 --> 46:28.390
The period from the 1490s to
the nineteenth century,

46:28.389 --> 46:33.409
the period that emplaced both
plague and the Great Pox,

46:33.409 --> 46:37.549
and then modern syphilis,
marked an era of transition.

46:37.550 --> 46:41.970
And I would argue that syphilis
was something that propelled

46:41.971 --> 46:43.921
this transition forward.

46:43.920 --> 46:47.200
Remember how traditional
medicine, as taught at

46:47.195 --> 46:51.035
universities and practiced by
the elite physicians,

46:51.039 --> 46:55.369
was that the truth about
disease was to read the

46:55.367 --> 46:59.597
classics: Hippocrates and Galen,
supplemented later,

46:59.601 --> 47:02.981
in the Middle Ages,
by astrology.

47:02.980 --> 47:05.660
So, for humoralist physicians,
then,

47:05.659 --> 47:09.329
that was the way it was
preceded, and when syphilis

47:09.333 --> 47:12.513
first struck,
there were disputations in

47:12.510 --> 47:17.280
which people sought the truth of
the disease by looking through

47:17.282 --> 47:21.742
into Hippocrates,
or what Galen had written.

47:21.739 --> 47:27.439
And so there were disputes,
disputations that were formally

47:27.443 --> 47:30.593
held through library medicine.

47:30.590 --> 47:36.060
The challenge of syphilis was
that it was a pandemic that was

47:36.059 --> 47:41.069
difficult to explain within the
traditional framework of

47:41.072 --> 47:42.442
humoralism.

47:42.440 --> 47:46.170
At the same time,
the disease had no real place

47:46.170 --> 47:47.630
in the Classics.

47:47.630 --> 47:51.640
Humoralism was static,
and had no way of accommodating

47:51.643 --> 47:53.163
emerging diseases.

47:53.159 --> 47:57.659
So, what do you do with a
disease that was unknown to the

47:57.655 --> 47:58.535
Ancients?

47:58.539 --> 48:02.069
Syphilis was also clearly
contagious,

48:02.070 --> 48:06.330
everyone could see that,
and so there was obviously some

48:06.327 --> 48:10.817
morbific substance that passed
from one body to another.

48:10.820 --> 48:12.590
The disease,
in other words,

48:12.585 --> 48:14.805
seemed to be something
specific;

48:14.809 --> 48:20.199
and this helped to promote also
the idea of a new concept of

48:20.195 --> 48:21.105
disease.

48:21.110 --> 48:25.600
And syphilis tried physicians
because it really was an

48:25.596 --> 48:30.536
incurable disease at the time,
and until the late twentieth

48:30.543 --> 48:35.003
century didn't respond to the
classical recommendations for

48:35.003 --> 48:35.853
therapy.

48:35.849 --> 48:40.549
All of this made it a major
challenge to humoralist

48:40.550 --> 48:41.680
orthodoxy.

48:41.679 --> 48:46.639
And with that,
I would say we've reviewed this

48:46.641 --> 48:53.371
period of syphilis and plague
that presented a major impact on

48:53.365 --> 48:57.325
society,
and a major impact on medical

48:57.333 --> 48:58.123
science.

48:58.119 --> 49:00.789
And we've run out of time this
morning.

49:00.789 --> 49:04.299
Next time, having had our
review session,

49:04.300 --> 49:08.670
we'll come back to the
nineteenth century and deal with

49:08.666 --> 49:12.316
the debate,
the huge medical debate,

49:12.320 --> 49:17.150
between contagionists and
anti-contagionists.

49:17.150 --> 49:22.000