Syphilis historical perspective

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]

Overview

The name "syphilis" was coined by the Italian physician and poet Girolamo Fracastoro in his epic noted poem, written in Latin, entitled Syphilis sive morbus gallicus (Latin for "Syphilis or The French Disease") in 1530. The protagonist of the poem is a shepherd named Syphilus (perhaps a variant spelling of Sipylus, a character in Ovid's Metamorphoses). Syphilus is presented as the first man to contract the disease, sent by the god Apollo as punishment for the defiance that Syphilus and his followers had shown him. From this character Fracastoro derived a new name for the disease, which he also used in his medical text De Contagionibus ("On Contagious Diseases"). Until that time, as Fracastoro notes, syphilis had been called the "French disease" in Italy and Germany, and the "Italian disease" in France. In addition, the Dutch called it the "Spanish disease", the Russians called it the "Polish disease", the Turks called it the "Christian disease" or "Frank disease" (frengi) and the Tahitians called it the "British disease". These 'national' names are due to the disease often being present among invading armies or sea crews, due to their high amount of unprotected sexual contacts with prostitutes. It's interesting to notice how the invaders named it after the invaded country and vice versa. It was also called "Great pox" in the 16th century to distinguish it from smallpox. In its early stages, the Great pox produced a rash similar to smallpox (also known as variola). However, the name is misleading, as smallpox was a far more deadly disease. The terms "Lues" (or Lues venerea, Latin for "venereal plague") and "Cupid's disease" have also been used to refer to syphilis. In Scotland, Syphilis was referred to as the Grandgore. It was also called The Black Lion.

Historical Perspective

Origin

Public Domain, https://commons.wikimedia.org/w/index.php?curid=1819475 - In this medical illustration attributed to Albrecht Dürer (1496), the disease is believed to have astrological causes.

There have been three theories on the origin of syphilis which formed an ongoing debate in anthropological and historical fields.

The pre-Columbian theory holds that syphilis symptoms are described by Hippocrates in Classical Greece in its venereal/tertiary form. There are other suspected syphilis findings for pre-contact Europe, including at a 13–14th century Augustinian friary in the northeastern English port of Kingston upon Hull. This city's maritime history is thought to have been a key factor in the transmission of syphilis.[1] Carbon dated skeletons of monks who lived in the friary showed bone lesions typical of venereal syphilis. Skeletons in pre-Columbus Pompeii and Metaponto in Italy demonstrating signs of congenital syphilis have also been found[2], although the interpretation of the evidence has been disputed.[3]

The Columbian Exchange theory holds that syphilis was a New World disease brought back by Columbus and Martin Alonzo Pinzon. Supporters of the Columbian theory find syphilis lesions on pre-contact Native Americans and cite documentary evidence linking crewmen of Columbus's voyages to the Naples outbreak of 1494.[4] A recent study of the genes of venereal syphilis and related bacteria have supported this theory, by locating an intermediate disease between yaws and syphilis in Guyana, South America.[5][6]

Historian Alfred Crosby suggests both theories are correct in a combination theory. Crosby's argument is built on the similarities of the species of bacteria which cause yaws and syphilis. The bacteria that causes syphilis belongs to the same phylogenetic family as the bacteria which cause yaws and several other diseases. Despite a tradition of assigning yaws's homeland to sub-Saharan Africa, Crosby notes that there is no unequivocal evidence of any related disease being present in pre-Columbian Europe, Africa, or Asia, while there is indisputable evidence of syphilis' presence in the pre-Columbian Americas. Conceding this point, Crosby writes, "It is not impossible that the organisms causing treponematosis arrived from America in the 1490s...and evolved into both venereal and non-venereal syphilis and yaws."[7]

However, Crosby considers it somewhat more likely that a highly contagious ancestral species of bacteria moved with early human ancestors across the land bridge of the Bering Straits many thousands of years ago without dying out in the original source population. He hypothesizes that "the differing ecological conditions produced different types of treponematosis and, in time, closely related but different diseases".[8] Thus, a weak, non-syphilitic bacteria survived in the Old World to eventually give rise to yaws or bejel, while a New World version evolved into the milder pinta and the more aggressive syphilis.

Going further than Crosby in arguing for worldwide incidence of syphilis prior to Columbus, Douglas Owsley, the famed physical anthropologist at the Smithsonian Institute, has written that many medieval European cases of leprosy, colloquially called "lepra," were actually cases of syphilis. Although folklore claimed that syphilis was unknown in Europe until the return of the diseased sailors of the Columbian voyages,

. . . syphilis probably cannot be "blamed"—as it often is—on any geographical area or specific race. The evidence suggests that the disease existed in both hemispheres from prehistoric times. It is only coincidental with the Columbus expeditions that the syphilis previously thought of as "lepra" flared into virulence at the end of the fifteenth century.[9]

Owsley noted that a Chinese medical case recorded in 2637 B.C.E. seems to be describing a case of syphilis, and that a European writer who recorded an outbreak of "lepra" in 1303 C.E. is "clearly describing syphilis".[9]

While working at the Rockefeller Institute in 1913, Hideyo Noguchi, a Japanese scientist, demonstrated the presence of the spirochete Treponema pallidum in the brain of a progressive paralysis patient, proving that Treponema pallidum was the cause of the disease. [3] Prior to Noguchi's discovery, syphilis had been a burden to humanity in many lands, sometimes misdiagnosed and often misattributed to political enemies.

The insanity caused by late-stage syphilis was once one of the more common forms of dementia; this was known as the general paresis of the insane. One suspected example is the insanity of noted composer Robert Schumann, although the precise cause of his death is still disputed by scholars.

European outbreak

The first well-recorded European outbreak of what is now known as syphilis occurred in 1494 when it broke out among French troops besieging Naples.[10] The French may have caught it via Spanish mercenaries serving King Charles of France in that siege.[9] From this centre, the disease swept across Europe. As Jared Diamond describes it, "when syphilis was first definitely recorded in Europe in 1495, its pustules often covered the body from the head to the knees, caused flesh to fall from people's faces, and led to death within a few months." In addition, the disease was more frequently fatal than it is today. Diamond concludes that "by 1546, the disease had evolved into the disease with the symptoms so well known to us today."[11] The epidemiology of this first syphilis epidemic shows that the disease was either new or a mutated form of an earlier disease.

Syphilis in art and literature

Art

The artist Kees van Dongen produced a series of illustrations for the anarchist publication L'Assiette au Beurre showing the descent of a young prostitute from poverty to her death from syphilis as a criticism of the social order at the end of the 19th century.

The artist Jan van der Straet, also known as Johannes Stradanus or simply Stradanus, painted a scene of a wealthy man receiving treatment of syphilis with the tropical wood guaiacum sometime around 1580.[12] The title of the work is "Preparation and Use of Guayaco for Treating Syphilis." That the artist chose to include this image in a series of works celebrating the New World indicates how important a "cure" (however ineffective) for syphilis was to the European elite at that time. The richly colored and detailed work depicts four servants preparing the concoction while a physician looks on, hiding something behind his back while the hapless patient drinks.[13]

Classic and antique literature

Delicado also featured the effects of syphilis in his Portrait of Lozana: The Lusty Andalusian Woman (1528).

There are references to syphilis in William Shakespeare's play Measure for Measure, particularly in a number of early passages spoken by the character Lucio. For example, Lucio says "[...] thy bones are hollow"; this is a reference to the brittleness of bones engendered by the use of mercury which was then widely used to treat syphilis.

In Shakespeare's play Othello, the clown at the beginning of Act III makes jest of Cassio, who is leading a musician troupe for Othello, by asking him if he had just arrived from Naples and playing with his nose. (Alluding to the reputation of Naples of being a likely place to contract syphilis, which eats away at the bridge of the nose.)

Francisco de Quevedo puns in his Buscón[14] about a nose entre Roma y Francia meaning both "between Rome and France" and "between dull and eaten by the French illness".

Jonathan Swift's poetry mentions syphilis as a condition of prostitution which reaches the highest ranks of society. See, for example, "A Beautiful Young Nymph Going To Bed" and "The Progress of Beauty".

Moll dies of syphillis, Hogarth's A Harlot's Progress.

William Hogarth's works frequently show his subject's infection with syphilis. Two examples are A Harlot's Progress and Marriage à-la-mode. In both instances it is used to indicate the moral profligacy of the infected.

Some critics have argued that the character of Edward Rochester's first wife, Bertha, in Charlotte Brontë's novel Jane Eyre, suffers from the advanced stages of syphilitic infection, general paresis of the insane, and point to corroborative evidence within the text to substantiate this view.

The novel Candide by Voltaire describes Candide's mentor and teacher, Pangloss, as having contracted syphilis from a maidservant he slept with; the syphilis has ravaged and deformed his body. Pangloss explains to Candide that syphilis is 'necessary in the best of worlds' because the line of infection - which he explains - leads back to Christopher Columbus. If Columbus had not sailed to America and brought back syphilis, Pangloss states, the Europeans would not have been able to enjoy 'New World wonders' such as chocolate. (One of the purposes of the novel was to satirize Leibniz's philosophy as Pangloss's disingenuous rose-tinted viewpoint.) Pangloss eventually loses an eye and an ear to the syphilis before he is cured.

Also, in Charles Dickens' novel Tale of Two Cities, references are made that allude to the main character, Sydney Carton, having syphilis.

In Eça de Queiroz's novel written in 1870, "The Mystery of the Sintra Road", some of the characters have syphilis, and it plays an important role in the plot of a recent movie adaptation.[15]

Henrik Ibsen's once-controversial play Ghosts has a young man who is suffering from a mysterious unnamed disease. Though it is never named, the events of the play make it plain that this is syphilis, an inheritance from his dissolute father. However, the young man's mother remains unaffected - this is because it is possible for a woman to carry syphillis and transmit it to her child in the womb without exhibiting any noticeable symptoms. Dr. Rank in Ibsen's play A Doll's House also has inherited syphilis.

Modern literature

Unnamed American medical students described syphilis in a series of early 20th-century American limericks, using medical terminology to ghastly comic effect in the Journal of the American Medical Association January 1942.[16]

Thomas Disch in his novel Camp Concentration describe a fictional strain of syphilis that enhances intelligence but is lethal.

In Thomas Mann's novel Doktor Faustus, the Faust character, Adrian Leverkühn, acquires his genius for musical composition from the neurological effects of syphilis.

In Dick Francis' novel, Bonecrack the character Enso Rivera is suffering from megalomania caused by syphilis.

Neal Stephenson's trilogy The Baroque Cycle has multiple characters and historical figures who have syphilis, most notably James II of England and Jack Shaftoe; the latter is cured of the disease by running a high fever.

In Leonard Cohen's second novel Beautiful Losers, the character F. is described in detail as having the terminal stages of syphilis.

In Christina Garcia's novel "Dreaming in Cuban," Felica contracts syphilis from her unfaithful husband. The syphilis and her family history lead Felica down a path towards insanity.

In Ken Follett's novel "A Dangerous Fortune," the wealthy Edward Pilaster contracts syphilis from his frequency of using brothels. When Edward's cohort Micky Miranda finds out, it looks as though his diabolical plans may have a snag.

In Josilyn Jackson's novel "Between, Georgia", the protagonist Nonny Frett suffers from syphilis from a cheating husband she can't seem to rid herself of.

Film, Television and Stage

Syphilis is used as a plot device in many dramatic films, television shows, and plays. While some, such as Warner Bros.' 1940 film, Dr. Ehrlich's The Magic Bullet, focus on the history of the disease, most involve late-stage syphilis because the neurological damage common to late-stage syphilis provides an excuse for strange behaviors. In recent years, syphilis has been mentioned on Grey's Anatomy, House M.D., Law & Order: SVU, Buffy the Vampire Slayer, Angel and other television shows. A few particularly notable appearances include:

  • Miss Evers' Boys is a 1992 stage play written by Dr. David Feldshuh based on the true story of the decades-long Tuskegee syphillis experiment. The play was subsequently adapted into a 1997 HBO TV movie directed by Joseph Sargent and starring Alfre Woodard and Laurence Fishburne. The film was nominated for eleven Emmy Awards and won in four categories, including Outstanding Made for Television Movie.
  • In Akira Kurosawa's Japanese movie "The Quiet Duel" (1949) Toshirô Mifune plays a doctor who gets infected with syphilis while operating on a soldier.
  • In big budget Spanish film Alatriste, the main character finds the love of his life, actress María de Castro, dying in a hospital for syphilitics. It is implied that she caught the disease from an affair with Philip IV of Spain.
  • In the Masterpiece Theatre version of Bram Stoker's "Dracula", Arthur Holmwood, whose father dies of syphilitic insanity, enlists the services of Count Dracula in hopes of curing his congenital syphilis.

Diagnosis

Early 20th century

In 1906, the first effective test for syphilis, the Wassermann test, was developed. Although it had some false positive results, it was a major advance in the prevention of syphilis. By allowing testing before the acute symptoms of the disease had developed, this test allowed the prevention of transmission of syphilis to others, even though it did not provide a cure for those infected.

In the 1930s the Hinton test, developed by William Augustus Hinton, and based on flocculation, was shown to have fewer false positive reactions than the Wassermann test. Both of these early tests have been superseded by newer analytical methods.

Modern diagnostic tests

It was only in the 20th century that effective tests and treatments for syphilis were developed. Microscopy of fluid from the primary or secondary lesion using darkfield illumination can diagnose treponemal disease with high accuracy. As there are other treponemes that may be confused with T. pallidum, care must be taken in evaluating with microscopy to correlate symptoms with the correct disease.

Treatment

There were originally no effective treatments for syphilis. The Spanish priest Francisco Delicado wrote El modo de adoperare el legno de India (Rome, 1525) about the use of Guaiacum in the treatment of syphilis. He himself suffered from syphilis. Another common remedy was mercury: the use of which gave rise to the saying "A night in the arms of Venus leads to a lifetime on Mercury".[17] It was administered multiple ways including by mouth and by rubbing it on the skin. One of the more curious methods was fumigation, in which the patient was placed in a closed box with his head sticking out. Mercury was placed in the box and a fire was started under the box which caused the mercury to vaporize. It was a grueling process for the patient and the least effective for delivering mercury to the body.

As the disease became better understood, more effective treatments were found. The first antibiotic to be used for treating disease was the arsenic-containing drug Salvarsan, developed in 1908 by Sahachiro Hata while working in the laboratory of Nobel prize winner Paul Ehrlich. This was later modified into Neosalvarsan. Unfortunately, these drugs were not 100% effective, especially in late disease. It had been observed that some who develop high fevers could be cured of syphilis. Thus, for a brief time malaria was used as treatment for tertiary syphilis because it produced prolonged and high fevers. This was considered an acceptable risk because the malaria could later be treated with quinine which was available at that time. This discovery was championed by Julius Wagner-Jauregg, who won the 1927 Nobel Prize for Medicine for his work in this area. Malaria as a treatment for syphilis was usually reserved for late disease, especially neurosyphilis, and then followed by either Salvarsan or Neosalvarsan as adjuvant therapy. These treatments were finally rendered obsolete by the discovery of penicillin, and its widespread manufacture after World War II allowed syphilis to be effectively and reliably cured.[18]

References

  1. Keys, David (2007). "English syphilis epidemic pre-dated European outbreaks by 150 years". Independent News and Media Limited.
  2. Henneberg M, Henneberg RJ, 1994, Treponematosis in an Ancient Greek colony of Metaponto, Southern Italy 580-250 BCE [in:] O Dutour, G Palfi, J Berato, J-P Brun (eds), The Origin of Syphilis in Europe, Before or After 1493?, Centre Archeologique du Var, Editions Errance Toulon-Paris, pp. 92-98, Henneberg M, Henneberg RJ, 2002 Reconstructing Medical Knowledge in Ancient Pompeii from the Hard Evidence of Bones and Teeth. In: J Renn, G Castagnetti (eds) Homo Faber: Studies on Nature. Technology and Science at the Time of Pompeii, “L’ERMA” di Bretschneider, Rome, pp.169-187.
  3. Origins of Syphilis
  4. Baker, et al.
  5. http://www.newscientist.com/article/dn13186-columbus-blamed-for-spread-of-syphilis-.html
  6. http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000148
  7. ref:225 Crosby
  8. ref:225 Crosby
  9. 9.0 9.1 9.2 [1] John Lobdell and Douglas Owsley, Journal of Sex Research, August 1974, Vol. 10:1 pp. 76-79. Accessed via JSTOR August 5, 2007.
  10. Oriel, J.D. (1994). The Scars of Venus: A History of Venereology. London: Springer-Verlag.
  11. Diamond, Jared (1997). Guns, Germs and Steel. New York: W.W. Norton. p. 210.
  12. Johannes Stradanus undated brief review of works hosted at the University of York in the United Kingdom. Accessed August 6, 2007.
  13. Jan van der Straet's "Preparation..." at commercial art site. Accessed August 6, 2007.
  14. :wikisource:es:Historia de la vida del Buscón: Libro Primero: Capítulo III: continues with [...] porque se le había comido de unas búas de resfriado, que aun no fueron de vicio porque cuestan dinero;: "[...] because it had been eaten by the bubons of a cold, which were not of vice because they cost money;".
  15. "O Misterio da Estrada de Sintra".
  16. http://www.ucolick.org/~randi/aecom/syphilis.txt
  17. "The magical properties of Mercury, the metal the EU wants to ban". Text " the Daily Mail " ignored (help)
  18. Brown, Kevin (2006). The Pox: The Life and Near Death of a Very Social Disease. Stroud: WSutton. pp. 85–111, 185–91.

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