GROUP 1 Reading Questions

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A quick overview of Syphilis through mid-20th Century (collated by Beth Hutchison)

The first definitive appearance of the disease we now call syphilis dates to the mid-1490s, when King Charles VIII of France led 50,000 soldiers into northern Italy. The soldiers were mostly mercenaries – Flemish, Gascon, Swiss, Italian, and Spanish, accompanied by 800 camp followers including cooks, medical attendants and prostitutes. After an extended siege, the successful invaders celebrated their occupation of the city-state of Naples, and soon exhibited signs of a horrible new disease. Too sick to bear arms, they retreated to France in disarray, and soon after most returned to their homes.

Centuries later, Voltaire noted “On their flippant way through Italy, the French carelessly picked up Genoa, Naples and syphilis. Then they were thrown out and deprived of Naples and Genoa. But they did not lose everything – syphilis went with them.” Sure enough, the epidemic quickly spread from France, Switzerland and Germany to England and Scotland and then to Scandinavia, Hungary, Poland, Russia and Greece. Thanks to European exploration, syphilis reached the port of Calcutta in 1498, by 1520, Africa and the Near East, China, Japan, and Oceania.

From its first appearance in Europe, the pestilence was seen as divine punishment with prayer the cure. As early as 1495, the Holy Roman Emperor Maximilian I declared that this uniquely horrifying disease was God’s punishment for blasphemy.

In its early European form, raw, pus-filled syphilitic sores covered people’s bodies (note the sufferers on the left side of Fig 1, the right and lower center of Fig 2); flesh fell from people’s faces and death followed within a few months. In its advanced stages, syphilis attacked both flesh and nervous system: “It ate away the nose and half the face” wrote one witness; pustules and ulcers “gnawed away as far as the marrow” (from The Dancing Plague by John Waller, 2009).

Figure 1 (Left) Prayer to St. Minus against Pox mala frantzoza (syphilis). Praying women (on right) Drawn by Wolfgang Hamer, Nuremberg.

Figure 2 (Right) Infected women praying,

male corpse in foreground.

Both woodcuts from Graphische und typographische Erstlinge der Syphilisliteratur aus den Jahren 1495 und 1496; Credit: Wellcome Library, London

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Syphilis first appeared as genital ulcers, followed by fever, rashes and joint and muscle pains. Weeks or even

months later, large, painful and foul-smelling abscesses and sores appeared all over the body. Severe pain in muscles and bones tormented sufferers, particularly at night. The sores frequently developed into ulcers that weakened bones and attacked noses, lips, and even eyes. It appears from descriptions by scholars and from woodcut drawings at the time that the disease was much more severe than the syphilis of today: along with its higher and more rapid mortality, it was more easily spread, possibly Europeans had no immunity against the new disease.

Descriptions from contemporary woodcuts and subsequent scholarship suggest that the disease was more virulent in those first several decades: it was more easily spread, the postules were more evident and repellent, and the disease resulted in faster and higher proportions of deaths among those infected. However, in less than 100 years, the bacterium evolved to the stealthier form known today, where initially minor symptoms may appear and disappear without treatment (or despite quack treatments), with severe forms of physical and neurological damage only revealed after decades of infection.

The following illustration and discussion are based on the abstract of CT Eisler’s article, “Who Is Dürer’s

‘Syphilitic Man’?” (Perspectives in Biological Medicine Winter 2009; 52[1]:48-60), which supports the thesis that the disease was spread in part by soldiers engaged in conflicts across Europe in the late 15th and early 16th centuries.

Syphilis was probably brought by from the New World to Naples in the 1490s and was then transmitted throughout Western Europe by Northern mercenaries (Landsknechten) returning from armed conflict in Italy to their native Germany and Switzerland.

The German artist Albrecht Dürer had ample opportunity to study such mercenaries during his journeyman years in present-day Switzerland and Strasbourg, since most of them came from those impoverished territories. Among Dürer's first known woodcuts is the earliest depiction of an individual suffering from this illness. His “Syphilitic Man” wears the clothes of a Northern mercenary; the coats of arms by his head refer to Nuremberg, a city in Bavaria (southern Germany).

Thus, the image is not only the earliest image of a person with syphilis, but also implicates itinerant soldiers in spreading the disease. The image itself proposes an astrological connection by alluding to the appearance of the sun, moon, and four planets in Scorpio in 1484 (depicted in the illustration of the scorpion above the first 4 in the celestial sphere above the man’s head).

BH note: The currently prevailing scientific opinion is that the bacterium causing syphilis evolved from the version carried by Columbus and his crew back to Europe. For the last couple of centuries, the initial presentation has been much less prominent than the oozing, body- covering boils depicted in the 15th century images on this and the previous page.

Albrecht Dürer, Syphilitic Man (Darstellung eines Syphilitikers), 1496

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Although a number of treatments were proposed, no effective cure was identified until the early 20th century.

Figure 3: A physician examines a woman’s urine for signs of disease while another applies a salve to sores on her husband’s leg.

Earliest known medical illustration of people with syphilis being treated by doctors, Vienna, 1498; http://en.wikipedia.org/wiki/Syphilis

From Bill Bryson's book At Home: A Short History of Private Life (NY: Anchor Books, 2010, pages 391-393):

There was, it must be said, one very sound reason for being fearful of sex in the premodern era: syphilis. There has never been a more appalling disease, at least for the unlucky portion who get what is known as third-stage syphilis. . . . To many, it seemed a clear message from God that sex outside the bounds of marriage was an invitation to divine retribution.

. . . As early as 1495, just three years after the voyage of Christopher Columbus that introduced it to Europe, some soldiers in Italy developed pustules "like grains of millet" all over their faces and bodies, which is thought to be the first medical reference to syphilis in Europe. It spread rapidly--so rapidly that people couldn't agree where it came from. The first recorded mention of it in English is as "the French pox" in 1503. Elsewhere it was known as the Spanish disease, the Celtic humors, the Neapolitan pox, or perhaps most tellingly, "the Christian disease." The disease name comes from a poem by [the Italian writer] Hieronymus Francastorius in 1530. In [his] poem “Syphilis Sive Morbus Gallicus” (“Syphilis or the French Disease”), the shepherd who contracts the disease is named Syphilis. However, the term syphilis does not appear in English until 1718.

Syphilis was for a long time a particularly unnerving disease because of the way it came and went in three stages, each successively worse than the last. The first stage usually showed itself as a genital chancre, ugly but painless. This was followed some time later by a second stage that involved anything from aches and pains to hair loss. Like first-stage syphilis, this would also resolve itself after a month or so whether it was treated or not. For two-thirds of syphilis sufferers, that was it. The disease was over. For the unfortunate one-third, however, the real dread was yet to come. The infection would lie dormant for as long as twenty years before erupting in third-stage syphilis. This is the stage nobody wants to go through. It eats away the body, destroying bones and tissue without pause or mercy. Noses frequently collapsed and vanished. (London for a time had a "No-Nose'd Club.") The mouth may lose its roof. The death of nerve cells can turn the victim into a stumbling wretch. Symptoms vary, but every one of them is horrible. Despite the dangers, people put up with the risks to an amazing degree. James Boswell contracted venereal diseases nineteen times in thirty years.

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Treatments for syphilis were severe. In the early days a lead solution was injected into the bladder via the urethra. Then mercury became the drug of choice and remained so right up to the twentieth century and the invention of the first antibiotics. Mercury produced all kinds of toxic symptoms-- bones grew spongy, teeth fell out--but there was no alternative. "A night with Venus and a lifetime with Mercury" was the axiom of the day. Yet the mercury didn't actually cure the disease; it merely moderated the worst of the symptoms while inflicting others. [end of quotes from Bryson]

By at least 1527, the connection between syphilis and sexual activity had been noted when the term Morbus venerus, or ‘ venereal disease’ was introduced in the book New Litany of Penitence by Jacques de Bethencourt, who rejected the term

morbus gallicus (the French illness), proposing instead that “since the disease arises from illicit love it should be called the

malady of Venus or venereal disease.”

There was no conclusive treatment for syphilis for several centuries. Then in the early 20th century, German physician and researcher Paul Ehrlich had a breakthrough while trying to find a cure for sleeping sickness. As reported in "Ehrlich Finds Cure for Syphilis 1909" (PBS A Science Odyssey: People and Discoveries; http://www.pbs.org/wgbh/aso/databank/entries/dm09sy.html):

He found that a chemical called Atoxyl worked well but was a fairly strong arsenic compound, and arsenic was poisonous. Ehrlich began an exhaustive search for an arsenic compound that would be a "magic bullet": kill the microbe but not the person with the disease. In 1909, after testing over 900 different compounds on mice, Ehrlich's new colleague Sahachiro Hata went back to #606. It didn't do much for the sleeping sickness microbe, but it seemed to kill another (recently discovered) microbe, the one which causes syphilis. At that time, syphilis was a disabling and prevalent -- though little talked about -- disease. Ehrlich and Hata tested 606 over and over on mice, guinea pigs, and then rabbits with syphilis. They achieved complete cures within three weeks, with no dead animals. In 1910 the drug was released, called Salvarsan, or sometimes just 606. It was an almost immediate success and was sold all over the world. It spurred Germany to become a leader in chemical and drug production. And it made syphilis a curable disease.

Salvarsan and its successor, Neosalvarsan, weren't always effective in late-stage syphilis. Only the use of penicillin (first discovered in 1928, used to treat syphilis since the 1940s, especially post-WWII) made syphilis truly curable--especially in the early stages, before irreversible damage occurs. Nevertheless, the disease has not been eradicated.

After 1906, the availability of the Wasserman test, a fairly reliable blood test for syphilis, led to a wider awareness of the prevalence of the disease in the U.S. which spurred attempts to combat it, first among

servicemen in WWI, then in peacetime. At the same time, development and provision of effective

treatments for syphilis had long been controversial because of the perception that a widely available cure would encourage “immoral” behavior without consequences. [Named after its inventor, the Wasserman] test was sufficiently familiar to American movie audiences that the 1934 exploitation film The Road to Ruin simply showed a card with a positive Wassermann test (misspelled in the film) without any further explanation to indicate a character had contracted syphilis. (Image and text from Wikipedia; https://en.wikipedia.org/wiki/Wassermann_test)

(text on card from The Road to Ruin: Eve Monroe, “Sex Delinquent,” has had a positive Wasserman result and is “to be held for treatment.”)

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The Wasserman test was first required in Connecticut as a precondition for issuing a marriage licenses; by 1938 over half the states required Wasserman test results (both parties had to be tested and found negative). However, some 2 to 14% of Wasserman test results were false positives--preventing uninfected people from marriage, and often ruining their lives due to the unfounded “evidence” that they had contracted a sexually transmitted infection.

Image from No Magic Bullet: A Social History of Venereal Disease

in the United States by Allan M. Brandt (Oxford, 1987)

The National Venereal Disease Control Act of 1938 unleashed the

powers of the federal government, from public education via posters to public health treatment, to fight syphilis. The image below is just one of many public health awareness posters produced as part of the campaign.

However well-intentioned this public movement to identify and understand syphilis may have been, it also led to the infamous Tuskegee Syphilis Study, which began in 1932-- before there was an effective treatment for late-stage syphilis- -but ended only in 1972, after hundreds of black men (and in some cases, their wives, and children born with congenital syphilis) had been exploited as medical guinea pigs, decades after penicillin was recognized as a cure for syphilis.

Although they received some free medical care, meals and burial insurance, the study participants were never told they had syphilis, nor treated for it. Lacking informed consent of their diagnosis and deprived of penicillin treatment, which had been used against syphilis since the early 1940s, the men were “studied” as they endured the progression of the disease through disfigurement, physical and mental incapacity. Their symptoms were simply tracked and noted, even though no new meaningful knowledge resulted from the inhumane “research,” which ended only after information was leaked to the press. (More on this in “Ethical Lapses” in this section of readings.)

The public outrage over the tragedy of the Tuskegee study was foundational to the principles of informed consent which guide research today. The ramifications of the outrage about this and other exploitive studies can also resulted in the system of research checks and balances know as IRB,

Created/Published: Rochester, N.Y.: WPA Federal Art Project,between 1936 and 1938. Creator: Hans Erik Krause, born 1899, artist. Repository: Library of Congress Prints and Photographs Division Washington, D.C. 20540 USA

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(Institutional Review Boards, mandated by the federal government and operating in universities and other research facilities). For research studies involving human subjects (including interviews), students and professors must document the research methods, any predictable impact on participants, and receive formal permission before beginning the research.

WWII-era Posters

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Today, syphilis is understood as a sexually transmitted disease caused by Treponema pallidum, a spirochete bacterium. It is sometimes referred to as “the great imitator” because many of its symptoms are indistinguishable from those of other diseases. Disease transmission results from direct contact with the mucous membranes and, during the early stages of infection, moist lesions of the skin of infected people, most often during sexual contact. Exposure can occur from oral, anal, or vaginal intercourse. People with syphilis are at greater risk for HIV infection through the genital ulcers (open sores) characterizing syphilis.

Primary syphilis is the first and most infectious stage of the disease. A chancre or moist, open sore will appear at the spot where the spirochete entered the body. This firm, round, small, painless ulcer appears 10 to 90 days after exposure (usually about 3 weeks after exposure). After 3 to 6 weeks, the ulcer will heal whether or not it is treated; but the underlying infection will remain without treatment. Syphilitic rectal, cervical, or oral chancres are often not noticed, increasing the risk of spreading infection and of not realizing that treatment is necessary.

Without treatment, primary syphilis will progress to secondary syphilis, which is characterized by a skin rash and mucous membrane lesions. The skin rash usually occurs within 4 weeks after the chancre has healed and typically takes the form of rough, reddish brown spots on the palms of the hands and the bottoms of the feet. Headache, muscle pain, sore throat, patchy hair loss, fatigue, weight loss, fever, or rashes may occur. These will spontaneously resolve over a period of weeks, even if not treated. Transmission can occur at this stage if there are moist lesions. If untreated, secondary syphilis will evolve into latent syphilis, in which there are no signs or symptoms, but the person will be test positive for syphilis.

Congenital syphilis—when the fetus is infected in utero—occurs with high frequency when pregnant women have untreated early syphilis and often results in unintended abortion or stillbirth. Preterm birth due to low birth weight or generalized disease may also result in infant death. Infants born with congenital syphilis may also have central nervous system anomalies.

The post-WWII history of syphilis in the US is marked by cycles of increased and decreasing rates of infection. Whenever decreasing levels of infection seemed to indicate the possibility of eradicating syphilis as a public health concern, diagnosis rates have rebounded, leading to the increasing rates of infection seen today. More on that in the next set of STI/STD readings later in the term.