prof: welcome back. and what i want to do thismorning is to be cognizant of the fact that you have,as you all know, the hour exam later this week. it's in a different format,and i've written to you about that. because of that,what i thought would be useful to do this morning would be tohave something of a review session,in which we make explicit some
of the ways in which it's usefulto think about epidemic diseases,and in which we go over some of the terrain that we've coveredthus far in the semester. at the same time,i want to talk about-- introduce a new and importantdisease, which is syphilis,and provide a bit of background for the book that you're readingthis week, which is allan brandt's nomagic bullet. and you'll be wanting to know,well where did syphilis come
from, what's the historicalbackground? so, i'm going to try tointroduce that, while going over some of theissues that we've already presented. you'll find a lot that'salready familiar this morning, as we go back in time,covering major issues that we've dealt with. and i hope, at the same time,to be introducing something new, which is syphilis.
so, we'll look at the periodwe've covered in the course, through the lens of syphilis. that's the direction in whichwe're headed. now, in order to talk about avariety of epidemic diseases and their impact,we ought to have some comparative questions that wemake explicit. that is, what is it that weneed to know about each of the diseases that we're talkingabout? what are the crucial aspectsthat make it a transformative
force or not? what are the historicalvariables? i have a sort of suggestion ofmaybe ten major questions that we ought to be thinking aboutwith regard to each of the diseases that we examinethroughout the semester. a first one is--thesequestions, by the way, are not canonical. i don't mean that you shouldn'tbe asking other questions as well, and indeed i hope youwill.
but i think we should know atleast the answers to these ten questions and then build on thatas a foundation. the first major question,for any of the diseases we're talking about,was what's the total mortality and morbidity that's caused bythe epidemic in question? the mortality,the total numbers of deaths. morbidity, the total number ofcases. that's an important factor thatneeds to be taken into account in assessing the impact of theepidemic.
a second question has to dowith a term we introduced long ago, a phrase,which was the case fatality rate. and a related question withthat is, is there an effective therapyor means of prevention, or instead does a societyexperience the disease in feeling itself to be helpless,and physicians feeling the same? the case fatality rate is--wecould call it the kill rate of a disease, the percentage of casesthat terminate in death.
and we know that,for example, in dealing with plague,one of the features of it--and asiatic cholera as well--was a very high case fatality rate,of plague, fifty to eighty percent,cholera, something like fifty percent. at the other extreme,when we come to it, we'll see that influenza has avery high morbidity, but quite a low case fatalityrate,
and that's related,i think, to the impact that that disease,influenza, has on society, which isn't associated withsuch terror as say plague or cholera. that's an important variable,the kill rate of the disease. another factor,a third question we need to ask, is what's the nature of thesymptoms of the infectious disease in question? are they particularly painful?
are they degrading,according to the norms of the time? and we've seen,for example, in dealing with plague andcholera that a major feature about them was that theirsymptoms were agonizing and dehumanizing. clearly, as we turn tosyphilis, its symptoms also were extremely important in the waythat the disease was experienced.
tuberculosis,on the other hand--and we'll be looking at that--was seen, at the time, to make its sufferers moreintelligent, more romantic,more beautiful in some sense, at least in the first half ofthe nineteenth century. so, that--what is the nature ofthe symptoms, is a crucially importantquestion. another, fourth question,that i hope you'll bear in mind throughout the course,and in your review for the
exercise this week,is the question, is this disease new,or is it familiar to the population? familiar diseases tend not tobe so terrifying. the population is also likelyto have some degree of immunity to the disease,and the disease is likely, or may have,already mutated to become less deadly. examples are the so-calleddiseases of childhood,
like chickenpox,mumps and measles; normally relatively mild,but in populations to which they're newly introduced,they can be devastating. a fifth question has to dowith, what's the profile of the victims of the disease? is this a disease that's anaffliction of the young and the elderly;that is, experienced as a more normal course of a disease,in accord with society's expectations and pastexperience?
or does it instead strike downparticularly those who are in the prime of life,thereby no longer seeming natural but as somethingextraordinary in the experience of the population? and it also means that thedisease is likely to maximize its economic and financialimpact, to be particularly destabilizing to a community. cholera, in this regard,for example, was terrifying because of theway in which it seemed to
afflict those who were thebulwarks of families and of communities. a sixth question that'simportant: what's the class profile of the sufferers? what sorts of people in societyare stricken with the affliction? is this a disease of poverty,such as cholera is usually thought of? or is it an affliction thatstrikes everyone,
without particular reference toclass or social and economic status, like influenza orsyphilis, indeed? a seventh important question iswhat is the mode of transmission of the disease? is it transmitted person toperson? is it transmitted bycontaminated food and water? are vectors involved? is it spread through the air bydroplets? is it spread by sexual contact?
and clearly,i think we'll be arguing that the mode of transmission isreally crucial, and in sexually transmitteddiseases i think that that is fairly self-evident and a veryimportant factor in the social impact of those diseases. an eighth important question iswhether the disease is fulminant in its course,or is it slow acting and a wasting disease? if we look, for example,at cholera, one of the
features, and a striking one,is that it was one of the most fulminant of diseases. it would strike down asufferer, and you could board a train and die before you reachedyour destination, as the disease ran its coursethat quickly through the human body. or, on the other hand,is the disease one that takes years, perhaps even decades,to run its course? and an example of that,of course, would be
tuberculosis or hiv-aids,in our own time. a ninth important question weneed always to bear in mind is how is the disease understood bythe population that it's infecting? is it seen as a punishment ofgod? is it later on thought to besomething that comes from the dangerous classes? or later on,is it understood to be a microbial infection?
and those ways in which thedisease is understood have enormous impact on how thepopulation reacts to the disease. a tenth variable is what's theduration of the epidemic? influenza, for example,passes through a locality in a matter of weeks,normally. cholera or plague tend to haveepidemics that last for months. and tuberculosis,one might describe as an epidemic in slow motion thatafflicts a community for a whole
century or more. so, those are ten majorquestions that i hope that you'll be bearing in mindthroughout the course. i think they'll help you indealing with the diseases in a comparative manner,and finding out and teasing out why some diseases have an impactof one kind, and others are very different. well, this morning i'd like togo through some of this material again, in a review manner,by looking at syphilis.
why syphilis at this stage ofthe course? i think that it providesbackground for no magic bullet,and it also helps us to look at some of the material that we'vealready covered, and that you'll be writingabout in the next few days. well, first let's deal thenwith the chronology, and this helps us to step backin time from the nineteenth century;to go back, indeed, to the plague years.
syphilis, in fact,was contemporary in its onset with plague,and like plague, at the time it was a newdisease that first struck europe,in this case, in the late 1490s. and we'll see that there's animportant darwinian evolution that takes place,which is to say that the syphilis of the fifteenth andsixteenth centuries is quite different from syphilisthereafter. syphilis in its first centuryor so was what we might call the
"great pox,"a disease that was much more severe than modern syphilis. so, syphilis clearly begins asa dreadful epidemic that swept europe and then the world. after the sixteenth century,it's still a very serious illness, but it's much milder,less fatal and less agonizing. today we're going to dealprimarily with the early syphilis, the syphilis of thegreat pox. now, the mode of transmissionis clearly important,
and we need to examine what arethe particular features of stds, of sexually transmitteddiseases. among the venereal diseases--touse an older term-- syphilis was king from thefifteenth century until the late twentieth,when there was the appearance of a much more threateningcompetitor, hiv/aids. and in more recent times,after world war ii and the introduction of the era ofantibiotics--
particularly penicillin--andsex education, there's been a radical declinein the incidence of syphilis. and for a time there were evenheady hopes that it could be eradicated altogether. but most recently,unfortunately, it's made something of acomeback. now, keep in mind,too, that historically the stds weren't carefully distinguished,one from another. until late in the nineteenthcentury, other significant
stds--gonorrhea and chancre,in particular--weren't known to be separate diseases. they were thought to be simplymilder manifestations of syphilis. so, there was,we might say, a unicity theory of thevenereal diseases; there was thought to be onedisease. a reason for dealing withsyphilis now, at this point in the course,is that it had a significant
impact on medical science,in ways that we've already touched upon with regard tobubonic plague. that is to say,like plague, syphilis seemed clearly to becontagious, and it was understood,from the beginning, to be spread somehow--no onequite knew how-- through sexual contact. and, so, like plague,syphilis challenged the reigning orthodoxy ofhumoralism,
and gave rise through someonewe've already met, and we can look at again in amoment, through girolamo fracastoro,in particular, to the doctrine of contagion. and it generated also the ideathat disease might be a specific entity. syphilis was clearly somethingdistinctive, and many people regarded it as a disease on itsown, rather than an example of humoral imbalance.
so, syphilis had an impact onmedical science and influenced, along with plague the--if welike, began to make humoral doctrine less stable at itsfoundations. well, where does syphilis comefrom? what are its origins? and here there's a majordebate, that has not been resolved, and it continues downto this day. i'll put forward a couple ofcandidates. and i think it's more importantto note these different origins,
theories of the origins ofsyphilis, because they have a big impacton how the disease is rather than expecting us toresolve the issue of where the disease came from in fact,let's note how people thought the disease appeared. a first theory was the oneassociated with christopher columbus. this is the americanist idea ofthe origins of syphilis. and we've talked already aboutthe columbian exchange.
so, i just wanted to reviewthat again. that's columbus's first trip,and this is the idea of the columbian exchange,of what was transmitted from the old world to the new,the old world contributing various foodstuffs,like coffee beans and rice, livestock--cows--and various diseases; as you already know,smallpox, measles and so on, and the new world being thesource for europeans of corn, potatoes and so on,certain precious metals,
tobacco. and there is the idea that theamericanists--so called--argued that it was columbus and hiscrew who brought back syphilis from the new world. this idea held that syphiliswas endemic in the new world, spread to columbus's sailors,and was reported to europe on their return. the problem,of course, for the theory, is that there isn't,in fact, any definitive
evidence that syphilis did existin the new world at the time, or that columbus's sailors wereactually infected in the manner required by the theory. so, the evidence in support ofthis is entirely circumstantial. the chronology works. that's one factor. and another is that thereisn't, in fact, in the medical literature,before this time a disease like syphilis anywhere in europe.
and more recently,paleopathologists haven't unearthed evidence of syphilisin european cemeteries. it clearly seems to be adisease that was a new--or let us use an anachronistic term--anemerging disease in the 1490s. and because of eurocentrism,and perhaps xenophobia, there was a preference to blamethe other. a second idea that was verypopular was that syphilis, instead of being of american ornew world origins, was of spanish or africanorigin.
this theory held that perhapsthe disease was present in europe for a long time,but had been confined to a small corner of the continent,perhaps--and one can see certain sinister views here--confined perhaps to jews, or moors in spain,and unnoticed by outsiders. then with the expulsion of thejews in the 1490s, the disease was disseminatedacross europe. now, among those who propoundedthis view, there was clearly a current of racism,anti-semitism and xenophobia.
syphilis was supposed to havebeen endemic among the jews, having come perhaps earlierfrom africa, and was prevalent in thosepopulations because their sex in some way was unnatural and outof control. so, syphilis was confined ineurope to spain, this theory argues,until the expulsion of the jews in 1492,when they unleashed their contagion on the rest of europe. in any case,what's really clear is that
absolutely no one wanted toacknowledge syphilis as his or her own. for italians,syphilis was somebody else's, it was the french disease. for the french,it was the neapolitan disease. for russians,it was the polish disease. and for everyone,it was the great pox, or the clap. now, how do we get the termsyphilis, where does that come
from? the word itself was coined bythe italian physician, whom you've already met,fracastoro, who did something extraordinaryin 1531, which was that he wrote a workcalled syphilis. and here was fracastoro,whose face you've seen again. now, this work was odd,or unusual, in a number of respects. it was a poem,written in latin,
and modeled on virgil. and, as i think about it,i can't think at the moment of another poem about an epidemicdisease. it was also an instant success. it rapidly went through lots ofeditions, and established fracastoro's fame,even more than his more scientific works. it also offered what i think wecould say was a clearly moralizing, judgmental analysisof this disease as a scourge of
god. you know the drill by now. in the poem,the first victim of the disease was a shepherd whose name wassyphilis. and the shepherd had offendedthe gods by turning against them and worshipping a king as adeity. so, in their anger,the gods afflicted syphilis with this terrible pox. we can see that built into it,from the beginning,
was the idea that syphilis wasbest understood as the wages of sin. and there's a further polemicalthrust that's not made explicit but is a subtle undertow in thepoem. remember, the poem was writtenin the 1530s, in the midst of a religiousschism with martin luther, a devout adherent oforthodoxy--that is, fracastoro was--and of thecatholic church. he was a physician to bishops,archbishops and cardinals.
and syphilis,as i've said, was a shepherd,and in latin the word for shepherd ispastor. the man who was punished was apastor, not a priest; that is, possibly a protestantleader. so, there's a sly hint herethat syphilis, the disease,is a divine punishment for the reformation. so, fracastoro didn't adhere tothe americanist position.
then there's perhaps a thirdmore modern idea, or hypothesis,is that perhaps the causative agent of syphilis emerged in adarwinian manner; the spirochete or treponemapallidum, arose perhaps as a mutation ofsome pre-existing treponemes that are morphologically verysimilar under the microscope, and perhaps it was--it emergedas an evolution from the treponeme that causes yaws. in any case,it was clear that whatever the
site of its origin,it spread across europe with terrifying rapidity. one can see the role ofwarfare, in particular, in promoting the movement ofsyphilis. and its spread across europewas closely associated with charles viii of france,known as charles the affable, who lived from 1470 to '98,and launched a series of wars with italy,which he invaded in 1494, at the head of a large,large army.
the army marched across theitalian peninsula and reached naples, that charles besiegedand captured. he then found himself facing apowerful coalition of powers that have ultimately defeatedhim. and after his forcedwithdrawal--the point is that his army disbanded. and this was a large army,a mercenary force of tens of thousands of men from variousnationalities. a feature of war is that it'salways a providential time for
epidemic disease,and sexually transmitted diseases in particular. the army of charles viii waspoorly disciplined. it indulged in pillage,plunder and rape, and it had its numerous campfollowers of beggars and prostitutes. so, among the troops,and those who consorted with them, the disease flared up. and after their disbanding anddemobilization,
it was disseminated across thecontinent. between 1495 and 1520,something frightful happened as the epidemic swept europe fromnaples to moscow; to oslo, madrid,london, and every place in between. so, this is the origin ofsyphilis. however it arose--whether itwas imported, whether it was a newly emergingdisease, perhaps a mutation from yaws,from a disease already present
in europe--it was clearly spread by this favorable opportunity of warfareand the army of charles viii. well, what's the etiology andsymptomatology of syphilis? and here, this is the causativeagent, the treponema pallidum,or spirochete. this, the treponemapallidum, has a special feature,in that it's exquisitely fastidious and fragile,and re quires very precise conditions in order to live.
it cannot survive outside ofbodily fluids and the warmth of the human body,and therefore it can only be transmitted by intimate contact. indeed, the spirochete is sodelicate that it can hardly be cultivated in vitro,and that's one of the reasons that the development of avaccine has proved so difficult. well, there's an initialincubation period with syphilis, and we'll talk about threestages in its impact on the individual human body.
the first stage--and we'retalking now about the great pox, this early stage in the historyof syphilis-- the first stage lasted a monthor two, and was marked by a painful andalarming chancre at the site of entry of the spirochete into thebody. but this chancre healsspontaneously, just like lesions in chickenpoxor herpes. but that doesn't mean that thepatient is cured. the disease in fact persists,but for a time without
generating symptoms. then there's the onset of thesecond stage of syphilis, between forty-five days afterthe disappearance of the chancre and a year. there are numerous symptoms,but in the second stage of syphilis only the superficialtissues of the skin are affected, with rash and boils. now, it was this second stageof syphilis that was of extraordinary severity duringthe era of the great pox.
it was painful,disfiguring, incapacitating and often fatal. there were sores and swellingsall over the body, from the soles of the foot tothe crown of the head, leaving disfiguring scabs andpockmarks. worse, the disease wasdescribed as attacking the whole of the body. it was said to eat it away andconsume it. the body stank,and the sufferers were
afflicted,in addition, with fever and pain in theirjoints, so intense, one contemporarywrote, that the victims screamed dayand night, envying the very dead. let's listen to fracastorohimself, who described the great pox like this. he wrote--remember,he was a physician as well as a poet--"in the majority ofcases, small ulcers began to
appear on the sexual organs. they were intractable and wouldnot depart. next, the skin broke out withencrusted pustules. they soon grew,little by little, until they were the size of anacorn; which they in fact resembled. then these ulcerated pustulesate away the skin and sometimes infected not only the fleshyparts, but the very bones as well.
in cases where the malady wasfirmly established, in the upper parts of the body,the patient suffered from pernicious catarrh that erodedthe palate, or the pharynx and tonsils. in some cases the lips,the nose and eyes were eaten away, or in others,the whole of the sexual organs. moreover, many patientssuffered from the great deformity, or gummatathat developed. besides all of the abovesymptoms, as if they were not
bad enough, violent painsattacked the muscles. these pains were persistent,tormented the sufferer chiefly at night, and were the mostcruel of all the symptoms." there is a theory that maybeeven the disease was too virulent for its own good,that its symptoms were so debilitating as to preventsufferers from transmitting it, and so the modern diseaseevolved during the sixteenth and seventeenth centuries as amilder form of the great pox. i'll show you a couple ofimages of extreme forms of
modern syphilis,that's said to give us some idea of what the great pox waslike. they're rather,of course, unpleasant slides. so, i would tell you that inadvance. but this will give you someidea of how terrible the great pox was. it looked like that,or indeed like that. we'll move on. then there's third-stagesyphilis, tertiary syphilis,
and in this phase you haveinvolvement of the deep tissues. and its symptoms are thingssuch as what's called tabes dorsalis,which is a degeneration of the neurons in the spinal cord,and leads therefore to lack of coordination,to a stumbling gait, and symptoms of that kind;to ataxia, which means the stumbling gait. it also leads,in this phase, to cardiovascular disease,often to insanity and dementia,
to general paralysis,and to death. so, tertiary syphilis can bethe cause of death. what were--if that's what thedisease looked like--what were some of its effects on society? well, because of its mode oftransmission, syphilis was associated withterrible social effects, with anxiety,guilt, pain, broken relationships,breakdowns in trust within families,infertility among women.
and like the plague,and unlike some of the diseases that we'll be studying,syphilis was no respecter of persons, of social class orstatus. we might perhaps ironicallycall it a democratic disease, in that it afflicted everyone,from the bottom of the social scale,to aristocrats, learned professionals,kings, cardinals, bishops, occasionally evenpopes, such as julius ii,who was also a syphilitic.
so, accordingly,one might argue, syphilis caused a great strainon society, but not along the fissuresrunning between classes, as did, for example,asiatic cholera. it was also unlike plague inthat it was not terrifyingly swift, and its obviousassociation with sex meant that the means to avoid it wereclear. and so there was no generalizedterror, of the kind that accompanied say bubonic plagueor asiatic cholera.
everyone knew how syphiliscould be avoided. what were the effects on then? one was a new asceticism. there was a suspicion ofpleasures. in the protestant world,an epidemic of syphilis was perfectly timed not to create--and here i don't want to be saying that epidemic diseasescreated puritanism; i would argue instead simplythat this is a disease that reinforced it.
asceticism indeed had long beenpresent in european culture, but syphilis helped make itmore popular and a widely held sentiment. in the catholic world,one can see a new piety as well, in the catholicreformation, in jansenism, for example. another impact clearly was interms of tensions between the sexes. now, this is familiar to you;we're going back over old
ground in our course. remember paintings that we sawearlier of the garden of eden and origin sin,adam drawn into evil by his helpmate eve,the original temptress. well, the passage of syphiliswas marked by a sinister undertow of misogyny. in a patriarchal society,male fears, anxieties, and indeed guilt,were projected onto women, who were seen as the crucialagents in the spread of this
disease to men. and two groups of women wereparticularly suspect, prostitutes first. and here was a prime example ofa new male double standard. the passage of syphilis wasmarked by harsh police measures against prostitutes,including the closing of brothels and the rounding up andexile of people from there was also a hunt forscapegoats, and witch hunts were part of that.
another feature was a newreligious cult; the cult, in particular,of a new saint. and this is rather unique,which is there's only, as far as i know,one saint who wasn't a christian,and this is job, from the book of job in the oldtestament. job, however,was actually said--in the book of job, he had an especiallyconvincing defense attorney, and that was god himself.
because god says in the book ofjob that this is the most just of all men, he's the best andmost innocent. and yet to try his faith,he was scourged by satan. this is a painting by williamblake of this scourging of job by satan, who's pouring outboils that will soon torment him from head to foot. and the description of thedisease that afflicted job, in the book of job,is highly suggestive of what we might call a venereal disease orstd.
he was covered from head tofoot in boils. and yet job was reassuringlyfree from sin. we know that because god tellsus so. and, so, job became the patronsaint of syphilitics. there was also a public healthresponse; that is to say,the building of hospitals for the incurables,who were the syphilitics. and there was a newphilanthropy, and religious orders that tookover their care.
let's look for a moment at someof the treatment regimens that were also important in thisdisease. one was the beginning--itbegan, the most common treatment regimen,with a forty-day period, beginning with fasting,and then the administration of mercury,which had been used in the treatment of skin disorders overthe centuries, diseases such as scabies. so, mercury was sometimesapplied--it was applied in lots
of different ways. disparate remedies for adesperate disease. ointments were applied to theskin lesions. there was a so-called generalfriction in which applications of mercury were made to thewhole body. sometimes it was administeredinternally. but as you know,mercury is extremely toxic. it causes great salivation,the falling out of the teeth, and then serious and oftenlife-threatening symptoms.
but salivation seemed to be theright approach. according to humoralistprinciples, it would lead to an evacuation of the peccant humor. and it also--and here was afactor-- it seemed to work when appliedto second-stage syphilis, perhaps simply because,as we've already seen, second-stage syphilis goes intospontaneous and often lengthy remission. and it was possible to arguethat it was the therapy,
the treatment,that had been effective. and perhaps the suffering thataccompanied this particular treatment provided some moralsatisfaction to those who administered it. another remedy that was triedwas guaiac, which is a hardwood from a tree in the new world. it was ground into sawdust andmade into a decoction that patients drank twice a day forforty days. we see these forty daysappearing over and over:
in quarantine;the forty day fasting; the regimen for mercury;the regimen for guaiac. well, all of this,of course, had a religious background. and, so, the guaiac wasadministered for forty days, during which there was fasting. at the same time then--soguaiac and mercury were, so we might say,the miracle drugs, the wonder drugs of their era.
there were other indicationsalso recommended for syphilis: bloodletting,baths, purgation, cauterization of the boils. an important impact,then--the next thing i want to point out--is the impact ofsyphilis on medical science. we already--and this gives us amoment of review--we know already the traditional approachto these and other diseases; that they were an imbalance ofhumors. there had been no idea ofdiscrete entities that were
diseases. diseases were an individualmatter, depending on the constitution of the patient andthe environmental influences that acted on him or her. in the nineteenth century,however, we've seen already thatdiseases fully crystallized into forms of specific entities,that were actually biological entities that existed apart fromthe body of the individual sufferer.
the period from the 1490s tothe nineteenth century, the period that emplaced bothplague and the great pox, and then modern syphilis,marked an era of transition. and i would argue that syphiliswas something that propelled this transition forward. remember how traditionalmedicine, as taught at universities and practiced bythe elite physicians, was that the truth aboutdisease was to read the classics: hippocrates and galen,supplemented later,
in the middle ages,by astrology. so, for humoralist physicians,then, that was the way it waspreceded, and when syphilis first struck,there were disputations in which people sought the truth ofthe disease by looking through into hippocrates,or what galen had written. and so there were disputes,disputations that were formally held through library medicine. the challenge of syphilis wasthat it was a pandemic that was
difficult to explain within thetraditional framework of humoralism. at the same time,the disease had no real place in the classics. humoralism was static,and had no way of accommodating emerging diseases. so, what do you do with adisease that was unknown to the ancients? syphilis was also clearlycontagious,
everyone could see that,and so there was obviously some morbific substance that passedfrom one body to another. the disease,in other words, seemed to be somethingspecific; and this helped to promote alsothe idea of a new concept of and syphilis tried physiciansbecause it really was an incurable disease at the time,and until the late twentieth century didn't respond to theclassical recommendations for therapy.
all of this made it a majorchallenge to humoralist orthodoxy. and with that,i would say we've reviewed this period of syphilis and plaguethat presented a major impact on society,and a major impact on medical science. and we've run out of time thismorning. next time, having had ourreview session, we'll come back to thenineteenth century and deal with
the debate,the huge medical debate, between contagionists andanti-contagionists.