Thorns-o-Rose-art

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Thorns-o-Rose-art - 2/3/10

"Thorns on a Rose - The History and Historical Epidemiology of Syphilis in Renaissance Europe" by THLady Maimuna al-Bukhariyya.

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Mark S. Harris...AKA:..Stefan li Rous

stefan at florilegium.org

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Thorns on a Rose -

The History and Historical Epidemiology of Syphilis in Renaissance Europe

by THLady Maimuna al-Bukhariyya.

"… Christopher Columbus has discovered a continent, untold islands, uncouth savages, and treasures of gold and silver, but … the precious metals conceal a thorn." (Quétel, 1992, attributed to Gabriello Falloppio)

Abstract

The purpose of this research paper is to identify and discuss the history and epidemiology of syphilis during Renaissance Europe and compare Renaissance stages of the disease, disease prevention methods, disease transmission modes, and treatment protocols with those of modern-day medicine.

The origin of syphilis (or, venereal disease, as it was called in Renaissance Europe) has three separate theories. Regardless of the origins, the transmission of syphilis was a serious concern for sexual beings during the European Renaissance.

This research paper will focus, primarily, on the history and historical epidemiology of syphilis. There will be a brief discussion of modern-day syphilis, its epidemiology, disease prevention methods, disease transmission modes, and stages, with the purpose to compare the disease of antiquity with the disease of the modern-day.

History of Syphilis

Syphilis appeared in Europe in the 1500s. Syphilis was endemic (or prevalent) throughout Europe in the latter part of the fifteenth century (Holmes, et. al., 1999). Syphilis has gone by many names: the Venetian disease, the disease of Naples, the French disease, the French pox (Morbus gallicus), the Turkish disease, the Spanish disease, the Great Pox (Pusey, 1933; Quétel, 1992; Arrizabalaga, et. al., 1997, Rose, 1997; Clancy, 1999; Holmes, et. al., 1999; Hayden, 2004; Collier, 2007). Commonly, the other name for syphilis usually came from the "enemy" country, e.g., the English called syphilis the French disease. The Great Pox was termed as such to distinguish it from another scourge, smallpox (Holmes, et. al., 1999). The term "syphilis" came from a poem written by the Italian physician Fracastoro (Arrizabalaga, et. al., 1997; Collier, 2007).

There are three prevailing theories on the origin of syphilis, as a disease (Rose, 1997):

1. Columbus and his ships' crews transmitted syphilis to the European countries after his conquest/discovery of the New World.

2. Syphilis developed in both hemispheres from the related diseases, yaws and bejel.

3. Syphilis was always present in the Old World, but was not recognized as a separate disease until 1500s AD.

The first theory is that syphilis was localized to the New World and that Columbus and other New World explorers brought the disease back to the Old World upon their return (Pusey, 1933; Rose, 1997; Clancy, 1999; Holmes, et. al., 1999; Hayden, 2004; Karras, 2005; Rothschild, 2005; Collier, 2007; Harper, et. al., 2008). A key component to this theory is that syphilis was not documented or diagnosed in the Old World prior to the return of Columbus from the New World.

A second theory is that syphilis developed out of two related diseases: bejel and yaws (McNeill, 1977; Rose, 1997; Clancy, 1999; Rothschild, 2005). A related hypothesis posits that syphilis presented, originally as yaws, in northern Africa and migrated north into Europe with the slave trade and mutated into the disease commonly identified as the Great Pox. New World skeletons showing signs of yaws have been dated to 6,000 years old, whereas New World skeletons showing signs of syphilis have been dated to 800 to 1,600 years old. Syphilis has a more documentable movement from the New World to the Old World (Rose, 1997). Interestingly, the serology of syphilis cannot distinguish between the four different treponematoses (syphilis, yaws, bejel, and pinta) (Egglestone and Turner, 2000). Yaws, and bejel were treponematosic diseases that thrived in warmer climates (Holmes, et. al., 1999; Harper, et. al., 2008) and pinta is a treponematosic disease that is active in remote, rural areas of Central and South America (Holmes, et. al., 1999).

A related belief is that syphilis mutated into a sexually transmitted disease so that it could thrive in a colder, non-tropical climate (Arrizabalaga, et. al., 1997; Clancy, 1999). As posited by Harper, et. al. (2008), referring to the similarities between yaws, bejel, pinta, and syphilis, "the topology of the (phylogenetic) tree is consistent with the long-held belief that treponemal disease is very old and has traveled with humans during their migrations, evolving from ancestral subspecies endemicum as people settled in cooler and drier areas, and finally into subspecies pallidum."

Treponemal infections, including venereal syphilis and the nonvenereal treponematoses (such as yaws, bejel, or pinta) have similarities between the clinical manifestations of disease that are remarkable, presenting with initial lesions, then extensive secondary manifestations, and, finally, latency (Holmes, et. al., 1999).

The third theory is that syphilis was present in the Old World and was originally identified as leprosy and that, after 1500 AD, it was medically determined that syphilis and leprosy were two separate diseases (Rose, 1997; Clancy, 1999; Rothschild, 2005; Collier, 2007). Ancient and medieval sources indicate that returning Crusaders brought "Saracen ointment," which contained mercury, to treat lepers (which is now known as an appropriate treatment for syphilis, not leprosy) (Rose, 1997). Medical references from the thirteenth and fourteenth centuries identify treatments for "venereal leprosy" which is more likely syphilis, as leprosy is not a sexually transmitted disease (Rose, 1997).

Renaissance astrologers "claimed that a conjunction of Saturn and Jupiter at 6:04 PM on 25 November 1484 presaged this sexual plague. Unfavorably-placed Mars combined with Saturn to overcome Jupiter, they wrote; chaos on earth results, with floods, earthquakes, wars, famines, and the dreadful venereal plague" (Hayden, 2004; also paraphrased from Quétel, 1992, and Arrizabalaga, et. al., 1997).

Based on the lack of skeletal signs of syphilis in pre-Columbian Europe, some researchers support the first theory as the strongest theory around the origination of syphilis (Harper, et. al., 2008). The researcher supports this line of thought. There are archaeological finds that indicate pre-Columbian syphilitic damage from the New World (in the Dominican Republic [the former Hispaniola], Florida, New York State, Ohio, Alaska, New Mexico, Wisconsin, Ecuador, Michigan, and West Virginia) (Hayden, 2004; Rothschild, 2005). Rothschild, et. al. (2005), has asserted that there is an obvious "absence of skeletal evidence of any treponemal disease in continental Europe before the time of Columbus excludes (Europe) as site of origin of syphilis." It is Rothschild's assertion that the original treponemal disease spread from Africa through Asia, entering North America through the land-bridge and, eventually, it mutated into syphilis (Rothschild, et. al., 2005), following the assertions of McNeill, 1977; Arrizabalaga, et. al., 1997; Rose, 1997; Clancy, 1999; Holmes, et. al., 1999; Egglestone and Turner, 2000; Rothschild, 2005; and, Harper, et. al., 2008.

Historical Epidemiology of Syphilis

Due to the lack of knowledge around syphilis and the interrelatedness of many diseases, it is difficult to assess the death rate of syphilis in Renaissance Europe (Arrizabalaga, et. al., 1997). It is estimated that not more than 20 percent of the population was afflicted with syphilis (percentages ranged between 12 and 13 percent for men in the Renaissance and 16 to 18 percent for women during the same period) (Arrizabalaga, et. al., 1997). The two main occupational groupings for men afflicted with syphilis were ecclesiastical and military (Arrizabalaga, et. al., 1997).

Stages of Pox, as Recorded in Renaissance Europe

The first stage of syphilis is reported to be pains, usually attacking the joints and combined with fevers, and sores or abscesses at the genital areas (Arrizabalaga, et. al., 1997; Diamond, 1997). The second stage consists of pustules and ulcers that destroy tissue deep into the bone (Pusey, 1933; Quétel, 1992; Arrizabalaga, et. al., 1997; Diamond, 1997; Hayden, 2004).

Girolamo Fracastoro, an Italian physician and poet, in 1546, discovered that syphilis was a constantly-changing disease: the disease from the early 1500s was different than the disease of the mid 1500s (Quétel, 1992).

One of the first documented case histories of a syphilitic indicates the initial presentation with small ulcers on the sexual organs, following by encrusted pustules in the same area, followed by skin necrosis, decay of body parts, widespread boils or pustules, and painful muscle aches. The stages lasted for about a year, disappeared, and then recurred after one-year's time (Arrizabalaga, et. al., 1997).

Disease Prevention Methods, as Recorded in Renaissance Europe

The main disease prevention method, invented during the Renaissance to prevent the transmission of syphilis, was a small linen cloth (a precursor to the modern-day condom). Bullough (1976) and Dickens (2000) quote from Gabriello Falloppio's treatise on the great pox about the disease prevention successes of the small piece of linen cloth in the fight against the scourge known as syphilis:

As often as a man has intercourse, he should (if possible) wash the genitals, or wipe them with a cloth; afterward he should use a small linen cloth made to fit the glans, and draw forward the prepuce over the glans; if he can do so, it is well to moisten it with saliva or with a lotion. However, it does not matter; if you fear lest caries (syphilis) be produced (in the midst of) the canal, take the sheath of linen cloth and place it in the canal; I tried the experiment on eleven hundred men, and I call immortal God to witness that not one of them was infected" (attributed to G. Falloppio).

Some Renaissance physicians thought that circumcision or having an exposed glans prevented the man from contracting syphilis (Quétel, 1992). Others believed that washing after sexual intercourse would prevent the transmission of syphilis (Quétel, 1992).

Another disease-prevention method that was employed to detect venereal infection in women was using a lemon or lemon juice to detect a raw surface on the labia (like a sore or a chancre) (Himes, 1936). Condoms were also soaked with lemon juice; the acidity of the juice acted as a sufficient spermicide (Himes, 1936; Bullough, 1976). This researcher's hypothesis is that the lemon juice also could have reacted with chancres present on the labia or in the vagina, possibly warning the man of possible venereal disease.

Disease Transmission Modes, as Recorded in Renaissance Europe

Niccolò Leoniceno, an Italian physician, recognized that syphilis was sexually transmitted, but he attributed the transmission to the "additional heat during copulation" (Hayden, 2004). With the invention of the small linen cloth (or, the precursor to the modern-day condom), Gabriello Falloppio supported the theory that the disease was sexually-transmitted (Bullough, 1976; McLaren, 1990; Riddle, 1992; Quétel, 1992; Arrizabalaga, et., al., 1997; Dickens, 2000). Quétel (1992) provides further justification that the disease is sexually-transmitted, attributed to Pedro Pintor, a Renaissance physician: "the disease does not develop in childhood, and rarely in old age; it begins in the genital organs, especially the male glans and the female vulva ('in proeputio capitis virgae et in vulva mulierum')."

Treatment of Pox, as Recorded in Renaissance Europe

Renaissance physicians believed that pox, like all diseases, resulted from humoral imbalances and the treatments included bleeding and spitting and sweating. Treatment methods included ingestion of guaiacum wood (Pusey, 1933; Quétel, 1992; Arrizabalaga, et. al., 1997; Hayden, 2004), mercury (Pusey, 1933; Quétel, 1992; Arrizabalaga, et. al., 1997; Hayden, 2004), and arsenic (Pusey, 1933). Eventually, the treatment for syphilis was believed to be found in guaiacum (a type of wood). The patient would grind the guaiacum, boil it in water, drink it, and then lock himself in a heated, sealed room and proceed to sweat out the "ill-humors" or phlegm (Clancy, 1999; Collier, 2007). It is now believed that the massive phlegm expulsion is a sign of mercury poisoning (Clancy, 1999). Two historical studies, conducted during the nineteenth and twentieth centuries, conducted testing to determine if the treatments of mercurials and arsenicals were effective methods (Holmes, et. al., 1999): both the Oslo and Tuskegee studies found that the treatment methods were more detrimental to the patient than the actual disease. Clothing historians have pondered the history of the codpiece; some researchers have identified the codpiece's role in protecting garments from the treatment of syphilis, which stained the tender and painful penis, and the surrounding clothing, a bright orange (Collier, 2007).

Other Renaissance physicians used caustics (to burn out the ulcer) or salves to treat the great pox (Quétel, 1992) or suggested more herbal or magical treatments: "if the penis is ulcerated and infected (it is always the male sex for which the doctor feels pity, the woman being strictly confined to the role of contaminator, whose chancre, moreover is difficult to discover), you must immediately wash it thoroughly with soft soap, or apply to it a cock or a pigeon plucked and flayed alive, or else a live frog cut in two" (Quétel, 1992, attributed to Gaspare Torella). Many syphilitics preferred death to these "barbarous" procedures (Quétel, 1992).

Saint Job quickly became the patron saint of those suffering from syphilis and syphilitic hospitals, such as the hospital in Bologna, Italy, were named after him (Arrizabalaga, et. al., 1997). Saint Radegund, whose feast day is August 13, is identified as the patron saint of women who suffer from the pox (Fitzgerald, 2007).

Modern-Day Epidemiology of Syphilis

Syphilis is one of a group of diseases that is caused by spirochete organisms from the genus Treponema. "Syphilis, as one form of pathologic treponematosis, has a skeletal signature. It alters the appearance of bones in a highly specific manner..." (Rothschild, 2005). The sexually-transmitted syphilis is now a worldwide occurrence and is caused by T. pallidum. Related treponemas are bejel, or endemic syphilis (T. pallidum endemicum), yaws (T. pallidum pertenue), and pinta (T. carateum). The course of a syphilitic infection can span many years. The classification stages range from early stages (infectious) to late stages (non-infectious). Early syphilis is divided into primary, secondary, and early latent syphilis. Late syphilis includes late latent and tertiary syphilis. The serology (or or the laboratory testing) cannot distinguish between the four different treponematoses (syphilis, bejel, yaws, and pinta) (Egglestone and Turner, 2000).

Sometimes called the "great masquerader" or the "great pox," syphilis is a highly transmissible, infectious disease. It is contracted through skin-to-skin contact. The spirochetes (or bacteria that contain syphilis) burrows into the subcutaneous tissue and causes lesions (Jennison, personal communication, 2007).

Syphilis is one of the diseases identified by the State of New Mexico's Department of Health (NMDOH) as a notifiable disease, on a routine 24-hour reporting schedule (NMDOH, 2006).

Prior to the advent of penicillin (the main modern-day treatment method for syphilis), the infection rate was 25 percent or more (Holmes, et. al., 1999). The infection rate of syphilis, between the years of 2002 and 2006, has increased from 2.9 cases per 100,000 population to 3.3 cases per 100,000 population (an increase of more than 13 percent). The rate for men, during the time-period between 2005 and 2006, has increased almost 12 percent, from 5.1 per 100,000 population to 5.7 per 100,000 population (CDC, 2007). The rate for women, during the time-period between 2005 and 2006, has increased a little more than 11 percent, 0.9 per 100,000 to 1.0 per 100,000. The rate of congenital syphilis increased slightly between 2005 and 2006, from 8.2 per 100,000 live births to 8.5 per 100,000 live births (CDC, 2007). The Centers for Disease Control and Prevention determined, through data-analysis, that increases in congenital syphilis historically follow increases in syphilis in the female population (CDC, 2007). The rate of transmission of syphilis through sexual contact is about 30 percent (Holmes, et. al., 1999).

Fritz Schaudinn, in 1905, discovered the spirochete that causes syphilis: a silvery organism that had a snake-like shape with evenly-spaced spirals tapered at both ends. The bacterium was the diameter of a red blood cell (4 to 20 microns long) and 0.1 to 0.2 microns wide. The bacterium moved three ways: a rapid spinning motion, a forward or backward motion, and a lateral bending motion. The spirochete reproduced by dividing in half, length-wise, once every 30 to 33 hours, during active infection, and once every six months in passive infection (Hayden, 2004).

Stages of Syphilis, as Recorded by Modern Medicine

The clinical stages of early, or infectious, syphilis are primary (which present with the infection and presence of a chancre and usually lasts between nine and 90 days), secondary (which present after the primary lesion and with a fever and rash and usually appears six weeks to six months after the primary lesion), and tertiary (or early latent) (which present with paresis, tabes dorsalis, cardiovascular problems, and meningeal problems and usually appears less than two years after the primary lesion) (Pusey, 1933; Holmes, et. al., 1999; Egglestone and Turner, 2000; Hayden, 2004; Heymann, 2004; Pickering, 2006; CDC, 2008). The clinical stages of late, or non-infectious, syphilis are late latent (which usually appears two years after the primary lesion) and tertiary (which usually appears three to 20 years after the primary lesion) (Holmes, et. al., 1999; Egglestone and Turner, 2000; Heymann, 2004; Pickering, 2006; Jennison, 2007; CDC, 2008).

Primary syphilis presents as chancres, or ulcers, that are painless. The painlessness of the chancres is the key to the successful spread of the disease. Men are commonly afflicted with single chancres, whereas women are commonly afflicted with multiple chancres (commonly known as "kissing chancres," due to the closeness of the genital tract, providing for ease in skin-to-skin contact). Secondary syphilis is known as palasquamous syphilis and presents with a rash all over the body. This type of syphilis is incorporated into the lymphatic system (Jennison, personal communication, 2007).

A classification of syphilis is included in the table, on the next page, (attributed to Egglestone and Turner, 2000). Primary syphilis usually presents between nine and 90 days post-exposure. Secondary syphilis usually presents between six weeks and six months post-exposure, usually between four to eight weeks after the appearance of the primary lesion. Early latent syphilis usually presents less than two years post-exposure. After two years post-exposure, the patient is considered non-infectious and his/her medical condition is identified as late latent syphilis. Between three and 20 years post-exposure, the patient is afflicted with tertiary syphilis, which usually presents with neurological problems and cardiovascular issues.

Table 1: Syphilis Exposure Timeline

Early (infectious) Syphilis
Time After Exposure	Type of Syphilis
9-90 days	Primary
6 weeks – 6 months (4-8 weeks after the primary lesion)	Secondary
≤ 2 years	(Early) Latent
Late (non-infectious) Syphilis
> 2 years	(Late) Latent
3-20 years	Tertiary Gummatous Cardiovascular Neurosyphilis
Congenital Syphilis
< 2 years since birth (includes stillbirths)	Early Congenital
≥ 2 years	Late Congenital
Notes: Syphilis is most infectious to other adults through sexual contact during primary and secondary syphilis, but transmission has also been recorded during stages of early latent syphilis. Mother-to-child transmission can occur throughout early syphilis in the mother, which is also called congenitally transmissible syphilis. Transmission has been reported from mothers with late latent syphilis.

Disease Prevention Methods, as Recorded by Modern Medicine

A latex condom will prevent the spread of syphilis if the chancre is covered with the condom. If the chancre is not easily covered by a condom, the only true prevention method is abstinence. For couples who are in a monogamous, disease-free relationship, safe sexual intercourse is one means of prevention (CDC, 2006; CDC, 2008).

Disease Transmission Modes, as Recorded by Modern Medicine

Modern-day syphilis is transmitted through direct contact with the syphilitic sore (through vaginal, oral, or anal sexual intercourse or through childbirth) (CDC, 2008). The syphilitic sore can be found on the external genitalia, lips, or mouth, or in the vagina, anus, or rectum (CDC, 2008). Individuals who receive treatment for syphilis must abstain from sexual intercourse with new partners until the chances are completely healed (CDC, 2008). The usual transmission mode is through sexual contact (unless the disease is congenital syphilis and that is transmitted in utero through the placenta) (Holmes, et. al., 1999).

Infants can contract syphilis from their infected mother (a disease termed "congenital syphilis") either in utero or during the birthing process (CDC, 2006; CDC, 2008). Transmission of syphilis in utero can occur as early as nine weeks into pregnancy (Holmes, et. al., 1999). Congenital syphilis can be treated through a course of penicillin (CDC, 2006; CDC, 2008).

Treatment of Syphilis, as Recorded by Modern Medicine

Modern-day syphilis is detected through the use of antibody testing (a reagin test and an antitreponemal antibody test) (Cavanaugh, 2003; Heymann, 2004). A single dose of an intramuscular penicillin injection will treat syphilis, if diagnosed in the primary stage, but does not protect against future infection or seroreversal (Holmes, et. al., 1999; Pickering, 2006; CDC, 2008). For treatment of an individual who has late latent syphilis or latent syphilis of an unknown duration, three doses of penicillin are prescribed (CDC, 2006). The penicillin that is usually used in the treatment process is benzathine penicillin, or, if the patient is allergic to penicillin, tetracycline, doxycycline, or erythromycin are used, in the same dosages (Holmes, et. al., 1999). "Infection leads to gradual development of immunity against T. pallidum and, to some extent, against heterologous treponemes; immunity often fails to develop because of early treatment in the primary and secondary stages" (Heymann, 2004). Patients with late latent syphilis are immune to re-infection with syphilis (Holmes, et. al., 1999).

Two historical studies (the Oslo study and the Tuskegee study) attempted to challenge the Renaissance treatment methods of mercurials and arsenicals, respectively. The hypotheses of both studies were that the principal antisyphilitic of the time was worse than the actual disease (Holmes, et. al, 1999).

At this time, only a darkfield examination can be used to establish the diagnosis of primary syphilis. But, serological tests are more reliable for testing for secondary syphilis (Holmes, et. al., 1999).

Conclusion

Regardless of the various theories presented, syphilis was not considered a serious or separately documented problem in Renaissance Europe until after 1492, when the disease's vector became highly mobile, widespread, and virulent. After 1492, the prevention methods changed direction from pregnancy-prevention (with the use of herbal birth control methods) to disease-prevention (with the use of condoms and other methods to prevent the spread of syphilis).

The disease prevention and transmission methods remained similar throughout history, with doctors realizing the importance of sheathing the penis to prevent the spread of syphilis, sexual partners realizing the importance of preventing the spread of syphilis through disease detection techniques, and doctors realizing how syphilis was transmitted.

However, there was a drastic shift with the disease treatment methods, from mercurials, arsenicals, and sweats to the use of modern-day penicillin to treat syphilis, after 1928. Interestingly, the Renaissance treatment methods did not "stand the test of time" and were replaced by modern pharmacology methods using intramuscular antibiotics.

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Copyright 2009 by Kate Daniel. <thlmaimuna at gmail.com>. Permission is granted for republication in SCA-related publications, provided the author is credited. Addresses change, but a reasonable attempt should be made to ensure that the author is notified of the publication and if possible receives a copy.

If this article is reprinted in a publication, I would appreciate a notice in the publication that you found this article in the Florilegium. I would also appreciate an email to myself, so that I can track which articles are being reprinted. Thanks. -Stefan.