The Cambridge World History of Human Disease
Editor KENNETH F. KIPLE Executive Editor Rachael Rockwell Graham Associate Editors David Frey Brian T. Higgins Kerry Stewart H. Micheal Tarver Thomas W. Wilson Brent Zerger Assistant Editors Alicia Browne Roger Hall Paul Henggeler Bruce O. Solheim Dalila de Sousa
CAMBRIDGE UNIVERSITY PRESS 1025
Syphilis took its name from GiroIamo Fracastoro's well-known poem, Syphilis, sive morbus gallicus (1530), in which the Italian humanist-physician in vented this phrase to name the disease then known aU over Europe as morbus gallicus. However, the term syphilis did not become widely used until the late eighteenth century, and that usage was vague and applied to many other symptoms besides those of venereal syphilis until the development of the germ theory in the late nineteenth and earIy twenti eth centuries.
Distribution and Incidence Unlike human nonvenereal treponematoses (pinta, 5 yaws, and endemic syphilis), venereal syphilis has managed to establish a worldwide distribution, al though íts incidence patterns are somewhat differ 1 ent in developed and developing countries. The incidence of syphilis, for example, has continu s ously declined in the Western world since the 1860s, although major wars have momentarily interrupted this trend. After the Second World War, late and congenitaI syphilis almost disappeared, mainly as a result of public heaIth measures and penicillin. ,... Since the 1950s, however, both primary and secon dary syphilis have steadily increased (nearly 29,000 cases in the United States in 1984) with its peak 1~~~~~iS 1incidence in the 15- to 34-year age group. A strik ingly high maIe/femaIe ratio (2.6:1 in the United States in 1983) is due to a considerable incidence of Syphilis or, more properly, venereaI syphilis is a syphilis in maIe homosexuals. In 1980, 58 percent of chronic communicable disease, which, until the ac aU syphilitic men in England were homosexuals as quired immunodeficíency syndrome emerged in the were 50 percent in the United States (Csonka 1987; early 1980s, was the most serious and dreaded of Holmes and Lukehart 1987). the so-called sexually transmitted diseases (STD) In developing countries, syphilis continues to be a formerIy, venereal disease (VD). Caused by Trepo widespread disease, although interpretative prob nema pallidum subspecies pallidum, a spirochetal lems of serologic tests for syphilis make it difficult to bacteríum, the only known natural host of which is estímate the numbers of infected people in those the human being, venereal syphilis is thus one of regions. Syphilis is íncreasing in areas where yaws the human treponematoses - along with pinta, yaws, was previously endemic, such as tropical and equato and endemic syphilis. Although predominantly rial Ameríca and Africa, and Southeast Asia. In transferred by sexual contact, pallidum is also capa feded prostítutes seem to play an important role in bIe of being transmítted from an infected mother to the spread of syphilis in these areas, most noticeably her fetus across the placenta at any stage of preg in the Far East. The risk of congenital syphilis con nancy (congenital syphilis). tinues to be considerable in many developing coun Syphilis develops naturally through three clínical tries, resulting in fetal wastage, neonatal mortality, stages (primary, secondary, and tertiary or late), and infant morbidity (WHO 1986; Csonka 1987). each separated by a subclinical periodo Of the sub clínical periods, the one between the secondary and Etiology and Epidemiology tertiary stages Oatent syphilis) ís the most pro Although syphilis is transferred predominantly by nounced. Clínical manifestations of syphilis are ex sexual contact, it may also be transmitted in nonsex tremely protean, and capable, at the tertiary stage, ual ways, such as by close contact with either an of affecting any system of the human body. open lesion of early syphilis or infected fomites, by 1026 VIII. Major Human Diseases Past and Present
Table VIII. 134.1. Etiology, epidemiology, and clinical manifestations ofthe human treponematoses
Venereal syphilis Endemic syphilis Yaws Pinta Organism T.pallidum T. pallidum endemicum T.pertenue T. carateum Occurrence Sporadic, urban Endemic, rural Endemic, rural Endemic, rural Geographic Worldwide Southwest Asia, sub- Africa, Southeast Asia, Central and South distribution Saharan regions of Af- Western Pacific, South America, Mexico rica, Bosnia America, Caribbean Climate in which the AH types Arid, warm Humid, warm Semiarid, warm disease mostly occurs Age group with peak in 18-30 2-10 2-10 15-30 cidence (years) Transmissibility High High High Low Reservoir of infection Adults Children 2-15 years Children 2-15 years Cases with long oldj contacts in home, old; contacts in home, standing skin school and villagej la school and village; la lesions tent caseS capable of tent cases capable of becoming active becoming active Mode of transmission Sexual, Household contacts: Skin-to-skín; ? insect Skin-to-skin; ? in transplacentalo mouth-to-mouth or vía vector sect vector drinking, eating uten sils Usual age Adult EarIy childhood Early childhood Adolescent Primary lesíon Cutaneous ulcer Rarely seen Framboise (raspberry), Nonulcerating (chancre) or "mother yaw" papule with satellites Secondary lesion Mucocutaneous; oc- Florid mucocutaneous le- Cutaneous papulo- Pintides casional periostitis sions (mucous patch, squamous lesions; split papule, condyloma osteoperíostitis latum); osteoperiostitis Tertiary lesion Gumma, cardiovas- Destructive cutaneous Destructive cutaneous Dyschromic, cular, and CNS lues osteoarticular gummas osteoarticular gummas achromic macules
aBecause the nonvenereal treponematoses are usually acquired in chíldhood, and beca use treponemal bacteremia ceases with time, only in adult-onset venereal syphilis is there any likelihood of a mother giving birth to an infected child. Sources: Adapted from Perine et al. (1984, 2); Perine (1987, 650).
ínfection of an unborn infant in utero, and by trans bones occurring in rural populations of the humid fusions of infected blood. tropics, caused by Treponema pallidum subspecies As noted above, T. pallidum, the causal agent of pertenue; (3) endemic syphílis, similar to yaws, but syphilis, is a member of the order Spirochetales. found only in warm, arid c1imates, and caused by T. This order of bacteria includes three genera patho pallidum subspecies endemicum; and (4) venereal geníc for humans and several other animals: (1) syphílis, which has no c1imatic restrictions and may Borrelia, responsible for Vincent's angina (Borrelia affect any tissue of the body including internal or recurrentis), relapsíng fever (Borrelia vincentii), and gans, and is caused by T. pallidum subspecies pal. Lyme disease (Borrelia burgdorferi); (2) Leptospira, lidum. These and other major features concerning whích causes human leptospirosis; and (3) Trepo the human treponematoses are indicated in Table nema, responsible for a group of diseases known as VIII.134.1. Surprisingly, in spite of the differenti treponema toses (Holmes and Lukehart 1987). ated (both clinically and epidemiologica11y) disease The Treponema genus includes several pathogenic entities they produce, these four trepo nemes cannot specíes and subspecies responsible for four different be morphologica11y distinguished from one another. human díseases: (1) pinta, a Central and South Moreover, they elicit the same immunologic reac· American dísease, which affects the skin, caused by tions, and are a11 susceptible to penicillin (Hackett Treponema carateum; (2) yaws, a dísease of skin and 1963; Perine et al. 1984; Csonka 1987). -" -- VII1.134. Syphilis 1027
'l> Almost from the time of Columbus's arrival in S'" .!il .!:'.l (¡) := ;S;S ~ == .c.c Ameriea, but partieularly from the European En - = .c .c o. o. -=~o ~ & ~ ~ >. >. .... o. lightenment, the uneertain geographie and histori Kl Ql
... VIII.134. Syphilis 1029
Congenital Syphilis HOST The risk of congenital syphilis to the fetus is high during the first 2 years after the mother has ac e.g., increasing the moisture on quired the infection. An infected fetus may die dur the skin and creatíng new ing pregnancy, be stillbom, or be bom prematurely. e.g., resistance portals of entry for invaders Secondary-type lesions are present at birth or ap PHYSICAL PARASITE pear within the first 6 months of life (Perine et al. ENVIRONMENT < SOCIAL 1984; Csonka 1987; Holmes and Lukehart 1987). Figure VIII.134.2. Infectious diseases considered as a dy History and Geography namic triangular interaction among host, parasite, and Medical historiography has in the past usually iden environment (according to E. H. Hudson, 1958, 8-9.) tified the disease known today as venereal syphilis (Adapted from E. H. Hudson. 1958. Non-uenereal syphi with the morbus gallicus that was mentioned for the lis. Edinburgh-London.J first time in European medical and lay writings of the late fifteenth century. Indeed, nineteenth- and been reached (Hackett 1963; Hudson 1965; Wood twentieth-century medical historians, in looking at 1978). past medical and lay descriptions ofmorbus gallicus, Given these circumstances, a third approach seems have systematically practiced a retrospective diagno appropriate, which actually deals with the history of sis ofsyphilis. the concept ofsyphilis, rather than with the history of According to them, the history of syphilis began the disease itself. This third way renounces retrospec with the eruption of morbus gallicus in Europe in tive diagnosis of syphilis and insists on the need to the 1490s, and can be traced throughout the centu contemplate the disease entity caBed syphilis within ríes until today, although neither its geographic ori the strict historicocultural context in which it occurs, gins nor the precise date of its appearance has been and from which it receives its true significance. Put established. Since the European Enlightenment, plainly, every disease entity is an intellectual con both of these questions have been the object of a struction that is peculiar to sorne form of medicine; continuous - and often tart - controversy between and every form ofmedicine is nothing but a historical the defenders of an American origin of syphilis and variable in any human community. Thus the disease those who have claimed that syphilis did exist in the entity known today as venereal syphilis can be con Old World long before Columbus arrived in the New ceived of, at this point, as a paradigmatic example as World. The most varied documental proofs (medical was demonstrated by a Polish microbiologist, Ludwik and lay writings, iconography) and - increasingly Fleck, in the mid-1930s in a monograph in which since the late nineteenth century - material proofs there has been renewed interest since the late 1970s (paleopathological remains) have been wielded in (Fleck 1979). this debate. It is an unfinished debate, however, for Furthermore, in looking at what we call infectious in claiming that present-day venere al syphilis was diseases, we must distinguish between what may be already known and had been described under sev termed disease entities and the diseases themselves. eral names before or after the Europeans' arrival in As disease entities, infectious illnesses assumed America, 'historians have produced the kind of con their present shape only in late nineteenth- and tradictory conclusions that serve only to keep it early twentieth-century Westem medicine as a re alive (Guerra 1978; Wood 1978). sult of the development of germ theory. But as dis A second way of approaching the history of syphi eases in themselves they have existed for a long lis has already been referred to in the section on the time. etiology and epidemiology of syphilis. This approach Infectious diseases, moreover, cannot be regarded líes in studying the disease and the germ responsi ontologically as natural beings in the same way as ble for it in the broad biological and epidemiological the microbiological agents that cause them can be context of the development of human treponema regarded (Reznek 1987). Rather, as Hudson (1958) toses, and integrates results provided by both paleo has demonstrated, in the case of human treponema pathologicaI and historicoepidemiological studies. A toses, they should be considered the result of a dy result of this approach has been sorne attractive namic interaction among host, parasite, and environ and promising hypotheses on the history ofsyphilis, ment, as portrayed in Figure VIII. 134.2. Moreover, .. but at the moment, no definitive conclusions have any such interaction that has occurred in the past 1030 VIII. Major Human Diseases PastandPresent can neither be reproduced under experimental condí· were regarded as the newest barbari stranierí to tions, nor be easily reconstructed historically. devasta te Italy. The great prestige of Renaissance To be precise, venereal syphilis took shape in West Italy and its cultural hegemony throughout Europe ern scientific medicine only as a result of deep were important factors, among others, in ensuring changes, both intellectual and social, during the sec the rapid popularization of both the term morbus ond halfof the nineteenth and the first decade of the gallicus and the theory of its American origino twentieth century; foremost among these changes Through the sixteenth eentury, the phrase "Freneh was the formulation of germ theory. Yet an exhaus Pox" aehieved in Europe and overseas an overwhelm· tive bibliographical survey on venereal diseases done ing dominance over any other names for the disease, J. K. Proksch in 1889-1900 makes clear that the not only in the medical academic world, but also at term syphilis, though ínvented by Fracastoro in the popular levels. Only Freneh physicians - those na sixteenth century, did not become widely used until tive to or settled in France - seem, understandably, the late eighteenth or early nineteenth century. So, it to have rejeeted this name, and put forth others. For may be anachronistic to refer to as syphilis either the example, in 1552 Thierry de Héry ofParis suggested disease entity that we call "venereal syphilis" before maladíe vénérienne or grosse vairolle; in 1553 Auger the late nineteenth or early twentieth century, or a Ferrier ofToulouse proposed pudendagra or lues hís disease entity named "syphilis" before the late eigh. panica; in 1560 Antoine Chaumette ofParís put forth teenth or early nineteenth century. the denomination morbus venereus; and in 1563 Leo· nardo Botallo, also of Paris, used the term lues Let us now consider the origins, emergence, and venerea, as did Jean Fernel in posthumous publica development of the concept of syphilis. Our depar tion in 1579. ture point will be the disease entity that began to be called morbus gallícus in late fifteenth-century Eu· 1600-1750 rope. Although for the above-mentioned reasons we During the seventeenth century this new term, lues cannot agree with those who have identified morbus venerea (venereal disease), was adopted all over Eu gallicus with syphilis, it is obvious that the former rope, sharing an ex aequo leadershíp with that of may well be considered the earliest identifiable con morbus gallieus. In eighteenth-century Europe the ceptual ancestor of the disease entity that we now term "lues venerea" eventually superseded that of cal! venereal syphilís (Fleck 1979). morbus gallieus, and the use of the latter declíned dramatieally. 1400-1600 Two points may be raised about the expression Morbus gallicus is the name that soon beca me domi· lues venerea. First, the adjeetive "venerea" stresses nant in designating a disease generally considered as the direet relationship existing between the French new in Europe of the 1490s. It was perceived as an Pox and the pleasures ofVenus and, thus, the individ incurable and loathesome disease consisting of se ual responsibility of those who eontract the disease. vere aches in the bones, and of sores usually begin· Applied to the morbus gallicus, this adjective seems ning in the genitals, but eventually covering most or to have appeared for the first time in 1527 in a work all of the body. Contemporary medical and lay evi by French physician Jaeques de Bethencourt, enti dence concurred in including it among the numerous tled Nova poenitentialis Quadragesíma, nec non calamities (fioods, earthquakes, epidemics, famines, Purgatoríum in Morbum Gallicum sive Venereum. wars) that Europeans - especially Italians - suffered Both the title and contents of this book evoke the at the end of the fifteenth century. cUmate of religious exaltation and of moral rearma ltalian sources show us that the "French Pox" ment present in Reformation Europe (Temkin 1977). spread in ltaly during the períod 1494-5, after the The second point has to do with the name "lues," clash between the armies of France and Spain over which underscores the perception of the disease, at the question ofthe kingdom ofNaples. The notoriety that time, as a contagious and calamitous one from a the phrase morbus gallicus soon achieved all over physical, and even from a moral, viewpoint. ltaly was cIosely associated with the tragic conse A good example of the dominanee exerted by the quences of the impact of the French invasion on the expression "lues venerea" on eighteenth-century Eu fragile ltalian political equilibrium. Similarly, the ropean university medicine is offered to us by an prompt acceptance in early sixteenth-century Italy infiuentiaI work of the French royal physician Jean of the theory of an American origin for morbus gal Astruc, De Morbis Veneris, published in 1736, which may be explained by the fact that Spaniards was reissued many times and translated into a great
...... • VIII.134. Syphilis 1031 number of European languages before the end of the discharge - usually called gonorrhea - happening in nineteenth century. The work argues that the lues many venere al patients, constituted a disease entity venerea was caused by a unique and specific virus, different from lues venere a, or (as thought before), venereum. It treats the particular morbi venerei as was just a peculiar clinical form or stage of lues species making up the genus Lues venerea, and it venerea (FlegeI1974). The beginning ofthis process differentiates between lues venerea incipiens and con of disease differentiation, which, roughly speaking, firmata. The first was composed of different morbi took place in Europe and North America throughout venerei (gonorrhea, hernia venerea, bubones ven the century 1750-1850, may be found in the influen erei, caries pudendorum, and porri, among others); tial work by Giovanni Battista Morgagni, De Sedibus whereas the second, the lues venerea confirmata, et Causis Morborum per Anatomen Indagatis, pub also called morbus venereus universalis, comprised lished in Venice in 1761. He found at autopsy that numerous complaints affecting the whole human venereal patients with blennorrhagic discharge and body. Among these were morbi genitalium, vitia no evidence of chancre rarely had hidden in the geni cutis, morbi oris et narium, dolores venerei, morbi tal passages the expected chancre, which was sup ossium,'tumores, glandulosi et lymphatici, oculorum posed to provoke the discharge in the first place. morbí, morbi aurium, and lesiones functionum. During the following decades, numerous physi cians argued the single or dual nature of lues 1750-1850 venerea, resorting to anatomoclinical observations Whether venereal disease was caused by an aní and to autoinoculative and heteroinoculative experi mated contagion or by a chemical poison, until the ments with pus from venereal lesions. This contro mid-eighteenth century almost every intellectual versy did not end until the 1830s in part, at least, stream in European academic medicine seems to because there was tremendous ambiguity in the use have defended the unity of lues venerea on the of terms referring to venereal complaints. Although basis of a unique and specific virus venereum. How terms like syphilis, maladíe(s) syphilitique( s), and so ever, after 1750 the concept of lues venerea began forth spread rapidly in the European medical liter to be challenged as a result of nosographic and ature during the first two decades of the nineteenth nosological efforts made by Enlightenment patholo century, the term syphilis became almost dominant gists, who (with the support of clínical observations, after the 1820s. The word nonetheless continued to anatomopathological analyses, and inoculatíon ex appear in sorne works as an alternative term or one periments) began to question whether lues venerea complementary to that of "venereal diseases." was a single disease entity after a11. The result of The controversy, however, over whether venereal this challenge was the progressive dísappearance of disease was a single disease entity or more than one the expression lues venerea from the literature. illness was brought to an end in the late 1830s. And although it did not entirely disappear until the During this period the French venereologist Phi nineteenth century, it was increasingly replaced by lippe Ricord had developed a vast clinical and experi the plural expression morbi venerei (venereal dis mental program at the Paris Hopital du Midi, includ eases), which began to be used at the beginning of ing both the systematic use of the uterine speculum the eighteenth century. At about the same time, and numerous (more than 2,500) autoinoculative ex specific denominations given to each one of the periments with pus from venereal patients. In 1838 "morbi venerei" (chancre, gonorrhea, bubo, and he presented his results and conclusions in Traité syphilis, among others) started to appear with in pratique sur les maladies véneriennes, ou recherches creasing frequency. From the early nineteenth cen critiques et experimentales sur l'inoculation appli tury, the number of medical works specifically de quée a l'étude de ces maladies. These experiments, voted to certain among these diseases .. mainly to asserted Ricord, had permitted him to demonstrate gonorrhea and syphilis .. began to proliferate. the existence of the so-called virus syphilitique, so Let us look in more detail at how the concept oflues that chancre and blennorrhagia could be definitely venerea was destroyed during the period 1750-1850, separated. Moreover the expectations had also al while keeping in mind that it was during this period lowed him to distinguish the primary lesions of that specialized hospital s emerged, including those vérole from those that are not primary, and primary for the treatment of venereal disease and that symptoms from secondary symptoms. As a result, dermatovenerology was born as a medical specialty. Ricord proposed the division of syphilis symptoms Enlightenment controversies over lues venere a carne into primary, successive, secondary, transitional, to concentrate most1y on whether the blennorrhagic and tertiary. 1 1032 VIII. Major Human Diseases Past and Present
1850-1950 T. pallídum was also found in lesions of tertiary During the second half of the nineteenth and the syphilis, verifying Fournier's theory. Karl Reuter, beginning of the twentieth century, Ricord's concept for example, in 1906 found the germ in the wall of a of syphilis was gradualIy reshaped, as other disease syphilitic aorta, whereas Hideyo Noguchi in 1913 entities recognized today as sexually transmitted proved its presence in brain tissue from paretics diseases (gonorrhea, chancroid, lymphogranuloma (QuéteI1986). venereum, genital herpes, venereal warts, and oth By way of conclusion it should be emphasized that, ers) were emerging. If most of these new disease as has been the case with many other disease en entities were first shaped according to anatomoclini tities, a crisis of a disease entity concept based upon cal criteria, each one of them (syphilis included) its specific biological cause (Laín-Entralgo 1982) has eventually got its definitive "identity card" when also ensnared venereal syphilis. In 1935, whereas the relevant germ causing it was isolated. most bacteriologists and pathologists still claimed Gonorrhea and chancroid are two illustrative ex specificity ofa causal microorganism to be the defini amples in this respect. Ricord, who definitely sepa tive nosographic criterion for an infectíous disease, rated chancre and blennorrhagia, asserted that the Fleck lucidly insisted upon the essential incomplete latter might be the result of local irritation, exces ness of the concept of syphilis (Fleck 1979). sive sexual intercourse, or excessive sexual excite Time has confirmed Fleck's insight. Put plainly, it mento The present clínical picture of gonorrhea was should be obvious from the foregoing that Western completed only in 1879, when Albert Neisser discov medicine has had enormous difficulties in establish ered the germ responsible for it, which he called ing scientific criteria that delimit precisely the so gonococcus. On the other hand, chancro id or soft sore called venere al syphilis from the remaining human (ulcus molle) emerged as a disease entity in 1852, treponematoses (Hackett 1963; Hudson 1965; Perine when a pupil of Ricord, Léon Bassereau, demon et al. 1984). strated that the two kinds of luetic chancre - one Jon Arrizabalaga hard, painless, and unique; the other soft, painful, and frequently multiple - resulted from exposure to Bibliography a like lesiono In addition, the latter was autoinocula Baker, Brenda J., and George J. Armelagos. 1988. The ble. 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