The Pox E-Book

Kevin Brown

• Herausgeber: The History Press
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 518

Veröffentlichungsjahr: 2006

Beschreibung

From almost the time when man first discovered the pleasures of sin, he has also experienced the torments of the Pox. Drawing on references from art and literature, stories of famous sufferers and medical documents, this book presents the history of syphilis and gonorrhoea, and their treatment, from the Renaissance to the antibiotic age.

Leseprobe

THE LIFE AND NEAR DEATHOF A VERY SOCIAL DISEASE

KEVIN BROWN

To Jackie and Iain Grace

First published in 2006 by Sutton Publishing Limited

The History Press

The Mill, Brimscombe PortStroud, Gloucestershire, gl5 2qg

www.thehistorypress.co.uk

This ebook edition first published in 2013

All rights reserved

© Kevin Brown, 2006, 2013

The right of Kevin Brown to be identified as the Author of this work has been asserted in accordance with the Copyrights, Designs and Patents Act 1988.

This ebook is copyright material and must not be copied, reproduced, transferred, distributed, leased, licensed or publicly performed or used in any way except as specifically permitted in writing by the publishers, as allowed under the terms and conditions under which it was purchased or as strictly permitted by applicable copyright law. Any unauthorised distribution or use of this text may be a direct infringement of the author’s and publisher’s rights, and those responsible may be liable in law accordingly.

EPUB ISBN 978 0 7524 9570 5

Original typesetting by The History Press

Contents

Preface and Acknowledgements

One

The Wrath of Apollo

Two

‘Gentleman’s Sniffles’

Three

Containing the Contagion

Four

The ‘Magic Bullet’

Five

Fit to Fight

Six

Tuskegee: ‘Shadow on the Land’

Seven

The ‘Best Military Advantage’

Eight

‘No Medicine for Regret’: Complacency andResurgence

Notes

Bibliography

Preface and Acknowledgements

‘Know syphilis in all its manifestations and relations, and all other things clinical will be added unto you,’ wrote William Osler, the doyen of medical humanism.1 It might equally be claimed that to know something of the history of syphilis, popularly referred to as ‘the pox’, since it first burst with all its horror on the consciousness of Western Europe in the late fifteenth century is to learn something about the history of modern medicine. This book is the history, covering over five centuries, of a disease that evokes in most people a certain frisson of fascinated horror. No disease is pleasant, but those that are sexually transmitted are also generally seen as shameful and smutty, not to be talked about in polite society but rather the subject of a furtive, almost forbidden, interest. Sex, violent death and toilets always arouse a prurient interest from school students upwards, and the story of the pox certainly contains all these elements to grab the attention. Even in an age that sees itself as liberated from the sexual prudishness of years gone by, there is still a notion of sinfulness about syphilis. In that lies a great deal of the fascination of a subject that tells us as much about shifting notions of social and individual virtue and the interaction between disease and morality as it does about the history of medicine. Its story is grounded in the social history of its times and in the varied responses of mankind to the unknown, to changing moral certainties and to the darker side of sexuality. Syphilis is a disease that has certainly had a dramatic impact upon mankind, and the story of how sufferers have come to terms with it and how doctors and reformers have fought against it is a gripping one.

What can often be forgotten when syphilis and other sexually transmitted diseases are regarded from a moralistic standpoint is that these are bacterial infections like any others. The difference lies in the way that they are transmitted and it is this that colours perceptions of them. The fact that they are so unpleasant in their symptoms also evokes a fascinated horror, with which such infections can be perceived as somehow worse than other illnesses.

Syphilis was commonly known as ‘the pox’. This has led to popular confusion with other ‘poxes’ with which it has no connection, other than that all the infections are noted for nasty skin eruptions. It is in no way related to smallpox, chickenpox or cowpox. All these infections got their names from the pustules or ‘pocks’ that marked the skin of their sufferers. By far the most dreaded of these infections, syphilis, was often referred to as ‘the great pox’ (though popularly shortened to ‘the pox’) to distinguish it from other skin eruptions and diseases. It may not have been the first disease to inflict pock marks on its victims, but it was the most feared and thus the ‘great’ one.

The anti-hero or villain of this book, whichever way it may have been regarded throughout its long history, is syphilis, but a supporting role is played by gonorrhoea, popularly known as the clap, the dose or strain. For a long time, it was believed that this very different infection was merely the first stage of syphilis, and that it might or might not develop into a full-blown pox, depending on the luck of the sufferer. It was not until 1879 that the bacterium that causes it, Neisseria gonorrhoea, was first identified and only then was it realised that they were two distinct diseases. Inevitably, their stories must be told together.

It is almost a given that any history of sexually transmitted infections should have some contemporary relevance and resonance. For the late twentieth century, AIDS was the new syphilis, a frightening disease when it first appeared. The story of HIV and AIDS, though recent, is a big one, and any full treatment of it is outside the scope of this book, which concentrates on syphilis from its first appearance in Western Europe to the present day when it has enjoyed a resurgence.

It is all too easy to look for and find victims of syphilis in historical figures. A whole industry seems to have developed in outing such victims and diagnosing them from their medical symptoms and their behaviour.2 However, the situation is not as simple as that. Until the development of a reliable test, the Wassermann reaction, in 1905, there was no sure way of diagnosing syphilis. Depending merely on recorded medical symptoms could be misleading, as they could be equally applicable to syphilis or to some other disease. Before the twentieth century, it was ‘almost impossible to describe its clinical symptoms without mentioning almost every symptom of every disease known’.3 Perhaps more important is people’s attitude to the loathesome disease when they believed that they or others had it. Identifying people diagnosed with syphilis once there was an accurate test for it also had its difficulties, since the stigma still attached to the disease meant that it was often hushed up both by the victims and by their families. The confidentiality of medical records also means that the evidence will invariably remain elusive as to whether any prominent figure has actually suffered from the disease. It does not stop people speculating, but that may be as far as such surmises can ever go.

It has also been argued that a history of syphilis covering more than half a millennium is impossible because what is understood by the disease has changed over time. Also, the terminology for it has altered radically; all we can be sure of is that we are studying the cultural connotations and construction of an illness at any one time.4 Such an approach has some validity in encouraging the questioning of what an illness is and in challenging the idea of any absolute certainties, but important in the study of history is an appreciation of change. Syphilis has changed in its manifestations over time and the bacteria causing it have evolved, just as surely as perceptions of the disease have altered. Both its changing character and how it has been perceived are the proper objects of this study. It is often difficult to be absolutely certain that the same disease is meant by sixteenth-century terminology and descriptions compared with our understanding of them in the twenty-first century. However, it is possible to make an educated and informed retrospective diagnosis that equates the French Disease, the Italian Disease and the pox with each other and with modern syphilis, especially when the symptoms are so similar and the textual evidence can be supplemented with that from ancient bones that show the marks of something similar to the modern effects of syphilis.

My own interest in the history of syphilis and the issues it raises began when I was asked to give a special Christmas lecture in 1999 to staff of the Jefferiss Wing at St Mary’s Hospital, Paddington, on the history of the treatment of sexually transmissible diseases (STD) in their department. Like most STD clinics, the Jefferiss Wing is a Cinderella service within the National Health Service serving a large clientele close to a mainline London railway station. In the years since then, I have been invited back to give regular lectures to new staff on the history of the speciality in which they are working. This gives them a context that they might not otherwise get in the midst of their busy workload. I am grateful to them for their patience in listening to my views, and to those members of staff who have come back and heard me speak many years running. By their very nature, these talks were intended to be more entertaining than most clinical presentations, but also to give insights into current issues. In return I have been grateful for the insights that these current practitioners, whether doctors, nurses, social workers or administrative staff, have given me into their work. Their dedication, enthusiasm and cheerfulness stand out, though they do not always get the appreciation they deserve. Among them I must particularly single out Sarah Gill, who gave up her time to discuss with me the current resurgence in sexually transmissible infections and the issues facing specialists in that area today.

As always, I owe a debt of gratitude to a number of other friends and colleagues for their interest, support and suggestions. Tudor Allen, Neil Handley, Katy Goff and Tony Rippon have been assiduous ‘pox hunters’ of eminent syphilitics, drawing my attention to people who may have had the disease. Visits to museums and art galleries with friends have certainly been enlivened by the search for signs of syphilis in portraits. Other visitors must have wondered at the nature of some of the conversations they may have overheard. Maria Lorentzon has again happily offered her translation skills over a bottle of wine or two. Bill Frankland shared his memories of working as a newly qualified doctor in a special clinic in the 1930s. Michael Wolach passed on anecdotes of doctors he knew in his youth in pre-war Poland, though socially, not as their patient. Per Lundqvist drew my attention to Swedish references. I am grateful to Simon Chaplin, senior curator at the Royal College of Surgeons and an expert on John Hunter, who suggested some sources for the study of Hunter’s probable self-inoculation with syphilis. Briony Hudson and Peter Homan of the Museum of the Royal Pharmaceutical Society of Great Britain have been of great assistance with the sourcing of pharmaceutical material.

There are a number of people in Frankfurt I wish to thank for their help and hospitality during my research trip there. At the Paul Ehrlich Institut at Langen, just outside Frankfurt, I wish to thank Suzanne Stöcker, head of press and public relations, for giving me access to the Paul Ehrlich Museum and allowing me the freedom to explore its wonderful resources. I am grateful to Dr Bernd Groner, director of the Georg-Speyer Haus, for allowing me access to the laboratory in which Ehrlich developed salvarsan, the first effective modern treatment for syphilis, and to its archives, as well as for the time he spent discussing my project with me during my visit. My thanks also go to Christine Kost of the Georg-Speyer Haus for facilitating my visit. At the Städel art gallery, I must thank Michael Maeck-Gerard, curator of baroque art, for allowing me to see Luca Giordano’s Allegory of Youth Tempted by the Vices, with its figure of syphilis, and for supplying me with some references to it in art journals. The massive Giordano painting was in storage and I will not forget the search through the basement storerooms of the Städel for it, nor squeezing between it and other canvases to view it intimately and closer up than I might have done had it been on display.

I am grateful to Craig Hendrix of Johns Hopkins University Medical School, Baltimore, for inviting me to lecture there and introducing me to a number of his colleagues with an interest in the history of sexually transmitted diseases, particularly Jonathan Zenilman and John Ticehurst, who in turn recommended to me other useful leads. On the same visit to the United States, after lecturing at the Lyceum, Alexandria, on Alexander Fleming and Scotland at a National Tartan Day event, I was sent some references on the history of syphilis and AIDS by one of the audience, Lesli Rothwell of Massachusetts, in one of those serendipitous occasions when someone offered unexpected information at the unlikeliest of events.

It would be pleasant if all the necessary information could be gleaned from social interaction, but much of the research for this book has been conducted in dusty archives and libraries, although there was something magical about reading Fracastoro’s poem on syphilis in Verona and Padua, and at Lake Garda, the places that inspired him. As for scholarly institutions, I would like to thank the helpful staff of the Wellcome Institute, the British Library, The National Archives, Kew (formerly the Public Records Office), the Bodleian Library, the Library of Congress, the National Academy of Sciences in Washington DC, the National Library of Medicine at the National Institute of Health, Bethesda, Maryland, and the National Archives and Records Service of the United States.

I am grateful to staff at the Museo La Specola in Florence, especially front-of-house attendants, for admitting an insistent latecomer to see the wax anatomical models when they clearly would have preferred to close; in particular, they must have been a bit alarmed at his avowed interest in seeing Gaetano Zumbo’s Morbus Gallicus, which is reproduced in this book with the kind permission of photographer Saulo Bambi. They must have wondered even more when I eagerly returned to see that wax tableau on syphilis a second time the following day. I am sure that they and other curators of medical museums accepted that my interest was professional rather than stemming from some weird and morbid curiosity about diseased sexuality.

Finally, at Sutton Publishing, I wish to thank, as ever, Jaqueline Mitchell and her team: Hilary Walford, Jane Entrican and Elizabeth Teague.

London

December 2005

ONE

The Wrath of Apollo

It was an age in turmoil, a time when the excitement of the new was such that it seemed to those living through it to be a time of fundamental change for mankind. In Renaissance Italy there was a brilliant burst of achievement in scholarship, literature, architecture, sculpture and painting that accompanied a rediscovery of the splendours of classical antiquity and the appreciation of the capabilities of the individual. In the quest for the fabled wealth of the Indies, a New World had been discovered and an era of exploration initiated that was to expand the horizons of the Old World, albeit at the expense of older, if previously unknown cultures. Knowledge was opened up and resources and diseases exchanged. Yet, even as a golden age seemingly dawned, there were troubles ahead. Italy, cradle of the rebirth of the arts, became a battleground for foreign powers seeking supremacy, and from the smoke of battle came a fearful new disease destined to wreak havoc, cause great personal suffering and upturn long-established ideas in medicine and society.1

The invasion of Italy by Charles VIII of France in 1494 in pursuit of his claims to the throne of Naples initiated thirty-six fruitless years of campaigning for supremacy in the Italian peninsula that changed very little politically except for the acquisition by Spain of the Duchy of Milan and the Kingdom of Naples and Sicily. For Italy, these were indeed years of woe, heralded by a succession of natural disasters such as floods, severe snowstorms, famine and outbreaks of pestilent disease.2 Foremost among these disasters was a new and frightening disease that was to be the scourge not only of Italy for an age but of the entire world for centuries to come. The earliest written reports of it followed the battle of Fornovo on 6 July 1495. Marcello Cumano, a military doctor serving with the Venetian troops, wrote:

Several men-at-arms or foot soldiers, owing to the ferment of the humours, had pustules on their faces and all over their bodies. These looked rather like grains of millet and usually appeared on the outer surface of the foreskin or on the glans, accompanied by a mild pruritis. Sometimes the first sign would be a single pustule looking like a painless cyst, but the scratching provoked by the pruritis subsequently produced a gnawing ulceration. Some days later, the sufferers were driven to distraction by the pains they experienced in their arms, legs and feet, and by an eruption of enormous pustules which lasted . . . for a year and more if left untreated.3

This new disease among the soldiers fighting at Fornovo was also observed by another doctor from the Veneto serving as chief surgeon to the Italian armies massed against Charles VIII. Alessandro Benedetti, 45-year-old Professor of Medicine at the University of Padua, was a humanist physician and epidemiologist convinced of the importance of naturalistic observation as the basis of all medical progress.4 He was quick not only to record the repulsive symptoms but also to establish how this new disease was transmitted from person to person:

Through sexual contact, an ailment which is new, or at least unknown to previous doctors, the French sickness, has worked its way in from the West to this spot as I write. The entire body is so repulsive to look at and the suffering so great, especially at night, that this sickness is even more horrifying than incurable leprosy or elephantiasis, and it can be fatal.

It is remarkable that the sexual nature of the disease should have been apparent so early after it first caught the attention of the medical profession. However, it was not only in soldiers that Benedetti had investigated the effects of the disease. He had also performed an autopsy on a woman suffering from it and observed that her bones were tumorous and suppurated to the very marrow, even though the membrane covering her bone was still intact.6 Moreover, licentiousness and marauding soldiers went hand in hand; the disease had first been observed the previous year among French troops at the siege of Naples, where they had come into intimate contact not only with their own camp-followers but also with the Neapolitan prostitutes who had plied their trade with mercenaries from all over Europe recruited for defence against the invaders. Former Florentine ambassador to Spain and adviser to three popes, Francesco Guicciardini wrote in 1537 in his magisterial history of Italy in his own lifetime that at ‘those very times when it seemed destined that the woes of Italy should have begun with the passage of the French . . . was the same period when there first appeared that malady which the French called the Neapolitan disease and the Italians commonly called either the boils or the French disease’.7

This new disease was what we now know as venereal syphilis. It is caused by the corkscrew-shaped spirochaete Treponema pallidum, a bacterium not discovered until 1905.8 It is passed on primarily by sexual intercourse, but can also be transferred by infected mothers to foetuses during pregnancy. As a disease, it has three very distinct stages: primary, secondary and tertiary syphilis, separated by latent periods with no visible symptoms. Primary syphilis usually appears between a fortnight and a month after infection. It is characterised by the development of a chancre, a small, firm, hard-edged but painless ulcer, on the genitals where it has entered the body. If it is left untreated this primary lesion will usually heal spontaneously within a few weeks. Buboes, swellings of the lymph glands, can also appear. In women, this primary stage may go undetected if the chancre has formed inside the body, and the disease is revealed only in the secondary stage. However, syphilis is at its most infectious during the primary stage.9

If early syphilis has been left untreated, most sufferers will go on to the secondary stage after the spirochaete has spread through the body. Extensive but painless skin rashes develop all over the body, often accompanied by fever, headaches, a general exhaustion and aching bones. There may also be patchy hair loss or alopecia, resulting in an almost moth-eaten appearance to the scalp. Then, after a few weeks these secondary lesions and symptoms disappear in their turn. Sometimes these symptoms will recur after a latent period. Both the latent and secondary periods remain infectious.

Tertiary syphilis develops only in roughly one-third of untreated cases after a further latent period of anywhere between 12 months and 20 years. It progressively destroys the skin, mucous membranes, bones and internal organs, inflicting the greatest horrors on its victims. Gumma, a small rubbery, benign tumour, can develop anywhere in the body. The attack on the bones can cause small depressions where the tumours have been or eat away the bone entirely, producing especially horrific mutilations when the nasal and palate bones have been destroyed. Meanwhile, late syphilis can also attack the cardiovascular and central nervous system. Cardiovascular syphilis may weaken the walls of the aorta, causing aneurysms (balloon-like swellings of the artery wall), which may sooner or later burst, with fatal results. Neurosyphilis can take a number of forms. With tabes dorsalis (a form of neurosyphilis that progressively destroys the sensory nerves), the destruction of the nerve cells in the spinal cord produces a stumbling gait and very poor coordination in its victims. Paresis or general paralysis of the insane is caused by a general softening of the brain resulting in a form of insanity often linked with a form of creative genius but actually more destructive in its effects. Such an array of symptoms led the physician and medical humanist William Osler to dub it ‘the great imitator’ in the early twentieth century and explains why deaths from tertiary syphilis might be ascribed variously to heart disease, insanity or meningitis.10 Since the introduction of antibiotics, tertiary syphilis has virtually disappeared, but it was once a great killer. Yet, even if they correctly diagnosed the cause of death, doctors often put on the death certificate the more socially acceptable disease that the symptoms resembled, prompting Osler to comment wryly that ‘men do not die of the diseases that afflict them’.11

One manifestation of syphilis that has all but disappeared in the Western world since the 1960s is congenital syphilis, although it can still be found in underdeveloped countries. This is transmitted to the foetus during pregnancy by an infected mother. Children unfortunate enough to be born with the affliction bore the stigmata of shame. Often they would be small in stature because their skeletons were underdeveloped. Generally they could be recognised by their ‘family appearance’ of flat faces with saddle-noses. Sometimes the septum (partition) of their noses and their palates would be eaten away by gumma. Linear scars radiated from their noses and mouths, and the wrinkling of their skin gave an ‘old-man look’, whatever age they may actually have been. Patchy hair loss and a skin discoloration that gave them a ‘café-au-lait’ tinge were further signs of the disease. Most characteristic of all were notched and peg-shaped Hutchinson’s teeth.12 Such were the manifestations of syphilis that now struck Europe with terrible effect.

The pox may have first erupted into public consciousness in Naples, but it had its origins elsewhere. It had been noticed that some of the Spanish soldiers defending Naples against the French had accompanied Columbus on his second voyage. The Spanish mercenaries had withdrawn before the arrival of the French, but not before they had had the opportunity to sleep with local prostitutes. That this was the origin of the pox was proposed by Fernandez de Oviedo in 1525, and the theory was supported in 1539 by Ruy Diaz de Isla, who had attended Columbus’s crew in March 1493 when he reported his discoveries in the New World to Ferdinand and Isabella, the Catholic Kings, at Barcelona. These pox-stricken sailors had originally thought that their disease was merely the effect of the hardships of their voyage, but had then spread it among the inhabitants of Barcelona, who responded with prayers and fasting in an attempt to avert the malady. The mercenaries had subsequently taken it to Naples. Diaz de Isla identified it with the Serpent in the Eden of the newly discovered demi-paradise of Hispaniola, now better known as Haiti, and named it the serpentine disease because, ‘as the serpent is abominable, terrifying and horrible, so is this disease’.13 Although other sixteenth-century physicians denied that the disease was new to Europe and tried to link it with elephantiasis and leprosy in the classical writings of Hippocrates and Galen, the idea that the disease had been imported from the Americas became dominant, especially as it could be depicted as evidence of a decay or weakness in the New World that might justify its conquest and colonisation by the European powers. The theory depended on the coincidence of the date of Columbus’s return from his second voyage with the first great European epidemic of syphilis. Spanish sailors had undoubtedly raped Indian women, and there were frequent allusions to sickness and exhaustion of his sailors in Columbus’s own accounts of his voyages, but no conclusive evidence as to the nature of that illness.14 In the twentieth century, this explanation of the origin of syphilis was given new prominence with the idea of the Columban Exchange: syphilis was the only serious disease to be transmitted from the New to the Old World, whereas the Europeans had brought with them to the Americas many pathogens to which the indigenous population had no immunity. By contrast, the Amerindians experienced much milder cases of syphilis than the Europeans, since they had immunity to that disease.15

Indeed, the medical lore of the indigenous cultures of Central and South America was well aware of syphilis-like diseases. Mayan medical texts had terms for gonorrhoea (kazay), syphilitic sores (yaah) and buboes (zali). Meanwhile the Aztecs had several gods concerned with venereal diseases. Titlacahuan, Tezcatlipoca, Macullxochital (god of pleasure) and Xochiquetzal (goddess of love) all punished any breach of vows or unchaste behaviour with an infliction of nasty diseases affecting the genitals of their victims.16 This would suggest that the disease was already familiar in these parts of the New World when the conquistadores arrived.

There was a certain symmetry and indeed justice to the idea of the Columban Exchange, but the notion has not gone unchallenged. Some European skeletons from before 1493 have been excavated that showed such signs of syphilitic infection as star-shaped scars on the skull and traces of inflammation in the bones.17 If syphilis was already present in Europe, its apparently sudden appearance in the 1490s could be accounted for only by a great increase in the virulence of the infection by a mutation of the bacterium, Treponema pallidum, causing it. This theory was based on the idea that a non-venereal syphilitic infection known as yaws may have originated in Central Africa. It had spread east and north from the earliest times, its dispersal encouraged by slave trading, reaching first Egypt and then Mesopotamia, where it was called bejel. It had then spread into Europe by the eighth century, when the Crusades had encouraged travel and made the slave trade from Africa more popular. The discovery in the nineteenth century of a number of yaws-like diseases in poor, remote, backward rural areas on the fringes of Europe, such as spirocolon in Greece and Bosnia, button scurvy in Ireland, radesgye in Norway and sibbens in Scotland, showed that yaws-like infections were indeed present in Europe, transmitted by social contact and commonest in children. If such relatively benign treponemal diseases were already present in Europe, their survival was threatened from the fourteenth century onwards by greater attention to personal hygiene and the use of soap. The theory is that, in order to survive, the bacteria mutated into a more infectious and lethal organism spread by sexual contact rather than by touch.18 Another plausible explanation was that treponemal infections native to Europe had combined with others imported from overseas, such as non-venereal yaws, which the Portuguese may have brought from Africa as a result of their voyages of discovery in the half-century before Columbus set out on his voyages, and that this combination proved more potent and devastating than the two infections had ever been singly.19 Thomas Sydenham, a seventeenth-century physician, actually blamed the slave trade, ‘that barbarous custom of changing men for ware’, for the introduction into Europe of what he called ‘the contagion of the Blacks bought in Africa’.20 However, the evidence still remains strongest for an American origin for syphilis. The indications of the presence of the disease in medieval Europe remain inconclusive, because signs of syphilis in skeletons are difficult to distinguish from damage caused by other diseases such as leprosy. Moreover, relatively few European skeletons show signs of syphilis before 1492 compared with later, although many more indications are found in skeletons in the Americas from the pre-Columban era.21

Although the pox in the form it took in the late fifteenth century was new in Europe, sexually transmitted diseases were nothing unusual. Gonorrhoea, which was believed by many people before the nineteenth century to be the first stage of syphilis, had been a problem since antiquity. Like the bacterium that causes syphilis, the gonococcus is primarily spread through sexual contact. In men, its most common symptom is white or yellowish milky pus discharging from the penis, accompanied by pain when urinating. However, some men may be infected and show no symptoms, although asymptomatic infection is more common in women, who otherwise suffer from vaginal discharges and infection of the uterine cervix. In the past, because fewer women than men displayed any symptoms, it was commonly believed to be a less serious disease for women. In fact, it can destroy the female reproductive organs.22 William Osler described it as ‘not a great destroyer of life’ but ‘the greatest known preventer of life’.23

In Egypt the Ebers papyrus of c. 1550 bc mentioned herbal extracts as treatment to soothe painful urination, the result of what may possibly have been gonorrhoeal infections. Another medical text from ancient Egypt, the Kahun papyrus, describes what may be a gonococcal infection that had caused a woman to suffer a discharge from her vagina and given her problems with her eyes.24 The biblical book of Leviticus advised the children of Israel to avoid contact with any man or woman who ‘hath a running issue’ and to cleanse themselves by bathing and washing their clothes if they came in to contact with anyone ‘unclean’.25 Hippocrates and Galen, the prime authorities of classical medicine, recognised the venereal nature of the disease.26 In medieval England, gonorrhoea was referred to as ‘the brennynge’ or ‘the burning’, a name reflecting the symptom of painful and sometimes bloody urination that afflicted sufferers. The French term for the disease, chaude pisse (‘hot piss’), was just as descriptive. Polite society in England preferred to call the disease by its French name until the sixteenth century, when all classes began to call it ‘the clap’. John Aderne, physician to Richard II, recommended syringing a lead lotion into the urethra to relieve the burning sensation. Although actually a very different disease, syphilis when it first made its appearance was sometimes described in the same way as gonorrhoea as ‘the burning’.27

Stricken with the seemingly novel illness of the pox, whatever its origins, Charles VIII of France and his army of mercenaries were forced to retreat from Naples and withdraw from Italy. In the wake of their passage across northern Italy, they left a terrible trail of victims afflicted by this frightening new epidemic. An outbreak was recorded in Cremona in 1495.28 The notary Bernadino Zambotti reported its first appearance in Ferrara in December 1496 with the observation that it seemed to be incurable and for most of the sufferers proved fatal, following excruciating pains in the bones and nerves, accompanied by massive pustules all over the body.29 These pains in the joints could be so intense, according to Sigismondo dei Conti da Foligno, secretary to Pope Julius II, that sufferers from them ‘screamed day and night without respite, envying the very dead’.30 The pustules and ulcers ‘gnawed away as far as the marrow’.31 In Perugia, a merchant was ‘so consumed by the disease between the thigh and the torso that it was possible to see everything that he had inside his body’.32 In Bologna, the pox ‘ate away the nose and half the face’ of another of its victims.33

Very soon this virulent disease had spread across the Alps with the disbandment of the French army and its bands of mercenaries. By 1496 its symptoms were being reported in France, Switzerland, Germany and Holland, a year later it had reached both England and Scotland, and by 1499 it was noted east of Prague in Hungary, Poland and Russia. It was taken to India in 1498 by the crews of sailors on Vasco da Gama’s voyage that left Lisbon in July 1498. Early on an association was made between the spread of the pox and disbanded soldiers. The Swiss artist Niklaus Manuel in a painting of 1517 depicted Death in the tattered remnants of a soldier’s uniform fingering the genitalia of a young woman.34

Yet there was also a measure of displacement of responsibility as nation after nation named the disease after enemy countries. The Italians called it the ‘Spanish’ or the ‘French Disease’. The French, in turn, referred to it as the ‘Pox of Naples’. In Japan, to which it had been brought in 1569, as indeed also to Africa and India, by Portuguese explorers it was known as manakabassam or the ‘Portuguese Sickness’. Later, the Tahitians in the eighteenth century called it Apna no Britannia, the British disease, to the chagrin of Captain James Cook, who thought that it was not his men who were to blame for spreading it to Tahiti but that it was the fault of the French.35 To the Turks, it was simply the ‘Christian Disease’.36

One of the early victims to have left a personal account of his sufferings was the Christian cleric Tommaso di Silvestro, a canon of Orvieto Cathedral. The symptoms first appeared at Christmas 1496, when he was afflicted with pains in his knees, followed in January by even greater pains at the top of his left shoulder and in his kidneys and buttocks. By May these symptoms had cleared up, only to return a year later.37 In April 1498 he was suffering pains in his penis, and his head was covered with scabs, while his arms ached so much that ‘I could never find rest’. The treatment at this stage of his affliction began with blood letting. He was confined to his bed for six days and then ‘washed with a bath of wine and many herbs, such as bitter infusions, rue, mint, rosemary, mulberry, sage and other herbs’. Only then was he allowed to go outside his house, but he was left with an ulcerated mouth that proved so sore that he could hardly bear to eat bread. After a fortnight the pains in his arm and the pustules disappeared, but his mouth still remained painful and he was to suffer ‘a great flux . . . from which I could have died’. A period of remission from his illness then occurred, only for a recurrence of the symptoms to begin in November 1498.38 Tommaso di Silvestro continued to keep his diary for a further fifteen years without mentioning his symptoms again, so it is likely that he was one of those lucky enough to recover.

Most contemporary doctors, on the other hand, were sceptical of any effective treatment for this new disease. Luca Landucci, a Florentine apothecary, regretted that it was impossible to find any medicines that could treat it.39 Fileno dale Tutte of Bologna and Sigismondo dei Conti da Foligno were equally pessimistic in the belief that the remedies, ointments and drugs of the physicians, doctors and apothecaries had no effect and that no one knew how to produce a cure.40 This view of the incurability of the disease was shared by the majority of the physicians at the papal court faced with all too many clerical cases of it, although Gaspar Torella, physician to Pope Alexander VI, did not share the pessimism of most of his colleagues, an attitude that could only augment his prestige as someone confident of success in tending his patients.41 Jacopo Cattaneo of Genoa was even more optimistic in claiming that, if treated early enough, the disease could be cured, although he admitted that relapses were common.42

It was the very strangeness of the disease and its sudden appearance that perplexed the doctors and made them despair of finding a cure. No one knew what had caused it or where it had come from. Seemingly the disease had appeared in Naples from nowhere, yet there must be an explanation for it. While there were also anti-Semitic suggestions that its progress had followed the diaspora of the Jews following their expulsion from Spain in 1492, Francis Bacon later reported rumours that it was the result of ‘certain wicked merchants that barrelled up man’s flesh of some that had been lately slain in Barbary and sold it for tunney’, noting that cannibalism and the pox seemed to go alongside each other in the West Indies.43 Most people, however, associated it with other sins of the flesh. Not surprisingly, the disease, which was soon linked with sexual contact and sin, was seized on by moralists as a divine punishment for the licentiousness of the age. In the apocalyptic preaching of the Florentine Dominican friar Girolamo Savonarola, the signs of God’s displeasure and of the Last Days included the French invasion of Italy and the pox, twin calamities that reinforced his calls for radical moral and political reform in the name of God. The expulsion of the Medici from Florence in 1494 gave Savonarola predominance in the new Florentine Republic, which he saw as the ‘New Jerusalem’; yet his 1497 ‘bonfire of the vanities’, a collective act of expiation, merely foreshadowed his own burning at the stake in 1498.44 Nevertheless, for many the pox remained a chastisement for sin. John Calvin in Geneva pronounced that ‘God has raised up new diseases against debauchery’.45 That sin was not merely sexual. At the Diet of Worms in 1521, the French pox became a symbol of the corruption of the Church of Rome and was denounced more as divine retribution for blasphemy than for licentiousness.46

Humanist scholars looked for an astrological cause of the scourge afflicting mankind, described by 23-year-old Joseph Grünpeck, later to be court historian to the Emperor Maximilian, as ‘a disease so cruel, so distressing, so appalling that until now nothing so horrifying, nothing more terrible or disgusting has ever been known on this earth’. He had himself caught the pox at an entertainment organised by his fellow humanist Celtis and had no shame in publishing an account of his own symptoms in his attempt to understand the disease, even though his first attempts to conceal his illness from his friends had been unsuccessful and had resulted in them shunning him: he had an ulcerated penis and scrotum, pustule-covered body and putrid-smelling ulcers.47 His metaphor for the disease was of a weapon hurled at mankind by the gods of the classical pantheon. This was reflected in Christian iconography in the frontispiece to his book, which showed the infant Jesus throwing thunderbolts at women, seen here as the main transmitters of the disease, while a prostrate male victim lay before them covered in deadly pustules. Meanwhile the Virgin Mary was shown rewarding a suppliant monarch.48 Grünpeck was suspicious of doctors and their inability to cure or understand his illness. His own explanation of the origin of the French Disease was based on the belief from classical Arabic astrology that the ‘Great Conjunction’ of Saturn and Jupiter foreshadowed changes in kingdoms and brought on natural disasters by causing a corruption of the air, which could be prevented from affecting mankind only by the lighting of aromatic fires containing myrrh, white frankincense and juniper berries. This fateful conjunction of the stars had taken place at four minutes past six on the evening of 25 November 1484 at a time when Mars was at an unfavourable aspect in its own house. The combined evil forces of Mars, a hot and dry planet associated with war and sharp, acute disease, and Saturn, cold and dry and predisposed towards chronic diseases, were enough to overcome the benign influences of Jupiter. Although this happened ten years before the advent of the pox, the astrological event was followed by pestilences, wars, famines and finally syphilis, which had the sharpness of an acute disease linked with Mars and the duration of a chronic disease influenced by Saturn. The first places and people to be affected by the new disease were those most susceptible to the influences of the planets that had caused the problem.49 This explanation was accepted by Albrecht Dürer in a woodcut of 1496 depicting the syphilitic, a pox-stricken aristocrat covered with sinister pustules, standing below the zodiac, on which is inscribed the dreaded date 1484. Such an astrological explanation was popular in humanist circles when Grünpeck published his book in 1496, but in that very same year the leading humanist scholar of the age, Giovanni Pico della Mirandola, argued that the freedom of the human spirit was not restricted by the stars but rather owed its range to supreme providence.50 As a result of Pico della Mirandola’s ideas, many doctors downplayed the role of astrology in their conception of the pox, though not the role of religion.

If the disease was to be seen in moralistic terms, the practical response to it was equally moralistic, though clearly dictated by a rising sense of panic and fear. Some observers had from the start of the epidemic made the connection between it and sexual activity, such as Marin Sanudo of Venice and Giovanni Portoveneri of Pisa, who noticed that ‘it is spread through having sex with women who have these sicknesses, especially prostitutes’.51 Since the early commentators on the new illness were men, women were unjustly seen as the cause of the disease rather than as its victims, while men were most often assumed to be the victims rather than the contaminators. Others believed that it could be caught from sharing a bed, using the same bathwater or even from kissing.52 Henry VIII was said to have caught it from a kiss from Cardinal Wolsey.53 The canons of the Duomo in Florence feared that they might catch the pox from communicants and even demanded a separate cupboard for chasubles, chalices and liturgical vestments used in public.54

Panic evoked varied responses. In northern France, syphilitics were driven from the towns. When the pox first appeared in Paris in the autumn of 1496, the Hôtel-Dieu, the city’s hospital, was besieged by pox-sufferers who were turned away for fear that they may have had a form of leprosy that might be caught by innocent people. The response of the Paris parlement was to issue a decree giving sufferers twenty-four hours in which either to confine themselves to their own homes or to accept expulsion from the city, the penalty for non-compliance with the edict being hanging. Such decrees were periodically renewed until the early years of the sixteenth century, when the illness had become so common that it was no longer viable even to consider such draconian measures.55 In Scotland, the town council of Aberdeen issued an order on 21 April 1497 forbidding prostitution on pain of being branded on the cheek, and on 22 September 1497 the town council of Edinburgh passed a ‘Grandgore Act’ banishing all syphilitics and also anyone claiming to be able to cure the infection to the barren island of Inchkeith in the Firth of Forth.56 Throughout Europe, anxiety about the spread of the pox led to a tightening of control over places in which sexual freedom could spread the disease. In some parts of Europe innkeepers were banned from accepting as guests travellers displaying any sign of the dreaded disease. Elsewhere there was a decline in the late medieval practice of communal bathing since bathhouses were seen as breeding grounds of syphilis; in France and Southern Germany bathhouses were compulsorily closed.57 When Montaigne visited the spa at Plombières in eastern France in 1580, the regulations were strict in excluding anyone showing signs of plague or syphilis, and prostitutes, who were forbidden to come nearer the baths than one hundred paces.58

If bathhouses were dangerous places, even more so were the brothels with which many of them were associated, and these too were not exempt from suppression. In 1500 Gaspar Torella suggested that ‘the Pope, the Emperor, kings and other lords should send matrons to investigate the disease, especially among prostitutes, who if they are found to be infected, should be confined to a place designated for the purpose . . . and treated by a physician or surgeon paid to do so’.59 Martin Luther also called for the closure of licensed brothels in 1520.60 Yet only slowly were initiatives taken to control or attempt to suppress prostitution. The bishops of Winchester had since the early Middle Ages derived a substantial income from the Bankside brothels, known colloquially as ‘Winchester stews’, under their jurisdiction and close to the episcopal palace in Southwark. So notorious were the prostitutes of the stews that the term ‘Winchester Goose’ became a widely used euphemism for syphilis. In Shakespeare’s Troilus and Cressida, Pandarus expresses his fear that ‘Some galled goose of Winchester would hiss: | Till then I’ll sweat and seek about for eases, | And at that time bequeathe you my diseases.’61 Indeed, it has even been suggested that there are sexual overtones to the popular nursery rhyme ‘Goosey, Goosey, Gander’.62 Whatever the origins of the children’s verse, the links between the licensed brothels of the Bishop of Winchester’s stews and the spread of syphilis were so apparent that in 1506 Henry VII took action to close them, but only for a short time.63 It was left to his son Henry VIII, fresh from the suppression of religious houses, finally to close them in 1546 in an attempt to extirpate ‘their abominable and detestable sin . . . as not only provoke instantly the anger and wrath of Almighty God, but also engender such corruption among the people as tendeth to the intolerable annoyance of the Commonwealth’.64 Paris followed, with the closure of its brothels in 1561, and the popes attempted to eradicate prostitution in Rome in 1555 and 1556.65 Vice was not suppressed but merely driven away from any regulation.

Official attempts to control the epidemic were perhaps more prophylactic than therapeutic in aim, but there remained a need to do something to treat the poorer sufferers from the disease and thus prevent it from becoming a threat to the social order. Poor victims were an eyesore and a public nuisance, begging in the streets. Their smell was not only offensive but also might be considered a threat to their social betters at a time when some people thought that foul airs could spread disease. In Florence, Piero di Marco Parenti complained that ‘this putrefaction stank and was a most awful filth’.66 In papal Rome, syphilitics were rounded up and compulsorily hospitalised because they polluted the atmosphere.67 Nevertheless, the impetus for the foundation of hospitals for sufferers from the pox, the incurabili hospitals in Italy, was often private charity rather than an official response to the problem. In Italy the initiative came from religious fraternities such as the Oratories and Confraternities of the Divine Love operating in urban centres. This movement had begun in Genoa in 1497 with the foundation of the Company of Divine Love by a layman, Ettore Vernazza, who had been influenced by the noble-born mystic Caterina Adorna, dedicated to the twin principles of celebrating individual faith through the Eucharist and providing charitable aid for the sick. A refuge for the sick was established by Vernazza and his colleagues in 1497, and inevitably many of their patients were syphilis-sufferers. The movement spread throughout the towns of northern Italy, and alongside the religious impulse came the foundation of hospitals for the incurabili, the chronically sick among whom pox victims loomed large, culminating in the foundation of the Oratory of the Divine Love in Rome in 1517.68 Two years earlier in 1515 the hospital of San Giacomo had been founded in Rome with a moralistic and reformatory atmosphere. Patients were forbidden from swearing, playing games, making a noise and, above all, displaying the ‘dishonest parts of the body’. Even Camilo de Lellis, who, after being treated for the pox, contracted during military service, went on to found a nursing religious order, the Ministri degli Infirmi, dedicated solely to the service of the sick, was expelled for his addiction to card playing.69 Other Counter-Reformation religious orders were active in treating the incurabili. The constitution of the Jesuits indeed laid down the requirement for a novice to spend a month of his training in a hospital, usually the Spedale di San Giacomo in Augusta in Rome. In 1537, the founder of the order, Ignatius Loyola himself, had nursed in the Spedale degli Incurabili in Venice, founded in 1522 and later famed both for its buildings designed by Sansovino and for the girls’ choir of its attached orphanage. The Capuchin Order was founded in 1528 in a small house close to the Spedale di San Giacomo, and the monks cleaned the wards and nursed the sick in hospitals for incurables in Rome, Naples and Genoa.70

One group of victims of the new disease who could not be morally blamed for their affliction were children. Not only were babies being born who had been infected in the womb, but horror stories were also abroad of diseased wet-nurses infecting innocent children with the pox. The sixteenth-century London surgeon William Clowes warned of the dangers in the ‘corrupt milk’ of ‘lewd and filthy nurses’. He cited the example of three children born in the same parish of the City of London who had been sent out to different wet-nurses at about the same time. After six months all three children had returned to their parents, ‘miserably spoiled and consumed with extreme pains and great breaking out upon their bodies, and being so young, sick and weak, impossible to be weaned’. Their desperate parents did everything they could to care for them and ‘ere those children could be cured, they had infected five sundry good and honest nurses’.71 For the honest nurses, their health, reputations and livelihood were at stake. The dangers of passing on infection provoked criticism of the widespread employment of wet-nurses, although the practice continued despite the risks.

Sufferers from the pox also acquired their own patron saint to whom they could pray for relief. The Old Testament patriarch Job was seen as an innocent suffering from an undeserved grief, as many of the sufferers from syphilis also considered themselves to be afflicted through little fault of their own. Job had already been adopted as the patron saint of sufferers from worms, leprosy, skin diseases, melancholy and plague and, despite being born before Christianity, had been canonised.72 Pox, which was identified with the mysterious disease inflicted upon him by God, was rapidly added to his expanding portfolio of ailments.73 In Bologna, the religious confraternity of Santa Marina dei Guarini and its hospital were formally rededicated to St Giobbe in the early sixteenth century because the hospital now specialised in treating victims of the pox, who would otherwise have been reduced to wandering the streets as outcasts, forbidden even the relief of other hospitals.74 If intercession to St Job failed to work, the syphilis-sufferer had three other patrons saints who might be better able to help: St George, the warrior patron saint of England, had already given his protection to lepers and sufferers from other skin diseases, so it made sense for him to be recruited to slay the new dragon of the pox; St Fiacre, a seventh-century hermit, had been noted in his lifetime for his gift of healing and was considered particularly effective against fevers; the martyred St Symphorian of Autun, a patron of students and children, was also considered effective against eye problems.

Protestant countries might be able to forgo the intercession of St Job and the other saints, but could not ignore the problem of the pox. As elsewhere, there was a prejudice against admitting such noticeable sinners to the wards of a general hospital, yet there was a need to accommodate them rather than leave them to pollute the streets. At St Bartholomew’s Hospital in London, a quarter of the patients giving gratuities to the surgeons in 1547–8 had been diagnosed as suffering from syphilis. However, these patients were segregated in a separate ward with their own nurses, clothing and mattresses. At one time, the hospital needed twenty extra mattresses to cope with the demand from syphilitic patients and prevent contamination of others. A sweating ward, known as a ‘stothouse’, was set up where patients could be encouraged to sweat the infection from their bodies. Yet separate wards were not enough to accommodate this group of patients, and at St Bartholomew’s it proved necessary to accommodate some syphilitics in houses leased to tenants of the hospital. There was also a solution to the accommodation problem to be found in the now empty lazar houses, originally established to house lepers but now eminently suitable for the segregation of their successors, the poxed. In London, former lazar houses attached to the medieval hospitals refounded after the Reformation, St Bartholomew’s, St Thomas’s and Christ’s Hospitals, were turned into refuges for the new outcasts.75 Such hospitals had originally been founded in the twelfth and thirteenth centuries for the segregation of lepers, but the decline of leprosy after 1350 had made them redundant. For the surviving lazar houses, syphilis gave them a new use. Many of these hospitals were known as lock hospitals, deriving their names from the enclosures in which the lepers had been confined, although it has also been suggested that ‘lokes’ may have been the rags in which these unfortunates were dressed.76

The pox not only posed an institutional problem, but also challenged the medical profession to find new responses and forge new ideas about the very nature of medicine. Renaissance medical theory and practice continued to be based on the ideas of the Greek Hippocrates, the Roman Galen and the Arab Avicenna, especially the idea that disease was the result of an imbalance of the four humours in the human body. It was believed that the world was made up of the four elements of earth, air, fire and water. In the human body these were paralleled by the four humours, each of which was characterised by paired qualities: the blood was hot and dry; red or yellow bile was hot and dry, black bile or melancholy was cold and dry; and phlegm was wet and cold. In the healthy body the humours were in proportion to each other, but, if this balance were to break down, disease would result. A poor health regime and bad diet or an innate weakness could make the individual susceptible to disease, which was seen as particular to the individual rather than something that could affect large groups of people simultaneously and in similar ways.77 Physicians brought up on this Galenic model of medicine attempted to fit the new disease into the familiar pattern. Konrad Schellig, physician to Philip, Elector of the Palatinate, argued that the contagious pustules characteristic of the French Disease were the result of the excessive heating and putrefaction of the humours, especially black bile, which could be cured by a moderate diet of bland foods to reduce the excessive production of the humours and by abstention from sex to conserve the strength of the patient.78

Many traditionally trained doctors were unable to accept that the pox could be a new disease. For them, the medicine of the ancient world was the ultimate authority; if a disease had not been described by Hippocrates or Galen, it could not exist at all. Nicolo Leoniceno, a teacher of medicine at the universities of Ferrara and Bologna, influenced by the Greek scholars who had fled to Italy after the fall of Constantinople to the Turks in 1453, believed that it was only by applying the principles of classical medicine that disease could be fought. If a disease could not be named and a description of it not found in the classical texts, it would be wrongly treated and the patient might be harmed. He went so far as to aver that, ‘When I see that men are endowed with the same nature, born under the same heavens and brought up under the same stars, I tend to think that they have always been subject to the same diseases, and my mind is unable to comprehend that this scourge, so suddenly appearing, has infected only our age and never earlier times.’79 For him, the pox belonged within the group of diseases caused by a warm and humid intemperance of the air, very frequent in summer, as described by Hippocrates.80 The genitals were more exposed to putrefaction because they were naturally hot and moist and thus more sensitive to changes in the air.81 Other doctors believed that the pox was similar to the dermatological disease elephantiasis as described by Galen and Pliny the Elder, characterised by a swelling of the limbs and thickening of the skin.82

If the disease could be categorised according to traditional ideas, then it could be treated accordingly. However, the use of bleeding, the customary means of drawing out the corrupted humours, proved ineffective, and other means of expelling this morbid matter from the body had to be found. Ointments and baths of wine and herbs were employed to draw out the poisons. Sometimes olive oil was used as an alternative to bathing in wine and herbs. In 1498, the Health Board of Venice forbade the resale of ‘wretched oils . . . of a very bad quality in which people who have or have had the Mal Francese have been immersed, for as a result of these bodies being in these oils there has been a great deal of filth, scabs and dirt’.83

Heat was seen as being particularly useful for driving the corruption from the body. Sores would be cauterised and attempts made to induce sweating through the use of dry stoves. A wine barrel big enough for a patient to sit in was heated up with hot stones placed in a bed of sand at the bottom of the tub. The patient was then seated on a large perforated seat placed in the barrel, which was further enclosed within a framework covered by a cloth to retain the heat, and left to sweat for as long as he could stand the high temperatures. This treatment continued twice a day for between three days and a week and throughout it the unfortunate patient was denied food in case it allowed noxious odours to build up.84

Diet was also considered important once the patient was ready to begin eating again. William Clowes, surgeon at St Bartholomew’s Hospital, forbade the eating of pork, salty meats, geese, ducks, fish, cheese, raw fruits and sweet wines by anyone wishing to be cured of syphilis. Instead he prescribed what he considered to be more easily digestible foods, such as mutton, veal, lamb, kid, hares, chicken, capons, hens, partridges and pheasants.85