On the evening of Monday, January 20, DeAnne Edwards (RN, MSN) presented a special program at the Mebane Historical Museum. Titled “The History of Social Diseases,” Edwards’ program discussed this history of social diseases, or those diseases whose incidence is directly associated with social and economic factors, such as syphilis, gonorrhea, and tuberculosis.
Edwards began her program by discussing the history of syphilis - also known as the “great pox.” She indicated that most scholars believe that the form of syphilis we know of today came from the Naples occupation around 1495 during the first of the Italian Wars, when French soldiers indulged in a “long bout of celebration and debauchery.”
Weeks to months later, the soldiers began receiving large, painful, foul-smelling abscesses and sores or “poxes,” with severe muscle pain at night. Eventually, the symptoms often developed into dementia and insanity. It was believed to be a much more severe form than syphilis of today, with a higher and more rapid mortality rate.
The disease rapidly spread. And as a new disease, there was initially no immunity to it. It was believed that followers of Charles VIII’s army took it back to the French homeland. By the end of 1495, the epidemic had spread throughout Europe. That same year, Holy Roman Emperor Maximilian I proclaimed that syphilis was punishment from God for blasphemy.
Italian physician Girolamo Fracastoro first used the word syphilis in a late 15th century poem. In the poem, Shepherd Syphilius and hunter Liceus were warned by Fracastoro of yielding to sexual temptation. The clinical term “syphilis” was not used until the 19th century.
The origin of syphilis is still debated. Many think that Christopher Columbus’s soldiers brought it back to their Italian homeland. Columbus was the first European to reach the islands of the West Indies in North America. Some believe it was endemic in Europe before 1492, and was confused with other disfiguring diseases such as yaws, pinta, and bejel.
Gonorrhea has been around from ancient times. Syphilis was believed at first to be the same disease. Gonorrhea was present in both the New and Old World, but mutated to become more virulent in the late 15th century. Syphilis was the first new disease discovered after the invention of printing, and was also the first disease to be widely regarded as a sexually-transmitted disease.
In Europe, authorities were concerned with the rise of venereal diseases during this period. Henry VIII of England (1509-1547) tried to close down brothels and communal bathhouses in London. Strict regulations were issued for brothels and bathhouses. Prostitutes who were infected were forced out of employment. Mixed bathing was prohibited.
16th and 17th century writers were divided on the moral components of syphilis. Many insisted that syphilis was divine punishment from sin, and only harsh treatment would cure it, while some people shouldn’t be treated at all. It was directly associated with loose women. Earlier syphilis was untreatable and usually progressed to later stages, where it was disfiguring. Defects to the face and nose were common - a phenomenon known as “nasal collapse.” Artificial noses were sometimes used, made of gold, silver, and leather. In the 16th century, doctors began efforts to attempt surgical reconstruction of nose defects. The goal of treatment was to expel the disease-causing substance from the body. Treatments included blood-letting, laxative use, wines and herbs, and olive oil baths. With its variety of symptoms, syphilis was often referred to as “the great pretender.”
In an address to the New York Academy of Medicine in 1897, Sir William Osler stated, “I often tell my students that it (syphilis) is the only disease on which they require to know thoroughly. Know syphilis in all its manifestations and relations and all other things clinical will be added unto you.”
In the 1500s, the basic theory was that, just as the disease had originated in the Americas, so God had provided a cure in the same place. Residents of the era used substances such as guaiacum, a holy wood from Hispaniola which was a popular treatment for syphilis in the 16th century. Used externally dressing ulcers and pustules, guaiacum could be drank, but proved ineffective in stunting the effects of syphilis.
Paracelsus (1493-1541) promoted the use of mercury, which was also used for leprosy, in treating syphilis. Treatment would go on for years, which evoked the popular phrase, ‘one night with Venus and a lifetime of mercury.” Patients were wrapped in blankets, and left to sweat by a hot tub or fire. Mercury treatment was an ointment from metallic mercury, rubbed into skin or entering the body by fumigation - inhaling and bathing in fumes. Some used it as a drink or an ointment for sores. The goal of mercury treatments was to produce saliva. It was believed at the time that a patient needed at least three pints of saliva for the poison to be expelled from the body. In time, they finally recognized the toxicity of administering mercury as an elixir, resulting in neuropathies and kidney failure, among other ailments.
In 1879, German bacteriologist Albert Neisser identified the bacterium causing gonorrhea, which became known as Neisseria gonorrhoeae. In 1906, the first blood test for syphilis came upon the market - the Wassermann reaction. The Wassermann reaction yielded many false positives, eventually giving way to the RPR system for gonorrhea testing that is still used today.
In 1908, the Arsenic-containing drug Salvarsan for #606 was developed by Sahachiro Hata while working inside the lab of Nobel prize winner Paul Ehrlich. Popularly called “the magic bullet,” it was a water-based arsenic compound. Not quite as toxic as mercury, Salvarsan could be injected or given by IV. Arsenic had to be mixed with mercury or bismuth in order for it to be effective. Bismuth is used today for Pepto Bismol.
During World War I, there was tremendous fear that returning soldiers would spread syphilis infection when they returned home, as was the case in the 15th century. As a result, there was a widespread public relations campaign to motivate soldiers to try and avoid catching the disease. World War I-era soldiers who contracted syphilis or gonorrhea lost pay. Ironically, however, condoms were discouraged, as the suggestion was that they would encourage “licentious behavior.”
By 1926, syphilis was viewed as a major health problem - prevalent in more than one third of the reproductive age population (35 percent) of the United States at that time. A major health initiative started. In 1928, penicillin was discovered, though mercury and bismuth were aggressively used for syphilis treatment during this period, with less than a 30 percent cure rate. Penicillin wasn’t mass produced for several more years. A lack of funding throughout the Great Depression led to even more problems.
By the onset of World War II, there was considerably more concern for public health and families. Campaigns promoted ways to avoid infection and treatment. Condoms were encouraged. In 1943, additional treatments for syphilis, gonorrhea, strep throat, and bacterial infections were developed. Today, third-generation penicillin is used for gonorrhea and syphilis patients, with doxycycline injections and pills available for people who are allergic to penicillin. Famous people who are believed to have died from syphilis include Al Capone, Charles VIII, Leo Tolstoy, Adolf Hitler, Mary Todd Lincoln, Scott Joplin, Oliver Wilde.
One of the worst cases of questionable ethics in the 20th century was the Tuskegee Syphilis Study, which was conducted at the Tuskegee Institute in Alabama. Starting in 1932, the Tuskegee Study of Untreated Syphilis in the Negro Male was initiated. The Public Health Service, working with the Tuskegee Institute, began the study to record the natural history of syphilis to justify treatment programs for black people.
Approximately 600 black men enrolled - 399 with latent syphilis, and 201 without syphilis who served as the control group. The men were primarily sharecroppers. Many had never been seen by a physician before. The study was conducted without informed consent, with the men told they were being treated for bad blood and anemia. The men did not receive treatment needed to cure their illnesses. No evidence has been presented to suggest that they were ever given a chance to quit the study, despite effective treatment being widely available to the population. Men went blind. They received free medical exams, free meals, and burial insurance. The program was projected to last six months, but went on for 40 years.
In 1936, after a major national newspaper published an article on the Tuskegee project without revealing the full details of the nature of the experiment, local physicians were asked to assist in the study by not treating the men infected with syphilis within the program. The decision was made to follow them until the men died. In 1947, the United States Public Health Service established Rapid Treatment Centers for syphilis treatment, but the men in the Tuskegee study were specifically declined for treatment.
In 1972, Peter Buxton, a Public Health Service venereal diseases researcher, leaked the story with the full details of the Tuskegee project to the national media. The first new articles published related to the Tuskegee project promoted outrage, and the study was forced to stop. When it was over, 28 men died from syphilis, 100 more died from various complications, while many others lived with the disease and were unable to receive proper treatment for years.
A 1974 Congressional hearing resulted in a $10 million out of court settlement, along with lifetime medical benefits and services to all living participants of the Tuskegee program. In addition, the Tuskegee Health Benefit program was established. In 1975, the wives, widows, and children of the men were included. By 1995, the program was expanded to include health and medical benefits, while new guidelines were issued to protect human subjects in US government funded research. In 1997, American President Bill Clinton offered a formal apology while announcing the establishment of the Tuskegee University National Center for Bioethics in Research.
In 2010, President Barack Obama, Secretary of State Hilary Clinton and U.S. Secretary of Health and Human Services Kathleen Sebelius apologized for another unethical US-sponsored medical study. Between 1946 and 1948, approximately 700 men, women, prisoners, soldiers and mental patients were intentionally infected with syphilis in Guatemala. Hundreds more were exposed to other STDs as part of the study without knowledge or consent. The United States received cooperation from Guatemalan government for the project, which was never published.
In the 1950s, syphilis was at an all-time low. But by the1980s, the institution of HIV/AIDS became the most devastating sexually-transmitted disease since the institution of syphilis in the late 1400s. Fortunately, by the turn of the new century in 2000 and 2001, there was a historic low of incidences of syphilis in the United States - though the numbers have been trickling up in recent years. In 2017, the United States reported its highest number of syphilis since 1993. Up until 2013, incidents of syphilis that were reported were primarily among homosexual men. But between 2013 and 2017, there was a 72.7 increase in primary and secondary syphilis in heterosexual men, and a 155.6 percent increase in women. Edwards attributed the dramatic increases in methamphetamine, heroin, and other intravenous drugs in recent years as contributing to the spike in syphilis cases.
“We have two intersecting epidemics, Edwards explained. “We have an increase in women of reproductive age as well as incidents of newborns with congenital syphilis. We must address the methamphetamine and IV drug use in order to eradicate syphilis and congenital syphilis.”
Sexual and social factors for the recent increase in STDs include multiple partners, inconsistent or no condom use, exchanging sex for drugs and money, mistrust of the health care system, unstable housing and homelessness, poverty, incarceration, and a lack of health insurance. This leads to a lack of use of the health care system, an inability to identify sex partners, and delays in diagnosis and treatment.
In North Carolina, there were 1,218 new HIV cases in patients over the age of 13 in 2018 - a slight decrease from 2017. Cases of chlamydia were up to 66,763 from 62,988 cases in 2017, with a 21 percent increase in women, and a 71 percent increase in men. Edwards indicated that North Carolina is currently listed as No. 6 in the nation per capita for incidences of chlamydia.
There was a 42 percent increase in incidences of gonorrhea among women in North Carolina between 2017 and 2018, with a 75 percent increase in men. North Carolina ranks No. 9 in the nation in gonorrhea incidences. In cases of early syphilis, there were 1,914 reported in North Carolina in 2018, which is very similar to the 1,919 cases reported in 2017. North Carolina ranks No. 15 in the country in early syphilis cases per capita.
Alamance County ranks 33 in North Carolina in HIV/AIDs, No. 13 in syphilis cases, and No. 50 for gonorrhea cases. Pilot projects have demonstrated the feasibility and benefit of Substance Abuse Disorder interventions in STD clinics. The United States Centers for Disease Control recommends collaboration between STD programs and Substance Abuse Disorder services, along with clinical and preventative services, and education.