Thursday, 21 August 2014

The Pox: Syphilis, Stigma & Shame

“A pox on both your houses!” or so goes the popular (mis)quotation from Shakespeare’s Romeo and Juliet.[1]

Whether called the pox, the French disease or morbus gallicus, the Spanish sickness or the Spanish itch, the evil of Naples or the Neapolitan disease, or very simply the venereal infection, syphilis and other sexually transmitted infections plagued the early modern European people.[2]

Indeed, venereal diseases were so widespread, devastating, and stigmatized that people sought to name the disease after enemy countries to which they ascribed the disease’s origins.[3] 

It’s unsurprising then that many English called it the French pox.

Origins

But where did the pox come from?  Tests on medieval bone fragments suggest that it was not a disease that afflicted Europeans before the 15th century.  Though still a somewhat contested idea, the pox was, most likely, brought back from the New World by explorers.[4]

From Marten's A Treatise of Veneral Disease.
Peter Lowe, a 16th century Scottish surgeon, believed that this was the most probable origin of the disease, and cited that even “Spanish Historiographers” and “divers other learned men” held the opinion.[5] 

Gideon Harvey, the 17th century English physician, noted that it was the “Spaniards at Naples, in the year 1494” who first showed symptoms of the disease.  These explorers, he wrote, brought “new pretty curious fangles…[and] this new pock toy” from the West Indies, which they “soon made present of to several of their dearest Julietta’s at Naples.”[6] 

From there, the pox spread to other sexual partners and even to children.    

Both Lowe and Harvey record other opinions of the pox’s origins that help reveal contemporary beliefs and anxieties.

Some, for example, believed the pox was sent from God to punish sin.  Others that it was engendered in French soldiers who turned to cannibalism in times of war, or through sexual intercourse between a French leper and a Neapolitan prostitute who was menstruating at the time, or through the movements of the planets, or even by drinking wine tainted with a leper’s blood.

Symptoms…

Such beliefs reveal much about contemporary anxieties surrounding religion, female sexuality, uncleanliness, and war.

What precisely was the pox, however, is a bit difficult to pin down.  Though primarily referring to syphilis, it seems that early modern medical practitioners used the word “pox” as a catchall that referred to almost all venereal diseases. 

In an effort to better understand this new disease, practitioners drew parallels between its symptoms and those of the ailments with which they were already familiar.  To that end, they noted the similarities between pox and other diseases that manifested externally like smallpox, plague, and leprosy. 

Syphilis is a complicated ailment with many stages of differing symptoms.  First, come the raised sores at site of infection.  Once resolved, the disease begins a second stage that involves rash-like formations of other sores that tend to scab and scar.  This is accompanied by fevers, general feelings of malaise, hair loss, and an attack on the nervous system. 

While the disease may go into a latent stage, the patient is still infectious and women could (and did) give birth to babies already infected with the disease.

18th C skull of woman who suffered from syphilis
The very last stage of syphilis means even larger and more serious sores, further debilitating attacks on the nervous system, and blindness.  If he sores appeared on softer cartilage, perhaps on the nose for example, the patient could in fact lose the whole nose.

Needless to say, it was very difficult to hide the symptoms of the pox.  But it was easy to confuse the symptoms with another disease.  As Harvey wrote, “In short, the Pox is a Monarch, all other Diseases are its subjects, for there is no Disease, but one time or other is noted to accompany it.”[7]

18thC ivory replacement nose
& Stigma

There was pretty wide-spread recognition that syphilis was contracted through sexual activity.  Nevertheless, surgeons like Peter Lowe suggested that patients, such as one “Gentlewoman of a great Family” who he declared a virgin, could contract the disease from an infected toilet.  While yet another patient, a young apprentice of 15, was thought to have been infected by stepping on his master’s spit.[8]

Lowe did, however, recognize that infection also came through sexual activity and noted the case of 35 soldiers who slept with a single infected prostitute.  Of these, he noted, only 7 men were eventually infected – and these men were “weake” and “long in performing the act.”[9]

This association with loose morals, coupled with the disease’s foul symptoms, meant that syphilis was demonized and stigmatized by the early modern English.

Surgeon William Clowes argued that many infected were “rogues and vagabonds” who spread the disease in “lewd alehouses.”  In a short tract on the pox attached to Clowes’s A Prooved Practice, physician John Almenar pointed out that “they which are carefull to escape the French Pockes, let them first eschue sinne.”[10]  As Thomas Rosewell wrote, venereal diseases were a punishment for sin.  The “beastly adulterer, thou filthy fornicator, and unclean liver” needed to change their ways “lest the severity of God take hold of thee” through infection.[11]

Indeed, patients being treated for venereal diseases at St. Thomas Hospital in London were whipped in punishment. 

John Marten, surgeon, wrote a very popular book on venereal diseases where he laid blame on women.  Indeed, many of his case examples highlight women as a source of the disease, spreading it through vengeance, lies, and other behaviours.[12]

Women’s bodies were thought to be especially good breeding ground for the disease and blame for spreading the disease was linked to women of all walks of life – not just prostitutes.  Wet nurses and mothers, for example, were blamed for spreading the disease to children.

From Marten's A Treatise of Veneral Disease
Shame, Privacy, & Treatments

The stigma attached to syphilis meant that patients sought frequently to hide their ailment or how they contracted it.  Marten met frequently with those who sought to hide that they were infected with syphilis or to hide their manner of contracting the disease.  As he wrote, “nothing indeed is more common than that the Patient [lies] to avoid the Shame and Disgrace of having gotten it by Copulation.”[13]

Unsurprising, really!

In addition, this stigma meant that patients demanded privacy and medical practitioners, seeing increased revenue, were happy to comply.

1689 depiction of mercurial salivation.
Medical advertisements and handbills, for example, show that there was patient demand for secrecy:
 
Indeed, some medical practitioners offered secret or back entrances so others could not observe the patient.  Others even offered private lodging where the patient could be confined and cured without others noticing the telltale signs of mercury – the popular pox treatment.

The anonymous author of An Herculean Antidote even offered to send medicines by post for those too “ashamed to come.”  While yet others, likely as a marketing tool, insisted that syphilis could be contracted accidentally through falls, bruises, and heavy labour rather than through sexual impropriety with “foul women.”[14]

As noted earlier, the pox was frequently treated by mercury – it was dabbed onto the sores or ingested.  While this had some effect on syphilis, it was harsh and also had the negative side effect of slowly killing the patient with mercury poisoning.  This was also a treatment that could not be hidden.  When mercury was taken inwardly, patients salivated frequently and had a noticeable odour.

Instead, patients sought less harsh and less noticeable treatments.  To that end, those irregular practitioners who advertised their treatments promised to treat without mercury.[15] 
18th century Italian jar for mercury pills.
Kevin Siena has written and edited some fantastic work on VD, stigma, and shame if you’d like a detailed analysis.[16]

Let me know what you think here or on Twitter – I’m @medhistorian.



[1] Shakespeare wrote “plague” not “pox.”
[2] Girolamo Fracastoro coined the word “syphilis” in his 1530 Syphilis sive Morbus Gallicus.  The word did not come into popular usage until centuries later.
[3] Claude Quétel, History of Syphilis, 16.
[4] A. Carmichael,Syphilis and the Columbian exchange: was the disease really new?” In: Marques MG, Cule J, editors. The great maritime discoveries and world health. Lisbon: Ecola Nacional de Saúde Pública (1991), p 187-200 & Mary Lindemann, Medicine and Society in Early Modern Europe, 69.
[5] Peter Lowe, An Easie Certaine and Perfect Method (1576), Bv.
[6] Gideon Harvey, Little Venus Unmask’d (1670), 4.
[7] Harvey, 28.
[8] Lowe, B2v.
[9] Ibid., B2v.
[10] William Clowes, A Prooved Practice, 111.
[11] Thomas Rosewell, The Causes & Cure (1665), 67.
[12] John Marten, A Treatise of the Veneral Disease, 319.
[13] Ibid., 300-301.
[14] Anon. At the Sign of the Two Faces (17th century).
[15] Anon. At the Boot and Spatterdash (17th century).
[16] Kevin Siena,Venereal Disease Hospitals and the Urban Poor: London's Foul Wards,1600-1800 (Rochester, NY & Suffolk,UK: University of Rochester Press & Boydell and Brewer,2004); Sins of the Flesh: Responding to Sexual Disease in Early Modern Europe (Toronto: Centre for Reformation and Renaissance Studies, 2006); “The “Foul Disease” and Privacy: The Effects of the Venereal Disease and Patient Demand on the Medical Marketplace in Early Modern London,” Bulletin of the History of Medicine 75,2 (2001), 199-224.

Thursday, 7 August 2014

Surgeons at War



Invasive operations – its accompanying pains and potential complications – gave early modern surgeons and surgery a somewhat negative reputation.  Surgeons belonged to an ignoble profession, one joke noted, because they made a living “by the hurts of other men.”[1]

Despite this characterization, surgeons – along with barbers and apothecaries – provided the bulk of day-to-day medical advice and treatment at this time.  Physicians were few and too expensive.[2] 

Surgeons were even more important and necessary on the battlefield.  Indeed, seventeenth-century soldiers and naval men were treated almost exclusively by surgeons rather than physicians.

The almost continuous warfare throughout the period provided surgical practitioners with numerous opportunities for state service and a plentiful supply of wounded men to treat.  War contributed significantly to surgery’s growth in terms of both organization and practical techniques. 

In addition to honing their skills, war encouraged surgeons’ creativity as they sought better ways to treat wounds rather than relying on older and accepted knowledge.

Ambroise Paré, for example, discovered the use of ligatures in amputations, researched amputation’s effects,
Paré's prosthetic
and even designed prosthetics.

As early as the 1530s, Paré admitted to searching actively for other methods to treat gunshot wounds, and moreover, that both himself and other surgeons knew to use suppuratives rather than boiling oil due to their wartime experience.[3] 

It was Paré, famously, who popularized the idea that gunshot wounds were not poisonous and that the wounds did not need to be cauterized.  He was, in particular, moved by the pain his patients suffered – those cauterized with hot oil suffered from fevers and “great pain” due to inflamed wounds.  Viewing them with horror Paré “resolved with my selfe, never to burn so cruelly the wounded Patients by Gunshot any more.”[4]

Though less painful for the patients, Paré’s new method of treating gunshot wounds horrifyingly required boiled puppies and worms in alcohol. 

The infamous boiled puppy recipe was given to Paré by a surgeon in Turin and required:

“two young whelpes, one pound of earth-wormes, two pounds of the oyle of Lillies, six ounces of the Terebinth of Venice, and one ounce of Aqua-vitae: and in my presence he boiled the whelpes alive in the saide Oyle, until the flesh departed from the bones. Afterward, he tooke the wormes (having before killed and purified them in white wine, to purge themselves of the earth which they have always in their bodies) being so prepared, he boyled them also in the said Oyle till they became dry, this he strained through a Napkin, without any great expressions, that done, he added thereto the Terebinth, and lastly, the Aqua-vitae, and called God to witnesse, that this was his Balme which is used in all wounds made by Gunshot.”[5]

Though Paré was well known and his work widely disseminated, it is unknown just how popular his puppy cure came to be. 

On 23 October 1642, at the Battle of Edgehill, a soldier named Christpher Wally was shot with a pistol just an inch above the clavicle on the right side of his neck.  The pistol ball traveled into his mouth, embedding broken teeth into his cheek and damaging significantly his jaw.  The damage was so severe that when Wally drank broth, it “come out at his wound in ye necke soe as when he dranke he put his fingers on the wound.  Incredibly, as surgeon Joseph Binns related, Wally survived after being bled, his wound dressed, and given numerous liquids to gargle.  Wally was recorded as cured on 20 December of the same year.

In 1662, English surgeons Joseph Binns, Thomas Hollier, and Thomas Arris treated the son of a fourth surgeon, one Mr. Dickson, who had been shot with a musket in the arm.  The musket ball traveled up the man’s arm and “fractured all the bone to peeces.”  The patient was dressed with various herbs including sage and wormwood, various infusions in alcohol, was bled, and given a glister.  He too survived. 

Roughly 130 years after Paré’s The Method of Curing, Richard Wiseman would repeat a similar puppy cure in his Several Chirurgical Treatises.[6]   

Wiseman was easily one of the most important English surgeons of the early modern period.  His mammoth treatises, years as a naval surgeon, and time at Charles’s side during the English Civil War make him an intriguing figure. 

Like Paré before him, Wiseman believed that a combination of experience and accepted knowledge was key to a successful surgical practice. 

Though his contributions to surgery do not compare to Paré’s innovations, Wiseman’s many publications included over 100 case studies in A Treatise of Wounds (1672) and roughly 600 case studies in Severall Chirurgical Treatises (1676). 

These case histories or observations were an important part of communicating surgical innovations and reflects neatly the new science’s emphasis on experiment and experience.  Cases such as these helped showcase surgical knowledge and disseminate it to other surgeons, physicians, and natural philosophers.

It was one of the many ways in which surgical practitioners could gain occupational and personal credit.

The Royal Society’s Philosophical Transactions benefited from Wiseman’s dedication to printing detailed reports of his case observations.

As I’ve written about here, styptics – external medicines that staunched the flow of blood – were an integral part of the army surgeon’s chest and a matter of some debate in the seventeenth century.

Though he did not develop or test the so-called “Royal Stiptick Water” on the battlefield, Wiseman experimented with it and described its effects in the Phil. Trans. for the benefit of other army and naval surgeons.

Tales of the liquid styptic reached English shores through the Philosophical Transactions of the Royal Society.  In 1673 Jean-Baptiste Denys, the personal physician to Louis XIV, wrote to the journal from Paris and related the experiments he made on dogs and men to test the styptic’s efficacy.[7]  Intrigued by the letter, Wiseman and Dr. Walter Needham requested samples of the liquid with which to perform their own experiments.

Combined, the men performed six separate experiments on dogs, calves, and, spontaneously, on one human.  Unlike Denys’ brief letter, Wiseman and Needham’s notes to the journal were quite extensive and included details of how and where incisions were made, how the styptic was applied, and the outcome of the process.[8]

The royal styptic was tested privately by Wiseman and Needham, before members of the Royal Society, and at Whitehall by the king’s command.  The repeated testing was not a sign that the men sought replicability of results.  Indeed, the initial private test was on a dog, the styptic’s use on a female patient was entirely unplanned, the experiment before the Royal Society was also on a dog, while the experiment before the king was made on two calves.[9] 

Indeed, Wiseman was not prepared to perform an experiment on humans at the time and he ended up lightly cauterizing the wound with a hot iron and using tight bandages in addition to using the styptic. 

These were not carefully the controlled experiments of modern science.  At no time did either Wiseman or Needham suggest that the tests’ parameters needed to be controlled or even comment that the slightly different results of each test was significant.  Rather, they noted that the styptic was effective because the dogs and calves were “still found alive and well” and “went away without any bandage.”[10] 

The experiments’ steps, it seemed, were recorded more to lend authority to the account rather than as a guide to further experimenters on what to expect.  Indeed, it seems more likely that the details were included to allow readers to become virtual witnesses. 

In the same way, Wiseman and Needham witnessed the experiments together, then with the Royal Society, and then it was again witnessed by the king and “several” of  his physicians and surgeons until “his Majesty himself declared publickly to be very well satisfied with it.”[11] 

Monarchical approval – from both sides of Channel – lent Denys’ styptic significant cachet.  Indeed, it was the royal stypic.  

Battle wounds, especially from gunshot, were exceptionally deadly and uncontrolled bloodless a major worry.  War forced early modern surgeons to experiment and innovate.  From puppies to liquid styptics, they sought less painful and more effective methods with which to treat their patients.

For more on early modern military surgery check out Jennifer Evans’ recent post Wounded at War (featuring more Wiseman!).

Let me know what you think here or on Twitter – I’m @medhistorian.


[1] Ashton, Humour Wit & Satire, 341.
[2] Mary Lindemann, Medicine and Society in Early Modern Europe (Cambridge: Cambridge University Press, 1999), 216; Margaret Pelling and Charles Webster, “Medical Practitioners,” in ed. Charles Webster, Health, Medicine, and Mortality in the Sixteenth Century (Cambridge, Cambridge University Press, 1979), 182.
[3] Ambroise Paré, The Method of Curing Wounds Made by Gun-shot, 8.
[4] Ibid., 4.
[5] Paré, The Method of Curing Wounds Made by Gun-shot, 5.  Also, please do not try to make this recipe.
[6] Wiseman, Severall Chirurgical Treatises (1676), 413.
[7] Jean-Baptiste Denys, “An Extract of  a Letter, Written to the Publisher by M. Denys from Paris,” Phil. Trans. 8 (1673), 6039.  For more on Denys see Holly Tucker, Blood Work: A Tale of Medicine and Murder in the Scientific Revolution (New York: W.W. Norton and Company, 2011).
[8] Denis, “Experiments of a Present and Safe Way of Staunching,” Phil. Trans. 8 (1673), 6052-6059.
[9] Ibid., 6052-6054.  See also: Wiseman, Severall Chirurgicall Treatises, 273.
[10] Denis, “Experiments of a Present and Safe Way of Staunching,” 6053-6054.
[11] Ibid.