Original scientific article Acta Med Hist Adriat 2018; 16(2);185-202 Izvorni znanstveni ~lanak https://doi.org/10.31952/amha.16.2.1
A HISTORICAL APPROACH TO SYPHILIS INFECTION IN KOREA POVIJESNI OSVRT NA INFEKCIJU
SIFILISA U KOREJI
Dong Hoon Shin
*, Hye Jin Lee
*,**, Jong Ha Hong
*, Eun Jin Woo
***, Eunkyoung Shin
****, Yi-Suk Kim
*****, Ho Chul Ki
******, Eunju Lee
*******Summary
From the end of the 15th century, syphilis spread worldwide, posing a serious threat to public health. Venereal syphilis has been a major research topic, not only in clinical medicine but also in paleopathology, especially because it is a disease of questionable origin and of high prevalence until the discovery of antibiotics. Syphilis in history has been studied extensively in Europe and the Americas, though less so in Asia. In this review, based on extant historical documents and available paleopathological data, we pinpoint the introduction and trace the spread of venereal syphilis in Korea to the end of the 19
thcentury. This review provides
*
Lab of Bioanthropology, Paleopathology and History of Diseases, Department of Anatomy/Institute of Forensic Science, Seoul National University College of Medicine, Seoul, South Korea.
**
Ministry of National Defense Agency KIA Recovery & Identification, Seoul, South Korea.
***
Department of History, Sejong University, Seoul, South Korea.
****
Department of Social Welfare, Dankook University, Cheonan, South Korea.
*****
Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
******
Ancient Institute of Heritage, Jukhyun-ro 514, Hwasun-gun, South Korea.
*******
Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
Correspondence Address: Dong Hoon Shin, Department of Anatomy/Institute of
Forensic Science, Seoul National University College of Medicine, Daehak-ro 103,
Chongno-gu, Seoul 110-799, South Korea. E-mail: cuteminjae@gmail.com.
fundamental information that will be of great help to future research on pre-20th century syphilis in Korea.
Keywords: Syphilis, Joseon Dynasty, Korea, origin, history, paleopathology
Introduction
Treponemal diseases are caused by the genus Treponema, a spirochete bacterium. Various treponemal diseases, including pinta caused by T. car- ateum, yaws by T. pallidum subsp. pertenue, and bejel or endemic syphilis by T. pallidum subsp. Endemicum, are known to infect human beings [1]. Apart from these treponemal diseases of non-venereal contact, T. pallidum sub- sp. pallidum, the most destructive subtype causing serious harm to health and sometimes leading to death, is transmitted by sexual contact (venere- al syphilis) [2, 3]. In addition to the general symptoms of sexually transmit- ted disease (STD) and the characteristic whole-body rash, venereal syphilis sometimes invades various internal organs, causing damage especially in the nervous (tabes dorsalis) and cardiovascular (syphilitic aortic aneurysm) systems. It sometimes involves the skeleton, leading to serious degenerative conditions such as caries sicca in the skull, saddle nose, or saber shin in the tibia. As venereal syphilis’ clinical features are so variable, it is called ‘the great imitator’ [2, 4].
Until relatively recently an optimistic view had prevailed, in that venere- al syphilis was seen to be readily eradicable by antimicrobial therapy, popu- lation screening, and improvements in social health care systems [5]. In fact, during the worldwide campaign against syphilis in the 1960s, its infection prevalence dropped dramatically, and endemic treponematoses (bejel, pinta and yaws) were almost eradicated [2, 6]. However, in the 1980s, syphilis re- emerged in close association with AIDS infection worldwide and economic booms in developing countries [2, 7, 8]. In 2002, 157,000 people died of syphi- lis, and 270,000 suffered from congenital syphilis in Africa [10]. In this light, more attention to the prevention and treatment of syphilis is needed in clin- ical medicine around the world.
Historical syphilis infection also has been of great interest to paleopa-
thologists over the past several decades. Venereal syphilis was a devastating
disease, one of the most feared in human history [11]. In fact, it was so severe
and rapidly transmitted, that it made a very strong impression on the people
at the time of its initial emergence. In particular, as the appearance of syphi-
lis occurred nearly at the same time as Columbus and his men returned from
the New World, the idea that these two historical events were closely related to each other has long been popularly accepted [12]. However, new arguments against this allegation having been made [13, 14], the origin of syphilis came to be hotly disputed, which debate is still ongoing among paleopathologists and historians of medicine.
Interest in venereal syphilis in East Asia is similar to that in other coun- tries. Since the disease shows serious signs and symptoms that were rarely identified in the region, it has attracted the attention of contemporary doc- tors and the general public from the time of its first appearance. Since the early 20th century, the history of syphilis has been well studied in East Asian countries such as Japan. However, the volume of research on syphilis in East Asia is far smaller than that on other continents [15]. Especially in Korea, its history has been only scantily studied to date. This review summarizes the findings and achievements of medical history and paleopathological re- search reported to date, which information will prove valuable to future re- lated research in South Korea and elsewhere.
The Dispute on the Origin of Syphilis
Syphilis first appeared in the 15
thcentury [16, 17]. This new STD was called by different names such as French disease (pox), Neapolitan disease, Spanish disease, the great pox, and so on [17]. The new term ‘Morbus venerus’ (ve- nereal disease) was coined in 1527 by Jacques de Bethencourt, and, finally,
‘syphilis’ in 1530 by Girolamo Fracastoro [17]. When syphilis first appeared in Europe, the signs and symptoms were very different from the syphilis of today. It was a disease of severe virulence that inflicted very high mortality rates [3, 17]. As time passed, however, its virulence weakened, its lethality re- markably lessened, and finally, it came to exhibit symptoms almost identical to those seen today [17].
Regarding the origin of syphilis, there has been a very old claim that it was closely related to Columbus’ discovery of the New World. In this
‘Columbian hypothesis,’ the seamen joining in Columbus’ expedition to
the New World brought the syphilis pathogen back to Europe, which then
spread more widely, eventually covering the entire world. From the first time
this claim was made, it has continued to be supported by many scholars as
the most reliable hypothesis [12, 18]. Briefly, Rodrigo Ruiz Diaz de Isla and
Gonzalo Fernandez de Oviedo chronicled the first outbreak of a syphilis epi-
demic in 1493, specifically in Barcelona after Columbus and his men’s return
from Haiti. In his book (published in 1539), Ruiz Diaz de Isla, a Barcelona physician who had treated Columbus’ men, also stated about the illness that it was unknown disease, so far not seen and never described [12, 18-20].
Significantly, this newly emerging disease reappeared during the war (1494-1498) conducted by the French King Charles VIII against the Kingdom of Naples. An outbreak occurred in the French army that was besieging Naples in 1495 [21, 22]. When Charles VIII’s army retreated back home, many soldiers were already infected by and seriously suffering from this disease [17]. Moreover, as the war had been prosecuted mainly by the employment of mercenaries from various countries, the disease spread rapidly all over Europe soon after those soldiers returned to their home countries [17, 23, 24].
Thereby, the disease spread to France, Switzerland and Germany in 1495, Britain and Scotland in 1497, and the Scandinavian countries, Hungary, Greece, Poland and Russia in 1500. By 1520, it also had spread to Africa, the Near East, East Asia, and Oceania [17]. According to supporters of this the- ory, this disease, which manifested as a dramatic onset followed by rapid spread, originated from the New World [12, 20].
However, this theory has been seriously challenged by other researchers.
A JAMA editorial for the 1935 issue [25] stated that the syphilis originally present in the Old World was not recognized as a separate, independent dis- ease, but for many years was confused with other illnesses such as leprosy. In 1934, Richmond Cranston Holcomb [13, 14] likewise proposed that syphilis might have existed in the Old World even before 1493 (the Pre-Columbian hypothesis). In 1974, two researchers [26] made similar claims. According to this hypothesis, Columbus’ expedition to and return from the New World was coincidental with a sudden spike in syphilis virulence, which disease was mistakenly identified as a new, New World-origin disease [17]. This ar- gument is appealing in that it can explain why syphilis-like signs have been occasionally found in bones unearthed at Old World sites dated pre-1493 [12, 20, 27]. According to this theory, the syphilis was actually present in the Old World even before the 1490s [28, 29].
However, objections to this hypothesis have been made as well. After re-
viewing the previous paleopathological reports, Harper et al. argued that,
with respect to the diagnostic criteria, the certainty of diagnosis and the ac-
curacy and reliability of archaeological dating, there was no single case of
an Old-World skeleton that could indisputably support the pre-Columbian
hypothesis, whereas there were abundant confirmed pre-Columbian cases
[12]. This counter-argument is supported by a phylogenetic analysis based on 26 geographically disparate Treponema strains, which data showed that those venereal syphilis strains were not so old, but had originated recent- ly from yaws strains in South America [1]. Baker and Armelagos [20], more- over, claimed that a treponematosis spread to Europe was non-venereal, and that when pathogenic Treponema was introduced from the New World to Europe, the environment of the latter induced its evolution into venereal form [20]. All of these analyses and reports support the original, Columbian hypothesis.
Although these two hypotheses (Columbian and Pre-Columbian) are the most influential nowadays, some researchers, contrarily, have argued that all treponematoses are caused by the same species of which syphilis is one variant, and that specific diseases can be differentiated only by differ- ences in social and natural environments (the Unitarian hypothesis) [30, 31].
They speculated that in the latter half of the 15th century, venereal syphilis emerged from the existing non-venereal Treponema as the result of the en- vironmental change represented by Europe [12]. Although this hypothesis initially attracted researchers’ attention, its significance has been greatly re- duced as recent studies have re-confirmed that the species responsible for trepanematoses are genetically distinct from each other [1, 23, 32-34].
The Emergence of Syphilis in East Asia
On a global scale, the origin of syphilis is a subject of great interest for paleopathologists. However, in East Asia, uniquely, there has been little con- troversy. Researchers generally have agreed that venereal syphilis originated from the outside, based on the compelling fact that all of the extant docu- mentation of Korea, Japan, and China indicate this.
According to these historical records, syphilis initially was spread to India by Vasco Da Gama’s expedition of 1498 [4]. Next, it spread further to Guangdong (Canton) province of China in 1505, where the disease was called
‘Canton sores’ or ‘Canton rash’ (kuang chuang) or ‘plum-blossom sores’
(yangmei chuang) [7]. Chinese officials at that time were certain that the dis- ease had originated from the outside world. In 1632, Chén Sī Chéng described the new disease in his book (Méi Chuāng Mì Lù) as follows: “I could not find any similar diseases in the detailed reading of the extant medical literatures.
Considering its origin, it began in the Ling nan area (including Guangdong,
Guangxi and Hainan) and spread throughout the country.”
Paleopathologists in Japan presented a hypothesis that syphilis was trans- mitted from the east coast of China (possibly Gwangdong) to Japan [35, 36].
In 1512, the first outbreak of syphilis, in Gekkai-roku, was reported by Shukei Takeda, a medical doctor at Kyoto, who described Kansai district patients manifesting typical signs of syphilis. The next year (1513), a syphilis epidemic was recorded in Myohoji-ki, a Buddhist temple’s record [35, 36]. Interestingly, this means that within a year, syphilis epidemics were reported for two dif- ferent, far distant places in Japan. Taking these two reports into consider- ation, it seems that syphilis was introduced into Japan in 1512-1513 at the latest and that it spread very fast thereafter [36].
As for Korea, Yi Soo-Kwang (1563-1628), a famous Korean scholar of the early Joseon period (the full period: 1392-1910 CE), wrote in his book Jibong yuseol the following: “Considering the medical literature of our country, Cheonpochang is a disease that originated from China between 1506 and 1521.
China did not have this kind of disease in the past. It must have been trans- mitted from the western world.” In Sallim gyeongje, a book written by Hong Man-seon (1643-1715), the signs and symptoms of Cheonpochang were de- scribed as follows: “It is transmitted by sexual intercourse. Erosion occurs in the nose and eyes. Genitalia are also damaged. Severe pains occur in muscle and bone. It is not much different from leprosy. The skin sometimes bursts.
Nose and mouth collapse. The patient eventually dies.” As judged by these symptoms, the disease called Cheonpochang is highly likely to have been ve- nereal syphilis. Koreans at that time knew that there were no syphilis-like diseases in the country before, at the latest, 1506.
How could syphilis in East Asia be so clearly recognized as having orig-
inated from the outside world? This level of assurance might have been due
to a well-established tradition of meticulous record-keeping in the relevant
countries at that time. Another factor we must note is that non-venereal
trepanematoses (pinta, yaws, and bejel), easily confused with venereal syph-
ilis, were very rare in East Asia. These facts clearly made the Korean people
at that time well aware that the newly emerging disease was an unusual one
that had not been seen before. The historical studies to date clearly show that
the first East Asian country in which syphilis was introduced was China,
possibly through maritime trade, and that subsequently the disease spread
very rapidly to Korea and Japan. At least by the early 16th century, syphilis
must have been known to the people of East Asia.
Syphilis Infection from the 16
thto 19
thCenturies
It is still unclear what the situation of syphilis in East Asia was from the 16th to 19th centuries, the period between the first introduction of the dis- ease and the beginning of modernization. In the case of Korea, although a tremendous amount of documentation was accumulated during the Joseon period, it is very difficult for historians to find concrete facts about STDs, especially with regard to syphilis, in the records.
Nonetheless, we were able to find a good description of syphilis infection in a Joseon diary (Bubuk ilgi). In 1644-1646, Park Chui-mun (1617-1690) was sta- tioned on the border area with Manchuria as a military officer. In his diary, he thoroughly documented the details of traveling from his hometown to the service area, his life on the border for a year, and an itinerary for his re- turn back home. Among the everyday life described in the diary, the most relevant information to our research is a thorough record of his and others’
sexual affairs with women [37].
In general, when military officers of the Joseon Dynasty served on the border area, they usually did so alone while their wives and other family members remained home. While traveling from home to their posts, they stayed at public or private accommodations. There, sexual liaisons with prostitutes sometimes occurred [37]. Also, at officers’ military ports and forts at the border, female servants were assigned to them. The servants’ job was officially limited to housework, but they sometimes had affairs with the offi- cers as well [37]. As there were few brothels or red-light districts at that time, these types of contact with socially disadvantaged people such as gisaeng (Korean geisha), female servants, or prostitutes (in the accommodations etc.) were the easiest ways to get in touch with women. In Park Chui-mun’s diary, incidences of sexual affairs are clearly and frankly depicted as summarized in Table 1.
Table 1. The list of females from a diary, who had relationships with males
Date Names Social status of female
Dec 11, 1644 Tongjin Female servant
Dec 15, 1644 Buni Female servant
Dec 16, 1644 Chunil Jutang
aMaehwa Jutang
Dec 17, 1644 Okchun Jutang
Dec 22, 1644 Hyanghwan Jutang
Guiik ?
Date Names Social status of female
Dec 26, 1644 Yehyun Jutang
Doseon Jutang
Dec 30, 1644 Yeonhyang** Gisaeng
bJan 2, 1645 Geonligae Gisaeng
Daehyang Gisaeng
Makgae Gisaeng
Jan 23, 1645 Okhwan** Female servant
Feb 5, 1645 Yeje Daughter of servant
Hoedeok*** Female servant
Feb 6, 1645 Okmaehyang ?
Taehyang Jutang
Feb 11, 1645 Oksun Gisaeng
Feb 13, 1645 Yuldeok Female servant
Feb 14, 1645 Hyangchun Daughter of servant
Okseon ?
Hwasun ?
Hyanggae Gisaeng
Feb 17, 1645 Weolmae Gisaeng
Feb 19, 1645 Hoedeok*** Gisaeng
Feb 23, 1645 Nojong Female servant
May 11, 1645 Seolmae
May 15, 1645 Seolmae
Jun 28, 1645 Sunjin Gisaeng
Jun 2, 1645* Seolmae
Jun 19, 1645* Seolmae
Aug 13, 1645 Ok-yi Gisaeng
Aug 14, 1645 Hyanga
Aug 15, 1645 Gyeokhyang Gisaeng
Oct 21, 1645 Okmae Gisaeng
Oct 23, 1645 Aeseng Female servant
Oct 25, 1645 Hyangseng Gisaeng
Cheonsi Gisaeng
a