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The Hidden Affliction

Professor Simon Szreter

‘A riddle, wrapped in a mystery, inside an enigma’

Winston Churchill’s celebrated phrase seemed to me most apt in describing the intellectual task that I and a number of colleagues set ourselves in trying to study the impact of the pre-HIV sexually transmitted diseases on infertility in history.  The Hidden Affliction (HA) is the product of the most multi-disciplinary small conference I have ever been involved in, held in CRASSH in September 2015. The book includes chapters studying the history and pre-history of most periods, scholars of France and Germany, Africa, Australia and the Pacific along with paleopathology, medicine and evolutionary biology.

szreter book cover
Published by Boydell and Brewer/ Rochester University Press in October 2019.

Why the need for this book?

Gonorrhea and chlamydia remain the main cause of the most preventable condition responsible for infertility today, tubal factor infertility (TFI). In USA, chlamydia is the most common reportable disease (1.5 million annually) and gonorrhea is the second most common; while 30% of female infertility is attributed to TFI.

Yet we know almost nothing about the historical epidemiology of the sexually transmitted infections (STIs) themselves throughout the centuries before the 20th, let alone their influence on fertility.  We have superb, detailed knowledge of the demographic history of England from as far back as Henry VIII’s 16th-century parish registers, thanks mainly to the work since the 1960s of the Cambridge Group for the History of Population. But the STIs are completely missing from this account.

This is despite the fact that exactly 100 years before the 2015 conference there was an acute public awareness of the threat which venereal diseases posed to the nation’s health and in particular to its fertility. The government was so concerned, it appointed a Royal Commission on Venereal Diseases, which sat during 3 years (1913-16), took literally hundreds of pages of testimony and then created, in effect, a blueprint for the NHS: a free, anonymous nationwide service for disease diagnosis and treatment. My own chapter, co-written with Kevin Schurer, has confirmed that the Commissioners were right to be worried; it can be shown that STIs were causing a significant degree of childlessness in Britain.

So, what were the principal pre-HIV historic STIs and what could they do to fertility? 

The gonococcus was first seen under the microscope by Albert Neisser (1855-1916) in 1879, while the elusive transparent spirochete of syphilis was not rendered visible until 1905. Finally, chlamydia was only identified gradually during the course of the 1970s and Mick Worboys’ chapter in this volume is the first full scholarly account of that process of discovery.

Both gonorrhea and chlamydia can cause permanent sterility in a proportion of women infected through salpingitis, which is the form of pelvic inflammatory disease (PID) specific to the fallopian tubes, resulting in tubal factor infertility (TFI). Gonorrhea (but not chalmydia) additionally has a significant capacity to render infected males infertile through epididymitis

Syphilis, by contrast, has no direct effect on the capacity of either sex to conceive. But it causes miscarriages, stillbirths and early deaths among infants, who can contract the disease from infectious mothers either in utero or during parturition shortly after childbirth. The great value of syphilis to historians trying to study the possible impact of STIs on infertility in the past is the far greater visibility of syphilis in the historical record. It was rarely asymptomatic, unlike both gonorrhea and chlamydia. There are consequently a much greater range of opportunities available for historians to study various quite detailed medical, legal, military and other records, not least including skeletons. Tertiary syphilis leaves its characteristic marks both on skull bones and the tibia, the long bones of the legs. As a result, one of HA’s chapters was contributed by leading bio-archeologists, Charlotte Roberts and Rebecca Redfern.

The potential of STIs to endanger even the very survival of some island populations was first conclusively demonstrated by the extraordinary pioneering study conducted during the early 1950s by Roy Scragg OBE, among the dwindling population of the island of Tabar in New Ireland (today a province of Papua New Guinea). The 90-year-old was able to join us at the conference and entertained us royally, not only with his public lecture but also with his unforgettable irreverent antipodean songs at the end of the conference dinner in St John’s college!

Tim Bayliss-Smith’s chapter explores this theme further with an insightful comparative historical demographic study of four different island societies of Oceania in the Solomon Islands. On Simbo and Vella Lavella there was a sexually libertarian ‘aphrodisian’ culture, not dissimilar to Tabar. Bayliss-Smith presents evidence that gonorrhea became prevalent there following first contact in the nineteenth century with Western sailors, whalers and traders, resulting in low birth rates and a documented shrinking population in subsequent generations. By contrast he shows that the inhabitants of Malaita and Guadalcanal subscribed to an entirely distinct sexual code of strict virgin marriage. On these islands, Bayliss-Smith is able to document stable high birth-rates throughout the period of contact with the West. 

Thus, as not only Scragg’s and Bayliss-Smith’s chapters make clear, but also Shane Doyle’s comparative chapter on the Baganda and Haya peoples in East Africa, the gonococcus alone does not have the autonomous power to cause the decline of a population. This depends critically also on the moral codes, cultural practices and accepted behaviours of a society and how these interact with the presence of the diseases in the population.

One of the most extraordinary outcomes of the conference for most of us attending was the conclusion that the research presented suggested that the chronological order in which these three diseases appeared in human history was almost certainly diametrically opposite to that which most of us had believed to be the case prior to the meeting.

With gonorrhea being a term found in the classical medical texts, it seemed we could be most certain that this was the longest-standing ‘hidden affliction’. Secondly, it seemed likely that syphilis, not observed or described in the classical texts, had appeared sometime in the early modern era, with a strong chance that Columbus’s first contact with South America and his return to Europe may have been a precipitating factor, at least as regards the Afro-Eurasian landmass and peoples. Thirdly, chlamydia seemed, like HIV-AIDs, to be a twentieth-century eruption, whose apparently rapid spread had horrified public health experts during the 1970s and 1980s. 

However, as the chapter by Hugh Taylor, world expert on eye trachoma, and evolutionary biologist Ian Clarke make clear, chlamydia trachomatis, to give it its full name, has been an unwanted companion of the human species (and indeed many other species, too) for millennia. This is confirmed by Mick Worboys’ pioneering historical account, which shows how the illusion of a new chlamydia epidemic was created because of rapidly improving scientific techniques for observing the infecting agent from the 1970s onwards. HA also includes another example of historical scholarship and cutting-edge biological science confirming each other’s new findings. In the volume’s opening chapter, Rebecca Flemming’s re-reading of the classical texts makes the case that although the term gonorrhoea is used, they are not in fact describing the symptoms of this disease. Since she delivered this presentation at the conference, the latest findings from the new scientific techniques of gene sequencing have indicated that gonorrhea may be a relative newcomer, not emerging until c.1544-1622. So our current best guess, on order of co-existence among humans, is: Chlamydia c.3-8 thousand years ago, syphilis; c.1000-1493 AD, gonorrhea c.1544-1622.

Lest it be thought that HA only addresses the history of science, microbes and epidemiology, there is plenty both on the more human and emotional aspects of the hidden affliction and on the associated highly gendered politics of government policies, which are discussed comparatively in Britain and USA, and in chapters focused on France and Germany. It is interesting to discover, for instance, that whereas the French were quite blasé about the threat to male fertility posed by gonorrhoea, and the English simply ignored the issue, the Germans were already committed to sperm tests for husbands in infertile marriages from the 1890s onwards. 

Olivia Weisser’s study of early modern medical practitioners’ boasting of their detective skills in getting patients to confess to the sexual misdemeanors that had resulted in their ‘distemper’ was the inspiration for the volume’s title, reminding us that these diseases were often actively concealed by ashamed sufferers. The chapter by Janet McCalman and Rebecca Kippen uncovers the physical and emotional suffering and subsequent infertility which many victims of the diseases, including many indigenous peoples, had to endure in Australia. They focus in particular on detailed medical records from the Melbourne Lying-in Hospital and documentation of the plight of some of Britain’s most desperate poor in the mid-nineteenth century, picked up literally off the streets and transported to Van Diemen’s land.

To uncover the Hidden Aflliction is not only to engage with an extraordinary, multiply-concealed intellectual puzzle, but also to explore dimensions of human suffering entangled with gender, race and political power, as well as science, medicine and biology.

The Hidden Affliction: sexually-transmitted infections and infertility in history was edited by Simon Szreter and published by Boydell and Brewer/ Rochester University Press in October 2019.