Syphilis in the City

As the largest assembly of images attributed any single disease in our collection, the eight files marked 'Syphilis' held at the Pathology Learning Centre testify to the prevalence of this disease witnessed at the University of Cape Town medical school between 1920 and 1970. Prior to the availablility of penicillin in the 1950s, the disease was so common that public hospitals like Groote Schuur adopted the practice of administering a routine blood test for syphilis on patients upon admission (Brock, 1967). Indeed, syphilis was second only to tuberculosis as the largest threat to public health in South Africa during the first half of the 20th century (Jeeves, 2009).

For more clinical photographs from this collection, visit our AtoM page

A man displaying signs of tertiary syphilis affecting the skull

Two x-rays depicting symptoms of congenital syphilis including skull erosion and osteitis of the tibia

The high rate of venereal and congentital syphilis was a hazard for midwives. This chancre on the finger was the result of an accidental infection of a midwife

A syphilitic gumma in the arm of a 61 year-old man

Syphilis persistently featured as a subject of discussion in medical publications, taking up a large portion of the city's annual public health reports even after the western world had begun to see a decrease in instances of this disease. During the 1940s, the cases of syphilis witnessed in Cape Town's hospital wards were discussed as 'fascinating rarities' no longer seen in Europe and North America (O'Malley, 1940). Indeed, the patients at Groote Schuur were considered such a clinical phenomenon that visiting physicians from overseas were invited to bear witness to the effects of this disease in the hospital's wards (Brock, 1949). The photographs and x-rays depicting the symptoms and resultant damage of syphilis in our collection of surgical photographs illustrate the many manifestations of the disease and the need for examples in the teaching of student doctors. And the number of these photographs published as part of case reports in the South African Medical Journal illustrate the professional interest this material.

Artificial nose, made of plated metal, used to replace an original lost due syphilis

An illustration depicting a positive and negative serological (blood) test for syphilis called the Wassermann Reaction

Charcot's joints occur secondary to syphilis of the spinal cord; the slow destruction of the joints is due to loss of sensation

A case of 'sabre tibia', one of the late stigmata of congenital syphilis.

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The Disease

The disease is commonly referred to as 'the great imitator' as it disseminates throughout the body and may lead to highly varied symptoms (Quétel, 1990). The syphilis organism is the spirochete Treponima pallidum and the natural progression of syphilis is generally classified into primary, secondary, and tertiary stages. In periods of latency it can lie dormant for years. The most severe pathology occurs in the tertiary stage, many years after initial infection.

Features of tertiary syphilis include gummata, cardiovascular syphilis, and neuro-syphilis. It is the tertiary symptoms of syphilis that are most well-known to the laymen. These include conspicuous 'visual markers' like the infamous disfigurement of the nose. So common was this symptom of tertiary syphilis that artificial noses were used during the 17^th and 18^th centuries to disguise the destruction of this body-part.

Congenital syphilis may also occur as a result of in-utero infection. Untreated children who survive go on to develop the late lesions of syphilis, a result of chronic inflammation of their bones, cartilage, eyes, ears and internal organs. Common signs include chronic interstitial keratitis (inflammation of the cornea), malformed teeth, and eighth nerve deafness (together referred to as Hutchinson's triad), as well as saddle nose, and Clutton’s joints.

A Short History of Syphilis in South Africa

The fact that syphilis is spread through sexual transmission was realised early in its recorded history and through the centuries it was the prostitute that became labelled its harbinger. While featured in poems and plays of the 18^th and 19^th centuries, the connection between prostitution and infection was clearly communicated in the 20^th century in the health propaganda of both World War I and World War II. Away from their families, soldiers were often seen as vulnerable to the allure of 'loose women' deemed likely to spread venereal disease (VD) to these healthy young men. As a result, the 20^th century saw the rolling out of both educational material and army-issued prophylactic kits to prevent the spread of the disease among military and naval recruits.

In South Africa, prostitutes were similarly earmarked as the reason of the spread of this disease during the late 19^th century with the discovery of diamonds, and then gold. Between 1871 and 1895, around 100 000 men of all races came from all parts of southern Africa to the Kimberley diamond diggings. As men were forced to leave their families behind for 6-10 months of the year, sex workers and casual sexual partners replaced wives. With squalid accommodation, lack of recreational activities or psychosocial support, alcohol abuse was rife; and these conditions fuelled the massive spread of sexually transmitted infections. Chronically sick miners were dismissed back to their homes, thus actively exporting disease to rural areas. As economic conditions worsened in rural areas worsened during the 20^th century, black women began to migrate to towns, joining male kin or living independently (Jochelson, 2001). These 'loose town women' were blamed for spreading VD among black men, and the high rate of syphilis identified in South Africa during the 1930s and 1940s became defined in terms of South Africa's syphilis epidemic.

The ongoing industrial revolution and enforced migrant labour system profoundly disturbed the family unit and social stability of millions of black South Africans. Factors influencing the syphilis epidemic of the 1930s and 1940s were still at play in the emergence of the AIDS epidemic 50 years later.

American public health poster from the 1940s indicating the connection between VD and prostitution

British troops burning the house and confiscating the goods of a Boer

During the South African War (1899-1902), British troops moved around the country spreading VD in their wake through liasons with prostitutes, compromised Boer women and black tradeswomen

Group of workers in compound, Kimberley diamond mines

A 1975 leaflet from Zimbabwe (then Rhodesia) linking the spread of venereal disease to communist terrorists

A Word War II Venereal Prophylactic Unit that would have been issued to the “Pro-Station”

Race, Stigma, and Statistics

In Cape Town, the Contagious Disease Act of 1863 had meant the implementation of compulsory registration and forced confinement in the Cape Town Lock Hospital situated next to the then the Roeland Street gaol (now the Cape Town Archives Repository). But the clinical advances of the early 20^th century culminated in the passing of the 1919 Public Health Act that saw those infected with syphilis allowed access to general hospitals and given subsidised treatment as well as free diagnosis (Jochelson, 2001; Van Heyningen, 1984). Rather than being forcibly treated in lock hospitals, individuals diagnosed with syphilis were thus to receive voluntary and anonymous treatment. What followed in Cape Town was the establishment of its first VD clinic in 1920 and the appointment of its first full-time VD officer in 1921 (Higgins, 1942).

As perceived hotbeds for immoral conduct in the form of crime, alcoholism, and prostitution (Louw, 1969), the city's impoverished racially mixed areas received ever greater public health attention during the first half of the 20^th century. Documented in the official reports and published writings of both Dr TS Higgins (Cape Town's Medical Officer of Health) and Dr CK O'Malley (the city's Venereal Disease Officer), the high level of syphilis recorded in the non-European population was largely the result of statistics originating in VD and prenatal clinics that offered subsidised diagnoses and treatment options in impoverished racially mixed areas across the city (O'Malley, 1932). Because affluent and primarily white individuals could afford private care – and thus avoided becoming part of these statistic (Cohen, 1952; Jochelson, 2001) – locally-published discussions framed the high level of syphilis in relation to the supposedly unnatural and immoral nature of Cape Town's (principally coloured) non-European population.

A table from the City of Cape Town's annual public health report of 1950. It depicts newly identified cases of venereal disease according to race and sex