歷史案例—梅毒

資料來源：刺胳針醫學期刊，www.thelancet.com Vol 391 April 14, 2018. 財團法人台灣紅絲帶基金會編譯

對於早期的現代醫師而言梅毒是「偉大的模仿者」，這是一種令人神秘莫測的疾病，由其全範圍的症狀和可能需要的時間長短來展現自我。梅毒首次在歐洲被記錄是在十五世紀90年代中期，和哥倫布帶領著當代的醫生（伴隨著近代的考古學家和歷史學家）首次航程到新世界時間的巧合，得出這樣的結論，他的水手同時將疾病帶回來了。

在17世紀，汞已成為歐洲治療這種新瘟疫的標準治劑。汞劑可能會口服，用注射器注入尿道，或製成油膏並用以揉搓到皮膚上。這個治療方法可是像疾病本身一樣令人生畏，引發無法控制的流涎伴隨著潰瘍、鬆動的牙齒、脆弱的骨頭和神經上的傷害以試圖擺脫身體腐敗的幽怨。

從18世紀中葉開始，醫生和外科醫生就開始爭論梅毒和淋病是否是兩個不同的疾病，或是同一種疾病的兩種表現。 1767年英國外科醫生John Hunter聲稱他已經證明，基於他自己將淋病接種在自己身上的實驗基礎，認為他們是相同的；但他似乎在不知情之情況下已經使用了一個也被梅毒污染的針頭。 1837年法裔美籍醫師Philippe Ricord重複了這一個實驗，只不過不是在他自己身上，而是在巴黎監獄的17名囚犯身上，顯示淋病是一種單獨的疾病，而不是梅毒的症狀。Ricord接著描述了梅毒的三個階段：初期和二期的梅毒在感染的數週或幾個月內出現，但三期梅毒可能需要十年或更長，在延遲一段潛伏期後發展。他的學生皮膚科醫生Jean Alfred Fournier向我們展示了兩種顯然是精神上的異常 – 精神普遍的麻痺性痴呆，一種嚴重的癡呆形式；以及行動失調，一種逐步蔓延的失明和癱瘓 – 是三期梅毒的症狀。

歷史上歐洲社會已經對梅毒和其他性病引起公眾的擔憂作出回應，藉由規範和懲罰那些被視為應對其傳播負責的人–性工作者。在一項對於克里米亞戰爭中的士兵和水手之性病的抗議聲中，導致了英國政府在1860年代下半期通過一系列傳染病法案。根據這項立法，警察可以逮捕並檢查在軍隊或海軍營房一定距離內發現的任何女人– 這項措施在一般大眾、醫學專業人士以及第一波女權主義者如Josephine Butler等人間引發了巨大的反彈。

於20世紀的第一個十年裡，在德國實驗室工作的科學家們對「偉大的模仿者」獲得了許多新的瞭解。在1905年皮膚科醫師Erich Hoffmann和動物學家Fritz Schaudinn，確定了一種密螺旋體Treponema pallidum為梅毒的病原體，以及一年後的細菌學家August von Wassermann亦開發出了一種對梅毒感染的診斷試驗。 1909年Paul Ehrlich醫師宣布發現一種梅毒治療藥物。撒爾佛散Salvarsan（砷凡納明或稱606，arsphenamine）雖毒性很高但卻有效，且是第一個從新的實驗醫學範例中脫穎而出的特定化學治療藥物。

經過20世紀對性病的研究和治療，慢慢地其亦成為主流醫學中一個值得尊敬的部分。從1945年開始，青黴素提供了一種有效的治療並且沒有撒爾佛散的副作用，但是對於性和種族的歧視仍被證明是持久的。公共衛生的運動經過了兩次世界大戰仍繼續描繪「淫蕩的女人」作為疾病的來源，以及1972年不合醫學倫理的塔斯基吉梅毒研究 (Tuskegee syphilis study) 的揭露，亦透露了美國公共衛生服務機構在共謀下剝奪了數百名美國男性黑人梅毒的治療，甚至在青黴素已被引入之後仍然如是。

在21世紀初期，梅毒在中、低收入國家仍然是一個普遍問題，儘管產前篩查方案降低了先天性梅毒發病率。過去十年，西歐國家和美國亦目睹了梅毒的快速增加，特別是在男男間性行為者當中，而青黴素的價值 – 仍然是唯一的推薦治療藥物 – 亦正受到抗生素耐藥性菌株的威脅。

Case histories

Syphilis

For early modern physicians syphilis was “the great imitator”, a disease that mystified with the sheer range of its symptoms and the length of time it might take to show itself. Syphilis was first recorded in Europe in the mid-1490s, and the coincidence with Christopher Columbus’ first voyage to the New World led contemporary physicians (along with more recent archaeologists and historians) to conclude that

his sailors had brought the disease back with them.

By the 17th century, mercury had become the standardEuropean therapeutic for this new plague. Mercury could be taken orally, injected into the urethra with a syringe, or made into an unguent and rubbed onto the skin. This cure could be as fearsome as the disease, provoking uncontrollable salivation along with ulcers, loose teeth, fragile bones, and nerve damage in an attempt to rid the body of corrupted humours.

 From the mid-18th century, physicians and surgeons arguedover whether syphilis and gonorrhoea were two different diseases, or two expressions of the same disease. In 1767 British surgeon John Hunter claimed to have proved, on the basis of an experiment in which he inoculated himself with gonorrhoea, that they were identical; he seems unwittingly to have used a needle also contaminated with syphilis. In 1837 the French–American physician Philippe Ricord repeated theexperiment, not on himself but on 17 prisoners in Parisian jails, showing that gonorrhoea was a separate disease and not a symptom of syphilis. Ricord went on to describe three stages of syphilis: primary and secondary arose within weeks or months of infection, but tertiary syphilis might take a decade or more to develop after a period of latency. His student, the dermatologist Jean Alfred Fournier, showed that two apparently psychiatric disorders—general paresis of the insane, a severe form of dementia, and tabes dorsalis, a creeping blindness and paralysis—were symptoms of tertiary syphilis.

Historically, European societies had responded to public concerns over syphilis and other venereal diseases by regulating and punishing those seen to be responsible for their spread—sex workers. An outcry over venereal disease among soldiers and sailors in the Crimean War led the UK Government to pass a series of Contagious Diseases Acts in the second half of the 1860s. Under this legislation, police officers could arrestand examine any woman found within a certain distance of army or navy barracks—a measure that generated enormous opposition among the public, the medical profession, and first-wave feminists such as Josephine Butler.

In the first decade of the 20th century, scientists working in German laboratories gained fresh purchase on “the great imitator”. The dermatologist Erich Hoffmann and the zoologist Fritz Schaudinn identified a bacterium, Treponema pallidum, as the causative agent of syphilis in 1905, and a yearlater the bacteriologist August von Wassermann developed a diagnostic test for infection. In 1909 the physicianPaul Ehrlich announced the discovery of a pharmaceuticaltreatment for syphilis. Salvarsan (arsphenamine) was highlytoxic but effective, and the first specific chemical therapeuticto emerge from the new paradigm of laboratory medicine.

Through the 20th century the study and treatmentof venereal diseases slowly became a respectable part ofmainstream medicine. From 1945 penicillin offered aneffective cure without the side-effects of arsphenamine, butsexual and racial stigma has proved persistent. Public healthcampaigns through both World Wars continued to portray“loose women” as the source of the disease, and the exposureof the ethically unjustified Tuskegee syphilis study in 1972revealed the complicity of the US Public Health Service indepriving hundreds of black American men of treatment fortheir syphilis, even after penicillin had been introduced.

In the early 21st century, syphilis is still a common problemin low-income and middle-income nations, though antenatalscreening programmes have reduced rates of congenitaldisease. The past decade has witnessed an increase in westernEurope and the USA, particularly in men who have sex withmen, and the value of penicillin—still the only recommendedtreatment—is under threat from antibiotic-resistant strains.

Richard Barnett

richard@richardbarnettwriter.com

www.thelancet.com Vol 391 April 14, 2018.