Syphilis and psychiatry at the Mysore Government Mental Hospital (NIMHANS) in the early 20th century.

Prior to the advent of the Wasserman Test as a diagnostic tool for Syphilis, the identification rate for Syphilis at the Mysore Government Mental Hospital in Southern India was 1%. With the introduction of the test, there was a dramatic increase in the diagnosis of Syphilis, with 17% of the patients testing positive. This paper throws light on the early notions of Syphilis and GPI, societal responses to the disease, early misdiagnosis, the advent of the Wasserman test and treatment management as reflected in the records of the early 20th century at the Mysore Government Mental Hospital (currently known as NIMHANS).

“If I were asked which is the most destructive of all diseases I should unhesitatingly reply, it is that which for some years has been raging with impunity. What contagion does thus invade the whole body, so much resist medical art, becomes inoculated so readily, and so cruelly tortures the patient?” Desiderius Erasmus, 1520.

INTRODUCTION

Syphilis was said to be endemic both in Bangalore and in the Mysore Kingdom by the mid-19th century, according to B. L. Rice, the historian, archaeologist, and educationist who compiled the first volume of the Mysore Gazetteer. Rice further observed that syphilis not only had a high prevalence, but also when neglected, as it often was, it assumed a very virulent form.[1] Somasundaram, reviewing the history of syphilis more than a century later, emphasized that syphilis in general and neurosyphilis, in particular, are “the integral parts of the history of psychiatry”.[2] Syphilis in many ways encapsulated the entire range of psychiatric practice, from the range of definitions of its various stages and syndromes, the discovery of its biological causes, and the social response of stigma and exclusion. Its history has been extensively reviewed in the European context. In the 19th century, psychiatrists such as Griesinger and Kraepelin found that almost one-third of the psychiatric patients had various manifestation of neurosyphilis. This report explores the presentation and management of syphilis at the Mysore Government Mental Hospital (MGMH) at the turn of the twentieth century.

SYPHILIS AND GENERAL PARALYSIS OF THE INSANE

General paralysis of the insane (GPI), which is a late manifestation of syphilis, emerged as a new syndrome of insanity during the early nineteenth century. The specific etiology of GPI had been suggested as early as in 1857, but it continued to be thought of as multicausal. The course of GPI was one of steady, progressive mental and physical deterioration, ending in death. The disease resulted in muscular incoordination and paralysis along with the development of degenerative dementia; hence, the disease's pseudonym “dementia paralytica.”[3] It was only in the early twentieth century that the “syphilitic hypothesis” began to achieve widespread acceptance, when, in 1913, Hideyo Noguchi demonstrated the presence of the organism, then called Spirochaete pallida, in the brain of a patient who had died of GPI.[4]

The identification of Treponema pallidum, a spirochaete bacterium with subspecies that cause treponemal diseases such as syphilis,[5] by Fritz Schaudinn and Erich Hoffmann in 1905 was followed by the development of a serologic test. A specific reaction to detect antibodies, apparently indicative of infection with syphilis, by August von Wassermann, Neisser, and Bruck was developed in 1906. This was, however, discovered to be fallible later, as the assay required neither specific antibodies nor a specific antigen to yield a positive result. Fleck commented, saying that it was “possible to obtain a positive Wassermann reaction from a normal blood sample and a negative one from a syphilitic sample without any major technical errors.”[6] Nonetheless, the Wassermann test proved to be a very popular diagnostic test for syphilis in the early years, with immense practical value in medicine.

The first effective treatment was Arsphenamine, which also known as salvarsan or compound 606, developed by Paul Ehrlich in 1910, and it proved to be a great improvement in comparison to the earlier mercury based-treatments in terms of time, administering technique, and side effects.[7] Extensive research and etiological discoveries gradually improved the understanding of this condition. Wagner Jauregg in 1917 found that the bacillus was peculiarly sensitive to heat and that inducing fever was thus an effective way of treating GPI.[8] Fever therapy was thus a therapeutic milestone, as it was based on the extensive research and collection of empirical observations done in the early twentieth century.

HISTORY OF SERUM TESTING IN INDIA

In India, the British government made public health one of its responsibilities and took many steps to fight the disease. The Contagious Diseases Acts were enforced between 1864 and 1869. Under the Act, sex workers were subject to compulsory medical examinations, and if found to be infected, they would be confined to a Lock Hospital for up to 3 months; after which they were regarded as cured.[4] This policy, instead of protecting the women involved in this trade, was actually meant to protect or their clients.[9] Later, at a conference in Belgium, the Brussels Agreement of 1924 was signed wherein the British government proposed a resolution, stating that there should be adequate international facilities providing diagnosis for venereal diseases and their treatment in every major port, free of charge to any seafarer employed for the purposes of commerce on ocean and river vessels, regardless of nationality, race, or rank.[10]

The sanitary regulations were created by the British Government to control the houses of ill-fame and to prevent the spreading of venereal diseases. The sanitary regulations regulated certain registered prostitutes to only accept British clients and would also enforce that the sex-workers were examined at the Lock Hospitals regularly. This, it was felt, was the best way to fight VD in British troops,[11] and thus, the military often had their own brothels, and the women who worked in these were examined for VD every 2 weeks in Lock Hospitals.[12]

Accounts of early serology in India can be traced back to the Harrison study (1903). Harrison was a bacteriologist who recorded the examinations of cervical smears. At this time, cultures of Neisseria gonorrhoea as a diagnostic aid, to diagnose gonorrhea (another common sexually transmitted disease) were not available in India. It was only after 1906 that the Wasserman and dark ground microscopy became available, but their use in the army was delayed because of poor microscopy and technical problems. In 1910, microscopy and serology came into general use throughout the British Empire when proper training in Venereology was started.[4] Many cases of early syphilis were thus either diagnosed as chancroid or missed altogether before the advent of serology. To come to a definitive diagnosis doubtful, atypical cases were at times left untreated to see whether or not they developed secondary syphilis.[13]

However, it took some time for the screening and treatment to make its way to India. Its use in Asylums and Mental hospitals, where those with GPI would be likely to be admitted, was introduced only after the First World War. The Wasserman Test was first introduced in the MGMH in 1924, a little earlier than it was introduced in the Ranchi Indian Mental Hospital (1927).[14] The early introduction of the Wasserman Test in the Mysore Hospital can be credited to doctors like Francis Noronha, then Medical Superintendent, who applied the training he had received at the Maudsley Hospital in England, as well as the support extended by the Mysore Government for improving healthcare.[15]

SYPHILIS AND GENERAL PARALYSIS OF THE INSANE AT THE MYSORE GOVERNMENT MENTAL HOSPITAL

The first mention of syphilis in Bangalore appears in the diary of Dr. Charles Irving Smith. He worked as a Medical Officer at the Pettah Hospital for Soldiers, Peons, and Paupers in Bangalore. The diary contains the earliest recordings of the soldiers he had seen at the hospital. The diary indicates that among the troops from 1834 to 1838, there were 681 European patients and 212 Indian Patients diagnosed with syphilis. The diary also indicates that from July 1846 to December 1849 there were 1315 soldiers diagnosed with syphilis, which is relatively high.

In the case records of the MGMH, the first mention of syphilis as a diagnostic category is made in 1907; Mr. N, a 45-year-old Hindu male, was diagnosed with “mania syphilitic.” The first case of GPI is recorded in 1910; a Mr. S, a 35-year-old married Rajput pensioner from Kolar, who was admitted on October 06, 1910, with ganja, opium, and arrack also listed as causes. He died a few weeks later, on December 30, 1910. The cause of his illness is recorded as “moral,” as syphilis was viewed as a subject beyond the “boundaries of decency,” as it was a disease that was believed to affect only people who were immoral.[16]

Structured case notes and record-keeping were introduced at the Hospital in 1924, the same year that the Wasserman Test was introduced [Figure 1]. The use of the laboratory-based tests had a significant impact on diagnosis. Before such tests, diagnosis was based on aspects of history and phenomenology, as well as physical findings. We can see from the hospital records that the use of technology helped in diagnosing patients effectively.

Figure 1

The image of a patient's case record describing the doctor's notes on the patient's treatment

Before the introduction of Wasserman's Test, between 1907 and 1924, only 12 (1%) out of 837 admitted patients were diagnosed with syphilis. Among them, 6 were diagnosed with syphilis and 6 were diagnosed with GPI. After the introduction of Wasserman's Test, within a few years (1924–1930), 173 (17%) patients out of 988 patients who were admitted were diagnosed with syphilis. There was thus a 17-fold increase in the identification rate of syphilis.

CASE VIGNETTES

Below are described few of the case vignettes of patients who were admitted to the MGMH from 1921 to 1930. The vignettes are presented to illustrate the different kinds of patients admitted with difference in Class, Religion, Background, Symptoms, Treatments, and Outcomes.

Mrs. M, a 25-year-old widowed Roman Catholic, and a mother, was a resident of Bangalore. After the death of her husband some years ago, she lived with her mother for 3 years but later moved to a house, where she lived alone. She used to earn money by doing needle-work. She was presented with symptoms of being dull, apathetic, absent-minded, and indifferent to a certain amount; incoherent in speech and dirty in habits, she laughed without any purpose. Patient tested positive on the Wasserman Test. She was treated with neosalvarsan injections for syphilis. She died 8 months after being admitted.

Mr. B, a 50-year-old widowed Jain priest, was admitted as he was said to be dangerous to others. He was diagnosed with GPI and the cause of insanity was said to be syphilis.

Mr. B, a 25-year-old unmarried Muslim, was a resident of Mysore. He was diagnosed with delusional insanity. He presented with “escalating anxiety symptoms,” like being boisterous, at times violent, having dirty habits, and talking incoherently. Most of his complaints were related to anxiety behavior, but he had a history of delusions. He said he had been given the title of colonel. He said he had Rs. 40,000 in the Mysore Bank and that he got Rs. 50,000 per year as colonel. He said that after being discharged from the hospital, he would become a white man, join the Germans, and become a lawyer in Mysore. He was diagnosed with syphilis following the Wasserman Test. He was prescribed calomel. He developed a left hemiparesis and died. His overall stay in the asylum was for 54 months.

Mr. C was a 45-year-old Hindu Brahmin priest, residing in Bangalore. He had earlier diagnosed with “acute excitement mania.” The patient's wife had died in 1923 and his son, who was a university student, also died in the same year. He had been brought in with symptoms of becoming ill-tempered and violent. He had thrown off his holy thread and created lot of trouble at home, shaking the garuda khamba (sacred pillar) in the Chickpet temple and beating his brother. His physical condition was normal. He was diagnosed as having syphilis when the Wasserman Test was conducted. He underwent tub bath therapy (a bath at 105°C, probably an early local variation of malarial therapy) for half an hour, followed by supplement q30 in hot milk. After 1 month of stay in the asylum, he was discharged as his condition had improved and he showed normal behavior.

Mr. D, a 35-year-old Muslim residing in Birur, was working as a servant. He was diagnosed with dementia. He was brought in with symptoms of experiencing hallucinations, “dirty habits, tendency to injure himself and others.” He had delusions that he was the Raja of Mysore and that another patient, S, in the asylum was his brother-in-law. Physical condition such as body weight, temperature, and state of skin was normal. Patient tested positive on the Wasserman Test. His condition worsened, and he died because of diarrhea. His overall stay in the asylum was for 8 months.

Mr. J was a 35-year-old married Hindu residing in Bangalore and working as a trader. He was diagnosed with “dementia syphilis.” He presented with symptoms of dirty habits, violent behavior, and abusive language. Physical conditions such as body weight, temperature, and state of skin were normal. Patient showed a positive on the Wasserman Test. He was treated with neosalvarsan, but his health did not improve, and he died just 20 days after being admitted to the hospital.

Mr. T was a 58-year-old married Christian from the Cantonment, Bangalore. He was a mining engineer and builder. His supposed cause of insanity was mentioned as syphilitic. The patient was diagnosed with GPI. He said that he had left England in 1887, gone to New Zealand for 6 and a half years, and then to Burma before he returned to England. He had finally come to India 7 months before being admitted. He presented with symptoms of wandering the streets at night. He had delusions: he believed that he had tamed a mad horse and that his right foot was broken. He had also said that he would be going back to New Zealand in a week. The patient tested positive on the Wasserman Test. He was treated with calomel and sodium bicarbonate. His condition became worse, and he died 6 months after being admitted, due to emaciation.

Mr. R was a 65-year-old widowed Hindu from Shimoga. He was a forester by profession. The supposed cause of illness was mentioned as prolonged mental stress. He was diagnosed with “dementia senile.” He presented with symptoms of being very talkative, misbehaving, and having wandering ideas and dirty habits. He cried and laughed for no reason. The patient showed a positive on the Wasserman Test. He was treated with calomel and sodium bicarbonate. His condition became worse, and he died due to diarrhea after 5 months of being in the hospital.

Mr. S was a widowed 45-year-old Hindu Brahmin from Mysore. He was a Shanbagne. The patient recounted that he had been to Puttadevarabhatti (a nearby village) to ask for a bride. He then went to Chamundi (a temple on a hill) 3 days later, and on his way, he was detained by police and subsequently brought to Bangalore. He was diagnosed “insane” with excitement and delusions. He presented with symptoms of talking incoherently and was obedient but did not answer questions. He said that he was 5-year-old and that he did not know anything. His supposed cause of illness was mentioned as his wife's death. The patient tested positive on the Wasserman Test. He later became very weak, vomited, and suddenly collapsed. He died after 2 years and 8 months in the hospital.

Mr. V was a single 38-year-old Vokaliga Hindu from the Kolar District. He was an agriculturist. Duration of attack was 5 years. He was diagnosed with “dementia praecox” (paranoid). He presented with symptoms of incoherent talk, sometimes laughing and singing to himself. At times, he would become irritable and had tried to beat his servant. He had hallucinations of the earth is sinking down and seemed to believe that there was no one living on the earth. He had become impulsive and cut his throat with a sickle. His Wasserman Test was positive. He suffered from severe dysentery, for which he was treated with antidysentery serum, 3000 cc of normal saline solution, and adrenaline injections. He died 7 months after being admitted.

Some of the patients described above diagnosed with syphilis and GPI were quite young in age. They exhibit a range of symptoms, ranging from changes in affect, psychotic symptoms and cognitive decline, highlighting the complex symptoms of syphilis. In contrast, patients admitted with GPI in asylums in the UK in the 19th century were usually in their late 30s or 40s. However, the younger age of presentation seen at the Government Mental Hospital matches more recent hospital scenarios, where, with a reappearance of syphilis, we see even younger patients (in the age group of 20–29) admitted with syphilis and GPI.[17]

MEDICAL AND SOCIAL EPIDEMIOLOGY IN THE MYSORE GOVERNMENT MENTAL HOSPITAL

The case records available at the MGMH from the year 1924 give detailed information regarding admissions rates as well as other clinical and sociodemographic details.

The case records also give information regarding the total number of patients admitted each year, the number of patients on whom the Wasserman Test was administered, as well as the number of patients who tested positive according on it. The following table gives a detailed account of the numbers from 1924 to 1930 [Table 1].

Table 1

Annual admissions at the Mysore Government Mental Hospital and positive diagnosis on Wasserman's test

The Wasserman Test was thus conducted on 336 patients out of 988 (34%), of whom about half 173 (51%) tested positive on the Wasserman Test. Syphilis was thus suspected in about 17% of patients admitted at MGMH in this period.

From the above data, it can be understood that the doctors carried out the test only in a proportion of patients based on clinical suspicion, and it is thus likely that there was an underreporting of prevalence. The decision for conducting the Wasserman Test was probably determined not just by clinical suspicion, but perhaps the costs as well, as both the necessary technology, as well as trained manpower, were limited. Nevertheless, the high rate of detection, and its role in improving the diagnosis of syphilis, is evident.

The case records provided information regarding various sociodemographic trends as well medical data. The most common clinical diagnosis among the patients who were later suspected of syphilis and GPI were “mania” and “dementia praecox,” as is expected in view of the overlap of psychotic symptoms with syphilis. These diagnoses were more frequent in men than women, most often diagnosed in married patients in the age group of 25–60 years. The patients were from varied religious backgrounds. They included domestic servants, as well as actors and priests. This shows that the disease was well established in society and that the disease had cut across class, caste, and religious groups. The increasing rate of syphilis, and clinical presentation at the hospital, thus allows us some insight into what was going on in the community.

Early treatments for syphilis included iodine douches, potassium iodide, “hot baths,” and neosalvarsan. Fever (malaria) therapy had been introduced earlier, as it was seen that the Treponema bacteria were sensitive to the fever produced by malaria,[18] but the methods were probably not available easily in Bangalore. Sustained exposure to hot water, described in one case, was perhaps used in an attempt to raise core body temperature, to recapitulate and mimic the actions attributed to malaria therapy. This indicates that the incorporation of new treatments was guided by plausible scientific explanations, rather than by merely following trends. Potassium iodide and neosalvarsan are first mentioned in the year 1924. Some patients were given as many as 4 injections of neosalvarsan (four 0.6 g doses) on each occasion, which seemed to have helped. Patients are also seen to be given sodium bromide and sulfasenol.

GLOBAL IMPRESSION OF SYPHILIS

Syphilis has been one of the most interesting of diseases from a historical standpoint. It has held interest not just on account of its origin, and the arguments regarding its etiology, but also on account of the sway it held on morals and measures toward public health. It appeared at the end of the 14th century in Europe, and by the 16th century, had spread to the major countries of the continent. Syphilis was brought to Calicut, in India, by the Portuguese explorer Vasco da Gama in 1498 who completed his voyage to the Cape of Good Hope and landed on the Malabar Coast on May 20th, 1498.[19] By 1520, syphilis had reached Africa and China, and it was considered the sexual curse of the 16th century. In India, the Muslims blamed the Hindus for the outbreak of the disease, while the Hindus blamed the Muslims, but in the end, everyone blamed the Europeans[20] and called it “phirangiroga” (the disease of foreigners).[21] Its treatment around the globe included such items as mercurials, arsenic, and ash from snakeskin and was broadly analogous to methods used in contemporary European and Arabic medicine. Ayurveda called it phirangiroga and used mercury to treat it which was derived from Unani.[22] This suggests that the various schools of medicine shared ideas and treatments in the fifteenth and sixteenth centuries, and this exchange of scientific ideas continues to this date.

DISCUSSION

This study focuses on the early understanding of syphilis and GPI, the global impressions that existed in society, early misdiagnosis, the Wasserman Test, and the treatment of syphilis in the early twentieth century.

As earlier mentioned, the Diary of Dr. Charles Irving illustrates that from July 1846 to December 1849, there were 1315 soldiers diagnosed with syphilis which is higher than the numbers mentioned in the current paper. This could be because, the Hospital catered to the Soldiers, and it was made compulsory by the British Government to examine all the Soldiers in the Cantonment, which might have been why higher number of soldiers were diagnosed with syphilis.

While the clinical syndrome of GPI and various forms of syphilis were reflected in the Hospital records, it was introduction of the Wasserman Test that increased the frequency of diagnosis of syphilis. Whether these cases reflected “false positives,” or were true cases, which reflected the protean manifestations of syphilis, cannot be differentiated at this juncture. Empirical biomarkers continue to have an ambiguous correlation with psychiatric syndromes.

At Mysore, the treatment for syphilis included “hot baths” in 1924. Cold baths, as well as hydrotherapy, were used as a treatment for patients with mania to calm them down. In this instance, however, it is likely that hot baths as a treatment for syphilis were based on the observation that raised body temperature, salivation, and sweating attenuated the syphilitic poisons.[23] This was based on epidemiological observations in tropical South America, as well as the fever therapy of Juaregg.[18] Hot baths were used extensively in asylums, but the use of the specific hot bath of definite duration specified in a Wasserman positive person indicates that an effort was being made to mimic the raised temperature as seen in fever therapy. Both diagnoses and treatment were thus guided by supposedly empirical, scientific data and showed that contemporary ideas in biomedicine were quick to be incorporated, and adapted, into medical care in India.

The social issues raised by syphilis as a communicable disease, linked to “high-risk” behavior, also mirrors contemporary concerns. The British Colonial Government's plan to fight the disease was to limit spread, by subjecting female sex workers to compulsory intrusive examinations. There was little evident effort to reduce high-risk behavior by the men (who were more frequently diagnosed with syphilis compared to women) or to impose any strict rules for men who visited these sex workers. Responses to syphilis in the past are also not dissimilar to the current scenario with respect to HIV/AIDS. AIDS is considered to be the twin of syphilis, born generations apart, and there is remarkable resemblance between these two so-called “blood brothers” in terms of doom, sex, and death.[24] Female sex workers who work along highways are being educated by different researchers/organisations about AIDS and the use of condoms, while no steps are being taken to either interview or educate the male truck drivers who visit these sex workers.[25] It is the same story in red light areas, where female sex workers are given condoms and encouraged to use them, but the men visiting them are completely ignored. Gender distortions in public health approaches continue to persist.[26]

CONCLUSION

Syphilis was not recognized as a psychiatric disease until the late 18th century; syphilis as being the cause for the deadly disease GPI was not accepted until the early twentieth century. These diseases, which were among the most feared diseases that prevailed in nineteenth-century asylums, have almost been eradicated. However, recent studies have shown the reemergence of syphilis[27] and that the eradication of syphilis may only be possible, if at all, by 2020.[28]

The oscillation of syphilis from a moral transgression, to a diagnostic syndrome, to a circumscribed bacterial infection, encapsulates many trends in psychiatric diagnoses. Over a few centuries, syphilis, which was first seen as a moral scourge, was soon identified as merely a bacterial infection, and after the discovery of penicillin, a not particularly lethal one. Advances in medicine and the sciences of bacteriology and pharmacology helped this change immensely. The use of the Wasserman Test and related somatic treatments for syphilis show how contemporary biomedicine was introduced in Mysore Kingdom, and the rest of British India, during the colonial period, and its use became widespread quite rapidly. The sharing of ideas and training had a positive impact on disease recognition and treatment. Both local and global trends in the understanding of disease were evident then and need to be kept in mind even at present.

Financial support and sponsorship

The authors are thankful to Wellcome Trust, UK (Wellcome Trust, UK, Turning the Pages, 096493/Z/11/Z) for funding the study.

Conflicts of interest

There are no conflicts of interest.

The story of syphilis dates back to the 1500s, to an epic poem written by an Italian physician about a young shepherd called Syphilis, who angered Apollo such that the good struck him down with a malady that destroyed his good looks. The disease, named after this fictional shepherd, ravaged the 16th – century world and continued to affect people all over the world, and has reemerged in the times of HIV. Syphilis also made its advent in India in the 16th century, when it came to first be known as a “firangi roga.” Syphilization, a procedure pioneered in the 1840s by the French clinician Joseph-Alexandere Auzias-Turenne, aimed to inoculate individuals repeatedly with the infected material, to eventually obtain immunity against reinfection, continues to draws intense debate.

The authors in this paper discuss the presentation and early management of syphilis at the Mysore Government Mental Hospital at the turn of the twentieth century. Although the disease had been around for nearly five centuries, the discovery of Treponema pallidum and the development of tests for syphilis in the early twentieth century, followed by several empirical treatments led to a great enthusiasm to test patients for this disease. The arrival of microscopy and serology into general use throughout the Empire saw a surge in testing for venereal diseases. In the 1920s, wide use of the Wasserman's test became apparent and replaced the largely clinical diagnosis of syphilis, which had occurred earlier, leading to a surge in diagnosis. While the paper focuses primarily on the diagnosis of syphilis in the mental hospital, it sweeps its gaze across the wider notions of syphilis in society, particularly from the social gaze.