An analysis of the recognition of syphilis disease and the ways of its entry to Iran during the Safawi era with an emphasis on Ateshak (Syphilis) treatise

Introduction

The establishment of the Safavid dynasty in Iran initiated a period of security and peace, which next to the establishment of national unity, through the declaration of a common official national religion, the foundations of many social changes and developments were laid. In that context, one of the primary concerns of the people is health and treatment and monitoring medical issues. Urbanization, on a great scale like what is observed in the Safavid era, required complex devices and extensive planning in all aspects, especially public health. There existed many physicians who, while being the bearers and inheritors of Iran's ancient medical traditions, sought to improve this vital field. The existence of many medical treatises left from that period exposes a big question mark in front of the theory, Algod, who believed that Iranian physicians, unaware of the similar new lifestyle that had spread throughout Europe, made themselves the intelligent successors of Avicenna, and thought that medical science and knowledge was in complete stagnation during this period (Algod, 1371).

One of these treatises, that reveals the intelligence and accuracy of Iranian physicians in the field of diagnosing and treating diseases, is "Fire" written by Emaduddin Mahmoud bin Masoud Shirazi, a famous physicians. He sought to describe the symptoms, prevention, and treatment of this disease by writing an independent treatise for the first time. In the introduction of his workbook, he refers to the history of this disease which was considered a new imported disease from abroad (the West). Before him, Baha al-Dawlah Razi had referred to this disease in his book and explained it. Following Razi, Emaduddin explained it in an independent treatise, while what occupies the reader's mind is the answer to the following questions:

- Is this a disease imported from the West or it is domestic of Iran?

- Were physicians able to diagnose it before the Safavid era?

- To what extent are the descriptions of the causes and treatment methods correspond to today's reality?

The objective here is to search the biography of Emaduddin Mahmoud Shirazi through different narratives by referring to historical sources and explaining the reason for authoring the Treatise on Atshak (syphilis) and its importance. After a brief statement about the history of syphilis by analyzing the data and explaining the causes of the disease and its treatment methods in the past, to reach a correct understanding of what it is and the degree of conformity of the descriptions of the past with today's realities will be discussed.

According to the studies run to date, there exists no independent article or book on this issue except Willem Fleur in the book "History of Sex in Iran" where a brief history of syphilis, especially in the contemporary era. Yunus Karamati and Ruqieh Hosseini in an article titled "The oldest Persian reports about Atashak" introduce the book “Summary of Experiments” written by Baha al-Dawlah Razi, where, like all other writings, and unlike this article the core is based on the believe that this disease is imported.

Imad al-Din Mahmoud bin Masoud

During the Safavid era, the court medical group included a chief physician and a few court physicians. The head physician of the royal family was called "Hakeem Bashi" who enjoyed special favors by meeting with the king's generals and participating in private gatherings, next to occasional involvement in politics. One of the famous court physicians was Emadaldin Mahmoud Shirazi, famous for medicine and wisdom, who will be remembered in the history of Iranian and Indian medicine.

According to (Zol al-Rahman, 1978: 40), "The chain of discipleship of two high-ranking medical families in India the Sharifi family (Delhi) and Azizi family (Lucknow) embodies Emadaldin Mahmoud Shirazi. Khawaja Mahmoud, the heir of the noble Sharif family, was his student. Hakim Mohammad Yaqub Lakhnavi is related to him through intermediaries. Hakim Mir Mohammad Baqer, the son of Borumand Emad al-Din is among those mediators."

Among his students Mirghiyath al-Din Mansour Dashtaki, who, according to Qazi Shoushtari in Shafi'a's treatise on medicine, "had studied it with Hakeem Fazil Hazeq Maulana Imad al-Din Mahmud Shirazi in the beginning of his study of medicine is the outstanding, (Madrasi, 1374: 259). Dashtaki was one of the physicians known for taking care of personal hygiene and health, especially when dealing with patients in his community (Jaafari, 1390: 33).

After his father died, Imad al-Din Mahmud Shirazi was forced by the King to go to Shirvan, to serve the governor of Shirvan, Abdullah Khan Stajlu (Algoud, 1357: 25), but because being too close to the rulers is not without risks for any servant, he experienced such a punishment due to the anger of the ruler, and was kept in the middle of a pound full of ice. Of course, his medical knowledge made him survive: according to the author of the book Khaled Berin, because he was addicted to opium, consuming extra doses of opium that night saved his life (Vale Isfahanian 1372).

This incident made him lose the esteem of the ruler of Shirvan, and after a while, he joined the service of Tahmasb and spent some time in Qazvin, the capital of the Safavid government. Apparently, after some time, he decided that it was better to keep away from the courtiers, and according to Shah Tahmasb's order, he left Qazvin for Mashhad and practiced medicine in Mashhad Dar Ol-shafa (Hospital). There, Shirazi, with a free spirit began to compose ballads, next to medical writings on scabies and syphilis. He wrote about the waste of his life in court-related works with a regretful expression: "... he spent most of his life, even though he remembered what he knew and could be accomplished, but unfortunately his life span prevented his desires..." (Shirazi, 2012: 2)

Manuscripts of many books he authored are available in libraries in Iran and abroad. According to Hakim Syed Zal-ul-Rahman, his works, which are in the libraries of India and Pakistan, consist of:

1- Commentary on the law (Arabic)

2- Book of Commentary (Arabic)

3- Description of the law (Arabic)

4- Al-Murkabbat al-Shahiyah (Arabic)

5- Treatise on Afion (opium) (Farsi)

6- Treatise on Ateshak (syphilis) (Farsi)

7- Treatise on Yakuti (Farsi)

8- Treatise on Fadzahar's (Farsi)

9- Treatise on Chinese wood (Farsi)

10- Treatise on Jadri (Farsi)

11- Treatise on the effect of Tin (Farsi)

12- Treatise on toxins (Farsi)

13- Treatise on Atrilal (Farsi)

14- Treatise on boys’-related diseases (Farsi)

15- Treatise on curing manuscripts (Farsi)

16- Treatise on Michael's weights (Farsi)

17- Treatise on the experiences of Imad al-Din (Farsi)

Among these treatments the one with Chinese wood is outstanding. In addition to being effective on some diseases, Chinese wood was a special medicine for anthrax. According to Mirza Qazi bin Kashf al-Din Yazidi Hamavi, Chinese wood was discovered in 1494 AD and it became common in Iran through the eastern physicians, when Ateshek was discovered in Iran. This claim is questionable because, before the middle of the 17th century in Europe, no one was aware of Chinese wood (Zall-ur-Rahman, Bita: 342). Baha'u-d-Dawlah Razi not only mentions syphilis for the first time but discusses its treatment in detail in his book, "Summary of Experience", without referring to this drug (Noorbakhshi, 1909 AD: 381). Elgood considers Imaduddin as its discoverer and some others refer to it in amazing stories. What is certain is that for the first time, Hakim Imaduddin wrote an article about this plant, and even people like Hakim Noorallah Aladdin Tabrizi. These treatises are available in the library of Imam Reza, peace is upon him, and the right of precedence is that of Hakim Emaduddin (Tabrizi, vol. 2/172).

A brief history of mixed diseases

The concept of mixed diseases has always occupied patients’ and physicians' minds. Baha'-Dulah Razi, a famous physician of the Safavid era (died in 928 AH), in his book “Summary of Experiences” described the disease of syphilis, which at that time was known as Ateshak, and introduced treatment methods

Less than half a century after him, another physician named Imad al-Din Mahmoud Shirazi (about 1515-1592 AD) described this disease and explained his special treatment thereof, and after him, another physician named Dashtaki emphasized the physicians' sensitivity to this disease. According to Dashtaki, "Mir was extremely safe from anthrax" (Qami, 1359: 296). Another historian writes, " Mir was afraid of this disease, thus, hated all the people of the world, and he did not touch anybody (Romola 1357). Some of his behaviors in this regard were refraining from shaking hands, even with the elders of the country, except with the hand inside the sleeve, and asking his companions during a short or a long journey, about the history of contracting this disease.

These behaviors gradually led to extreme obsessions, a sense that his acquaintances and those around, him sometimes abused Mir's sensitivity, and to discredit some people, accused them of having smallpox and in this way, Mir's relationship with them broke down. In this context, there exists poetic verse in the description of Mir: (Qami, 1359: 297)

Being dressed from the fear of this obsession He constantly was in fear of syphilis

He was not obsessed with touching his clothes Though he always washed his hands

This disease was known as a shameful disease at that time and Flor writes:

"Babar, who is one of the first referring to this disease, writes in his memoirs about the high judge of Qazi Khwaja Abdallah Marwarid: due to extremism, he fell ill with a shameful disease and suffered for years and eventually died. Sam Mirza mentions seven poets who died of this disease. Infectious diseases have become a major problem in big urban areas. According to French monk Raphael Duman in 1101 AD, the team in Isfahan become adults in the whorehouse, consequently, about half of the population of that city became entangled in this aphrodisiac disease" (Floor, 2008:134).

The reasons for the spread of this disease in Iran varied, apart from the cases that were transmitted during child delivery or through contact with an infected wound, the existence of marriage traditions and the prevalence of some sexual promiscuity among the classes of people, lead to the spread of this disease.

According to Flore, "Getting close to male or female prostitutes, taking a concubine, basically in big trading and pilgrimage cities, and prostitution among men caused the spread of sexually transmitted diseases more than anything else... The prevalence of prostitution in the streets back alleys, parks, cemeteries, nightstands, and coffee houses, or at home, next to bringing in singers, dancers, or others contributed to the transmission of these diseases." (Ibid: 145)

Though it is a bit difficult for us to believe this opinion of Flora today, it is an undeniable fact. Referring to some sources concerning the type of women's makeup then reveals that some of the aforementioned sexual deviations became a habit among the social strata which caused women to compete with young men. According to the writings where the focus is on the history and style of makeup. A type of Qajar court women's makeup was to grow a short mustache, was for this purpose:

(Barjesteh, 2003: 110) depicts "... an obvious example of this strange fashion in the photo of Prince Gohar Malek Taj Kikavsi. This artificial image can be seen in two pictures of Baghban Bashi, one of Naseruddin Shah's beloved wives. Mrs. McNeil observed that the line above the lips causes ugliness and defects the natural beauty of the women of Mahd Alia Shrine... Based on the written and pained evidence of this fashion in the past, it should be assumed that it was limited to the era after Fath Ali Shah, and never been exercised in the scope of beauty items. This discussion reveals a kind of unconscious desire of women to compete with young men who, as competitors of women, attract men who have extreme freedom in sexual deviance.

About authoring the book

There exists no direct reference to syphilis in traditional medicine books until the Safavid era, because before this era, either the physicians were not able to distinguish between this disease and similar diseases, or according to the author of Ateshak treatise:

"Because the disease that is known as anthrax did not exist before this era and none of the physicians diagnosed and commented on it, there was no author, who considered that disease and wrote more or less about it" (Shirazi, 1382: 3).

Of course, about a quarter of a century before Shirazi, in his book “Summary of Experiments”, Baha'd-Dawla Razi gave a brief description and interpretation of this disease and quoted Greek and Indian physicians regarding the treatment of this disease. The author of Ateshak's treatise believes that this secret writing is not sufficient and at the same time complains that the rest of the physicians were either busy with other matters like studying drugs and dementia or matters related to cannabis and opium with little care about this disease. He regretfully mentions the court physicians who were so involved in government affairs and served courtiers with no concern about others.

The writing of this treatise was completed on the fifth day of Rabi' al-Thani 977 AH by Imad al-Din Mahmoud bin Masoud Shirazi, the book version of which was written seven years later, on the first day of Jumadi 984 AH, by Ali Reza bin Hassan b. Masoud al-Tabbi, probably the nephew of the author, in 48 pages.

The manuscript of this treatise is kept in the library of the National Assembly, under the number 16239/6307, and in 1382 AH, one hundred copies were made from it by the efforts of the Institute of Medical History, Islamic Medicine and Complementary Studies affiliated to the Iran University of Medical Sciences, placed at the disposal of some universities.

Image No. 1 of the first page of the manuscript of the treatise of Atshak

This treatise, which is the first independent Farsi work on anthrax written in that period (Algod, 1371: 429), can be divided into six sections:  1) the reason for writing the book, 2) the name of smallpox disease is explained, 3) the symptoms of the disease in general and then in different moods are explained in detail and the causes of this disease have been discussed, 4) The next part of the book, 5) explains the methods of its treatment in different temperaments, and 6) examining and criticizing the opinions of Baha-ud-Dawlah Razi in this regard.

The fame of this disease

Regarding the vocabulary related to this disease, foreign smallpox, syphilis, and Armenian seed, Shirazi believes that:

"… and the fact that they called it Farang smallpox, proves that just like smallpox it boils, referred to as Jadri in Arabic, named fire because of the burning excitation, and attributed it to as an imported disease from the European countries or a country close to Iran, and the fact that they named it the Armenian seed is because it appeared in the Armenian the neighboring country in the North of Iran..." (Shirazi, 2012: 3)

According to some authors, this disease appeared or at least was described in the West for the first time at the end of the 15th century after the return of the Spanish soldiers from America, and they considered it to be the curse of the Native American Gods. In France, it appeared as an epidemic for the first time in Charles VIII’s army described in detail by Girolamo Fracastro in three volumes. In Iran, it was initiated due to the presence of Benamim Western foreigners, which is not close to reality, and there are many reasons to doubt this claim.

The communication among societies, especially the communication between East and West, was very limited, by land, and only a few western ambassadors traveled. Then the Muslims did not favor them and did not have much dealing with them. Even the king's behavior was not very kind to them, for example when Anthony Jenkinson, the English ambassador, left the court; one was assigned to sprinkle dirt behind his head, and on his footprints, to remove the impurity from the ground (Tahmasabi, 1396: 110). However, how can it be imagined that such a few people with such a position could become the source of spreading some kind of sexually transmitted disease in Muslim countries, whose scope can be extended to distant pilgrimage cities like Mashhad?

The available records indicate that this disease was not common in Europe. In the same era, sea transportation was in its infancy, though it expanded to such an extent that a small group of Portuguese, led by Vascodgama, could bypass the Good Hope Cape in South Africa and reach the islands of the Persian Gulf with difficulty. The presence of Portuguese sailors could not justify the spread of the disease through their interactions with the natives. This disease, for the first time, was described by Baha al-Dawlah Razi, around 1490, naturally, the cause should be looked for elsewhere.

Perhaps the most important hypothesis is that the physicians due to the similarity of the symptoms of this disease with similar diseases, because they were not able to make a distinction. This issue is unprecedented in the history of medicine, but the first who was able to differentiate between smallpox and measles was Abu Bakr Razi. In support of this assumption, perhaps the most important reference is the author of Ateshak's treatise, who clearly states that the physicians of that period had many differences of opinion regarding the symptoms and diagnosis of this disease and confused it with some other diseases like the Persian Nar disease. Some physicians took this disease as scabies and were not able to distinguish between the two. Mohammad ibn Masud Shirazi believes that the appearance of symptoms and the contents of skin lesions reveal that this disease is completely different from scabies. To him, unlike scabies, anthrax is found on the skin, flesh, and big muscles, and sometimes it even involves the internal organs, thus making the body heavy and weak so the patient is not able even to pick up a cup or jug. He believes that syphilis is more common in the upper body parts, while scabies is more common in the hands, feet, and armpits, (Shirazi, 1382: 5); consequently, it can be stated that this disease was probably common, but the physicians were not able to distinguish it from similar disease.

About the causes of the disease

Today, doctors consider the cause of syphilis to be a type of bacteria (www.cdc.gov/std/syphilis/stats.htm) the main transmission methods of which are uncontrolled sex and non-hygienic lifestyle. The method of transmission from mother to fetus and in some cases through infections blood prevail as well, but transmission through normal relations like any physical contact via the bathroom and swimming pool, etc. are not reported. /syphilis.emedtv.com/syphilis/syphilis-transmission.html)

Shirazi considers the main cause of anthrax disease being the atrabilious nature of the patient is excessive burning and stinky feeling and he explains its main cause as follows: "be aware that anthrax is a disease caused by burning or stinking soda in a certain way. If it is found in the inner body, it is caused by the natural elimination of boiling, which causes the separation of the components of the stomach, whether inflated or not, in the latter case it does not apply to any of the subject diseases, because of the absence of atrabilious nature" (Shirazi, 2012: 3).

Shirazi is the first who emphasize the contagiousness of the disease and believes that this disease is sometimes found "due to contagion" and the most important type of contagion is that: "... it happens in the bathroom, because the vapors of the patient's body, which is similar to the quality of the rind, are evaporated more in the bathroom, and it has a great effect on the outside and the inside through the inhalation and penetration into the pores (Shirazi, 2012: 3). He believes that one of the ways of spreading the disease is the use of shared razors, which can transmit the disease from a sick person to the healthy.

Shirazi has a very interesting and decisive opinion about the lack of role of heredity in this disease and emphasizes that this disease is not one of the hereditary diseases that appear in the next generations and even if it occurs in the child by chance, it is through contagion not heredity. As to nutrition, he believes that consumption of some types of food can cause disease, with a high emphasis on the role of disease transmission through dairy products. To him using a sick person’s glass may cause the transmission and contagion of the disease. Wearing the clothes of a sick person, especially underwear or shirt, even if they are completely washed, can cause disease transmission (Shirazi, 1382: 12).

The symptoms and treatment of the disease

In introducing the symptoms of this disease, Shirazi first explains the common symptoms that all patients have and next, explains the specific signs therein in different temperaments. In describing the common symptoms, he believes that the feeling of heaviness in the whole body next to an overwhelming weakness in nerves and muscles is inevitable. The severity of this weakness is unable the patient to carry and lift even light weights. It is interesting to know that he claims that at this stage the subject has no fever.

Image number 2 of a page from Atseh's treatise

According to Mohammad ibn Masoud Shirazi:

If the causation is due to the atrabilious nature of the patient expressed as bloody the signs are:

- Large pimples with red surrounding and surface

- Visible and protruding vessels

- Swollen and bloated skin

If the disease is biliary, the signs are:

- Appearance of small sharp-headed pimples "Namle"

- No severe redness

- Smoothness around the pimples without bloating

- The pain and burning of the pimples and early bleeding that injures wherever it spills

If the substance of this disease is phlegm, the prevailing signs are:

- The low count of juicy pimples

- Big, flat, and whitish pimples

- Puffed eyes

- Mild burning and combustion feeling

- Drowsiness next to excessive heaviness and weakness in the body

If the substance of this disease is atrabilious, the signs are:

- Less juicy Pimples

- Flat-headed pimple and the lack of early healing of the wound caused thereof

- The pimples with black surrounding

- Low degree of burning and combustion

As to the treatment of this disease, though in a general statement, Shirazi believes that the treatment of this disease first, is to improve the diet and "...generate and spit healthy phlegm to extract rotten material". Following this, thirty-five pages of the treatise are written in detail explaining different treatment methods, beginning with herbal medicines and ending with diets, cupping, and emasculation, and in every case where Baha'ul-Dawlah Razi has commented on this matter, he criticizes and examines the issue.

Result

Contrary to the general opinion originated from the words of Emad al-Din, who considers the spread of syphilis disease as an imported disease from Europe to Iran. According to the information available today the methods of transmission of this disease, are mostly caused due to unsanitary and non-hygienic sexual contact and through mother to infant, it can be claimed that the reason for the spread of this disease was sexual intercourse between Europeans and Iranians. By assessing Mohammad ibn Masoud Shirazi's statements, it can be assumed that the physicians then were not able to differentiate this disease from similar diseases and the honor of explaining this disease went to Baha'd Doulah Razi and after Mohammad ibn Masoud Shirazi. It should be noted that he was the first who realize the contagiousness of syphilis at a time when even the role of bacteria and microorganisms in the transmission of this disease was not discovered