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Syphilis

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In 1495, after Charles VIII of France fought the Spanish for control of Naples, a new disease spread across Europe. The army of mercenaries went back to their homelands, taking a new sexually transmitted disease with them1.

On their flippant way through Italy, the French carelessly picked up Genoa, Naples and syphilis. Then they were thrown out and deprived of Naples and Genoa. But they did not lose everything - syphilis went with them
- Voltaire

Each side blamed the other for The Great Pox2. The French called it 'The Neapolitan Disease' whilst the Italians called it 'The French Disease'3. The Christian Church saw it as divine retribution for increased sexual immorality. In 1530, Girolamo Fracastoro wrote a long poem on the plight of a shepherd infected with the disease as a punishment for blaspheming Apollo. The main character was given a name to indicate his profession, meaning 'pig-lover': Syphilis. Thus the new disease was named.

What is Syphilis?

Patients today with syphilis have the same symptoms as the soldiers returning from Naples in 1495. They can be roughly divided into three stages.

Primary Syphilis

The first sign is a painless ulcer at the site of infection, known as a chancre (pronounced 'shank-ra'). It's found at the place where the infection entered the body, usually on the genitals; but, it can also be found around the anal region or the mouth4. Many people don't notice this sore. It can be on the internal parts of the vagina or underneath the foreskin. Usually there's only one sore, which has a clean base and discharges a clear fluid. However, occasionally there can be more than one sore and sometimes they do not occur free of pain. There may also be a swelling of the lymph nodes.

After a few weeks the ulcer will heal spontaneously and the lymph nodes will subside. Two thirds of patients will never have any further symptoms of syphilis. However one third will go on to get:

Secondary Syphilis

Secondary Syphilis causes a variety of different symptoms:

  • Rash. A brown painless rash appearing on any part of the body, often covering a large area. It commonly affects the palms of the hands and soles of the feet. When the blisters break, highly infectious sores are revealed, riddled with active bacteria.
  • Condylomata lata. These are wart-like growths on the vulva, the area around the anus, and other moist surfaces of the body.
  • Swollen Lymph Glands. Occurring throughout the body.

Less common evidence of the condition includes:

  • Patchy Hair Loss.
  • Anterior Uveitis. Inflammation of the part of the eye in front of the pupil and iris.
  • Meningitis. Inflammation of the tissue lining of the brain and spinal cord.
  • Shallow ulcers in the mouth. These ulcers are often said to have the appearance of snail tracks.

Secondary syphilis may come and go for up to two years, after which it will disappear of its own accord. The symptoms subside and the patient is no longer infectious. In a third of these patients there will be further complications: tertiary syphilis may develop.

Tertiary Syphilis

Before modern treatments these late complications of syphilis were devastating and feared.

  • Gummas. A soft, tumour-like growth, that can ulcerate and destroy the underlying structures. They can occur anywhere in the body, commonly on the skin, especially where it has been damaged, and in bones. Occasionally they affect the liver or testes. When they occur on the nose they may eventually cause the whole nose to fall off. In the past it was said that this was a blessing, as it prevented the dying syphilitic from smelling his own sores. In his series of paintings 'The Harlot's Progress' Hogarth painted an elderly woman without a nose, to indicate that she had been a prostitute.

  • Cardiovascular Syphilis. Syphilis can affect the heart in a number of ways, including inflammation of the aorta, the blood vessel leading away from the heart and damage to the valve at the entrance to this vessel, leading to aortic regurgitation.

  • Neurosyphilis. Syphilis affects the nervous system in two ways. In Tabes Dorsalis some of the nerves entering the spinal cord are affected. This leads to, shooting pains, a characteristic broad based gait, known as ataxia, damage to joints, pupils that don't react to changes in light and sometimes other eye damage. It can also cause a combination of loss of brain function and weakness of the limbs leading, eventually, to what was known as 'generalised paralysis of the insane.'

If a woman with untreated syphilis becomes pregnant there can be devastating effects on her child, even if she has no symptoms.

Congenital Syphilis

A child born to a mother who has syphilis may suffer from congenital syphilis. The first symptoms may be lesions in the mouth and other mucous membranes as well as sores in the skin. As the child gets older they may have damaged bones, peg-like teeth and common features of tertiary syphilis.

For this reason pregnant women in the UK are still routinely offered a blood test for syphilis as part of their ante natal care.

The Culprit: Treponema pallidum

The bacteria Treponema pallidum causes syphilis, as well as other diseases, such as yaws and bejel.

The Treponema is a spirochete - a long, slender, gram-negative5 bacteria whose cell is curled in a helix not unlike a spring. First detected in 1600 by Anton van Leeuwenhoek, the first man to 'discover' unicellular micro-organisms, these special microbes are set apart from the rest of the bacterial world by their unique shape and unusual method of locomotion. A number of flagella-like organelles called axial filaments are anchored to each pole of the cell, they rotate and propel the bacteria forward like a corkscrew.

There are 13 species of Treponema recognised by Bergey's Manual of Systematic Bacteriology (Vol 1). Ten are anaerobic6, and the remaining three are microaerophilic 7 or aerobic.

Three subspecies of Treponema pallidum exist: Treponema pallidum subspecies pallidum, T. pallidum subspecies pertenue and T. pallidum subspecies endemicum, distinguishable by the manifestations of the diseases they cause. Treponema pallidum subspecies pallidum is generally the only one attributed to the spread of syphilis. Although there are microbiology experts who assert that the yaws-causing subspecies pertenue, which is less virulent and causes different clinical symptoms, is actually only a variant of subspecies palldium, these two subspecies are 100% similar in their DNA/DNA profile. Unfortunately for patients, the existing molecular diagnosis methods are unable to differentiate between these two subspecies, resulting in rather embarrassing problems, for example, among Muslims who live under Shirya law, where sexual contact outside of marriage is outlawed.

Detection of Syphilis

Treponema pallidum cannot be cultured on artificial media preventing simple laboratory stain identification methods. The most common diagnostic method for syphilis is serological testing, which can be divided into non-treponemal tests and treponema-specific tests. Non-treponeam tests cover a broad range of sexually transmitted diseases, and are targeted at antigens in the lipid layer of the microbes, whereas treponema-specific tests detect the microbe itself. Non-treponeam tests are relatively inexpensive, simple to perform, generate rapid results, and are generally used to monitor disease activity. Treponema-specific tests are not completely specific because they can also detect other disease-causing spirochetes, such as leptospira and borellia burgdoferi, giving false positive results.

A direct examination for spirochetes in positive samples may also be carried out by means of a microscopic darkfield examination or by direct fluorescent antibody tests. However, oral cavity specimens cannot be used for this method because non-pathogenic species of treponema are common flora of this region.

Cerebro-spinal fluid analysis is another traditional laboratory test, as treponema will be present in the CSF of 40% of infected patients. This is used for evaluating seropositive patients displaying neurological signs and symptoms. A complete blood count will detect anaemia, thrombocytopaenia and either leukopaenia or leukocytosis, all of which are characteristic of syphilis.

Because congenital syphilis infects various bone sites, including the joints, X-rays may be used to detect bone lesions.

Where Did it Come From?

Since emerging in the 16th Century the exact origins of syphilis have been hotly debated. At first the Europeans blamed each other. Then it was thought that it was brought back from the New World by Christopher Columbus and his sailors. Others suggest that syphilis has been present in Europe for centuries.

Syphilis certainly became widespread about the same time as Columbus and his sailors arrived back from America. Yaws, bejel and syphilis all leave distinctive marks on bones. Analysis of a large quantity of skeletons from deaths prior to Columbus's time showed that whilst lots of New World skeletons showed signs of syphilis, few Old World skeletons did. It also showed that skeletons with signs of yaws were far older than skeletons with signs of syphilis. This was thought to mean that syphilis was a mutation of yaws that occurred in the New World.

However, some skeletons bearing the marks of syphilis have been discovered in the Old World that are thought to be dated from before Columbus's time:

  • The skeleton of a woman aged between 25 and 50 was discovered in a graveyard in Rivendall, Essex, in the UK. Radiocarbon dating suggests that she died at least fifty years before Columbus returned from The Americas.
  • The remains of a group of monks thought to be showing signs of syphilis were discovered at a monastery in Hull, UK. Radiocarbon dating suggested that they died between 1300 and 1400. However other scientists think that the radiocarbon dating was inaccurate due to the amount of fish the monks would have eaten. Others think that the monks were in fact suffering from yaws.
  • The skeleton of a child, from the 4th Century, thought to bear the signs of congenital syphilis was found in Costa Bella, France. It has been suggested that this was in fact a case of lithopedion, or 'stone baby', a rare complication of pregnancy when the baby dies in the womb, and instead of being adsorbed into the mother's body it becomes calcified.

Other evidence against the Columbus origins of syphilis is that syphilis could easily be confused with other diseases. The sores could have been confused with leprosy. In the later stages syphilis could be confused with so many other diseases that it was known as 'the great imitator'. In fact mercury was brought back from the crusades as a cure for leprosy, it would not have been effective against leprosy, but it would have had some effect against syphilis.

Famous Suffers of Syphilis

You should take any list of historical figures that have suffered from syphilis with a large pinch of salt. Many loathsome historical figures - dictators, crazy painters, mad philosophers and womanisers - were specially associated with this disease, either honestly or in an attempt to further stain their character. In some cases it is not known or even improbable that they had syphilis, in other cases, however, it is probable or even proven that they had the disease.

Here's just a few of the historical figures that have been rumoured to suffer from syphilis:

Syphilis can cause so many symptoms that a historian with a fertile imagination can easily find evidence that a person was infected with little effort or corroboration.

Treatments for syphilis through the ages

Since its discovery, syphilis has gone from being a deadly scourge to a rare disease easily treated with antibiotics.

Mercury

'A night with Venus, a lifetime with mercury!'

For centuries the treatment of choice for syphilis was mercury, which was painted onto the lesions8. This had the unfortunate side effect of causing a slow death by mercury poisoning.

Salvarsan, the Magic Bullet

In the early 20th Century, Paul Ehrlich, a public health doctor in Frankfurt, postulated that certain chemicals might have a greater affinity for diseased cells than healthy cells and act as 'magic bullets'. At the same time in Berlin, T Pallidium was identified as the cause of syphilis. Ehrlich set to work finding a cure. In 1909, Ehrlich and his colleague, Sahachiro Hata, discovered a that compound 606, arsephenamine, was effective against syphilis. The compound was named Salvarsan and immediately thought to be a miracle cure for syphilis.

Like most miracle drugs, Salvarsan wasn't as good as was first thought. For an effective cure 8-12 week courses of injections with bismuth and Salvarsan were given, without a break, for a total of sixty weeks. Salvarsan contained arsenic, which lead to arsenic poisoning over the protracted course of the treatment. If a patient had neurosyphilis, even if it was asymptomatic, the Salvarsan could cause a sudden death.

Modern Day Treatment

Since penicillin became widely available in 1945 syphilis has been easily treated. Even 50 years later syphilis remains sensitive to penicillin and is now a rare curable disease.

The Dark Side of Medicine, the Tuskegee Syphilis Experiment

In 1932, the US Public Health Department conducted a study to see if black people with untreated syphilis responded differently to white people. To test this a group of 399 black men with syphilis were left untreated. They were told that they were receiving a special treatment free of charge, receiving pink pills containing nothing more than aspirin. Even when penicillin was discovered, the men were denied a treatment that could have cured them.

The men were treated with useless pills for what was then a treatable disease until they died. 128 died of syphilis or its complications, 40 infected their wives, and 19 children were born with the terrible effects of congenital syphilis. Nothing useful about the treatment of syphilis was discovered.

Help! I think I've got Syphilis

Had it been written in the late 1990s, this entry would advise you that it's downright unlikely that you'd catch syphilis in the UK. During the 1980s, the emergence of HIV had led to safer sexual practices, with a net result that most sexually-transmitted diseases, including syphilis, became less widespread. However, this effect has since worn off and the numbers are beginning to grow once more. Though syphilis is still rare, the number of new diagnoses in the UK increased twenty-fold between 1998 and 2007, indicating that syphilis is making a comeback. It's still a rare disease, but not to the same extent as it used to be.

If you do have any symptoms suggestive of syphilis, especially a painless ulcer on the genitals or a rash on the palms of your hands or the soles of your feet, then you should seek urgent medical attention. Visit you GP or a Gentio-Urinary Medicine (GUM) Clinic. In the UK, NHS Direct can advise on the location of your local GUM clinic, where you can get free treatment from doctors that specialise in sexually transmitted diseases. You don't have to be referred by your GP or even give your real name.

Still Interested? Read on...

  • Stephen Jay Gould's excellent essay on the naming of syphilis, comparing Girolam Fracastoro's poem to a 1998 scientific paper on the disease.

1Although Syphilis is usually sexually transmitted it can also be caught from blood. For this reason all donated blood in the UK is tested for syphilis.2Termed 'Great' so as to distinguish it from the other deadly pox, smallpox.3Indeed, Morbus gallicus was the first medical name used.4Entirely dependent on the sort of sex you had when you acquired the infection.5A bacterium that does not retain the violet stain used in Gram's method, a staining technique used for bacterial classification.6They live in non-oxygenated environments.7Requiring small amounts of oxygen to live.8The word quack, referring to a doctor of doubtful qualification, comes from the use of mercury as a treatment for syphilis. Mercury, also known as quicksilver, was sold by travelling peddlers, known as quacksalvers, who claimed their preparations would cure all illness. The term was ultimately shortened to 'quack'.

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