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One cannot help but be amazed and humbled when examining the microscopic spirochete, Treponema pallidum. Such a small creature with such a sordid past. This bacterium has been a part of hundreds of year’s worth of human history, and probably thousands of year’s worth of prehistory. It has been written about, debated over, and has affected every culture it has come into contact with. This is the corkscrew shaped bacteria responsible for the infection that we call syphilis.

Its long journey to nearly every corner of the globe is a trek that is still hotly debated today. It seems that nobody can agree on where and when this little organism started to dig out its own niche in human history. Books, articles, dissertations, and passionate speeches have all been devoted to convincing an audience that syphilis originated in either the Old World, the New World, or in both places independently. While its origins are a fascinating topic, the purpose of this paper is not to persuade the reader that one argument is more valid than the other. In this paper, we will examine syphilis and its history to get a view of how one disease has shaped western medicine and our approach to public health. We will examine the disease itself and how it is spread. Then, we will discuss its prevalence historically through modern times. Historical through modern treatments will also be examined. Treatment is rarely enough to control a disease within a population, and syphilis is no exception. We will conclude by looking at the status of syphilis in our culture today and discussing what public health measures appear to be the most effective. Before we dive into these discussions, let us first meet the antagonist.

Treponema pallidum

Naming and identifying bacteria is never as simple as it may seem at first blush. In the order Spirochetes, Treponema is one of five genera. (www1) How many species or subspecies of these bacteria actually exist is a question left unanswered by modern biomedical science. Treponema pallidum is the name of the species that infects humans and gives them the disease we call syphilis. Its relatives Treponema petennue and Treponema caratium are identified as causing yaws and pinta respectively. How close is their relationship to T. pallidum? This is where it may get confusing. Some pathologists argue that pinta, yaws and syphilis are caused by the same spirochete, T. pallidum. Others claim that T. pallidum has several subspecies that cause different sort of infections. Despite our great advances in microbiology, we are still unable to differentiate these organisms that cause the different infections. They all look the same, they all respond to our elaborate tests, such as the direct florescent antibody test, in an identical manner.

So how do we know that T. pallidum isn't acting alone in causing all of these different diseases? We don't. The agents that cause syphilis, yaws, non-venereal endemic syphilis and pinta seem to be completely homologous. We diagnose treponemal infections based on their symptoms. When the pathologist finds bacteria, he finds a treponemal bacteria. Depending on his own personal school of thought, he may call all treponemal bacteria T. pallidum, or he may look at the symptoms of the disease and then specify a different treponemal agent that he considers to be a subspecies of T. pallidum or a different species all together.

The genus treponema causes both syphilis and several non-venereal treponematoses. The non-venereal forms include yaws, pinta, and bejel. This paper will focus solely on venereal syphilis.

Syphilis

Venereal syphilis (which will just be called 'syphilis' for simplicity) is usually transmitted through sexual contact. About thirty percent of those that come into contact with syphilis during sex will become infected. It can also be caught by any direct inoculation through contact with infected lesions or through blood transfusions. Syphilis is most easily spread through bodily fluids since T. pallidum needs a moist, dark environment to survive.

There are four stages of syphilis: Primary, secondary, latent and tertiary. Following the initial infection, it takes about 2-4 weeks before the first signs of syphilis will appear. The specific area of infection will develop a chancre. If left untreated, this sore will go away on it's own within 3-8 weeks. Once this has occurred, the patient has lost the opportunity of treating syphilis in the earliest of its stages. The disease will now progress to secondary syphilis.

A variety of symptoms accompany secondary syphilis. Six to eight weeks after the initial sore disappears the patient will feel tired, may experience a headache with a fever, have swollen lymph nodes and a sore throat. Some patients may even experience weight loss, hair loss and a skin rash at this stage. These symptoms can last for over three months, and sometimes as long as six months. During this period the symptoms disappear and reappear seemingly at random. If the patient has not yet been treated at this time, the syphilis will begin to affect the entire body.

The next stage of the disease is the period of latency. There are no obvious symptoms during this period, except for some vague discomforts and occasionally an eye disorder. Although it is not as likely for a patient in this stage to pass on the disease, it is still a possibility. The latency stage is the time when the spirochete is lodging itself into the tissue of its host. The bacteria infest the bone marrow, lymph glands, vital organs and the central nervous system. This can take a month, or it could take the individual's entire lifetime. The latency period is sometimes subdivided into early and late stages. The early latent period begins when the symptoms of secondary syphilis disappear. The late latency period begins somewhat arbitrarily 1-4 years after the symptoms disappear. The late stage of latency can continue indefinitely. It has been found that fifty to seventy percent of patients in this stage live out the rest of their lives without the disease progressing to the infamous tertiary phase.

Tertiary syphilis is one of the most dreaded diseases a person can suffer. At this stage, the individual is no longer infectious but is in great danger of losing his or her own life to the disease. Lesions develop on the skin, bone, and vital organs. On any part of the body, the spirochetes can concentrate and form painful lesions or gummas. Gummas are ugly and painful tumors that result from the T. pallidum concentrating on a small area of body tissue. The bones of the individual also get eaten away in a way that is similar to osteomyelitis. There are two particular kinds of tertiary syphilis, named for where the spirochetes do the most damage. One is cardiovascular syphilis in which the bacteria concentrate on the aorta and cause the valves to degenerate. The other is neurosyphilis in which the brain can be affected. Horrible personality changes can occur and the end result can be a helpless maniac suffering from GPI (general paralysis of the insane).

Syphilis is clearly a disease worth trying to eradicate from human existence. Treatments were developed over time, some more effective than others, with the hope of finding the 'magic bullet' that would end the suffering once and for all.

Treating Syphilis

Treatment of syphilis has altered the way it affects us both socially and physically. By 1557, leper colonies were being set up throughout Europe specifically for people with venereal disease. In 1690, as the epidemic slowed down a bit, hospitals were the place for most syphilitic patients. The treatment of choice at this time was mercury.

Mercury the earliest chemical treatments for syphilis. Ore cinnabar, a form of mercury, had been used in the 1300's for the treatment of various skin diseases including leprosy. The application of the ointment to syphilitic lesions was an obvious choice. Giorgio Sommariva of Verona was the first person on record to use mercury to treat syphilis in 1496. Jacopo Berengario da Carpi became famous in Italy soon after this first treatment for successfully administering mercury to syphilitic patients. Mercury was used in the form of ointments, oral administration, and vapor baths. Such treatments remained popular for three centuries. In the 1800's, mercury was used so liberally to nearly any ulcer found, that many patients were more injured from the treatment then from their ailment.

The next chemical treatment to be developed specifically for syphilis was Potassium Iodide in the 1840's. The treatment was amazingly effective, even on patients with later stages of the illness. Mercury had been only moderately effective on late stages of syphilis and was not effective on very deep lesions. The introduction of Potassium Iodide gave people new hope that there could be a better cure in the future. It set the stage of the introduction of Salvarson, and later penicillin.

In 1905, an important discovery was made. Microbiologists Schmudinn and Hoffman discovered and isolated the bacteria that cause syphilis. With the enemy now in sight, Paul Ehrlich began his research to find a better drug to fight the disease in 1908. He knew arsenic was one of the treatments of choice since syphilis was first documented, so he tried hundreds of different arsenic compounds out on laboratory rats. He worked in a laboratory filled with syphilitic rats trying compound after compound. Finally, the 606th compound he tired was successful. Number 606, as he temporarily called it, effectively destroyed the syphilis without destroying the rat. He was so enthusiastic about his results that he called the compound Salvarsan, which means I save. In 1910 he introduced this arsenic compound that could be used against syphilis.

Ehrlich used the phrase 'silver bullet' to describe the way he wished to use chemicals to destroy pathogens. The use of Salvarson to treat syphilis was one landmark in the beginning of modern medicine. While his 'silver bullet' wasn't as miraculous as many had hoped, it inspired other researchers to continue the search. Even today the attitude of searching for a 'silver' or 'magic' bullet to treat illnesses pushes research forward.

With the advent of the first modern 'silver bullet' cure, Salvarson, came a strange cultural backlash. One might imagine that any disease that was affecting a large portion of the population and devastating the lives of many should be cured if at all possible. One might expect that if a supposed 'cure', like Salvarson, were discovered, the community would breathe a collective sigh of relief and support the new findings. To the contrary, many small, but vocal, segments of western society were outraged at the new treatment. They believed that supporting a cure for the disease would also support sexual promiscuity. Due to their beliefs on sexuality in general, anything that may promote it must be wrong too.

The backlash that occurred when Salvarson was discovered was not unlike the new emphasis on chastity that occurred in the Renaissance early in the epidemic A new importance was placed on sexual virtues and people saw the disease as a punishment from God for their sinful ways. Even today there are some extremists that do not believe should try to find a cure for syphilis or any other venereal disease because it may promote promiscuity.

Despite the cultural backlash, research continued efforts to find a more effective cure for syphilis. Soon after Salvarson, a new drug was introduced that was as close to being a magic bullet as any other. This new treatment for syphilis ushered in the dawn of the antibiotic era. In 1929, Alexander Fleming discovered the anti-bacterial qualities of the mold penicillin.

Penicillin has led to a dramatic drop in the prevalence of treponemal infections. Penicillin was introduced in a time when less than one out of every one hundred syphilis patients ever recovered. Penicillin is still used today to treat syphilis in an injectable form called benzathine penicillin or penicillin G.

Unfortunately, penicillin is not a magic bullet, as no drug really can be. Like all life forms, T. Pallidum was evolving and continues to evolve. Resistant strains continually crop up. Our 'cures' do not generally destroy the entire population of pathogens. They merely give them a new, albeit extreme, environment in which they will have to contend. Some pathogens are more successful than others in this challenge. Finding a cure, therefore, is rarely a magic bullet. While treatments like penicillin decreases prevalence by effectively curing the infected individual, they cannot prevent new cases of the disease from occurring in a population. In order to prevent a disease, we also need to know who is most vulnerable to it. Otherwise, epidemics are likely to catch us off guard.

Tracking Syphilis


How can we go from looking at a microscopic foe and the individual humans it infects, to seeing how it is effecting the population as a whole? Epidemiology is a field that is responsible for focusing this big picture. Epidemiologists study not only the disease itself, but also the patterns of disease throughout a population and the world. The tools of an epidemiologist are largely mathematical the conclusions are based strongly on inference. These particular tools are beyond the realm of this paper, but many of the statistics mentioned here are results of modern epidemiological studies. These studies are carried out by local public health organizations as well as national and international organizations such as the Centers for Disease Control (CDC) and the Worldwide Health Organization (WHO).

The first unquestionable epidemic of syphilis occurred in Europe at the end of the 15th century. With this first epidemic, came the first chorus of blames. Travelers were blamed, prostitutes were blamed, soldiers were blamed, and of course Columbus was blamed. The Muscuvitles called syphilis the Polish sickness. The Poles called it the German sickness. By most historical accounts, it does seem that France was the likely starting point of the European epidemic. During Charles the VIII's Italian campaign in 1495, his mercenaries returned home with this new sickness. It spread quickly and viciously. The city of Lyons became so 'contaminated' with diseased people that in March of 1496 the infected people were expelled outside of the city walls. By 1497, the disease had spread throughout France. Less then a decade later, nearly all corners of Europe were already infected as well.

Shortly after the outbreak, it was noted that babies were born with a disease that seemed similar to syphilis. It seemed as if the entire continent, adults and newborns alike, were affected by this epidemic. Perhaps as early as the first part of the 1600's, congenital syphilis was recognized as being distinct from adult onset syphilis. They believed it came from the fathers or the wet nurses. It wasn't until the early 1900's that they realized syphilis was transmitted through the placenta.

A second epidemic occurred after the Second World War. The rate of syphilis peaked in the US in 1947 at 106,000 cases. The prevalence of the disease dropped as penicillin became more widely used. Quickly realizing that penicillin wasn't enough to control the disease, a massive educational campaign was launched in 1948. Syphilis and other venereal diseases were targeted by public health officials using every form of media available to them. Posters, pamphlets, films, radio shows and newspaper articles were all devoted to informing the public about staying safe. As the program saw success, the number of new cases of STD's dropped, hitting a low in 1956-1957 of only 3.9 new cases per 100,000.

The 1960's saw another jump in the rate of syphilis, but it did not reach epidemic proportions. This was attributed to both the sexual revolution and the reduction of funding for STD awareness programs. It seemed that the public once again needed reminding of the dangers of STD's and awareness campaigns started up once more.

In the 1970's there was a decline in the number of cases and this could be seen as evidence that STD awareness education was working. As tracking of the disease became more sophisticated and survey methods more specific, it became easier to determine which segments of the population the STD prevention programs needed to be directed at. They found that most new cases of syphilis in the 1970's were in homosexual males. This information gave them a new target to direct their programs at.

With continued monitoring, the CDC found a rise in the cases of syphilis in the 1980's in large cities. They found that it was especially devastating among disadvantaged minority groups. This led the CDC to start a prevention education program targeted at people age 15-30 living in urban areas. This has led us to the lowest rates for syphilis in forty years.

Epidemiologists are essential in tracking a disease and determining who is at risk. Programs must be specific to the group of people most at risk. Without the efforts of the CDC and local public health programs, syphilis would be unlikely to be so under control today.

Conclusion

Most people now consider prevention to be just as vital to public health as finding a cure. Public health education measures seem to be extremely effective when dealing with syphilis. We can see this by the drop in the rates of new cases when the CDC makes a push for education. Today, the CDC puts 106 million dollars into controlling STD's every year with their prevention education. In 1996, according to the CDC, there were 4.4 new cases of syphilis for every 100,000 people. This is the lowest it has been since the drop in 1956-1957. Seventy-three percent of these nations’ counties reported no new cases in 1996.

Another key factor to controlling syphilis has been routine testing. By promoting the idea that everyone has to get tested, we remove the stigma attached to testing. This can be done by requiring an STD test when people get new jobs, medical procedures, pregnancy consultations and married. This is a public health approach that many people find less offensive or intimidating then searching out 'likely suspects' that might carry a disease.

The history of syphilis has taught us several things. We can see how quick we are to look for someone or something to blame when an epidemic occurs. We can see there is a stigma that is attached to certain diseases and even to the research for treating an 'unclean' disease. We can see how the modern medical ideal of a magic bullet might be impossible to achieve. Most importantly, we can see how prevention is key to control. Over time the focus in dealing with syphilis has gone from finding better treatment, to finding better preventative measures. By monitoring a disease and predicating those who are at risk, we can implement public education programs. We can try to remove the stigma attached to the disease by normalizing testing. It is only through the efforts of both medical treatment and public health education that a disease such as syphilis can be controlled.