Syphilis (Deadly Diseases and Epidemics)

SYPHILIS

Anthrax

Meningitis

Avian Flu

Mononucleosis

Botulism Campylobacteriosis

Pelvic Inflammatory Disease

Cholera

Plague

Ebola

Polio

Encephalitis

Salmonella

Escherichia coli Infections

SARS

Gonorrhea Hepatitis Herpes HIV/AIDS Influenza Leprosy Lyme Disease

Smallpox Streptococcus (Group A) Staphylococcus aureus Infections Syphilis Toxic Shock Syndrome

Mad Cow Disease Tuberculosis (Bovine Spongiform Typhoid Fever Encephalopathy) Malaria

West Nile Virus

SYPHILIS

Brian Shmaefsky CONSULTING EDITOR

I. Edward Alcamo Distinguished Teaching Professor of Microbiology, SUNY Farmingdale FOREWORD BY

David Heymann World Health Organization

Dedication We dedicate the books in the DEADLY DISEASES AND EPIDEMICS series to Ed Alcamo, whose wit, ch a rm , i n telligen ce , and com m i tm ent to bi o l ogy edu c a ti on were second to none.

Syphilis Copyright © 2003 by Infobase Publishing All ri ghts re s erved. No part of this book may be reprodu ced or uti l i zed in any form or by any means, electronic or mechanical, including photocopying, record i n g, or by any inform a ti on stora ge or retri eval sys tem s , wi t h o ut permission in writing from the publisher. For information contact: Chelsea House An imprint of Infobase Publishing 132 West 31st Street New York NY 10001 Library of Congress Cataloging-in-Publication Data Shmaefsky, Brian. Syphilis / Brian Shmaefsky. p. cm. —(Deadly diseases and epidemics) Includes index. ISBN 0-7910-7308-4 1. Syphilis—Juvenile literature. I. Title. II. Series. RC201.1.S476 2003 616.95'13—dc21

2002155109

Chelsea House books are available at special discounts when purchased in bulk quantities for businesses, associations, institutions, or sales promotions. Please call our S pecial Sales Dep a rtment in New York at (212) 967-8800 or (800) 322-8755. You can find Chelsea House on the World Wide Web at http://www.chelseahouse.com Series design by Terry Mallon Cover design by Takeshi Takahashi Printed in the United States of America Lake 21C 10 9 8 7 6 5 4 3 2 This book is printed on acid-free paper.

Table of Contents Foreword David Heymann, World Health Organization

6

1.

History and Lore of Syphilis

8

2.

Syphilis As an STD

22

3.

Syphilis: The Organism

36

4.

Syphilis: The Disease

52

5.

Syphilis: Cures, Prevention, and Treatment

68

6.

Syphilis: Epidemiology

82

7.

Syphilis in Modern Society

98

8.

A Case Study in Syphilis Research

112

Glossary

128

Further Reading

132

Websites

133

Index

134

Foreword In the 1960s, infectious diseases—which had terrorized generations—

were tamed. Building on a century of discoveries, the leading killers of Americans both young and old were being prevented with new vaccines or cured with new medicines. The risk of death from pneumonia, tuberculosis, meningitis, influenza, whooping cough and diphtheria declined dramatically. New vaccines lifted the fear that su m m er would bring polio and a gl obal campaign was approaching the global eradication of the smallpox. New pesticides like DDT cleared mosquitoes from homes and fields, thus reducing the incidence of malaria which was present in the southern United States and a leading killer of children worldwide. New technologies produced safe drinking water and removed the risk of cholera and other water-borne diseases. Science seemed unstoppable. Disease seemed destined to almost disappear. But the euphoria of the 1960s has evaporated. Microbes fight back. Those causing diseases like TB and malaria evolved resistance to cheap and ef fective dru gs . The mosqu i to evolved the ability to defuse pesticides. New diseases emerged including AIDS, Legionnaires, and Lyme disease. And diseases which haven’t been seen in decades re-emerge, as the hantavirus did in the Navajo Nation in 1993. Technology itself actually created new health risks. The global transportation network, for example, meant that diseases like West Nile virus could spread beyond isolated regions in distant countries and quickly become global threats. Even modern public health pro tections som etimes failed, as they did in Mi lw a u kee, Wisconsin in 1993 which resulted in 400,000 cases of the digestive system illness cryptosporidiosis. And, more recently, the threat from smallpox, a disease completely eradicated, has returned along with other potential bioterrorism weapons such as anthrax. The lesson is that the fight against infectious diseases wi ll n ever en d . In this constant struggle against disease we as individuals have a weapon that does not require vaccines or drugs, the warehouse of knowledge. We learn from the history of science that “modern” beliefs can be wrong. In this series of books, for example, you will

6

learn that diseases like syphilis were once thought to be caused by eating po t a toes. The inven ti on of the microscope set scien ce on the ri ght path. Th ere are more po s i tive lessons from history. For example, smallpox was eliminated by vaccinating everyone who had come in contact with an infected person. This “ring” approach to controlling smallpox is still the preferred method for c onfronting a smallpox outbreak should the disease be intentionally reintroduced. At the same time, we are constantly adding new drugs, new vaccines and new information to the warehouse. Recently, the entire human genome was decoded. So too was the genome of the parasite that causes malaria. Perhaps by looking at the m i c robe and the vi ctim thro u gh the lens of genetics we wi ll to be able to discover new ways of fighting malaria, still the leading killer of children in many countries. Because of the knowledge gained abo ut such diseases as A I D S , en ti re new classes of a n ti - retrovi ral dru gs have been developed. But resistance to all these drugs has already been detected , so we know that AIDS drug devel opm en t must continue. Education, experimentation and the discoveries which grow out of them are the best tools to protect health. Opening this book may put you on the path of discovery. I hope so, because new vaccines, new antibiotics, new technologies and, most importantly, new scientists are needed now more than ever if we are to remain on the winning side of this struggle with microbes. David Heymann Executive Director Communicable Diseases Section World Health Organization Geneva, Switzerland

7

1 History and Lore of Syphilis To Naples first it came From France, and justly took from France his name Companion from the war . . . Excerpt from Syphilis save morgues Gallicus Girolamo Fracastoro It is amazing how one name can conjure up such contrasting feelings as

shame and bravado. Throughout history, some people commonly used this name to defame others. Others awarded the name as a badge of achievement. History has been of two minds about the disease known today as syphilis. Its role in civilization goes well beyond the disease’s true identity and current name. Syphilis, like many ancient com mu n i c a ble diseases, was virtu a lly disregarded until detailed accounts of the disease appeared regularly in books on medicine and healing. Earlier stories about syphilis were inconsistent and erroneous. This is because syphilis was confused with other diseases. Even some genetic conditions were attributed to the symptoms thought to be caused by syphilis. Most people today take for granted the fact that communicable diseases are caused by microbes su ch as bacteria and viruses. Mi c robe s were unknown to the people of the 1400s who first recogn i zed the s pre ad of s yphilis. All they knew was that it came about from sen sual thoughts or sexual con t act. Sin was con s i dered the major cause of the disease. So, syphilis bypassed the innocent and struck those who indu l ged in an act having little social virtu e . 8

Figure 1.1 Christopher Columbus is one of the earliest historical f i g u res to have an illness documented as syphilis. He was accused of bringing the disease back to Europe from the New Wo r l d , although this is most likely untrue, according to historians.

A NEW DISEASE APPEARS Many of our ideas about syphilis came from European stories dating back to the time of Christopher Columbus (Figure 1.1). Syphilis en tered Europe su rrounded by deb a te and disagreem ent 9

10

SYPHILIS

about its natu re and discovery. The first dispute arose from its purported date of discovery. Some argue that syphilis first appeared in Naples, Italy, during the disease outbreak of 1495. Hence, the ignoble disease was coined Neapolitan Disease or mal de Napl e s. Nobody knew how the disease aro s e ; therefore it was assumed that it originated in Naples. Others thought the origin was from an outbreak in nearby Venice and gave it the name Venetian Disease. This title and background for syphilis did not make m a ny Italians happy. After all, syphilis was assoc i a ted with unacceptable sexual mores. Th erefore many Italians argued that Ch ri s toph er Co lumbu s’ crew bro u ght this plague to Italy from the New World. Italians then felt free to rename the disease the Spanish Disease, referring to the Spanish c rew that served Co lu m bus on his journ ey (Figure 1.2). As expected, the Spanish scof fed at this su gge s tion. They believed that syphilis origi n a ted in Germ a ny because of an app a rent outbreak there . For this re a s on, the Spanish called syphilis the German Disease. German author and revolutionary Ulrich von Hutten (1488-1523) admitted to having syphilis in his writings. Few would publ i cly ack n owledge having the disease in that era. Von Hutten explained how the disease affected his body and described his encounters with the different types of treatments. His accounts were more accurate and detailed than the medical writings of the time. Descriptions of painful boils and dark green pus from ulcerated skin horrified the afflicted as well as healthy people. Syphilis spread rapidly thro u ghout Europe de s p i te its name and uncertain origins. Ma ny Eu ropeans bl a m ed the unrestrained spread of syphilis on the Gauls, who are now known as the French. It was believed that the troops of King Charles VIII of France introduced syphilis everywhere else in Europe. King Charles used paid soldiers from various regions of Europe. It was alleged that the solders brought syphilis back

History and Lore of Syphilis

Figure 1.2 Christopher Columbus arrives at the New World. Syphilis was seen as a curse on the explorers for their maltreatment of the Native Americans. Accounts of sexual encounters between the crew and the native people are well documented.

to their homelands after serving in Charles’ army. Syphilis then took on the title of French Disease, or morbus gallicus, adding to its repertoire of names. The modern term syphilis as we know it came abo ut in 1530 upon the publ i c a ti on of a poem called Syphilis save morgues Ga llicus by Italian physician Girolamo Frac a s toro.

11

12

SYPHILIS

His ficti onal ch a racter Syph i l i s , a romantic sheph erd in the mythical story, was cl a i m ed to have origi n a ted the sco u r ge. Syphilis’ s i n i s ter deeds, and not his sexual activity, bro u ght a bo ut the disease as punishmen t . Thu s , the sheph erd Syphilis’ name became slang for the disease. By 1600 most of the parts of the world that had been visi ted by con qu erors, traders, and travel ers su f fered from syph i l i s . Its swift spre ad, spanning mountains and oce a n s , bewi l dered the cl er gy and medical com mu n i ty alike . Eu ropean cl er gy at the time attri buted the disease to God’s fury against sinners. Prophets and priests in other regi ons bl a m ed astron omical phen om ena and a host of o t h er causes. Th e explanati ons given by physicians were no more acc u rate than those of the cl er gy. Even more misleading was the fact that m a ny medical practi ti on ers call ed the new disease the “n ew p l a g u e” or “pox.” These erron eous appellati ons caused people to confuse the malady with bl ack plague and smallpox. In spite of disagreements abo ut its origin and cause, almost all agreed that the disease was assoc i a ted with an illicit activity, u su a lly sex. The fact that syphilis was confused with many other diseases led nineteenth century physician Sir William Osler to call syphilis “The Great Imposter” or “The Great Masquerader.” American physicians encountering what they thought was syphilis during that period simply called it “bad blood.” Syphilis’ dishon orable history fueled many debates, f rom its first discovery up until tod ay. S ch o l a rs of the initial period of s yphilis outbre a k s , su ch as English novelist Gideon Ha rvey, had heated arguments abo ut the arrival of syphilis in Eu rope . No one wanted the disease attributed to his or her nati onal origin or cultu re . What started out as rati on a l explanati ons for its originati on tu rned into finger poi n ting based on po l i tical viewpoi n t s . For example, Ha rvey attri buted the Fren ch’s “s l oven ly sexual atti tudes” to the origin of syph i l i s . Wi lliam Shakespe a re even took part in the syphilis

History and Lore of Syphilis

debate, calling it the Fren ch Disease in many of his works. L i terary sch o l a rs believed he did this to poke fun at the Fren ch du ring the An gl o - Fren ch Wa rs . There are passages in the early Greek and Roman literatu re indicating that syphilis may have been in Europe lon g before Co lumbus return ed from the New World. In additi on , tre a tments for a disease known as “ ven ereal lepro s y ” were reported in twelfth century medical doc u m en t s . The med i c ati on on ly worked for that particular con d i ti on , m e a n i n g that the disease was not being con f u s ed with true lepro s y. Archeo l ogists stu dying these accounts believe that ven ere a l leprosy was con f u s ed with yaws, a con d i ti on rel a ted to syph i l i s . Yaws may have been bro u ght back from Greek and Roman settlem ents in North Af rica and the Mi d dle East. Others believe that ancient Hebrew circ u m c i s i on practi ce s a re linked to sexually transmitted diseases su ch as syph i l i s . This was based on ob s ervati ons that Jewish pop u l a ti ons had fewer cases of syphilis than Ch ri s ti a n s . THE TABOO OF SYPHILIS Un l i ke other disease outbreaks occ u rring between 1500 and 1 6 0 0 , s yphilis spre ad su bt ly and showed up in a va ri ety of w ays . Ma ny people had mild sym ptoms and spre ad the d i s e a s e , not knowing they were infected . Ot h ers qu i ck ly su cc u m bed to syph i l i s , devel oping severe ailments that s om etimes re su l ted in de a t h . Most people who showed even the earliest signs of syphilis were shu n n ed . Phys i c i a n s were even repulsed by syphilis pati ents and many avoi ded to u ching them. Hospitals thro u ghout Eu rope refused to admit syphilis pati ents, fe a ring pro l i ferati on of the disease throughout the fac i l i ty and com mu n i ty. The meager hospital care that was ava i l a ble to syphilis pati ents was pathetic and despicable even by early Eu ropean standards. Ne a rly all pati ents en ded up in crowded ward s and got little care or tre a tm en t . The wards were merely

13

14

SYPHILIS

a s p ace to live out the co u rse of the disease until de a t h . Lu ck i er pati ents were assigned to leprosy clinics and mental health institutions where they at least received some comfort.

SYPHILIS AND CREATIVITY Many people suffered from syphilis throughout history. Few were bold enough to admit having the disease. The stigma of syphilis took a hiatus for a brief period in the middle 1800s through the early 1900s. Those individuals whose condition was public were noted for being some of the most creative, and in many cases eccentric, people in society. A cadre of famous French artists and writers used syphilis as a badge of their passion for life. Included were the illustrious artists Edgar Degas, Paul Gauguin, Edouard Manet, Henri de ToulouseLautrec, and Vincent Van Gogh as mentioned in this chapter. However, few knew that nineteenth century Irish writer Oscar Wilde lamented of syphilis believing he captured this disease of romance and free spirit. Apparently, his escapades warranted having the disease. Wilde, like many of the creative afflicted, even partook of absinthe, a strong alcoholic beverage, commonly thought to be a cure for syphilis. However, friends and physicians quickly recognized that Wilde was suffering fro m other ailments probably related to absinthe poisoning. The fact that he never showed sores and had chronically itchy skin revealed the condition as not being syphilis. A comtemporary of Wilde, American chess genius Harry Pillsbury, endured the disease of artistic people. Pillsbury was the most articulate chess and checker player, renowned for playing 20 competitors at one time and beating all the top masters of the era. Similarly to the other artists, his troubled creativity was linked to syphilis which killed him at the age of 34 years. Billionaire H o w a rd Hughes also suff e red from syphilis. It is believed that the disease contributed to his mental decline leaving him with eccentricities that included a fear of germs, the need to be an e x t reme recluse, and an obsession with saving his urine.

History and Lore of Syphilis

Tre a tment of syphilis varied, with much of it assoc i a ted with the aton ement of sin. Syphilis did not stand alone as being attributed to sinfulness. Ot h er common diseases of that period were said to be caused by evil thoughts, inappropriate to u ch i n g, foul moods, laziness, and dirty and unkempt living con d i tions. Reports of the disease were tainted by the disdain for it. P hysicians gen erally included statem ents su ch as “revo l ting sore s” and “foul pus” in their de s c ripti on s . Pa ti ents were of ten described as “loa t h s om e” or decl a red to be invo lved in “acts of debauchery.” De s c ripti ons of the disease overlapped those of o t h er con d i ti ons beleaguering Eu rope. This made accura te diagnosis and therapy difficult. It was not until the 1800s that physicians starting making sense of s yph i l i s . Th ree hu n d red ye a rs of i gn ora n ce abo ut syphilis were stripped aw ay as microorganisms became identified as the cause of infectious disease. Un l i ke many other diseases, syphilis still retained an ign oble role in history because of its s exual transmission. Syphilis rem a i n ed a mys terious malady even up to the Vi ctorian era in England. In the late 1800s, the death and morbidity f rom syphilis were sti ll escalati n g. The ph i l o s ophy of Vi ctorian England produ ced a belief that syphilis was spre ad on ly among lower class peop l e , including pro s ti tute s . For a bri ef peri od , pro s ti tuti on was stri ct ly reg u l a ted to prevent lower class people from infecting the aristocrats. Af ter all , the nobi l i ty bel i eved that dign i f i ed people co u l d acqu i re syphilis but not pass it alon g. Pro s ti tutes wi t h syphilis were jailed while nobl emen with the disease were s p a red incarceration. Ot h er Eu ropean co u n tries foll owed this bias by mandating the registrati on and inspecti on of pro s ti tutes in an attem pt to reduce syphilis. Not all people shunned syphilis. For some men, syphilis became a label of a m orous con qu e s t s . It meant that the pers on had been successful at securing many sexual partners.

15

16

SYPHILIS

Rebellious people who opposed the contemporary morality also considered syphilis an emblem of protest. Famous people who were noted for numerous affairs were usually labe led syphilitic whether or not they had the disease. VAMPIRISM AND SYPHILIS Vampires are part of a fanciful ancient myth that is sti ll perva s ive in modern movies and tel evision shows. The contem pora ry vi ew of va m p i res comes from Bram Stoker ’s famous Dra c u l a novel . However, the idea of vampires, humans, or other creatures that subsist on bl ood pred a tes the Old Testament. One might won der why va m p i res are being included in a d i s c u s s i on of the history of syph i l i s . Mu ch like syph i l i s , vampirism was used as a sym bol of social devi a n ce , especially for out of the ord i n a ry beh aviors rel a ted to sex u a l i ty. Ma ny litera ry sch o l a rs bel i eve that va m p i rism was used by Vi ctorian era wri ters to repre s ent the grip of s yph i l i s on soc i ety. Vampires and syphilis were both perceived as ruinous to soc i ety. Both seemed to defy Chri s tian morality. In additi on , m a ny stories portray vampirism as contagious. It spre ad from the va m p i re to an unfortu n a te vi cti m , u su a lly through an unnatu ral act su ch as punctu ring the victi m’s body with teeth. Vampirism passed from one pers on to another mu ch in the same way that syphilis was alleged to be spre ad thro u gh aberrant beh avi or. Pu blic panic over syphilis and other diseases led to the wide s pre ad mu rder of people acc u s ed of vampirism. Unfortu n a te people with a vari ety of debi l i t a ting diseases, including adva n ced syphilis, were labeled as va m p i res and kill ed to prevent further spre ad of the disease. A vari ety of methods were devel oped to kill va m p i re s . Each method was cre a ted from a com binati on of local and borrowed folklore about the el i m i n a ti on of u n godly cre a tu res. De ad peop l e acc u s ed of vampirism had to be exhumed and disposed of according to the trad i ti ons of killing va m p i re s .

History and Lore of Syphilis

Figure 1.3 King Henry VIII of England also suffered from syphilis. At the time, many people thought his insanity was linked to the disease.

FAMOUS PEOPLE AND SYPHILIS Dishonorable nicknames and titles given to famous people go far back in human history. This and the assigning of certain diseases to these people was an effective way of discrediting foes, scoundrels, and incompetent leaders. However, few diseases gained the high stature of syphilis in being associated with so many noteworthy people.

17

18

SYPHILIS

Figure 1.4 Anne Boleyn, the unfaithful wife of Henry VIII, is said to have passed the disease on to her husband the King. This is one theory as to why King Henry had her beheaded.

Chri s toph er Co lumbus was the first famous Eu ropean acc u s ed of h aving syphilis. His detractors bl a m ed him for seeking sexual favors with the Am erican Indians. He was thereby bl a m ed for introducing syphilis to Eu rope. However, there is no evidence in Co lu m bu s’ high ly ch ron i cled life that he su f fered from syphilis. Most historians believe he was a scapegoa t . His crew, h owever, most likely carried syphilis

History and Lore of Syphilis

back to Eu rope. Accounts of s exual en co u n ters bet ween the crew and the native people are well doc u m en ted. Syphilis was con s i dered a curse on the crew because of their cru el tre a tment of the In d i a n s . The most esteemed person said to have succumbed to the ef fects of syphilis was sixteenth cen tury English King Henry VIII. Claims of his syph i l i tic con d i ti on were attri but a ble in part to his insanity. Many books cite that he died with his brain destroyed by sy philis. Many historians believe that he contracted the disease from his adulterous wife, Anne Boleyn. She probably contracted it from her lovers and then spread it to Henry VIII. Anne Boleyn’s daughter, who later became Queen Elizabeth I, may have been born with syphilis, according to accounts by attending physicians. The fact that Henry VIII contracted syphilis at that point in his life may have been his reasoning for having Anne Boleyn beheaded. Pri n ce Albert Vi ctor, the Du ke of Cl a ren ce and gra n d s on of Q u een Victoria, was thought to be Jack the Ri pper because of his afflicti on with syph i l i s . Criminologists at the ti m e believed that Prince Al bert’s syph i l i tic insanity drove him to mu rder and muti l a ti on of the assaulted wom en . He was known to seek out hom o s exual bro t h els and is said to have con tracted the disease from these en co u n ters. A family cover-up is believed to have qu elled any further investigati on into his guilt. Syphilis was said to have molded the life and art of n i n eteenth cen tu ry Dutch artist Vi n cent Van Gogh. Com bi n ed with his app a rent depre s s i on, the disease was cl a i m ed to be respon s i ble for Van Gogh’s despair and eccentricity. Much of his art ref l ected both con d i ti ons. According to many arti s t s , Van Gogh’s works took on the progre s s ive hopelessness of his life as the disease advanced and worsened his health. Van Gogh com m i t ted su i c i de before any of his medical conditi ons could be confirmed. Chicago gangster Al Capone (1899-1947) was one of the

19

20

SYPHILIS

Figure 1.5 Al Capone died of syphilis in 1947 while serving a sentence for tax evasion.

most notorious syph i l i tics (Figure 1.5). He is one of t h e few mentioned here whose case was confirmed by medical examination. Capone succumbed to the disease while serving a jail sen ten ce for tax evasion. The American government was hoping to find enough evi den ce to keep Capone jailed for life or put to death for his crimes. Syphilis allegedly fulfilled the wish of law enforcement agents. Hen ri de To u l o u s e - L a utrec , the nineteenth cen tu ry

History and Lore of Syphilis

Fren ch arti s t , was most noted for the bi rth defects leading to his dw a rfism and twi s ted body statu re . Ot h ers cl a i m ed he was sickly and weak because of family inbreeding. His parents were first co u s i n s . To u l o u s e - L a utrec’s fondness for bro t h el s resu l ted in his con tracting the syphilis that app a rently shorted his life. Other famous people who supposedly had syphilis were French emperor Na poleon Bon a p a rte (1769-1821), French p a i n ter and revo lutionary Edo u a rd Ma n et (1832-1883), Fren ch painter Edgar Degas (1834-1917), French painter Paul Gauguin (1848-1903), and French poet Arthur Rimbaud (1855-1891). Many of these cases cannot be con f i rmed because of the lack of medical evidence.

21

2 Syphilis As an STD Men have died from time to time, and worms have eaten them, —but not for love. From As You Like It William Shakespeare Without being disrespectful to William Shakespeare’s thought, love can be

equated with death and decay, particularly if the act of love caused the spread of a sexually transmitted disease (abbreviated STD). Syphilis is one of many diseases that is spread through sexual contact. It has the ignoble distinction of decaying the body until death mercifully eases the agony of the disease for the patient. Syphilis was not alw ays recognized as an STD. Cultural taboo s , m i s concepti ons, and myths hid the facts of h ow the disease was re a lly transmitted. Finally, scruti ny and con s i s tent ob s erva tions of the disease by early physicians con f i rm ed that it was spre ad by sex. It was not unti l l a ter in history that the scientific com mu n i ty recogn i zed it as a disease caused by a microor ganism invading the body. It was the initial use of the micro s cope in 1665 by English scientist Robert Hooke that led scientists to the road of discovering the organic basis of disease. Around the same time in Ho lland, Dutch a m a teur scientist An ton van Leeuwenhoek became the first person to see microor ganisms, wh i ch he labeled animacules. However, scientists and society did not accept the fact that or ganisms could cause disease until it was establ i s h ed by meticulous research of Italian physician France s co Redi and French chemist Louis Pa s teur in the middle 1800s.

22

Figure 2.1 One way that syphilis can enter the body is t h rough the urinary tract which is pictured here.

WHAT IS AN STD? Microbiologists and physicians characterize STDs as one category of gen i tourinary infections. This inclu des microorganisms that cause disease to enter the body through the urinary tract and reproductive system. Urinary tract infections are usually localized to the urethra, urinary bladder, ureters, and kidneys (see Figure 2.1). Genital tract infections also attack the urinary tract but also affect the reprodu ctive sys tem . In males ( s ee Figure 2.2a), this may include the penis, vas deferens, and te s ti cles. In fections in females can cause probl ems to the vagina, cervix, uterus, fallopian tubes, and ovaries, as shown in Figure 2.2b.

23

24

SYPHILIS

a)

Figure 2.2 Infections of the urinary tract can affect both the male (above) and female (p. 25) reproductive systems.

Today it is commonly accepted that microscopic creatures called microorganisms cause genitourinary infections. The types of microorganisms that cause genitourinary infections a re bacteria, fungi, protozoa, and viruses. Bacteria are pri m i tive , minuscule singl e - cell ed or ganisms that gen era lly feed by breaking down decaying and living material (Figure 2.3). They are found almost any where on the earth, even in our own bodies and in the bodies of other creatures. Most bacteria cause no harm . However, there are many pathogenic bacteria that cause disease in animals, plant, and people. The microorganism causing syphilis bel ongs to this category of living things . For many people the term fungus evo kes a variety of images, ranging from mushrooms that cause allergies to the colorful growth found on foods left too long in the refrigerator. Fungi are comprised of an assorted group of organisms that gen era lly grow as strands of cells call ed a mycel ium (Figure 2.4). They fee d by breaking down decaying complex matter. Like bacteria, some are pathogens and cause disease as they invade

Syphilis As an STD

b)

the bodies of living organisms. Protozoa are com p l ex , singl e - celled or ganisms that live like animals or plants (Figure 2.5). They are identified by the way they move around. Some crawl, using structures called pseudopods, while others swim, propelled by whip-like parts called cilia and flagella. Most pro tozoa cause few disease problems for people. Nevertheless, there are pathogenic ones that cause devastating diseases in animals and people. Malaria and sleeping sickness are two protozoan diseases that are responsible for numerous deaths in Africa, Asia, Southern Europe, and South America. A protozoan called Trypanosoma causes African sleeping sickness. Viruses are the ultimately harmful pathogen. None are k n own that do not cause some type of disease. No or ganism is immune to viral pathogens. Viruses attack bacteria, fungi, protozoa, plants, and animals. Some even tag along as uninvited guests of other viruses, living off the host virus’ activity. It is difficult to say if viruses are living organisms. They lack all the structures found in other creatures and can only survive on the metabolism of their host. Therefore, they can only live within the cells of a host organism. Their make-up is no more

25

26

SYPHILIS

Figure 2.3 Bacteria are tiny, single-celled organisms, similar to those picture d here. Some bacteria are harmful, but most are harmless or are even helpful to the body.

complex than a small piece of genetic material covered by a protein capsule, as shown in Figure 2.6. As a rule, harmless microorganisms inhabit some parts of the urinary tract and reproductive system of humans. For ex a m p l e , the va gina norm a lly has ben eficial lactob ac i ll i bacteria that reduce the ch a n ces of assault by pathogenic microorganisms. Fungi called vaginal yeast also reside in the vagina. Males are usually free of genitourinary microorganisms except for at the extreme end of the urethra, where typically

Syphilis As an STD

Figure 2.4 Fungi take many shapes, such as mushrooms, mold, and yeast. Here, yeast grows in culture on a Petri dish.

harmless bacteria such as Corynebacterium, Haemophilus, La ctoba ci ll i s, Staphyl o co ccus, and Strepto co ccus are found. Mu ch of the urinary tract and reproductive sys tem is kept sterile by a variety of effective body defenses. An STD occ u rs wh en microor ganisms in the uri n a ry tract and reproductive sys tem bre ach the body’s defense mechanisms. Opportunistic STDs occur when the normal genitourinary inhabitants get out of control. This can happen when they accidentally enter other parts of the urinary tract

27

28

SYPHILIS

Figure 2.5 Protozoa, like bacteria, are single-celled organisms. Protozoa are much more complex than bacterial cells and are defined by the way they move in their environment.

and reproductive system. Disease can also occur if the person’s immune system is weakened. The immune system then cannot knock down any obstacles that keep these microo rganisms from overpopulating and subsequently causing discomfort and ailments. Even when the immune system is functioning, sometimes simple conditions such as a lack of urine flow can create disease by genitourinary microorganisms. STDs com m only re sult wh en pathogens or microorganisms from other body parts en ter the urinary tract and reprodu ctive

Syphilis As an STD

Figure 2.6 Vi ruses are unlike any of the other pathogens. They lack all stru c t u res found in other organisms and cannot live without feeding off their host. They are much smaller than bacteria and are composed only of genetic material in a protein capsule.

s ys tem . This usu a lly occ u rs du ring sexual activi ty. Syphilis is one of many microorganisms causing this kind of STD. TYPES OF STDS Urinary tract infections caused by inte s tinal bacteria are probably the most common although least diagnosed type of S T D. Esch eri chia col i, an ord i n a ry den i zen of the large i n te s ti n e , reg u l a rly makes its way to the penis and va gi n a thro u gh sexual contact . It accounts for approximately 60 percent

29

30

SYPHILIS

of the diagn o s ed urinary tract infections. The percentage of Esch eri chia coli i n fections caused by sexual con t act is unknown. Other intestinal bacteria that commonly cause STDs include Enterobacter aeroginosa, Pseudomonas aeruginosa, and various species of Proteus. Luckily, these diseases are usually short-lived and easy to treat with conventional medications. Gonorrhea is caused by a pathogenic bacterium called Neisseria gonorrhoeae. It is related to other bacteria that cause ear infections, sore throats, and even meningitis in children and young adults. Gonorrhea ranks with syphilis as one of the most common STDs spread by pathogenic bacteria. Military physicians in the United States and Europe noted outbreaks of gonorrhea during World War I. The disease was difficult to diagnosis earlier in history because it was overshadowed by syphilis infecti ons. G on orrhea is usu a lly more evident in males because it causes painful urinati on as the or ganism inflames the urethra and vas deferens. The disease is not as noticeable and symptomatic in females. Many women do not feel any pain or discomfort while the bacteria travel from the vagina up to the f a ll opian tu bes. This unaw a reness of the disease cre a te s a dangerous situation because the disease can go untre a ted, resulting in pelvic inflammatory disease, infertility, or death. Commonly confused with gonorrh e a , the STD known as chlamydia su rpri s ed the medical community with its high ra te of preva l ence (the nu m ber of cases of a disease that are present in a populati on at a spec i f i ed time). The disease is caused by an u nu sual para s i tic bacterium call ed Chlamydia tra ch o m a ti s. Symptoms in males and females are very similar to those of gonorrhea and often are misdiagn o s ed in males and undetected in females. Studies done on sexually active co ll ege stu dents in the 1990s showed that an alarming nu m ber of stu dents were carrying and spre ading the microor ganism. The disease can spre ad to ch i l d ren du ring va ginal childbirth, causing eye and respira tory i n fections. Unch ecked chlamydial infections produ ce the same end results as untreated gonorrhea.

Syphilis As an STD Chancroid is a little known STD caused by the pathogen i c bacterium Ha emophilus ducreyi. Rel a ted bacteria cause eye i n fecti ons and re s p i ra tory disease in animals and peop l e . The disease is preva l ent in devel oping nations, particularly in tropical regi ons wh ere it can infect whole communities. Most cases of chancroid in the United States and Europe are felt to be s pre ad by prosti tution in major urban areas. It produ ces sores similar to those produ ced by syphilis and was prob a bly mistaken for syphilis before it was po s i tively iden ti f i ed . However, unlike the sores of syph i l i s , chancroid sores are painful. Chancroid is on the rise and curren t ly can be tre a ted with antibiotics. Bacterial vaginosis, or irritation of the vaginal tract, is a mysterious STD. Considering the amount of technology available for stu dying disease, little is known abo ut the cause of b acterial va ginosis. Cases of the disease show a host of p a t h ogen s and naturally occurring bacteria. The disease is usually found in sexually active women, meaning that most likely it is not an acc i dental disease. Com m on anti biotics are used to treat the condition which is often diagnosed along with syphilis. A normally benign fungus that inhabits the intestines and vagina causes an STD almost exclusive to females. Candida albicans, a single-celled fungus called a ye a s t , produces a disease called candidiasis. Candidiasis can cause disease in the mouth, skin, and nails; however, it is most noted for creating probl ems in the female reproductive system. Commonly spre ad by sexual activity, candidiasis can produ ce a variety of problems ranging from vaginal itching to irritating vaginal discharges. Most cases are not severe and can be cured with anti f u n gal drugs. An ti bi o tic tre a tm ents will aggrava te the disease by encouraging furt h er growth of the yeast. Candidiasis in males is rare and is usually limited to the surface of the penis. It is easily treated with prescription antifungal creams. Trichomoniasis, caused by Trichomonas vaginalis, is probably the least known STD to most people. Yet, it is one of the most com m on causes of va ginal discom fort re su l ting from

31

32

SYPHILIS

s exual contact. A pathogenic protozoan found throughout the world causes the disease. It is related to the organisms causing sleeping sickness and conditions leading to the decay of bone, cartilage, and skin. As with candidiasis and vaginitis, trichomoniasis is mostly found in females. The disease causes severe vaginal itching and extremely painful urination. It is usually apparent because the vagina produces a foamy yellowgreen discharge. Infections in males can go undetected. This is just the opposite of gonorrhea, which is most evident in males. However, some males may feel discomfort and suffer pain in the te s ti cl e s . The con d i tion is difficult to treat and is be s t prevented by using condoms. Medications especially designed to kill pro tozoa must be used to con trol the con d i ti on . Trichomoniasis is common alone, but can be found with other common STDs such as syphilis and gonorrhea. Vi ruses also plague the urinary tract and reprodu ctive system. The most common of the viral STDs is genital herpes. People who have the disease know it when small painful blisters appear around the vagina or penis. These blisters are very similar those found with cold sores and chicken pox. That is because related viruses cause these three diseases. Genital herpes starts out with severe symptoms, leaving the person with rapidly healing ulcers created by the virus as it reproduces in the skin and urinary tract lining. The blisters then become infrequent and less severe as the disease progresses. It is a lifelong disease that often accompanies other STDs. Prevention is the best precaution. Antiviral treatments such as aciclovir do not remove the virus from the body. Rather, they reduce the i n c i dence of blister flare-ups. People with the disease can spre ad it the rest of their lives. It is possible to spread the disease even if the person has no blisters. In many places children learn the common belief that warts are caused by touching toads. As silly as this seems, it appears equally ridiculous to believe that contagious viruses cause warts. The STD called genital warts is caused by the

Syphilis As an STD

human papillomavirus. It is related to the viruses causing warts commonly found on the hands and feet. Genital warts are exclusively spr ead by sexual contact. In males, the disease appears as lumpy growths, usually located near the tip of the penis. The warts are usually painless and must be removed by surgery. There is no cure for this disease. Removing the warts surgically does not rid the body of the virus and does not

SYPHILIS AND FOOD — AN UNUSUAL ASSOCIATION Today it is commonly accepted that syphilis is generally spread by sexual contact. However, this was not true before the discove ry of its bacterial origins. Initially, most people supposed syphilis was caused by sinful behavior or thoughts. This was consistent with the overall belief of human disease. However, few diseases got the reputation of being caused by eating a p a rticular food. Many people in seventeenth century Europe attributed syphilis, as well as other diseases such as lepro s y, to the then lowly potato. Europeans first encountered potatoes during the Spanish explorations of Peru in the 1500s. Pedro Cieza de Leon noticed the natives dining on a variety of potatoes and used them to feed his conquistadors. The connection of potatoes to syphilis helped explain the introduction of the disease into Europe. Archeological records show that Aymara Indians cultivated potatoes before A.D. 400. The Central and South American Indians regularly traded potatoes. To many of the Indians, the potato was a symbol of surplus and was incorporated into art and pottery. However, to many fifteenth century E u ropeans, the potato was viewed as repulsive and dangerous. After all, it was botanically related to a poisonous plant called the deadly nightshade. For the same reason, tomatoes were also c o n s i d e red deadly during that period. Potatoes were eventually f reed from the stigma of syphilis as they became cultivated t h roughout Europe in the 1600s and 1700s.

33

34

SYPHILIS

redu ce its frequ en c y. Females also devel op warts on the genitals. In addition to the warts, viruses located on the cervix can lead to a fatal disease called cervical cancer. Surgery and chemotherapy treatments are available for the cervical c a n cer stage. As with many of the other STDs mentioned, genital warts are frequently found with other STDs. The most famous, or ra t h er infamous, vi ral STD is abbreviated AIDS for acquired immunodeficiency syndrome. Caused by the human immunodeficiency virus, or HIV, AIDS is the most ruthless and fatal STD. The virus primarily gains access to the body through sexual contact. It then travels to the blood s tre a m , wh ere it degrades the immune system. Peop l e do not directly die from the virus. Their weakened immune system makes them susceptible to other microorganisms and cancers. There are several sexually transmitted HIV viruses, most of which cause diseases leading to cancer. Current AIDS treatments do not cure the disease. Rather, they slow down its progress, prolonging the victim’s life. AIDS is commonly found with bacterial STDs such as chlamydial infection, gonorrhea, and syphilis. HOW DO THEY SPREAD? Circumstances ranging from inappropriate touching of the genitals to bathing in a dirty bathtub have been implicated in the spread of STDs. Most of the microorganisms causing STDs do not survive well out of the host’s body. Therefore, it is unlikely that objects or water can spread them. Trichomonas is probably the most likely candidate for being spread by objects. There is some evidence that the organism can survive for a short period on moist towels, undergarments, and feminine hygiene napkins. Unclean instruments used for gynecologic and rectal examinations may also pose a risk of STD spread. Most of the STD microorganisms are killed by exposu re to air and light. The air in many bu i l d i n gs and houses is kept d ry by air con d i ti oning or heati n g. This dehyd ra tes the

Syphilis As an STD

microorganisms, rendering them incapable of surviving for long. Sunlight and bright indoor lights may destroy the microorganisms’ gen etic material, thereby reducing their chance of reproducing. Note that most STDs are found in conju n ction with another STD. Scientists bel i eve that having one STD pred i s poses the body to others . A weakening of the body ’s antimicrobial defen s e mechanisms is the most prob a ble explanation for this ob s ervation. Casual touching and kissing are unlikely met h ods of s pre ading most STDs. The microorganisms usu a lly en ter the body thro u gh the urinary tract and reprodu ctive system . Th i s makes females more vulnera ble to get ting STDs. The anatomy of the female reprodu ctive system redu ces the chance that the microorganisms wi ll be flushed out by uri n a tion after sexual contact . Some physicians believe that uncircumcised males have an increased chance of acquiring STDs. It is thought that the m i c roor ganisms can be hidden and pro tected under the folds of the foreskin. STDs are equ a lly likely to en ter the body t h ro u gh the mouth and rectum. Many cases of AIDS and syphilis were most likely acqu i red this way. STDs that invade the bl ood , su ch as AIDS and syphilis, are re ad i ly tra n s m i t ted t h ro u gh fresh bl ood con t act. This may occur thro u gh needl e sharing, tra n s f us i on with contaminated bl ood, and carel e s s h a n dling of bl ood from infected people.

35

3 Syphilis: The Organism Disease is an experience of the so-called mortal mind. It is fear made manifest on the body. From Science and Health Mary Baker Eddy With all due apologies to Ms. Eddy, syphilis is not a disease of the mind.

Like any other infectious disease, an invading or ganism causes it. As m en ti on ed in Ch a pter 2, the microor ganism causing syphilis is a b acteriu m . The syphilis bacteriu m , c a ll ed Trepo n ema pa ll i du m, belongs to a group of bacteria called spirochetes. Their name com e s from the fact that their spiral shape is used to identify them (Figure 3.1). These usu a lly large and elabora tely shaped bacteria are able to wiggle themselves in a rigid wormlike manner using structu res not found in other bacteria. S p i rochetes caught the eye of Anton van Leeuwenhoek in 1683. He was the first person to view them during the micro s cop i c ex a m i n a ti on of s a l iva samples. Th ey com prise a wi de s pre ad gro u p of organisms found in water, soil, and the bodies of other cre a tures. However, most spiroch etes have ex acting envi ron m ental requ i rements, making them difficult to grow in the labora tory. Th erefore m a ny have to be stu d i ed in their natu ral envi ron m en t s . Not every s p iral-shaped bacterium is a spirochete . A helical bacterium called Spirilla volutans resem bles spirochetes but is unrel a ted. This intere s ting bacterium is harve s ted from fresh water as a food for animals and hu m a n s . Ma ny health food and veget a rian stores sell spiru llu m food produ ct s . Trepo n em a is named for the fact that it looks like a twi s ti n g,

36

Figure 3.1 Treponema pallidum is the bacterium that causes syphilis. It has a spiral shape as can be seen in this picture, and is thus classified as a spirochete bacterium.

pulsating thread. It belongs to an evil collection of s p i rochetes noted for causing diseases in plants, animals, and humans. Borrelia bu rgdorferi is a spirochete found in several types of bl ood - sucking relatives of the spiders call ed ticks.

37

38

SYPHILIS

Relatives of this cre a tu re infect a large vari ety of insects and other arthropods that suck sap or feed on blood. Over the past 20 ye a rs , Borrelia bu rgdorferi has come under the scruti ny of scientists and public health officials. The organism causes a condition called Lyme disease when it enters humans. Borrelia bu rg d o rferi enters the body thro u gh the bi te of an infected ti ck . It proceeds through o ut the body causing fever, joint pain, and even paralys i s . Deer are known to carry Borrelia bu rg d o rferi wi t h o ut showing any significant signs of disease. Another dangerous spiroch ete is Leptospira interro ga n s. It is noted for a type of food poi s oning called leptospirosis. It is regularly found in the kidneys of domesti c a ted animals. Th e organism exits the animal through the urine, making it poss i ble to be spre ad thro u gh con t a m i n a ted soil and water. S erpula a n d S erpu l i n a, wh i ch are of ten miscl a s s i f i ed as Treponema, are inte s tinal spirochetes of m a ny mammals. They are con f i rm ed to cause diarrheal diseases in pigs . Little else is known abo ut these or ga n i s m s . BIOLOGY AND NATURAL HISTORY OF TREPONEMA All Trepo n em a or ganisms cause some type of mild to s evere disease in hu m a n s . Even though different species of Trepo n ema cause disti n ct ly dissimilar diseases, t h ey all share a com m on sign a tu re of bone scarring after the lon g term infecti on has rava ged the body (Figure 3.2). Th i s bone scarring was noted in early examination of syphilitic cadavers and is now routinely used by archeologists to assess diseases endemic to ancient humans. Unfortu n a tely, the bone scarring does not all ow the arch eo l ogists to d i stinguish between the different types of Trepo n em a. In ad d i ti on, the scarring must be found on a number of bon e s to avoid con f u s i on with other con d i tions that could scar individual bones. Some disti n cti on between the different Trepo n em a s pecies is po s s i ble because syphilis alon e produ ces scars on the skull bones. It makes the skull appear

Syphilis: The Organism

Figure 3.2 Treponema organisms can cause many diseases, and not all of the diseases have visible symptoms at all stages. This becomes evident in the picture of the man, above, who has tertiary syphilis, but does not show any physical signs or symptoms. However, Treponema can cause internal problems such as gummas and bone scarring.

to have been ch ewed on by worms. This scarring pattern is called caries sicca. Most microbiologists agree that human Treponema organisms can be divi ded into three spec i e s . One is Trepo n em a amyl ovoru m, a n o t h er Treponema cara teum, and the third Treponema pallidum. Treponema pallidum can be divided into three distinct kinds called serotypes, strains, or su b s pecies:

39

40

SYPHILIS

Trepo n ema pa ll i dum en d em i c u m, Trepo n ema pa ll i du m pa ll i du m , and Trepo n ema pa ll i dum pertenu e. This cl a s s i f i c ati on system is based on trad i ti onal met h ods of identifying bacteria and has not yet been con f i rmed by genetic stu d i e s . Scientists at the Un iversity of Texas Health Science Center in Ho u s ton and the In s titute for Gen omic Re s e a rch in Maryland performed DNA analysis on Treponema pall i du m pall i du m in 1998. Th eir intent was to develop effective syphilis tre a tments by bet ter understanding the genetics of the or ga n i s m’s metabolism. The studies were not done to understand the organism’s origins or classification. The DNA of the other Treponema subspecies has yet to be completely stu d i ed . Th erefore a full understanding of Treponema t a xonomy is not curren t ly available. However, the diseases they cause are well stu d i ed. The newly discovered Treponema amylovorum was isolated from human periodontal lesions in 1997. This organism feeds off sugars that accumulate in the human mouth and is primarily seen in people with poor dental hygiene. It was discovered growing in gum lesions associated with advanced periodontal disease. Further research on Treponema amylovorum indicates that it causes the lesions and is related to other oral Treponema that may or may not cause disease. Trepo n ema cara teu m causes a little-known disease called pinta . The or ganism is very difficult to tell from any of the Treponema pa ll i dum strains. Pinta is found on ly in isolated parts of Central Am erica, Co lu m bia, and the southern most tip of Mex i co. The disease is limited to rural areas. O f ten called a nonvenereal trepon ematosis, pinta is recogn i zed by the large patches of flat, red skin lesions that form within months after infecti on. The lesions are most l i kely to appear on the scalp, feet , and hands. Pinta is u sually contracted during childhood and remains for the life of the person. It is spread by direct con t act. People with the pinta skin lesions can pass the disease to unaffected

Syphilis: The Organism

people by casual to u ch . Probably, one con t act is not enough to spread the disease. Most likely it is spre ad by continuous con t act between family members. Bones are rarely scarred by pinta because Treponema cara teum confines its attack to the skin. Bejel, or endemic syphilis, is a conditi on similar to pinta in many ways but is caused by Trepo n ema pa ll i dum en d em i c u m. This disease is also found among isolated populati ons of people living in warm regions. However, bej el is con f i n ed to the Middle East. Bejel, l i ke pinta, starts during yo uth by continuous contact with contaminated family members and friends. It first appears as a small red lesion at the point where it has entered the body. Unlike pinta, bejel typically infects the skin of the mouth and may progress to the nose and throat lining. Therefore, it is spread by contact with shared drinking and eating utensils as well as direct contact with lesions. This disease can spread beyond the skin to the heart and nervous system, causing premature death. It also can spread to infants during childbirth as a condition called congenital endemic syphilis. Bone scarring does occur with this disease, especially later in life. Yaws , c a u s ed by a nonven ereal Trepo n ema, is believed to be the closest relative to syphilis. It is found worldwide, predom i n a n t ly in rural areas of tropical regi on s . It is caused by Treponema pallidum pertenue. The bacterium starts out by causing a large red painless lesion called the mother yaw. It appears approximately one month after infection. This initial condition is similar to bejel. The mother yaw lesion ulcerates and later heals, making it seem that the disease has left the body. Usually, a large reddened patch of skin persists around the mother yaw lesion. Other lesions then start to appear all over the body within months or years after the initial infection. Lesions occ u rring on the face regularly cause deform i ties of the ears, mouth, and nose. This disease readily invades the body, causing severe bone pain, scarring, and deformities of

41

42

SYPHILIS

the skeleton. It is easy to detect yaws damage in ancient human skel eton s . Un l i ke bej el , yaws does not attack the heart or n ervous system. The infection is likely to occur during childhood when it is acquired by continuous contact with afflicted individuals. In some regions, the disease is found in 90 percent of the population, indicating that it is moderately contagious. Syphilis, caused by Treponema pa ll i dum pall i du m , is the most com m on and wide s pread of the Treponema diseases. L i ke its sister diseases, syphilis starts out as a skin ailment, also producing a lesion wh ere the or ganism en ters the body. This lesion , c a ll ed a chancre, even tu a lly disappe a rs as the b acterium spre ads thro u gh o ut the body (see Figure 3.3). At this point in the disease, m a ny people are foo l ed into thinking it has gone aw ay. Next, a rash appears, accom p a n i ed by a feeling of being ill. The disease seems to disappear again, t h o u gh , as the or ganism becomes furt h er establ i s h ed in the body. Syphilis causes the most internal damage of the Treponema diseases. It causes de s tru cti on of m a ny internal or ga n s , doing extreme damage to the brain. Significant bon e scarring and deformati on , including bl emishing of the skull, characterize syphilis. Th ro u ghout the course of the disease it usu a lly can be spre ad thro u gh sexual con t act . Thu s , i t gets the name ven ereal disease, meaning it is tra n s m i t ted by s exual intercourse. The disease will transfer to infants through the placenta or du ring ch i l d bi rth, causing a con d i tion called con genital syphilis (Figure 3.4). ORIGINS AND EVOLUTION OF HUMAN DISEASES Bi o l ogists have strong eviden ce that most human diseases s t a rted out from p a r a s i t e s or ailments in other animals. Pa ra s i tes are or ganisms that take the bod i ly re s o u rces of a host. Although para s i tes are harmful to the host, they generally will not kill it, as the host provides the para s i te with the resources it needs to su rvive . Ma ny internal parasites remain throughout the life of the host. Pa t h ogens are or ganisms that

Syphilis: The Organism

Figure 3.3 During the early stages of the disease, syphilis causes chancres (like the one on this man’s chin), that form around the area where it entered the body. Chancres usually disappear as syphilis spreads throughout the body and moves towards the secondary stage.

cause diseases in others . Th eir pre s en ce som eh ow alters the host’s body, causing illness or death. A pathogen’s survival is based on the fact that it wi ll reprodu ce or su cce s s f u lly tra n s fer to another host before the ori ginal host dies. Pa ras i tes are thought to be form er pathogens that have had long con t act with their host. Organisms that cannot ad a pt to

43

44

SYPHILIS

Figure 3.4 Syphilis can be passed from a mother to her unborn child by crossing the placenta. This can lead to birth defects including deformities and organ failure.

the inva s i on of pathogens ulti m a tely die of f . Pa t h ogens that a re too aggre s s ive will also die of f if they wipe out all their hosts. Th erefore , over many gen erations a balancing proce s s takes place that converts pathogens to para s i te s . Interacti on s bet ween the gen etic mut a tions of the pathogen and the host lead to this harmony. How does one animal acquire the para s i tes or diseases of another? Firs t , there needs to be proximity bet ween the animals. The two animals must share a similar space so they can have enough con t act for the disease to spre ad. Human settlement into wilderness areas is one way that brings people into regular con t act with animals. It is known that

Syphilis: The Organism bubonic plague, also known as the Bl ack Death, and hanta virus, wh i ch produ ces a type of hemorrhagic fever, a re bo t h acquired from rodents. The disease-producing or ga n i s m s made their way into humans as rodents were forced to live among humans. The rodents rem a i n ed around the human dwellings as they lost their habitat and access to food . Th i s gre a t ly incre a s ed the ch a n ce that the rodent diseases wo u l d m a ke con t act with hu m a n s . Som etimes con t act with an animal does not have to be direct to pick up another animal’s diseases. Bl ood - su ck i n g animals typ i c a lly spre ad a va ri ety of diseases within a pop ulati on of animals and even plants. Fleas carry bu bonic plague f rom one rat to another. Lyme disease and Rocky Mountain spo t ted fever are spre ad among grazing animals by ticks. Malaria, one of the most devastating diseases in the world, is tra n s m i t ted thro u gh the bi te of the Anopheles m o s qu i to. As animals come into proximity with other animals, it is expected that any bi ting pests will be shared. This sharing becomes the means of tra n s ferring parasites and pathogens among the different animals. Pa t h ogen contact alone does not produ ce a disease. The new host must provi de a good envi ron m ent for the invading pathogen. Mut a ti ons normally found in a pop u l a tion of pathogens make some individuals more likely to su rvive in other animals. Regular contact bet ween different animals increases the chance that a mutant form will find a new host that it can successfully invade. Influenza viruses, which cause flu, s h ow a high rate of mutati on and easily tra n s fer from one type of host to another. Recently, this has been n o ted with a disease caused by West Nile virus which is fatal in birds and causes a type of meningitis in mammals. Researchers are confirming that subtle mutations in the virus permit the spre ad of the disease from bi rds to humans. The com m on form, or wild type, found in bi rds does not cause significant probl ems in humans.

45

46

SYPHILIS

Figure 3.5 Cows on a farm share close quarters and aid the spread of communicable diseases. Animals that share small habitats, such as farms or zoos, are more at risk of catching certain diseases, and contact with people can spread diseases to the human population. The smallpox virus, for example, is believed to have originated from human contact with animals infected with the related cowpox virus.

The domestication of animals and the formation of huge urban areas is now known to be a major reason for the abundance and great diversity of human diseases (see Figure 3.5). Few diseases were recorded by ancient civilizations. It is believed that this was not due to a lack of diagnosis but due to an absence of disease. Close contact with domesticated animals provided the opportunity for many animal diseases to spread throughout the human population. The common ailment of ch i l d ren call ed pink eye is iden tical to a con t a gious eye disease of cattle. Similarly, the notorious small pox virus, fe a red for its use

Syphilis: The Organism

in biological warfare, is closely related to the cowpox virus of cattle. Domesticated cattle date back almost 10,000 years. This long relationship with cattle also gave us measles and tuberculosis. Likewise, the domestication of pigs introduced humans to flu and pertussis. Urbanizati on incre a s ed the spre ad of animal diseases in humans. First, the housing found in early urban areas provided a favorable environ m ent for disease spre ading among family members. Many bacteria and viruses were safe in the stagnant and dark environ m ent of early dwellings. Th erefore , any or ganisms remaining on su rf aces of beds, tables, and other surf aces su rvived out s i de of the body lon ger than they wo u l d o ut in the open . The high den s i ty of people living in c i ti e s increased the chances that the new diseases would successfully move from one human host to another. In effect, humans cre a ted their diseases as civilizati on expanded from tribal settlem ents to major metropolitan regi on s . The best-studied contemporary example of diseases being transmitted from animals to humans is AIDS. Viruses related to the AIDS virus are found in a variety of animals, including com m on dom e s ti c a ted ones su ch as cats and horses. It is n ow accepted that humans picked up the AIDS virus, HIV 3, from apes carrying a related virus call ed the simian immu nodeficiency virus (SIV). The virus produces cancer- type diseases in the primate carriers. Similarly, so do the other HIVs that afflict humans. HIV 3 just happens to cause a va ri a ti on of disease that leads to AIDS ra t h er than to cancer. Re s e a rchers con ti nue to debate the period wh en the HIV mutation appe a red. Japanese re s e a rch ers argue that HIV came abo ut around 300 years ago. Jonas Sa l k , d i s coverer of the polio vaccine, con ten ded that the virus ju m ped from apes to humans abo ut 900 years ago. How the disease ju m ped from apes to humans is hotly disputed. No matter wh en the mut a ti on occ u rred and how the virus spre ad to humans, its impact on humans has been deva s t a ting.

47

48

SYPHILIS

The origin of syphilis may also be rel a ted to con t act with animals harboring Treponema and rel a ted spirochete s . Som e ancient animal skeletons gave faint eviden ce of Trepo n em a in mammals other than humans. However, the spirochete bon e scarring cannot be con f i rmed as coming from Treponema. The recent discovery of a novel strain of Treponema called Trepo n ema bren n a b o ren se in dairy cows provi des a direct link to how it may have become assoc i a ted with early humans. In cattle, this or ganism causes an ulcer- produ c i n g disease called digital derm a titis. Early humans may have con tracted Treponema by handling the flesh of wild cattle and rel a ted grazing animals. Cattle also carry Treponema brya n tii, a ben eficial bacterium that helps with the dige s tive bre a k down of plants. It is prob a bly unrel a ted to the types of Treponema that cause human disease. Ra bbits also carry a pathogenic Treponema call ed Treponema cuniculi. It produ ce s a con d i ti on called rabbit syphilis, a disease cl o s ely re s embling syphilis in hu m a n s . This also may have been the source of human syphilis. Most bi o l ogists agree that Trepo n ema cara teu m a n d Treponema pallidum came from some common ancestor over 1.5 million years ago. Too little is known about the evolution of Treponema amylovorum to reach any conclusions about its relationship to syphilis. Evidence about the origins of syphilis was uncovered in a stud y showing Treponema scarring in 500,000-year-old Homo erectus bones from southern Italy. This indicates that Treponema had a long association with humans. Treponema carateum probably spread through ancient humans as pinta, unchanged over the 500,000 years. However, it is very difficult to trace the history and incidence of pinta because it rarely causes bone scarring. More is known about the different varieties of Treponema pallidum. Again, there are no studies i nve s ti ga ting the pre s en ce of Trepo n ema amyl ovo ru m i n ancient human skeletons or old dental specimens. A com p a rison of bejel, yaws , and syphilis gives a fairly

Syphilis: The Organism

accura te depicti on of how syphilis came abo ut. Bejel, f rom Treponema pall i dum en d em i c u m, and yaws , f rom Treponema pa ll i dum pertenu e, produ ce a su perficial skin infecti on that minimally invades internal or ga n s . These two diseases h ave been con f i rmed in ancient skel etons co llected aro u n d the worl d . Yaws was con f i rm ed on bones co ll ected from the Ma riana Is l a n d s , in the Pacific Ocean, dated A.D. 850 Inhabitants of these islands could not have picked up the disease from the new locati on . They had to bring it there . So it appe a rs that the disease hitch h i ked with early humans as they left Af rica for Asia, Eu rope, North Am erica, and various islands scattered around the oce a n s . Syphilis does not show up in ancient peop l e . Th ere are no records of it before it started showing up in Europe during the 1600s. The severity of the disease indicates that it m ay have devel oped from a more dangerous type of bej el or yaws that re ad i ly invaded the body. Some intere s ting data s h ow that syphilis was introdu ced after bej el and yaws . In regi ons with both bejel and syphilis, the syphilis on ly shows up in urban areas of the regi on , wh ere bejel is not com m on . People living in regi ons having yaws on ly get syphilis wh en yaws is erad i c a ted thro u gh public health programs. Bejel and yaws provide immu n i ty from syphilis; therefore a pers on h aving one of those diseases is unlikely to con tract syph i l i s . Syphilis did not establish a stron ghold in these regi on s because the pre - ex i s ting trepon emal diseases, bej el and yaws , re s tri cted its spre ad. Al s o, Trepo n ema pa ll i du m’s role as a pathogen rather than as a benign para s i te prob a bly means it has not had the time to evo lve a harm onious relati on s h i p with humans. Although some changes have come to the disease, it is a mu ch milder disease tod ay than when it firs t rava ged Eu rope in the 1600s. The types of mutations turning Treponema into the sexually transmitted disease syphilis are not known. It is thought that these mut a ti ons arose in the New World around 1,600 years

49

50

SYPHILIS

THE PSYCHOLOGY OF SYPHILIS Fears are a normal part of the human experience. Many fears have legitimate origins such as the ancient dread of being bitten by snakes or the modern fear of flying in airplanes. Both have a risk that can be life threatening. Certain snakebites can be poisonous and airplanes can malfunction. Fear abounded in E u rope as diseases spread unrelentingly throughout the population. Bubonic plague, cholera, and leprosy were worthy of fear. They were incurable diseases that traveled with stealth from one community to another. The condition was usually severe and in most cases resulted in a horrible death. People took any precaution possible to avoid contracting these diseases. The outbre a k of syphilis caused unequalled concern. It was a new disease with no definite cause or remedies. The disease also remained hidden in some people making it almost impossible to predict who should be avoided and who should be quarantined. Fears a re acceptable in society as long as they do not turn into phobias. A phobia is an extreme reaction to a fear. People with phobias feel undue stress that can lead to severe restrictions in the person’s lifestyle. For example, people with agoraphobia, the fear of large spaces, have trouble leaving their houses because they want to avoid the expansive outdoors. Syphilophobia, a d read fear of syphilis, ran throughout eighteenth and nineteenth century Europe and Asia as the disease spread. This condition, recognized as a legitimate psychological disorder, drove people to avoid any action that might cause syphilis. Some people avoided even the casual touch of others. Toilet seats, locker rooms, and money became the targets of disease spread for syphilophobics. Syphilophobia struck the British royal family when it was requested that King Charles II use condoms to avoid the disease. In American history, the condition affected whole communities leading to campaigns to eradicate illicit sexual activities. Chicago was the largest city to express syphilophobia. The city implemented a highly controversial War on Syphilis campaign that lasted from 1937 to 1940.

Syphilis: The Organism

a go, well before Ch ri s toph er Co lu m bu s’ vi s i t . However, scientists agree that the change from a contact disease of youth to a sexually transmitted disease was beneficial for the surviva l Treponema. Young people with bej el and yaws are likely to die before reprodu ctive age or are less likely to have children as a result of the disease. This obviously reduces the spread of the pathogen . Its spre ad by sexual con t act pro tects yo u n ger individuals and ensu res it will be passed on to previously healthy adults. Its spread around the world was also facilitated by travelers transmitting it thro u gh repeated sexual con t acts with native s .

51

4 Syphilis: The Disease Let them stew in their own grease. Prince Otto Eduard Leopold von Bismark B i s m a r k ’s attitudes about political decisions paralleled early public

s en timent about syph i l i s : t h ey got what they de s erved . Even tod ay, people suffering from syphilis elicit a different sen timent than those afflicted wi t h influenza, leukemia, or pneumonia. After all , the deva s t a ting disease caused by Trepo n ema pa ll i dum pa llidum is attri buted almost exclusively to sexual intercourse. This is not an innocen t ly acqu i red disease. In the past and to some ex tent today, few people are wi lling to admit to having syphilis because of the nega tive social sti gma attach ed to it and the lack of p u blic sympathy for the afflicted. These attitudes made it difficult to track sy philis in its early days and tainted the accuracy of its reporti n g.D ra m a tic accounts of the disease fo llowed the precedent set by Italian physician Girolamo Frac a s toro in his 1530 work, Syphilis save morgues Gallicus: He first wore buboes dreadful To the sight, First felt strange pains and sleepless passed the night; From him the malady received its name. The neighboring shepherds caught the spreading flame: at last in city and in court ‘twas known, And seized t’ambitious monarch on his throne. 52

Figure 4.1 Treponema pallidum, a spirochete bacterium, has a spiral appearance much like curled spaghetti. Treponema pallidum enters the body through mucous membranes, which supply a moist, sticky surface that is attractive to the bacteria.

After Frac a s toro, physicians regularly ad ded emoti on filled descriptions to their recording of the disease. This was even true up until the late 1950s in the United States. It was hoped that the horrible imagery su rrounding the disease would discourage people from having illicit sex. S c i en tists now bel i eve that many of the accounts of 53

54

SYPHILIS

s yphilis recorded in the 1600s and 1700s were prob a bly not ex a ggerated. Nu m erous reports cl a i m ed that syphilis produ ced horren do u s ly painful sores and could qu i ck ly lead to mental dec ay and de a t h . This is ra rely noted today. Disease specialists now agree that syphilis appe a rs to have mell owed over time as it spre ad thro u ghout the human pop u l a ti on over the past 500 ye a rs . Most of what we know abo ut syphilis today comes from informati on gathered within the past 100 ye a rs of more exacting scientific inve s tigati on . Syphilis co u l d not be stu d i ed in re s e a rch animals because it on ly affects humans. Therefore, everything scientists know about syphilis had to be derived from ob s erva tion and experimentati on on human su bj ects. Tod ay, Trepo n ema pall i dum pa ll i du m holds few sec rets, espec i a lly now that its DNA sequ en ce has been com p l etely unveiled. SYPHILIS: HOW IS IT TRANSMITTED? Nobody truly knew how syphilis moved from person to pers on when it first hit Eu rope around the 1500s. Various ideas were formu l a ted based on the cultu ral vi ews of disease tra n s m i s s i on . Not su rpri s i n gly, most people attri buted syphilis to sin, this convi cti on being con s i s tent with a belief sys tem call ed spon t a n eous gen erati on . The idea of spon t aneous generation accepted the principle that disease and pests could originate from filth, b ad habi t s , and sinful acts. Through time people re a l i zed that it was a sexually tra n sm i t ted disease. However, it was not until 1905 that they recogn i zed that the infectious agent Treponema pall i du m pall i du m caused the disease. Trepo n ema pa ll i dum pa ll i du m comes from a long line of harmless spiroch etes that live within the dige s tive sys tems of animals ra n ging from insects to cattle. In order to remain lod ged in the body, Trepo n em a produce an attach m ent stru ctu re that sti cks them to the lining of the dige s tive sys tem. Th e stru ctu re ensu res that they are not flushed out of the body.

Syphilis: The Disease

This attach m ent structu re , c a ll ed a bacterial ligand, is a protein found on the su rf ace of the Trepo n em a. The ligand protein attaches to ch emicals su ch as su ga rs and pro teins found

CONDOMS IN EUROPE: For Syphilis or Birth Control? Condoms became popular in Europe right around the time syphilis made its nefarious appearance. Some scholars argue that the demand for condoms was prompted by syphilis. Others debate that it was used solely for birth control. A history of the condom and early attitudes about syphilis provide support for both views. The oldest evidence of condom use goes back to ancient Egypt. Drawings from 3,000-year-old Egyptian writings indicate condom use during sex. It is not known if the condom had an unexplained religious significance or was used for birth control. Early Romans also used condoms. However, many believed it was for a ritual that brought strength or providence to the user. Stories recount that the Roman condoms were made from the muscles of defeated enemies. The first regular use of condoms in Europe started around 1640 in England. Condoms made of cattle, fish, goat and sheep intestine were discovered in Birmingham, England. The name condom also dates to that time period. It may come from a Dr. Condom who supposedly served King Charles II or a military Colonel Cundum. Some speculate that the English modified the Latin word condo meaning to store up or hold. It is believed that the condom was p rescribed to King Charles to reduce the chances of him fathering illegitimate children from his numerous a ffairs. Condoms were also allocated to soldiers fighting during the battle between King Charles I and Oliver Cromwell. It may have been recognized then that condoms reduced syphilis transmission from the prostitutes frequented by soldiers. The disease was known to take its toll on soldiers, diminishing their ability to fight in the prolonged battles of that period.

55

56

SYPHILIS

t h ro u gh o ut an animal’s body. Sl i ght altera ti ons of this ligand pro tein, c a u s edby gen etic mut a ti on s , ch a n ge the abi l i ty of the ligand to attach to the different parts of an animal. It is believed that ch a n ges to this attach m ent protein perm i t ted Trepo n ema pa ll i dum pa ll i du m to cause syphilis in hu m a n s . Trepo n ema pa ll i dum pa ll i dum has a form of ligand that en a bles the or ganism to bind to a protein call ed fibronecti n . The significance of u n derstanding the natu re of a t t achment pro teins is discussed later in Ch a pter 5. Syphilis’ relatives, bejel and yaws , a re more re ad i ly tra n sm i t ted than syphilis because they requ i re on ly casual con t act with the lesion s . The Treponema i nvolved in these diseases re ad i ly en ter the skin, prob a bly thro u gh small cuts and sores that come in contact with the lesions of infected peop l e . Regular con t act is prob a bly needed to get a full infecti on . Af ter all , the body does fight of f s m a ll inva s i ons of t h e b acteria. The tra n s m i s s i on of syphilis is more exacting than that of bej el and yaws . O n ly special regi ons of the body, called mucous membranes or mu cosal epithelia, a re suscepti ble to Trepo n ema pall i dum pall i du m. One job of these membranes is to protect the body. However, certain organisms can en ter the body by exploi ting weaknesses in the mucous membrane’s defenses. ( F i g u re 4.1) SYPHILIS: THE DISEASE Two medical terms have to be def i n ed before con ti nu i n g with a de s c ripti on of syphilis. The term “sign” describes a medical condition that can be measu red or seen, su ch as redness, a sore , or a swelling. Symptoms refer to con d i ti on s that cannot be observed and are related to the pati en t’s s en s i tivi ty to disease sign s . Di z z i n e s s , m a l a i s e , and pain a re sym ptom s . Syphilis is a mu l ti s t a ge disease with sign s and sym ptoms that re s em ble those of o t h er diseases. Th i s explains mu ch of the con f u s i on su rrounding syphilis wh en it was first seen in Eu rope . Ex ten s ive medical studies on

Syphilis: The Disease

humans su f fering from syphilis identified five stages of the disease. S t a ge one is not visible, and it is difficult to predict its onset. The second through fifth stages are clinically visible and are used as the basis of naming the different stage s : p r imary, secondary, latent, and tertiary syphilis. It must be rem em bered that syphilis is not a malicious fiend trying to h a rm those it inhabi t s . The or ganism is solely intere s ted in perpetu a ting the species. To accomplish this, Treponema pallidum pallidum, l i ke almost all spirochete s , must find food and a safe place in the body of another creatu re . Its metabolic needs can on ly be sati s f i ed at the expense of s om e animal. The animal host of Treponema pall i dum pall i du m is just a temporary abode . Treponema pall i dum pall i du m mu s t con ti nu o u s ly find a way into new hosts to prevent it from dying out with the death of its current host. Stage 1: Getting in the Body Syphilis gets its start in a new pers on wh en it is tra n s ferred to one of several regi ons of the body containing mu cous membranes. Mu cous mem branes inclu de the lining or coverings of the dige s tive sys tem, eye s , reprodu ctive sys tem, and urinary tract . Mu cous mem branes are loaded with fibron ecti n and o t h er pro teins su i t a ble for microor ganism attachment. Trepo n ema pa ll i dum pa ll i du m can sti ck re ad i ly to the eye s , mouth, nasal lining, rectu m , u ret h ra , and vagina. No t su rprisingly, these are the main loc a ti ons wh ere syph i l i s en ters the body. A fe a tu re of Trepo n ema pa ll i dum pa ll i du m is that it someh ow indu ces the body to produ ce a sore or lesion wh ere it attaches to the mu cous mem bra n e . Bejel and yaws work in a similar manner except that they attach to skin i n s te ad of mu cous mem branes. Most cases of syphilis occur when Treponema pall i du m pall i du m is directly tra n s m i t ted thro u gh some form of s ex u a l con t act. The or ganism does not su rvive well out s i de of the body. S p i rochetes have a long assoc i a tion with animals. Most

57

58

SYPHILIS

Figure 4.2 Secondary syphilis results in a spotty, copper- c o l o red rash.

a re stri ct ly ad a pted to the resources provided by the animals they inhabi t . Like many spirochete s , Treponema pall i du m pall i du m can on ly live two hours out s i de of the body, and on ly under favora ble con d i tions su ch as on moi s t , warm su rfaces pro tected from light. So, it is unlikely that the disease can spre ad by obj ects. However, it is possible that obj ects f re s h ly con t a m i n a ted with Treponema pa ll i dum pall i du m can infect a pers on if the obj ect comes in con t act with mucous membranes. Syphilis can spre ad thro u gh blood transfusions and con t act with open wounds because the or ganism spen d s

Syphilis: The Disease

time circ u l a ting thro u gh o ut the body in the bl ood. Pregnant wom en can pass syphilis to the fetus thro u gh the placen t a and can con t a m i n a te the baby during va ginal delivery. Stage 2: Primary Stage of Syphilis Treponema pall i dum pall i dum has now made con t act with the body. The or ga n i s m’s next mission is to bre ach the protective barri ers of the body in order for it to gain access to the host’s re s o u rce s . For Trepo n ema pall i dum pa ll i du m to survive , it must now find food and a safe ref u ge to carry out uninterrupted reprodu cti on. The settlem ent of Treponema pall i dum pall i du m in the body begins the con d i ti on called primary syphilis . This first stage of syphilis usu a lly appears f rom ten days to abo ut one month after Treponema pall i du m pall i du m m a kes con t act with the mucous membrane. Th e i n fection site forms a small , hard, circular lesion call ed a chancre (pronounced “shanker”). Such lesions usually appear on the penis and in the vagina. However, chancres also appear on the mouth, nose, rectum, and anus. Chancres start out small and may even be undetectable when they form on a place not so readily visible on the body. At least 70 percent of the people who develop ch a n c res claim they produce no pain. Other people develop additional problems such as inflammation of the lymph nodes near the chancre. The chancre represents the body’s reaction to Treponema pa ll i dum pa ll i du m. This means that the body and not Treponema pallidum pallidum produ ces the lesion . Un l i ke m a ny animals, humans natu ra lly produ ce a strong immune response to spiroch ete s . The body mounts a full attack invo lving the cooperation of the wh i te blood cells. The white blood cells produ ce a variety of ch emicals used to fight off the infecti on . One group of ch emicals called antibodies is designed by the wh i te blood cells to specifically assault Treponema pallidum pallidu m. Ot h er ch emicals in f act harm the body, c re a ting the lesion wh ere attacks on

59

60

SYPHILIS

Treponema pallidum pall i dum are occurring. Un fortu n a tely for the afflicted pers on , Trepo n ema pa ll i dum pa ll i du m u sually grows and spreads faster than the body can de s troy it. The ch a n c re is an area of active growth for Treponema pall i dum pallidum. Con t act with the ch a n c re spreads the disease to another victi m . The delicate mu cous membranes of the digestive sys tem, reprodu ctive sys tem, and urinary tract are most su s ceptible to con tracting syphilis by con t act with a ch a n c re . Th ey are most likely to con t act the ch a n c re and are not as good a barrier as skin. The next event is typical of all Trepo n em a diseases in humans. The ch a n c re usu a lly does not last long. For most people it heals after abo ut six weeks, s om etimes leaving a scar that can last several mon t h s . This occ u rs in bejel and yaws as well. This leaves people with the miscon cepti on that the disease has been fo u ght of f by the body and cured. In bejel and yaws new sores appear, making people re a l i ze that the disease is still present. However, in syphilis no new sores arise, giving the appeara n ce that Trepo n ema pall i du m pallidum has died off. Actually, just the opposite is true. Treponema pa ll i dum pa ll i du m is now on its way to invading the rest of the body and becoming secondary syphilis . Stage 3: Secondary Stage of Syphilis Treponema pallidum pallidum is now in the body and focused on the goal of reproducing wi t h o ut prem a tu rely kill i n g its host. Upon healing of the ch a n c re , Treponema pallidum pa ll i dum migrates through the body, starting another series of s i gns and sym ptoms call ed secon d a ry syph i l i s . Th e s e con d itions appear two to ten weeks after the chancre hardens and heals. The time it takes for secondary syphilis to appear depends on the age , health, and gender of the person. Th e disease usually progresses faster and much more severely in people with we a ken ed immune systems. Malnutrition, pre -existing diseases, and stress decrease the immune system’s

Syphilis: The Disease

Figure 4.3 During the latency stage of syphilis, the bacteria invade all parts of the body, including the liver, lymph nodes, bones, kidneys, and nervous system.

effectiveness, giving the disease more freedom to spread. Ironically, people previously afflicted with bejel and yaws, caused by close relatives of Treponema pallidum pallidum, are better able to resist the spread of syphilis at the secondary syphilis stage.

61

62

SYPHILIS

Apparently the immune response produced by bejel and yaws protects against syphilis. Secondary syphilis is difficult to recognize, giving syphilis the label of the “Great Imitator.” The major signs include a fever, hair loss, rash, sore throat, and wei ght loss (see Figure 4.2). In many cases Treponema pallidum pallidum produces sores around the genitals and anus. These sores are highly infectious. Sym ptoms can consist of head aches, joint pains, and loss of appetite. Unfortunately, many people do not have all of these problems. The conditi ons noted here can also be m i sinterpreted as many other illnesses ranging from allergies to flu. As all these ailments are appearing, Treponema pallidum pall i du m crafti ly runs down the immune sys tem making it easier for syphilis to progress in the body and sp read to other people. This also makes it easier for other sexually transmitted diseases to attack the body. Secondary syphilis can last from three weeks to as long as a year. Once this stage is completed, it leads into the fourth stage of syphilis. Stage 4: Latency Stage of Syphilis The latency stage was not initi a lly recogn i zed as a disti n ct peri od of d i s e a s e . One re a s on was that almost half t h e people get ting the disease before tre a tm ents were developed died after the disease progre s s ed to secondary syphilis. In addition, at the latency stage all the signs and symptoms of secon d a ry syphilis disappear. Typically for this disease, it appears that Treponema pallidum pallidum has left the body and the person is cured. The latency stage can go on for s everal months or up to several ye a rs . For many peop l e , Treponema pall i dum pall i du m can remain in the latency stage for the rest of their live s . A lack of signs and symptoms is typical of the latency stage . Some people devel op eye m a l adies and other con d i ti ons not direct ly rel a ted to syph i l i s . Ma ny of these con d i ti ons prob a bly arise as a re su l t of a we a ken ed immune sys tem.

Syphilis: The Disease

Figure 4.4 Children can acquire syphilis from their mothers who have the disease during pregnancy and/or childbirth. Congenital syphilis can lead to disfigurement of the face, teeth, and internal organs.

During the latency period Trepo n ema pa ll i dum pall i du m invades every part of the body (Figure 4.3). The spirochetes enter the bon e s , kidneys , liver, lym ph nodes, nervous sys tem, and sensory or gans. Bone scarring, as discussed in Ch a pter 3, occ u rs at this point of the disease. It is not fully unders tood i f people with latency stage syphilis are able to spre ad the

63

64

SYPHILIS

disease. Treponema pallidum pallidum does not appear in body f luids or sores. Th ere appe a rs , therefore , to be little ch a n ce that it can be transmitted to others by con t act. However, it can be passed along to the fetus in pregnant wom en with latency stage syphilis. The or ganism re adily travels ac ro s s barri ers in the placenta to invade the developing baby ’s body. Ch i l d ren picking up syphilis this way acqu i re con gen i t a l syphilis. Congenital syphilis can lead to identifiable disfigurem ent of the face , i n ternal or ga n s , and teet h , as shown in Figure 4.4. Stage 5: Tertiary Stage of Syphilis If syphilis leaves the latency stage, it begins an app a rently non i n fectious but potentially lethal junctu re called terti a ry syphilis. Once again the disease re a ppears with a host of s i gns and sym ptom s . However, this final showing of t h e d i sease can lead to rapid death. Terti a ry syphilis produ ces a vari ety of probl ems assoc i a ted with the destructi on of major body or gans. The most evi dent and least destru ctive sign is a skin lesion called gumma or syph i l oma shown in Figure 4.5. Gummas are very painful and can form on internal or gans as well . Th ey ulti m a tely cause or gan failu re and complications leading to death. Bone scarring occurs rapi dly during terti a ry syph i l i s , causing the dec ay of small bones in the face. Damage to the inside of the bones produ ces a degenerative con d i tion called osteomyel i ti s . Osteomyelitis, or inflammati on of the bone and marrow, is typically caused by microor ganism infecti ons. Si gns of the con d i tion inclu de fever and sharp pain in the mu s cle and skin around the infected bon e . Specific body or gans can come under heavy attack by Treponema pallidum pallidum in the tertiary syphilis stage. For example, cardiovascular syphilis is localized to the heart and major blood vessels. This can lead to heart failure or rupture of the major blood vessels. The heart damage from neurosyphilis

Syphilis: The Disease

65

Figure 4.5 The man in this picture has gummas on the back of his neck. Gummas, a symptom of tert i a ry syphilis, are painful sores that can occur both internally and externally.

results when Treponema pallidum pallidum destroys the brain, cen tral nervous sys tem coveri n gs , s en s ory stru ctu res, and major nerves (Figure 4.6). Pers on a l i ty ch a n ges inclu d i n g depression, hallucinations, insanity, mania, and memory loss are typical of this infection. Syphilitic mood changes were blamed for the institutionalization of many famous people accused of having the disease. Paralysis can also occur as well as the loss of certain senses such as sight, smell, or touch. Some people display seizures and uncontrollable movements similar to muscle spasms. Swelling of the membranes covering the brain creates intense headaches.

66

SYPHILIS

Figure 4.6 Syphilis can attack many diff e rent organs of the body. The disease can affect the kidneys and liver (left), the nervous system (center), and the circulatory system (right).

People with terti a ry syphilis have a redu ced ch a n ce of spre ading the disease thro u gh con t act. However, open sores on the skin, in the mout h , and in the re p roductive tract can transmit the or ganism to the mucous mem branes and open wounds of o t h er peop l e . Pregnant wom en can sti ll pass

Syphilis: The Disease

Treponema pall i dum pall i du m to the fetus if they are capabl e of get ting pregnant or carrying out the pregnancy. In ra re i n s t a n ces syphilis was purportedly acqu i red by handl i n g contaminated body samples and nicking the skin of syphilitic patients during surgery. It is not certain if the disease can be acquired from dissecting sy philitic cadavers. Other diseases, particularly viruses, have been contracted by handling living and dead body specimens.

67

5 Syphilis: Cures, Prevention, and Treatment He’s the best physician that knows the worthlessness of the most medicines. Poor Richard’s Almanac Benjamin Franklin Benjamin Franklin made this comment not too long after syphilis made its

way through the American colonies. He observed the unusual and dangerous strategies used with little success to treat a variety of ailments plaguing society. Treatments that would be considered quackery today, such as bloodletting and the breathing of “healing” fragrances, dominated medical practices. Syphilis, the “Great Imitator,” created many problems wh en it was firs t recogn i zed in Europe as a distinct disease. Little was known about iden ti f ying and tre a ting the disease. At first it was confused as another form of other diseases su ch as anthra x , black plague, leprosy, and small pox. Th erefore either it was treated inappropri a tely or not treated at all because it was cons i dered incura bl e . An ad d i ti onal probl em abo ut syphilis was that nobody knew for su re what caused it and how it spre ad . Early cures and preven t ative measures had little va lue because they were founded on met a physical principles rather than medical eviden ce. A third problem with trying to con trol syphilis was the newness of the disease. It was a modern disease wi t h no trad i ti onal tre a tm ents in the ancient Gree k , Hebrew, or Roman herb a l s and medical wri tings. Even the Ara bic and Asian healing arts en tering Europe bit by bit provi ded no opti ons for get ting rid of s yphilis.

68

Figure 5.1 Many ancient remedies were used to cure the sick before scientists understood how diseases worked. Bloodletting was a common practice. People believed that syphilis was caused by an accumulation of bad humors (fluids) in the body and removing those humors would re s t o re the patient’s health.

EARLY VIEWS OF THERAPY At the on s et of syphilis in the late 1400s, the severi ty and a pp a lling natu re of the disease re s tricted medical analys i s . P hysicians were afraid to visit syphilis pati ents and ref u s ed to to u ch them. Most physicians rej ected all syphilis pati en t s because they were afraid of con tracting the disease. Th ey saw h ow the body qu i ck ly devel oped “acorn - s i zed boils that em i tted a fo u l , dark green pus,” as descri bed by Germ a n knight Ul ri ch von Hut ten in his popular book abo ut syph i l i s

69

70

SYPHILIS

publ i s h ed in the early 1500s. Even Girolamo Fracastoro, the Italian physician who unwi t ti n gly gave syphilis its name, vi ewed it as a terri bly fatal disease accom p a n i ed by “u l cers that dissolved the skin, mu s cl e , bone, p a l a te , and ton s i l s .” His de s c ri pti on of the disease was intended to indu ce fear in an attem pt to con trol its spre ad thro u gh o ut Eu rope. Im a gi n e what it was like to re ad abo ut an incura ble disease wi t h s ym ptoms su ch as “violent pains torm en ting the afflicted, who were ex h a u s ted but could not sleep, su f fered starva ti on without feeling hu n gry.” No won der physicians wanted nothing to do with syphilis pati en t s . Initially, syphilis patients were not treated mostly because of the philosophy of physicians such as M. Flamand of France, who believed that venereal diseases were the “just rewards of unbridled lust.” It was thought that the sin of sex, and not the actual intercourse, spread the condition. Therefore, syphilis was ju s ti f i a bly impo s ed by God as punishment for sin. Phys icians questioned if it was wise to go against the wisdom of God by easing the affliction. This analysis added to the tacit refusal of physicians to treat syphilis, some of whom went so far as to cast patients into the streets. Any treatments app l i ed to syphilis in Europe from the 1400s t h ro u gh the 1500s were founded on local cultu ral and rel i gi o u s bel i efs . Sin was considered the foremost cause of diseases in humans as well as in domesticated animals and plants. Dirty h a bits around the house, a sin in those times, created infestations of lice, fleas, and roaches. Ot h er sins, su ch as an unclean mind, l ed to different degrees of ailments ra n ging from com m on colds to black plague determ i n ed by the severi ty of sinning. So the horri ble sin of i llicit sex obviously was punished with the equ a lly terri ble affliction of s yphilis. Enco u n ters with “l awless” people and “barbari a n s” were also viewed as acti ons that cre a ted disease. This pers pective el i m i n a ted the idea that local citizen s were invo lved in heinous sins. The problem was more of an invasion by sin or miasmas.

Syphilis: Cures, Prevention, and Treatment

Diseases of sins and miasmas were treated according to the various cures developed in Europe during the Roman influence of Europe, starting about 200 B.C. and ending around A.D. 900, after the reign of Charlemagne. These therapies were then

SYPHILIS: A Rationale for Various Treatments Each culture ’s interpretation of syphilis determined the type of preventative methods and cures that were used. Today, most people in the world readily accept that syphilis is caused by a bacterium and can be treated with antibiotics. However, little if anything was known about the cause of syphilis when it first materialized in Europe. So, coming up with strategies to contro l the disease were based on previous experience with other disorders. At first, common poisons believed to have purifying effects on the body were used as treatments. Pure metals such as gold and merc u ry served that role. These remedies had little effect, but that did not stop people from believing in their use. The common ideology was that a person would be worse off without the therapy. A known toxin called Salvarsan, or arsphenamine, which contains arsenic, was even promoted by noted scientists such as Paul Erhlich who won a Noble Prize for his work on disease tre a tment. Other purifying methods such as bloodletting and herbal medicines followed. Some herbal therapies are still used today to ward off syphilis. Many homeopathic practitioners prescribe herbs that interact with the syphilitic psyche. For e x a m p l e , syphilis makes a person feel desperate, destructive and hopeless. Thus, treatments that bring people out of those states of mental anguish help alleviate the syphilis. Probably the most obscure use of herbs in treating syphilis involves a common salad component. During the Middle Ages carrots were thought to relieve the body of syphilis and other ailments. The vegetable made its way to Europe from Afghanistan in the tenth century by trade under the Byzantine Empire .

71

72

SYPHILIS

modified by Christian clerics during the Dark Ages. Treatments were made more applicable to the sins creating the ailments. New views of medicine were heralded during the 1200s and 1400s through various developm en t s : the growth of scholasticism in Eu ropean universities, the introducti on of Middle Eastern philosophy during the crusades, and the influence of Asian therapies brought in by trade. Metaphysical syphilis therapies prevailed during the early outbreak of this STD scourge. They included custom i zed prayers by the afflicted, incantations by clerics, the we a ring of amulets or religious symbols by the afflicted, and herbal remedies similar to aromatherapy. Some physicians took a blended metaphysical and medical approach by administering herbal potions intended to flush disease and sin from the body. Skin disorders associated with syphilis were likely treated with chicken broth and saliva. It was thought that chicken broth and saliva had magical powers that rid the body of demons, serpents, and worms derived from sinful acts. The use of poi s onous metals and salts was also com m on in tre a ting a variety of diseases. Gold, mercury, and silver were ingested or introduced into the patient’s blood as a means of purifying the body. By accident, these metals had some benefits because they killed the microorganisms and reduced damage caused by the immune system. Bl oodl et ting and leeching were prob a bly also app l i ed to syphilis during its early outbreaks. The practi ce of draining bl ood is based on the principle that bl ood contains the hu m ors con tro lling the body’s health, and an accumulation of b ad hu m ors in the bl ood produ ces disease. Bl ood was dra i n ed from the body using su r gical instru m ents or leeches (Figure 5.1). Som etimes bl oodl et ting led direct ly to death from ex treme and rapid bl ood loss. However, the calming ef fects of bl oodl et ti n g, attri but a ble to a we a ken ed state cre a ted by bl ood loss, were measu red as su ccessful treatment. Rel a ted tre a tm ents inclu ded d ri lling holes in the skull to prevent or rel i eve mental afflictions.

Syphilis: Cures, Prevention, and Treatment

True medical tre a tm ents include cauterizing syphilis sores wi t h a hot iron to steri l i ze and seal the wounds. Tow a rd the 1600s it was well establ i s h ed that the act of s ex spre ad som ething that caused syphilis. This insight, p lu s the growing de s pera ti on to combat the swift spre ad of syphilis, coerced hospitals and physicians to seek rational ways of s temming the tide of the disease. In d i gnities against pro s titutes in the form of regulati ons against fornicati on led the preventi on methods. It was believed that syphilis was spread by sex with “inferi or ” and “b a s e” i n d ividuals. Prostitutes with syphilis who did not stop their corrupted practi ces were banished, branded, and som etimes killed. Dutch scholar De s i derius Era s mus (1496-1536) went as far as proposing the binding and castrati on of wom en with syph i l i s . The immigrati on of syph i l i tics was also re s tri cted in order to reduce its spre ad in a co u n try or regi on . Ho s p i t a l s tre a ted syph i l i tic s similar to people with leprosy and tu berculosis by placing them in quarantine clinics. THE ROAD TO TREATING SYPHILIS This discovery of Treponema pa ll i dum pa ll i dum as the cause of syphilis open ed the door for rati onal preven tive methods and cure s . Trepo n ema pa ll i dum pa ll i du m was difficult to link to syphilis because of its elusive natu re . L i ke many spirochete s , Treponema pall i dum pallidum is difficult to isolate in the laboratory. It does not su rvive under the conditi on s trad i ti on a lly used to maintain many disease-causing microor ganisms. Th erefore re s e a rch ers were not able to grow Trepo n ema pa ll i dum pa ll i du m f rom wounds and ti s sues of syph i l i tic pati en t s . Un fortu n a tely, this met h od con s ti tuted an important step for iden tifying microbial disease devel oped by Robert Koch in the 1870s. Koch’s criteria for determining the cause of a disease, k n own as Koch’s Po s tu l a te s , a re shown in Figure 5.2. An o t h er factor con founding the discovery of Trepo n ema pa ll i dum pa ll i du m was that it did not cause actu a l

73

74

SYPHILIS

syphilis in trad i ti onal labora tory animals used by early scientists. It could on ly be stu d i ed on human su bj ects, wh i ch is also true for AIDS tod ay. The meticulous work of Russian scien tist Elie Metchnikoff, with the assistance of Fren ch scientist Pierre Roux, set the stage for the discovery and treatment of Treponema pallidum pa ll i dum as the cause of syphilis (see Figure 5.3). In 1903 they su ccessfully transferred the then unknown or ganism from humans to chimpanzees. Treponema pallidum pallidum survived in the chimpanzees and caused lesions similar to those of humans su f fering from syphilis. The two scientists were also able to transmit syphilis between chimpanzees using the same tech n i que of inoc u l a ting the chimpanzees with i n fected ti s su e . Metch n i kof f and Roux also learn ed that i n ocu l a ti on with small amounts of the organism provided slight re s i s t a n ce at the time of su b s equ ent expo su re . This was

KOCH’S POSTULATES 1. The specific organism should be shown to be present in all cases of animals suffering from a specific disease but should not be found in healthy animals. 2. The specific microorganism should be isolated from the diseased animal and grown in pure culture on artificial laboratory media. 3. This freshly isolated microorganism, when inoculated into a healthy laboratory animal, should cause the same disease seen in the original animal. 4. The microorganism should be reisolated in pure culture from the experimental infection. Figure 5.2 Robert Koch proposed four rules that allowed scientists to identify infectious diseases.

Syphilis: Cures, Prevention, and Treatment

75

Figure 5.3 Elie Metchnikoff, pictured here in his laboratory, discovered that Treponema pallidum pallidum caused syphilis.

proved many ye a rs later with the observations that exposure to bejel and yaws reduces the chance of contracting syphilis. Italian scientists were later able to induce syphilis-like sores on the scrotums of rabbits using a similar technique. It was not until 1905 that Treponema pallidum pallidum made its appearance under the microscope. Fritz Schaudinn and Erich Hoffman isolated the spirochete from chancres on people confirmed to have syphilis. Normal microscopic analysis would not have shown Treponema pallidum pallidum. They had to use techniques reserved for blood-borne parasites and

76

SYPHILIS

Figure 5.4 Penicillin, a common antibiotic that is widely used today, was d i s c o v e red in 1929 by Alexander Fleming. Fleming is shown here, hard at work in his laboratory.

pathogens developed by hematologists. Scientists were now ready to precisely combat the disease knowing that syphilis was caused by a bacterium. However, adequate syphilis therapy was not available until drugs called antibiotics were discovered. An ti bi o tic thera py would not have been discovered if it were not for a fortu i tous ob s erva ti on by Al ex a n der Flem i n g in 1929 (Figure 5.4). He discovered that the fungus Penicillium produced a secretion that kills bacteria in laboratory cultures. The sec reti on tu rn ed out to be the anti bi o tic pen i c i ll i n .

Syphilis: Cures, Prevention, and Treatment

Fleming and other re s e a rchers turned this ob s ervation into a possible therapy for tre a ting bacterial diseases. By 1940, English scien tists How a rd Florey and Ernst Chain con f i rm ed the ef fectiveness of penicillin on killing bacteria in animal and human trials. Its gre a test use came du ring World War II to treat a va ri ety of bacterial infecti ons of wo u n d s . Now there was hope for controlling the unrelenting spread of other bacterial diseases su ch as syphilis. MODERN SYPHILIS THERAPY The first step in ridding the world of syphilis invo lved the use of a n ti biotics. In i tial su ccesses curing bacterial diseases ju s tif i ed their use for tre a ting syph i l i s . Fleming’s penicillin became the choice treatment for syphilis during World War II. Its ef fectiveness du ring the war tra n s l a ted into its regular use throughout the world. Penicillin injecti ons proved effective against the primary and secon d a ry stages of syph i l i s . It kill ed Trepo n ema pa ll i dum pa ll i du m i m m ed i a tely, preven ti n g them f rom spre ading throughout the body and advancing the disease. Latent and terti a ry syphilis are not as simple to tre a t as the earl i er stage s . Th ey requ i re lon g - term penicillin tre a tments to catch the bacteria at a time wh en they are norm a lly vu l n era ble to anti bi o tic tre a tm en t s . Pen i c i llin is mostly ef fective wh en bacteria are reproducing ra p i dly. Treponema pall i dum pa ll i dum is not invo lved in mu ch growth du ring the latent and terti a ry stage s . In 1998, the Cen ters for Disease Con trol in Atlanta, Georgia, continued recommending the original type of penicillin called penicillin G as the primary treatment for new cases of syphilis. A single dose at 2.4 million units injected into the muscles is found to work well for pri m a ry and secon d a ry syph i l i s (Figure 5.5). This therapy is also recommended for treating syphilis in preg nant women because the penicillin is not known to harm the fetus. Latent and tertiary syphilis must be treated with a total of 7.2 million units of penicillin G, also

77

78

SYPHILIS

Figure 5.5 Penicillin works against primary and secondary syphilis. It is usually administered via an injection to a large muscle group (upper arm or thigh).

injected into the muscle over a period of three weekly doses. Neurosyphilis, resulting from a long-term syphilis infection, is treated with aggressive pen i c i llin G treatments. Similar treatment regimens prove effective against other Treponema pallidum diseases such as bejel and yaws.

Syphilis: Cures, Prevention, and Treatment

Unfortunately for many people, the penicillin treatments given for syphilis can cause an intense fever called the JarischH e rxheimer re a c t i o n . The con d i ti on devel ops within two days after treatment and may lead to headaches and muscle pain. Fever- reducing drugs are usu a lly given at the first signs of Jari s ch - Herxheimer. So far, no effective oral or topical pen i c i llin therapies ex i s t . Metch n i kof f ’s ori ginal stu d i e s focused on controlling syphilis sores with topical applications to the chancres. Sadly, the antibiotic treatments for syphilis do not undo any damage caused by the bacteria; the bone decay, skin scarring, and any organ damage remain. Luckily, the body may slowly heal some of the damage, assuming the person is healthy and remains free of other infectious diseases. Many people suffer fro m antibiotic allergies. The penicillins in particular cause dangerous allergic reactions that at their mildest lead to fever and hives. At its worst, penicillin can induce the cessation of breathing during what is termed an anaphylactic reaction. Therefore, other antibiotics may have to be administered instead to prevent harm to the patient during syphilis treatment. Doxycycline and tetracycline are commonly recommended for patients with penicillin allergies. The treatment regime is different than that for penicillin. First, both of these drugs must be taken orally, possibly reducing their effectiveness if they are not taken properly. Doxycycline is taken in 100-mg doses twice a day for 14 days. Tetracycline must be administered in 500-mg amounts four times a day for 14 days. The unfortunate overuse of a n ti biotics in Eu rope and North Am erica has lead to the produ ction of antibi o tic resistant bacteria call ed “superbu gs .” Su perbugs are microor ganisms u n a f fected by common drug thera p i e s . For syph i l i s , that means types of Trepo n ema pa ll i dum pa llidum that are not kill ed by pen i c i llin and the common altern a tives doxyc ycline and tetrac ycline. G en etic mutations in the bacteria protect them from the antibiotics. These mutations are en co u ra ged wh en antibiotics are overu s ed or not administered properly. The United Ki n gdom’s

79

80

SYPHILIS

House of Lords Sel ect Com m i t tee on Scien ce and Tech n o l ogy best ack n owl ed ged the severi ty of the su perbug problem in a 1998 report. It stated , “This en quiry [into antibiotic resistance] has been an alarming experience, which leaves us convinced that resistance to antibiotics and other anti-infective agents constitutes a major threat to public health and ought to be recognised as such much more widely than it is at present.” The report made medical officials aware that the uncontrolled spread of superbugs can cause public health to regress back to the days before antibiotics. Syphilis patients worldwide are being found to have infections with penicillin-resistant Treponema pallidum pallidum. This necessitates the use of other antibiotics to treat syphilis, including potent ones such as vancomycin. Worsening the problem is the appearance of Treponema pallidum pallidum that is resistant to doxycycline and tetracycline in addition to penicillin. Other antibiotic treatments must be developed. This is not such an easy task because not all antibiotics are effective at controlling Treponema pallidum pallidum. The ultimate n i gh tm a re is the appe a ra n ce of b acteria resistant to all k n own antibiotics. This dreadful event has already occurred for Treponema pallidum pallidum. People carrying these bacteria either die as if untreated or must be given chemotherapy with highly toxic chemicals similar to those used to treat cancer. Developing nations are at a severe disadvantage when they encounter multiple antibiotic-resistant bacteria because they have little or no access to expensive alternative therapies. Prob a bly the best way to con trol syphilis is to focus on contro lling its spre ad. Use of condoms designed for STD redu ction greatly dec reases the chance of con tracting syphilis during intercourse. Not all condoms are effective and if improperly used, condoms provide no protection. Old and torn condoms are ineffective, as are condoms used with lubricants that decay the protective material. Other birth control devices are not effective in preventing the spread of syphilis.

Syphilis: Cures, Prevention, and Treatment

The recent growth of homeopathy and natural medicine is producing a d emand for alternative medical treatments for syphilis. Many of these treatments date back to the Roman and Greek herbal remedies used around 400 B.C. Their purported effectiveness is not based on medical experimentation or study. So, physicians and scientists highly doubt that the treatments work. Herbal treatments for controlling or preventing syphilis include the use of tropical trees, such as lignum vitae sap applied to sores and lignum sanctum bark given as a broth. Dri ed eart hworms used as lignum tre a tm ents even tu a lly proved ineffective. An old treatment using ingested almond oil is still used tod ay. Ot h er trad i ti onal herbal therapies for syphilis com m only recom m ended tod ay inclu de extracts or leaves of plants related to blueber ries, daisies, lilies, lobelias, mustards, and tomatoes. A new candidate is a cure-all plant from India called neem. Neem produces an oil that purportedly cures syphilis when used as a sexual lubricant.

81

6 Syphilis: Epidemiology Believe nothing and be on your guard against anything. Latin proverb Investigators who study the science of epidemiology exercise the same

skepticism ex pre s s ed in this Latin adage. Ep i demiology investiga tes the cause and spread of disease. Ma ny think that it is a simple task to determine how diseases spre ad. However, the oppo s i te is true, even given the abu n d a n ce of c u rrent medical tech n o l ogy. This difficulty is re ad i ly evident in the media’s reporting of medical findings. Re s e a rchers are regularly reported as disputing the causes of widespre ad maladies su ch as cancer and heart disease. Even the causes and spre ad of i n fectious diseases were su bj ects of h e a ted deb a tes until more was learned thro u gh rigorous inve s tigati on and fortu i tous findings. Little was known abo ut the cause, diagnosis, and spre ad of AIDS unti l m a ny years after its first recogn i zed appearance. People and physicians had no sys tem a tic means of a n a lyzing the spre ad of disease in the 1400s during the first syphilis outbreak in Eu rope. Th ey bl a m ed the sco u r ge on a va ri ety of factors , u su a lly rel a ted to a bre ach of cultural va lues or a plague acqu i red from unde s i ra ble peop l e . The disease spre ad worl dwide because of the ignora n ce abo ut its diagnosis and transmission. It was not until the 1840s that peop l e obt a i n ed a firm grasp of a pp lying scien ti f i c a lly sound rati onales to u n derstanding the spre ad of i n fectious diseases. A Hu n ga rian phys i c i a n named Ignaz Semmelweis set the foundations for epidemiology methods while inve s tigating the spre ad of puerperal fever in maternity ward s ( F i g u re 6.1). His astute ob s ervati ons traced the spre ad of the bacterial

82

Figure 6.1 We now know how important it is to wash your hands after you sneeze, to prevent the transmission of germs. Scientists did not always understand how diseases were passed from person to person. Ignaz Semmelweis, shown here, provided an understanding of infectious disease transmission.

disease to improper hand washing and sanitary prac tices by physicians. Unfortunately, Semmelweis’ contemporaries were not willing to accept his findings and failed to exercise his precautions for reducing the spread of bacteria. It did not become a recommended practice until a short time after Semmelweis’

83

84

SYPHILIS

de a t h . To this day, though, physicians stri ct ly app ly the cl e a n l iness practices (sterile tech n i ques in tod ay’s language) prom o ted by Sem m elwei s . Epidemiological studies have taught scien tists mu ch abo ut the causes of the initial on s et of syphilis in fifteenth century Europe. Epidemiology also explains syphilis’ persistent global presence today. With this knowledge, public health officials can reduce the impact of the disease and prevent a repeat of the horrible outbreaks that took place throughout Europe and European settled lands between the late 1400s and early 1900s. Understanding the ep i dem i o l ogy of s yphilis requ i res knowl ed ge of its diagnosis and transmission. A disease cannot be adequ a tely s tu d i ed if it is difficult to detect in infected indivi du a l s . In addition, knowledge of how syphilis spreads from one person to another is needed to develop strategies for preventing its uncontrollable proliferation. DIAGNOSING SYPHILIS Determining whether a person has a disease invo lves two critical ob s ervations: (1) recognizing characteristic signs and symptoms of the disease, and (2) confirming the pre sen ce of the disease by isolating and identifying the organism causing that ailment. Syphilis was at first difficult to diagnosis because its victims manife s ted signs and sym ptoms similar to those of other com m on disorders. In addition, the body shows little evi den ce of the disease until abo ut three weeks after infection. Un l i ke a cold or flu , it does not hit all at on ce . This makes it difficult to tell wh en and from wh om the disease was contracted. Today, the characteristic diagn o s tic features of syphilis are hard ch a n c res at predict a ble parts of the body that could become infected. Si n ce syphilis is an STD, chancres are predominantly found around the genitals. Lesions on mu cous membranes, a spotting skin rash, and general aches and pains best identify secon d a ry syph i l i s . Latent syphilis con founds diagnosis because it provi des no

Syphilis: Epidemiology

a)

b)

c)

Figure 6.2 The three stages of syphilis: a) primary syphilis is defined by the presence of hard chancres at the site of infection; b) a patient with secondary syphilis develops a spotty rash; c) tertiary syphilis results in the formation of gummas on the surface of the skin as well as internally.

85

86

SYPHILIS

easily ob s ervable signs or symptoms. Terti a ry syphilis is be s t identified by linking the pre s en ce of gummas and other signs to the pati en t’s disease history (Figure 6.2). A meeting of dermatologists in 1889 established the first or ga n i zed attempt at standardizing the identificati on of syphilis during routine medical diagnosis. French physician Hen ri Feu l a rd su m m on ed an internati onal group of derm ato l ogists to con s tru ct criteria for recognizing syphilis. Th ey settled on the cri teria descri bed above with other evi den ce of immune sys tem attack by spirochete s . Over the years the group establ i s h ed cri teria for a host of o t h er diseases that can be characterized by specific skin con d i ti on s . Iden ti f ying the signs and sym ptoms alone is not su f f ic i ent for con f i rming the pre s en ce of s yph i l i s . Di a gn o s ti c tests indicating the pre s en ce of Trepo n ema pa ll i du m pa llidum, and nothing else, substantiate that a patient has the disease. Patients su s pected of h aving syphilis are first interviewed to assess their level of sexual activity. People who were actively engaged in sex two to four weeks prior to the suspected indications of primary syphilis are very likely to have the disease. It would be highly unu sual for a patient to have the early stages of syphilis if he or she was not engaged in any type of sexual activity. Similar background can be ga t h ered for ob s erva ti ons poi n ting to s econ d a ry and terti a ry syphilis. At this point physicians can spec u l a te if the syphilis was con genital or acqu i red by sexual contact. Luckily, syphilis is not spread by casual encounters, contact with animals, or insect and tick bites. This restricts the search for how the disease suspected to be syphilis was probably acquired. As menti on ed in Ch a pter 5, Metch n i kof f and Roux were the first to learn that the ch a n c res and sores of syph i l i tic pati ents con t a i n ed and tra n s m i t ted the infectious agent now known as Treponema pallidum pallidum. In effect, they provided the basis for determining syphilis by seeing if the

Syphilis: Epidemiology

i s o l a ted or ganism caused similar lesions in ch i m p a n zees. Unfortu n a tely, this test was not su i t a ble for qu i ck tre a tm en t because it took at least two weeks for ch i m p a n zees to show the signs of syphilis if at all. Al s o, the test was very ex pensive , requiring the sacrifice of several chimpanzees for one pati en t . The same would be true if the test was perform ed on ra bbi t s . Most important, Metch n i kof f and Roux did not know the natu re of the or ganism being tra n s m i t ted. Th ere was no proof that it was Treponema pa ll i dum pall i du m . It could have been another or ganism causing the disease. Th e pre s en ce of Trepo n ema pall i dum pall i du m in the wounds, as determ i n ed by Schaudinn and Eri ch Hof f m a n , may have been purely coi n c i dental. Koch’s con tributi ons to disease diagnosis rem oved the n ext hu rdle for devel oping a way to po s i tively iden ti f y Trepo n ema pa ll i dum pa ll i du m in pati ents su s pected of having syphilis. His postulates provided a guideline by which s c i en tists could show that Trepo n ema pa ll i dum pa ll i du m acting alone indeed was the cause of syphilis. The race began to find qu i ck ways to confirm the pre s en ce of Treponema pall i dum pallidum to attest that a pati ent was afflicted with syphilis. The bre a k t h ro u gh came in 1906 thanks to the ef forts of G erman microbiologist Paul von Wa s s ermann, who formu l a ted a test for Treponema pallidum pallidum t h a t now be a rs his name. Wassermann found a way of con f i rming the pre s en ce of Treponema pall i dum pall i du m using information and strategies gathered from the new scien ce of immunology. The te s t , now called the Wassermann re acti on, begins with a sample of bl ood serum collected from the p a ti en t . The bl ood is then caref u lly mixed with de ad or l iving Treponema pall i dum pallidum obt a i n ed from pure l a bora tory cultu re s . Pa ti ents ex po s ed to syphilis show a po sitive test wh en the immune sys tem com pon ents in the blood immed i a tely re act to the bacteriu m . The serum of pati ents not infected with Treponema pallidum pall i du m

87

88

SYPHILIS

gives a negative test indicated by no reacti on . Some syphilis pati ents have negative test re su l t s , adding some inaccuracy to the te s t . Wassermann was able to adapt the test as a way of telling wh et h er syphilis had re s pon ded to tre a tment. Removal of Treponema pall i dum pall i du m f rom the body is con f i rmed by several negative Wa s s ermann re acti ons over a period of a few ye a rs after treatment. Over the years the Wassermann re acti on was gradu a lly improved to increase its sensitivity and acc u racy. It is now one of several tests used to confirm infection with Treponema pall i dum pa ll i du m. The latest modification of the Wasserman test is called the Treponema pallidum hemaggluti n a ti on assay, a bbreviated TPHA. T PHA detects pati ent anti bodies that spec i f i c a lly attack Trepo n ema pa ll i dum pa ll i du m. Most people produ ce defen s ive pro teins call ed anti bodies when m i c roor ganisms invade their bod i e s . Wh i te bl ood cells manu f actu re the anti bodies for the purpose of bi n d i n g to the attacking or ga n i s m . The anti bodies then serve as markers, labeling the bacteria for de s tru cti on and removal by various com pon ents of the immune sys tem . Pa ti en t s h aving Treponema pall i dum pallidum antibodies show a clumping of red bl ood cells or hemaggluti n a ti on in the serum. T PHA is useful for indicating all stages of s yph i l i s but is most sensitive to primary and secon d a ry syph i l i s . However, many public health officials are not sati s f i ed with the TPHA because it is inheren t ly not very sensitive . Peop l e with light or undeveloped infecti ons of Treponema pall i du m pall i du m m ay have negative test re sults with this assay. A more sensitive test is the Venereal Disease Re s e a rch Labora tory te s t , k n own as the VDRL te s t . This test is commonly used to check for primary and secon d a ry syphilis. VDRL also indicates the pre s en ce of Treponema pallidum pa ll i dum antibodies in patient serum and ti s sue samples. Samples collected from suspect sores or bl ood are mixed with purified Treponema pallidum pa ll i dum antigens . An

Syphilis: Epidemiology

easy to visualize re action called flocc u l a ti on occurs if the p a ti en t’s bl ood has Trepo n ema pa ll i dum pa ll i du m a n tibodies. The test is highly sen s i tive and can detect low levels of infection. Kit forms of the test are re ad i ly available to clinics and physicians and are sold as the rapid plasma re agin c a rd te s t . Pa tient samples are placed on a small plasti c card that gives test re sults that are easily seen by simply viewing the card. Another way of detecting Trepo n ema pa ll i dum pall i du m antibodies i nvo lves the use of f l u o re s c e n t antibodies. The flu orescence, or bright glow, acts as a loud alarm announcing the pre s en ce of Treponema pallidum pallidum antibodies in serum and tissue samples. Treponema pallidum pallidum antibodies attached to fluore s cent dyes are integrated into a test called the flu ore s cent treponemal a n t i b o d y absorpti on test or F TA - A B S . Samples containing Trepo n em a pa llidum pallidum antibodies give off a green gl ow when exposed to ultraviolet light. Fluore s cent tests are much more sensitive than agglutination te s ting, which permits their use with all stages of syphilis. A related test uses proteins called enzymes to enhance the glow. These are called enzyme linked immunoabsorption assays or E L I S A . They are usu a lly sold as simple kits that give immediate re sults (Figure 6.3). The advent of simple diagnostic kits for detecting syph i l i s has cre a ted many probl ems for public health of f i c i a l s . Health workers administering the kits som etimes do not qu e s ti on the acc u racy and prec i s i onof the te s ti n g. This oversight could po s s i bly lead to misdiagnosis. Test kits are inef fective if they are not correct ly used and handled. Kits require proper storage and must be used under the specific con d i tions stipulated by the manu f actu rer. Most govern m ents pro h i bit sale of the syphilis test kits to the public because of the severe con s equ en ces of i n correct re su l t s . In Ja nu a ry 2002, t h e Medical Devices Agency in England had to ban a syphilis

89

90

SYPHILIS

Figure 6.3 ELISA, or enzyme linked immunoabsorption assay, is one way to test for syphilis. This test involves using a fluorescent tag to identify the presence of Treponema pallidum pallidum antibodies.

ELISA kit because it was giving false data. The test regularly gave false-nega tive te s t s , meaning that people with syph i l i s were shown to be free of the disease. This cre a ted many legal probl ems wh en a pregnant woman using the test unknowingly passed along the disease to her ch i l d .

Syphilis: Epidemiology

A recent report in Canada put a scare into the medical com mu n i ty. It found that all the current syphilis tests do not re s pond to people with AIDS. The immune dec ay caused by the AIDS virus reduces the number of a n ti bodies produ ced against syphilis and other diseases. In many cases the antibody nu m ber falls bel ow what is needed for detecti on by the various tests described above . Neal den Ho ll a n der, the University of Ontario microbi o l ogist who led the stu dy, sees a need for developing more effective ways of detecti n g syphilis in patients with immune sys tems we a kened by ill health or infectious diseases. Diagnosing syphilis with clinical tests is on ly part of the syphilis con trol scenario. Pu blic health agencies must try to trace the path of the particular infecti on that was just diagnosed and con f i rm ed . Tracking the disease invo lves intensive intervi ews with the infected pers on . The pers on is obl i ga ted to report all the con t acts that could have caused and further s pre ad his or her case of s yph i l i s . In most cases this may i n clu de ad m i t ting em b a rrassing pers onal details and may com promise the inti m acy of certain rel a ti on s h i p s . Ma ny married individuals found their marri a ges jeop a rdized wh en it was discovered that they had con tracted syphilis thro u gh extramarital sex. All sexual partn ers must be noti f i ed to ensu re that they are diagnosed and tre a ted. THE PREVALENCE OF SYPHILIS TODAY One would think that syphilis would be a disease of the past con s i dering all the marvelous medical and scien ti f i c adva n ces for detecting and con tro lling Trepo n ema pall i du m pall i du m. This bel i ef is far from the trut h . Epidem i o l ogic studies worl dwi de show that syphilis is sti ll com m on and widely tra n s m i t ted in spite of m a ny attem pts to limit its spre ad. Syphilis sti ll accounts for a majority of s ex u a lly transmitted diseases found thro u gh o ut the world. In the United States, approximately 0.03 percent of the population is

91

92

SYPHILIS

afflicted with syph i l i s , meaning approximately 10,000 peop l e know they have the disease. This is an all-time low and has decreased by 84 percent between 1980 and 1997. However, the disease is sti ll pre s ent and in recent studies is showing signs of i n c reasing in Ca n ada and Un i ted State s . Re s e a rch studies show that in developed nati ons syphilis is mostly spre ad by hetero s exual sex in young adu l t s . Young female drug ad d i cts are curren t ly the faste s t - growing gro u p con tracting syph i l i s . It is believed that they acqu i re syphilis through sexual favors or pro s ti tuti on perform ed to obt a i n the drugs. This has cre a ted a stark increase in the nu m ber of con genital syphilis cases. Male hom o s exuals account for another growing sector of syphilis. The app a rent waning of AIDS is making people less cautious of high - risk sexual beh avi ors . In ad d i ti on , h om o s exuals are less likely than h etero s exuals to use con dom s . Con doms are con s i dered an inconvenience by many people and are used almost exclusively to prevent pregnancy. Syphilis in developing nati ons is m o s t ly a probl em among pro s ti tutes and people who are not edu c a ted abo ut safe sex. Crowded urban areas have the highest inciden ce of STDs in these nati on s . However, the probl em is com po u n ded because few people seek tre a tm en t even if they know they are infected. Syphilis tod ay is most com m on ly found in assoc i a ti on with other STDs. People with AIDS trad i ti on a lly are candidates for a con c u rrent syphilis infecti on. Syphilis is more l i kely to spre ad unch ecked wh en afflicted indivi du a l s h ave a we a ken ed immune sys tem typ i c a lly caused by A I D S . Ch l a mydial infecti on and gon orrhea also reg u l a rly accom p a ny syphilis according to reports by the Cen ters for Disease Con tro l . The nu m ber of STDs found in an i n d ivi dual is linked to the amount and frequ ency of his or h er sexual con t act s . Although the inciden ce of syphilis is now lower than ever before in history, p u blic health officials are fe a rful of the

Syphilis: Epidemiology

A SYPHILIS VACCINE? Public health officials are well aware that the best way to contro l disease is by preventing it. Treating the disease with medication does not necessarily remove the disease. Many diseases have become resistant to current drug treatments and withstand the best efforts to eradicate them. Syphilis is no exception. Although syphilis can be cured, the disease is best contained by preventing it from spreading throughout the population. This way, syphilis may ultimately disappear quickly or become so infrequent that the remaining cases can be eradicated after a while. Early campaigns to rid society of syphilis did not work because of u n realistic expectations. The government tried unsuccessfully to c o n t rol people’s sexual habits, thinking that strict codes against illicit sex, prostitution, and sodomy would be sufficient. However, people ignored and protested these regulations as they did drinking restrictions during the Prohibition. In 2002, San Francisco, C a l i f o rnia, implemented the latest effort by a city to try imposing limitations on sexual behavior to curb the spread of STDs. The city started a public ad campaign in the schools advocating abstinence. As expected, it was unrealistic to enforce rules on sexual activity. The use of vaccines to rid the world of disease was proven successful with smallpox. Smallpox was a devastating disease that killed thousands of people in its mildest sweeps across the world. Aggressive vaccination programs ensured that nobody in the world was infected with the virus by the end of the 1900s. As early as 1881, medical professionals were proposing the development of vaccines to wipe out syphilis. However, the p roject was abandoned because of the possibility of inducing syphilis from the vaccine. Vaccines produced up until the 1970s were usually made with weakened organisms. Sometimes the organisms were not weakened properly and managed to cause syphilis. Today it is known that syphilis vaccines would not impart full immunity. The way Treponema pallidum pallidum enters and resides in the body prevents the immune system from completely countering an infection.

93

94

SYPHILIS

growing incidence of antibiotic resistant Treponema pallidum pall i du m. These bacteria are difficult to treat in developed nati ons and cannot be tre a ted at all in developing nati on s . Un d i a gn o s ed indivi duals carrying these su perbu gs can produ ce a dramatic rise in the inciden ce of syphilis possibly equ ivalent to what was seen in the 1500s in Eu rope. Pu blic health officials already see an increase in other pathogenic multiple anti bi o ti c - resistant bacteria su ch as the Mycobacterium that causes tu berculosis. The incidence of syphilis worldwide remained unchanged from its first occ u rrence up until the 1950s. It then dra m a tically declined after that peri od . Much of the re a s on for the decrease in syphilis immed i a tely after 1950 was the advent of anti bi o ti c s . Syphilis was su cce s s f u lly curtailed and in som e cases erad i c a ted wh en anti bi o tics were ad m i n i s tered to i n fected soldiers and pro s ti tute s . However, this did not explain furt h er declines in the disease. Pu blic aw a reness p l ayed a big role after 1950. G overn m ent campaigns aimed at reducing STDs changed the ph i l o s ophy of syphilis con tro l from curing to preven ting. Ma n d a tory bl ood tests on solders guaranteed that they would not bring syphilis back hom e . Ma ny states began requ i ring syphilis tests for couples con s i dering marri a ge . This caught many cases that would have gone undetected and redu ced the tra n s m i s s i on of the disease to spouses and ch i l d ren. Churches, civic gro u p s , and schools also contributed to the later decline of syphilis and other STDs. Children were continu o u s ly edu c a ted abo ut abstinen ce and safe sex as methods for containing the spre ad of STDs (Figure 6.4). This inclu ded lessons on the proper sel ecti on and use of con dom s . Some agencies started programs tailored for educating prostitutes about syphilis protection. Governments allowing legalized prostitution were even coerced to provide mandatory syphilis education and training tagged to a license for con ducting pro s tituti on businesses (Figure 6.5).

Syphilis: Epidemiology

Figure 6.4 Education is a key element in controlling the spread of syphilis. Today, even young children are taught about the disease and how to prevent transmission.

95

96

SYPHILIS

Figure 6.5 In areas where prostitution is legal, prostitutes are regularly tested for STDs such as syphilis.

Syphilis: Epidemiology

This general public awareness of the disease also helped people better recognize syphilis. It also facilitated a better understanding of how it was contracted. Many of the successful programs were carri ed over to different nati ons thro u gh progra m s s ponsored by the United Nations World Health Organization. Tod ay, syphilis is not a mystery. It will con ti nue to decline over the next decade as long as people remain aw a re of its potential to spread again in spite of accurate rapid diagnoses and effective treatments.

97

7 Syphilis in Modern Society It is a good thing to learn caution by the misfortunes of others. Publius Syrus (First century Roman slave) History is supposed to teach lessons for future generations. According to

Syrus, this is particularly true for events that cause misfortunes to others. Syphilis’ first onslaught in Europe definitely brought extreme calamity. People had little past history with diseases resembling syphilis. The closest epidemics they experienced we re anthrax, black plague, cholera, and smallpox. Syphilis, however, did not fo ll ow the same pattern of deva s t a tion presented by those diseases. Th erefore, it was approach ed as a new situation involving all the trial and error learning strategies evident throughout recorded history. Since there was no universal interpretation of syphilis, people responded to the disease according to local beliefs. P hysicians in the 1500s handl ed syphilis as they would any other contagious disease. They limited their exposure to the patient to prevent t h eir own de a t h s , as was learn ed after several sweeps of bl ack p l a g u e . The physicians also learn ed that tre a tm ent was inef fective and just aided furt h er spre ad . Even tu a lly, they discovered that syphilis was not as easily con t a gious as anthrax, black plague, ch o l era, and small pox. Th erefore, it was approach ed like lepro s y, wh i ch the physicians unders tood requ i red close mu l tiple con t acts for tra n s m i s s i on of i n fecti on. Un fortunately, a l ong with its similarity to leprosy came the social sti gm a . People with syphilis were tu cked aw ay in sanitariums to su ccumb to the disgusting disease— hidden from the eyes of the public. Hints of s ex u a l

98

Figure 7.1 In the 15th and 16th centuries, syphilis was seen as a punishment for sin. Those who acquired the disease had brought it upon themselves by doing something illicit, such as having promiscuous sexual relationships. The man in this painting is using leeches to draw blood, in hopes of curing his disease.

tra n smission were becoming associated with syphilis, leading to a new line of thought that syphilis was a disease of illicit sexual activity. In the 1600s thro u gh the 1700s, syphilis was seen as a de s erving ailment for those afflicted (Figure 7.1). It did not

99

100 SYPHILIS

spre ad to the innocent. The disease was most prevalent in people who had promiscuous sex or visited prostitutes. Unfortunately, these nega tive attitu des preven ted any organized efforts

SYPHILIS AND THE VIRGIN QUEEN Queen Elizabeth I reined over England and Ireland from 1558 to 1603, during the height of the syphilis epidemic plaguing Europe. The Queen succeeded Queen Mary Tudor and was a daughter of Henry VIII, who was noted for many infamous acts during his reign. Her life was well-chronicled with many facts and an equal number of myths. The two most noted events of her life were how she s e c u red the throne and how she maintained the status of being a virgin. Her virginity was debated especially because of rumors about her being afflicted with syphilis. Elizabeth I was not a shoe-in for the Queen position. Her mother’s marriage to Henry VIII was annulled making Elizabeth an illegitimate successor to the throne. By luck there were no other natural heirs left to inherit the royalty. So she was the only person bearing Henry VIII’s bloodline and was able to hold on to her tenuous position as Queen. Her status as a virgin was more difficult to assess. The queen publicly asserted her virginity using it as a hallmark of her moral rectitude and righteousness. She also made it known to the British Parliament that she had no desire to produce an heir to the throne. Anecdotal evidence supports her claim of virginity. Her lack of privacy prevented any secret encounters leading to an affair. The idea that Elizabeth I had syphilis was probably a rumor set up to detract from her noble image. Her persistent stature as a virgin obviously excluded her from contracting syphilis by sexual means. Claims that she acquired congenital syphilis from Henry VIII is unfounded because it was never proven that he or any of his wives had syphilis. No bone analysis was performed on the bodies to confirm the assertions of syphilis. Also, there are no re c o rds of the royal family having any physical signs of syphilis, although they displayed emotional and psychological symptoms that, at the time, were attributed to the disease.

Syphilis in Modern Society 101

to specifically control and treat the disease. Syphilis became a lesson: learn from those who have sinned to avoid the ravages of syphilis. Even the most well-respected public figures were denigrated to the ranks of people of weak character when it was discovered that they had con tracted syph i l i s . We a l t hy people were able to seek treatment for the symptoms —not to cure the disease but to alleviate the aches and pains. A growing concern for public health drove governments to find syphilis treatments, solely to limit the disease’s unintentional distribution to all elements of society. Governments were afraid that people who acquired the disease through lewd means would spread it to innocent spouses and ultimately to their children. Changing attitudes about sex for tuitously accompanied monu m ental discoveries in science and medicine. Just as Trepo n ema pa ll i dum pa ll i du m was discovered , soc i ety was begi nning to treat sex with less disdain. Medicine was allowed to cure the disease without criticism that it was perpetuating sin or contributing to the moral decline of society. Some small segments of Am erican and European soc i ety protested devel oping cures for syphilis, refusing to abandon trad i ti onal bel i efs. These people felt medicine was interfering with the punishmen t s meted out by God. Su rprisingly, the con cerns of these few trad itionalists became evi dent in soc i ety. An ti biotic cures lu ll ed people into the bel i ef that infectious disease was simply an inconven i ence that could be eliminated with an injection or a pill. People, including many re s pected scien tists and public health officials, saw antibiotics and vaccines as ways to completely eradicate disease. This lifted many intense fears about the controllabi l i ty of infectious disease outbreaks. It also era s ed many worries about bel i efs and taboos bel i eved to lead to disease. Could this atti tu de translate into the sen ti m ent that sex would be less ri s ky if s yphilis were easily tre a t a ble or not a risk at all ? The initial introduction and unrelenting success of antibiotics, particularly the very effective penicillin G, brought joy to many people. However, it also aroused deep fears in just as

102 SYPHILIS

many others. Some scientists felt that easy cures for syphilis would not discourage the improper attitudes leading to its propagation. Sometimes penicillin treatments were prohibited for certain “undesirable” people of society. This behavior may appear prejudiced and callous today, but bet ween 1860 and 1940 it was acceptable to allow natural selection to eliminate “weak” individuals from a population. A growing distaste for eugenics stifled this movement. Eugenics in humans is best described as the elimination of indivi duals having ch a racteri s tics that, according to some people, genetically weaken humanity and could ultimately lead to human extinction (Figure 7.2). Tod ay, m a ny people assume that scien ce can come up with therapies for any human ailment. Every day, scientists find tre a tm ents for ac utely fatal con d i ti ons su ch as leu kemia and stro ke . The pace of d i s covery is so mind-boggling that older physicians are not accustomed to the unpreceden ted su ccesses of their acti on s . Ma ny of these physicians gro s s ly undere s ti m a te the ch a n ce of su rvival for va rious difficult to treat conditions. However, the yo u n ger physicians acc u s tom ed to the great ra te of m edical adva n ces proj ect unbri dl ed optimism about a pati en t’s ch a n ces of being cured. These past su ccesses explain the fru s tra ti ons of scien tists and soc i ety over AIDS. People are a s to u n ded that scien ce has not yet come up with a cure for AIDS. Af ter all , m ore is known abo ut AIDS than any other vi rus and the disease has been known for over 20 ye a rs . S c i en tists are also fru s trated. Th ey cannot accept that fact that they may never be able to discover a treatm ent that rem oves HIV from the body as well as pen i c i llin G ex tracted Trepo n ema pa ll i dum pa ll i du m f rom syph i l i tic bod i e s . SYPHILIS IN THE FABRIC OF SOCIAL NORMS STDs, unlike other infectious diseases, tell specific details about a person’s life. In adults, such an infection screams out that one has had unpro tected sex. P hysicians know all too well the humiliation or anger they see when patients are told they have

Syphilis in Modern Society 103

Figure 7.2 Antibiotics, often delivered by hypodermic needle, are used to treat syphilis today. However, not everyone always agreed with the treatment of such diseases. Some people believed in the practice of eugenics — that nature should be allowed to eliminate those who were weak or sickly.

syphilis. The patients’ feelings can be attributed to the stigma of having syphilis or the fact that their personal lives have been exposed to a stranger. These negative emotions can also arise from the knowledge that the disease was given to them by an obviously unfaithful partner. From its onset, syphilis became interwoven with society norms on ce it was identified as an

104 SYPHILIS

STD. In the 1500s and 1600s, syphilis was thought to belittle particular cultures in which it was common because it was assumed that the disease accompanied vulgar sex. So emerged the terms French Disease, German Disease, and Italian Disease. For those within a culture, syphilis was a sign of sexual intercourse with undesirable individuals such as foreigners, the depraved , and prostitutes. Obviously, a pers on diligen t ly ad h ering to cultural norms would not have contracted this sexually transmitted disease. The libera ti on of s exual atti tu des and advent of serious tre a tments in the late 1800s and early 1900s ch a n ged the position of syphilis in soc i ety. The Vi ctorian Era was a time of incre a s ed freedom of art and em o ti on (Figure 7.3). Havi n g syphilis became more of an indiscreti on rather than an unforgiva ble ch a racter flaw. Syphilis was no lon ger seen as a eu gen i c p u n i s h m ent but as a slap on the wrist. This slap em b a rra s s ed s ome people, while becoming a bad ge of ach i evem ent for others . Visits to prostitutes were perm i s s i ble as long as they were not flaunted or shared freely in daily conversation. Carrying the disease wi t h o ut seeking treatment was a for giva ble weakness similar to con suming too mu ch alcohol or smoking too many cigaret te s . Pu blic officials and high - profile people who contracted syphilis du ring this era were acc u s ed of folly ra t h er than sin. This atti tu de changed as percepti ons of sex changed . A moral backlash hit America and Eu rope during the middle of the 1900s. Overt sexuality was not the norm anymore, especially for females. A rebirth of Freudian psychology set an ideology in motion that society must repress basic primitive instincts such as sexual enjoyment, including sexual activities such as masturbation. However, the onset of World War II put people in atypical situ a tions that prom o ted sex uality. Soldiers left home pledging that they would remain sexually loyal to their current or future partners. Females were left with an unw a n ted and abrupt loss of intimacy as men disappeared into the war. Sex became a way to relieve the stress

Syphilis in Modern Society 105

Figure 7.3 The reign of Queen Victoria (r. 1837-1901), p i c t u red above, was a time of personal liberation and revolution. This resulted in sexual practices that promoted the spread of syphilis.

and consequen t ly there was a re surgence of syphilis. One important use of antibiotics during World War II was to minimize the rampant spread of syph i l i s . Soldiers were en couraged not to have sex . Mi l i t a ry educati on programs taught soldiers how to avoid and recognize syphilis (Figure 7.4). However, imprudence was forgiven and the soldiers were given treatment as if they had received a war casualty. Women at home were also treated. But these affairs were kept secret and su bject to great ad m on i s h m ent if d i s covered. Syphilis

106 SYPHILIS

Figure 7.4 The armed forces were very interested in controlling syphilis transmission amongst soldiers during and after World War II. Posters like this one were used to remind soldiers to think twice before having sex.

temporarily tarnished a soldier’s reputation but permanently destroyed the moral character of women. Among men, syphilis was a joke shared with buddies; for women it was a secret not even shared with closest friends. A peak in sexual repre s s i on hit Am erica just after World

Syphilis in Modern Society 107

War II. Sex was not even ack n owl ed ged among couples with ch i l d ren (Figure 7.5). It was re s erved for brazen and outc a s t peop l e . Syphilis was on ce again vi ewed in a nef a rious sense. Un l i ke the previous dec ade, syphilis was again the re sult of serious ch a racter flaws . Syphilis screening progra m s reached all sectors of s oc i ety. Couples seeking marri a ge were i n clu ded in the ranks of m a n d a ted syphilis testing candidate s a l ong with prison ers and soldiers. A po s i tive test for syph i l i s meant that a couple could not obtain a m a rriage license unti l the disease was treated and fo ll owed by su b s equ ent nega tive te s t s . Th ere was great con cern that a positive test could result in the termination of the marriage plans. Un der these attitudes, s yphilis started becoming as much of a mys tery disease as it was in the 1500s. Th ere was more of an emphasis on teaching abstinence than on promoting the values of safe sex. Syphilis education was pri m a ri ly needed in high - ri s k situations such as in prison and military settings. These strict views of syphilis led to regulations requiring the reporting of syphilis cases to govern m ental agencies. The fear of being reported forced many people to seek altern a tive therapies, i ll ega l care from unscrupulous physicians, or no treatment at all. The 1950s ended with a dramatic swing in American sexual attitudes that identified the following decade as the era of the sexual revolution. Sexual freedom was not just an acceptable ideology by the younger population most likely to be sexually active. It became a prerequisite for fitting in with society. Syphilis became a sign of nonconformity with the repressive attitudes of the previous decade. It was also easily cured. Penicillin shots for syphilis were handled as nonchalantly as administering aspirin for headaches. Sex education shifted its focus from abstinence to safe sexual practices. The same types of condom-use classes taught to soldiers during World War II were being used in high schools and colleges in the 1960s (Figure 7.6). Syphilis was no lon ger a sti gma, and this new atti tu de permitted local govern m ents to bet ter

108 SYPHILIS

Figure 7.5 America withdrew into a period of sexual repression during the 1950s. Television and other forms of entertainment reflected this sexual conservatism.

track and document syphilis. People felt more willing to share information about sexual partners, making it easier for the government to stop local outbreaks. This led to today’s standard practice of questioning people about sexual partners after syphilis is diagnosed. This would not have been possible if the attitudes of the 1950s had prevailed. Rel a xed atti tu des abo ut sex fo ll owed the 1960s and remain part of con tempora ry Am erican cultu re . Sex edu c a ti on, wh i ch in the 1950s was a topic best left at home and given on ly ju s t before marri a ge , filtered down into the elem en t a ry edu c a ti on curriculum. At first, the safe sex information taught to ch i ld ren en tering puberty was more of an attem pt to ward off pregnancy than to redu ce STDs. AIDS ch a n ged that atti tu de ,

Syphilis in Modern Society 109

and now STDs share in a significant part of the instru cti on. Sex edu c ation has become such a commonplace theme in school that most children have little anticipation of the lessons and may at times ignore the informati on or put it in the same category as learning about math or grammar. Syphilis has taken on a role similar to that of the common cold. It is handled unemotionally as a preventable and curable disease. It does not carry the same badge of independence heralded in the 1960s. Rather, it is a sign that a person was careless or ignorant. SYPHILIS IN RELATION TO OTHER STDS Syphilis was the first known STD and has many more stories associated with it than the other diseases. However, the gradual eradication of syphilis has uncovered the other STDs described in Chapter 2. Gonorrhea was discovered during World War I but was not often recognized by the public until sex education became pop u l a r. This initial unaw a reness all owed it to perpetu a te and remain as com m on as syphilis. By lu ck , it was restrained with the same precautions and tre a tments as s yph i l i s , preven ting it from becoming a modern plague. Gonorrhea did not get the same chance as syphilis to achieve universal notoriety. It was just another common sexually transmitted disease. Similarly, chlamydial infection, chancroid, and the other bacterial STDs gain more interest among public health officials than among the average person. They are not a threat as long as they can be cured as simply as syphilis. AIDS and genital herpes are not taken as ligh t ly as syph i l i s . These vi ral diseases are proving to be incura ble in spite of mu ch effort using trem en dous resource s . AIDS has had mu ch more impact on soc i ety because it is ac utely fatal and there was no tre a tm ent for a nu m ber of years. It even kills ra p i dly wh en there is aggre s s ive thera peutic care. Any tre a tm ents that were developed on ly slowed down the progress of the disease or just rel i eved the signs and sym ptom s . The severi ty of these diseases con ju red up atti tu des that were almost iden tical to those abo ut

110 SYPHILIS

Figure 7.6 Changing values of the 1960s and 1970s brought sex education into the high school classroom. Today even young children are educated about sex and STDs.

syphilis in the 1500s. Much blame has been directed at how this n ew uncontro ll a ble plague bega n . First it was bl a m ed on hom os exuals and call ed the “gay cancer.” This initial atti tude va l i d a ted any ill feel i n gs abo ut hom o s exuals de s p i te the open - m i n ded a t ti tu des that had tri ck l ed down from the civil ri ghts movem en t . As had occ u rred with syph i l i s , govern m ents were battling over the origin of the first occurren ce of AIDS. Most blamed the United State s , while the United States was loo king into eviden ce that the virus was imported from Eu rope by way of a gay male Canadian flight attendant. Recen t ly, African nations were insulted over the research that indicated that AIDS got its start in their countries. Myths and erron eo u s

Syphilis in Modern Society 111

s tories still abound a bo ut the evil deeds that led up to AIDS’ becoming a human disease. Syphilis made sex risky as soon as it was established as a sexually transmitted disease. However, the concerns died down once antibiotics proved successful at fully curing the disease. AIDS refueled the idea that sex could have dangerous consequences. However, unlike syphilis, there are no indications of an immed i a te cure for AIDS, wh i ch is el eva ting soc i etal concern s about the disease. Society is now redefining its attitudes about sex, thanks again to the widespread occurrence of a stigmatic STD. Television shows and movies portraying casual and extramarital sex are gaining much criticism as a result of the spread of AIDS. Such entertainment is being accused of expanding unhealthy attitudes about sex and is being blamed for the high prevalen ce of unpro tected sex. The rise in teen pregnancy and the reoccurrence of STDs are being used as evidence of the con s equ en ces of relaxed sexual atti tu des. Even safe sex using con doms does not ensu re total pro tecti on from AIDS. Sex educati on programs are now being com pell ed to stre s s abstinence or altern a te forms of sexual pleasu re. A further limitation to sexual freedom is the growing number of cases of multiple antibiotic-resistant bacterial STDs. This could raise syphilis to the status of AIDS if it on ce again proves to be an incurable disease due to antibiotic resistance. Of all the STDs, syphilis is unwaveringly the symbol of sexual indiscretion. Jokes alluding to STDs mostly mention syphilis as the culprit disease, labeling the unfortunate central character as infamous. Syphilis humor greatly outnumbers the numerous gonorrhea or “clap” jokes. AIDS has rivaled syphilis as a topic for crude and demeaning humor, but it is used in a different context. AIDS humor is used as an attack on homosexual cultu re as an indicati on that hom o s ex u a l i ty is bad. For both diseases, the humor is not a way of poking fun at the ailment but as a way of degrading a particular cultu re , ideology, or individual.

8 A Case Study in Syphilis Research But nothing is more estimable than a physician who, having studied nature from his youth, knows the pro p e rties of the human body, the disease which assails it, the remedies which will benefit it, exercises his art with caution and pays equal attention to the rich and the poor. Voltaire (Francois Marie Arouet) Scientists learn about nature through extensive observations and precise

ex peri m ental investiga ti on s . The proce s s , call ed the scientific method, en su res that any interpret a ti ons of n a tu re made by scien tists are as acc ura te and rati onal as po s s i bl e . It provides a universal understanding of n a tu re that is not bi a s ed by cultural differences, pers onal goals, or po l i tical motiva ti on s . S t a n d a rd procedu res su ch as Koch’s Postu l a tes are de s i gn ed to prom o te con s i s tency for particular types of investiga ti on s . Th erefore , a ny microbi o l ogist wishing to stu dy the cause of a disease just has to ad h ere to Koch’s Postulates to find the su s pect pathogen. Scientists claiming they know the cause of a disease using other m et h odo l ogy are ju s ti f i a bly scruti n i zed . Th eir findings are not acknowled ged until similar con clu s i ons are found using the accepted procedu re s . This initial reluct a n ce to believe scientists using other techn i ques is not a form of s n obbery but rather a way to pro tect the i n tegri ty of s c i en tific inform a ti on (Figure 8.1). Two important assu m pti ons are needed to perform the scien ti f i c m et h od. First, scien tists must assume that they can on ly investiga te

112

Figure 8.1 The scientific method allows for the consistency and accuracy of research. This scientist carefully inoculates bacteria on a plate to grow for further experiments. She must make sure that her results can be duplicated.

measura ble ph en om en a . Whatever they are stu dying must be detected using univers a lly accepted criteria and measurem en t s . For example, a scien tist inve s ti ga ting the cause of an infectious disease looks for a tangi ble life form su ch as a microor ganism as the culpri t . Vi ewing the or ganism under the micro s cope or detecting some c haracteristic chemical component easily

113

114 SYPHILIS

determines the pre s en ce or absen ce of a microorganism. Un i que metabolic changes to the body can also be a clue to the or ganism’s existence. These pieces of evidence can be doc u m en ted and interpreted similarly by different people. Seeking a metaphysical or nonmeasurable disease agent, such as sin, provides no proof to su b s t a n tiate the claim. Th ere are no standard ways to measu re sin. An alleged sinful act in one cultu re may be normal beh avi or in another. Sin is no longer con s i dered a cause of disease like it was before diseases were understood. A second assu m ption of the scientific method is that experi m ents must show a cause and effect relati on s h i p. Wh en studying disease, this means that the scien tist has to provide irref ut a ble evi dence that the su s pect or ganism is causing the disease. Isolating Trepo n ema pa ll i dum pa ll i du m from a primary syphilis ch a n c re or from the blood of an afflicted pers on doe s not prove it causes the disease. This is true even if every patient with syphilis had the same Trepo n ema pa ll i dum pa ll i du m f i n d i n gs . All it means is that syphilis is accom p a n i ed by a Treponema pa ll i dum pa ll i du m infecti on . Therefore, a researcher trying to prove that Treponema pa ll i dum pa ll i du m is the cause of s yphilis must be able to introduce the disease into an organism with the intent of producing syph i l i s . Probl ems arise wh en diseases cannot be modeled in other organisms, su ch as the case with AIDS, where humans have to be the model. Walter Reed, a U.S. Army physician, came upon this problem wh en heading a commission stu dying yell ow fever in Panama during the early 1900s. His ded i c a ted team decided to infect them s elve s with the conjectu red source of disease, sacrificing their health and the life of colleague Dr. Jesse Lazear when he died of the self-inflicted illness. Th eir altruism provided the information needed to control and prevent the debi l i t a ti n g and som etimes fatal disease (Figure 8.2). The scientific method contains no components describi n g

A Case Study in Syphilis Research 115

Figure 8.2 Walter Reed and his team of scientists researched the cause of yellow fever by experimenting on themselves. Some diseases, such as yellow fever, AIDS, and syphilis, can only be modeled in humans.

morally correct ways to conduct experiments. However, most scientists would agree that it is implicit in the scientific method that ethical practices must be used to collect data and formulate conclusions. Walter Reed’s research borders the boundary between ethical and unethical. Some would argue it was unethical to sac ri f i ce his team to gain the knowl ed ge they did. Others

116 SYPHILIS

can counter by saying that their sacrifice was small compared to all the good it produced. However, what if Reed had tested his hypothesis on Panamanian villagers? Would his decision have had the same ethical foundation as his original choice? Reed’s decision to use his team as experimental su bj ects ad d resses another percepti on of s c i en ce that its ulti m a te goa l is for the bet term ent of human soc i ety. Scien ce con tribute s to soc i ety ei t h er by adding to a pool of k n owl ed ge that provides a bet ter understanding of n a tu re or by making life less precarious for people through the erad i c a tion of d a n gers and disease. However, i n equities bet ween co u n tries and different segments of society prevent the remunerations of science from ben ef i ting all hu m a n s . The eigh teenth century ph i l o s oph er Vo l t a i re would find this som ewhat distu rbing con s i dering his humanitarian con cerns for social equality, meaning that all people should be re s pected and tre a ted fairly (Figure 8.3). Flem i n g’s discovery of antibiotics was inten ded to help all of humanity. However, it only benefited those who could afford treatments and nations that had the money to fund re s e a rch and produce curative drugs. Co u n tries with the finances and technology to manufactu re antibiotics gained great adva n t a ges by improving public health, thereby contributing to the further advancement of society. A co u n try that has healthy citi zens who can work and con tribute to society translates into a bet ter econ omy that permits innova ti ons beyond what is needed for basic su rvival. Mi llions of people in developing nations do not h ave access to F l em i n g’s sixty - ye a r-old discovery. This misfortune give s these nati ons little opportu n i ty to progress equ i t a bly with countries that have regular access to curative therapies. This ethical issue is slowly being re s o lved with diplom acy, foreign aid, and the establ i s h m ent of agencies su ch as the Un i ted Na ti ons World Health Organization. However, the question of using humans as re s e a rch models sti ll remains unanswered.

A Case Study in Syphilis Research 117

Figure 8.3 Voltaire, the eighteenth century French philosopher, believed that all of society should benefit equally from scientific and medical advances.

During World War II, syphilis became a hallmark case stu dy for eva lu a ting and standardizing ethical practi ces in scientific research, particularly for research involving diseases that could on ly be stu d i ed on human su bj ects. A group of scien tists pushed the boundaries of ethically accept a ble research practices in an attempt to study the effectiveness of treating

118 SYPHILIS

syphilis. The research had to be done. However, the way it was conducted left many wondering about the value of the benefits achieved compared with the suffering caused by the study. THE TUSKEGEE STUDY An extraordinary speech made by President Bill Clinton on May 16, 1997, put syphilis and research ethics together as top stories in the news. “Today all we can do is apologize but you have the power. O n ly you have the power to for give. Your pre s ence here shows us that you have shown a better path than your government did so long ago,” commented President Clinton to the predom i n a n t ly African American audience (Figure 8.4). The people he was asking forgiveness from were survivors of the Tuskegee Syphilis Experiment. This infamous experiment used 600 underprivileged African American residents of Alabama as guinea pigs for syphilis re s e a rch. Hermann Shaw, one of the experimental subjects, accepted the government’s apology but followed it up w ith the statement, “We were treated unfairly, to some extent like guinea pigs. The wounds that were inflicted upon us cannot be undone.” What started out as a gov ernment query into syphilis ended up a symbol for reforming ethics in human experimentation. The Tu s kegee Syphilis Experiment started out as an aspiration to better understand the progress of the theni n c u ra ble disease syph i l i s . In 1932, wh en the stu dy was commission ed , syphilis tre a tments were on ly capable of rem edying the signs and symptoms of the disease. Be s i de s being ineffective , the standard tre a tm ents of bi s muth and mercury, both highly toxic chemicals, sometimes caused m ore harm than the disease. Tre a tm ents usu a lly led to k i d n ey damage , l iver failu re , and neu ro l ogic con d i ti on s . Antibiotics had just been discovered in 1929 and were not yet in full use. It was not known until World War II that Flemi n g’s penicillin would adequately rid the body of the disease. Most accounts of s yphilis were bits and pieces of anecdotal references

A Case Study in Syphilis Research 119

Figure 8.4 President Bill Clinton formally apologized to the surviving subjects of the Tuskegee Syphilis Experiment, 65 years after the unethical experiment began. Hermann Shaw (left), one of the remaining survivors, stands next to President Clinton after the address.

from medical records. The traditional accounts from the 1700s and 1800s were incon s i s tent and seem ed to be descri bi n g complications other than from syphilis. The United States Public Health Service searched for a way to stu dy the progress of syphilis using a large nu m ber of

120 SYPHILIS

human su bjects. After all, the re s e a rch of Metch n i koff and others showed that Trepo n ema pa llidum pallidum causes syphilis only in humans. The Public Health Service could have approached the stu dy two ways: (1) infect a large group of volunteer human subjects with syphilis, or (2) find a large con f i n edpopulati on of people alre ady infected with the disease. This first opti on was unde s i ra ble but viable because the governm ent could ju s tify condu cting the ex periment on soldiers or prisoners. The second option would be difficult to carry out because a sizeable investigation would have to be done to find a population of subjects meeting the requirements of the study. A chance econ omic development ob s ervation drove the Public Health Servi ce to seek the second option for stu dying syphilis. In 1895, African American botanist Boo ker T. Wa s h i n g ton (Figure 8.5) call ed for a plan to improve econ omic gains for Af rican Am eri c a n s . He wanted an i nve sti gation into the factors keeping African Americans from gaining equal econ omic status with wh i te Americans. A 1900 stu dy con ducted by the Tu s kegee Institute showed that public health probl ems cre a ted issues hindering the econ omic growth in Af rican Am erican pop u l a ti on s . Accom p a nying this report were data abo ut the incidence of syphilis among a poor African American com munity in Macon Co u n ty, Alabama. It was found that 35 percent of the county’s African American pop u l a tion had syphilis. An aggressive plan to redu ce the incidence of syphilis in the community began with the Ju l ius Ro s enwald Fu n d . Factors rel a ted to the 1929 Wall Street Crash and su b s equent Gre a t Depre s s i on forced the Ju l ius Ro s enwald Fund to drop the syphilis program in 1931. This left a large proportion of Macon Country re s i dents again without syphilis treatment. It was instantly recogn i zed that this now negl ected populati on would be perfect for the Pu blic Health Servi ce stu dy. So, in 1932 the Pu blic Health Service worked together with the Tu s kegee In s ti tute to stu dy the progress of syphilis

A Case Study in Syphilis Research 121

Figure 8.5 Booker T. Washington (left) was born into slavery, but he procured an education and became a teacher. In 1881, he founded the Tuskegee Institute. Booker T. Washington’s dream of improving the plight of African Americans was construed into a study exploiting them. Ironically, the Tuskegee Institute was involved in the study that exploited hundreds of African Americans.

on the Macon Co u n ty re s i dents. The proj ect was call ed the Tu s kegee Stu dy of Untre a ted Syphilis in the Negro Ma l e . It was agreed that no tre a tm ents could be given in order to study the scope of the disease from secondary syphilis through the tertiary stage . Su bj ects with primary syphilis were stu d i ed and then given standard tre a tments for the

122 SYPHILIS

time. App a ren t ly, there were enough su bj ects with progre ss ive syphilis that it was vi ewed as unnece s s a ry to withhold tre a tment from new syphilis cases. Death of the su bj ects was con s i dered acceptable and important for the inve s tigati on . Syphilis was not inten ti on a lly inoc u l a ted into any of t h e subjects, contrary to what was claimed by many critics of the stu dy. In ad d i ti on, nobody was mu rdered to stu dy the disease by autop s y. The experiment used 399 Af rican Am erican men diagnosed with syphilis and 201 without any indicati ons of the disease. Su bj ects were unaw a re that they had syphilis and thought they were part of a stu dy for a less severe ailment. Su bjects were provided with free meals and other medical c a re as long as long as they rem a i n ed with the stu dy. Data started flowing from as early as 1932 as inve s tiga tors were fo ll owing the progre s s i on of the disease as it infected n ew i n d ividuals and progre s s ed from primary to secon d a ry syphilis in others. The stu dy con ti nu ed to produ ce useful data for the m edical com mu n i ty well into World War II. Yet, by then it was establ i s h ed that penicillin was a suitable cure for syph i l i s . Re s e a rchers hit a critical point of the stu dy. Th ey could end the inve s ti ga ti on at that point by curing all the people with anti bi o tics, or they could con tinue their pact to withhold tre a tment until the stu dy was completed. In 1945, the re s e a rch team decided to hold back anti bi o tic tre a tments f rom some su bj ects in spite of m a s s ive federa lly funded c a mpaigns by the Pu blic Health Servi ce to erad i c a te syphilis in the Un i ted State s . Aga i n , su bjects who developed primary syphilis during that time were tre a ted with penicillin and su b s equ en t ly dropped from the stu dy. At first, the stu dy was intended as a six-month project. However, the valuable inform a ti on being co llected perm i t ted the inve s ti ga tors to keep the proj ect goi n g. So, as syphilis waned in the United States, the Tuskegee Stu dy su bj ects were sti ll su f fering and dying from the now easily tre a t a ble disease.

A Case Study in Syphilis Research 123

All was going well with the stu dy until the late 1960s during the bi rth of the civil rights movem ent. Pu blic scruti ny of govern m ent agencies bro u ght the Tu s kegee Stu dy into the light. It was no lon ger a cl a n de s tine stu dy but a cause to promote stricter ethical treatm ent of human su bjects. A 1969 assessment by the Cen ters for Disease Con trol affirmed the need for the stu dy as a necessary evil and su pported the way it was being con du cted. It was also backed by many physicians and by profe s s i onal medical associati on s . Th i s apparen t ly did not satisfy civil rights gro u p s . By 1970, the Tu s kegee Stu dy of Untre a ted Syphilis in the Negro Male was being disparaged in the pre s s , which cre a ted strong publ i c sen ti m ent against the stu dy. The publ i c i ty led the United States Con gress to hold a hearing abo ut term i n a ting the proj ect . In 1971, Con gress agreed to end the study and provide antibiotic tre a tm ent for the remaining su bj ects. Un fortu n a tely, pen i c i llin does not undo the damage of s econdary, latent and terti a ry syph i l i s . Am a z i n gly, no formal apo l ogy was given to the su bj ects until Pre s i dent Cl i n ton’s 1997 ad d ress to the Tu s kegee Stu dy su rvivors . THE FUTURE OF HUMAN EXPERIMENTATION The Tuskegee Study opened the door to inquiries into other human subject experiments carried out by various governments spanning 1880 through the 1970s. Eugenics programs carried out by the United States government from the 1920s through the 1950s were uncovered after persistent investigation by civil liberties groups. Forced sterilizations and medical maltreatment had been used in an attempt to eliminate socially unacceptable characteristics from the American population. Much of the research was paid for with government funds and conducted by premier re s e a rch organizations su ch as Co l d Spring Ha rbor Labora tory, the ren own ed gen etics think tank in New York. Eu genics programs were banned after the 1950s as a result of public distaste for the strategies and new findings

124 SYPHILIS

Figure 8.6 The military has conducted human studies by using unsuspecting troops. Some soldiers received unnecessary doses of radiation or were given drugs such as LSD to test the effects of these chemicals on the human body. The government supposedly used this information to better prepare the military for performance under certain circumstances.

in inheritance research that exposed the naïve and incorrect assumptions of eugenics proponents. Military scientists came under intense attack over many of the re s e a rch studies carri ed out in their labora tori e s and medical hospitals. Especially during times of war, the indivi dual rights of s o l d i ers were waived for the ben efit of national security (Figure 8.6). Many veterans of World War II were su bj ected to nu clear radiation experi m ents to stu dy soldier performance during nu clear war. By 1953, it was becoming evi dent that military troops were purpo s ely

A Case Study in Syphilis Research 125

ordered to con du ct maneuvers in areas having dangerous levels of radiation. The troops were then su btly inve s tigated for any health effects related to the rad i a ti on exposure. Rad i a ti on exposu re was mon i tored with radiati on badges, and the soldiers were not given any opportu n i ties to discuss com m on illnesses that could be linked to con t act wi t h rad iation. Field perform a n ce studies were also con du cted. Sadly, a ny soldiers who left the military were not provided with medical fo ll ow-ups or tre a tm ent for illnesses rel a ted to rad i a ti on ex po su re . It is now known that many of t h e s o l d i ers in these ex peri m ents devel oped cancers of the bl ood and major body or gans. Another set of military studies that gathered bad press was the Army’s drug testing program on lysergic acid diethylamide (LSD) and related experiments on biological and chemical warfare. The LSD studies took place between 1955 and 1958. Troops were given LSD to investigate its effects as a warfareincapacitating agent. Over 1,000 soldiers were given the drug and eva lu a ted for battle perform a n ce . The Army was hop i n g to find ways of introducing LSD into enemy troops as a form of chemical warfare. The difficulties that would be involved in getting LSD into the rival troops caused military officials to seek a new direction for the research. They then conducted studies using LSD as a type of truth serum for interrogation. This line of research was also abandoned and the LSD studies were dropped. At least another 6,000 soldiers were believed to be involved in other chemical and biological warfare studies. Any documentation is currently top secret. All accounts of the experiments are from the research subjects and retired military researchers involved in the pro jects. America is not alone in using soldiers as experimental subjects. A 2001 news story from Au s tralia ex po s ed similar ex peri m ents con du cted by the British government. Prisoners are also used as supposed volunteers for human ex peri m en t a ti on . Re s e a rch on pri s on ers was com m on in

126 SYPHILIS

Germany during World War II. It was the basis for prosecuting and sen tencing to death Nazi physicians invo lved in the research. Yet, during that period human subject research on prisoners was also taking place in the United States. Illinois’s Stateville Prison was the location of several research projects that took place during the 1940s. Hundreds of prisoners were infected with tropical diseases in attempts to study the diseases and find cure s . Pu blic aw a reness of the stu dy coerced the governor of Illinois to form a medical ethics committ ee in 1947. The committee formu l a ted stri ct guidelines for sel ecting and tre a ting human research su bj ect s . Many cri ticisms were m ade abo ut using pri s on volunteers . Prisoners were coa xed into

THE TUSKEGEE LEGACY— AN AIDS CONSPIRACY THEORY Medical experimentation on human volunteers is regularly conducted to gain information about new medications and treatments. These experiments, called clinical trials, are only conducted once a therapy has been proven safe on experimental animals. Special groups called contract research organizations perform these experiments for medical researchers and pharmaceutical companies. It is illegal and outright unethical to perf o rm dangerous trials on humans. Government regulations and strict documentation guidelines must be followed when doing human research studies. However, consideration for human well-being was not the situation in the Tuskegee Syphilis Experiment. The 399 African American males with advanced syphilis were given no information about the experiment in which they were the subjects. They were not volunteers, but rather unwilling participants whose dead bodies were autopsied to better understand the ravages of a prolonged syphilis infection. One physician involved in the experiment was quoted as saying, “We have no further interest in these patients until they die.” Throughout the experiment, the men were led

A Case Study in Syphilis Research 127

dangerous research studies by incen tives such as redu ced senten ces and early parole. These en ticem ents were heavi ly cri ticized because they forced pri s on ers into parti c i p a ting in activi ties for wh i ch they would norm a lly not volunteer. In ad d i ti on , it a pp a ll ed the public wh en they learn ed that prisoners who would norm a lly not have been rel e a s ed from pri s on were bei n g let out on parole only because they parti c i p a ted in the research studies. A com bi n a ti on of public outra ge and new views on civil l i berties has halted human research studies on unsu s pecting su bjects and people su s cepti ble to being coerced into volunteering. Syph i l i s , t h ro u gh the Tuskegee Study, played a big role in defining medical research ethics in the twen ty - f i rst cen tu ry.

to believe that they were getting medical care for the disease. It is known that at least 40 of the men spread the disease to their wives who then gave birth to a total of 19 children with congenital syphilis. The inevitable discovery of the experiment by the media in 1972 of course caused pubic outrage. People became very cautious about new medical treatments believing that they may be the unwitting subjects of an experiment. The African American community in particular grew very cautious of medical re s e a rch and treatment. They were afraid of being victimized again because of racial prejudices. A 1990 survey indicated the long-term impact of the Tuskegee Syphilis Experiment on the African American community. It showed that 30 percent of the people involved suspected that AIDS may have been created by the government as an experimental organism designed to eliminate African Americans. This sentiment got international news coverage causing governmental agencies to publicly respond and discredit the allegation. Memories of the Tuskegee Syphilis Experiment were used to support the feelings of the survey respondents.

Glossary Acquired–A disease term meaning that a condition is picked up from a

chemical, object, or organism. AIDS–Abbreviation for Acquired Immunodeficiency Syndrome. A sexually

transmitted disease caused by the Human Immunodeficiency Virus (HIV). Allergy–A condition in which the bod y prod uces an abnormally strong

response to combating disease. Antibiotic–A drug used to kill or slow down the growth of bacteria. Antibody–Chemical produced by the immune system used to fight disease. Antigen–A chemical on organisms that stimulates an immune response. Assay–A laboratory test used to detect chemicals or disease. Bacteria–A large group of simple microscopic organisms composed of one

cell. Singular is bacterium. Bejal–Also call ed en demic syphilis, it is a contagious disease of tropical regi on s

c a u s ed by a rel a tive of s yphilis called Trepo n ema pa ll i dum en d em i c u m. Bloodletting–An old medical practice of draining blood and other fluids

from the body to cure disease. Bubo–A swo ll en gland under the skin usu a lly forming a bl ack , i n f l a m edlump.

It is usually related to plague but sometimes confused with syphilis sores. Plural is buboes. Candida–A type of yeast that natura lly lives in the digestive sys tem and

reproductive tract of humans. Candidiasis–A disease caused by the yeast Candida albicans. Chancre–A hard sore or ulcer that forms at the point of contact with syphilis. Chancroid–A contagious sexually transmitted disease cause by bacteria. It is

caused by Haemophilus dycreyi. Chlamydia–A com m on sexually transmitted disease caused by bacteria

called chlamydia. Condom–A covering placed over the penis worn during sexual intercourse. Congenital–A disease obtained by an infant before or after birth. Contagious–A disease con d i ti on that can re ad i ly spre ad from one organism

to another. Curative–A treatment designed to remove disease from the body.

128

Diagnosis–A medical term describing the identificati on and naming of a disease

in a pers on by recognizing the signs and sym ptoms. Disease–Any con d i ti on that causes illness or produ ces abn ormal effects in

the body. ELISA–Abbreviation for enzyme linked immunosorption assay. A method for

detecting small amounts of a chemical or disease organism. Epidemiological studies–Investigations into the cause and spread of disease. Fever–An unusual rise in body temperature resulting from disease. Fluorescent–Giving off a glow under certain conditions. FTA-ABS–Abbreviation for fluorescent treponemal antibody absorption test. A

method for detecting syphilis. Fungi–A plant-like microscopic organism that feeds on decaying matter and

living organisms. Genital herpes –A sexually transmitted disease caused by the herpes virus. Genitals–The external or visible parts of the reproductive organs. Genital warts–A sexually transmitted disease caused by the human papillo-

mavirus (HPV). Gonorrhea–A sex u a lly tra n s m i t ted disease caused by bacteria. Neisseria

gonorrhea is the organism that causes gonorrhea. Gumma–A large soft lesion on the skin or internal organs. Herbal remedies–Medical therapies using special plants or drugs extracted

from these plants. Herpes–A contagious disease caused by the herpes virus. One type is a

sexually transmitted disease. Homeopathy–A philosophy of treating disease using very small amounts of

drugs that usually produce the disease signs and symptoms. Human Immunodeficiency Virus–The vi rus that causes AIDS. It is abbrevi a ted

HIV. Immune system–A com p l ex system of body parts and cells that help recogn i ze

and fight off disease. Certain cells of the immune system produce anti bodies. Infection–Invasion of the body by a disease organism. Infectious–The ability of a disease to spread throughout the body and from

one organism to another. 129

Inflammation–A reaction to injury involving pain, reddening, and swelling. Jarisch-Herxheimer reaction–A severe fever caused by the use of s ome antibiotics. Latent syphilis–The stage following secondary syphilis. It shows no signs or

symptoms of disease. The disease is spread throughout the body at this stage. It can last the lifetime of the infected person. Lesion–An open sore on the skin or internal body parts. Leeching–An old medical practice of using blood sucking worms called

leeches to drain blood from a patient. Miasma–A foul odor or spirit of mystical origin thought to cause disease. Microbe–Same as microorganism. A microscopic organism usually composed

of one cell. Bacteria, fungi, protozoa and viruses are microorganisms. Microorganism–Same as microbe. A microscopic organism usually composed

of one cell. Bacteria, fungi, protozoa and viruses are microorganisms. Morbidity–Illness or disease attributed to an infectious agent or activity. Mucous membrane–A moist protective lining of the body that prod uces

mucus. The digestive system, lungs and reproductive tract are lined with mucus membranes. Mucus–A sticky fluid produced by mucous membranes. Parasite –An or ganism that invades and feeds off a n o t h er or ganism (the host),

u su a lly causing mild disease or harm. The para s i tegen era lly wi ll not kill the host because it provides resources that the para s i te needs to su rvive. Pathogen–An organism that causes disease. Pelvic inflammatory disease–An infecti on of the internal organs of the

abdomen in females. It can be caused by untreated sexually transmitted diseases. Abbreviated PID. Penicillin G–An antibi o tic used to treat a va ri ety of diseases caused by bacteria. Pinta–A little known contagious disease of tropical regi ons caused by a rel a tive

of syphilis called Treponema carateum. Primary syphilis– The first indicati on of s yphilis. It is vi s i ble by the appearance

of a chancre. The stage can last from six weeks up till several months. People are very contagious at this stage. Protozoa –Simple micro s copic organisms composed of one cell. They are

more complex than bacteria. Reproductive tract– All the ex ternal and internal parts of the body used in repro-

du cti on. It shares parts with the urinary system. 130

Scientific method – The process by which scientists formu l a te an idea (a

hypothesis), test that ide a , and formulate new hypotheses from their results. Secondary syphilis–The stage following primary syphilis. At this stage, the

organism spreads through the body causing sores and pain. It usually lasts three weeks to as long as a year. Sexually Transmitted Disease – An infectious disease spre ad by inti m a te

contact and sexually activity. Sign–A disease term. A con d i tion that can be measured or seen du ring

diagnosis. Redness, sores, and swelling are examples of disease signs. Spirochete–A group of spiral-shaped bacteria that cause disease in a variety

of organisms. Lyme disease and syphilis are caused by spirochetes. STD–Abbreviation for sexually transmitted disease. Symptom–A disease term. A subjective condition due to the patient’s feelings.

Dizziness, a headache, nausea, and pain are examples of disease symptoms. S y p h i l i s –A sexually tra n s m i t ted disease caused by bacteria. Treponema

pallidum pallidum causes syphilis. Tertiary syphilis– The final stage of syphilis following the latent stage . It is

recognized by fatal damage to many body organs including the brain. Therapy–A treatment for curing or lessening a disease. T P H A –Abbreviation for Treponema pallidum hemagglutination assay. A

method for detecting syphilis. Treponema–A group of spirochete bacteria known to cause disease in many

organisms. Trichomoniasis–A sexually transmitted disease caused by a protozoan. It is

caused by Trichomonas vaginalis. Urethritis–Irritation of the urethra caused by disease. The urethra carries

urine from the urinary bladder to outside the body. Vaginosis–A sexually transmitted disease causing irritation of vagina. It is

cause by a variety of microorganisms. VDRL–Abbreviation for Venereal Disease Research Laboratory. Virus–A very small infectious agent that can only live within the cells of other

organisms. It is gen erally composed of only gen etic material and a protein coat. Yaws–A contagious skin disease of tropical regions caused by a relative of

syphilis called Treponema pallidum pertenue. 131

Further Reading An d re s k i , S t a n i s l av. Syphilis, Pu ritanism and Witch Hunts: Historical Explanations in the Light of Medicine and Psychoanalysis with a Forecast about AIDS. Palgrave Macmillian: New York, NY. 1990. Arrizabalaga, Jon. The Great Pox: The French Disease in Renaissance Europe. Yale University Press: New Haven, CT. 1997. Brown, William Jordan. Syphilis: A Synopsis. U.S. Public Health Service: Washington, D.C. 2001. Cef rey, Ho lly. Syphilis and Other Sex u a lly Tra n s m i t ted Di se a se s. Ro s en Publishing Group: New York, NY. 2002. Diamond, Jared. Guns, Germs and Steel: The Fates of Human Societies. Norton: New York, NY. 1997. Eatough, Geoffry. Fracastoro’s Syphilis: Introduction, Text, Translation and Notes. David Brown Book Company: Oakville, CT. 1984. Hayden, Deborah. Pox: Genius, Madness, and the Mysteries of Syphilis. Basic Books: New York, NY. Jones, James Howard. Bad Blood: Tuskegee Syphilis Experiment. Free Press: New York, NY. 1993. Larsen, Sandra, Victoria Pope, and Robert E. Johnson. Syphilis: A Manual of Tests and Supplement. 9th Edition. American Public Health Association: Washington, D.C. 1999. Ne s ter, Eu gen e , et al. Microbi ol o gy: A Human Pers pe ctive, 3 rd Editi on. McGraw-Hill: New York, NY. 2001. Poirier, Suzanne. Chicago’s War on Syphilis, 1937-1940: The Times, the Trib, and the Clap Doctor. University of Illinois Press: Urbana, IL. 1995. Quetel, Claude, Brian Pike, and Judith Braddock. History of Syphilis. Johns Hopkins University Press: Baltimore, MD. 1999. Reverby, Susan. Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study. University of North Carolina Press: Chapel Hill, NC. 2000. Tilden, J.H. Gonorrhea and Syphilis–1912: A Drugless Treatment of Venereal Diseases. Kessinger Publishing Company: Kila, MT. 1998. World Health Organization. Handbook of Endemic Treponematoses: Yaws, Endemic Syphilis and Pinta. WHO Publications Centre: New York, NY. 2001.

132

Websites The American Academy of Family Physicians http://www.aafp.org

Centers for Disease Control and Prevention http://www.cdc.gov

Electronic Dictionary of Dermatology http://telemedicine.org/std.htm

eMedicine http://www.emedicine.com

Handbook of Dermatology and Venereology http://www.hkmj.org.hk/skin/syphilis.htm

History of Syphilis http://medinfo.ufl.edu/other/histmed/clancy/

National Institute of Allergy and Infectious Diseases (National Institutes of Health) http://www.niaid.nih.gov

Syphilis: Diagnosis and Management http://www.stdservices.on.net/std/ syphilis/management.htm

WebMD http://my.webmd.com

133

Index African Am ericans, and Tuskegee Study, 118123, 127 AIDS (acquired immu n odef i c i ency syndrome), 34, 47, 74, 82, 91, 92, 102, 108-111 Al bert Vi ctor, Prince (Jack the Ri pper), 19 Al m ond oil, 81 Al tern a tive medical treatments, 81 Amu l ets, 72 An a phyl actic reacti on , 79 Animacules, 22 Animals and diseases to humans, 44-47 and syphilis, 48 Anopheles mosquito, 45 Anthrax, 68, 98 Antibiotics, 31, 76-80, 92, 94, 101-103, 105, 107, 118 in devel oping nations, 116 resistance to, 79-80, 82, 94, 111 and Tuskegee Study, 122-123 Antigens, 88 Asian therapies, 72 As tron omical ph en omena, 12 Attachment proteins, 5456, 57 Bacteria, 8, 24, 26, 27, 29-31 See also Treponema Bacterial va gi n o s i s , 31 Bad bl ood , 12 Bejel, 41, 48-49, 531, 56, 57, 60, 61-63, 75, 78 Bi och emical warf a re studies, on soldiers, 125

134

Birds, and West Nile vi ru s , 45 Bismark, Ot to von , 52 Bi s muth, 118 Bl ood , and transmission, 35, 58-59 Bl oodl etti n g, 68, 72 Blu eberries, 81 Body samples, and transmission, 67 Bo l eyn, Anne, 19 Bone scarring, 38, 42, 48, 63, 64, 79 Bo rrel i a bu rg d o rferi , 37-38 Brain, d a m a ge to, 42, 65 Bu bonic plague (Bl ack Death), 12, 45, 68, 98 Cad avers , and transmission, 67 Candida albicans, 31 Candidiasis, 31 Capon e , Al, 19-20 Cardiovascular syph i l i s , 64-65 C a ries sicca, 38-39 Cattle and human diseases, 46-47 and syphilis, 48 Cauterizing sores, 73 Centers for Disease Control and Prevention,77,92,123 Central nervous system, d a m a ge to, 42, 65 Cervical cancer, 34 Chain, Ernst, 77 Chancres, 42, 59-60, 79, 84, 86-87 Chancroi d , 31, 109 Ch a rles VIII, King of France, 10-11 Chemothera py, 80 Chicken broth, 72 Chimpanzees, and Trepo n ema pa ll i dum pa ll i dum, 74-75, 86-87

Chlamydia, 30, 92, 109 Chlamydia trachomatis, 30 Cholera , 98 Circumcision, 13, 35 Cities, 46, 47, 92 Civil ri ghts movement, and Tuskegee Study, 123 “Clap” jokes, 111 Cleanliness, and disease, 82-84 Clerics, 72 Clinton , Bi ll , 118, 123 Cold Spring Ha rbor Labora tory, 123 Columbus, Christopher, 9, 10, 13, 18-19 Con doms, 32, 80, 92, 107, 111 Con genital endemic s yphilis, 41 Con genital syphilis, 42, 59, 64, 66-67, 77, 86, 8990, 92 Cowpox vi ru s , 47 Cura tive dru gs , 116 See also Antibiotics Daisies, 81 D a rk Age s , 71-72 De a t h , and syph i l i s , 15, 62, 64 Deer, and Bo rrel i a bu rg d o rferi , 38 Dega s , Edgar, 21 denHollander, Neal, 91 Di a gn o s i s , 15, 84, 86-91, 108 Di gital dermatitis, 48 Diseases from animals to humans, 44-48 ori gins and evo luti on of , 15, 22, 42-48 Disease, syphilis as, 42, 52-67 and bone scarri n g, 3839, 42, 48, 63, 64, 79

and brain damage, 42, 65 cause of. See Treponema pa ll i dum pa ll i dum and chancres, 42, 5960, 79, 84, 86-87 and confusion wi t h o t h er diseases, 12, 13, 56-57, 62, 68, 84 and de a t h , 15, 62, 64 and early descripti on, 9, 10, 15, 52-54, 69-70, 118-119 and gummas, 64, 86 and immune sys tem, 60-62 and internal or ga n damage, 42, 63-65, 79 and latent syphilis, 57, 62-64, 77-78, 84, 86 and mu cous membra n e s , 56, 57, 58, 59, 60 ori gins of , 9-13, 48-49, 51 and primary syphilis, 57, 59-60, 77, 86, 88 and ra s h , 42, 84 and secon d a ry syphilis, 57, 60-62, 77, 84, 86, 88 and skull blemishes, 42 and sores around gen itals and anus, 62 and stage one, 57-59 and tertiary syphilis, 57, 64-67, 77-78, 86 See also Transmission Doxycycline, 79, 80 D rug ad d i cts, 92 Earthworm s , 81 E d dy, Ma ry Baker, 36 Education, and prevention, 94, 97, 105, 107-112, 113

Elizabeth I, Queen of England, 19 Endemic syphilis. See Bej el England, s yphilis in, 15, 16, 19 Enteroba cter aero gi n o s a , 30 Enzyme linked immunoabsorption assays (ELISA), 89-90 Epidem i o l ogy, 82-97 and cleanliness, 82-84 and diagn o s i s , 84, 8691, 108 and ori gins of syphilis, 84 and prevalence of syphilis tod ay, 84, 91-92, 94, 97 and spread in Eu rope , 10-15, 18-19, 55, 82, 84 See also Transmission Erasmus, De s i derius, 73 Esch eri chia coli, 29-30 Ethics and developing nations, 116 and humans in research, 114-127 Eugenics, 102, 123-124 Europe, and spread of syphilis, 10-15, 18-19, 49, 55, 82, 84, 98-101, 104 Fetus, s yphilis in, 42, 59, 64, 66-67, 77, 86, 8990, 92 Feulard, Hen ri , 86 Fibron ectin, 56, 57 Flamand, M., 70 Fleas, 45 Flem i n g, Alexander, 76-77, 116, 118 Flocculation, 89 Florey, Howard, 77 Flu, 45, 47

Flu orescent treponemal anti body absorption test (FTA-ABS), 89 Forced sterilizations, 123 Frac a s toro, Girolamo, 1112, 52, 70 France, and ori gin of syphilis, 10-11, 12-13 Franklin, Benjamin, 68 French Di s e a s e , 11, 13 Freudian psychology, 104 Fungi, 24-25, 26, 31-32 Gauguin, Paul, 21 Gauls, and ori gin of syphilis, 10-11, 12-13 Genital herpes, 109 Genital tract infections, 23 See also Sex u a lly tra n smitted diseases Genital wart s , 32-34 GermanDi s e a s e , 10 Germany and ori gin of s yphilis, 10 and research on pri soners , 125-126 Gold, 72 Gon orrhea, 30, 92, 109, 111 Great Imitator, 12, 13, 5657, 62, 68, 84 Greece, syphilis in, 13, 81 Gum lesion s , 40 Gummas, 64, 86 Haemophilus ducreyi, 31 Hanta vi ru s , 45 Ha rvey, Gideon , 12 Hen ry VIII, King of England, 19 Herbal remedies, 72, 81 History of syphilis, 8-21 and confusion wi t h other diseases, 12, 13, 56-57, 68 and deaths, 15

135

and diagnosis, 86-88 and early accounts, 9, 10, 15, 52-54, 6970, 118-119 and early names, 10, 11, 12, 13 and famous people with syphilis, 9, 10, 13, 17-21 and ori gin of name, 11-12, 70 and origins, 9-13, 48-4 9 , 51, 84 and preventi on , 73 and sin as cause, 54, 70-72, 99-101, 114 and social norms, 101-109, 111 and spread in Europe, 10-15, 18-19, 55, 82, 84, 98-101, 104 and syphilis as emblem of protest, 16 and syphilis as label of amorous conquests, 15-16 and taboo of syphilis, 13-16, 53-54, 98-99 and treatment, 13-15, 68-73, 81, 101, 118 and vampirism, 16 HIV (human immu n odef i c i ency vi ru s ) , 34, 47 Hoffman, Eri ch , 75, 87 Hom eop a t hy, 81 Homosexuals, 92, 110 Hoo ke, Robert , 22 House of Lords Sel ect Committee on Science and Technology, 80 Human papillomavirus, 33 Humans, in scientific research, 114-127 Hu m or, 111 Im m i gra ti on, 73

136

Immune system, 28, 34, 60-62, 92 Incantations, 72 Infants, s yphilis in, 42, 59, 64, 66-67, 797, 86, 8990, 93 Infectious disease, 15 Influ enza vi ru s e s , 45 Italy, and ori gin of s yphilis, 10 Jarisch-Herxheimer reacti on , 79 Julius Ro s enwald Fund, 120 Koch’s Postulates, 73, 87, 112 Latent syphilis, 57, 62-64, 77-78, 84, 86 Lazear, Jesse, 114 Leeching, 72 Leprosy, 14, 68, 98 Leptospira interrogans, 38 Leptospirosis, 38 Ligand, 54-56, 57 L i gnum treatments, 81 Lilies, 81 Lobelias, 81 Lyme disease, 38, 45 Lym ph nodes, 59 Lyser gic acid diethyl a m i de studies, on soldiers , 125 Macon Co u n ty, Alabama, and Tuskegee Study, 118-123 Malaria, 45 Manet, Edouard, 21 Ma rriage, syphilis tests for, 94, 107 Measles, 47 Mental asylums, s yphilis pati ents in, 14 Merc u ry, 72, 118

Metals, 72 Met a physical thera p i e s , 72 Metchnikoff, Elie, 74-75, 79, 86-87 Miasmas, 70-72 Mi c roor ga n i s m s , 8, 15, 22 genito u ri n a ry infections, 24-29 and sexually transmitted diseases, 34-35 Mi c roscope, 22 Mi d dle Age s , 71-72 Mi d dle Eastern philosophy, 72 Mi l i t a ry, and soldiers as research su bject s , 117118, 124-125 Mood changes, 65 Morbi ty, 15 Morbus gallicus, 11 Mouth, and transmission, 35 Mucous mem branes, 56, 57, 58, 59, 60, 66, 84 Mustards, 81 Mutations and ligand protei n , 56 in pathogens, 45 and su perbu gs , 79-80, 82, 94 Naples, It a ly, and ori gin of s yphilis, 10 Napoleon Bon a p a rte, 21 Na tu ral medicine, 81 Nazis, 125-126 Ne a politan Disease (mal de Naples), 10 Neem, 81 Nei s seria go n o rrh oe a e , 30 Neurosyph i l i s , 64-65, 78 New plague, 12 New World, and ori gin of s yphilis, 10 Nonvenereal trepon ematosis, 40

Organs, damage to, 42, 63-6 5 , 79 O s l er, Sir William, 12 Osteomyelitis, 64 Paralys i s , 65 Parasites, 42-45 Pasteur, Louis, 22 Pathogens, 28-29, 42-45 Pelvic inflammatory disease, 30 Penicillin, 76-79, 101-102, 107, 118, 122-123 Pen i c i llinG, 77-78, 101 Pers on a l i ty changes, 65 Pertussis, 47 Pink eye, 46 Pinta, 40-41, 48 Pox, 12 Prayers, 72 Pregnancy, and syph i llis in fetus, 42, 59, 64, 66-67, 77, 86, 89-90 Prevalence of s yphilis, 84, 91-92, 94, 97 Prevention, 73, 80, 92, 94, 97, 105, 107-112 Pri m a ry syphilis, 57, 59-60, 77, 86, 88 Prisoners, as research subjects, 125-127 Prostitution, 15, 31, 73, 92, 94, 104 Proteu s , 30 Protozoa , 24, 25 Pseudomonas aeru gi n o s a , 30 Pu erperal fever, 82-83 Quarantine, 73 Ra bbits and syphilis, 48 and Treponema pallidum pallidum, 74, 87 Radiation studies, on soldiers, 124-125

Rapid plasma re a gin card test, 89 Rash, 42 Rectum, and transmission, 35 Red i , Francesco, 22 Reed, Wa l ter, 114-116 Research on syphilis, 112127 Rimbaud, Art hu r, 21 Rocky Mountain spo t ted fever, 45 Rodents, 45 Rome, s yphilis in, 13, 7172, 81 Roux, Pierre, 74-75, 86-87 Saliva, 72 Salk, Jon a s , 47 Salts, 72 Schaudinn, Fritz, 75, 87 Scholasticism, 72 S c i en tific met h od , 112116 Secon d a ry syphilis, 57, 6062, 77, 84, 86, 88 Seizures, 65 Semmelweis, Ignaz, 82-84 Sen sual though t s , 8 Serpu l a , 38 Serpu l i n a , 38 Sex education, 107-109 Sexual atti tu des, 101-109, 111 Sexually transmitted diseases, 13, 22-35, 47, 48-49, 92, 109-111 See also AIDS Sexual transmission, 8, 14, 15, 22, 42, 51, 52-53, 57, 70, 73, 86, 92, 98101 Shakespeare, William, 1213, 22 Shaw, Hermann, 118 Signs, 56 Silver, 72

Simian immu n odeficiency vi rus (SIV) , 47 Sin, as cause, 8, 12, 15, 54, 70-72, 99-102, 114 Sk u ll dri lling holes in, 72 scars on , 38-39, 42 Smallpox, 12, 46-47, 68, 98 Social norms, 101-109, 1131 Spanish Disease, 10 Sp i ri lla volutans, 36 Spiroch etes, 36-38, 48, 57 See also Trepo n em a Spontaneous genera ti on, 54 Stages 1: 57-59 2: 57, 59-60, 77, 86, 88 3: 57, 60-62, 77, 84, 86, 88 4: 57, 62-64, 75-78, 84, 86 5: 57, 64-67, 77-78, 88 Stateville Prison, and studies on prisoners, 126 Su perbu gs , 79-80, 92, 94 Sym ptom s , 56 Syphilis save morgues Gallicus (Frac a s toro), 11-12, 52 Syru s , Publius, 98 Ta boo, s yphilis as, 13-15, 52-53, 98-99 Tertiary syphilis, 57, 64-67, 77-78, 86 Test kits, 89-90 Tetrac ycline, 79, 80 Ticks, 37-38, 45 Tom a toe s , 81 Toulouse-Lautrec , Hen ri de, 20-21 Tracking syph i l i s , 91, 108

137

Index Transmission, 54-56, 57-59 and bl ood , 35, 58-59 and body samples, 67 and cad avers , 67 and cleanliness, 82-84 of disease, 44-47 and early spread in Eu rope, 10-15, 1819, 49, 82, 88, 98101, 104 to fetus, 42, 59, 64, 6667, 86, 89-90, 92 and microorganism, 8, 15, 22, 24-29. See a l so Trepo n ema pa ll i dum pa ll i du m and mouth and rectum, 35 sexual, 12, 15, 22, 42, 51, 52-53, 57, 70, 73, 82, 86, 98-101. See also Sex u a lly transmitted diseases Treatment, 68-81 altern a tive, 81 and antibiotics, 76-80, 92, 94, 101-102, 105, 107, 111, 118 and attitudes tow a rd s yphilis, 101-109, 111 avoidance of , 92, 104, 107 and discovery of Trepo n ema pa llidum pa ll i dum, 73-76, 101 and DNA analysis, 40 in history, 13-15, 6873, 81, 101-102, 118 and preventi on , 73, 80, 92, 94, 97, 105, 107, 108-109 and Tuskegee Study, 118-123, 127

138

Treponema amyl ovo rum, 39, 40, 48 and attachment stru ctu re , 54-56, 57 bi o l ogy and natu ra l history of , 38-42 b rennaboren se , 48 bryantii, 48 cara teum, 39, 40-41, 48 cuniculi, 48 and mut a ti ons, 49, 51 and origin of s yphilis, 48 and spiroch etes, 36-38, 48 Trepo n ema pa ll i dum, 36, 39, 48 and bej el, 78 endemicum, 40, 41, 49 pertenue, 40, 41, 49 and treatment, 78 and yaws , 78 Trepo n ema pa ll i dum hemagglutination assay (T PH A ) , 88 Trepo n ema pa ll i dum pa ll i dum, 40, 42, 52, 54-67, 57 and diagnosis, 86-90 discovery of , 73-76, 101 and scientific met h od, 114 and stages, 54-67 and treatment, 77-80, 92, 94 Trichomonas, 34 vaginalis, 31-32 Tri ch om oniasis, 31-32 Tropical tree s , 81 Tuberculosis, 47 Tuskegee Study, 118-123, 127 United Na ti ons World Health Organization, 97, 116

United States Public Health Service, and Tuskegee Study, 118123, 127 Uri n a ry tract infections, 23 See also Sexually transm i t ted diseases Vampirism, 16 Vancomycin, 80 Van Gogh , Vincent, 19 Van Leeuwenhoek, Anton , 22, 36 Ven ereal disease, 42 Ven ereal Disease Research Labora tory test (VDRL test), 88-89 Ven ereal leprosy, 13 Ven etianDi s e a s e , 10 Ven i ce, and ori gin of s yphilis, 10 Victorian era, 15, 16, 104 Viruses, 8, 24, 25-26, 3234, 109-111 Voltaire, 116 von Hut ten , Ul ri ch , 10, 69-70 Washington , Boo ker T., 120 Wassermann, Paul von , 87-88 Wassermann reaction, 87-88 West Nile vi ru s , 45 World War II and experiments on soldiers , 117-118 and syphilis, 77, 94, 104-107 Yaws , 13, 41-42, 48-49, 51, 56, 57, 61-63, 75, 78

Picture Credits 9: 11: 17: 18: 20: 23: 24: 25: 26: 27: 28: 29: 37: 39: 43: 44: 53: 58: 61:

© Bettmann/Corbis © Historical Picture Archive/Corbis © Bettmann/Corbis © Hulton-Deutsch Collection/Corbis AP/Wide World Photos Lambda Science Artwork Lambda Science Artwork Lambda Science Artwork Courtesy CDC/Janice Carr Courtesy CDC Courtesy CDC Courtesy CDC Courtesy CDC/Dr. Edwin P. Ewing, Jr. National Library of Medicine Courtesy CDC Lambda Science Artwork Courtesy CDC/Dr. David Cox Courtesy CDC Lambda Science Artwork

63: 65: 69: 75: 76: 83: 85: 90: 99: 105: 106: 108: 115: 117: 119: 121: 124:

National Library of Medicine Courtesy CDC © Bettmann/Corbis © Bettmann/Corbis © Corbis Semmelwies Museum Courtesy CDC and © Lester V. Bergman/Corbis © Lester V. Bergman/Corbis © Gianni Dagli Orti/Corbis © Hulton-Deutsch Collection/Corbis National Library of Medicine © H. Armstrong Roberts/Corbis AP/Wide World Photos © Archivo Iconografico SA/Corbis AP/Wide World Photos Library of Congress © H. Armstrong Roberts/Corbis

Cover: Courtesy CDC

139

About the Author Brian Shmaefsky is a professor of bi o l ogy and envi ronmental scien ces at Kingwood Co llege near Ho u s ton, Texas. He did his under graduate studies in bi o l ogy at Brooklyn Co ll ege in New York and com p l eted masters and doctora l s tudies at So uthern Ill i n ois Univers i ty at Edwardsville. His research em phasis is in envi ronmental physiology. Dr. S h m aefsky has many publ i c a ti ons on scien ce education, some appearing in Am erican Biology Teacher and the Journal of College Scien ce Teach i n g. He regularly con sults on gen eral bi o l ogy and m i c robio l ogy tex tbook project s . Dr. S h m aefsky is also very active serving on environmental awareness and policy committees in Texas. He has two ch i l d ren Kathleen, 11, and Timothy, 13, and lives in Kingwood with his dog Dusty.

About the Editor The late I. Edward Alcamo was a Distinguished Teaching Professor of Mi c robi o l ogy at the State Un iversity of New York at Farmingdale. Al c a m o stu d i ed biology at Iona Co ll ege in New York and earn ed his M.S. and Ph.D. degrees in microbi o l ogy at St. John’s Un iversity, also in New York. He had taught at Fa rm i n gdale for over 30 ye a rs . In 2000, Alcamo won the Ca rs k i Aw a rd for Distinguished Teaching in Mi c robi o l ogy, the highest hon or for m i c robi o l ogy te ach ers in the United State s . He was a mem ber of the Am erican Soc i ety for Mi c robi o l ogy, the National As s oc i a ti on of Bi o l ogy Te ach ers, and the Am erican Medical Wri ters As s oc i a ti on . Alcamo aut h ored nu m erous books on the su bjects of microbiology, AIDS, and DNA tech n o logy as well as the aw a rd - winning tex tbook Fundamentals of Microbi ol o gy, n ow in its sixth ed i ti on .

140