During my fourth year of medicine (68 years ago) my small clinical group was led to the bedside of a man recently admitted with the diagnosis of syphilis. “Remember this visit!” said our clinical instructor, “you will probably never see another patient with syphilis in your future practice.” Indeed, I have not.
Around the year 2000, syphilis was nearly eradicated in the United States.[1] Now, a headline in a recent BCMJ article on sexually transmitted infections in British Columbia starts with this warning: “Physicians should be aware of rising rates of gonorrhea, chlamydia, and syphilis.”[2]
Focusing on syphilis, there is a still unresolved debate around the role of Christopher Columbus and his fleet in bringing this affliction to Europe on their return from America in 1493. However, radio-carbon dating of ancient bone fragments in Europe suggest evidence of the disease thousands of years ago.[3]
Confusing the history somewhat is the fact that, for many centuries, various sexually transmitted diseases were seen as a single disease. An experiment in 1767 seemed to prove that. John Hunter (1728–1793), a famous physician of the time, inoculated the urethral secretions of a patient with gonorrhea in the prepuce of an apparently healthy patient, who developed symptoms of syphilis shortly after. It was another 60 years until, in 1831, Philippe Ricord designed a large study with over 600 patients with gonorrhea and 1500 patients with symptoms of syphilis to show that syphilis occurred only after contact with syphilis patients.[4]
Over 100 years ago, Sir William Osler said about syphilis, “He who knows syphilis knows medicine.”[5] In his day, physicians were attuned to the myriad clinical presentations of this disease. Medical writers like W. Somerset Maugham and Anton Chekhov portrayed the ravages of syphilis in some of their stories. Sir Arthur Conan Doyle of Adventures of Sherlock Holmes fame wrote his doctoral thesis on tabes dorsalis in 1885 and described the symptoms of general paresis of the insane in his fictional short story, “A medical document.”[6]
In the European field of art of the 18th and 19th centuries, there was a connection between representation of syphilis and sex workers. The Henri de Toulouse-Lautrec painting, “The medical inspection” (1894) shows two women with their skirts drawn up ready for an exam, and the Edward Munch painting, “The Inheritance” (1897) portrays a mother with a child with congenital syphilis.[7] The artists seem to blame women who infect men, or fate, or the sufferers themselves. The list of sufferers included Leo Tolstoy, Friedrich Nietzsche, Vladimir Lenin, Al Capone, Idi Amin, and Henri de Toulouse-Lautrec. Adolf Hitler was also suspected of having had syphilis.[8]
Early attempts to treat syphilis were in the hands of barber-surgeons. Sweat baths were popular along with administration of Guaiacum and mercury ointments. Recognizing the toxic effects of mercury, physicians used the roots of sarsaparilla and tried metals like platinum and gold. In 1906, Paul Ehrlich experimented with arsenic without success but eventually found a degree of success with arsenaphine, which was eventually known as Salvarsan—later improved as Neosalvarsan or drug 914. Eventually bismuth along with small amounts of mercury provided a mainstay of treatment until the advent of penicillin in 1943. Introduced by John Mahoney, Richard Arnold, and A.D. Harris, this became a turning point in the treatment of the infection’s primary or second stages.[9]
In British Columbia, the BC Centre for Disease Control considers syphilis prevention and control to be a provincial public health priority. The Syphilis Action Plan[10] focuses on groups who are more likely to be infected with syphilis and groups that may experience morbidity from syphilis. All reactive syphilis testing results are reviewed by clinicians at the provincial STI clinic. BCCDC syphilis nurses and sessional physicians develop a treatment plan, coordinate treatment delivery, and follow up. The syphilis nurses engage with clients to identify partners who may have been exposed to syphilis to ensure they are tested and treated if required. While the drivers of syphilis infection among men in BC are varied, a large portion of women with cases of syphilis reported street involvement, substance use, housing instability, need for income assistance, and mental illness.[10,11]
Physicians must be aware of rising rates of STIs. The recent BCMJ article[2] is an outstanding summary and guide to diagnostic workup, treatment, and surveillance programs for STIs, including syphilis.
—George Szasz, CM MD
References
1. Hemarajata P. American Society of Microbiology. Revisiting the great imitator: The origin and history of syphilis. Accessed 2 June 2022. https://asm.org/Articles/2019/June/Revisiting-the-Great-Imitator,-Part-I....
2. Zewuda R, Deans GD, Press N. Sexually transmitted infections in British Columbia: An update. BCMJ 2022;64:174-178.
3. Maatouk I, Moutran R. History of syphilis: Between poetry and medicine. J Sex Med 2014;11:307-310.
4. Tampa M, Sarbu I, Matei C, et al. Brief history of Syphilis. J Med Life 2014;7:4-10.
5. Rayment M, Sullivan AK. “He who knows syphilis knows medicine”—the return of an old friend. Br J Cardiol 2011;18:56-58.
6. Somasumdaran O. Neuro syphilis: Portrayals by Sir Arthur Conan Doyle. Indian J Psychiatry 2009:51:235-237.
7. How to talk about art history. Depictions of STDs in art history. Accessed 2 June 2022. https://howtotalkaboutarthistory.wordpress.com/2016/06/22/depictions-of-....
8. Wikipedia. List of syphilis cases. Accessed 2 June 2022. https://en.wikipedia.org/wiki/list_of_syphilis_cases.
9. Frith J. Syphilis—its early history and treatment until penicillin and the debate on its origins. JMVH 2012;20:49-58.
10. BC Centre for Disease Control. BC syphilis action plan. January 2016. Accessed 2 June 2022. www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Stat....
11. Willemsma K, Barton L, Stimpson R, et al. Characterizing female infectious syphilis cases in British Columbia to identify opportunities for optimization of care. CCDR 2022;48:68-75. Accessed 7 June 2022. www.canada.ca/en/public-health/services/reports-publications/canada-comm....
This post has not been peer reviewed by the BCMJ Editorial Board.
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The only other thing that I can add to that article about syphilis, is not to forget that the disease has 4 stages of presentation and for that reason it has been known as "the great imitator". To me its like Tuberculosis - be constantly aware of not missing the diagnosis.