Syphilis And Gonorrhea
SYPHILIS AND GONORRHEA: OLD-FASHIONED AND STILL FLOURISHING, Evelyn Zamula
The following article is reprinted form the April 1986 issue of the FDA Consumer, a publication of the Food and Drug Administration.
After penicillin was discovered in 1943, it was soon found to be effective against the age-old venereal diseases, syphilis and gonorrhea. Doctors were hopeful that in time both diseases would be as unknown to future generations as smallpox is to ours.
It hasn’t happened yet. Though the last few years have seen a drop in the number of cases, syphilis and gonorrhea have not disappeared; they are, in fact, still flourishing.
In 1984, gonorrhea had the dubious distinction of being No. 1 among diseases reported to the U.S. Public Health Service’s Centers for Disease Control, with 878,000 cases among civilians. (State and local health departments have been required to report cases of both syphilis and gonorrhea to the Public Health Service since 1919.) CDC estimates that there are probably another million unreported cases. Syphilis was No. 3, with 69,886 cases reported in 1984. CDC believes the actual count is nearer 90,000.
The World Health Organization estimates that each year there are about 250 million new cases of gonorrhea and 50 million new cases of syphilis worldwide. These diseases are not as lethal as the newest sexually transmitted disease, AIDS, which is so far incurable. But they still present staggering health problems.
Of the two, syphilis is the more complex and variable. A case may go on for years, involving a progression of symptoms that have been divided into three stages. This doesn’t necessarily mean the disease goes from bad to worse– it often doesn’t–but it does go from an infectious to a noninfectious state, often with an elusive now-you-see-it, now-you-don’t quality. The first stage, which includes primary and secondary syphilis, is the most infectious and may last up to two years. After that, the disease becomes less and less contagious.
Syphilis is acquired chiefly by direct contact–almost always sexual–with the infectious lesions of someone with the disease. The lesion in primary syphilis is a small, firm, button-like sore (chancre) that appears most commonly on the genital organs, though it may appear on any mucous membranes that have been exposed to the syphilis bacterium. In secondary syphilis the lesions may take the form of an all-over body rash, or a peculiar rash only on the hands and feet, or patches of eroded tissue in the mucous membranes of the mouth and the genital organs. When the lesions are disturbed, as during intercourse, they exude a clear serum containing the corkscrew-shaped bacteria (Treponema pallidum), or spirochetes, that cause syphilis.
The disease can also be contracted by kissing, biting, or exposing an open area of the skin to the lesions. Because the bacteria live only a short time outside the body, syphilis is not usually transmitted from contaminated towels or toilet seats.
If the sexual partner of a person infected with syphilis is one of the unlucky 30 percent who go on to develop the disease, that person, in turn, will develop his or her own chancre in about 10 days to three months after exposure, in the part of the body where the infection was introduced. The chancre usually lasts from two to four weeks, and then disappears without treatment, leaving a small scar. But rejoicing is not in order, because the disease marches on into the next phase.
In secondary syphilis, which occurs about six weeks after the chancre emerged, more symptoms appear as the spirochetes multiply in the body. Besides the characteristic rash and mucous patches, the untreated patient may feel generally unwell and may experience poor appetite, fever, swollen lymph glands, headaches and aching bones. (Sometimes the sole symptom of secondary syphilis is patchy loss of hair on the scalp–described as “moth- eaten” alopecia–or a distinctive loss of the outer half of the eyebrows, eyelashes and beard.) The disease can affect any organ of the body during this stage.
At this point in the disease, it would seem that the symptoms would be telling the sufferer to seek treatment, and most people do. But the symptoms are not always that obvious. Sometimes the chancre can’t be seen because it occurs deep in the vagina or on the cervix (or, as a result of other sex practices, in the throat or rectum). It eventually clears up by itself anyway so even if it was visible, medical help may not be sought.
The rash of secondary syphilis may be difficult to diagnose because it’s often atypical, meaning it may be mistaken for a rash due to some other condition, such as German measles, infectious mononucleosis, or a drug reaction. So it may be incorrectly treated. (This ability to mimic other diseases is why syphilis was known in days gone by as the “great masquerader.” Sir William Osler, a superb physician and one of the founders of Johns Hopkins Medical School, said, “He who knows syphilis, knows medicine.”)
Even without treatment, though, the rash also vanishes, followed by the disappearance of the rest of the secondary symptoms. From here on, untreated syphilis victims involuntarily participate in a game of medical Russian roulette. When the disease enters the latent stage, a lucky 25 percent are spontaneously cured; another 25 percent, while not cured, never show any further signs of the disease. About the same number backslide into the secondary stage and become infectious again, and so are subject to a rerun of the process.
The remaining unlucky ones–from 15 to 40 percent according to three large studies–go on to develop late (or tertiary) syphilis, the final stage, which can occur so many years later that the victims can’t even remember when they were first infected. Here the bacteria insidiously work their way through the body, taking a heavy toll on the central nervous system and the heart and blood vessels. Insanity, blindness, deafness, heart disease, inflammation of the bones, ulcerous skin tumors (gummas), and more are the disease’s legacy.
Fewer cases of latent or late syphilis are being seen today because the disease is usually identified and cured in the early infectious stage. In fact, many doctors are unfamiliar with the later forms of syphilis. In the decade between 1969 and 1979, reported cases of late or latent syphilis declined 30 percent.
Doctors can diagnose syphilis by the symptoms and history of exposure, along with positive blood tests and identification of the spirochetes taken from the lesions and examined under a microscope. In late syphilis, the spinal fluid will also show evidence of syphilis.
In days gone by, rather heroic measures were taken to cure syphilis. During the Middle Ages, mercury salts were taken by mouth or rubbed on syphilitic lesions. Mercury induced excessive salivation, sometimes as much as four pints a day. But it didn’t cure the disease and often poisoned the patient. The first drug effective against syphilis was discovered in 1906 by the German physician Paul Ehrilich. His “magic bullet,” or preparation 606, an arsenic compound known as salvarsan (later as neosalvarsan), was the most widely used anti-syphilis drug until just a few decades ago.
Today, penicillin via injection cures all stages of syphilis. A single large dose (millions of units) will knock out the disease in the early stages. Later stages of syphilis need even larger doses and longer therapy. The antibiotics tetracycline and erythromycin may be used for those allergic to penicillin.
Pregnant women may be treated with penicillin–which is 98 percent effective in preventing congenital syphilis in babies–or erythromycin. (Tetracylcine shouldn’t be used because it causes permanent discoloration of the baby’s teeth).
If a pregnant woman in the early stages of syphilis is not treated, she may miscarry or have a stillborn baby. (In 1917, Osler claimed that 20 percent of all stillbirths and 18 to 22 percent of infant deaths in the United States were due to syphilis.) An untreated pregnant mother in the later stages of syphilis may give birth to a baby with congenital syphilis. In one major study conducted in Oslo, Norway, from 1890 to 1910, about 50 percent of babies born to untreated mothers had some signs of the disease, among them deformities such as abnormal teeth, misshapen leg bones, an unusually shaped “saddle” nose, and highly contagious skin lesions. Babies with congenital syphilis can be treated with penicillin, although the deformities remain.
Use of condoms is one way to lessen exposure to syphilis, though this is not necessarily foolproof. It is perfectly possible to get syphilis from–or give syphilis to–someone from an area not covered by the condom. Diaphragms and other contraceptives do not offer any protection. One bout of the disease doesn’t confer immunity, so it is possible to become infected again and again.
People in the early infectious stage of syphilis should avoid sexual relations until they’re cured. In preventing the spread of the disease it is essential that all sexual contacts of the individual with the disease be notified and report for testing and, if necessary, treatment. Premarital blood tests, testing during pregnancy, and testing the blood in the umbilical cord in newborns have helped stem the spread of syphilis.
Syphilis may be a big-league disease because of its serious complications, but gonorrhea is more widespread. Dr. Stephen H. Zinner, author of “STD’s: Sexually Transmitted Diseases,” believes that CDC’s figures do not reflect the true incidence of gonorrhea in this country, which he estimates at around 3 or 4 million cases each year. Cases are almost evenly divided between the sexes, says CDC’s Dr. William Darrow. (Cases of syphilis occur in a ratio of about three males to one female; about 50 percent of cases of infectious syphilis occur in homosexual males.)
Gonorrheal infections occur from sexual contact with the mucous membranes of someone who has the disease–most frequently with the urethra (the canal that carries urine from the bladder to the outside of the body) or the female’s endocervix (the lining of the neck of the uterus). The male may also contract gonorrhea from infected tissue in the vagina. Just as in syphilis, one exposure to an infected person doesn’t guarantee gonorrhea, but the odds get better with repeated tries. The risk of a male acquiring gonorrhea following a single (vaginal) exposure to an infected female is 20 percent, but after four exposures it increases to between 60 and 80 percent.
Females probably catch the disease from infected males more readily than vice versa, with an estimated 90 percent of females with infected partners usually contracting the disease. Infection from inanimate objects is extremely unlikely, as the gonorrhea bacterium is fragile and dies quickly outside the body. It is not transmitted by kissing. When children get gonorrhea, it is from sexual contact.
The initial symptoms show up quickly in males, usually within one to 14 days after exposure. A tingling sensation in the urethra may be the first sign, followed by pain and burning upon urination and a discharge of pus–the “drip”–from the urethra. In women the incubation period may be a little longer–from seven to 21 days. Most women have mild symptoms, though some develop an inflamed cervix with a discharge from the vaginal canal and inflammation of the urethra, causing painful urination.
Many men and women have no symptoms at all and don’t realize they are infected–one reason why the disease is so difficult to control. In any case, even in those who know they have the disease, symptoms eventually go away.
As Dr. Jonathan Zenilman, a CDC expert on sexually transmitted diseases (now preferred to the old term “venereal diseases”) notes: “The symptoms of gonorrhea do dissipate after several weeks, but people can become asymptomatic carriers of the disease. Besides being able to transmit the disease to others, these people run a risk of developing some problems of their own. A long-term complication of chronic infection in males is urethral stricture, a narrowing of the urethra that can make urination difficult and produce urinary blockages. Females can acquire pelvic inflammatory disease, an inflammation of the Fallopian tubes that may lead to infertility and ectopic pregnancies (pregnancies, sometimes life- threatening, that take place outside the uterus).”
In both sexes, the bacteria may infect the joints, causing arthritis. The bacteria may also get into the bloodstream, leading to several potentially fatal complications.
Premature births and stillbirths are common among infected pregnant women. Babies rarely get gonorrhea from their mothers while in the uterus, but they may contract a gonococcal eye infection while passing through the birth canal. As a precaution, hospital nurseries routinely treat babies’ eyes with various medications shortly after birth.
The disease is diagnosed by examining specimens of the discharge under a microscope for presence of the gonococcal bacteria, or by culturing infected material from any other suspected sites. The culture test usually takes a few days but is considered more reliable than the discharge “smear,” especially for females. The search for a faster test goes on. Under study is a test using horseshoe crab blood, which forms a clot within 30 minutes in the presence of the type of bacteria that cause gonorrhea. Other tests using monoclonal antibodies, a product of DNA technology, are also under investigation.
A rapid, accurate test would be immensely helpful, especially in public health settings, where doctors prefer to be cautious and treat suspected cases right on the spot–without waiting for culture results–to stop possible transmission of the disease. This means that in a few cases people who do not have gonorrhea are treated unnecessarily.
Some bacteria can outsmart people, and the gonococcal bactrium is one of them. Gonococci have mutated so that some drugs are no longer effective against them. So far they have managed to outwit the sulfonamides, introduced in 1937, and have proved so adept at building up resistance to penicillin that the present dose is 100 times greater than when the drug was introduced in the 1940s.
Today–for uncomplicated infections in adults–CDC recommends 4.8 million units of penicillin, injected into the muscle, or oral amoxicillin or ampicillin, all taken with a tablet or probenecid, which increases the effectiveness of other drugs. Since more than one sexually transmitted disease can occur in the same patient, CDC also recommends oral tetracycline in addition to the above drugs because it is effective against Chlamydia trachomatis, which coexists with gonorrhea in up to 45 percent of cases, and against some strains of Ureaplasma urealyticum.
New strains of gonorrhea introduced from the Far East in 1976 have proved resistant to penicillin, tetracycline, and even to the antibiotic spectinomycin, which is usually reserved for cases where nothing else works. Other new antibiotics known as third-generation cephalosporins are effective against the bacteria, but they are expensive and more apt to be used by private doctors than in clinics or other public settings. Cases of one type of penicillin-resistant gonorrhea (penicillnase-producing N. gonorrhoeae) doubled in the United States in 1985, accounting for over 6,000 cases in the first nine months of the year.
Though there’s evidence that the body builds up some antibodies to the bacteria, it’s possible to get the infection again and again. (This is amply proved by James Boswell, Samuel Johnson’s famed biographer, who loved not wisely but too well, contracting the disease 12 times.)
Condom use helps prevent transmission of the disease; use of barrier contraceptives by women, such as the diaphragm with spermicide or the cervical cap, may offer some protection but can’t be depended on completely. As in syphilis, attempts should be made to reach and treat recent partners of infected persons, although the asymptomatic nature of the disease in many people makes that difficult.
A vaccine to control gonorrhea would be a boon, but that’s easier said that done, as experience has proved in the search for a genital herpes vaccine. One way to reduce incidence of both syphilis and gonorrhea may be by limiting, or being more selective about, sexual contacts–as is increasingly occurring in the male homosexual population as a result of AIDS fears. Another alternative, advanced by experts in the field, is a return to old- fashioned monogamy. Whatever the approach, public health efforts need to include an increasing emphasis on education to the consequences of syphilis, gonorrhea and other sexually transmitted diseases.
THE LEGACY OF VD
Unlike AIDS, both syphilis and gonorrhea have been around a long time and have afflicted many prominent people throughout history. A disease of the genital organs that included many syphilis symptoms was described in Chinese medical writings as far back as 2637 B.C. The Old Testament also refers to a disease or diseases that may have been a form of syphilis.
What has been described in some ancient and medieval texts as leprosy was probably syphilis in many cases. That’s not hard to understand, because syphilis in late stages may attack the tissues in the nose, causing it to “disappear,” as with a nasal deformity caused by leprosy.
Gonorrhea has the honor of being the first bacterial infection to be specifically documented–the disease was accurately described in the papyrus scrolls of ancient Egypt. Because syphilis and gonorrhea were known to be sexually transmitted, many physicians of long ago believed they were the same disease, much as syphilis and leprosy were confused.
In 1767, John Hunter, a famous British physician, conducted an experiment daring for his day–and ours, too. To determine whether the “poison” that produced gonorrhea was the same that produced syphilis, he inoculated himself through the urethra with pus from a gonorrhea patient. Hunter developed the usual gonorrhea symptoms and the classic chancre and coppercolored rash that go with syphilis, leading him to incorrectly conclude that they were one and the same disease. What Hunter didn’t know was that the patient had syphilis as well as gonorrhea.
This misconception continued until 1838, when Philip Ricord, the great French syphilologist, concluded that they were different diseases. Definitive proof was furnished by Albert Neisser’s discovery in 1879 of the organism that causes gonorrhea, Neisseria gonorrhoeae, and the identification of the bacterium that causes syphilis in 1905 by Fritz Shaudinn and Erik Hoffmann.
The names of people who have contracted either disease in the past reads like a Who’s Who. Because syphilis–with its long-term effects on the brain–afflicted so many great leaders, it can be said with certainty that the disease has had considerable impact on world history. Syphilis also has influenced the lives of artists, writers and musicians.
Among suffers from the “great pox” was Henry VIII of England. In spite of his well-known amorous proclivities, Henry hypocritically blamed his syphilis on Cardinal Wolsey, another syphilitic, who was supposed to have transmitted it to the king by blowing upon him with his “perilous and most infectious breath.” At least that’s what Henry said when he indicted Wolsey for conspiring with the pope against him. (Lucky Wolsey died of natural causes before the king could behead him.)
Leg ulcers caused Henry horrible pain, and when they acted up he sentenced hundreds of people to death. In his last years, when syphilis affected his brain, he became even more murderous. He is said to have executed 3 percent of the British population during his lifetime. It is also thought that his son Edward VI and daughter Mary Tudor–“Bloody Mary”–had congenital syphilis. Edward was frail and died at 15, while Mary had the prematurely wrinkled skin and thin, moth-eaten hair characteristic of syphilis.
The English poet John Donne, who in his youth was a “great visitor” of ladies, regretted his indiscretions in his later years, when the late symptoms of syphilis appeared. Arthur Schopenhauer, the famous philosopher, became a confirmed woman-hater as a result of contracting syphilis in his university days. His gloomy view on life were no doubt influenced by his long battle with the disease. Guy de Maupassant, the famous French short story writer, died at the age of 43 of general paralysis and insanity due to syphilis. Vincent van Goh’s removal of his own ear and his subsequent suicide were probably prompted by the artist’s insanity caused by late syphilis.
Napoleon is said to have suffered from both syphilis and gonorrhea. It is certain that as a young lieutenant he contracted gonorrhea, which left him with a stricture of the urethra that made urination difficult. In more recent times, Benito Mussolini contracted both diseases, while Adolph Hitler had gonorrhea as a young man. Thanks to penicillin, which arrived on the scene during World War II, the names of more recent notables who have had these diseases can remain hidden in their doctors’ files.