Syphilis
28852
226024972
2008-07-16T14:19:47Z
165.124.2.88
/* Notable known and suspected syphilis-infected people in previous centuries */
{{Infobox Disease
| Name = Syphilis (camille)
| Image = Treponema pallidum.jpg
| Caption = Image of spiral-shaped organisms responsible for causing syphilis
| ICD10 = {{ICD10|A|50||a|50}}-{{ICD10|A|53||a|50}}
| ICD9 = {{ICD9|090}}-{{ICD9|097}}
| ICDO =
| OMIM =
| DiseasesDB =
| MedlinePlus = 001327
| eMedicineSubj = med
| eMedicineTopic = 2224
| eMedicine_mult = {{eMedicine2|emerg|563}} {{eMedicine2|derm|413}}
}}
'''Syphilis''' is a curable [[sexually transmitted disease]] caused by the ''[[Treponema pallidum]]'' [[spirochete]]. The route of transmission of syphilis is almost always by [[sexual]] contact, although there are examples of [[congenital syphilis]] via transmission from mother to child [[in utero]]. The signs and [[symptoms]] of syphilis are numerous; before the advent of [[serological testing]], precise [[diagnosis]] was very difficult. In fact, the disease was dubbed the "Great Imitator" because it was often confused with other diseases, particularly in its tertiary stage. Syphilis (unless [[antibiotic resistance|antibiotic-resistant]]) can be easily treated with [[antibiotics]] including [[penicillin]]. The oldest and still most effective method is an [[intramuscular injection]] of [[Penicillin#Benzathine benzylpenicillin|benzathine penicillin]]. If not treated, syphilis can cause serious effects such as damage to the [[heart]], [[aorta]], [[brain]], [[eyes]], and [[bones]]. In some cases these effects can be fatal. In 1998, the complete [[genetic sequence]] of ''T. pallidum'' was published which may aid understanding of the [[pathogenesis]] of syphilis.
== Alternative names==
The name "syphilis" was coined by the Italian physician and poet [[Girolamo Fracastoro]] in his [[Epic poetry|epic]] noted poem, written in Latin, entitled ''Syphilis sive morbus gallicus'' ([[Latin]] for "Syphilis or The French Disease") in 1530. The protagonist of the poem is a [[shepherd]] named Syphilus (perhaps a variant spelling of Sipylus, a character in [[Ovid]]'s ''[[Metamorphoses]]''). Syphilus is presented as the first man to contract the disease, sent by the god [[Apollo]] as punishment for the defiance that Syphilus and his followers had shown him. From this character Fracastoro derived a new name for the disease, which he also used in his medical text ''De Contagionibus'' ("On Contagious Diseases").<ref>{{cite web | title = Syphilis | url = http://www.etymonline.com/ | publisher = Online Etymology Dictionary | date = 2001}}</ref>
Until that time, as Fracastoro notes, syphilis had been called the "French disease" in Italy and Germany, and the "Italian disease" in France. In addition, the Dutch called it the "Spanish disease", the Russians called it the "Polish disease", the Turks called it the "Christian disease" or "Frank disease" (''frengi'') and the Tahitians called it the "British disease". These 'national' names are due to the disease often being present among invading armies or sea crews, due to the high instance of unprotected sexual contact with [[prostitutes]]. It was also called "Great pox" in the 16th century to distinguish it from [[smallpox]]. In its early stages, the Great pox produced a rash similar to smallpox (also known as [[variola]]). However, the name is misleading, as smallpox was a far more deadly disease. The terms "[http://www.merriam-webster.com/dictionary/lues Lues]" (or ''Lues venerea'', [[Latin language|Latin]] for "venereal plague") and "[[Cupid]]'s disease" have also been used to refer to syphilis. In [[Scotland]], Syphilis was referred to as the ''Grandgore''. The ulcers suffered by British soldiers in Portugal was termed "The Black Lion".<ref>{{cite web |author=Rudy's List of Archaic Medical Terms |title="B" |url=http://www.antiquusmorbus.com/English/EnglishB.htm |date=04/27/2007 |publisher=Antiquus Morbus |accessdate=2008-04-28}}<br/>'''Referencing:'''<br/>{{cite book |author=Robley Dunglison |title=Dunglison's Medical Dictionary – A Dictionary of Medical Science |date=1874 |publisher=Collins |location=Philadelphia, USA}}</ref>
== Origins ==
There have been three theories on the origin of syphilis which formed an ongoing debate in [[anthropological]] and [[history|historical]] fields.
The '''[[pre-Columbian]] theory''' holds that syphilis symptoms are described by [[Hippocrates]] in [[Classical Greece]] in its [[venereal]]/tertiary form. There are other suspected syphilis findings for pre-contact Europe, including at a 13–14th century [[Augustinian]] [[friary]] in the northeastern English port of [[Kingston upon Hull]]. This city's maritime history is thought to have been a key factor in the transmission of syphilis.<ref>{{cite web |author=Keys D |title=English syphilis epidemic pre-dated European outbreaks by 150 years |url=http://news.independent.co.uk/health/article266422.ece |date=2007 |publisher=Independent News and Media Limited |accessdate = 2007-09-22}}</ref> [[carbon dating|Carbon dated]] skeletons of monks who lived in the friary showed bone lesions typical of venereal syphilis. Skeletons in pre-Columbus [[Pompeii]] and [[Metaponto]] in Italy demonstrating signs of congenital syphilis have also been found,<ref>{{cite book |author=Henneberg M, Henneberg RJ |date=1994 |chapter=Treponematosis in an Ancient Greek colony of Metaponto, Southern Italy 580-250 BCE |editor=O Dutour, G Palfi, J Berato, J-P Brun (eds) |title=The Origin of Syphilis in Europe, Before or After 1493? |publisher=Centre Archeologique du Var, Editions Errance |location=Toulon-Paris |pages=pp. 92-98}}</ref><ref>{{cite book |author=Henneberg M, Henneberg RJ |date=2002 |chapter=Reconstructing Medical Knowledge in Ancient Pompeii from the Hard Evidence of Bones and Teeth |editor=J Renn, G Castagnetti (eds) |title=Homo Faber: Studies on Nature. Technology and Science at the Time of Pompeii, |publisher=“L’ERMA” di Bretschneider |location=Rome |pages=pp.169-187}}</ref> although the interpretation of the evidence has been disputed.<ref>{{cite journal |author=Rose M |title=Origins of Syphilis |journal=Archaeology |volume=50 |issue=1 |month=January/February |year=1997 |url=http://www.archaeology.org/9701/newsbriefs/syphilis.html}}</ref>
The '''[[Columbian Exchange]] theory''' holds that syphilis was a [[New World]] disease brought back by [[Christopher Columbus|Columbus]] and [[Martin Alonzo Pinzon]]. Supporters of the Columbian theory find syphilis [[lesion]]s on pre-contact [[Indigenous peoples of the Americas|Native Americans]] and cite documentary evidence linking crewmen of Columbus's voyages to the Naples outbreak of 1494.<ref>Baker, et al.{{fact|date=April 2008}}<!-- absence of citation details (?book name or journal paper) makes this pretty meaningless--></ref> A recent study of the genes of venereal syphilis and related bacteria has supported this theory, by locating an intermediate disease between [[yaws]] and syphilis in Guyana, South America.<ref>{{cite news |author=Debora MacKenzie |title=Columbus blamed for spread of syphilis |publisher=NewScientist |date=15 January 2008 |url=http://www.newscientist.com/article/dn13186-columbus-blamed-for-spread-of-syphilis-.html}}</ref><ref name="pmid18235852">{{cite journal |author=Harper KN, Ocampo PS, Steiner BM, ''et al'' |title=On the origin of the treponematoses: a phylogenetic approach |journal=PLoS Negl Trop Dis |volume=2 |issue=1 |pages=e148 |year=2008 |pmid=18235852 |doi=10.1371/journal.pntd.0000148 |url=http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000148}}</ref>
Historian [[Alfred Crosby]] suggests both theories are correct in a '''combination theory.''' Crosby's argument is built on the similarities of the species of [[bacteria]] which cause yaws and syphilis. The bacterium that causes syphilis belongs to the same phylogenetic family as the bacteria which cause [[yaws]] and several other diseases. Despite a tradition of assigning yaws's homeland to [[sub-Saharan Africa]], Crosby notes that there is no unequivocal evidence of any related disease being present in pre-Columbian Europe, Africa, or Asia, while there is indisputable evidence of syphilis' presence in the pre-Columbian Americas. Conceding this point, Crosby writes, "It is not impossible that the organisms causing [[treponema]]tosis arrived from America in the 1490s...and evolved into both venereal and non-venereal syphilis and yaws."<ref name="225 Crosby">ref:225 Crosby{{fact|date=April 2008}}<!-- absence of citation details (?book name or journal paper) makes this pretty meaningless - ?"The Columbian Exchange: Biological and Cultural Consequences of 1492" or some other work ? --></ref>
However, Crosby considers it somewhat more likely that a highly contagious ancestral species of bacteria moved with early human ancestors across the land bridge of the [[Bering Straits]] many thousands of years ago without dying out in the original source population. He hypothesizes that "the differing ecological conditions produced different types of [[treponema]]tosis and, in time, closely related but different diseases."<ref name="225 Crosby" />
Thus, a weak, non-syphilitic bacteria survived in the Old World to eventually give rise to yaws or [[bejel]], while a New World version evolved into the milder [[Pinta (disease)|pinta]] and the more aggressive syphilis.
Going further than Crosby in arguing for worldwide incidence of syphilis prior to Columbus, Douglas Owsley, the famed [[physical anthropologist]] at the [[Smithsonian Institution]], has written that many medieval European cases of leprosy, colloquially called "lepra," were actually cases of syphilis. Although folklore claimed that syphilis was unknown in Europe until the return of the diseased sailors of the Columbian voyages, {{cquote|... syphilis probably cannot be "blamed"—as it often is—on any geographical area or specific race. The evidence suggests that the disease existed in both hemispheres from prehistoric times. It is only coincidental with the Columbus expeditions that the syphilis previously thought of as "lepra" flared into virulence at the end of the fifteenth century.<ref name="OWSLEY">{{cite journal |author=Lobdell J, Owsley D |title=The origin of syphilis |journal=Journal of Sex Research |month=August |year=1974 |volume=10 |issue=1 |pages=76–79}} (via [[JSTOR]])</ref>}} Owsley noted that a Chinese medical case recorded in 2637 B.C.E. seems to be describing a case of syphilis, and that a European writer who recorded an outbreak of "lepra" in 1303 C.E. is "clearly describing syphilis".<ref name="OWSLEY"/>
== History ==
[[Image:Rembrandt Harmensz. van Rijn 095.jpg|thumb|200px|Portrait of [[Gerard de Lairesse]] by [[Rembrandt van Rijn]], ca. 1665–67, oil on canvas. De Lairesse, himself a painter and art theorist, suffered from congenital syphilis that severely deformed his face and eventually blinded him.<ref>''[[Metropolitan Museum of Art|The Metropolitan Museum of Art Bulletin]]'', Summer 2007, pp. 55-56.</ref>]]
While working at the [[Rockefeller University]] (then called the Rockefeller Institute for Medical Research) in 1913, [[Hideyo Noguchi]], a [[Japan]]ese scientist, demonstrated the presence of the spirochete ''[[Treponema pallidum]]'' in the brain of a progressive paralysis patient, proving that ''Treponema pallidum'' was the cause of the disease.<ref>{{cite book|chapter=Noguchi, Hideyo |url=http://www.bartleby.net/65/no/NoguchiH.html |title=The Columbia Encyclopedia |edition=Sixth Edition}}</ref> Prior to Noguchi's discovery, syphilis had been a burden to humanity in many lands, sometimes misdiagnosed and often misattributed to political enemies.
Some famous historical personages, including [[Franz Schubert]], [[Charles VIII of France]], [[Hernán Cortés|Hernando Cortez]] of Spain, [[Adolf Hitler]], [[Benito Mussolini]], and [[Ivan the Terrible]], have been alleged to have had syphilis. [[Guy de Maupassant]] and possibly [[Friedrich Nietzsche]] are thought to have been driven [[insanity|insane]] and ultimately killed by the disease. [[Al Capone]] contracted syphilis as a young man. By the time he was incarcerated at [[Alcatraz]], it reached its third stage, ''neurosyphilis'', leaving him confused and disoriented. Syphilis led to the death of artist [[Edouard Manet]] and artist [[Paul Gauguin]] is also said to have suffered from syphilis. Composers who succumbed to syphilis include [[Hugo Wolf]], [[Frederick Delius]], [[Scott Joplin]], [[Gaetano Donizetti]], and possibly [[Franz Schubert]] and [[Niccolò Paganini]].
The insanity caused by late-stage syphilis was once one of the more common forms of [[dementia]]; this was known as the [[general paresis of the insane]]. One suspected example is the insanity of noted composer [[Robert Schumann]], although the precise cause of his death is still disputed by scholars.
The Russian author [[Leo Tolstoy]] suffered from syphilis during his youth, which was cured using arsenic treatment.<ref name="isbn0-393-32122-3">{{cite book |author=Wilson, A. G. |title=Tolstoy: A Biography |publisher=Norton |location=New York |year=2001 |pages= |isbn=0-393-32122-3 |oclc= |doi= |accessdate=}}</ref>
A recent article in the ''European Journal of Neurology'' (June 2004) hypothesized that the founder of communism in Russia, [[Vladimir Ilyich Lenin]], died of neurosyphilis.<ref name="pmid15171732">{{cite journal |author=Lerner V, Finkelstein Y, Witztum E |title=The enigma of Lenin's (1870-1924) malady |journal=Eur. J. Neurol. |volume=11 |issue=6 |pages=371–6 |year=2004 |month=June |pmid=15171732 |doi=10.1111/j.1468-1331.2004.00839.x |url=http://www.blackwell-synergy.com/action/showFullText?submitFullText=Full+Text+HTML&doi=10.1111%2Fj.1468-1331.2004.00839.x}}</ref>
[[Karen Blixen]], the author of ''Out of Africa'', contracted syphilis from her husband while living in Africa. He had contracted the disease from an African woman with whom he had been unfaithful. After having undergone treatment in Denmark, she returned to Africa. Blixen was unable to have children.
===European outbreak===
[[Image:DürerSyphilis1496.jpg|thumb|100px|A medical illustration attributed to [[Albrecht Dürer]] (1496) depicting a person with syphilis. Here, the disease is believed to have [[astrology|astrological]] causes.]]
The first well-recorded European outbreak of what is now known as syphilis occurred in 1494 when it broke out among French troops besieging [[Naples]].<ref name=Scars_of_Venus>{{cite book | author=Oriel, J.D. | title=The Scars of Venus: A History of Venereology | location=London | publisher= Springer-Verlag | date=1994 }}</ref> The French may have caught it via Spanish mercenaries serving King Charles of France in that siege.<ref name="OWSLEY"/> From this centre, the disease swept across Europe. As [[Jared Diamond]] describes it, "when syphilis was first definitely recorded in Europe in 1495, its [[pustule]]s often covered the body from the head to the knees, caused flesh to fall from people's faces, and led to death within a few months." In addition, the disease was more frequently fatal than it is today. Diamond concludes that "by 1546, the disease had evolved into the disease with the symptoms so well known to us today."<ref name=Diamond1>{{cite book | author=Diamond, Jared | date=1997 | title=Guns, Germs and Steel | location=New York | publisher=W.W. Norton | pages=210}}</ref> The [[epidemiology]] of this first syphilis epidemic shows that the disease was either new or a mutated form of an earlier disease.
=== Notable known and suspected syphilis-infected people in previous centuries ===
Keys: '''S''' - suspected case; '''†''' - died of syphilis
<!-- Note that this article is subject to Wikipedia's Bio of Living Person's rules.
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*** All names listed here must meet ALL of these basic criteria:
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*** (1) people must have died before the year 2000,
*** (2) a reliable source must document the syphilis infection, and
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*[[Idi Amin]] (1928-2003) Ugandan dictator S
*[[Maurice Barrymore]] (1849-1905) actor †
*[[Charles Baudelaire]] (1821-1867), poet †
*[[Isabella Beeton]] (1836-1865), author of ''Mrs. Beeton's Book of Household Management'' S
*[[Karen Blixen]] (1885-1962), writer
*[[Manuel Maria Barbosa du Bocage]] (1765-1805), poet †
*[[António Botto]] (1897-1959), poet
*[[Camilo Castelo Branco]] (1825-1890), writer
*[[Beau Brummell]] (1778-1840), fashion arbiter
*[[Al Capone]] (1899-1947), gangster †
*[[Lord Randolph Churchill|Randolph Churchill, Lord]] (1849-1895), British statesman and father of [[Winston S. Churchill]] S
*[[Henry Stuart, Lord Darnley]] (1545-1567), second husband of Mary Queen of Scots
*[[Frederick Delius]] (1862-1934), composer †
*[[Gaetano Donizetti]] (1797-1848), composer
*[[Edward VI of England|King Edward VI]] (1538-1553), King of England and third Tudor monarch S
*[[Mihai Eminescu]] (1850-1889), poet S
*[[Paul Gauguin]] (1848-1903), painter †
*[[Heinrich Heine]] (1797-1856), poet †
*[[Henry VIII of England|King Henry VIII]] (1491-1547), King of England and second monarch of the [[Tudor dynasty]] S
*[[Adolf Hitler]] (1889–1945), German dictator S
*[[Howard Hughes]] (1905-1976), aviator, billionaire
*[[Ivan IV of Russia|Ivan the Terrible]] (1530-1584), Czar of Russia
*[[Scott Joplin]] (1867/8-1917), composer †
*[[Vladimir Lenin]] (1870-1924), communist leader S
*[[Édouard Manet]] (1832-1883), painter †
*[[Guy de Maupassant]] (1850-1893), writer †
*[[Friedrich Nietzsche|Friedrich Wilhelm Nietzsche]] (1844-1900), nineteenth-century German philosopher S
*[[Jack Pickford]] (1896-1933), actor †
*[[Martin Alonzo Pinzon]] (1441-1493) captain of the ''[[Pinta (ship)|Pinta]]'' †
*[[Franz Schubert]] (1797-1828), composer S
*[[Robert Schumann]] (1810-1856), composer S
*[[Bedřich Smetana]] (1824-1884), Czech composer S
*[[Tongzhi Emperor|Tongzhi]] (1856-1875), ninth Manchu emperor in the Qing dynasty S
*[[Henri de Toulouse-Lautrec]] (1864-1901), painter †
*[[John Wilmot]] (1647-1680), 2nd Earl of Rochester, writer, debaucher S
*[[Oscar Wilde]] (1854-1900), writer S
*[[Hugo Wolf]] (1860-1903), composer †
*[[Mikhail Vrubel]] (1856-1910), painter
*[[Mary I of England|Mary I]], [[Queen of England]] and fourth monarch of the [[Tudor dynasty]] S
*[[Vincent Van Gogh]] (1853-1890), painter
{{div col end}}
==Syphilis infection==
Different manifestations occur depending on the stage of the disease:
===Primary syphilis===
[[Image:Extragenital syphilitic chancre of the left index finger PHIL 4147 lores.jpg|thumb|200px|Primary [[chancre]] of syphilis at the site of infection on the hand]]
''Primary syphilis'' is typically acquired via direct sexual contact with the infectious lesions of a person with syphilis.<ref name=RedBookSyphilis>{{citation | editor=Pickering LK | contribution=Syphilis | title= Red Book | publisher=American Academy of Pediatrics | location= Elk Grove Village, IL | date=2006 | pages=631–644}}</ref> Approximately 10-90 days after the initial exposure (average 21 days), a skin lesion appears at the point of contact, which is usually the [[genitalia]], but can be anywhere on the body. This lesion, called a ''[[chancre]]'', is a firm, painless skin ulceration localized at the point of initial exposure to the spirochete, often on the [[penis]], [[vagina]] or [[rectum]]. Rarely, there may be multiple lesions present although typically only one lesion is seen. The [[lesion]] may persist for 4 to 6 weeks and usually heals spontaneously. Local [[lymph node]] swelling can occur. During the initial incubation period, individuals are otherwise [[asymptomatic]]. As a result, many patients do not seek medical care immediately.
Syphilis can ''not'' be contracted through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing.<ref>{{cite web | last = Centers for Disease Control (CDC) | authorlink = Centers for Disease Control and Prevention | title =STD Facts - Syphilis | publisher = [[Centers for Disease Control]] | date = 05-2004 | url = http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm | accessdate = 2007-05-30 }}</ref>
[[Image:Secondary Syphilis on palms CDC 6809 lores.rsh.jpg|right| thumb|200px|Typical presentation of secondary syphilis rash on the palms of the hands and usually also seen on soles of feet]]
===Secondary syphilis===
''Secondary syphilis'' occurs approximately 1-6 months (commonly 6 to 8 weeks) after the primary infection. There are many different manifestations of secondary disease. There may be a symmetrical reddish-pink non-itchy rash on the trunk and extremities.<ref name=2darySyphilis>{{cite journal | author=Dylewski J, Duong M | title=The rash of secondary syphilis | journal=CMAJ. | date= 2 January 2007 | volume=176 | issue=1 | pages=33–5 | doi= 10.1503/cmaj.060665 | pmid=17200385}}</ref> The rash can involve the palms of the hands and the soles of the feet. In moist areas of the body, the rash becomes flat broad whitish lesions known as condylomata lata. Mucous patches may also appear on the genitals or in the mouth. All of these lesions are infectious and harbor active treponeme organisms. A patient with syphilis is most contagious when he or she has secondary syphilis. Other symptoms common at this stage include [[fever]], [[sore throat]], [[malaise]], [[weight loss]], [[headache]], [[meningismus]], and enlarged [[lymph node]]s. Rare manifestations include an acute [[meningitis]] that occurs in about 2% of patients, [[hepatitis]], [[kidney|renal]] disease, hypertrophic [[gastritis]], patchy [[proctitis]], [[ulcerative colitis]], [[rectum|rectosigmoid]] mass, [[arthritis]], [[periostitis]], [[optic neuritis]], intersitial keratitis, [[iritis]], and [[uveitis]].
===Latent syphilis===
''Latent syphilis'' is defined as having serologic proof of infection without signs or symptoms of disease.<ref name=RedBookSyphilis/> Latent syphilis is further described as either early or late. Early latent syphilis is defined as having syphilis for two years or less from the time of initial infection without signs or symptoms of disease. Late latent syphilis is infection for greater than two years but without clinical evidence of disease. The distinction is important for both therapy and risk for transmission. In the real-world, the timing of infection is often not known and should be presumed to be late for the purpose of therapy. Early latent syphilis may be treated with a single intramuscular injection of a long-acting penicillin. Late latent syphilis, however, requires three weekly injections. For infectiousness, however, late latent syphilis is not considered as contagious as early latent syphilis.
===Tertiary syphilis===
''Tertiary syphilis'' usually occurs 1-10 years after the initial infection, though in some cases it can take up to 50 years. This stage is characterized by the formation of [[gumma (pathology)|gummas]] which are soft, tumor-like balls of inflammation known as [[granuloma]]s. The granulomas are chronic and represent an inability of the immune system to completely clear the organism. Gummas were once readily seen in the skin and mucous membranes although they tend to occur internally in recent history. They may appear almost anywhere in the body including in the skeleton. The gummas produce a [[chronic inflammatory]] state in the body with mass-effects upon the local anatomy. Other characteristics of untreated tertiary syphilis include [[neuropathic joint disease]], which is a degeneration of joint surfaces resulting from loss of sensation and fine position sense ([[proprioception]]). The more severe manifestations include [[neurosyphilis]] and cardiovascular syphilis. In a study of untreated syphilis, 10% of patients developed cardiovascular syphilis, 16% had gumma formation, and 7% had neurosyphilis.<ref name=Oslo>{{cite journal | author=Clark EG, Danbolt N |title=The Oslo study of the natural course of untreated syphilis: An epidemiologic investigation based on a re-study of the Boeck-Bruusgaard material | journal=Med Clin North Am. | date=1964 | volume=48 | pages=613}}</ref>
[[Nervous system|Neurological]] complications at this stage can be diverse. In some patients, manifestations include [[general paresis of the insane|generalized paresis of the insane]] which results in personality changes, changes in emotional affect, hyperactive reflexes, and [[Argyll-Robertson pupil]]. This is a diagnostic sign in which the small and irregular pupils constrict in response to focusing the eyes, but not to light. [[Tabes dorsalis]], also known as [[locomotor ataxia]], a disorder of the [[spinal cord]], often results in a characteristic shuffling gait. See below for more information about neurosyphilis.
[[Cardiovascular system|Cardiovascular]] complications include [[syphilitic aortitis]], [[aortic aneurysm]], [[aneurysm of sinus of Valsalva]], and [[aortic regurgitation]]. Syphilis infects the ascending [[aorta]] causing [[dilation]] and [[aortic regurgitation]]. This can be heard with a stethoscope as a [[heart murmur]]. The course can be insidious, and [[heart failure]] may be the presenting sign after years of disease. The infection can also occur in the [[coronary artery|coronary arteries]] and cause narrowing of the vessels. Syphilitic aortitis can cause ''[[de Musset's sign]]'',<ref name="pmid7013091">{{cite journal |author=Sapira JD |title=Quincke, de Musset, Duroziez, and Hill: some aortic regurgitations |journal=South. Med. J. |volume=74 |issue=4 |pages=459–67 |year=1981 |month=April |pmid=7013091 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0038-4348&volume=74&issue=4&spage=459}}</ref> a bobbing of the head that de Musset first noted in Parisian prostitutes.
===Neurosyphilis===
''Neurosyphilis'' refers to a site of infection involving the [[central nervous system]] (CNS). Neurosyphilis may occur at any stage of syphilis. Before the advent of antibiotics, it was typically seen in 25-35% of patients with syphilis. Neurosyphilis is now most common in patients with [[HIV]] infection. Reports of neurosyphilis in HIV-infected persons are similar to cases reported before the HIV [[pandemic]]. The precise extent and significance of neurologic involvement in HIV-infected patients with syphilis, reflected by either laboratory or clinical criteria, have not been well characterized. Furthermore, the alteration of host [[immunosuppression]] by [[antiretroviral drug|antiretroviral therapy]] in recent years has further complicated such characterization.
Approximately 35% to 40% of persons with secondary syphilis have [[asymptomatic]] [[central nervous system]] (CNS) involvement, as demonstrated by any of these on [[cerebrospinal fluid]] (CSF) examination:
*An abnormal leukocyte cell count, protein level, or glucose level
*Demonstrated reactivity to Venereal Disease Research Laboratory ([[VDRL]]) antibody test
There are four clinical types of neurosyphilis:
* Asymptomatic neurosyphilis
* Meningovascular syphilis
* [[General paresis]]<ref name=AMN>{{cite journal | author = Richard B. Jamess, MD, PhD | title = [http://www.health.am/sex/syphilis/ Syphilis- Sexually Transmitted Infections], 2006. | journal =Sexually transmitted diseases treatment guidelines | volume = | issue = | pages = | year = 2002}}</ref>
* [[Tabes dorsalis]]
The late forms of neurosyphilis (tabes dorsalis and general paresis) are seen much less frequently since the advent of antibiotics. The most common manifestations today are asymptomatic or symptomatic meningitis. Acute syphilitic [[meningitis]] usually occurs within the first year of infection; 10% of cases are diagnosed at the time of the secondary rash. Patients present with headache, meningeal irritation, and [[cranial nerve]] abnormalities, especially the [[optic nerve]], [[facial nerve]], and the [[vestibulocochlear nerve]]. Rarely, it affects the spine instead of the brain, causing focal muscle weakness or sensory loss.
Meningovascular syphilis occurs a few months to 10 years (average, 7 years) after the primary syphilis infection. Meningovascular syphilis can be associated with [[prodromal]] symptoms lasting weeks to months before focal deficits are identifiable. Prodromal symptoms include unilateral numbness, [[paresthesia]]s, upper or lower extremity weakness, [[headache]], [[vertigo (medical)|vertigo]], [[insomnia]], and psychiatric abnormalities such as personality changes. The focal deficits initially are intermittent or progress slowly over a few days. However, it can also present as an infectious [[arteritis]] and cause an [[ischemia|ischemic]] [[stroke]], an outcome more commonly seen in younger patients. [[Angiography]] may be able to demonstrate areas of narrowing in the blood vessels or total occlusion.
General paresis, otherwise known as general paresis of the insane, is a severe manifestation of neurosyphilis. It is a chronic [[dementia]] which ultimately results in death in as little as 2-3 years. Patients generally have progressive personality changes, memory loss, and poor judgment. More rarely, they can have [[psychosis]], [[clinical depression|depression]], or [[mania]]. Imaging of the brain usually shows atrophy.
==Diagnostic tests==
===Early 20th century===
In 1906, the first effective test for syphilis, the [[Wassermann test]], was developed. Although it had some false positive results, it was a major advance in the prevention of syphilis. By allowing testing before the acute symptoms of the disease had developed, this test allowed the prevention of transmission of syphilis to others, even though it did not provide a cure for those infected. In the 1930s the '''Hinton test''', developed by [[William Augustus Hinton]], and based on [[flocculation]], was shown to have fewer [[Type I and type II errors|false positive]] reactions than the Wassermann test. Both of these early tests have been superseded by newer analytical methods.
===Modern diagnostic tests===
It was only in the 20th century that effective tests and treatments for syphilis were developed. [[Microscopy]] of fluid from the primary or secondary lesion using darkfield illumination can diagnose treponemal disease with high accuracy. As there are other treponemes that may be confused with ''T. pallidum,'' care must be taken in evaluating with microscopy to correlate symptoms with the correct disease.
[[Image:2005 seattle star wars penis.jpg|thumb|left|Star Wars themed parade float promoting syphilis testing at a 2005 parade in Seattle, Washington, United States.]]
Present-day syphilis screening tests, such as the [[Rapid Plasma Reagin]] (RPR) and [[Venereal Disease Research Laboratory test|Venereal Disease Research Laboratory]] (VDRL) tests are cheap and fast but not completely [[specificity (tests)|specific]], as many other conditions can cause a positive result. These tests are routinely used to screen [[Blood Donation|blood donors]]. Notably, the spirochete that causes syphilis does not survive the conditions used to store blood and the number of transfusion transmitted cases of syphilis is minuscule, but the test is used to identify donors that might have contracted [[HIV]] from high risk sexual activity. The requirement to test for syphilis has been challenged due to the vast improvements in [[HIV testing]]. False positives on the rapid tests can be seen in viral infections ([[Epstein-Barr]], [[hepatitis]], [[varicella]], [[measles]]), [[lymphoma]], [[tuberculosis]], [[malaria]], [[Chagas Disease]], [[endocarditis]], [[connective tissue disease]], [[pregnancy]], intravenous drug abuse, or contamination.<ref name=RedBookSyphilis/> As a result, these two screening tests should always be followed up by a more specific treponemal test. Tests based on [[monoclonal antibodies]] and [[immunofluorescence]], including Treponema pallidum hemagglutination assay ([[TPHA]]) and Fluorescent Treponemal Antibody Absorption ([[FTA-ABS]]) are more specific and more expensive. Unfortunately, false positives can still occur in related treponomal infections such as [[yaws]] and [[Pinta (disease)|pinta]]. Tests based on [[enzyme]]-linked [[immunoassay]]s are also used to confirm the results of simpler screening tests for syphilis.
Neurosyphilis is diagnosed by finding high numbers of [[leukocytes]] in the [[cerebrospinal fluid|CSF]] or abnormally high protein concentration in the setting of syphilis infection.<ref name=RedBookSyphilis/> In addition, CSF should be tested with the VDRL test although some advocate using the FTA-ABS test to improve sensitivity. There is anecdotal evidence that the incidence of neurosyphilis is higher in HIV patients, and some have recommended that all HIV-positive patients with syphilis should have a [[lumbar puncture]] to look for asymptomatic neurosyphilis.<ref>{{cite journal | author=Walter T, Lebouche B, Miailhes P, ''et al.'' | title=Symptomatic relapse of neurologic syphilis after benzathine penicillin G therapy for primary or secondary syphilis in HIV-infected patients | journal=Clin Infect Dis | year=2006 | volume=43 | issue=6 | pages=787–90 | pmid=16912958 | doi = 10.1086/507099 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
===Diseases caused by other species of Treponema===
These diseases are caused by other species or subspecies of ''[[Treponema]]'':
*[[Yaws]] is a tropical disease characterized by an infection of the skin, bones and joints; it is caused by a spirochete bacterium, ''Treponema pallidum, sp. pertenue'', also called ''Treponema pertenue''
*[[Pinta (disease)|Pinta]] - caused by ''Treponema carateum''
*[[Bejel]] - caused by ''Treponema endemicum''
==Treatment==
[[Image:Syphilis-poster-wpa-cure.jpg|thumb|175px|Depression-era U.S. poster advocating early syphilis treatment]][[Image:400Behandlung der Syphilis.jpg|thumb|175px|Application of mercury.]]
===Prevention===
While abstinence from any sexual activity is very effective at helping prevent syphilis, it should be noted that ''T. pallidum'' readily crosses intact [[mucosa]] and cut skin, including areas not covered by a condom. Proper and consistent use of a [[latex]] [[condom]] is effective against the spread of syphilis through sexual contact.[http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm#protect]
Individuals sexually exposed to a person with primary, secondary, or early latent syphilis within 90 days preceding the diagnosis should be assumed to be infected and treated for syphilis, even if they are currently [[seronegative]]. If the exposure was more than 90 days before the diagnosis, presumptive treatment is recommended if serologic testing is not immediately available or if follow-up is uncertain. Patients with syphilis of unknown duration and nontreponemal serologic titers ≥1:32 may be considered as having early syphilis for purposes of partner notification and presumptive treatment of sex partners. Long-term sex partners of patients with late syphilis should be evaluated clinically and serologically and treated appropriately. All patients with syphilis should be tested for HIV. Patient education is important as well.
===History of treatments===
There were originally no effective treatments for syphilis. The Spanish priest [[Francisco Delicado]] wrote ''[[El modo de adoperare el legno de India]]'' (Rome, 1525) about the use of ''[[Guaiacum]]'' in the treatment of syphilis. He himself suffered from syphilis. Another common remedy was [[mercury (element)|mercury]]: the use of which gave rise to the saying "A night in the arms of [[Venus (goddess)|Venus]] leads to a lifetime on [[Mercury (god)|Mercury]]".<ref>{{cite news |author=Hanlon M |title=The magical properties of Mercury, the metal the EU wants to ban |date=7 June 2007 |publisher=The Daily Mail |url=http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=460406&in_page_id=1770 |accessdate=2007-08-07}}</ref> It was administered multiple ways including by mouth and by rubbing it on the skin. One of the more curious methods was fumigation, in which the patient was placed in a closed box with his head sticking out. Mercury was placed in the box and a fire was started under the box which caused the mercury to vaporize. It was a grueling process for the patient and the least effective for delivering mercury to the body.
As the disease became better understood, more effective treatments were found. The first antibiotic to be used for treating disease was the [[arsenic]]-containing drug [[Arsphenamine|Salvarsan]], developed in 1908 by [[Sahachiro Hata]] while working in the laboratory of [[Nobel prize]] winner [[Paul Ehrlich]]. This was later modified into [[Neosalvarsan]]. Unfortunately, these drugs were not 100% effective, especially in late disease. It had been observed that some who develop high fevers could be cured of syphilis. Thus, for a brief time [[malaria]] was used as treatment for tertiary syphilis because it produced prolonged and high fevers. This was considered an acceptable risk because the malaria could later be treated with [[quinine]] which was available at that time. This discovery was championed by [[Julius Wagner-Jauregg]], who won the 1927 [[Nobel Prize for Medicine]] for his work in this area. Malaria as a treatment for syphilis was usually reserved for late disease, especially neurosyphilis, and then followed by either Salvarsan or Neosalvarsan as adjuvant therapy. These treatments were finally rendered obsolete by the discovery of [[penicillin]], and its widespread [[manufacture]] after [[World War II]] allowed syphilis to be effectively and reliably cured.<ref name=Brown>{{cite book | author=Brown, Kevin| date=2006 | title=The Pox: The Life and Near Death of a Very Social Disease | location=Stroud | publisher=WSutton | pages=85-111, 185-91}}</ref>
===Current treatment===
The first-choice treatment for all manifestations of syphilis remains [[penicillin]] in the form of [[Penicillin#Benzylpenicillin .28penicillin G.29|penicillin G]].<ref name=CDC>{{cite journal | author=Centers for Disease Control | title=Sexually Transmitted Diseases Treatment Guidelines, 2006 | journal=MMWR | volume=55 | date=08-04-2006 | issue=RR-11 | pages=24–32}}</ref> The effect of penicillin on syphilis was widely known before randomized clinical trials were used; as a result, treatment with penicillin is largely based on case series, expert opinion, and years of clinical experience. [[Parenteral]] penicillin G is the only therapy with documented effect during pregnancy. For early syphilis, one dose of penicillin is sufficient.
Non-pregnant individuals who have severe allergic reactions to penicillin (e.g., [[anaphylaxis]]) may be effectively treated with oral [[tetracycline]] or [[doxycycline]] although data to support this is limited. [[Ceftriaxone]] may be considered as an alternative therapy, although the optimal dose is not yet defined. However, cross-reactions in penicillin-allergic patients with [[cephalosporin]]s such as ceftriaxone are possible. [[Azithromycin]] was suggested as an alternative. However, there have been reports of treatment failure due to resistance in some areas.<ref name=Azith>{{cite journal |author=Lukehart SA, Godornes C, Molini BJ, ''et al'' |title=Macrolide resistance in Treponema pallidum in the United States and Ireland |journal=N. Engl. J. Med. |volume=351 |issue=2 |pages=154–8 |year=2004 |month=July |pmid=15247355 |doi=10.1056/NEJMoa040216 |url=}}</ref> If compliance and follow-up cannot be ensured, the [[Centers for Disease Control and Prevention|CDC]] recommends [[Desensitization (medicine)|desensitization]] with penicillin followed by penicillin treatment. All pregnant women with syphilis should be desensitized and treated with penicillin. Follow-up includes clinical evaluation at 1 to 2 weeks followed by clinical and serologic evaluation at 3, 6, 9, 12, and 24 months after treatment.
Azithromycin has been used to treat syphilis in the past because of easy once-only dosing. However, in one study in San Francisco, azithromycin-resistance rates in syphilis, which were 0% in 2000, were 56% by 2004.<ref name="pmid16392078">{{cite journal |author=Mitchell SJ, Engelman J, Kent CK, Lukehart SA, Godornes C, Klausner JD |title=Azithromycin-resistant syphilis infection: San Francisco, California, 2000-2004 |journal=Clin. Infect. Dis. |volume=42 |issue=3 |pages=337–45 |year=2006 |month=February |pmid=16392078 |doi=10.1086/498899 |url=}}</ref>
====Late latent and infections of unknown duration====
Late latent syphilis is defined as latency for greater than one year. If CSF examination yields no evidence of neurosyphilis, then penicillin G is recommended as weekly doses for 3 weeks. If allergic, then tetracycline or doxycycline may also be used for this stage, but for 28 days instead of the normal 14. As with before, the data to support use of tetracycline and ceftriaxone are limited.
====Treatment of neurosyphilis====
For patients diagnosed with neurosyphilis including ocular or auditory syphilis with or without positive CSF results, aqueous crystalline penicillin G is the treatment of choice. The recommended regimen is intravenous treatment every 4 hours or continuously for 10-14 days. If intravenous administration is not possible, then [[Penicillin#Procaine benzylpenicillin|procaine penicillin]] is an alternative (administered daily with [[probenecid]] for two weeks). Procaine injections are painful, however, and patient compliance may be difficult to ensure. To approximate the 21-day course of therapy for late latent disease and to address concerns about slowly dividing treponemes, most experts now recommend 3 weekly doses of benzathine penicillin G after the completion of a 14-day course of aqueous crystalline or aqueous procaine penicillin G for neurosyphilis. No oral antibiotic alternatives are recommended for the treatment of neurosyphilis. The only alternative that has been studied and shown to be effective is intramuscular [[ceftriaxone]] daily for 14 days. Neurosyphilis dementia is also a psychiatric diagnosis where as a multitude of atypical anti-psychotic medications are used to help control the patient's irrational behaviors with limited success.
Also used in traditional classification of Organic Disorders in the brain. Also commonly called Brain Syphilis.
====Alternative regimens====
Alternative regimens such as tetracyclines are not well studied in HIV infection and a careful follow-up is recommended. Tetra-cyclines are contraindicated in pregnancy.
HIV-infected patients with early syphilis may have a higher risk of neurological complications and a higher rate of treatment failure with currently recommended regimens. The magnitude of these risks, however, although not precisely defined, is probably small. Skin testing or desensitization is recommended in latent syphilis and neurosyphilis in other patients with HIV infection.
===Jarisch-Herxheimer reaction===
Before administering any treatment, clinicians should warn all patients about the possibility of a [[Jarisch-Herxheimer reaction]], which occurs most often in secondary syphilis and with penicillin therapy, and may be more common in HIV-infected patients.<ref name="pmid9235493">{{cite journal |author=Rolfs RT, Joesoef MR, Hendershot EF, ''et al'' |title=A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group |journal=N. Engl. J. Med. |volume=337 |issue=5 |pages=307–14 |year=1997 |month=July |pmid=9235493 |doi= 10.1056/NEJM199707313370504 |url=http://content.nejm.org/cgi/content/full/337/5/307}}</ref> This reaction is characterized by fever, fatigue, and transient worsening of any mucocutaneous symptoms, and usually subsides within 24 hours. These symptoms can be alleviated with [[acetaminophen]] (paracetamol) and should not be mistaken for drug allergy. In addition, clinicians should inform HIV-infected patients that currently recommended regimens may be less effective for them than for patients without HIV infection and that close serologic follow-up is therefore essential.
===Tuskegee syphilis study===
{{main|Tuskegee Study of Untreated Syphilis in the Negro Male}}
One of the best-documented cases of [[medical ethics|unethical human medical experimentation]] in the twentieth century was the [[Tuskegee syphilis study]]. The study took place in [[Tuskegee, Alabama]] and was supported by the [[Tuskegee Institute]] and the [[U.S. Public Health Service]] (PHS).<ref>{{cite web |url=http://www.pbs.org/wnet/aaworld/reference/articles/tuskegee_syphilis_study.html |title=A A World. Reference Room. Articles. Tuskegee Syphilis Study | PBS |accessdate=2007-08-07 |format= |work=}}</ref>
The study began in 1932 using a group of 600 black [[sharecropping|sharecropper]]s. Of these 600, 399 of the men had the disease and 201 were uninfected control patients. The PHS stated at first that treatment was supposed to be a part of the study, but they were unable to produce any useful data. It was then discovered that the PHS had decided to leave the men untreated and follow the course of the disease to these men's eventual deaths. They thought they were receiving experimental treatment for "bad blood" in exchange for free meals and a $50 death benefit. However, the study was designed to measure the progression of untreated syphilis and to determine whether syphilis caused [[cardiovascular]] damage more often than neurological damage, and to determine if the natural course of the disease was different in black men versus white men. By 1947 penicillin had become the standard treatment of syphilis. The men were never advised that they had syphilis, nor were they offered a treatment including [[Salvarsan]] or the other arsenical drugs that were in use at the beginning of the study.
The original study was meant to last six to nine months, but continued for 40 years, ending in 1972, long after forty wives and nineteen children had been infected, and many of the men had died of syphilis. Twenty-eight men died directly from syphilis, and one hundred from other complications, during the study. The study ended because of a story printed in the ''[[Washington Star]]''. A class-action lawsuit was then filed against the federal government for the study. This lawsuit was settled out of court and the living subjects and their descendants were awarded a total of ten million dollars. After the settlement was awarded, the government passed the [[National Research Act]], which required the government to review and approve all medical studies involving human subjects.
== Syphilis in art and literature ==
{{Cleanup-rewrite|List of trivia rather than an overview|section|date=May 2007}}
===Art===
The artist [[Kees van Dongen]] produced a series of illustrations for the [[anarchism|anarchist]] publication ''[[L'Assiette au Beurre]]'' showing the descent of a young prostitute from poverty to her death from syphilis as a criticism of the social order at the end of the 19th century.
The artist [[Jan van der Straet]], also known as ''Johannes Stradanus'' or simply '''Stradanus''', painted a scene of a wealthy man receiving treatment of syphilis with the tropical wood ''[[guaiacum]]'' sometime around 1580.<ref name="JH">[http://www.york.ac.uk/crems/downloads/MA%20Description%20May%2006/Nova%20Reperta%20description.html Johannes Stradanus] undated brief review of works hosted at the [[University of York]] in the [[United Kingdom]]. Accessed [[August 6]], [[2007]].</ref> The title of the work is "Preparation and Use of Guayaco for Treating Syphilis." That the artist chose to include this image in a series of works celebrating the New World indicates how important a "cure" (however ineffective) for syphilis was to the European elite at that time. The richly colored and detailed work depicts four servants preparing the concoction while a physician looks on, hiding something behind his back while the hapless patient drinks.<ref name="ALLPOSTERS">[http://www.allposters.com/-sp/Preparation-and-Use-of-Guayaco-for-Treating-Syphilis-Posters_i1587366_.htm Jan van der Straet's "Preparation..."] at commercial art site. Accessed [[August 6]], [[2007]].</ref>
The Norwegian, Edvard Munch painted "The sins of the father", a portrayal of a horrified woman with her baby, covered in a rash and with a deformed face lying on a cloth across her knees. This was to portray congenital syphilis, presumably common at the time.
===Classic and antique literature===
Delicado also featured the effects of syphilis in his ''[[Portrait of Lozana: The Lusty Andalusian Woman]]'' (1528).
There are references to syphilis in [[William Shakespeare]]'s [[Play (theatre)|play]] ''[[Measure for Measure]],'' particularly in a number of early passages spoken by the character Lucio. For example, Lucio says "[...] thy bones are hollow"; this is a reference to the brittleness of bones engendered by the use of [[mercury (element)|mercury]] which was then widely used to treat syphilis.
In Shakespeare's play ''[[Othello]]'', the clown at the beginning of Act III makes jest of Cassio, who is leading a musician troupe for Othello, by asking him if he had just arrived from [[Naples]] and playing with his nose. (Alluding to the reputation of Naples of being a likely place to contract syphilis, which eats away at the bridge of the nose.)
It has been suggested that the main character in Edgar Allan Poe's "The Tell-Tale Heart" may have been infected with neurosyphilis, due to his strange obsessions and apparent insanity.{{fact|date=March 2008}}
[[Francisco de Quevedo]] puns in his ''[[Buscón]]''<ref name="Buscón">[[:wikisource:es:Historia de la vida del Buscón: Libro Primero: Capítulo III]]: continues with ''[...] porque se le había comido de unas búas de resfriado, que aun no fueron de vicio porque cuestan dinero;'': "[...] because it had been eaten by the [[bubon]]s of a cold, which were not of vice because they cost money;".</ref> about a nose ''entre Roma y Francia'' meaning both "between Rome and France" and "between dull and eaten by the French illness".
[[Jonathan Swift]]'s poetry mentions syphilis as a condition of [[prostitution]] which reaches the highest ranks of society. See, for example, "A Beautiful Young Nymph Going To Bed" and "The Progress of Beauty".
[[Image:Hogarth-Harlot-5.png|thumb|Moll dies of syphillis, Hogarth's ''A Harlot's Progress''.]]
[[William Hogarth]]'s works frequently show his subject's infection with syphilis. Two examples are [[A Harlot's Progress]] and [[Marriage à-la-mode]]. In both instances it is used to indicate the moral profligacy of the infected.
Some critics have argued that the character of Edward Rochester's first wife, Bertha, in [[Charlotte Brontë]]'s novel ''[[Jane Eyre]]'', suffers from the advanced stages of syphilitic infection, general paresis of the insane, and point to corroborative evidence within the text to substantiate this view.
The novel ''[[Candide]]'' by [[Voltaire]] describes Candide's mentor and teacher, [[Pangloss]], as having contracted syphilis from a maidservant he slept with; the syphilis has ravaged and deformed his body. Pangloss explains to Candide that syphilis is 'necessary in the best of worlds' because the line of infection - which he explains - leads back to [[Christopher Columbus]]. If Columbus had not sailed to America and brought back syphilis, Pangloss states, the Europeans would not have been able to enjoy 'New World wonders' such as chocolate. (One of the purposes of the novel was to [[satire|satirize]] [[Gottfried Leibniz|Leibniz]]'s philosophy as Pangloss's disingenuous rose-tinted viewpoint.) Pangloss eventually loses an eye and an ear to the syphilis before he is cured.
Also, in Charles Dickens' novel ''[[Tale of Two Cities]]'', references are made that allude to the main character, [[Sydney Carton]], having syphilis.
In [[Eça de Queiroz]]'s novel written in 1870, "[[The Mystery of the Sintra Road]]", some of the characters have syphilis, and it plays an important role in the plot of a recent movie adaptation.<ref>{{cite web |url=http://www.filmesfundo.com/omisteriodaestradadesintra |title=O Mist�rio da Estrada de Sintra |accessdate=2007-08-07 |format= |work=}}</ref>
[[Henrik Ibsen]]'s once-controversial play ''[[Ghosts (play)|Ghosts]]'' has a young man who is suffering from a mysterious unnamed disease. Though it is never named, the events of the play make it plain that this is syphilis, an inheritance from his dissolute father. However, the young man's mother remains unaffected - this is because it is possible for a woman to carry syphillis and transmit it to her child in the womb without exhibiting any noticeable symptoms. Dr. Rank in Ibsen's play ''[[A Doll's House]]'' also has inherited syphilis.
===Modern literature===
Unnamed American medical students described syphilis in a series of early 20th-century American limericks, using medical terminology to ghastly comic effect in the ''[[Journal of the American Medical Association]]'' January 1942.<ref>http://www.ucolick.org/~randi/aecom/syphilis.txt</ref>
[[Thomas Disch]] in his novel ''[[Camp Concentration]]'' describe a fictional strain of syphilis that enhances intelligence but is lethal.
In [[Thomas Mann]]'s novel ''[[Doktor Faustus]]'', the Faust character, Adrian Leverkühn, acquires his genius for musical composition from the neurological effects of syphilis.
In [[Dick Francis]]' novel, ''Bonecrack'' the character Enso Rivera is suffering from [[megalomania]] caused by syphilis.
[[Neal Stephenson|Neal Stephenson's]] trilogy ''[[The Baroque Cycle]]'' has multiple characters and historical figures who have syphilis, most notably [[James II of England]] and [[Jack Shaftoe]]; the latter is cured of the disease by running a high fever.
In [[Leonard Cohen]]'s second novel [[Beautiful Losers]], the character F. is described in detail as having the terminal stages of syphilis.
In [[Christina Garcia]]'s novel "Dreaming in Cuban," Felica contracts syphilis from her unfaithful husband. The syphilis and her family history lead Felica down a path towards insanity.
In [[Ken Follett]]'s novel "A Dangerous Fortune," the wealthy Edward Pilaster contracts syphilis from his frequency of using brothels. When Edward's cohort Micky Miranda finds out, it looks as though his diabolical plans may have a snag.
In [[Josilyn Jackson]]'s novel "[[Between, Georgia]]", the protagonist Nonny Frett suffers from syphilis from a cheating husband she can't seem to rid herself of.
===Film, Television and Stage===
Syphilis is used as a plot device in many dramatic films, television shows, and plays. While some, such as the [[Warner Brothers]] film ''[[The Magic Bullet|Dr. Ehrlich's Magic Bullet]]'' (1940), focus on the history of the disease, most involve late-stage syphilis because the neurological damage common to late-stage syphilis provides an excuse for strange behaviors. In recent years, syphilis has been mentioned on ''[[Grey's Anatomy]]'', ''[[House M.D.]]'', ''[[Law & Order: SVU]]'', ''[[Buffy the Vampire Slayer (TV series)|Buffy the Vampire Slayer]]'', ''[[Angel (TV series)|Angel]]'', and other television shows. A few particularly notable appearances include:
* ''[[Miss Evers' Boys]]'' is a 1992 stage play written by Dr. David Feldshuh based on the true story of the decades-long Tuskegee syphillis experiment. The play was subsequently adapted into a 1997 [[HBO]] [[Miss Evers' Boys|TV movie]] directed by [[Joseph Sargent]] and starring [[Alfre Woodard]] and [[Laurence Fishburne]]. The film was nominated for eleven [[Emmy Awards]] and won in four categories, including Outstanding Made for Television Movie.
* In Japanese director [[Akira Kurosawa]]'s film ''[[The Quiet Duel]]'' (1949), [[Toshirô Mifune]] plays a doctor who gets infected with syphilis while operating on a soldier.
* In big budget Spanish film ''[[Alatriste]]'', the main character finds the love of his life, actress María de Castro, dying in a hospital for syphilitics. It is implied that she caught the disease from an affair with [[Philip IV of Spain]].
* In the [[Masterpiece Theatre]] version of [[Bram Stoker]]'s ''[[Dracula]]'', Arthur Holmwood, whose father dies of syphilitic insanity, enlists the services of Count Dracula in hopes of curing his congenital syphilis.
* In ''[[The Libertine]]'', a 2004 film with Johnny Depp, the main character [[John Wilmot]], second Earl of Rochester, is portrayed as having died of syphilis.
===Historical studies===
''Amalia's Tale'', published in 2008, is a study by [[David I. Kertzer]] about a poor peasant woman, Amalia Bagnacavalli, in the Italy of the 1890s. She was believed to have contracted syphilis from an infant child of a foundling hospital after serving as a wet-nurse for the baby. The book explores the story of a long court case and her lawyer Augusto Barbieri's untiring pursuit of compensation from that hospital on behalf of his client.
==See also==
* [[Tuberculosis]] ([[TB]])
* [[Diphtheria]]
* [[Side-chain theory]]
* [[Paul Ehrlich]]
* [[Felix Milgrom]]
* [[Hideyo Noguchi Africa Prize]] – May 2008
* [[Treponema pallidum]]
==References==
{{Reflist|2}}
==External links==
{{commonscat|Syphilis}}
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*[http://www.cdc.gov/std/Syphilis/STDFact-Syphilis.htm "Syphilis fact sheet" from the Center for Disease Control]
*[http://hivinsite.ucsf.edu/InSite?page=kb-05-01-04 UCSF HIV InSite Knowledge Base Chapter: Syphilis and HIV]
*[http://digilander.libero.it/camdic/Syphilis.htm "History of Syphilis" 14th Congress of the European Academy of Dermatology and Venereology] (2005 "video" with no text for hearing-impaired people)
*[http://colman.net/eadv/index.html "A New Gold Standard For Syphilis?" Poster Presentation for European Academy of Dermatology and Venereology 2004 Spring Symposium]
*[http://medinfo.ufl.edu/other/histmed/clancy/ Kipkeepers, Pox and Gleet Vendors: A Rapid History of Syphilis]
*[http://www.pbs.org/wnet/secrets/case_syphilis/index.html Secrets of the Dead (PBS): The Syphilis Enigma]
*[http://www.cbc.ca/ideas/Aids Syphilis and AIDS: Lessons from history]
*[http://www.nobel.se/medicine/laureates/1927/wagner-jauregg-lecture.html The treatment of dementia paralytica by malaria inoculation (A Nobel Prize lecture, [[December 13]], [[1927]])]
*[http://uk.reuters.com/article/oddlyEnoughNews/idUKN1443055520080115 New study blames Columbus for syphilis spread] [[Reuters]] [[January 15]] [[2008]]
*[http://www.nytimes.com/2008/04/29/health/29essa.html? Origins of Syphilis] [[NYTimes]] [[April 29]] [[2008]]
{{STD/STI}}
{{Spirochetal diseases}}
[[Category:Bacterial diseases]]
[[Category:Sexually transmitted diseases and infections]]
[[Category:Spirochaetes]]
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[[vi:Giang mai]]
[[tr:Frengi]]
[[uk:Сифіліс]]
[[zh:梅毒]]