This resource presents an overview of syphilis and its treatments through history to provide necessary background information for The Least of My Brothers. Sources are listed at the bottom of this file. Close this window when you are ready to return to the scenario.
The origins of syphilis have been a subject of much contentious debate. Some scientists suggest that syphilis and the microorganism that causes it – Treponema pallidum – came into being in the Old World. Others argue that its beginnings were in the New World. A few maintain that syphilis emerged in the Old World and the New World independently. Whatever the case, syphilis has been with humankind for hundreds – and probably thousands – of years and has shaped western medicine in substantial ways ("The History of Syphilis and Its Treatment").
Syphilis is caused by an organism called Treponema pallidum, which is a type of bacterium called a spirochete.
Syphilis is characterized by three stages: primary syphilis, secondary syphilis, and tertiary syphilis. Syphilitics often experience a period of latency, in which no symptoms are visible. Syphilis is usually transmitted though sexual intercourse but can also be transmitted from mother to child in utero, a condition known as congenital syphilis.
Mercury, applied as an ointment to syphilitic lesions, is the earliest known chemical treatment for syphilis. As early as the late-fifteenth century, mercury was administered both topically and orally, and remained the treatment of choice for more than three centuries.
In the mid-nineteenth century, mercury was still widely used by trained physicians. At the same time, entrepreneurial "doctors" distributed misinformation about syphilis and marketed fantastic remedies for the disease. For example, in 1858 William Earl claimed that treatment with mercury could be supplanted by his "new" method: an "ANTI DETERSIVE ESSENCE" that effected "a complete and radical cure" without the use of "deleterious drugs or chemicals" (129). Such fantastic claims went unchallenged in part because in Victorian society, attitudes toward sexuality and the human body precluded open discussion of venereal disease.
Not every remedy that came out of the nineteenth century was fantastic. The development and use of potassium iodide was an important advancement in the treatment of syphilis-first, because it was effective even in the late stages of the disease (mercury was not), and second, because it paved the way for the discovery of an even more potent and effective treatment ("The History of Syphilis and Its Treatment").
Salvarsan
In 1908, scientist Paul Ehrlich began attempts to cure "sleeping sickness" by isolating an arsenic compound that would work selectively on the bacteria that caused it-that is, would destroy the bacteria without destroying the host. He experimented with hundreds of different arsenic compounds. In 1909 Ehrlich and his colleague, Sahachiro Hata, found that compound number 606, or arsephenamine, while it did not work to destroy the bacterium that caused sleeping sickness, did work to destroy Treponema pallidum. Ehrlich dubbed the compound salvarsan. In 1910, salvarsan was heralded as a sort of miracle cure for syphilis. However, it soon became apparent that the "magic bullet," a term which Ehrlich himself coined, was neither miraculous nor a cure. Within a year, patients thought to have been cured had relapsed. Treatments were both expensive and painful, and in some cases produced severe side effects. Physician John Stokes wrote in 1939 that treatment was "a long, slow, painful and expensive grind" (qtd. in Benedek 8).
Salvarsan (arsephenamine, Ehrlich 606) and its derivative, neosalvarsan (neoarsephenamine, Ehrlich 914) were first administered by injection: "If either injection was not entirely within the vein severe local pain resulted" (Benedek 6). Salvarsan, even when administered properly, often caused necrosis (tissue death) or thrombophlebitis (a blood clot that causes the vein to swell and become irritated; may lead to infection) at the site of injection. Because the drugs were so difficult to administer by injection, many physicians came to administer them intravenously (Benedek 6).
In 1913, Henry Pulsford M.D., a New Jersey dermatologist, recorded that injection with salvarsan or neosalvarsan was followed within six to eight hours by nausea, vomiting, abdominal pain, and diarrhea. He attributed this reaction to the toxic effects of arsenic: either too large a dose had been administered, or the patient was particularly susceptible to arsenic. Pulsford described other symptoms, such as chills, fever, headache, and "general malaise," as an anaphylactic reaction to the destruction of a large number of spirochetes (qtd. in T. Wallhauser 44). Pulsford warned that an ordinary dose of salvarsan contained more than the lethal quantity of arsenic, and that the drug had to be prepared and administered with caution in order to prevent fatalities. Henry J.F. Wallhauser M.D., another New Jersey physician, elaborated on Pulsford's conclusion: "the original claim of 'Sterilisans Magna,' or possible cure by one dose, has failed" (Wallhauser 45). He implored that salvarsan be administered like other "dangerous remedies:" by giving "small, repeated doses at varying intervals" (Wallhauser 45). Ultimately, it was established that twenty to forty injections over the course of a year were necessary to effect a cure.
In 1914, Wallhauser grouped the deaths resulting from treatment with salvarsan into two categories: degenerative and sudden. The latter category perplexed doctors. Patients would fall into a coma on the third or fourth day following injection. In one case, an apparently robust woman was treated for hand lesions. On the fifth day following injection, the woman's symptoms worsened-so much so that she required symptomatic treatment. A lumbar puncture, or spinal tap, revealed blood in the cerebral-spinal fluid. Several days later, the woman passed into a coma, and on the tenth day following injection she died. The autopsy revealed "syphilitic miliary gummata in the menninges with secondary hemorrhagic encephalitis" (45). Wallhauser drew an important conclusion from his observations: in the early stages of syphilis or in the absence of particular susceptibility to arsenic compounds, salvarsan could be given safely. However, as syphilis progressed, it damaged various tissues and organs that rendered individuals more susceptible to the toxic effects of arsenic. The woman, who had (not obviously) been suffering from neurosyphilis, was consequently highly vulnerable to the toxic effects of arsenic. "Syphilis," Wallhauser wrote, "causes the condition in which it is contraindicated" (45). That is, syphilis causes the condition that renders treatment with salvarsan improper or undesirable.
Physicians eventually discovered that treatment with salvarsan and neosalvarsan had to be supplemented by applications of mercury or bismuth ointments. According to Thomas Benedek, "the 'best treatment' of early syphilis in 1939 consisted of alternating 8- to 12-week courses of bismuth and neoarsephenamine without interruption for a total of 60 weeks" (8). Even the augmented formula did not have ideal results. Physicians eventually resigned themselves to the fact that curing syphilis was not an easy matter, although they retained their optimism that the disease would be eradicated in their lifetimes (Jones 46).
In 1928 Alexander Fleming discovered penicillin. It became widely used during World War II, owing in large part to the work of biologists Howard Florey and Ernst Chain. Florey and Chain took up Fleming's research and found a way to purify penicillin, making it safe and effective for use in humans. The United States Department of Agriculture first grew large quantities of penicillin in 1941. Shortly thereafter, in 1942, the drug was used on the battlefront to prevent and cure infections in wounded American troops (Krebs H01).
In 1945 penicillin became widely available and accepted as the treatment of choice for syphilis. Initially, however, "optimal dosage schedules had [yet] to be established" and "there was no rapid way to determine whether the long term effect of penicillin on tertiary forms of the disease would be superior to that of metallo-therapy." Optimal penicillin doses were finally standardized in 1960 (Benedek 228). After 1960 syphilis outbreaks are rare, the last occuring in Mexico, which reached epidemic proportions.
Syphilis Outbreaks
Mexican Outbreak
During the mid-1970's an outbreak of syphilis accured outside the Quintana Roo state of Mexico, about 300 miles southwest of Mexico City. The outbreak reached epidemic proportions spreading from prostitutes all the way to Mexican state officials. Although the start of the outbreak can be traced back to prostitutes, mainly from then "legal" brothels, the real epidemic began as a result of promiscuous behavior from a Mexican gang, known as "Los Barrio Rejes" or "The Barrio Kings". Although the prostitutes were the originial carriers, the barrio kings are blamed for spreading the disease from the slums to upper income areas of Mexico through their connection with local politicians. In the summer of 1976 Mexican Disease Control (MDC) officials devised a plan to identify syphilis carriers. They used a tattoo, already in use by the barrio kings, to brand known carriers. An initiation into the barrio kings gang required a branding of three burns usually on the member's hand or wrist. The burn marks were often found in the shape of a triangle, formed by three cigarette burns. At the time the meaning of the three dots, as told by the barrio kings, was "mi vida loca", which means "my crazy life" and indicates that they didn't care about anything. In Vietnamese it translates to "toi o can gi ca". MDC officials began tattooing and sometimes branding protitutes with the three dots. Mexican officials would brand the girls around the genital region, as a warning to potential "Johns" that the girl was infected. It wasn't until the outbreak subsided, in the early 1980's, that Mexican officials stopped these barbaric pratices. In March of 1984 a class action law suit was brought on by the barrio kings alleging mistreatment by the MDC in connection with the syphilis outbreak. The barrio kings alleged that MDC officials lied to the public about their culpability in spreading the disease. In October of 1986 the case ended in a not guilty verdict for the MDC. Although questions regarding the authenticity of the trial itself have been raised, headlines in Quintana Roo the day of the verdict read "Syphilis Kings Responsible for Outbreak" (translated). During the seven year span of the outbreak more than 6,750 individuals were known to have been infected. "The Syphilis Kings" outbreak is, to date, the worst syphilis outbreak in recorded history.
New York: A New Battle Ground
An increase in syphilis infections among gay and bisexual men in New York and elsewhere indicates they may be letting their guard down against sexually transmitted diseases. Syphilis infections more than doubled in New York City in the year 2001, mostly among gay and bisexual men. The increase suggests the men may be abandoning safe sex practices because life-extending AIDS-treatment drugs are more widely available. The transmission of HIV, the virus that causes AIDS, is enhanced by sexually transmitted diseases. "Increased sexual risk-taking might also be related to 'AIDS burnout,' which is associated with years of exposure to prevention messages and long-term efforts to maintain safer sex practices," the CDC said. New York had 282 cases of syphilis in 2001, up from 117 in 2000, according to city health officials. Ninety-three percent of those cases were among men; of those, 79 percent reported having male sexual partners. Outbreaks of syphilis among gay men also have been recorded in Seattle, Chicago, San Francisco and Miami since 1997, the CDC said. The increase in syphilis cases in New York follows record lows recorded in 2000.
Benedek, Thomas. "The 'Tuskegee Study' of Syphilis: Analysis of Moral versus Methodologic Aspects."In Tuskegee's Truths: Rethinking the Tuskegee Syphilis Study. Ed. Susan M. Reverby. Chapel Hill: University of North Carolina Press, 2000. 213-235.
Benedek, Thomas G. and Erlen, Jonathon. "The Scientific Environment of the Tuskegee Study of Syphilis, 1920 - 1960." Perspectives in Biology and Medicine 43:1 (Autumn 1999), 1 - 30.
Earl, William. The Illustrated Silent Friend; Being a Complete Guide to Health, Marriage, and Happiness. New York: 1858.
Jones, James H. Bad Blood: The Tuskegee Syphilis Experiment. New York: The Free Press, 1993.
Krebs, Brian. "How a Lowly Fungus Saves Human Lives." In The Washington Post. 11 March 1998. H01.
Wallhauser, Henry T. "The Introduction of "606" in New Jersey." In New Jersey Medicine: The Journal of the Medical Society of New Jersey 94:7 (Jul. 1997), 43-46.
"Ehrlich finds cure for syphilis: 1909." Science Odyssey: People and Discoveries. PBS Online. Available: http://www.pbs.org/wgbh/aso/databank/entries/dm09sy.html. Copyright 1998.
"The History of Syphilis and Its Treatment." Articles, hints, tips, and ideas. Online. Copyright 2001.
Thanks to Victoria Berdon for undertaking the research for this Resource and writing early drafts. Jennifer Flavin did additional research and edited and prepared the current version.
Indiana University and WisdomTools, Inc., have made every effort to secure the necessary permissions and provide appropriate credits for materials used in this WisdomTools ScenarioTM and the related resources. In the event any questions arise as to the use of any material, we express regret for any inadvertent error and will be pleased to make the necessary corrections.
Development of The Least of My Brothers was funded by the Poynter Center for the Study of Ethics and American Institutions, Indiana University-Bloomington, and the National Institutes of Health (Grant Number 1 T15 AI07601).
Last updated: 09 July 2002
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