Syphilis is forever linked in my mind with Elizabethan times. It may even be responsible for them, as Henry the Eight was allegedly infected. Syphilis may have been responsible for the high incidence of miscarriage seen in his first wife, leading to his divorce, the creation of the Church of England and his infamous marriage to Anne Boylan. As the new world opened up to explorers and spread the diseases of medieval Europe across two continents, one disease moved the other way.

Making A Comeback

Treponema pallidum, a spiral shaped bacteria that under the microscope almost looks cute as it corkscrews its way across the slide. The symptoms, however, are terrible. In the year 2000 it looked as if it was on its way out, reaching the lowest incidence in the USA since reporting began in 1941. Since then however the disease has made a comeback, doubling in incidence between 2005 and 2013. Control has been less successful in the developing world with an estimated 12 million new cases in 1999 and notable recent outbreaks in Russian and China.

Symptoms

Syphilis is a disease for the long term and has three distinct stages. The first stage (primary syphilis) consists of highly infectious skin lesions. These commonly occur on or around the genitals or mouth but can appear on any part of the body. The sores usually last about 3 weeks but can be present for as long as 90 days. They are painless, sometimes go unnoticed by the patient and will resolve even without treatment.

If untreated, however, secondary syphilis may occur one to six months later with a rash around the groin and commonly on the palm of the hand. The rash is often described as a rosy “copper penny” rash and is easily identifiable as syphilis, but can occur as a nondescript rash that may be misdiagnosed. Other symptoms include possible warts around the genitals, sores in the mouth, fever and weight loss. Like primary syphilis, secondary syphilis will appear to resolve without treatment within a few months.

The bacteria can then lay dormant in your system for years, a period known as latent syphilis without causing any symptoms.

The Final Stages

Tertiary syphilis is the reason that Treponema pallidum should be feared. Following the latent period, the bacteria can then re-emerge to cause systemic disease, infecting essential organs such as the heart, nervous system and brain. Symptoms can include heart disease, blindness, deafness, arthritis and brain damage leading to dementia. If untreated the disease will eventually prove fatal.

Treatment

Treatment with penicillin once proved exceptionally effective and resulted in almost wiping out the disease. In most cases the bacteria are still highly susceptible to a single dose of intramuscular Penicillin, but there has been a rise in macrolide (erythromycin), tetracycline and rifampicin resistance in Treponema pallidum making treatment of penicillin-sensitive people difficult. Even with treatment if the syphilis bacteria have invaded the cerebral spinal area (brain and spinal column) many antibiotics struggle to reach this area and may not reach levels fatal to the bacteria. Relapse can occur and patients should be monitored following treatment.

What To Do

People diagnosed with syphilis will need to notify sexual partners. Condoms provide limited protection against the spread of syphilis as sores are often not covered so anyone with Syphilis must abstain from sex while sores are present to prevent infecting others. Incidence in of syphilis in Singapore is low compared to most countries but care should always be taken. Remember the best protection against any STD is abstinence or to be in a monogamous relationship where both partners are known to be STD free.

“We have received feedback from those with close links to HIV/AIDS patients, that some HIV positive persons deliberately spread the disease as a form of revenge on society.” Dr Balaji Sadasivan, Senior Minister of State for Information, Communications and The Arts, and Health, 4^th Singapore AIDS conference 2004.

You would think that being diagnosed with a horrible disease that your instinct would be to protect other people from the same fate. So often you see people who are affected with a devastating disease or who have lost a family member to that disease, supporting campaigns to find a cure, or educate others to avoid it. But with AIDS we see a nastier side to humanity, those who feel cheated by life, used by those who infected them. Who either ignore the risk to others or continue with their promiscuous lifestyle uncaring of who they infect, or worse, who deliberately infect others in order to get their own back, or share their pain.

If cancer was infectious would we see the same pattern, cancer patients infecting others to share the misery or is it to do with the social stigma? If AIDS was not linked to prostitution and homosexuality would we see the same reaction? Is it a person already stigmatised for their lifestyle lashing out at the world for this new indignity?

Then there is a new trend in the USA known as bug seeking, where young homeless men are intentionally contracting the disease in order to receive assistance from the state.

Gaétan Dugas, a Canadian flight attendant is rightly or wrongly credited with spreading the HIV virus through the gay community of the USA, at a rate estimated at 250 partners a year and linking the AIDS epidemic in the USA forever with homosexuality. Sources vary as to whether Gaétan spread the virus knowingly or not.

Hans-Otto Schiemann, a German man living in Thailand, allegedly offered young women large sums of money to sleep with him despite being HIV positive. According to The Age (October 13, 2004) between 400-500 girls were at risk of infection from his actions from when he was first diagnosed in 2001 to being jailed in 2004.

David Mannum in the USA was jailed in 2013 for deliberately infecting up to 300 people. According to CBS New (September 5, 2013) he did not disclose his HIV status due to fear of rejection.

It is not just men, German pop star Nadja Benaissa was convicted in 2010 of infecting her partner with HIV. English hairdresser Sarah Jane Porter was jailed in 2006 for having unprotected sex with multiple partners following her HIV diagnosis. While it is harder for men to contract the virus than women during sexual intercourse it is still a high risk to take.

Few cases however get darker than that reported in the New York Times (January 9, 1999) of Brian Stewart, who in 1992 infected his 11 month old son with contaminated blood when the boy was recovering in hospital following an asthma attack. The reason behind the attack was that he did not want to pay child support. In 1999 he was sentenced to life in prison.

Rumours abound of men and women who recklessly and deliberately spread the HIV to multiple partners, but the cases of HIV sociopaths are rare. More often they are terrified and unable to face the truth about their condition. They do not tell others for fear of being rejected. Unfortunately, it is not a problem that goes away if ignored and many people can be hurt from non-disclosure.

In some countries, it is against the law to transmit the disease to another once you know you are HIV positive. Other countries use existing laws to prosecute those who deliberately infect others. In Singapore, the law is very clear. “It is an offence for persons who know that they are infected with HIV not to inform their sex partners of their HIV status before sexual intercourse,” under the Infectious Disease Act. There have been no cases of large-scale deliberate infections with HIV in Singapore. The first conviction under the act was in 2008 and since then there have been two more. None passed the disease to more than two people.

Most people are honest and will do the right things. Those who are out to deliberately infect people are looking for the act themselves. Beware one night stands. Get to know the person before you get into bed and ask the hard questions. Not asking can be much harder in the end.

If you are HIV positive or suspect you may be, please consult your healthcare professional. There is support available. If you suspect you have been deliberately infected, consult your doctor and mention that it may have been deliberate, they will be able to give you support in approaching law enforcement agencies.

We live in troubled times, medically speaking. The antibiotics that seemed so close to conquering the world of bacterial disease are failing. There is a very real possibility of a gonococcal superbug, resistant to all forms of antibiotic. As early as 2012 Dr. Gail Bolan, director of the Division of STD Prevention at the CDC advised that “Untreatable gonorrhea is a real possibility” and this is not the only STD that is powering its way through genetic mutation to apparent invincibility.

The post-antibiotic age is fraught with uncertainty, but things could be worse. We have a scientific powerhouse to fall back on, with a solution more likely than not. But what was it like to live in pre-antibiotic times?

Gonorrhea, herpes and genital warts are mentioned in historical documents going back to Ancient Egypt and Ancient Greece. There is a plethora of social and medical solutions to the sexually transmitted poxes that followed armies across the ancient world.

Have cankers or warts on the genitals? No problem for a Greek surgeon. The obvious solution is to cut them off. Anaesthetic? Not really but here is some hemlock that might dull the pain, possibly permanently.

Herpes on the rise in your city? A ban on kissing is an easy, if unpopular, solution. Even less popular I suspect was the cure for  lesions. Application of a red-hot poker will solve that problem.

The clap cutting a swath through the population? The English have the solution. Yes, youth clubs for the peasantry. Get the young men out rowing, bell ringing, playing at archery or learning to swim is sure to “distract them from moral carelessness.” Should you be unfortunate enough to contract it, a urinary blockage is easily cleared by insertion of a metal catheter into the urethra.

Syphilis introduced by sailors from the new world was so feared that the French King banished suffers from the city. King Henry VIII of England ordered an immediate, and as it turned out temporary, closure of brothels in London and a ban on mixed-sex bathing. But a cure was on its way, fresh from the Islamic scholars. The miraculous cure of mercury injected into the infected urethra or vagina. Sure to prevent the progression to tertiary syphilis with its accompanying lesions and madness (side effects may cause lesions and madness). If mercury failed, why not add lead to the heavy metal treatment with a lead infusion in almond oil?

If the problem persists, bloodletting was commonly used as well as arsenic, more mercury (ingested this time), and when all else fails, a prayer to the god(s) will most definitely work (most effective when combined with a generous donation to your local monastery).

Can’t perform in the bedroom? No Viagra as yet, but why not try the new craze on the block. Yes, it is the early 1800s and a new age has dawned. Lightning has been tamed and for a one-time special offer you can purchase an electrifying belt, sure to give you a jolt in just the right place. Warning: electrification may result in burns or death (no refund).

Mercury injection was a common treatment for syphilis up until the late 1800s despite its hideous side effects, in the absence of a better treatment. It was gradually replaced by silver nitrate, potassium iodine and into the 1900s with the sulphonamides and penicillin in 1943.

So not matter the outcome of any test. No matter the tedious instructions to take with food, or before eating, after eating, at night, one 5^th of a tablet five times a day, the threat of an intramuscular injection or even a suppository. Give a small prayer of thanks that you will never see the words injection of mercury solution or application of heated iron on the doctor’s prescription pad.

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SEXUALLY TRANSMITTED DISEASES: AN HISTORICAL RETROSPECT by Brian Plumb

There was a time, when lice were so much a part of daily life that a good infestation was considered a sign of good health. Bill Bryon in his masterpiece of domestic history “At Home” tells of people forming this idea due to body lice fleeing the heat of a feverish body and poets imagining a lecherous louse crawling on the body of a beautiful woman and reaching places they could not. In modern times, the increase in hygiene has removed lice as a daily infestation. Most of us will have a passing experience with head lice as a child (or a parent) but few with think of checking for pubic lice.

Lice are small insects, the pubic lice are a different genus and smaller size than the body or hair lice we are more familiar with. There are three stages in the life cycle of a louse, nits (eggs) which show as white dots on the hair, three stages of nymphs and the adult louse or crab.

Pubic lice are human specific and cannot live more than 24hrs off the body. The nymph and louse both feed solely on human blood and cause bites that vary from 0.2 to 3 mm initially red turning to blue spots. The bites and droppings of the louse can cause itching and irritation that tends to be worse at night.

Pubic lice show a preference for secondary sexual hair. They will not live on head hair or other body hair, but, as well as pubic hair, they will happily dwell in armpit hair, coarser leg hair and, disturbingly, moustaches or beards and, in very rare cases, the eyelashes.

Infestations are most commonly seen in teenagers and are spread mostly via sexual contact. They can be spread by sharing clothing or sheets but this is not a common form of transmission due to their short life span once off the body. They do not adhere to toilet seats and cannot be passed by use of public facilities. It is thought that about 2% of the global population is infected, though many scholars believe that the popularity of the Brazilian wax may be causing a reduction in lice populations.

Unlike body lice, pubic lice have not been known to carry dangerous bacteria in their stomachs. Long-term infection can result chronic dermatitis and scratching can cause a secondary infection through broken skin.

Treatment involves washing with special body wash and using a nit comb to remove any remaining nits. Clothing and bedding should be treated with a hot wash of clothing. Family members and sexual partners should be advised to get themselves checked. Infection with lice often occurs in conjunction with other STD infection so it is a good idea to get tested for the most common STDs if crabs are seen.