Brit. 7. vener. Dis. (1974) 50, 169

Changing patterns of treponemal disease

R. R. WILLCOX*
St. Mary's Hospital, London, and King Edward VII Hospital, Windsor

It has been postulated that T. pallidum of syphilis
arose originally from free-living treponemes in mud,
of which T. zuelzerae still remains representative
(Veldkamp, 1960). These organisms then came to be
carried commensally by man, as are the dental
treponemes today. Disease syndromes then developed
as natural selection ensured the optimal survival of
mutants most likely to produce the lesions best
suited for onward transmission from host to host in
the prevailing environment (Willcox, 1972).
The three treponemes which are pathogenic to

man are T. pallidum, the cause of venereal and non-
venereal syphilis, T. pertenue of yaws, and T. carateum
of pinta, all of which have a similar morphology and
evoke so-far indistinguishable antibodies in infected
persons. In animals, T. cuniculi has evolved sep-
arately in the rabbit in which it is responsible for a
naturally occurring venereal disease (cuniculosis),
while a more recently discovered member of the
group, T. Fribourg-Blanc, has been isolated from
monkeys in yaws areas (Fribourg-Blanc, Niel, and
Mollaret, 1963).
Of the treponematoses affecting man, venereal

syphilis is ubiquitous, yaws is a disease of the
tropical belt, endemic syphilis is encountered in
adjacent dry areas, while pinta is confined to the
Central and South Americas.

Evolution of pinta

It has been postulated (Cockburn, 1961; Hackett,
1963) that pinta was the first treponematosis to
evolve within the Afro-Asian land mass, from which
it gained world-wide distribution, finally persisting
amongst underprivileged peoples in the remoter
areas of the Central Americas and the Northern part
of the South American continent-being most
prevalent today in Mexico, Colombia, Peru, Ecuador,
and Venezuela. Some i million cases of pinta were

Received for publication October 15, 1973
Presented at the II Venezuelan Congress of Dermatology, Caracas,
Venezuela, in September, 1973
*Member of the W.H.O. Expert Panel on Venereal Infections and
Treponematoses

believed to exist 20 years ago (Guthe and Willcox,
1954).
The understanding of this disease owes much to

the pioneering work of Herrejon (1938) and later of
Varela and others in Mexico (Rein, Kitchen, Marquez,
and Varela, 1952); Guimaraes, Rodriquez, Costa,
Silva, and Padilha Goncalves in Brazil; Leon Blanco
in Cuba; and Sainz in Ecuador.

In Venezuela it has been studied by Iriate, Rossi,
and others but particularly by Dr. Martin Vegas,
Honorary President of this Congress, and its Co-
ordinating Secretary, Dr. Rafael Medina. Dr.
Medina has been described (Smith and 14 others,
1971) as 'the world authority on the non-venereal
treponematoses having had more experience with
clinical yaws and pinta than virtually any other
living physician'. He has contributed much to our
knowledge of cross-immunity between the tre-
ponematoses (Medina, 1967), and with Dr. Kuhn and
colleagues in Atlanta has successfully established the
disease in the chimpanzee (Kuhn, Medina, Cohen,
and Vegas, 1970).
The lesions of pinta virtually only affect the skin

(apart from the odd juxta-articular node) although a
case with co-existing interstitial keratitis has been
described (Smith and others, 1971). It starts with
an initial lesion, and subsequently satellite or more
remote skin lesions (pintides) of various hues develop,
which may be pink, brown, blue, and black, finally
becoming white or achromic. It is spread by direct
skin contact amongst poor peoples, particularly in the
lower age groups. Half of the series of Rein and
others (1952) comprised persons below 15 years of
age.

Evolution of yaws
It has been considered that yaws evolved from pita
as a humid warm environment developed in Afro-
Asia. The new climate, resulting in much local
moisture from sweating, favoured the production of
exuberant skin lesions containing vast numbers of
treponemes such as are found in the papillomata, nd
other infective manifestations characteristic of fram-
boesia or yaws (Hackett, 1957). The surface lesions of

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170 British Journal of Venereal Diseases

yaws, like those of pinta, may remain infective for
long periods of time. The absence of clothes with
resultant liability to trauma, which facilitates the
entry of the organism, and person-to-person contact
of sweaty skins in a tropical environment, facilitated
its rapid spread amongst primitive communities and
its very contagiousness ensured that it was mainly a
disease of childhood.
Through the centuries yaws has been one of the

world's most prevalent infections, which for practical
purposes had been contained between the Tropics of
Cancer and Capricorn although with modern travel
the occasional case may be encountered in temperate
zones (Fig. 1). Before the WHO-assisted mass
campaigns were extensively mounted, it was esti-
mated that some 50 million cases existed, half of
them in Africa (Guthe and Willcox, 1954). In these
campaigns against the endemic treponematoses
organized by WHO in 46 countries, the prodigious
total of 160 million people has been examined and
50 million treated with penicillin as clinical cases of
yaws or endemic syphilis, or as latent cases or
contacts (Guthe, Ridet, Vorst, D'Costa, and Grab,
1972). The incidence of the disease has been reduced
to extremely low levels in many areas (e.g. from
2-95 to 0 005 per cent. of clinically active cases in
Western Samoa), although continued seroreactivity to
tests with treponemal antigens has suggested that the
disease continues to be transmitted in the community,
possibly at a subclinical level. It is stated that early
infectious cases are now virtually eliminated from
Venezuela.
Yaws, unlike pinta, can have more serious compli-

cations remote from the skin, such as early osseous

involvement and late gummatous manifestations.
Although not thought to have cardiovascular or
neurological complications, or to be transmitted to
the fetus, in the so-called Caracas project, Smith
and others (1971) found ocular abnormalities, raised
immunoglobulin levels in the cerebrospinal fluid,
and treponemes in the aqueous humour of some
patients with late yaws.

Evolution of endemic syphilis
A further development followed in the more arid
regions bordering on the yaws areas where the still
very warm but now dry climate, frequently cold at
night, necessitated the wearing of clothes, thus
preventing skin-to-skin transmission. Only organisms
producing lesions of the mucous membranes could
now survive by means of direct transmission by
kissing, or indirectly through the intermediary of
common eating or drinking vessels (Grin, 1953) or
fingers (Guthe and Luger, 1957), although condy-
lomata lata and skin lesions are encountered, parti-
cularly in moist areas. Because infection tended to
occur before puberty, sexual spread was seldom
noted as by the time the children were old enough
for sexual intercourse they had already acquired the
disease. In all of the endemic treponematoses, there
is the vicious circle of poverty creating disease and
disease creating poverty (Fig. 2).
Endemic syphilis acquired prominence when it

was described usually in desert or near-desert
regions in a number of Middle-Eastern countries
under the name bejel (Hudson, 1928; Csonka, 1952)
or balash. It is also found today in Africa in countries

FIG. 1 Primary dark-field
positive yaw on ankle of West
Indian child who had been resident
in Londonfor only a few months

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Changing patterns of treponemal disease 171

only at the end of the 15th century, when Christopher
Columbus and parts of the Americas were unfairly
incriminated.

Like other sexually-transmitted diseases the inci-
dence of venereal syphilis has been high in times of
war, and the period during and immediately after
the second war was no exception. The more settled
conditions of peace and the introduction of effective
treatment with penicillin led to a dramatic fall, but
in the past 10 to 15 years numbers have again risen in
many countries although in most they remain at less
than one-tenth of the wartime peak.

F IG. 2 Vicious circles of endemic treponematoses

bordering on the Sahara desert in the North (Basset
and Boiron, 1965), and it has also been found in the
South adjacent to the Kalahari desert in present-day
Rhodesia-where under the name njovera it was
observed by the author when making a survey
(Willcox, 1951a, b), and in adjacent Botswana
(Murray, Merriweather, Freidman, and de Villiers,
1956). It also still exists in the Karoo in the Transvaal
(Du Toit, 1969) and in the North-Western Cape
areas, and has recently been observed around
Bloemfontein (Scott and Lups, 1973). In these areas
gangosa-like lesions and other late complications
may be encountered. The 'give-away' sign of its
existence is the finding of a nipple chancre in a
mother caused by her infected child.

Foci of endemic syphilis were present in Europe,
in Bosnia, Yugoslavia, even after the second world
war, but have since been successfully eradicated by
mass campaigns (Grin and Guthe, 1973). Between
the wars it extended over wide areas of the Southern
U.S.S.R., Turkey, and the then Palestine. There are
also many historical examples, including the sibbens
of Scotland, the button scurvy of Ireland and the
radesyge of Norway (Lancereux, 1868).

Emergence of venereal syphilis

Venereal syphilis develops from endemic syphilis as
social advance limits transmission between children;
as the children grow up they are then susceptible to
its sexual transmission (Willcox, 1960). With this
trend some unhygienic habits still persist (e.g.
sharing of pipes and toothpicks, widespread mouth-
to-mouth kissing, wet nurse practices, etc.), and both
venereal and non-venereal syphilis exist together, the
former being found in the older age groups in those
who have not experienced the childhood infection.
It is considered probable that endemic syphilis was
once widespread in non-tropical regions including
Europe, where it was recognized as a venereal disease

Continuing evolution of syphilis

EFFECTS OF DETERIORATING ENVIRONMENT

Changes in the distribution, severity, clinical ap-
pearances, and other features of syphilis still continue
as man's habits and environment alter for the better
or worse, particularly since the introduction of
penicillin and other antibiotics. The gradually
extending process of urbanization has itself contri-
buted to the waning of pinta, yaws, and endemic
syphilis in many areas, but a reversal of this process
is possible and is reported from time to time when
social conditions deteriorate and infections once
again occur among children.

Such a reversal from venereal to non-venereal
syphilis has been recorded from a number of coun-
tries even in the penicillin era (Murrell and Gray,
1947; Fejer, 1948; Eisenberg, Plotke, and Baker,
1949; Rajam and Rangiah, 1952; Rees, 1954; Taylor,
1954). A more recent experience was described by
Luger (1972); three children were infected in a
crowded ex-barrack building in Vienna, although
the room occupied by the family of nine also contained
the luxury items of a refrigerator, television set,
record-player, and two transistor radios.
With the present population explosion and

increasing accommodation difficulties, including the
unwelcome growth of shanty towns near to modem
cities in many parts of the world, such small-scale
reversals of treponemal evolution are to be expected
from time to time.

EFFECTS OF PENICILLIN

Action of penicillin
This antibiotic acts during the growth and division
of T. pallidum and related treponemes when the
cross-linked chains of N. acetyl glucosamine and
N. acetyl muramic acid, which form a matrix in the
outer cell wall to contain the inner protoplast like

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172 British J7ournal of Venereal Diseases

the outer skin of a football (Fig. 3), are breached by
the hydrolytic action of a lysozyme manufactured by
the organism (Fig. 4). The enlarging gap is restored

|Transpeptidasel

Mureine
precursors

INN*
/ 00; l

ITranspeptidasel
fZAP

FIG. 5 Cell wall biosynthesis. Stage two

a N-acetyl-muramic acid ( N-acetyl.glucosamine
FIG. 3 Mureine structure of T. pallidum cell wall
after Pelzer (1967), Kern (1972), and Luger (1973)

FIG. 6 Cell wall biosynthesis. Stage two

M

FIG. 4 Cell wall biosynthesis. Stage one (after
Luger (1973) andKern (1972))

by means of mureine precursors, which pass through
the cytoplasmic membrane of the protoplast to be
reconstituted through the action of several enzymes
including carboxypeptidases and particularly trans-
peptidase (Fig. 5). These enzymes affect the strength-
ening cross-bondings between the adjacent reforming
chains (Pelzer, 1967; Kern, 1972; Luger, 1973)
(Fig. 6).
By the affinity of penicillin for these enzymes,

particularly transpeptidase (Fig. 7), and by inter-
fering with the proper assembly and production of
the mureine precursors, the antibiotic prevents their
effective peformance, thereby allowing the un-
affected lysozyme to continue to breach the cell wall
more quickly than it is being renewed. Internal

osmotic pressure will then cause the protoplast to
bulge through the rent in the outer casing and this
may ultimately burst or destroy the organism
(Fig. 8).

Effectiveness of penicillin
Penicillin has been shown to be effective in the
treatment of early infections with pinta, yaws, and
syphilis, both endemic and venereal, even in single
injections of the right preparation, notably procaine
penicillin in oil with aluminium monostearate
(PAM) and benzathine penicillin. There are no
signs that T. pallidum is becoming resistant to
penicillin, although the inability to culture the
virulent organism in vivo makes precise assessment
of this point impossible (Schamberg, 1963).
The antibiotic has proved virtually 100 per cent.

successful in the incubation period, when it is widely
used for epidemiological treatment, and in seronega-
tive primary syphilis; in serpositive primary and in
secondary syphilis the clinical results are excellent,
with re-treatment rates around 3 to 10 per cent., and
even then many such recurrences are probably
re-infections (Idsoe, Guthe, and Willcox, 1972).
Seroreversal of reagin tests is the rule, although the
treponemal immobilization and FTA-ABS tests may
continue to show reactivity which may or may not be
associated with persistence of the organism.

In the late infection gummata quickly heal and
good results are also obtained in neurosyphilis with

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Changing patterns of treponemal disease 173

,-Lactam ring l

(3NH-CH-CH/ \Co3I-CLH
C7- N CH-COO-(

|Transpeptidase I
+ HOH

-CH-CH-

O=C7 N-

|Transpeptidase |

FIG. 7 Action of penicillin

Lysozyme

'dose

s

Penicillin

Penicillin -
Tra nspeptidase

FIG. 8 Action of penicillin

meningeal involvement. The outcome is less striking
in parenchymatous neurosyphilis, in cardiovascular
syphilis, and in complicated late congenital syphilis.
In late latent syphilis, and indeed in late syphilis as a
whole, seropositivity usually persists, although
future complications are largely prevented.

Changes in the clinical pattern
There have been striking changes in the clinical
manifestations of syphilis since the introduction of
penicillin. Exuberant secondary lesions of skin and
mucous membranes are now rare in many areas as are
ulcerative skin lesions, and syphilis seems to be
becoming a milder disease. This may be partly due
to better nutrition and to better standards of hygiene
which may well explain the decline in the prevalence
of condylomata lata. However, it would not be
unreasonable to suppose that the disease would
become milder under 'antibiotic bombardment', as
those strains of the organism which did not draw
attention to themselves by provoking a marked host
response would be those more likely to survive.

In the untreated disease approximately one-
quarter of the patients used to undergo secondary
infectious relapse (Gjestland, 1955) but today this is

seldom seen. Likewise the total incidence of late
complications are observed to fall wherever figures
are compiled (Kiraly and Causse, 1973). Gummata,
which were at one time rife-especially when the
incidence of early infection was high (Grin, 1953)-
have virtually disappeared in many places; at St.
Mary's, where around 10 per cent. of the annual total
of cases of early syphilis in England and Wales are
encountered, a year or more may pass without a
gumma being seen.

Early congenital syphilis has also become very
rare, infection in the child having been prevented
pre-natally or cured by penicillin while still in utero.
On the other hand, as penicillin is so quickly

effective, re-infections with syphilis, at one time
seldom encountered, are now common. In 1972, of
165 patients with early infectious syphilis seen at
St. Mary's, 22 (13 3 per cent.) had experienced 26
earlier attacks of the disease, in eighteen instances
3 o 11 years previously.

Persistence of treponemal forms
After very painstaking examinations Collart, Borel,
and Durel (1962), in France, found treponemal forms
in the lymph glands and cerebrospinal fluid of both
penicillin-treated rabbits and humans who had not
been treated early in the disease. They were later
found in the cerebrospinal fluid of patients with
untreated and treated late syphilis (Rice, Dunlop,
Jones, Hare, King, Rodin, Mushin, and Wilkinson,
1970) and also in the aqueous humour (Smith and
Israel, 1967) and more recently in Venezuela in
patients with yaws (Smith and others, 1971). In only
a few instances have these organisms been passaged
in rabbits (Turner, Hardy, and Newman, 1969),
but animals which have received passaged material
may develop positive serological reactions to trepo-
nemal antigens and some of these have later been
shown to carry treponemes (Yobs, Clark, Mothershed,
Bullard, and Artley, 1968). This phenomenon could
be related to the occurrence of such reactions
amongst apparently normal children in yaws areas
where near-eradication of the early clinical disease
has apparently been achieved by mass treatment
(Guthe and others, 1972).
While some doubt exists as to the significance of

these organisms, e.g. whether they are derived from
the mouth or other sources, the possibility remains
that they are T. pallidum which have not been over-
come by the low levels of penicillin commonly
encountered in the fluids in which they are found or
which may have survived as 'L' forms. These have
been observed for some years with cultured tre-
ponemes in an unfavourable penicillin environment,
and have also been observed in syphilitic tissues

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174 British Journal of Venereal Diseases

under the electron microscope (Ovcinnikov and
Delektorskij, 1971).

Collart, Franceschini, and Durel (1971) believe
that, if penicillin treatment is given during the first 3
months of a syphilitic infection, the treponemes
disappear and there is no persistent reactivity to the
TPI test. In infections of 2 or more years' duration,
treponemes are still found after penicillin therapy.
Lymph node transfer tests are positive in about 5 per
cent. of such cases and cortisone therapy can activate
some infections to produce clinical lesions. It is
postulated that, in the latent period, the untreated
host develops resistance so that the parasites vegetate
in a commensal state, but the possibility cannot be
excluded that under unknown biological conditions
they may recover their virulence.

Venereal syphilis fills treponemal disease vacuum
In areas where near-eradication of yaws has been
achieved by mass campaigns or by advancing
civilization resulting in urbanization and the wearing
of clothes, the herd immunity to syphilis due to past
yaws is now removed and venereal syphilis tends to
take its place. Such an event has been reported in
Tahiti (Van der Sluis, 1969), Western Samoa
(Guthe and others, 1972), and in New Guinea
(Rhodes and Anderson, 1970; Bell, 1971).
The writer has had the good fortune to witness

the situation in New Guinea. Here venereal syphilis
has spread through the centre of the country along
the new highway, in some parts a rough winding
mountainous road, which extends from the port of
Lae in the east to Mount Hagen in the Western
Highlands.

Syphilis did not exist in this area up to 3 years or
so ago, although gonorrhoea was prevalent, as was
yaws until a mass campaign was undertaken in 1957.
Today syphilis is being carried by the truck-drivers
and the so-called 'passenger-meris', who prostitute
themselves in the villages along the route and with
the drivers in their journeys to and from more
prolonged prostitutional activities in Lae.
The dissemination of the disease amongst the local

population is in proportion to the prevailing sexual
freedom, the spread being most extensive amongst
the promiscuous Chimbu.

In the male, primary chancres are encountered in
half the clinical cases, although many are atypical.
Most of the remainder of clinically affected males
show condylomata lata, sometimes in the axillae
(Fig. 9). In the female, secondary condylomatous
lesions are usual but primary lesions are sometimes
observed. Secondary rashes are only occasionally
encountered but maybe these by themselves do not

FIG. 9 Condylomata lata in the axilla (Courtesy of
Bell, 1971)

prompt patients to seek treatment. The same applies
to oral mucous patches.
Treponemes resembling T. pallidum can be found

in the lesions. Donovanosis (granuloma inguinale),
of which the number of reported cases exceeds 40
per cent. of the reported cases of syphilis in adjacent
Papua, need cause no confusion when the lesions are
extensive, and can be confirmed by appropriate
pathological tests, but may well do so when no
darkfield tests for treponemes or smears for Donovan
bodies are made.

Thus, even now, towards the end of the 20th
century, an opportunity still exists of observing the
rapid 'syphilization' of a susceptible community.

EFFECTS OF MAN'S BEHAVIOUR
Population movement
All the treponematoses have been distributed during
mass migrations (Hudson, 1965), including religious
pilgrimages (Hudson, 1963), and the African slave
trade (Hudson, 1964). The role of the seaman and
soldier in the spread of syphilis and other sexually-
transmitted diseases is traditional. In modern times,
of no less importance are migrations in search of
work or fleeing from oppression, and latterly the
'travel explosion' of tourists (Guthe and Willcox,
1971).

It is estimated that there are now more than six
million migrant workers in Europe alone, 20 to 30
per cent. of whom return to their countries each year
to be replaced by more recruits. The world figure
for tourists in 1971 was around 170 million, approxi-
mately three-quarters involving Europe (WHO,

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Changing patterns of treponemal disease 175

1972). These movements, and the accompanying
social circumstances, make possible a far greater
international exchange of syphilis and other venereal
diseases than ever before and, in the case of the
tourist, the diseases may be brought home to the
smallest towns and villages.

Increased promiscuity
With greater opportunity for the two sexes to meet
without supervision and with the removal of pre-
viously inhibitory influences, there has been an
increase in promiscuity, both heterosexual and
homosexual. Quite small increases in promiscuity
can have alarming effects in closed groups. In any
'closed' group of any size, it only needs one additional
outside sexual link to introduce venereal disease,
possibly to all. This can happen in groups in which
half or even two-thirds have only one sexual partner
(Willcox, 1973) (Fig. 10).

2/3 of this qroup
have only one consort

yet
one outside link
could result in
all infected

It is presumed that the numbers of different
contacts per unit of time has increased, although
there are no firm data to support or refute this.
Certainly anal chancres are a more commonly
recognized presentation of early syphilis today,
although it might be argued that previously they
were frequently missed.
Although many individual physicians have presen-

ted data concerning the incidence of homosexual
infections, there are few nation-wide data. One
such study has been recently undertaken in the
United Kingdom (British Cooperative Clinical
Group, 1973), in which 176 clinics in 153 towns and
cities participated and the cases included comprised
90 per cent. of the reported national totals of
primary and secondary syphilis treated during the
year, and 86-1 per cent. for gonorrhoea.
Of the total of 924 male infections treated, 532

penile infections were believed to have been hetero-
sexually acquired and 172 homosexually; 220
infections were anorectal. Thus homosexuals were
responsible for 42-4 per cent. The percentage was
highest (45 -9 per cent.) in England, those for Scotland
and Wales being 13-5 and 9 5 per cent. respectively.

In England, outside London, the percentage of
known homosexuals with early syphilis was 25-1, but
reached 62-1 in the twenty participating clinics in
the capital. In London four out of five of the homo-
sexuals with syphilis were treated in but five clinics
in the West End, where they comprised no less than
73-3 per cent. of infections compared with 37 2 per
cent. in the other fifteen clinics. (Fig. 11).

80

FIG. 10 Diagram to show how a slight extra
degree of promiscuity may cause a large increase in
venereal disease

Male homosexuality
A noteworthy feature has been the much more
frequently recognized association of early syphilis
in males with homosexuality, particularly in the
larger cities where homosexuals may be responsible
for the bulk of infections. Although this would appear
fundamentally to be a problem of the more permissive
society and greater promiscuity amongst homosexuals,
the observed increase is also due at least in part to
the fact that such persons now feel freer to discuss
their behaviour.

Homosexuality involves about 4 per cent. of adult
males and a moderately active homosexual man may
have contact with 100 different males each year
(Gebhard, 1971).

70

c

.2_
tU60
u 0r-

20
20-

37.2
London

25.1 except

England West
13.5 except End9.5 Scotland London

I Wales

73.3
London
West
End

FIG. 1 1 Percentage of homosexually acquired
infections with primary and secondary syphilis in
males

A similar pattern was seen in gonococcal infections
(Fig. 12); homosexuals represented 9-8 per cent. of
the total and 27-6 per cent. in the five clinics in the

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176 British Journal of Venereal Diseases

30-

2- 20-
0

.0-

1 0 7.7
4.0 4.1 4.6 London

I Wnl . IQntnlln9!.nt W.,t End

27.6
London
West
End

01 I Yvies la u w IL mdcp l -- I -
FIG. 12 Percentage of homosexually acquired
infections with gonorrhoea in males

West End of London. However, as approximately
forty times as much gonorrhoea as primary and
secondary syphilis occurred in males, gonorrhoea
represents the greater numerical problem (Fig. 13).

EJ Heterosexual
0 Penile homosexual
E Ano-rectal homosexual

Syphilis Gonorrhoea

F I G. 13 Relative importance of homosexual
infections with syphilis and gonorrhoea in males

It is difficult to explain why syphilis has lurked
more commonly in the homosexual male than in the
heterosexual female (where the chancre may also be
concealed, e.g. on the cervix), unless it is agreed that
greater promiscuity in terms of sexual partners over
a period of time has occurred in homosexuals now
that previously strong taboos have been removed
from such behaviour in many countries.

Oral sexual contact
The influence of oral sex in relation to venereal
disease has recently been highlighted by Bro-
Jorgensen and Jensen (1971), who found gonococci
in the throat of 6 per cent. of Danish men and 9 per
cent. of Danish women, and by Hellgren (1971) who
noted that fifty of 200 Swedish patients with uro-
genital gonorrhoea admitted to oral sex at their last
intercourse.

Oral infections with syphilis remain relatively
uncommon. Those which are found today are more

likely to be associated with oral intercourse than with
kissing, which was regarded as the usual method of
contraction 25 years ago.

It has been thought likely that, possibly following
the greater dissemination of pornographic and near
pornographic films, the practice of oral intercourse is
increasing in Western Society. In a recent series of
105 female gonorrhoea contacts seen at St. Mary's,
41 0 per cent. admitted to oral sex with the partner
or partners recently involved. (Rectal intercourse
had also occurred in 18-1 per cent. of patients-
Cornthwaite, Savage, and Willcox, 1974). But here
again it must be noted that 20 years ago Kinsey,
Pomeroy, Martin, and Gebhard (1953) found that, of
younger females who had had some but not extensive
coital experience, 16 per cent. had indulged in oral
stimulation of the male genitalia as had 43 per cent.
of those with more extensive experience. The latter
figure (which reached 62 per cent. amongst the more
educated) varied little from the 38 per cent. noted
in those born before 1900.

In view of the success of a recent film in the U.S.A.,
the report is awaited of the first case of a chancre
at the lower end of the oesophagus!

Other behavioural factors
Other changes in the presentation of syphilis have
been brought about by new industrial and other
practices. No longer do oral chancres occur in
glassblowers, although these were once not so
uncommon (Royal Commission on Venereal Diseases,
1916). An interesting recent presentation is that of
double chancre arising in the vasectomy scars of a
patient who had cooperated in the Indian steriliza-
tion programme and who had had a night 'on the
town' shortly afterwards (Bai, 1973) (Fig. 14).

Summary and conclusions
(1) The evolutionary patterns of the treponematoses,
occasioned by environmental circumstances, from
pinta and yaws through endemic to venereal syphilis
are outlined. A reversal from venereal to endemic
syphilis may occur should social conditions deterio-
rate.
(2) Changes are still occurring today in the patterns
of venereal syphilis, particularly as a result of the
introduction of penicillin and of human behaviour.
(3) The mode of action of penicillin and its effects
in the various stages of syphilis are outlined. The
significance of the treponemal forms found in cases
of treated late disease is considered, but notwith-
standing these the practical results obtained by
penicillin treatment remain excellent.

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Changing patterns of treponemal disease 177

F I G. 14 Chancres arising in vasectomy scars
(Courtesy of Bai, 1973)

(4) In developed countries today, syphilis is ap-
parently becoming a milder disease with fewer
exuberant lesions, a low incidence of previously
common secondary relapses and gummata, and a
much reduced incidence of other late manifestations.
On the other hand, re-infections and ano-rectal
infections have become more common. For this a
number of factors are responsible, including better
nutrition, better hygiene, and above all the discovery
of penicillin, treatment with which would be expected
to tend towards the removal of the more virulent
strains leaving the more insidious.
(5) Behavioural patterns have also contributed,
especially in relation to ano-rectal infections. Data
concerning homosexual infections and oral inter-
course are presented.

(6) Doubtless, as long as human behaviour changes
and the environment evolves, these alterations will be
reflected also in the patterns of treponemal disease.

References
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Modifications des aspects des tr6pon6matoses
SOMMAIRE
(1) On decrit 1'evolution des aspects des treponematoses
due aux circonstances de 1'environnement, menant de la
pinta et du pian a la syphilis v6n6rienne en passant par la
syphilis endemique. De venerienne, la syphilis peut
prendre le type endemique si les conditions sociales se
deteriorent.
(2) Les aspects se modifient aujourd'hui encore pour la
syphilis venerienne, ceci resultant particulierement de
l'introduction de la penicilline et du comportement
humain.
(3) On examine le mode d'action de la penicilline et ses
effets aux divers stades de la syphilis. On examine la
signification des formes treponemiques trouvees dans des
cas traites tardivement mais, quoi qu'il en soit, les
resultats pratiques obtenus par le traitement par la
penicilline restent excellents.
(4) De nos jours, dans les pays developpes, la syphilis
parait devenir plus benigne, avec moins de lesions
exuberantes, une faible incidence des reprises secondaires
et des gommes, faits communs anterieurement, et une
forte diminution de l'incidence des autres manifestations
tardives. Par contre, les reinfections et les atteintes ano-
rectales sont devenues plus frequentes. Un certain
nombre de facteurs en sont responsables, dont une
meilleure nutrition, une meilleure hygiene et, par dessus
tout, la decouverte de la p6nicilline, traitement dont on
peut penser qu'il tend a supprimer les souches les plus
virulentes, laissant subsister les souches les plus insidi-
euses.
(5) Les types de comportement ont aussi joue un role,
specialement en ce qui concerne les infections ano-
rectales. On presente des informations sur les infections
homosexuelles et celles dues aux rapports oraux.
(6) I1 n'est pas douteux qu'aussi longtemps que le
comportement humain changera et que l'environnement
evoluera, ceci influencera les aspects de la maladie
treponemique.

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