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The 68 year old with a 15-year history of HIV stated he had not been compliant with his HIV medications over the last year and had developed cauliflower-like vegetative red-brown papules on his genitals and gluteal cleft (Figs. 8.1 and 8.2).

Although anorectal sexually transmitted diseases (STIs) commonly present directly to “sexual health clinics,” patients may not necessarily attribute their symptoms and signs to such diseases and consequently may present to a colorectal surgeon for further investigation and management.

Infection of the fetus is more likely to occur when the mother’s infection is in the early stage, as at this time considerable numbers of treponemes are present in the circulation. During the first year of infection in an untreated woman there is an 80–90% probability that the infection will be transmitted to the fetus. The chance of fetal infection declines rapidly after the second year of infection in the mother and becomes rare after the fourth year. In general, the greater the duration of syphilis in the mother, the less chance there is of the fetus being affected. If a mother with early-stage syphilis is not treated, 25–30% of fetuses die in utero; 25–30% die after birth; and of the infected survivors 40% develop late symptomatic syphilis.

Between the sixteenth and eighteenth centuries the study of venereal diseases made only slow progress. The main clinical features of primary and secondary syphilis had been recognised, although estimates of its incubation period, and of the temporal relationship between its various stages, were very inexact. Extragenital infection, for example of the mouth, was recognised. By the beginning of the eighteenth century some of the features of late syphilis had also been described — lesions of the skin and bones, for instance — but nothing was yet known about cardiovascular or neurosyphilis, and very little about visceral involvement.

Since the time of Ricord it has been customary to divide the “syphilis drama” into three stages. Nowadays the signs of tertiary syphilis rarely appear less than two years from the original infection, but in earlier times some of these seem to have appeared well before this; indeed, a “galloping syphilis” was described in which tertiary lesions followed the secondary stage after only a few months. This makes it more than usually difficult to interpret many of the early clinical descriptions, in particular to decide whether the authors were describing late syphilis or merely a prolonged secondary stage.

At the beginning of the syphilis epidemic doctors had no idea how they should treat its victims. Measures such as diet, bleeding, purging and sweating were used while the pharmacopoeias were hurriedly consulted. External applications of mercury compounds had been used on a small scale by the ancient Greeks, and in the early Middle Ages were studied more thoroughly by Arabian physicians. In the. twelfth century applications of mercury (Unguentum Saracenicum) were advocated by Roger of Salerno for the treatment of some chronic skin diseases. Toxic symptoms such as salivation, which had been noted by the Arabs, were now regarded as beneficial, and “salivation cures” were initiated, chiefly for gouty conditions1. Mercury was prescribed for syphilis because Celsus had advised doctors confronted with a new disease to try remedies which had been found to be effective against similar conditions; syphilitic skin eruptions often resembled other skin diseases, so mercury was used by many of the early syphilologists, including Torella, Cataneus and de Vigo. Ointments of various strength were applied, sometimes just to the lesiolis but often more widely.

The appearance of syphilis was an epoch-making event, and doctors schooled in Galenic and Arabian medicine were ill-prepared for it. The disease struck in 1493. Cases were already occurring throughout Western Europe when a major epidemic broke out in the army that the French King Charles VIII led against the Kingdom of Naples in 1494. Charles, described by the historian H.A.L. Fisher as “a young and licentious hunchback of doubtful sanity”, led a cosmopolitan force of about 30 000 men, mostly mercenaries and including some from Spain; among the raggle-taggle group of civilians accompanying the army were hundreds of prostitutes. Naples was held by King Alphonso II with the help of Spanish mercenaries sent by Ferdinand and Isabella. At first Charles was successful and he captured Naples early in 1495 without difficulty, but this success was completely reversed when an Italian league was formed to eject the invaders. To make matters worse, prostitution and debauchery on both sides were followed by a widespread outbreak of the new disease. The Italian surgeon Marcellus Cum anus (fl. 1495), who was working in Naples, later claimed to have seen the earliest cases. Charles was forced to withdraw from Italy and discharge his soldiers, who spread the disease far and wide as they returned to their own countries. The King himself died of it in 1498.

The idea that some human diseases might be caused by the transmission of minute living creatures originated among the myths and legends of the ancient world, and had been seriously suggested by Fracastoro in his On contagion in 1546. Proof that such agents existed had to await the construction of microscopes. The first instruments of good quality were built by the Dutch naturalist Anton von Leeuwenhoek (1632–1723); some of these could magnify objects more than 250 times. The examination of various body fluids revealed many “animalcules” and “infusoria”, but nobody knew what these were or what they meant. A major step was taken by the French microscopist Alexandre Donne (1801–1878), who later became Inspector General of the University of Paris. The design and performance of microscopes was by now much improved, and Donne made some important discoveries, which included blood platelets and the leucocytosis of leukaemia. In 1836 he published his studies “as to the nature of various genito-urinary discharges in both sexes”1. In specimens from women with vaginitis he had seen many flagellated protozoa: “The animalcule is of a size double that of a human erythrocyte, or about the size of a pus cell, namely 1140 mm in diameter. The body is round, but may elongate and assume diverse forms. At the anterior end is a long flagellum-like appendage, very thin, which may wave back and forth with great rapidity. On the under part are a number of very fine cilia [later found to be an undulating membrane] that cause a rotating movement. At the posterior end are a number of appendages of uncertain structure.”

Contagious ulcers of the genitals were well known in ancient and medieval times. Writing in 1306, the Italian physician Lanfranc described “ulcers arising from the rupture of hot pustules of young men … from connection with an unclean woman”, and went on to say: “If you wish to preserve the member from complete corruption, after connection with a woman whom you suspect of uncleanliness, wash it with water mixed with vinegar”1. A rapidly spreading necrosis of the external genitalia, called phagedenic ulceration or phagedenea, was often described in the early literature. In its destructive potential it resembled the synergistic bacterial gangrene which sometimes affects the genital area today. Phagedenea commonly followed genital ulceration, probably through superinfection by Vincent’s or other organisms. The following report describing a case of the disease was written in 1810 by William Fergusson (1772–1846), inspector general of hospitals to the Portuguese army