Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Plus ça Change: The Rise And Rise of Syphilis


Syphilis cases have reached an all-time high. To turn the tide, the first thing we need to do is ask patients an open-ended question about sexual activity, like "When was the last time you had sex?"

The UK stories

The slap, slap of feet down a hall heralded my first encounter with syphilis—the feet belonged to a man in his seventies with dementia living in a long-term care facility. He was isolated, alone, and unvisited. The tabetic feet, disconnected from the brain, and an inability to make himself understood were the devastating effects of late neurosyphilis. The memory I retain is auditory—a diagnosis with your eyes closed. I wonder who he was when he could still tell his story—the man before the treponeme. His story lost as inexorably as his neurons. Not even the skill of Sherlock Holmes could unearth his truth*.


At the start of my career in England I never thought about syphilis much—we didn’t see it. Or, knowing what I know now, we didn’t recognize it if we saw it. My second memory is of a woman, in her eighties, confused and with an unstable gait. She tested positive for syphilis. Our team discussed what this might mean when she clearly had normal pressure hydrocephalus. The local STI expert came and advised. He signed off his note with “consultant venerologist,” an arcane and quaint description of a specialty in decline. The woman didn’t survive. She never returned from neurosurgery. It was one of many times in those days where I felt I could have done more, or better.


My two foundational experiences of syphilis were linked by the observation that both people were alone and deprived of their ability to tell their stories. This was due to a fragile, delicate, spiral shaped bacteria.


In the U.S.

After a peak of cases in 1991, by 2000 there was an excitement about syphilis elimination. Syphilis as the new smallpox, or polio at the very least.


Blink forward to 2021—STIs have increased for the sixth straight year reaching an all-time high. Elimination is a distance memory. Today the venerologist’s skills would be most welcome, his insights eagerly sought—nothing quaint about it.


We’re again in the updraft of what the CDC calls a cyclical national epidemic. Between 2015-2019 there was a 74% increase in syphilis cases in America.


The hidden truth

Syphilis wreaks havoc in some of the most vulnerable in our society—those whose story is so seldom heard—a silent epidemic in those who use drugs or exchange sex. The grumbling epidemic in men who have sex with men has morphed into a roar.


The rapid increases of syphilis in women has led to a wholly predictable outcome—a wave of congenital syphilis that saw a 279% increase between 2015-2019. It’s a heartbreaking intergenerational disaster. All the more devastating as it could be so easily prevented.


Call to action

I ask myself how would the country react to a 279% increase in prostate cancer or SIDS? There would be an outcry and a demand for action. Operation ultra-warp speed would emerge in weeks.


Here’s how you can take action to mitigate the rise in syphilis: 


1. Talk.

Ask a simple open question about sexual activity, like “Are you in a relationship, when was the last time you had sex?” This can open a doorway to talking about so much more than STIs, like how your patient is feeling in general, both physically and emotionally.


2. Think.

The great mimic can trick us all. It always has and will continue to. Proteinuria, hepatitis, hearing loss, miscarriage, stroke. A baffling history can sometimes be simply explained.


3. Test.

Ask yourself if you should order a syphilis serology, along with the anti-dsDNA, and/or CT scan when the diagnosis isn’t clear and basic investigations haven’t helped.


4. Treat with penicillin.

Many institutions offer expertise in syphilis to help us all interpret serologies and advise on treatments.


“He who knows syphilis knows medicine.”

—Dr. William Osler’s quotation has stood the test of time.


Sir Arthur Conan Doyle, the author of the Sherlock Holmes novels, wrote his doctoral thesis on “tabes dorsalis.”




This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.