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During the second half of the nineteenth and the beginning of the twentieth century, Ricord's concept of syphilis was gradually reshaped, as other disease entities recognized today as sexually transmitted diseases (gonorrhea, chancroid, lymphogranuloma venereum, genital herpes, venereal warts, and others) were emerging. If most of these new disease entities were first shaped according to anatomoclini-cal criteria, each one of them (syphilis included) eventually got its definitive "identity card" when the relevant germ causing it was isolated.

Gonorrhea and chancroid are two illustrative examples in this respect. Ricord, who definitely separated chancre and blennorrhagia, asserted that the latter might be the result of local irritation, excessive sexual intercourse, or excessive sexual excitement. The present clinical picture of gonorrhea was completed only in 1879, when Albert Neisser discovered the germ responsible for it, which he called gonococcus. On the other hand, chancroid or soft sore (ulcus molle) emerged as a disease entity in 1852, when a pupil of Ricord, Léon Bassereau, demonstrated that the two kinds of luetic chancre - one hard, painless, and unique; the other soft, painful, and frequently multiple - resulted from exposure to a like lesion. In addition, the latter was autoinocula-ble. Almost 40 years later, in 1889, August Ducrey identified the bacillum responsible for it (Kamp-meier 1984).

As for the concept of syphilis, it developed and changed profoundly during the second half of the nineteenth century as the disease became a major research area in Western scientific medicine. Perhaps the person who contributed most to the development of the concept of syphilis during this period was the French venereologist Jean-Alfred Fournier. It was Fournier who propounded the concept of latency in both acquired and congenital syphilis, definitely established the relationship between syphilis and so-called parasyphilitic affections (mainly tabes dorsalis and general paresis of the insane), and began a social campaign against the disease.

But the discovery of the germ responsible for syphilis did not occur until 1905, when Fritz Schaudinn and Erich Hoffmann isolated it in serum from a lesion of secondary syphilis. In 1906 the collective work of August von Wassermann, Albert Neisser, Carl Bruck, and others made possible the invention, in Germany, of the first serologic procedure for the diagnosis of syphilis. This was the complement-fixation test, which soon became well known as the Wassermann Reaction (WR). In the following years,

T. pallidum was also found in lesions of tertiary syphilis, verifying Fournier's theory. Karl Reuter, for example, in 1906 found the germ in the wall of a syphilitic aorta, whereas Hideyo Noguchi in 1913 proved its presence in brain tissue from paretics (Quétel 1986).

By way of conclusion it should be emphasized that, as has been the case with many other disease entities, a crisis of a disease entity concept based upon its specific biological cause (Lafn-Entralgo 1982) has also ensnared venereal syphilis. In 1935, whereas most bacteriologists and pathologists still claimed specificity of a causal microorganism to be the definitive nosographic criterion for an infectious disease, Fleck lucidly insisted upon the essential incompleteness of the concept of syphilis (Fleck 1979).

Time has confirmed Fleck's insight. Put plainly, it should be obvious from the foregoing that Western medicine has had enormous difficulties in establishing scientific criteria that delimit precisely the so-called venereal syphilis from the remaining human treponematoses (Hackett 1963; Hudson 1965; Perine et al. 1984).

Jon Arrizabalaga

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