The Third Great Plague A Discussion of Syphilis for Everyday People online

any worse by the proper treatment. For paresis, in our present state of
knowledge, nothing can be done once the disease passes its earliest
stages. In both these diseases only too often the physician is called
upon to lock the stable door after the horse is stolen. The problem of
what to do for the victims of these two conditions is the same as the
problem in other serious complications of syphilis - keep the disease
from ever reaching such a stage by recognizing every case early, and
treating it thoroughly from the very beginning.


SUMMARY

Summing up briefly the main points to bear in mind about the course of
syphilis - there is a time, at the very beginning of the disease, even
after the first sore appears, when the condition is still at or near the
place where it entered the body. At this time it can be permanently
cured by quick recognition and thorough treatment. There are no fixed
characteristics of the early stages of the disease, and it often escapes
attention entirely or is regarded as a trifle. The symptoms that follow
the spread of the disease over the body may be severe or mild, but they
seldom endanger life, and again often escape notice, leaving the victim
for some years a danger to other people from relapses about which he may
know nothing whatever. Serious syphilis is the late syphilis which
overtakes those whose earlier symptoms passed unrecognized or were
insufficiently treated. Late syphilis of the skin and bones, disfiguring
and horrible to look at, is less dangerous than the hidden syphilis of
the blood-vessels, the nerves, and the internal organs, which, under
cover of a whole skin and apparent health, maims and destroys its
victims. Locomotor ataxia and softening of the brain, early apoplexy,
blindness and deafness, paralysis, chronic fatal kidney and liver
disease, heart failure, hardening of the blood-vessels early in life,
with sudden or lingering death from any of these causes, are among the
ways in which syphilis destroys innocent and guilty alike. And yet, for
all its destructive power, it is one of the easiest of diseases to hold
in check, and if intelligently treated at almost any but the last
stages, can, in the great majority of cases, be kept from endangering
life.




Chapter VI

The Blood Test for Syphilis


It seems desirable at this point, while we are trying to fix in mind the
great value of recognizing syphilis in a person in order to treat it and
thus prevent dangerous complications, to say something about the blood
test for syphilis, the second great advance in our means of recognizing
doubtful or hidden forms of the disease. The first, it will be recalled,
is the identification of the germ in the secretions from the early
sores.

+Antibodies in the Blood in Disease.+ - It is part of the new
understanding we have of many diseases that we are able to recognize
them by finding in the blood of the sick person substances which the
body makes to neutralize or destroy the poisons made by the invading
germs, even when we cannot find the germs themselves. These substances
are called antibodies, and the search for antibodies in different
diseases has been an enthusiastic one. If we can by any scheme teach the
body to make antibodies for a germ, we can teach it to cure for itself
the disease caused by that germ. So, for example, by injecting dead
germs as a vaccine in typhoid fever and certain other diseases, we are
able to teach the body to form protective substances which will kill any
of the living germs of that particular kind which gain entrance to the
body. Conversely, if the body is invaded by a particular kind of germ,
and we are in doubt as to just which one it is, we can identify it by
finding in the blood of the sick person the antibody which we know by
certain tests will kill or injure a certain germ. This sort of medical
detective work was first applied to syphilis successfully by Wassermann,
Neisser, and Bruck in 1904, and for that reason the test for these
antibodies in the blood in syphilis is called the Wassermann reaction.
To be sure, it is now known that in syphilis it is not a true antibody
for the poisons of the Spirochæta pallida for which we are testing, but
rather a physical-chemical change in the serum of patients with
syphilis, which can be produced by other things besides this one
disease. But this fact has not impaired the practical value of the test,
since the other conditions which give it are not likely to be confused
with syphilis in this part of the world. The fact that no true antibody
is formed simply makes it unlikely that we shall ever have a vaccine for
syphilis.

+Difficulties of the Test.+ - The Wassermann blood test for syphilis is
one of the most complex tests in medicine. The theory of it is beyond
the average man's comprehension. A large number of factors enter into
the production of a correct result, and the attaining of that result
involves a high degree of technical skill and a large experience. It is
no affair for the amateur. The test should be made by a specialist of
recognized standing, and this term does not include many of the
commercial laboratories which spring up like mushrooms in these days of
laboratory methods.

+The Recognition of Syphilis by the Blood Test.+ - When the Wassermann
test shows the presence of syphilis, we speak of it as "positive."
Granted that the test is properly done, a strong positive reaction means
syphilis, unless it is covered by the limited list of exceptions. After
the first few weeks of the disease, and through the early secondary
period, the blood test is positive in practically all cases. Its
reliability is, therefore, greatest at this time. Before the infection
has spread beyond the first sore, however, the Wassermann test is
negative, and this fact makes it of little value in recognizing early
primary lesions. In about 20 to 30 per cent of syphilitic individuals
the test returns to negative after the active secondary stage is passed.
This does not necessarily mean that the person is recovering. It is even
possible to have the roof fall out of the mouth from gummatous changes
and the Wassermann test yet be negative. It is equally possible, though
unusual, for a negative Wassermann test to be coincident with contagious
sores in the mouth or on the genitals. So it is apparent that as an
infallible test for syphilis it is not an unqualified success. But
infallibility is a rare thing in medicine, and must be replaced in most
cases by skilful interpretation of a test based on a knowledge of the
sources of error. We understand pretty clearly now that the Wassermann
test is only one of the signs of syphilis and that it has quite
well-understood limitations. It has revealed an immense amount of
hidden syphilis, and in its proper field has had a value past all
counting. Experience has shown, however, that it should be checked up by
a medical examination to give it its greatest value. Just as all
syphilis does not show a positive blood test, so a single negative test
is not sufficient to establish the absence of syphilis without a medical
examination. In a syphilitic, least of all, is a single negative
Wassermann test proof that his syphilis has left him. In spite of these
rather important exceptions, the Wassermann test, skilfully done and
well interpreted, is one of the most valuable of modern medical
discoveries.

+The Blood Test in the Treatment and Cure of Syphilis.+ - In addition to
its value in recognizing the disease, the Wassermann test has a second
field of usefulness in determining when a person is cured of syphilis,
and is an excellent guide to the effect of treatment. Good treatment
early in a case of syphilis usually makes the Wassermann test negative
in a comparatively short time, and even a little treatment will do it in
some cases. But will it stay negative if treatment is then stopped? In
the high percentage of cases it will not. It will become positive again
after a variable interval, showing that the disease has been suppressed
but not destroyed. For that reason, if we wish to be sure of cure, we
must continue treatment until the blood test has become negative and
stays negative. This usually means repeated tests, over a period of
several years, in connection with such a course of treatment as will be
described later. During a large part of this time the blood test will
be the only means of finding out how the disease is being affected by
the treatment. To all outward appearance the patient will be well. He
may even have been negative in repeated tests, and yet we know by
experience that if treatment is stopped too soon, he will become
positive again. There is no set rule for the number of negative tests
necessary to indicate a cure. The whole thing is a matter of judgment on
the part of an experienced physician, and to that judgment the patient
should commit himself unhesitatingly. If a patient could once have
displayed before him in visible form the immense amount of knowledge,
experience, and labor which has gone into the devising and goes into the
performing of this test, he would be more content to leave the decision
of such questions to his physician than he sometimes is, and would be
more alive to its reality and importance. The average man thinks it a
rather shadowy and indefinite affair on which to insist that he shall
keep on doctoring, especially after the test has been negative once or
twice.

Just as a negative test may occur while syphilis is still actively
present and doing damage in the body, so a positive Wassermann test may
persist long after all outward and even inward signs of the disease have
disappeared. These fixed positives are still a puzzle to physicians. But
many patients with fixed positives, if well treated regardless of their
blood test, do not seem to develop the late accidents of the disease. If
their nervous systems, on careful examination, are found not to be
affected, they are reasonably safe as far as our present knowledge
goes. People with fixed positives should accept the judgment of their
physicians and follow their recommendations for treatment without
worrying themselves gray over complications which may never develop.

+Practical Points About the Test.+ - Certain practical details about this
test are of interest to every one. Blood for it is usually drawn from a
small vein in the arm. The discomfort is insignificant - no more than
that of a sharp pin-prick. Blood is drawn in the same way for other
kinds of blood tests, so that a needle-prick in the arm is not
necessarily for a Wassermann test. There is no cutting and no scar
remains. The amount of blood drawn is small and does not weaken one in
the least. The test is done on the serum or fluid part of the blood,
after the corpuscles are removed. It can also be done on the clear fluid
taken from around the spinal cord, and this is necessary in certain
syphilitic nervous diseases. There is nothing about the test that need
make anybody hesitate in taking it, and it is safe to say that, when
properly done, the information that it gives is more than worth the
trouble, especially to those who have at any time been exposed, even
remotely, to the risk of infection. But the test must be well done, by a
large hospital or through a competent physician or specialist, and the
results interpreted to the patient by the physician and not by the
laboratory that does the test, or in the light of the patient's own
half-knowledge of the matter.




Chapter VII

The Treatment of Syphilis


GENERAL CONSIDERATIONS

+Scientific Methods of Treating Disease.+ - In trying to treat diseases
caused by germs, the physician finds himself confronted by several
different problems. Certain of these diseases run their course and the
patient gets well or dies, pretty much regardless of anything that can
be done for him. In certain others, because of our knowledge of the way
in which the body makes its fight against the germ, we are able either
to prepare it against attack, as in the case of protective vaccination,
or we are able to help it to come to its own defense after the disease
has developed. This can be done either by supplying it with antitoxin
from an outside source, or helping it to make its own antitoxin by
giving it dead germs to practise on. In the third group, the smallest of
the three, we are fortunate enough to know of some substance which will
kill the germ in the body without killing the patient. For such diseases
we are said to have a "specific" method of treatment. Syphilis is one of
these diseases. It is not to be understood that there is a sharp line of
division between these three groups, since in every disease we try as
far as possible to use all the methods we can bring to bear. In
pneumonia we have to let the body largely make its own fight, and simply
help it to clear out the poisons formed by the germ, and keep the heart
going until the crisis is past. In diphtheria, nowadays, we help the
body out promptly by supplying it with antitoxin from an outside source,
before it has time to make any for itself. We do the same thing for
lockjaw if we are early enough. We practise the body on dead typhoid
germs by vaccination until it is able to fight the living ones and
destroy them before they get a foothold. The diseases for which we have
specific methods of treatment are few in number, and each has associated
with it the name of a particular drug. Quinin kills the germ of malaria,
sodium salicylate cures inflammatory rheumatism, and mercury cures
syphilis. To mercury in the case of syphilis must now be added salvarsan
or arsenobenzol ("606"), the substance devised by Ehrlich in 1910, which
will be considered in the next chapter.

The action of a specific is, of course, not infallible, but the failures
are exceptional, so that one feels in attacking one of these diseases
with its specific remedy as a man called upon to resist a savage beast
would feel if he were armed with a powerful rifle instead of a stick.
The situation in syphilis, for which there is a specific, as compared
with tuberculosis, for which there is no specific, is incomparably in
favor of the former. If we had as powerful weapons against tuberculosis
as we have against syphilis, the disease would now be a rarity instead
of the disastrous plague it is. Comparing the situation in two diseases
for which we have specifics, such as syphilis and malaria, malaria has
lost most of its seriousness as a problem in any part of the world,
while syphilis is rampant everywhere. Malaria has, of course, been
extinguished not only through the efficiency of quinin, but also through
preventive measures directed at mosquitos, which are the carriers of the
disease from person to person. But allowing for this, if it becomes
possible to apply mercury and salvarsan as thoroughly to the prevention
and treatment of syphilis as quinin can be applied to malaria, syphilis
will soon be a rarity over the larger part of the civilized world. To
bring the specific remedies for syphilis and the patient together
constitutes, then, one of the greatest problems which confronts us in
the control of the disease at the present day.


MERCURY

+Mercury in the Treatment of Syphilis.+ - Mercury is, of course, familiar
to every one, and there is nothing peculiar about the mercury used in
the treatment of syphilis. The fluid metallic mercury itself may be used
in the form of salves, in which the mercury is mixed with fatty
substances and rubbed into the skin. Mercury can be vaporized and the
vapor inhaled, and probably the efficiency of mercury when rubbed into
the skin depends to no small extent on the inhalation of the vapor which
is driven off by the warmth of the body. Mercury in the form of chemical
salts or compounds with other substances can be given as pills or as
liquid medicine. Similarly, the metal itself or some of its compounds
can be injected in oil with a hypodermic needle into the muscles, and
the drug absorbed in this way.

+Misconceptions Concerning Mercury.+ - The use of mercury in syphilis is
nearly as old, in Europe at least, as the disease itself. The drug was
in common use in the fifteenth century for other conditions, and was
promptly tried in the new and terrible disease as it spread over Europe,
with remarkable results. But doses in the old days were anything but
homeopathic, and overdoses of mercury did so much damage that for a time
the drug fell into undeserved disfavor. Many of the superstitions and
popular notions about mercury originated at this period in its history.
It was supposed to make the bones "rot" and the teeth fall out, an idea
which one patient in every ten still entertains and offers as an
objection when told he must take mercury. Insufficiently treated
syphilis is, of course, what makes the bones "rot," and not the mercury
used in treating the disease. Mercury apparently has no effect on the
bones whatever. The influence of the drug on the teeth is more direct
and refers to the symptoms caused by overdoses. No physician who knows
his business ever gives mercury at the present time to the point where
the teeth are in any danger of falling out.

+The Action of Mercury.+ - The action of mercury on syphilis is not
entirely clear. The probabilities are that the drug, carried to all
parts of the body by the blood, helps to build up the body's resistance
and stimulates it to produce substances which kill the germs. In
addition, of course, it kills the germs by its own poisonous qualities.
Its action is somewhat slow, and it is even possible for syphilitic
sores containing the germs to appear, especially in the mouth and throat
and about the genitals, while the person is taking mercury. Just as
quinin must be used in malaria for some time after all signs of chill
and fever have disappeared, to kill off all germs lurking in
out-of-the-way corners of the body, or especially resistant to the drug,
so it is necessary to continue the use of mercury long after it has
disposed of all the obvious signs of the disease, like the eruption,
headaches, and other symptoms, in order to prevent a relapse. No matter
in what form it is used, the action of mercury on syphilis is one of the
marvels of medicine. It can clear up the most terrific eruption with
scarcely a scar, and transform a bed-ridden patient into a seemingly
healthy man or woman, able to work, in the course of a few weeks or
months. Symptoms often vanish before it like snow in a thaw. This
naturally makes a decided impression, and often an unfavorable one, on
the patient. It is only too easy to think that a disease which vanishes
under the magic influence of a few pills is a trifle, and that outwardly
cured means the same thing as inwardly cured. Mercury therefore carries
its disadvantages with its advantages, and by its marvelous but
transient effect only too often gives the patient a false idea of his
progress toward cure.

+Methods of Administering Mercury.+ - As has been said, mercury is given
principally in three ways at the present time. It can be given by the
mouth, in the form of pills and liquids, and in this form is not
infrequently incorporated into patent medicine blood purifiers. Mercury
in pills and liquid medicine has the advantage for the patient of being
an easy and inconspicuous way of taking the drug, and for that reason
patients usually take it willingly or even insist on it if they know no
better. Even small doses taken in this way will hide the evidences of
syphilis so completely that only a blood test will show that it exists.
If it were true that large doses taken by mouth could always be relied
on to cure the disease, there would be little need for other ways of
giving it. But there is a considerable proportion of persons with
syphilis treated with pills who do not get rid of the disease even
though the dose is as large as the stomach can stand. Such patients
often have all the serious late complications which befall untreated
patients. It seems almost impossible to give enough mercury by mouth to
effect a cure. Thus pill treatment has come to be a second-best method,
and suitable only in those instances in which we simply expect to
control the outward signs rather than effect a cure.

The mercury rub or inunction, under ideal conditions, all things
considered, is the best method of administering mercury to a patient
with the hope of securing a permanent result. In this form of treatment
the mercury made up with a salve is rubbed into the skin. The
effectiveness of the mercurial rub is reduced considerably by its
obvious disadvantages. It requires time to do the rubbing, and the
ointment used seems uncleanly because of its color and because it is
necessary to leave what is not rubbed in on the skin so that it
discolors the underwear. The mercurial rub is at its best when it is
given by some one else, since few patients have the needed combination
of conscientiousness, energy, and determination to carry through a long
course. The advantages of the method properly carried out cannot be
overestimated. It is entirely possible in a given case of syphilis to
accomplish by a sufficient number of inunctions everything that mercury
can accomplish, and with the least possible damage to the body.
Treatment by mouth cannot compare with inunctions and cannot be made to
replace them, when the only objection to the rubs is the patient's
unwillingness to be bothered by them. The patient who is determined,
therefore, to do the best thing by himself will take rubs
conscientiously as long as his physician wishes him to do so, even
though it means, as it usually does, not a dozen or two, but several
hundreds of them, extending over a period of two or three years, and
given at the rate of four to six rubs a week.

The giving of mercury by injections is a very powerful method of using
the drug for the cure of syphilis. It reduces the inconvenience of
effective treatment to a minimum and has all the other advantages of
secrecy and convenience. It keeps the patient, moreover, in close touch
with his physician and under careful observation. Injections by some
methods are given daily, by others once or twice a week. The main
disadvantage is the discomfort which follows each injection for a few
hours. For any one who has one of the serious complications of
syphilis, injections may be a life and death necessity. Mercurial
injections are a difficult form of treatment and should be given only by
experts and physicians who are thoroughly familiar with their use.

Like every important drug in medicine, mercury is a poison if it is
abused. Its earliest effect is on the mouth and teeth, and for that
reason the physician, in treating syphilis by vigorous methods, has his
patients give special attention to the care of their mouths and teeth
and of their digestions as well. Mercury also affects the kidneys and
the blood, if not properly given, and for that reason the person who is
taking it must be under the care and observation of a physician from
time to time. Only the ignorant undertake to treat themselves for
syphilis, though how many of these there are can be inferred from the
amount of patent medicine and quack treatment there is in these fields.
Properly given, mercury has no harmful effects, and there is no ground
whatever for the notion some people have, that mercury will do them more
harm than a syphilitic infection. Improperly used, either as too much or
too little, it is capable of doing great harm, not only directly, but
indirectly, by making it impossible later for the patient to take enough
to cure the disease. The extent to which some overconfident persons fail
in their efforts to treat and cure themselves explains the necessity for
such a warning.

+Effect of Mercurial Treatment on the Blood Test.+ - The effect of
mercury on the Wassermann blood test for syphilis should also be
generally understood. In many cases it is possible, especially early in
the disease, by a few rubs of mercurial ointment, or a few injections of
mercury, or even in some cases by the use of pills or liquid medicine,
to make a positive blood test for syphilis negative. But this negative
test is only temporary. Within a short time, usually after treatment is
stopped, the test becomes positive again, showing that the mercury has
not yet cured, but simply checked, the disease, and that it may at any
time break out again or do internal damage. It must be understood that a
negative blood test just after a patient has been taking mercury _has no
meaning_, so far as guaranteeing a cure is concerned. It is only the
blood test that is repeatedly negative after the effect of mercury wears