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

off, which shows the disease is cured. Yet many a syphilitic may and
does think himself cured, and may marry in good faith, or be allowed a
health certificate, only to become positive again. He may then develop
new sores without his knowledge even, and perhaps infect his wife, or
may himself in later years develop some of the serious consequences of
the disease.

Whenever one talks to a person who knows something about the advances in
knowledge in the past few years about the treatment of syphilis, and
goes into detail about mercury, the odds are two to one that he will be
interrupted by the question, "But what about '606'?" Before talking
about salvarsan, or "606," it is well to say here that this new drug,
wonderful though it is, has in no sense done away with the necessity for
the use of mercury in the treatment of syphilis. Mercury has as high a
reputation and is as indispensable in the cure of syphilis today as it
was four centuries ago. It has as yet no substitutes. We appreciate
every day, more and more, how thoroughly it can be depended on to do the
work we ask of it.[8]

[8] A drug known as the iodid of potash (or soda) is widely used in
the treatment of syphilis, and especially of the late forms of the
disease, such as gummas and gummatous sores. It has a peculiar
effect on gummatous tissue, causing it to melt away, so to speak,
and greatly hastening the healing process. So remarkable is this
effect that it gives the impression that iodids are really curing
the syphilis itself. It has been shown, however, that iodids have no
effect on the germs of syphilis, and therefore on the cause of the
disease, although they can promote the healing of the sores in the
late stages. For this reason iodids must always be used in
connection with mercury or salvarsan if the disease itself is to be
influenced. It is occasionally difficult to get patients to
understand this after they have once taken "drops," as the medicine
is often called. Otherwise the use of iodids in syphilis is of
medical rather than general interest.




Chapter VIII

The Treatment of Syphilis (Continued)


SALVARSAN

+The Discovery of Salvarsan ("606").+ - Salvarsan, or "606," is a
chemical compound used in the modern treatment of syphilis. It was
announced to the world by Paul Ehrlich, its brilliant discoverer, in
December, 1910. Ehrlich and his Japanese co-worker, Hata, had some years
before been impressed with the remarkable effect certain dyes had on the
parasites infesting certain animals and which resemble the germs that
cause the African sleeping sickness in man. When one of these dyes was
dissolved and injected into the blood of the sick animal, the dye
promptly picked out and killed all the parasites, but did not kill the
animal. Dyes are very complex chemical substances and certain of them
seem to have an affinity for germs. It occurred to Ehrlich that if a
substance could be devised which was poisonous for the germ and not for
the patient it might be possible to prepare a specific for a given
disease, acting as quinin does in malaria. By combining a poison with a
dye it might be made to pick out the germs and leave the body unharmed.

[Illustration: PAUL EHRLICH [1854-1915]

(From "Year Book of Skin and Venereal Diseases," 1916, vol. ix.
"Practical Medicine Series," Year Book Publishers, Chicago.)]

The poison which had already been shown to be especially effective in
killing germs like those of syphilis was arsenic. The problem was to
get arsenic into such a combination with other chemical substances that
it would lose its poisonous quality for man, but still be poisonous for
the spirochete of syphilis. Ehrlich and Hata began to make chemical
compounds of arsenic in the laboratory with chemical substances like the
dyes. As the compounds grew more complex they were tested on animals and
some of them found to have the qualities for which their inventors were
searching. Some of them are even used at the present time in the
treatment of certain diseases. The six hundred and sixth compound in
this series, when tested on syphilitic animals, was found to be
extraordinarily efficient in killing the germ of syphilis, even when
used in quantities so small as not to injure the animal. Among other
things, there could be no better example of the importance of animal
experiment in medicine. If the cause of syphilis had not been known, and
the disease not given to animals, the discovery of salvarsan might never
have been made. After extensive experiments on syphilitic rabbits, which
showed that the drug could be given safely in amounts large enough to
cure the animal at a single dose, it was tried on man, two physicians,
Drs. Hoppe and Wittneben, volunteering for the test. When it was found
that the drug did them no harm, it was used on syphilitic patients for
the first time. As soon as its remarkable effect on the disease in them
was fully established, Ehrlich announced the discovery before the
medical society of Magdeburg, and the results were published in one of
the most important of the German medical journals. Ehrlich then sent
out from his own laboratory several thousands of doses of the new drug
to all the principal clinics and large hospitals of the world for an
extended trial. It was not until the results of this trial became
apparent that he permitted its manufacture on a commercial scale. There
could scarcely be a more ideal way of introducing a new form of
treatment than the one adopted by Ehrlich, or one better surrounded by
all the safeguards that conservatism could suggest.

+The Mistaken Conception of "Single Dose Cure."+ - In the light of his
experience with salvarsan in animals, Ehrlich hoped to accomplish the
cure of syphilis in man by a single dose of the new drug, as he had been
able to cure it in rabbits. All the earlier use of salvarsan in the
treatment of syphilis was carried out with this idea in view, and the
remarkable way in which the symptoms vanished before the large doses
used encouraged the belief that Ehrlich's ideal for it had been
fulfilled. But it was not long before it was found that syphilis had a
stronger hold on the human body than on animals, and that patients
relapsed after a single dose, either as shown by the blood test or by
the reappearance, after varying intervals, of the eruption or other
symptoms of the disease. Unfortunately, the news of the discovery of
salvarsan, and with it Ehrlich's original idea that it would cure
syphilis by a single dose, had gotten into the newspapers. Numbers of
syphilitics treated with it have been deceived by this notion into
believing themselves cured. In those whose symptoms came back in severe
form, the trouble was, of course, found out. But there are at the
present time, undoubtedly, many persons who received a single dose of
salvarsan for a syphilis contracted at this time, and who today, having
never seen any further outward signs of the disease, believe themselves
cured, when in reality they are not. In the next twenty years the
introduction of salvarsan will probably result in a wave of serious late
syphilis, the result of cases insufficiently treated in the early days
of its use. It was not long before it was found that not one but several
doses of salvarsan were necessary in the treatment of syphilis, and soon
many physicians of wide experience began to call in mercury again for
help when salvarsan proved insufficient for cure. At the present time
the use of both mercury and salvarsan in the treatment of the disease is
the most widely accepted practice, and seems to offer the greatest
assurance of cure.

+The Value of Salvarsan.+ - Salvarsan has done for the treatment of
syphilis certain things of the most far-reaching importance from the
standpoint of the interests of society at large. It has first of all
made possible the control of the _contagious_ lesions of the disease.
Secondly, as was said before, it has made possible the cure of the
infection in the primary stage, before it has spread from the
starting-point in the chancre to the rest of the body. To understand how
it accomplishes these results it is important to understand its mode of
action.

+The Action of Salvarsan.+ - It will be recalled that Ehrlich planned
salvarsan to kill the germs of syphilis, just as quinin kills the germs
of malaria. It was intended that when the drug entered the blood it
should be carried to every part of the body, and fastening itself on the
spirochetes, kill them without hurting the body. This is seemingly
exactly what the drug does, and it does it so well that within
twenty-four hours after a dose of it is given into the blood there is
not a living germ of syphilis, apparently, in any sore on the body. If
the same thing happened in all the out-of-the-way corners of the body,
the cure would be complete. The natural result of removing the cause of
the disease in this fashion is that the sores produced by it heal up.
They heal with a speed and completeness that is an even greater marvel
than the action of mercury. The more superficial the eruption, the
quicker it vanishes, so that in the course of a few days all evidence of
the disease may disappear. This is especially true of the grayish
patches in the mouth and about the genitals, which have already been
described as the most dangerously contagious lesions of syphilis. It is
evident, therefore, that to give salvarsan in a case of contagious
syphilis is to do away with the risk of spreading the disease in the
quickest and most effective fashion. It is as if a person with scarlet
fever could be dipped in a disinfecting bath and then turned loose in
the community without the slightest danger of his infecting others. How
much scarlet fever would there be if every case of the disease could be
treated in this way? There would be as little of it as there now is of
smallpox, compared to the wholesale plagues of that disease which used
to kill off the population of whole towns and counties in the old days.
If we could head off the crops of contagious sores in every syphilitic
by the use of "606," syphilis in the same way would take a long step
toward its disappearance. It is not a question, in this connection, of
curing the disease with salvarsan, but of preventing its spread, and in
doing that, salvarsan is one of the things we have been looking for for
centuries.

+The Treatment of Syphilis With Salvarsan.+ - Salvarsan, the original
"606," was improved on by Ehrlich in certain ways, which make it easier
for the ordinary physician to use it. The improved salvarsan is called
neosalvarsan ("914") and has no decided advantages over the older
preparation except on the score of convenience. Both salvarsan and
neosalvarsan are yellow powders, which must be manufactured under the
most exacting precautions, to prevent their being intensely poisonous,
and must be sealed up in glass tubes to prevent their spoiling in the
air. They were formerly administered by dissolving them or by mixing
with oil and then injecting them into the muscles, much as mercury is
given by injection. At the present time, however, the majority of
experts prefer to dissolve the drug in water or salt solution and to
inject it into the blood directly, through one of the arm veins. There
is very little discomfort in the method, as a rule - no more than there
is to the taking of blood for a blood test. At the present time the
quantity of the drug injected is relatively small for the first
injection, growing larger with each following injection. The intervals
between injections vary a good deal, but a week is an average. The
number of injections that should be given depends largely on the purpose
in view. If the salvarsan is relied on to produce a cure, the number may
be large - as high as twenty or more. If it is used only to clear up a
contagious sore, a single injection may be enough for the time being.
But when only a few injections are used, mercury becomes the main
reliance, and a patient who cannot have all the salvarsan he needs
should not expect two or three doses of it to produce a cure. The
publicity which has been given to this form of treatment has led many
patients to take matters into their own hands and to go to a physician
and ask him to give them a dose of salvarsan, much as they might order a
highball on a cold day. The physician who is put in a position like this
is at a disadvantage in caring for his patient, and the patient in the
end pays for his mistaken idea that he knows what is good for himself.
The only judge of the necessity of giving salvarsan, and the amount and
the frequency with which to give it, is the expert physician, and no
patient who is wise will try to take the thing into his own hands. There
are even good reasons for believing that the patient who is
insufficiently treated with salvarsan is at times worse off than the
patient who, unable to afford the drug at all, has had to depend for his
cure entirely on mercury.

It is one of the tragedies of the modern private practice of medicine
that the physician has so often to consult the patient's purse in giving
or withholding salvarsan, and for that reason, except in the
well-to-do, it is seldom used to the best advantage. Such a drug, so
powerful an agent in the conservation of the public health, should be
available to all who need it in as large amounts as necessary, without a
moment's hesitation as to whether the patient can afford it or not. It
is not too much to urge that private patent rights should not be allowed
to control the price and distribution of such a commodity to the public.
Upon the payment of suitable royalties to the inventor the manufacture
of such a drug should be thrown open to properly supervised competition,
as in the case of diphtheria antitoxin, or be taken over by the
Government and distributed at cost, at least to hospitals. To bring
about such a revision of our patent law every thinking man and woman may
well devote a share of personal energy and influence.

The manner of giving salvarsan is as important for the patient as the
correct performance of an operation, and the safeguards which surround
it are essentially the same. The drug is an extremely powerful one, more
powerful than any other known, and in the usual doses it carries with it
into the body for the destruction of the germs of syphilis many times
the amount of arsenic needed to kill a human being. If something should
go astray, the patient might lose his life as promptly as if the surgeon
or the anesthetist should make a slip during an operation. To make the
giving of salvarsan safe, the judgment, experience, and training of the
specialist are not too much to ask.

The dangers of salvarsan are easily exaggerated, and some people have a
foolish fear of it. The wonderful thing about the drug is that, with all
the possibility for harm that one might expect in it, it so seldom makes
any trouble. It is, of course, first carefully tested on animals when it
is manufactured, so that no poisonous product is placed on the market.
It is as safe to take salvarsan at the hands of an expert as it is to
take ether for an operation or to take antitoxin for diphtheria, and
that is saying a good deal. Most of the stories of accidents that go the
rounds among laymen date back to the days when first doses were too
large and made the patients rather sick for a time. Present methods and
cautions about administering the drug are such that, except for the
improvement in their condition, patients seldom know they have received
it. The first dose may light the eruption up a little, but this is only
because the drug stirs the germs up before it kills them, and
improvement begins promptly within a few hours or a day or two.

The first characteristic of salvarsan which we should bear in mind
especially, in our interest in the social aspects of syphilis, is then
the rapidity rather than the thoroughness of its action. It is a social
asset to us because it protects us from the infected person, and it is
an asset to the patient because it will set him on his feet, able to
work and go about his business, in a fraction of the time that mercury
can do it.

The efficiency of salvarsan in the cure of syphilis in the early stages
is due, first, to the large amount of it that can be introduced into the
body without killing the patient, and second, to the promptness with
which it gets to the source of trouble. In the old days, while we were
laboriously getting enough mercury into the patient to help him to stop
the invading infection, the germs marched on into his blood and through
his body. With salvarsan, the first dose, given into the blood, reaches
the germs forthwith and destroys them. There is enough of it and to
spare. Twenty-four hours later scarcely a living germ remains. The few
stragglers who escape the fate of the main army are picked up by
subsequent doses of salvarsan and mercury, and a cure is assured. There
is all the difference between stopping a charge with a machine gun and
stopping it with a single-shot rifle, in the relative effectiveness of
salvarsan and mercury at the beginning of a syphilitic infection.

In syphilis affecting the central nervous system, salvarsan,
modified in various ways, may be injected into the spinal canal in
an effort to reach the trouble more directly. The method, which is
known as _intradural therapy_, has had considerable vogue, but a
growing experience with it seems to indicate that it has less value
than was supposed, and is a last resort more often than anything
else. It involves some risk, and is no substitute for efficient
treatment by the more familiar methods. If necessary, a patient can
have the benefit of both.

The _luetin test_ was devised by Noguchi for the presence of
syphilis, and is performed by injecting into the skin an emulsion
of dead germs. A pustule forms if the test is positive. It is of
practical value only in late syphilis, and a negative test is no
proof of the absence of the disease. Positive tests are sometimes
obtained when syphilis is not present. For these reasons the test
is not as valuable as was at first thought.




Chapter IX

The Cure of Syphilis


There are few things about our situation with regard to syphilis that
deserve more urgent attention than questions connected with the cure of
the disease, and few things in which it is harder to get the necessary
coöperation. On the one hand, syphilis is one of the most curable of
diseases, and on the other, it is one of the most incurable. At the one
extreme we have the situation in our own hands, at our own terms - at the
other, we have a record of disappointing failure. As matters stand now,
we do not cure syphilis. We simply cloak it, gloss it over, keep it
under the surface. Nobody knows how much syphilis is cured, partly
because nobody knows how much syphilis there really is, and partly
because it is almost an axiom that few, except persons of high
intelligence and sufficient means, stick to treatment until they can be
discharged as cured. Take into consideration, too, the fact that the
older methods of treating syphilis were scarcely equal to the task of
curing the disease, and it is easy to see why the idea has arisen, even
among physicians, that once a syphilitic means always a syphilitic, and
that the disease is incurable.

+Radical or Complete Cure.+ - In speaking of the cure of syphilis, it is
worth while to define the terms we use rather clearly. It is worth while
to speak in connection with this disease of radical as distinguished
from symptomatic cure. In a radical cure we clear up the patient so
completely that he never suffers a relapse. In symptomatic cure, which
is not really cure at all, we simply clear up the symptoms for which he
seeks medical advice, without thought for what he may develop next.
Theoretically, the radical cure of syphilis should mean ridding the body
of every single germ of the disease. Practically speaking, we have no
means of telling with certainty when this has been done, or as yet,
whether it ever can be done. It may well be that further study of the
disease will show that, especially in fully developed cases, we simply
reduce the infection to harmlessness, or suppress it, without
eradicating the last few germs. Recent work by Warthin tends to
substantiate this idea. So we are compelled in practice to limit our
conception of radical cure to the condition in which we have not only
gotten rid of every single symptom of active syphilis in the patient,
but have carried the treatment to the point where, so far as we can
detect in life, he never develops any further evidence of the disease.
He lives out his normal span of years in the normal way, and without
having his efficiency as a human being affected by it. In interpreting
this ideal for a given case we should not forget that radical methods of
treating syphilis are new. Only time can pass full verdict upon them.
Yet the efficiency of older methods was sufficient to control the
disease in a considerable percentage of those affected. There is,
therefore, every reason to believe that radical cure under the newer
methods is a practical and attainable ideal in an even higher percentage
of cases and offers all the assurance that any reasonable person need
ask for the conduct of life. It should, therefore, be sought for in
every case in which expert judgment deems it worth while. It cannot be
said too often that prospect of radical cure depends first and foremost
upon the stage of the disease at which treatment is begun, and that it
is unreasonable to judge it by what it fails to accomplish in persons
upon whom the infection has once thoroughly fastened itself.

+Symptomatic or Incomplete Cure.+ - Symptomatic "cure" is essentially a
process of cloaking or glossing over the infection. It is easy to obtain
in the early stages of the disease, and in a certain sense, the earlier
in the course of the disease such half-way methods are applied, the
worse it is for patient and public. In the late stages of the disease
symptomatic cure of certain lesions is sometimes justifiable on the
score that damage already done cannot be repaired, the risk of infecting
others is over, and all that can be hoped for is to make some
improvement in the condition. But applied early, symptomatic methods
whisk the outward evidences temporarily out of sight, create a false
sense of security, and leave the disease to proceed quietly below the
surface, to the undoing of its victim. Such patients get an entirely
false idea of their condition, and may refuse to believe that they are
not really cured, or may have no occasion even to wonder whether they
are or not until they are beyond help. Every statement that can be made
about the danger of syphilis to the public health applies with full
force to the symptomatically treated early case. Trifling relapses,
highly contagious sores in the mouth, or elsewhere, are not prevented by
symptomatic treatment and pass unnoticed the more readily because the
patient feels himself secure in what has been done for him. In the first
five years of an inefficiently treated infection, and sometimes longer,
this danger is a very near and terrible one, to which thousands fall
victims every year, and among them, perhaps, some of your friends and
mine. Dangerous syphilis is imperfectly treated syphilis, and at any
moment it may confront us in our drawing rooms, in the swimming pool,
across the counter of the store, or in the milkman, the waitress, the
barber. It confronts thousands of wives and children in the person of
half-cured fathers, infected nurse-maids, and others intimately
associated with their personal life. These dangers can be effectively
removed from our midst by the substitution of radical for symptomatic
methods and ideals of cure. A person under vigorous treatment with a
view to radical cure, with the observation of his condition by a
physician which that implies, is nearly harmless. In a reasonable time
he can be made fit even for marriage. The whole contagious period of
syphilis would lose its contagiousness if every patient and physician
refused to think of anything but radical cure.

In such a demand as this for the highest ideals in the treatment of a
disease like syphilis, the medical profession must, of course, stand
prepared to do its share toward securing the best results. No one
concedes more freely than the physician himself that, in the recognition
and radical treatment of syphilis, not all the members of the medical