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
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.