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
profession are abreast of the most advanced knowledge of the subject.
Syphilis, almost up to the present day, has never been adequately taught
as part of a medical training. Those who obtained a smattering of
knowledge about it from half a dozen sources in their school days were
fortunate. Thorough knowledge of the disease, of the infinite variety of
its forms, of the surest means of recognizing it, and the best methods
of treating it, is only beginning to be available for medical students
at the hands of expert teachers of the subject. The profession, by the
great advances in the medical teaching of syphilis in the past ten
years, and the greater advances yet to come, is, however, doing its best
to meet its share of responsibility in preparation for a successful
campaign. The combination of the physician who insists on curing
syphilis, with the patient who insists on being cured, may well be
irresistible.
+Factors Influencing the Cure of Syphilis.--Cost.+--We must admit that,
as matters stand now, few patients are interested in more than a
symptomatic cure. Yet the increasing demand for blood tests, for
example, shows that they are waking up. Ignorance of the possibility and
necessity for radical cure, and of the means of obtaining it, explains
much of the indifference which leads patients to disappear from their
physician's care just as the goal is in sight. But there is another
reason why syphilis is so seldom cured, and this is one which every
forward-looking man and woman should heed. The cure of syphilis means
from two to four years of medical care. All of us know the cost of such
services for even a brief illness. A prolonged one often sets the victim
farther back in purse than forward in health. The better the services
which we wish to command in these days, usually, the greater the cost,
and expert supervision, at least, is desirable in syphilis. It is a
financial impossibility for many of the victims of syphilis to meet the
cost of a radical cure. It is all they can do to pay for symptomatic
care in order to get themselves back into condition to work. We cannot
then reasonably demand of these patients that they shall be cured, in
the interest of others, unless we provide them with the means. In
talking about public effort against syphilis, this matter will be taken
up again. We have recognized the obligation in tuberculosis. Let us now
provide for it in syphilis.
+Factors Controlling the Cure of Syphilis--Stage, Time, Effective
Treatment.+--Three factors enter into the radical cure of syphilis, upon
which the possibility of accomplishing it absolutely depends. The first
of these concerns the stage of the disease at which treatment is begun;
the second is the time for which it is kept up; and the third is the
coöperation of doctor and patient in the use of effective methods of
treatment.
+Cure in the Primary Stage.+--It goes almost without saying that the
prospect of curing a disease is better the earlier treatment is begun.
This is peculiarly so in syphilis. In the earliest days of the disease,
while the infection is still local and the blood test negative, the
prospects of radical cure are practically 100 per cent. This is the
so-called abortive cure, the greatest gift which salvarsan has made to
our power to fight syphilis. It depends on immediate recognition of the
chancre and immediate and strenuous treatment. So valuable is it that
several physicians of large experience have expressed the belief that
even in cases in which we are not entirely sure the first sore is
syphilitic, we should undertake an abortive treatment for syphilis. This
view may be extreme, but it illustrates how enormously worth while the
early treatment of syphilis is.
+Cure in the Secondary Stage.+--The estimation of the prospect of
recovery when the secondary symptoms have appeared and the germs are in
the blood is difficult, owing to the rapid changes in our knowledge of
the disease, which are taking place almost from day to day. The patient
usually presses his physician for an estimate of his chances, and in
such cases, after carefully explaining why our knowledge is fallible and
subject to change, I usually estimate that for a patient who will
absolutely follow the advice of an expert, the prospects are well over
90 per cent good.
+The Outlook in Late Syphilis.+--After the first year of the infection
is passed, or even six months after the appearance of the secondary
rash, the outlook for permanent cure begins to diminish and falls
rapidly from this point on. That means that we are less and less able
to tell where we stand by the tests we now have.
In the later stages of the disease we are gradually forced back to
symptomatic measures, and are often rather glad to be able to say to the
patient that we can clear up his immediate trouble without mentioning
anything about his future.
The gist of the first essential, then, is to treat syphilis early rather
than late. If this is done, the prospect of recovery is better than in
many of the acute fevers, such as scarlet fever, a matter of every day
familiarity, and better, on the whole, than in such a disease as
tuberculosis. _Yet this does not mean that the men or women whose
syphilis is discovered only after a lapse of years, must be abandoned to
a hopeless fate._ For them, too, excellent prospects still exist, and
careful, persistent treatment may, in a high percentage of cases, keep
their symptoms under control for years, if not for the ordinary
life-time.
+The Time Required for Cure.+--Time is the second vital essential for
cure. Here we stand on less certain ground than in the matter of the
stage of the disease. The time necessary for cure is not a fixed one,
and depends on the individual case. Long experience has taught us that
the cure of syphilis is not a matter of weeks or months, as patients so
often expect, but of years. For the cure of early primary syphilis
("abortive" cure) not the most enthusiastic will discharge a patient
short of a year, and the conservative insist on two years or more of
observation at least. In the fully developed infection in the secondary
stage, three years is a minimum and four years an average for treatment
to produce a cure. Five years of treatment and observation is not an
uncommon period. In the later stages of the disease, when we are
compelled to give up the ideal of radical cure, our best advice to
syphilitic patients, as to those with old tuberculosis, is that after
they have had two years of good treatment, they should submit to
examination once or twice a year, and not grumble if they are called
upon to carry life insurance in the form of occasional short courses of
treatment for the rest of their days.
+Efficient Treatment.+--The third essential is efficient treatment,
about the nature of which there is still some dispute. The controversy,
however, is mainly about details. In the modern methods for treatment of
syphilis both salvarsan and mercury are used, as a rule, and keep the
patient decidedly busy for the first year taking rubs and injections,
and pretty busy for the second. The patient is not incapacitated for
carrying on his usual work. The intervals of rest between courses of
salvarsan and mercury are short. In the third year the intervals of rest
grow longer, and in the absence of symptoms the patient has more chance
to forget the trouble. Here the doctor's difficulties begin, for after
two or three negative blood tests with a clear skin, all but the most
conscientious patients disappear from observation. These are the ones
who may pay later for the folly of their earlier years.
The aim in syphilis, then, is to crush the disease at its outset by a
vigorous campaign. Not until an amount of treatment which experience
has shown to be an average requirement has been given, is it safe to
draw breath and wait to see what the effect on the enemy has been.
Dilatory tactics and compromises are often more dangerous than giving a
little more than the least amount of treatment possible, for good
measure. This is, of course, always provided the behavior of the body
under the ordeal of treatment is closely studied and observed by an
expert and that it is not blindly pushed to the point where injury is
done by the medicine rather than the disease.
+The Importance of Salvarsan.+--Salvarsan is an absolute essential in
the treatment of those early infections in which an abortive cure can be
hoped for, and in them it must be begun without a day's delay. To some
extent, the abortive cure of the disease, with its 100 per cent
certainty, will therefore remain a luxury until the public is aroused to
the necessity of providing it under safe conditions and without
restrictions for all who need it. At all stages of the disease after the
earliest it is an aid, and a powerful one, but it cannot do the work
alone, as mercury usually can. But though mercury is efficient, it is
slow, and the greater rapidity of action of salvarsan and its power to
control infectious lesions give it a unique place. The combination of
the two is powerful enough to fully justify the statement that none of
the great scourges of the human race offers its victim a better prospect
of recovery than does syphilis.
Is a cure worth while? There is only one thing that is more so, and
that is never to have had syphilis at all. The uncured syphilitic has a
sword hanging over his head. At any day or hour the disease which he
scorned or ignored may crush him, or what is worse, may crush what is
nearest and dearest to him in the world. It does it with a certainty
which not even the physician who sees syphilis all the time as his
life-work can get callous to. It is gambling with the cards stacked
against one to let a syphilitic infection go untreated, or treated short
of cure. It is criminal to force on others the risks to which an
untreated syphilitic subjects those in intimate contact with him.
+The Meaning of "You are Cured."+--How do we judge whether a patient is
radically cured or not? Here again we confront the problem of what
constitutes the eradication of the disease. In part we reckon from long
experience, and in part depend upon the refinement of our modern tests.
Repeated negative Wassermann tests on the blood over several years,
especially after treatment is stopped, are an essential sign of cure.
This must be reinforced, as a rule, by a searching examination of the
nervous system, including a test on the fluid of the spinal cord. This
is especially necessary when we have used some of the quick methods of
cure, like the abortive treatment. When we have used the old reliable
course, it is less essential, but desirable. Can we ever say to a
patient in so many words, "Go! you are cured"? This is the gravest
question before experts on syphilis today, and in all frankness it must
be said that the conservative man will not answer with an unqualified
"Yes." He will reserve the right to say to the patient that he must from
time to time, in his own interest, be reëxamined for signs of
recurrence, and perhaps from time to time reinforce his immunity by a
course of rubs or a few mercurial injections. Such a statement is not
pessimism, but merely the same deliberate recognition of the fallibility
of human judgment and the uncertainty of life which we show when we
sleep out-of-doors after we have been suspected of having tuberculosis,
or when we take out accident or life insurance.