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.