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

by John H. Stokes

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.