SYPHILIS COMPARATIVE STUDY OF DIAGNOSIS AND CURE


This shows that we do not succeed in curing syphilis. If our therapeutic means are impotent to cure syphilis and sterilize the system of treponema, they are incapable of curing all syphilitic lesions which arise in the course of the disease, and they cannot hinder the development of all syphilitic lesions. They have, however, the power of preventing hereditary transmission of syphilis.


IN ARRIVING at the present status of syphilitic therapy, research has brought to light the following :.

From Modern Clinical Syphilology, 2nd Edition, 1936, by John H. Stokes, M.D., Professor of Syphilology, University of Pennsylvania, formerly head of the Section on Syphilology at the Mayo Clinic, member of Commission on Syphilis, League of Nations Health Organization, and Consultant in the U. S. Public Health Service.

“At the League of Nations Conference on Syphilis Treatment, Queyrat, from a large French experience, made the informal statement that the detoxification of antisyphilitic medicaments had proceeded to the point where many of them were therapeutically worthless. Other observers, both in this country and abroad, including Kolmer and myself, have mentioned this position.

The work of Dale and White, and of Voegtlin and his associates in demonstrating the extraordinary fluctuations in therapeutic effectiveness that occur in market lots of neoarsphenamine will be more fully discussed later. The recent demonstration by Kolmer, Schamberg and Brown that the currently used trypanocidal test for arsphenamine therapeutic efficiency is not satisfactory as a test of spirillicidal activity” (p. 173).

“To decide with accuracy and promptitude, first, whether the patient has syphilis or not, and second, what form of modern treatment will most nearly approach the curative goal, is anything but a simple matter from the standpoint of the public health” (p. 174).

“Weigh the risks against the benefits : There are risks so serious, especially in the treatment of late cases by intensive methods, that the patient should not be asked to take them. There are benefits so doubtful and methods so double-edged that a hair- line judgment can every properly be drawn between the decision to do or not to do” (p. 175).

“Therapeutic shock : Jadassohn, in 1898, and Finger, in 1910, gave confirmation, the latter observer first noting the much more striking effect of arsphenamine as a source of such reaction. The term “therapeutic shock” used throughout this work impersonalizes the observation but emphasizes its potential gravity and significance, which are often paramount in the later stages of syphilis and in the involvement of vital structures in which local edema and reaction can have serious and even fatal consequences” (p. 177).

“Therapeutic paradox : The intense action, particularly of the arsphenamines, produces not only therapeutic shock but a rapidity of healing which has disadvantages sometimes far exceeding any possible advantage. In early syphilis, rapid healing provided it be accompanied by adequate spirillicidal action, is ideally desirable. In late syphilis rapid healing is tantamount in many cases to a high degree of fibrosis and replacement of organ parenchyma, which may have the most serious effects.

It was presumably with such considerations in mind that the original directions for the use of arsphenamine, as pointed out by Wile, contained explicit cautions against the indiscriminate use of the drug in late syphilis of the visceral and cardiovascular apparatus. To Wile belongs the distinction of having formally revived these cautions after a decade of indiscriminate enthusiasm and to have pointed out the seriousness of what he has called therapeutic paradox as a general problem of treatment. My contacts with the older clinicians have gradually weaned me away from the excessive confidence in the arsphenamines which I shared with the arsphenamine therapeutic generation a decade ago” (p. 179).

“A typical example of arsphenamine therapeutic paradox appears in the treatment of syphilitic cirrhosis of the liver. The patient with a markedly enlarged, diffusely involved cirrhotic liver, but showing no evidence of portal obstruction, is placed at the outset on arsphenamine treatment, and makes an initial rapid response with improvement in general condition and marked reduction in the size of the liver. This therapeutics gain, however, is too often short-lived.

Presently the patient begins to lose ground; the shrinking of the liver by the rapidly developed fibrosis is accompanied by obstruction of portal circulation, ascites appears and serious complications with perhaps an ultimately fatal outcome, too often ensue. In a case of this sort the rapid healing effects have so seriously interfered with the circulation and function of the liver that by virtually reducing an important viscus to a mass of fibrous tissue, the drug has killed the patient while curing the disease.

In coronary and myocardial involvement the rapid advance of myocardial fibrosis and embarrassment of circulation by coronary occlusion is one of the distressing sequels of the too ready use of arsphenamine in syphilitic cardiovascular disease. DeSchweinitz has repeatedly emphasized to me the damage done by fibrotic healing under arsphenamine treatment as applied to ocular syphilis” (pp. 179-180).

“Intuitive and experiential factors : It has always been hard to realize that our vision of what is really happening under treatment is indirect and subject to unknown correction in term of peculiarities of host and organism, for which we have no means of measurement or detection. We expect standard results for standard amounts of treatment, as if we were carving a block of known hardness with stools of a known edge.

Instead, we obtain a central group of good results, a margin of medium results, and a fringe of failures which, when seen in itemized form, looms large. It is not too much to say that there is a modern technic whose effectiveness can be expected to range from 50 to 100 per cent for the achievement of every practical therapeutic aim in connection with the disease. To refer to hearsay or to the instructions on the drug wrapper, may lead to a catastrophic denouncement” (pp. 180-180).

“System vs. individualization : While this phase of the disease may tolerate the therapeutic pounding appropriate to the radical cure objective in the early weeks or months of the disease, it is a very proper question, involving many still unsolved problems in the defense mechanism, as to whether such routinized and perhaps overenergetic treatment is necessary or desirable. Certainly, with respect to the older patient suffering under the handicap of increasing years with their attendant incapacities of syphilitic and other origin, therapeutic bludge can not be made a routine” (p. 182).

“The parasitotropic views : A number of investigations have shown that the mode of action of one therapeutic compound upon two different types of organisms or even upon two species within the same family, may vary considerably and that compounds within the same group, as for example, the arsphenamines, may act in different ways upon the same organism. This makes grouping extremely difficult but none the less not wholly impractical” (p.187).

A schematic comparison of arsphenamine, bismuth and.

mercury (p. 188).

Arsphenamines | Bismuth | Mercury

Induces therapeutic |Too slow for |Practically not directly.

paradox & healing

|public health | spirillicidal.

fibrosis. |purposes. |Does not control infectious

Hence dangerous at the | | lesions.

outset in late syphilis | |Totally inadequate

alone.

of vital structure. | | in early syphilis.

Toxic for heart and | |

blood vessels. | |

Toxic for liver and skin.| |

Gastro-intestinal | |

toxicity annoying, not | |

serious. | |

“Treatment allergy : The arsphenamines have a distinctive and unfortunate peculiarity of great importance to the general management of treatment for syphilis. This is the ability, when insufficiently used, particularly, to induce a state of hypersusceptibility in the patient, which results in fulminating relapse, provided the infection has not been extinguished. The analogy of this peculiar state to the umstimmung or allergy of late syphilis is quite apparent clinically, for the allergic type of relapse usually takes on the clinical characteristic of huge and destructive gumma formation in skin, bones, or even the nervous system.

A convenient though by no means an evaluated theory of this sometimes disastrous result of insufficient treatment is the view that the rapid destruction of the organisms of the disease by the arsphenamine group of drugs deprives the body of its one primordial and essential stimulus to fight the infection on its own account, namely, the presence over a long period of time of the pathogenic agent” (p. 197).

“The radical or complete curability of syphilis in man remains to be proved. The control of the disease by prevention of infection is possible” (p. 230).

“Warnings of hepatic complications : Some liver injury probably accompanies all treatment with arsenicals and may be serious” (p. 482).

“Therapeutic shock : as has been stated, occurs in all acute processes in the eye when treatment for syphilis begins, even, paradoxically, when there is no syphilis present, as in nonspecific therapy (see p. 203). Haemorrhages into the vitreous may be precipitated in patients who have had them before, and a nonspecific uveitis may show a marked flare-up with subsequent improvement.

C.P.Bryant
C. P. BRYANT, M. D.
Seattle.
Chairman, Bureau of Surgery