Syphilis: A Motion Picture Clinic (USPHS, 1937)

Syphilis: A Motion Picture Clinic (USPHS, 1937)

January 13, 2020 14 By Peter Engel


[Music] [Narrator:] This motion picture clinic is
the first attempt of its kind to present, for the use of physicians only, a clinic covering
the diagnosis, treatment, and general care of a disease. We present first Dr. Charles Gordon Heyd of New York City, president of the American Medical Association, who speaks to you from the headquarters of the Association in Chicago. [Dr. Heyd:] The American Medical Association is delighted to join forces with the United States Public Health Service in the endeavor to stamp out syphilis. Other nations have shown us that much can
be done. Man has the ability to banish infectious diseases from the earth. The purpose of this film is to provide every
doctor with a complete resume of the present-day knowledge of syphilis in all of its phases. There comes from the public an insistent demand for medical services in the prevention, the diagnosis, and the treatment of this disease. The time is opportune. The necessity for eradication
is imperative. The American Medical Association offers this
motion picture to the medical profession as a new type of medical teaching, and as a significant
contribution to graduate medical instruction. [Narrator:] We move next to the headquarters
of the United States Public Health Service in Washington DC. Dr. Thomas Parran, Surgeon
General, speaks. [Dr. Parran:] Our two great medical forces,
the private physicians and the health officers, have joined hands in this campaign against
syphilis. To the private physician, I would say, diagnose
syphilis early. Treat syphilis adequately. Report your new cases, and your last cases.
Teach syphilis to your individual patients. To the health officer, I would say, learn
the extent of your syphilis problem. Provide adequate treatment facilities and a complete laboratory service. Find new cases. Maintain an efficient follow-up
service. And teach syphilis to the masses. By the consistent application of these principles,
this disease can be brought under control. Our children will hold us criminally careless and incompetent if, with the means at hand, we fail to end this scourge within our generation. Syphilis must be the next great plague to go. We must attack it now. [Narrator:] Dr. John A. Stokes, Professor
of Dermatology and Syphilology in the University of Pennsylvania’s School of Medicine, presents
the diagnosis of early syphilis. [Dr. Stokes:] The diagnosis of early syphilis, primary and secondary, is a laboratory problem. The physician in practice must therefore suspect,
examine, closely and completely. Collect diagnostic material. Collect it again
and again. If you cannot do so, call an expert who can. Follow tenaciously and relentlessly,
through time, and with the aid of contact tracing and serologic follow-up, each case
to a definite conclusion. The old-time clinical criteria for differentiation
of early syphilis are unsound diagnostically in primary syphilis, intricate and puzzling
in secondary syphilis, procrastinating and dangerous in both. The chancre may occur anywhere except on the teeth and nails. May be too small to be visible to the patient. So large as to deceive the physician. May not develop at all. May be superposed
on any open wound or sore. Does not require previous abrasion. May be out of sight in urethra or on cervix. May be masked by the discharge of a gonorrhea or produce its own urethral discharge. Histories of exposure and calculated incubation periods are unreliable. Do not expect to see typical lesions. Regard
all genital lesions with some suspicion. And in all lesions, genital or extra-genital,
look for but do not overweigh the three great suspicion-arousing features of indolence: induration, firm or cartilaginous feel, satellite adenopathy, a local lymph node enlargement- bilateral on the genitalia, unilateral elsewhere, discrete, usually not tender. In particular, make no final clinical diagnosis of chancroid, exclusive of syphilis on any but serologic follow-up tests. Mixed ulcers
are common. The darkfield examination is critically important
in the first week of the primary lesion, less so the second week, and merely confirmatory of serologic diagnosis, though usefully so, thereafter. Though an untreated lesion is desirable, it
is not indispensable. Salt-solution soaking for 24 hours, aspiration of an indurated base, [The physician holds up the various instruments needed to perform these tests.] suction after vigorous rubbing or scraping, aspiration of adjacent lymph nodes. Repeated collection of material on successive days may yield a positive darkfield. The inexperienced physician is not encouraged
to use the darkfield microscope. The direct darkfield examination from the fresh specimen is, however, the ideal when performed by the experienced or expert. The essential requirements for satisfactory
material intended for darkfield examination for Spirochaeta pallida are: lymph or blood
serum, not blood, from the deeper parts of the lesion. Clean and abrade the surface gently, but with determination. Collect in a capillary tube, with or without the aid of a suction bulb. [The physician holds up first a capillary tube, then a suction bulb as he describes the necessary steps.] The ends of the tube then seal by thrusting
into sterile petrolatum. The blank form filled out. And the capillary tube then returned to the container which is sealed and sent at once. Request report by phone or wire if positive.
In his eagerness to prove a case, let no physician be betrayed into doing either a provocative
procedure or a therapeutic test in a doubtful situation. If the patient will not wait, he should agree
to go ahead under such circumstances with a full year or more of standard treatment
for syphilis regardless of the test results. If the first darkfield fails or is negative,
repeat at one or two-day intervals, using salt-solution wet dressings or soaks between time. Persistence over a week, if possible, is essential. Examination of women patients for primary syphilis is rarely adequate. Lesions on the external genitalia are inconspicuous and symptomless. About 60 percent of chancres of the genitalia
in women occur on the cervix and require darkfield on a specimen obtained with a long capillary
pipette, on speculum exposure of the cervix. The clinical appearances ranging from a vesicle
to a pseudo-carcinoma are totally deceiving. Make speculum examination of all exposed women. Most syphilis in women is not diagnosed until
secondaries appear, and often not then, since the tendency is towards constitutional rather than eruptive manifestation. Watch for the extragenital primary lesions.
Be chronically suspicious of all slow-healing, indolent, indurated lesions with associated
regional lymph adenopathy. Why is a physician’s own primary infection
so rarely diagnosed before secondaries appear? Not because he has no chancre, though this
may occur in needle-prick inoculations, but because he has a low index of suspicion for the disease. Either he never suspects at all, or he gets
panicked and makes diagnosis impossible by premature treatment. He rarely turns to the
darkfield. Seldom to the blood test until too late. If the darkfield is reported repeatedly negative,
and the blood likewise is syphilis-excluded, not within the first three months, serologic
follow-up of blood tests every week after the third week… …monthly after the second month, dating
from the time the lesion was first seen, is as necessary in the diagnosis of early syphilis as the initial darkfield. Early syphilis develops slowly, often inconspicuously. Must be followed along with tests. Serologic follow-up for syphilis should be performed in all cases of gonorrhea. And in many nonspecific urethritity developing
after sexual exposure. Piecemeal and incomplete examination defeats many diagnoses of early syphilis. Strip every patient at the first visit, and examine the skin and mucosae, as well as the suspected chancre or the part complained of. Secondaries may be found to prove a primary,
or a primary to prove up secondary Some lesions that look like chancres are merely relapses in older infections. The ensemble of the case may determine the
diagnosis and treatment as much as the blood test alone. The diagnosis of secondary syphilis today
rests on the fact that a competent laboratory gives little short of 100 percent positive
Wassermann and precipitation tests on florid secondary syphilis. A repeatedly negative blood test practically
excludes secondary syphilis. The problem is, therefore, to get suspicion aroused to the point of an adequate examination, then to then to take a blood test, and lastly to avoid the gross occasional mistake of calling a non-syphilitic eruption syphilitic. The constitutional symptoms of early syphilis
are seldom specific enough to arouse suspicion. Suspicion should therefore attain the automatic status of a blood test for the disease on every new patient. Chronic headache, chronic sore throat, bone pains, and localized tenderness, persistent persistent anemia and weight loss in young women, would achieve new significance. A general lymph node enlargement or a palpable
spleen may be a diagnostic landmark. Relapses and recurrences of early syphilis are common under insufficient treatment with the arsenicals and mercury by mouth. Mucosal and genital relapses are gravely infectious, inconspicuous, evanescent, and numerically important. Examine the mouth and genitalia where most
of them occur. Have darkfields, for these patients may be
seronegative. Suspect moist spots, moist papule, fissures, split papules. Suspect piles. Suspect all rings, especially about the genitalia,
all groups of darkish, firm, or fleshy papules. And take blood tests. If you will undress patients, use good light
and sharp eyes and suspect, eternally suspect. With the laboratory at your elbow, you will
rarely miss early symptoms. But a moment’s loss of vigilance may let it pass. [Fix?] or study the lesion, or part,
with one gloved hand. Tell the patient what you are aiming to do. Have him or her lie down. Do not use local anesthetics. Cautioning the
patient, rub the surface boldly with gauze. [The physician uses gauze to rub a patient’s penis to obtain a fluid sample for testing.] Scraping is rarely necessary unless dry or
crusted. Allow bleeding to subside spontaneously, and wipe off the clot. Gently squeeze the base of the lesion between thumb and forefinger, tipping so as to collect the serum toward one side. [The physician demonstrates as he describes the procedure.] Holding the capillary tube at a low angle
from the horizontal, allow capillarity to draw the fluid into it. Or if a bulb is supplied, suck it in with very slight suction. [The physician continues to draw the sample into the tube.] Seal the ends of the tube with sterile petrolatum. If the lesion is dry despite manipulation,
proceed as follows: If an isolated part like penis or finger is involved, take hold of it, please, both hands. Throw a broad rubber band about it. In a number of turns, making congestive but not extreme pressure. [The patient’s penis is wrapped in gauze and a rubber band.] Protect with gauze wrapping first. Wait five
to 15 minutes. Use the suction bulb. [The physician demonstrates the technique as he speaks.] Or rig and use the sucker…. applying the mouth of the smaller syringe to the lesion while you aspirate with the larger. Usually an abundance of serum is obtainable one way or the other. Aspiration of base or nodes requires experience. Of course, sterilize all infected materials. Gonorrhea masks the onset of perhaps 15 to 20 percent of syphilis in males. The late discharge of a gonorrhea, or of a
nonspecific urethritis, should be examined for spriochetes more frequently than it is. Smears are not satisfactory for such work. Immediately the specimen for darkfield examination is obtained. Draw blood for serologic tests for syphilis. Always use the two procedures parallel. Too often this is forgotten even in the best clinics in the world. The older the suspected lesion,
the more apt it is to be darkfield negative. The more probably seropositive the patient. This demonstrates the simple method of examining the anal-genital region in women for infectious lesions, that which can be used in ordinary office practice. The patient lies on her right side on the
table under a divided sheet. The nurse raises the left knee and carries it well up onto the abdomen so that the patient assumes a modified Sims position. The buttocks are then separated and you can see how complete is the exposure of the external genitalia and the anal region. Secondary syphilis is usually hard, not easy, to see. Use good light. Expect faint macules. And papules. Groups of follicular lesions, rather than
pustules, rings, and sores. A fleshy field of papules is suspicious. Patchy hair and eyebrows warrant Wassermann. Peer into the corners. Especially never forget the lips. [Dr. Stokes to patient:] Stick your tongue out. Put it over to the right. Over to the left. Out of your mouth. Way out. Go like that. Say “ahhhh.” [Male patient:] Ahhhh. [Dr. Stokes:] Close your mouth. The anus and genitalia. Drop your trousers to your knees. Especially the foreskin… the anterior surface of the scrotum. Turn around. Stoop forward. The posterior
surface of the scrotum. The anus. Stand up. Turn back. The labia and perineum in women. The palms and soles may show flat papules
which give the whole case away. The darkfield is useful in secondary syphilis. Obtain specimens for it as with chancre, even
by scraping dry papules. Use it for the serologic tests. Make up the ensemble of a completely established case. Always look for the chancre and its [inaudible] when examining for secondary syphilis. Finding it often makes the case complete. [Audience clapping] [Narrator:] This treatment of syphilis is
presented by Dr. Harold N. Cole, of Western Reserve University in Cleveland. Dr. Cole is a member of the Council on Pharmacy and Chemistry of the American Medical Association. [Dr. Cole:] Fournier advised treating syphilis by alternating courses of mercury and purposeful rest periods over a term of three to four years, the so-called intermittent treatment. The courses of treatment were shortened, and the rest periods were lengthened, as time went on. He claimed this mode of treatment
was necessary, as mercury is too toxic a drug to be used continuously. Limit your selection of drugs to preparations
accepted by the Council on Pharmacy and Chemistry of the American Medical Association. The perfect anti-syphilitic drug should destroy
all the organisms of the disease in the body without attendant harm to the host. Unfortunately,
no such drug exists. Certain salts of arsenic and of bismuth best
answer these requirements. If it were possible to give syphilitic patients large enough doses of arsenicals and bismuth to cure them in one course of treatment, there would be no necessity for planned treatment. Human syphilis cannot be overwhelmed at one
fell swoop. It is a chronic disease in which the organisms only gradually disappear. Larson claimed that the disease is merely
arrested. That the spirochetes never disappear. Such being the case, the fallacious argument of Fournier for the intermittent treatment of syphilis is exposed. In the rest periods, the organisms start to
multiply. Investigations have shown that a continuous, rather than an intermittent type
of therapy, is preferable in early syphilis. The spirochetes have no opportunity to increase
in numbers. Instead of purposeful rest periods, following a course of arsenical injections, this is followed, at once, by a further course
of bismuth treatment, and this in turn, by further arsenical therapy, and so on. To illustrate the point, each circle indicates
an intravenous arsenical. [Lecturer begins drawing on chalkboard.] Each cross, an insoluble bismuth, given intramuscularly once a week. Indeed, the injections may overlap so that
there is actually continuous therapy. The first bismuth injection being given with the last arsenical treatment and vice versa. Thus… [doctor writes on chalkboard] note the overlap of the drugs. Generally
the arsenical treatments are given in courses of ten. The bismuth injections of six, eight
and later, ten or twelve. Often the first three arsenical treatments
in acute syphilis are given in a period of one week, this in the hope of overcoming the acute infectious lesions of the disease. Reactions are occasionally encountered from
these preparations used to combat syphilis. With bismuth and with mercury, the urine should
be examined weekly, and the teeth watched for evidence of stomatitis and a bismuth line. Rarely with bismuth therapy are severe reactions noted. With arsenic on the other hand, gastrointestinal upsets are not uncommon. And cutaneous disturbances from a fleeting
erythema or urticaria, to a generalized exfoliation may be seen. Hemorrhagic reactions are a signal for immediate discontinuance of further therapy. [Inaudible] likewise calls for great caution. In fact, any untoward reaction demands careful questioning and examination before further treatment. It is much easier to prevent reactions
than to treat them afterwards. In treating an acute syphilis, the earliest
possible diagnosis and administration of therapy are the goals. Know a few efficient anti-syphilitic
remedies and know them well. Arsphenamine is rarely employed outside of hospital and clinic practice. In administering the arsenicals, all apparatus must be carefully sterilized and cooled. [Doctor demonstrates handling of equipment.] Neo-arsphenamine is administered through carefully
pouring the contents of the glass containers previously floated in alcohol to ensure freedom from cracks. Over the surface apply to 8ccs of sterile
distilled water. Gently rotate the container to ensure solutions. Draw up the contents in a 10cc syringe, using
a one and one-half inch fine needle. Introduce the needle through the skin parallel to and alongside the vein at the fold of the arm, using a tourniquet to swell up the vein. Then gently push the needle point well into
the vein, not through it. Never inject the drug until sure, through aspiration and backflow of blood, that the entire needle aperture is in the vessel. After removing the tourniquet, then slowly
inject the drug, employing at least two minutes. If the drug does not flow in smoothly and
easily, or if a swelling appears at the site of injection, the needle point is outside
the vessel wall and requires further manipulation or complete withdrawal. Be sure the needlepoint is free in the vessel. Moreover, be careful that the opening is not is not pressed against the vessel wall obstructing the easy flow. Now we will repeat the action in slow motion and animation. [Animated image of skin showing subcutaneous tissue, fat, and vein.] [Animated image of point of needle piercing the skin and subcutaneous layer, then entering the vein.] [Live action of procedure as doctor manipulates needle.] [Animated image of needle being withdrawn from vein.] [Image alternates between live action as doctor releases tourniquet and animated sequence of solution flowing through vein.] [Animated images of needle puncturing vein, partially puncturing vein, and infiltration of subcutaneous tissue.] If mapharsen is employed, it should be thoroughly aerated after being dissolved to draw it up into the syringe and forcibly expelling into the beaker. Mapharsen, in contra-distinction to the other arsenicals, should be rapidly injected. Bismuth injections are given by the intramuscular route only. The injections are given in the inner angle of the upper and outer quadrants of the buttocks. Employing a syringe with a one and one half inch needle, gauge 21 or 22, the drug has been drawn up from its container after careful
shaking. Now sterilize the site with cotton and alcohol. Holding the syringe with needle attached like a pen…with a slight movement of the wrist backwards and forwards, the needle is boldly plunged deeply into the muscles. Then aspirate with the piston of the syringe
several times to be sure that the needle is not in a blood vessel. Holding the needle
base firmly with a free hand, the contents are then slowly injected into the muscle,
and the needle quickly withdrawn. A good bismuth preparation, where rapid action
is not essential, though prolonged in character, is an oil suspension of the bismuth subsalicylate, 12 hundredths of a gram, two grains, metallic bismuth administered weekly. With bismuth salts dissolved in water or in
ethylene glycol, the injections should be given two or three times a week to keep the
therapeutic level at its proper height. To illustrate, in seronegative primary syphilis, give neo-arsphenamine, three-tenths of a gram. Repeat in three days. And three days
later with 45 hundredths to six-tenths of a gram. For the first three weeks, a bismuth injection
should be given once a week with the added hope of overcoming acute infectious symptoms. Thereafter, only between courses of therapy. Thus… [Doctor writes figures on the chalkboard.] Ten more arsenicals… and ten more bismuth injections. A Wassermann test is taken at the end of each course of arsenical therapy, and one day after, and five days after the first injection of each succeeding course. The so-called provocative Wassermann reaction. A Wassermann reversal which persists negative has some significance; however syphilologists are more and more, emphasizing the necessity of a certain amount of treatment despite a
negative test. Potassium iodide may be used along with the
heavy metal injections. A lumbar puncture should be performed early in the course of syphilis to rule out central nervous system involvement. With seropositive primary and secondary syphilis,
a further course of arsenical injections and bismuth treatments are in order, thus aggregating a total of 40 of each given in a continuous manner. In certain contigencies, it may be necessary to employ mercury instead of bismuth. An excellent substitute would be 80 injections of four grams each of [inaudible] hydrogent 40R rubbed in, 30 minutes, by the clock. If all signs and symptoms of the disease have
disappeared at the end of one year, the patient may be put on probation and Wassermann tests
taken every two months. At the end of two and a half years there should
be general checkup, lumbar puncture, and examination of cardiovascular apparatus. Thereafter, Wassermann tests and physical
examination every six months. At the end of five years, a Wassermann test and physical examination once a year suffices. Cooperative clinical studies have shown a
greatly lessened incidence of relapse since the institution of continuous therapy. The
infectious, moist papules of the lips and genitalia, the paraplegias, the ocular-motor
paralyses, are not seen so often. Moreover, the frequency of the Wassermann relapse seen early in the course of syphilis has dropped enormously. Relapse, that bugaboo of the physician, coming early in the course of syphilis, 85 percent of them intervening before the end of the
second year of the disease. Many of them infectious in character; for
example, a moist papule of the lip and of the genitalia. Intermittent, irregular treatment predisposes to relapse. Voluntary discontinuance of treatment and
inadequate treatment likewise contribute to the frequency of this symptom. Many more relapses
will be seen where the patient receives less than 20 injections of arsenical and of a bismuth
preparation. In fact, every case of acute syphilis should
receive at least 33 to 40 injections of an arsenical and of a bismuth preparation given
in such a manner that the patient is continuously under therapy. In conclusion, in acute syphilis, make the
earliest possible diagnosis, and institute treatment at once. Check all contexts and sources. Employ only tried and accepted drugs. Follow continuous therapy, of alternating courses of bismuth and of arsenicals. In a seronegative primary syphilis, use at least 30 injections of an arsenical and of a bismuth preparation, given in such a manner, that the patient is under continuous therapy. With secondary syphilis, give at least 40
injections of each. Eternal vigilance is the price of the syphilis problem. [Narrator:] Dr. Paul A. O’Leary, Professor
of Dermatology and Syphilology in the Graduate School of Medicine of the University of Minnesota at Rochester, Minnesota. He discusses latent syphilis. [Dr. O’Leary:] In latent syphilis, there are
no clinical signs or symptoms. Latency may develop spontaneously by the fourth year of the disease, or it may be produced earlier in the course by energetic treatment. It is during this phase of the disease that
it is possible to determine whether or not the patient is developing a defense mechanism against his infection or is lacking in this respect. Latency may be a temporary or a permanent
state. When temporary, the patient is in the process of developing aortitis, or changes,
in his central nervous system. [X-ray image shows an enlarged heart.] A patient who develops a permanent state of
latency is fortunate. When cure is not obtained in early syphilis, we endeavor then to produce
a permanent state of latency. Diagnosis of latent syphilis can be made only
after a complete physical examination has eliminated all evidence of cardiovascular
involvement. In addition, it is essential that the evidence
of syphilis be lacking in other viscera and the nervous system, and that the examination
of the spinal fluid be completely negative. If the examination reveals even presumptive evidence of an involvement of the heart, or the viscera, or the central nervous system, of course the diagnosis of latency is then discarded. If the x-ray of the chest shows evidence of
early aortitis, as is manifested in this plate, of course the diagnosis of latency is discarded and cardiovascular disease is substituted. The Wassermann or flocculation tests in latent
syphilis, may be either negative or positive. The treatment of latent syphilis cannot be
standardized. Indications for treatment, however, vary according
to various factors, such as the age of the patient, the duration of the syphilis, the amount of previous treatment, and the sex of the individual. If the disease has been present for 20 years or more, and there are no clinical signs or symptoms, and the patient presents only a positive Wassermann test, the likelihood is that he is in a permanent state of latency. If a young woman in whom the period of latency
is not known, because of the fact that the early manifestations of the disease were not recognized, it probably is advisable to treat such a patient. A few case examples will illustrate the variation
in the indication for the treatment of latency. A 62-year-old farmer has had syphilis for
40 years and had received treatment with pills when the secondary syphilis was recognized. He’s had no treatment since, and is free from symptoms of syphilis. Flocculation tests of the blood are strongly
positive. In this type, treatment is not indicated. The patient is not infectious, and he has
controlled the disease for 40 years. He should be told that the syphilis may be
ignored, except that he report once a year for re-examination. A positive blood test
may also be ignored. Nothing is to be gained by repeating this test at subsequent visits. A man, 41 years old, has had syphilis for
12 years. He had a small amount of treatment at the time of the chancre, and a secondary
infection, and now has only a positive blood test as evidence of his having syphilis. His spinal fluid test is negative, and he
has no signs of cardiovascular syphilis. Treat this patient, giving him several courses of arsphenamine, and at least six courses of bismuth, 12 injections to the course. During the treatment period, re-examine him
for signs of cardiovascular syphilis. A young married woman of 33 does not know
when she acquired the disease. The blood tests are positive, the spinal fluid is negative and no signs of visceral syphilis are present. She is anxious to have a child, and should
be intensively and energetically treated. She should have at least four courses of arsphenamine, six courses of bismuth. A woman with latent syphilis may give birth
to a syphilitic child even though she has been well-treated for the disease before she
became pregnant. Liberal use of bismuth in the treatment of
latent syphilis has resulted in the reversal of the Wassermann to negative in the great
majority. In fact, in 85 percent of these patients, when treated and observed for a
period of 10 years, the persistently positive Wassermann test,
or so-called Wassermann-Fast, is not a diagnosis. It’s merely an accumulation of serological
reports. The persistently positive Wassermann has different
significance, not only in various patients, but also in various manifestations of syphilis. In the patient who remains a positive Wassermann,
in spite of continued treatment, the treatment should be stopped until the patient can be
clinically scrutinized in an effort to explain the Wassermann-Fast. In early syphilis, the Wassermann test may
remain positive when treatment is given insufficiently, or when it is inadequate, or when the spinal fluid Wassermann remains positive. In latent syphilis the serologic tests may
be permanently positive. If the clinical signs of syphilis are not present, and if the spinal
fluid test is negative, the age of the patient, the duration of the syphilis, and the amount of previous treatment are the
factors that determine whether the positive Wassermann has any significance. The serologic tends to become negative spontaneously
in the majority of patients with latent syphilis. Before permitting a patient with this type
of syphilis to go untreated, impress on him the need for annual re-examination to make
certain the signs of visceral syphilis are not becoming manifest. Only by these repeated clinical examinations
is it possible to determine if the patient is developing a permanent state of latency. Accordingly, in a patient with latent syphilis
who appears to be Wassermann-Fast, it is advisable to give an adequate amount of treatment if
this treatment has not been given previously. The treatment should consist of at least 24
injections of an arsphenamine preparation and 48 injections of bismuth. If this amount of treatment has been given
and the patient is still greatly concerned because the serologic tests remain positive,
the subsequent treatment may be limited to bismuth therapy. Two courses of bismuth, 12 injections to the
course, may be given each year for three years. In late syphilis, permanently positive serological
tests have different significance. In cardiovascular disease, neurosyphilis,
in visceral syphilis, and a type of hepatitis or cirrhosis, and osteosyphilis, and
in the latent syphilitic lesions of the mucous membranes, the tests tend to remain permanently
positive. In such cases, it is advisable to not treat
solely with the idea of reverting a serological test to negative, but it is rather with the
idea of treating according to the symptomatology and to the response displayed. If a patient with syphilis who has been under
your care wishes to marry it is urged that you have him bring his fiancee to your office, so that you may discuss with her the fact
that he has had syphilis, that he has had adequate treatment, but that he should report
to you for re- examination once a year for at least several years to come. Miss Carlton, Frank has told me that he wants to marry you, but before he does there are certain things about him that I think you
should know that I would like to discuss with you. Physicians now believe that it’s more advisable
to discuss such affairs before marriage rather than after in order to avoid future trouble. [Miss Carlton:] Yes, Doctor. [Dr. O’Leary:] Six years ago I started to
treat Frank for syphilis. How he acquired the disease is of no importance now. The important point is that you should know the facts. [Miss Carlton:] But, Doctor, doesn’t that
make our marriage impossible? [Dr. O’Leary:] No indeed. Here are the circumstances
of Frank’s case. The patient with acute syphilis is adequately and thoroughly treated. And if the blood tests remain negative for
a period of five years after the treatment has been completed, he may marry without danger
of spreading the infection. The same is true of patients with latent syphilis.
If they undergo adequate treatment and have negative blood tests for a period of five
years following the treatment, they likewise may marry without danger of infecting. Frank has had acute syphilis and has had good
treatment and observation. There are now no clinical signs of the disease and he may marry without danger to you. [Miss Carlton:] Oh, I thought that disease
could not be cured. [Dr. O’Leary:] Miss Carlton, Frank had the
good fortune to start treatment at the beginning of his infection. He has been regular in his treatments, and I don’t believe he has missed a single one. With the result that his tests have now been
negative for the past five years. In addition, his spinal fluid is likewise negative. All of these facts, [inaudible], taken together,
constitute what we today call the criteria for the cure of syphilis. Each year hereafter, if these tests remain negative, the greater is the factor of cure. [Miss Carlton:] Is there no danger of my getting
syphilis from him? [Dr. O’Leary:] No, not now. Frank is past
the infectious period of the disease. [Miss Carlton:] Even so, I do not believe
we should have children. [Dr. O’Leary:] On the contrary, it will be
quite all right for you to have children. You know, syphilis is transmitted to the child
by the mother. So I’ll ask but one thing of you, and one
of Frank. When you believe you are pregnant, I think you should come in immediately and
have a Wassermann test made. As to Frank, I’m anxious that he come back
once a year for a general examination. Otherwise, I have nothing to offer you but my good wishes. [Narrator:] The treatment of syphilis in the
prospective mother is presented by Dr. James R. McCord, Professor of Obstetrics and Gynecology
in Emory University School of Medicine, Atlanta, Georgia. [Dr. McCord:] Syphilis, as a complication
of pregnancy, occurs frequently. The effect of syphilis upon pregnancy depends upon the activity of the disease in the mother. Syphilis may be recent and active, it may be moderately active, or it may be latent and inactive. If the disease is active, the baby will surely be syphilitic. If it is moderately active, the baby may be
syphilitic. Babies born apparently free of the disease of syphilitic mothers,
are born of those mothers who have a latent and inactive syphilis. Babies born alive, of mothers with positive
Wassermann reactions, are hazardous risks. Only prolonged observation and repeated Wassermann
tests should convince one that these babies are free of the disease. A well-done blood Wassermann test that is
strongly positive on a pregnant woman means syphilis. Pregnancy has no influence upon the reliability of this positive test. It cannot be too strongly emphasized that
the test be made by a competent laboratory, and not by incompetent technicians and doctors’
office laboratories. The positive blood Wassermann reaction is
the only means of making diagnosis of syphilis in the great majority of pregnant women who have the disease. If in doubt, repeat the test. Certain treatment during pregnancy prevents
the disease in the baby in 95 percent of cases regardless of the activity of the disease in the mother. It is a generally accepted opinion that the
object of this treatment during pregnancy is to prevent syphilis in the baby. Make no
effort to cure the disease in the mother. Begin treatment immediately the diagnosis
is made. Treat weekly until labor begins. Repeat blood Wassermann tests are not necessary
and probably not desirable. Cessation of the treatment because of a negative
Wassermann reaction is inexcusable. Ten consecutive weekly treatments are effective in the very large majority of pregnancies. However, make every effort to begin the treatment before the fifth month of pregnancy. Arsenic is a drug of greatest value. Shall arsphenamine
or neo-arsphenamine be given? Use the one with which you are the more familiar and can the better administer. The commandment is use arsenic in small doses,
constantly and continuously. Give with the stomach empty and after a mild laxative. Take the blood pressure. Examine the urine for [inaudible]. Question the patient carefully about any sort of reaction from the last dose. If in doubt, play safe. Omit the arsenic for
a time. The arsenic must be given slowly. No preparation of the patient. Rapid injection
in large doses often leads to trouble. Unfortunately treatment is not begun with
a majority of pregnant women until after the fifth month of pregnancy. Because of this,
we prefer the concurrent use of arsenic and a heavy metal. A dose of arsenic, neo-arsphenamine in our clinic, is 45-hundredths of a gram. Never more, very rarely less. Two mild mercurial inunctions are given weekly. We think that mercury is tolerated better
by pregnant women than bismuth. It causes no discomfort, and is more apt to be continued without interruption. Mercury has the additional advantage of being cheaper. We repeat, make every effort to begin treatment
early, during the first two months of pregnancy. If the treatment is begun early, alternating
courses of arsenic and a heavy metal, preferably bismuth, may be given upon the best authority. Care should be exercised at the first and
last courses of the arsenic. Treat every syphlitic woman throughout each pregnancy without regard to the duration of the syphilis or to previous treatment. Pregnancy does not cause any more false positive reactions than occur among the average non-syphilitic population. It does cause many false negative reactions. The benefits of present knowledge as to the
prevention of congenital syphilis can only be used to the full advantage when women are
universally taught the necessity for early and continuous prenatal care. There can be no doubt but that almost the entire responsibility for safe teaching is ours. Syphilis is no respecter of person or social
standards. Make an opportunity to get blood for a Wassermann on every pregnant woman. Treat those with positive reactions gently
and continuously. The ideal of the medical profession is the saving of human life. When, where, and how can it be more beautifully illustrated than in the prevention of congenital syphilis? [Narrator:] Congenital syphilis is the topic
of Dr. Philip C. Jeans, Professor of Pediatrics in the State University of Iowa College of
Medicine at Iowa City. [Dr. Jeans:] Syphilis in the child differs
from syphilis in the adult in only a few important ways. Such differences as occur are dependent
on differences in the host rather than in the spirochetes. The high mortality of infantile syphilis has
no counterpart in early syphilis of the adult. This is true also for the extensive bone changes. And the deeply infiltrating and scarring skin
lesions of the face found frequently in syphilitic infants. [Film of child’s mouth being held open to
show crooked and missing teeth.] And the dystrophic changes in the teeth sometimes observed in older children as a result of infantile syphilis. Keratitis is by far the most frequent lesion
of late congenital syphilis. But it is rare in acquired syphilis of the adult in whom it occurs in the secondary stage of the disease. Congenital syphilis differs from acquired
syphilis also in that the infection is transmitted by way of the placenta to the infant, and
no primary lesion exists in the infant. Because of the absence of a primary lesion,
syphilis of the infant is often designated early or infantile syphilis instead of secondary syphilis. And for the same reason the tertiary stage is often called the late stage. The diagnosis of syphilis is made in the same manner in the child as in the adult. Darkfield examination is useful when early skin lesions exist. Without interpretation, the Wassermann reaction is not reliable for diagnosis in
the first two months of life. A syphilitic baby may have a negative reaction at birth, and a non-syphilitic baby of a syphilitic mother may have a positive reaction for a short time by passive transfer from the mother. By two months, or at most, three months of
age, these irregularities disappear, and a properly performed Wassermann reaction may be accepted as proof of the presence or absence of syphilis. Throughout the remainder of childhood, a positive
reaction is obtained as long as any activity of the spirochetes exists. And a persistently
negative reaction may be accepted as good evidence of absence of the disease, or its cure, either spontaneously or as a result of treatment. The diagnosis of syphilis in the child cannot
be made by examination of the parents. Syphilitic parents may not have transmitted the infection. Or the examination may give negative results even though the child is syphilitic. Syphilis is to be diagnosed only by examination of the individual in question. The clinical signs of syphilis are valuable in diagnosis.
But as compared to the value of a properly performed Wassermann test, they are relatively unimportant. The diagnosis is incomplete in all instances
without the results of a Wassermann test. Blood for the test is obtained from an older child as easily and in the same manner as from an adult. Obtaining blood from an infant is easy when
the mental hazard of belief in its difficulty has been overcome. Usually some suitable vein
is found accessible. This may be at the elbow, wrist, or ankle,
or it may be in the scalp. In the majority of infants, the external jugular vein is the one most readily available. This vein is brought into prominence by placing
the baby on its back, with the shoulders elevated on a pillow or sandbag, and the neck extended
and rotated. The crying of the baby when the skin is pricked
with the needle causes the vein to stand out firmly so that it is easily entered. The treatment of the infant and child with
syphilis depends on the same fundamental principles as at any other age, and the same general
plan of treatment is successful. In the case of the young infant with active
or florid syphilis, it is necessary to start treatment cautiously. Starting treatment in such a baby with a full
dose of one of the arsphenamines would usually be a direct cause of its death. It is preferable to get preliminary treatment with bismuth or mercury. This is to be followed by fractional and increasing
doses of arsphenamine until the full dose has been reached, after which time the regular
full dosage routine may be followed. For the arsphenamine treatment of syphilis
in infants and children, it is our own preference to use the intravenous route. For those who
prefer the intramuscular route, the choices among the arsphenamines is limited practically to sulpharsphenamine. Consequently, sulpharsphenamine has become popular in the treatment of syphilis in infants and children. Because dermatitis and other
reactions are more common with sulpharsphenamine than with old salvarsan, the latter drug administered by the intravenous route is to be preferred. A little practice makes intravenous therapy
relatively simple, even in the infant. Although congenital syphilis is reputed to
be most difficult or even impossible to cure, with few exceptions the disease is curable.
In the infant, cure is accomplished easily and often with only a few months of appropriate treatment. In the older child, the disease is more persistent, and in a few instances, as much as seven or eight years of uninterrupted, systematic therapy is required. In these cases, perseverance on on the part of the physician and faithfulness of treatment on the part of the patient are essential. [Narrator:] Late manifestations and neurosyphilis
are presented by Dr. Joseph Earl Moore of John Hopkins University School of Medicine,
Baltimore. [Dr. Moore:] Syphilis of the central nervous
system is responsible for as many deaths as cardiovascular syphilis. It causes a far larger proportion of invalidism and incapacity. Syphilis of these two systems accounts for
at least 90 percent of the deaths from this infection. Though the nervous system is probably invaded by the organism in every infected person, only about 25 percent of them, if untreated
or badly treated, will subsequently develop clinical evidences of neurosyphilis. The interval between infection and the development
of symptoms varies from a few weeks or months in the case of acute syphilitic meningitis,
to many years in the cases of late meningo-vascular neurosyphilis, tabes dorsalis, or paresis. This interval may be materially shortened
by the improper treatment of early syphilis. Remember the following simple facts: First, invasion of the nervous system may
be detected early in the course of the disease, usually years before the appearance of symptoms. This form of neurosyphilis, known as asymptomatic, must be searched for in every patient, early or late, by routine lumbar puncture and examination of the spinal fluid. Second, neurosyphilis is a great imitator. Acute syphilitic meningitis often mimics four other conditions. For example, tuberculous-meningitis, and brain tumor. Late meningo-vascular neurosyphilis is easily confused with at least 17 other diseases. Disseminated sclerosis, Bell’s palsy, migraine,
and cerebral arterial sclerosis are examples. Tabes dorsalis, usually so typical, may nevertheless
masquerade for years as one of 12 other fairly common conditions, including neuritis or rheumatism for lightning pains, infected corns for perforating ulcer, or hypertrophic arthritis for Charcot’s joint. Dementia paralytica is often recognized too
late because the physician suspected instead one of 13 other conditions, such as neurasthenia, psychoneurosis, hysteria, epilepsy, or chronic alcoholism. Remember that neurosyphilis may imitate or be imitated by many other diseases, medical or neurologic. Use your flashlight to look for one of the commonest physical signs present in all types. The Argyll Robertson pupil in its early or
late stages. And use your reflex hammer to look for the other, changes in the deep reflexes. Employ a routine blood Wassermann test in every patient with any neurologic or psychiatric abnormality. When the blood Wassermann is positive or even if it is negative, when history and physical findings are highly suggestive, examine the cerebrospinal fluid. In taking spinal fluid for examination, the
patient is placed on his side with his back to the operator. The skin is sterilized with iodine and alcohol. The shoulders are placed on a level with the
hips. The head is flexed as far as possible, and the knees drawn up on the thigh. The back should be in a straight line. Sterile towels are placed beneath the patient’s side and on top over the patient’s back. The operator thoroughly washes his hands. The use of sterile rubber gloves is not mandatory.
If the patient is nervous or highly excitable and can stand little pain, it is best to use
local anesthesia to avoid pain and struggling. The space between the second and third, third and fourth, or fourth and fifth lumbar interspaces is utilized. The widest space should be chosen. Since post-puncture headaches are due to fluid
leakage through the puncture wound of the dura, a fine needle, sharply pointed with
a well-fitting stillett should be used. The needle is inserted directly, or with a
slightly oblique tilt toward the head and inward. Resistance is met until the dura is pierced. The needle should not be pushed further inward as it may strike the opposite vertebral wall and either cause bleeding from an epidural
vein or become blocked. [The spinal tap procedure is demonstrated.] As the fluid comes from the needle, it should be collected in a suitable sterile tube, various samples being used for the necessary examination. [The tube is shown filling with spinal fluid
from the needle inserted into the spinal area.] After the needle is removed, the puncture
wound is covered with a sterile dressing. The patient may then rest under observation until the physician considers his condition satisfactory. [A gauze bandage is placed over the puncture area.] For prognosis and for successful treatment
we must know the type of neurosyphilis. The management and outcome of acute syphilitic meningitis differ from those of late meningo-vascular neurosyphilis, and this in turn, from those of tabes dorsalis or paresis. [A man wearing a hat and using a cane walks slowly along a path through a garden or park.] The decision as to type of neurosyphilis requires,
for the asymptomatic variety, expert knowledge of the interpretation of spinal fluid tests
and of the response of these tests to treatment. For the late forms of clinical neurosyphilis,
we must apply expert knowledge of the biology and course of syphilitic infection, and more
than average experience in neurology, psychiatry and ophthalmology, coupled with a wide general
medical training. This latter permits not only neurologic localization
of the disease process, but also an appreciation of the importance of syphilitic lesions or
other coexisting diseases outside the nervous system. The physician who attempts to treat neurosyphilis without more exact information then this catch-basket diagnosis, and by the same routine standard procedure applicable to early or latent syphilis, will do his patients far less than justice, and
he may actually do much harm. How shall a physician choose the treatment
method appropriate for his particular patient? Shall he use an arsphenamine and bismuth, and if so which preparations, and in what dosage? Shall he employ Tryparsamide with its attendant risk of visual damage and perhaps blindness. If so, how and under what circumstances? The subdural treatment by the Swift-Ellis
technique, or some modification of it, still indicated, and if so, under what conditions? Shall fever therapy be employed and if so,
when and by which of the multitudinous methods? Shall it be tertian or quartan malaria,
foreign protein shock, or electrically or mechanically-induced fever? Certain forms of neurosyphilis demand certain
forms of treatment; for example, dementia paralytica and fever, especially malaria. Certain broad principles apply to diagnosis
and treatment. These are, first: Identify the type of neurosyphilis as accurately as possible by neurologic, psychiatric, and serologic examinations. Second, be familiar with the patient’s general physical condition. Has he cardiovascular syphilis or other complicating diseases? Third, be familiar with the possibilities
and dangers of, and the special indications for, various treatment methods, including
tryparsamide, subdural, and febrile therapy. Fourth, the aim of treatment is, in order
of desirability: symptomatic relief, clinical arrest with freedom from subsequent progression
or relapse, and least important, serologic normality. Fifth, proceed by a system of trial and error
and except for special indications, use least dangerous and drastic treatment methods first. Sixth, the age changes in treatment by clinical
progress first, next by serologic progress. Seven, give each method of treatment a trial of at least six months, controlled by spinal fluid examination. Eight, treatment must be prolonged. The minimum
under any circumstances is two to three years. Nine, if spinal fluid changes are refractory
to treatment, give serious consideration to fever therapy before probation. Ten, post-treatment observation must be rigidly controlled by a lifetime of periodic physical and serologic re-examination. Eleven, the neurosyphilitic patient has a disease which was once, if it is not now, infectious. Examine his family. There are too many patients
with, and too few experts in, neurosyphilis. For some patients, continued expert care is essential throughout. For others, a periodic consultant is called. First, diagnosis and the planning of treatment to be carried out by the family physician. Second, to check the results at six to 12 month intervals, and to re-plan future progress. Third, in the application of special treatment methods, such as induced fever which, like gallbladder surgery, the inexperienced physician should never risk unaided. [Narrator:] This production is a cooperative
venture of the United States Public Health Service and the American Medical Association. In charge of the campaign against syphilis for the United States Public Health service is Dr. R. A. van der Linden. [Dr. van der Linden:] Twice as many people as live in the nation’s capital are infected with syphilis each year. The Public Health Service estimates that approximately 518,000 new patients with early syphilis each year seek treatment from physicians, clinics, and hospitals. According to the American Social Hygiene Association,
a second half million people seek treatment over drugstore counters, from quacks, or other
unauthorized sources. Many remain untreated. The control of syphilis is related to the
private practice of medicine in a way which is unique in public health work. For any program to be successful, it is essential
that the physician and the health agency cooperate. The widespread prevalence of syphilis indicates that there is a grave need for the coordination of the work of both groups. The physician who accepts for treatment a
patient with syphilis, assumes a very definite public obligation. The practice of administering a few doses
of arsphenamine to a syphilitic patient unable to pay private fees for the prolonged course
of treatment, and of charging large fees which the patient is barely able to pay, later permitting him to lapse permanently from treatment, is no
less than criminal. Such inadequately treated patients frequently become public health problems because of the development of infectious relapse and the frequency with which the late, crippling manifestations of the disease develop. When you accept a patient with syphilis, you
should likewise accept the responsibility of assuring yourself that he completes the
treatment schedule. He should be told in the beginning that if he fails to do so, he will be reported to the health authorities. As a physician, you would not fail to report
to the proper health officials a case of smallpox who was not abiding by public health laws. Public opinion makes it absolutely necessary that you take this action. Early syphilis is just as important from a
public health standpoint as is smallpox, and more apt to kill. Your responsibility to the
health department in the control of syphilis is no less than with smallpox or any other
infectious disease. Opinions differ as to the character and content of morbidity report forms. It is generally agreed that such forms should be simple and require that the physician provide only essential information, such as the patient’s age, sex, color, marital status, diagnosis and stage of disease, and information as to the date of onset. Most health departments make optional a system of reporting which does not require the identification of the patient. Every patient with early syphilis should be
questioned as to his sexual contact, and the possibility that syphilis may have been so spread. Much can be accomplished by attempting to bring in these contacts on a voluntary basis. Send a message to them by the patient, or
a letter by mail. If these simple methods fail to produce results, send your nurse or
request the health authorities to provide the services of a satisfactorily trained person. Use the same system of follow-up for the holding of patients under treatment. In doing case-finding and case-holding work for the private physician, a public health nurse loaned by the health
department should act as the agent of the private physician and not as an official representative
of the health department. Remember, however, that compulsory methods may be employed to advantage, at times, in holding patients under treatment, whereas such methods are apt to fail in the finding of new cases. The health department, likewise, has definite
obligations to the physician in private practice. Health departments should provide free diagnostic services to physicians, should distribute, without charge, anti-syphilitic drugs to the private physicians for the treatment of all patients with this disease, and should provide consultation service including roentgenologic and other expensive laboratory examinations for indigent patients. Booklets and pamphlets should be provided
by the health department for the public and particularly for the patients of private physicians. The United States Public Health Service, the
American Society of Clinical Pathologists, and state departments of health are now cooperating fully in the development of a system which ensures the performance of reliable sero-diagnostic tests for syphilis. The assistance and cooperation, which the
American Medical Association has given to national agencies, is a most favorable indication that a successful program, acceptable to health offices and physicians alike, is being organized
throughout the United States. Many state medical societies have likewise
exhibited an active interest. The vast prevalence of syphilis at the present time will be regarded as a reflection upon the ability of the present-day physician and health officer if this problem
is neglected and the disease permitted to run rampant. [Narrator:] If the campaign against syphilis
is to succeed, the general practitioner into whose office will come the great majority
of patients with this disease, must be aware of modern methods of diagnosis and treatment. He must take most seriously his obligation
in relation to the control of syphilis as a public health problem. The United States Public Health Service and the American Medical Association are ready at all times to give to the physician every aid that they can give in this work. [Music]