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 co?peration. 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[pg 81] 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[pg 82] 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[pg 83] 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[pg 84] 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[pg 85] 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 co?peration of doctor and patient in the use of effective methods of treatment.
cure in the primary stage.—it goes almost without[pg 86] 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[pg 87] 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[pg 88] 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[pg 89] 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[pg 90] 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[pg 91] 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 re?xamined 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.
