STRUGGLE AGAINST SYPHILIS
by Major M. P. Vora,
Hon. Senior Venereologist,
St. George’s Hospital, Bombay.
The Indian Practitioner
A monthly journal of Medicine and Surgery.
Volume No – XVII, Number – 4 of April 1964.
Page No. 361 to 364.
The struggle against syphilis has been on for the last few centuries. With the passing of years, it is good to take stocks. Are we approaching the day when syphilis will no longer be a major problem? With the advent of long-acting penicillin, are we in sight of Public Health Victory? Where do we stand today in this age-old struggle?
Syphilis has always provided the perfect opportunity for quackery and encouraged dangerous self-medication or resort to treatment at the hands of unqualified and unknown practitioners because of the moral aspects surrounding the infection. Whatever medicine is tried, it seems to work. When the signs and symptoms disappear, the patient credits the medicine with a cure.
Press and Public Health Authorities in the country have generally maintained the total black-out. The word syphilis is invariably avoided as it carried contagion or implied sin. Generally this policy of silence, accepted good manner in the older times, has become a serious problem today. It is essential that we develop towards syphilis as a new attitude based on the results of scientific progress. It is not appreciated that syphilis is not necessarily the result of an immoral life or the inevitable consequence of promiscuous sex relations and that it affects both the guilty and the innocent alike. Ignorance, which is maintained by continuous silence hampers the struggle against syphilis. It is ignorance which leads syphilitic patients to conceal their first signs and symptoms, to try self-medication on the advise of their friends or to go to quacks for treatment and finally to accept disappearance of early signs and symptoms as “Cure”. Year after year ignorance has swollen the reservoir of infection and the untreated. An attack on the conspiracy of silence must be aimed at all points. Frank discussion on the subject and education of the people with regard to the disease, are the best weapons against syphilis.
In the beginning of the twentieth century, a series of developments took place which laid the basis of the modern concept of the attack on syphilis.
In 1905, Schaudinn and Hoffmann discovered the Treponema pallidum, the causative germ of syphilis.
In 1906, August Wassermann presented a serologic test for syphilis universally known as Wassermann reaction.
Landstainer and Mucha developed, in the same year, the technique of dark-field microscopy for the demonstration of live Tr. pallidum. In 1910, Ehrlich and Hatta developed the 606th arsenic compound, salvarson; it caused a revolution by introducing a chemotherapy in the treatment of syphilis. It replaced the mercurial era which was in vogue till then. It seemed at first as if “therapia sterilisans magna” had been achieved. But soon it was found to be baseless. To cope up with the new situation, additional use of bismuth preparations either soluble or insoluble, came in force. Results of regular and prolonged treatment were found to be good and reliable.
In 1943, Mahoney used penicillin successfully for the first time in human syphilis. This was a great event in syphilotherapy. Now syphilis could be treated with safety, economy and speed in a few days.
In 1949, Venereal Diseases Research Laboratory perfected V.D.R.L. slide and micro-flocculation tests for syphilis.
Nelson and Mayer developed, in the same year, Treponema pallidum Immobilisation (T.P.I.) test, and in 1952, Treponema pallidum Immune Adherance (T.P.I.A.) test to solve the problem of biologic positive serologic suspected latent syphilis. In 1953, Fletcher and Knappt developed long-acting aqueous Benzathin penicillin, and Benethamine penicillin.
In 1960, Nicol developed Reiter’s Protein Complement Fixation Test, (R.P.C.F.) which could do away with the complicated T.P.I. test. In 1961, Joseph Portnoy perfected three minute field test to detect syphilis. The test is known as Rapid Plasma Reagin card test (R.P.R.) and needs three drops of blood.
The identification of Tr. pallidum under dark-field microscopy was an event of great significance. It opened the most effective and reliable way to diagnose syphilis in the early stages long before blood test for syphilis became positive. The germs of syphilis are always found in the primary sore and can be identified by their morphology and movements. Now it has become a must-be procedure for the early diagnosis of syphilis.
The announcement of the first successful blood test for the diagnosis of syphilis was another event of great significance. The test can help physicians to detect syphilis even when there are no visible signs or symptoms. It reveals in the blood not the germs of syphilis but an antibody substance, indicative of the presence of germs in the body.
The development of salvarsan was another great event in the treatment of syphilis. It was then thought it could cure syphilis with a few injections. But subsequently this was found to be a mistaken notion.
Thus in the first decade of the twentieth century, physicians had acquired three new weapons to fight the scourge of syphilis i.e. two for the diagnosis and one for the treatment.
During the second decade of the twentieth century, it became quite clear how difficult was the task to fight against syphilis. The hope of curing syphilis with an injection of salvarsan proved futile. It was found necessary to continue the injection for months. Soon the use of bismuth in addition to arsenic came into vogue. Such a combination did result in a “cure” the treatment was continued for a period of two years. But most of the patients lacked patience to complete such a prolonged course and wished for “all right” for the moment. They often considered it unnecessary to continue the treatment when all the visible signs and symptoms disappeared. They did not know the significance of latency of disease, which often became inwardly active and dangerous to vital organs of the body. As the result of failure on the part of most of the patients to complete treatment, it became an accepted practice to employ trained social workers to achieve what is known as “case-holding” to complete an adequate and regular treatment in syphilis.
Before the blood test for syphilis became available, the prevalence of syphilis was a mere guess-work. With the advent of blood test, it is now possible to estimate the “reservoir” of infection. By means of it, the untreated and inadequately treated syphilitics, who were unaware of the infection, could be exposed and brought under treatment. To disclose untreated and unsuspected cases of syphilis, the following procedure is used:
Now the quantitative serologic test has stolen a march on the customary qualitative serologic test as it has a distinct value in predicting a failure of therapy or impending relapse of syphilis.
Little progress can be made in the struggle against syphilis, so long as the medical practitioner treats only those who come to him voluntarily; while others are left untreated. Would not many of these continue to infect more people and spread the disease? How can one, with the sense of duty and responsibility, ignore the untreated or the unknown cases of syphilis? As the result, the problem of “case-finding” become an accepted practice in the control of syphilis. This is also called contact investigation. It is now a common practice on all clinics to interview patients undergoing treatment and to seek their co-operation in finding out other cases. Every new case of syphilis can lead directly to at least one other case and indirectly to still more cases. Many of them may be unaware of the existing infection. Through these interviews, the chain of infection can be traced, untreated cases can be located and brought under treatment. In the investigation, the patient’s name is never mentioned. When the patient fully understands that he may be helping to bring under treatment unsuspected cases, he will be generally ready and willing to co-operate with the investigator. Since this procedure discovers many cases in the infectious stage and prevents further spread, it has become a “must be” procedure at all clinics. It is only right that the people should be made to understand their responsibilities through proper education so that they will act voluntarily. Once they know the facts, their co-operation will follow automatically. Hence the urgent need to make information on the subject freely available to the public, could not be exaggerated.
With the introduction of penicillin and long-acting penicillin in the treatment of syphilis, there came a feeling, at one time, of impending victory over the old and stubborn enemy. Anti-syphilitic treatment can now be completed safely, economically and speedily in a few days. This is indeed a great achievement. But along with optimism came grave warnings. “Don’t be fooled. Again and again syphilis has shown itself the most deceptive of all diseases. In its long history, it has fooled again and again those who thought they had found an answer.” And this warning has once again found to be a real one as can be seen from the recent trends of rising rates of syphilis and re-infection all over the world.
High rate of incidence and prevalence of syphilis in the country, as revealed at the last seminar on V.D., organised by the Maharashtra Branch of Association for Moral and Social Hygiene, India, is not only frightening but alarming too. At least one out of every ten tested has been found to have syphilis, many without even suspecting it. This may be astonishing for the layman but the venereologist knows the situation.
No case should be treated on suspicion. Before the institution of anti-syphilitic therapy, proper diagnosis and its confirmation by laboratory tests are essential in every case. For, on this fact will depend the further procedures which are inherent in the diagnosis of syphilis such as case-finding, follow-up, education, etc. early syphilis needs regular and adequate treatment for a “cure”. A shot of penicillin or irregular treatment at this stage does not mean cure of syphilis; it merely means relief of symptoms; on the contrary, such a treatment makes the vital organs of the body more vulnerable to the attacks of infection, leading often to permanent crippling effects. Since penicillin is now used for a number of diseases such as cold, fever, sore-throat, etc. due care should be taken in every case, to have adequate inquiry and a sample of blood for S.T.S. before the administration of penicillin, which is likely to prevent ultimately the outward appearance of early syphilis. In fact it is the considered opinion of the experts that a large number of syphilitics are masked in the early stages (subclinical syphilis), making early detection of infection a difficult problem. It would not be an exaggeration if one is tempted to say that penicillin has become an instrument of quackery to a certain extent. Penicillin is a priceless medical weapon against syphilis only when it is used correctly and its results are evaluated, in every case, by sub-sequent check-up, physical examination and laboratory tests at regular intervals, spread over at least two years. Then and then alone the use of penicillin in syphilotherapy can be considered as a great achievement in the struggle against syphilis. Worse, the progress has lead to premature complacency, in the minds of some people, towards the problem of syphilis, which has often proved deceptive and dangerous. As the result, there has occurred slackening in efforts, leading to a sharp rise, to the utter dismay of venereologists, in the incidence and prevalence of syphilis in the country. It is high time that we awake before it is too late to mend. Will the medical practitioner take due share of his responsibility in the struggle against syphilis? For, in detecting syphilis, he is usually the key-figure since he is the one to meet syphilitics early.
The very fact that more than 75% of the early syphilitics are treated by private physicians in general practice, suggests that all physicians in the country have a good reason to concern themselves with their responsibility for the control of this health problem in their community. The effective techniques for the control and therapy to check the spread of syphilis are freely available but need to be applied conscientiously and widely enough to meet the situation.