SYPHILIS 
TODAY 
A RESUME OF CURRENT DIAGNOSTIC 
AND RAPID TREATMENT METHODS 
COMPILED UNDER THE DIRECTION OF THE 
MISSISSIPPI STATE BOARD OF HEALTH 
JANUARY, 1947 SYPHILIS TODAY 
A Resume of Current Diagnostic and Rapid Treatment Methods 
COPYRIGHT 1947, BY THE 
MISSISSIPPI STATE BOARD OF HEALTH 
COMPILED UNDER THE DIRECTION OF THE 
MISSISSIPPI STATE BOARD OF HEALTH 
N > 
JACKSON 113, MISSISSIPPI 
JANUARY 1947 INTRODUCTION 
This booklet was prepared under the direction of the State Board of 
Health for use of the private physicians in the State of Mississippi. It 
is an answer to numerous requests for information on currently accept- 
able diagnostic and rapid treatment techniques in the control of syphilis. 
I sincerely hope that it will prove helpful in eradicating syphilis from 
our state. 
{/ Executive Officer, 
Mississippi State Board of Health. CONTENTS 
PAGE 
Introduction by Felix J. Underwood, M.D. ........ 3 
Foreword .............. 7 
Diagnosis .............. 9 
Laboratory Tests and Their Interpretation ........ 14 
Latest Acceptable Rapid Treatment Schedules ....... 17 
Treatment Reactions ............ 21 
Posttreatment Observation and Indications for Re-treatment ..... 22 
Referral and Consultation ........... 24 
Case Finding ............. 26 
Published by the Mississippi State Boatd of Health, Jackson 113, Mississippi. 
Printed in U. S. A. FOREWORD 
Within the past four years the treatment of syphilis has been revolutionized by the introduc- 
tion of penicillin into the physican’s armamentarium. This antibiotic, alone or in combination with other 
drugs, olfers the treatment of choice in syphilis. Calcium penicillin suspended in peanut oil and beeswax 
—Romansky formula—adapts penicillin therapy to office practice. 
Penicillin therapy has displaced the older types of treatment in the management of early syphilis. 
With the traditional types of treatment, unpleasant to the patient and burdensome to the physician, 
the syphilitic usually lapsed from treatment soon after the disappearance of symptoms. Returning the 
patient to treatment was difficult, and those who were not returned served as feeders of infection to 
their families and the community and were themselves subject to the late ravages of the disease. 
The Mississippi State Board of Health recognizes the important contribution to the control of 
syphilis that is made by the private physician. In order that the physician may better serve both the 
individual patient and the public health, it is felt that the experience and general conclusions gained in 
the treatment of over 40,000 patients with intensive methods should be placed at his disposal. 
The purpose of this booklet is to set forth briefly facts pertinent to the diagnosis and treatment 
of syphilis, together with a description of the facilities which have been developed and which are avail- 
able for laboratory and clinical aid. 
Cl. X. JfyuLy, ynd: 
Director, Division of Preventable Disease Control 
Supervisor, Venereal Disease Control. DIAGNOSIS 
The demands on the family physician’s time do not per- 
mit him to master all the techniques of the specialties; he can, 
however, diagnose almost all patients with syphilis by applying 
a few maxims for each of the various stages of the disease. 
The few general rules that apply to syphilis as a disease are: 
Suspect syphilis in everyone 
Blood test every patient 
Prove your diagnosis 
Treat when diagnosis is proven 
Serologic Tests for Syphilis 
The serologic tests for syphilis presently in use, if per- 
formed by a competent technician, are 99% specific and 90% 
sensitive. 
Specificity: Of 1,000 non-syphilitic persons, not more 
than 10 will have a positive or doubtful blood test as a result 
of other disease, technical error, etc. 
Sensitivity: Of 1,000 syphilitics, 900 will have a frank 
positive blood test. For all practical purposes, two positive blood 
tests mean that the patient has, or has had syphilis. 
Blood tests are made positive by the production of anti- 
body-like substances in response to infection with Treponema 
pallidum. Remember: A case of syphilis which has had adequate 
treatment may retain a positive blood test for life, just as a pa- 
tient who has had typhoid fever may show for years a positive 
agglutination test in a high titer. 
History 
The history of the patient, in syphilis as in other diseases, 
is of great importance in diagnosis. 
Is there a history of lesions—genital, oral, or cutaneous? 
Is there a history of bubo? 
Is there a history of sexual exposure? 
Have there been miscarriages, stillbirths, premature births, 
puny children, or children with positive blood tests? 
What were the results of previous blood tests? 
Has there been treatment? How much? 
What is the serologic status of the sex partner? 
Physical Examination 
Evidence of active syphilis may be detected by physical 
examination; clinical evidence of active syphilis can not be de- 
tected without examination. 
Examine Carefully 
In early syphilis: 
The skin 
The mucous membranes 
The genitalia 
The lymph nodes 
The eyes 
In late syphilis: 
The heart 
The eyes 
The skin 
The reflexes 
9 Early Syphilis 
Since most of the physicians of Mississippi are already 
familiar with the lesions of early syphilis, detailed descriptions 
of them should be unnecessary here. There are, however, a 
few important diagnostic maxims which should be kept in mind. 
Primary 
The Diagnostic Maxims of Primary Syphilis: 
Regard any genital lesion in the male or female 
as syphilitic until proven otherwise. 
Remember that the diagnosis of primary syphilis 
is a laboratory procedure; clinical diagnosis is not 
adequate. 
Prove your diagnosis. Do not treat on suspicion. 
Treat, if darkfield examination or blood test is 
positive. 
Do not treat the lesion or give any anti-syphilitic 
drug if the blood test is negative and no dark- 
field examination is available. Wait until the diag- 
nosis is established. 
Request an examination from the nearest Rapid 
Treatment Center if no darkfield is available in 
your local health department or in a clinical 
laboratory. Rapid Treatment Centers will be glad 
to offer facilities for this examination. 
Do serologic follow-up for three months on every 
patient with apparently non-syphilitic genital le- 
sion or with gonorrhea. 
Secondary 
The Diagnostic Maxims of Secondary Syphilis: 
Take a blood test for every skin eruption or muc- 
ous membrane lesion. 
Take a blood test first, then give atropine, for 
iritis. 
Take a blood test for sore throat which does not 
heal in 10 days. 
AREAS OF PREDILECTION FOR SECONDARY SYPHILIS 
lesions mo/mq //ese areas a/mgs suggestsgp/ii/s. Latent Syphilis 
The Diagnostic Maxims of Latent Syphilis: 
Take a blood test to diagnose latent syphilis. 
The definition of latent syphilis is hidden syphilis. 
The diagnosis of latent syphilis by clinical means is im- 
possible. 
Remember that: 
Syphilis becomes latent when the lesions of early 
syphilis heal. 
All syphilitic infections are latent at some time; 
most of the time until breakdown. 
Every case of paresis, tabes, aneurism, and gumma 
was clinically latent at one time or another. At 
any given time, at least half of all syphilis cases 
are in the stage of latency. 
A person with untreated syphilis becomes non-in- 
fectious within four years except the pregnant 
woman who can infect the fetus. 
As an aid to more precise diagnosis and treatment of 
latent syphilis, this stage of the disease is arbitrarily divided into 
two classifications—early latent and late latent. 
Early latent: Classify latent syphilis as early 
latent if the infection is known to be of less than 
four years’ duration, or if the patient is under 25 
years of age, and if there is no history of lesion, 
blood tests, stigmata of congenital syphilis, etc. 
Late latent: Classify as late latent if the infec- 
tion is known to be of more than four years’ 
duration, or if the patient is over 25 years of age, 
and if there is no history of lesions, blood tests, 
stigmata of congenital syphilis, etc. 
Prenatal Syphilis 
The diagnosis of prenatal syphilis does not vary essen- 
tially from that of other types, save that the incidence of latency 
is raised in pregnant women and the health of the infant is at 
stake. 
Remember that: 
In untreated syphilitic mothers, 8 out of 10 babies 
are born dead or syphilitic. 
In treated syphilitic mothers, 9 out of 10 babies 
are born healthy and normal. 
The birth of syphilitic children is preventable. 
Take a blood test on every pregnant woman. 
11 Congenital Syphilis 
Every child born of a syphilitic mother, even if she has 
been treated, is a suspect. Blood tests in such children are not 
reliable until the age of three months, due to the carry-over of 
antibody-like substances from the maternal to the fetal circula- 
tion. However, if there is clinical evidence and the blood test is 
positive, treat immediately. 
To Find Congenital Syphilis in Babies: 
Suspect every child born of a syphilitic mother. 
Suspect skin rashes in infants. 
Suspect the baby that "won’t gain”. 
Do a darkfield examination on lesions. 
Take a routine blood test at three to four months of age. 
Late Syphilis 
Late syphilis may attack any part of the body. The 
lesions produced by it can mimic any syndrome in medicine. 
However, eight out of ten cases of late manifest syphilis in- 
volve the following systems: 
The central nervous system 
The cardiovascular system 
The skin and mucous membranes 
Central Nervous System Syphilis 
Central nervous system syphilis is so complex a process 
that there can be no list of "land marks.” It is one of the kill- 
ing complications of the disease. 
The nervous system is involved in one patient out of five 
in late untreated syphilis. 
A quiescent period of 10 to 25 years often precedes the 
onset of symptoms (paresis, tabes, etc.) but, during this time, 
the spinal fluid is positive. 
The only way in which central nervous system syphilis 
can be diagnosed with certainty, before or after the appearance 
of symptoms, is by examination of the spinal fluid. 
Suspect Neurosyphilis: 
In every "Wassermann-fast” patient 
In every case of "latent” syphilis 
In every facial palsy 
In every ocular palsy 
In every case of cerebral hemorrhage 
In every case of mental disturbance 
Neurosyphilis: Present or Absent? Prove It! 
Spinal fluid examination will demonstrate the presence 
or absence of central nervous system syphilis. 
A physician at the nearest Rapid Treatment Center will 
be glad to discuss your problem patients with you and make a 
diagnostic survey if you desire. Cardiovascular Syphilis 
Cardiovascular syphilis is a killing complication. Rule 
out cardiovascular syphilis before starting treatment for latent 
syphilis—a Herxheimer reaction may cause death. 
Suspect cardiovascular syphilis and take a blood test when: 
There is an aortic murmur 
There is unexplained shortness of breath or nocturnal 
dyspnea 
The aortic second sound is loud and ringing 
There is precordial pain 
The value of adequate treatment of early syphilis in pre- 
venting the development of cardiovascular syphilis is illustrated 
by the well known study of Kemp & Cochems. 
Late Syphilis of the Skin and 
Mucous Membranes 
Late syphilis of the skin can imitate any skin disease 
from primary syphilis to carcinoma. Ten basic points in the 
clinical diagnosis of late cutaneous syphilis are outlined below. 
These are the suspicion-arousers. Clinch the diagnosis with a 
blood test. 
The Lesions of Late Syphilis of the Skin: 
Are usually few in number 
Distribution is not symmetrical 
Are indurated 
Are indolent 
Form circles, or segments of circles 
Are "punched out” 
Are destructive 
Tend to heal in the center or on one side and 
spread at the border 
Leave a "cigarette paper” scar 
Leave scars with a pigmented border 
In any chronic skin eruption, suspect syphilis and take a 
blood test. 
Amount of Early Treatment 
Number of 
Patients 
Percent Cul- 
minating in 
Cardiovascular 
Syphilis 
None or very little 
92 
18.5 
Inadequate 
81 
7.4 
Adequate 
249 
0.4 LABORATORY TESTS 
And Their Interpretation 
The diagnosis of syphilis is largely based on laboratory 
procedures with supporting evidence from history and physical 
examination. Generally speaking, laboratory tests for the diag- 
nosis of syphilis rely on two procedures: the demonstration of 
the causative organism, or of the host’s production of antibody- 
like substances. 
The first named is useful clinically only in primary, 
secondary, and early congenital syphilis. In these conditions, 
Treponema pallidum is found in the lesions (chancre, bubo, 
skin, or mucous membrane) characteristic of the disease. 
Darkfield Examination 
In primary, secondary, and early congenital syphilis, dark- 
field examination is an important procedure, since it allows the 
physician to arrive at a positive diagnosis within a relatively short 
period of time. Treatment, local or systemic, often causes the 
disappearance of organisms from lesions, sometimes for long 
periods. 
Do not treat until the diagnosis is established by dark- 
field examination or blood tests. 
The general practitioner does not often have equipment 
for darkfield examination in his office. Such tests can be made 
at the Rapid Treatment Centers, the State Hygienic Labora- 
tory, and some clinical laboratories. Private patients who are 
referred to Rapid Treatment Centers for such procedures will 
be shown every consideration. 
Serologic Tests 
Serologic tests for syphilis, to be reliable, must be per- 
formed by a recognized laboratory, using a standard procedure 
with adequate equipment and competent technicians. 
Serologic tests for syphilis are essentially examinations to 
determine the presence or absence of antibody-like substances in 
response to infection with Treponema pallidum. As is the case 
in any infection, a certain amount of time elapses between the 
moment of inoculation and the development of a positive test 
for the disease. Usually, a positive serologic test for syphilis 
appears soon after the development of the primary sore. In the 
absence of adequate treatment early in the disease, blood tests 
will often remain positive for many years. 
The serologic test for syphilis now in use in the Hygienic 
Laboratory of the Mississippi State Board of Health is known 
as the Mazzini flocculation test. This test employs the same 
principle as other flocculation tests (Kahn, Kline, etc.) and 
has been chosen because of: 
Sensitivity: Its ability to detect positivity at low levels. 
Specificity: Its ability to give negative results in the 
absence of syphilis. 
Utility: It can be performed more rapidly and with less 
chance of laboratory error than the Wassermann reaction for- 
merly used. Blood tests for syphilis in modern laboratory practice usu- 
ally are of two types: 
Qualitative: A standard test performed on whole serum 
only which will determine the presence of positivity, but not its 
degree. 
Quantitative: A standard test performed on series of 
dilutions of a sample of serum, for the purpose of showing the 
greatest dilution which will give a positive test. 
As a patient infected with syphilis gradually develops 
manifestations, a series of quantitative tests shows that his sero- 
logic response tends to keep pace with the disease process. Thus, 
in a hypothetical case, when the chancre first appears, the blood 
test is negative. With the passage of time, the blood test be- 
comes positive in whole serum but not in dilution. Later the 
test is found to be positive when the serum is diluted to five 
parts with water, but negative beyond this point; still later, a 
test is found positive when diluted to 20 parts with water, but 
negative when diluted to 40 parts, and so on, until, when there 
are generalized secondaries present, positive results are given with 
a sample diluted as high as 1:320. As the florid manifestations 
of syphilis recede without treatment, the serologic titer falls also, 
but with a certain time lag. 
Thus, after one year of infection, the patient is found 
to have no clinical evidence of syphilis but a quantitative sero- 
logic test positive in such titer as 1:20, 1:40 or 1:80. Should 
late manifestations of syphilis appear, the serologic titer might 
again rise. Or, if the reactive processes of the body be ex- 
hausted, the serologic titer might remain unchanged or even 
reach negativity. 
With the institution of treatment in syphilis, organisms 
are killed in large numbers, and the degree of the positivity of 
the blood test gradually declines. In seronegative primary sy- 
philis, if adequate therapy is instituted, the serologic test for 
syphilis may never become positive. On the other hand, if treat- 
ment is not begun until the disease process is flourishing, and 
the serologic test is positive in a high dilution, there will be a 
lapse of time before the serologic test shows a notable fall in 
titer. Usually, the titer will not become negative for 4 to 6 
months or even longer. The brakes have been applied, but the 
car is still in motion. 
If the disease is of long duration before treatment, the 
serologic tests for syphilis may never become negative. 
Spinal Fluid Examination 
Central nervous system syphilis is one of the killing com- 
plications of the disease. No syphilitic patient is exempt from 
the danger of it. Clinical neurosyphilis is preceded by a period 
of clinical quiescence. During this time, spinal fluid examination 
will reveal neurosyphilis before the occurrence of irreparable 
clinical damage. 
To be accurate, spinal fluid examinations must include 
cell count, protein content, and serologic test. Cell Count 
In central nervous system syphilis the cell count is a sen- 
sitive indication of the activity of the process. Cell counts 
must be done within an hour after the fluid is withdrawn. 
A cell count of over four lymphocytes/cmm. is abnormal. 
A high cell count in a syphilitic patient means neuro- 
syphilis until proved otherwise. 
Total Protein 
The total protein content of the cerebrospinal fluid tends 
to run parallel to the cell count in active neurosyphilitic 
processes. Total protein determinations must be per- 
formed soon after the fluid is withdrawn to prevent er- 
roneous results as a consequence of bacterial contamina- 
tion. For accurate determinations, a photo-electric colori- 
meter (as used at present in the Rapid Treatment 
Centers) is essential. The method whereby protein con- 
tent is determined by gauging turbidity of precipitated 
specimens in comparison with prepared standards is in- 
accurate, but may be considered a procedure of crude 
determination of abnormal protein content. Normal to- 
tal protein content of specimens obtained from lumbar 
puncture should not exceed 40 milligrams/100 cc. 
Serologic Tests 
Properly performed spinal fluid serologic tests are of great 
value in the diagnosis of neurosyphilis. A modification 
of the Wassermann reaction is used in spinal fluid test- 
ing. In the performance of this test, six serial dilutions 
of a spinal fluid sample are used, so that the completed 
test gives a quantitative result. 
The usual spinal fluid report shows the following serial 
dilutions: 
1.0 
0.8 
0.6 
0.4 
0.2 
0.1 
1.0 cc. 
spinal 
fluid 
0.8 cc. 
spinal 
fluid 
0.2 cc. 
water 
0.6 cc. 
spinal 
fluid 
0.4 cc. 
water 
0.4 cc. 
spinal 
fluid 
0.6 cc. 
water 
0.2 cc. 
spinal 
fluid 
0.8 cc. 
water 
0.1 cc. 
spinal 
fluid 
0.9 cc. 
water 
Thus, a test which is positive in 1.0, and negative in the 
rest, is not nearly so strongly positive as a test which is positive 
in 1.0, 0.8, 0.6, 0.4, doubtful in 0.2, and negative in 0.1. 
Examination of the spinal fluid is the only reliable method 
of confirming the diagnosis of neurosyphilis. A series of spinal 
fluid examinations gives the only satisfactory indication of regres- 
sion or progression of a syphilitic process in the nervous system. 
Clinical findings and central nervous system damage do not al- 
ways run parallel. Complete spinal fluid examination is the only 
reliable method of assessing the status of a patient. LATEST ACCEPTABLE 
RAPID TREATMENT SCHEDULES 
JANUARY, 1947 
PAGE 
Early Acquired Syphilis ........... 18 
Primary 
Secondary 
Early Latent 
Late Latent Syphilis ............ 19 
Congenital Syphilis .... ........ 19 
Neurosyphilis ............. 20 
Interstitial Keratitis ............ 20 
Cardiovascular Syphilis............ 20 
Other Late Manifest Syphilis .......... 20 
Children with Acquired Syphilis .......... 20 
17 Early Acquired Syphilis 
1 - 
or 
2 - 
Stage 
Diagnostic Criteria 
Clinical Findings Laboratory Findings 
Primary 
Chancre 
Satellite bubo 
Darkfield—usually positive 
Blood test—positive after 1 to 2 weeks 
Secondary 
Rash on skin or mucous membranes, condyloma, 
sore throat, etc. 
Darkfield o,f rash—usually positive 
Blood test—positive 
Early Latent 
No lesions or symptoms 
Syphilis is of less than 4 years’ duration or in 
the absence of history of disease the patient is 
under 25 years of age 
Blood test—positive 
Spinal fluid examination—negative 
RAPID TREATMENT SCHEDULES FOR PATIENTS OVER 10 YEARS OF AGE 
Drug 
Dosage per Injection 
Number of Injections 
Total 
Injections 
1st 
day 
2nd 
day 
3rd 
day 
4th 
day 
5th 
day 
6th 
day 
7th 
day 
8th 
day 
9th 
day 
Arsenoxide* 
(mapharsen, clorarsen, or 
phenarsine HC1) 
.06 gm.—125 lbs. body weight or over 
.04 gm.—under 125 lbs. body weight 
(Intravenously) 
1 
1 
1 
1 
1 
5 
(.200- 
.300 gm.) 
Penicillin in oil and 
beeswax—Romans\y formula 
(calcium penicillin) 
300,000 units every 24 hours 
(Intramuscularly) 
1 
1 
1 
1 
1 
1 
1 
1 
1 
9 
(2,700,000 
units) 
Bismuth in oil 
1/4 c.c. (0.2 gm.) 
(Intramuscularly) 
1 
1 
1 
3 
(.6 gm.) 
Drug 
Dosage per Injection 
Number of Injections 
Total 
Injections 
1st 
day 
2nd 
day 
3rd 
day 
4th 
day 
5th 
day 
6th 
day 
7th 
day 
8th 
day 
9th 
day 
Arsenoxide* 
(mapharsen, clorarsen, or 
phenarsine HCl) 
.06 gm.—125 lbs. body weight or over 
.04 gm.—under 125 lbs. body weight 
(Intravenously) 
1 
1 
1 
1 
1 
5 
(.200- 
.300 gm.) 
Sodium penicillin 
40,000 units every 3 hours day and night 
(Intramuscularly) 
8 
8 
8 
8 
8 
8 
8 
8 
4 
68 
(2,700,000 
units) 
Bismuth in oil 
V/z c.c. (0.2. gm.) 
(Intramuscularly) 
1 
1 
1 
3 
(.6 gm.) 
to arsenicals: Toxic goiter, pulmonary tuberculosis, nephritis, congestive heart failure or past history of it. Late Latent Syphilis 
Stage 
Diagnostic Criteria 
Clinical Findings 
Laboratory Findings 
Late latent 
? 
No lesions or symptoms 
Syphilis of more than 4 years’ duration or pa- 
tient is over 25 years of age with no history of 
syphilis 
Blood test—positive 
Spinal fluid examination— 
negative 
RAPID TREATMENT SCHEDULES FOR ALL AGES 
Drug 
Number of Injections 
Total 
Injections 
Dosage per Injection 
1st 
day 
2nd 
day 
3rd 
day 
4th 
day 
5th 
day 
6th 
day 
7th 
day 
‘ 8th' 
day 
‘ 9th 
day 
1 
Penicillin in oil and 
beeswax—Romans\y formula 
(calcium penicillin) 
300,000 units daily 
(I ntramuscularly ) 
1 
1 
1 
1 
1 
1 
1 
1 
1 
9 
(2,700,000 
units) 
or 
Number of Injections 
Total 
Injections 
Drug 
Dosage per Injection 
1st 
day 
2nd 
day 
3rd 
day 
4th 
day 
5th 
day 
6th 
day 
’ 7th 
day 
' 8th ' 
day 
9th 
day 
2 
Sodium Penicillin 
40,000 units every 3 hours 
(Intramuscularly) 
8 
8 
8 
8 
8 
8 
8 
8 
4 
68 
(2,700,000 
units) 
Congenital Syphilis 
(Except Interstitial Keratitis) 
Stage 
Diagnostic Criteria 
Clinical Findings 
Laboratory Findings 
Early congenital 
Snuffles, skin rash, failure to gain weight 
May be no lesions 
Darkfield usually positive if lesions are present 
Blood test—positive after third month 
Blood test may not be reliable under three months 
Late congenital 
May be: 
Hutchinson’s teeth 
Deafness 
Interstitial keratitis 
(See Interstitial Keratitis treatment) 
Blood test—positive 
Same Treatment Schedules As For Late Latent Syphilis Neurosyphilis 
(Symptomatic and Asymptomatic) 
Stage 
Diagnostic Criteria 
Clinical Findings 
Laboratory Findings 
Neurosyphilis 
May be clinically negative 
Neurologic and mental abnormalities may be present 
Spinal fluid—positive 
RAPID TREATMENT SCHEDULE 
Drug 
Dosage per Injection 
Number of Injections 
Total Injections 
Penicillin in oil and beeswax—Ro- 
mans\y formula (calcium penicillin) 
300,000 units daily 
(Intramuscularly ) 
One injection per day for 20 days 
20 
(6,000,000 units) 
Exceptions; Optic atrophy with remaining useful vision 
Tabes with severe crises 
Treatment failures after the above neurosyphilis schedule 
f Refer patients in these three categories to Rapid Treatment Centers to 
be evaluated for possible fever-chemotherapy 
Interstitial Keratitis 
Refer to a Rapid Treatment Center or confer with consultant for treatment of choice. 
Cardiovascular Syphilis 
Rapid treatment is not recommended. Three to four months of 
weekly bismuth injections followed by small doses of arsenoxide 
(mapharsen, clorasen, or phenarsen) administered weekly. 
Thereafter, courses of arsenoxide should be alternated with 
bismuth. Special care should be taken to avoid arsenical reaction*. 
Other Late Manifest Syphilis 
I 
Penicillin in oil and beeswax—Romansky formula (calcium penicillin) 300,000 units daily for nine days or a total of 2,700,000 units. No 
or 
arsenic or bismuth. 
2 
Sodium penicillin—40,000 units every three hours—day and night for 9 days or a total of 2,700,000 units. No arsenic or bismuth. 
Children With Acquired Syphilis 
(Under 10 Years of Age) Same treatment schedule as for Late Latent Syphilis 
to arsenicals: Toxic goiter, pulmonary tuberculosis, nephritis, congestive heart failure or past history of it. TREATMENT REACTIONS 
The relative safety of schedules using penicillin alone 
or in combination with small amounts of an arsenical, as sug- 
gested in earlier pages, is illustrated by Heller’s report on a large 
series of cases treated in Rapid Treatment Centers throughout 
the country. Among 3569 early syphilis cases receiving penicillin 
alone, nine (2.5 per thousand) experienced severe reactions, with 
no deaths occurring. Among 17,249 cases receiving penicillin 
plus small amounts of mapharsen and bismuth, 153 severe re- 
actions occurred (8.9 per thousand), with 4 deaths. 
By contrast, among 1873 cases treated by "multiple in- 
jection” intensive arsenotherapy schedules (11-20 days) there 
were 77 severe reactions (41.1 per thousand) and one death. 
Under a schedule administering arsenic by intravenous drip over 
five days, there were 78 severe reactions in 1,041 cases (74.9 
per thousand), and seven deaths. 
Penicillin Reactions 
Allergy: Penicillin-oil-beeswax (P.O.B.) and sodium 
penicillin occasionally produce allergic reactions, e.g., hives, an- 
gioneurotic edema. Benadryl is useful in treatment and should 
be kept on hand when using P.O.B. Adrenalin is useful as an 
emergency measure. 
Herxheimer reaction: Danger is chiefly in cardiovas- 
cular syphilis and in early congenital syphilis. In the former, 
it may result in coronary occlusion or rupture of aortic aneurysm; 
in the latter, in high fever. 
Care should he exercised that P.O.B. never be injected 
into a vein or artery. 
Arsenical Reactions 
Although total dosage of arsenic in any penicillin sched- 
ule is small, the physician should nevertheless be aware of the 
following danger signs: 
High fever 
Bleeding, especially from mouth or kidneys 
Purpura 
Skin rash or erythema and itching 
Jaundice 
Casts or albuminuria 
Mental stupor or convulsions 
Complications: Exfoliative dermatitis, hemorrhagic en- 
cephalitis, cardiovascular Herxheimer reaction, hepatitis, and 
blood dyscrasias, although rare with these recommended treat- 
ment schedules, are dangerous conditions which may develop. 
Antidote: A new drug, known as BAL (British Anti- 
Lewisite) is an effective arsenical detoxicant. When a physician 
has a patient with a serious arsenical reaction, he may obtain 
BAL and instructions for its use from the State Board of Health 
or Rapid Treatment Center. However, the limited supply of 
the drug does not make it possible for a general distribution in 
anticipation of possible reactions. POSTTREATMENT OBSERVATION 
Indications for Re-Treatment 
The purpose of posttreatment observation is to discover 
treatment failures—clinical or serologic. Patients with treatment 
failure of either type need re-treatment. Posttreatment obser- 
vation is best considered in three categories: early syphilis, late 
syphilis, and syphilis in pregnancy. 
Early Syphilis 
Acquired or Congenital 
Take blood tests monthly for the first year, every three 
months for the second year, and if possible, annually thereafter 
until five years have elapsed following treatment. In most cases, 
four to six months or longer will be required to attain seronega- 
tivity. Seldom will blood tests become negative at the comple- 
tion of treatment or shortly afterward. 
Quantitative blood tests always should be used rather 
than qualitative. This type of test will measure the response 
of the patient from month to month. If the quantitative titer 
continues to fall, progress is satisfactory. 
Serologic relapse means that the quantitative titer has 
shown a sustained rise in two or more tests after a preliminary 
fall, or after negativity has been attained. Always re-treat in 
cases of serologic relapse, using the same treatment schedule. 
Do not be misled, however, by minor fluctuations in titer which 
may be caused by day-to-day laboratory performance. 
If, one year after treatment, the quantitative serologic 
tests remain positive, the case can be considered sero-resistant 
and re-treatment may be indicated. 
At the time the blood tests are taken, at least for the 
first six months, it is wise to inspect the skin, mucous membranes, 
and genitalia for the lesions of recurrent early syphilis. This 
condition is known as mucocutaneous or infectious relapse. 
Many times it cannot be differentiated from reinfection. In 
either instance, such patients always should be re-treated. 
In primary and secondary syphilis, spinal fluid examina- 
tion should be done six months after treatment; in early latent 
syphilis, it should be done before, during, or as soon as possible 
after treatment. Spinal fluid examinations should always in- 
clude cell count, total protein, and quantitative complement fixa- 
tion tests. Other types of tests (Pandy, colloidal gold, etc.) may 
be performed if desired by the physician. Rapid Treatment Center facilities are available for lumbar puncture and the per- 
formance of complete spinal fluid examinations (other than col- 
loidal gold tests). 
When abnormal spinal fluid findings are obtained, the 
patient deserves a neurologic examination before neurosyphilis 
treatment is started. This provides a "base line” against which 
to measure later the posttreatment status of the patient. (See 
below under Late Syphilis.) 
Late Syphilis 
Acquired or Congenital 
Perform spinal fluid examination before treatment or as 
soon thereafter as practicable. If negative at this time, the ex- 
amination need not be repeated subsequently. 
Follow-up in late syphilis relates only to the detection of 
clinical or spinal fluid relapse or progression. Posttreatment 
blood tests in late cases have no value whatever in determining 
whether re-treatment is needed. Re-treatment, of course, should 
be given if there is clinical or spinal fluid serologic relapse, or 
if any lesions of late syphilis appear. 
In symptomatic or asymptomatic neurosyphilis of any 
type, the determination of the need for re-treatment is a com- 
plex matter, and it is recommended that the general practitioner 
seek consultation (available at the Rapid Treatment Centers). 
Spinal fluid examination should be repeated every six months. 
In general, it may be stated that the schedules recommended for 
neurosyphilis in the section on "Latest Acceptable Rapid Treat- 
ment Schedule” (pages 18, 19, 20), if successful, should result 
in reversal of spinal fluid findings to negative in approximately 
the following order: 
Cell count: Within four to six months. 
Protein: Within six months to two years. 
Complement fixation: Variable, usually two to five 
years. 
Prenatal and Congenital Syphilis 
Mothers: The posttreatment observation of the ex- 
pectant mother does not differ from that of other patients with 
syphilis. 
Infants: In infants of syphilitic mothers, regardless of 
whether the mother has been treated, be alert for snuffles, loss 
of weight, or skin lesions during the first three months following 
birth. After a congenital syphilitic infant has been treated, the 
posttreatment observation is the same as that of any other pa- 
tient with syphilis. 
Take blood tests on the infant at three to four months 
of age. 
Infants may be referred to Rapid Treatment Centers for 
blood testing. REFERRAL AND CONSULTATION 
The State Board of Health operates three centers for the 
treatment of syphilis. These centers are located at Brookhaven, 
Greenwood, and Meridian. Thousands of cases have been treated 
in these facilities by rapid treatment schedules and considerable 
experience has been acquired in the diagnosis and treatment of 
syphilis. Physicians in these centers will be glad to give you any 
assistance which you may request. 
The busy general practitioner may not have time 
for many of the specialized laboratory procedures indicated. De- 
mands on his time may even preclude his treating certain cases. 
Therefore, the Rapid Treatment Centers are prepared to ac- 
cept patients from any private physician in the state for con- 
firmatory diagnosis and/or treatment of syphilis. On the basis 
of your decision, your patient may be referred for confirmatory 
diagnosis alone and returned to you for rapid treatment; or he 
may be referred for confirmatory diagnosis and rapid treatment 
in the center. In the latter instance, the patient will be returned 
to you for posttreatment observation unless you prefer other ar- 
rangements. 
Patients may be referred directly to the center or you may 
request the assistance of your County Health Officer in arrang- 
ing referral and transportation. The Rapid Treatment Centers 
have found it necessary to limit their admissions to those pa- 
tients who are not bed-ridden and who are not mentally or phy- 
sically incompetent. 
RAPID TREATMENT CENTER DISTRICTS 
SHOW//VGLOCRT/OA/ OF CENTERS 
AND COC/NT/ES //V EACH D/STR/CT 
DELTA MEDICAL CENTER 
P.O. BOX N2 937 
GREENWOOD, MISS. 
TEL.NUMBER 2260 
PUBLIC HEALTH 
TREATMENT CENTER 
P.O.BOX N2 190 
MERIDIAN . MISS. 
TELNUMBER 2203 
PUBLIC HEALTH 
TREATMENT CENTER 
P. 0. BOX N2 272 
BROOKHAVEN, MISS. 
TEL. NUMBER 760 Services Available to Private Physicians 
At The Rapid Treatment Centers 
Type of Service 
Usual Time 
Required 
Darkfield examination 
One day 
Lumbar puncture and spinal fluid examination 
One day 
Neurological examination 
Two days 
Complete evaluation of syphilis patients before, during, or after treatment 
Two days 
Serologic blood tests of infants 
One day 
Confirmatory diagnosis of patients to be returned to physician for treatment 
Two days 
Treatment of early and latent syphilis patients to be returned to physician for 
post-treatment observation 
Twelve to 
Fourteen days 
Treatment of neurosyphilis patients to be returned to physician for post-treatment observation 
Three to four weeks 
Consultations on treatment reactions 
Immediately upon request 
Furnishing of BAL for treatment of arsenical reactions 
Immediately upon request CASE FINDING 
People expect the ultimate control of syphilis. To achieve 
this control, they depend upon two professional groups—the 
private physicians and the public health workers. 
These groups must: 
Find the source of infection of each new case. 
Find the people who have been infected by each 
new case. 
Treat all known cases adequately. 
For each 100 cases of primary and secondary syphilis 
coming under the care of public health clinics and treatment 
centers in Mississippi, at least 153 contacts (presumably exposed 
persons) are examined, leading to the discovery of at least 69 
new cases of syphilis. 
Obtaining contact information from the syphilis patients 
of private physicians is one of the major unsolved problems in 
the ultimate control of syphilis. The failure to discover and treat 
infection among these contacts leaves an unchecked source of in- 
fection in the general population. 
Self-Interview Form 
In order to help solve this problem, the Council of the 
State Medical Association approved the "Self-Interview Form” 
for obtaining contact information from patients of private phy- 
sicians. This form has been used with good results. If all phy- 
sicians were to adopt its use, it is estimated that there would be 
38,000 new patient office visits for examination per year, of 
which 50% would be found infected with a venereal disease. 
The "Self-Interview Form” is to be handed to each new 
patient with syphilis under care of a private physician with a 
word by the physician as to the importance of filling out and 
mailing the form. This form does not require the name of either 
the patient or the private physician. 
The State Board of Health mails a "Cooperation Notice” 
to each contact listed on the "Self-Interview Form.” If the 
contact fails to report to a physician within two weeks, he or 
she is followed up by a representative of the Health Department. 
Other Important Methods of Case Finding: 
Examine all sex partners of known cases. 
Do blood tests on all expectant mothers. 
Do routine blood tests on all patients under your 
care. The importance of this procedure is illus- 
trated by the fact that routine blood tests per- 
formed on all patients admitted to the John Gas- 
ton Hospital, Memphis, in 1945, resulted in 13.8 
percent positive or doubtful results. 
Collaborate with your colleagues in developing 
procedures whereby routine blood tests will be per- 
formed on all patients admitted to the hospitals 
in your community. 
Look for genital, mucous membrane, and skin 
lesions. 
Do blood tests and physical examinations on all 
children of infected mothers. 
Do blood tests monthly for at least three months 
on all patients with apparently nonsyphilitic geni- 
tal lesions or with gonorrhea. 
Call upon County Health Departments regarding 
patient interview and contact follow-up in private 
practice. BIBLIOGRAPHY 
1. Delayed Serum Sickness Reaction to Penicillin. E. J. Gordon. 
J.A.M.A. Vol. 131: pp. 727-730, 1946. 
2. Dermatitis from Penicillin. L. Goldman, F. Friend, and L. M. 
Mason. J.A.M.A. Vol. 131: pp. 883-890, 1946. 
3. Generalized Angioneurotic Edema Due to Penicillin Inhalations 
Treated with Benadryl. D, Scheinberg. J.A.M.A. Vol. 132: pp. 
78-79, 1946. 
4. Laboratory Diagnosis of Syphilis. H. Eagle. C. V. Mosby Co., 
St. Louis. 1937. Pp. 242, 300, 361. 
5. Modern Clinical Syphilology. 3rd Ed. J. H. Stokes. W. B. 
Saunders Co., Philadelphia. 1944. Pp. 73, 181, 477, 679. 
6. Penicillin: Its Practical Application. Sir Alexander Fleming. 
Blakiston, Philadelphia. 1946. P. 282. 
7. Personal Communication to Mississippi State Board of Health. 
1946. John Mahoney. 
8. Resolutions Adopted at the Conference on the Control of Venereal 
Diseases in the Southern States. Supplement No. 12 to Yen. Dis. 
Inform,, U. S. Public Health Service. 1940. P. 9. 
9. Results of Rapid Treatment of Early Syphilis. J. R. Heller, Jr. 
J. Yen. Dis. Inform. Vol. 27: pp. 217-225, 1946. 
10. Seroresistance (Wassermann-fastness) in Syphilis, J. E. Moore. 
Am. J. Syph., Conor., & Yen. Dis. Yol. 30: pp. 125-133, 1946. 
11. Studies in the Epidemiology of Syphilis: III. Conjugal Syphilis. 
L. J. Klingbeil and E. G. Clark. Yen. Dis. Inform. Vol. 22: p. 
1, 1941. 
12. The Control of Venereal Disease. R. A. Vonderlehr and J. R. 
Heller, Jr. Reynal and Hitchcock, New York. 1946. P. 61. 
13. The Management of Neurosyphilis. B. Dattner. Grune and Strat- 
ton, New York. 1944. 
14. The Modern Treatment of Syphilis. 2nd Ed. J. E. Moore. 
Charles C. Thomas, Springfield. 1941. Pp. 251, 344, 348-350, 
489, 520. 
15. The Systemic Treatment of Arsenic Poisoning with BAL (2, 
3-Dimercaptopropanol). H. Eagle. T. Yen. Dis. Inform. Vol. 27: 
pp. 114-121, 1946. 
16. The Treatment of Cardiovascular Syphilis with Penicillin. R. E. 
Dolkart and G. X. Schwemlein. J.A.M.A. Vol. 129: pp. 515-516, 
1945. 
27