WEBVTT 00:00:16.540 --> 00:00:26.730 [This tape was duplicated from a 16mm film by Erickson Archival for the National Library of Medicine, December 2003. NLM call number HF0689A] 00:00:30.900 --> 00:00:32.510 [Music] 00:00:32.510 --> 00:00:40.030 [Syphilis: A Motion Picture Clinic] 00:00:40.030 --> 00:00:48.450 [Produced jointly by the American Medical Assn. and the United States Public Health Service] 00:00:48.450 --> 00:00:54.250 [Under the auspices of the Board of Trustees of the American Medical Assn. with the following committee - Morris Fishbein, M. D., Austin A. Hayden, M. D., Olin West, M.D.] 00:00:54.250 --> 00:01:00.720 [Produced by Burton Holmes Films, Inc. Supervised by Herbert C. Hoagland, Directed by C. F. Van Arsdale] 00:01:00.720 --> 00:01:08.770 [Initiated and edited by Morris Fishbein, M. D., Editor Journal American Medical Assn.] 00:01:08.770 --> 00:01:20.610 [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. 00:01:20.610 --> 00:01:33.160 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. 00:01:33.160 --> 00:01:45.680 [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. 00:01:45.680 --> 00:01:48.460 [Chart with title, "Syphilis in Sweden. New Cases in 1916 2,500. New cases in 1919 6,000. New cases in 1922 1,500. New cases in 1929 1,000. New cases in 1934 500.] 00:01:48.460 --> 00:01:54.990 Other nations have shown us that much can be done. Man has the ability to banish the infectious diseases from the earth. 00:01:54.990 --> 00:02:06.810 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. 00:02:06.810 --> 00:02:18.270 There comes from the public an insistent demand for medical services in the prevention, diagnosis, and the treatment of this disease. 00:02:18.270 --> 00:02:24.500 The time is opportune. The necessity for eradication is imperative. 00:02:24.500 --> 00:02:41.260 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. 00:02:41.260 --> 00:02:54.540 [Narrator:] We move next to the headquarters of the United States Public Health Service in Washington DC. Dr. Thomas Parran, Surgeon General, speaks. 00:02:54.540 --> 00:03:01.460 [Dr. Parran:] Our two great medical forces, the private physicians and the health officers, have joined hands in his campaign against syphilis. 00:03:01.460 --> 00:03:07.520 To the private physician, I would say, diagnose syphilis early. Treat syphilis adequately. 00:03:07.520 --> 00:03:16.370 Report your new cases, and your last cases. Teach syphilis to your individual patients. 00:03:16.370 --> 00:03:27.450 To the health officer, I would say, learn the extent of your syphilis problem. Provide adequate treatment facilities and a complete laboratory service. 00:03:27.450 --> 00:03:40.370 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. 00:03:40.370 --> 00:03:56.060 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. 00:03:57.440 --> 00:04:07.720 [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. 00:04:07.720 --> 00:04:17.700 [Dr. Stokes:] Diagnosis of early syphilis, primary and secondary, is a laboratory problem. The physician in practice must therefore suspect, examine, closely and completely. 00:04:17.700 --> 00:04:33.720 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. 00:04:33.720 --> 00:04:45.850 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. 00:04:45.850 --> 00:04:55.620 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. 00:04:55.620 --> 00:05:05.860 May not develop at all. May be superimposed on any open wound or sore. Does not require previous abrasion. May be out of sight in urethra or on cervix. 00:05:05.860 --> 00:05:17.940 May be masked by the discharge of a gonorrhea or produce its own urethral discharge. Mysteries of exposure and calculated incubation periods are unreliable. 00:05:17.940 --> 00:05:32.110 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 three great suspicion-arousing features of indolence. 00:05:32.110 --> 00:05:46.700 Induration-firm or cartilaginous feel. Satellite adenopathy. A local lymph node enlargement-bilateral on genitalia, unilateral elsewhere, discrete, usually not tender. 00:05:46.700 --> 00:05:59.070 In particular, make no final clinical diagnosis of chancroid exclusive of syphilis on any but serologic follow-up tests. Mixed ulcers are common. 00:05:59.070 --> 00:06:10.880 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. 00:06:10.880 --> 00:06:25.320 Though an untreated lesion is desirable, it is not indispensable. Salt solution soaking for 24 hours. Aspiration of an indurated base. 00:06:25.320 --> 00:06:42.610 Suction after vigorous rubbing or scraping. Aspiration of adjacent lymph nodes. Repeated collection of material on successive days may yield a positive darkfield. 00:06:42.610 --> 00:06:55.900 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. 00:06:55.900 --> 00:07:08.770 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. 00:07:08.770 --> 00:07:22.550 Clean and abrade the surface gently, but with determination. Collect in a capillary tube, with or without the aid of a suction bulb. 00:07:22.550 --> 00:07:42.100 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. 00:07:42.100 --> 00:07:58.550 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. 00:07:58.550 --> 00:08:09.850 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. 00:08:09.850 --> 00:08:19.100 If the first darkfield fails or is negative, repeat at one or two-day intervals, using salt solutions, wet dressings, or soaks between time. 00:08:19.100 --> 00:08:31.760 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. 00:08:31.760 --> 00:08:45.040 About 60 percent of chancres on 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. 00:08:45.040 --> 00:08:54.290 The clinical appearances ranging from a vesicle to a pseudo-carcinoma are totally deceiving. Make speculum examination of all exposed women. 00:08:54.290 --> 00:09:05.240 Most syphilis in women is not diagnosed until secondaries appear, and often not then, since the tendency is toward constitutional rather than eruptive manifestation. 00:09:05.240 --> 00:09:16.820 Watch for the extragenital primary lesions. Be chronically suspicious of all slow-healing, indolent, indurated lesions with associated regional lymph adenopathy. 00:09:16.820 --> 00:09:33.030 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. 00:09:33.030 --> 00:09:47.060 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. 00:09:47.060 --> 00:10:02.900 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... 00:10:02.900 --> 00:10:14.110 ...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. 00:10:14.110 --> 00:10:26.810 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. 00:10:26.810 --> 00:10:37.630 And in many nonspecific urethritis developing after sexual exposure. Piecemeal and incomplete examination defeats many diagnoses of early syphilis. 00:10:37.630 --> 00:10:46.540 Strip every patient at first visit, and examine the skin and mucosae, as well as the suspected chancre or the part complained of. 00:10:46.540 --> 00:10:56.400 Secondaries may be found to prove a primary, or a primary to prove out secondary. Some lesions that look like chancres are merely relapses in older infections. 00:10:56.400 --> 00:11:04.570 The ensemble of the case may determine the diagnosis and treatment as much as the blood test alone. 00:11:04.570 --> 00:11:18.460 The diagnosis of secondary syphilis today rests on the fact that competent laboratory gives a little short of 100 percent positive Wassermann and precipitation tests on florid secondary syphilis. 00:11:18.460 --> 00:11:38.180 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 take a blood test, and lastly to avoid the gross occasional mistake of calling a non-syphilitic eruption syphilitic. 00:11:38.180 --> 00:11:50.530 The constitutional symptoms of early syphilis are seldom specific enough to arouse suspicion. Suspicion should therefore obtain the automatic status of a blood test for the disease on every new patient. 00:11:50.530 --> 00:12:02.560 Chronic headache, chronic sore throat, bone pain, and localized tenderness, persistent anemia and weight loss in young women, would achieve new significance. 00:12:02.560 --> 00:12:16.200 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. 00:12:16.200 --> 00:12:28.120 Mucosal and genital relapses are greatly infectious, inconspicuous, evanescent, numerically important. Examine the mouth and genitalia where most of them occur. 00:12:28.120 --> 00:12:38.610 Have darkfields, for these patients may be seronegative. Suspect moist spots, moist papule, fissures, split papules. Suspect piles. 00:12:38.610 --> 00:12:52.240 Suspect all rings, especially about the genitalia, all groups of darkish, firm or fleshy papules. And take blood tests. 00:12:52.240 --> 00:13:09.020 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. 00:13:09.020 --> 00:13:20.800 [Method of obtaining blood serum, for darkfield examination, from chancre on genitalia of patient with primary syphilis] 00:13:20.800 --> 00:13:31.010 [Inaudible] 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. 00:13:31.010 --> 00:13:45.340 Do not use local anesthetics. Cautioning the patient, rub the surface boldly with gauze. 00:13:45.340 --> 00:14:02.750 Scraping is rarely necessary unless dry or crusted. Allow bleeding to subside spontaneously, and wipe off the clot. 00:14:02.750 --> 00:14:18.530 Gently squeeze the base of the lesion between thumb and forefinger, tipping, so as to collect the serum toward one side. 00:14:18.530 --> 00:14:40.900 Holding the capillary tube at a low angle from the horizontal, allow capillarity to draw the fluid to it. Or if a bulb is supplied, suck it in with very slight suction. 00:14:40.900 --> 00:14:55.190 Seal the ends of the tube with sterile petrolatum. 00:14:55.190 --> 00:15:06.660 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. 00:15:06.660 --> 00:15:27.830 Throw a broad rubber band about it. In a number of turns making congestive but not extreme pressure. 00:15:27.830 --> 00:15:47.490 Protect with gauze wrapping first. Wait five to 15 minutes. Use the suction bulb. 00:15:47.490 --> 00:16:08.980 Or rig and use the sucker. Applying the mouth of the smaller syringe to the lesion. While you aspirate with the larger. 00:16:08.980 --> 00:16:20.480 Usually an abundance of serum is obtainable one way or the other. Aspiration of base or nodes requires experience. 00:16:20.480 --> 00:16:33.000 Of course, sterilize all infected materials. Gonorrhea masks the onset of perhaps 15 to 20 percent of syphilis in males. 00:16:33.000 --> 00:16:42.300 The late discharge of a gonorrhea, or of a nonspecific urethritis, should be examined for spriochetes more frequently than it is. 00:16:42.300 --> 00:16:52.130 Smears are not satisfactory for such work. Immediately the specimen for darkfield examination is obtained. Draw blood for serologic tests for syphilis. 00:16:52.130 --> 00:17:09.200 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. 00:17:12.470 --> 00:17:22.760 [Method suitable for ordinary office practice in the examination of the external genitalia and anal region of women] 00:17:22.760 --> 00:17:30.830 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. 00:17:30.830 --> 00:17:47.350 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. 00:17:47.350 --> 00:17:59.040 The buttocks are then separated and you can see how complete is the exposure of the external genitalia and the anal region. 00:17:59.040 --> 00:18:06.820 [Physical examination of male patient for symptoms of secondary syphilis] 00:18:08.620 --> 00:18:20.020 Secondary syphilis is usually hard, not easy, to see. Use good light. Expect faint macules. And papules. 00:18:20.020 --> 00:18:34.740 Groups of follicular lesions, rather than pustules, rings, and sores. A fleshy field of papules is suspicious. 00:18:34.740 --> 00:18:51.030 Patchy hair and eyebrows warrant Wassermann. Peer into the corners. Especially never forget the lips. 00:18:51.030 --> 00:19:03.940 Stick your tongue out. Put it over to the right. Pull it to the left. Out of your mouth. Way out. Go like that. Say "ahhhh." 00:19:03.940 --> 00:19:05.000 [Male patient:] Ahhhh. 00:19:05.000 --> 00:19:06.870 [Dr. Stokes:] Ahhhh. 00:19:06.870 --> 00:19:07.590 [Male patient:] Ahhhh. 00:19:07.590 --> 00:19:31.780 [Dr. Stokes:] Close your mouth. The anus and genitalia. Drop your trousers to your knees, especially the foreskin, the anterior surface of the scrotum. 00:19:31.780 --> 00:19:51.310 Turn around. Stoop forward. The posterior surface of the scrotum. The anus. Stand up. Turn back. The labia and perineum in women. 00:19:51.310 --> 00:20:03.000 The palms and soles may show flat papules which give the whole case away. The darkfield is useful in secondary syphilis. 00:20:03.000 --> 00:20:12.720 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. 00:20:12.720 --> 00:20:24.100 Always look for the chancre and its [inaudible]. When examining for secondary syphilis, finding it often makes the case complete. 00:20:24.100 --> 00:20:28.510 [Audience clapping] 00:20:28.510 --> 00:20:42.550 [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. 00:20:42.550 --> 00:20:52.220 [Dr. Cole:] Forney 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. 00:20:52.220 --> 00:21:05.490 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. 00:21:05.490 --> 00:21:12.260 Limit your selection of drugs to preparations accepted by the Council on Pharmacy and Chemistry of the American Medical Association. 00:21:12.260 --> 00:21:26.520 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. 00:21:26.520 --> 00:21:38.660 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. 00:21:38.660 --> 00:21:47.610 Human syphilis cannot be overwhelmed at one fell swoop. It is a chronic disease in which the organisms only gradually disappear. 00:21:47.610 --> 00:22:01.270 Larkin claimed that the disease is merely arrested. That the spirochetes never disappear. Such being the case, the fallacious argument of Forney for the intermittent treatment of syphilis is exposed. 00:22:01.270 --> 00:22:14.760 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. 00:22:14.760 --> 00:22:25.580 The spirochetes have no opportunity to increase in numbers. Instead of purposeful rest periods, following a course of arsenical injections. 00:22:25.580 --> 00:22:35.710 This is followed, at once, by a further course of a bismuth treatment, and this in turn, by further arsenical therapy, and so on. 00:22:35.710 --> 00:22:53.810 To illustrate the point, each circle indicates an intravenous arsenical. Each cross and inside of a bismuth, given intramuscularly once a week. 00:22:53.810 --> 00:23:08.410 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. 00:23:08.410 --> 00:23:28.700 Thus, 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. 00:23:28.700 --> 00:23:43.240 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. 00:23:43.240 --> 00:23:59.030 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. 00:23:59.030 --> 00:24:09.710 Rarely with bismuth therapy are severe reactions noted. With arsenic on the other hand, gastrointestinal upsets are not uncommon. 00:24:09.710 --> 00:24:18.280 And cutaneous disturbances from a fleeting erythema or urticaria, to a generalized exfoliation may be seen. 00:24:18.280 --> 00:24:28.070 Hemorrhagic reactions are a signal for immediate discontinuance of further therapy. [Inaudible]] likewise calls for great caution. 00:24:28.070 --> 00:24:41.500 In fact, any untoward reactions demand careful questioning and examination before further treatment. It is much easier to prevent reactions than to treat them afterwards. 00:24:41.500 --> 00:24:57.430 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. 00:24:57.430 --> 00:25:18.940 Arsphenamine is rarely employed outside of hospital and clinic practice. In administering the arsenicals, all apparatus must be carefully sterilized and cooled. 00:25:18.940 --> 00:25:29.090 Arsphenamine is administered through carefully pouring the contents of the glass containers previously floated in alcohol to ensure freedom from cracks. 00:25:29.090 --> 00:25:43.050 Over the surface apply to 8cc's of sterile distilled water. Gently rotate the container to ensure solutions. 00:25:43.050 --> 00:25:59.160 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. 00:25:59.160 --> 00:26:14.140 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. 00:26:14.140 --> 00:26:21.700 After removing the tourniquet, then slowly inject the drug, employing at least two minutes. 00:26:21.700 --> 00:26:35.250 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. 00:26:35.250 --> 00:26:54.790 Be sure the needlepoint is free in the vessel. Moreover, be careful that the opening is not pressed against the vessel wall obstructing the easy flow. Now we will repeat the action in slow motion and animation. 00:26:54.790 --> 00:27:07.930 [Image of skin showing subcutaneous tissue, fat and vein. Image of point of needle piercing the skin, piercing the subcutaneous layer with label reading, "Motion No. 1. Downward through skin." Needle nearly enters vein, 00:27:07.930 --> 00:27:30.010 "Motion No. 2. Horizontal ready to enter vein." Needle enters vein, "Motion No. 3. Downward into vein." Needle enters blood, blood flows up needle, "Motion No. 4. Advancing 1 cm in vein." 00:27:30.010 --> 00:27:48.380 [Doctor releases tourniquet. Image of solution moving from needle into blood.] 00:27:48.380 --> 00:27:52.170 [Wrong Methods] 00:27:52.170 --> 00:27:57.760 [Image of needle piercing vein wall with solution flowing through needle, "Needle punctures entire vein."] 00:27:57.760 --> 00:28:02.580 [Image of needle half in subcutaneous layer and half in vein, "Partial puncture."] 00:28:02.580 --> 00:28:07.040 [Image of needle half in subcutaneous layer and half in vein and solution flowing into both, "Infiltration of subcutaneous tissue after a return of blood."] 00:28:07.040 --> 00:28:24.320 If arsphenamine is employed it should be thoroughly aerated after being dissolved and drawing it up the syringe and forcibly expelling it out of the beaker. The arsphenamine in contra-distinction to the other arsenicals should be rapidly injected. 00:28:24.320 --> 00:28:42.670 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. 00:28:42.670 --> 00:28:55.020 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. 00:28:55.020 --> 00:29:05.550 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. 00:29:05.550 --> 00:29:21.850 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. 00:29:21.850 --> 00:29:36.390 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. 00:29:36.390 --> 00:29:48.570 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. 00:29:48.570 --> 00:30:05.020 To illustrate, in seronegative primary syphilis, [inaudible] arsphenamine, three-tenths of a gram. Repeat in three days. And three days later with 45 hundredths to six-tenths of a gram. 00:30:05.020 --> 00:30:19.050 For the first three weeks, a bismuth injection should be given once a week with the added help of overcoming acute infectious symptoms. Thereafter only between courses of therapy. Thus... 00:30:19.050 --> 00:30:37.960 [Doctor writes X's and O's on the chalkboard.] 00:30:37.960 --> 00:31:01.900 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. 00:31:01.900 --> 00:31:18.060 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. 00:31:18.060 --> 00:31:30.930 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. 00:31:30.930 --> 00:31:46.370 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. 00:31:46.370 --> 00:32:00.990 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 cloth. 00:32:00.990 --> 00:32:12.070 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. 00:32:12.070 --> 00:32:18.810 At the end of two and a half years there should be general checkup, lumbar puncture, and examination of cardiovascular apparatus. 00:32:18.810 --> 00:32:28.170 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. 00:32:28.170 --> 00:32:46.880 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. 00:32:46.880 --> 00:32:53.310 Moreover, the frequency of the Wassermann relapse seen early in the course of syphilis has dropped enormously. 00:32:53.310 --> 00:33:06.180 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. 00:33:06.180 --> 00:33:17.360 Many of them infectious in character; for example, a moist papule of the lip and of the genitalia. Intermittent, irregular treatment predisposes to relapse. 00:33:17.360 --> 00:33:34.560 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. 00:33:34.560 --> 00:33:49.310 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. 00:33:49.310 --> 00:33:57.160 In conclusion, in acute syphilis, make the earliest possible diagnosis, and institute treatment at once. 00:33:57.160 --> 00:34:13.670 Check all contexts and sources. Employ only tried and accepted drugs. Follow continuous therapy, of alternating courses of bismuth and of arsenicals. 00:34:13.670 --> 00:34:27.180 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. 00:34:27.180 --> 00:34:36.490 With secondary syphilis, give at least 40 injections of each. Eternal vigilance is the price of the syphilis problem. 00:34:39.740 --> 00:34:54.380 [Narrator:] Dr. Paul A. O'Leary, Professor of Dermatology and Syphilology in the Graduate School of Medicine at the University of Minnesota at Rochester, Minnesota. He discusses latent syphilis. 00:34:54.380 --> 00:35:09.860 [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. 00:35:09.860 --> 00:35:22.940 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. 00:35:22.940 --> 00:35:30.500 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. 00:35:30.500 --> 00:35:34.270 [X-ray image with words "Enlarged heart."] 00:35:34.270 --> 00:35:47.060 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. 00:35:47.060 --> 00:35:49.610 [Image of a cross-section with words "Gummacous Sclerosis of the liver."] 00:35:49.610 --> 00:35:54.590 Diagnosis of latent syphilis can be made only after a complete physical examination has eliminated all evidence of cardiovascular involvement. 00:35:54.590 --> 00:36:01.270 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. 00:36:01.270 --> 00:36:05.430 [Image with words "Syphilitic Gastritis with hour-glass deformity."] 00:36:05.430 --> 00:36:12.990 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. 00:36:12.990 --> 00:36:15.680 [Image with the words "Ulcerative Syphilitic gastritis."] 00:36:15.680 --> 00:36:31.530 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. 00:36:31.530 --> 00:36:41.160 The Wassermann or flocculation tests in latent syphilis, may be either negative or positive. The treatment of latent syphilis cannot be standardized. 00:36:41.160 --> 00:36:54.780 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. 00:36:54.780 --> 00:37:09.900 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. 00:37:09.900 --> 00:37:24.840 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. 00:37:24.840 --> 00:37:31.090 A few case examples will illustrate the variation in the indication for the treatment of latency. 00:37:31.090 --> 00:37:43.950 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. 00:37:43.950 --> 00:37:54.930 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. 00:37:54.930 --> 00:38:11.120 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. 00:38:11.120 --> 00:38:25.060 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. 00:38:25.060 --> 00:38:38.570 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. 00:38:38.570 --> 00:38:46.110 During the treatment period, re-examine him for signs of cardiovascular syphilis. 00:38:46.110 --> 00:38:58.760 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. 00:38:58.760 --> 00:39:09.400 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. 00:39:09.400 --> 00:39:19.230 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. 00:39:19.230 --> 00:39:33.080 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. 00:39:33.080 --> 00:39:42.260 The consistently positive Wassermann test, or so-called Wassermann-Fast is not a diagnosis. It's merely an accumulation of serological reports. 00:39:42.260 --> 00:39:52.630 The consistently positive Wassermann has different significance, not only in various patients, but also in various manifestations of syphilis. 00:39:52.630 --> 00:40:06.760 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. 00:40:06.760 --> 00:40:19.770 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. 00:40:19.770 --> 00:40:34.360 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, 00:40:34.360 --> 00:40:40.990 and the amount of previous treatment are the factors that determine whether the positive Wassermann has any significance. 00:40:40.990 --> 00:40:47.180 The serologic tends to become negative spontaneously in the majority of patients with latent syphilis. 00:40:47.180 --> 00:41:01.790 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. 00:41:01.790 --> 00:41:08.990 Only by these repeated clinical examinations is it possible to determine if the patient is developing a permanent state of latency. 00:41:08.990 --> 00:41:19.520 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. 00:41:19.520 --> 00:41:27.750 The treatment should consist of at least 24 injections of an arsphenamine preparation and 48 injections of bismuth. 00:41:27.750 --> 00:41:38.850 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. 00:41:38.850 --> 00:41:52.020 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. 00:41:52.020 --> 00:42:12.400 In cardiovascular disease, neurosyphilis, in visceral syphilis, and a type of hepatitis or cirrhosis, and [inaudible] syphilis, and in the latent syphilitic lesions of the mucous membranes, the tests tend to remain permanently positive. 00:42:12.400 --> 00:42:29.440 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. 00:42:29.440 --> 00:42:39.020 If a patient with syphilis who has been under your care wishes to marry it is urged that you have him bring his fiancée to your office, 00:42:39.020 --> 00:42:53.320 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. 00:42:53.320 --> 00:43:03.390 Miss Carlton, Frank has told me that he wants to marry you, but before he does there are certain things about them that I think you should know that I would like to discuss with you. 00:43:03.390 --> 00:43:09.840 Physicians now believe that it's more advisable to discuss such affairs before marriage rather than after in order to avoid future trouble. 00:43:09.840 --> 00:43:11.750 [Miss Carlton, the fiancee:] Yes, Doctor. 00:43:11.750 --> 00:43:25.220 [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. 00:43:25.220 --> 00:43:27.570 [Miss Carlton:] But, Doctor, doesn't that make our marriage impossible? 00:43:27.570 --> 00:43:36.770 [Dr. O'Leary:] No indeed. Here are the circumstances of Frank's case. The patient with acute syphilis is adequately and thoroughly treated. 00:43:36.770 --> 00:43:46.890 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. 00:43:46.890 --> 00:43:59.350 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 treatment, they likewise may marry without danger of infecting. 00:43:59.350 --> 00:44:10.800 Frank has had acute syphilis and has had good treatment and observation. There are now no clinical signs of the disease and you may marry without danger to you. 00:44:10.800 --> 00:44:14.520 [Miss Carlton:] Oh, I thought that disease could not be cured. 00:44:14.520 --> 00:44:23.810 [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. 00:44:23.810 --> 00:44:32.750 With the result that his tests have now been negative for the past five years. In addition, his spinal fluid is likewise negative. 00:44:32.750 --> 00:44:45.440 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. 00:44:45.440 --> 00:44:48.600 [Miss Carlton:] Is there no danger of my getting syphilis from him? 00:44:48.600 --> 00:44:54.500 [Dr. O'Leary:] No, not now. Frank is past the infectious period of the disease. 00:44:54.500 --> 00:44:57.780 [Miss Carlton:] Even so, I do not believe we should have children. 00:44:57.780 --> 00:45:03.970 [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. 00:45:03.970 --> 00:45:13.700 So I'll ask but one thing if you, and one of Frank. When you believe you are pregnant, I think you should come in immediately and have a Wassermann test made. 00:45:13.700 --> 00:45:23.990 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. 00:45:25.220 --> 00:45:38.270 [Narrator:] The treatment of syphilis in the expectant mother is presented by Dr. James R. McCord, Professor of Obstetrics and Gynecology in Emory University School of Medicine-Atlanta, Georgia. 00:45:38.270 --> 00:45:49.950 [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. 00:45:49.950 --> 00:46:03.170 The 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. 00:46:03.170 --> 00:46:13.020 If it is moderately active, the baby may be syphilitic. Babies born apparently free of the disease of syphilitic mother mothers, are born of those mothers who have a latent and inactive syphilis. 00:46:13.020 --> 00:46:18.060 [Chart with title, "Outcome of latent untreated syphilis during pregnancy."] 00:46:18.060 --> 00:46:34.130 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. 00:46:34.130 --> 00:46:46.140 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. 00:46:46.140 --> 00:46:52.600 It cannot be too strongly emphasized that the test be made by a competent laboratory, and not by incompetent technicians and doctors' office laboratories. 00:46:52.600 --> 00:46:57.860 [Chart with title, "Syphilis in Pregnancy." Figures of women in black above label, "Routine Blood Test," are on the left side. Figures of women in white above label, "No Routine Blood Test." Caption reads, "Where blood test was not routine at least 72 cases out of 73 were probably overlooked."] 00:46:57.860 --> 00:47:11.750 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. 00:47:11.750 --> 00:47:21.860 Certain treatment during pregnancy prevents the disease in the baby in 95 percent of the cases regardless of the activity of the disease in the mother. 00:47:21.860 --> 00:47:25.840 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. 00:47:25.840 --> 00:47:33.870 [Pie chart with title, "Prevention of Congenital Syphilis." Caption reads, "Treatment of 5 months or more during pregnancy normally assures." Pie chart divided with labels, "95% healthy babies apparently without syphilis," and "5% stillborn or living with congenital syphilis."] 00:47:33.870 --> 00:47:47.320 Begin treatment immediately the diagnosis is made. Treat weekly until labor begins. Repeat blood Wassermann tests are not necessary and probably not desirable. 00:47:47.320 --> 00:47:58.430 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. 00:47:58.430 --> 00:48:16.560 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 tend to better administer. 00:48:16.560 --> 00:48:26.570 The commandment is use arsenic in small doses, constantly and continuously. Give with the stomach empty and after a mild laxative. 00:48:26.570 --> 00:48:40.360 Take the blood pressure. Examine the urine for [inaudible]. Question the patient carefully about any sort of reaction from the last dose. 00:48:40.360 --> 00:48:55.150 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. 00:48:55.150 --> 00:49:06.620 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. 00:49:06.620 --> 00:49:18.860 A dose of arsenic, neo-arsphenamine [inaudible] is 4500 per gram. Never more, very rarely less. Two mild mercurial [inaudible] are given weekly. 00:49:18.860 --> 00:49:33.670 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 an additional advantage of being cheaper. 00:49:33.670 --> 00:49:51.070 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. 00:49:51.070 --> 00:50:02.780 Care should be exercised at the first and last courses of the arsenic. Treat every syphilitic woman throughout each pregnancy without regard to the duration of the syphilis or the previous treatment. 00:50:02.780 --> 00:50:16.890 Pregnancy does not cause any more false positive reactions than occur among the average non-syphilitic population. It does cause many false negative reactions. 00:50:16.890 --> 00:50:30.640 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. 00:50:30.640 --> 00:50:48.390 There can be no doubt 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. 00:50:48.390 --> 00:51:08.510 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? 00:51:08.510 --> 00:51:19.420 [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. 00:51:19.420 --> 00:51:33.560 [Dr. Jeans:] Syphilis in the child differs from syphilis in the adult in only a few important ways. Such differences as occurs are dependent on differences in the host rather than in the spirochetes. 00:51:33.560 --> 00:51:40.790 The high mortality of infantile syphilis has no counterpart in early syphilis of the adult. 00:51:40.790 --> 00:51:41.560 [X-ray of a leg, ankle and foot with caption, "Osteitis and Epiphysitis of the leg due to syphilis."] 00:51:41.560 --> 00:51:47.140 This is true also by the extensive bone changes. 00:51:47.140 --> 00:51:48.190 [Photo of the side of infant with caption, "Scarring skin lesions."] 00:51:48.190 --> 00:51:53.480 And deeply infiltrating and scarring skin lesions of the face found frequently in syphilitic infants. 00:51:53.480 --> 00:51:56.340 [Film of child's mouth being held open to show crooked and missing teeth.] 00:51:56.340 --> 00:52:03.580 And the dystrophic changes in the teeth sometimes observed in older children as a result of infantile syphilis. 00:52:03.580 --> 00:52:06.090 [Photo of two eyes, left eye labeled "Normal Eye" and right eye labeled "Keratitis."] 00:52:06.090 --> 00:52:08.640 Keratitis is by far the most frequent lesion of late congenital syphilis. 00:52:08.640 --> 00:52:16.660 But it is rare in acquired syphilis, that the adult in whom it occurs in the secondary stage of the disease. 00:52:16.660 --> 00:52:24.410 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. 00:52:24.410 --> 00:52:29.820 [Image of child with flattened appearance to face, and nose in particular. Words "Congential leuetic, Saddle nose, Rhagades" appear over child's head.] 00:52:29.820 --> 00:52:46.880 Because of the absence of a primary lesion, syphilis in 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. 00:52:46.880 --> 00:53:06.600 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. 00:53:06.600 --> 00:53:18.970 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. 00:53:18.970 --> 00:53:32.260 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. 00:53:32.260 --> 00:53:54.250 Throughout the remainder of childhood, a positive reaction is obtained as long as any activity of 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. 00:53:54.250 --> 00:54:12.910 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. 00:54:12.910 --> 00:54:31.410 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. 00:54:31.410 --> 00:54:45.880 The diagnosis is incomplete in all instances without the result 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. 00:54:45.880 --> 00:54:58.740 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. 00:54:58.740 --> 00:55:13.920 This may be at the elbow, wrist, or ankle, or may be in the scalp. In the majority of infants the external jugular vein is the one most readily available. 00:55:13.920 --> 00:55:30.250 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. 00:55:30.250 --> 00:55:40.140 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. 00:55:40.140 --> 00:55:53.660 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. 00:55:53.660 --> 00:55:57.720 [Photo of child with title, "Serpiginous syphilid."] 00:55:57.720 --> 00:56:00.460 In the case of the young infant with active or florid syphilis, it is necessary to start treatment cautiously. 00:56:00.460 --> 00:56:02.380 [Photo of child's leg with title, "Gumma."] 00:56:02.380 --> 00:56:16.010 Starting treatment in such a baby with a full dose of one of the arsphenamines would easily be a direct cause of its death. It is preferable to get preliminary treatment with bismuth or mercury. 00:56:16.010 --> 00:56:29.560 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. 00:56:29.560 --> 00:56:46.200 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. 00:56:46.200 --> 00:57:07.140 Consequently sulpharsphenamine has become popular in the treatment of syphilis in infants and children. Because dermatitis and other reactions are more common with arsphenamine and old salvarsan, the latter drug administered by the intravenous route is to be preferred. 00:57:07.140 --> 00:57:13.310 A little practice makes intravenous therapy relatively simple, even in the infant. 00:57:13.310 --> 00:57:20.030 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 in only a few months of appropriate treatment. 00:57:20.030 --> 00:57:32.700 [Chart with title, "Treatment of Congenital Syphilis" with caption, "What happened to 384 congenital syphilitic children treated from 6 months to 6 years." Left pie chart with caption, "Less than 1 year old, Treated: 6 months or more." Pie divided with labels, "72% cured" and "28% not cured." Middle pie chart with caption, "Over 1 year old, Treated: more than a year." Pie divided with labels, "56% not cured" and "44% cured." Right pie chart with caption, "Over 1 year old, Treated: 6 mo's. but less than 1 yr. Pie divided with labels "88% not cured" and "12% cured."] 00:57:32.700 --> 00:57:55.460 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 the part of the physician and faithfulness of treatment on the part of the patient are essential. 00:57:56.380 --> 00:58:08.360 [Narrator:] Late manifestations and neurosyphilis are presented by Dr. Joseph Earl Moore of John Hopkins University School of Medicine, Baltimore. 00:58:08.360 --> 00:58:17.470 [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. 00:58:17.470 --> 00:58:24.590 Syphilis of these two systems accounts for at least 90 percent of the deaths from this infection. 00:58:24.590 --> 00:58:36.360 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. 00:58:36.360 --> 00:58:50.610 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 meningeal vascular neurosyphilis, tabes dorsalis, or paresis. 00:58:50.610 --> 00:58:58.800 This interval may be materially shortened by the improper treatment of early syphilis. Remember the following simple facts: 00:58:58.800 --> 00:59:07.280 First, invasion of the nervous system may be detected early in the course of the disease, usually years before the appearance of symptoms. 00:59:07.280 --> 00:59:16.940 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. 00:59:16.940 --> 00:59:23.730 Second, neurosyphilis is a great imitator. Acute syphilitic meningitis often mimics four other conditions. For example, tuberculosis, meningitis, and brain tumor. 00:59:23.730 --> 00:59:27.730 [Acute Syphilitic Meningitis, Tuberculous meningitis, Brain tumor, Brain abscess, Acute infectious meningitis 00:59:27.730 --> 00:59:33.640 Late meningeal vascular neurosyphilis is easily confused with at least 17 other diseases. Disseminated sclerosis, Bell's palsy, migraine, and cerebral arterial sclerosis are examples. 00:59:33.640 --> 00:59:42.640 [Late Meningo-Vascular Neurosyphilis, Epidemic encephalitis, Paralysis agitans, Peripheral neuritis, Cord tumor, Post-diphtheritic paralysis, Brain tumor, Cerebral arteriosclerosis, Bell's palsy, Disseminated sclerosis, Migraine, Cerebral vascular accident, Syringomyelia, Chronic alcoholism, Epilepsy, Acute or chronic anterior poliomyelitis, Subacute combined sclerosis, Amytrophic lateral sclerosis 00:59:42.640 --> 00:59:51.490 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 or perforating ulcer, or hypertrophic arthritis for Charcot's joint. 00:59:51.490 --> 01:00:00.090 [Tabes Dorsalis, Lesions of peripheral sensory nerves, Tumors or chronic sclerosis of posterior columns, Subacute combined sclerosis, Vestibular ataxia, Friedreich's ataxia, Brain tumor (optic atrophy), Leber's disease (optic atrophy), Retrobulbar neuritis (opic atrophy), Hypertrophic arthritis (Charcot joint), Syringomyelia (Charcot joint), Diabetic pseudotabes, Infected callus of soles (malum perforans)] 01:00:00.090 --> 01:00:12.920 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. 01:00:12.920 --> 01:00:16.300 [General Paresis, Lead encephalopathy, Psychoneuroses, Cerebral arteriosclerosis, Neurasthenia, Brain tumor (frontal lobe), Hysteria, Simple depressions, Epilepsy, Schizophrenia, Uremia, Chronic alcoholism, Encephalitis, Manic depressive insanity] 01:00:16.300 --> 01:00:20.640 [The foregoing charts appear in the published text of this film.] 01:00:20.640 --> 01:00:33.060 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. 01:00:33.060 --> 01:00:56.130 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. 01:00:56.130 --> 01:01:05.660 When the blood Wassermann is positive or even if it is negative, when history and physical findings are highly suggestive, examine the serum of the spinal fluid. 01:01:05.660 --> 01:01:16.110 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. 01:01:16.110 --> 01:01:28.080 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 side. The back should be in a straight line. 01:01:28.080 --> 01:01:35.960 Sterile towels are placed beneath that the patient's side and on top over the patient's back. The operator thoroughly washes his hands. 01:01:35.960 --> 01:01:50.260 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. 01:01:50.260 --> 01:01:59.360 The space between the second and third, third and fourth, or fourth and fifth lumbar interspaces is utilized. The widest space should be chosen. 01:01:59.360 --> 01:02:10.770 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. 01:02:10.770 --> 01:02:20.160 The needle is inserted directly or with a slightly oblique tilt toward the head and inward. Resistance is met until the dura is pierced. 01:02:20.160 --> 01:02:43.680 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. 01:02:43.680 --> 01:02:57.580 As the fluid comes from the needle, it should be collected in a suitable sterile tube, various samples being used for the necessary examination. 01:02:57.580 --> 01:03:51.670 [The tube is shown filling with spinal fluid from the needle inserted into the spinal area.] 01:03:51.670 --> 01:04:16.600 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. 01:04:16.600 --> 01:04:21.460 For prognosis and for successful treatment we must know the type of neurosyphilis. 01:04:21.460 --> 01:04:41.520 The management and outcome of syphilitic meningitis differ from those of late meningeal vascular neurosyphilis, and this in turn, from those of Tabes dorsalis or paresis. 01:04:41.520 --> 01:04:54.810 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. 01:04:54.810 --> 01:05:11.880 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. 01:05:11.880 --> 01:05:24.300 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. 01:05:24.300 --> 01:05:33.560 The physician who attempts to treat neurosyphilis without more exact information then this catch-basket diagnosis, 01:05:33.560 --> 01:05:42.880 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. 01:05:42.880 --> 01:05:56.210 How shall a physician choose the treatment method appropriate for his particular patient? Shall he used an arsphenamine and bismuth, and if so which preparations, and in what dosage? 01:05:56.210 --> 01:06:06.160 Shall he employ Tryparsamide with its attendant risk of visual damage, perhaps blindness. If so, how and under what circumstances? 01:06:06.160 --> 01:06:16.180 The subdural treatment by the Swift-Ellis technique, or some modification of it, still indicated, and if so, under what conditions? 01:06:16.180 --> 01:06:31.100 Shall fever therapy be employed and if so, when and by which of the multitudinous methods? Shall it be tertian or quotidian malaria, quartan shock, or electrically or mechanically-induced fever? 01:06:31.100 --> 01:06:40.100 Certain forms of neurosyphilis demand certain forms of treatment, for example, dementia paralytica and fever, especially malaria. 01:06:40.100 --> 01:06:54.800 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. 01:06:54.800 --> 01:07:05.340 Second, be familiar with the patient's general physical condition. Has he cardiovascular syphilis or other complicating diseases? 01:07:05.340 --> 01:07:17.340 Third, be familiar with the possibilities and dangers of, and the special indications for, various treatment methods, including tryparsamide, subdural, and febrile therapy. 01:07:17.340 --> 01:07:30.780 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. 01:07:30.780 --> 01:07:41.580 Fifth, proceed by a system of trial and error and except for special indications, use least dangerous and drastic treatment methods first. 01:07:41.580 --> 01:07:58.410 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. 01:07:58.410 --> 01:08:14.400 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. 01:08:14.400 --> 01:08:28.370 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. 01:08:28.370 --> 01:08:39.890 Examine his family. There are too many patients with, and too few experts in, neurosyphilis. For some patients, continued expert care is essential throughout. 01:08:39.890 --> 01:08:54.420 For others, a periodic consultant is called. First in 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. 01:08:54.420 --> 01:09:06.550 Third, in the application of special treatment method, such as induced fever, which like gallbladder surgery, the inexperienced physician should never risk unaided. 01:09:06.550 --> 01:09:19.970 [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. 01:09:19.970 --> 01:09:41.890 [van der Linden:] Twice as many people as live in the nation's capital are infected with syphilis each year. [inaudible?] estimates that approximately 518,000 new patients with early syphilis each year seek treatment from physicians, clinics, and hospitals. 01:09:41.890 --> 01:09:52.140 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. 01:09:52.140 --> 01:09:57.330 [Placard reading Competent Medical Care vs. Self-Treatment] 01:09:57.330 --> 01:10:07.340 The control of syphilis is related to the private practice of medicine in a way which is unique in public health work. 01:10:07.340 --> 01:10:18.390 For any program to be successful, it is essential that the physician and the health agency cooperate. 01:10:18.390 --> 01:10:22.220 The widespread prevalence of syphilis indicates that there is a grave need for the coordination of the work of both groups. 01:10:22.220 --> 01:10:28.300 [Chart stating Syphilis Strikes One out of every 10 adults] 01:10:28.300 --> 01:10:35.160 The physician who accepts for treatment a patient with syphilis, assumes a very definite public obligation. 01:10:35.160 --> 01:10:44.350 The practice of administering a few doses of arsphenamine to a syphilitic patient unable to pay private fees for the prolonged course of treatment, 01:10:44.350 --> 01:10:55.570 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. [Chart titled Result of Treatment Methods -- Satisfactory/Otherwise] 01:10:55.570 --> 01:11:12.350 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. 01:11:12.350 --> 01:11:32.890 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. 01:11:32.890 --> 01:11:50.370 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. 01:11:50.370 --> 01:12:09.690 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. [Chart comparing rates of syphilis in Scandinavia vs New York State] 01:12:09.690 --> 01:12:39.860 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. 01:12:39.860 --> 01:12:50.510 Most health departments make optional a system of reporting which does not require the identification of the patient. 01:12:50.510 --> 01:13:09.690 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. [Chart titled 17 Infected from One Source] 01:13:09.690 --> 01:13:28.160 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. 01:13:28.160 --> 01:13:39.790 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, 01:13:39.790 --> 01:13:52.230 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. 01:13:52.230 --> 01:14:08.610 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. 01:14:08.610 --> 01:14:15.910 The health department, likewise, has definite obligations to the physician in private practice. 01:14:15.910 --> 01:14:30.180 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, 01:14:30.180 --> 01:14:41.030 and should provide consultation service including [inaudible] and other expensive laboratory examinations for indigent patients. 01:14:41.030 --> 01:14:51.200 Booklets and pamphlets should be provided by the health department for the public and particularly for the patients of private physicians. 01:14:51.200 --> 01:15:09.570 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. 01:15:09.570 --> 01:15:29.370 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. 01:15:29.370 --> 01:15:54.530 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. 01:15:54.530 --> 01:16:07.870 [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. 01:16:07.870 --> 01:16:14.630 He must take most seriously his obligation in relation to the control of syphilis as a public health problem. 01:16:14.630 --> 01:16:28.210 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. 01:16:29.700 --> 01:16:43.090 [The exact text of this film illustrated with scenes from the film, will be available in pamphlet form address American Medical Association, Chicago] 01:16:43.090 --> 01:16:53.390 [Appreciation is extended to Northwestern University School of Medicine and Cook County Hospital, Cook County, Illinois, for their cooperation; and to V. Mueller and Company, of Chicago, for apparatus and supplies. 01:16:53.390 --> 01:16:58.820 [The End. Pproduced by Burton Holmes Films, Inc., Chicago, Illinois.]