[This tape was duplicated from a 1" video master by Colorlab for the National Library of Medicine, January 2006, NLM call number HF 0376]

[Management of Syphilis in General Practice, United States Public Health Service]

[Narrator:] This young man, John, has returned to his doctor for a checkup because a premarital blood test was reported positive. Dr. Johnson now inquires into John's history.

Thereafter, he proceeds to a thorough physical examination which he records completely on a permanent record form. He takes a specimen of blood for a second serologic test and instructs John to return later for the report.

[Dr. Johnson:] So, this positive blood test confirms the first one we took. There's no doubt in my mind now, John, that you have syphilis.

[John:] Well doctor, what--

[Dr. Johnson:] It means that we will begin treatment right away. It will take a year and a half at least.

[John:] A year and a half, it's--that's a long time. But if you think you can cure me, I guess it's worth it.

[Dr. Johnson:] Now John, the important thing is that you must take your treatments regularly every week. You see, if we don't find syphilis soon enough, or the treatment isn't regular or long enough, serious conditions often result.

But in your case, if you stick to it and come in for every treatment, there's not much doubt that we can make you well.

[John:] Well, the trouble is doctor, I haven't very much money.

[Dr. Johnson:] Well, you see, the health department provides me with drugs at no charge. I think we can arrange things so you can afford your treatments.

[John:] That's swell, Dr. Johnson, and I sure want to stick with you.

[Dr. Johnson:] Now, there's another thing that you should know, John. You can give your disease to other people. So it's very important that you shouldn't have sexual relations or kiss anyone until I say it's all right.

Unfortunately, this means that you cannot be married as soon as you had planned. It wouldn't be fair to your girl.

[John:] Well, will I ever be able to be married, doctor?

[Dr. Johnson:] Oh yes, of course John. Only you must wait until I tell you it's all right. Now, you should see that your fiancee has an examination. You will take care of that, won't you?

[John:] Yeah. I guess that's the square thing to do, doctor.

[Dr. Johnson:] Of course, it is John. Now John, I want you to tell me where you think you picked up this disease.

You should tell me all about it because whoever gave it to you, can give it to others, and she should receive the same attention you are getting. Of course, your name won't be used.

[John:] Well, it was about a year ago. I don't know who she was. The name was Sally I think.

[Dr. Johnson:] Sally. Hmm. Do you remember her address?

[John:] Ah, Third Street, next to the store in the corner of Cypress.

[Dr. Johnson:] Third.

[Narrator:] Every case of a venereal disease should be reported to the health officer. The report should include information about contacts.

Once the case is diagnosed, the doctor's attention is focused upon the plan of treatment. This table shows the arsenical drugs which are best to use in various types of syphilitic infection, and the arsenical drugs which should not be used in certain types.

For early acquired syphilis, the arsenical drugs of choice are arsphenamine, neoarsphenamine, and arsenoxide. Bismuth has largely replace mercury particularly in the treatment of early syphilis.

Of the many bismuth compounds which are available, perhaps the most frequently used is a suspension of bismuth subsalicylate in oil. The iodides are of little or no value in the treatment of early syphilis.

The dosages given in this recommended scheme of treatment for early syphilis are for arsphenamine. The recommended dose is higher for neoarsphenamine and lower for arsenoxide.

Treatment for early syphilis should start with an arsenical drug in order to control infectiousness quickly. Regularity is extremely important, particularly during the first six months of treatment.

Arsenicals are alternated with bismuth in order to avoid the development of drug resistance. The first course of bismuth should be short consisting of about four doses, subsequently increasing to six, eight, and 10 doses.

A minimum of 30 injections of arsenical and 40 injections of bismuth should be given. This makes a total of 18 months of treatment for cases of early syphilis.

After this eighteen months, the patient may be placed on probation if physical examination, blood test, spinal fluid examination and x-ray examination of the heart and aorta are negative.

The probationary period should extend for at least one year after treatment is stopped. During this time, blood tests should be made and the skin and mucus membranes inspected at intervals of from one to three months.

In a case of early syphilis, if the blood tests remain positive after six or eight months of treatment, perform a complete physical examination and examine the spinal fluid.

The most frequent cause of zero resistance in early syphilis is involvement of the central nervous system. Therefore, in early syphilis, failure of the blood test to show response to treatment should cause apprehension.

In late syphilis, either acquired or congenital, zero resistance in itself is not important.

The gravity method of administrating arsenicals is most frequently used for old arsphenamine. This drug should never be used except under rigidly controlled conditions since the danger of improper neutralization is otherwise great.

The syringe technique is usually used for other arsenical drugs. Neoarsphenamine should be injected slowly and arsenoxide should be injected rapidly.

Bismuth and mercury should be injected very deeply into the upper outer quadrant of the buttock so that the drug is deposited under the deepest layer of muscle.

The barrel of the syringe should be pulled back before the drug is injected to make sure that the needle is not in a blood vessel. The physician should study the anatomic position of the sciatic nerves so that he can avoid striking it.

[Paper reads, "Reactions Following Injection of the Arsphenamines"]

Before administering antisyphilitic treatment, a physician should make himself thoroughly familiar with the reactions which may occur and the danger signals which call for discontinuance of the treatment or change in the type of treatment.

Question each patient in regard to reactions to the previous injection. Inspect the skin at each visit for toxic dermatosis such as this erythema or this purpura.

Inspect the sclera for jaundice. Look for early signs of exfoliated dermatitis which is one of the most frequent serious reactions to arsenicals.

An important danger signal is itching. Bismuth may cause pigmentation of the gums, ulceration of the tongue or pigmented papules.

In the management of late latent syphilis, one should perform a physical examination, a spinal fluid examination and an x-ray examination of the heart before treatment is started or as soon thereafter as possible.

During the first year, give arsenicals and bismuth in alternating courses of eight to 12 doses each. During the second year, give about three 12-dose courses of bismuth.

[Paper reads, "The Management of Late Syphilis."]

In this presentation, no attempt can be made to provide a detailed portrayal of the treatment of late syphilis. In general, treatment should be guided by the fact that radical cure can no longer be accomplished as in early syphilis.

The best that can be hoped for is the alleviation of symptoms, healing of lesions, restoration and maintenance of health and prevention of further progression or relapse.

Neurosyphilis, however, presents certain special problems in therapy. So-called Wasserman fastness is not an indication for the use of tryparsamide. This drug is use only in neurosyphilis.

Trivalent arsenicals should always be chosen when the central nervous system is not involved. Before using tryparsamide, look for power of the optic discs and measure the visual fields carefully.

Optic atrophy in any degree is a contraindication to the use of tryparsamide since sudden blindness may result if this condition is present.

Before each injection of tryparsamide, question the patient in regard to symptoms such as shimmering vision following the last injection. If such history is given, repeat the visual field examination.

Contraction of the visual fields calls for immediate discontinuance of the drug. Malaria is induced in neurosyphilitic patients by transfer of blood from a malaria patient. The non-tertian or quartan malaria is used.

Malaria therapy is used in severe or resistant cases of asymptomatic neurosyphilis and in clinical neurosyphilis such as paresis, tabes and optic atrophy.

Fever therapy should not be used in the treatment of neurorecurrence in early syphilis unless intensified routine therapy fails to eradicate the condition.

Artificial fever therapy induced by mechanical means is also widely used in the treatment of neurosyphilis.

Specially-trained personnel must be used in this method but under properly controlled conditions, it is as safe and effective as malaria therapy.

Swift-Ellis Treatment is a highly technical procedure which should be used only by an expert. It is useful in optic atrophy and in the treatment of lightning pains and gastric crises of tabes dorsalis.

Now, having reviewed the highlights of modern antisyphilitic therapy, let us return to Dr. Johnson.

The case report which he makes to the health department is a practical value to him in the management of his patient and results often in the referral to him of new patients.

Further interviews after a satisfactory doctor-patient relationship has been established may reveal additional contacts. These contacts should of course be reported also.

Let us see what happens now that Dr. Johnson has sent his report to the health officer.

It will be incorporated into the health department morbidity records. It also becomes a credit so to speak against which the doctor may obtain drugs supplied by the state health department.

On the contact portion of the report, the doctor has noted an alleged contact whom he would like the health department to investigate by a home visit.

The health officer turns the information over to a followup worker.

She visits the alleged contact explaining that the health department has information that the person may have been exposed to a communicable disease and should see the doctor for an examination.

The doctor examines the alleged contact and sends a specimen of blood to the health department laboratory.

The specimen, identified by a number, is carefully handled by trained technicians.

Usually, two or more tests are run on each specimen.

The laboratory reports to the doctor in non-ambiguous terms, positive, doubtful or negative. This specimen is positive.

[Dr. Johnson:] Your report is positive. It rather looks as though you have syphilis. If this report is confirmed by a checkup, you will have to begin treatment.

[Sally:] But doctor, I have no money.

[Dr. Johnson:] I understand. I think the best thing for me to do is to send you to Dr. Ramsey at the health department. You can get good treatment there at no cost.

[Narrator:] Here is the clinic to which Sally has been sent. This is the waiting room. To encourage patients to return to it week after week, it should be orderly and cheerful.

Here for example, colorful, educational posters brighten the walls. There is always someone around to answer questions.

In fact, time spent here by the patients [can?] and will be utilized to good advantage by informal educational discussions and by motion pictures.

Evening hours are arranged for the convenience of working patients. Privacy and quiet are provided for the physical examinations.

Booths with a full complement of treatment equipment make possible rapid yet considered arsenical therapy. A separate room for bismuth injections contributes convenience and comfort. Spinal punctures can also be given here.

A clinic this large would have equipment for dark field examinations and gonorrhea smears. The patient's first impression of a clinic may be the last unless he is made to feel at ease and aware of the clinic's real interest in the case.

Therefore, introduction to clinic routine is made by a specially-trained worker chosen for her pleasing personality as well as educational qualifications.

The social worker's interview with the patient is part of an extensive educational program carried on by the health department. This includes distribution of folders and pamphlets telling the public about syphilis and gonorrhea and what to do about them.

[Pamphlet reads, "Syphilis, Its Cause, Its Spread...Its cure!"]

It includes programs over radio stations. It includes posters in public places urging people to see their doctors for blood tests. It includes movies before all kinds of organizations and in theaters.

And it includes talks and lectures before many kinds of audiences. For example, here is the health officer telling a group of men the facts about syphilis and gonorrhea. He is giving them practical information about prophylaxis.

[Paper reads, "Prophylaxis: Report of Special Joint Committee"]

When the physician is called upon to give instruction in regard to prophylaxis, he should warn his patients that the only sure prophylaxis is abstinence from sexual promiscuity.

When specific instruction is indicated, however, a condom should be advised since this method imposes a mechanical barrier against the transference of the infective agent.

Patients should be advised against the purchase of condoms of inferior quality.

The use of the condom should be supplemented by thorough washing of the genitalia and adjacent parts with soap and water for five minutes as soon as possible after exposure.

Care should be taken to include the undersurface of the prepuce and the scrotum, the inner surfaces of the thighs and the lower portion of the abdomen.

A brush should not be used since this causes abrasions of the skin through which the infective agent may enter. After washing, the patient should urinate.

Six cubic centimeters of two percent strong silver protein solution is next injected into the urethra and the patient holds it there for five minutes.

The protargol solution should be freshly prepared. The last step of the procedure is to rub 33 percent chamomile ointment into the genitalia and adjacent parts.

Prophylaxis in women is only occasionally useful, chiefly in cases of rape. The anatomy of the region makes the procedure more difficult than in the male.

Antisyphilitic treatment should never be used as a prophylactic measure following exposure. Treatment for syphilis is not justified unless the diagnosis of a syphilitic infection has been established by clinical and laboratory evidence.

To keep abreast of current developments in the diagnosis, treatment and public health aspects of syphilis, read Venereal Disease Information, one of the medical journals published by the United States Public Health Service.

[Dr. Johnson:] We as private practitioners have an indispensable function in this nation's program for the control of syphilis. We must recognize our responsibilities and our obligations.

Do you remember what Sir William Osler said? Listen, "I see an incredulous look on some faces and I hear the whispered comment, 'tis heard often enough.

'Where is all this syphilis? It does not come my way.'' Yes, it does. The syphilis we see but do not recognize everywhere awaits diagnosis, so protean are its manifestations."

[ Music ]

[This film is in three parts: I. Diagnosis of Early Syphilis. II. Diagnosis of Late and Latent Syphilis. III. The Management of Syphilis.]

[A United States Public Health Service Production. Clinical Photography...Carroll T. Bowen, Passed Assistant Surgeon (R), Medical Direction...Glenn S. Usher, Passed Assistant Surgeon, General Direction...W. Allen Luey, Production...Howard Ennes, Medical Consultants Harold N. Cole, M. D., Cleveland, Ohio, Joseph E. Moore, M. D., Baltimore, Maryland, Paul A. O'Leary, M. D., Rochester, Minnesota, Thomas Parran, Surgeon General, U. S. Public Health Service, Washington, D. C., Francis E. Senear, M. D., Chicago, Illinois, John H. Stokes, M. D., Philadelphia, Pa., Lida J. Usilton, M. A., U. S. Public Health Service, Washington, D. C., Raymond A. Vonderlehr, Assistant Surgeon General, U. S. Public Health Service, Washington, D. C.]

[Federal Security Agency Paul V. McNutt, Administrator. U. S. Public Health Service Thomas Parran, Surgeon General]

[U. S. Public Health Service, 1798]

[The End]