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cillin therapy is sufficient to supply answers to all questions. The second is based upon the assumption that preliminary studies have already progressed to a point at which practical deductions are warranted. These concern the ability of penicillin therapy to shorten the infectious period of early disease with consequent restriction of opportunity for transmission.

If full and early advantage is to be taken of this ability, certain alterations in the structure of the control machinery should be effected as a means of implementing the newer therapy. In this connection the following considerations are suggested:

(a) That arsenic and bismuth therapy in early syphilis be abandoned and a suitable routine of penicillin treatment be adopted in control work.

(b) That the practice of providing medical treatment for types of syphilis other than infectious or potentially infectious be abandoned.

(c) That all efforts, educational and otherwise, directed toward case finding in early syphilis be intensified.

(d) That hospital beds be provided at the community level for use in the treatment of early infections.

(e) That laboratory facilities concerned with the early diagnosis of syphilis be made as freely available as possible and be maintained at a high level of efficiency at all times.

(f) That general educational efforts be intensified in order that the less burdensome, less dangerous and more rapidly effective therapy may not lead to an undue disregard for the disease.

(g) That the major portion of the energy at present being expended in follow-up of treated patients be diverted to case finding of early infections.

The above program would serve to take an early advantage of penicillin therapy in the control of syphilis, and risks only that the inferences as to spirocheticidal action, which appear evident at this time, will be proved incorrect by future studies.

The Chairman: The discussion will be opened by Dr. Paul A. O'Leary, of the Mayo Clinic.

DISCUSSION

PAUL A. O'LEARY, M.D.,

Professor of Dermatology and Syphilology
Graduate School University of Minnesota,

Mayo Clinic, Rochester, Minn.

My apprasial of the value of penicillin has been limited primarily to patients with neurosyphilis. However, I have had the opportunity of observing some patients with other forms of the disease who have been treated with this remedy. Since September 1943, I have treated 70 patients with various manifestations of neurosyphilis, and of this group there are 49 who have been observed for periods varying from 4 to 14 months, while the remainder of the group have been lost sight of or have not been reexamined recently enough to admit of inclusion in this report. Of these 49 patients, 10 had asymptomatic neurosyphilis, 9 had the meningovascular type of the disease; there were 10 tabetics,

15 paretics, 1 case of spastic paraplegia, 2 with optic atrophy, 1 a congenital asymptomatic neurosyphilitic, and 1 patient with optic neuritis.

Variation in the percentage of penicillin in the ampule may account for some treatment failures.

We have been primarily interested in the significance of the blood levels of penicillin, so that in many of these patients we studied the blood levels following intravenous as well as intramuscular injection. Up to the moment, I have not been able to formulate any concrete opinion as to the superiority of one measure over the other. Neither have I been able to determine what level of blood concentration of penicillin, irrespective of the method of injection, is materially superior. The reactions have been conspicuously absent with the exception of one patient, a meningovascular neurosyphilitic, who was given intraspinal penicillin in the form of 50,000 units and who had convulsive attacks following each of two intraspinal treatments. He had not had convulsive seizures previously, nor has he had any since.

I have given malaria therapy in conjunction with penicillin in 19 of these 49 patients. The penicillin does not in any way inhibit the course of malaria, nor have I been able as yet to note any benefit from this particular combined form of treatment. It is much too early to attempt an evaluation of this system of treatment, but up to the moment the results seem to parallel those that follow a course of malaria when given alone.

Approximately one-half of the patients with clinical signs of neurosyphilis who received penicillin alone reported some improvement in their well-being. This was not constant but I have noted that those who derived a satisfactory serologic reversal to normal also derived considerable gain in weight, one patient gaining as much as 25 pounds in 6 months. They commented also on the fact that they were better, were some stronger, and from psychic reasons or otherwise believed that the penicillin made them feel better. I think this observation goes back to the days of tryparsamide as well as to the days of early malaria therapy. In other words, the improvement in the somatic complaints, I feel, has always had a favorable prognostic sign, preceding the serologic reversal perhaps by years. The serologic reversals of the blood or spinal fluid have not been so numerous nor have they been so encouraging to me as the clinical improvement. It seems that the amount of penicillin given is not the factor that alone determines the eventual outcome of treatment. In other words, favorable serologic reversal has followed the use of 1,000,000 units and failure has occurred following 10,000,000 units given in three courses. The duration of the syphilis, especially the duration of neurosyphilis, has been of considerably more prognostic significance; for example, the best results occurred in patients whose syphilis was of comparatively short periods, of essentially 3 years or less.

Strange as it may seem to some of you, the only two patients of this entire group who derived a complete spinal fluid serologic reversal to the negative received 1,000,000 units of penicillin intravenously and 20,000,000 units intraspinally. One was an asymptomatic and the other was a meningovascular neurosyphilitic, both of whom reverted to negative within periods of 6 and 7 months,

respectively. There have been no reversals of the serologic tests of the blood to negative in my small group of patients, although the quantitative titer in each case has been reduced. In other words, there has not been a parallelism between the serologic reversal of the blood and spinal fluid reversal. Practically every case displayed some reduction in the intensity of the spinal fluid findings, however. A reduction in the cell count was the outstanding finding, with decrease in the protein as the next most common change. The colloidal gold reductions were inconsistent while the flocculation and complement fixation tests of the spinal fluid, although frequently reduced, tended to maintain some degree of positivity.

I cannot but comment at this time on the effort to streamline the spinal fluid test. I have seen in several institutions lately a spinal fluid test that consisted of a flocculation on the spinal fluid, a cell count, and a protein estimation. The cell count was done. anywhere from 2 to 3 days after the fluid was withdrawn, and I think in practically all of those cases it varied from 3 to 9 cells. Then when I was told that the 44000 complement fixation test on the spinal fluid was of no significance, I could see nothing but the protein left to evaluate the result. So I think that we must be a bit careful in tending to streamline, as I call it, our present spinal fluid examinations.

The influence on the subjective manifestations of tabes dorsalis in my experience has been slight. Leg pains were somewhat improved, but the gastric crisis continued as heretofore, and incontinence and ataxia remained unchanged. Of course, as anticipated there has been no change in the objective signs of the disease, such as pupillary reactions, deep reflexes, or sensory changes. However, the patients did note a sense of well-being and a gain in weight, both of which suggest to me that perhaps the future will produce. more worth while changes than have been recorded thus far in this group.

The results in the patients with meningovascular neurosyphilis as a group were more encouraging than were the tabetics. In one patient ocular palsy disappeared; one patient with hemiplegia likewise regained approximately 75 percent of the use of her arm and leg. The results can be briefly summarized in that the patients felt better and were improving when last reexamined. However, the results in the patients who were given malaria and penicillin were better than those who received only penicillin.

The paretics who received only penicillin derived little or no benefit from 4,000,000 units or less, and I was not able to estimate the superiority of either an intramuscular or an intravenous technic in this particular group. As no improvement of a conspicuous nature had been noted in any of my patients from 4 to 6 months after they had undergone the course of penicillin, I found it necessary to give all of them a course of malaria, and I think in some the clinical improvement was a comparatively crisp reaction in contrast to the result we had received from the penicillin.

The patient with spastic paraplegia and the two patients with optic atrophy have as yet shown no material change, either good or bad, from the drug.

I have not had the opportunity of treating a patient with a

gummatous hepatitis, nor one with gastric phlebosis, so that my observations on the whole are pretty well-limited to the neurosyphilitic group.

I cannot close my comments without expressing a very favorable attitude toward the manner in which this study is being carried out. For those of us who went through the early days of tryparsamide and, subsequently, fever therapy, to have the opportunity of correlating and pooling our material in the manner that is now being done is to me a very marked advance in the progress of syphilis research.

The Chairman: We have a few minutes for further discussion of this very important topic. Will Brigadier General Hugh Morgan be willing to say a few words on the subject?

Brig. Gen. Hugh J. Morgan (Chief Consultant in Medicine, U. S. Army): I am extremely glad to be able to identify myself with this third meeting; it was my good fortune to attend the first and second conferences on venereal disease control. The program is less than 10 years old, I believe, and finds itself now in a position to gird up its loins for a new and more vigorous attack to gain its objective. It seems to me that the over-all program has become energized as a result of circumstances that have developed during this war and of the efficient, effective way in which the opportunity has been seized by the group that has been interested in it.

I think one of the most exciting chapters in medicine has been the development that has taken place, and the clinical investigation that has been carried out in the field of venereal diseases. Certainly we are at the beginning, of what, in my judgment, is the last chapter of a history which has been written with travail and which has required an enormous amount of hope and industry.

I cannot take my seat without paying tribute to the leadership that this movement has been so fortunate to have. I am perfectly certain that the reason we have had 10 years of venereal disease control, and that we may look forward to another decade in which, in my humble opinion, the problem will be mastered is because we have had the leader to envision the problem, to organize the program, to implement it, and to carry it through. I am referring, of course, to Surgeon General Thomas Parran.

The Chairman: Whether you believe it or not, I did not coach General Morgan to make that speech. Thank you very much, General Morgan.

Is there further discussion? I see the Dean of Johns Hopkins Medical School, who had been a distinguished worker in the syphilis field until he became Dean; perhaps he has been able to continue some of his scientific work. Dr. Alan Chesney, would you have anything to say?

Dr. Alan Chesney: I don't think I can add anything to the discussion, except to compliment John Mahoney; I think he deserves a grand hand. The Chairman: Dr. H. G. Irvine of Minneapolis, Minn.

Dr. H. G. Irvine: I should like to express my pleasure at being here and seeing Dr. Parran, with whom I had the pleasure of working soon after the first World War. I suppose there are not very many in the audience whose experience dates back to the last war in the venereal control program. During the 25 years in which Minnesota has conducted its control program we have reduced our venereal disease prevalence to a point where early syphilis is almost unknown. It has been difficult to find sufficient teaching material for our university. We are faced now with a lot of old syphilis, and that is a problem that we have to think of for the future.

The problem of the follow-up work is not going to be reduced by rapid treatment. It seems to me that the benefits of follow-up work are more likely to accrue when the patient is in contact with the physician over rather a long period of time. My observation is that it is not possible for social workers to get patients to follow treatment. This must be a matter between doctor and patient, and if the doctor isn't interested, he isn't going to get anywhere with his patient. If he is interested, he must have a contact over a longer period of time than 7 or 8 days in the hospital to make any patient realize the seriousness of syphilis and the need of follow-up.

This point should be remembered in our consideration of the more than 4,000 cases treated in the rapid treatment centers over the country. Eighteen

percent of these cases were never seen after they left the hospital, two-thirds were not seen up to a year, and 85 percent were not seen up to 2 years. We thus have nearly 4,000 people wandering around for whom the possibility of_cardiovascular syphilis or neurosyphilis is not known.

I can but express at least a word of warning against what may be untoward enthusiasm, especially from the public health viewpoint, toward the potentialities of penicillin.

I think we should plan to get the greatest benefit from penicillin treatment and rapid treatment centers. But I also think that we must emphasize the need for follow-up of these cases. Those of us who are not concerned primarily with research must continue to follow those methods whose final results have been proved, as well as the methods bringing quicker results in checking the spread of infection.

Some of the men here went through the period when salvarsan first came in. I saw some of the first injections of salvarsan in Vienna before it was brought to this country. I saw one dose given, and two doses, and so on, and over a period of 10 to 15 years all of us saw variations in the amount of treatment and the methods of treatment. For years those methods were judged on the basis of clearing up lesions and changing serologic reaction. Only after a considerable time did we realize this was not necessarily proving anything so far as the final effect of syphilis was concerned.

We must remember that many cases got well in those old days with only a dose or two of salvarsan or neosalvarsan; they did not all require 6 or 8 months of treatment. We must remember that many cases that were never treated at all finally got well. We must also remember that in some cases syphilis remained about the same in spite of all sorts of treatment. In other words, we must bear in mind the fact that certainty of final cure is in many respects just as important as reducing the spread by means of the present short treatments.

The Chairman: I see the city health officers of the two largest cities of the country present here. Dr. Stebbins, of New York City, have you any comment or discussion on this symposium?

Dr. Ernest Stebbins: I do not have any comment to make on the papers other than to say that as an administrative health officer I am very much excited about the whole presentation of the subject. I had the fortunate experience about a year and a half ago of having a visitor in my office, Dr. Mahoney, who came to us with some limited data which he said he very seriously hesitated to present to any scientific group. I was Secretary of the Epidemiology Section of the American Public Health Association at the time, and I felt that he had something important. While it was perfectly true, as he said, that it was far from proved, it was something that would be of interest to every health officer and venereal disease control officer in the country. He reported his very limited number of cases treated with penicillin, and none of us felt then that in so short a time we would have presented us such sound evidence of the value of this drug in the treatment of syphilis.

Health officers are anxious for the day when we can see wide use of penicillin in the treatment of both gonorrhea and syphilis.

The Chairman: Dr. Herman Bundesen of the city of Chicago? Dr. Bundesen declines.

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The Chairman: We have two papers on the afternoon program on "Venereal Disease Control in the European Theater of Operations." We are very fortunate to have two medical officers of the Army who have just returned from that theater. The first speaker will be Colonel Donald M. Pillsbury of the Medical Corps, Army of the United States.

TREATMENT OF VENEREAL DISEASES IN THE EUROPEAN
THEATER OF OPERATIONS

DONALD M. PILLSBURY, Colonel, M. C.,
Army of the United States

The problem of the diagnosis and treatment of venereal disease

3 Senior Consultant in Dermatology, Office of The Chief Surgeon, European Theater of Operations.

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