leprosy drugs

[narrator:] this young man, john, has returnedto his doctor for a checkup because a premarital blood test was reportedpositive. dr. johnson now inquires into john's history. thereafter, he proceeds to a thorough physicalexamination, which he records completely on a permanent record form. he takes a specimen of blood for a secondserologic test and instructs john to return later for the report. [dr. johnson:] so, this positive blood testconfirms 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 begintreatment right away. it will take a year and a half at least. [john:] a year and a half, it's--that's along time. but if you think you can cure me, i guessit's worth it. [dr. johnson:] now john, the important thingis 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 comein for every treatment, there's not much doubt that we can make youwell. [john:] well, the trouble is doctor, i haven'tvery much money. [dr. johnson:] well, you see, the health departmentprovides me with drugs at no charge. i think we can arrange things so you can affordyour treatments. [john:] that's swell, dr. johnson, and i surewant to stick with you. [dr. johnson:] now, there's another thingthat you should know, john. you can give your disease to other people. so it's very important that you shouldn'thave sexual relations or kiss anyone

until i say it's all right. unfortunately, this means that you can'tbe 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 allright. now, you should see that your fiancee hasan examination. you will take care of that, won't you? [john:] yeah. i guess that's the square thingto do, doctor.

[dr. johnson:] of course, it is john. now john, i want you to tell me where youthink you picked up this disease. you should tell me all about it because whoevergave it to you, can give it to others, and she should receive the same attentionyou are getting. of course, your name won't be used. [john:] well, it was about a year ago. i don'tknow who she was. her name was sally i think. [dr. johnson:] sally. hmm. do you rememberher address? [john:] ah, third street, next to the storeon the corner of cypress.

[dr. johnson:] third. [narrator:] every case of venereal diseaseshould be reported to the health officer. the report should include information aboutcontacts. once the case is diagnosed, the doctor's attentionis focused upon the plan of treatment. this table shows the arsenical drugs whichare 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 arsenicaldrugs of choice are arsphenamine, neoarsphenamine, and arsenoxide. bismuth has largely replaced mercury, particularly in the treatment of early syphilis.

of the many bismuth compounds which are available, perhaps the most frequently used is a suspensionof bismuth subsalicylate in oil. the iodides are of little or no value in thetreatment of early syphilis. the dosages given in this recommended schemeof treatment for early syphilis are for arsphenamine. the recommended dose is higher for neoarsphenamineand lower for arsenoxide. treatment for early syphilis should startwith an arsenical drug in order to control infectiousness quickly. regularity is extremely important, particularlyduring the first six months of treatment. arsenicals are alternated with bismuth inorder 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, and10 doses. a minimum of 30 injections of an arsenical and40 injections of bismuth should be given. this makes a total of 18 months of treatmentfor cases of early syphilis. after this eighteen months, the patient maybe placed on probation if physical examination, blood test, spinalfluid examination, and x-ray examination of the heart and aorta are negative. the probationary period should extend forat least one year after treatment is stopped. during this time, blood tests should be made

and the skin and mucus membranes inspectedat 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 sero-resistance in early syphilis is involvement of the central nervous system. therefore, in early syphilis, failure of theblood test to show response to treatment should cause apprehension. in late syphilis, either acquired or congenital, sero-resistance in itself is not important. the gravity method of administrating arsenicalsis most frequently used for old arsphenamine.

this drug should never be used except underrigidly controlled conditions, since the danger of improper neutralizationis otherwise great. the syringe technique is usually used forother arsenical drugs. neoarsphenamine should be injected slowlyand 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 deepestlayer of muscle. the barrel of the syringe should be pulledback before the drug is injected to make sure that the needle is not in a bloodvessel.

the physician should study the anatomic positionof the sciatic nerves so that he can avoid striking it. before administering antisyphilitic treatment, a physician should make himself thoroughly familiar with the reactions which may occur and the danger signals whichcall for discontinuance of the treatment or change in the type of treatment. question each patient in regard to reactionsto 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 andbismuth in alternating courses of eight to 12 doses each. during the second year, give about three 12-dosecourses of bismuth. 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 earlysyphilis. the best that can be hoped for is the alleviationof symptoms, healing of lesions, restoration and maintenance of health, andprevention of further progression or relapse.

neurosyphilis, however, presents certain specialproblems in therapy. so-called wasserman fastness is not an indicationfor the use of tryparsamide. this drug is useful only in neurosyphilis. trivalent arsenicals should always be chosenwhen the central nervous system is not involved. before using tryparsamide, look for powerof 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 thiscondition is present. before each injection of tryparsamide, questionthe patient

in regard to symptoms such as shimmering visionfollowing the last injection. if such history is given, repeat the visualfield examination. contraction of the visual fields calls forimmediate discontinuance of the drug. malaria is induced in neurosyphilitic patientsby transfer of blood from a malaria patient. the non-tertian or quartan malaria is used. malaria therapy is used in severe or resistantcases of asymptomatic neurosyphilis and in clinical neurosyphilis such as paresis, tabes, and optic atrophy. fever therapy should not be used in the treatmentof neurorecurrence in early syphilis unless intensified routine therapy fails toeradicate the condition.

artificial fever therapy induced by mechanicalmeans is also widely used in the treatment of neurosyphilis. specially-trained personnel must be used inthis method, but under properly controlled conditions,it is as safe and effective as malaria therapy. swift-ellis treatment is a highly technicalprocedure 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 of 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 reportedalso. let us see what happens now that dr. johnsonhas sent his report to the health officer. it will be incorporated into the health departmentmorbidity records. it also becomes a credit, so to speak, against which the doctor may obtain drugssupplied by the state health department. on the contact portion of the report, thedoctor has noted an alleged contact whom he would like the health department toinvestigate by a home visit.

the health officer turns the information overto a followup worker. she visits the alleged contact, explainingthat 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 healthdepartment laboratory. the specimen, identified by a number, is carefullyhandled by trained technicians. usually, two or more tests are run on eachspecimen. the laboratory reports to the doctor in non-ambiguous terms, positive, doubtful, or negative.

this specimen is positive. [dr. johnson:] your report is positive. itrather 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 bestthing 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 sallyhas been sent. this is the waiting room.

to encourage patients to return to it weekafter week, it should be orderly and cheerful. here for example, colorful, educational postersbrighten 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 bymotion pictures. evening hours are arranged for the convenienceof working patients. privacy and quiet are provided for the physicalexaminations. booths with a full complement of treatment equipment make possible rapid yet considered arsenical therapy.

a separate room for bismuth injections contributesconvenience and comfort. spinal punctures can also be given here. a clinic this large would have equipment fordarkfield examinations and gonorrhea smears. the patient's first impression of a clinicmay be the last, unless he is made to feel at ease and awareof the clinic's real interest in the case. therefore, introduction to clinic routineis made by a specially-trained worker chosen for her pleasing personality as well as educationalqualifications. the social worker's interview with the patientis part of an extensive educational program carried on by the health department.

this includes distribution of folders andpamphlets telling the public about syphilis and gonorrhea and what to do about them. it includes programs over radio stations. it includes posters in public places urgingpeople to see their doctors for blood tests. it includes movies before all kinds of organizationsand in theaters. and it includes talks and lectures beforemany 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. when the physician is called upon to giveinstruction in regard to prophylaxis,

he should warn his patients that the onlysure 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 purchaseof condoms of inferior quality. the use of the condom should be supplementedby thorough washing of the genitalia and adjacent parts with soap and water forfive 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 strongsilver protein solution is next injected into the urethra and thepatient holds it there for five minutes. the protargol solution should be freshly prepared. the last step of the procedure is to rub 33percent calomel ointment into the genitalia and adjacent parts. prophylaxis in women is only occasionallyuseful, chiefly in cases of rape. the anatomy of the region makes the proceduremore difficult than in the male.

antisyphilitic treatment should never be usedas a prophylactic measure following exposure. treatment for syphilis is not justified unlessthe diagnosis of a syphilitic infection has been established by clinical and laboratoryevidence. to keep abreast of current developments inthe diagnosis, treatment, and public health aspects of syphilis, read venereal disease information, one of the medical journals published by theunited states public health service. [dr. johnson:] we as private practitionershave an indispensable function in this nation's program for the control of syphilis.

we must recognize our responsibilities andour obligations. do you remember what sir william osler said? listen, "i see an incredulous look on somefaces, and i hear the whispered comment --'tis heard often enough-- 'where is all this syphilis? it does not comemy way.' yes, it does. the syphilis we see but do not recognize everywhereawaits diagnosis, so protean are its manifestations." [ music ]