497

Penicillin in Syphilis

THE LANCETLONDON : SATURDAY, SEPT. 25, 1948

PENICILLIN IN SYPHILIS

FIVE years have passed since penicillin was firstused in syphilis, and it is doubtful whether its valuecan be fully assessed for at least another five. Yet,in spite of some early doubts and disappointments,it has been accepted almost universally and there canbe no doubt that it has come to stay. In the UnitedStates a report,! based on the treatment of half amillion cases, assesses the present position. Crystallinepenicillin ia (G) is regarded as superior to the impurecommercial product, and it is best given intramuscu-larly in doses of 20,000 to 100,000 units dissolved insterile water or isotonic saline every two or threehours day and night. The alternative is to inject asuspension of calcium per.icillin in arachis oil with

4-8% beeswax in a daily dose of 600,000 units. Thefirst method requires admission to hospital and thedose recommended for early syphilis is 4.8 millionunits given in 96 doses, each of 50,000 units at two-hour intervals day and right for eight days. With oil-wax mixture the daily dose is given for ten days, thetotal dosage being 6 million units. With both methods,when penicillin is used alone, the failure-rate of resis-tant cases and relapses is about 15% at the end ofa year. The addition to this treatment of arsphenoxidegiven intensively in the form of 8 injections each of60 mg. daily or every other day, and bismuth sub-salicylate in 5 doses each of 0-2 g. every two or threedays, does little to diminish the failure-rate. Withadditional fever therapy results have been little better,but this supplementary treatment adds to the diffi-culty of getting patients to cooperate.2 Such accessorymethods also involve increased risks to the patientand are therefore reserved for resistant cases, inwhich they are combined with more penicillin.

For latent syphilis, in which the duration of infectionis often uncertain, penicillin has been used in the samedosage on the assumption that it will heal undetectedlesions and may prevent the development of clinicalmanifestations later. It seems to be no more effectivethan arsenicals and bismuth in converting positiveserum tests to negative in cases of late and latentinfection, a finding which accords with the experienceof WILLCOX 3 in this country. Penicillin has provedas effective as older remedies in healing the cutaneous,mucous, osseous, and visceral lesions of so-calledbenign late syphilis; but with these conditions, aswith latent syphilis, many years must pass beforestatistics can show whether it will secure a goodultimate prognosis. The same applies to cardio-vascular syphilis, and the possibility of dangerous1. Syphilis Study Section, National Institute of Health, U.S.

Public Health Service. J. Amer. med. Ass. 1948, 136, 873.2. Schwemlein, G. X., Bauer, T. J., Craig, R. M., Rodriquez, J.,

Bundesen, H. N. Ibid, 137, 1209.3. Willcox, R. R. Lancet, 1947, ii, 8.

Herxheimer reactions remains where syphilitic aortitisis complicated by aortic regurgitation, saccular aneu-rysm, or involvement of the coronary ostia ; in suchcases penicillin, if it is used at all, should only followprotracted treatment with heavy metals. For neuro-syphilis of the meningeal and vascular types a dosageof 4-10 million units is recommended, given in

aqueous solution over a period of seven to twenty-onedays without adjuvant treatment. For parenchy-matous neurosyphilis 10-20 million units is given intwelve to twenty days, accompanied by -malariatherapy unless this is contra-indicated. In neuro-

syphilis of all kinds intramuscular administrationseems to be as effective as intrathecal and is certainlymuch safer. For the prevention of syphilis in theunborn child penicillin has been remarkably successfuland seems to be almost fully effective at whateverstage of pregnancy it is given. Dosage varies from4.8 to 6 million units, given in aqueous solution atintervals of two to three hours over eight to fifteendays. Additional treatment is regarded as unnecessaryand undesirable. For infantile congerital syphilispenicillin in aqueous solution is given every two orthree hours day and night in a total dosage of 100,000to 400,000 urits per kg. of body-weight over one totwo weeks. The results are excellent ard the death-rate has been no higher than with other methods,.most deaths being attributable to nutritional diffi-culties or intercurrent disease. For the later mani--festatior,s of congenital syphilis the results with peni-cillin have been much the same as in late acquiredsyphilis, and the ultimate outcome in these cases

remains equally in doubt. Like other forms of treat-ment penicillin is of uncertain value for interstitialkeratitis. -

.

Penicillin has the outstanding advantage that, as itstoxic effects are few and not dangerous, a massivedosage can be given in a short time. Because of its

safety and its prompt and satisfactory effect it maynow be accepted as the remedy of choice for syphiliticpregnant women and for infants with congenitalsyphilis. In cases of benign tertiary syphilis thepatient’s immunity processes have already given him alarge measure of protection, and treatment will readilyrestore a temporary loss of balance between infectionand immunity. Here penicillin appears to have greatadvantages whether used alone or supplemented byother measures. The chief outstanding problem iswhether we are justified in treating early syphiliswith penicillin alone, for at this stage the immurityreactions are not, fully developed and insufficienttreatment may be worse than none.’ The verdict inthe United States so far is in favour of penicillin alone,and it may be said that this treatment is free fromdanger, the proportion of successes seems reasonablyhigh, and the short duration of treatment throws intosharp relief the small number of cases which are likelyto be resistant to any form of treatment and willrequire special measures.

,

In most British clinics the practice is to supplementadequate penicillin therapy with at least one fullcourse of arsenicals and bismuth, given in weeklydoses for ten weeks or so. This prolongs treatmentconsiderably and increases its dangers. If it canbe shown that this procedure greatly reduces theincidence of failures then it - - is probably justified-

498 HOW MANY NURSES ? P

MCELLIGOTT and his colleagues, at St. Mary’s Hos-pital, Paddington, treated 275 patients for primaryor secondary syphilis with 2’4—4 million units ofpenicillin over seven to twelve days, followed in mostcases by 12 injections of neoarsphenamine and ofbismuth during six to ten weeks. About half of thesepatients were followed for twelve months or more,and the remainder for shorter periods. During thistime there were 11 cases (4%) in which treatmentwas known to have failed. Severe toxic effects fromthe arsericals occurred in 10 cases. In MontrealMARIN and others 6 treated 201 patients for earlysyphilis with 2-4 million urits of penicillin given ina week, followed by 4 injections a week of 60 mg. ofarsphenoxide and 2 injections a week of bismuth

during a period of five weeks. Three-quarters of thepatients were observed for six months or more. Thetreatment failed in 9 cases (4.5%), and the outcomeseemed doubtful in another 6%. One patient diedfrom arsenical encephalopathy. Both these studiesconcern too few patients followed for too short a timefor defirite conclusions to be drawn from the results.Penicillin has not proved an unmixed blessing forthose who treat syphilis. When it is given for thetreatment of gonorrhoea in patients who are incubatingsyphilis the early signs may be delayed or even

suppressed. In the same way, the wide use of thisremedy for all kinds of infections, major and minor,must mean that syphilis will be masked, and mayproduce a considerable crop of late syphiliticmanifestations in the future.

How Many Nurses?Mr. JOHN COHEN, PH.D., whose minority report 6 as

a member of the Working Party on the Recruitmentand Training of Nurses has just appeared, asks us topause and consider, not how many nurses we wouldlike or think we need, but how many can in fact beobtained from the woman-power of the country. Norwould this give the complete answer : we have toconsider, too, how many nurses we can afford. A

planned health service, as he points out, "

presupposesa planned economy in which a correct proportion ofour national resources is devoted to health." As an

impoverished country, we must bear in mind thatwhat we spend; however advantageously, on medicalservices will have to be saved on something else, andwe shall have to decide what that is to be. Even if theTreasury were inexhaustible, the supply of women isnot: Nursing-like teaching, secretarial work, thesocial services, the medical auxiliary services, andother occupations open to intelligent women—can

only hope to enrol its " fair share " of candidates ;and -what that fair share may be, he suggests, hasnever so far been determined. We have yet to dis-cover the optimum number of beds per 1000 of

population, and the optimum number of nurses neededto look after them. These things should not be matters

- of opinion but matters of ascertainable fact.Pursuing the question whether it is economi-

cally justifiable to employ more nurses, Dr. COHEN

4. McElligott, G. L. M., Jefferiss, F. J. G., Willcox, R. R. Brit. J.ven. Dis. 1948, 24, 45.

5. Marin, A., Boulais, F.L., Lambert, A., Foisy, J. P., Leclerc, G.Canad. med. Ass. J. 1948, 59, 1.

6. Working Party on the Recruitment and Training of Nurses,Minority Report. London: H.M. Stationery Office. 1948.Pp. 78. 1s. 6d.

endeavours to compare the " output " of different hospi.tals which have different ratios of patients to staff. Ifit could be shown that patients return to work soonerafter treatment in hospitals having relatively largenursing staffs, then we might have evidence that thecommunity could profitably spend more of its resourceson employing and training nurses. Arguing that " thetask of nurses and doctors alike... is, presumably,to speed the patient’s recovery he takes as theeconomic criterion of nursing (or medical) effectivenessthe duration of the patient’s stay in hospital. Findingthat this is, on the whole, shorter in well- staffed hospitals,he compares the national cost of good staffing with therational gain in working days saved for production-the evidence providing him with " a prima-faciecase, on economic grounds, for substantially increasingthe number of trained nurses in general hospitals."Unfortunately, few will agree with the initial assump-tion on which all this is founded-namely, that theduration of the patient’s stay in hospital is a satis-factory " objective measure of the task of nurses anddoctors." The length of stay is in fact affected bymany variables other than the ratio of staff to patients.Apart from the type of illness (for like groups can becompared with like groups), it may vary with thecustom of the hospital, its facilities for investigationand treatment, the pressure of the waiting-list, theprovision of convalescent homes, and even the qualityof the hospital diet. Nor do the figures he suppliesjustify Dr. COHEN’S prepossession with this particularyardstick.to demonstrate a not very striking inverse relationshipto demonstrate a not very striking inverse relationshipbetween the duration of stay and the ratio of trainednurses to beds. (The figures were taken from surveysmade as long ago as 1938.) But this is in fact the onlypiece of evidence he presents in favour of his hypothesis ;and the equivocal results of applying it to other groupsof nurses and to doctors should have convinced him thathe had lashed himself to the tail of a red herring. Thusthe presence of student nurses, in general hospitals,*’ seems to have little or no effect on the patient’sduration of stay," results " offer little support for theview " that the duration of stay could be affected bychanging the ratio of doctors to patients ; and data frommental hospitals (surveyed in 1934-38) suggest that" an increase in trained nurses alone without increasing

the number of other nurses and medical staff is unlikelyto reduce patient stay " ; whereas an increase of 1-5untrained nursing assistants per 100 beds (an additionof 800 to our total complement of such assistants)" would apparently reduce stay, on the average, by asmuch as three months." (The same effect, he believes,might be achieved by adding another 200 part-timedoctors to the staffs of our mental hospitals-thoughan addition to the full-time staff would be likely to haveno effect at all.) Faced with all this conflicting evidenceDr. COHEN argues ingeniously that the trained generalnurse is more " effective " than the student of generalnursing, whereas the nursing assistant is more " effec-tive " than the trained mental nurse ; and that full-timedoctors in a mental hospital fail to reduce patient staybecause they " sometimes tend to persuade some patientsto stay on at the- hospital so as to improve their conditionstill more "-an argument which does little to support hishypothesis that the length of patients’ stay is a

measure of the effectiveness of the doctor.

The fact that this attempt to provide a workingmeasure of nursing production is so questionable doesnot, however, invalidate Dr. CoHEN’s general thesisthat we are still very ignorant about this subject,and that it is time we studied it more objectively.Since he is concerned only to give an idea of what