1 Boring Old Man

“He who knows syphilis knows medicine”
Sir William Osler, the Father of Modern Medicine

Some years back, I saw a play, Miss Evers’ Boys, about the Tuskegee syphilis study. In 1932. 600 black men were recruited into a Public Healtrh Service study that went on for forty years. In return for participating, they were given free medical care and burial insurance. The back story was that this was a study about the natural course of syphilis and 399 of these men had the disease, but weren’t told. They were only told they had the bad blood [a colloquialism with many meanings]. When penicillin came along in the 1940s, the definitive treatment for the disease, it was neither used nor discussed. The play centered on the study nurse, the Miss Evers of the play, who "saw after" the participants all those years knowing they weren’t being treated. The study was finally leaked in 1972, and the aftermath brought many changes in the safeguards for human experimentation [see Wikipedia’s Tuskegee syphilis experiment]. By the end of the study in 1972, only 74 of the test subjects were alive. Of the original 399 men, 28 had died of syphilis, 100 were dead of related complications, 40 of their wives had been infected and 19 of their children were born with congenital syphilis. It’s a story of epidemiology; of racism; and of the origin of Informed Consent and Institutional Review Boards. The entire 1997 HBO Movie of Miss Evers’ Boys is available on-line [1:57:59]…

[1964] I paid my room and board in early medical school by being the house manager for a medical fraternity house. That essentially entailed keeping up with the elderly black man who had actually run the place since the dawn of time. One day I returned from a lecture where I’d heard for the first time about Tabes Dorsalis [tertiary syphilis of the spine], and I noticed that his walk looked a lot like the film I’d seen in class that day. I asked him about it and he said he was just "getting old." I engaged an upper classman who went to the hospital and got his chart. Sure enough, he’d been treated with heavy metal injections as a young man [for bad blood], but nothing since. We escorted him to the neurology clinic where he was treated with Penicillin [and became a Grand Rounds case].

[1967] The first patient I had as an Intern was an elderly man admitted after abruptly losing his voice. The next day, we got an emergency page and found him in extremis coughing up blood and he quickly arrested and died. That afternoon, his VDRL [lab test for syphilis] came back positive. At autopsy, he had a syphilitic aortic aneurism that had ruptured into his trachea. The hoarseness was from the compromised recurrent laryngeal nerve [that wraps under the aorta on its way to the vocal cord].

[1973] When I was an Air Force Doctor overseas, an older civilian administrator was admitted with jaundice and delirium from liver failure. He had the physical findings of chronic cirrhosis though he was not a drinker. But he also had fever and signs of some acute process. He had a history of hepatitis in the South Pacific in World War II and we speculated he had Chronic Active Hepatitis. But then on the second hospital day, he developed a generalized rash, present on his hands and feet [a characteristic sign of secondary syphilis]. Scrapings of the rash revealed those little corkscrew Treponema pallidum organisms bending in the middle that I’d only seen in pictures [the organisms that cause Syphilis]. In spite of our starting him on a very low dose of penicillin, he had a Jarisch–Herxheimer reaction [toxicity from the sudden death of the organisms] requiring high doses of steroids. He had been infected by a dalliance with the wife of a ranking officer at a base in another European country [a delicate and touchy point]. He recovered nicely, but unfortunately we were right the first time. On a subsequent liver biopsy, he also had Chronic Active Hepatitis that had been complicated by the Syphilis infection.

William Osler was "the Father of Modern Medicine" in part because he exemplified the era of the grand clinician – physicians who spent their lives carefully mapping the signs and symptoms, the clinical course, the family and environmental histories of diseases. They collected detailed case histories extracting patterns that became syndromes, many of which still carry their names. Their treatment options were limited, but hard won advances informed by their clinical precision. As monstrous as it was to withhold the diagnosis in the Tuskegee Study early on, and even worse, to withhold treatment when it became available, the idea of gathering precise epidemiological data was consistent with the way medicine operated in the latter nineteenth and early twentieth century.

In our current era, there is a race to treatment based on small differences and speculation, both measured and hypothesized. Each evening, we expect our evening news to be accompanied by an announcement of some medical advance or breakthrough, punctuated by direct to consumer ads with their mumbled warnings. We’ve become used to questionnaires, rating scales, laboratory examinations, and loud whirring machines replacing the classic history and physical examinations of the past. My point here is not simply nostalgia for former days, it’s about the hurried pace with which we race into action, to treatment. The current Tamiflu debacle is an exempler. Billions have been spent on a medication to stave off a hypothesized global epidemic. Now it appears that that medication, while not inert, is hardly suited to the task. We’ve defined Mild Neurocognitive Disorder and the Attenuated Psychosis Syndrome without having a solid anchor that tells us that they are, indeed, the precursors we seek. We are subjected to recurrent studies that try to convince us to use SSRIs in teens with little evidence that they even treat adolescent depression itself, much less prevent anything, and with that come accusations of withholding treatment.