238 THE B R I T I S H HOM(EOPAT]:[IC J O U R N A L

la Lift, E., Buchanan, D. S., and Levens, A. J . : Bull. Sch. Med. Univ. Maryland, 47, 17, 1962. Wetherill, J . H., Webb, I t . E., and Cattcrall, R. D.: Brit. Med. J. , 1, 1157, 1965. Ravault , P. P., Lejeuno, E., Gauthicr, J . , Bert rand, N. J. , and Vauzelle, J . L.: Lyon Med., 210, 1107, 1963. Novo-Josserand, G., Duffau, E., and I)esfossez, J . : Strasbourg Med., 14, 891, 1963. Boudin, G., and Barbizet , J . : Rev. Neurol., 104, 346, 1961. Wissner, F., and Parsons, T.: J. Clin. Psychol., 17, 421, 1961. Belsham, A. J . , and Dunlop., E. M. C.: Brit. J . Vener. Dis., 40, 106, 1964.

A reply to G. Vithoulkas

I am very glad that Mr. Vithoulkas has seen fit to elaborate his position in regard to the question of penicillin therapy in syphilis, since when I originally read his book I found it difficult to believe tha t he really meant what he appeared to say; he has now made it quite clear tha t he did.

His argument falls into two sections: (1) he claims tha t penicillin therapy is not wholly effective as a cure for syphilis, and (2) he goes on to say tha t penicillin is actually harmful in the t rea tment of syphilis. Let us look at each of these ideas in turn.

Probably no venereologist today would claim that penicillin is a complete answer to the problem of syphilis. The fact tha t it is possible by appropriate techniques to demonstrate what appear to be persistent treponemes in the lymph nodes, cerebrospinal fluid and aqueous humour of rabbits and human patients who have received therapeutic doses of penicillin is well known to venereologists, and a good deal of debate has gone on about the significance of these findings. I t is also known that T. pallidum can maintain its virulence after incubation with high concentrations of penicillin,1 probably because the organisms are not actively dividing in the culture medium.

From the clinical point of view, no one would expect to reverse the late effects of syphilis, such as aortitis or cerebral damage, by means of penicillin. Similarly, the fact tha t delicate serological tests remain positive in syphilis treated some time after the primary phase is hardly surprising; one would not expect to eliminate such "serological scars", any more than one would expect to reverse the Mantoux reaction in a case of post-primary tuberculosis by means of anti-tuberculosis t reatment (which, incidentally, I suppose Mr. Vithoulkas would also regard as an undesirable form of therapy). In early syphilis, all serological tests do become normal after treatment.

There is of course no doubt that inadequate (i.e. insufficiently prolonged) penicillin t reatment can result in the masking of syphilis. I have myself reported a case in which dark-ground-positive pr imary syphilis developed shortly after penicillin had been given at a dosage tha t would ordinarily be expected to abort incubating syphilis, 2 and a similar case has more recently been reported by Wright. a I t is for this reason tha t venereologists t ry to follow up cases of gonorrhoea by means of serological tests for syphilis at three months. However, these findings by no means show tha t adequate (10-day) courses of penicillin do not cure early syphilis. Anyone who still doubts this should refer to the authoritative monograph by Idsoe, Guthe and Willcox, 4 which contains some 630 references to the world literature and tabulates the results of penicillin t reatment in 5,640 patients with early syphilis and 8,819 patients with late latent or late symptomatic syphilis; the results wholly confirm the confidence that venereologists have come to place in penicillin.

C O R R E S P O N D E N C E 239

The answer to the first part of Mr. Vithoulkas's argument, then, is that it is extremely misleading to imply that adequate penicillin therapy of early syphilis is ineffective, since we have very good evidence that it is effective. Of course penicillin does not offer a perfect fool-proof solution to the problem of syphilis; but no one has ever claimed that it does.

Mr. Vithoulkas's second contention, namely that penicillin is actually harmful because it "suppresses" syphilis, is a good deal more dangerously misleading. The only evidence he offers in support of his opinion is a table published in 1967 whose relevance is not clear to me. Why should the fact that "syphilitic insanity" is commoner than tabes dorsalis (where?) be so important? In any case, the quoted figures refer to 1963, and hence can tell us nothing about the efficacy or otherwise of penicillin treatment of early or latent syphilis since, owing to the length of time required for central nervous system syphilis to develop, the cases referred to must have originated in the period before penicillin came into general use as a treatment for syphilis.

Let us be quite clear about this whole debate. Does Mr. Vithoulkas really believe that a doctor who is called upon to treat a case of primary syphilis, with a chancre teeming with virulent T. pa l l idum, should withhold penicillin for fear of "suppressing syphilis into the deeper regions of the organism"? I f so, I find the suggestion quite appalling, and not only because of the likely effects on the patients themselves. What about the patients' unfortunate contacts, whom Mr. Vithoulkas does not mention at all? Are they to be callously exposed to infectious syphilis?

I must state quite unequivocally that I find the proposition that we should refrain from treating syphilis by means of penicillin wildly irresponsible, and I cannot see how any physician, homceopathic or otherwise, could conceivably adopt such a course. Indeed, I think it very likely that to do so would be to lay oneself open to an action for negligence; in my view, rightly so.

A N T H O N Y C A M P B E L L

R E F E R E N C E S

Collart, P., Pech~re, J. CI., Francheschini, P., Dunoyer, R. (1972) Persisting virulence of T. pallidum after incubation with penicillin in Nelson-Mayer medium. Br. J. Ven. Dis., 48, 29.

2 Campbell, A. (1974) Effect on incubating syphilis of penicillin treatment for gonorrhoea. Br. J. Ven. Dis., 50, 270.

8 Wright, J. T. (1975) Single dose penicillin therapy. Br. J . Ven. Dis., 51, 410. 4 Ids~e, O., Guthe, T., and Willcox, R. R. (1972) Penicillin in the ~rea~ment of syphilis.

The experience of three decades. Supplement to the Bulletin of the World Health Organization, 47.