Syphilis, malaria, and other oddities

Sep 14 2010 Published by under Medicine

When I was younger, I used to lead canoe trips in Ontario.  These trips were often out of touch for days at a time, and the only way to get emergency help was to take a canoe and paddle toward an outpost of civilization as quickly as possible.   Because of this uncomfortable fact, we got quite a bit of first aid training, including how to clear an airway using the Heimlich Maneuver, which the Canadian medics insisted on calling an "abdominal thrust".

Thankfully, I never needed to use an abdominal thrust on a canoe trip (although I used plenty of other lifeguarding and first aid skills), but everyone seems to know the Heimlich maneuver, or at least what it is.  So I was shocked when I got an email from a Peter Heimlich, the son of the Dr. Heimlich.  In addition to reminding me that Dr. Heimlich did not, in fact, invent his eponymous maneuver, he told me that Heimlich had become involved in some pretty sketchy pseudoscience.  In fact, Heimlich was purposely giving malaria to people with HIV disease, something that is both ineffective and dangerous.

The use of fevers to treat diseases is certainly not new.  One of the most interesting cases was that of Dr. William Coley, a surgeon who treated sarcomas in the late 19th and early 20th centuries.  He noted that patients who acquired erysipelas, a severe infection marked by high fevers, would sometimes have improvement in their tumors.  He moved from observation to intervention, placing sarcoma patients in soiled beds recently vacated by erysipelas patients.  Eventually, he created a potion of "toxins" isolated from erysipelas bacteria, injecting it directly into patients.   While we no longer give patients crushed up bacteria to treat cancer, interleukin 2, a biologic agent used as chemotherapy for some cancers, has an outwardly similar effect, often giving patients fevers and dropping their blood pressure inducing a state similar to septic shock.

So I wasn't entirely surprised when, in digging through some old journals, I found an article on treating advanced syphilis by giving patients malaria.

Syphilis is still a common sexually transmitted disease, but the late stages of the disease are not so common anymore.  The standard treatment for syphilis is penicillin, and many people receive penicillin for infections unrelated to syphilis, perhaps being inadvertently treated. But in the days before penicillin, syphilis relentlessly progressed, often leading to a condition known as "general paralysis of the insane".  A modern case report in the Southern Journal of Medicine is typical.  A 48 year old woman came to her doctor with vague complaints of fatigue and memory problems.  Her family was a bit less vague, telling the doctors of the patient's conversations with non-existent visitors, and her belief that her husband was the devil.  The patient also had significant neurologic problems including weakness of her facial muscles and frequent falls.   She rapidly declined, and became, essentially, comatose.

Neurosyphilis can be permanently disabling and deadly.  Before penicillin, doctors would try almost anything to save patients from this easy to catch but hard to cure illness.  Most treatments available in the pre-penicillin era were of questionable efficacy and undeniable toxicity, mostly involving heavy metals like arsenic and mercury (an old saw went, "One night with Venus, a lifetime with Mercury").  Doctors and patients were stuck with a horrible disease, and a poisonous cure.

But many of the doctors treating syphilis were ferociously smart, and made excellent observations.  In the inaugural issue of the British Journal of Venereal Diseases, one expert noted:

It has been noted for over a hundred years that an intercurrent infection or an artificially produced fever may effect a remission in the course of general paralysis.

Using this observation, and other hypotheses regarding the effect of fever on disease, some doctors  tried using a more-or-less controllable source of fever: malaria parasites. But even in the 1920's Britain, you couldn't just give people malaria (at least, not the un-incarcerated).

The consent of the patient and his relatives having been obtained, the patient is admitted to hospital. The tolerance to quinine is enquired into or tested.

The reference to "consent" is encouraging, although the meaning of the term was much different than the "informed consent" that is now the standard. The quinine tolerance was also important. Quinine was the only treatment available for malaria, so if you're going to give someone a potentially fatal disease, you'd better make sure you can cure it.

But what I really like about the paper is the caution with which the author approached his results:

In interpreting the results of any method of treatment of general paralysis it is necessary to bear in mind the well-known tendency of this disease to show natural remissions.

One of the keys to medical charlatanism, a problem then as now, is taking advantage of the natural course of a disease to take credit for nature's work.   The author would have been aware of this, and of the many "cures" for syphilis that had come and gone.  He framed his conclusions recognizing the seriousness of the disease and the risk of the cure:

Conclusions. (i) The optimism of the Continental writers cannot be confirmed, but the treatment has justified-itself until a better method can be found.(2) Success of treatment depends on the choosing of earlycases free from arterial disease and bronchial infection.(3) The treatment should be withheld from all debilitatedparetics and from all cases over fifty years of age.(4) The method of inoculation giving most satisfactory results seems to be natural infection from mosquitoes.

The forty-eight year old woman left in a coma had a diagnosis of syphilis confirmed by spinal tap.  She was treated with penicillin and was able to walk out of the hospital.  She did not, however, return to normal.  With well over a century of experience treating syphilis, we still do better with prevention than with treatment.

Selected References

Redvers N. Ironside (1925). ON THE TREATMENT OF GENERAL PARALYSIS BY MALARIA INOCULATION
British Journal of Venereal Diseases, 1 (1), 58-63 DOI: 10.1136/sti.1.1.58

Schiff E, & Lindberg M (2002). Neurosyphilis. Southern medical journal, 95 (9), 1083-7 PMID: 12356119

Lewis Gates (1925). Neurosyphilis Southern Medical Journal, 18 (10), 723-726

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