We need to anticipate a little at this point to recognize that immunity in syphilis, such as it is, develops very slowly. The details must wait for our examination of the possibility of making a vaccine. Slow development means that when syphilis is completely cured in its early stages there is no immunity at all. One of the peculiar things about syphilis is that the untreated syphilitic has an odd kind of immunity to a new infection, odd because it doesn't do him much good, since he is sick anyway. But the fact is that if he has a chance, or has once had one and has not been treated, he does not develop another no matter how often or how massively he may be re exposed. But once completely cured of early syphilis he can be reinfected and have another chance and all its sequels. As a result, if syphilis is treated in only one of a pair of sexually active partners, the treated partner may develop new chancres once, twice, or many times. This repeating pattern had never been seen before the introduction of penicillin. It was quickly called "ping pong" syphilis.

Such "reinfection" has often been mistaken for relapse, and it has taken some years and many pages of type to reorder our thinking away from the pessimism of the quotation from Klein we saw a few pages back. Penicillin, it was becoming clear, was giving fast and full cures such as had never been known before. Arsphenamines may have cured completely, but cure was so slow that a certain immunity always had time to develop, and second chances were unknown. With penicillin it was reinfection, not relapse.

Usually relapse certainly happened with penicillin sometimes when the drug was started in later stages or when not enough was given. A common difficulty arose when gonorrhea and syphilis were present together, especially during the 1940s and 1950s, when gonorrhea was treatable with smaller doses of penicillin than were needed for syphilis. The gonorrhea, with its shorter incubation period, showed up first, and treatment aimed at it alone could merely mask the chancre so that it failed to appear or went unnoticed; but blood reactions and secondaries appeared later. Evan Thomas says,

“...patients may have infectious relapses and later may develop serious late lesions of syphilis, if the relapse was undetected. This fact explains the old dictum that inadequate therapy of early syphilis may do more harm than good, and also explains why it is so essential to keep patients under observation for long periods after treatment is completed.”

But that was said in 1949, and ought to be thought of as the opinion of an older clinician still steeped in the old pessimism. Caution is a virtue; but if you have ever walked across traffic with somebody holding your arm who had the virtue a little too highly developed I needn't push the point that there can be too much of a good thing. Anticipating one small part of the large question we must face later the question of control of VD it seems plain that we must not unduly prolong the agony and uncertainty of treatment. In syphilis treatment can be done and done with: delay may spoil its value.

But finally to finish the subject of treatment of syphilis in the only way the whole story allows, which is on a note of foreboding we must face the truth that there are no absolutes in biology, and no disease is less absolute than syphilis. If the treatment of early syphilis approaches the ideal, so far, at all events and it does the treatment of late syphilis falls short of it. There is a story to be told her that has been unfolding only in the last few years. Its full significance has come to be accepted in responsible quarters only with the greatest reluctance. (see PROBLEMS IN THE TREATMENT OF SYPHILIS PART III)