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 | Science in the Cinema 2008 Transcript: The Quiet Duel |
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National Institutes of Health
Science in the Cinema 2008 — "The Quiet Duel”
Post-Film Discussion — Dr. Robert Martensen and Dr. David Cantor
Dr. Fuchs: Our speakers this evening are Robert Martensen, M.D., Ph.D., and David Cantor, Ph.D. Dr. Martensen is the director of the Office of NIH History. His interests range widely across medical practice, biomedical science, and culture. He received his Bachelor of Arts degree from Harvard, his M.D. from Dartmouth, and his Master’s and Ph.D. from the University of California at San Francisco. He has explored the origins of neuroscience in the Scientific Revolution and the scientific transformation of United States medicine that took place during the Progressive Era.
Dr. Cantor is deputy director and senior research historian in the Office of NIH History. He also works as a historian for the National Library of Medicine and the National Cancer Institute. His scholarly work focuses on the 20th-century history of medicine and most recently, the history of cancer. He is currently the editor of Reinventing Hippocrates, Cancer in the Twentieth Century, and the series editor of Studies for the Society of the Social History of Medicine.
Please help me welcome tonight's guests, Drs. Martensen and Cantor.
Dr. Cantor: I'm the deputy, just in case you’re wondering. There you go. I think if you read what most of the critics have written on this movie, most would say that this was not one of Kurosawa's best movies. Some may disagree. Some would just say it's a bad movie. Others would say, well, he's young, he's learning, he's trying something out. Maybe you saw that in this movie.
The point that I am mostly going to concentrate on today is the role of the censors in this film. Historians argue that the censors intervened so much in this movie that Kurosawa just lost interest in it. He kind of ambles through this movie.
I'll give you a clue as to why the censors might have been so concerned about this movie. It is based on a play that Kurosawa saw in Tokyo. I think this was just after World War II, and the name of the play was “The Abortion Doctor.” Just a clue. In some ways, the film that we've just seen is neither that of Kurosawa nor the playwright who wrote the original play.
Before Kurosawa could begin production, he had to get the project approved by the American Occupation Government's Civil Information and Education section (CIE). CIE actually wanted this movie. They wanted to educate the public about the dangers of venereal disease (VD). But they had a number of concerns about Kurosawa's script, and it's those concerns that changed the script somewhat and I suspect it led Kurosawa to lose much of his initial enthusiasm for the movie.
First was a concern of the extent to which Kurosawa emphasized the terror of VD. In the view of the censors, the worry was that if Kurosawa overemphasized the danger of the VD, the consequences of the disease, and its treatment, people would just give up on treatment altogether.
In other words, these censors saw fear not as a way of encouraging people to seek treatment, but rather fear, or too much fear, might paralyze them into inaction. Consequently, this fear might cause them either to avoid going to the doctor altogether or to give up treatment before the cure was effective.
Whatever the truth of such assumptions, it was a very common assumption in mid-20th-century American disease campaigns, including those against venereal disease.
Kurosawa was forced to tone down the terrors of the disease. Consequently, the film lost some of the dramatic force that he intended for the movie in its original incarnation.
The second concern of the censors was portrayal of the doctor, Fujisaki. In the original screenplay Fujisaki does not treat his syphilis until it is too late. It is he who goes insane, not Nakata.
From the point of view of the censors, and remember they're thinking of this as an educational film as well as an entertainment movie, no doctor would behave this way. No doctor could behave so irresponsibly as to leave syphilis untreated and lapse into insanity.
That was the role, of course, of the alcoholic, the irresponsible Nakata. Basically, they swapped the roles. In the revised script, as we’ve just seen, it's no longer Fujisaki, but Nakata who goes insane. Only the morally corrupt people go insane, according to this sort of morality. This is a morality play in which salvation comes through Salvarsan. I think Robert will mention that.
The third concern on the part of the censors is the focus on abortion. Remember the title of the original play, “The Abortion Doctor?” In the original play, before he goes to the war, Fujisaki performs an abortion to save the life of a pregnant woman. He's cleared his conscience about that. But it ruins his reputation as a doctor. In the finished film, as we've just seen, did anybody spot that episode? I'm afraid you didn't. It's gone, it's no longer there.
The timing of this removal is really interesting. This film was made in 1949, the year after Japan legalized abortion under certain conditions. Remember, Japan legalized abortion in 1948, long before most other countries. So the original play and Kurosawa's original script can be seen as sort of interventions in this issue, interventions which the censors disallowed.
With that said, the censors sort of turned it into a morality play. They weakened its dramatic impact. My guess is that is why Kurosawa lost some of his initial enthusiasm for the movie.
Now I will hand you over to Bob, my director.
Dr. Robert Martensen: David, thank you very much. First, I also want to thank Bruce Fuchs and the Office of Science Education for arranging the film and for inviting us to comment.
My training was in emergency medicine. I did it at San Francisco General, so this is just an aside; it's a large public hospital in San Francisco and a hospital of last resort for many people. I did this in the ’70s and actually have had hundreds of patients with syphilis, many of them diagnosed with primary syphilis—typically a canker sore on the genitalia.
We had so many patients with syphilis that we used to have a special microscope in the emergency department lab with what's called a dark-field prep. One can swab a primary lesion and see the spirochetes swimming around when they're illuminated in this kind of preparation.
That was my introduction to syphilis in San Francisco in the 1970s, when it was very active sexually in all dimensions. One of the challenges, and I think David set up what I'd like to say a bit, is this movie is embodying what we’ve seen. It embodies very American attitudes that started at the turn of the late 19th century, through the 20th century, right up to this film.
Attitudes typically focused on the man and not the woman. They assumed that the man would be responsible, that the bride is innocent, that syphilis is primarily a moral problem. The movie is trying to make the point very effectively, I think, that one cannot assume that the disease is gone when the primary lesion is healed.
Syphilis is still a major public education project because the cankers heal up in a few weeks and therefore, people may just let it go, assume it has healed, and don't get treatment.
The film is making the point very explicitly. At one point, they say you can even get it from saliva. Obviously, the doctor gets it from a cut during an operation, and the patient has already healed up and stops getting treated. The patient, Nakata, is the bad guy in the film.
It's still a challenge. I think this movie is reflecting the views of the early 20th century. Physicians were trying to work out the natural history of syphilis. They knew it had three stages: primary, secondary, and tertiary. But many remained to be convinced that if you just treated the primary, you didn't have a transmission problem.
It was very convenient in a sense, professionally. It meant that if you thought you were curing the disease, whether it was with Salvarsan or organic mercurials, you didn't have the awkward professional problem of informing partners. You could just take care of it with the patient before you. The public health response to syphilis was mitigated, particularly in the United States. European countries took a somewhat different approach.
Salvarsan and salvation—the resonance is so clear. Salvarsan was developed between 1905 and 1910. The co-discoverer of Salvarsan was a Japanese scientist who worked with Paul Ehrlich. His name was Hata. Ehrlich got the Nobel Prize for the work, but the spirochete, Treponema pallidum, was discovered between 1905 and 1910. You also heard the term Wasserman used. The Wassermann reaction is the diagnostic test for syphilis. You heard references by the doctor in the film that his Wassermann was still three plus, at one point.
It's what's called a complement-fixation test. It's rather nonspecific, which means that there are many false-positive Wassermann tests. It's also not a reliable gauge of treatment success. In other words, one can be getting much better and still have a Wassermann of four. A Wassermann of four would have been thought to be a sign of the most serious infection. You can have a four when you are getting better and you can have a one when you are getting worse; so it wasn't a very reliable test in that way. Because there were many false positives, many people were treated for syphilis that actually had other diseases. There are now other diagnostic tests.
The problem with Salvarsan is that it is an organic arsenical — a heavy metal treatment. Like other heavy metal treatments, it was very widely used worldwide in scientific medicine up through the 1930s. It's very difficult to recall, but organic mercury salts, which are another heavy metal, were a mainstay in the treatment of hypertension in the 1930s.
Huge amounts of organic mercury were given routinely to patients to treat hypertension. This reflects the fact that these metals were known to be toxic. The task was to sort out the proper dose, timing, and route of administration. One of the challenges of Salvarsan was dosing. If it was done in massive dosings, you could kill the patient. Doctors took between 20 and 30 years to figure out the right dosing, timing, length of treatment, etc. That's why the film emphasizes that one must do it calmly, patiently, and perhaps for a long time. They didn't have a reliable way to know when the treatment was successful. So there was a lot of uncertainty in science about treating syphilis and its natural history.
Well into the 20th century, penicillin emerges in commercial quantities in 1945. Japan is an occupied country. I don't know how much penicillin was made available to the Japanese, so it could be there was a lag. But certainly Americans had penicillin available to the military as well as domestically.
I will stop there. There are many other things I could go on about in this film. If I could make one more comment, I think that to some extent, VD treatment as a public health issue in the United States still resonates with lots of cultural values. This film enacts American attitudes toward appropriate sexual behavior and gender behavior in the early part of the 20th century.
For instance, in the handout today, it mentions that syphilis disproportionately affects African–Americans. My sense is, yes, that it does. I spent most of my medical career in public hospitals. It affects people who go to public hospitals disproportionately reported as having venereal diseases. One is required to report syphilis to the Centers for Disease Control. There's a mandatory reporting form. Public hospitals observe the forms. We have to. We operate under those kinds of rules for public institutions. Doctors don’t ordinarily fill out these forms for people who seek treatment from private physicians.
One can understand why, because there's mandatory contact tracing with syphilis. The public health department follows up and tries to find the sexual contacts, which create socially awkward situations. So in that sense, some things change, and for some things, there are long continuities.
Question: Doesn't this also bring up the present debate about AIDS — whether the doctor or the patient can give it to each other? Isn't the same thing happening here, since he got it from a patient? Couldn't he likewise give it to a patient if he bled during an operation? I was surprised to see him using plastic gloves during that operation. I thought wearing gloves didn't become standard procedure until recently because of AIDS.
Dr. Martensen: If I can respond to some of what you are saying. I'm glad you mentioned the gloves. Rubber gloves that were sufficiently pliable to do surgery were developed late in the 19th century. William Halstad was a major innovator in developing rubber gloves.
If you notice at the beginning of the film, the surgeon is not replacing his gloves between patients. He's sitting there with a cigarette in his mouth — standard operating room procedure. He’s holding his hands as though they are sterile. This would be a standard surgeon’s pose with sterile gloves, but they are not sterile. He goes and washes his hands and then moves to the next patient.
I'm assuming that's because it's a field hospital. They are losing the war. Everything is in short supply. He then breaks protocol. He takes off his gloves, presumably to have better tactile control of the instruments and gets cut.
The difference between that and how one works with AIDS patients, emergency patients, and working around bodily fluids is quite different today. We use universal precautions so that the transmission risk is minimal. HIV is also a more difficult disease to catch. It takes a larger dose of virus and a deeper penetration.
Question: How do you know that the penicillin works? It came out in the 1940s sometime? Did you just have the Wassermann test then? So how can you tell that syphilis is cured?
Dr. Martensen: That's a good question. Using the Wassermann test, you could not tell with every patient. You could tell in terms of cell culture. The doses of penicillin used initially were much, much lower than now. I think the current treatment dose is 2.4 million units. When penicillin was first used for the treatment of syphilis, I believe the standard dose was about 40 or 50,000 units. It likely killed very effectively in culture. The early dose determinations were done by its effect in cultures. But in terms of Wassermann, that’s a good question.
The spirochete Treponema doesn't seem to have much resistance to penicillin. Zithromicen (sold as Zithromax) is used as an oral therapy and also works in the treatment of syphilis.
Question: Given your recent comment that AIDS is much harder to transmit and that it takes a lot more effort for AIDS to transmit from person to person, is it possible that you can have a partner that doesn't catch what you have? Can a father have syphilis, but not the mother, and pass it to the child? Does it have to come through the mother?
Dr. Martensen: The question of whether there was paternal transmission was a very lively debate from the 1890s all the way through the period of this film. I did not read up on that point, so don't quote me. I think there is paternal transmission, but I'm not sure. I apologize for not having that information.
Question: I have a question. After watching this film, I wonder what you think about the doctor in the film. Do you think he's a responsible doctor, given that he did not take his situation seriously? Could he have taken the more direct approach to Nakata to make sure that he sought treatment immediately and directly?
Dr. Martensen: To answer your first question, did he take personal responsibility; I think he certainly behaved admirably towards this woman, who was the love of his life.
In terms of what happened during the war, I presume that conditions were awful and that he had no say over what he did.
His ethic is demonstrated at the end. He doesn't get the injection after the dramatic scene after he is about to. I assume that he is preoccupied with duty. Duty for him trumps everything. I imagine at times he neglected himself. Whether it was possible, whether Salvarsan was in all these field stations, who knows?
Dr. Cantor: I think there's a point in the movie where he actually mentions that he was unable to get Salvarsan at certain points because of where he was posted during the war. I think the message is that he wanted to take the drug but was unable to.
Question: I was thinking that since he knows he has the disease, should he continue practicing medicine or should he just give it up? It will definitely increase the chance of him infecting another patient.
Dr. Martensen: That is an interesting point, and they don't develop that in the film. Should he, for instance, disclose to his patients? You notice he doesn't tell his father. He doesn't tell his most intimate living connection that we're aware of. So it's a very lively question and it resonates back to HIV. Certainly that was a huge issue in the late ’80s and ’90s, particularly before there were effective antiretrovirals.
Question: I think that you said the film depicted American moral values and attitudes towards sex and the disease. I'm not sure that it depicts erroneously Japanese moral values and beliefs at that time. Could you touch on that?
Dr. Martensen: Japanese attitudes towards?
Question: Morality, sex, sexually transmitted diseases, premarital sex, and fidelity in the 1940s and previously?
Dr. Martensen: I'm not qualified to answer that.
Dr. Martensen: There's a very good book on Japanese attitudes towards abortion going from the 1880 period onward published by a professor at Harvard. I can give you the reference afterward because I have it with me.
Question: I'm recalling in the late 1940s and early 1950s when one went for a marriage license, you had to have a Wassermann test. What was done with that information, were you allowed to marry?
Dr. Martensen: You had to be treated then before you could be married. It varies by state law. Michigan was the first state in the late 19th century to even have a premarital exam. It was in the form of an interview with the prospective bridegroom. The woman would not be interviewed. It was presumed the woman was innocent and that the bridegroom was the one who needed to be watched. But now, in order to marry in states that require that, if you have a positive reaction to either of the two current tests — Rapid Plasma Reagin or Venereal Disease Research Laboratory — I believe that you have to have treatment before you can be legally married.
Question: I was wondering if you would care to comment on the Tuskegee experiment and whether or not the U.S. Public Health Service was involved.
Dr. Martensen: Tuskegee is a huge topic. I'd be happy to talk about it with you afterwards. The Tuskegee experiments were sponsored by the Public Health Service. They were initially started by the Rosenwald Foundation. The Public Health Service picked it up and made changes to the Rosenwald study. It started in 1934 and stopped in 1974. There's vast literature, but I am not an expert on the topic. I would be happy to talk with you afterwards, and Dr. Cantor may know much more about it.
Dr. Cantor: I'm not sure I know much more than you.
Question: I am curious about the way the baby was used and the woman was being protected or encouraged not to see the child in the film. The father was being encouraged to see the child. What would this child have looked like? Would they have looked horrendous?
Dr. Martensen: That’s the benefit of dramatic license. The babies can look normal and be infected. They can also have severe malformations, craniofacial malformations, as well as other cardiac malformations, etc.
Presumably, they’ve set the film up as if the fetus was dead. They pointed that out. Presumably, the baby had profound craniofacial malformations. We can assume this because of their reaction sound—you heard the man's scream.
Question: Without getting into the medical issues, but the film, it's questioned if it was a great film. I was one of the people that really liked the film, because the directing was wonderful and the acting was wonderful.
Dr. Cantor: I enjoyed it, too. This is a film shown very rarely on the big screen. It was a real treat to see it up there, although I think some of the acting is a little hammy at places.
Dr. Martensen: David is expressing his own views on this film.
Question: If you were to make this film today, how would you update it? You said it was censored in the period of 1949. How would it be made today?
Dr. Martensen: That’s a hypothetical. I love Kurosawa’s films, but I can't imagine how I would do it. First of all, if this film were made today, it probably wouldn't be about syphilis. Syphilis has disappeared from public concern. In this country, as well as in countries where it is prevalent, it is a real public health problem. The incidence is on the rise, and the incidence is in populations where there is a lot of unacknowledged same-sex behavior and unprotected sex.
Look at a state like North Carolina, for instance. North Carolina has one of the most rapidly ascending incidence rates of HIV. When those populations are looked at — those that are newly infected with HIV — they’re disproportionately African–Americans and Hispanic women. In both these groups, there's a very active culture of same sex between men. I don't know what Kurosawa would do with that.
Question: Simple current medical question. Is syphilis at all like some of the other diseases that are developing medically resistant varieties; is that a public health problem?
Dr. Martensen: No, it's not. We use the same antibiotic for syphilis that we used 60 years ago. There are very few infections for which that's true. Resistance is not an issue.
Dr. Fuchs: It’s been a long time since I had seen this film, and I had actually forgotten about the discussion about Salvarsan. We've had three films in our series now that have focused mainly on syphilis. We actually did a film a few years ago, Miss Evers’ Boys, which focused on the Tuskegee incident. So you touched a little bit on this issue of the role of syphilis in public consciousness. So would any of you want to make any more observations about that and how that's changed?
Dr. Cantor: How has it changed?
Dr. Martensen: I think it's been supplanted in a mild way by herpes and in a much more consequential way by HIV. Herpes is ubiquitous. Seventy to eighty percent of adults carry it. So I think that that has really supplanted it. Rates for gonorrhea are increasing more rapidly than syphilis. It's not in the imagination, either.
Dr. Fuchs: You kind of answered part of my question. Though it has kind of disappeared from the public consciousness, is that realistic? For a while it was just taken in a blasé way, as though a little bit of penicillin would easily cure it, but then I read it's not so easily cured. So what is the reality of syphilis in this country? Not the public awareness.
Dr. Martensen: Your question is a good one, and it deserves an answer from a public health expert on syphilis. The reality is that much syphilis goes unreported because the surveillance mechanism only really effectively captures people who come before publicly funded healthcare facilities. The second reality is that unless there's a pretty vigorous awareness campaign, which there isn't anymore; people may just assume it's a sore and let it go. And lo and behold, it goes away and they think, That's not something I need to pay attention to.
So the public health education effort has fallen off fairly dramatically about Gonococcus syphilis. It's moved toward herpes, Chlamydia, and some other things.
Dr. Fuchs: I also wanted to ask about the education of young people. I have seen students come to the library with assignments on sexually transmitted diseases (STDs) in general. I don't know whether you have seen any improvement in education of young people.
Dr. Martensen: I'm not qualified to answer. I think that one of the best public education tools for the young is the Internet because the information is so accessible. That is where young people are finding their information. The information on the Internet about STDs is very good. If you just hit syphilis or Gonococcus on Google, you get very good information. My hunch is they're not going to public libraries. They are probably looking on their computers in the privacy of their rooms or their handhelds.
Dr. Fuchs: A brief observation about in-school information and how that varies dramatically by school district across this country. We have 16,000 or so different school districts in this nation. In some areas, information about human sexuality and STDs is part of the curriculum. In other areas, teachers are all but forbidden to mention it. So it varies dramatically.
Before I ask you to help me thank our guests, I'll invite you back next week, when we're going to watch the 2007 film “Life Support.” This is about an HIV-positive woman who struggles to overcome her drug addiction and dedicates herself to fighting against HIV infection in the African-American community. Our speaker will be Dr. Lauren Wood, from the U.S. Public Health Service, Vaccine Branch, at the National Cancer Institute.
So please help me thank Drs. Martensen and Cantor for their observations. |
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