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+The Project Gutenberg EBook of The Third Great Plague, by John H. Stokes
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: The Third Great Plague
+       A Discussion of Syphilis for Everyday People
+
+Author: John H. Stokes
+
+Release Date: May 6, 2006 [EBook #18324]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK THE THIRD GREAT PLAGUE ***
+
+
+
+
+Produced by Audrey Longhurst, LN Yaddanapudi and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+file was produced from images from the Home Economics
+Archive: Research, Tradition and History, Albert R. Mann
+Library, Cornell University)
+
+
+
+
+
+
+
+
+
+
+The Third Great Plague
+
+A Discussion of Syphilis
+for Everyday People
+
+By
+
+John H. Stokes, A.B., M.D.
+
+Chief of the Section of Dermatology and Syphilology
+The Mayo Clinic, Rochester, Minnesota
+
+Assistant Professor of Medicine
+The Mayo Foundation Graduate School of the University
+of Minnesota
+
+
+Philadelphia and London
+W. B. Saunders Company
+1920
+
+
+
+
+Published, November, 1917
+
+Copyright, 1917, by W. B. Saunders Company
+
+Reprinted July, 1918
+
+Reprinted February, 1920
+
+
+PRINTED IN AMERICA
+
+
+
+
+PREFACE
+
+
+The struggle of man against his unseen and silent enemies, the lower or
+bacterial forms of life, once one becomes alive to it, has an
+irresistible fascination. More dramatic than any novel, more sombre and
+terrifying than a battle fought in the dark, would be the intimate
+picture of the battle of our bodies against the hosts of disease. If we
+could see with the eye of the microscope and feel and hear with the
+delicacy of chemical and physical interactions between atoms, the heat
+and intensity and the savage relentlessness of that battle would blot
+out all perception of anything but itself. Just as there are sounds we
+cannot hear, and light we cannot see, so there is a world of small
+things, living in us and around us, which sways our destiny and carries
+astray the best laid schemes of our wills and personalities. The gradual
+development of an awareness, a realization of the power of this world of
+minute things, has been the index of progress in the bodily well-being
+of the human race through the centuries marking the rebirth of medicine
+after the sleep of the Dark Ages.
+
+In these days of sanitary measures and successful public health
+activity, it is becoming more and more difficult for us to realize the
+terrors of the Black Plagues, the devastation, greater and more
+frightful than war, which centuries ago swept over Europe and Asia time
+and again, scarcely leaving enough of the living to bury the dead.
+Cholera, smallpox, bubonic plague, with terrifying suddenness fell upon
+a world of ignorance, and each in turn humbled humanity to the dust
+before its invisible enemies. Even within our own recollection, the
+germ of influenza, gaining a foothold inside our defenses, took the
+world by storm, and beginning probably at Hongkong, within the years
+1889-90, swept the entire habitable earth, affecting hundreds of
+thousands of human beings, and leaving a long train of debilitating and
+even crippling complications.
+
+Here and there through the various silent battles between human beings
+and bacteria there stand out heroic figures, men whose powers of mind
+and gifts of insight and observation have made them the generals in our
+fight against the armies of disease. But their gifts would have been
+wasted had they lacked the one essential aid without which leadership is
+futile. This is the force of enlightened public opinion, the backing of
+the every-day man. It is the cooeperation of every-day men, acting on the
+organized knowledge of leaders, which has made possible the virtual
+extinction of the ancient scourges of smallpox, cholera, and bubonic
+plague.
+
+Just as certain diseases are gradually passing into history through
+human effort, and the time is already in sight when malaria and yellow
+fever, the latest objects of attack, will disappear before the campaign
+of preventive medicine, so there are diseases, some of them ancient,
+others of more recent recognition, which are gradually being brought
+into the light of public understanding. Conspicuous among them is a
+group of three, which, in contrast to the spectacular course of great
+epidemics, pursue their work of destruction quietly, slowly undermining,
+in their long-drawn course, the very foundations of human life.
+Tuberculosis, or consumption, now the best known of the three, may
+perhaps be called the first of these great plagues, not because it is
+the oldest or the most wide-spread necessarily, but because it has been
+the longest known and most widely understood by the world at large.
+Cancer, still of unknown cause, is the second great modern plague. The
+third great plague is syphilis, a disease which, in these times of
+public enlightenment, is still shrouded in obscurity, entrenched behind
+a barrier of silence, and armed, by our own ignorance and false shame,
+with a thousand times its actual power to destroy. Against all of these
+three great plagues medicine has pitted the choicest personalities, the
+highest attainments, and the uttermost resources of human knowledge.
+Against all of them it has made headway. It is one of the ironies, the
+paradoxes, of fate that the disease against which the most tremendous
+advances have been made, the most brilliant victories won, is the third
+great plague, syphilis--the disease that still destroys us through our
+ignorance or our refusal to know the truth.
+
+We have crippled the power of tuberculosis through
+knowledge,--wide-spread, universal knowledge,--rather than through any
+miraculous discoveries other than that of the cause and the possibility
+of cure. We shall in time obliterate cancer by the same means. Make a
+disease a household word, and its power is gone. We are still far from
+that day with syphilis. The third great plague is just dawning upon
+us--a disease which in four centuries has already cost a whole inferno
+of human misery and a heaven of human happiness. When we awake, we shall
+in our turn destroy the destroyer--and the more swiftly because of the
+power now in the hands of medicine to blot out the disease. To the day
+of that awakening books like this are dedicated. The facts here
+presented are the common property of the medical profession, and it is
+impossible to claim originality for their substance. Almost every
+sentence is written under the shadow of some advance in knowledge which
+cost a life-time of some man's labor and self-sacrifice. The story of
+the conquest of syphilis is a fabric of great names, great thoughts,
+dazzling visions, epochal achievements. It is romance triumphant, not
+the tissue of loathsomeness that common misconception makes it.
+
+The purpose of this book is accordingly to put the accepted facts in
+such a form that they will the more readily become matters of common
+knowledge. By an appeal to those who can read the newspapers
+intelligently and remember a little of their high-school physiology, an
+immense body of interested citizens can be added to the forces of a
+modern campaign against the third great plague. For such an awakening of
+public opinion and such a movement for wider cooeperation, the times are
+ready.
+
+JOHN H. STOKES.
+
+ROCHESTER, MINN.
+
+
+
+
+CONTENTS
+
+                                                       PAGE
+CHAPTER I
+THE HISTORY OF SYPHILIS                                  11
+
+CHAPTER II
+SYPHILIS AS A SOCIAL PROBLEM                             15
+
+CHAPTER III
+THE NATURE AND COURSE OF SYPHILIS                        21
+  The Prevalence of Syphilis                             24
+  The Primary Stage                                      26
+
+CHAPTER IV
+THE NATURE AND COURSE OF SYPHILIS (_Continued_)          35
+  The Secondary Stage                                    35
+
+CHAPTER V
+THE NATURE AND COURSE OF SYPHILIS (_Continued_)          45
+  Late Syphilis (Tertiary Stage)                         45
+
+CHAPTER VI
+THE BLOOD TEST FOR SYPHILIS                              54
+
+CHAPTER VII
+THE TREATMENT OF SYPHILIS                                60
+  General Considerations                                 60
+  Mercury                                                62
+
+CHAPTER VIII
+THE TREATMENT OF SYPHILIS (_Continued_)                  70
+  Salvarsan                                              70
+
+CHAPTER IX
+THE CURE OF SYPHILIS                                     80
+
+CHAPTER X
+HEREDITARY SYPHILIS                                      92
+
+CHAPTER XI
+THE TRANSMISSION AND HYGIENE OF SYPHILIS                109
+
+CHAPTER XII
+THE TRANSMISSION AND HYGIENE OF SYPHILIS (_Continued_)  121
+  The Control of Infectiousness in Syphilis             121
+  Syphilis and Marriage                                 125
+
+CHAPTER XIII
+THE TRANSMISSION AND HYGIENE OF SYPHILIS (_Continued_)  133
+  Syphilis and Prostitution                             133
+  Personal Hygiene of Syphilis                          136
+
+CHAPTER XIV
+MENTAL ATTITUDES IN THEIR RELATION TO SYPHILIS          141
+
+CHAPTER XV
+MORAL AND PERSONAL PROPHYLAXIS                          156
+
+CHAPTER XVI
+PUBLIC EFFORT AGAINST SYPHILIS                          164
+
+INDEX                                                   187
+
+
+
+
+LIST OF ILLUSTRATIONS
+
+                                                       PAGE
+PAUL EHRLICH [1854-1915]                                 69
+
+FRITZ SCHAUDINN [1871-1906]                             112
+
+E. ROUX                                                 161
+
+ELIE METCHNIKOFF [1845-1916]                            161
+
+
+
+
+The Third Great Plague
+
+Chapter I
+
+The History of Syphilis
+
+
+Syphilis has a remarkable history,[1] about which it is worth while to
+say a few words. Many people think of the disease as at least as old as
+the Bible, and as having been one of the conditions included under the
+old idea of leprosy. Our growing knowledge of medical history, however,
+and the finding of new records of the disease, have shown this view to
+be in all probability a mistake. Syphilis was unknown in Europe until
+the return of Columbus and his sailors from America, and its progress
+over the civilized world can be traced step by step, or better, in leaps
+and bounds, from that date. It came from the island of Haiti, in which
+it was prevalent at the time the discoverers of America landed there,
+and the return of Columbus's infected sailors to Europe was the signal
+for a blasting epidemic, which in the sixteenth and seventeenth
+centuries devastated Spain, Italy, France, and England, and spread into
+India, Asia, China, and Japan.
+
+    [1] For a detailed account in English, see Pusey, W. A.: "Syphilis
+    as a Modern Problem," Amer. Med. Assoc., 1915.
+
+It is a well-recognized fact that a disease which has never appeared
+among a people before, when it does attack them, spreads with
+terrifying rapidity and pursues a violent and destructive course on the
+new soil which they offer. This was the course of syphilis in Europe in
+the years immediately following the return of Columbus in 1493. Invading
+armies, always a fruitful means of spreading disease, carried syphilis
+with them everywhere and left it to rage unchecked among the natives
+when the armies themselves went down to destruction or defeat. Explorers
+and voyagers carried it with them into every corner of the earth, so
+that it is safe to say that in this year of grace 1917 there probably
+does not exist a single race or people upon whom syphilis has not set
+its mark. The disease, in four centuries, coming seemingly out of
+nowhere, has become inseparably woven into the problems of civilization,
+and is part and parcel of the concerns of every human being. The
+helpless fear caused by the violence of the disease in its earlier days,
+when the suddenness of its attack on an unprepared people paralyzed
+comprehension, has given place to knowledge such as we can scarcely
+duplicate for any of the other scourges of humanity. The disease has in
+its turn become more subtle and deceiving, its course is seldom marked
+by the bold and glaring destructiveness, the melting away of resistance,
+so familiar in its early history. The masses of sores, the literal
+falling to pieces of skeletons, are replaced by the inconspicuous but no
+less real deaths from heart and brain and other internal diseases, the
+losses to sight and hearing, the crippling and death of children, and
+all the insidious, quiet deterioration and degeneration of our fiber
+which syphilis brings about. From devouring a man alive on the street,
+syphilis has taken to knifing him quietly in his bed.
+
+Although syphilis sprang upon the world from ambush, so to speak, it did
+the world one great service--it aroused Medicine from the sleep of the
+Middle Ages. Many of the greatest names in the history of the art are
+inseparably associated with the progress of our knowledge of this
+disease. As Pusey points out, it required the force of something wholly
+unprecedented to take men away from tradition and the old stock in trade
+of ideas and formulas, and to make them grasp new things. Syphilis was
+the new thing of the time in the sixteenth century and the study which
+it received went far toward putting us today in a position to control
+it. Before the beginning of the twentieth century almost all that
+ordinary observation of the diseased person could teach us was known of
+syphilis. It needed only laboratory study, such as has been given it
+during the past fifteen years, to put us where we could appeal to every
+intelligent man and woman to enlist in a brilliantly promising campaign.
+For a time syphilis was confused with gonorrhea, and there could be no
+better proof of the need for separating the two in our minds today than
+to study the way in which this confusion set back progress in our
+knowledge of syphilis. John Hunter, who fathered the idea of the
+identity of the two diseases, sacrificed his life to his idea
+indirectly. Ricord, a Frenchman, whose name deserves to be immortal, set
+Hunter's error right, and as the father of modern knowledge of syphilis,
+prepared us for the revolutionary advances of the last ten years.
+
+There is something awe-inspiring in the quiet way in which one great
+victory has succeeded another in the battle against syphilis in the last
+decade. If we are out of the current of these things, in the office or
+the store, or in the field of industry and business, announcements from
+the great laboratories of the world seldom reach us, and when they do,
+they have an impractical sound, an unreality for us. So one hears, as if
+in a speaking-tube from a long distance, the words that Schaudinn and
+Hoffmann, on April 19, 1905, discovered the germ that causes syphilis,
+not realizing that the fact contained in those few brief words can alter
+the undercurrent of human history, and may, within the lives of our
+children and our children's children, remake the destiny of man on the
+earth. A great spirit lives in the work of men like Metchnikoff and Roux
+and Maisonneuve, who made possible the prophylaxis of syphilis, in that
+of Bordet and Wassermann, who devised the remarkable blood test for the
+disease, and in that of Ehrlich and Hata, who built up by a combination
+of chemical and biological reasoning, salvarsan, one of the most
+powerful weapons in existence against it. Ehrlich conceived the whole
+make-up and properties of salvarsan when most of us find it a hardship
+to pronounce its name. Schaudinn saw with the ordinary lenses of the
+microscope in the living, moving germ, what dozens can scarcely see
+today with the germ glued to the spot and with all the aid of stains and
+dark-field apparatus. After all, it is brain-power focused to a point
+that moves events, and to the immensity of that power the history of our
+growing knowledge of syphilis bears the richest testimony.
+
+
+
+
+Chapter II
+
+Syphilis as a Social Problem
+
+
+The simple device of talking plain, matter-of-fact English about a thing
+has a value that we are growing to appreciate more and more every day.
+It is only too easy for an undercurrent of ill to make headway under
+cover of a false name, a false silence, or misleading speech. The fact
+that syphilis is a disease spread to a considerable extent by sexual
+relations too often forces us into an attitude of veiled insinuation
+about it, a mistaken delicacy which easily becomes prudish and
+insincere. It is a direct move in favor of vulgar thinking to misname
+anything which involves the intimacies of life, or to do other than look
+it squarely in the eye, when necessity demands, without shuffling or
+equivocation. On this principle it is worth while to meet the problem of
+a disease like syphilis with an open countenance and straightforward
+honesty of expression. It puts firm ground under our feet to talk about
+it in the impersonal way in which we talk about colds and pneumonia and
+bunions and rheumatism, as unfortunate, but not necessarily indecent,
+facts in human experience. Nothing in the past has done so much for the
+campaign against consumption as the unloosing of tongues. There is only
+one way to understand syphilis, and that is to give it impartial,
+discriminating discussion as an issue which concerns the general
+health. To color it up and hang it in a gallery of horrors, or to befog
+it with verbal turnings and twistings, are equally serious mistakes. The
+simple facts of syphilis can appeal to intelligent men and women as
+worthy of their most serious attention, without either stunning or
+disgusting them. It is in the unpretentious spirit of talking about a
+spade as a spade, and not as "an agricultural implement for the
+trituration of the soil," that we should take stock of the situation and
+of the resources we can muster to meet it.
+
++The Confusion of the Problem of Syphilis with Other Issues.+--Two
+points in our approach to the problem of syphilis are important at the
+outset. The first of these is to separate our thought about syphilis
+from that of the other two diseases, gonorrhea, or "clap," and
+chancroids, or "soft sores," which are conventionally linked with it
+under the label of "venereal diseases."[2] The second is to separate
+the question of syphilis at least temporarily from our thought about
+morals, from the problem of prostitution, from the question as to
+whether continence is possible or desirable, whether a man should be
+true to one woman, whether women should be the victims of a double
+standard, and all the other complicated issues which we must in time
+confront. Such a picking to pieces of the tangle is simply the method of
+scientific thought, and in this case, at least, has the advantage of
+making it possible to begin to do something, rather than saw the air
+with vain discussion.
+
+    [2] The three so-called venereal diseases are syphilis, gonorrhea,
+    and chancroid or soft ulcer. Gonorrhea is the commonest of the
+    three, and is an exceedingly prevalent disease. In man its first
+    symptom is a discharge of pus from the canal through which the urine
+    passes. Its later stages may involve the bladder, the testicles, and
+    other important glands. It may also produce crippling forms of
+    rheumatism, and affect the heart. Gonorrhea may recur, become
+    latent, and persist for years, doing slow, insidious damage. It is
+    transmitted largely by sexual intercourse. Gonorrhea in women is
+    frequently a serious and even fatal disease. It usually renders
+    women incapable of having children, and its treatment necessitates
+    often the most serious operations. Gonorrhea of the eyes, affecting
+    especially newborn children, is one of the principal causes of
+    blindness. Gonorrhea may be transmitted to little girls innocently
+    from infected toilet seats, and is all but incurable. Gonorrhea,
+    wherever it occurs, is an obstinate, treacherous, and resistant
+    disease, one of the most serious of modern medical problems, and
+    fully deserves a place as the fourth great plague.
+
+    Chancroid is an infectious ulcer of the genitals, local in
+    character, not affecting the body as a whole, but sometimes
+    destroying considerable portions of the parts involved.
+
+Let us think of syphilis, then, as a serious but by no means hopeless
+constitutional disease. Dismiss chancroid as a relatively insignificant
+local affair, seldom a serious problem under a physician's care.
+Separate syphilis from gonorrhea for the reason that gonorrhea is a
+problem in itself. Against its train of misfortune to innocence and
+guilt alike, we are as yet not nearly so well equipped to secure
+results. Against syphilis, the astonishing progress of our knowledge in
+the past ten years has armed us for triumph. When the fight against
+tuberculosis was brought to public attention, we were not half so well
+equipped to down the disease as we are today to down syphilis. For
+syphilis we now have reliable and practical methods of prevention, which
+have already proved their worth. The most powerful and efficient of
+drugs is available for the cure of the disease in its earlier stages,
+and early recognition is made possible by methods whose reliability is
+among the remarkable achievements of medicine. It is the sound opinion
+of conservative men that if the knowledge now in the hands of the
+medical profession could be put to wide-spread use, syphilis would
+dwindle in two generations from the unenviable position of the third
+great plague to the insignificance of malaria and yellow fever on the
+Isthmus of Panama. The influences that stand between humanity and this
+achievement are the lack of general public enlightenment on the disease
+itself, and public confusion of the problem with other sex issues for
+which no such clean-cut, satisfactory solution has been found. Think of
+syphilis as the wages of sin, as well-earned disgrace, as filth, as the
+badge of immorality, as a necessary defense against the loathesomeness
+of promiscuity, as a fearful warning against prostitution, and our
+advantage slips from us. The disease continues to spread wholesale
+disaster and degeneration while we wrangle over issues that were old
+when history began and are progressing with desperate slowness to a
+solution probably many centuries distant. Think of syphilis as a medical
+and a sanitary problem, and its last line of defense crumbles before our
+attack. It can and should be blotted out.
+
++Syphilis, a Problem of Public Health Rather than of Morals.+--Nothing
+that can be said about syphilis need make us forget the importance of
+moral issues. The fact which so persistently distorts our point of view,
+that it is so largely associated with our sexual life, is probably a
+mere incident, biologically speaking, due in no small part to the almost
+absurdly simple circumstance that the germ of the disease cannot grow in
+the presence of air, and must therefore find refuge, in most cases, in
+the cavities and inlets from the surface of the body. History affords
+little support to the lingering belief that if syphilis is done away
+with, licentiousness will overrun the world. Long before syphilis
+appeared in Europe there was sexual immorality. In the five centuries in
+which it has had free play over the civilized world, the most optimistic
+cannot successfully maintain that it has materially bettered conditions
+or acted as a check on loose morals, though its relation to sexual
+intercourse has been known. As a morals policeman, syphilis can be
+obliterated without material loss to the cause of sexual self-restraint,
+and with nothing but gain to the human race.
+
+It is easier to accept this point of view, that the stamping out of
+syphilis will not affect our ability to grapple with moral problems, and
+that there is nothing to be gained by refusing to do what can so easily
+be done, when we appreciate the immense amount of innocent suffering for
+which the disease is responsible. It must appeal to many as a bigoted
+and narrow virtue, little better than vice itself, which can derive any
+consolation in the thought that the sins of the fathers are being
+visited upon the children, as it watches a half-blind, groping child
+feel its way along a wall with one hand while it shields its face from
+the sunlight with the other. There are better ways of paying the wages
+of sin than this. Best of all, we can attack a sin at its source instead
+of at its fulfilment. How much better to have kept the mother free from
+syphilis by giving the father the benefit of our knowledge. The child
+who reaped his sowing gained nothing morally, and lost its physical
+heritage. Its mother lost her health and perhaps her self-respect.
+Neither one contributes anything through syphilis to the uplifting of
+the race. They are so much dead loss. To teach us to avoid such losses
+is the legitimate field of preventive medicine.
+
+On this simplified and practical basis, then, the remainder of this
+discussion will proceed. Syphilis is a preventable disease, usually
+curable when handled in time, and its successful management will depend
+in large part upon the cooeperation, not only of those who are victims of
+it, but of those who are not. It is much more controllable than
+tuberculosis, against which we are waging a war of increasing
+effectiveness, and its stamping out will rid humanity of an even greater
+curse. To know about syphilis is in no sense incompatible with clean
+living or thinking, and insofar as its removal from the world will rid
+us of a revolting scourge, it may even actually favor the solution of
+the moral problems which it now obscures.
+
+
+
+
+Chapter III
+
+The Nature and Course of Syphilis
+
+
+The simplest and most direct definition of syphilis is that it is a
+contagious constitutional disease, due to a germ, running a prolonged
+course, and at one time or another in that course is capable of
+affecting nearly every part of the body. One of the most important parts
+of this rather abstract statement is that which relates to the germ. To
+be able to put one's finger so definitely on the cause of syphilis is an
+advantage which cannot be overestimated. More than in almost any other
+disease the identification of syphilis at its very outset depends upon
+the seeing of the germ that causes it in the discharge from the sore or
+pimple which is the first evidence of syphilis on the body. On our
+ability to recognize the disease as syphilis in the first few days of
+its course depends the greatest hope of cure. On the recognition of the
+germ in the tissues and fluids of the body has depended our knowledge of
+the real extent and ravages of the disease. With the knowledge that the
+germ was related to certain other more familiar forms, Ehrlich set the
+trap for it that culminated in salvarsan, or "606," the powerful drug
+used in the modern treatment. By the finding of this same germ in the
+nervous system in locomotor ataxia and general paralysis of the insane,
+the last lingering doubt of their syphilitic character was dispelled.
+Every day and hour the man who deals with syphilis in accordance with
+the best modern practice brings to bear knowledge that arises from our
+knowledge of the germ cause of syphilis. No single fact except perhaps
+the knowledge that certain animals (monkeys and rabbits especially)
+could be infected with it has been of such immense practical utility in
+developing our power to deal with it.
+
+The germ of syphilis,[3] discovered by Schaudinn and Hoffmann in 1905,
+is an extremely minute spiral or corkscrew-shaped filament, visible
+under only the highest powers of the microscope, which increase the area
+of the object looked at hundreds of thousands of times, and sometimes
+more than a million of times. Even under such intense magnifications, it
+can be seen only with great difficulty, since it is colorless in life,
+and it is hard to color or stain it with dyes. Its spiral form and faint
+staining have led to its being called the _Spirochaeta pallida_.[4] It is
+best seen by the use of a special device, called a dark-field
+illuminator, which shows the germ, like a floating particle in a
+sunbeam, as a brilliant white spiral against a black background,
+floating and moving in the secretions taken from the sore in which it is
+found. Some means of showing the germ should be in the hands of every
+physician, hospital, or dispensary which makes a claim to recognize and
+treat syphilis.
+
+    [3] See frontispiece.
+
+    [4] Pronounced spi-ro-kee'-ta.
+
++Syphilis a Concealed Disease.+--Syphilis is not a grossly conspicuous
+figure in our every-day life, as leprosy was in the life of the Middle
+Ages, for example. To the casually minded, therefore, it is not at all
+unreasonable to ask why there should be so much agitation about it when
+so little of it is in evidence. It takes a good deal out of the graphic
+quality of the thing to say that most syphilis is concealed, that most
+syphilitics, during a long period of their disease, are socially
+presentable. Of course, when we hear that they may serve lunch to us,
+collect our carfare, manicure our nails, dance with us most
+enchantingly, or eat at our tables, it seems a little more real, but
+still a little too much to believe. Conviction seems to require that we
+see the damaged goods, the scars, the sores, the eaten bones, the
+hobbling cripples, the maimed, the halt, and the blind. There is no
+accurate estimate of its prevalence based on a census, because, as will
+appear later, even an actual impulse to self-betrayal would not disclose
+30 to 40 per cent of the victims of the disease. Approximately this
+percentage would either have forgotten the trivial beginnings of it, or
+with the germs of it still in their brains or the walls of their
+arteries or other out-of-the-way corners of their bodies, would think
+themselves free of the disease--long since "cured" and out of danger.
+
++How Much Syphilis is There?+--Our entire lack of a tangible idea of how
+much syphilis there really is among us is, of course, due to the absence
+of any form of registration or reporting of the disease to authorities
+such as health officers, whose duty it is to collect such statistics,
+and forms the principal argument in favor of dealing with syphilis
+legally as a contagious disease. Such conceptions of its prevalence as
+we have are based on individual opinions and data collected by men of
+large experience.
+
++Earlier Estimates of the Prevalence of Syphilis.+--It is generally
+conceded that there is more syphilis among men than women, although it
+should not be forgotten that low figures in women may be due to some
+extent to the milder and less outspoken course of the disease in them.
+Five times more syphilis in men than women conservatively summarizes our
+present conceptions. The importance of distinguishing between syphilis
+among the sick and among the well is often overlooked. For example,
+Landouzy, in the Laennec clinic in Paris, estimated recently that in the
+patients of this clinic, which deals with general medicine, 15 to 18 per
+cent of the women and 21 to 28 per cent of the men had syphilis. It is
+fair to presume, then, that such a percentage would be rather high for
+the general run of every-day people. This accords with the estimates,
+based on large experience, of such men as Lenoir and Fournier, that 13
+to 15 per cent of all adult males in Paris have syphilis. Erb estimated
+12 per cent for Berlin, and other estimates give 12 per cent for London.
+Collie's survey of British working men gives 9.2 per cent in those who,
+in spite of having passed a general health examination, showed the
+disease by a blood test. A large body of figures, covering thirty years,
+and dating back beyond the time when the most sensitive tests of the
+disease came into use, gives about 8 per cent of more than a million
+patients in the United States Public Health and Marine Hospital Service
+as having syphilis. It should be recalled that this includes essentially
+active rather than quiescent cases, and is therefore probably too low.
+
++Current Estimates of the Prevalence of Syphilis.+--The constant upward
+tendency of recent estimates of the amount of syphilis in the general
+population, as a result of the application of tests which will detect
+even concealed or quiescent cases, is a matter for grave thought. The
+opinion of such an authority as Blaschko, while apparently extreme,
+cannot be too lightly dismissed, when he rates the percentage of
+syphilitics in clerks and merchants in Berlin between the ages of 18 and
+28 as 45 per cent. Pinkus estimated that one man in five in Germany has
+had syphilis. Recently published data by Vedder, covering the condition
+of recruits drawn to the army from country and city populations,
+estimate 20 per cent syphilitics among young men who apply for
+enlistment, and 5 per cent among the type of young men who enter West
+Point and our colleges. It can be pointed out also with justice that the
+percentage of syphilis in any class grouped by age increases with the
+age, since so few of the cases are cured, and the number is simply added
+to up to a certain point as time elapses. Even the army, which
+represents in many ways a filtered group of men, passing a rigorous
+examination, and protected by an elaborate system of preventions which
+probably keeps the infection rate below that of the civil population, is
+conceded by careful observers (Nichols and others) to show from 5 to 7
+per cent syphilitics. Attention should be called to the difference
+between the percentage of syphilis in a population and the percentage
+of venereal disease. The inclusion of gonorrhea with syphilis increases
+the percentages enormously, since it is not infrequently estimated that
+as high as 70 per cent of adult males have gonorrhea at least once in a
+lifetime.
+
+On the whole, then, it is conservative to estimate that one man in ten
+has syphilis. Taking men and women together on the basis of one of the
+latter to five of the former, and excluding those under fifteen years of
+age from consideration, this country, with a population of
+91,972,266,[5] should be able to muster a very considerable army of
+3,842,526, whose influence can give a little appreciated but very
+undesirable degree of hyphenation to our American public health. In
+taking stock of ourselves for the future, and in all movements for
+national solidarity, efficiency, and defense, we must reckon this force
+of syphilo-Americans among our debits.
+
+    [5] Figures based on 1910 census.
+
+
+THE PRIMARY STAGE OF SYPHILIS
+
++The So-called Stages of Syphilis.+--The division of the course of
+syphilis into definite stages is an older and more arbitrary conception
+than the one now developing, and was based on outward signs of the
+disease rather than on a real understanding of what goes on in the body
+during these periods. The primary stage was supposed to extend from the
+appearance of the first sore or chancre to the time when an eruption
+appeared over the whole body. Since the discovery of the Spirochaeta
+pallida, the germ of the disease, our knowledge of what the germ does
+in the body, where it goes, and what influence it has upon the infected
+individual, has rapidly extended. We now appreciate much more fully than
+formerly that at the very beginning of the disease there is a time when
+it is almost purely local, confined to the first sore itself, and
+perhaps to the glands or kernels in its immediate neighborhood. Thorough
+and prompt treatment with the new and powerful aid of salvarsan ("606")
+at this stage of the disease can kill all the germs and prevent the
+disease from getting a foothold in the body which only years of
+treatment subsequently can break. This is the critical moment of
+syphilis for the individual and for society, and its importance and the
+value of treatment at this time cannot be too widely understood.
+
++Peculiarities of the Germ.+--Many interesting facts about the
+Spirochaeta pallida explain peculiarities in the disease of which it is
+the cause. Many germs can be grown artificially, some in the presence of
+air, others only when air is removed. The germ of syphilis belongs in
+the latter class. The germ that causes tuberculosis, a rod-like organism
+or bacillus, can stand drying without losing its power to produce the
+disease, and has a very appreciable ability to resist antiseptic agents.
+If the germ of syphilis were equally hard to kill, syphilis would be an
+almost universal disease. Fortunately it dies at once on drying, and is
+easily destroyed by the weaker antiseptics provided it has not gained a
+foothold on favorable ground. Its inability to live long in the presence
+of air confines the source of infection largely to those parts of the
+body which are moist and protected, and especially to secretions and
+discharges which contain it. Its contagiousness is, therefore, more
+readily controlled than that of tuberculosis. It is impossible for a
+syphilitic to leave a room or a house infected for the next occupants,
+and it is not necessary to do more than disinfect objects that come in
+contact with open lesions or their secretions, to prevent its spread by
+indirect means. Such details will be considered more fully under the
+transmission and hygiene of the disease.
+
++Mode of Entry of the Germ.+--The germ of the disease probably gains
+entrance to the body through a break or abrasion in the skin or the
+moist red mucous surfaces of the body, such as those which line the
+mouth and the genital tract. The break in the surface need not be
+visible as a chafe or scratch, but may be microscopic in size, so that
+the first sore seems to develop on what is, to all appearances, healthy
+surface. It should not be forgotten that this surface need not be
+confined to the genital organs, since syphilis may and often does begin
+at any part of the body where the germ finds favorable conditions for
+growth.
+
++Incubation or Quiescent Period.+--Almost all germ diseases have what is
+called a period of incubation, in which the germ, after it has gained
+entrance to the body, multiplies with varying rapidity until the
+conditions are such that the body begins to show signs of the injury
+which their presence is causing. The germ of syphilis is no exception to
+this rule. Its entry into the body is followed by a period in which
+there is no external sign of its presence to warn the infected person
+of what is coming. This period of quiescence between the moment of
+infection with syphilis and the appearance of the first signs of the
+disease in the form of the chancre may vary from a week to six weeks or
+even two months or more, with an average of about two or three weeks.
+
+In the length of the incubation period and the comparatively trifling
+character of the early signs, the germ of syphilis betrays one of its
+most dangerous characteristics. The germ of pneumonia, for example, may
+be present on the surface of the body, in the mouth or elsewhere, for a
+long time, but the moment it gets a real foothold, there is an immediate
+and severe reaction, the body puts up a fight, and in ten days or so has
+either lost or won. The germ of syphilis, on the other hand, secures its
+place in the body without exciting very strenuous or wide-spread
+opposition. The body does not come to its own defense so well as with a
+more active enemy. The fitness of the germ of syphilis for
+long-continued life in the body, and the difficulty of marshaling a
+sufficient defense against it, is what makes it impossible to cure the
+disease by any short and easy method.
+
++The First Sore or Chancre.+--The primary lesion, first sore or
+chancre,[6] is the earliest sign of reaction which the body makes to the
+presence of the growing germs of syphilis. This always develops at the
+point where the germs entered the body. The incubation period ends with
+the appearance of a small hard knot or lump under the skin, which may
+remain relatively insignificant in some cases and in others grow to a
+considerable size. Primary lesions show the greatest variety in their
+appearance and degree of development. If the base of the knot widens and
+flattens so that it feels and looks like a button under the skin, and
+the top rubs off, leaving an exposed raw surface, we may have the
+typical hard chancre, easily recognized by the experienced physician,
+and perhaps even by the layman as well. On the other hand, no such
+typical lesion may develop. The chancre may be small and hidden in some
+out-of-the-way fold or cleft, and because it is apt to be painless,
+escape recognition entirely. In women the opportunity for concealment of
+a primary sore itself is especially good, since it may occur inside the
+vagina or on the neck of the womb. In men it may even occur inside the
+canal through which the urine passes (urethra). The name "sore" is
+deceptive and often misleads laymen, since there may be no actual
+sore--merely a pinhead-sized pimple, a hard place, or a slight chafe.
+The development of a syphilitic infection can also be completely
+concealed by the occurrence of some other infection in the same place at
+the same time, as in the case of a mixed infection with syphilis and
+soft ulcers or chancroids. Even a cold-sore on the mouth or genitals may
+become the seat of a syphilitic infection which will be misunderstood or
+escape notice.
+
+    [6] Pronounced shan'-ker.
+
++Syphilis and Gonorrhea may Coexist.+--It is a not uncommon thing for
+gonorrhea in men to hide the development of a chancre at the same time
+or later. In fact, it was in an experimental inoculation from such a
+case that the great John Hunter acquired the syphilis which cost him his
+life, and which led him to declare that because he had inoculated
+himself with pus from a gonorrhea and developed syphilis, the two
+diseases were identical. Just how common such cases are is not known,
+but the newer tests for syphilis are showing increasing numbers of men
+who never to their knowledge had anything but gonorrhea, yet who have
+syphilis, too.
+
++Serious Misconceptions About the Chancre.+--Misconceptions about the
+primary lesion or chancre of syphilis are numerous and serious, and are
+not infrequently the cause for ignoring or misunderstanding later signs
+of the disease. A patient who has gotten a fixed conception of a chancre
+into his head will argue insistently that he never had a hard sore, that
+his was soft, or painful instead of painless, or that it was only a
+pimple or a chafe. All these forms are easily within the ordinary limits
+of variation of the chancre from the typical form described in books,
+and an expert has them all in mind as possibilities. But the layman who
+has gathered a little hearsay knowledge will maintain his opinion as if
+it were the product of lifelong experience, and will only too often pay
+for his folly and presumption accordingly.
+
++Importance of Prompt and Expert Medical Advice.+--The recognition of
+syphilis in the primary stage does not follow any rule of thumb, and is
+as much an affair for expert judgment as a strictly engineering or legal
+problem. In the great majority of cases a correct decision of the matter
+can be reached in the primary stage by careful study and examination,
+but not by any slipshod or guesswork means. To secure the benefit of
+modern methods for the early recognition of syphilis those who expose
+themselves, or are exposed knowingly, to the risk of getting the disease
+by any of the commoner sources of infection, should seek expert medical
+advice at once on the appearance of anything out of the ordinary, no
+matter how trivial, on the parts exposed. The commoner sources of
+infection may be taken to be the kissing of strangers, the careless use
+of common personal and toilet articles which come in contact with the
+mouth especially,--all of which are explained later,--and illicit sexual
+relations. While this by no means includes all the means for the
+transmission of the disease, those who do these things are in direct
+danger, and should be warned accordingly.
+
++Modern Methods of Identifying an Early Syphilitic Infection.+--The
+practice of tampering with sores, chafes, etc., which are open to
+suspicion, whether done by the patient himself or by the doctor before
+reaching a decision as to the nature of the trouble, is unwise. An
+attempt to "burn it out" with caustic or otherwise, which is the first
+impulse of the layman with a half-way knowledge and even of some
+doctors, promptly makes impossible a real decision as to whether or not
+syphilis is present. Even a salve, a wash, or a powder may spoil the
+best efforts to find out what the matter is. A patient seeking advice
+should go to his doctor _at once_, and absolutely _untreated_. Then,
+again, irritating treatment applied unwisely to even a harmless sore may
+make a mere chafe look like a hard chancre, and result in the patient's
+being treated for months or longer for syphilis. Nowadays our first
+effort after studying the appearance of the suspected lesion is to try
+to find the germs, with the dark-field microscope or a stain. Having
+found them, the question is largely settled, although we also take a
+blood test. If we fail to find the germs, it is no proof that syphilis
+is absent, and we reexamine and take blood tests at intervals for some
+months to come, to be sure that the infection has not escaped our
+vigilance, as it sometimes does if we relax our precautions. In
+recognizing syphilis, the wise layman is the one who knows he does not
+know. The clever one who is familiar with everything "they say" about
+the disease, and has read about the matter in medical books into the
+bargain, is the best sort of target for trouble. Such men are about as
+well armed as the man who attacks a lion with a toothpick. He may stop
+him with his eye, but it is a safer bet he will be eaten.
+
++Enlargement of Neighboring Glands.+--Nearly every one is familiar with
+the kernels or knots that can be felt in the neck, often after
+tonsillitis, or with eruptions in the scalp. These are lymph-glands,
+which are numerous in different parts of the body, and their duty is,
+among other things, to help fight off any infection which tries to get
+beyond the point at which it started. The lymph-glands in the
+neighborhood of the chancre, on whatever part of the body it is
+situated, take an early part in the fight against syphilis. If, for
+example, the chancre is on the genitals, the glands in the groin will be
+the first ones affected. If it is on the lip, the neck glands become
+swollen. The affected glands actually contain the germs which have made
+their way to them through lymph channels under the skin. When the glands
+begin to swell, the critical period of limitation of the disease to the
+starting-point will soon be over and the last chances for a quick cure
+will soon be gone. At any moment they may gain entrance to the blood
+stream in large numbers. While the swelling of these glands occurs in
+other conditions, there are peculiarities about their enlargement which
+the physician looking for signs of the disease may recognize. Especially
+in case of a doubtful lesion about the neck or face, when a bunch of
+large swollen glands develops under the jaw in the course of a few days
+or a couple of weeks, the question of syphilis should be thoroughly
+investigated.
+
++Vital Significance of Early Recognition.+--The critical period of
+localization of an early infection will be brought up again in
+subsequent pages. As Pusey says, it is the "golden opportunity" of
+syphilis. It seldom lasts more than two weeks from the first appearance
+of the primary sore or chancre, and its duration is more often only a
+matter of four or five days before the disease is in the blood, the
+blood test becomes positive, and the prospect of what we call abortive
+cure is past. Nothing can justify or make up for delay in identifying
+the trouble in this early period, and the person who does not take the
+matter seriously often pays the price of his indifference many times
+over.
+
+
+
+
+Chapter IV
+
+The Nature and Course of Syphilis (Continued)
+
+
+THE SECONDARY STAGE
+
++The Spread of the Germs Over the Body.+--The secondary stage of
+syphilis, like the primary stage, is an arbitrary division whose
+beginning and ending can scarcely be sharply defined. Broadly speaking,
+the secondary stage of syphilis is the one in which the infection ceases
+to be confined to the neighborhood of the chancre and affects the entire
+body. The spread of the germs of the disease to the lymph-glands in the
+neighborhood of the primary sore is followed by their invasion of the
+blood itself. While this may begin some time before the body shows signs
+of it, the serious outburst usually occurs suddenly in the course of a
+few days, and fills the circulating blood with the little corkscrew
+filaments, sending showers of them to every corner of the body and
+involving every organ and tissue to a greater or less extent. This
+explosion marks the beginning of the active secondary stage of syphilis.
+The germs are now everywhere, and the effect on the patient begins to
+suggest such infectious diseases as measles, chickenpox, etc., which are
+associated with eruptions on the skin. But there can be no more serious
+mistake than to suppose that the eruptions which usually break out on
+the skin at this time represent the whole, or even a very important
+part, of the story. They may be the most conspicuous sign to the patient
+and to others, but the changes which are to affect the future of the
+syphilitic are going on just at this time, not in his skin, but in his
+internal organs, and especially in his heart and blood-vessels and in
+his nervous system.
+
++Constitutional Symptoms.+--It is surprising how mild a thing secondary
+syphilis is in many persons. A considerable proportion experience little
+or nothing at this time in the way of disturbances of the general health
+to suggest that they have a serious illness. A fair percentage of them
+lose 5 or 10 pounds in weight, have severe or mild headaches, usually
+worse at night, with pains in the bones and joints that may suggest
+rheumatism. Nervous disturbances of the most varied character may
+appear. Painful points on the bones or skull may develop, and there may
+be serious disturbances of eye-sight and hearing. A few are severely
+ill, lose a great deal of weight, endure excruciating pains, pass
+sleepless nights, and suffer with symptoms suggesting that their nervous
+systems have been profoundly affected. As a general thing, however, the
+constitutional symptoms are mild compared with those of the severe
+infectious fevers, such as typhoid or malaria.
+
++The Secondary Eruption or Rash.+--The eruption of secondary syphilis is
+generally the feature which most alarms the average patient. It is
+usually rather abundant, in keeping with the wide-spread character of
+the infection, and is especially noticeable on the chest and abdomen,
+the face, palms, and soles. It is apt to appear in the scalp in the
+severer forms. The eruption may consist of almost anything, from faint
+pink spots to small lumps and nodules, pimples and pustules, or large
+ulcerating or crusted sores. The eruption is not necessarily
+conspicuous, and may be entirely overlooked by the patient himself, or
+it may be so disfiguring as to attract attention.
+
++Common Misconceptions Regarding Syphilitic Rashes.+--Laymen should be
+warned against the temptation to call an eruption syphilitic. The
+commonest error is for the ordinary person to mistake a severe case of
+acne, the common "pimples" of early manhood, for syphilis. Psoriasis,
+another harmless, non-contagious, and very common skin disease, is often
+mistaken for syphilis. Gross injustice and often much mental distress
+are inflicted on unfortunates who have some skin trouble by the
+readiness with which persons who know nothing about the matter insist on
+thinking that any conspicuous eruption is syphilis, and telling others
+about it. Even with an eye trained to recognize such things on sight, in
+the crowds of a large city, one very seldom sees any skin condition
+which even suggests syphilis. It usually requires more than a passing
+glance at the whole body to identify the disease. If, under such
+circumstances, one becomes concerned for the health of a friend, he
+would much better frankly ask what is the matter, than make him the
+victim of a layman's speculations. It is always well to remember that
+profuse eruptions of a conspicuous nature, which have been present for
+months or years, are less likely to be syphilitic.
+
++The Contagious Sores in the Mouth, Throat, and Genitals.+--Accompanying
+the outbreaks of syphilis on the skin, in the secondary period, a
+soreness may appear in the mouth and throat, and peculiar patches seen
+on the tongue and lips, and flat growths be noticed around the moist
+surfaces, such as those of the genitals. These throat, mouth, and
+genital eruptions are the most dangerous signs of the disease from the
+standpoint of contagiousness. Just as the chancre swarms with the germs
+of syphilis, so every secondary spot, pimple, and lump contains them in
+enormous numbers. But so long as the skin is not broken or rubbed off
+over them, they are securely shut in. There is no danger of infection
+from the dry, unbroken skin, even over the eruption itself. But in the
+mouth and throat and about the genitals, where the surface is moist and
+thin, the covering quickly rubs or dissolves off, leaving the gray or
+pinkish patches and the flattened raised growths from which the germs
+escape in immense numbers and in the most active condition. Such patches
+may occur under the breasts and in the armpits, as well as in the places
+mentioned. The saliva of a person in this condition may be filled with
+the germs, and the person have only to cough in one's face to make one a
+target for them.
+
++Distribution of the Germs in the Body.+--The germs of syphilis have in
+the past few years been found in every part of the body and in every
+lesion of syphilis. While the secondary stage is at its height, they
+are in the blood in considerable numbers, so that the blood may at these
+times be infectious to a slight degree. They are present, of course, in
+large numbers in the secretions from open sores and under the skin in
+closed sores. The nervous system, the walls of the blood-vessels, the
+internal organs, such as the liver and spleen, the bones and the
+bone-marrow, contain them. They are not, however, apparently found in
+the secretions of the sweat glands, but, on the other hand, they have
+been shown to be present in the breast milk of nursing mothers who have
+active syphilis. The seminal fluid may contain the germs, but they have
+not been shown to be present either in the egg cells of the female or in
+the sperm cells of the male.
+
++Fate of the Germs.+--The fate of all these vast numbers of syphilitic
+germs, distributed over the whole body at the height of the disease, is
+one of the most remarkable imaginable. As the acute secondary stage
+passes, whether the patient is treated or not, by far the larger number
+of the spirochetes in the body is destroyed by the body's own power of
+resistance. This explains the statement, that cannot be too often
+repeated, that the outward evidences of secondary syphilis tend to
+disappear of themselves, whether or not the patient is treated. Of the
+hordes of germs present in the beginning of the trouble, only a few
+persist until the later stages, scattered about in the parts which were
+subject to the overwhelming invasion. Yet because of some change which
+the disease brought about in the parts thus affected, these few germs
+are able to produce much more dangerous changes than the armies which
+preceded them. In some way the body has become sensitive to them, and a
+handful of them in course of time are able to do damage which billions
+could not earlier in the disease. The man in whom the few remaining
+germs are confined largely to the skin is fortunate. The unfortunates
+are those who, with the spirochetes in their artery walls, heart muscle,
+brain, and spinal cord, develop the destructive arterial and nervous
+changes which lead to the crippling of life at its root and premature
+death.
+
++Variations in the Behavior of the Germ of Syphilis.+--Differences in
+the behavior of the same germ in different people are very familiar in
+medicine and are of importance in syphilis. As an example, the germ of
+pneumonia may be responsible for a trifling cold in one person, for an
+attack of grippe in the next, and may hurry the next person out of the
+world within forty-eight hours with pneumonia. Part of this difference
+in the behavior of a given germ may be due to differences among the
+various strains or families of germs in the same general group. Another
+part is due to the habit which germs have, of singling out for attack
+the weakest spot in a person's body. The germ that causes rheumatism has
+strains which produce simply tonsillitis, and others which, instead of
+attacking joints, tend to attack the valves of the heart. Our recent
+knowledge suggests that somewhat the same thing is at work in syphilis.
+Certain strains of Spirochaeta pallida tend to thrive in the nervous
+system, others perhaps in the skin. On the other hand, in certain
+persons, for example, heavy drinkers, the nervous system is most open
+to attack, in others the bones may be most affected, in still others,
+the skin.
+
++Variations in the Course of Syphilis in Different Persons.+--So it
+comes about that in the secondary stage there may be wide differences in
+the amount and the location of the damage done by syphilis. One patient
+may have a violent eruption, and very little else. Another will scarcely
+show an outward sign of the disease and yet will be riddled by one
+destructive internal change after another. In such a case the secondary
+stage of the disease may pass with half a dozen red spots on the body
+and no constitutional symptoms, and the patient go to pieces a few years
+later with locomotor ataxia or general paralysis of the insane. On the
+other hand, a patient may have a stormy time in the secondary period and
+have abundant reason to realize he has syphilis, and under only moderate
+treatment recover entirely. Still another will have a bad infection from
+the start, and run a severe course in spite of good treatment, to end in
+an early wreck. The last type is fortunately not common, but the first
+type is entirely too abundant. It cannot be said too forcibly that in
+the secondary as in the primary stage, syphilis may entirely escape the
+notice of the infected person, and he may not realize what ails him
+until years after it is too late to do anything for him. Here, as in the
+primary stage, the lucky person is the one who shows his condition so
+plainly that he cannot overlook it, and who has an opportunity to
+realize the seriousness of his disease. It used to be an old rule not
+to treat people who seemed careless and indifferent until their
+secondary eruption appeared, in the hope that this flare-up would bring
+them to their senses. The necessity for such a rule shows plainly how
+serious a matter a mild early syphilis may be.
+
++The Dangerous Contagious Relapses.+--Secondary syphilis does not begin
+like a race, at the drop of a hat, or end with the breaking of a tape.
+When the first outburst has subsided, a series of lesser outbreaks,
+often covering a series of years, may follow. These minor relapses or
+recurrences are mainly what make the syphilitic a danger to his fellows.
+They are to a large extent preventable by thorough modern treatment. Few
+people are so reckless as wholly to disregard precautions when the
+severe outburst is on. But the lesser outbreaks, if they occur on the
+skin, attract little or no attention or are entirely misunderstood by
+the patient. Only too often they occur as the flat, grayish patches in
+the mouth and genital tract, such as are seen in the secondary stage,
+where, because they are out of sight and not painful, they pass
+unnoticed. The tonsils, the under side and edges of the tongue, and the
+angles of the mouth just inside the lips are favorite places for these
+recurrent mucous patches. They are thus ideally placed to spread
+infection, for, as in the secondary stage, each of these grayish patches
+swarms with the germs of syphilis. Similar recurrences about the
+genitals often grow, because of the moisture, into buttons and flat,
+cauliflower-like warts from which millions of the germs can be squeezed.
+Sometimes they are mistaken for hemorrhoids or "piles." With all the
+opportunities that these sores offer for infection, it is surprising
+that the disease is not universal. Irritation from friction, dirt, and
+discharges, and in the mouth the use of tobacco, are the principal
+influences acting to encourage these recurrences.
+
++Relapses in the Nervous System and Elsewhere.+--Mucous patches are, of
+course, not the only recurrences, though they are very common. At any
+time a little patch of secondary eruption may appear and disappear in
+the course of a short time. Recurrences are not confined to the skin,
+and those which take place in the nervous system may result in temporary
+or permanent paralysis of important nerves, including those of the eyes
+and ears. Again, recurrences may show themselves in the form of a
+general running down of the patient from time to time, with loss of
+weight and general symptoms like those of the active secondary period.
+
+The secondary period as a whole is not in itself the serious stage of
+syphilis. Most of the symptoms are easily controlled by treatment if
+they are recognized. Now and then instances of serious damage to sight,
+hearing, or important organs elsewhere occur, but these are relatively
+few in spite of the enormous numbers and wide distribution of the germs.
+Accordingly, the problems that the secondary stage offers the physician
+and society at large must center around the recognition of mild and
+obscure cases and adequate treatment for all cases. The identification
+of the former is vital because of the recurrence of extremely infectious
+periods throughout this stage of the disease, and the latter is
+essential because vigorous treatment, carried out for a long enough
+time, prevents not only the late complications which destroy the
+syphilitic himself, but does away with the menace to society that arises
+through his infecting others, whether in marriage and sexual contact or
+in the less intimate relations of life.
+
+
+
+
+Chapter V
+
+The Nature and Course of Syphilis (Continued)
+
+
+LATE SYPHILIS (TERTIARY STAGE)
+
++The Seriousness of Late Syphilis.+--While we recognize a group of
+symptoms in syphilis which we call late or tertiary, there is no
+definite or sharp boundary of time separating secondary from tertiary
+periods. The man who calculates that he will have had his fling in the
+ten or twenty years before tertiary troubles appear may be astonished to
+find that he can develop tertiary complications in his brain almost
+before he is well rid of his chancre. "Late accidents," as we call them,
+are the serious complications of syphilis. They are, as has been said,
+brought about by relatively few germs, the left-overs from the flooding
+of the body during the secondary period. There is still a good deal of
+uncertainty as to just what the distribution of the germs which takes
+place in the secondary period foreshadows in the way of prospects for
+trouble when we come to the tertiary period. It may well be that the man
+who had many germs in his skin and a blazing eruption when he was in the
+second stage, may have all his trouble in the skin when he comes to the
+late stage. It is the verdict of experience, however, that people who
+have never noticed their secondary eruption because it was so mild are
+more likely to be affected in the nervous system later on. But this may
+be merely because the condition, being unrecognized, escapes treatment.
+It is at least safe to say that those whose skins are the most affected
+early in the disease are the fortunate ones, because their recognition
+and treatment in the secondary stage help them to escape locomotor
+ataxia and softening of the brain. Conversely the victim who judges the
+extent and severity of his syphilis by the presence or absence of a
+"breaking out" is just the one to think himself well for ten or twenty
+years because his skin is clean, and then to wake up some fine morning
+to find that he cannot keep his feet because his concealed syphilis is
+beginning to affect his nervous system.
+
++Nature of the Tissue Change in Late Syphilis--Gummatous
+Infiltration.+--The essential happening in late syphilis is that body
+tissue in which the germs are present is replaced by an abnormal tissue,
+not unlike a tumor growth. The process is usually painless. This
+material is shoddy, so to speak, and goes to pieces soon after it grows.
+The shoddy tissue is called "gummatous infiltration," and the tumor, if
+one is formed, is called a "gumma." The syphilitic process at the edge
+of the gumma shuts off the blood supply and the tissue dies, as a finger
+would if a tight band were wound around it, cutting off the blood
+supply. Gumma can develop almost anywhere, and where it does, there is a
+loss of tissue that can be replaced only by a scar. In this way gummas
+can eat holes in bone, or leave ulcerating sores in the skin where the
+gumma formed and died, or take the roof out of a mouth, or weaken the
+wall of a blood-vessel so that it bulges and bursts. The sunken noses
+and roofless mouths are usually syphilitic--yet if they are recognized
+in time and put under treatment, all these horrible things yield as by
+magic. There are few greater satisfactions open to the physician than to
+see a tertiary sore which has refused to heal for months or years
+disappear under the influence of mercury and iodids within a few weeks.
+Still better, if treatment had been begun early in the disease, and
+efficiently and completely carried out, none of these conditions need
+ever have been.
+
++Destructive Effects of Late Syphilis.+--Late syphilis is, therefore,
+destructive, and the harm that it does cannot, except within narrow
+limits, be repaired. It is responsible for the kind of damaged goods
+which gives the disease its reality for the every-day person. It is a
+matter of desperate importance where the damage is done. Late syphilis
+in the skin and bones, while horrible enough to look at, and disfiguring
+for life, is not the most serious syphilis, because we can put up with
+considerable loss of tissue and scarring in these quarters and still
+keep on living. But when late syphilis gets at the base of the aorta,
+the great vessel by which the blood leaves the heart, and damages the
+valves there, the numbering of the syphilitic's days begins. Few can
+afford to replace much brain substance by tertiary growths and expect to
+maintain their front against the world. Few are so young that they can
+meet the handicap that old age and hardening of the arteries, brought on
+prematurely by late syphilis, put upon them. When late syphilis affects
+the vital structures and gains headway, the victim goes to the wall.
+This is the really dangerous syphilis--the kind of syphilis that
+shortens and cripples life.
+
+There are few good estimates of the extent of late accidents, as we
+often call the serious later complications in syphilis, or of the part
+that they play in medicine as a whole. Too many of them are
+inconspicuous, or confused with other internal troubles that result from
+them. Deaths from syphilis are all the time being hidden under the
+general terms "Bright's disease," or "heart disease," or "paralysis," or
+"apoplexy." It is a hopeful fact that, even under unfavorable
+conditions, only a comparatively small percentage, from 10 to 20 per
+cent, seem to develop obvious late accidents. On the other hand, it must
+not be forgotten that the obscure costs of syphilis are becoming more
+apparent all the time, and the influence of the disease in shortening
+the life of our arteries and of other vital structures is more and more
+evident. There is still good reason for avoiding the effects of syphilis
+by every means at our disposal--by avoiding syphilis itself in the first
+place, and by early recognition of the disease and efficient treatment,
+in the second.
+
++Late Syphilis of the Nervous System--Locomotor Ataxia.+--The ways in
+which late syphilis can attack the nervous system form the real terrors
+of the disease to most people. Locomotor ataxia and general paralysis of
+the insane (or softening of the brain) are the best known to the laity,
+_though only two of many ways in which syphilis can attack the nervous
+system_. Though their relation to the disease was long suspected, the
+final touch of proof came only as recently as 1913, when Noguchi and
+Moore, of the Rockefeller Institute, found the germs of the disease in
+the spinal cords of patients who had died of locomotor ataxia, and in
+the brains of those who had died of paresis. The way in which the damage
+is done can scarcely be explained in ordinary terms, but, as in all late
+syphilis, a certain amount of the damage once done is beyond repair.
+Locomotor ataxia begins to affect the lower part of the spinal cord
+first, so that the earliest symptoms often come from the legs and from
+the bladder and rectum, whose nerves are injured. Other parts higher up
+may be affected, and changes resulting in total blindness and deafness
+not infrequently occur. Through the nervous system, various organs,
+especially the stomach, may be seriously affected, and excruciating
+attacks of pain with unmanageable attacks of vomiting (gastric crises)
+are apt to follow. This does not, of course, mean that all pain in the
+stomach with vomiting means locomotor ataxia. All sorts of obscure
+symptoms may develop in this disease, but the signs in the eyes and
+elsewhere are such that a decision as to what is the matter can usually
+be made without considering how the patient feels, and by evidence which
+is beyond his control.
+
++Late Syphilis of the Nervous System--General Paralysis.+--General
+paralysis, or paresis, is a progressive mental degeneration, with
+relapses and periods of improvement which reduce the patient by
+successive stages to a jibbering idiocy ending invariably in death. Such
+patients may, in the course of their decline, have delusions which lead
+them to acts of violence. The only place for a paretic is in an asylum,
+since the changes in judgment, will-power, and moral control which occur
+early in the disease are such that, before the patient gets
+unmanageable, he may have pretty effectually wrecked his business and
+the happiness of his family and associates. When the condition is
+recognized, the family must at least be forewarned, so that they can
+take action when it seems necessary. Both locomotor ataxia and paresis
+may develop in the same person, producing a combined form known as
+taboparesis.
+
+The importance of locomotor ataxia and paresis in persons who carry
+heavy responsibilities is very great. In railroad men, for example, the
+harm that can be done in the early stages of paresis is as great as or
+even greater than the harm that an epileptic can do. A surgeon with
+beginning taboparesis may commit the gravest errors of judgment before
+his condition is discovered. Men of high ability, on whom great
+responsibilities are placed, may bring down with them, in their
+collapse, great industrial and financial structures dependent on the
+integrity of their judgment. The extent of such damage to the welfare of
+society by syphilis is unknown, though here and there some investigation
+scratches the surface of it. It will remain for the future to show us
+more clearly the cost of syphilis in this direction.
+
++Syphilis and Mental Disease.+--Williams,[7] before the American Public
+Health Association, has recently carefully summarized the role of
+syphilis in the production of insanity, and the cost of the disease to
+the State from the standpoint of mental disease alone. He estimates
+that 10 per cent of the patients who enter the Massachusetts State
+hospitals for the insane are suffering from syphilitic insanity. Fifteen
+per cent of those at the Boston Psychopathic Hospital have syphilis. In
+New York State hospitals, 12.7 per cent of those admitted have
+syphilitic mental diseases. In Ohio, 12 per cent were admitted to
+hospitals for the same reason. An economic study undertaken by Williams
+of 100 men who died at the Boston State Hospital of syphilitic mental
+disease, the cases being taken at random, showed that the shortening of
+life in the individual cases ranged from eight to thirty-eight years,
+and the total life loss was 2259 years. Of ten of these men the earning
+capacity was definitely known, and through their premature death there
+was an estimated financial loss of $212,248. It cost the State of
+Massachusetts $39,312 to care for the 100 men until their death.
+Seventy-eight were married and left dependent wives at the time of their
+commission to the hospital. In addition to the 100 men who became public
+charges, 109 children were thrown upon society without the protection of
+a wage-earner. Williams estimates, on the basis of published admission
+figures to Massachusetts hospitals, that there are now in active life,
+in that state alone, 1500 persons who will, within the next five years,
+be taken to state hospitals with syphilitic insanity.
+
+    [7] Williams, F. E.: "Preaching Health," Amer. Jour. Pub. Health,
+    1917, vi, 1273.
+
++Frequency of Locomotor Ataxia and General Paralysis.+--The percentage
+of all syphilitic patients who develop either locomotor ataxia or
+paresis varies in different estimates from 1 to 6 per cent of the total
+number who acquire syphilis. The susceptibility to any syphilitic
+disease of the nervous system is hastened by the use of alcohol and by
+overwork or dissipation, so that the prevalence of them depends on the
+class of patients considered. It is evident, though, that only a
+relatively small proportion of the total number of syphilitics are
+doomed to either of these fates. Taking the population as a whole, the
+percentage of syphilitics who develop this form of late involvement
+probably does not greatly exceed 1 per cent.
+
++Treatment and Prevention of Late Syphilis of the Nervous
+System.+--Locomotor ataxia and paresis, even more than other syphilitic
+diseases of the nervous system, are extremely hard to affect by
+medicines circulating in the blood, and for that reason do not respond
+to treatment with the ease that syphilis does in many other parts of the
+body. Early locomotor ataxia can often be benefited or kept from getting
+any worse by the proper treatment. For paresis, in our present state of
+knowledge, nothing can be done once the disease passes its earliest
+stages. In both these diseases only too often the physician is called
+upon to lock the stable door after the horse is stolen. The problem of
+what to do for the victims of these two conditions is the same as the
+problem in other serious complications of syphilis--keep the disease
+from ever reaching such a stage by recognizing every case early, and
+treating it thoroughly from the very beginning.
+
+
+SUMMARY
+
+Summing up briefly the main points to bear in mind about the course of
+syphilis--there is a time, at the very beginning of the disease, even
+after the first sore appears, when the condition is still at or near the
+place where it entered the body. At this time it can be permanently
+cured by quick recognition and thorough treatment. There are no fixed
+characteristics of the early stages of the disease, and it often escapes
+attention entirely or is regarded as a trifle. The symptoms that follow
+the spread of the disease over the body may be severe or mild, but they
+seldom endanger life, and again often escape notice, leaving the victim
+for some years a danger to other people from relapses about which he may
+know nothing whatever. Serious syphilis is the late syphilis which
+overtakes those whose earlier symptoms passed unrecognized or were
+insufficiently treated. Late syphilis of the skin and bones, disfiguring
+and horrible to look at, is less dangerous than the hidden syphilis of
+the blood-vessels, the nerves, and the internal organs, which, under
+cover of a whole skin and apparent health, maims and destroys its
+victims. Locomotor ataxia and softening of the brain, early apoplexy,
+blindness and deafness, paralysis, chronic fatal kidney and liver
+disease, heart failure, hardening of the blood-vessels early in life,
+with sudden or lingering death from any of these causes, are among the
+ways in which syphilis destroys innocent and guilty alike. And yet, for
+all its destructive power, it is one of the easiest of diseases to hold
+in check, and if intelligently treated at almost any but the last
+stages, can, in the great majority of cases, be kept from endangering
+life.
+
+
+
+
+Chapter VI
+
+The Blood Test for Syphilis
+
+
+It seems desirable at this point, while we are trying to fix in mind the
+great value of recognizing syphilis in a person in order to treat it and
+thus prevent dangerous complications, to say something about the blood
+test for syphilis, the second great advance in our means of recognizing
+doubtful or hidden forms of the disease. The first, it will be recalled,
+is the identification of the germ in the secretions from the early
+sores.
+
++Antibodies in the Blood in Disease.+--It is part of the new
+understanding we have of many diseases that we are able to recognize
+them by finding in the blood of the sick person substances which the
+body makes to neutralize or destroy the poisons made by the invading
+germs, even when we cannot find the germs themselves. These substances
+are called antibodies, and the search for antibodies in different
+diseases has been an enthusiastic one. If we can by any scheme teach the
+body to make antibodies for a germ, we can teach it to cure for itself
+the disease caused by that germ. So, for example, by injecting dead
+germs as a vaccine in typhoid fever and certain other diseases, we are
+able to teach the body to form protective substances which will kill any
+of the living germs of that particular kind which gain entrance to the
+body. Conversely, if the body is invaded by a particular kind of germ,
+and we are in doubt as to just which one it is, we can identify it by
+finding in the blood of the sick person the antibody which we know by
+certain tests will kill or injure a certain germ. This sort of medical
+detective work was first applied to syphilis successfully by Wassermann,
+Neisser, and Bruck in 1904, and for that reason the test for these
+antibodies in the blood in syphilis is called the Wassermann reaction.
+To be sure, it is now known that in syphilis it is not a true antibody
+for the poisons of the Spirochaeta pallida for which we are testing, but
+rather a physical-chemical change in the serum of patients with
+syphilis, which can be produced by other things besides this one
+disease. But this fact has not impaired the practical value of the test,
+since the other conditions which give it are not likely to be confused
+with syphilis in this part of the world. The fact that no true antibody
+is formed simply makes it unlikely that we shall ever have a vaccine for
+syphilis.
+
++Difficulties of the Test.+--The Wassermann blood test for syphilis is
+one of the most complex tests in medicine. The theory of it is beyond
+the average man's comprehension. A large number of factors enter into
+the production of a correct result, and the attaining of that result
+involves a high degree of technical skill and a large experience. It is
+no affair for the amateur. The test should be made by a specialist of
+recognized standing, and this term does not include many of the
+commercial laboratories which spring up like mushrooms in these days of
+laboratory methods.
+
++The Recognition of Syphilis by the Blood Test.+--When the Wassermann
+test shows the presence of syphilis, we speak of it as "positive."
+Granted that the test is properly done, a strong positive reaction means
+syphilis, unless it is covered by the limited list of exceptions. After
+the first few weeks of the disease, and through the early secondary
+period, the blood test is positive in practically all cases. Its
+reliability is, therefore, greatest at this time. Before the infection
+has spread beyond the first sore, however, the Wassermann test is
+negative, and this fact makes it of little value in recognizing early
+primary lesions. In about 20 to 30 per cent of syphilitic individuals
+the test returns to negative after the active secondary stage is passed.
+This does not necessarily mean that the person is recovering. It is even
+possible to have the roof fall out of the mouth from gummatous changes
+and the Wassermann test yet be negative. It is equally possible, though
+unusual, for a negative Wassermann test to be coincident with contagious
+sores in the mouth or on the genitals. So it is apparent that as an
+infallible test for syphilis it is not an unqualified success. But
+infallibility is a rare thing in medicine, and must be replaced in most
+cases by skilful interpretation of a test based on a knowledge of the
+sources of error. We understand pretty clearly now that the Wassermann
+test is only one of the signs of syphilis and that it has quite
+well-understood limitations. It has revealed an immense amount of
+hidden syphilis, and in its proper field has had a value past all
+counting. Experience has shown, however, that it should be checked up by
+a medical examination to give it its greatest value. Just as all
+syphilis does not show a positive blood test, so a single negative test
+is not sufficient to establish the absence of syphilis without a medical
+examination. In a syphilitic, least of all, is a single negative
+Wassermann test proof that his syphilis has left him. In spite of these
+rather important exceptions, the Wassermann test, skilfully done and
+well interpreted, is one of the most valuable of modern medical
+discoveries.
+
++The Blood Test in the Treatment and Cure of Syphilis.+--In addition to
+its value in recognizing the disease, the Wassermann test has a second
+field of usefulness in determining when a person is cured of syphilis,
+and is an excellent guide to the effect of treatment. Good treatment
+early in a case of syphilis usually makes the Wassermann test negative
+in a comparatively short time, and even a little treatment will do it in
+some cases. But will it stay negative if treatment is then stopped? In
+the high percentage of cases it will not. It will become positive again
+after a variable interval, showing that the disease has been suppressed
+but not destroyed. For that reason, if we wish to be sure of cure, we
+must continue treatment until the blood test has become negative and
+stays negative. This usually means repeated tests, over a period of
+several years, in connection with such a course of treatment as will be
+described later. During a large part of this time the blood test will
+be the only means of finding out how the disease is being affected by
+the treatment. To all outward appearance the patient will be well. He
+may even have been negative in repeated tests, and yet we know by
+experience that if treatment is stopped too soon, he will become
+positive again. There is no set rule for the number of negative tests
+necessary to indicate a cure. The whole thing is a matter of judgment on
+the part of an experienced physician, and to that judgment the patient
+should commit himself unhesitatingly. If a patient could once have
+displayed before him in visible form the immense amount of knowledge,
+experience, and labor which has gone into the devising and goes into the
+performing of this test, he would be more content to leave the decision
+of such questions to his physician than he sometimes is, and would be
+more alive to its reality and importance. The average man thinks it a
+rather shadowy and indefinite affair on which to insist that he shall
+keep on doctoring, especially after the test has been negative once or
+twice.
+
+Just as a negative test may occur while syphilis is still actively
+present and doing damage in the body, so a positive Wassermann test may
+persist long after all outward and even inward signs of the disease have
+disappeared. These fixed positives are still a puzzle to physicians. But
+many patients with fixed positives, if well treated regardless of their
+blood test, do not seem to develop the late accidents of the disease. If
+their nervous systems, on careful examination, are found not to be
+affected, they are reasonably safe as far as our present knowledge
+goes. People with fixed positives should accept the judgment of their
+physicians and follow their recommendations for treatment without
+worrying themselves gray over complications which may never develop.
+
++Practical Points About the Test.+--Certain practical details about this
+test are of interest to every one. Blood for it is usually drawn from a
+small vein in the arm. The discomfort is insignificant--no more than
+that of a sharp pin-prick. Blood is drawn in the same way for other
+kinds of blood tests, so that a needle-prick in the arm is not
+necessarily for a Wassermann test. There is no cutting and no scar
+remains. The amount of blood drawn is small and does not weaken one in
+the least. The test is done on the serum or fluid part of the blood,
+after the corpuscles are removed. It can also be done on the clear fluid
+taken from around the spinal cord, and this is necessary in certain
+syphilitic nervous diseases. There is nothing about the test that need
+make anybody hesitate in taking it, and it is safe to say that, when
+properly done, the information that it gives is more than worth the
+trouble, especially to those who have at any time been exposed, even
+remotely, to the risk of infection. But the test must be well done, by a
+large hospital or through a competent physician or specialist, and the
+results interpreted to the patient by the physician and not by the
+laboratory that does the test, or in the light of the patient's own
+half-knowledge of the matter.
+
+
+
+
+Chapter VII
+
+The Treatment of Syphilis
+
+
+GENERAL CONSIDERATIONS
+
++Scientific Methods of Treating Disease.+--In trying to treat diseases
+caused by germs, the physician finds himself confronted by several
+different problems. Certain of these diseases run their course and the
+patient gets well or dies, pretty much regardless of anything that can
+be done for him. In certain others, because of our knowledge of the way
+in which the body makes its fight against the germ, we are able either
+to prepare it against attack, as in the case of protective vaccination,
+or we are able to help it to come to its own defense after the disease
+has developed. This can be done either by supplying it with antitoxin
+from an outside source, or helping it to make its own antitoxin by
+giving it dead germs to practise on. In the third group, the smallest of
+the three, we are fortunate enough to know of some substance which will
+kill the germ in the body without killing the patient. For such diseases
+we are said to have a "specific" method of treatment. Syphilis is one of
+these diseases. It is not to be understood that there is a sharp line of
+division between these three groups, since in every disease we try as
+far as possible to use all the methods we can bring to bear. In
+pneumonia we have to let the body largely make its own fight, and simply
+help it to clear out the poisons formed by the germ, and keep the heart
+going until the crisis is past. In diphtheria, nowadays, we help the
+body out promptly by supplying it with antitoxin from an outside source,
+before it has time to make any for itself. We do the same thing for
+lockjaw if we are early enough. We practise the body on dead typhoid
+germs by vaccination until it is able to fight the living ones and
+destroy them before they get a foothold. The diseases for which we have
+specific methods of treatment are few in number, and each has associated
+with it the name of a particular drug. Quinin kills the germ of malaria,
+sodium salicylate cures inflammatory rheumatism, and mercury cures
+syphilis. To mercury in the case of syphilis must now be added salvarsan
+or arsenobenzol ("606"), the substance devised by Ehrlich in 1910, which
+will be considered in the next chapter.
+
+The action of a specific is, of course, not infallible, but the failures
+are exceptional, so that one feels in attacking one of these diseases
+with its specific remedy as a man called upon to resist a savage beast
+would feel if he were armed with a powerful rifle instead of a stick.
+The situation in syphilis, for which there is a specific, as compared
+with tuberculosis, for which there is no specific, is incomparably in
+favor of the former. If we had as powerful weapons against tuberculosis
+as we have against syphilis, the disease would now be a rarity instead
+of the disastrous plague it is. Comparing the situation in two diseases
+for which we have specifics, such as syphilis and malaria, malaria has
+lost most of its seriousness as a problem in any part of the world,
+while syphilis is rampant everywhere. Malaria has, of course, been
+extinguished not only through the efficiency of quinin, but also through
+preventive measures directed at mosquitos, which are the carriers of the
+disease from person to person. But allowing for this, if it becomes
+possible to apply mercury and salvarsan as thoroughly to the prevention
+and treatment of syphilis as quinin can be applied to malaria, syphilis
+will soon be a rarity over the larger part of the civilized world. To
+bring the specific remedies for syphilis and the patient together
+constitutes, then, one of the greatest problems which confronts us in
+the control of the disease at the present day.
+
+
+MERCURY
+
++Mercury in the Treatment of Syphilis.+--Mercury is, of course, familiar
+to every one, and there is nothing peculiar about the mercury used in
+the treatment of syphilis. The fluid metallic mercury itself may be used
+in the form of salves, in which the mercury is mixed with fatty
+substances and rubbed into the skin. Mercury can be vaporized and the
+vapor inhaled, and probably the efficiency of mercury when rubbed into
+the skin depends to no small extent on the inhalation of the vapor which
+is driven off by the warmth of the body. Mercury in the form of chemical
+salts or compounds with other substances can be given as pills or as
+liquid medicine. Similarly, the metal itself or some of its compounds
+can be injected in oil with a hypodermic needle into the muscles, and
+the drug absorbed in this way.
+
++Misconceptions Concerning Mercury.+--The use of mercury in syphilis is
+nearly as old, in Europe at least, as the disease itself. The drug was
+in common use in the fifteenth century for other conditions, and was
+promptly tried in the new and terrible disease as it spread over Europe,
+with remarkable results. But doses in the old days were anything but
+homeopathic, and overdoses of mercury did so much damage that for a time
+the drug fell into undeserved disfavor. Many of the superstitions and
+popular notions about mercury originated at this period in its history.
+It was supposed to make the bones "rot" and the teeth fall out, an idea
+which one patient in every ten still entertains and offers as an
+objection when told he must take mercury. Insufficiently treated
+syphilis is, of course, what makes the bones "rot," and not the mercury
+used in treating the disease. Mercury apparently has no effect on the
+bones whatever. The influence of the drug on the teeth is more direct
+and refers to the symptoms caused by overdoses. No physician who knows
+his business ever gives mercury at the present time to the point where
+the teeth are in any danger of falling out.
+
++The Action of Mercury.+--The action of mercury on syphilis is not
+entirely clear. The probabilities are that the drug, carried to all
+parts of the body by the blood, helps to build up the body's resistance
+and stimulates it to produce substances which kill the germs. In
+addition, of course, it kills the germs by its own poisonous qualities.
+Its action is somewhat slow, and it is even possible for syphilitic
+sores containing the germs to appear, especially in the mouth and throat
+and about the genitals, while the person is taking mercury. Just as
+quinin must be used in malaria for some time after all signs of chill
+and fever have disappeared, to kill off all germs lurking in
+out-of-the-way corners of the body, or especially resistant to the drug,
+so it is necessary to continue the use of mercury long after it has
+disposed of all the obvious signs of the disease, like the eruption,
+headaches, and other symptoms, in order to prevent a relapse. No matter
+in what form it is used, the action of mercury on syphilis is one of the
+marvels of medicine. It can clear up the most terrific eruption with
+scarcely a scar, and transform a bed-ridden patient into a seemingly
+healthy man or woman, able to work, in the course of a few weeks or
+months. Symptoms often vanish before it like snow in a thaw. This
+naturally makes a decided impression, and often an unfavorable one, on
+the patient. It is only too easy to think that a disease which vanishes
+under the magic influence of a few pills is a trifle, and that outwardly
+cured means the same thing as inwardly cured. Mercury therefore carries
+its disadvantages with its advantages, and by its marvelous but
+transient effect only too often gives the patient a false idea of his
+progress toward cure.
+
++Methods of Administering Mercury.+--As has been said, mercury is given
+principally in three ways at the present time. It can be given by the
+mouth, in the form of pills and liquids, and in this form is not
+infrequently incorporated into patent medicine blood purifiers. Mercury
+in pills and liquid medicine has the advantage for the patient of being
+an easy and inconspicuous way of taking the drug, and for that reason
+patients usually take it willingly or even insist on it if they know no
+better. Even small doses taken in this way will hide the evidences of
+syphilis so completely that only a blood test will show that it exists.
+If it were true that large doses taken by mouth could always be relied
+on to cure the disease, there would be little need for other ways of
+giving it. But there is a considerable proportion of persons with
+syphilis treated with pills who do not get rid of the disease even
+though the dose is as large as the stomach can stand. Such patients
+often have all the serious late complications which befall untreated
+patients. It seems almost impossible to give enough mercury by mouth to
+effect a cure. Thus pill treatment has come to be a second-best method,
+and suitable only in those instances in which we simply expect to
+control the outward signs rather than effect a cure.
+
+The mercury rub or inunction, under ideal conditions, all things
+considered, is the best method of administering mercury to a patient
+with the hope of securing a permanent result. In this form of treatment
+the mercury made up with a salve is rubbed into the skin. The
+effectiveness of the mercurial rub is reduced considerably by its
+obvious disadvantages. It requires time to do the rubbing, and the
+ointment used seems uncleanly because of its color and because it is
+necessary to leave what is not rubbed in on the skin so that it
+discolors the underwear. The mercurial rub is at its best when it is
+given by some one else, since few patients have the needed combination
+of conscientiousness, energy, and determination to carry through a long
+course. The advantages of the method properly carried out cannot be
+overestimated. It is entirely possible in a given case of syphilis to
+accomplish by a sufficient number of inunctions everything that mercury
+can accomplish, and with the least possible damage to the body.
+Treatment by mouth cannot compare with inunctions and cannot be made to
+replace them, when the only objection to the rubs is the patient's
+unwillingness to be bothered by them. The patient who is determined,
+therefore, to do the best thing by himself will take rubs
+conscientiously as long as his physician wishes him to do so, even
+though it means, as it usually does, not a dozen or two, but several
+hundreds of them, extending over a period of two or three years, and
+given at the rate of four to six rubs a week.
+
+The giving of mercury by injections is a very powerful method of using
+the drug for the cure of syphilis. It reduces the inconvenience of
+effective treatment to a minimum and has all the other advantages of
+secrecy and convenience. It keeps the patient, moreover, in close touch
+with his physician and under careful observation. Injections by some
+methods are given daily, by others once or twice a week. The main
+disadvantage is the discomfort which follows each injection for a few
+hours. For any one who has one of the serious complications of
+syphilis, injections may be a life and death necessity. Mercurial
+injections are a difficult form of treatment and should be given only by
+experts and physicians who are thoroughly familiar with their use.
+
+Like every important drug in medicine, mercury is a poison if it is
+abused. Its earliest effect is on the mouth and teeth, and for that
+reason the physician, in treating syphilis by vigorous methods, has his
+patients give special attention to the care of their mouths and teeth
+and of their digestions as well. Mercury also affects the kidneys and
+the blood, if not properly given, and for that reason the person who is
+taking it must be under the care and observation of a physician from
+time to time. Only the ignorant undertake to treat themselves for
+syphilis, though how many of these there are can be inferred from the
+amount of patent medicine and quack treatment there is in these fields.
+Properly given, mercury has no harmful effects, and there is no ground
+whatever for the notion some people have, that mercury will do them more
+harm than a syphilitic infection. Improperly used, either as too much or
+too little, it is capable of doing great harm, not only directly, but
+indirectly, by making it impossible later for the patient to take enough
+to cure the disease. The extent to which some overconfident persons fail
+in their efforts to treat and cure themselves explains the necessity for
+such a warning.
+
++Effect of Mercurial Treatment on the Blood Test.+--The effect of
+mercury on the Wassermann blood test for syphilis should also be
+generally understood. In many cases it is possible, especially early in
+the disease, by a few rubs of mercurial ointment, or a few injections of
+mercury, or even in some cases by the use of pills or liquid medicine,
+to make a positive blood test for syphilis negative. But this negative
+test is only temporary. Within a short time, usually after treatment is
+stopped, the test becomes positive again, showing that the mercury has
+not yet cured, but simply checked, the disease, and that it may at any
+time break out again or do internal damage. It must be understood that a
+negative blood test just after a patient has been taking mercury _has no
+meaning_, so far as guaranteeing a cure is concerned. It is only the
+blood test that is repeatedly negative after the effect of mercury wears
+off, which shows the disease is cured. Yet many a syphilitic may and
+does think himself cured, and may marry in good faith, or be allowed a
+health certificate, only to become positive again. He may then develop
+new sores without his knowledge even, and perhaps infect his wife, or
+may himself in later years develop some of the serious consequences of
+the disease.
+
+Whenever one talks to a person who knows something about the advances in
+knowledge in the past few years about the treatment of syphilis, and
+goes into detail about mercury, the odds are two to one that he will be
+interrupted by the question, "But what about '606'?" Before talking
+about salvarsan, or "606," it is well to say here that this new drug,
+wonderful though it is, has in no sense done away with the necessity for
+the use of mercury in the treatment of syphilis. Mercury has as high a
+reputation and is as indispensable in the cure of syphilis today as it
+was four centuries ago. It has as yet no substitutes. We appreciate
+every day, more and more, how thoroughly it can be depended on to do the
+work we ask of it.[8]
+
+    [8] A drug known as the iodid of potash (or soda) is widely used in
+    the treatment of syphilis, and especially of the late forms of the
+    disease, such as gummas and gummatous sores. It has a peculiar
+    effect on gummatous tissue, causing it to melt away, so to speak,
+    and greatly hastening the healing process. So remarkable is this
+    effect that it gives the impression that iodids are really curing
+    the syphilis itself. It has been shown, however, that iodids have no
+    effect on the germs of syphilis, and therefore on the cause of the
+    disease, although they can promote the healing of the sores in the
+    late stages. For this reason iodids must always be used in
+    connection with mercury or salvarsan if the disease itself is to be
+    influenced. It is occasionally difficult to get patients to
+    understand this after they have once taken "drops," as the medicine
+    is often called. Otherwise the use of iodids in syphilis is of
+    medical rather than general interest.
+
+
+
+
+Chapter VIII
+
+The Treatment of Syphilis (Continued)
+
+
+SALVARSAN
+
++The Discovery of Salvarsan ("606").+--Salvarsan, or "606," is a
+chemical compound used in the modern treatment of syphilis. It was
+announced to the world by Paul Ehrlich, its brilliant discoverer, in
+December, 1910. Ehrlich and his Japanese co-worker, Hata, had some years
+before been impressed with the remarkable effect certain dyes had on the
+parasites infesting certain animals and which resemble the germs that
+cause the African sleeping sickness in man. When one of these dyes was
+dissolved and injected into the blood of the sick animal, the dye
+promptly picked out and killed all the parasites, but did not kill the
+animal. Dyes are very complex chemical substances and certain of them
+seem to have an affinity for germs. It occurred to Ehrlich that if a
+substance could be devised which was poisonous for the germ and not for
+the patient it might be possible to prepare a specific for a given
+disease, acting as quinin does in malaria. By combining a poison with a
+dye it might be made to pick out the germs and leave the body unharmed.
+
+    [Illustration: PAUL EHRLICH [1854-1915]
+
+    (From "Year Book of Skin and Venereal Diseases," 1916, vol. ix.
+    "Practical Medicine Series," Year Book Publishers, Chicago.)]
+
+The poison which had already been shown to be especially effective in
+killing germs like those of syphilis was arsenic. The problem was to
+get arsenic into such a combination with other chemical substances that
+it would lose its poisonous quality for man, but still be poisonous for
+the spirochete of syphilis. Ehrlich and Hata began to make chemical
+compounds of arsenic in the laboratory with chemical substances like the
+dyes. As the compounds grew more complex they were tested on animals and
+some of them found to have the qualities for which their inventors were
+searching. Some of them are even used at the present time in the
+treatment of certain diseases. The six hundred and sixth compound in
+this series, when tested on syphilitic animals, was found to be
+extraordinarily efficient in killing the germ of syphilis, even when
+used in quantities so small as not to injure the animal. Among other
+things, there could be no better example of the importance of animal
+experiment in medicine. If the cause of syphilis had not been known, and
+the disease not given to animals, the discovery of salvarsan might never
+have been made. After extensive experiments on syphilitic rabbits, which
+showed that the drug could be given safely in amounts large enough to
+cure the animal at a single dose, it was tried on man, two physicians,
+Drs. Hoppe and Wittneben, volunteering for the test. When it was found
+that the drug did them no harm, it was used on syphilitic patients for
+the first time. As soon as its remarkable effect on the disease in them
+was fully established, Ehrlich announced the discovery before the
+medical society of Magdeburg, and the results were published in one of
+the most important of the German medical journals. Ehrlich then sent
+out from his own laboratory several thousands of doses of the new drug
+to all the principal clinics and large hospitals of the world for an
+extended trial. It was not until the results of this trial became
+apparent that he permitted its manufacture on a commercial scale. There
+could scarcely be a more ideal way of introducing a new form of
+treatment than the one adopted by Ehrlich, or one better surrounded by
+all the safeguards that conservatism could suggest.
+
++The Mistaken Conception of "Single Dose Cure."+--In the light of his
+experience with salvarsan in animals, Ehrlich hoped to accomplish the
+cure of syphilis in man by a single dose of the new drug, as he had been
+able to cure it in rabbits. All the earlier use of salvarsan in the
+treatment of syphilis was carried out with this idea in view, and the
+remarkable way in which the symptoms vanished before the large doses
+used encouraged the belief that Ehrlich's ideal for it had been
+fulfilled. But it was not long before it was found that syphilis had a
+stronger hold on the human body than on animals, and that patients
+relapsed after a single dose, either as shown by the blood test or by
+the reappearance, after varying intervals, of the eruption or other
+symptoms of the disease. Unfortunately, the news of the discovery of
+salvarsan, and with it Ehrlich's original idea that it would cure
+syphilis by a single dose, had gotten into the newspapers. Numbers of
+syphilitics treated with it have been deceived by this notion into
+believing themselves cured. In those whose symptoms came back in severe
+form, the trouble was, of course, found out. But there are at the
+present time, undoubtedly, many persons who received a single dose of
+salvarsan for a syphilis contracted at this time, and who today, having
+never seen any further outward signs of the disease, believe themselves
+cured, when in reality they are not. In the next twenty years the
+introduction of salvarsan will probably result in a wave of serious late
+syphilis, the result of cases insufficiently treated in the early days
+of its use. It was not long before it was found that not one but several
+doses of salvarsan were necessary in the treatment of syphilis, and soon
+many physicians of wide experience began to call in mercury again for
+help when salvarsan proved insufficient for cure. At the present time
+the use of both mercury and salvarsan in the treatment of the disease is
+the most widely accepted practice, and seems to offer the greatest
+assurance of cure.
+
++The Value of Salvarsan.+--Salvarsan has done for the treatment of
+syphilis certain things of the most far-reaching importance from the
+standpoint of the interests of society at large. It has first of all
+made possible the control of the _contagious_ lesions of the disease.
+Secondly, as was said before, it has made possible the cure of the
+infection in the primary stage, before it has spread from the
+starting-point in the chancre to the rest of the body. To understand how
+it accomplishes these results it is important to understand its mode of
+action.
+
++The Action of Salvarsan.+--It will be recalled that Ehrlich planned
+salvarsan to kill the germs of syphilis, just as quinin kills the germs
+of malaria. It was intended that when the drug entered the blood it
+should be carried to every part of the body, and fastening itself on the
+spirochetes, kill them without hurting the body. This is seemingly
+exactly what the drug does, and it does it so well that within
+twenty-four hours after a dose of it is given into the blood there is
+not a living germ of syphilis, apparently, in any sore on the body. If
+the same thing happened in all the out-of-the-way corners of the body,
+the cure would be complete. The natural result of removing the cause of
+the disease in this fashion is that the sores produced by it heal up.
+They heal with a speed and completeness that is an even greater marvel
+than the action of mercury. The more superficial the eruption, the
+quicker it vanishes, so that in the course of a few days all evidence of
+the disease may disappear. This is especially true of the grayish
+patches in the mouth and about the genitals, which have already been
+described as the most dangerously contagious lesions of syphilis. It is
+evident, therefore, that to give salvarsan in a case of contagious
+syphilis is to do away with the risk of spreading the disease in the
+quickest and most effective fashion. It is as if a person with scarlet
+fever could be dipped in a disinfecting bath and then turned loose in
+the community without the slightest danger of his infecting others. How
+much scarlet fever would there be if every case of the disease could be
+treated in this way? There would be as little of it as there now is of
+smallpox, compared to the wholesale plagues of that disease which used
+to kill off the population of whole towns and counties in the old days.
+If we could head off the crops of contagious sores in every syphilitic
+by the use of "606," syphilis in the same way would take a long step
+toward its disappearance. It is not a question, in this connection, of
+curing the disease with salvarsan, but of preventing its spread, and in
+doing that, salvarsan is one of the things we have been looking for for
+centuries.
+
++The Treatment of Syphilis With Salvarsan.+--Salvarsan, the original
+"606," was improved on by Ehrlich in certain ways, which make it easier
+for the ordinary physician to use it. The improved salvarsan is called
+neosalvarsan ("914") and has no decided advantages over the older
+preparation except on the score of convenience. Both salvarsan and
+neosalvarsan are yellow powders, which must be manufactured under the
+most exacting precautions, to prevent their being intensely poisonous,
+and must be sealed up in glass tubes to prevent their spoiling in the
+air. They were formerly administered by dissolving them or by mixing
+with oil and then injecting them into the muscles, much as mercury is
+given by injection. At the present time, however, the majority of
+experts prefer to dissolve the drug in water or salt solution and to
+inject it into the blood directly, through one of the arm veins. There
+is very little discomfort in the method, as a rule--no more than there
+is to the taking of blood for a blood test. At the present time the
+quantity of the drug injected is relatively small for the first
+injection, growing larger with each following injection. The intervals
+between injections vary a good deal, but a week is an average. The
+number of injections that should be given depends largely on the purpose
+in view. If the salvarsan is relied on to produce a cure, the number may
+be large--as high as twenty or more. If it is used only to clear up a
+contagious sore, a single injection may be enough for the time being.
+But when only a few injections are used, mercury becomes the main
+reliance, and a patient who cannot have all the salvarsan he needs
+should not expect two or three doses of it to produce a cure. The
+publicity which has been given to this form of treatment has led many
+patients to take matters into their own hands and to go to a physician
+and ask him to give them a dose of salvarsan, much as they might order a
+highball on a cold day. The physician who is put in a position like this
+is at a disadvantage in caring for his patient, and the patient in the
+end pays for his mistaken idea that he knows what is good for himself.
+The only judge of the necessity of giving salvarsan, and the amount and
+the frequency with which to give it, is the expert physician, and no
+patient who is wise will try to take the thing into his own hands. There
+are even good reasons for believing that the patient who is
+insufficiently treated with salvarsan is at times worse off than the
+patient who, unable to afford the drug at all, has had to depend for his
+cure entirely on mercury.
+
+It is one of the tragedies of the modern private practice of medicine
+that the physician has so often to consult the patient's purse in giving
+or withholding salvarsan, and for that reason, except in the
+well-to-do, it is seldom used to the best advantage. Such a drug, so
+powerful an agent in the conservation of the public health, should be
+available to all who need it in as large amounts as necessary, without a
+moment's hesitation as to whether the patient can afford it or not. It
+is not too much to urge that private patent rights should not be allowed
+to control the price and distribution of such a commodity to the public.
+Upon the payment of suitable royalties to the inventor the manufacture
+of such a drug should be thrown open to properly supervised competition,
+as in the case of diphtheria antitoxin, or be taken over by the
+Government and distributed at cost, at least to hospitals. To bring
+about such a revision of our patent law every thinking man and woman may
+well devote a share of personal energy and influence.
+
+The manner of giving salvarsan is as important for the patient as the
+correct performance of an operation, and the safeguards which surround
+it are essentially the same. The drug is an extremely powerful one, more
+powerful than any other known, and in the usual doses it carries with it
+into the body for the destruction of the germs of syphilis many times
+the amount of arsenic needed to kill a human being. If something should
+go astray, the patient might lose his life as promptly as if the surgeon
+or the anesthetist should make a slip during an operation. To make the
+giving of salvarsan safe, the judgment, experience, and training of the
+specialist are not too much to ask.
+
+The dangers of salvarsan are easily exaggerated, and some people have a
+foolish fear of it. The wonderful thing about the drug is that, with all
+the possibility for harm that one might expect in it, it so seldom makes
+any trouble. It is, of course, first carefully tested on animals when it
+is manufactured, so that no poisonous product is placed on the market.
+It is as safe to take salvarsan at the hands of an expert as it is to
+take ether for an operation or to take antitoxin for diphtheria, and
+that is saying a good deal. Most of the stories of accidents that go the
+rounds among laymen date back to the days when first doses were too
+large and made the patients rather sick for a time. Present methods and
+cautions about administering the drug are such that, except for the
+improvement in their condition, patients seldom know they have received
+it. The first dose may light the eruption up a little, but this is only
+because the drug stirs the germs up before it kills them, and
+improvement begins promptly within a few hours or a day or two.
+
+The first characteristic of salvarsan which we should bear in mind
+especially, in our interest in the social aspects of syphilis, is then
+the rapidity rather than the thoroughness of its action. It is a social
+asset to us because it protects us from the infected person, and it is
+an asset to the patient because it will set him on his feet, able to
+work and go about his business, in a fraction of the time that mercury
+can do it.
+
+The efficiency of salvarsan in the cure of syphilis in the early stages
+is due, first, to the large amount of it that can be introduced into the
+body without killing the patient, and second, to the promptness with
+which it gets to the source of trouble. In the old days, while we were
+laboriously getting enough mercury into the patient to help him to stop
+the invading infection, the germs marched on into his blood and through
+his body. With salvarsan, the first dose, given into the blood, reaches
+the germs forthwith and destroys them. There is enough of it and to
+spare. Twenty-four hours later scarcely a living germ remains. The few
+stragglers who escape the fate of the main army are picked up by
+subsequent doses of salvarsan and mercury, and a cure is assured. There
+is all the difference between stopping a charge with a machine gun and
+stopping it with a single-shot rifle, in the relative effectiveness of
+salvarsan and mercury at the beginning of a syphilitic infection.
+
+     In syphilis affecting the central nervous system, salvarsan,
+     modified in various ways, may be injected into the spinal canal in
+     an effort to reach the trouble more directly. The method, which is
+     known as _intradural therapy_, has had considerable vogue, but a
+     growing experience with it seems to indicate that it has less value
+     than was supposed, and is a last resort more often than anything
+     else. It involves some risk, and is no substitute for efficient
+     treatment by the more familiar methods. If necessary, a patient can
+     have the benefit of both.
+
+     The _luetin test_ was devised by Noguchi for the presence of
+     syphilis, and is performed by injecting into the skin an emulsion
+     of dead germs. A pustule forms if the test is positive. It is of
+     practical value only in late syphilis, and a negative test is no
+     proof of the absence of the disease. Positive tests are sometimes
+     obtained when syphilis is not present. For these reasons the test
+     is not as valuable as was at first thought.
+
+
+
+
+Chapter IX
+
+The Cure of Syphilis
+
+
+There are few things about our situation with regard to syphilis that
+deserve more urgent attention than questions connected with the cure of
+the disease, and few things in which it is harder to get the necessary
+cooeperation. On the one hand, syphilis is one of the most curable of
+diseases, and on the other, it is one of the most incurable. At the one
+extreme we have the situation in our own hands, at our own terms--at the
+other, we have a record of disappointing failure. As matters stand now,
+we do not cure syphilis. We simply cloak it, gloss it over, keep it
+under the surface. Nobody knows how much syphilis is cured, partly
+because nobody knows how much syphilis there really is, and partly
+because it is almost an axiom that few, except persons of high
+intelligence and sufficient means, stick to treatment until they can be
+discharged as cured. Take into consideration, too, the fact that the
+older methods of treating syphilis were scarcely equal to the task of
+curing the disease, and it is easy to see why the idea has arisen, even
+among physicians, that once a syphilitic means always a syphilitic, and
+that the disease is incurable.
+
++Radical or Complete Cure.+--In speaking of the cure of syphilis, it is
+worth while to define the terms we use rather clearly. It is worth while
+to speak in connection with this disease of radical as distinguished
+from symptomatic cure. In a radical cure we clear up the patient so
+completely that he never suffers a relapse. In symptomatic cure, which
+is not really cure at all, we simply clear up the symptoms for which he
+seeks medical advice, without thought for what he may develop next.
+Theoretically, the radical cure of syphilis should mean ridding the body
+of every single germ of the disease. Practically speaking, we have no
+means of telling with certainty when this has been done, or as yet,
+whether it ever can be done. It may well be that further study of the
+disease will show that, especially in fully developed cases, we simply
+reduce the infection to harmlessness, or suppress it, without
+eradicating the last few germs. Recent work by Warthin tends to
+substantiate this idea. So we are compelled in practice to limit our
+conception of radical cure to the condition in which we have not only
+gotten rid of every single symptom of active syphilis in the patient,
+but have carried the treatment to the point where, so far as we can
+detect in life, he never develops any further evidence of the disease.
+He lives out his normal span of years in the normal way, and without
+having his efficiency as a human being affected by it. In interpreting
+this ideal for a given case we should not forget that radical methods of
+treating syphilis are new. Only time can pass full verdict upon them.
+Yet the efficiency of older methods was sufficient to control the
+disease in a considerable percentage of those affected. There is,
+therefore, every reason to believe that radical cure under the newer
+methods is a practical and attainable ideal in an even higher percentage
+of cases and offers all the assurance that any reasonable person need
+ask for the conduct of life. It should, therefore, be sought for in
+every case in which expert judgment deems it worth while. It cannot be
+said too often that prospect of radical cure depends first and foremost
+upon the stage of the disease at which treatment is begun, and that it
+is unreasonable to judge it by what it fails to accomplish in persons
+upon whom the infection has once thoroughly fastened itself.
+
++Symptomatic or Incomplete Cure.+--Symptomatic "cure" is essentially a
+process of cloaking or glossing over the infection. It is easy to obtain
+in the early stages of the disease, and in a certain sense, the earlier
+in the course of the disease such half-way methods are applied, the
+worse it is for patient and public. In the late stages of the disease
+symptomatic cure of certain lesions is sometimes justifiable on the
+score that damage already done cannot be repaired, the risk of infecting
+others is over, and all that can be hoped for is to make some
+improvement in the condition. But applied early, symptomatic methods
+whisk the outward evidences temporarily out of sight, create a false
+sense of security, and leave the disease to proceed quietly below the
+surface, to the undoing of its victim. Such patients get an entirely
+false idea of their condition, and may refuse to believe that they are
+not really cured, or may have no occasion even to wonder whether they
+are or not until they are beyond help. Every statement that can be made
+about the danger of syphilis to the public health applies with full
+force to the symptomatically treated early case. Trifling relapses,
+highly contagious sores in the mouth, or elsewhere, are not prevented by
+symptomatic treatment and pass unnoticed the more readily because the
+patient feels himself secure in what has been done for him. In the first
+five years of an inefficiently treated infection, and sometimes longer,
+this danger is a very near and terrible one, to which thousands fall
+victims every year, and among them, perhaps, some of your friends and
+mine. Dangerous syphilis is imperfectly treated syphilis, and at any
+moment it may confront us in our drawing rooms, in the swimming pool,
+across the counter of the store, or in the milkman, the waitress, the
+barber. It confronts thousands of wives and children in the person of
+half-cured fathers, infected nurse-maids, and others intimately
+associated with their personal life. These dangers can be effectively
+removed from our midst by the substitution of radical for symptomatic
+methods and ideals of cure. A person under vigorous treatment with a
+view to radical cure, with the observation of his condition by a
+physician which that implies, is nearly harmless. In a reasonable time
+he can be made fit even for marriage. The whole contagious period of
+syphilis would lose its contagiousness if every patient and physician
+refused to think of anything but radical cure.
+
+In such a demand as this for the highest ideals in the treatment of a
+disease like syphilis, the medical profession must, of course, stand
+prepared to do its share toward securing the best results. No one
+concedes more freely than the physician himself that, in the recognition
+and radical treatment of syphilis, not all the members of the medical
+profession are abreast of the most advanced knowledge of the subject.
+Syphilis, almost up to the present day, has never been adequately taught
+as part of a medical training. Those who obtained a smattering of
+knowledge about it from half a dozen sources in their school days were
+fortunate. Thorough knowledge of the disease, of the infinite variety of
+its forms, of the surest means of recognizing it, and the best methods
+of treating it, is only beginning to be available for medical students
+at the hands of expert teachers of the subject. The profession, by the
+great advances in the medical teaching of syphilis in the past ten
+years, and the greater advances yet to come, is, however, doing its best
+to meet its share of responsibility in preparation for a successful
+campaign. The combination of the physician who insists on curing
+syphilis, with the patient who insists on being cured, may well be
+irresistible.
+
++Factors Influencing the Cure of Syphilis.--Cost.+--We must admit that,
+as matters stand now, few patients are interested in more than a
+symptomatic cure. Yet the increasing demand for blood tests, for
+example, shows that they are waking up. Ignorance of the possibility and
+necessity for radical cure, and of the means of obtaining it, explains
+much of the indifference which leads patients to disappear from their
+physician's care just as the goal is in sight. But there is another
+reason why syphilis is so seldom cured, and this is one which every
+forward-looking man and woman should heed. The cure of syphilis means
+from two to four years of medical care. All of us know the cost of such
+services for even a brief illness. A prolonged one often sets the victim
+farther back in purse than forward in health. The better the services
+which we wish to command in these days, usually, the greater the cost,
+and expert supervision, at least, is desirable in syphilis. It is a
+financial impossibility for many of the victims of syphilis to meet the
+cost of a radical cure. It is all they can do to pay for symptomatic
+care in order to get themselves back into condition to work. We cannot
+then reasonably demand of these patients that they shall be cured, in
+the interest of others, unless we provide them with the means. In
+talking about public effort against syphilis, this matter will be taken
+up again. We have recognized the obligation in tuberculosis. Let us now
+provide for it in syphilis.
+
++Factors Controlling the Cure of Syphilis--Stage, Time, Effective
+Treatment.+--Three factors enter into the radical cure of syphilis, upon
+which the possibility of accomplishing it absolutely depends. The first
+of these concerns the stage of the disease at which treatment is begun;
+the second is the time for which it is kept up; and the third is the
+cooeperation of doctor and patient in the use of effective methods of
+treatment.
+
++Cure in the Primary Stage.+--It goes almost without saying that the
+prospect of curing a disease is better the earlier treatment is begun.
+This is peculiarly so in syphilis. In the earliest days of the disease,
+while the infection is still local and the blood test negative, the
+prospects of radical cure are practically 100 per cent. This is the
+so-called abortive cure, the greatest gift which salvarsan has made to
+our power to fight syphilis. It depends on immediate recognition of the
+chancre and immediate and strenuous treatment. So valuable is it that
+several physicians of large experience have expressed the belief that
+even in cases in which we are not entirely sure the first sore is
+syphilitic, we should undertake an abortive treatment for syphilis. This
+view may be extreme, but it illustrates how enormously worth while the
+early treatment of syphilis is.
+
++Cure in the Secondary Stage.+--The estimation of the prospect of
+recovery when the secondary symptoms have appeared and the germs are in
+the blood is difficult, owing to the rapid changes in our knowledge of
+the disease, which are taking place almost from day to day. The patient
+usually presses his physician for an estimate of his chances, and in
+such cases, after carefully explaining why our knowledge is fallible and
+subject to change, I usually estimate that for a patient who will
+absolutely follow the advice of an expert, the prospects are well over
+90 per cent good.
+
++The Outlook in Late Syphilis.+--After the first year of the infection
+is passed, or even six months after the appearance of the secondary
+rash, the outlook for permanent cure begins to diminish and falls
+rapidly from this point on. That means that we are less and less able
+to tell where we stand by the tests we now have.
+
+In the later stages of the disease we are gradually forced back to
+symptomatic measures, and are often rather glad to be able to say to the
+patient that we can clear up his immediate trouble without mentioning
+anything about his future.
+
+The gist of the first essential, then, is to treat syphilis early rather
+than late. If this is done, the prospect of recovery is better than in
+many of the acute fevers, such as scarlet fever, a matter of every day
+familiarity, and better, on the whole, than in such a disease as
+tuberculosis. _Yet this does not mean that the men or women whose
+syphilis is discovered only after a lapse of years, must be abandoned to
+a hopeless fate._ For them, too, excellent prospects still exist, and
+careful, persistent treatment may, in a high percentage of cases, keep
+their symptoms under control for years, if not for the ordinary
+life-time.
+
++The Time Required for Cure.+--Time is the second vital essential for
+cure. Here we stand on less certain ground than in the matter of the
+stage of the disease. The time necessary for cure is not a fixed one,
+and depends on the individual case. Long experience has taught us that
+the cure of syphilis is not a matter of weeks or months, as patients so
+often expect, but of years. For the cure of early primary syphilis
+("abortive" cure) not the most enthusiastic will discharge a patient
+short of a year, and the conservative insist on two years or more of
+observation at least. In the fully developed infection in the secondary
+stage, three years is a minimum and four years an average for treatment
+to produce a cure. Five years of treatment and observation is not an
+uncommon period. In the later stages of the disease, when we are
+compelled to give up the ideal of radical cure, our best advice to
+syphilitic patients, as to those with old tuberculosis, is that after
+they have had two years of good treatment, they should submit to
+examination once or twice a year, and not grumble if they are called
+upon to carry life insurance in the form of occasional short courses of
+treatment for the rest of their days.
+
++Efficient Treatment.+--The third essential is efficient treatment,
+about the nature of which there is still some dispute. The controversy,
+however, is mainly about details. In the modern methods for treatment of
+syphilis both salvarsan and mercury are used, as a rule, and keep the
+patient decidedly busy for the first year taking rubs and injections,
+and pretty busy for the second. The patient is not incapacitated for
+carrying on his usual work. The intervals of rest between courses of
+salvarsan and mercury are short. In the third year the intervals of rest
+grow longer, and in the absence of symptoms the patient has more chance
+to forget the trouble. Here the doctor's difficulties begin, for after
+two or three negative blood tests with a clear skin, all but the most
+conscientious patients disappear from observation. These are the ones
+who may pay later for the folly of their earlier years.
+
+The aim in syphilis, then, is to crush the disease at its outset by a
+vigorous campaign. Not until an amount of treatment which experience
+has shown to be an average requirement has been given, is it safe to
+draw breath and wait to see what the effect on the enemy has been.
+Dilatory tactics and compromises are often more dangerous than giving a
+little more than the least amount of treatment possible, for good
+measure. This is, of course, always provided the behavior of the body
+under the ordeal of treatment is closely studied and observed by an
+expert and that it is not blindly pushed to the point where injury is
+done by the medicine rather than the disease.
+
++The Importance of Salvarsan.+--Salvarsan is an absolute essential in
+the treatment of those early infections in which an abortive cure can be
+hoped for, and in them it must be begun without a day's delay. To some
+extent, the abortive cure of the disease, with its 100 per cent
+certainty, will therefore remain a luxury until the public is aroused to
+the necessity of providing it under safe conditions and without
+restrictions for all who need it. At all stages of the disease after the
+earliest it is an aid, and a powerful one, but it cannot do the work
+alone, as mercury usually can. But though mercury is efficient, it is
+slow, and the greater rapidity of action of salvarsan and its power to
+control infectious lesions give it a unique place. The combination of
+the two is powerful enough to fully justify the statement that none of
+the great scourges of the human race offers its victim a better prospect
+of recovery than does syphilis.
+
+Is a cure worth while? There is only one thing that is more so, and
+that is never to have had syphilis at all. The uncured syphilitic has a
+sword hanging over his head. At any day or hour the disease which he
+scorned or ignored may crush him, or what is worse, may crush what is
+nearest and dearest to him in the world. It does it with a certainty
+which not even the physician who sees syphilis all the time as his
+life-work can get callous to. It is gambling with the cards stacked
+against one to let a syphilitic infection go untreated, or treated short
+of cure. It is criminal to force on others the risks to which an
+untreated syphilitic subjects those in intimate contact with him.
+
++The Meaning of "You are Cured."+--How do we judge whether a patient is
+radically cured or not? Here again we confront the problem of what
+constitutes the eradication of the disease. In part we reckon from long
+experience, and in part depend upon the refinement of our modern tests.
+Repeated negative Wassermann tests on the blood over several years,
+especially after treatment is stopped, are an essential sign of cure.
+This must be reinforced, as a rule, by a searching examination of the
+nervous system, including a test on the fluid of the spinal cord. This
+is especially necessary when we have used some of the quick methods of
+cure, like the abortive treatment. When we have used the old reliable
+course, it is less essential, but desirable. Can we ever say to a
+patient in so many words, "Go! you are cured"? This is the gravest
+question before experts on syphilis today, and in all frankness it must
+be said that the conservative man will not answer with an unqualified
+"Yes." He will reserve the right to say to the patient that he must from
+time to time, in his own interest, be reexamined for signs of
+recurrence, and perhaps from time to time reinforce his immunity by a
+course of rubs or a few mercurial injections. Such a statement is not
+pessimism, but merely the same deliberate recognition of the fallibility
+of human judgment and the uncertainty of life which we show when we
+sleep out-of-doors after we have been suspected of having tuberculosis,
+or when we take out accident or life insurance.
+
+
+
+
+Chapter X
+
+Hereditary Syphilis
+
+
+It seems desirable, at this point, to take up the hereditary
+transmission of syphilis in advance of the other modes of transmitting
+the disease, since it is practically a problem all to itself.
+
+Syphilis is one of the diseases whose transmission from parent to child
+is frequent enough to make it a matter of grave concern. It is, in fact,
+the great example of a disease which may be acquired before birth. Just
+as syphilis is caused only by a particular germ, so hereditary syphilis
+is also due to the same germ, and occurs as a result of the passage of
+that germ from the mother's body through the membranes and parts
+connecting the mother and child, into the child. Hereditary syphilis is
+not some vague, indefinite constitutional tendency, but syphilis, as
+definite as if gotten from a chancre, though differing in some of its
+outward signs.
+
++Transmission of Syphilis From Mother to Child.+--It is a well-known
+fact that the mothers of syphilitic children often seem conspicuously
+healthy. For a long time it was believed that the child could have
+syphilis and the mother escape infection. The child's infection was
+supposed to occur through the infection of the sperm cells of the father
+with the germ of syphilis. When the sperm and the egg united in the
+mother's body, and the child developed, it was supposed to have syphilis
+contracted from the father, and the mother was supposed to escape it
+entirely in the majority of such cases. This older idea has been largely
+given up, chiefly as a result of the enormous mass of evidence which the
+Wassermann test has brought to light about the condition of mothers who
+bear syphilitic children, but themselves show no outward sign of the
+disease. It is now generally believed that there is no transmission of
+syphilis to the child by its father, the father's share of
+responsibility for the syphilis lying in his having infected the mother.
+None the less, it must be conceded that this is still debatable ground,
+and that quite recently the belief that syphilis can be transmitted by
+the father has been supported on theoretical grounds by good observers.
+
++Absence of Outward Signs in Syphilitic Mothers.+--The discovery that
+the mother of a syphilitic child has syphilis is of great importance in
+teaching us how hereditary syphilis can be avoided by preventing
+infection of the mother. It is even more important to understand because
+of the difficulty of convincing the seemingly healthy mother of a
+syphilitic child that she herself has the disease and should be treated
+for it, or she will have other syphilitic children. Just why the mother
+may never have shown an outward sign of syphilis and yet have the
+disease and bear syphilitic children is a question we cannot entirely
+answer, any more than we can explain why all obvious signs of syphilis
+are absent in some patients even without treatment, while others have
+one outbreak after another, and are never without evidence of their
+infection, unless it is suppressed by treatment. Probably at least a
+part of the explanation lies in the fact, already mentioned, that
+syphilis is a milder disease in women than in men, and has more
+opportunities for concealing its identity.
+
++Healthy Children of Syphilitic Mothers.+--If the mother of a syphilitic
+child has the disease, is it equally true that a syphilitic mother can
+never bear a healthy child? It certainly is not, especially in the late
+years of the disease, after it has spent much of its force. When the
+multitudes of germs present in the secondary period have died out,
+whether as a result of treatment or in the normal course of the disease,
+a woman who still has syphilis latent in her or even in active tertiary
+form, may bear a healthy child. Such a child may be perfectly healthy in
+every particular, and not only not have syphilis, but show no sign that
+the mother had the disease. It is in the period of active syphilis, the
+three, four, or five years following her infection, that the syphilitic
+mother is most likely to bear syphilitic children.
+
++Non-hereditary Syphilis in Children.+--Syphilis in children is not
+always hereditary, even though the signs of it appear only a short time
+after birth. A woman who at the beginning of her pregnancy was free from
+the disease, may acquire it while she is still carrying the child as a
+result of her husband's becoming infected from some outside source. The
+limitation which pregnancy may put on sexual indulgence leads some men
+to seek sexual gratification elsewhere than with their wives. The
+husband becoming infected, then infects his pregnant wife. There are no
+absolute rules about the matter, but if the mother is not infected until
+the seventh month of her pregnancy, the child is likely to escape the
+hereditary form of the disease. On the other hand, imagine the prospects
+for infection when the child is born through a birth-canal filled with
+mucous patches or with a chancre on the neck of the womb. Children
+infected in this way at birth do not develop the true hereditary form of
+the disease, but get the acquired form with a chancre and secondary
+period, just as in later life.
+
++Effect of Syphilis on the Child-bearing Woman.+--What does syphilis
+mean for the woman who is in the child-bearing period? In the first
+place, unlike gonorrhea, which is apt to make women sterile, syphilis
+does not materially reduce the power to conceive in most cases. A woman
+with active syphilis alone may conceive with great frequency, but she
+cannot carry her children through to normal birth. The syphilitic woman
+usually has a series of abortions or miscarriages, in which she loses
+the child at any time from the first to the seventh or eighth month. Of
+course, there are other causes of repeated miscarriages, but syphilis is
+one of the commonest, and the occurrence of several miscarriages in a
+woman should usually be carefully investigated. The miscarriage or
+abortion occurs because the unborn child is killed by the germs of the
+disease, and is cast out by the womb as if it were a foreign body.
+Usually the more active the mother's syphilis, the sooner the child is
+infected and killed, and the earlier in her pregnancy will she abort.
+Later in the disease the child may not be infected until well along, and
+may die only at the ninth month or just as it is born. In other words,
+the rule is that the abortions are followed later by one or more still
+births. This is by no means invariable. The mother may abort once at the
+third month, and with the next pregnancy bear a living syphilitic child.
+The living syphilitic children are usually the results of infection in
+the later months of the child's life inside its mother, or are the
+result of higher resistance to the disease on the part of the child or
+of the efficient treatment of the mother's syphilis.
+
++Variations on the Rule.+--It should never be forgotten that all these
+rules are subject to variation, and that where one woman may have a
+series of miscarriages so close together that she mistakes them for
+heavy, irregular menstrual flows, and never realizes she is pregnant,
+another may bear a living child the first time after her infection, or
+still another woman after one miscarriage may have a child so nearly
+normal that it may attain the age of twenty or older, before it is
+suspected that it has hereditary syphilis. Again a woman with syphilis
+may remain childless through all the years of her active infection, and
+finally, in her first pregnancy, give birth to a healthy child, even
+though she still has the disease in latent form herself. Still another
+may have a miscarriage or two and then bear one or two healthy children,
+only to have the last child, years after her infection, be stillborn
+and syphilitic. The series of abortions, followed by stillborn or
+syphilitic children, and finally by healthy ones, is only the general
+and by no means the invariable rule.
+
++Treatment of the Mother.+--For the mother, then, syphilis may mean all
+the disappointments of a thwarted and defeated maternity, and the
+horrors of bearing diseased and malformed children. She is herself
+subject to the risk of death from blood poisoning which may follow
+abortion. But here, as in all syphilis, early recognition and thorough
+treatment of the disease may totally transform the situation. In the old
+days of giving mercury by mouth and without salvarsan, there was little
+hope of doing anything for the children during the active infectious
+period in the mother. Now we are realizing that even while the child is
+in the womb the vigorous treatment of the mother may save the day for
+it, and bring it into the world with a fair chance for useful and
+efficient life. More especially is this true when the mother has been
+infected while carrying the child, or just before or as conception
+occurred. In these cases, salvarsan and mercury, carefully given, seem
+not only not harmful to mother and child, but may entirely prevent the
+child's getting the disease. For this reason every maternity hospital or
+ward should be in a position to make good Wassermann blood tests,
+conduct expert examinations, and give thorough treatment to women who
+are found to have syphilis. There does not seem to be any good reason
+why a Wassermann test should not be made part of the examination which
+every intelligent mother expects a physician to make at the beginning
+of her pregnancy. Such a test would bring to light some otherwise
+undiscovered syphilis, and protect the lives of numbers of mothers and
+children whose health and happiness, not to say life, are now sacrificed
+to blind ignorance.
+
++Effect of Hereditary Syphilis on the Unborn Child.+--In the effect of
+hereditary syphilis on the child, we see the most direct illustration of
+the deteriorating influence of the disease on the race. Here again we
+must allow for wide variation, dependent on circumstances and on
+differences in the course of the disease. This does not, however,
+conceal the tragedy expressed in the statement that, under anything but
+the most expert care, more than 75 per cent of the children born with
+syphilis die within the first year of life. Good estimates show that
+more often 95 per cent than fewer of untreated children die. Such
+figures as those of Still are not at all exceptional--of 187 children of
+syphilitic parents, born or unborn, 113 were lost, whether by
+miscarriage, still-birth, or in spite of treatment after they were born.
+It is estimated that not more than 28 per cent of syphilitic children
+survive their first year. Those that survive the first year seem to have
+a fighting chance for life. Statistics based on over 100,000 cases show
+that about one child in every 148 from two to twelve years of age has
+hereditary syphilis. Realizing the difficulty in recognizing the disease
+by examination alone, it is entirely safe to suppose that the actual
+figures are probably higher. The statistics given at least illustrate
+how few syphilitic children survive to be included in such an estimate.
+
++Moral Effect on the Parents.+--The real extent of the damage done by
+the disease as a cause of death in infancy is scarcely appreciated from
+figures alone. There is something more to be reckoned with, which comes
+home to every man or woman who has ever watched for the birth of a child
+and planned and worked to make a place for it in the world. The loss or
+crippling of the new-born child jars the character and morale of the
+father and mother to the root. When the object of these ideals dies,
+something precious and irreplaceable is taken from the life of the
+world. The toll of syphilis in misery, in desolation, in
+heart-breakings, in broken bonds and defeated ideals can never be
+estimated in numbers or in words.
+
++Course of Hereditary Syphilis in the Infant.+--The course of syphilis
+in the child tends to follow certain general lines. The disease, being
+contracted before birth, shows its most active manifestations early in
+life. The stillborn child is dead of its disease. The living child may
+be born with an eruption, or it may not develop it for several weeks or
+months. It is thought by some that these delayed eruptions represent
+infections at birth. Hereditarily syphilitic children are filled with
+the spirochetes, the germs of the disease. They are in every tissue and
+organ; the child is literally riddled with them. In spite of this it may
+for a time seem well. The typical syphilitic child, however, is thin,
+weak, and wasted. Syphilis hastens old age even in the strong. It turns
+the young child into an old man or woman at birth. The skin is
+wrinkled, the flesh flabby. The face is that of an old man--weazened,
+pinched, pathetic, with watery, bleary eyes, and snuffling nose. The
+mother often says that all the baby's trouble started with a bad cold.
+The disease attacks the throat, and turns the normal robust cry of a
+healthy infant into a feeble squawk. The belly may become enormously
+distended from enlargement of the internal organs, and the rest of the
+child dwindle to a skeleton. The eruptions are only a part of the
+picture and may be absent, but when they occur, are quite
+characteristic, as a rule, especially about the mouth and buttocks, and
+do not usually resemble the commoner skin complaints of infants. It is
+important to remember here that a badly nourished, sickly child with a
+distressing eczema is not necessarily syphilitic, and that only a
+physician is competent to pass an opinion on the matter. Syphilitic
+children in a contagious state are usually too sick to be around much,
+so that the risk to the general public is small. On the other hand, the
+risk to some woman who tries to mother or care for some one else's
+syphilitic child, if the disease is active, should be thoroughly
+appreciated. Women who are not specially trained or under the direction
+of a physician should not attempt the personal care of other people's
+sick children.
+
++The Wet Nurse.+--This is also the proper place to introduce a warning
+about the wet nurse. Women who must have the assistance of a wet nurse
+to feed their babies should, under no circumstances, make such
+arrangements without the full supervision of their physicians. There is
+no better method for transmitting syphilis to a healthy woman than for
+her to nurse a syphilitic child. Conversely, the healthy child who is
+nursed by a syphilitic woman stands an excellent chance of contracting
+the disease, since the woman may have sores about the nipples and since
+the germs of syphilis have been found in the milk of syphilitic women.
+The only person who should nurse a syphilitic child is its own mother,
+who has syphilis and, therefore, cannot be infected. A Wassermann blood
+test with a thorough examination is the least that should be expected
+where any exchanges are to take place. Nothing whatever should be taken
+for granted in such cases, and the necessary examinations and questions
+should not give offense to either party to the bargain. Syphilis is not
+a respecter of persons, and exists among the rich as well as among the
+poor.
+
++Hereditary Syphilis in Older Children.+--Hereditary syphilis may become
+a latent or concealed disease, just as acquired syphilis does. None the
+less, it leaves certain traces of its existence which can be recognized
+on examination. These are chiefly changes in the bones, which do not
+grow normally. The shin bones are apt to be bowed forward, not sideways,
+as in rickets. The skull sometimes develops a peculiar shape, the joints
+are apt to be large, and so on. Syphilis may affect the mental
+development of children in various ways. Perhaps 5 per cent of children
+are idiots as a result of syphilis. Certain forms of epilepsy are due to
+syphilitic changes in the brain. On the other hand, syphilitic children
+may be extraordinarily bright and capable for their years. Some are
+stunted in their growth and develop their sexual characteristics very
+late or imperfectly. It is one of the wonders of medicine to see a
+sickly runt of a child at fifteen or sixteen develop in a few months
+into a very presentable young man or girl under the influence of
+salvarsan and mercury. A few syphilitic children seem robust and healthy
+from the start. The signs of the disease may be very slight, and pass
+unrecognized even by the majority of physicians. Some of them may be
+splendid specimens of physical and mental development, but they are
+exceptional. The majority are apt to be below par, and nothing shows
+more plainly the insidious injury done by the disease than the way in
+which they thrive and change under treatment. Even those who are
+mentally affected often show surprising benefits.
+
++Destructive Changes, Bones, Teeth, Etc.+--Syphilis in children, since
+it is essentially late syphilis, may produce gummatous changes of the
+most disfiguring type, fully as extreme as those in acquired syphilis
+and resulting in the destruction or injury of important organs, and the
+loss of parts of bones, especially about the mouth and nose. Certain
+changes in the teeth, especially the upper incisors in the second set,
+are frequent in hereditarily syphilitic children, but do not always
+occur. These peg-shaped teeth are called Hutchinson's teeth. Individuals
+with hereditary syphilis who survive the early years of life are less
+likely to develop trouble with the heart, blood vessels, or nervous
+system than are those with acquired syphilis.
+
++Eye Trouble--Interstitial Keratitis.+--Two manifestations of
+hereditary syphilis are of obvious social importance. One of these is
+the peculiar form of eye trouble which such children may develop. It is
+known as interstitial keratitis, and takes the form of a gradual, slow
+clouding of the clear, transparent convex surface of the eyeball, the
+cornea, through which the light passes to reach the lens. While the
+process is active, the child is made miserable by an extreme
+sensitiveness to light, the eye is reddened, and there is pain and a
+burning sensation. When the condition passes off, the child may scarcely
+be able to distinguish light from dark, to say nothing of reading,
+finding its way about, or doing fine work. A certain amount of the
+damage, once done, cannot be repaired, although cases improve
+surprisingly if the process is still active and is properly treated. The
+course is slow, often a matter of years, and only too many patients do
+very poorly on the sort of care they can get at home. One eye case in
+every 180 has interstitial keratitis, according to reliable figures.[9]
+Of 152 with this trouble, only 60 per cent recovered useful eye-sight
+and the remaining 40 per cent were disabled partly or completely.
+Forty-three out of 71 persons lost more or less of their capacity for
+earning a living. In practically all cases it means the loss of months
+or years of school between the ages of five and ten and a permanent
+handicap in later life. These patients would belong in school-hospitals,
+if such things existed, where they could get the elaborate treatment
+that might save their eyes, and at the same time not come to a
+stand-still mentally. Any chronic inflammatory eye disease in children
+urgently needs early medical attention, and those who know of such cases
+should do what they can to secure it for them.
+
+    [9] Iglesheimer, quoted by Derby.
+
+Blindness in hereditary syphilis may, of course, take the same form that
+it does in the acquired disease, resulting from changes in the nerve of
+sight (optic nerve). This form is entirely beyond help by treatment.
+
++Ear Trouble--Nerve Deafness.+--The second important complication of
+hereditary syphilis is deafness. This occurs from changes in the nerve
+of hearing and may be present at birth or may come on many years later.
+The deaf infant is usually recognized by its failure to learn to talk,
+although it may seem perfectly normal in every other way. Again, the
+child may hear well at birth and deafness may come on in later life,--as
+late as the twentieth year,--suddenly or gradually, and become complete
+and permanent. It is often ascribed to colds or to falls and accidents
+that happen to occur at the same time. If syphilitic deafness comes on
+before the age of ten years, it is very apt to result in the child's
+forgetting how to talk, and becoming dumb as well. It goes without
+saying that children whose syphilis made them deaf at birth never learn
+to talk at all, and are therefore deaf and dumb. Very little is known
+about how many of the inmates of asylums for the deaf are hereditary
+syphilitics, but there is reason to suspect the percentage to be rather
+large. Deafness in hereditary syphilis is practically uninfluenced by
+treatment.
+
++Accident and Injury in Hereditary Syphilis.+--It is a matter of great
+importance to realize the large part played by accidents, injury, poor
+health, or lowered resistance in bringing a hidden hereditary syphilis
+to the surface. A child may show no special signs of the disease until
+some time during its childhood it has a fall which injures or bruises a
+bone or breaks a limb. Then suddenly at the place where the injury was
+done a gumma or tertiary syphilitic change will take place and the bone
+refuses to heal or unite or a large sore may develop which may be
+operated on before the nature of the condition is realized. In the same
+way a woman with hereditary syphilis may seem in perfect health, marry,
+and suddenly after the birth of her first child, even as late as her
+twenty-fifth year, may develop syphilitic eye trouble. It must be
+realized that hereditary syphilis is as treacherous as the acquired
+disease, and can show as little outward signs before a serious outbreak.
+It is part of the duty of every person who suspects syphilis in his
+family or who has it himself to let his physician know of it, for the
+sake of the help which it may give in recognizing obscure conditions in
+himself or his children.
+
++Marriage and Contagion in Hereditary Syphilis.+--In general it may be
+said that, in the matter of marriage, persons who have hereditary
+syphilis and live to adult life with good general health can, after
+reasonable treatment, marry without fear of passing on the disease.
+Hereditary syphilis apparently is not transmitted to the children as
+acquired syphilis is. Hereditary syphilis practically is not contagious
+except during the eruptions and active manifestations in infancy, such
+as the nasal discharge and the other sores in the mouth and about the
+genitals. As adults they can enter into the intimate relations of life
+without risk. Many of them, while perhaps having positive blood tests
+while the disease is active, later become negative without treatment.
+Some of them even recover from the disease to the extent that they can
+acquire it again, since there is no absolute immunity.
+
++Syphilis in Adopted Children.+--A word might well be said at this point
+on the adoption of children with hereditary syphilis. In all probability
+this is not a common occurrence, certain factors tending to diminish the
+risk. A child adopted after its second year will not be so likely to
+have the disease, since most syphilitic children die before this age is
+reached. Agencies which arrange for the adoption of children are now
+much more careful about the matter than formerly, and a Wassermann test
+on the mother and also on the child, as well as a careful history in the
+case of the mother, is frequently available. The information in regard
+to the mother is quite as important as that about the child, since the
+child may have a negative test while the mother's may be positive.
+Children who have hereditary syphilis, even in latent form, should not
+be offered for adoption, and should become a charge upon the state.
+Families in which it later develops that an adopted child was syphilitic
+should not, however, be needlessly alarmed for their own safety, since,
+from the standpoint of infectiousness, the late forms of hereditary
+syphilis are not dangerous to others. The agency from which the child
+was adopted should assume responsibility for the child if the family
+cannot meet the situation. The state of Michigan has been a pioneer in
+this country in legislation which provides for the welfare of these
+children among others. A law has been enacted making it possible to
+provide for their medical treatment for an indefinite period in the
+state hospital at Ann Arbor, at the cost of the state.
+
++Treatment of Hereditary Syphilis.+--The question of the treatment and
+cure of a person with hereditary syphilis is in many respects a
+different one from that in an acquired case. The foothold which the germ
+has in the body in hereditary syphilis is stronger even than in an
+untreated acquired case. Many of the changes produced by it are
+permanent, and the prospects of completely eradicating it are
+correspondingly small. On the other hand, the child who survives
+hereditary syphilis has probably an enormous resistance to the disease,
+which in a measure compensates for the hold which it has on him.
+Treatment in hereditary syphilis becomes an extremely difficult problem
+because it must in many cases be carried out during infancy, and for
+that reason the cooeperation of the patient cannot be secured. By
+treating the mother, we now know that we can accomplish a great deal for
+the unborn child. Once the child is born, its salvation will depend on
+unremitting care and labor. If it is skilfully treated and kept at the
+breast, it is estimated that it has even as high as ninety chances in
+one hundred of surviving to a useful life. Salvarsan can be given to
+even very small babies, and mercury also is employed with excellent
+results. Persistence and skill are essential, and for that reason, if
+possible, hereditary syphilis in active form in later childhood should
+have the advantage of occasional or prolonged treatment in special
+hospitals or sanitariums where the child could go to school while he is
+being built up and cared for. This is not like trying to salvage
+wreckage. Many syphilitic children are brilliant, and if treated before
+they are crippled by the disease, give every sign of capacity and great
+usefulness to the world. Welander, who was one of the greatest of
+European experts on syphilis, has left himself an enduring monument in
+the form of the so-called Welander homes, which have been established by
+cities like Copenhagen, Berlin, and Vienna to provide for such children
+the combined benefits of the school and the hospital. We cannot be too
+prompt in adopting similar provision for such cases in this country.
+There can be little excuse, eugenic or otherwise, for not doing the
+utmost that modern medical science is capable of for their benefit.
+
+
+
+
+Chapter XI
+
+The Transmission and Hygiene of Syphilis
+
+
+The problem of the control of syphilis as a contagious disease is the
+least appreciated and the most important one in the whole field. It
+should be the key to our whole attitude toward the disease, and once
+given its rightful place in our minds, will revolutionize our situation
+with regard to it. For that reason, while some repetition of what has
+gone before may be unavoidable, it will be worth while to gather in one
+chapter the details relating to the question of how the disease is
+spread about.
+
+Two bed-rock facts stand out as the basis for the whole discussion.
+First, for practical purposes syphilis is contagious only in the primary
+and secondary stages. Second, syphilis is transmitted only by open sores
+or lesions whose discharges contain the germs, or by objects which are
+contaminated by those discharges. Infection with syphilis by such fluids
+as the blood, milk, or spermatic fluid uncontaminated by contact with
+active lesions is at least unusual.
+
++Contagiousness in the Primary Stage.+--The chancre is always
+contagious. If it is covered with a dry crust, it is, of course, less
+so, but as soon as the crust is rubbed off, the germ-infested surface is
+exposed and the thin, watery discharge contains immense numbers of the
+organisms, especially in the first two or three weeks. This is just as
+true of a chancre on the lip or chin as on the genitals. Chancres which
+are in moist places, as in the mouth, or on the neck of the womb, or
+under the foreskin, are especially dangerous, because the moisture keeps
+the germs on the surface.
+
++Contagiousness in the Secondary Stage.+--In the secondary period, when
+the body is simply filled with germs, one would expect the risk to be
+even greater than in the primary stage. As a matter of fact, however, no
+matter how many germs there are in the body, the only ones that are
+dangerous to others are those that are able to get to the surface. A
+syphilitic nodule or hard pimple on the hand or face is not contagious
+so long as the skin is dry and unbroken over it. The sores which occur
+in the moist, warm, protected places, like the mouth, on the lips, about
+the genitals, and in the folds of the body, such as the thighs, groins,
+armpits, and under the breasts in women, are, like the chancre, the real
+sources of danger in the spread of the disease.
+
++Relatively Non-contagious Character of Late Syphilis.+--The older a
+syphilis is, the less dangerous it becomes. It is the fresh infection
+and the early years which are a menace to others. It will be recalled
+that the germs die out in the body in immense numbers after the active
+secondary period is over, so that when the tertiary stage is reached,
+there is only a handful left, so to speak. The germs in a tertiary sore
+are so few in number that for practical purposes it is safe to say they
+may be disregarded, and that for that reason late syphilis is
+practically harmless for others. Just as every syphilitic runs a gradual
+course to a tertiary period, so every syphilitic in time becomes
+non-contagious, almost regardless of treatment.
+
++The Time Element in Contagiousness.+--It is the time that it takes an
+untreated case to reach a non-infectious stage and the events or
+conditions which can occur in the interval, that perpetuate syphilis
+among us. The chancre is contagious for several weeks, and few
+syphilitics escape having some contagious secondary lesions the first
+year. These are often inconspicuous and misunderstood. They may be
+mistaken for cold sores or the lesions about the opening of the rectum
+may be mistaken for hemorrhoids, or piles. The recurrence of these same
+kinds of sores may make the patient dangerous from time to time to those
+about him, without his knowledge. It is an unfortunate thing that the
+most contagious lesions of syphilis often give the patient least warning
+of their presence in the form of pain or discomfort. While they can
+often be recognized on sight by a physician, it is sometimes necessary
+to examine them with a dark-field microscope to prove their character by
+finding the germs. It is a safer rule to regard every open sore or
+suspicious patch in a syphilitic as infectious until it is proved not to
+be so.
+
++Contagious Recurrences or Relapses.+--The duration of the infectious
+period in untreated cases and the proportion of infectious lesions in a
+given case vary a good deal and both may be matters of the utmost
+importance. Some persons with syphilis may have almost no recognizable
+lesions after the chancre has disappeared. Others under the same
+conditions may have crop after crop of them. There is a kind of case in
+which recurrences are especially common on the mucous or moist surfaces
+of the mouth and throat, and such patients may hardly be free from them
+or from warty and moist growths about the genitals during the first five
+years of the disease, unless they are continuously and thoroughly
+treated. Irritation about the genitals and the use of tobacco in the
+mouth encourage the appearance of contagious patches. Smokers, chewers,
+persons with foul mouths and bad teeth, and prostitutes are especially
+dangerous for these reasons.
+
++Average Contagious Period.+--It is a safe general rule, the product of
+long experience, to consider a person with an untreated[10] syphilis as
+decidedly infectious for the first three years of his disease, and
+somewhat so the next two years. The duration of infectiousness may be
+longer, although it is not the rule. It must be said, however, that more
+exact study of this matter since the germ of syphilis was discovered has
+tended to show that the contagious period is apt to be longer than was
+at first supposed, and has taught us the importance of hidden sores in
+such places as the throat and vagina.
+
+    [10] The control of infectiousness in syphilis through treatment is
+    considered in the next chapter.
+
+    [Illustration: FRITZ SCHAUDINN [1871-1906]
+
+    (From the "Galerie hervorragender Aerzte und Naturforscher."
+    Supplement to the Muenchener med. Wochenschrift, 1906. J. F. Lehmann,
+    Munich.)]
+
++Individual Resistance to Infection.+--The contagiousness of untreated
+syphilis is influenced by two other factors besides the mere lapse of
+time. The first of these is the resistance or opposition offered to
+the germ by the person to whom the infection is carried. The second is
+the feebleness of the germ itself, and the ease with which it dies when
+removed from the body. In regard to the first of these factors, while
+natural resistance to the disease in uninfected persons is an uncertain
+quantity, it is very probable that it exists. It is certain that the
+absence of any break in the skin on which the germs are deposited makes
+a decided difference if it does not entirely remove the risk of
+infection. A favorable place for the germ to get a foothold is a matter
+of the greatest importance. When, however, it is remembered that such a
+break may exist and not be visible, it is evident that little reliance
+should be placed on this factor in estimating the risk or possibility of
+infection.
+
++Transmission by Infected Articles.+--The feebleness of the germ and the
+ease with which it is destroyed are its redeeming qualities. This is of
+special importance in considering transmission by contact with infected
+articles. Nothing which is absolutely dry will transmit syphilis.
+Moisture is necessary to infection with it, and only articles which have
+been moistened, such as dressings containing the discharges, and
+objects, such as cups, eating utensils, pipes, common towels, and
+instruments which come in contact with open sores or their discharges,
+are likely to be dangerous. Moreover, even though these objects remain
+moist, the spirochetes are likely to die out within six or seven hours,
+and may lose their infectiousness before this. Smooth, non-absorbent
+surfaces, especially of metal, are unfavorable for the germ.
+Wash-basins, dishes, silverware, and toilet articles are usually
+satisfactorily disinfected by hot soapsuds, followed by drying. Barbers,
+dentists, nurses, and physicians who take care at least to disinfect
+instruments and other objects brought into contact with patients with
+carbolic acid and alcohol will never transmit syphilitic infection to
+others. Toilet-seats, bath-tubs, and door-knobs, although theoretically
+dangerous, are practically never so, and syphilitic infection
+transmitted by them can be dismissed as all but unknown. This is in
+marked contrast to gonorrhea, which in the case of little girls can be
+transmitted apparently by toilet-seats. Much depends, as has been said,
+on placing the germ on a favorable ground for inoculation, and the bare
+skin, unless the virus is massaged or rubbed in, is certainly not a
+favorable situation. Many experts do not hesitate to handle infectious
+lesions with the fingers provided the skin is not broken, relying simply
+on the immediate use of soap and water, and perhaps alcohol, to remove
+the germ. While this may be a risk, it should, none the less, reassure
+those who are inclined to an unreasoning terror of infection whenever
+they encounter the disease.
+
++Transmission Under the Conditions of Every-day Life.+--The question of
+just how dangerous the worker with foodstuffs may be to others when he
+has active contagious lesions is unsettled. Recent surveys of various
+types of workers have tended to show that syphilis in transmissible form
+is not especially prevalent among them. The same general principle
+applies here as elsewhere. The risk of infection with syphilis
+increases with dirty and unsanitary conditions, and becomes serious when
+there is opportunity for moist materials to be transferred to sensitive
+surfaces, like the mouth, sufficiently soon after they have left the
+syphilitic person for the germs to be still alive. That the real extent
+of the risk is not known does not make it any the less important that
+persons who have opportunity to handle materials in which this may occur
+should be subject to frequent sanitary inspection. Restaurants in which
+the silverware is not properly cleaned, and is used over and over at
+frequent intervals, and in which there is a careless and unsanitary type
+of personal service, can hardly be regarded as safe. While there is no
+need for hysterical alarm over such possibilities, it is just as well to
+provide for them. Crowding, close quarters, and insufficient sanitary
+conveniences in stores and offices, in restaurants or tenements, provide
+just the conditions in which accidental infection may occur. A gang of
+men with a common bucket and drinking cup may be at the mercy of
+syphilis if one member is in a contagious condition. A syphilitic might
+cough into the air with little risk, since the germs would die before
+they could find a favorable place to infect. But a syphilitic who coughs
+directly into one's face with a mouth full of spirochetes multiplies the
+risk considerably. The public towel is certainly dangerous--almost as
+much so as the common drinking cup. The possibility of syphilitic
+infection by cutting the knuckle of the hand against the teeth of an
+opponent in striking a blow upon his mouth should not be overlooked, and
+the occurrence is common enough for this type of chancre to have
+received the special name of brawl, or fist, chancre.
+
++Accidental Syphilis in Physicians and Nurses.+--Another type of
+infection ought not to go unmentioned--that to which physicians and
+nurses are exposed in operating on or handling patients with active
+syphilis. Before the day of rubber gloves such things were much more
+common perhaps than they are now, yet they are common enough at the
+present time. Most of the risk occurs in exploring or working in
+cavities of the body containing infected discharges. The blood may
+become infected in passing over active sores. The risk from all these
+sources is so considerable that it is justifiable as a measure of
+protection to a hospital staff to take a blood test on every patient who
+applies for treatment in a hospital, to say nothing of the advantage
+which this would be to the patient.
+
++Transmission by Intimate Contacts--Kissing.+--As we pass from the less
+to the more intimate means of contact between the syphilitic person and
+others, the risk of transmitting syphilis may be said to increase
+enormously. The fundamental conditions of moisture, a susceptible
+surface, protection of the germ from drying and from air, and possibly
+also massage or rubbing, are here better satisfied than in the risks
+thus far considered. Kissing, caresses, and sexual relations make up the
+origin of an overwhelming proportion of syphilitic infection. Infections
+are, of course, traceable to the nursing of syphilitic infants. It is
+through these sources of contact that syphilis invades the family
+especially. Many a syphilitic who realizes that he should not have
+sexual relations with his wife while he has the disease in active form
+will thoughtlessly infect her or his children by kissing. Kissing games
+are potentially dangerous, and a classical example of this danger is
+that of a reported case[11] in which a young man in Philadelphia
+infected seven young girls in one game, all of whom developed chancres
+on the lips or cheeks. It is no great rarity to find a syphilis dating
+from a sore on the lip that developed while a young couple were engaged.
+Certainly the indiscriminate kissing of strangers is as dangerous an
+indulgence as can be imagined. Syphilis does not by any means invariably
+follow a syphilitic's kiss, but the risk, although not computable in
+figures, is large enough to make even the impulsive pause. The
+combination of a cold sore or a small crack on the lip of the one and a
+mucous patch inside the lip of the other brings disaster very near.
+Children are sometimes the unhappy victims of this sort of thing, and it
+should be resented as an insult for a stranger to attempt to kiss
+another's child, no matter on what part of the body. It would be easy to
+multiply instances of the ways in which syphilis may be spread by the
+careless or ignorant in the close associations of family life, but
+little would be accomplished by such elaboration that would not occur to
+one who took the trouble to acquaint himself with the principles already
+discussed.
+
+    [11] Schamberg, J. F.: "An Epidemic of Chancres of the Lip from
+    Kissing," Jour. Amer. Med. Assoc., 1911, lvii, 783.
+
++The Sexual Transmission of Syphilis.+--The sexual transmission of
+syphilis is beyond question the most important factor in the spread of
+the disease. Here all the essential conditions for giving the germ a
+foothold on the body are satisfied. The genitals are especially fitted
+to keep the germs in an active condition because of the ease with which
+air is excluded from the numerous folds about these parts. It is
+remarkable what trifling lesions can harbor them by the million, and how
+completely, especially in the case of women, syphilitic persons may be
+ignorant of the danger for others. Sexual transmission of syphilis is
+simply a physiologic fact, and in no sense to be confounded with
+questions of innocence and guilt in relation to the acquiring of the
+disease. A chancre acquired from a drinking cup or pipe may be
+transmitted to husband or wife through a mucous patch on the genitals
+and to children through an infected mother, without the question of
+innocence or guilt ever having arisen. On the other hand, chancres on
+parts other than the genitals may be _acquired in any but innocent
+ways_. It is impossible to be fair or to think clearly so long as we
+allow the question of innocence or guilt to color our thought about the
+genital transmission of syphilis. That syphilis is so largely a sexually
+transmitted disease is an incidental rather than the essential fact from
+the broadly social point of view. We should recognize it only to the
+extent that is necessary to give us control over it--not allow it to
+hold us helplessly in its grip because we cannot separate it from the
+idea of sexual indiscretion. There is a form of narrow-minded
+self-righteousness about these things that sets the stamp of vice on
+innocent and guilty alike simply on the strength of the sexual
+transmission of syphilis. In the effort to avoid so mistaken and
+heartless a view, we cannot remind ourselves too often that syphilis is
+a disease and not a crime, and as such must be approached with the
+impulse to heal and make whole, and not to heap further misfortune on
+its victim or take vengeance on him.
+
++Extragenital and Marital Syphilis.+--Estimates of the ratio of genital
+to non-genital or so-called extra-genital infection in syphilis vary a
+good deal, and are largely the products of the clinical period in the
+history of the disease before the days of more exact methods of
+detecting its presence. The older statistics estimate from 5 to 10 per
+cent of all syphilitic infections to be of non-genital origin, while the
+remaining 90 per cent are genital. As we become better able to recognize
+hidden syphilis, we shall probably find that the percentage of
+non-genital infections will increase.
+
+The physician's suspicions are easily aroused by a genital sore, less so
+by one on the lip or the tonsil, for example. The same thing is true of
+the layman. Syphilis which starts from a chancre elsewhere than on the
+genitals runs the same course and may conceal itself quite as
+effectively as syphilis from the usual sources, and for that reason may
+even more easily escape notice because misinterpreted at the start. It
+is my personal impression that careful study of patients with syphilis,
+and of those who live with them, would bring to light many overlooked
+extragenital infections, especially among those who are the victims of
+crowding, poor living conditions, and ignorance. Estimates on the amount
+of syphilis which is contracted in marriage are apt to be largely
+guesswork in the absence of reliable vital statistics on the disease.
+Fournier believed that 20 per cent of syphilis in women was contracted
+in marriage. So much syphilis in married women is unsuspected, and so
+little of what is recognized is traceable to outside sources, that 50
+per cent seems a nearer estimate than twenty.
+
+
+
+
+Chapter XII
+
+The Transmission and Hygiene of Syphilis (Continued)
+
+
+THE CONTROL OF INFECTIOUSNESS IN SYPHILIS.--SYPHILIS AND MARRIAGE
+
++Means for Controlling Infectiousness.+--The usual method of controlling
+a very contagious disease, such as scarlet fever or measles, is to put
+the patient off by himself with those who have to care for him and to
+keep others away--that is, to quarantine them. This works very well for
+diseases which run a reasonably short course, and in which contagious
+periods are not apt to recur after the patient has been released. But in
+diseases such as tuberculosis and syphilis, in which contagiousness may
+extend over months and years, such a procedure is evidently out of the
+question. We cannot deprive a patient of his power to earn a living, to
+say nothing of his liberty, without providing for his support and for
+that of those who are dependent on him. To do this in so common a
+disease as syphilis would involve an expenditure of money and an amount
+of machinery that is unthinkable. Accordingly, as a practical scheme for
+preventing its spread, the quarantine of syphilis throughout the
+infectious period is out of the question. We must, therefore, consider
+the other two means available for diminishing the risk to others. The
+first of these, and the most important, is to treat the disease
+efficiently right from the start, so that contagious sores and patches
+will be as few in number as possible, and will recur as little as
+possible in the course of the disease. This will be in effect a
+shortening of the contagious period, and should be recognized as one of
+the great aims of treatment. The second means will be to teach the
+syphilitic and the general public those things which one who has the
+disease can do to make himself as harmless as possible to others. This
+demands the education of the patient if we hope for his cooeperation, and
+demands also the cooeperation of those around him in order that the
+pressure of public sentiment may oblige him to do his part in case he
+does not do it of his own free will.
+
++Control of Infectiousness by Treatment--Importance of Salvarsan.+--In a
+disease which yields so exceptionally well to treatment as syphilis, a
+great deal can be done to shorten the contagious period. Especially is
+this so when we are able to employ an agent such as salvarsan, which
+kills off the germs on the surface within twenty-four hours after its
+injection. When a patient is discovered to be in a contagious state, in
+a large majority of cases the risk to the community which he represents
+can be quickly eliminated, at least for the time being. Combining the
+use of mercury and salvarsan in accordance with the best modern
+standards, the actively contagious period as a whole can be reduced in
+average cases from a matter of years to one of a few weeks or months.
+Certainly, so far as recognizable dangerous sores are concerned,
+periodic examination, with salvarsan whenever necessary, would seem to
+dispose of much of the difficulty.
+
++Obstacles to Control by Treatment.+--There are, however, obstacles in
+the way of complete control of infectiousness by treatment. For example,
+one might ask whether a single negative blood test would not be
+sufficient assurance that the patient was free from contagious sores. It
+is, however, a well-recognized fact that a person with syphilis may
+develop infectious sores about the mouth and the genitals even while the
+blood test is negative. An examination, moreover, is not invariably
+sufficient to determine if a patient is in a contagious state. The value
+of an examination depends, of course, entirely on its thoroughness and
+on the experience of the physician who makes it. It is only too easy to
+overlook one of the faint grayish patches in the mouth or a trifling
+pimple on the genitals. The time and special apparatus for a microscopic
+examination are not always available. Moreover, contagious lesions come
+and go. One may appear on the genitals one day and a few days later be
+gone, without the patient's ever realizing that it was there--yet in
+this interval a married man might infect his wife by sexual contact. The
+patient with a concealed syphilis often lacks even the incentive to seek
+examination by a doctor. It is important also to realize that when
+mercury has to be the only reliance, the risk of infection cannot be
+entirely controlled by treatment. Contagious sores may develop even
+during a course of mercurial injections, especially in early cases. It
+requires the combination of mercury and salvarsan to secure the highest
+percentage of good results.
+
++The Five-year Rule.+--The truth of the matter is that, as Hoffmann
+says, no treatment can _guarantee_ the non-infectiousness of a
+syphilitic in the first five years of his disease. Time is thus an
+essential element in pronouncing a person non-infectious and hence in
+deciding his fitness for marriage, for example. The person with active
+syphilis who has intimate relations with uninfected persons, who will
+not abandon smoking or take special precautions about articles of
+personal use which are likely to transmit the disease, is unsafe no
+matter what is done for him. In spite of this qualifying statement it
+may be reiterated, however, that good treatment with salvarsan and
+mercury reduces the risk of infecting others in the ordinary relations
+of life practically to the vanishing point, and of course reduces, but
+not entirely eliminates, the dangers of the intimate contacts.
+
++Personal Responsibility of the Patient.+--If we are compelled then to
+fall back to some extent upon the personal sense of responsibility of
+the patient himself to fill in the gap where treatment does not entirely
+control the situation, it becomes increasingly important that in the
+irresponsible and ignorant, when the patient fails to meet his
+obligation, we should push treatment to the uttermost in our effort to
+prevent the spread of the disease. To supply this necessary treatment to
+every syphilitic who cannot afford it for himself, and make it
+obligatory, if need be, will be a long step forward in the control of
+the disease. The educational campaign for it is well under way all over
+the world, and the money and the practical machinery will inevitably
+follow. We have the precedents of the control of tuberculosis, smallpox,
+malaria, and yellow fever to guide us, to say nothing of a practical
+system against sexual disease already in operation in Norway, Sweden,
+Denmark, and Italy.
+
++Syphilis and Marriage.+--The problem of the relation of syphilis to
+marriage is simply an aspect of the transmission of an infectious
+disease. The infection of one party to the marriage by the other and the
+transmission of that infection to children summarizes the social
+problem. Through the intimate contacts of family life, syphilis attacks
+the future of the human race.
+
++Estimated Risk of Infecting the Wife.+--How serious is the risk of
+infecting the wife if a man should marry during the contagious period of
+syphilis? This will depend a good deal on the frequency of relapses
+after the active secondary stage. On this point Sperk estimated that in
+1518 patients, only ten escaped relapses entirely. These were, however,
+not patients that had been specially well treated. Keyes, quoted by
+Pusey, estimated, on the basis of his private records, that the chances
+taken by a syphilitic husband who used no special precautions to prevent
+infecting his wife were twelve to one the first year in favor of
+infection, five to two the second year, and one to four the third year,
+being negligible after the fourth year.
+
++Syphilis in the Father.+--Even while we recognize the infection of
+women and children as the greatest risk in marriage we should not lose
+sight of the cost to society which syphilis in the father of the family
+himself may entail. For such a man to be stricken by some of the serious
+accidents of late syphilis throws his family as well as himself upon
+society. A syphilitic infection which has not been cured not only makes
+a man a poor risk to an insurance company, but a poor risk to the family
+which has to look to him for support and for his share and influence in
+the bringing up of the children. A sufficient number of men and women in
+the thirties and forties are crippled, made dependent, or lost to the
+world entirely, to make the responsibilities of the family when assumed
+by persons with untreated or poorly treated syphilis a matter of some
+concern, whether or not they are still able to transmit the disease to
+others.
+
++The Time-treatment Principle and the Five-year Rule.+--In setting a
+modern standard for the fitness of syphilitics for marriage it may be
+said at the outset that there is little justification for making the
+mere fact of a previous syphilitic infection a permanent bar in the
+majority of cases. The risk of economic disaster to the parent and
+wage-earner, and the risk of transmission of the disease to the partner
+and the children, are both controllable by a combination of efficient
+treatment and time. The man who has conformed to the best practice in
+both particulars may usually marry and have healthy children. The woman
+under the same circumstances need not fear that the risk of having
+offspring injured by her disease is any greater than the risk that they
+will be injured by any other of the unforeseen risks that surround the
+bringing of a child into the world. A vast experience underlies what
+might be called the time-treatment principle on which permission to
+marry after syphilis should be based. It has recently been ably
+summarized again, and with commendable conservatism, by Hoffmann in the
+rule that a syphilitic who has been efficiently treated by modern
+standards, with mercury and salvarsan, over a period of two to three
+years, and who has remained free from all symptoms and signs of the
+disease for two years after all treatment was stopped, including
+negative blood and spinal fluid tests, may marry in from four to five
+years from the beginning of his infection. Variations of this rule must
+be allowed only with great conservatism, since salvarsan, on whose
+efficiency many pleas for a shortening of probation have been based, is
+still too recent an addition to our implements of warfare to justify a
+rash dependence upon it. The abortive cure in relation to marriage is a
+problem in itself, and the shortening of time allowed in such cases must
+be individually determined by an expert who has had the case in charge
+from the beginning, and not, at least as yet, by the average doctor.
+Such a standard as this for the marriage of persons who have had
+syphilis steers essentially a middle course between those who condemn
+syphilitics to an unreasonable and needless deprivation of all the joys
+of family life, and those who are too ready to take our conquest of
+syphilis for granted and to cast to the winds centuries of experience
+with the treachery of the disease.
+
+Even while we concede the value of generations of experience with
+syphilis in determining the probable risk of infection, it is a duty to
+investigate thoroughly by the modern methods, such as the Wassermann
+blood test, the condition of all members of a family in which syphilis
+has appeared. This means, for example, that even though the husband with
+syphilis may have married years after the usual period of infectiousness
+has passed, his wife, though outwardly healthy, should have a Wassermann
+test, and his children would be none the worse for an examination, even
+though they seem normal. Syphilis is an insidious disease, a consummate
+master of deceit, able to strike from what seems a clear sky. The latest
+means for its recognition have already revolutionized some of our
+conceptions of its dangers and its transmission. It is only common
+prudence to take advantage of them in every case, to forestall even the
+remotest possibility of mistake or oversight.
+
+Where both husband and wife have had syphilis, even though both are past
+the infectious stage, both should be treated, and a complete cure for
+the wife is advisable before they undertake to have children. This must
+mean an added burden of responsibility on both physician and patient,
+and one extremely difficult to meet under existing conditions. A
+reliable means of birth control used in such cases would place the
+problem in women on a par with that in men, and give the physician's
+insistence on a complete cure for the woman a reasonable prospect of
+being needed. Where his advice is disregarded and a pregnancy results,
+the woman should be efficiently treated while she is carrying the child.
+
++Syphilis and Engagements to Marry.+--If a five-year rule is to be
+applied to marriage, a similar rule should cover the engagement of a
+syphilitic to marry, and it should cover the sexual relations of married
+people who acquire syphilis. It is not too much to expect that an
+engaged person who contracts syphilis shall break his engagement, and
+not renew it or contract another until by the five-year rule he would be
+able to marry with safety.
+
+Engagements nowadays may well be thought of as equivalent to marriage
+when the question of syphilis is considered. They not infrequently offer
+innumerable opportunities for intimacies which may or may not fall short
+of actual sexual relations. Attention has been called to this situation
+by social workers among wage-earning girls. It has been a distressingly
+frequent experience in my special practice to find that the young man,
+overwrought by the excitement of wooing, has exposed himself elsewhere
+to infection and unwittingly punished the trustfulness of his fiancee by
+infecting her with syphilis through a subsequent kiss. The publication
+of banns before marriage is worth while, and unmistakable testimony as
+to the character and health of the parties concerned might well be
+exchanged before a wooing is permitted to assume the character of an
+engagement. It is of little use to say that a Wassermann and a medical
+examination should be made before marriage, when the damage may be done
+long before that point is reached.
+
++Medical Examination for Syphilis before Marriage.+--How shall we
+recognize syphilis in a candidate for marriage? The prevailing idea is
+to demand a negative Wassermann test. Assuredly this is good as far as
+it goes, but it is not so reliable as to deserve incorporation into law
+as sole sufficient evidence of the absence of syphilis, as has been done
+in one state. From what has been said, it is plain that a single
+negative Wassermann is no proof of the absence of syphilis. The subject
+must be approached from other angles, and when syphilis may be
+suspected, the question should be decided _by an expert_. A thorough
+general or physical examination is desirable, and if this reveals
+suspicious signs, such as scars, enlarged glands, etc., it is then
+possible to investigate the Wassermann report more thoroughly by
+repeating the test, sending it to another expert for confirmation. In
+some cases it may even be necessary to insist that the patient submit to
+a special test, called the provocative test, in which a small injection
+of salvarsan is used to bring out a positive blood test if there is a
+concealed syphilis. These are, of course, measures which are seldom
+necessary except in patients who have had the disease. Much depends on
+the attitude of the patient toward the examination and his willingness
+to cooeperate. A resourceful physician can usually settle the question of
+a person's fitness for marriage, and the result of a reliable
+examination offers a reasonable assurance of safety.
+
++Laws Crippling Physicians in Such Matters.+--What shall the physician
+do when confronted with positive evidence that a patient who is about to
+marry has an active syphilis? It is important for laymen to understand
+that the law relating to professional confidence between physician and
+patient ties the hands of the physician in such a situation. For the
+doctor to tell the relatives of the healthy party to such an intended
+marriage that the other has active syphilis would make him subject to
+severe penalties in many states for a violation of professional
+confidence, or to suit for libel. Of course, if the patient has agreed
+to submit to examination to determine his fitness for marriage, the
+physician's path is clear, but if the condition is discovered in
+ordinary professional relations, there is nothing to be done except to
+try to persuade the patient not to marry--advice he usually rejects. To
+this blind policy of protecting the guilty at the expense of the
+innocent an immeasurable amount of human efficiency and happiness has
+been sacrificed. Fortunately there are signs of an awakening. For
+example, Ohio has recently amended the law so as to permit a physician
+to disclose to the parties concerned that a person about to be married
+has a venereal disease (Amendment to Section 1275, General Code, page
+177). This is preventive legislation, as distinguished from the old
+policy of locking the stable door after the horse was stolen by laws
+punishing one who infects another with a venereal disease after
+marriage has been contracted. Recent Supreme Court decisions (Wisconsin)
+have also taken the ground that a venereal disease existing at the time
+of marriage and concealed from the other party is ground for annulment
+of the marriage, provided the uninfected party ceases to have marital
+relations as soon as the fact is discovered.
+
+The problem of syphilis in its relation to marriage is, of course, a
+serious one. It is safe to say that it will never be completely met
+except by a vigorous general public program against syphilis as a
+sanitary problem. It is by no means so serious, however, that it need
+lead clean young men and women to remain single for fear they will
+encounter it. The medical examination of both parties before marriage,
+efficiently carried out by disinterested experts, each perhaps of the
+other's appointing, is the best insurance a man and woman can secure at
+the present day against the risk that syphilis will mar their
+happiness.[12]
+
+    [12] The problem of gonorrhea is not considered in the framing of
+    this statement.
+
+
+
+
+Chapter XIII
+
+The Transmission and Hygiene of Syphilis (Continued)
+
+
+SYPHILIS AND PROSTITUTION
+
+In taking up the consideration of the relation of syphilis to illicit
+sexual relations, we must again remind ourselves that we are approaching
+this subject, not as moralists, important though their point of view may
+be, but for the time being as sanitarians, considering it from the
+standpoint of a method of transmission of a contagious disease.
+
++Genital and Non-genital Syphilis in Lax Individuals.+--The prevalence
+of syphilis among women who receive promiscuous attentions is enormous.
+It is practically an axiom that no woman who is lax in her relations
+with men is safe from the danger of the disease, or can long remain free
+from it. The type of man who is a Light o' Love does not go far before
+he meets the partner who has been infected by some one else. Becoming
+infected himself, he passes on his infection to his next partner.
+Syphilis is not so often transmitted in prostitution, open or secret, as
+gonorrhea, but it is sufficiently so to make the odds overwhelmingly
+against even the knowing ones who hope to indulge and yet escape. The
+acquiring of syphilis from loose men or women is usually thought of as
+entirely an affair of genital contacts. Yet it is notable that
+extra-genital chancres are the not uncommon result of liberties taken
+with light women which do not go to the extent of sexual relation. Women
+who accept intimacies of men who, while unwilling to commit an outright
+breach of decency, will take liberties with a woman who will accept them
+have only themselves to blame if it suddenly develops that the infection
+has been transmitted from one to the other by kisses or other supposedly
+mild offenses against the proprieties.
+
++Syphilis Among Prostitutes.+--As to the prevalence of syphilis among
+both public and clandestine or secret prostitutes, several notable
+surveys of more or less typical conditions have been made. With the aid
+of the Wassermann test much heretofore undiscovered syphilis has been
+revealed. Eighty to 85 per cent of prostitutes at some time in their
+careers acquire the disease.[13] About half this number are likely to
+have active evidence of the disease. Thirty per cent of the prostitutes
+investigated by Papee in Lemberg were in the most dangerous period--the
+first to the third year of the disease. Three-fourths of these dangerous
+cases were in women under twenty-five years of age--in the most
+attractive period of their lives. Averaging a number of large European
+cities, it was found that not more than 40 per cent of prostitutes were
+even free of the outward signs of syphilis, to say nothing of what
+laboratory tests might have revealed. It is more than evident that
+prostitution is admirably fitted to play the leading role in the
+dissemination of this disease. The young and attractive prostitute,
+whether in a house of ill-fame, on the street, or in the more secret and
+private highways and by-ways of illicit sexual life, is the one who
+attracts the largest number with the most certain prospect of infecting
+them.
+
+    [13] The figures here given are based on those of Papee, Wwednesky,
+    Raff, Sederholm, and others. The recently published investigations
+    of the Baltimore Vice Commission showed that 63.7 per cent of 289
+    prostitutes examined by the Wassermann test had syphilis. Of 266
+    examined for gonorrhea, 92.1 per cent showed its presence. Nearly
+    half the girls examined had both diseases and only 3.39 per cent had
+    neither. (Survey, March 25, 1916, Vol. 35, p. 749.)
+
++Concealed Syphilis and Medical Examinations of Prostitutes.+--A number
+of delusions center around the relation of open and secret prostitution
+to disease. From the description of syphilis given in the foregoing
+pages, it must be apparent how little reliance can be placed, for
+example, on the ordinary medical examination of prostitutes as practised
+in segregated districts. The difficulties of efficient examination are
+enormous, especially in women. Even with the best facilities and a high
+degree of personal skill, with plenty of time and laboratory help in
+addition, extremely contagious syphilis can escape observation entirely,
+and even the negative result of one day's examination may be reversed by
+the appearance of a contagious sore on the next. Women can transmit
+syphilis passively by the presence of infected secretions in the genital
+canal even when they themselves are not in a contagious state. In the
+same way a woman may find herself infected by a man without any idea
+that he was in an infectious state. She may in turn develop active
+syphilis without ever realizing the fact. Medical examination of
+prostitutes as ordinarily carried out does actual harm by deluding both
+the women and their partners into a false sense of security. The life
+which such women lead, with the combination of local irritation,
+disease, and fast living, makes them especially likely to develop the
+contagious mucous patches, warts, and other recurrences, and to relapse
+so often that there can be little assurance that they are not contagious
+all the time.
+
+Under such circumstances one might almost expect every contact with a
+prostitute on the part of a non-syphilitic individual to result in a new
+infection. The factors which interfere to prevent such wholesale
+disaster are the same which govern infectiousness throughout the
+disease. Local conditions may be unfavorable, even though the germs are
+present, or there may be no break in the skin for the germs to enter. If
+the syphilitic individual is beyond the infectious period, there may be
+no dangerous lesions. Here, as all through the history of infections
+with syphilis, there is an element of the unexpected, a favoring
+combination of circumstances. Sometimes when infection is most to be
+expected it is escaped, and conversely it seems at times that in the
+"sure thing," the "safe chance," and the place where infection seems
+most improbable, it is most certain to occur.
+
+
+PERSONAL HYGIENE IN SYPHILIS
+
+Syphilis is a constitutional disease, affecting in one way or another
+the whole body. For that reason, measures directed to improving the
+general health and maintaining the resistance of the patient at the
+highest point have an important place in the management of the disease.
+By his habits and mode of life a person with syphilis does much to help
+or hinder his cure, and to protect or endanger those around him. For
+that reason a statement of general principles may well be drawn up to
+indicate what is desirable in these regards.
+
++A Well-balanced Life.+--First, for his own sake, a syphilitic should
+live a well-balanced and simple life so far as possible. In this disease
+the organs and structures of the body which are subject to greatest
+strain are the ones most likely to suffer the serious effects of the
+disease. Worry and anxiety, excessive mental work, long hours without
+proper rest, strain the nervous system and predispose it to attack.
+Excessive physical work, fatigue, exhaustion, poor food, bad air,
+exposure, injure the bodily resistance. Excesses of any kind are as
+injurious as deprivation. In fact, it is the dissipated, the high
+livers, who go to the ground with the disease even quicker than those
+who have to pinch.
+
++Alcohol.+--Alcohol in any form, in particular, has been shown by
+extensive experience, especially since the study of the nervous system
+in syphilis has been carried to a fine point, to have an especially
+dangerous effect on the syphilitic. Alcohol damages not only the nervous
+system, but also the blood vessels, and makes an unrivaled combination
+in favor of early syphilitic apoplexy, general paresis, and locomotor
+ataxia. A syphilitic who drinks at all is a bad risk, busily engaged in
+throwing away his chances of cure. Even mild alcoholic beverages are
+undesirable and the patient should lose no time in dropping them
+entirely.
+
++Tobacco.+--Tobacco has a special place reserved for it as an
+unfavorable influence on the course of syphilis. It is dangerous to
+others for a syphilitic to smoke or chew because, more than any other
+one thing, it causes the recurrence of contagious patches in the mouth.
+It is remarkable how selfish many syphilitic men are on this point. In
+spite of the most positive representations, they will keep on smoking.
+Not a few of them pay for their selfishness with their lives. These
+mucous patches in the mouth, often called "smoker's patches," predispose
+the person who develops them to one of the most dangerous forms of
+cancer, which is especially likely to develop on tissues, like those of
+the mouth and tongue, which have been the seat of these sores.
+
++Sexual Relations, Kissing, Etc.--Contagious Sores.+--Sexual indulgence,
+kissing, and other intimate contacts during the active stage of
+syphilis, as has been indicated, directly expose others to the risk of
+getting the disease. For that reason they should not be indulged in
+during the first two years of the average well-treated case receiving
+salvarsan and mercury by the most modern methods. Exceptions to this
+rule should be granted only by the physician, and should be preceded by
+careful and repeated examination in connection with the treatment. Under
+no circumstances should a patient kiss or have intercourse if there is
+even the slightest sore or chafe on the parts, regardless of whether or
+not it is thought to be syphilitic.
+
++Articles of Personal Use.+--Persons with a tendency to recurrences in
+the mouth or elsewhere should report to the physician any sore they may
+discover and should watch for them. Persons with syphilitic sores in the
+mouth or elsewhere should have their own dishes, towels, toilet
+articles, shaving tools, pipes, silverware, and personal articles, and
+should not exchange or permit others to use them.
+
++Secrecy.+--Professional secrecy is something to which the syphilitic is
+most certainly entitled when it can be had without danger to the public
+health. So long as a syphilitic in the contagious period carefully
+observes the principles which ought to govern him in his relations to
+others, his condition is his own concern. But there is one person within
+the family who should, as a rule, know of his infection if it is still
+in the contagious period, since it is almost impossible to secure
+cooeperation otherwise. No matter how painful it may be, a person with
+syphilis, if advised to do so by his physician, should tell husband or
+wife the true state of affairs. There is no harder duty, often, and none
+which, if manfully performed, should inspire more respect. For those who
+will not follow his advice in this matter the physician cannot assume
+any responsibility, and is fully justified, and in fact wise, if he
+decline to undertake the case.
+
++Re-infection.+--Since it is a common misconception, it cannot be said
+too forcibly that no person with syphilis should forget that his having
+had the disease does not confer any immunity, and that as soon as he is
+cured he may acquire it again. It is possible, by a single exposure to
+infection, to undo the whole effect of what has been done, just after a
+cure is accomplished. There can be only one safe rule for infected as
+well as uninfected persons--to keep away from the risk of syphilis.
+
++Quacks and Self-treatment.--Hot Springs.+--The temptation to take up
+quack forms of treatment or to treat himself without the advice of a
+physician besets the path of the syphilitic throughout the course of the
+disease; an enormous number of fraudulent enterprises thrive on the
+credulity of its victims. Most of them are of the patent medicine
+specific type. Others, however, have a tinge of respectability and are
+dangerous simply because they are insufficient and not carried out under
+proper direction. Many popular superstitions as to the value of baths in
+syphilis and of the usefulness of a short course of rubs with bathing,
+or a "trip to the springs," are of this kind. Enough has been said in
+the foregoing chapters to make it plain to any one who is open to
+conviction that syphilis is no affair for the patient himself to attempt
+to treat. The best judgment of the most skilled physicians is the least
+that the victim owes himself in his effort to get well.
+
++Patient and Physician.+--For the same reasons every person who has or
+has had syphilis, cured or not, or has been exposed to it, should make
+it an absolute rule to inform his physician of the fact. The recognition
+of many obscure conditions in medicine depends on this knowledge. For a
+patient to falsify the facts or to ignore or conceal them is simply to
+work against his own interests and to hinder his physician in his
+efforts to benefit him.
+
+
+
+
+Chapter XIV
+
+Mental Attitudes in Their Relation to Syphilis
+
+
+One's way of looking at a thing has an immense influence on what one
+does about it. Obvious as this principle is in the every-day affairs of
+life, it becomes still more obvious as one studies a disease and watches
+the way in which different individuals react to it. The state of mind of
+a few people infected with a rare condition may not seem a matter of
+more than passing interest, but in a disease which is a wide-spread and
+disastrous influence in human life, the sum-total of our states of mind
+about it determines what we do against it and, to no small degree, what
+it does to us. Syphilis as a medical problem offers comparatively few
+difficulties at the present day. What blocks our progress now is largely
+an affair of mental attitudes, of prejudices, of fears, or shame, of
+ignorance, stupidity, or indifference. Mental strain, a powerful
+influence in many diseases, is a factor in syphilis also, and the state
+of mind of the patient has often almost as much to do with the success
+of his treatment as has salvarsan or mercury. For that reason it is
+worth while to devote a chapter to picturing in a general way the mental
+side of syphilis.
+
++The Public Attitude Toward Syphilis.+--First of all, in order to
+understand the mental state of the patient, consider once more the
+attitude of the world at large toward the victim of syphilis. A few who
+are frankly ignorant of the existence of the disease to start with are
+unprejudiced when approached in the right way. But ninety-eight persons
+in a hundred who know that there is such a disease as syphilis are alive
+to the fact that it is considered a disgrace to have it, and to little
+else. Such a feeling naturally chokes all but secret discussion of it.
+Most of us remember the day when newspaper copy containing reference to
+tuberculosis did not find ready publication. Syphilis is just crossing
+this same threshold into publicity. It is now possible to get the name
+of the disease into print outside of medical works and to have it
+referred to in other ways than as "blood poisoning" in quack
+advertisements. The mention of it in lectures on sex hygiene is an
+affair of the last twenty years, and the earlier discussions of the
+disease on such occasions were only too often vague, prejudiced, and
+inaccurate. There are many who still believe, as did an old librarian
+whom I met in my effort to reach an important reference work on syphilis
+in a great public library. "We used to keep them on the shelves," he
+said, "until the high school boys began to get interested, and then we
+thought we would reserve the subject for the profession." Syphilis has
+been reserved for the profession for five hundred years and the disease
+has grown fat on it. The lean times will come when a reasonable
+curiosity about syphilis can be satisfied without either shame or
+secrecy by a reasonable presentation of the facts. We need the light on
+this subject and the light on reserved shelves is notoriously poor. The
+stigma attaching to syphilis as a disease is one of the most tragic
+examples of a great wrong done to do a little right. What if there are a
+few who deserve what they got? We may well ask ourselves how free we are
+to cast the first stone. And why single out syphilis as the badge of
+venery? The "itch" is transmitted by sexual relations too. Why not make
+the itch a sign of shame? The power that has done the damage is not the
+intrinsic viciousness of syphilis, but the survival of the old idea of
+sexual taboo, the feeling that sex is a secret, shameful thing,
+essentially unclean. To this age-old myth some one added the idea of
+punishment, and brutalized our conception of syphilis for centuries. If
+there were a semblance of crude, stern justice in accepting syphilis as
+the divinely established punishment for sexual wrong-doing, protest
+would lose half its meaning. Not only does syphilis fail to punish
+justly, but there is also something savage, akin almost to the mental
+attitude that makes "frightfulness" possible in war, in the belief that
+it is necessary to make headway against a sexual enemy by torturing,
+ruining, and dismembering men, women, and children, putting out the eyes
+of the boy who made a slip through bad companionship and mutilating the
+girl who loved "not wisely but too well." Only innocence pays the
+spiritual price of syphilis. The very ones whose punishment it should be
+are the most indifferent to it, and the least influenced by fear of it
+in their pursuit of sexual gratification. I always recall with a shock
+the utterance of a university professor in the days when salvarsan was
+expected to cure syphilis at a single dose. He rated it as a catastrophe
+that any such drug should have been discovered, because he felt that it
+would remove a great barrier to promiscuous relations between men and
+women--the fear of venereal disease. This is the point of view that
+perpetuates the disease among us. It is this attitude of mind that
+maintains an atmosphere of disgrace and secrecy and shame about a great
+problem in public health and muddles our every attempt to solve it.
+Those who feel syphilis to be an instrument adapted to warfare against
+sexual mistakes, and are prepared to concede "frightfulness" to be
+honorable warfare, will, of course, fold their hands and smugly roll
+their eyes as they repeat the words of the secretary of a London Lock
+hospital, "I don't believe in making it safe."[14]
+
+    [14] Quoted by Flexner in "Prostitution in Europe."
+
++Syphilis as a "Disgrace" and a "Moral Force."+--If syphilis really
+deterred, really acted as an efficient preventive of license, we might
+have to tolerate this attitude of mind, even though we disagreed with
+it. I had occasion, during a period of two years, to live in the most
+intimate association with about 800 people who had syphilis--every kind
+of person from the top to the bottom of the social scale. It was not a
+simple matter of ordering pills for them from the pharmacy, or castor
+oil from the medicine room. I had to sit beside their beds when they
+heard the truth; I had to see the women crumple up and go limp; I had
+to tell the blind child's father that he did it, to bolster up the weak
+girl, to rebuild the wife's broken ideals, to suppress the rowdy and the
+roysterer, to hear the vows of the boy who was paying for his first
+mistake, and listen to the stories of the pimp and the seducer. What
+made syphilis terrible to the many really fine and upright spirits in
+the mass thus flung together in a common bondage? It was not the fear of
+paresis, or of any other consequence of the disease. It was the torture
+of disgrace, unearned shame, burnt into their backs by those who think
+syphilis a weapon against prostitution and a punishment for sin. It
+wrecked some of them effectually--left them nothing to live for. It
+case-hardened others against the world in a way you and I can well pray
+we may never be case-hardened. It left scars on others, and others
+laughed it off. Hundreds of sexual offenders passed through my hands,
+and in the closest study of their points of view I was unable to find
+that in more than rare cases had the risk of syphilis any real power to
+control the expression of their desires. Sexual morality is a complex
+affair, in which the habit of self-control in many other activities of
+life plays an important part. The man or woman who best deserves to be
+called clean and honorable and sexually blameless has not become so
+through a negative morality and an enlightened selfishness. The man who
+does not have bred into him from childhood the instinct to say the
+"everlasting no" to his passions will never learn to say it from the
+fear of syphilis. Sexual self-control is a habit, not a reasoned-out
+affair, and its foundation must rest on the rock bottom of character
+and not in the muck of venereal disease.
+
++The Broader Outlook.+--If, then, it avails nothing in the uplifting of
+our morals to treat syphilis as a disgrace, if the disease is
+ineffective as a deterrent, and barbarously undiscriminating, inhuman,
+and unjust as a punishment, let us in all fairness lay aside the
+attitude of mind which has so hindered and defeated our efforts to deal
+with it as an arch enemy to human health, happiness, and effectiveness.
+In the face of all our harsh traditions it takes a good deal of breadth
+of view to look on the disease impersonally, rather than in the light of
+one or two contemptible examples of it whom we may happen to know. But,
+after all, to think in large terms and with a sympathy that can separate
+the sinner from his sin and the sick man from the folly that got the
+best of him, is no mean achievement, well worthy of the Samaritan in
+contrast with the Levite. To the remaking of the traditional attitude of
+harsh, unkindly judgment upon those unfortunate enough to have a
+terrible disease, we must look for our soundest hope of progress.
+
++The Mental States of Syphilitics.+--The mental outlook of the person
+with syphilis is in its turn as important a factor in our campaign
+against the disease as is that of the person without it. In order to
+give some idea of the ways in which this can influence the situation it
+may be well to sketch what might be called the four types of mind with
+which one has to deal--the conscientious, the average, the
+irresponsible, and the morbid. Under the morbid type are included those
+persons who, without having syphilis, are in morbid fear of the disease,
+or have the fixed belief that they are infected with it, even when they
+are not.
+
++The Conscientious Type.+--Conscientious patients, speaking from the
+physician's standpoint, are the product of intelligence and character
+combined. Though distinctly in the minority, and usually met in the
+better grades of private practice, one is often surprised how many there
+are, considering the treacherous and deceptive features of the disease,
+which leave so much excuse for laxity and misunderstanding on the part
+of the laymen. A conscientious patient is one who is not content with
+any ideal short of that of radical cure. It takes unselfishness and
+self-control to go without those things which make the patient in the
+infectious stage dangerous to others. For a time life seems pretty well
+stripped of its pleasures for the man who may not smoke, must always
+think beforehand whether any contact which he makes with persons or
+things about him may subject others to risk of infection, and perhaps
+must meet the misunderstanding and condemnation of others whom he has to
+take into his confidence for the same purpose. An element of moral
+courage and a keen sense of personal responsibility help to make the
+ideal patient in this disease. To meet a treatment appointment promptly
+at the same day and hour week after week, to go through the drudgery of
+rubbing mercurial ointment, for example, to say nothing of the
+unpleasantness of the method to a cleanly person, night after night for
+weeks, takes unmistakable grit and a well-developed sense of moral
+obligation. The man who has been cured of syphilis has passed through a
+discipline which calls for the best in him, and repays him in terms of
+better manhood as well as better health.
+
+The physician's cooeperation in the development of the necessary sense of
+responsibility and the requisite character basis for a successful
+treatment is invaluable. To the large majority of the victims of the
+disease it is a severe shock to find out what ails them. Many of them,
+without saying much about it, give up all hope for a worth-while life
+from the moment they learn of their condition. Just as in the old days
+the belief that consumption was incurable cost nearly as many lives as
+the disease itself, by leading victims to give up the fight when a
+little persistence would have won it, so among many who acquire
+syphilis, especially when it is contracted under distressing
+circumstances, there is a lowering of the victims' fighting strength, a
+sapping of their courage which makes them an easy prey to the
+indifference to cure that is so fatal in this disease. The person with
+syphilis should have the benefit of all the friendly counsel,
+reassurance, and moral support that his physician can give, and such
+time and labor on the latter's part are richly repaid.
+
++The Average State of Mind.+--The average mental attitude stops
+tantalizingly short of the best type of conscientiousness. Average
+patients are good cooeperators in the beginning of a course of treatment
+or while the symptoms are alarming or obvious, but their energy leaves
+them once they are outwardly cured. The average patient only too often
+overrules his physician's good judgment on trivial grounds, slight
+inconveniences, and temporary considerations, forgetting that cure is
+what he needs more than anything else in the world. The deprivations go
+hard with this type of patients, and it is difficult, almost impossible,
+to persuade them to stop smoking or to abstain from sexual relations or
+other contacts that are apt to subject others to risk. Average patients
+will almost never remain under the care of a physician until cured. A
+year, or at the most two years, is all that can be expected, and a
+second or third negative blood test is usually the signal for their
+disappearance. They are, of course, lost in the great unknown of
+syphilis, and swell the total of deaths from internal causes of
+syphilitic origin, such as diseases of the arteries and of the nervous
+system. A good many have to be treated for relapses, but the amount of
+infection spread by them, while of course unknown, is probably small
+considering how many of them there are.
+
++Effect of the High Cost of Treatment.+--A factor which is extremely
+influential in forcing average treatment and ideals on those who, if
+opportunity were more abundant, would be conscientious about the
+disease, has already been mentioned as the cost of treatment, which is
+such that persons with small incomes, who are too proud or sensitive to
+seek charitable aid, can scarcely be expected to meet. The cost of
+salvarsan under present conditions is a burden that few can hope to
+assume to the extent that modern treatment tends to require, and the
+slower methods of treatment are more of a tax on the patient's courage
+and determination, and less effective in preventing the danger of
+infectiousness, although quite as reliable for cure. There is no more
+serious problem in the public health movement against syphilis than to
+get for the average man who can pay a moderate but not a large fee the
+benefits of expensive and elaborate methods of recognizing and treating
+a disease such as syphilis. Some practical methods of doing this will be
+taken up in the next chapter.
+
++The Irresponsible.+--The irresponsible attitude of mind about syphilis
+forms the background of the darkest and most repellent chapter in the
+story of the disease. Yet we ought to confront it if we wish to master
+the situation. The irresponsible person has either no regard for, or no
+conception of, the rights of others where a dangerous contagious disease
+is concerned, and often little conception of, and less interest in, what
+is to his own ultimate advantage. Irresponsible syphilitics lack
+character first and sense next. Many of them, through the gods-defying
+combination of stupidity and ignorance, cannot be approached through any
+channel of reason or persuasion. The only argument capable of
+influencing such minds is compulsion. Others are, of course, mental
+defectives with criminal and perverted tendencies. Yet it is both
+amazing and discouraging to find how many irresponsibles there are in
+the ordinary and even in the better walks of life. To the wilful type of
+irresponsible person the transmission of a syphilitic infection is
+nothing, and cannot weigh a straw against the gratification of his
+desire or the pursuit of his own interest. The disease cannot teach such
+people anything, and if it cannot, how can the physician? Such people
+pursue their personal and sexual pleasure, marry, spread disaster around
+them, and outlive it all, perhaps brazenly to acknowledge the fact.
+Others, suave, attractive, agreeable, seductive, often masquerade as
+respectability, or constitute the perfumed, the romantic, the elegant
+carriers of disease. The proportion of ignorant to wilful
+irresponsibility can scarcely be estimated. But there is little choice
+between the two except on the score of the hopefulness of the latter. As
+examples of the mixture of types with which a large hospital is
+constantly dealing, I might offer the following at random, from my own
+recollections: A milkman came to a clinic one morning with an eruption
+all over his body and his mouth full of the most dangerously contagious
+patches. Two of us cornered him and explained to him in full why he
+should come in if only for twenty-four hours. He promised to be back
+next morning and disappeared. Another, a butcher in the same condition,
+put his wife, whom he had already infected, into the hospital, and in
+spite of every argument by all the members of the staff, went home to
+attend to his business--the selling of meat over the counter. A
+lunch-room helper, literally oozing germs, was after several days
+induced to come up for an examination and promised to begin treatment,
+whereupon he disappeared. A college student reported with an early
+primary sore. "X----," I said, "If you will pledge me your honor as a
+gentleman never to take another chance and not to marry until I say you
+are cured I will use salvarsan on you, which is just about as scarce as
+gold now, and give you a chance for abortive cure." He pledged himself,
+and six months later there was every sign that we were going to secure a
+perfect result. Suddenly he failed to appear for a treatment
+appointment, and I never saw him again. But I did see a letter written
+to him by the clinic which showed that he had come up for the
+examination with a newly acquired sore while he knew I was away--in all
+probability a reinfection. He was not even man enough to face me with
+his broken word. Three or four men with chancres may report in an
+afternoon and leave, the clinic powerless to detain them or to protect
+others against the damage they may do. One such, a Greek boy, had
+exposed four different women to infection before we saw him, and only
+the most strenuous efforts of the entire staff got him into the
+hospital, because he had neither money nor sense. Half-witted tramps,
+gang laborers, and foreigners who cannot understand a word of any other
+language than Lithuanian or some other of the European dialects for
+which no interpreter can be secured, pass in a steady stream through the
+free clinics of large cities. The impossibility of securing even the
+simplest cooeperation from such patients is scarcely realized by any one
+who is not called upon to deal with them face to face. Even with an
+interpreter, they display the wilfulness of irresponsibility. One
+Italian woman wiped her chancre, which was on her lip, with her fingers
+at every other shake of the head. She was cooking for two boarders and
+had two children. She did not like hospitals and was homesick and
+pettish. Would she go over to the dispensary in the next block and find
+out how to take care of herself? Not a bit of it. She was going home,
+and she went. I saw the children later in the children's ward, both
+infected with syphilis--a poor start in life. Criminal intent in the
+transmission of syphilis is common enough, and the writer can think
+off-hand of four or five cases in which men or women "got" their
+estranged partners later in their careers.
+
++The Necessity for Legal Control.+--All these repulsive details have a
+place in driving home a conception of the cost to society of the immoral
+and irresponsible syphilitic. Syphilis is an infectious disease,
+dangerous to the individual and to society. If it is rational to
+quarantine a mouth and throat full of diphtheria germs, it is rational
+to quarantine a mouth and throat full of syphilitic germs at least until
+the germs are killed off for the time being. There can be no more excuse
+for placing society at the mercy of the one than of the other.
+
++The Morbid Attitude of Mind: Syphilophobia.+--The morbid attitude of
+mind, whether in persons who have the disease or in those who fear they
+may have it, is one of the hardest the physician has to deal with. Any
+one who knows anything of the disease naturally has a healthy desire to
+avoid it, and if he is a victim of it, a considerable belief in its
+seriousness. But certain types of persons, who are usually predisposed
+to it by a nervous makeup, or who have a tendency to brood over things,
+or who perhaps have heard some needlessly dreadful presentation of the
+facts, become the victims of an actual mental disorder, a temporary
+unbalancing of their point of view. To the victims of syphilophobia, as
+this condition is called, syphilis fills the whole horizon. If they have
+not been too seriously disturbed by the idea, a simple statement of the
+facts does wonders toward relieving their minds. A few of them cling
+with the greatest tenacity to the most absurd notions. For those victims
+of the disease who are the prey of morbid anxiety the assurance that it
+is one of the most curable of all the serious diseases, and that if they
+are persistent and determined to get well, they can scarcely help doing
+so, usually sets their minds at rest. The idea that there is a cloud of
+disgrace over the whole subject, and the old-fashioned belief that
+syphilis is incurable and hopeless, inflict needless torture and may do
+serious damage to the highly organized sensitive spirits which it is to
+society's best interest to conserve. The overconscientious syphilitic
+hardly realizes that the real horrors of the disease are usually the
+rewards of indifference rather than overanxiety. Persons who subject
+themselves to the ordinary risks of infection which have been described
+in the preceding chapters do well to be on their guard and to maintain
+even a somewhat exaggerated caution. Those who do not expose themselves
+need not look upon the disease with morbid anxiety or alarm. In the
+relations of life in which syphilis is likely to be a factor it should,
+of course, be ferreted out. But there is no occasion for panic. We need
+a sane consciousness of the disease, a knowledge of its ways and of the
+means of prevention and cure for the world at large. We do not need
+hysteria, whether personal or general, and there is nothing in the facts
+of the situation to warrant the development of such a mental attitude
+either on the part of the syphilitic or of those by whom he is
+surrounded. Insofar as morbid fear in otherwise normal persons is the
+product of ignorance it can be dispelled by convincing them of this
+fact.
+
+
+
+
+Chapter XV
+
+Moral and Personal Prophylaxis
+
+
+Prophylaxis, of course, means prevention, and it has been a large part
+of the purpose of the present study to deal with syphilis from the
+standpoint of prevention and cure. The material of this chapter is,
+therefore, only a special aspect of the larger problem.
+
++Repression of Prostitution.+--By the moral prophylaxis of syphilis is
+meant the cultivation of such moral ideals as will contribute to the
+control of a disease which is so closely associated with sexual
+irregularities. Since public and secret prostitution serve as the
+principal agencies for the dissemination of the disease, it follows that
+anything tending to decrease the amount of disease in prostitutes, on
+the one hand, or to diminish the amount of promiscuous sexual activity,
+on the other, will retard the spread of syphilis. Systems based on the
+first ideas, aiming rather to control the disease in public women by
+inspection of their health and activities than by suppressing
+prostitution, have failed because the methods of control ordinarily
+practised are worthless for the detection of infectiousness. So-called
+regulation has, therefore, given way very largely in progressive
+communities to the second ideal of repressing or abolishing the outward
+evidences of vice as far as possible. In behalf of sanitary control of
+prostitution, leaving out of the question its moral aspect, it must be
+admitted that Neisser, probably the greatest authority on the sexual
+diseases, believed that, as far as syphilis is concerned, the use of
+salvarsan as a means of preventing infection from prostitutes has never
+had a satisfactory trial. In behalf of abolition it would seem that
+systematic stamping-out of the outward evidences of vice, the making of
+immorality less attractive and conspicuous, is, in theory at least, a
+valuable means of diminishing the extent and availability of an
+important source of infection.
+
++Educational Influences.+--To do something positive against an evil is
+certainly a more promising mode of attack than to use only the negative
+force of repression of temptation. Education of public opinion offers us
+just such a positive mode of attack. Men and women and boys and girls
+should first be taught sexual self-control even before being made aware
+of the risk they run in throwing aside the conventional moral code.
+Teach honor first and prudence next. The slogan of education in sexual
+self-restraint is the easiest to utter and the most difficult to put
+into practice of all the schemes for the control of sexual diseases. A
+large part of the difficulty of making education effective arises from
+one or two situations which are worth thinking over.
+
++Economic Forces Opposing Sexual Self-control.+--In the first place,
+while continence, or abstinence from sexual relations, is a valuable
+ideal in its place, it cannot be indefinitely extended with benefit
+either to the individual or to the race. The instinct to reproduce is as
+fundamental as the instinct of self-preservation and the desire for
+food. A social order which disregards it or defies it will meet defeat.
+To an alarming extent the tendency of the present economic system is to
+create unsocial impulses by making the normal gratification of sexual
+instinct in marriage and the assumption of the responsibility of a
+family more and more difficult. The cost of living is steadily rising
+without a corresponding certainty on the part of a large proportion of
+young men that they can meet it for themselves, to say nothing of
+meeting it for wife and children. The uncertainties of a 'job' are often
+serious enough to discourage the rashest of men from depending on a
+variable earning power to help him do his share for the advancement of
+the race. It will be an impossible task to convince even naturally
+clean-minded, healthy young men and women that they should live a life
+of hopeless virtue because it is part of the divine order that they
+should be so held down by hard times and small earnings as to make
+marrying and having children an unattainable luxury. Continence and
+clean living as preparations for decent and reasonably early marriage
+and the raising of a healthy family are the highest of ideals, and ought
+to be preached from every housetop. Continence as a life-long punishment
+for the impossible demands of an oppressive social and economic order
+gets as little attention as it deserves. First, let us make a clean
+sexual life lead with greater certainty to some of the rewards that make
+life worth living and we shall then have a more substantial basis for
+making continence before marriage other than empty words. If every
+father, for example, could say to his sons and daughters that if they
+showed themselves clean men and women he would back them in an early
+marriage, there would be an appreciable decrease in the amount of young
+manhood which is now squandered on indecency. If every employer, or the
+state itself, would give a clean marriage a preferred position in the
+social and economic scale, and, by helping to meet the cost of it,
+recognize in a substantial way the value to the race of a family of
+vigorous children, an important factor in youthful sexual laxity would
+be robbed of its power. No one will assert that such remedial proposals
+are of themselves cure-alls for present evils, but they must have at
+least an emphatic place in the future of moral prophylaxis.
+
++The Teaching of Sexual Self-control.+--First then, make the social
+order such that sexual self-control yields a reward and not a
+punishment. Second, teach sexual control itself, since it is one of the
+fundamental means of attack on the problem of syphilis. How can such
+control be taught? Information about the physical dangers of illicit
+sexual indulgence is of course of value, and should be spread broadcast.
+But taken by itself, the fear of disease, especially if it enters the
+individual's life after the age when he has already experienced the
+force of his sexual instincts, is a feeble influence. The person who has
+nothing but the knowledge that he is taking great risks between him and
+the gratification of his sexual desires will take the risks and take
+them once too often. One cannot begin to teach the boy or girl of high
+school age that sexual offenses mean physical disaster, and expect to
+control syphilis. The time to control the future of the sexual diseases
+is in the toddler at the knee, the child whose daily lesson in
+self-control will culminate when he says the final 'No' to his passions
+as a man. The child who does not learn to respect his body in the act of
+brushing his teeth and taking his bath and exercise, and whose thought
+and speech and temper are unbridled by any self-restraint, will give
+little heed when told not to abuse his manhood by exposing himself to
+filth. The prevention of syphilis by sexual self-control goes down to
+the foundations of character, and has practical value only in those
+whose self-control is the expression of a lifelong habit of
+self-discipline bred in the bone from childhood, not merely painted on
+the surface at puberty. Those who want their sons and daughters never to
+know by personal experience the meaning of syphilis must first build a
+foundation in character for them which will make self-control in them
+instinctive, almost automatic. Knowledge of sexual matters has power
+only in proportion to the strength of the character that wields it, and
+on well-rounded character education, rather than mere knowledge of the
+facts, the soundest results will be based.
+
+    [Illustration: E. ROUX
+
+    ELIE METCHNIKOFF [1845-1916]
+
+    (From McIntosh and Fildes, "Syphilis from the Modern Standpoint,"
+    New York, Longmans Green & Co., 1911.)]
+
+The moral prophylaxis of syphilis is then briefly summed up in the
+repression of as many of the recognized agencies for the spread of the
+disease as possible; the making of continence a preparation for a normal
+sex life rather than an end in itself; the control and remedying of
+those influences which are making normal marriage harder of attainment;
+and the development of an instinctive self-control and self-discipline
+in every field of life from childhood up as the character basis
+necessary to make knowledge about sexual life and sexual disease
+effective.
+
++Personal Preventive Methods.--Continence.+[15]--There remains to be
+considered what is often called the personal prophylaxis of syphilis,
+meaning thereby the methods by which the individual himself can diminish
+or escape the risk of infection. The first and most effective method of
+avoiding syphilis is abstinence from sexual relations and intimacies
+except in normal marriage with a healthy person. Although it has been
+alluded to under the moral prophylaxis of syphilis, it deserves to be
+reemphasized. No consideration as to the justice or desirability of
+continence and self-restraint can add anything to the simple fact that
+it is _the_ way to avoid disease, and can be unhesitatingly recommended
+as the standard for personal prophylaxis. In the experience of
+physicians it is an axiom that disillusionment sooner or later overtakes
+those who think they are exempt from this rule. Persons who discard
+continence in favor of what they believe to be some absolutely safe
+indulgence are so almost invariably deceived that the exceptions are not
+worth considering. Although infection with syphilis is no necessary
+evidence of unclean living, clean living will always remain the best
+method of avoiding syphilis.
+
+    [15] The American Social Hygiene Association, 105 W. 40th Street,
+    New York City, can supply pamphlets and lists of authoritative
+    publications bearing on this and related subjects.
+
++The Metchnikoff Prophylaxis.+--The second method of personal
+prophylaxis of syphilis was developed as a result of the discovery of
+Metchnikoff and Roux in 1906, that a specially prepared ointment
+containing a mercurial salt, if rubbed into the place on which the germs
+were deposited within a few hours (not exceeding eighteen hours, and the
+sooner the better) after exposure to the risk of syphilis, would prevent
+the disease by killing the germs before they could gain a foothold. This
+method of protection against syphilis has been subjected to rigid tests,
+with fairly satisfactory results. It has been adopted by the army and
+navy of practically every country in the world, and, as carried out
+under the direction of physicians and with military control of the
+patient, has apparently reduced the amount of syphilitic infection
+acquired in the armies and navies using it to a remarkable degree. The
+method, of course, cannot assume to be infallible, but if intelligently
+applied, it is one of the important weapons for the extinction of
+syphilis in our hands at the present day. It fails to meet expectations
+precisely in those circumstances and among those persons in whom
+intelligent employment of it cannot be expected. This of course covers a
+considerable number of those who acquire syphilis. What disposal an
+awakened opinion will make of this knowledge remains to be seen. At the
+present time it may well be doubted whether the indiscriminate placing
+of it in the hands of anybody and everybody would not work as much harm
+as good through ignorant and unintelligent use. This opinion is shared
+by European as well as American authorities. Administered under the
+direction of a physician, the Metchnikoff prophylaxis of syphilis would
+undoubtedly be at its best in the prevention of the disease. For these
+reasons, as well as to prevent the spread of the knowledge to those who
+would be damaged by it, those interested are referred to their
+physicians for a description of the method. Any one having the benefit
+of it should be able to convince his medical advisor that there is good
+reason why this kind of professional knowledge should be brought to bear
+on his case. The ordinary methods of preventing infection by washes and
+similar applications used by the "knowing ones" are most of them
+worthless or greatly inferior to the Metchnikoff prophylaxis. They are,
+moreover, a positive source of danger because of the false sense of
+security which they create. If every person who has run the risk of
+contracting syphilis should visit his physician _at once_ to receive
+prophylactic treatment, the effect on syphilis at large would probably
+be as good as in the army and navy. There would still be opportunity on
+such occasions to bring moral forces and influence to bear on those who
+would respond to them. There can be no object in withholding such
+knowledge from those who are confirmed in their irregular sexual habits.
+At the same time there could be few better influences thrown across the
+path of one just starting on a wrong track than that exerted by a
+physician of skill and character, to whom the individual had appealed to
+avert the possible disastrous result of an indiscretion.
+
+
+
+
+Chapter XVI
+
+Public Effort Against Syphilis
+
+
++The World-wide Movement Against Venereal Disease.+--This chapter is
+intended to give some account of the great movements now begun to
+control syphilis and its fellow-diseases throughout the world. A
+campaign of publicity was the starting-point of the organized attempt to
+control tuberculosis, and in the same way a similar campaign has been at
+the bottom of movements which now, under the pressure of the tremendous
+necessities of war, are making headway at a pace that generations of
+talking and thinking in peaceful times could not have brought about.
+Although this country at the present writing is probably farther in the
+rear than any other great nation of the world in its efforts to control
+the venereal diseases as a national problem, it is fortunate in having
+had the way paved for it by epoch-making movements such as those of the
+Scandinavian countries, and by the studies of the Sydenham Royal
+Commission on whose findings the British Government is now undertaking
+the greatest single movement against syphilis and gonorrhea that has
+ever been launched. For many years Germany has had a society whose roll
+includes some of the greatest names in modern science, directing all its
+energy toward the solution of the problem of sexual disease, and German
+sentiment on these matters is developing so fast that it is difficult,
+even for those in touch with such matters, to keep pace with it. In this
+country progress has been much slower, hampered by peculiarities of
+mental outlook and tradition very different from those which have
+controlled the thought of Europe. The association of syphilis with
+prostitution has been largely instrumental in putting much valuable
+statistical and general knowledge of the disease into semi-private
+reports and sources not available to the large mass of the thinking
+public. The effect of finding the problem of syphilis invariably bound
+up with discussions of the social evil has been to perpetuate in popular
+thought an association which simply blocks the way to any solution of
+the public health problem. While the control of prostitution will
+influence syphilis, ignoring syphilis, or treating it as incidental,
+will never contribute anything to the conquest of either. It is one of
+the most significant features of the great movements now on foot all
+over the world that they have finally adopted the direct route, and are
+attacking syphilis and gonorrhea as diseases and not by way of their
+association with prostitution.
+
+The agencies in this country which are making notable efforts to push
+the campaign against syphilis and gonorrhea deserve every possible
+support from the thinking public. The American Social Hygiene
+Association is a clearing-house for trustworthy information in regard to
+the problems of sexual disease, and publishes a quarterly journal.[16]
+The National Committee for Mental Hygiene and its branch societies are
+also engaged in spreading knowledge of the relation of syphilis to
+mental disease and degeneration. State and City Boards of Health are
+active in their efforts to further the campaign, and notable work is
+being done by New York City, Buffalo, Cleveland, and Rochester, New
+York, both on publicity and in the provision of facilities for
+recognizing and treating the diseases in question. Certain states, such
+as Ohio, Michigan, and Vermont, have made steps toward an intelligent
+legislative attack on different aspects of the problem. Influential
+newspapers and magazines have made the idea of a campaign against these
+diseases familiar enough to the public, for example, to bring a young
+girl to me to ask outright without affectation that she be told about
+syphilis, because she had seen the word in the paper and did not fully
+understand it. The aggregate of these forces is large, and an awakening
+is inevitable.
+
+    [16] Social Hygiene, New York.
+
+To prepare ourselves for an active and intelligent share in the
+movement, we should review briefly the essential elements of a public
+campaign against syphilis as they have been developed by recent
+investigations and legislative experiments.
+
++Undesirable and Freak Legislation.+--Syphilis has had a limited amount
+of recognition in law, unfortunately not always wise or timely. Freak
+legislation and half-baked schemes are the familiar preliminaries which
+precede the grim onset of a real attack supported by public sentiment.
+Typical examples of such premature legislation may be found in the
+setting up of the Wassermann test as evidence of fitness for marriage
+by certain states, and in the efforts of certain official agencies to
+enforce the reporting of syphilis and gonorrhea by name. Proposals to
+quarantine and placard all syphilis are in the same category, though
+seriously entertained by some. The plan to establish by state enactment
+or municipal appropriation special venereal hospitals falls in the same
+class, since it is obvious that in the present state of opinion none but
+down-and-outs would resort to them. The stigma attached to them would
+effectually make them useless to the very group of worth-while people
+which it is to the public interest to conserve and reeducate.
+
++Value of Conservative Action.+--It cannot be said too often that a
+reasonable conservatism should temper the ardor of reformers, or more
+harm than good will be done by the collapse and failure of
+ill-considered special legislation. Unified action against syphilis and
+gonorrhea as public health problems is as important as unified action on
+the problems of railroad control, child labor, or corporate monopoly.
+For that reason it is a matter of some uncertainty how much can be
+accomplished by individual states in this country in the way of
+restrictive legislation, such as that controlling the marriage of
+infected persons, or punishing persons who fail to carry treatment to
+the point of cure. Under the direction of a national bureau or
+department of health administration there is no doubt that the movement
+against syphilis would advance at a much more rapid pace than with the
+sporadic and scattered activities of mixed state and private agencies.
+
++The Essential Features of a Modern Campaign.+--The repeated sifting of
+the facts which has been done in recent years by important
+investigations, such as that of the Sydenham Commission in Great Britain
+and the Society for Combatting Sexual Disease in Germany, and the
+legislative programs already mentioned, have gradually crystallized into
+fairly definite form, the undoubted essentials of a program for
+controlling venereal diseases, syphilis among them. These may be
+summarized as follows:
+
+1. The provision of universally available good treatment, at the expense
+of the state, if necessary, for the diseases in question.
+
+2. The provision by the state of efficient means of recognizing the
+diseases at the earliest possible time and with the greatest possible
+certainty in any given case.
+
+3. The suppression of quack practice, drug-store prescribing, and
+advertising of cures for these diseases.
+
+4. Moral and educational prophylaxis and the vigorous suppression of
+prostitution.
+
+In addition to these measures, which are common to all proposals and
+working systems for the control of sexual disease, certain other
+recommendations may be classed as debatable, inasmuch as they are still
+under discussion and have been incorporated into some and omitted from
+others. These are as follows:
+
+1. General instruction in personal prophylaxis for the population at
+large.
+
+2. Compulsory measures and penalties obliging patients to receive
+treatment and continue it until cured, regardless of their own desires
+in the matter.
+
+3. Notification or reporting of cases of sexual disease to the health
+authorities.
+
+4. Indirect legislation, as it might be called, which aims to detect
+infected persons before they enter on marriage rather than at the outset
+of the disease, either by releasing the physician in charge of the case
+from the bond of professional confidence, or by requiring health
+certificates before marriage, and which annuls marriages after infection
+is discovered.
+
++Easily Available Treatment.+--It will be noticed that toleration of
+prostitution with supervision has finally disappeared from the modern
+program for the control of sexual diseases. The provision for
+universally available treatment, regardless of the patient's means or
+circumstances, should be thought of as the one fundamental requirement
+without which no program has made even a beginning. For over a century
+Denmark has provided for the free treatment of all patients with
+venereal disease. The Norwegian law, essentially similar, dates from
+1860. Italy a few years ago adopted a similar program, placing squarely
+upon the state the responsibility of providing for the care of all
+patients with venereal diseases. England has just adopted a mixed
+provision which will in practice place most of the responsibility upon
+the state and very little on the individual, as far as the expense of
+treatment is concerned. Germany has compelled her insurance companies
+to shoulder the burden, and under pressure of war is hastening matters
+by invoking more and more governmental aid. The recent West Australian
+Act provides that every medical officer in the pay of the state shall
+treat venereal disease free of charge. In comparison with the tremendous
+advances over previous indifference which such programs represent, this
+country makes a poor showing. Among us, no public agency is formally
+charged with any duty in the matter of preventing, recognizing, or
+treating the vast amount of venereal infection that mars our national
+health. Certain state boards of health are attempting to perform
+Wassermann tests, and certain municipalities have well-organized
+laboratories for the detection of syphilis and gonorrhea, but there are
+few purely public agencies that even pretend to have a specialist in
+their employ to assist in the recognition of cases and conduct the
+treatment of patients who cannot afford private care. Hospital and
+dispensary treatment of venereal diseases is almost entirely in
+semi-private hands, and a recent investigation of clinics and
+dispensaries for the treatment of syphilis and gonorrhea in New York
+city, for example, showed that many of them were so poorly equipped and
+run at such unreasonable hours that they were frequented only by
+vagabonds, were of no value in the early recognition of syphilis, could
+not administer salvarsan under conditions to which a discriminating
+patient would dare to trust himself, and made no pretense at following
+their cases beyond the door or discharging them from medical care as
+cured. One of the largest cities in this country until a year ago had
+not even a night clinic to which day workers could come, and is scarcely
+awake now to the necessity for such a thing.
+
++Dispensary Service.+--The provision of adequate treatment and
+diagnostic facilities, on a par with those which will presently cover
+Europe, will mean the following things: First of all, dispensaries, and
+many of them, for the identification of early cases, fully equipped with
+dark-field microscopes, with record systems, and with the means for
+following patients from the time they enter until they are cured. This
+means nurses, it means social service workers, it means doctors with
+special and not general knowledge of syphilis and gonorrhea. The
+Brooklyn Hospital Dispensary is an admirable example of what such an
+institution should be, but it is one where such institutions should be
+numbered by dozens and by hundreds. Copenhagen, with a population less
+than that of several cities in this country which have none, has seven
+municipal clinics whose hours and names are prominently advertised.
+
++Hospitals.+--In the second place there must be hospital facilities.
+They must not be venereal hospitals, but services or parts of general
+hospitals, so that patients who are received into them will be protected
+from stigma and comment. Pontopidan, a Danish expert, estimated that for
+the care of venereal disease one hospital bed to every 2000 of
+population was insufficient, and yet there are cities in this country
+which do not have one bed available for the purpose to 100,000 people.
+The hospital performs a peculiarly valuable function in the care of
+syphilis in particular. It provides for temporary quarantine, and for
+the education of the patient in his responsibility to the community when
+he is discharged. Three weeks or more under hospital direction is the
+best possible start for an active syphilis that is to be cured. The
+privacy of a syphilitic can be protected in a hospital as successfully
+as in a specialist's office, and the quality of treatment which can be
+given him is distinctly better than he can obtain while out and around.
+Hospitals in general have kept their doors closed to syphilis until
+recently, and it is only under the pressure of a growing understanding
+of what this means to the public health that they are awakening to their
+duty.
+
++Cheap Salvarsan.+--Before a general campaign for the successful
+treatment of syphilis can be made a fact, salvarsan must become, as has
+already been pointed out, a public and not a private asset. It must be
+available to all who need it at the lowest possible cost[17]--practically
+that of manufacture--and must be supplied by the state when necessary.
+The granting of patent rights which make possible the present
+exploitation for gain of such vital agents in the protection of the
+public health is a mistake which we should lose no time in remedying.
+While salvarsan does not mean the cure of syphilis, it does mean a
+large part of its control as an infectious disease. When it can be given
+only to the person who can muster from five to twenty-five dollars for
+each dose which he receives, it is evident that its usefulness is likely
+to be seriously restricted.
+
+    [17] The price of salvarsan before the war was $3.50 per full dose
+    for the drug alone. It can be profitably marketed at less than $1.00
+    per dose. The patent rights have been temporarily suspended during
+    the war, and their renewal by Congress should not be permitted.
+
++Reduction of the Expense of Efficient Treatment.+--Free treatment for
+those who cannot afford to pay is a necessary part of the successful
+operation of any scheme for the control of sexual disease. But for those
+who can and are willing to pay a moderate amount for what they receive,
+there should be pay clinics which will bridge the gap between the rough
+and ready quality and the unpleasant associations of a free dispensary,
+and the expensive luxuries of a specialist's office. This is a field
+which is almost virgin in this country, and which deserves public
+support. There is no reason why, for a reasonable fee, the patient with
+syphilis should not secure all the benefits of hospital care, the
+personal attention of specially trained men, an intelligent supervision
+of his case, and the benefit of cooeperation between a hospital service
+in charge of experts and the home doctor who must care for him during a
+considerable part of the course of his disease. Provision of this sort
+makes treatment both more attractive and more available to large numbers
+of people whose pride keeps them away from the public provision for
+charity cases, and whose limited means leave them at the mercy either of
+quackery or of well-meaning but entirely inexperienced physicians.
+
++Value of Expert Services.+--The factor of expert judgment in the care
+and recognition of syphilis is an important one, and a progressive
+public policy will not neglect to provide for it. The state, municipal
+or hospital laboratory which professes to do Wassermann tests should not
+be in charge of some poorly paid amateur or of a technician largely
+concerned with other matters, or its findings will be worthless. Every
+clinic and hospital should also attach to its staff an expert consultant
+on syphilis on whom it can draw for advice in doubtful cases and for the
+direction of its methods of work. Every city health board which
+undertakes a serious campaign against syphilis should not be satisfied
+merely with doing Wassermanns, but should enlist in behalf of the public
+consultation of the same grade which it expects to employ in the
+solution of its traction and lighting problems, and in the management of
+its legal affairs. No one would think nowadays of placing a physician in
+charge of a great tuberculosis sanitarium whose knowledge of the chest
+was confined to what he had learned in medical school twenty or more
+years before--yet in a parallel situation one often finds the subject of
+syphilis handled with as little attention to the value of expert
+knowledge. Expert service is expensive, and if the state wishes to
+command the whole energy of progressive men, it must be prepared to pay
+reasonably well for what it gets.
+
++Suppression of Quacks and Drug-store Prescribing.+--The suppression of
+quackery is nowhere more urgent than in the control of syphilis. Every
+important legislative scheme that has come into existence in recent
+years has recognized this fact. The devil may well be fought by fire,
+and reputable agencies should enter the field of publicity with some of
+the vigor of their disreputable opponents. The brilliant success of this
+scheme was admirably illustrated by the results of the recent efforts of
+the Brooklyn Hospital Dispensary, which, by replacing the placards of
+advertising quacks in public comfort and toilet rooms, and running a
+health exhibit on Coney Island, attracted to a clinic where modern
+diagnosis and treatment were to be had an astonishing number of young
+people who would have fallen victims to quacks. The evil influence of
+the drug store in perpetuating the hold of syphilis and gonorrhea upon
+us is just being understood. The patient with a beginning chancre, at
+the advice of a drug clerk, tries a little calomel powder on the sore,
+and it either "dries up" and secondary symptoms of syphilis appear in
+due course, or it gets worse or remains unchanged and the patient
+finally goes to a doctor or a dispensary to find that his meddling has
+lost him the golden opportunity of aborting the disease. If secondaries
+appear, a bottle or two of XYZ Specific, again at the suggestion of the
+all-knowing drug clerk, containing a little mercury and potassium iodid,
+disposes of a mild eruption, and a year or so later a marriage with
+subsequent mucous recurrences and the infection of the wife signalizes
+the triumph of ignorance and public shortsightedness. The health
+commissioner of one of the largest and most progressive cities in this
+country stated before a recent meeting of the American Public Health
+Association that he had sent a special investigator to twelve
+representative drug stores in his city, and that simply on describing
+some symptoms, without even the ceremony of an examination, he had
+received from ten of them something to use on a sore or to take for
+gonorrhea. It is only justice to say that occasionally one finds drug
+stores which will refer a patient to a doctor or a dispensary. Drastic
+legislation to suppress this sort of malpractice is part of the program
+of Great Britain, Germany, and West Australia, and we in this country
+cannot too quickly follow in their steps.
+
++Publicity Campaign.+--The educational campaign against sexual disease
+has already been discussed in theory. In close relation to it is the
+question of the use of publicity methods for legitimate ends, mentioned
+above. It has had a number of interesting applications in practice. The
+West Australian law has taken the stand of prohibiting all advertising,
+replacing the method of attracting the patient into coming for treatment
+of his own free will by the method of making treatment compulsory under
+heavy penalty. In this country, where compulsory legislation will be
+slow of adoption, publicity methods will have a certain vogue and a
+proper place. It has been of great service in the campaign against
+tuberculosis and in the movements for "Better Babies" and the like. It
+should never be forgotten that it is a two-edged weapon, however, and
+that where a stigma exists, as in the case of sexual disease, too much
+advertising of the place of treatment as distinguished from the need for
+it will drive away the very people whose sensitiveness or need for
+secrecy must be considered. On the other hand, the publication of
+material relating to sexual diseases in the public press has not yet
+reached the height of its possibilities, and should be pushed.
+
++Utilization of Personal Prophylaxis.+--Passing now to the debatable
+elements in a public campaign, opinion about the value of personal
+prophylaxis (Metchnikoff) against syphilis shows interesting variations
+in different countries at the present time. English-speaking countries
+hesitate over this. On the other hand, eminent German authorities, such
+as Neisser and Blaschko, urged it at the outset of the present war, and
+their views have apparently overcome a vigorous opposition. As a result,
+the knowledge of methods of preventing venereal infection are being
+spread broadcast over Germany in the hope of diminishing the inevitable
+risk that will arise with the disbanding of armies after peace is
+concluded, no matter how stringent the precautions taken to insure the
+health of soldiers before their return to civil life. The results of
+this experiment will be watched with the most intense interest by all
+those familiar with the situation, and the results will be of value as a
+guide for our own policy when we have had time to develop one. It is
+interesting that the most radical departure in the way of legislative
+provision for sexual disease, that of West Australia, takes up the
+patient at the point where his infection begins and promptly places him
+under penalty in the hands of a physician, but assumes no responsibility
+for other than indirect prevention. The most radical of all present-day
+legal measures against the disease has therefore not yet reached the
+radicalism of compulsory prophylaxis as it exists in armies, or even the
+radicalism of compulsory vaccination for smallpox.
+
++Reporting of Syphilis to Health Officers.+--The question of reporting
+syphilis to health officers as a contagious disease is a good one to
+raise in a meeting when a stormy session is desired. Upon this question
+wide differences of opinion exist all over the world. The right of a
+sick person to privacy, always deserving of consideration, becomes acute
+when it touches not only his physical but his social, economic, and
+moral welfare. It becomes a matter of importance to the state also when
+the prospect that his secret will not be kept leads him to conceal his
+disease and to avoid good public aid in favor of bad private care. It is
+a question whether the amount gained by collecting a few statistics as
+to the actual presence of the disease will be offset by the harm done in
+driving to cover persons who will not be reported. Modified forms of
+reporting sexual diseases, without name or address, for example, can be
+employed without betraying a patient's identity, thus doing away with
+some of the objections, and they have been in force in such cities as
+New York for some time. Vermont has recently adopted a compulsory
+reporting system, with the almost ludicrous result that by the figures
+her population shows 0.5 per cent syphilis, when the truth probably
+stands nearer 10 per cent. Much of the difficulty with reporting systems
+goes back to the lack of an educated public or professional sentiment
+behind them. For this reason they may be fairly placed in the category
+of premature legislative experiments, and should be postponed until a
+more favorable time. That this view has the sanction of students of such
+problems is borne out by the recent comment of Hugh Cabot on this issue,
+and by the decision of the British Royal Commission which, after careful
+deliberation, decided not to recommend to the Government at the present
+time any form of reporting for sexual disease. The West Australian law
+recognizes the wisdom of providing the patient having sexual disease
+with every safeguard for his secret provided he conforms to the
+requirement of the law in the continuance of his treatment. German
+sentiment is strongly against reporting, and no provision is made for it
+in the civil population. On the other hand, the very complete programs
+of the Scandinavian countries provide for reporting cases without names.
+It is, therefore, apparent, in view of this conflict of opinion, that we
+can afford to watch the experience of our neighbors a little longer
+before committing ourselves to the risk of arousing antagonism over a
+detail whose importance in the scheme of attack on syphilis is at best
+secondary to the fundamental principles of efficient treatment and
+diagnosis. There is no apparent reason why we should not be satisfied,
+for the present, at least, with drawing to our aid everything which can
+give us the confidence and the willing cooeperation of those we want to
+reach. Physicians who work with large numbers of these patients realize
+that privacy is one of the details which has an attraction that cannot
+be ignored.
+
++Compulsory Treatment.+--Compulsory provisions in the law form the
+third debatable feature of a modern program against syphilis. The
+Scandinavian countries have adopted it, and in them a patient who does
+not take treatment can be made to do so. If he is in a contagious
+condition, he can be committed to a hospital for treatment. If he
+infects another, knowing himself to have a venereal disease, he is
+subject, not to fine, but to a long term of imprisonment. The West
+Australian law is even more efficient than the Scandinavian in the vigor
+with which it supplies teeth for the bite. The penalties for violations
+of its provisions are so heavy as to most effectually discourage
+would-be irresponsibles. At the other end of the scale we find Great
+Britain relying thus far solely upon the provision of adequate
+treatment, and trusting to the enlightenment of patients and the
+education of public sentiment to induce them to continue treatment until
+cured. Italy has, in the same way, left the matter to the judgment of
+the patient. The Medical Association of Munich, Germany, in a recent
+study has subscribed to compulsory treatment along the same lines as the
+West Australia act, although thus far enforcement has been confined to
+military districts. The program for disbanding of the German army after
+the war, however, includes, under Blaschko's proposals, compulsion and
+surveillance carried to the finest details. A conservative summary of
+the situation seems to justify the belief that measures of compulsion
+will ultimately form an essential part of a fully developed legal code
+for the control of syphilis. The reasons for this belief have been
+extensively reviewed in the discussion of the nature of the disease
+itself (pages 104-105). On the whole, however, the method of Great
+Britain in looking first to the provision for adequate diagnosis and
+treatment, and then to the question as to who will not avail himself of
+it, is a logical mode of attacking the question, and as it develops
+public sentiment in its favor, will also pave the way for a sentiment
+which will stand back of compulsion if need be, and save it from being a
+dead letter.
+
++Backwardness of the United States in the Movement.+--It will be
+apparent, from the foregoing review of the world movement against
+syphilis, and the essentials of a public policy toward the disease, that
+the majority of our efforts in this direction have been decidedly
+indirect. We have no national program of which we as a people are
+conscious. It is all we can do to arouse a sentiment to the effect that
+something ought to be done. In these critical times we must mobilize for
+action in this direction with as much speed at least as we show in
+developing an army and navy, slow though we are in that. To limit our
+efforts to the passing of freak state legislation regulating the price
+of a Wassermann to determine the fitness of a person for marriage, when
+both Wassermann test itself, and Wassermann test as evidence of fitness
+for marriage, are likely, under the conditions, to be absolutely
+worthless, is to play penny eugenics. The move to take the gag from the
+mouth of the physician when an irresponsible with a venereal disease
+aims to spread his infection by marriage is at least intelligent,
+preventive, even if indirect, legislation, because it acts before and
+not after the event. Although at the present time we cannot boast a
+single example of a complete program of direct legislation, the example
+of Michigan, which is providing free hospital treatment for adults and
+children with syphilis, should be watched as the first radical step in
+the right direction. If war and our mobilization for defense leave us
+with every hospital and dispensary and public health resource and all
+the expert judgment we have available within our borders enlisted
+finally in a great campaign against gonorrhea and syphilis, it will have
+accomplished a miracle, though it will have done no more than war has
+done for Europe. If it leaves us even with our more progressive states
+committed to an expanding program of universal efficient and accessible
+diagnosis and treatment, it will have conferred a blessing.
+
++Relation of War to the Spread of Venereal Disease.+--The frequent
+reference to the relation of war to the problems of sexual disease seems
+to justify a concluding paragraph on this aspect of the matter. Much of
+the impetus which has carried European nations so far along the road
+toward an organized attack on syphilis and gonorrhea, as has been said,
+is undoubtedly due to the realization that war in the past has been the
+ally of these diseases, and that a campaign against them is as essential
+to national self-defense as the organization of a vast army. Conflicting
+reports are coming from various sources as to the prevalence of syphilis
+and gonorrhea among European troops, although hopeful indications seem
+to be that troops in the field may have even a lower rate of disability
+than in peace times (British figures). The most serious risks are
+encountered in troops withdrawn from the front or sent home on leave,
+often demoralized by the strain of the trenches. The steady rise in the
+amount of syphilis in a civil population during war is evidenced, for
+example, by the figures of Gaucher's clinic in Paris, in which, just
+before the war, 10 per cent of patients were syphilitic; after the first
+sixteen months of the war 16.6 per cent were syphilitic, and in the last
+eight months, up to December, 1916, 25 per cent had the disease. There
+can be no doubt that a campaign of publicity can do much to control the
+wholesale spread of infection under war conditions, and we should bend
+our efforts to it, and to the more substantial work of providing for
+treatment and the prevention of infectiousness, with as much energy as
+we devote to the other tasks which preparedness has forced upon us. The
+rigorous provisions proposed for continental armies should be carefully
+studied, and in no cases in which either syphilis or gonorrhea is active
+should leave or discharge be granted until the infectious period is
+over. Compelling infected men to remain in the army under military
+discipline until cured might have a deterrent effect upon promiscuous
+exposure. In addition we should create as rapidly as possible a
+mechanism for keeping inactive cases under surveillance after discharge
+until there can no longer be the slightest doubt as to their fitness to
+reenter civil life. Observers of European conditions in the population
+at large are emphatic in saying that home conditions must have as much
+attention as the army, and that suppression of open prostitution, a
+watchful eye on the conditions under which women are employed or left
+unemployed, and the control of contributory factors, such as the liquor
+traffic, must be rigorously carried out. Nation-wide prohibition will do
+much to control venereal disease.[18] It is interesting and significant
+that little reliance is being placed on the obsolete idea that
+prostitution can be made a legitimate and safe part of army life solely
+by personal prophylactic methods, or by any system of inspection of the
+women concerned. It is a hopeful sign that this conception is at last
+meeting with the discredit which has long been due it.
+
+    [18] Through the effect on prostitution. A well-known and very
+    intelligent prostitute, with whom this question was recently
+    discussed, rated the liquor traffic first among the influences
+    tending to promote prostitution.
+
+The question has occurred to those interested in compulsory military
+service as a measure of national defense as to whether the mobilization
+of troops for training will favor the spread of sexual disease.
+Unfortunately, there are no satisfactory figures for the civil
+population showing how many persons per thousand per year acquire
+syphilis or gonorrhea, to be compared with the known figures for the
+onset of such infections in the army. Arguing from general
+considerations, however, there seems to be no reason to suppose that the
+army will show a higher proportion of infections than civilians. In
+fact, there is every ground for believing that the percentage will be
+lower, since the army is protected by a fairly efficient and enforceable
+system of prophylaxis which is taught to the men, and they live,
+moreover, under a general medical discipline which reduces the risk of
+infection from other than genital sources to the lowest possible terms.
+In opposition to the conception that the sexual ideals of the army are
+low, it may be urged that they are no lower than those of corresponding
+grades in civil life, and that hard work and rigid discipline have a
+much better effect in stiffening moral backbone than the laxities of
+present-day social life. In the last analysis, the making of the moral
+tone of the army is in our own hands, and by putting into it good blood
+and high ideals, we can do as much to raise from it a clean manhood as
+by submitting that same manhood to the temptations and inducements to
+sexual laxity that it meets on every street corner.
+
+This chapter closes the discussion of syphilis as a problem for the
+every-day man and woman. It represents essentially the cross-section of
+a moving stream. Today's truth may be tomorrow's error in any field of
+human activity, and medicine is no exception to this law of change. It
+is impossible to speak gospel about many things connected with syphilis,
+or to offer more than current opinion, based on the keenest
+investigation of the facts which modern methods make possible. None the
+less, the great landmarks in our progress stand out with fair prospect
+of permanent place. The germ, the recognition of the disease by blood
+test and dark field microscope, the treatment and prevention seem built
+on a firm foundation. As they stand, without regard to further advances,
+they offer a brilliant future to a campaign for control To that
+campaign, each and every one of us can address himself with the
+prospect of adding his mite of energy to a tremendous movement for human
+betterment. For every man or woman to whom the word syphilis can be made
+to mean, not a secret, private, shameful disease, but a great open
+problem in public health, a recruit has been called to the colors. There
+are no signs more hopeful of the highest destiny for humanity than those
+of today which mark the transition of disease from a personal to a
+social problem. Such a transition foreshadows the passing of syphilis.
+In that transition, each one of us has his part. Toward that
+consummation, a goal only to be won by united and stubborn assault, each
+one of us can contribute the comprehension, the sympathetic support, the
+indomitable determination, which make victory.
+
+
+
+
+INDEX
+
+
+ABORTION, syphilis as cause of, 95
+
+Abortive cure and marriage, 127
+  of syphilis, 27, 86
+  salvarsan in, 73, 79, 89
+  time required for, 87
+
+Accidents, late, 45. _See also late syphilis_
+
+Advertising in regard to treatment for syphilis, 175, 176
+
+Alcohol, effects of, in syphilis, 137
+
+America, backwardness of, in movement against venereal diseases, 181
+  state control of venereal diseases in, 170
+
+American Social Hygiene Association, 165
+  pamphlets, 161
+
+Antibodies in disease, 54
+
+Antiseptics, effect of, on germ of syphilis, 27
+
+Appearance of chancre, time elapsing before, 29
+
+Armpits, contagious patches in, 38
+
+Army and navy, Metchnikoff prophylaxis in, 162
+  probable outlook for venereal diseases in, 184
+  proposed measures relative to venereal disease in, 183
+  syphilis in, 25
+
+Arsenic in salvarsan, 71
+
+Arteries, effect of syphilis on, 47
+
+Australia. _See West Australia_
+
+
+BABIES, hereditary syphilis in, 99
+
+Baltimore Vice Commission, report of, 134
+
+Baths in treatment of syphilis, 140
+
+Bath-tubs not means of transmitting syphilis, 114
+
+Berlin, syphilis in clerks and merchants of, 25
+
+Birth, premature, 95
+
+Blaschko and German sexual disease program, 177, 180
+  estimate of syphilis in Berlin, 25
+
+Blindness in hereditary syphilis, 104
+
+Blood, Spirochaeta pallida in, during secondary stage of syphilis, 35
+  test for syphilis, 54. _See also Wassermann test_
+  vessels, late syphilis in, 46
+
+Board of Health, activities of, against syphilis, 165
+  national, need for, 167
+
+Body, invasion of, by germs in secondary stage of syphilis, 35
+
+Bones in hereditary syphilis, 102
+  late syphilis (gumma) in, 46
+  Spirochaeta pallida in, 39
+  supposed effect of mercury on, 63
+
+Bordet and Wassermann, blood test for syphilis, 14
+
+Brain, late syphilis of, 48
+  softening of, 48
+Brawl chancre, 116
+
+Breasts, contagious patches on, 38
+
+Brooklyn Hospital Dispensary, 171
+  health exhibit by, 175
+
+
+CABOT, Hugh, comment on reporting syphilis, 179
+
+Cancer following smoker's patch, 138
+
+Chafe, chancre resembling, 30
+  relation of, to infection with syphilis, 28
+
+Chancre, 29
+  and cold sores, 30
+  appearance of, 30
+  brawl, 116
+  combined with chancroid, 30
+  concealment of, by gonorrhea, 30
+  contagiousness of, 109
+  contracted during engagement, 117
+  cure of syphilis in stage of, 85
+  developed from kissing game, 117
+  diagnosis of, prevented by improper treatment, 32
+  ease with which overlooked, 30
+  enlargement of glands near, 33
+  extra-genital, from lax relations, 134
+  importance of early recognition of, 31, 34
+  in women, 30
+  location of, 28
+  of the lip, 117, 119
+  on knuckle (brawl chancre), 116
+  painlessness of, 30
+  soft, 30. _See also chancroid_
+  tertiary symptoms following, 45
+  urethral, in men, 30
+  variations in, 30
+
+Chancroid, 16
+  and syphilitic infection, 30
+  confusion of, with syphilitic chancre, 31
+
+Child, death of, in syphilitic miscarriages or abortion, 95
+  early signs of hereditary syphilis in, 99
+  effect of syphilitic eye trouble on development of, 103
+  healthy, born of syphilitic mother, 94
+  infection of wet nurse by syphilitic, 100
+  necessity of teaching sexual self-control to, 160
+  older, effect of hereditary syphilis on, 102
+  transmission of syphilis from mother to, 92
+  treatment of syphilis in, before birth, 97
+  unborn, effect of syphilis on, 98
+
+Child-bearing, effect of syphilis on, 95
+
+Children, adopted, syphilis in, 106
+  syphilitic, mental condition of, 101
+
+Clap, 16.
+  _See also gonorrhea_
+
+Clinics for pay patients to secure better treatment, 173
+  inadequate, for venereal disease, 170
+  night, necessity for, 171
+
+Cold sores and chancres, 30
+
+College students, syphilis in, 25
+
+Commission, Baltimore Vice, 134
+  Sydenham Royal, 164
+
+Complications, serious, of syphilis, 45
+
+Compulsory treatment, state provision for, 169
+
+Conception, influence of syphilis on, 95
+  treatment of syphilis occurring in mother after, 97
+
+Coney Island Health Exhibit, 175
+
+Contagiousness of moist sores in syphilis, 27, 38, 110
+  of secondary relapses in syphilis, 42
+  syphilitic sores, 38
+  of syphilis, 109. _See also infectiousness, infection, and transmission_
+    and medical examination of prostitutes, 135
+    control of, by salvarsan, 73, 74, 122
+    detection of, by examination of patient, 123
+    disappearance of, in late syphilis, 110
+    duration of, in late syphilis, 112
+      under treatment, 123
+    effect of incomplete cure on, 83
+      of local irritation on, 43
+      of mercury on, 64
+      of moisture on, 27, 38, 110
+      of time on, 111
+      of tobacco on, 138
+    estimate of risk for wife, 125
+    factors tending to increase, 112
+    five-year rule in relation to, 124
+    hereditary, 100, 105
+    ignorance of, in women, 135
+    impracticability of quarantine in control of, 121
+    in wet nurses, 101
+    inability of mercury to control, 123
+    obstacles to control by treatment, 123
+
+Continence as personal prophylaxis, 161
+  economic forces opposing, 157
+
+Copenhagen, dispensaries for treatment in, 171
+
+Cost, economic, of mental disease due to syphilis, 51
+  of living, effect of, on marriage and sexual life, 158
+  of treatment, effect of, 84, 149
+
+Cups, drinking, transmission of syphilis by, 113
+
+Curability of syphilis, critical estimate of, 90
+
+Cure, importance of, for the wife, 128
+  incomplete or symptomatic, danger of, 82
+  of early syphilis, abortive, 27, 34, 86, 127
+  of hereditary syphilis, 107
+  of syphilis, 124, 126, 129. _See also five-year rule_
+    abortive, salvarsan in, 73, 79, 89
+    complete, responsibility of the physician in regard to, 84
+    effect of cost on, 84, 149
+      stage of disease on, 85
+    importance of, 90
+    in early stage, 27, 86
+    in primary stage, 85. _See also cure of syphilis, abortive_
+    in secondary stage, 86, 88
+    methods of determining, 90
+    obstacles to, 80
+    radical or complete, 80
+    Wassermann test in, 58
+  symptomatic, in late syphilis, 87
+  time required for, 87
+
+
+DARK-field examination, use of, in recognizing contagious recurrences, 111
+  germ of syphilis in, 22
+  importance of using, 22
+  use of, in recognizing early syphilis, 33
+
+Deafness and loss of speech due to hereditary syphilis, 104
+
+Deaths due to hereditary syphilis, 98, 99
+  due to late syphilis, 48
+
+Denmark, free treatment of syphilis in, 169
+
+Disgrace, syphilis and, 142, 144
+
+Disinfection of hands, dishes, etc., by washing and disinfectants, 114
+
+Dispensaries for syphilis in large cities, 170
+
+Drinking of alcoholic liquors, effect of, in syphilis, 137
+
+"Drops," 69
+
+Drug stores and drug clerks, evil influence of, 175
+  prescribing, suppression of, 168, 174
+
+Drying, effect on germ of syphilis, 27
+
+Dumbness (loss of speech) in hereditary syphilis, 104
+
+Dyes, relation of, to salvarsan, 70
+
+
+EARS, secondary recurrences affecting, 43
+
+Ears, trouble in, in hereditary syphilis, 104
+
+Eating utensils, transmission of syphilis by, 113, 115
+
+Education and character in the control of syphilis, 160
+  as means of controlling contagiousness of syphilis, 122
+
+Ehrlich, Paul, 70
+
+Engagements, syphilis contracted during, 117
+  to marry in syphilitics, precautions in connection with, 129
+
+England, action of, against drug stores prescribing for syphilis, 176
+  provision for treatment of venereal disease in, 169
+  treatment not compulsory in, 180
+
+English-speaking countries, attitude on Metchnikoff prophylaxis in, 177
+
+Eruptions, absence of, in serious syphilis, 46
+  effect of mercury on syphilitic, 64
+  in hereditary syphilis, 100
+  non-syphilitic, 37
+  recurrent, 42, 43
+  secondary syphilitic, 36
+  syphilitic, effect of salvarsan on, 74
+
+Estimate of damage caused by syphilitic eye trouble, 103
+  of frequency of relapse and recurrence in secondary syphilis, 125
+  of increase of syphilis during war, in Paris, 183
+  of percentage of marital syphilis, 119
+  of percentage of non-genital syphilis, 119
+  of prevalence of gonorrhea, 26
+  of syphilis, 24, 25
+  of risk of infecting wife, 125
+  of syphilis in prostitutes, 134
+
+Examination, medical, before marriage, 130
+  limitations of, in detecting contagiousness, 123
+
+Excesses, effect of, on the syphilitic, 137
+
+Expense of treatment, effect of, 77, 84, 149
+
+Expert advice, importance of, 32
+  in secondary stage of syphilis, 86
+  in pay patient clinics, 174
+  services, value of, in control and
+  treatment of syphilis, 173
+
+Eye trouble in hereditary syphilis, 103
+  in later life, 105
+  in secondary syphilis, 36
+
+Eyes, secondary syphilitic recurrences affecting, 43
+
+
+FAMILY, economic forces working against, 158
+  transmission of syphilis in, 116
+
+Fathers of families, encouragement of early marriages by, 159
+  syphilis in, 93, 126
+
+Fiancee, non-genital chancre in, 129
+
+First sore, 29. _See also chancre_
+
+Fist chancre, 116
+
+Five-year rule, 124, 126, 129
+  in relation to marriage, 126
+
+Founder's estimate of prevalence of syphilis, 24
+
+France, increase of syphilis in, during war, 183
+
+
+GAUCHER'S estimates of increase in syphilis during war in France, 183
+
+Genital syphilis in lax individuals, 133
+
+Genitals, contagious sores on, 38, 112
+  fitness of, for harboring germs of syphilis, 118
+
+Germ of syphilis, 40. _See also Spirochaeta pallida_
+
+Germany, action of, against drug store prescribing for syphilis, 176
+  attitude on Metchnikoff prophylaxis in, 177
+  compulsory treatment of venereal disease in, 180
+  sentiment against reporting of venereal disease in, 179
+  society for preventing sexual disease in, 164
+  syphilis in, 25
+
+Germs, behavior of, in various diseases, 40
+
+Glands, enlargement of, in neighborhood of chancre, 33
+  in chancre of the lip, 33
+
+Gonorrhea and syphilis, measures to prevent spread from army to general
+population, 183
+  concealment of chancre by, 31
+  confusion of, with syphilis, 13, 16, 31
+  drug store treatment of, 175
+  estimated prevalence of, 26
+  in prostitutes in Baltimore, 134
+Gonorrhea, transmission of, by toilet seats, 114
+
+Great Britain. _See England_
+
+Gumma, 46. _See also syphilis, late_
+  effect of treatment on, 47
+  nature of, 46
+
+Gummatous infiltration in hereditary
+  syphilis, 102
+  in late syphilis, 46
+
+
+HAITI, origin of syphilis in, 11
+
+Hata, 70
+
+Headaches in syphilis, 36
+
+Health, effect of secondary syphilis on, 36
+  Exhibit, Brooklyn Hospital Dispensary, 175
+
+Hearing, disturbances of, in hereditary syphilis, 104
+  in secondary syphilis, 36
+
+Heart in hereditary syphilis, 102
+
+Hereditary syphilis, apparently healthy children with, 101
+  as cause of abortions and miscarriages, 95
+    of death, 98
+  blindness in, 104
+  bones and teeth in, 102
+  contagiousness of, 100, 105
+  deafness in, 104
+  early signs of, 99, 100
+  effect of accident and injury in, 105
+  eye trouble in, 103
+  heart, blood-vessels and nervous system in, 102
+  Hutchinson's teeth in, 102
+  immunity in, 106
+  in adopted children, state provision for care of, 106
+  in infant, 99
+  in unborn child, 98
+  late, in older children and adults, 101
+  moral costs of, 99
+  non-transmission of, by marriage, 105
+  treatment of, 107
+    in school hospitals, 108
+
+Hoffmann's rule for marriage of syphilitics, 124
+
+Hospital beds, number of, needed for venereal disease, 171
+  treatment for hereditary syphilis, 108
+
+Hospitals in treating venereal disease, 171
+  special venereal, 167, 171
+
+Hot Springs in treatment of syphilis, 140
+
+Hunter, John, 13
+
+Husband, probability of infection of wife by, 125
+
+Hutchinson's teeth in hereditary syphilitics, 102
+
+Hygiene, personal, of the syphilitic, 136
+
+
+IDIOCY in hereditary syphilis, 101
+
+Immunity in syphilis, absence of, 139
+  hereditary, 106
+
+Incubation period of syphilis, 28, 29
+
+Infection, break in skin necessary to, 28
+  double, with gonorrhea and syphilis, 30
+  with syphilis and chancroid, 30
+  point of entry of, site of chancre, 29
+  risks of, 32
+  time elapsing after, before chancre appears, 29
+  unsuspected risk of, 161
+  with syphilis favored by moisture, 27
+
+Infectiousness of syphilis. _See contagiousness_
+  of syphilitic discharges, 28
+
+Infiltration, gummatous, in late syphilis, 46
+  in hereditary syphilis, 102
+
+Injections, mercurial, 66
+
+Innocence, question of, in transmission of syphilis, 118
+
+Inoculation, favorable ground for, 114
+
+Insane asylums, amount of syphilitic mental disease in, 50
+
+Inunctions, advantages of, 66
+  disadvantages of, 65
+  mercurial, 65
+  number required for cure, 66
+
+Iodid of potash, 69
+
+Irresponsible mental attitude in syphilis, 150, 151
+
+Irritation, effect of, on contagious recurrences, 43
+
+Italy, non-compulsory treatment in, 180
+  provision for treatment of venereal disease in, 169
+
+
+KERATITIS, interstitial, in hereditary syphilis, 103
+
+Kernels. _See glands_
+
+Keyes' estimate of risk of infection of wife by husband, 125
+
+Kissing, rules governing, in syphilitics, 138
+  transmission of syphilis by, 116
+
+Knuckle chancre, 116
+
+
+LATE syphilis, non-contagious character of, 110
+  premature development of, 45
+  prospects for cure in, 86
+
+Latent or concealed syphilis, 22
+
+Law, Ohio, relative to physicians and marriage of syphilitics, 131
+  controlling professional confidence, 131
+  crippling physician in relation to marriage of syphilitics, 131
+  providing for compulsory treatment in various countries, 180
+
+Legal control, necessity for, in irresponsible syphilitics, 153
+
+Legislation, conservative, 167
+  indirect, against venereal disease, 169
+  undesirable and freak, 166
+
+Legs in locomotor ataxia, 49
+
+Lemberg, study of prostitutes in city of, 134
+
+Lesion, primary. _See chancre; also sore_
+
+Life, well-balanced, for syphilitic, 137
+
+Lip, chancre of, glands in, 33
+
+Liquid medicine, giving of mercury in form of, 65
+
+Liquor, alcoholic, effect of, in syphilis, 137
+  traffic, importance of abolition of, in prevention of venereal
+  disease, 184
+
+Liver, Spirochaeta pallida in, 39
+
+Locomotor ataxia, 48
+  frequency of, 51
+  stomach symptoms in (gastric crises), 49
+  symptoms in legs, bladder and rectum, 49
+  syphilitic germs in spinal cord in, 49
+  treatment and prevention of, 52
+
+London, syphilis in, 24
+
+Luetin test, Noguchi, 79
+
+
+MALARIA, comparison of, with syphilis, 62
+
+Marriage and abortive cure of syphilis, 127
+  and five-year rule, 126
+  and syphilis, 125
+  and Wassermann test, 130
+  annulment of, for concealment of syphilitic infection, 132
+  early encouragement of, by state, parents, employers, 159
+  effect of economic forces on, 158
+  medical examination for syphilis before, 130
+  of hereditary syphilitics, 105
+  of persons with syphilis, inability of physician to prevent, 131
+  of syphilitics, Hoffmann's rule for, 124
+  syphilis acquired in, 120
+
+Massachusetts, syphilitic mental disease in, 51
+
+Medical examination before marriage, 130
+    in relation to syphilis, 130
+  of prostitutes, 135, 136
+
+Mental attitude in relation to syphilis, 141
+    morbid, in syphilis, 153
+  disease and hereditary syphilis, 101
+
+Mental disease and syphilis, 50
+  Hygiene, National Committee for, 166
+
+Mercury, 62
+  and salvarsan, combination of, in controlling contagiousness, 124
+  comparative value of, 68
+  deceptive value of, 64
+  effect of, on syphilis, 63
+  inability of, to control contagiousness, 123
+  ineffectiveness of, by mouth, 65
+  injections of, 66
+  injurious effects of, 67
+  inunctions (rubs), 65
+  methods of administering, 64
+  of using in treatment, 62
+  misconception in regard to, 63
+
+Metchnikoff and Roux, 14
+  prophylaxis in syphilis, 162
+
+Michigan, legislative measures against syphilis in, 182
+
+Military service, universal, and spread of venereal disease, 184
+
+Miscarriage and abortion, syphilis as cause of, 95
+  repeated, 95
+
+Misconceptions regarding cure of syphilis with salvarsan, 72
+  syphilis in children, 100
+
+Moisture, effect of, on contagiousness of syphilis, 27, 38, 110
+  relation of, to infection with syphilis, 27, 38, 110
+
+Moore, Noguchi and, 48
+
+Moral problems in relation to syphilis, 18
+
+Morality, sexual, in relation to syphilis, 18
+
+Morals, syphilis and, 144
+
+Morbidness in syphilitics, 153
+
+Mother, knowledge of, in adopting a child, 106
+  syphilitic, apparent good health of, 93
+    period of greatest danger to child, 94
+  treatment of syphilis in, 97
+
+Mouth, administration of mercury by, 64
+  contagious sores in, 38, 42. _See also mucous patches_
+  effect of mercury on, 67
+  late syphilis in, 47
+
+Mucous patches, 38, 42
+  cancer following, 138
+  effect of salvarsan on, 74
+    of tobacco in predisposing to, 43, 112
+  susceptibility of prostitutes to, 136
+
+
+NATIONAL Board of Health, need for, 167
+
+Neck, enlargement of glands in, 33, 34
+
+Neosalvarsan, 75
+
+Nervous strain, effect of, on syphilis, 137
+  system, complications, relation of, to mild secondary syphilis, 45, 46
+    examination of, in determining cure of syphilis, 90
+    relapses, 43
+    Spirochaeta pallida in, 39
+
+New York City, clinics and dispensaries in, 170
+  reporting of syphilis in, 178
+
+Noguchi, 48
+  test, luetin, 79
+
+Non-genital syphilis, estimate of percentage of, 119
+  in lax individuals, 133, 134
+
+Notification of venereal disease. _See reporting_
+
+Nurse, accidental infection of, with syphilis, 116
+  wet, syphilis in, 100
+
+Nursing mothers, syphilitic germs in milk of, 39
+  of syphilitic child by mother, 101
+
+
+OHIO, law permitting physician to prevent marriage of contagious
+syphilitic person, 131
+
+Overwork, effect of, on syphilitics, 137
+
+
+PAPEE'S study of prostitution in Lemberg, 134
+
+Paralysis, general, danger to others in, 49, 50
+  estimated frequency of, 51
+  mental symptoms in, 49
+  of insane, 48
+  syphilitic germs in brain in, 49
+  treatment and prevention of, 52
+
+Paresis, 48. _See also paralysis, general_
+
+Paris, increase of syphilis in, during war, 183
+
+Physician, accidental infection of, with syphilis, 116
+  cooeperation of, in educating syphilitic, 148
+  importance of informing, in regard to syphilis, 105, 140
+  inability of, to prevent marriage of persons with syphilis, 131
+
+Physician proper person to administer Metchnikoff prophylaxis, 163
+
+Piles, contagious sores mistaken for, 43
+
+Pills, ineffectiveness of, in treating syphilis, 65
+  mercury, 65
+
+Pinkus' estimate of syphilis in Germany, 25
+
+Pontopidan's estimate of number of hospitals needed for venereal
+diseases, 171
+
+Population, civil, syphilis in, 183
+  general, prevention of venereal disease in, during war time, 184
+
+Potash, iodid of, 69
+
+Pregnancy, syphilis acquired during, 94
+  treatment of mother during, 97
+
+Prevalence of gonorrhea, estimates of, 26
+  of syphilis, estimates of, 24, 25
+
+Prevention of locomotor ataxia and general paralysis, 52
+  of syphilis. _See prophylaxis_
+
+Primary lesion. _See chancre_
+  stage. _See also chancre_
+    contagiousness of syphilis in, 109
+    cure of syphilis in, 85
+
+Prohibition, national, importance of, in controlling venereal disease, 184
+
+Prophylaxis, educational, 157
+  state provision for, 168
+  Metchnikoff, 162
+    utilization of, in public campaign, 177
+  moral, of syphilis, 156
+
+Prophylaxis, personal, of syphilis, continence in, 161
+  general instruction in, 169
+  in army and navy, 162
+  physician proper person to administer, 163
+  unsatisfactory features of, 162
+
+Prostitutes in Baltimore, gonorrhea in, 134
+  medical examination of, 135
+  syphilis in, 134
+
+Prostitution, abolition or repression of, 156, 157
+  and syphilis, 18, 133
+  clandestine, risks of, 136
+  effects of liquor traffic on, 184
+  regulation of, 156
+
+Psoriasis, confusion of, with syphilitic eruptions, 37
+
+Public Health, syphilis as problem of, 18
+  Service, United States, estimates of prevalence of syphilis, 24
+  opinion about syphilis, 141
+  sentiment and reporting of syphilis to health officers, 178
+
+Publicity, campaign for, 176
+
+
+QUACKS, suppression of, 168, 174
+  treatment of syphilitics by, 140
+
+Quarantine and freak legislation, 167
+  compulsory, for irresponsible syphilitics, 153
+  limitations of, in controlling spread of syphilis, 121
+  temporary, for syphilis, in hospitals, 172
+
+Quiescent period following entry of germ, 28
+
+
+RAILROAD MEN, locomotor ataxia and general paralysis in, 50
+
+Rash. _See eruption_
+
+Recurrences, contagiousness of, 111
+  estimated frequency of, in secondary syphilis, 125
+  in secondary stage, 42, 43
+
+Re-infection with syphilis, 139
+
+Relapses, contagious, in syphilis, 42
+  frequency of, in secondary stage, 125
+  in nervous system, 43
+
+Reporting of syphilis, attitude of various countries on, 179
+  to health officers, 178
+
+Resistance of body to syphilis, 29, 107, 112
+
+Rest, need of, in syphilis, 137
+
+Restaurants, risk of transmitting syphilis under conditions found in, 115
+
+Rheumatism, symptoms resembling, in secondary syphilis, 36
+
+Ricord, founder of modern syphilology, 13
+
+Rub, mercurial. _See inunction_
+
+Rule, five-year, 124, 126, 129
+  for marriage of syphilitics. _See marriage_
+  for personal hygiene of syphilitics, 136
+  governing miscarriage and abortion due to syphilis, 96
+  sexual relations in syphilitics, 138
+  variations on, in hereditary syphilis, 96
+
+
+SALIVA, syphilitic germs in, 38
+
+Salvarsan, accidents due to, 78
+  action of, in syphilis, 73
+  and abortive cure, 73, 79, 89
+  and mercury, comparative value of, 68, 89
+    in pregnancy, 97
+  animal tests on, 71
+  arsenic in, 71
+  as a social asset, 78
+  cheap, vital importance of, 172
+  combination of arsenic and dye, 70, 71
+  correct administration of, 77
+  discovery of, 70
+  effect of first dose, 78
+    of insufficient treatment with, 76
+    on mucous patches, 74
+  expense of treatment with, 76
+  importance of, in controlling contagiousness of syphilis, 73, 74, 122
+  in treatment, 89
+  in control of syphilis in prostitutes, 157
+  methods of giving, 75
+  misconceptions regarding cure by single dose, 72
+  need for governmental control, 77
+  patent rights on, 172
+  preliminary tests of, on man, 71, 72
+  price of, 172
+  repeated doses, 76
+  use of, does not justify relaxation of rules for marriage, 127
+  value of, in syphilis, 73
+
+Scandinavian countries, compulsory treatment of venereal disease in, 180
+  free treatment of venereal diseases in, 169
+  provision for reporting venereal disease in, 179
+
+Scars following gummatous changes, 46
+
+Schaudinn and Hoffmann, 14, 22
+
+School-hospitals for hereditary syphilis, 108
+
+Secondary stage of syphilis, 35
+  contagious relapses in, 42
+  contagiousness in, 110
+  cure in, 86
+  eye trouble in, 36
+  headaches in, 36
+  loss of weight in, 36
+  problems of, 42
+  rash (eruption) in, 36
+  rheumatic pains in, 36
+  severe, 36
+  spontaneous disappearance of symptoms, 39
+  time required for cure, 88
+
+Secrecy, professional, right of syphilitics, 139
+  right of syphilitic, in connection with reporting of disease, 178
+
+Self-control. _See sexual self-control_
+
+Self-deception in regard to risk of infection, 161
+
+Self-treatment in syphilis, 140
+
+Semen, Spirochaeta pallida in, 39
+
+Sexual characteristics of syphilitic children, 102
+  morality, development of, 145
+  relations, abstinence from, economic influences opposing, 158
+  of syphilitics, rules governing, 129, 138
+
+Sexual relations, transmission of syphilis by, 117
+  self-control, economic forces opposing, 157
+  teaching of, 159
+  transmission of syphilis, question of guilt or innocence, 118
+
+Silverware, transmission of syphilis by, 115
+
+Single dose cure of syphilis with salvarsan, 72
+
+"606." _See salvarsan_
+
+Skin, recurrences of secondary eruption in, 43
+  unbroken, importance of, in preventing contagiousness of eruptions, 38
+
+Sleeping sickness, 70
+
+Smoker's patches, 138
+
+Smoking (tobacco) in syphilis, 138
+
+Snuffles in hereditary syphilis, 100
+
+Social evil and syphilis, 165. _See also prostitution_
+  problem of syphilis, 15
+
+Soft ulcer or sore, 16. _See also chancroid_
+
+Soldiers, syphilis and gonorrhea among, in present war, 183
+
+Sore throat in secondary syphilis, 38
+
+Sores, contagious, effect of salvarsan on, 74
+    in prostitutes, 136
+    in syphilis, 38
+    transitory character of, 123
+  contagiousness of moist, 27, 38, 110
+    of open, 109
+  on nipples in wet nurses, 101
+  primary. _See chancre_
+  soft, 16. _See also chancroid_
+  tertiary. _See syphilis, late, gumma_
+
+Sperk's estimate of frequency of relapse in secondary stage, 125
+
+Spirochaeta pallida, 27
+  average life of, on objects outside body, 113
+  destruction of, in body, 39
+  discovery of, 14, 22
+  distribution of, in internal organs, 39
+  effect of antiseptics on, 27
+    of drying on, 27
+    of salvarsan on, 74
+  growth of, 27
+  in brain, in general paralysis of insane, 48
+  in hereditary syphilitic children, 99
+  in late syphilis, 45
+  in lymph-glands, 34
+  in secondary syphilitic eruptions, 38
+  in spinal cord, in locomotor ataxia, 49
+  invasion of body by, in secondary stage, 35
+  low vitality of, 27
+  mode of entry into body, 28
+  sensitizing of body to, 39
+  strains or type of, 40
+  variations in behavior of, in different persons, 40
+
+Spleen, Spirochaeta pallida in, 39
+
+Stage of syphilis, relation of, to curability, 82
+  secondary, of syphilis, 35. _See also secondary stage; secondary
+  syphilis; contagiousness; transmission; and Spirochaeta pallida_
+
+Stage, tertiary, of syphilis, 45. _See also syphilis, late_
+
+State, encouragement of early marriage by, 159
+  provision of, for recognition and treatment of syphilis, 168
+
+Stigma attaching to syphilis, harm done by, 143
+  of syphilis, effect of, on venereal hospitals, 167
+
+Still birth, relation of syphilis to, 96
+
+Still's statistics on death from hereditary syphilis, 98
+
+Stomach in locomotor ataxia, 49
+
+Sweat-glands, absence of Spirochaeta pallida in, 39
+
+Sydenham Royal Commission, 164
+  views on reporting of venereal disease, 179
+
+Symptomatic cure in late syphilis, 87
+
+Symptoms, absence of, in syphilis, 23
+  constitutional, of secondary syphilis, 36
+
+Syphilis, absence of immunity in, 139
+  accidental, in physicians and nurses, 116
+  acquired, in children, 95
+    in marriage, 119
+  action of mercury in, 63
+    of salvarsan in, 74
+  active, relation of, to miscarriages and abortion, 96
+  adequate dispensary service for treating, 171
+  ageing effect of, in child, 99
+  and civil population, 183
+  and engagements to marry, 129
+
+Syphilis and marriage, 125
+  and mental disease, 50
+  and prostitution, 18, 133
+  and public prejudice, 141
+  and sexual problems, 18
+  and war, 183
+  as cause of death in children, 98
+    of miscarriages and abortion in women, 95
+  as public health problem, 18
+  as social problem, 15
+  blood test for, 54
+  broader outlook concerning, 146
+  comparison of, with malaria, 62
+  compulsory treatment of, 180
+  concealed forms of, 23
+  concealment of, by gonorrhea, 30
+  confusion of, with gonorrhea, 13, 16, 31
+  problem of, with various issues, 16, 17, 165
+  congenital, 94. _See also syphilis, non-hereditary_
+  constitutional symptoms of, 36
+  contagiousness of, in secondary stage, 110
+  course of, summary, 52
+  cure of, 90
+  danger from irresponsible persons infected with, 150
+  deaths from, 48
+  definition of, 21
+  diminishing virulence of, 12
+  early, methods of recognizing, 32
+  educational prophylaxis of, 157
+  epidemic of, in sixteenth century, 11
+  eruption in secondary stage, 36
+  essentials of campaign against, 168
+  false silence in regard to, 15
+  five-year rule regarding contagiousness, 124, 126, 129
+  freak legislation in regard to, 166
+  guilt or innocence in transmission, 118
+  harm done by stigma attaching to, 143
+  hereditary, 92
+    accident and injury in, 105
+    contagiousness of, 100, 105
+    destructive changes in, 101, 102
+    early signs of, in children, 99, 100
+    late signs of, 101
+    mental symptoms in, 101
+    of eye, 103
+    treatment of, 107
+  history of, 11
+  importance of prohibition in controlling, 184
+  important advances in knowledge of, 17
+  in adopted children, 106
+  in British working men, 24
+  in families, detection of, by Wassermann test, 128
+  in father or mother of family, 92, 93, 126
+  in men who have only had gonorrhea, 31
+  in prostitutes, 134
+  in United States, estimates of, 26
+  in wet nurses, 100, 101
+  inability of physician to prevent marriage of persons with, 131
+  incomplete cure of, 82
+  influence of, on progress of mediaeval medicine, 13
+  innocent, in fiancee, 129
+    suffering of, caused by, 19
+  late, attributable to insufficient salvarsan treatment, 73
+    curability of, 86
+    destructive effect of, 47
+    in nervous system, 48
+    most serious forms of, 47
+    seriousness of, 45
+    tissue changes in (gumma), 46
+  measure to prevent spread of, from army to general population, 183
+  medical examination for, as means of detecting contagiousness, 123
+    of prostitutes for, 135
+  mental attitudes in relation to, 141
+  Metchnikoff prophylaxis of, 162
+  mild, dangers of, 41
+    relation to complications in nervous system, 45
+  mistaken conceptions of, 13
+  moral prophylaxis of, 156
+  morbid fear of, 154
+  non-genital, 28
+    or extra-genital, 119
+  obstacles to control of contagiousness of, 123
+    to social control of, 141
+  passive, transmission of, by prostitutes, 135
+  personal hygiene of, 136
+  prevalence of, 23
+    in lax individuals, 133
+  prevention of, by sexual self-control, 159
+  public attitude toward, 141
+  quacks and self-treatment in, 140
+  radical or complete cure, 80
+  reinfection with, 139
+  relation of mouth and tongue cancers to, 138
+  reporting of, to health officer, 178
+  risk of acquiring, from prostitutes, 136
+    of infecting wife with, 125
+  secondary, cure of, 86
+    time required for cure of, 86
+  sexual transmission of, 117
+  stages of, 26
+  state provision for treatment of, in Denmark, Norway, Italy,
+    England, Germany, West Australia, 168, 169
+  tertiary, 45
+  transmission and hygiene of, 109
+    by kissing, 116
+    to and by wet nurse, 100, 101
+  treatment of, 60
+    at Hot Springs, 140
+    with salvarsan, 75
+  unnoticed manifestations of, 41
+  variations in course of, in different persons, 41
+  Wassermann test for, 54
+  world movement against, 164
+
+Syphilitic, average type of, 148
+  child, nursing of, by mother, 101
+  ideal conscientious type of, 147
+  irresponsible types of, 151
+  morbid mental states, 153
+  personal hygiene of, 136
+  should tell physician he has disease, 140
+  rule governing care of personal articles used by, 139
+  rules governing kissing in, 138
+  sexual relations in, 138
+  well-regulated life for, 137
+
+Syphilophobia, 153
+
+
+TABES dorsalis, 48. _See also locomotor ataxia_
+
+Taboparesis, 50
+
+Teeth, effect of mercury on, 63, 67
+  (Hutchinson's), in hereditary syphilis, 102
+
+Tertiary stage, 45
+
+Test for syphilis in blood, 54. _See also Wassermann test_
+  Noguchi, luetin, 79
+
+Throat, contagious sores in, 38
+
+Time treatment principle in relation to marriage, 124, 126, 129
+
+Tobacco, effect of, in syphilis, 43, 112, 138
+
+Toilet seats not means of transmitting syphilis, 114
+  transmission of gonorrhea by, 114
+
+Tongue and tonsils, contagious sores on, 42
+  cancer of, following contagious mucous patches, 138
+
+Towels, transmission of syphilis by, 113, 115
+
+Transmission of syphilis by dishes, etc., effect of washing and
+disinfection on, 114
+  by infected articles, 113
+  by kissing, 116
+  by sexual contact, 117
+  effect of treatment on risk of, 124
+  from father to mother, 93
+  from mother to child, 92
+  increased risk of, in tobacco users, 138
+  medical examination in prevention of, 123
+  not by door-knobs, bath-tubs, or toilet seats, 114
+  passive, by prostitutes, 135
+  personal responsibility in, 124 to wife, 125
+  under conditions of crowding and bad sanitation, 115
+    of everyday life, 114
+  unlikely in marriage of hereditary syphilitics, 105
+
+Treatment, intraspinal, in syphilis of nervous system, 79
+  lack of effect of, on deafness in hereditary syphilis, 104
+  obstacles to control of contagiousness of syphilis, 123
+  of chancre may prevent recognition, 32
+  of syphilis, 60
+    advertising in regard to, 176
+    backwardness of this country in public provision for, 170
+    by drug clerks, 175
+    by quacks, 140
+    compulsory, 180
+    control of contagiousness, 122, 124, 126
+    dispensary service necessary for, 171
+    efficient, 88
+    expense of, 76, 173
+    expert advice in, 174
+    hospitals in, 171
+    importance of salvarsan in, 89
+    in pay-patient clinics and hospitals, 173
+    necessity for cheap salvarsan in, 172
+    various state provisions for, 168, 169
+    Wassermann test in, 57
+    with salvarsan and mercury combined, 89
+  specific methods of, 60
+
+Troops, syphilis and gonorrhea in, 182
+
+
+UNITED STATES. _See America_
+
+
+VEDDER'S estimate of prevalence of syphilis, 25
+
+Venereal disease, 16
+    and marriage, annulment of, 132
+    effect of universal military service on, 184
+    European and American provision in regard to care of, 169, 170
+    importance of national prohibition in controlling, 184
+    proposed military measures in connection with, 183
+    relation of war to spread of, 182
+    world-wide movement against, 164
+  hospitals and freak legislation, 167
+
+Vermont, reporting of syphilis in, 178
+
+Vice Commission, Baltimore, syphilis in prostitutes, 134
+
+Virulence of syphilis in 15th and 16th centuries, 12
+
+Vomiting in locomotor ataxia, 49
+
+
+WAR, control of venereal diseases during, 183, 184
+
+War, relation of, to spread of venereal disease, 182
+
+Warts, contagious syphilitic, 42
+
+Washing, effect of, on transmission of syphilis by dishes, 114
+
+Wassermann test, 54
+  as evidence of fitness to marry, 130
+  difficulties of, 55
+  effect of mercury on, 67
+    of treatment on, 58
+  factor of error in, 56
+  importance of expert performance of, 174
+    to pregnant mother, 97
+  in connection with adoption of children, 106
+  in determining cure of syphilis, 58, 90
+  in family where one member is syphilitic, 128
+  in freak legislation, 167
+  in late hereditary syphilis, 106
+  in syphilitic mothers, 93
+  negative, development of infectious sores in spite of, 123
+    meaning of, 56
+  on spinal fluid, 59
+  persistently positive, 58
+  positive, meaning of, 56
+  practical details concerning, 59
+  provocative, 130
+  use of, in recognizing early syphilis, 33
+
+Weight, loss of, in secondary recurrences, 43
+  in secondary syphilis, 36
+
+Welander homes for hereditary syphilis, 108
+
+West Australia, action of, against drug stores prescribing for
+syphilis, 176
+  attitude of, on personal Metchnikoff prophylaxis, 177
+  compulsory treatment of syphilis in, 180
+  state provision of, for treatment of venereal diseases, 170
+
+Wet nurses, syphilis in, 100
+
+Wife, importance of cure for, 128
+  infection of, by husband during pregnancy, 94
+  risk of infecting, 125
+
+Williams, syphilis and mental diseases, statistics on, 50
+
+Womb, chancre on neck of, 30
+
+Women, child-bearing, effect of syphilis on, 95
+  employment of, in connection with problem of controlling venereal
+    diseases in war times, 184
+  miscarriages and abortions in, due to syphilis, 95
+  syphilis in lax, 133
+
+Worry and anxiety, effect of, on syphilitic, 137
+
+
+
+
+Transcriber's Note
+
+The following variably hyphenated words have been left as in the text.
+
+  Everyday       Every-day
+  everyday       every-day
+  extragenital   extra-genital
+  lifelong       life-long
+  lifetime       life-time
+  makeup         make-up
+  newborn        new-born
+
+All bold text has been surrounded by + symbols.
+
+A List of Illustrations has been added to the text of the file.
+
+
+
+
+
+
+End of Project Gutenberg's The Third Great Plague, by John H. Stokes
+
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