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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/18324-8.txt b/18324-8.txt new file mode 100644 index 0000000..d4ff994 --- /dev/null +++ b/18324-8.txt @@ -0,0 +1,6294 @@ +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: ISO-8859-1 + +*** 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 coöperation 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 coöperation, 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 + +ÉLIE 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 coöperation, 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 _Spirochæta 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 Laënnec 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 Spirochæta +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 +Spirochæta 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 reëxamine 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 Spirochæta 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 rôle 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 Spirochæta 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 +coöperation. 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 +coöperation 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 reëxamined 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 coöperation 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 Münchener 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 coöperation, and +demands also the coöperation 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 fiancée 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 coöperate. 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 rôle 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 +coöperation 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 coöperation 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 coöperators 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 coöperation 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 + + ÉLIE 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 +reëmphasized. 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 reëducate. + ++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 coöperation 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 coöperation 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 +reënter 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, Spirochæta 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 + Spirochæta 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 + +Fiancée, 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 Spirochæta 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, Spirochæta 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 + Spirochæta 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 + coöperation 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, Spirochæta 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 + +Spirochæta 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, Spirochæta pallida in, 39 + +Stage of syphilis, relation of, to curability, 82 + secondary, of syphilis, 35. _See also secondary stage; secondary + syphilis; contagiousness; transmission; and Spirochæta 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 Spirochæta 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 mediæval medicine, 13 + innocent, in fiancée, 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 + +*** END OF THIS PROJECT GUTENBERG EBOOK THE THIRD GREAT PLAGUE *** + +***** This file should be named 18324-8.txt or 18324-8.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/1/8/3/2/18324/ + +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) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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Stokes + </title> + <style type="text/css"> +/*<![CDATA[ XML blockout */ +<!-- + p { margin-top: .75em; + text-align: justify; + margin-bottom: .75em; + } + h1,h2,h3,h4 { + text-align: center; /* all headings centered */ + clear: both; + } + hr { width: 33%; + margin-top: 2em; + margin-bottom: 2em; + margin-left: auto; + margin-right: auto; + clear: both; + } + + table { margin-left: auto; margin-right: auto; } + + ul { list-style-type: none; } + + body{ margin-left: 10%; margin-right: 10%; } + + .pagenum { /* uncomment the next line for invisible page numbers */ + /* visibility: hidden; */ + position: absolute; + left: 92%; + font-size: smaller; + text-align: right; + } /* page numbers */ + + .blockquot{margin-left: 5%; margin-right: 10%;} + + .bbox {border: solid 1px;} + + .center {text-align: center;} + .smcap {font-variant: small-caps;} + .sf {font-size: small;} + .caption {font-weight: bold;} + + .figcenter {margin: auto; text-align: center;} + + .footnote {margin-left: 10%; margin-right: 10%; font-size: 0.9em;} + .footnote .label {position: absolute; right: 84%; text-align: right;} + .fnanchor {vertical-align: super; font-size: .8em; text-decoration: none;} + + .ralign {position: absolute; right: 10%; text-align: right;} + .mt {margin-top: 1em;} + // --> + /* XML end ]]>*/ + </style> + </head> +<body> + + +<pre> + +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: ISO-8859-1 + +*** 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) + + + + + + +</pre> + + +<h1>The Third Great Plague</h1> + +<h2>A Discussion of Syphilis +for Everyday People</h2> + +<h3>By</h3> + +<h2>John H. Stokes, A.B., M.D.</h2> + +<p class="center">Chief of the Section of Dermatology and Syphilology<br /> +The Mayo Clinic, Rochester, Minnesota</p> + +<p class="center">Assistant Professor of Medicine<br /> +The Mayo Foundation Graduate School of the University +of Minnesota</p> + + +<p class="center" style="margin-top: 5em;">Philadelphia and London<br /> +<span style="font-size: large; font-weight: bold;">W. B. Saunders Company</span><br /> +<span style="font-weight: bold;">1920</span></p> + + + +<div class="sf" style="margin-top: 5em;"><p class="center">Published, November, 1917</p> + +<p class="center">Copyright, 1917, by W. B. Saunders Company</p> + +<p class="center">Reprinted July, 1918</p> + +<p class="center">Reprinted February, 1920</p></div> + +<div class="sf" style="margin-top: 5em;"><p class="center">PRINTED IN AMERICA</p></div> + +<hr style="width: 65%;" /> +<p><span class='pagenum'><a name="Page_5" id="Page_5">[Pg 5]</a></span></p> +<h2><a name="PREFACE" id="PREFACE"></a>PREFACE</h2> + +<p>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.</p> + +<p>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.<span class='pagenum'><a name="Page_6" id="Page_6">[Pg 6]</a></span> +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.</p> + +<p>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 coöperation 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.</p> + +<p>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,<span class='pagenum'><a name="Page_7" id="Page_7">[Pg 7]</a></span> +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.</p> + +<p>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,<span class='pagenum'><a name="Page_8" id="Page_8">[Pg 8]</a></span> +dazzling visions, epochal achievements. It is romance +triumphant, not the tissue of loathsomeness +that common misconception makes it.</p> + +<p>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 coöperation, the times are ready.</p> + +<p><span class="smcap ralign">John H. Stokes.</span><br /> +<span class="smcap sf">Rochester, Minn.</span></p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_9" id="Page_9">[Pg 9]</a></span> +<h2><a name="CONTENTS" id="CONTENTS"></a>CONTENTS</h2> + +<p><span class="smcap ralign">Page</span><br /> + +<span class="smcap caption"><a href="#PREFACE">Preface</a></span><span class="ralign">5</span><br /><br /> + +<span class="smcap caption"><a href="#CONTENTS">Contents</a></span><span class="ralign">9</span><br /><br /> + +<span class="caption"><a href="#Chapter_I">CHAPTER I</a></span><br /> +<span class="smcap">The History of Syphilis</span><span class="ralign">11</span><br /><br /> + +<span class="caption"><a href="#Chapter_II">CHAPTER II</a></span><br /> +<span class="smcap">Syphilis as a Social Problem</span><span class="ralign">15</span><br /><br /> + +<span class="caption"><a href="#Chapter_III">CHAPTER III</a></span><br /> +<span class="smcap">The Nature and Course of Syphilis</span><span class="ralign">21</span><br /> +<span style="margin-left: 2em">The Prevalence of Syphilis</span><span class="ralign">24</span><br /> +<span style="margin-left: 2em">The Primary Stage</span><span class="ralign">26</span><br /><br /> + +<span class="caption"><a href="#Chapter_IV">CHAPTER IV</a></span><br /> +<span class="smcap">The Nature and Course of Syphilis</span> (<i>Continued</i>)<span class="ralign">35</span><br /> +<span style="margin-left: 2em">The Secondary Stage</span><span class="ralign">35</span><br /><br /> + +<span class="caption"><a href="#Chapter_V">CHAPTER V</a></span><br /> +<span class="smcap">The Nature and Course of Syphilis</span> (<i>Continued</i>)<span class="ralign">45</span><br /> +<span style="margin-left: 2em">Late Syphilis (Tertiary Stage)</span><span class="ralign">45</span><br /><br /> + +<span class="caption"><a href="#Chapter_VI">CHAPTER VI</a></span><br /> +<span class="smcap">The Blood Test for Syphilis</span><span class="ralign">54</span><br /><br /> + +<span class="caption"><a href="#Chapter_VII">CHAPTER VII</a></span><br /> +<span class="smcap">The Treatment of Syphilis</span><span class="ralign">60</span><br /> +<span style="margin-left: 2em">General Considerations</span><span class="ralign">60</span><br /> +<span style="margin-left: 2em">Mercury</span><span class="ralign">62</span><br /><br /> + +<span class="caption"><a href="#Chapter_VIII">CHAPTER VIII</a></span><br /> +<span class="smcap">The Treatment of Syphilis</span> (<i>Continued</i>)<span class="ralign">70</span><br /> +<span style="margin-left: 2em">Salvarsan</span><span class="ralign">70</span><br /><br /> + +<span class="caption"><a href="#Chapter_IX">CHAPTER IX</a></span><br /> +<span class="smcap">The Cure of Syphilis</span><span class="ralign">80</span><br /><br /> + +<span class="caption"><a href="#Chapter_X">CHAPTER X</a></span><br /> +<span class="smcap">Hereditary Syphilis</span><span class="ralign">92</span><span class='pagenum'><a name="Page_10" id="Page_10">[Pg 10]</a></span><br /><br /> + +<span class="caption"><a href="#Chapter_XI">CHAPTER XI</a></span><br /> +<span class="smcap">The Transmission and Hygiene of Syphilis</span><span class="ralign">109</span><br /><br /> + +<span class="caption"><a href="#Chapter_XII">CHAPTER XII</a></span><br /> +<span class="smcap">The Transmission and Hygiene of Syphilis</span> (<i>Continued</i>)<span class="ralign">121</span><br /> +<span style="margin-left: 2em">The Control of Infectiousness in Syphilis</span><span class="ralign">121</span><br /> +<span style="margin-left: 2em">Syphilis and Marriage</span><span class="ralign">125</span><br /><br /> + +<span class="caption"><a href="#Chapter_XIII">CHAPTER XIII</a></span><br /> +<span class="smcap">The Transmission and Hygiene of Syphilis</span> (<i>Continued</i>)<span class="ralign">133</span><br /> +<span style="margin-left: 2em">Syphilis and Prostitution</span><span class="ralign">133</span><br /> +<span style="margin-left: 2em">Personal Hygiene of Syphilis</span><span class="ralign">136</span><br /><br /> + +<span class="caption"><a href="#Chapter_XIV">CHAPTER XIV</a></span><br /> +<span class="smcap">Mental Attitudes in Their Relation to Syphilis</span><span class="ralign">141</span><br /><br /> + +<span class="caption"><a href="#Chapter_XV">CHAPTER XV</a></span><br /> +<span class="smcap">Moral and Personal Prophylaxis</span><span class="ralign">156</span><br /><br /> + +<span class="caption"><a href="#Chapter_XVI">CHAPTER XVI</a></span><br /> +<span class="smcap">Public Effort Against Syphilis</span><span class="ralign">164</span><br /><br /> + +<span class="smcap"><a href="#INDEX">Index</a></span><span class="ralign">187</span></p> + +<hr style="width: 65%;" /> +<h2><a name="ILLUSTRATIONS" id="ILLUSTRATIONS"></a>LIST OF ILLUSTRATIONS</h2> + +<ul><li> <span class="smcap ralign">Page</span></li> +<li><span class="smcap">Paul Ehrlich [1854-1915]</span><span class="ralign"><a href="#Page_70">70</a></span></li> + +<li><span class="smcap">Fritz Schaudinn [1871-1906]</span><span class="ralign"><a href="#Page_112">112</a></span></li> + +<li><span class="smcap">E. Roux</span><span class="ralign"><a href="#Page_160">160</a></span></li> + +<li><span class="smcap">Élie Metchnikoff [1845-1916]</span><span class="ralign"><a href="#Page_160">160</a></span></li></ul> + +<hr style="width: 65%;" /> + +<p><span class='pagenum'><a name="Page_11" id="Page_11">[Pg 11]</a></span></p> +<h1>The Third Great Plague</h1> + +<h2><a name="Chapter_I" id="Chapter_I"></a>Chapter I</h2> + +<h3>The History of Syphilis</h3> + +<p>Syphilis has a remarkable history,<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a> 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.</p> + +<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> +For a detailed account in English, see Pusey, W. A.: "Syphilis as a +Modern Problem," Amer. Med. Assoc., 1915.</p></div> + +<p>It is a well-recognized fact that a disease which +has never appeared among a people before, when it<span class='pagenum'><a name="Page_12" id="Page_12">[Pg 12]</a></span> +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<span class='pagenum'><a name="Page_13" id="Page_13">[Pg 13]</a></span> +devouring a man alive on the street, syphilis has +taken to knifing him quietly in his bed.</p> + +<p>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.</p> + +<p><span class='pagenum'><a name="Page_14" id="Page_14">[Pg 14]</a></span> +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.</p> + + + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_15" id="Page_15">[Pg 15]</a></span> +<h2><a name="Chapter_II" id="Chapter_II"></a>Chapter II</h2> + +<h3>Syphilis as a Social Problem</h3> + +<p>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<span class='pagenum'><a name="Page_16" id="Page_16">[Pg 16]</a></span> +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.</p> + +<p><span class="caption">The Confusion of the Problem of Syphilis with +Other Issues.</span>—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."<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a> The second is to separate<span class='pagenum'><a name="Page_17" id="Page_17">[Pg 17]</a></span> +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.</p> + +<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> +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. +</p> +<p>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.</p></div> + +<p>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<span class='pagenum'><a name="Page_18" id="Page_18">[Pg 18]</a></span> +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.</p> + +<p><span class="caption">Syphilis, a Problem of Public Health Rather than +of Morals.</span>—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<span class='pagenum'><a name="Page_19" id="Page_19">[Pg 19]</a></span> +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.</p> + +<p>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<span class='pagenum'><a name="Page_20" id="Page_20">[Pg 20]</a></span> +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.</p> + +<p>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 coöperation, 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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_21" id="Page_21">[Pg 21]</a></span> +<h2><a name="Chapter_III" id="Chapter_III"></a>Chapter III</h2> + +<h3>The Nature and Course of Syphilis</h3> + +<p>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<span class='pagenum'><a name="Page_22" id="Page_22">[Pg 22]</a></span> +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.</p> + +<p>The germ of syphilis,<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> 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 <i>Spirochæta pallida</i>.<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> 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.</p> + +<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> See frontispiece.</p></div> + +<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> Pronounced spi-ro-kee'-ta.</p></div> + +<p><span class="caption">Syphilis a Concealed Disease.</span>—Syphilis is not a +grossly conspicuous figure in our every-day life, as<span class='pagenum'><a name="Page_23" id="Page_23">[Pg 23]</a></span> +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.</p> + +<p><span class="caption">How Much Syphilis is There?</span>—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<span class='pagenum'><a name="Page_24" id="Page_24">[Pg 24]</a></span> +disease. Such conceptions of its prevalence as we +have are based on individual opinions and data collected +by men of large experience.</p> + +<p><span class="caption">Earlier Estimates of the Prevalence of Syphilis.</span>—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 Laënnec 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<span class='pagenum'><a name="Page_25" id="Page_25">[Pg 25]</a></span> +as having syphilis. It should be recalled that this +includes essentially active rather than quiescent +cases, and is therefore probably too low.</p> + +<p><span class="caption">Current Estimates of the Prevalence of Syphilis.</span>—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<span class='pagenum'><a name="Page_26" id="Page_26">[Pg 26]</a></span> +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.</p> + +<p>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,<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a> 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.</p> + +<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> Figures based on 1910 census.</p></div> + +<h4 class="smcap">The Primary Stage of Syphilis</h4> + +<p><span class="caption">The So-called Stages of Syphilis.</span>—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 Spirochæta pallida, the germ of +the disease, our knowledge of what the germ does in<span class='pagenum'><a name="Page_27" id="Page_27">[Pg 27]</a></span> +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.</p> + +<p><span class="caption">Peculiarities of the Germ.</span>—Many interesting facts +about the Spirochæta 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,<span class='pagenum'><a name="Page_28" id="Page_28">[Pg 28]</a></span> +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.</p> + +<p><span class="caption">Mode of Entry of the Germ.</span>—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.</p> + +<p><span class="caption">Incubation or Quiescent Period.</span>—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<span class='pagenum'><a name="Page_29" id="Page_29">[Pg 29]</a></span> +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.</p> + +<p>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.</p> + +<p><span class="caption">The First Sore or Chancre.</span>—The primary lesion, +first sore or chancre,<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> 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<span class='pagenum'><a name="Page_30" id="Page_30">[Pg 30]</a></span> +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.</p> + +<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> Pronounced shan'-ker.</p></div> + +<p><span class="caption">Syphilis and Gonorrhea may Coexist.</span>—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<span class='pagenum'><a name="Page_31" id="Page_31">[Pg 31]</a></span> +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.</p> + +<p><span class="caption">Serious Misconceptions About the Chancre.</span>—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.</p> + +<p><span class="caption">Importance of Prompt and Expert Medical Advice.</span>—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<span class='pagenum'><a name="Page_32" id="Page_32">[Pg 32]</a></span> +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.</p> + +<p><span class="caption">Modern Methods of Identifying an Early Syphilitic +Infection.</span>—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 <i>at once</i>, and absolutely <i>untreated</i>. +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<span class='pagenum'><a name="Page_33" id="Page_33">[Pg 33]</a></span> +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 reëxamine 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.</p> + +<p><span class="caption">Enlargement of Neighboring Glands.</span>—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<span class='pagenum'><a name="Page_34" id="Page_34">[Pg 34]</a></span> +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.</p> + +<p><span class="caption">Vital Significance of Early Recognition.</span>—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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_35" id="Page_35">[Pg 35]</a></span> +<h2><a name="Chapter_IV" id="Chapter_IV"></a>Chapter IV</h2> + +<h3>The Nature and Course of Syphilis (Continued)</h3> + +<h4 class="smcap">The Secondary Stage</h4> + +<p><span class="caption">The Spread of the Germs Over the Body.</span>—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<span class='pagenum'><a name="Page_36" id="Page_36">[Pg 36]</a></span> +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.</p> + +<p><span class="caption">Constitutional Symptoms.</span>—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.</p> + +<p><span class="caption">The Secondary Eruption or Rash.</span>—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<span class='pagenum'><a name="Page_37" id="Page_37">[Pg 37]</a></span> +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.</p> + +<p><span class="caption">Common Misconceptions Regarding Syphilitic +Rashes.</span>—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,<span class='pagenum'><a name="Page_38" id="Page_38">[Pg 38]</a></span> +which have been present for months or years, are +less likely to be syphilitic.</p> + +<p><span class="caption">The Contagious Sores in the Mouth, Throat, and +Genitals.</span>—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.</p> + +<p><span class="caption">Distribution of the Germs in the Body.</span>—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<span class='pagenum'><a name="Page_39" id="Page_39">[Pg 39]</a></span> +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.</p> + +<p><span class="caption">Fate of the Germs.</span>—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<span class='pagenum'><a name="Page_40" id="Page_40">[Pg 40]</a></span> +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.</p> + +<p><span class="caption">Variations in the Behavior of the Germ of Syphilis.</span>—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 Spirochæta pallida tend to thrive +in the nervous system, others perhaps in the skin. +On the other hand, in certain persons, for example,<span class='pagenum'><a name="Page_41" id="Page_41">[Pg 41]</a></span> +heavy drinkers, the nervous system is most open to +attack, in others the bones may be most affected, in +still others, the skin.</p> + +<p><span class="caption">Variations in the Course of Syphilis in Different +Persons.</span>—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<span class='pagenum'><a name="Page_42" id="Page_42">[Pg 42]</a></span> +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.</p> + +<p><span class="caption">The Dangerous Contagious Relapses.</span>—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<span class='pagenum'><a name="Page_43" id="Page_43">[Pg 43]</a></span> +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.</p> + +<p><span class="caption">Relapses in the Nervous System and Elsewhere.</span>—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.</p> + +<p>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<span class='pagenum'><a name="Page_44" id="Page_44">[Pg 44]</a></span> +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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_45" id="Page_45">[Pg 45]</a></span> +<h2><a name="Chapter_V" id="Chapter_V"></a>Chapter V</h2> + +<h3>The Nature and Course of Syphilis (Continued)</h3> + +<h4 class="smcap">Late Syphilis (Tertiary Stage)</h4> + +<p><span class="caption">The Seriousness of Late Syphilis.</span>—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<span class='pagenum'><a name="Page_46" id="Page_46">[Pg 46]</a></span> +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.</p> + +<p><span class="caption">Nature of the Tissue Change in Late Syphilis—Gummatous +Infiltration.</span>—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<span class='pagenum'><a name="Page_47" id="Page_47">[Pg 47]</a></span> +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.</p> + +<p><span class="caption">Destructive Effects of Late Syphilis.</span>—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<span class='pagenum'><a name="Page_48" id="Page_48">[Pg 48]</a></span> +wall. This is the really dangerous syphilis—the +kind of syphilis that shortens and cripples life.</p> + +<p>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.</p> + +<p><span class="caption">Late Syphilis of the Nervous System—Locomotor +Ataxia.</span>—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, <i>though only two of +many ways in which syphilis can attack the nervous +system</i>. 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<span class='pagenum'><a name="Page_49" id="Page_49">[Pg 49]</a></span> +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.</p> + +<p><span class="caption">Late Syphilis of the Nervous System—General +Paralysis.</span>—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<span class='pagenum'><a name="Page_50" id="Page_50">[Pg 50]</a></span> +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.</p> + +<p>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.</p> + +<p><span class="caption">Syphilis and Mental Disease.</span>—Williams,<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a> before +the American Public Health Association, has recently +carefully summarized the rôle of syphilis in the production +of insanity, and the cost of the disease to the +State from the standpoint of mental disease alone.<span class='pagenum'><a name="Page_51" id="Page_51">[Pg 51]</a></span> +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.</p> + +<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> Williams, F. E.: "Preaching Health," Amer. Jour. Pub. Health, +1917, vi, 1273.</p></div> + +<p><span class="caption">Frequency of Locomotor Ataxia and General +Paralysis.</span>—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<span class='pagenum'><a name="Page_52" id="Page_52">[Pg 52]</a></span> +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.</p> + +<p><span class="caption">Treatment and Prevention of Late Syphilis of the +Nervous System.</span>—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.</p> + +<h4 class="smcap">Summary</h4> + +<p>Summing up briefly the main points to bear in +mind about the course of syphilis—there is a time,<span class='pagenum'><a name="Page_53" id="Page_53">[Pg 53]</a></span> +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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_54" id="Page_54">[Pg 54]</a></span> +<h2><a name="Chapter_VI" id="Chapter_VI"></a>Chapter VI</h2> + +<h3>The Blood Test for Syphilis</h3> + +<p>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.</p> + +<p><span class="caption">Antibodies in the Blood in Disease.</span>—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<span class='pagenum'><a name="Page_55" id="Page_55">[Pg 55]</a></span> +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 Spirochæta 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.</p> + +<p><span class="caption">Difficulties of the Test.</span>—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<span class='pagenum'><a name="Page_56" id="Page_56">[Pg 56]</a></span> +which spring up like mushrooms in these days of +laboratory methods.</p> + +<p><span class="caption">The Recognition of Syphilis by the Blood Test.</span>—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<span class='pagenum'><a name="Page_57" id="Page_57">[Pg 57]</a></span> +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.</p> + +<p><span class="caption">The Blood Test in the Treatment and Cure of +Syphilis.</span>—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<span class='pagenum'><a name="Page_58" id="Page_58">[Pg 58]</a></span> +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.</p> + +<p>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<span class='pagenum'><a name="Page_59" id="Page_59">[Pg 59]</a></span> +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.</p> + +<p><span class="caption">Practical Points About the Test.</span>—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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_60" id="Page_60">[Pg 60]</a></span> +<h2><a name="Chapter_VII" id="Chapter_VII"></a>Chapter VII</h2> + +<h3>The Treatment of Syphilis</h3> + +<h4 class="smcap">General Considerations</h4> + +<p><span class="caption">Scientific Methods of Treating Disease.</span>—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.<span class='pagenum'><a name="Page_61" id="Page_61">[Pg 61]</a></span> +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.</p> + +<p>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<span class='pagenum'><a name="Page_62" id="Page_62">[Pg 62]</a></span> +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.</p> + +<h4 class="smcap">Mercury</h4> + +<p><span class="caption">Mercury in the Treatment of Syphilis.</span>—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.<span class='pagenum'><a name="Page_63" id="Page_63">[Pg 63]</a></span> +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.</p> + +<p><span class="caption">Misconceptions Concerning Mercury.</span>—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.</p> + +<p><span class="caption">The Action of Mercury.</span>—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<span class='pagenum'><a name="Page_64" id="Page_64">[Pg 64]</a></span> +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.</p> + +<p><span class="caption">Methods of Administering Mercury.</span>—As has been +said, mercury is given principally in three ways at +the present time. It can be given by the mouth, in<span class='pagenum'><a name="Page_65" id="Page_65">[Pg 65]</a></span> +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.</p> + +<p>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<span class='pagenum'><a name="Page_66" id="Page_66">[Pg 66]</a></span> +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.</p> + +<p>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<span class='pagenum'><a name="Page_67" id="Page_67">[Pg 67]</a></span> +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.</p> + +<p>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.</p> + +<p><span class="caption">Effect of Mercurial Treatment on the Blood Test.</span>—The +effect of mercury on the Wassermann blood +test for syphilis should also be generally understood.<span class='pagenum'><a name="Page_68" id="Page_68">[Pg 68]</a></span> +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 +<i>has no meaning</i>, 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.</p> + +<p>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<span class='pagenum'><a name="Page_69" id="Page_69">[Pg 69]</a></span> +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.<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a></p> + +<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> +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.</p></div> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_70" id="Page_70">[Pg 70]</a></span> +<h2><a name="Chapter_VIII" id="Chapter_VIII"></a>Chapter VIII</h2> + +<h3>The Treatment of Syphilis (Continued)</h3> + +<h4 class="smcap">Salvarsan</h4> + +<p><span class="caption">The Discovery of Salvarsan ("606").</span>—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.</p> + +<div class="center"><div class="figcenter" style="width: 400px;"> +<img src="images/illus_p69.png" width="400" height="491" alt="Paul Ehrlich [1854-1915]" title="Paul Ehrlich [1854-1915]" /> +<span class="caption">Paul Ehrlich [1854-1915]<br /><span class="sf">(From "Year Book of Skin and Venereal Diseases," 1916, vol. ix. "Practical +Medicine Series," Year Book Publishers, Chicago.)</span></span> +</div></div> + +<p>The poison which had already been shown to be +especially effective in killing germs like those of<span class='pagenum'><a name="Page_71" id="Page_71">[Pg 71]</a></span> +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<span class='pagenum'><a name="Page_72" id="Page_72">[Pg 72]</a></span> +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.</p> + +<p><span class="caption">The Mistaken Conception of "Single Dose Cure."</span>—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<span class='pagenum'><a name="Page_73" id="Page_73">[Pg 73]</a></span> +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.</p> + +<p><span class="caption">The Value of Salvarsan.</span>—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 <i>contagious</i> 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.</p> + +<p><span class="caption">The Action of Salvarsan.</span>—It will be recalled that +Ehrlich planned salvarsan to kill the germs of syphilis,<span class='pagenum'><a name="Page_74" id="Page_74">[Pg 74]</a></span> +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<span class='pagenum'><a name="Page_75" id="Page_75">[Pg 75]</a></span> +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.</p> + +<p><span class="caption">The Treatment of Syphilis With Salvarsan.</span>—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<span class='pagenum'><a name="Page_76" id="Page_76">[Pg 76]</a></span> +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.</p> + +<p>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,<span class='pagenum'><a name="Page_77" id="Page_77">[Pg 77]</a></span> +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.</p> + +<p>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.</p> + +<p>The dangers of salvarsan are easily exaggerated,<span class='pagenum'><a name="Page_78" id="Page_78">[Pg 78]</a></span> +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.</p> + +<p>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.</p> + +<p>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<span class='pagenum'><a name="Page_79" id="Page_79">[Pg 79]</a></span> +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.</p> + +<div class="blockquot"><p>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 <i>intradural +therapy</i>, 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.</p> + +<p>The <i>luetin test</i> 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.</p></div> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_80" id="Page_80">[Pg 80]</a></span> +<h2><a name="Chapter_IX" id="Chapter_IX"></a>Chapter IX</h2> + +<h3>The Cure of Syphilis</h3> + +<p>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 coöperation. 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.</p> + +<p><span class="caption">Radical or Complete Cure.</span>—In speaking of the<span class='pagenum'><a name="Page_81" id="Page_81">[Pg 81]</a></span> +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<span class='pagenum'><a name="Page_82" id="Page_82">[Pg 82]</a></span> +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.</p> + +<p><span class="caption">Symptomatic or Incomplete Cure.</span>—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<span class='pagenum'><a name="Page_83" id="Page_83">[Pg 83]</a></span> +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.</p> + +<p>In such a demand as this for the highest ideals in<span class='pagenum'><a name="Page_84" id="Page_84">[Pg 84]</a></span> +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.</p> + +<p><span class="caption">Factors Influencing the Cure of Syphilis.</span>—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<span class='pagenum'><a name="Page_85" id="Page_85">[Pg 85]</a></span> +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.</p> + +<p><span class="caption">Factors Controlling the Cure of Syphilis—Stage, +Time, Effective Treatment.</span>—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 coöperation +of doctor and patient in the use of effective methods +of treatment.</p> + +<p><span class="caption">Cure in the Primary Stage.</span>—It goes almost without<span class='pagenum'><a name="Page_86" id="Page_86">[Pg 86]</a></span> +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.</p> + +<p><span class="caption">Cure in the Secondary Stage.</span>—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.</p> + +<p><span class="caption">The Outlook in Late Syphilis.</span>—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<span class='pagenum'><a name="Page_87" id="Page_87">[Pg 87]</a></span> +from this point on. That means that we are +less and less able to tell where we stand by the tests +we now have.</p> + +<p>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.</p> + +<p>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. <i>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.</i> 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.</p> + +<p><span class="caption">The Time Required for Cure.</span>—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<span class='pagenum'><a name="Page_88" id="Page_88">[Pg 88]</a></span> +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.</p> + +<p><span class="caption">Efficient Treatment.</span>—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.</p> + +<p>The aim in syphilis, then, is to crush the disease +at its outset by a vigorous campaign. Not until<span class='pagenum'><a name="Page_89" id="Page_89">[Pg 89]</a></span> +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.</p> + +<p><span class="caption">The Importance of Salvarsan.</span>—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.</p> + +<p>Is a cure worth while? There is only one thing<span class='pagenum'><a name="Page_90" id="Page_90">[Pg 90]</a></span> +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.</p> + +<p><span class="caption">The Meaning of "You are Cured."</span>—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<span class='pagenum'><a name="Page_91" id="Page_91">[Pg 91]</a></span> +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 reëxamined 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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_92" id="Page_92">[Pg 92]</a></span> +<h2><a name="Chapter_X" id="Chapter_X"></a>Chapter X</h2> + +<h3>Hereditary Syphilis</h3> + + +<p>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.</p> + +<p>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.</p> + +<p><span class="caption">Transmission of Syphilis From Mother to Child.</span>—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<span class='pagenum'><a name="Page_93" id="Page_93">[Pg 93]</a></span> +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.</p> + +<p><span class="caption">Absence of Outward Signs in Syphilitic Mothers.</span>—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<span class='pagenum'><a name="Page_94" id="Page_94">[Pg 94]</a></span> +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.</p> + +<p><span class="caption">Healthy Children of Syphilitic Mothers.</span>—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.</p> + +<p><span class="caption">Non-hereditary Syphilis in Children.</span>—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<span class='pagenum'><a name="Page_95" id="Page_95">[Pg 95]</a></span> +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.</p> + +<p><span class="caption">Effect of Syphilis on the Child-bearing Woman.</span>—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.<span class='pagenum'><a name="Page_96" id="Page_96">[Pg 96]</a></span> +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.</p> + +<p><span class="caption">Variations on the Rule.</span>—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<span class='pagenum'><a name="Page_97" id="Page_97">[Pg 97]</a></span> +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.</p> + +<p><span class="caption">Treatment of the Mother.</span>—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<span class='pagenum'><a name="Page_98" id="Page_98">[Pg 98]</a></span> +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.</p> + +<p><span class="caption">Effect of Hereditary Syphilis on the Unborn Child.</span>—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<span class='pagenum'><a name="Page_99" id="Page_99">[Pg 99]</a></span> +given at least illustrate how few syphilitic children +survive to be included in such an estimate.</p> + +<p><span class="caption">Moral Effect on the Parents.</span>—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.</p> + +<p><span class="caption">Course of Hereditary Syphilis in the Infant.</span>—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.<span class='pagenum'><a name="Page_100" id="Page_100">[Pg 100]</a></span> +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.</p> + +<p><span class="caption">The Wet Nurse.</span>—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<span class='pagenum'><a name="Page_101" id="Page_101">[Pg 101]</a></span> +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.</p> + +<p><span class="caption">Hereditary Syphilis in Older Children.</span>—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<span class='pagenum'><a name="Page_102" id="Page_102">[Pg 102]</a></span> +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.</p> + +<p><span class="caption">Destructive Changes, Bones, Teeth, Etc.</span>—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.</p> + +<p><span class="caption">Eye Trouble—Interstitial Keratitis.</span>—Two manifestations<span class='pagenum'><a name="Page_103" id="Page_103">[Pg 103]</a></span> +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.<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a> +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<span class='pagenum'><a name="Page_104" id="Page_104">[Pg 104]</a></span> +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.</p> + +<div class="footnote"><p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a> Iglesheimer, quoted by Derby.</p></div> + +<p>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.</p> + +<p><span class="caption">Ear Trouble—Nerve Deafness.</span>—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<span class='pagenum'><a name="Page_105" id="Page_105">[Pg 105]</a></span> +hereditary syphilis is practically uninfluenced by +treatment.</p> + +<p><span class="caption">Accident and Injury in Hereditary Syphilis.</span>—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.</p> + +<p><span class="caption">Marriage and Contagion in Hereditary Syphilis.</span>—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<span class='pagenum'><a name="Page_106" id="Page_106">[Pg 106]</a></span> +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.</p> + +<p><span class="caption">Syphilis in Adopted Children.</span>—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<span class='pagenum'><a name="Page_107" id="Page_107">[Pg 107]</a></span> +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.</p> + +<p><span class="caption">Treatment of Hereditary Syphilis.</span>—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 coöperation 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<span class='pagenum'><a name="Page_108" id="Page_108">[Pg 108]</a></span> +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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_109" id="Page_109">[Pg 109]</a></span> +<h2><a name="Chapter_XI" id="Chapter_XI"></a>Chapter XI</h2> + +<h3>The Transmission and Hygiene of Syphilis</h3> + +<p>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.</p> + +<p>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.</p> + +<p><span class="caption">Contagiousness in the Primary Stage.</span>—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<span class='pagenum'><a name="Page_110" id="Page_110">[Pg 110]</a></span> +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.</p> + +<p><span class="caption">Contagiousness in the Secondary Stage.</span>—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.</p> + +<p><span class="caption">Relatively Non-contagious Character of Late Syphilis.</span>—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<span class='pagenum'><a name="Page_111" id="Page_111">[Pg 111]</a></span> +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.</p> + +<p><span class="caption">The Time Element in Contagiousness.</span>—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.</p> + +<p><span class="caption">Contagious Recurrences or Relapses.</span>—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<span class='pagenum'><a name="Page_112" id="Page_112">[Pg 112]</a></span> +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.</p> + +<p><span class="caption">Average Contagious Period.</span>—It is a safe general +rule, the product of long experience, to consider a +person with an untreated<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a> 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.</p> + +<div class="footnote"><p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a> +The control of infectiousness in syphilis through treatment is considered +in the next chapter.</p></div> + +<div class="center"><div class="figcenter" style="width: 400px;"> +<img src="images/illus_p112.png" width="400" height="571" alt="Fritz Schaudinn [1871-1906]" title="Fritz Schaudinn [1871-1906]" /> +<span class="caption">Fritz Schaudinn [1871-1906]<br /><span class="sf">(From the "Galerie hervorragender Aerzte und Naturforscher." +Supplement to the Münchener med. Wochenschrift, 1906. J. F. Lehmann, +Munich.)</span></span> +</div></div> + +<p><span class="caption">Individual Resistance to Infection.</span>—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<span class='pagenum'><a name="Page_113" id="Page_113">[Pg 113]</a></span> +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.</p> + +<p><span class="caption">Transmission by Infected Articles.</span>—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<span class='pagenum'><a name="Page_114" id="Page_114">[Pg 114]</a></span> +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.</p> + +<p><span class="caption">Transmission Under the Conditions of Every-day +Life.</span>—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<span class='pagenum'><a name="Page_115" id="Page_115">[Pg 115]</a></span> +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<span class='pagenum'><a name="Page_116" id="Page_116">[Pg 116]</a></span> +is common enough for this type of chancre to have +received the special name of brawl, or fist, chancre.</p> + +<p><span class="caption">Accidental Syphilis in Physicians and Nurses.</span>—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.</p> + +<p><span class="caption">Transmission by Intimate Contacts—Kissing.</span>—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<span class='pagenum'><a name="Page_117" id="Page_117">[Pg 117]</a></span> +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<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a> 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.</p> + +<div class="footnote"><p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a> Schamberg, J. F.: "An Epidemic of Chancres of the Lip from +Kissing," Jour. Amer. Med. Assoc., 1911, lvii, 783.</p></div> + +<p><span class="caption">The Sexual Transmission of Syphilis.</span>—The sexual<span class='pagenum'><a name="Page_118" id="Page_118">[Pg 118]</a></span> +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 +<i>acquired in any but innocent ways</i>. 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<span class='pagenum'><a name="Page_119" id="Page_119">[Pg 119]</a></span> +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.</p> + +<p><span class="caption">Extragenital and Marital Syphilis.</span>—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.</p> + +<p>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<span class='pagenum'><a name="Page_120" id="Page_120">[Pg 120]</a></span> +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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_121" id="Page_121">[Pg 121]</a></span> +<h2><a name="Chapter_XII" id="Chapter_XII"></a>Chapter XII</h2> + +<h3>The Transmission and Hygiene of Syphilis +(Continued)</h3> + +<h4 class="smcap">The Control of Infectiousness in Syphilis.—Syphilis +and Marriage</h4> + + +<p><span class="caption">Means for Controlling Infectiousness.</span>—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<span class='pagenum'><a name="Page_122" id="Page_122">[Pg 122]</a></span> +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 coöperation, and demands +also the coöperation 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.</p> + +<p><span class="caption">Control of Infectiousness by Treatment—Importance +of Salvarsan.</span>—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<span class='pagenum'><a name="Page_123" id="Page_123">[Pg 123]</a></span> +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.</p> + +<p><span class="caption">Obstacles to Control by Treatment.</span>—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<span class='pagenum'><a name="Page_124" id="Page_124">[Pg 124]</a></span> +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.</p> + +<p><span class="caption">The Five-year Rule.</span>—The truth of the matter is +that, as Hoffmann says, no treatment can <i>guarantee</i> +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.</p> + +<p><span class="caption">Personal Responsibility of the Patient.</span>—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<span class='pagenum'><a name="Page_125" id="Page_125">[Pg 125]</a></span> +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.</p> + +<p><span class="caption">Syphilis and Marriage.</span>—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.</p> + +<p><span class="caption">Estimated Risk of Infecting the Wife.</span>—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<span class='pagenum'><a name="Page_126" id="Page_126">[Pg 126]</a></span> +year, and one to four the third year, being negligible +after the fourth year.</p> + +<p><span class="caption">Syphilis in the Father.</span>—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.</p> + +<p><span class="caption">The Time-treatment Principle and the Five-year +Rule.</span>—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<span class='pagenum'><a name="Page_127" id="Page_127">[Pg 127]</a></span> +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<span class='pagenum'><a name="Page_128" id="Page_128">[Pg 128]</a></span> +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.</p> + +<p>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.</p> + +<p>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<span class='pagenum'><a name="Page_129" id="Page_129">[Pg 129]</a></span> +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.</p> + +<p><span class="caption">Syphilis and Engagements to Marry.</span>—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.</p> + +<p>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 fiancée 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<span class='pagenum'><a name="Page_130" id="Page_130">[Pg 130]</a></span> +and a medical examination should be made +before marriage, when the damage may be done long +before that point is reached.</p> + +<p><span class="caption">Medical Examination for Syphilis before Marriage.</span>—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 <i>by an expert</i>. +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 coöperate. +A resourceful physician can usually settle +the question of a person's fitness for marriage, and<span class='pagenum'><a name="Page_131" id="Page_131">[Pg 131]</a></span> +the result of a reliable examination offers a reasonable +assurance of safety.</p> + +<p><span class="caption">Laws Crippling Physicians in Such Matters.</span>—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<span class='pagenum'><a name="Page_132" id="Page_132">[Pg 132]</a></span> +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.</p> + +<p>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.<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a></p> + +<div class="footnote"><p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a> +The problem of gonorrhea is not considered in the framing of this +statement.</p></div> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_133" id="Page_133">[Pg 133]</a></span> +<h2><a name="Chapter_XIII" id="Chapter_XIII"></a>Chapter XIII</h2> + +<h3>The Transmission and Hygiene of Syphilis +(Continued)</h3> + +<h4 class="smcap">Syphilis and Prostitution</h4> + +<p>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.</p> + +<p><span class="caption">Genital and Non-genital Syphilis in Lax Individuals.</span>—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<span class='pagenum'><a name="Page_134" id="Page_134">[Pg 134]</a></span> +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.</p> + +<p><span class="caption">Syphilis Among Prostitutes.</span>—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.<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a> 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<span class='pagenum'><a name="Page_135" id="Page_135">[Pg 135]</a></span> +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 rôle 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.</p> + +<div class="footnote"><p><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">[13]</span></a> +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.)</p></div> + +<p><span class="caption">Concealed Syphilis and Medical Examinations of +Prostitutes.</span>—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<span class='pagenum'><a name="Page_136" id="Page_136">[Pg 136]</a></span> +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.</p> + +<p>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.</p> + +<h4 class="smcap">Personal Hygiene in Syphilis</h4> + +<p>Syphilis is a constitutional disease, affecting in +one way or another the whole body. For that +reason, measures directed to improving the general<span class='pagenum'><a name="Page_137" id="Page_137">[Pg 137]</a></span> +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.</p> + +<p><span class="caption">A Well-balanced Life.</span>—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.</p> + +<p><span class="caption">Alcohol.</span>—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<span class='pagenum'><a name="Page_138" id="Page_138">[Pg 138]</a></span> +of cure. Even mild alcoholic beverages are undesirable +and the patient should lose no time in dropping +them entirely.</p> + +<p><span class="caption">Tobacco.</span>—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.</p> + +<p><span class="caption">Sexual Relations, Kissing, Etc.</span>—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.</p> + +<p><span class="caption">Articles of Personal Use.</span>—Persons with a tendency<span class='pagenum'><a name="Page_139" id="Page_139">[Pg 139]</a></span> +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.</p> + +<p><span class="caption">Secrecy.</span>—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 coöperation 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.</p> + +<p><span class="caption">Re-infection.</span>—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<span class='pagenum'><a name="Page_140" id="Page_140">[Pg 140]</a></span> +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.</p> + +<p><span class="caption">Quacks and Self-treatment.</span>—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.</p> + +<p><span class="caption">Patient and Physician.</span>—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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_141" id="Page_141">[Pg 141]</a></span> +<h2><a name="Chapter_XIV" id="Chapter_XIV"></a>Chapter XIV</h2> + +<h3>Mental Attitudes in Their Relation to Syphilis</h3> + +<p>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.</p> + +<p><span class="caption">The Public Attitude Toward Syphilis.</span>—First of<span class='pagenum'><a name="Page_142" id="Page_142">[Pg 142]</a></span> +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<span class='pagenum'><a name="Page_143" id="Page_143">[Pg 143]</a></span> +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<span class='pagenum'><a name="Page_144" id="Page_144">[Pg 144]</a></span> +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."<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">[14]</a></p> + +<div class="footnote"><p><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">[14]</span></a> Quoted by Flexner in "Prostitution in Europe."</p></div> + +<p><span class="caption">Syphilis as a "Disgrace" and a "Moral Force."</span>—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<span class='pagenum'><a name="Page_145" id="Page_145">[Pg 145]</a></span> +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<span class='pagenum'><a name="Page_146" id="Page_146">[Pg 146]</a></span> +foundation must rest on the rock bottom of character +and not in the muck of venereal disease.</p> + +<p><span class="caption">The Broader Outlook.</span>—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.</p> + +<p><span class="caption">The Mental States of Syphilitics.</span>—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<span class='pagenum'><a name="Page_147" id="Page_147">[Pg 147]</a></span> +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.</p> + +<p><span class="caption">The Conscientious Type.</span>—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<span class='pagenum'><a name="Page_148" id="Page_148">[Pg 148]</a></span> +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.</p> + +<p>The physician's coöperation 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.</p> + +<p><span class="caption">The Average State of Mind.</span>—The average mental +attitude stops tantalizingly short of the best type of +conscientiousness. Average patients are good coöperators +in the beginning of a course of treatment +or while the symptoms are alarming or obvious, but<span class='pagenum'><a name="Page_149" id="Page_149">[Pg 149]</a></span> +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.</p> + +<p><span class="caption">Effect of the High Cost of Treatment.</span>—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<span class='pagenum'><a name="Page_150" id="Page_150">[Pg 150]</a></span> +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.</p> + +<p><span class="caption">The Irresponsible.</span>—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<span class='pagenum'><a name="Page_151" id="Page_151">[Pg 151]</a></span> +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<span class='pagenum'><a name="Page_152" id="Page_152">[Pg 152]</a></span> +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 coöperation 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<span class='pagenum'><a name="Page_153" id="Page_153">[Pg 153]</a></span> +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.</p> + +<p><span class="caption">The Necessity for Legal Control.</span>—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.</p> + +<p><span class="caption">The Morbid Attitude of Mind: Syphilophobia.</span>—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<span class='pagenum'><a name="Page_154" id="Page_154">[Pg 154]</a></span> +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<span class='pagenum'><a name="Page_155" id="Page_155">[Pg 155]</a></span> +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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_156" id="Page_156">[Pg 156]</a></span> +<h2><a name="Chapter_XV" id="Chapter_XV"></a>Chapter XV</h2> + +<h3>Moral and Personal Prophylaxis</h3> + +<p>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.</p> + +<p><span class="caption">Repression of Prostitution.</span>—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<span class='pagenum'><a name="Page_157" id="Page_157">[Pg 157]</a></span> +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.</p> + +<p><span class="caption">Educational Influences.</span>—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.</p> + +<p><span class="caption">Economic Forces Opposing Sexual Self-control.</span>—In +the first place, while continence, or abstinence +from sexual relations, is a valuable ideal in its place,<span class='pagenum'><a name="Page_158" id="Page_158">[Pg 158]</a></span> +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<span class='pagenum'><a name="Page_159" id="Page_159">[Pg 159]</a></span> +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.</p> + +<p><span class="caption">The Teaching of Sexual Self-control.</span>—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<span class='pagenum'><a name="Page_160" id="Page_160">[Pg 160]</a></span> +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.</p> + +<div class="center"> +<table border="0" cellpadding="4" cellspacing="0" summary=""> +<tr><td><div class="figcenter" style="width: 400px;"> +<img src="images/illus_p161a.png" width="400" height="538" alt="E. Roux" title="E. Roux" /> +<span class="caption">E. Roux</span> +</div></td> + +<td><div class="figcenter" style="width: 400px;"> +<img src="images/illus_p161b.png" width="400" height="539" alt="Élie Metchnikoff [1845-1916]" title="Élie Metchnikoff [1845-1916]" /> +<span class="caption">Élie Metchnikoff [1845-1916]</span> +</div></td></tr> +<tr><td class="center" colspan="2"><span class="caption sf">(From McIntosh and Fildes, "Syphilis from the Modern Standpoint," New York, Longmans +Green & Co., 1911.)</span></td></tr></table></div> + +<p>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<span class='pagenum'><a name="Page_161" id="Page_161">[Pg 161]</a></span> +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.</p> + +<p><span class="caption">Personal Preventive Methods.</span>—Continence.<a name="FNanchor_15_15" id="FNanchor_15_15"></a><a href="#Footnote_15_15" class="fnanchor">[15]</a>—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 reëmphasized. +No consideration as to the justice or desirability +of continence and self-restraint can add anything +to the simple fact that it is <i>the</i> 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<span class='pagenum'><a name="Page_162" id="Page_162">[Pg 162]</a></span> +evidence of unclean living, clean living will +always remain the best method of avoiding syphilis.</p> + +<div class="footnote"><p><a name="Footnote_15_15" id="Footnote_15_15"></a><a href="#FNanchor_15_15"><span class="label">[15]</span></a> 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.</p></div> + +<p><span class="caption">The Metchnikoff Prophylaxis.</span>—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<span class='pagenum'><a name="Page_163" id="Page_163">[Pg 163]</a></span> +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 <i>at once</i> 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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_164" id="Page_164">[Pg 164]</a></span> +<h2><a name="Chapter_XVI" id="Chapter_XVI"></a>Chapter XVI</h2> + +<h3>Public Effort Against Syphilis</h3> + +<p><span class="caption">The World-wide Movement Against Venereal +Disease.</span>—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<span class='pagenum'><a name="Page_165" id="Page_165">[Pg 165]</a></span> +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.</p> + +<p>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.<a name="FNanchor_16_16" id="FNanchor_16_16"></a><a href="#Footnote_16_16" class="fnanchor">[16]</a> The National<span class='pagenum'><a name="Page_166" id="Page_166">[Pg 166]</a></span> +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.</p> + +<div class="footnote"><p><a name="Footnote_16_16" id="Footnote_16_16"></a><a href="#FNanchor_16_16"><span class="label">[16]</span></a> Social Hygiene, New York.</p></div> + +<p>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.</p> + +<p><span class="caption">Undesirable and Freak Legislation.</span>—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<span class='pagenum'><a name="Page_167" id="Page_167">[Pg 167]</a></span> +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 reëducate.</p> + +<p><span class="caption">Value of Conservative Action.</span>—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<span class='pagenum'><a name="Page_168" id="Page_168">[Pg 168]</a></span> +than with the sporadic and scattered activities of +mixed state and private agencies.</p> + +<p><span class="caption">The Essential Features of a Modern Campaign.</span>—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:</p> + +<ol> +<li>The provision of universally available good +treatment, at the expense of the state, if necessary, +for the diseases in question.</li> + +<li>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.</li> + +<li>The suppression of quack practice, drug-store +prescribing, and advertising of cures for these diseases.</li> + +<li>Moral and educational prophylaxis and the +vigorous suppression of prostitution.</li> +</ol> + +<p>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:<span class='pagenum'><a name="Page_169" id="Page_169">[Pg 169]</a></span></p> + +<ol> +<li>General instruction in personal prophylaxis for +the population at large.</li> + +<li>Compulsory measures and penalties obliging +patients to receive treatment and continue it until +cured, regardless of their own desires in the matter.</li> + +<li>Notification or reporting of cases of sexual disease +to the health authorities.</li> + +<li>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.</li> +</ol> + +<p><span class="caption">Easily Available Treatment.</span>—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.<span class='pagenum'><a name="Page_170" id="Page_170">[Pg 170]</a></span> +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<span class='pagenum'><a name="Page_171" id="Page_171">[Pg 171]</a></span> +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.</p> + +<p><span class="caption">Dispensary Service.</span>—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.</p> + +<p><span class="caption">Hospitals.</span>—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<span class='pagenum'><a name="Page_172" id="Page_172">[Pg 172]</a></span> +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.</p> + +<p><span class="caption">Cheap Salvarsan.</span>—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<a name="FNanchor_17_17" id="FNanchor_17_17"></a><a href="#Footnote_17_17" class="fnanchor">[17]</a>—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<span class='pagenum'><a name="Page_173" id="Page_173">[Pg 173]</a></span> +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.</p> + +<div class="footnote"><p><a name="Footnote_17_17" id="Footnote_17_17"></a><a href="#FNanchor_17_17"><span class="label">[17]</span></a> +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.</p></div> + +<p><span class="caption">Reduction of the Expense of Efficient Treatment.</span>—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 coöperation 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.</p> + +<p><span class="caption">Value of Expert Services.</span>—The factor of expert +judgment in the care and recognition of syphilis is<span class='pagenum'><a name="Page_174" id="Page_174">[Pg 174]</a></span> +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.</p> + +<p><span class="caption">Suppression of Quacks and Drug-store Prescribing.</span>—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<span class='pagenum'><a name="Page_175" id="Page_175">[Pg 175]</a></span> +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<span class='pagenum'><a name="Page_176" id="Page_176">[Pg 176]</a></span> +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.</p> + +<p><span class="caption">Publicity Campaign.</span>—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<span class='pagenum'><a name="Page_177" id="Page_177">[Pg 177]</a></span> +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.</p> + +<p><span class="caption">Utilization of Personal Prophylaxis.</span>—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<span class='pagenum'><a name="Page_178" id="Page_178">[Pg 178]</a></span> +has therefore not yet reached the radicalism of compulsory +prophylaxis as it exists in armies, or even the +radicalism of compulsory vaccination for smallpox.</p> + +<p><span class="caption">Reporting of Syphilis to Health Officers.</span>—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<span class='pagenum'><a name="Page_179" id="Page_179">[Pg 179]</a></span> +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 coöperation +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.</p> + +<p><span class="caption">Compulsory Treatment.</span>—Compulsory provisions<span class='pagenum'><a name="Page_180" id="Page_180">[Pg 180]</a></span> +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<span class='pagenum'><a name="Page_181" id="Page_181">[Pg 181]</a></span> +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.</p> + +<p><span class="caption">Backwardness of the United States in the Movement.</span>—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<span class='pagenum'><a name="Page_182" id="Page_182">[Pg 182]</a></span> +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.</p> + +<p><span class="caption">Relation of War to the Spread of Venereal Disease.</span>—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<span class='pagenum'><a name="Page_183" id="Page_183">[Pg 183]</a></span> +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 reënter 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<span class='pagenum'><a name="Page_184" id="Page_184">[Pg 184]</a></span> +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.<a name="FNanchor_18_18" id="FNanchor_18_18"></a><a href="#Footnote_18_18" class="fnanchor">[18]</a> 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.</p> + +<div class="footnote"><p><a name="Footnote_18_18" id="Footnote_18_18"></a><a href="#FNanchor_18_18"><span class="label">[18]</span></a> +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.</p></div> + +<p>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,<span class='pagenum'><a name="Page_185" id="Page_185">[Pg 185]</a></span> +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.</p> + +<p>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<span class='pagenum'><a name="Page_186" id="Page_186">[Pg 186]</a></span> +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.</p> + +<hr style="width: 65%;" /> +<span class='pagenum'><a name="Page_187" id="Page_187">[Pg 187]</a></span> +<h2><a name="INDEX" id="INDEX"></a>INDEX</h2> + +<ul><li class="mt"><span class="smcap">Abortion</span>, syphilis as cause of, <a href="#Page_95">95</a></li> + +<li>Abortive cure and marriage, <a href="#Page_127">127</a> +<ul><li>of syphilis, <a href="#Page_27">27</a>, <a href="#Page_86">86</a></li> +<li>salvarsan in, <a href="#Page_73">73</a>, <a href="#Page_79">79</a>, <a href="#Page_89">89</a></li> +<li>time required for, <a href="#Page_87">87</a></li></ul></li> + +<li>Accidents, late, <a href="#Page_45">45</a>. <i>See also late syphilis</i></li> + +<li>Advertising in regard to treatment for syphilis, <a href="#Page_175">175</a>, <a href="#Page_176">176</a></li> + +<li>Alcohol, effects of, in syphilis, <a href="#Page_137">137</a></li> + +<li>America, backwardness of, in movement against venereal diseases, <a href="#Page_181">181</a> +<ul><li>state control of venereal diseases in, <a href="#Page_170">170</a></li></ul></li> + +<li>American Social Hygiene Association, <a href="#Page_165">165</a> +<ul><li>pamphlets, <a href="#Page_161">161</a></li></ul></li> + +<li>Antibodies in disease, <a href="#Page_54">54</a></li> + +<li>Antiseptics, effect of, on germ of syphilis, <a href="#Page_27">27</a></li> + +<li>Appearance of chancre, time elapsing before, <a href="#Page_29">29</a></li> + +<li>Armpits, contagious patches in, <a href="#Page_38">38</a></li> + +<li>Army and navy, Metchnikoff prophylaxis in, <a href="#Page_162">162</a> +<ul><li>probable outlook for venereal diseases in, <a href="#Page_184">184</a></li> +<li>proposed measures relative to venereal disease in, <a href="#Page_183">183</a></li> +<li>syphilis in, <a href="#Page_25">25</a></li></ul></li> + +<li>Arsenic in salvarsan, <a href="#Page_71">71</a></li> + +<li>Arteries, effect of syphilis on, <a href="#Page_47">47</a></li> + +<li>Australia. <i>See West Australia</i></li> + + +<li class="mt"><span class="smcap">Babies</span>, hereditary syphilis in, <a href="#Page_99">99</a></li> + +<li>Baltimore Vice Commission, report of, <a href="#Page_134">134</a></li> + +<li>Baths in treatment of syphilis, <a href="#Page_140">140</a></li> + +<li>Bath-tubs not means of transmitting syphilis, <a href="#Page_114">114</a></li> + +<li>Berlin, syphilis in clerks and merchants of, <a href="#Page_25">25</a></li> + +<li>Birth, premature, <a href="#Page_95">95</a></li> + +<li>Blaschko and German sexual disease program, <a href="#Page_177">177</a>, <a href="#Page_180">180</a> +<ul><li>estimate of syphilis in Berlin, <a href="#Page_25">25</a></li></ul></li> + +<li>Blindness in hereditary syphilis, <a href="#Page_104">104</a></li> + +<li>Blood, Spirochæta pallida in, during secondary stage of syphilis, <a href="#Page_35">35</a> +<ul><li>test for syphilis, <a href="#Page_54">54</a>. <i>See also Wassermann test</i></li> +<li>vessels, late syphilis in, <a href="#Page_46">46</a></li></ul></li> + +<li>Board of Health, activities of, against syphilis, <a href="#Page_165">165</a> +<ul><li>national, need for, <a href="#Page_167">167</a></li></ul></li> + +<li>Body, invasion of, by germs in secondary stage of syphilis, <a href="#Page_35">35</a></li> + +<li>Bones in hereditary syphilis, <a href="#Page_102">102</a> +<ul><li>late syphilis (gumma) in, <a href="#Page_46">46</a></li> +<li>Spirochæta pallida in, <a href="#Page_39">39</a></li> +<li>supposed effect of mercury on, <a href="#Page_63">63</a></li></ul></li> + +<li>Bordet and Wassermann, blood test for syphilis, <a href="#Page_14">14</a></li> + +<li>Brain, late syphilis of, <a href="#Page_48">48</a> +<ul><li><span class='pagenum'><a name="Page_188" id="Page_188">[Pg 188]</a></span>softening of, <a href="#Page_48">48</a></li></ul></li> + +<li>Brawl chancre, <a href="#Page_116">116</a></li> + +<li>Breasts, contagious patches on, <a href="#Page_38">38</a></li> + +<li>Brooklyn Hospital Dispensary, <a href="#Page_171">171</a> +<ul><li>health exhibit by, <a href="#Page_175">175</a></li></ul></li> + + +<li class="mt"><span class="smcap">Cabot</span>, Hugh, comment on reporting syphilis, <a href="#Page_179">179</a></li> + +<li>Cancer following smoker's patch, <a href="#Page_138">138</a></li> + +<li>Chafe, chancre resembling, <a href="#Page_30">30</a> +<ul><li>relation of, to infection with syphilis, <a href="#Page_28">28</a></li></ul></li> + +<li>Chancre, <a href="#Page_29">29</a> +<ul><li>and cold sores, <a href="#Page_30">30</a></li> +<li>appearance of, <a href="#Page_30">30</a></li> +<li>brawl, <a href="#Page_116">116</a></li> +<li>combined with chancroid, <a href="#Page_30">30</a></li> +<li>concealment of, by gonorrhea, <a href="#Page_30">30</a></li> +<li>contagiousness of, <a href="#Page_109">109</a></li> +<li>contracted during engagement, <a href="#Page_117">117</a></li> +<li>cure of syphilis in stage of, <a href="#Page_85">85</a></li> +<li>developed from kissing game, <a href="#Page_117">117</a></li> +<li>diagnosis of, prevented by improper treatment, <a href="#Page_32">32</a></li> +<li>ease with which overlooked, <a href="#Page_30">30</a></li> +<li>enlargement of glands near, <a href="#Page_33">33</a></li> +<li>extra-genital, from lax relations, <a href="#Page_134">134</a></li> +<li>importance of early recognition of, <a href="#Page_31">31</a>, <a href="#Page_34">34</a></li> +<li>in women, <a href="#Page_30">30</a></li> +<li>location of, <a href="#Page_28">28</a></li> +<li>of the lip, <a href="#Page_117">117</a>, <a href="#Page_119">119</a></li> +<li>on knuckle (brawl chancre), <a href="#Page_116">116</a></li> +<li>painlessness of, <a href="#Page_30">30</a></li> +<li>soft, <a href="#Page_30">30</a>. <i>See also chancroid</i></li> +<li>tertiary symptoms following, <a href="#Page_45">45</a></li> +<li>urethral, in men, <a href="#Page_30">30</a></li> +<li>variations in, <a href="#Page_30">30</a></li></ul></li> + +<li>Chancroid, <a href="#Page_16">16</a> +<ul><li>and syphilitic infection, <a href="#Page_30">30</a></li> +<li>confusion of, with syphilitic chancre, <a href="#Page_31">31</a></li></ul></li> + +<li>Child, death of, in syphilitic miscarriages or abortion, <a href="#Page_95">95</a> +<ul><li>early signs of hereditary syphilis in, <a href="#Page_99">99</a></li> +<li>effect of syphilitic eye trouble on development of, <a href="#Page_103">103</a></li> +<li>healthy, born of syphilitic mother, <a href="#Page_94">94</a></li> +<li>infection of wet nurse by syphilitic, <a href="#Page_100">100</a></li> +<li>necessity of teaching sexual self-control to, <a href="#Page_160">160</a></li> +<li>older, effect of hereditary syphilis on, <a href="#Page_102">102</a></li> +<li>transmission of syphilis from mother to, <a href="#Page_92">92</a></li> +<li>treatment of syphilis in, before birth, <a href="#Page_97">97</a></li> +<li>unborn, effect of syphilis on, <a href="#Page_98">98</a></li></ul></li> + +<li>Child-bearing, effect of syphilis on, <a href="#Page_95">95</a></li> + +<li>Children, adopted, syphilis in, <a href="#Page_106">106</a> +<ul><li>syphilitic, mental condition of, <a href="#Page_101">101</a></li></ul></li> + +<li>Clap, <a href="#Page_16">16</a>. +<ul><li><i>See also gonorrhea</i></li></ul></li> + +<li>Clinics for pay patients to secure better treatment, <a href="#Page_173">173</a> +<ul><li>inadequate, for venereal disease, <a href="#Page_170">170</a></li> +<li>night, necessity for, <a href="#Page_171">171</a></li></ul></li> + +<li>Cold sores and chancres, <a href="#Page_30">30</a></li> + +<li>College students, syphilis in, <a href="#Page_25">25</a></li> + +<li>Commission, Baltimore Vice, <a href="#Page_134">134</a> +<ul><li>Sydenham Royal, <a href="#Page_164">164</a></li></ul></li> + +<li><span class='pagenum'><a name="Page_189" id="Page_189">[Pg 189]</a></span>Complications, serious, of syphilis, <a href="#Page_45">45</a></li> + +<li>Compulsory treatment, state provision for, <a href="#Page_169">169</a></li> + +<li>Conception, influence of syphilis on, <a href="#Page_95">95</a> +<ul><li>treatment of syphilis occurring in mother after, <a href="#Page_97">97</a></li></ul></li> + +<li>Coney Island Health Exhibit, <a href="#Page_175">175</a></li> + +<li>Contagiousness of moist sores in syphilis, <a href="#Page_27">27</a>, <a href="#Page_38">38</a>, <a href="#Page_110">110</a> +<ul><li>of secondary relapses in syphilis, <a href="#Page_42">42</a> +<ul><li>syphilitic sores, <a href="#Page_38">38</a></li></ul></li> +<li>of syphilis, <a href="#Page_109">109</a>. <i>See also infectiousness, infection, and transmission</i> +<ul><li>and medical examination of prostitutes, <a href="#Page_135">135</a></li> +<li>control of, by salvarsan, <a href="#Page_73">73</a>, <a href="#Page_74">74</a>, <a href="#Page_122">122</a></li> +<li>detection of, by examination of patient, <a href="#Page_123">123</a></li> +<li>disappearance of, in late syphilis, <a href="#Page_110">110</a></li> +<li>duration of, in late syphilis, <a href="#Page_112">112</a> +<ul><li>under treatment, <a href="#Page_123">123</a></li></ul></li> +<li>effect of incomplete cure on, <a href="#Page_83">83</a> +<ul><li>of local irritation on, <a href="#Page_43">43</a></li> +<li>of mercury on, <a href="#Page_64">64</a></li> +<li>of moisture on, <a href="#Page_27">27</a>, <a href="#Page_38">38</a>, <a href="#Page_110">110</a></li> +<li>of time on, <a href="#Page_111">111</a></li> +<li>of tobacco on, <a href="#Page_138">138</a></li></ul></li> +<li>estimate of risk for wife, <a href="#Page_125">125</a></li> +<li>factors tending to increase, <a href="#Page_112">112</a></li> +<li>five-year rule in relation to, <a href="#Page_124">124</a></li> +<li>hereditary, <a href="#Page_100">100</a>, <a href="#Page_105">105</a></li> +<li>ignorance of, in women, <a href="#Page_135">135</a></li> +<li>impracticability of quarantine in control of, <a href="#Page_121">121</a></li> +<li>in wet nurses, <a href="#Page_101">101</a></li> +<li>inability of mercury to control, <a href="#Page_123">123</a></li> +<li>obstacles to control by treatment, <a href="#Page_123">123</a></li></ul></li></ul></li> + +<li>Continence as personal prophylaxis, <a href="#Page_161">161</a> +<ul><li>economic forces opposing, <a href="#Page_157">157</a></li></ul></li> + +<li>Copenhagen, dispensaries for treatment in, <a href="#Page_171">171</a></li> + +<li>Cost, economic, of mental disease due to syphilis, <a href="#Page_51">51</a> +<ul><li>of living, effect of, on marriage and sexual life, <a href="#Page_158">158</a></li> +<li>of treatment, effect of, <a href="#Page_84">84</a>, <a href="#Page_149">149</a></li></ul></li> + +<li>Cups, drinking, transmission of syphilis by, <a href="#Page_113">113</a></li> + +<li>Curability of syphilis, critical estimate of, <a href="#Page_90">90</a></li> + +<li>Cure, importance of, for the wife, <a href="#Page_128">128</a> +<ul><li>incomplete or symptomatic, danger of, <a href="#Page_82">82</a></li> +<li>of early syphilis, abortive, <a href="#Page_27">27</a>, <a href="#Page_34">34</a>, <a href="#Page_86">86</a>, <a href="#Page_127">127</a></li> +<li>of hereditary syphilis, <a href="#Page_107">107</a></li> +<li>of syphilis, <a href="#Page_124">124</a>, <a href="#Page_126">126</a>, <a href="#Page_129">129</a>. <i>See also five-year rule</i> +<ul><li>abortive, salvarsan in, <a href="#Page_73">73</a>, <a href="#Page_79">79</a>, <a href="#Page_89">89</a></li> +<li>complete, responsibility of the physician in regard to, <a href="#Page_84">84</a></li> +<li>effect of cost on, <a href="#Page_84">84</a>, <a href="#Page_149">149</a> +<ul><li>stage of disease on, <a href="#Page_85">85</a></li></ul></li> +<li>importance of, <a href="#Page_90">90</a></li> +<li>in early stage, <a href="#Page_27">27</a>, <a href="#Page_86">86</a></li> +<li>in primary stage, <a href="#Page_85">85</a>. <i>See also cure of syphilis, abortive</i></li> +<li>in secondary stage, <a href="#Page_86">86</a>, <a href="#Page_88">88</a></li> +<li><span class='pagenum'><a name="Page_190" id="Page_190">[Pg 190]</a></span>methods of determining, <a href="#Page_90">90</a></li> +<li>obstacles to, <a href="#Page_80">80</a></li> +<li>radical or complete, <a href="#Page_80">80</a></li> +<li>Wassermann test in, <a href="#Page_58">58</a></li></ul></li> +<li>symptomatic, in late syphilis, <a href="#Page_87">87</a></li> +<li>time required for, <a href="#Page_87">87</a></li></ul></li> + + +<li class="mt"><span class="smcap">Dark</span>-field examination, use of, in recognizing contagious recurrences, <a href="#Page_111">111</a> +<ul><li>germ of syphilis in, <a href="#Page_22">22</a></li> +<li>importance of using, <a href="#Page_22">22</a></li> +<li>use of, in recognizing early syphilis, <a href="#Page_33">33</a></li></ul></li> + +<li>Deafness and loss of speech due to hereditary syphilis, <a href="#Page_104">104</a></li> + +<li>Deaths due to hereditary syphilis, <a href="#Page_98">98</a>, <a href="#Page_99">99</a> +<ul><li>due to late syphilis, <a href="#Page_48">48</a></li></ul></li> + +<li>Denmark, free treatment of syphilis in, <a href="#Page_169">169</a></li> + +<li>Disgrace, syphilis and, <a href="#Page_142">142</a>, <a href="#Page_144">144</a></li> + +<li>Disinfection of hands, dishes, etc., by washing and disinfectants, <a href="#Page_114">114</a></li> + +<li>Dispensaries for syphilis in large cities, <a href="#Page_170">170</a></li> + +<li>Drinking of alcoholic liquors, effect of, in syphilis, <a href="#Page_137">137</a></li> + +<li>"Drops," <a href="#Page_69">69</a></li> + +<li>Drug stores and drug clerks, evil influence of, <a href="#Page_175">175</a> +<ul><li>prescribing, suppression of, <a href="#Page_168">168</a>, <a href="#Page_174">174</a></li></ul></li> + +<li>Drying, effect on germ of syphilis, <a href="#Page_27">27</a></li> + +<li>Dumbness (loss of speech) in hereditary syphilis, <a href="#Page_104">104</a></li> + +<li>Dyes, relation of, to salvarsan, <a href="#Page_70">70</a></li> + + +<li class="mt"><span class="smcap">Ears</span>, secondary recurrences affecting, <a href="#Page_43">43</a></li> + +<li>Ears, trouble in, in hereditary syphilis, <a href="#Page_104">104</a></li> + +<li>Eating utensils, transmission of syphilis by, <a href="#Page_113">113</a>, <a href="#Page_115">115</a></li> + +<li>Education and character in the control of syphilis, <a href="#Page_160">160</a> +<ul><li>as means of controlling contagiousness of syphilis, <a href="#Page_122">122</a></li></ul></li> + +<li>Ehrlich, Paul, <a href="#Page_70">70</a></li> + +<li>Engagements, syphilis contracted during, <a href="#Page_117">117</a> +<ul><li>to marry in syphilitics, precautions in connection with, <a href="#Page_129">129</a></li></ul></li> + +<li>England, action of, against drug stores prescribing for syphilis, <a href="#Page_176">176</a> +<ul><li>provision for treatment of venereal disease in, <a href="#Page_169">169</a></li> +<li>treatment not compulsory in, <a href="#Page_180">180</a></li></ul></li> + +<li>English-speaking countries, attitude on Metchnikoff prophylaxis in, <a href="#Page_177">177</a></li> + +<li>Eruptions, absence of, in serious syphilis, <a href="#Page_46">46</a> +<ul><li>effect of mercury on syphilitic, <a href="#Page_64">64</a></li> +<li>in hereditary syphilis, <a href="#Page_100">100</a></li> +<li>non-syphilitic, <a href="#Page_37">37</a></li> +<li>recurrent, <a href="#Page_42">42</a>, <a href="#Page_43">43</a></li> +<li>secondary syphilitic, <a href="#Page_36">36</a></li> +<li>syphilitic, effect of salvarsan on, <a href="#Page_74">74</a></li></ul></li> + +<li>Estimate of damage caused by syphilitic eye trouble, <a href="#Page_103">103</a> +<ul><li>of frequency of relapse and recurrence in secondary syphilis, <a href="#Page_125">125</a></li> +<li>of increase of syphilis during war, in Paris, <a href="#Page_183">183</a></li> +<li><span class='pagenum'><a name="Page_191" id="Page_191">[Pg 191]</a></span>of percentage of marital syphilis, <a href="#Page_119">119</a></li> +<li>of percentage of non-genital syphilis, <a href="#Page_119">119</a></li> +<li>of prevalence of gonorrhea, <a href="#Page_26">26</a></li> +<li>of syphilis, <a href="#Page_24">24</a>, <a href="#Page_25">25</a></li> +<li>of risk of infecting wife, <a href="#Page_125">125</a></li> +<li>of syphilis in prostitutes, <a href="#Page_134">134</a></li></ul></li> + +<li>Examination, medical, before marriage, <a href="#Page_130">130</a> +<ul><li>limitations of, in detecting contagiousness, <a href="#Page_123">123</a></li></ul></li> + +<li>Excesses, effect of, on the syphilitic, <a href="#Page_137">137</a></li> + +<li>Expense of treatment, effect of, <a href="#Page_77">77</a>, <a href="#Page_84">84</a>, <a href="#Page_149">149</a></li> + +<li>Expert advice, importance of, <a href="#Page_32">32</a> +<ul><li>in secondary stage of syphilis, <a href="#Page_86">86</a></li> +<li>in pay patient clinics, <a href="#Page_174">174</a></li> +<li>services, value of, in control and</li> +<li>treatment of syphilis, <a href="#Page_173">173</a></li></ul></li> + +<li>Eye trouble in hereditary syphilis, <a href="#Page_103">103</a> +<ul><li>in later life, <a href="#Page_105">105</a></li> +<li>in secondary syphilis, <a href="#Page_36">36</a></li></ul></li> + +<li>Eyes, secondary syphilitic recurrences affecting, <a href="#Page_43">43</a></li> + + +<li class="mt"><span class="smcap">Family</span>, economic forces working against, <a href="#Page_158">158</a> +<ul><li>transmission of syphilis in, <a href="#Page_116">116</a></li></ul></li> + +<li>Fathers of families, encouragement of early marriages by, <a href="#Page_159">159</a> +<ul><li>syphilis in, <a href="#Page_93">93</a>, <a href="#Page_126">126</a></li></ul></li> + +<li>Fiancée, non-genital chancre in, <a href="#Page_129">129</a></li> + +<li>First sore, <a href="#Page_29">29</a>. <i>See also chancre</i></li> + +<li>Fist chancre, <a href="#Page_116">116</a></li> + +<li>Five-year rule, <a href="#Page_124">124</a>, <a href="#Page_126">126</a>, <a href="#Page_129">129</a> +<ul><li>in relation to marriage, <a href="#Page_126">126</a></li></ul></li> + +<li>Founder's estimate of prevalence of syphilis, <a href="#Page_24">24</a></li> + +<li>France, increase of syphilis in, during war, <a href="#Page_183">183</a></li> + + +<li class="mt"><span class="smcap">Gaucher's</span> estimates of increase in syphilis during war in France, <a href="#Page_183">183</a></li> + +<li>Genital syphilis in lax individuals, <a href="#Page_133">133</a></li> + +<li>Genitals, contagious sores on, <a href="#Page_38">38</a>, <a href="#Page_112">112</a> +<ul><li>fitness of, for harboring germs of syphilis, <a href="#Page_118">118</a></li></ul></li> + +<li>Germ of syphilis, <a href="#Page_40">40</a>. <i>See also Spirochæta pallida</i></li> + +<li>Germany, action of, against drug store prescribing for syphilis, <a href="#Page_176">176</a> +<ul><li>attitude on Metchnikoff prophylaxis in, <a href="#Page_177">177</a></li> +<li>compulsory treatment of venereal disease in, <a href="#Page_180">180</a></li> +<li>sentiment against reporting of venereal disease in, <a href="#Page_179">179</a></li> +<li>society for preventing sexual disease in, <a href="#Page_164">164</a></li> +<li>syphilis in, <a href="#Page_25">25</a></li></ul></li> + +<li>Germs, behavior of, in various diseases, <a href="#Page_40">40</a></li> + +<li>Glands, enlargement of, in neighborhood of chancre, <a href="#Page_33">33</a> +<ul><li>in chancre of the lip, <a href="#Page_33">33</a></li></ul></li> + +<li>Gonorrhea and syphilis, measures to prevent spread from army to general population, <a href="#Page_183">183</a> +<ul><li>concealment of chancre by, <a href="#Page_31">31</a></li> +<li>confusion of, with syphilis, <a href="#Page_13">13</a>, <a href="#Page_16">16</a>, <a href="#Page_31">31</a></li> +<li>drug store treatment of, <a href="#Page_175">175</a></li> +<li>estimated prevalence of, <a href="#Page_26">26</a></li> +<li><span class='pagenum'><a name="Page_192" id="Page_192">[Pg 192]</a></span>in prostitutes in Baltimore, <a href="#Page_134">134</a></li></ul></li> + +<li>Gonorrhea, transmission of, by toilet seats, <a href="#Page_114">114</a></li> + +<li>Great Britain. <i>See England</i></li> + +<li>Gumma, <a href="#Page_46">46</a>. <i>See also syphilis, late</i> +<ul><li>effect of treatment on, <a href="#Page_47">47</a></li> +<li>nature of, <a href="#Page_46">46</a></li></ul></li> + +<li>Gummatous infiltration in hereditary +<ul><li>syphilis, <a href="#Page_102">102</a></li> +<li>in late syphilis, <a href="#Page_46">46</a></li></ul></li> + + +<li class="mt"><span class="smcap">Haiti</span>, origin of syphilis in, <a href="#Page_11">11</a></li> + +<li>Hata, <a href="#Page_70">70</a></li> + +<li>Headaches in syphilis, <a href="#Page_36">36</a></li> + +<li>Health, effect of secondary syphilis on, <a href="#Page_36">36</a> +<ul><li>Exhibit, Brooklyn Hospital Dispensary, <a href="#Page_175">175</a></li></ul></li> + +<li>Hearing, disturbances of, in hereditary syphilis, <a href="#Page_104">104</a> +<ul><li>in secondary syphilis, <a href="#Page_36">36</a></li></ul></li> + +<li>Heart in hereditary syphilis, <a href="#Page_102">102</a></li> + +<li>Hereditary syphilis, apparently healthy children with, <a href="#Page_101">101</a> +<ul><li>as cause of abortions and miscarriages, <a href="#Page_95">95</a> +<ul><li>of death, <a href="#Page_98">98</a></li></ul></li> +<li>blindness in, <a href="#Page_104">104</a></li> +<li>bones and teeth in, <a href="#Page_102">102</a></li> +<li>contagiousness of, <a href="#Page_100">100</a>, <a href="#Page_105">105</a></li> +<li>deafness in, <a href="#Page_104">104</a></li> +<li>early signs of, <a href="#Page_99">99</a>, <a href="#Page_100">100</a></li> +<li>effect of accident and injury in, <a href="#Page_105">105</a></li> +<li>eye trouble in, <a href="#Page_103">103</a></li> +<li>heart, blood-vessels and nervous system in, <a href="#Page_102">102</a></li> +<li>Hutchinson's teeth in, <a href="#Page_102">102</a></li> +<li>immunity in, <a href="#Page_106">106</a></li> +<li>in adopted children, state provision for care of, <a href="#Page_106">106</a></li> +<li>in infant, <a href="#Page_99">99</a></li> +<li>in unborn child, <a href="#Page_98">98</a></li> +<li>late, in older children and adults, <a href="#Page_101">101</a></li> +<li>moral costs of, <a href="#Page_99">99</a></li> +<li>non-transmission of, by marriage, <a href="#Page_105">105</a></li> +<li>treatment of, <a href="#Page_107">107</a> +<ul><li>in school hospitals, <a href="#Page_108">108</a></li></ul></li></ul></li> + +<li>Hoffmann's rule for marriage of syphilitics, <a href="#Page_124">124</a></li> + +<li>Hospital beds, number of, needed for venereal disease, <a href="#Page_171">171</a> +<ul><li>treatment for hereditary syphilis, <a href="#Page_108">108</a></li></ul></li> + +<li>Hospitals in treating venereal disease, <a href="#Page_171">171</a> +<ul><li>special venereal, <a href="#Page_167">167</a>, <a href="#Page_171">171</a></li></ul></li> + +<li>Hot Springs in treatment of syphilis, <a href="#Page_140">140</a></li> + +<li>Hunter, John, <a href="#Page_13">13</a></li> + +<li>Husband, probability of infection of wife by, <a href="#Page_125">125</a></li> + +<li>Hutchinson's teeth in hereditary syphilitics, <a href="#Page_102">102</a></li> + +<li>Hygiene, personal, of the syphilitic, <a href="#Page_136">136</a></li> + + +<li class="mt"><span class="smcap">Idiocy</span> in hereditary syphilis, <a href="#Page_101">101</a></li> + +<li>Immunity in syphilis, absence of, <a href="#Page_139">139</a> +<ul><li>hereditary, <a href="#Page_106">106</a></li></ul></li> + +<li>Incubation period of syphilis, <a href="#Page_28">28</a>, <a href="#Page_29">29</a></li> + +<li>Infection, break in skin necessary to, <a href="#Page_28">28</a> +<ul><li>double, with gonorrhea and syphilis, <a href="#Page_30">30</a></li> +<li>with syphilis and chancroid, <a href="#Page_30">30</a></li> +<li>point of entry of, site of chancre, 29</li> +<li><span class='pagenum'><a name="Page_193" id="Page_193">[Pg 193]</a></span>risks of, <a href="#Page_32">32</a></li> +<li>time elapsing after, before chancre appears, <a href="#Page_29">29</a></li> +<li>unsuspected risk of, <a href="#Page_161">161</a></li> +<li>with syphilis favored by moisture, <a href="#Page_27">27</a></li></ul></li> + +<li>Infectiousness of syphilis. <i>See contagiousness</i> +<ul><li>of syphilitic discharges, <a href="#Page_28">28</a></li></ul></li> + +<li>Infiltration, gummatous, in late syphilis, <a href="#Page_46">46</a> +<ul><li>in hereditary syphilis, <a href="#Page_102">102</a></li></ul></li> + +<li>Injections, mercurial, <a href="#Page_66">66</a></li> + +<li>Innocence, question of, in transmission of syphilis, <a href="#Page_118">118</a></li> + +<li>Inoculation, favorable ground for, <a href="#Page_114">114</a></li> + +<li>Insane asylums, amount of syphilitic mental disease in, <a href="#Page_50">50</a></li> + +<li>Inunctions, advantages of, <a href="#Page_66">66</a> +<ul><li>disadvantages of, <a href="#Page_65">65</a></li> +<li>mercurial, <a href="#Page_65">65</a></li> +<li>number required for cure, <a href="#Page_66">66</a></li></ul></li> + +<li>Iodid of potash, <a href="#Page_69">69</a></li> + +<li>Irresponsible mental attitude in syphilis, <a href="#Page_150">150</a>, <a href="#Page_151">151</a></li> + +<li>Irritation, effect of, on contagious recurrences, <a href="#Page_43">43</a></li> + +<li>Italy, non-compulsory treatment in, <a href="#Page_180">180</a> +<ul><li>provision for treatment of venereal disease in, <a href="#Page_169">169</a></li></ul></li> + + +<li class="mt"><span class="smcap">Keratitis</span>, interstitial, in hereditary syphilis, <a href="#Page_103">103</a></li> + +<li>Kernels. <i>See glands</i></li> + +<li>Keyes' estimate of risk of infection of wife by husband, <a href="#Page_125">125</a></li> + +<li>Kissing, rules governing, in syphilitics, <a href="#Page_138">138</a> +<ul><li>transmission of syphilis by, <a href="#Page_116">116</a></li></ul></li> + +<li>Knuckle chancre, <a href="#Page_116">116</a></li> + + +<li class="mt"><span class="smcap">Late</span> syphilis, non-contagious character of, <a href="#Page_110">110</a> +<ul><li>premature development of, <a href="#Page_45">45</a></li> +<li>prospects for cure in, <a href="#Page_86">86</a></li></ul></li> + +<li>Latent or concealed syphilis, <a href="#Page_22">22</a></li> + +<li>Law, Ohio, relative to physicians and marriage of syphilitics, <a href="#Page_131">131</a> +<ul><li>controlling professional confidence, <a href="#Page_131">131</a></li> +<li>crippling physician in relation to marriage of syphilitics, <a href="#Page_131">131</a></li> +<li>providing for compulsory treatment in various countries, <a href="#Page_180">180</a></li></ul></li> + +<li>Legal control, necessity for, in irresponsible syphilitics, <a href="#Page_153">153</a></li> + +<li>Legislation, conservative, <a href="#Page_167">167</a> +<ul><li>indirect, against venereal disease, <a href="#Page_169">169</a></li> +<li>undesirable and freak, <a href="#Page_166">166</a></li></ul></li> + +<li>Legs in locomotor ataxia, <a href="#Page_49">49</a></li> + +<li>Lemberg, study of prostitutes in city of, <a href="#Page_134">134</a></li> + +<li>Lesion, primary. <i>See chancre; also sore</i></li> + +<li>Life, well-balanced, for syphilitic, <a href="#Page_137">137</a></li> + +<li>Lip, chancre of, glands in, <a href="#Page_33">33</a></li> + +<li>Liquid medicine, giving of mercury in form of, <a href="#Page_65">65</a></li> + +<li>Liquor, alcoholic, effect of, in syphilis, <a href="#Page_137">137</a> +<ul><li>traffic, importance of abolition of, in prevention of venereal disease, <a href="#Page_184">184</a></li></ul></li> + +<li>Liver, Spirochæta pallida in, <a href="#Page_39">39</a></li> + +<li>Locomotor ataxia, <a href="#Page_48">48</a> +<ul><li>frequency of, <a href="#Page_51">51</a></li> +<li><span class='pagenum'><a name="Page_194" id="Page_194">[Pg 194]</a></span>stomach symptoms in (gastric crises), <a href="#Page_49">49</a></li> +<li>symptoms in legs, bladder and rectum, <a href="#Page_49">49</a></li> +<li>syphilitic germs in spinal cord in, <a href="#Page_49">49</a></li> +<li>treatment and prevention of, <a href="#Page_52">52</a></li></ul></li> + +<li>London, syphilis in, <a href="#Page_24">24</a></li> + +<li>Luetin test, Noguchi, <a href="#Page_79">79</a></li> + + +<li class="mt"><span class="smcap">Malaria</span>, comparison of, with syphilis, <a href="#Page_62">62</a></li> + +<li>Marriage and abortive cure of syphilis, <a href="#Page_127">127</a> +<ul><li>and five-year rule, <a href="#Page_126">126</a></li> +<li>and syphilis, <a href="#Page_125">125</a></li> +<li>and Wassermann test, <a href="#Page_130">130</a></li> +<li>annulment of, for concealment of syphilitic infection, <a href="#Page_132">132</a></li> +<li>early encouragement of, by state, parents, employers, <a href="#Page_159">159</a></li> +<li>effect of economic forces on, <a href="#Page_158">158</a></li> +<li>medical examination for syphilis before, <a href="#Page_130">130</a></li> +<li>of hereditary syphilitics, <a href="#Page_105">105</a></li> +<li>of persons with syphilis, inability of physician to prevent, <a href="#Page_131">131</a></li> +<li>of syphilitics, Hoffmann's rule for, <a href="#Page_124">124</a></li> +<li>syphilis acquired in, <a href="#Page_120">120</a></li></ul></li> + +<li>Massachusetts, syphilitic mental disease in, <a href="#Page_51">51</a></li> + +<li>Medical examination before marriage, <a href="#Page_130">130</a> +<ul><li><ul><li>in relation to syphilis, <a href="#Page_130">130</a></li></ul></li> +<li>of prostitutes, <a href="#Page_135">135</a>, <a href="#Page_136">136</a></li></ul></li> + +<li>Mental attitude in relation to syphilis, <a href="#Page_141">141</a> +<ul><li><ul><li>morbid, in syphilis, <a href="#Page_153">153</a></li></ul></li> +<li>disease and hereditary syphilis, <a href="#Page_101">101</a></li></ul></li> + +<li>Mental disease and syphilis, <a href="#Page_50">50</a> +<ul><li>Hygiene, National Committee for, <a href="#Page_166">166</a></li></ul></li> + +<li>Mercury, <a href="#Page_62">62</a> +<ul><li>and salvarsan, combination of, in controlling contagiousness, <a href="#Page_124">124</a></li> +<li>comparative value of, <a href="#Page_68">68</a></li> +<li>deceptive value of, <a href="#Page_64">64</a></li> +<li>effect of, on syphilis, <a href="#Page_63">63</a></li> +<li>inability of, to control contagiousness, <a href="#Page_123">123</a></li> +<li>ineffectiveness of, by mouth, <a href="#Page_65">65</a></li> +<li>injections of, <a href="#Page_66">66</a></li> +<li>injurious effects of, <a href="#Page_67">67</a></li> +<li>inunctions (rubs), <a href="#Page_65">65</a></li> +<li>methods of administering, <a href="#Page_64">64</a></li> +<li>of using in treatment, <a href="#Page_62">62</a></li> +<li>misconception in regard to, <a href="#Page_63">63</a></li></ul></li> + +<li>Metchnikoff and Roux, <a href="#Page_14">14</a> +<ul><li>prophylaxis in syphilis, <a href="#Page_162">162</a></li></ul></li> + +<li>Michigan, legislative measures against syphilis in, <a href="#Page_182">182</a></li> + +<li>Military service, universal, and spread of venereal disease, <a href="#Page_184">184</a></li> + +<li>Miscarriage and abortion, syphilis as cause of, <a href="#Page_95">95</a> +<ul><li>repeated, <a href="#Page_95">95</a></li></ul></li> + +<li>Misconceptions regarding cure of syphilis with salvarsan, <a href="#Page_72">72</a> +<ul><li>syphilis in children, <a href="#Page_100">100</a></li></ul></li> + +<li>Moisture, effect of, on contagiousness of syphilis, <a href="#Page_27">27</a>, <a href="#Page_38">38</a>, <a href="#Page_110">110</a> +<ul><li>relation of, to infection with syphilis, <a href="#Page_27">27</a>, <a href="#Page_38">38</a>, <a href="#Page_110">110</a></li></ul></li> + +<li>Moore, Noguchi and, <a href="#Page_48">48</a></li> + +<li>Moral problems in relation to syphilis, <a href="#Page_18">18</a></li> + +<li>Morality, sexual, in relation to syphilis, <a href="#Page_18">18</a></li> + +<li><span class='pagenum'><a name="Page_195" id="Page_195">[Pg 195]</a></span>Morals, syphilis and, 144</li> + +<li>Morbidness in syphilitics, <a href="#Page_153">153</a></li> + +<li>Mother, knowledge of, in adopting a child, <a href="#Page_106">106</a> +<ul><li>syphilitic, apparent good health of, <a href="#Page_93">93</a> +<ul><li>period of greatest danger to child, <a href="#Page_94">94</a></li></ul></li> +<li>treatment of syphilis in, <a href="#Page_97">97</a></li></ul></li> + +<li>Mouth, administration of mercury by, <a href="#Page_64">64</a> +<ul><li>contagious sores in, <a href="#Page_38">38</a>, <a href="#Page_42">42</a>. <i>See also mucous patches</i></li> +<li>effect of mercury on, <a href="#Page_67">67</a></li> +<li>late syphilis in, <a href="#Page_47">47</a></li></ul></li> + +<li>Mucous patches, <a href="#Page_38">38</a>, <a href="#Page_42">42</a> +<ul><li>cancer following, <a href="#Page_138">138</a></li> +<li>effect of salvarsan on, <a href="#Page_74">74</a> +<ul><li>of tobacco in predisposing to, <a href="#Page_43">43</a>, <a href="#Page_112">112</a></li></ul></li> +<li>susceptibility of prostitutes to, <a href="#Page_136">136</a></li></ul></li> + + +<li class="mt"><span class="smcap">National</span> Board of Health, need for, <a href="#Page_167">167</a></li> + +<li>Neck, enlargement of glands in, <a href="#Page_33">33</a>, <a href="#Page_34">34</a></li> + +<li>Neosalvarsan, <a href="#Page_75">75</a></li> + +<li>Nervous strain, effect of, on syphilis, <a href="#Page_137">137</a> +<ul><li>system, complications, relation of, to mild secondary syphilis, <a href="#Page_45">45</a>, <a href="#Page_46">46</a> +<ul><li>examination of, in determining cure of syphilis, <a href="#Page_90">90</a></li> +<li>relapses, <a href="#Page_43">43</a></li> +<li>Spirochæta pallida in, <a href="#Page_39">39</a></li></ul></li></ul></li> + +<li>New York City, clinics and dispensaries in, <a href="#Page_170">170</a> +<ul><li>reporting of syphilis in, <a href="#Page_178">178</a></li></ul></li> + +<li>Noguchi, <a href="#Page_48">48</a> +<ul><li>test, luetin, <a href="#Page_79">79</a></li></ul></li> + +<li>Non-genital syphilis, estimate of percentage of, <a href="#Page_119">119</a> +<ul><li>in lax individuals, <a href="#Page_133">133</a>, <a href="#Page_134">134</a></li></ul></li> + +<li>Notification of venereal disease. <i>See reporting</i></li> + +<li>Nurse, accidental infection of, with syphilis, <a href="#Page_116">116</a> +<ul><li>wet, syphilis in, <a href="#Page_100">100</a></li></ul></li> + +<li>Nursing mothers, syphilitic germs in milk of, <a href="#Page_39">39</a> +<ul><li>of syphilitic child by mother, <a href="#Page_101">101</a></li></ul></li> + + +<li class="mt"><span class="smcap">Ohio</span>, law permitting physician to prevent marriage of contagious syphilitic person, <a href="#Page_131">131</a></li> + +<li>Overwork, effect of, on syphilitics, <a href="#Page_137">137</a></li> + + +<li class="mt"><span class="smcap">Papee's</span> study of prostitution in Lemberg, <a href="#Page_134">134</a></li> + +<li>Paralysis, general, danger to others in, <a href="#Page_49">49</a>, <a href="#Page_50">50</a> +<ul><li>estimated frequency of, <a href="#Page_51">51</a></li> +<li>mental symptoms in, <a href="#Page_49">49</a></li> +<li>of insane, <a href="#Page_48">48</a></li> +<li>syphilitic germs in brain in, <a href="#Page_49">49</a></li> +<li>treatment and prevention of, <a href="#Page_52">52</a></li></ul></li> + +<li>Paresis, 48. <i>See also paralysis, general</i></li> + +<li>Paris, increase of syphilis in, during war, <a href="#Page_183">183</a></li> + +<li>Physician, accidental infection of, with syphilis, <a href="#Page_116">116</a> +<ul><li>coöperation of, in educating syphilitic, <a href="#Page_148">148</a></li> +<li>importance of informing, in regard to syphilis, <a href="#Page_105">105</a>, <a href="#Page_140">140</a></li> +<li><span class='pagenum'><a name="Page_196" id="Page_196">[Pg 196]</a></span>inability of, to prevent marriage of persons with syphilis, <a href="#Page_131">131</a></li></ul></li> + +<li>Physician proper person to administer Metchnikoff prophylaxis, <a href="#Page_163">163</a></li> + +<li>Piles, contagious sores mistaken for, <a href="#Page_43">43</a></li> + +<li>Pills, ineffectiveness of, in treating syphilis, <a href="#Page_65">65</a> +<ul><li>mercury, <a href="#Page_65">65</a></li></ul></li> + +<li>Pinkus' estimate of syphilis in Germany, <a href="#Page_25">25</a></li> + +<li>Pontopidan's estimate of number of hospitals needed for venereal diseases, <a href="#Page_171">171</a></li> + +<li>Population, civil, syphilis in, <a href="#Page_183">183</a> +<ul><li>general, prevention of venereal disease in, during war time, <a href="#Page_184">184</a></li></ul></li> + +<li>Potash, iodid of, <a href="#Page_69">69</a></li> + +<li>Pregnancy, syphilis acquired during, <a href="#Page_94">94</a> +<ul><li>treatment of mother during, <a href="#Page_97">97</a></li></ul></li> + +<li>Prevalence of gonorrhea, estimates of, <a href="#Page_26">26</a> +<ul><li>of syphilis, estimates of, <a href="#Page_24">24</a>, <a href="#Page_25">25</a></li></ul></li> + +<li>Prevention of locomotor ataxia and general paralysis, <a href="#Page_52">52</a> +<ul><li>of syphilis. <i>See prophylaxis</i></li></ul></li> + +<li>Primary lesion. <i>See chancre</i> +<ul><li>stage. <i>See also chancre</i> +<ul><li>contagiousness of syphilis in, <a href="#Page_109">109</a></li> +<li>cure of syphilis in, <a href="#Page_85">85</a></li></ul></li></ul></li> + +<li>Prohibition, national, importance of, in controlling venereal disease, <a href="#Page_184">184</a></li> + +<li>Prophylaxis, educational, <a href="#Page_157">157</a> +<ul><li>state provision for, <a href="#Page_168">168</a></li> +<li>Metchnikoff, <a href="#Page_162">162</a> +<ul><li>utilization of, in public campaign, <a href="#Page_177">177</a></li></ul></li> +<li>moral, of syphilis, <a href="#Page_156">156</a></li></ul></li> + +<li>Prophylaxis, personal, of syphilis, continence in, <a href="#Page_161">161</a> +<ul><li>general instruction in, <a href="#Page_169">169</a></li> +<li>in army and navy, <a href="#Page_162">162</a></li> +<li>physician proper person to administer, <a href="#Page_163">163</a></li> +<li>unsatisfactory features of, <a href="#Page_162">162</a></li></ul></li> + +<li>Prostitutes in Baltimore, gonorrhea in, <a href="#Page_134">134</a> +<ul><li>medical examination of, <a href="#Page_135">135</a></li> +<li>syphilis in, <a href="#Page_134">134</a></li></ul></li> + +<li>Prostitution, abolition or repression of, <a href="#Page_156">156</a>, <a href="#Page_157">157</a> +<ul><li>and syphilis, <a href="#Page_18">18</a>, <a href="#Page_133">133</a></li> +<li>clandestine, risks of, <a href="#Page_136">136</a></li> +<li>effects of liquor traffic on, <a href="#Page_184">184</a></li> +<li>regulation of, <a href="#Page_156">156</a></li></ul></li> + +<li>Psoriasis, confusion of, with syphilitic eruptions, <a href="#Page_37">37</a></li> + +<li>Public Health, syphilis as problem of, <a href="#Page_18">18</a> +<ul><li>Service, United States, estimates of prevalence of syphilis, <a href="#Page_24">24</a></li> +<li>opinion about syphilis, <a href="#Page_141">141</a></li> +<li>sentiment and reporting of syphilis to health officers, <a href="#Page_178">178</a></li></ul></li> + +<li>Publicity, campaign for, <a href="#Page_176">176</a></li> + + +<li class="mt"><span class="smcap">Quacks</span>, suppression of, <a href="#Page_168">168</a>, <a href="#Page_174">174</a> +<ul><li>treatment of syphilitics by, <a href="#Page_140">140</a></li></ul></li> + +<li>Quarantine and freak legislation, <a href="#Page_167">167</a> +<ul><li>compulsory, for irresponsible syphilitics, <a href="#Page_153">153</a></li> +<li>limitations of, in controlling spread of syphilis, <a href="#Page_121">121</a></li> +<li>temporary, for syphilis, in hospitals, <a href="#Page_172">172</a></li></ul></li> + +<li><span class='pagenum'><a name="Page_197" id="Page_197">[Pg 197]</a></span>Quiescent period following entry of germ, <a href="#Page_28">28</a></li> + + +<li class="mt"><span class="smcap">Railroad men</span>, locomotor ataxia and general paralysis in, <a href="#Page_50">50</a></li> + +<li>Rash. <i>See eruption</i></li> + +<li>Recurrences, contagiousness of, <a href="#Page_111">111</a> +<ul><li>estimated frequency of, in secondary syphilis, <a href="#Page_125">125</a></li> +<li>in secondary stage, <a href="#Page_42">42</a>, <a href="#Page_43">43</a></li></ul></li> + +<li>Re-infection with syphilis, <a href="#Page_139">139</a></li> + +<li>Relapses, contagious, in syphilis, <a href="#Page_42">42</a> +<ul><li>frequency of, in secondary stage, <a href="#Page_125">125</a></li> +<li>in nervous system, <a href="#Page_43">43</a></li></ul></li> + +<li>Reporting of syphilis, attitude of various countries on, <a href="#Page_179">179</a> +<ul><li>to health officers, <a href="#Page_178">178</a></li></ul></li> + +<li>Resistance of body to syphilis, <a href="#Page_29">29</a>, <a href="#Page_107">107</a>, <a href="#Page_112">112</a></li> + +<li>Rest, need of, in syphilis, <a href="#Page_137">137</a></li> + +<li>Restaurants, risk of transmitting syphilis under conditions found in, <a href="#Page_115">115</a></li> + +<li>Rheumatism, symptoms resembling, in secondary syphilis, <a href="#Page_36">36</a></li> + +<li>Ricord, founder of modern syphilology, <a href="#Page_13">13</a></li> + +<li>Rub, mercurial. <i>See inunction</i></li> + +<li>Rule, five-year, <a href="#Page_124">124</a>, <a href="#Page_126">126</a>, <a href="#Page_129">129</a> +<ul><li>for marriage of syphilitics. <i>See marriage</i></li> +<li>for personal hygiene of syphilitics, <a href="#Page_136">136</a></li> +<li>governing miscarriage and abortion due to syphilis, <a href="#Page_96">96</a></li> +<li>sexual relations in syphilitics, <a href="#Page_138">138</a></li> +<li>variations on, in hereditary syphilis, <a href="#Page_96">96</a></li></ul></li> + + +<li class="mt"><span class="smcap">Saliva</span>, syphilitic germs in, <a href="#Page_38">38</a></li> + +<li>Salvarsan, accidents due to, <a href="#Page_78">78</a> +<ul><li>action of, in syphilis, <a href="#Page_73">73</a></li> +<li>and abortive cure, <a href="#Page_73">73</a>, <a href="#Page_79">79</a>, <a href="#Page_89">89</a></li> +<li>and mercury, comparative value of, <a href="#Page_68">68</a>, <a href="#Page_89">89</a> +<ul><li>in pregnancy, <a href="#Page_97">97</a></li></ul></li> +<li>animal tests on, <a href="#Page_71">71</a></li> +<li>arsenic in, <a href="#Page_71">71</a></li> +<li>as a social asset, <a href="#Page_78">78</a></li> +<li>cheap, vital importance of, <a href="#Page_172">172</a></li> +<li>combination of arsenic and dye, <a href="#Page_70">70</a>, <a href="#Page_71">71</a></li> +<li>correct administration of, <a href="#Page_77">77</a></li> +<li>discovery of, <a href="#Page_70">70</a></li> +<li>effect of first dose, <a href="#Page_78">78</a> +<ul><li>of insufficient treatment with, <a href="#Page_76">76</a></li> +<li>on mucous patches, <a href="#Page_74">74</a></li></ul></li> +<li>expense of treatment with, <a href="#Page_76">76</a></li> +<li>importance of, in controlling contagiousness of syphilis, <a href="#Page_73">73</a>, <a href="#Page_74">74</a>, <a href="#Page_122">122</a></li> +<li>in treatment, <a href="#Page_89">89</a></li> +<li>in control of syphilis in prostitutes, <a href="#Page_157">157</a></li> +<li>methods of giving, <a href="#Page_75">75</a></li> +<li>misconceptions regarding cure by single dose, <a href="#Page_72">72</a></li> +<li>need for governmental control, <a href="#Page_77">77</a></li> +<li>patent rights on, <a href="#Page_172">172</a></li> +<li>preliminary tests of, on man, <a href="#Page_71">71</a>, <a href="#Page_72">72</a></li> +<li>price of, <a href="#Page_172">172</a></li> +<li>repeated doses, <a href="#Page_76">76</a></li> +<li>use of, does not justify relaxation of rules for marriage, <a href="#Page_127">127</a></li> +<li>value of, in syphilis, <a href="#Page_73">73</a></li></ul></li> + +<li><span class='pagenum'><a name="Page_198" id="Page_198">[Pg 198]</a></span>Scandinavian countries, compulsory treatment of venereal disease in, <a href="#Page_180">180</a> +<ul><li>free treatment of venereal diseases in, <a href="#Page_169">169</a></li> +<li>provision for reporting venereal disease in, <a href="#Page_179">179</a></li></ul></li> + +<li>Scars following gummatous changes, <a href="#Page_46">46</a></li> + +<li>Schaudinn and Hoffmann, <a href="#Page_14">14</a>, <a href="#Page_22">22</a></li> + +<li>School-hospitals for hereditary syphilis, <a href="#Page_108">108</a></li> + +<li>Secondary stage of syphilis, <a href="#Page_35">35</a> +<ul><li>contagious relapses in, <a href="#Page_42">42</a></li> +<li>contagiousness in, <a href="#Page_110">110</a></li> +<li>cure in, <a href="#Page_86">86</a></li> +<li>eye trouble in, <a href="#Page_36">36</a></li> +<li>headaches in, <a href="#Page_36">36</a></li> +<li>loss of weight in, <a href="#Page_36">36</a></li> +<li>problems of, <a href="#Page_42">42</a></li> +<li>rash (eruption) in, <a href="#Page_36">36</a></li> +<li>rheumatic pains in, <a href="#Page_36">36</a></li> +<li>severe, <a href="#Page_36">36</a></li> +<li>spontaneous disappearance of symptoms, <a href="#Page_39">39</a></li> +<li>time required for cure, <a href="#Page_88">88</a></li></ul></li> + +<li>Secrecy, professional, right of syphilitics, <a href="#Page_139">139</a> +<ul><li>right of syphilitic, in connection with reporting of disease, <a href="#Page_178">178</a></li></ul></li> + +<li>Self-control. <i>See sexual self-control</i></li> + +<li>Self-deception in regard to risk of infection, <a href="#Page_161">161</a></li> + +<li>Self-treatment in syphilis, <a href="#Page_140">140</a></li> + +<li>Semen, Spirochæta pallida in, <a href="#Page_39">39</a></li> + +<li>Sexual characteristics of syphilitic children, <a href="#Page_102">102</a> +<ul><li>morality, development of, <a href="#Page_145">145</a></li> +<li>relations, abstinence from, economic influences opposing, <a href="#Page_158">158</a></li> +<li>of syphilitics, rules governing, <a href="#Page_129">129</a>, <a href="#Page_138">138</a></li></ul></li> + +<li>Sexual relations, transmission of syphilis by, <a href="#Page_117">117</a> +<ul><li>self-control, economic forces opposing, <a href="#Page_157">157</a></li> +<li>teaching of, <a href="#Page_159">159</a></li> +<li>transmission of syphilis, question of guilt or innocence, <a href="#Page_118">118</a></li></ul></li> + +<li>Silverware, transmission of syphilis by, <a href="#Page_115">115</a></li> + +<li>Single dose cure of syphilis with salvarsan, <a href="#Page_72">72</a></li> + +<li>"606." <i>See salvarsan</i></li> + +<li>Skin, recurrences of secondary eruption in, <a href="#Page_43">43</a> +<ul><li>unbroken, importance of, in preventing contagiousness of eruptions, <a href="#Page_38">38</a></li></ul></li> + +<li>Sleeping sickness, <a href="#Page_70">70</a></li> + +<li>Smoker's patches, <a href="#Page_138">138</a></li> + +<li>Smoking (tobacco) in syphilis, <a href="#Page_138">138</a></li> + +<li>Snuffles in hereditary syphilis, <a href="#Page_100">100</a></li> + +<li>Social evil and syphilis, <a href="#Page_165">165</a>. <i>See also prostitution</i> +<ul><li>problem of syphilis, <a href="#Page_15">15</a></li></ul></li> + +<li>Soft ulcer or sore, <a href="#Page_16">16</a>. <i>See also chancroid</i></li> + +<li>Soldiers, syphilis and gonorrhea among, in present war, <a href="#Page_183">183</a></li> + +<li>Sore throat in secondary syphilis, <a href="#Page_38">38</a></li> + +<li>Sores, contagious, effect of salvarsan on, <a href="#Page_74">74</a> +<ul><li><ul><li>in prostitutes, <a href="#Page_136">136</a></li> +<li>in syphilis, <a href="#Page_38">38</a></li> +<li>transitory character of, <a href="#Page_123">123</a></li></ul></li> +<li>contagiousness of moist, <a href="#Page_27">27</a>, <a href="#Page_38">38</a>, <a href="#Page_110">110</a> +<ul><li>of open, <a href="#Page_109">109</a></li></ul></li> +<li>on nipples in wet nurses, <a href="#Page_101">101</a></li> +<li>primary. <i>See chancre</i></li> +<li><span class='pagenum'><a name="Page_199" id="Page_199">[Pg 199]</a></span>soft, <a href="#Page_16">16</a>. <i>See also chancroid</i></li> +<li>tertiary. <i>See syphilis, late, gumma</i></li></ul></li> + +<li>Sperk's estimate of frequency of relapse in secondary stage, <a href="#Page_125">125</a></li> + +<li>Spirochæta pallida, <a href="#Page_27">27</a> +<ul><li>average life of, on objects outside body, <a href="#Page_113">113</a></li> +<li>destruction of, in body, <a href="#Page_39">39</a></li> +<li>discovery of, <a href="#Page_14">14</a>, <a href="#Page_22">22</a></li> +<li>distribution of, in internal organs, <a href="#Page_39">39</a></li> +<li>effect of antiseptics on, <a href="#Page_27">27</a> +<ul><li>of drying on, <a href="#Page_27">27</a></li> +<li>of salvarsan on, <a href="#Page_74">74</a></li></ul></li> +<li>growth of, <a href="#Page_27">27</a></li> +<li>in brain, in general paralysis of insane, <a href="#Page_48">48</a></li> +<li>in hereditary syphilitic children, <a href="#Page_99">99</a></li> +<li>in late syphilis, <a href="#Page_45">45</a></li> +<li>in lymph-glands, <a href="#Page_34">34</a></li> +<li>in secondary syphilitic eruptions, <a href="#Page_38">38</a></li> +<li>in spinal cord, in locomotor ataxia, <a href="#Page_49">49</a></li> +<li>invasion of body by, in secondary stage, <a href="#Page_35">35</a></li> +<li>low vitality of, <a href="#Page_27">27</a></li> +<li>mode of entry into body, <a href="#Page_28">28</a></li> +<li>sensitizing of body to, <a href="#Page_39">39</a></li> +<li>strains or type of, <a href="#Page_40">40</a></li> +<li>variations in behavior of, in different persons, <a href="#Page_40">40</a></li></ul></li> + +<li>Spleen, Spirochæta pallida in, <a href="#Page_39">39</a></li> + +<li>Stage of syphilis, relation of, to curability, <a href="#Page_82">82</a> +<ul><li>secondary, of syphilis, <a href="#Page_35">35</a>. <i>See also secondary stage; secondary syphilis; contagiousness; transmission; and Spirochæta pallida</i></li></ul></li> + +<li>Stage, tertiary, of syphilis, <a href="#Page_45">45</a>. <i>See also syphilis, late</i></li> + +<li>State, encouragement of early marriage by, <a href="#Page_159">159</a> +<ul><li>provision of, for recognition and treatment of syphilis, <a href="#Page_168">168</a></li></ul></li> + +<li>Stigma attaching to syphilis, harm done by, <a href="#Page_143">143</a> +<ul><li>of syphilis, effect of, on venereal hospitals, <a href="#Page_167">167</a></li></ul></li> + +<li>Still birth, relation of syphilis to, <a href="#Page_96">96</a></li> + +<li>Still's statistics on death from hereditary syphilis, <a href="#Page_98">98</a></li> + +<li>Stomach in locomotor ataxia, <a href="#Page_49">49</a></li> + +<li>Sweat-glands, absence of Spirochæta pallida in, <a href="#Page_39">39</a></li> + +<li>Sydenham Royal Commission, <a href="#Page_164">164</a> +<ul><li>views on reporting of venereal disease, <a href="#Page_179">179</a></li></ul></li> + +<li>Symptomatic cure in late syphilis, <a href="#Page_87">87</a></li> + +<li>Symptoms, absence of, in syphilis, <a href="#Page_23">23</a> +<ul><li>constitutional, of secondary syphilis, <a href="#Page_36">36</a></li></ul></li> + +<li>Syphilis, absence of immunity in, <a href="#Page_139">139</a> +<ul><li>accidental, in physicians and nurses, <a href="#Page_116">116</a></li> +<li>acquired, in children, <a href="#Page_95">95</a> +<ul><li>in marriage, <a href="#Page_119">119</a></li></ul></li> +<li>action of mercury in, <a href="#Page_63">63</a> +<ul><li>of salvarsan in, <a href="#Page_74">74</a></li></ul></li> +<li>active, relation of, to miscarriages and abortion, <a href="#Page_96">96</a></li> +<li>adequate dispensary service for treating, <a href="#Page_171">171</a></li> +<li>ageing effect of, in child, <a href="#Page_99">99</a></li> +<li>and civil population, <a href="#Page_183">183</a></li> +<li><span class='pagenum'><a name="Page_200" id="Page_200">[Pg 200]</a></span>and engagements to marry, <a href="#Page_129">129</a></li></ul></li> + +<li>Syphilis and marriage, <a href="#Page_125">125</a> +<ul><li>and mental disease, <a href="#Page_50">50</a></li> +<li>and prostitution, <a href="#Page_18">18</a>, <a href="#Page_133">133</a></li> +<li>and public prejudice, <a href="#Page_141">141</a></li> +<li>and sexual problems, <a href="#Page_18">18</a></li> +<li>and war, <a href="#Page_183">183</a></li> +<li>as cause of death in children, <a href="#Page_98">98</a> +<ul><li>of miscarriages and abortion in women, <a href="#Page_95">95</a></li></ul></li> +<li>as public health problem, <a href="#Page_18">18</a></li> +<li>as social problem, <a href="#Page_15">15</a></li> +<li>blood test for, <a href="#Page_54">54</a></li> +<li>broader outlook concerning, <a href="#Page_146">146</a></li> +<li>comparison of, with malaria, <a href="#Page_62">62</a></li> +<li>compulsory treatment of, <a href="#Page_180">180</a></li> +<li>concealed forms of, <a href="#Page_23">23</a></li> +<li>concealment of, by gonorrhea, <a href="#Page_30">30</a></li> +<li>confusion of, with gonorrhea, <a href="#Page_13">13</a>, <a href="#Page_16">16</a>, <a href="#Page_31">31</a></li> +<li>problem of, with various issues, <a href="#Page_16">16</a>, <a href="#Page_17">17</a>, <a href="#Page_165">165</a></li> +<li>congenital, <a href="#Page_94">94</a>. <i>See also syphilis, non-hereditary</i></li> +<li>constitutional symptoms of, <a href="#Page_36">36</a></li> +<li>contagiousness of, in secondary stage, <a href="#Page_110">110</a></li> +<li>course of, summary, <a href="#Page_52">52</a></li> +<li>cure of, <a href="#Page_90">90</a></li> +<li>danger from irresponsible persons infected with, <a href="#Page_150">150</a></li> +<li>deaths from, <a href="#Page_48">48</a></li> +<li>definition of, <a href="#Page_21">21</a></li> +<li>diminishing virulence of, <a href="#Page_12">12</a></li> +<li>early, methods of recognizing, <a href="#Page_32">32</a></li> +<li>educational prophylaxis of, <a href="#Page_157">157</a></li> +<li>epidemic of, in sixteenth century, <a href="#Page_11">11</a></li> +<li>eruption in secondary stage, <a href="#Page_36">36</a></li> +<li>essentials of campaign against, <a href="#Page_168">168</a></li> +<li>false silence in regard to, <a href="#Page_15">15</a></li> +<li>five-year rule regarding contagiousness, <a href="#Page_124">124</a>, <a href="#Page_126">126</a>, <a href="#Page_129">129</a></li> +<li>freak legislation in regard to, <a href="#Page_166">166</a></li> +<li>guilt or innocence in transmission, <a href="#Page_118">118</a></li> +<li>harm done by stigma attaching to, <a href="#Page_143">143</a></li> +<li>hereditary, <a href="#Page_92">92</a> +<ul><li>accident and injury in, <a href="#Page_105">105</a></li> +<li>contagiousness of, <a href="#Page_100">100</a>, <a href="#Page_105">105</a></li> +<li>destructive changes in, <a href="#Page_101">101</a>, <a href="#Page_102">102</a></li> +<li>early signs of, in children, <a href="#Page_99">99</a>, <a href="#Page_100">100</a></li> +<li>late signs of, <a href="#Page_101">101</a></li> +<li>mental symptoms in, <a href="#Page_101">101</a></li> +<li>of eye, <a href="#Page_103">103</a></li> +<li>treatment of, <a href="#Page_107">107</a></li></ul></li> +<li>history of, <a href="#Page_11">11</a></li> +<li>importance of prohibition in controlling, <a href="#Page_184">184</a></li> +<li>important advances in knowledge of, <a href="#Page_17">17</a></li> +<li>in adopted children, <a href="#Page_106">106</a></li> +<li>in British working men, <a href="#Page_24">24</a></li> +<li>in families, detection of, by Wassermann test, <a href="#Page_128">128</a></li> +<li>in father or mother of family, <a href="#Page_92">92</a>, <a href="#Page_93">93</a>, <a href="#Page_126">126</a></li> +<li>in men who have only had gonorrhea, <a href="#Page_31">31</a></li> +<li>in prostitutes, <a href="#Page_134">134</a></li> +<li>in United States, estimates of, <a href="#Page_26">26</a></li> +<li>in wet nurses, <a href="#Page_100">100</a>, <a href="#Page_101">101</a></li> +<li>inability of physician to prevent marriage of persons with, <a href="#Page_131">131</a></li> +<li>incomplete cure of, <a href="#Page_82">82</a></li> +<li>influence of, on progress of mediæval medicine, <a href="#Page_13">13</a></li> +<li>innocent, in fiancée, <a href="#Page_129">129</a> +<ul><li><span class='pagenum'><a name="Page_201" id="Page_201">[Pg 201]</a></span>suffering of, caused by, <a href="#Page_19">19</a></li></ul></li> +<li>late, attributable to insufficient salvarsan treatment, <a href="#Page_73">73</a> +<ul><li>curability of, <a href="#Page_86">86</a></li> +<li>destructive effect of, <a href="#Page_47">47</a></li> +<li>in nervous system, <a href="#Page_48">48</a></li> +<li>most serious forms of, <a href="#Page_47">47</a></li> +<li>seriousness of, <a href="#Page_45">45</a></li> +<li>tissue changes in (gumma), <a href="#Page_46">46</a></li></ul></li> +<li>measure to prevent spread of, from army to general population, <a href="#Page_183">183</a></li> +<li>medical examination for, as means of detecting contagiousness, <a href="#Page_123">123</a> +<ul><li>of prostitutes for, <a href="#Page_135">135</a></li></ul></li> +<li>mental attitudes in relation to, <a href="#Page_141">141</a></li> +<li>Metchnikoff prophylaxis of, <a href="#Page_162">162</a></li> +<li>mild, dangers of, <a href="#Page_41">41</a> +<ul><li>relation to complications in nervous system, <a href="#Page_45">45</a></li></ul></li> +<li>mistaken conceptions of, <a href="#Page_13">13</a></li> +<li>moral prophylaxis of, <a href="#Page_156">156</a></li> +<li>morbid fear of, <a href="#Page_154">154</a></li> +<li>non-genital, <a href="#Page_28">28</a> +<ul><li>or extra-genital, <a href="#Page_119">119</a></li></ul></li> +<li>obstacles to control of contagiousness of, <a href="#Page_123">123</a> +<ul><li>to social control of, <a href="#Page_141">141</a></li></ul></li> +<li>passive, transmission of, by prostitutes, <a href="#Page_135">135</a></li> +<li>personal hygiene of, <a href="#Page_136">136</a></li> +<li>prevalence of, <a href="#Page_23">23</a> +<ul><li>in lax individuals, <a href="#Page_133">133</a></li></ul></li> +<li>prevention of, by sexual self-control, <a href="#Page_159">159</a></li> +<li>public attitude toward, <a href="#Page_141">141</a></li> +<li>quacks and self-treatment in, <a href="#Page_140">140</a></li> +<li>radical or complete cure, <a href="#Page_80">80</a></li> +<li>reinfection with, <a href="#Page_139">139</a></li> +<li>relation of mouth and tongue cancers to, <a href="#Page_138">138</a></li> +<li>reporting of, to health officer, <a href="#Page_178">178</a></li> +<li>risk of acquiring, from prostitutes, <a href="#Page_136">136</a> +<ul><li>of infecting wife with, <a href="#Page_125">125</a></li></ul></li> +<li>secondary, cure of, <a href="#Page_86">86</a> +<ul><li>time required for cure of, <a href="#Page_86">86</a></li></ul></li> +<li>sexual transmission of, <a href="#Page_117">117</a></li> +<li>stages of, <a href="#Page_26">26</a></li> +<li>state provision for treatment of, in Denmark, Norway, Italy, England, Germany, West Australia, <a href="#Page_168">168</a>, <a href="#Page_169">169</a></li> +<li>tertiary, <a href="#Page_45">45</a></li> +<li>transmission and hygiene of, <a href="#Page_109">109</a> +<ul><li>by kissing, <a href="#Page_116">116</a></li> +<li>to and by wet nurse, <a href="#Page_100">100</a>, <a href="#Page_101">101</a></li></ul></li> +<li>treatment of, <a href="#Page_60">60</a> +<ul><li>at Hot Springs, <a href="#Page_140">140</a></li> +<li>with salvarsan, <a href="#Page_75">75</a></li></ul></li> +<li>unnoticed manifestations of, <a href="#Page_41">41</a></li> +<li>variations in course of, in different persons, <a href="#Page_41">41</a></li> +<li>Wassermann test for, <a href="#Page_54">54</a></li> +<li>world movement against, <a href="#Page_164">164</a></li></ul></li> + +<li>Syphilitic, average type of, <a href="#Page_148">148</a> +<ul><li>child, nursing of, by mother, <a href="#Page_101">101</a></li> +<li>ideal conscientious type of, <a href="#Page_147">147</a></li> +<li>irresponsible types of, <a href="#Page_151">151</a></li> +<li>morbid mental states, <a href="#Page_153">153</a></li> +<li>personal hygiene of, <a href="#Page_136">136</a></li> +<li>should tell physician he has disease, <a href="#Page_140">140</a></li> +<li>rule governing care of personal articles used by, <a href="#Page_139">139</a></li> +<li>rules governing kissing in, <a href="#Page_138">138</a></li> +<li><span class='pagenum'><a name="Page_202" id="Page_202">[Pg 202]</a></span>sexual relations in, <a href="#Page_138">138</a></li> +<li>well-regulated life for, <a href="#Page_137">137</a></li></ul></li> + +<li>Syphilophobia, <a href="#Page_153">153</a></li> + + +<li class="mt"><span class="smcap">Tabes</span> dorsalis, <a href="#Page_48">48</a>. <i>See also locomotor ataxia</i></li> + +<li>Taboparesis, <a href="#Page_50">50</a></li> + +<li>Teeth, effect of mercury on, <a href="#Page_63">63</a>, <a href="#Page_67">67</a> +<ul><li>(Hutchinson's), in hereditary syphilis, <a href="#Page_102">102</a></li></ul></li> + +<li>Tertiary stage, <a href="#Page_45">45</a></li> + +<li>Test for syphilis in blood, <a href="#Page_54">54</a>. <i>See also Wassermann test</i> +<ul><li>Noguchi, luetin, <a href="#Page_79">79</a></li></ul></li> + +<li>Throat, contagious sores in, <a href="#Page_38">38</a></li> + +<li>Time treatment principle in relation to marriage, <a href="#Page_124">124</a>, <a href="#Page_126">126</a>, <a href="#Page_129">129</a></li> + +<li>Tobacco, effect of, in syphilis, <a href="#Page_43">43</a>, <a href="#Page_112">112</a>, <a href="#Page_138">138</a></li> + +<li>Toilet seats not means of transmitting syphilis, <a href="#Page_114">114</a> +<ul><li>transmission of gonorrhea by, <a href="#Page_114">114</a></li></ul></li> + +<li>Tongue and tonsils, contagious sores on, <a href="#Page_42">42</a> +<ul><li>cancer of, following contagious mucous patches, <a href="#Page_138">138</a></li></ul></li> + +<li>Towels, transmission of syphilis by, <a href="#Page_113">113</a>, <a href="#Page_115">115</a></li> + +<li>Transmission of syphilis by dishes, etc., effect of washing and disinfection on, <a href="#Page_114">114</a> +<ul><li>by infected articles, <a href="#Page_113">113</a></li> +<li>by kissing, <a href="#Page_116">116</a></li> +<li>by sexual contact, <a href="#Page_117">117</a></li> +<li>effect of treatment on risk of, <a href="#Page_124">124</a></li> +<li>from father to mother, <a href="#Page_93">93</a></li> +<li>from mother to child, <a href="#Page_92">92</a></li> +<li>increased risk of, in tobacco users, <a href="#Page_138">138</a></li> +<li>medical examination in prevention of, <a href="#Page_123">123</a></li> +<li>not by door-knobs, bath-tubs, or toilet seats, <a href="#Page_114">114</a></li> +<li>passive, by prostitutes, <a href="#Page_135">135</a></li> +<li>personal responsibility in, <a href="#Page_124">124</a> to wife, <a href="#Page_125">125</a></li> +<li>under conditions of crowding and bad sanitation, <a href="#Page_115">115</a> +<ul><li>of everyday life, <a href="#Page_114">114</a></li></ul></li> +<li>unlikely in marriage of hereditary syphilitics, <a href="#Page_105">105</a></li></ul></li> + +<li>Treatment, intraspinal, in syphilis of nervous system, <a href="#Page_79">79</a> +<ul><li>lack of effect of, on deafness in hereditary syphilis, <a href="#Page_104">104</a></li> +<li>obstacles to control of contagiousness of syphilis, <a href="#Page_123">123</a></li> +<li>of chancre may prevent recognition, <a href="#Page_32">32</a>></li> +<li>of syphilis, <a href="#Page_60">60</a> +<ul><li>advertising in regard to, <a href="#Page_176">176</a></li> +<li>backwardness of this country in public provision for, <a href="#Page_170">170</a></li> +<li>by drug clerks, <a href="#Page_175">175</a></li> +<li>by quacks, <a href="#Page_140">140</a></li> +<li>compulsory, <a href="#Page_180">180</a></li> +<li>control of contagiousness, <a href="#Page_122">122</a>, <a href="#Page_124">124</a>, <a href="#Page_126">126</a></li> +<li>dispensary service necessary for, <a href="#Page_171">171</a></li> +<li>efficient, <a href="#Page_88">88</a></li> +<li>expense of, <a href="#Page_76">76</a>, <a href="#Page_173">173</a></li> +<li>expert advice in, <a href="#Page_174">174</a></li> +<li>hospitals in, <a href="#Page_171">171</a></li> +<li>importance of salvarsan in, <a href="#Page_89">89</a></li> +<li>in pay-patient clinics and hospitals, <a href="#Page_173">173</a></li> +<li><span class='pagenum'><a name="Page_203" id="Page_203">[Pg 203]</a></span>necessity for cheap salvarsan in, <a href="#Page_172">172</a></li> +<li>various state provisions for, <a href="#Page_168">168</a>, <a href="#Page_169">169</a></li> +<li>Wassermann test in, <a href="#Page_57">57</a></li> +<li>with salvarsan and mercury combined, <a href="#Page_89">89</a></li></ul></li> +<li>specific methods of, <a href="#Page_60">60</a></li></ul></li> + +<li>Troops, syphilis and gonorrhea in, <a href="#Page_182">182</a></li> + + +<li class="mt"><span class="smcap">United States</span>. <i>See America</i></li> + + +<li class="mt"><span class="smcap">Vedder's</span> estimate of prevalence of syphilis, <a href="#Page_25">25</a></li> + +<li>Venereal disease, <a href="#Page_16">16</a> +<ul><li><ul><li>and marriage, annulment of, <a href="#Page_132">132</a></li> +<li>effect of universal military service on, <a href="#Page_184">184</a></li> +<li>European and American provision in regard to care of, <a href="#Page_169">169</a>, <a href="#Page_170">170</a></li> +<li>importance of national prohibition in controlling, <a href="#Page_184">184</a></li> +<li>proposed military measures in connection with, <a href="#Page_183">183</a></li> +<li>relation of war to spread of, <a href="#Page_182">182</a></li> +<li>world-wide movement against, <a href="#Page_164">164</a></li></ul></li> +<li>hospitals and freak legislation, <a href="#Page_167">167</a></li></ul></li> + +<li>Vermont, reporting of syphilis in, <a href="#Page_178">178</a></li> + +<li>Vice Commission, Baltimore, syphilis in prostitutes, <a href="#Page_134">134</a></li> + +<li>Virulence of syphilis in 15th and 16th centuries, <a href="#Page_12">12</a></li> + +<li>Vomiting in locomotor ataxia, <a href="#Page_49">49</a></li> + + +<li class="mt"><span class="smcap">War</span>, control of venereal diseases during, <a href="#Page_183">183</a>, <a href="#Page_184">184</a></li> + +<li>War, relation of, to spread of venereal disease, <a href="#Page_182">182</a></li> + +<li>Warts, contagious syphilitic, <a href="#Page_42">42</a></li> + +<li>Washing, effect of, on transmission of syphilis by dishes, <a href="#Page_114">114</a></li> + +<li>Wassermann test, <a href="#Page_54">54</a> +<ul><li>as evidence of fitness to marry, <a href="#Page_130">130</a></li> +<li>difficulties of, <a href="#Page_55">55</a></li> +<li>effect of mercury on, <a href="#Page_67">67</a> +<ul><li>of treatment on, <a href="#Page_58">58</a></li></ul></li> +<li>factor of error in, <a href="#Page_56">56</a></li> +<li>importance of expert performance of, <a href="#Page_174">174</a> +<ul><li>to pregnant mother, <a href="#Page_97">97</a></li></ul></li> +<li>in connection with adoption of children, <a href="#Page_106">106</a></li> +<li>in determining cure of syphilis, <a href="#Page_58">58</a>, <a href="#Page_90">90</a></li> +<li>in family where one member is syphilitic, <a href="#Page_128">128</a></li> +<li>in freak legislation, <a href="#Page_167">167</a></li> +<li>in late hereditary syphilis, <a href="#Page_106">106</a></li> +<li>in syphilitic mothers, <a href="#Page_93">93</a></li> +<li>negative, development of infectious sores in spite of, <a href="#Page_123">123</a> +<ul><li>meaning of, <a href="#Page_56">56</a></li></ul></li> +<li>on spinal fluid, <a href="#Page_59">59</a></li> +<li>persistently positive, <a href="#Page_58">58</a></li> +<li>positive, meaning of, <a href="#Page_56">56</a></li> +<li>practical details concerning, <a href="#Page_59">59</a></li> +<li>provocative, <a href="#Page_130">130</a></li> +<li>use of, in recognizing early syphilis, <a href="#Page_33">33</a></li></ul></li> + +<li>Weight, loss of, in secondary recurrences, <a href="#Page_43">43</a> +<ul><li>in secondary syphilis, <a href="#Page_36">36</a></li></ul></li> + +<li><span class='pagenum'><a name="Page_204" id="Page_204">[Pg 204]</a></span>Welander homes for hereditary syphilis, <a href="#Page_108">108</a></li> + +<li>West Australia, action of, against drug stores prescribing for syphilis, <a href="#Page_176">176</a> +<ul><li>attitude of, on personal Metchnikoff prophylaxis, <a href="#Page_177">177</a></li> +<li>compulsory treatment of syphilis in, <a href="#Page_180">180</a></li> +<li>state provision of, for treatment of venereal diseases, <a href="#Page_170">170</a></li></ul></li> + +<li>Wet nurses, syphilis in, <a href="#Page_100">100</a></li> + +<li>Wife, importance of cure for, <a href="#Page_128">128</a> +<ul><li>infection of, by husband during pregnancy, <a href="#Page_94">94</a></li> +<li>risk of infecting, <a href="#Page_125">125</a></li></ul></li> + +<li>Williams, syphilis and mental diseases, statistics on, <a href="#Page_50">50</a></li> + +<li>Womb, chancre on neck of, <a href="#Page_30">30</a></li> + +<li>Women, child-bearing, effect of syphilis on, <a href="#Page_95">95</a> +<ul><li>employment of, in connection with problem of controlling venereal diseases in war times, <a href="#Page_184">184</a></li> +<li>miscarriages and abortions in, due to syphilis, <a href="#Page_95">95</a></li> +<li>syphilis in lax, <a href="#Page_133">133</a></li></ul></li> + +<li>Worry and anxiety, effect of, on syphilitic, <a href="#Page_137">137</a></li> +</ul> + +<hr /> +<div class="bbox"> +<h3>Transcriber's Note</h3> + +<div class="center"><p class="center">The following variably hyphenated words have been left as in the text.</p> + +<table border="0" cellpadding="4" cellspacing="0" summary=""> +<tr><td align='left'>Everyday</td><td align='left'>Every-day</td></tr> +<tr><td align='left'>everyday</td><td align='left'>every-day</td></tr> +<tr><td align='left'>extragenital</td><td align='left'>extra-genital</td></tr> +<tr><td align='left'>lifelong</td><td align='left'>life-long</td></tr> +<tr><td align='left'>lifetime</td><td align='left'>life-time</td></tr> +<tr><td align='left'>makeup</td><td align='left'>make-up</td></tr> +<tr><td align='left'>newborn</td><td align='left'>new-born</td></tr> +</table></div> + +<p class="center">Two extra entries ("Preface" and "Contents") have been added to the Table of Contents.</p> + +<p class="center">A List of Illustrations hyperlinked to the appropriate pages has been added.</p> +</div> + + + + + + + +<pre> + + + + + +End of Project Gutenberg's The Third Great Plague, by John H. 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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 + +*** END OF THIS PROJECT GUTENBERG EBOOK THE THIRD GREAT PLAGUE *** + +***** This file should be named 18324.txt or 18324.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/1/8/3/2/18324/ + +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) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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