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diff --git a/18324.txt b/18324.txt new file mode 100644 index 0000000..8d6ccae --- /dev/null +++ b/18324.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: 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. 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