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Title: The Third Great Plague
       A Discussion of Syphilis for Everyday People

Author: John H. Stokes

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Language: English

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The Third Great Plague

A Discussion of Syphilis
for Everyday People

By

John H. Stokes, A.B., M.D.

Chief of the Section of Dermatology and Syphilology
The Mayo Clinic, Rochester, Minnesota

Assistant Professor of Medicine
The Mayo Foundation Graduate School of the University
of Minnesota


Philadelphia and London
W. B. Saunders Company
1920




Published, November, 1917

Copyright, 1917, by W. B. Saunders Company

Reprinted July, 1918

Reprinted February, 1920


PRINTED IN AMERICA




PREFACE


The struggle of man against his unseen and silent enemies, the lower or
bacterial forms of life, once one becomes alive to it, has an
irresistible fascination. More dramatic than any novel, more sombre and
terrifying than a battle fought in the dark, would be the intimate
picture of the battle of our bodies against the hosts of disease. If we
could see with the eye of the microscope and feel and hear with the
delicacy of chemical and physical interactions between atoms, the heat
and intensity and the savage relentlessness of that battle would blot
out all perception of anything but itself. Just as there are sounds we
cannot hear, and light we cannot see, so there is a world of small
things, living in us and around us, which sways our destiny and carries
astray the best laid schemes of our wills and personalities. The gradual
development of an awareness, a realization of the power of this world of
minute things, has been the index of progress in the bodily well-being
of the human race through the centuries marking the rebirth of medicine
after the sleep of the Dark Ages.

In these days of sanitary measures and successful public health
activity, it is becoming more and more difficult for us to realize the
terrors of the Black Plagues, the devastation, greater and more
frightful than war, which centuries ago swept over Europe and Asia time
and again, scarcely leaving enough of the living to bury the dead.
Cholera, smallpox, bubonic plague, with terrifying suddenness fell upon
a world of ignorance, and each in turn humbled humanity to the dust
before its invisible enemies. Even within our own recollection, the
germ of influenza, gaining a foothold inside our defenses, took the
world by storm, and beginning probably at Hongkong, within the years
1889-90, swept the entire habitable earth, affecting hundreds of
thousands of human beings, and leaving a long train of debilitating and
even crippling complications.

Here and there through the various silent battles between human beings
and bacteria there stand out heroic figures, men whose powers of mind
and gifts of insight and observation have made them the generals in our
fight against the armies of disease. But their gifts would have been
wasted had they lacked the one essential aid without which leadership is
futile. This is the force of enlightened public opinion, the backing of
the every-day man. It is the coöperation of every-day men, acting on the
organized knowledge of leaders, which has made possible the virtual
extinction of the ancient scourges of smallpox, cholera, and bubonic
plague.

Just as certain diseases are gradually passing into history through
human effort, and the time is already in sight when malaria and yellow
fever, the latest objects of attack, will disappear before the campaign
of preventive medicine, so there are diseases, some of them ancient,
others of more recent recognition, which are gradually being brought
into the light of public understanding. Conspicuous among them is a
group of three, which, in contrast to the spectacular course of great
epidemics, pursue their work of destruction quietly, slowly undermining,
in their long-drawn course, the very foundations of human life.
Tuberculosis, or consumption, now the best known of the three, may
perhaps be called the first of these great plagues, not because it is
the oldest or the most wide-spread necessarily, but because it has been
the longest known and most widely understood by the world at large.
Cancer, still of unknown cause, is the second great modern plague. The
third great plague is syphilis, a disease which, in these times of
public enlightenment, is still shrouded in obscurity, entrenched behind
a barrier of silence, and armed, by our own ignorance and false shame,
with a thousand times its actual power to destroy. Against all of these
three great plagues medicine has pitted the choicest personalities, the
highest attainments, and the uttermost resources of human knowledge.
Against all of them it has made headway. It is one of the ironies, the
paradoxes, of fate that the disease against which the most tremendous
advances have been made, the most brilliant victories won, is the third
great plague, syphilis--the disease that still destroys us through our
ignorance or our refusal to know the truth.

We have crippled the power of tuberculosis through
knowledge,--wide-spread, universal knowledge,--rather than through any
miraculous discoveries other than that of the cause and the possibility
of cure. We shall in time obliterate cancer by the same means. Make a
disease a household word, and its power is gone. We are still far from
that day with syphilis. The third great plague is just dawning upon
us--a disease which in four centuries has already cost a whole inferno
of human misery and a heaven of human happiness. When we awake, we shall
in our turn destroy the destroyer--and the more swiftly because of the
power now in the hands of medicine to blot out the disease. To the day
of that awakening books like this are dedicated. The facts here
presented are the common property of the medical profession, and it is
impossible to claim originality for their substance. Almost every
sentence is written under the shadow of some advance in knowledge which
cost a life-time of some man's labor and self-sacrifice. The story of
the conquest of syphilis is a fabric of great names, great thoughts,
dazzling visions, epochal achievements. It is romance triumphant, not
the tissue of loathsomeness that common misconception makes it.

The purpose of this book is accordingly to put the accepted facts in
such a form that they will the more readily become matters of common
knowledge. By an appeal to those who can read the newspapers
intelligently and remember a little of their high-school physiology, an
immense body of interested citizens can be added to the forces of a
modern campaign against the third great plague. For such an awakening of
public opinion and such a movement for wider coöperation, the times are
ready.

JOHN H. STOKES.

ROCHESTER, MINN.




CONTENTS

                                                       PAGE
CHAPTER I
THE HISTORY OF SYPHILIS                                  11

CHAPTER II
SYPHILIS AS A SOCIAL PROBLEM                             15

CHAPTER III
THE NATURE AND COURSE OF SYPHILIS                        21
  The Prevalence of Syphilis                             24
  The Primary Stage                                      26

CHAPTER IV
THE NATURE AND COURSE OF SYPHILIS (_Continued_)          35
  The Secondary Stage                                    35

CHAPTER V
THE NATURE AND COURSE OF SYPHILIS (_Continued_)          45
  Late Syphilis (Tertiary Stage)                         45

CHAPTER VI
THE BLOOD TEST FOR SYPHILIS                              54

CHAPTER VII
THE TREATMENT OF SYPHILIS                                60
  General Considerations                                 60
  Mercury                                                62

CHAPTER VIII
THE TREATMENT OF SYPHILIS (_Continued_)                  70
  Salvarsan                                              70

CHAPTER IX
THE CURE OF SYPHILIS                                     80

CHAPTER X
HEREDITARY SYPHILIS                                      92

CHAPTER XI
THE TRANSMISSION AND HYGIENE OF SYPHILIS                109

CHAPTER XII
THE TRANSMISSION AND HYGIENE OF SYPHILIS (_Continued_)  121
  The Control of Infectiousness in Syphilis             121
  Syphilis and Marriage                                 125

CHAPTER XIII
THE TRANSMISSION AND HYGIENE OF SYPHILIS (_Continued_)  133
  Syphilis and Prostitution                             133
  Personal Hygiene of Syphilis                          136

CHAPTER XIV
MENTAL ATTITUDES IN THEIR RELATION TO SYPHILIS          141

CHAPTER XV
MORAL AND PERSONAL PROPHYLAXIS                          156

CHAPTER XVI
PUBLIC EFFORT AGAINST SYPHILIS                          164

INDEX                                                   187




LIST OF ILLUSTRATIONS

                                                       PAGE
PAUL EHRLICH [1854-1915]                                 69

FRITZ SCHAUDINN [1871-1906]                             112

E. ROUX                                                 161

ÉLIE METCHNIKOFF [1845-1916]                            161




The Third Great Plague

Chapter I

The History of Syphilis


Syphilis has a remarkable history,[1] about which it is worth while to
say a few words. Many people think of the disease as at least as old as
the Bible, and as having been one of the conditions included under the
old idea of leprosy. Our growing knowledge of medical history, however,
and the finding of new records of the disease, have shown this view to
be in all probability a mistake. Syphilis was unknown in Europe until
the return of Columbus and his sailors from America, and its progress
over the civilized world can be traced step by step, or better, in leaps
and bounds, from that date. It came from the island of Haiti, in which
it was prevalent at the time the discoverers of America landed there,
and the return of Columbus's infected sailors to Europe was the signal
for a blasting epidemic, which in the sixteenth and seventeenth
centuries devastated Spain, Italy, France, and England, and spread into
India, Asia, China, and Japan.

    [1] For a detailed account in English, see Pusey, W. A.: "Syphilis
    as a Modern Problem," Amer. Med. Assoc., 1915.

It is a well-recognized fact that a disease which has never appeared
among a people before, when it does attack them, spreads with
terrifying rapidity and pursues a violent and destructive course on the
new soil which they offer. This was the course of syphilis in Europe in
the years immediately following the return of Columbus in 1493. Invading
armies, always a fruitful means of spreading disease, carried syphilis
with them everywhere and left it to rage unchecked among the natives
when the armies themselves went down to destruction or defeat. Explorers
and voyagers carried it with them into every corner of the earth, so
that it is safe to say that in this year of grace 1917 there probably
does not exist a single race or people upon whom syphilis has not set
its mark. The disease, in four centuries, coming seemingly out of
nowhere, has become inseparably woven into the problems of civilization,
and is part and parcel of the concerns of every human being. The
helpless fear caused by the violence of the disease in its earlier days,
when the suddenness of its attack on an unprepared people paralyzed
comprehension, has given place to knowledge such as we can scarcely
duplicate for any of the other scourges of humanity. The disease has in
its turn become more subtle and deceiving, its course is seldom marked
by the bold and glaring destructiveness, the melting away of resistance,
so familiar in its early history. The masses of sores, the literal
falling to pieces of skeletons, are replaced by the inconspicuous but no
less real deaths from heart and brain and other internal diseases, the
losses to sight and hearing, the crippling and death of children, and
all the insidious, quiet deterioration and degeneration of our fiber
which syphilis brings about. From devouring a man alive on the street,
syphilis has taken to knifing him quietly in his bed.

Although syphilis sprang upon the world from ambush, so to speak, it did
the world one great service--it aroused Medicine from the sleep of the
Middle Ages. Many of the greatest names in the history of the art are
inseparably associated with the progress of our knowledge of this
disease. As Pusey points out, it required the force of something wholly
unprecedented to take men away from tradition and the old stock in trade
of ideas and formulas, and to make them grasp new things. Syphilis was
the new thing of the time in the sixteenth century and the study which
it received went far toward putting us today in a position to control
it. Before the beginning of the twentieth century almost all that
ordinary observation of the diseased person could teach us was known of
syphilis. It needed only laboratory study, such as has been given it
during the past fifteen years, to put us where we could appeal to every
intelligent man and woman to enlist in a brilliantly promising campaign.
For a time syphilis was confused with gonorrhea, and there could be no
better proof of the need for separating the two in our minds today than
to study the way in which this confusion set back progress in our
knowledge of syphilis. John Hunter, who fathered the idea of the
identity of the two diseases, sacrificed his life to his idea
indirectly. Ricord, a Frenchman, whose name deserves to be immortal, set
Hunter's error right, and as the father of modern knowledge of syphilis,
prepared us for the revolutionary advances of the last ten years.

There is something awe-inspiring in the quiet way in which one great
victory has succeeded another in the battle against syphilis in the last
decade. If we are out of the current of these things, in the office or
the store, or in the field of industry and business, announcements from
the great laboratories of the world seldom reach us, and when they do,
they have an impractical sound, an unreality for us. So one hears, as if
in a speaking-tube from a long distance, the words that Schaudinn and
Hoffmann, on April 19, 1905, discovered the germ that causes syphilis,
not realizing that the fact contained in those few brief words can alter
the undercurrent of human history, and may, within the lives of our
children and our children's children, remake the destiny of man on the
earth. A great spirit lives in the work of men like Metchnikoff and Roux
and Maisonneuve, who made possible the prophylaxis of syphilis, in that
of Bordet and Wassermann, who devised the remarkable blood test for the
disease, and in that of Ehrlich and Hata, who built up by a combination
of chemical and biological reasoning, salvarsan, one of the most
powerful weapons in existence against it. Ehrlich conceived the whole
make-up and properties of salvarsan when most of us find it a hardship
to pronounce its name. Schaudinn saw with the ordinary lenses of the
microscope in the living, moving germ, what dozens can scarcely see
today with the germ glued to the spot and with all the aid of stains and
dark-field apparatus. After all, it is brain-power focused to a point
that moves events, and to the immensity of that power the history of our
growing knowledge of syphilis bears the richest testimony.




Chapter II

Syphilis as a Social Problem


The simple device of talking plain, matter-of-fact English about a thing
has a value that we are growing to appreciate more and more every day.
It is only too easy for an undercurrent of ill to make headway under
cover of a false name, a false silence, or misleading speech. The fact
that syphilis is a disease spread to a considerable extent by sexual
relations too often forces us into an attitude of veiled insinuation
about it, a mistaken delicacy which easily becomes prudish and
insincere. It is a direct move in favor of vulgar thinking to misname
anything which involves the intimacies of life, or to do other than look
it squarely in the eye, when necessity demands, without shuffling or
equivocation. On this principle it is worth while to meet the problem of
a disease like syphilis with an open countenance and straightforward
honesty of expression. It puts firm ground under our feet to talk about
it in the impersonal way in which we talk about colds and pneumonia and
bunions and rheumatism, as unfortunate, but not necessarily indecent,
facts in human experience. Nothing in the past has done so much for the
campaign against consumption as the unloosing of tongues. There is only
one way to understand syphilis, and that is to give it impartial,
discriminating discussion as an issue which concerns the general
health. To color it up and hang it in a gallery of horrors, or to befog
it with verbal turnings and twistings, are equally serious mistakes. The
simple facts of syphilis can appeal to intelligent men and women as
worthy of their most serious attention, without either stunning or
disgusting them. It is in the unpretentious spirit of talking about a
spade as a spade, and not as "an agricultural implement for the
trituration of the soil," that we should take stock of the situation and
of the resources we can muster to meet it.

+The Confusion of the Problem of Syphilis with Other Issues.+--Two
points in our approach to the problem of syphilis are important at the
outset. The first of these is to separate our thought about syphilis
from that of the other two diseases, gonorrhea, or "clap," and
chancroids, or "soft sores," which are conventionally linked with it
under the label of "venereal diseases."[2] The second is to separate
the question of syphilis at least temporarily from our thought about
morals, from the problem of prostitution, from the question as to
whether continence is possible or desirable, whether a man should be
true to one woman, whether women should be the victims of a double
standard, and all the other complicated issues which we must in time
confront. Such a picking to pieces of the tangle is simply the method of
scientific thought, and in this case, at least, has the advantage of
making it possible to begin to do something, rather than saw the air
with vain discussion.

    [2] The three so-called venereal diseases are syphilis, gonorrhea,
    and chancroid or soft ulcer. Gonorrhea is the commonest of the
    three, and is an exceedingly prevalent disease. In man its first
    symptom is a discharge of pus from the canal through which the urine
    passes. Its later stages may involve the bladder, the testicles, and
    other important glands. It may also produce crippling forms of
    rheumatism, and affect the heart. Gonorrhea may recur, become
    latent, and persist for years, doing slow, insidious damage. It is
    transmitted largely by sexual intercourse. Gonorrhea in women is
    frequently a serious and even fatal disease. It usually renders
    women incapable of having children, and its treatment necessitates
    often the most serious operations. Gonorrhea of the eyes, affecting
    especially newborn children, is one of the principal causes of
    blindness. Gonorrhea may be transmitted to little girls innocently
    from infected toilet seats, and is all but incurable. Gonorrhea,
    wherever it occurs, is an obstinate, treacherous, and resistant
    disease, one of the most serious of modern medical problems, and
    fully deserves a place as the fourth great plague.

    Chancroid is an infectious ulcer of the genitals, local in
    character, not affecting the body as a whole, but sometimes
    destroying considerable portions of the parts involved.

Let us think of syphilis, then, as a serious but by no means hopeless
constitutional disease. Dismiss chancroid as a relatively insignificant
local affair, seldom a serious problem under a physician's care.
Separate syphilis from gonorrhea for the reason that gonorrhea is a
problem in itself. Against its train of misfortune to innocence and
guilt alike, we are as yet not nearly so well equipped to secure
results. Against syphilis, the astonishing progress of our knowledge in
the past ten years has armed us for triumph. When the fight against
tuberculosis was brought to public attention, we were not half so well
equipped to down the disease as we are today to down syphilis. For
syphilis we now have reliable and practical methods of prevention, which
have already proved their worth. The most powerful and efficient of
drugs is available for the cure of the disease in its earlier stages,
and early recognition is made possible by methods whose reliability is
among the remarkable achievements of medicine. It is the sound opinion
of conservative men that if the knowledge now in the hands of the
medical profession could be put to wide-spread use, syphilis would
dwindle in two generations from the unenviable position of the third
great plague to the insignificance of malaria and yellow fever on the
Isthmus of Panama. The influences that stand between humanity and this
achievement are the lack of general public enlightenment on the disease
itself, and public confusion of the problem with other sex issues for
which no such clean-cut, satisfactory solution has been found. Think of
syphilis as the wages of sin, as well-earned disgrace, as filth, as the
badge of immorality, as a necessary defense against the loathesomeness
of promiscuity, as a fearful warning against prostitution, and our
advantage slips from us. The disease continues to spread wholesale
disaster and degeneration while we wrangle over issues that were old
when history began and are progressing with desperate slowness to a
solution probably many centuries distant. Think of syphilis as a medical
and a sanitary problem, and its last line of defense crumbles before our
attack. It can and should be blotted out.

+Syphilis, a Problem of Public Health Rather than of Morals.+--Nothing
that can be said about syphilis need make us forget the importance of
moral issues. The fact which so persistently distorts our point of view,
that it is so largely associated with our sexual life, is probably a
mere incident, biologically speaking, due in no small part to the almost
absurdly simple circumstance that the germ of the disease cannot grow in
the presence of air, and must therefore find refuge, in most cases, in
the cavities and inlets from the surface of the body. History affords
little support to the lingering belief that if syphilis is done away
with, licentiousness will overrun the world. Long before syphilis
appeared in Europe there was sexual immorality. In the five centuries in
which it has had free play over the civilized world, the most optimistic
cannot successfully maintain that it has materially bettered conditions
or acted as a check on loose morals, though its relation to sexual
intercourse has been known. As a morals policeman, syphilis can be
obliterated without material loss to the cause of sexual self-restraint,
and with nothing but gain to the human race.

It is easier to accept this point of view, that the stamping out of
syphilis will not affect our ability to grapple with moral problems, and
that there is nothing to be gained by refusing to do what can so easily
be done, when we appreciate the immense amount of innocent suffering for
which the disease is responsible. It must appeal to many as a bigoted
and narrow virtue, little better than vice itself, which can derive any
consolation in the thought that the sins of the fathers are being
visited upon the children, as it watches a half-blind, groping child
feel its way along a wall with one hand while it shields its face from
the sunlight with the other. There are better ways of paying the wages
of sin than this. Best of all, we can attack a sin at its source instead
of at its fulfilment. How much better to have kept the mother free from
syphilis by giving the father the benefit of our knowledge. The child
who reaped his sowing gained nothing morally, and lost its physical
heritage. Its mother lost her health and perhaps her self-respect.
Neither one contributes anything through syphilis to the uplifting of
the race. They are so much dead loss. To teach us to avoid such losses
is the legitimate field of preventive medicine.

On this simplified and practical basis, then, the remainder of this
discussion will proceed. Syphilis is a preventable disease, usually
curable when handled in time, and its successful management will depend
in large part upon the coöperation, not only of those who are victims of
it, but of those who are not. It is much more controllable than
tuberculosis, against which we are waging a war of increasing
effectiveness, and its stamping out will rid humanity of an even greater
curse. To know about syphilis is in no sense incompatible with clean
living or thinking, and insofar as its removal from the world will rid
us of a revolting scourge, it may even actually favor the solution of
the moral problems which it now obscures.




Chapter III

The Nature and Course of Syphilis


The simplest and most direct definition of syphilis is that it is a
contagious constitutional disease, due to a germ, running a prolonged
course, and at one time or another in that course is capable of
affecting nearly every part of the body. One of the most important parts
of this rather abstract statement is that which relates to the germ. To
be able to put one's finger so definitely on the cause of syphilis is an
advantage which cannot be overestimated. More than in almost any other
disease the identification of syphilis at its very outset depends upon
the seeing of the germ that causes it in the discharge from the sore or
pimple which is the first evidence of syphilis on the body. On our
ability to recognize the disease as syphilis in the first few days of
its course depends the greatest hope of cure. On the recognition of the
germ in the tissues and fluids of the body has depended our knowledge of
the real extent and ravages of the disease. With the knowledge that the
germ was related to certain other more familiar forms, Ehrlich set the
trap for it that culminated in salvarsan, or "606," the powerful drug
used in the modern treatment. By the finding of this same germ in the
nervous system in locomotor ataxia and general paralysis of the insane,
the last lingering doubt of their syphilitic character was dispelled.
Every day and hour the man who deals with syphilis in accordance with
the best modern practice brings to bear knowledge that arises from our
knowledge of the germ cause of syphilis. No single fact except perhaps
the knowledge that certain animals (monkeys and rabbits especially)
could be infected with it has been of such immense practical utility in
developing our power to deal with it.

The germ of syphilis,[3] discovered by Schaudinn and Hoffmann in 1905,
is an extremely minute spiral or corkscrew-shaped filament, visible
under only the highest powers of the microscope, which increase the area
of the object looked at hundreds of thousands of times, and sometimes
more than a million of times. Even under such intense magnifications, it
can be seen only with great difficulty, since it is colorless in life,
and it is hard to color or stain it with dyes. Its spiral form and faint
staining have led to its being called the _Spirochæta pallida_.[4] It is
best seen by the use of a special device, called a dark-field
illuminator, which shows the germ, like a floating particle in a
sunbeam, as a brilliant white spiral against a black background,
floating and moving in the secretions taken from the sore in which it is
found. Some means of showing the germ should be in the hands of every
physician, hospital, or dispensary which makes a claim to recognize and
treat syphilis.

    [3] See frontispiece.

    [4] Pronounced spi-ro-kee'-ta.

+Syphilis a Concealed Disease.+--Syphilis is not a grossly conspicuous
figure in our every-day life, as leprosy was in the life of the Middle
Ages, for example. To the casually minded, therefore, it is not at all
unreasonable to ask why there should be so much agitation about it when
so little of it is in evidence. It takes a good deal out of the graphic
quality of the thing to say that most syphilis is concealed, that most
syphilitics, during a long period of their disease, are socially
presentable. Of course, when we hear that they may serve lunch to us,
collect our carfare, manicure our nails, dance with us most
enchantingly, or eat at our tables, it seems a little more real, but
still a little too much to believe. Conviction seems to require that we
see the damaged goods, the scars, the sores, the eaten bones, the
hobbling cripples, the maimed, the halt, and the blind. There is no
accurate estimate of its prevalence based on a census, because, as will
appear later, even an actual impulse to self-betrayal would not disclose
30 to 40 per cent of the victims of the disease. Approximately this
percentage would either have forgotten the trivial beginnings of it, or
with the germs of it still in their brains or the walls of their
arteries or other out-of-the-way corners of their bodies, would think
themselves free of the disease--long since "cured" and out of danger.

+How Much Syphilis is There?+--Our entire lack of a tangible idea of how
much syphilis there really is among us is, of course, due to the absence
of any form of registration or reporting of the disease to authorities
such as health officers, whose duty it is to collect such statistics,
and forms the principal argument in favor of dealing with syphilis
legally as a contagious disease. Such conceptions of its prevalence as
we have are based on individual opinions and data collected by men of
large experience.

+Earlier Estimates of the Prevalence of Syphilis.+--It is generally
conceded that there is more syphilis among men than women, although it
should not be forgotten that low figures in women may be due to some
extent to the milder and less outspoken course of the disease in them.
Five times more syphilis in men than women conservatively summarizes our
present conceptions. The importance of distinguishing between syphilis
among the sick and among the well is often overlooked. For example,
Landouzy, in the Laënnec clinic in Paris, estimated recently that in the
patients of this clinic, which deals with general medicine, 15 to 18 per
cent of the women and 21 to 28 per cent of the men had syphilis. It is
fair to presume, then, that such a percentage would be rather high for
the general run of every-day people. This accords with the estimates,
based on large experience, of such men as Lenoir and Fournier, that 13
to 15 per cent of all adult males in Paris have syphilis. Erb estimated
12 per cent for Berlin, and other estimates give 12 per cent for London.
Collie's survey of British working men gives 9.2 per cent in those who,
in spite of having passed a general health examination, showed the
disease by a blood test. A large body of figures, covering thirty years,
and dating back beyond the time when the most sensitive tests of the
disease came into use, gives about 8 per cent of more than a million
patients in the United States Public Health and Marine Hospital Service
as having syphilis. It should be recalled that this includes essentially
active rather than quiescent cases, and is therefore probably too low.

+Current Estimates of the Prevalence of Syphilis.+--The constant upward
tendency of recent estimates of the amount of syphilis in the general
population, as a result of the application of tests which will detect
even concealed or quiescent cases, is a matter for grave thought. The
opinion of such an authority as Blaschko, while apparently extreme,
cannot be too lightly dismissed, when he rates the percentage of
syphilitics in clerks and merchants in Berlin between the ages of 18 and
28 as 45 per cent. Pinkus estimated that one man in five in Germany has
had syphilis. Recently published data by Vedder, covering the condition
of recruits drawn to the army from country and city populations,
estimate 20 per cent syphilitics among young men who apply for
enlistment, and 5 per cent among the type of young men who enter West
Point and our colleges. It can be pointed out also with justice that the
percentage of syphilis in any class grouped by age increases with the
age, since so few of the cases are cured, and the number is simply added
to up to a certain point as time elapses. Even the army, which
represents in many ways a filtered group of men, passing a rigorous
examination, and protected by an elaborate system of preventions which
probably keeps the infection rate below that of the civil population, is
conceded by careful observers (Nichols and others) to show from 5 to 7
per cent syphilitics. Attention should be called to the difference
between the percentage of syphilis in a population and the percentage
of venereal disease. The inclusion of gonorrhea with syphilis increases
the percentages enormously, since it is not infrequently estimated that
as high as 70 per cent of adult males have gonorrhea at least once in a
lifetime.

On the whole, then, it is conservative to estimate that one man in ten
has syphilis. Taking men and women together on the basis of one of the
latter to five of the former, and excluding those under fifteen years of
age from consideration, this country, with a population of
91,972,266,[5] should be able to muster a very considerable army of
3,842,526, whose influence can give a little appreciated but very
undesirable degree of hyphenation to our American public health. In
taking stock of ourselves for the future, and in all movements for
national solidarity, efficiency, and defense, we must reckon this force
of syphilo-Americans among our debits.

    [5] Figures based on 1910 census.


THE PRIMARY STAGE OF SYPHILIS

+The So-called Stages of Syphilis.+--The division of the course of
syphilis into definite stages is an older and more arbitrary conception
than the one now developing, and was based on outward signs of the
disease rather than on a real understanding of what goes on in the body
during these periods. The primary stage was supposed to extend from the
appearance of the first sore or chancre to the time when an eruption
appeared over the whole body. Since the discovery of the Spirochæta
pallida, the germ of the disease, our knowledge of what the germ does
in the body, where it goes, and what influence it has upon the infected
individual, has rapidly extended. We now appreciate much more fully than
formerly that at the very beginning of the disease there is a time when
it is almost purely local, confined to the first sore itself, and
perhaps to the glands or kernels in its immediate neighborhood. Thorough
and prompt treatment with the new and powerful aid of salvarsan ("606")
at this stage of the disease can kill all the germs and prevent the
disease from getting a foothold in the body which only years of
treatment subsequently can break. This is the critical moment of
syphilis for the individual and for society, and its importance and the
value of treatment at this time cannot be too widely understood.

+Peculiarities of the Germ.+--Many interesting facts about the
Spirochæta pallida explain peculiarities in the disease of which it is
the cause. Many germs can be grown artificially, some in the presence of
air, others only when air is removed. The germ of syphilis belongs in
the latter class. The germ that causes tuberculosis, a rod-like organism
or bacillus, can stand drying without losing its power to produce the
disease, and has a very appreciable ability to resist antiseptic agents.
If the germ of syphilis were equally hard to kill, syphilis would be an
almost universal disease. Fortunately it dies at once on drying, and is
easily destroyed by the weaker antiseptics provided it has not gained a
foothold on favorable ground. Its inability to live long in the presence
of air confines the source of infection largely to those parts of the
body which are moist and protected, and especially to secretions and
discharges which contain it. Its contagiousness is, therefore, more
readily controlled than that of tuberculosis. It is impossible for a
syphilitic to leave a room or a house infected for the next occupants,
and it is not necessary to do more than disinfect objects that come in
contact with open lesions or their secretions, to prevent its spread by
indirect means. Such details will be considered more fully under the
transmission and hygiene of the disease.

+Mode of Entry of the Germ.+--The germ of the disease probably gains
entrance to the body through a break or abrasion in the skin or the
moist red mucous surfaces of the body, such as those which line the
mouth and the genital tract. The break in the surface need not be
visible as a chafe or scratch, but may be microscopic in size, so that
the first sore seems to develop on what is, to all appearances, healthy
surface. It should not be forgotten that this surface need not be
confined to the genital organs, since syphilis may and often does begin
at any part of the body where the germ finds favorable conditions for
growth.

+Incubation or Quiescent Period.+--Almost all germ diseases have what is
called a period of incubation, in which the germ, after it has gained
entrance to the body, multiplies with varying rapidity until the
conditions are such that the body begins to show signs of the injury
which their presence is causing. The germ of syphilis is no exception to
this rule. Its entry into the body is followed by a period in which
there is no external sign of its presence to warn the infected person
of what is coming. This period of quiescence between the moment of
infection with syphilis and the appearance of the first signs of the
disease in the form of the chancre may vary from a week to six weeks or
even two months or more, with an average of about two or three weeks.

In the length of the incubation period and the comparatively trifling
character of the early signs, the germ of syphilis betrays one of its
most dangerous characteristics. The germ of pneumonia, for example, may
be present on the surface of the body, in the mouth or elsewhere, for a
long time, but the moment it gets a real foothold, there is an immediate
and severe reaction, the body puts up a fight, and in ten days or so has
either lost or won. The germ of syphilis, on the other hand, secures its
place in the body without exciting very strenuous or wide-spread
opposition. The body does not come to its own defense so well as with a
more active enemy. The fitness of the germ of syphilis for
long-continued life in the body, and the difficulty of marshaling a
sufficient defense against it, is what makes it impossible to cure the
disease by any short and easy method.

+The First Sore or Chancre.+--The primary lesion, first sore or
chancre,[6] is the earliest sign of reaction which the body makes to the
presence of the growing germs of syphilis. This always develops at the
point where the germs entered the body. The incubation period ends with
the appearance of a small hard knot or lump under the skin, which may
remain relatively insignificant in some cases and in others grow to a
considerable size. Primary lesions show the greatest variety in their
appearance and degree of development. If the base of the knot widens and
flattens so that it feels and looks like a button under the skin, and
the top rubs off, leaving an exposed raw surface, we may have the
typical hard chancre, easily recognized by the experienced physician,
and perhaps even by the layman as well. On the other hand, no such
typical lesion may develop. The chancre may be small and hidden in some
out-of-the-way fold or cleft, and because it is apt to be painless,
escape recognition entirely. In women the opportunity for concealment of
a primary sore itself is especially good, since it may occur inside the
vagina or on the neck of the womb. In men it may even occur inside the
canal through which the urine passes (urethra). The name "sore" is
deceptive and often misleads laymen, since there may be no actual
sore--merely a pinhead-sized pimple, a hard place, or a slight chafe.
The development of a syphilitic infection can also be completely
concealed by the occurrence of some other infection in the same place at
the same time, as in the case of a mixed infection with syphilis and
soft ulcers or chancroids. Even a cold-sore on the mouth or genitals may
become the seat of a syphilitic infection which will be misunderstood or
escape notice.

    [6] Pronounced shan'-ker.

+Syphilis and Gonorrhea may Coexist.+--It is a not uncommon thing for
gonorrhea in men to hide the development of a chancre at the same time
or later. In fact, it was in an experimental inoculation from such a
case that the great John Hunter acquired the syphilis which cost him his
life, and which led him to declare that because he had inoculated
himself with pus from a gonorrhea and developed syphilis, the two
diseases were identical. Just how common such cases are is not known,
but the newer tests for syphilis are showing increasing numbers of men
who never to their knowledge had anything but gonorrhea, yet who have
syphilis, too.

+Serious Misconceptions About the Chancre.+--Misconceptions about the
primary lesion or chancre of syphilis are numerous and serious, and are
not infrequently the cause for ignoring or misunderstanding later signs
of the disease. A patient who has gotten a fixed conception of a chancre
into his head will argue insistently that he never had a hard sore, that
his was soft, or painful instead of painless, or that it was only a
pimple or a chafe. All these forms are easily within the ordinary limits
of variation of the chancre from the typical form described in books,
and an expert has them all in mind as possibilities. But the layman who
has gathered a little hearsay knowledge will maintain his opinion as if
it were the product of lifelong experience, and will only too often pay
for his folly and presumption accordingly.

+Importance of Prompt and Expert Medical Advice.+--The recognition of
syphilis in the primary stage does not follow any rule of thumb, and is
as much an affair for expert judgment as a strictly engineering or legal
problem. In the great majority of cases a correct decision of the matter
can be reached in the primary stage by careful study and examination,
but not by any slipshod or guesswork means. To secure the benefit of
modern methods for the early recognition of syphilis those who expose
themselves, or are exposed knowingly, to the risk of getting the disease
by any of the commoner sources of infection, should seek expert medical
advice at once on the appearance of anything out of the ordinary, no
matter how trivial, on the parts exposed. The commoner sources of
infection may be taken to be the kissing of strangers, the careless use
of common personal and toilet articles which come in contact with the
mouth especially,--all of which are explained later,--and illicit sexual
relations. While this by no means includes all the means for the
transmission of the disease, those who do these things are in direct
danger, and should be warned accordingly.

+Modern Methods of Identifying an Early Syphilitic Infection.+--The
practice of tampering with sores, chafes, etc., which are open to
suspicion, whether done by the patient himself or by the doctor before
reaching a decision as to the nature of the trouble, is unwise. An
attempt to "burn it out" with caustic or otherwise, which is the first
impulse of the layman with a half-way knowledge and even of some
doctors, promptly makes impossible a real decision as to whether or not
syphilis is present. Even a salve, a wash, or a powder may spoil the
best efforts to find out what the matter is. A patient seeking advice
should go to his doctor _at once_, and absolutely _untreated_. Then,
again, irritating treatment applied unwisely to even a harmless sore may
make a mere chafe look like a hard chancre, and result in the patient's
being treated for months or longer for syphilis. Nowadays our first
effort after studying the appearance of the suspected lesion is to try
to find the germs, with the dark-field microscope or a stain. Having
found them, the question is largely settled, although we also take a
blood test. If we fail to find the germs, it is no proof that syphilis
is absent, and we reëxamine and take blood tests at intervals for some
months to come, to be sure that the infection has not escaped our
vigilance, as it sometimes does if we relax our precautions. In
recognizing syphilis, the wise layman is the one who knows he does not
know. The clever one who is familiar with everything "they say" about
the disease, and has read about the matter in medical books into the
bargain, is the best sort of target for trouble. Such men are about as
well armed as the man who attacks a lion with a toothpick. He may stop
him with his eye, but it is a safer bet he will be eaten.

+Enlargement of Neighboring Glands.+--Nearly every one is familiar with
the kernels or knots that can be felt in the neck, often after
tonsillitis, or with eruptions in the scalp. These are lymph-glands,
which are numerous in different parts of the body, and their duty is,
among other things, to help fight off any infection which tries to get
beyond the point at which it started. The lymph-glands in the
neighborhood of the chancre, on whatever part of the body it is
situated, take an early part in the fight against syphilis. If, for
example, the chancre is on the genitals, the glands in the groin will be
the first ones affected. If it is on the lip, the neck glands become
swollen. The affected glands actually contain the germs which have made
their way to them through lymph channels under the skin. When the glands
begin to swell, the critical period of limitation of the disease to the
starting-point will soon be over and the last chances for a quick cure
will soon be gone. At any moment they may gain entrance to the blood
stream in large numbers. While the swelling of these glands occurs in
other conditions, there are peculiarities about their enlargement which
the physician looking for signs of the disease may recognize. Especially
in case of a doubtful lesion about the neck or face, when a bunch of
large swollen glands develops under the jaw in the course of a few days
or a couple of weeks, the question of syphilis should be thoroughly
investigated.

+Vital Significance of Early Recognition.+--The critical period of
localization of an early infection will be brought up again in
subsequent pages. As Pusey says, it is the "golden opportunity" of
syphilis. It seldom lasts more than two weeks from the first appearance
of the primary sore or chancre, and its duration is more often only a
matter of four or five days before the disease is in the blood, the
blood test becomes positive, and the prospect of what we call abortive
cure is past. Nothing can justify or make up for delay in identifying
the trouble in this early period, and the person who does not take the
matter seriously often pays the price of his indifference many times
over.




Chapter IV

The Nature and Course of Syphilis (Continued)


THE SECONDARY STAGE

+The Spread of the Germs Over the Body.+--The secondary stage of
syphilis, like the primary stage, is an arbitrary division whose
beginning and ending can scarcely be sharply defined. Broadly speaking,
the secondary stage of syphilis is the one in which the infection ceases
to be confined to the neighborhood of the chancre and affects the entire
body. The spread of the germs of the disease to the lymph-glands in the
neighborhood of the primary sore is followed by their invasion of the
blood itself. While this may begin some time before the body shows signs
of it, the serious outburst usually occurs suddenly in the course of a
few days, and fills the circulating blood with the little corkscrew
filaments, sending showers of them to every corner of the body and
involving every organ and tissue to a greater or less extent. This
explosion marks the beginning of the active secondary stage of syphilis.
The germs are now everywhere, and the effect on the patient begins to
suggest such infectious diseases as measles, chickenpox, etc., which are
associated with eruptions on the skin. But there can be no more serious
mistake than to suppose that the eruptions which usually break out on
the skin at this time represent the whole, or even a very important
part, of the story. They may be the most conspicuous sign to the patient
and to others, but the changes which are to affect the future of the
syphilitic are going on just at this time, not in his skin, but in his
internal organs, and especially in his heart and blood-vessels and in
his nervous system.

+Constitutional Symptoms.+--It is surprising how mild a thing secondary
syphilis is in many persons. A considerable proportion experience little
or nothing at this time in the way of disturbances of the general health
to suggest that they have a serious illness. A fair percentage of them
lose 5 or 10 pounds in weight, have severe or mild headaches, usually
worse at night, with pains in the bones and joints that may suggest
rheumatism. Nervous disturbances of the most varied character may
appear. Painful points on the bones or skull may develop, and there may
be serious disturbances of eye-sight and hearing. A few are severely
ill, lose a great deal of weight, endure excruciating pains, pass
sleepless nights, and suffer with symptoms suggesting that their nervous
systems have been profoundly affected. As a general thing, however, the
constitutional symptoms are mild compared with those of the severe
infectious fevers, such as typhoid or malaria.

+The Secondary Eruption or Rash.+--The eruption of secondary syphilis is
generally the feature which most alarms the average patient. It is
usually rather abundant, in keeping with the wide-spread character of
the infection, and is especially noticeable on the chest and abdomen,
the face, palms, and soles. It is apt to appear in the scalp in the
severer forms. The eruption may consist of almost anything, from faint
pink spots to small lumps and nodules, pimples and pustules, or large
ulcerating or crusted sores. The eruption is not necessarily
conspicuous, and may be entirely overlooked by the patient himself, or
it may be so disfiguring as to attract attention.

+Common Misconceptions Regarding Syphilitic Rashes.+--Laymen should be
warned against the temptation to call an eruption syphilitic. The
commonest error is for the ordinary person to mistake a severe case of
acne, the common "pimples" of early manhood, for syphilis. Psoriasis,
another harmless, non-contagious, and very common skin disease, is often
mistaken for syphilis. Gross injustice and often much mental distress
are inflicted on unfortunates who have some skin trouble by the
readiness with which persons who know nothing about the matter insist on
thinking that any conspicuous eruption is syphilis, and telling others
about it. Even with an eye trained to recognize such things on sight, in
the crowds of a large city, one very seldom sees any skin condition
which even suggests syphilis. It usually requires more than a passing
glance at the whole body to identify the disease. If, under such
circumstances, one becomes concerned for the health of a friend, he
would much better frankly ask what is the matter, than make him the
victim of a layman's speculations. It is always well to remember that
profuse eruptions of a conspicuous nature, which have been present for
months or years, are less likely to be syphilitic.

+The Contagious Sores in the Mouth, Throat, and Genitals.+--Accompanying
the outbreaks of syphilis on the skin, in the secondary period, a
soreness may appear in the mouth and throat, and peculiar patches seen
on the tongue and lips, and flat growths be noticed around the moist
surfaces, such as those of the genitals. These throat, mouth, and
genital eruptions are the most dangerous signs of the disease from the
standpoint of contagiousness. Just as the chancre swarms with the germs
of syphilis, so every secondary spot, pimple, and lump contains them in
enormous numbers. But so long as the skin is not broken or rubbed off
over them, they are securely shut in. There is no danger of infection
from the dry, unbroken skin, even over the eruption itself. But in the
mouth and throat and about the genitals, where the surface is moist and
thin, the covering quickly rubs or dissolves off, leaving the gray or
pinkish patches and the flattened raised growths from which the germs
escape in immense numbers and in the most active condition. Such patches
may occur under the breasts and in the armpits, as well as in the places
mentioned. The saliva of a person in this condition may be filled with
the germs, and the person have only to cough in one's face to make one a
target for them.

+Distribution of the Germs in the Body.+--The germs of syphilis have in
the past few years been found in every part of the body and in every
lesion of syphilis. While the secondary stage is at its height, they
are in the blood in considerable numbers, so that the blood may at these
times be infectious to a slight degree. They are present, of course, in
large numbers in the secretions from open sores and under the skin in
closed sores. The nervous system, the walls of the blood-vessels, the
internal organs, such as the liver and spleen, the bones and the
bone-marrow, contain them. They are not, however, apparently found in
the secretions of the sweat glands, but, on the other hand, they have
been shown to be present in the breast milk of nursing mothers who have
active syphilis. The seminal fluid may contain the germs, but they have
not been shown to be present either in the egg cells of the female or in
the sperm cells of the male.

+Fate of the Germs.+--The fate of all these vast numbers of syphilitic
germs, distributed over the whole body at the height of the disease, is
one of the most remarkable imaginable. As the acute secondary stage
passes, whether the patient is treated or not, by far the larger number
of the spirochetes in the body is destroyed by the body's own power of
resistance. This explains the statement, that cannot be too often
repeated, that the outward evidences of secondary syphilis tend to
disappear of themselves, whether or not the patient is treated. Of the
hordes of germs present in the beginning of the trouble, only a few
persist until the later stages, scattered about in the parts which were
subject to the overwhelming invasion. Yet because of some change which
the disease brought about in the parts thus affected, these few germs
are able to produce much more dangerous changes than the armies which
preceded them. In some way the body has become sensitive to them, and a
handful of them in course of time are able to do damage which billions
could not earlier in the disease. The man in whom the few remaining
germs are confined largely to the skin is fortunate. The unfortunates
are those who, with the spirochetes in their artery walls, heart muscle,
brain, and spinal cord, develop the destructive arterial and nervous
changes which lead to the crippling of life at its root and premature
death.

+Variations in the Behavior of the Germ of Syphilis.+--Differences in
the behavior of the same germ in different people are very familiar in
medicine and are of importance in syphilis. As an example, the germ of
pneumonia may be responsible for a trifling cold in one person, for an
attack of grippe in the next, and may hurry the next person out of the
world within forty-eight hours with pneumonia. Part of this difference
in the behavior of a given germ may be due to differences among the
various strains or families of germs in the same general group. Another
part is due to the habit which germs have, of singling out for attack
the weakest spot in a person's body. The germ that causes rheumatism has
strains which produce simply tonsillitis, and others which, instead of
attacking joints, tend to attack the valves of the heart. Our recent
knowledge suggests that somewhat the same thing is at work in syphilis.
Certain strains of Spirochæta pallida tend to thrive in the nervous
system, others perhaps in the skin. On the other hand, in certain
persons, for example, heavy drinkers, the nervous system is most open
to attack, in others the bones may be most affected, in still others,
the skin.

+Variations in the Course of Syphilis in Different Persons.+--So it
comes about that in the secondary stage there may be wide differences in
the amount and the location of the damage done by syphilis. One patient
may have a violent eruption, and very little else. Another will scarcely
show an outward sign of the disease and yet will be riddled by one
destructive internal change after another. In such a case the secondary
stage of the disease may pass with half a dozen red spots on the body
and no constitutional symptoms, and the patient go to pieces a few years
later with locomotor ataxia or general paralysis of the insane. On the
other hand, a patient may have a stormy time in the secondary period and
have abundant reason to realize he has syphilis, and under only moderate
treatment recover entirely. Still another will have a bad infection from
the start, and run a severe course in spite of good treatment, to end in
an early wreck. The last type is fortunately not common, but the first
type is entirely too abundant. It cannot be said too forcibly that in
the secondary as in the primary stage, syphilis may entirely escape the
notice of the infected person, and he may not realize what ails him
until years after it is too late to do anything for him. Here, as in the
primary stage, the lucky person is the one who shows his condition so
plainly that he cannot overlook it, and who has an opportunity to
realize the seriousness of his disease. It used to be an old rule not
to treat people who seemed careless and indifferent until their
secondary eruption appeared, in the hope that this flare-up would bring
them to their senses. The necessity for such a rule shows plainly how
serious a matter a mild early syphilis may be.

+The Dangerous Contagious Relapses.+--Secondary syphilis does not begin
like a race, at the drop of a hat, or end with the breaking of a tape.
When the first outburst has subsided, a series of lesser outbreaks,
often covering a series of years, may follow. These minor relapses or
recurrences are mainly what make the syphilitic a danger to his fellows.
They are to a large extent preventable by thorough modern treatment. Few
people are so reckless as wholly to disregard precautions when the
severe outburst is on. But the lesser outbreaks, if they occur on the
skin, attract little or no attention or are entirely misunderstood by
the patient. Only too often they occur as the flat, grayish patches in
the mouth and genital tract, such as are seen in the secondary stage,
where, because they are out of sight and not painful, they pass
unnoticed. The tonsils, the under side and edges of the tongue, and the
angles of the mouth just inside the lips are favorite places for these
recurrent mucous patches. They are thus ideally placed to spread
infection, for, as in the secondary stage, each of these grayish patches
swarms with the germs of syphilis. Similar recurrences about the
genitals often grow, because of the moisture, into buttons and flat,
cauliflower-like warts from which millions of the germs can be squeezed.
Sometimes they are mistaken for hemorrhoids or "piles." With all the
opportunities that these sores offer for infection, it is surprising
that the disease is not universal. Irritation from friction, dirt, and
discharges, and in the mouth the use of tobacco, are the principal
influences acting to encourage these recurrences.

+Relapses in the Nervous System and Elsewhere.+--Mucous patches are, of
course, not the only recurrences, though they are very common. At any
time a little patch of secondary eruption may appear and disappear in
the course of a short time. Recurrences are not confined to the skin,
and those which take place in the nervous system may result in temporary
or permanent paralysis of important nerves, including those of the eyes
and ears. Again, recurrences may show themselves in the form of a
general running down of the patient from time to time, with loss of
weight and general symptoms like those of the active secondary period.

The secondary period as a whole is not in itself the serious stage of
syphilis. Most of the symptoms are easily controlled by treatment if
they are recognized. Now and then instances of serious damage to sight,
hearing, or important organs elsewhere occur, but these are relatively
few in spite of the enormous numbers and wide distribution of the germs.
Accordingly, the problems that the secondary stage offers the physician
and society at large must center around the recognition of mild and
obscure cases and adequate treatment for all cases. The identification
of the former is vital because of the recurrence of extremely infectious
periods throughout this stage of the disease, and the latter is
essential because vigorous treatment, carried out for a long enough
time, prevents not only the late complications which destroy the
syphilitic himself, but does away with the menace to society that arises
through his infecting others, whether in marriage and sexual contact or
in the less intimate relations of life.




Chapter V

The Nature and Course of Syphilis (Continued)


LATE SYPHILIS (TERTIARY STAGE)

+The Seriousness of Late Syphilis.+--While we recognize a group of
symptoms in syphilis which we call late or tertiary, there is no
definite or sharp boundary of time separating secondary from tertiary
periods. The man who calculates that he will have had his fling in the
ten or twenty years before tertiary troubles appear may be astonished to
find that he can develop tertiary complications in his brain almost
before he is well rid of his chancre. "Late accidents," as we call them,
are the serious complications of syphilis. They are, as has been said,
brought about by relatively few germs, the left-overs from the flooding
of the body during the secondary period. There is still a good deal of
uncertainty as to just what the distribution of the germs which takes
place in the secondary period foreshadows in the way of prospects for
trouble when we come to the tertiary period. It may well be that the man
who had many germs in his skin and a blazing eruption when he was in the
second stage, may have all his trouble in the skin when he comes to the
late stage. It is the verdict of experience, however, that people who
have never noticed their secondary eruption because it was so mild are
more likely to be affected in the nervous system later on. But this may
be merely because the condition, being unrecognized, escapes treatment.
It is at least safe to say that those whose skins are the most affected
early in the disease are the fortunate ones, because their recognition
and treatment in the secondary stage help them to escape locomotor
ataxia and softening of the brain. Conversely the victim who judges the
extent and severity of his syphilis by the presence or absence of a
"breaking out" is just the one to think himself well for ten or twenty
years because his skin is clean, and then to wake up some fine morning
to find that he cannot keep his feet because his concealed syphilis is
beginning to affect his nervous system.

+Nature of the Tissue Change in Late Syphilis--Gummatous
Infiltration.+--The essential happening in late syphilis is that body
tissue in which the germs are present is replaced by an abnormal tissue,
not unlike a tumor growth. The process is usually painless. This
material is shoddy, so to speak, and goes to pieces soon after it grows.
The shoddy tissue is called "gummatous infiltration," and the tumor, if
one is formed, is called a "gumma." The syphilitic process at the edge
of the gumma shuts off the blood supply and the tissue dies, as a finger
would if a tight band were wound around it, cutting off the blood
supply. Gumma can develop almost anywhere, and where it does, there is a
loss of tissue that can be replaced only by a scar. In this way gummas
can eat holes in bone, or leave ulcerating sores in the skin where the
gumma formed and died, or take the roof out of a mouth, or weaken the
wall of a blood-vessel so that it bulges and bursts. The sunken noses
and roofless mouths are usually syphilitic--yet if they are recognized
in time and put under treatment, all these horrible things yield as by
magic. There are few greater satisfactions open to the physician than to
see a tertiary sore which has refused to heal for months or years
disappear under the influence of mercury and iodids within a few weeks.
Still better, if treatment had been begun early in the disease, and
efficiently and completely carried out, none of these conditions need
ever have been.

+Destructive Effects of Late Syphilis.+--Late syphilis is, therefore,
destructive, and the harm that it does cannot, except within narrow
limits, be repaired. It is responsible for the kind of damaged goods
which gives the disease its reality for the every-day person. It is a
matter of desperate importance where the damage is done. Late syphilis
in the skin and bones, while horrible enough to look at, and disfiguring
for life, is not the most serious syphilis, because we can put up with
considerable loss of tissue and scarring in these quarters and still
keep on living. But when late syphilis gets at the base of the aorta,
the great vessel by which the blood leaves the heart, and damages the
valves there, the numbering of the syphilitic's days begins. Few can
afford to replace much brain substance by tertiary growths and expect to
maintain their front against the world. Few are so young that they can
meet the handicap that old age and hardening of the arteries, brought on
prematurely by late syphilis, put upon them. When late syphilis affects
the vital structures and gains headway, the victim goes to the wall.
This is the really dangerous syphilis--the kind of syphilis that
shortens and cripples life.

There are few good estimates of the extent of late accidents, as we
often call the serious later complications in syphilis, or of the part
that they play in medicine as a whole. Too many of them are
inconspicuous, or confused with other internal troubles that result from
them. Deaths from syphilis are all the time being hidden under the
general terms "Bright's disease," or "heart disease," or "paralysis," or
"apoplexy." It is a hopeful fact that, even under unfavorable
conditions, only a comparatively small percentage, from 10 to 20 per
cent, seem to develop obvious late accidents. On the other hand, it must
not be forgotten that the obscure costs of syphilis are becoming more
apparent all the time, and the influence of the disease in shortening
the life of our arteries and of other vital structures is more and more
evident. There is still good reason for avoiding the effects of syphilis
by every means at our disposal--by avoiding syphilis itself in the first
place, and by early recognition of the disease and efficient treatment,
in the second.

+Late Syphilis of the Nervous System--Locomotor Ataxia.+--The ways in
which late syphilis can attack the nervous system form the real terrors
of the disease to most people. Locomotor ataxia and general paralysis of
the insane (or softening of the brain) are the best known to the laity,
_though only two of many ways in which syphilis can attack the nervous
system_. Though their relation to the disease was long suspected, the
final touch of proof came only as recently as 1913, when Noguchi and
Moore, of the Rockefeller Institute, found the germs of the disease in
the spinal cords of patients who had died of locomotor ataxia, and in
the brains of those who had died of paresis. The way in which the damage
is done can scarcely be explained in ordinary terms, but, as in all late
syphilis, a certain amount of the damage once done is beyond repair.
Locomotor ataxia begins to affect the lower part of the spinal cord
first, so that the earliest symptoms often come from the legs and from
the bladder and rectum, whose nerves are injured. Other parts higher up
may be affected, and changes resulting in total blindness and deafness
not infrequently occur. Through the nervous system, various organs,
especially the stomach, may be seriously affected, and excruciating
attacks of pain with unmanageable attacks of vomiting (gastric crises)
are apt to follow. This does not, of course, mean that all pain in the
stomach with vomiting means locomotor ataxia. All sorts of obscure
symptoms may develop in this disease, but the signs in the eyes and
elsewhere are such that a decision as to what is the matter can usually
be made without considering how the patient feels, and by evidence which
is beyond his control.

+Late Syphilis of the Nervous System--General Paralysis.+--General
paralysis, or paresis, is a progressive mental degeneration, with
relapses and periods of improvement which reduce the patient by
successive stages to a jibbering idiocy ending invariably in death. Such
patients may, in the course of their decline, have delusions which lead
them to acts of violence. The only place for a paretic is in an asylum,
since the changes in judgment, will-power, and moral control which occur
early in the disease are such that, before the patient gets
unmanageable, he may have pretty effectually wrecked his business and
the happiness of his family and associates. When the condition is
recognized, the family must at least be forewarned, so that they can
take action when it seems necessary. Both locomotor ataxia and paresis
may develop in the same person, producing a combined form known as
taboparesis.

The importance of locomotor ataxia and paresis in persons who carry
heavy responsibilities is very great. In railroad men, for example, the
harm that can be done in the early stages of paresis is as great as or
even greater than the harm that an epileptic can do. A surgeon with
beginning taboparesis may commit the gravest errors of judgment before
his condition is discovered. Men of high ability, on whom great
responsibilities are placed, may bring down with them, in their
collapse, great industrial and financial structures dependent on the
integrity of their judgment. The extent of such damage to the welfare of
society by syphilis is unknown, though here and there some investigation
scratches the surface of it. It will remain for the future to show us
more clearly the cost of syphilis in this direction.

+Syphilis and Mental Disease.+--Williams,[7] before the American Public
Health Association, has recently carefully summarized the rôle of
syphilis in the production of insanity, and the cost of the disease to
the State from the standpoint of mental disease alone. He estimates
that 10 per cent of the patients who enter the Massachusetts State
hospitals for the insane are suffering from syphilitic insanity. Fifteen
per cent of those at the Boston Psychopathic Hospital have syphilis. In
New York State hospitals, 12.7 per cent of those admitted have
syphilitic mental diseases. In Ohio, 12 per cent were admitted to
hospitals for the same reason. An economic study undertaken by Williams
of 100 men who died at the Boston State Hospital of syphilitic mental
disease, the cases being taken at random, showed that the shortening of
life in the individual cases ranged from eight to thirty-eight years,
and the total life loss was 2259 years. Of ten of these men the earning
capacity was definitely known, and through their premature death there
was an estimated financial loss of $212,248. It cost the State of
Massachusetts $39,312 to care for the 100 men until their death.
Seventy-eight were married and left dependent wives at the time of their
commission to the hospital. In addition to the 100 men who became public
charges, 109 children were thrown upon society without the protection of
a wage-earner. Williams estimates, on the basis of published admission
figures to Massachusetts hospitals, that there are now in active life,
in that state alone, 1500 persons who will, within the next five years,
be taken to state hospitals with syphilitic insanity.

    [7] Williams, F. E.: "Preaching Health," Amer. Jour. Pub. Health,
    1917, vi, 1273.

+Frequency of Locomotor Ataxia and General Paralysis.+--The percentage
of all syphilitic patients who develop either locomotor ataxia or
paresis varies in different estimates from 1 to 6 per cent of the total
number who acquire syphilis. The susceptibility to any syphilitic
disease of the nervous system is hastened by the use of alcohol and by
overwork or dissipation, so that the prevalence of them depends on the
class of patients considered. It is evident, though, that only a
relatively small proportion of the total number of syphilitics are
doomed to either of these fates. Taking the population as a whole, the
percentage of syphilitics who develop this form of late involvement
probably does not greatly exceed 1 per cent.

+Treatment and Prevention of Late Syphilis of the Nervous
System.+--Locomotor ataxia and paresis, even more than other syphilitic
diseases of the nervous system, are extremely hard to affect by
medicines circulating in the blood, and for that reason do not respond
to treatment with the ease that syphilis does in many other parts of the
body. Early locomotor ataxia can often be benefited or kept from getting
any worse by the proper treatment. For paresis, in our present state of
knowledge, nothing can be done once the disease passes its earliest
stages. In both these diseases only too often the physician is called
upon to lock the stable door after the horse is stolen. The problem of
what to do for the victims of these two conditions is the same as the
problem in other serious complications of syphilis--keep the disease
from ever reaching such a stage by recognizing every case early, and
treating it thoroughly from the very beginning.


SUMMARY

Summing up briefly the main points to bear in mind about the course of
syphilis--there is a time, at the very beginning of the disease, even
after the first sore appears, when the condition is still at or near the
place where it entered the body. At this time it can be permanently
cured by quick recognition and thorough treatment. There are no fixed
characteristics of the early stages of the disease, and it often escapes
attention entirely or is regarded as a trifle. The symptoms that follow
the spread of the disease over the body may be severe or mild, but they
seldom endanger life, and again often escape notice, leaving the victim
for some years a danger to other people from relapses about which he may
know nothing whatever. Serious syphilis is the late syphilis which
overtakes those whose earlier symptoms passed unrecognized or were
insufficiently treated. Late syphilis of the skin and bones, disfiguring
and horrible to look at, is less dangerous than the hidden syphilis of
the blood-vessels, the nerves, and the internal organs, which, under
cover of a whole skin and apparent health, maims and destroys its
victims. Locomotor ataxia and softening of the brain, early apoplexy,
blindness and deafness, paralysis, chronic fatal kidney and liver
disease, heart failure, hardening of the blood-vessels early in life,
with sudden or lingering death from any of these causes, are among the
ways in which syphilis destroys innocent and guilty alike. And yet, for
all its destructive power, it is one of the easiest of diseases to hold
in check, and if intelligently treated at almost any but the last
stages, can, in the great majority of cases, be kept from endangering
life.




Chapter VI

The Blood Test for Syphilis


It seems desirable at this point, while we are trying to fix in mind the
great value of recognizing syphilis in a person in order to treat it and
thus prevent dangerous complications, to say something about the blood
test for syphilis, the second great advance in our means of recognizing
doubtful or hidden forms of the disease. The first, it will be recalled,
is the identification of the germ in the secretions from the early
sores.

+Antibodies in the Blood in Disease.+--It is part of the new
understanding we have of many diseases that we are able to recognize
them by finding in the blood of the sick person substances which the
body makes to neutralize or destroy the poisons made by the invading
germs, even when we cannot find the germs themselves. These substances
are called antibodies, and the search for antibodies in different
diseases has been an enthusiastic one. If we can by any scheme teach the
body to make antibodies for a germ, we can teach it to cure for itself
the disease caused by that germ. So, for example, by injecting dead
germs as a vaccine in typhoid fever and certain other diseases, we are
able to teach the body to form protective substances which will kill any
of the living germs of that particular kind which gain entrance to the
body. Conversely, if the body is invaded by a particular kind of germ,
and we are in doubt as to just which one it is, we can identify it by
finding in the blood of the sick person the antibody which we know by
certain tests will kill or injure a certain germ. This sort of medical
detective work was first applied to syphilis successfully by Wassermann,
Neisser, and Bruck in 1904, and for that reason the test for these
antibodies in the blood in syphilis is called the Wassermann reaction.
To be sure, it is now known that in syphilis it is not a true antibody
for the poisons of the Spirochæta pallida for which we are testing, but
rather a physical-chemical change in the serum of patients with
syphilis, which can be produced by other things besides this one
disease. But this fact has not impaired the practical value of the test,
since the other conditions which give it are not likely to be confused
with syphilis in this part of the world. The fact that no true antibody
is formed simply makes it unlikely that we shall ever have a vaccine for
syphilis.

+Difficulties of the Test.+--The Wassermann blood test for syphilis is
one of the most complex tests in medicine. The theory of it is beyond
the average man's comprehension. A large number of factors enter into
the production of a correct result, and the attaining of that result
involves a high degree of technical skill and a large experience. It is
no affair for the amateur. The test should be made by a specialist of
recognized standing, and this term does not include many of the
commercial laboratories which spring up like mushrooms in these days of
laboratory methods.

+The Recognition of Syphilis by the Blood Test.+--When the Wassermann
test shows the presence of syphilis, we speak of it as "positive."
Granted that the test is properly done, a strong positive reaction means
syphilis, unless it is covered by the limited list of exceptions. After
the first few weeks of the disease, and through the early secondary
period, the blood test is positive in practically all cases. Its
reliability is, therefore, greatest at this time. Before the infection
has spread beyond the first sore, however, the Wassermann test is
negative, and this fact makes it of little value in recognizing early
primary lesions. In about 20 to 30 per cent of syphilitic individuals
the test returns to negative after the active secondary stage is passed.
This does not necessarily mean that the person is recovering. It is even
possible to have the roof fall out of the mouth from gummatous changes
and the Wassermann test yet be negative. It is equally possible, though
unusual, for a negative Wassermann test to be coincident with contagious
sores in the mouth or on the genitals. So it is apparent that as an
infallible test for syphilis it is not an unqualified success. But
infallibility is a rare thing in medicine, and must be replaced in most
cases by skilful interpretation of a test based on a knowledge of the
sources of error. We understand pretty clearly now that the Wassermann
test is only one of the signs of syphilis and that it has quite
well-understood limitations. It has revealed an immense amount of
hidden syphilis, and in its proper field has had a value past all
counting. Experience has shown, however, that it should be checked up by
a medical examination to give it its greatest value. Just as all
syphilis does not show a positive blood test, so a single negative test
is not sufficient to establish the absence of syphilis without a medical
examination. In a syphilitic, least of all, is a single negative
Wassermann test proof that his syphilis has left him. In spite of these
rather important exceptions, the Wassermann test, skilfully done and
well interpreted, is one of the most valuable of modern medical
discoveries.

+The Blood Test in the Treatment and Cure of Syphilis.+--In addition to
its value in recognizing the disease, the Wassermann test has a second
field of usefulness in determining when a person is cured of syphilis,
and is an excellent guide to the effect of treatment. Good treatment
early in a case of syphilis usually makes the Wassermann test negative
in a comparatively short time, and even a little treatment will do it in
some cases. But will it stay negative if treatment is then stopped? In
the high percentage of cases it will not. It will become positive again
after a variable interval, showing that the disease has been suppressed
but not destroyed. For that reason, if we wish to be sure of cure, we
must continue treatment until the blood test has become negative and
stays negative. This usually means repeated tests, over a period of
several years, in connection with such a course of treatment as will be
described later. During a large part of this time the blood test will
be the only means of finding out how the disease is being affected by
the treatment. To all outward appearance the patient will be well. He
may even have been negative in repeated tests, and yet we know by
experience that if treatment is stopped too soon, he will become
positive again. There is no set rule for the number of negative tests
necessary to indicate a cure. The whole thing is a matter of judgment on
the part of an experienced physician, and to that judgment the patient
should commit himself unhesitatingly. If a patient could once have
displayed before him in visible form the immense amount of knowledge,
experience, and labor which has gone into the devising and goes into the
performing of this test, he would be more content to leave the decision
of such questions to his physician than he sometimes is, and would be
more alive to its reality and importance. The average man thinks it a
rather shadowy and indefinite affair on which to insist that he shall
keep on doctoring, especially after the test has been negative once or
twice.

Just as a negative test may occur while syphilis is still actively
present and doing damage in the body, so a positive Wassermann test may
persist long after all outward and even inward signs of the disease have
disappeared. These fixed positives are still a puzzle to physicians. But
many patients with fixed positives, if well treated regardless of their
blood test, do not seem to develop the late accidents of the disease. If
their nervous systems, on careful examination, are found not to be
affected, they are reasonably safe as far as our present knowledge
goes. People with fixed positives should accept the judgment of their
physicians and follow their recommendations for treatment without
worrying themselves gray over complications which may never develop.

+Practical Points About the Test.+--Certain practical details about this
test are of interest to every one. Blood for it is usually drawn from a
small vein in the arm. The discomfort is insignificant--no more than
that of a sharp pin-prick. Blood is drawn in the same way for other
kinds of blood tests, so that a needle-prick in the arm is not
necessarily for a Wassermann test. There is no cutting and no scar
remains. The amount of blood drawn is small and does not weaken one in
the least. The test is done on the serum or fluid part of the blood,
after the corpuscles are removed. It can also be done on the clear fluid
taken from around the spinal cord, and this is necessary in certain
syphilitic nervous diseases. There is nothing about the test that need
make anybody hesitate in taking it, and it is safe to say that, when
properly done, the information that it gives is more than worth the
trouble, especially to those who have at any time been exposed, even
remotely, to the risk of infection. But the test must be well done, by a
large hospital or through a competent physician or specialist, and the
results interpreted to the patient by the physician and not by the
laboratory that does the test, or in the light of the patient's own
half-knowledge of the matter.




Chapter VII

The Treatment of Syphilis


GENERAL CONSIDERATIONS

+Scientific Methods of Treating Disease.+--In trying to treat diseases
caused by germs, the physician finds himself confronted by several
different problems. Certain of these diseases run their course and the
patient gets well or dies, pretty much regardless of anything that can
be done for him. In certain others, because of our knowledge of the way
in which the body makes its fight against the germ, we are able either
to prepare it against attack, as in the case of protective vaccination,
or we are able to help it to come to its own defense after the disease
has developed. This can be done either by supplying it with antitoxin
from an outside source, or helping it to make its own antitoxin by
giving it dead germs to practise on. In the third group, the smallest of
the three, we are fortunate enough to know of some substance which will
kill the germ in the body without killing the patient. For such diseases
we are said to have a "specific" method of treatment. Syphilis is one of
these diseases. It is not to be understood that there is a sharp line of
division between these three groups, since in every disease we try as
far as possible to use all the methods we can bring to bear. In
pneumonia we have to let the body largely make its own fight, and simply
help it to clear out the poisons formed by the germ, and keep the heart
going until the crisis is past. In diphtheria, nowadays, we help the
body out promptly by supplying it with antitoxin from an outside source,
before it has time to make any for itself. We do the same thing for
lockjaw if we are early enough. We practise the body on dead typhoid
germs by vaccination until it is able to fight the living ones and
destroy them before they get a foothold. The diseases for which we have
specific methods of treatment are few in number, and each has associated
with it the name of a particular drug. Quinin kills the germ of malaria,
sodium salicylate cures inflammatory rheumatism, and mercury cures
syphilis. To mercury in the case of syphilis must now be added salvarsan
or arsenobenzol ("606"), the substance devised by Ehrlich in 1910, which
will be considered in the next chapter.

The action of a specific is, of course, not infallible, but the failures
are exceptional, so that one feels in attacking one of these diseases
with its specific remedy as a man called upon to resist a savage beast
would feel if he were armed with a powerful rifle instead of a stick.
The situation in syphilis, for which there is a specific, as compared
with tuberculosis, for which there is no specific, is incomparably in
favor of the former. If we had as powerful weapons against tuberculosis
as we have against syphilis, the disease would now be a rarity instead
of the disastrous plague it is. Comparing the situation in two diseases
for which we have specifics, such as syphilis and malaria, malaria has
lost most of its seriousness as a problem in any part of the world,
while syphilis is rampant everywhere. Malaria has, of course, been
extinguished not only through the efficiency of quinin, but also through
preventive measures directed at mosquitos, which are the carriers of the
disease from person to person. But allowing for this, if it becomes
possible to apply mercury and salvarsan as thoroughly to the prevention
and treatment of syphilis as quinin can be applied to malaria, syphilis
will soon be a rarity over the larger part of the civilized world. To
bring the specific remedies for syphilis and the patient together
constitutes, then, one of the greatest problems which confronts us in
the control of the disease at the present day.


MERCURY

+Mercury in the Treatment of Syphilis.+--Mercury is, of course, familiar
to every one, and there is nothing peculiar about the mercury used in
the treatment of syphilis. The fluid metallic mercury itself may be used
in the form of salves, in which the mercury is mixed with fatty
substances and rubbed into the skin. Mercury can be vaporized and the
vapor inhaled, and probably the efficiency of mercury when rubbed into
the skin depends to no small extent on the inhalation of the vapor which
is driven off by the warmth of the body. Mercury in the form of chemical
salts or compounds with other substances can be given as pills or as
liquid medicine. Similarly, the metal itself or some of its compounds
can be injected in oil with a hypodermic needle into the muscles, and
the drug absorbed in this way.

+Misconceptions Concerning Mercury.+--The use of mercury in syphilis is
nearly as old, in Europe at least, as the disease itself. The drug was
in common use in the fifteenth century for other conditions, and was
promptly tried in the new and terrible disease as it spread over Europe,
with remarkable results. But doses in the old days were anything but
homeopathic, and overdoses of mercury did so much damage that for a time
the drug fell into undeserved disfavor. Many of the superstitions and
popular notions about mercury originated at this period in its history.
It was supposed to make the bones "rot" and the teeth fall out, an idea
which one patient in every ten still entertains and offers as an
objection when told he must take mercury. Insufficiently treated
syphilis is, of course, what makes the bones "rot," and not the mercury
used in treating the disease. Mercury apparently has no effect on the
bones whatever. The influence of the drug on the teeth is more direct
and refers to the symptoms caused by overdoses. No physician who knows
his business ever gives mercury at the present time to the point where
the teeth are in any danger of falling out.

+The Action of Mercury.+--The action of mercury on syphilis is not
entirely clear. The probabilities are that the drug, carried to all
parts of the body by the blood, helps to build up the body's resistance
and stimulates it to produce substances which kill the germs. In
addition, of course, it kills the germs by its own poisonous qualities.
Its action is somewhat slow, and it is even possible for syphilitic
sores containing the germs to appear, especially in the mouth and throat
and about the genitals, while the person is taking mercury. Just as
quinin must be used in malaria for some time after all signs of chill
and fever have disappeared, to kill off all germs lurking in
out-of-the-way corners of the body, or especially resistant to the drug,
so it is necessary to continue the use of mercury long after it has
disposed of all the obvious signs of the disease, like the eruption,
headaches, and other symptoms, in order to prevent a relapse. No matter
in what form it is used, the action of mercury on syphilis is one of the
marvels of medicine. It can clear up the most terrific eruption with
scarcely a scar, and transform a bed-ridden patient into a seemingly
healthy man or woman, able to work, in the course of a few weeks or
months. Symptoms often vanish before it like snow in a thaw. This
naturally makes a decided impression, and often an unfavorable one, on
the patient. It is only too easy to think that a disease which vanishes
under the magic influence of a few pills is a trifle, and that outwardly
cured means the same thing as inwardly cured. Mercury therefore carries
its disadvantages with its advantages, and by its marvelous but
transient effect only too often gives the patient a false idea of his
progress toward cure.

+Methods of Administering Mercury.+--As has been said, mercury is given
principally in three ways at the present time. It can be given by the
mouth, in the form of pills and liquids, and in this form is not
infrequently incorporated into patent medicine blood purifiers. Mercury
in pills and liquid medicine has the advantage for the patient of being
an easy and inconspicuous way of taking the drug, and for that reason
patients usually take it willingly or even insist on it if they know no
better. Even small doses taken in this way will hide the evidences of
syphilis so completely that only a blood test will show that it exists.
If it were true that large doses taken by mouth could always be relied
on to cure the disease, there would be little need for other ways of
giving it. But there is a considerable proportion of persons with
syphilis treated with pills who do not get rid of the disease even
though the dose is as large as the stomach can stand. Such patients
often have all the serious late complications which befall untreated
patients. It seems almost impossible to give enough mercury by mouth to
effect a cure. Thus pill treatment has come to be a second-best method,
and suitable only in those instances in which we simply expect to
control the outward signs rather than effect a cure.

The mercury rub or inunction, under ideal conditions, all things
considered, is the best method of administering mercury to a patient
with the hope of securing a permanent result. In this form of treatment
the mercury made up with a salve is rubbed into the skin. The
effectiveness of the mercurial rub is reduced considerably by its
obvious disadvantages. It requires time to do the rubbing, and the
ointment used seems uncleanly because of its color and because it is
necessary to leave what is not rubbed in on the skin so that it
discolors the underwear. The mercurial rub is at its best when it is
given by some one else, since few patients have the needed combination
of conscientiousness, energy, and determination to carry through a long
course. The advantages of the method properly carried out cannot be
overestimated. It is entirely possible in a given case of syphilis to
accomplish by a sufficient number of inunctions everything that mercury
can accomplish, and with the least possible damage to the body.
Treatment by mouth cannot compare with inunctions and cannot be made to
replace them, when the only objection to the rubs is the patient's
unwillingness to be bothered by them. The patient who is determined,
therefore, to do the best thing by himself will take rubs
conscientiously as long as his physician wishes him to do so, even
though it means, as it usually does, not a dozen or two, but several
hundreds of them, extending over a period of two or three years, and
given at the rate of four to six rubs a week.

The giving of mercury by injections is a very powerful method of using
the drug for the cure of syphilis. It reduces the inconvenience of
effective treatment to a minimum and has all the other advantages of
secrecy and convenience. It keeps the patient, moreover, in close touch
with his physician and under careful observation. Injections by some
methods are given daily, by others once or twice a week. The main
disadvantage is the discomfort which follows each injection for a few
hours. For any one who has one of the serious complications of
syphilis, injections may be a life and death necessity. Mercurial
injections are a difficult form of treatment and should be given only by
experts and physicians who are thoroughly familiar with their use.

Like every important drug in medicine, mercury is a poison if it is
abused. Its earliest effect is on the mouth and teeth, and for that
reason the physician, in treating syphilis by vigorous methods, has his
patients give special attention to the care of their mouths and teeth
and of their digestions as well. Mercury also affects the kidneys and
the blood, if not properly given, and for that reason the person who is
taking it must be under the care and observation of a physician from
time to time. Only the ignorant undertake to treat themselves for
syphilis, though how many of these there are can be inferred from the
amount of patent medicine and quack treatment there is in these fields.
Properly given, mercury has no harmful effects, and there is no ground
whatever for the notion some people have, that mercury will do them more
harm than a syphilitic infection. Improperly used, either as too much or
too little, it is capable of doing great harm, not only directly, but
indirectly, by making it impossible later for the patient to take enough
to cure the disease. The extent to which some overconfident persons fail
in their efforts to treat and cure themselves explains the necessity for
such a warning.

+Effect of Mercurial Treatment on the Blood Test.+--The effect of
mercury on the Wassermann blood test for syphilis should also be
generally understood. In many cases it is possible, especially early in
the disease, by a few rubs of mercurial ointment, or a few injections of
mercury, or even in some cases by the use of pills or liquid medicine,
to make a positive blood test for syphilis negative. But this negative
test is only temporary. Within a short time, usually after treatment is
stopped, the test becomes positive again, showing that the mercury has
not yet cured, but simply checked, the disease, and that it may at any
time break out again or do internal damage. It must be understood that a
negative blood test just after a patient has been taking mercury _has no
meaning_, so far as guaranteeing a cure is concerned. It is only the
blood test that is repeatedly negative after the effect of mercury wears
off, which shows the disease is cured. Yet many a syphilitic may and
does think himself cured, and may marry in good faith, or be allowed a
health certificate, only to become positive again. He may then develop
new sores without his knowledge even, and perhaps infect his wife, or
may himself in later years develop some of the serious consequences of
the disease.

Whenever one talks to a person who knows something about the advances in
knowledge in the past few years about the treatment of syphilis, and
goes into detail about mercury, the odds are two to one that he will be
interrupted by the question, "But what about '606'?" Before talking
about salvarsan, or "606," it is well to say here that this new drug,
wonderful though it is, has in no sense done away with the necessity for
the use of mercury in the treatment of syphilis. Mercury has as high a
reputation and is as indispensable in the cure of syphilis today as it
was four centuries ago. It has as yet no substitutes. We appreciate
every day, more and more, how thoroughly it can be depended on to do the
work we ask of it.[8]

    [8] A drug known as the iodid of potash (or soda) is widely used in
    the treatment of syphilis, and especially of the late forms of the
    disease, such as gummas and gummatous sores. It has a peculiar
    effect on gummatous tissue, causing it to melt away, so to speak,
    and greatly hastening the healing process. So remarkable is this
    effect that it gives the impression that iodids are really curing
    the syphilis itself. It has been shown, however, that iodids have no
    effect on the germs of syphilis, and therefore on the cause of the
    disease, although they can promote the healing of the sores in the
    late stages. For this reason iodids must always be used in
    connection with mercury or salvarsan if the disease itself is to be
    influenced. It is occasionally difficult to get patients to
    understand this after they have once taken "drops," as the medicine
    is often called. Otherwise the use of iodids in syphilis is of
    medical rather than general interest.




Chapter VIII

The Treatment of Syphilis (Continued)


SALVARSAN

+The Discovery of Salvarsan ("606").+--Salvarsan, or "606," is a
chemical compound used in the modern treatment of syphilis. It was
announced to the world by Paul Ehrlich, its brilliant discoverer, in
December, 1910. Ehrlich and his Japanese co-worker, Hata, had some years
before been impressed with the remarkable effect certain dyes had on the
parasites infesting certain animals and which resemble the germs that
cause the African sleeping sickness in man. When one of these dyes was
dissolved and injected into the blood of the sick animal, the dye
promptly picked out and killed all the parasites, but did not kill the
animal. Dyes are very complex chemical substances and certain of them
seem to have an affinity for germs. It occurred to Ehrlich that if a
substance could be devised which was poisonous for the germ and not for
the patient it might be possible to prepare a specific for a given
disease, acting as quinin does in malaria. By combining a poison with a
dye it might be made to pick out the germs and leave the body unharmed.

    [Illustration: PAUL EHRLICH [1854-1915]

    (From "Year Book of Skin and Venereal Diseases," 1916, vol. ix.
    "Practical Medicine Series," Year Book Publishers, Chicago.)]

The poison which had already been shown to be especially effective in
killing germs like those of syphilis was arsenic. The problem was to
get arsenic into such a combination with other chemical substances that
it would lose its poisonous quality for man, but still be poisonous for
the spirochete of syphilis. Ehrlich and Hata began to make chemical
compounds of arsenic in the laboratory with chemical substances like the
dyes. As the compounds grew more complex they were tested on animals and
some of them found to have the qualities for which their inventors were
searching. Some of them are even used at the present time in the
treatment of certain diseases. The six hundred and sixth compound in
this series, when tested on syphilitic animals, was found to be
extraordinarily efficient in killing the germ of syphilis, even when
used in quantities so small as not to injure the animal. Among other
things, there could be no better example of the importance of animal
experiment in medicine. If the cause of syphilis had not been known, and
the disease not given to animals, the discovery of salvarsan might never
have been made. After extensive experiments on syphilitic rabbits, which
showed that the drug could be given safely in amounts large enough to
cure the animal at a single dose, it was tried on man, two physicians,
Drs. Hoppe and Wittneben, volunteering for the test. When it was found
that the drug did them no harm, it was used on syphilitic patients for
the first time. As soon as its remarkable effect on the disease in them
was fully established, Ehrlich announced the discovery before the
medical society of Magdeburg, and the results were published in one of
the most important of the German medical journals. Ehrlich then sent
out from his own laboratory several thousands of doses of the new drug
to all the principal clinics and large hospitals of the world for an
extended trial. It was not until the results of this trial became
apparent that he permitted its manufacture on a commercial scale. There
could scarcely be a more ideal way of introducing a new form of
treatment than the one adopted by Ehrlich, or one better surrounded by
all the safeguards that conservatism could suggest.

+The Mistaken Conception of "Single Dose Cure."+--In the light of his
experience with salvarsan in animals, Ehrlich hoped to accomplish the
cure of syphilis in man by a single dose of the new drug, as he had been
able to cure it in rabbits. All the earlier use of salvarsan in the
treatment of syphilis was carried out with this idea in view, and the
remarkable way in which the symptoms vanished before the large doses
used encouraged the belief that Ehrlich's ideal for it had been
fulfilled. But it was not long before it was found that syphilis had a
stronger hold on the human body than on animals, and that patients
relapsed after a single dose, either as shown by the blood test or by
the reappearance, after varying intervals, of the eruption or other
symptoms of the disease. Unfortunately, the news of the discovery of
salvarsan, and with it Ehrlich's original idea that it would cure
syphilis by a single dose, had gotten into the newspapers. Numbers of
syphilitics treated with it have been deceived by this notion into
believing themselves cured. In those whose symptoms came back in severe
form, the trouble was, of course, found out. But there are at the
present time, undoubtedly, many persons who received a single dose of
salvarsan for a syphilis contracted at this time, and who today, having
never seen any further outward signs of the disease, believe themselves
cured, when in reality they are not. In the next twenty years the
introduction of salvarsan will probably result in a wave of serious late
syphilis, the result of cases insufficiently treated in the early days
of its use. It was not long before it was found that not one but several
doses of salvarsan were necessary in the treatment of syphilis, and soon
many physicians of wide experience began to call in mercury again for
help when salvarsan proved insufficient for cure. At the present time
the use of both mercury and salvarsan in the treatment of the disease is
the most widely accepted practice, and seems to offer the greatest
assurance of cure.

+The Value of Salvarsan.+--Salvarsan has done for the treatment of
syphilis certain things of the most far-reaching importance from the
standpoint of the interests of society at large. It has first of all
made possible the control of the _contagious_ lesions of the disease.
Secondly, as was said before, it has made possible the cure of the
infection in the primary stage, before it has spread from the
starting-point in the chancre to the rest of the body. To understand how
it accomplishes these results it is important to understand its mode of
action.

+The Action of Salvarsan.+--It will be recalled that Ehrlich planned
salvarsan to kill the germs of syphilis, just as quinin kills the germs
of malaria. It was intended that when the drug entered the blood it
should be carried to every part of the body, and fastening itself on the
spirochetes, kill them without hurting the body. This is seemingly
exactly what the drug does, and it does it so well that within
twenty-four hours after a dose of it is given into the blood there is
not a living germ of syphilis, apparently, in any sore on the body. If
the same thing happened in all the out-of-the-way corners of the body,
the cure would be complete. The natural result of removing the cause of
the disease in this fashion is that the sores produced by it heal up.
They heal with a speed and completeness that is an even greater marvel
than the action of mercury. The more superficial the eruption, the
quicker it vanishes, so that in the course of a few days all evidence of
the disease may disappear. This is especially true of the grayish
patches in the mouth and about the genitals, which have already been
described as the most dangerously contagious lesions of syphilis. It is
evident, therefore, that to give salvarsan in a case of contagious
syphilis is to do away with the risk of spreading the disease in the
quickest and most effective fashion. It is as if a person with scarlet
fever could be dipped in a disinfecting bath and then turned loose in
the community without the slightest danger of his infecting others. How
much scarlet fever would there be if every case of the disease could be
treated in this way? There would be as little of it as there now is of
smallpox, compared to the wholesale plagues of that disease which used
to kill off the population of whole towns and counties in the old days.
If we could head off the crops of contagious sores in every syphilitic
by the use of "606," syphilis in the same way would take a long step
toward its disappearance. It is not a question, in this connection, of
curing the disease with salvarsan, but of preventing its spread, and in
doing that, salvarsan is one of the things we have been looking for for
centuries.

+The Treatment of Syphilis With Salvarsan.+--Salvarsan, the original
"606," was improved on by Ehrlich in certain ways, which make it easier
for the ordinary physician to use it. The improved salvarsan is called
neosalvarsan ("914") and has no decided advantages over the older
preparation except on the score of convenience. Both salvarsan and
neosalvarsan are yellow powders, which must be manufactured under the
most exacting precautions, to prevent their being intensely poisonous,
and must be sealed up in glass tubes to prevent their spoiling in the
air. They were formerly administered by dissolving them or by mixing
with oil and then injecting them into the muscles, much as mercury is
given by injection. At the present time, however, the majority of
experts prefer to dissolve the drug in water or salt solution and to
inject it into the blood directly, through one of the arm veins. There
is very little discomfort in the method, as a rule--no more than there
is to the taking of blood for a blood test. At the present time the
quantity of the drug injected is relatively small for the first
injection, growing larger with each following injection. The intervals
between injections vary a good deal, but a week is an average. The
number of injections that should be given depends largely on the purpose
in view. If the salvarsan is relied on to produce a cure, the number may
be large--as high as twenty or more. If it is used only to clear up a
contagious sore, a single injection may be enough for the time being.
But when only a few injections are used, mercury becomes the main
reliance, and a patient who cannot have all the salvarsan he needs
should not expect two or three doses of it to produce a cure. The
publicity which has been given to this form of treatment has led many
patients to take matters into their own hands and to go to a physician
and ask him to give them a dose of salvarsan, much as they might order a
highball on a cold day. The physician who is put in a position like this
is at a disadvantage in caring for his patient, and the patient in the
end pays for his mistaken idea that he knows what is good for himself.
The only judge of the necessity of giving salvarsan, and the amount and
the frequency with which to give it, is the expert physician, and no
patient who is wise will try to take the thing into his own hands. There
are even good reasons for believing that the patient who is
insufficiently treated with salvarsan is at times worse off than the
patient who, unable to afford the drug at all, has had to depend for his
cure entirely on mercury.

It is one of the tragedies of the modern private practice of medicine
that the physician has so often to consult the patient's purse in giving
or withholding salvarsan, and for that reason, except in the
well-to-do, it is seldom used to the best advantage. Such a drug, so
powerful an agent in the conservation of the public health, should be
available to all who need it in as large amounts as necessary, without a
moment's hesitation as to whether the patient can afford it or not. It
is not too much to urge that private patent rights should not be allowed
to control the price and distribution of such a commodity to the public.
Upon the payment of suitable royalties to the inventor the manufacture
of such a drug should be thrown open to properly supervised competition,
as in the case of diphtheria antitoxin, or be taken over by the
Government and distributed at cost, at least to hospitals. To bring
about such a revision of our patent law every thinking man and woman may
well devote a share of personal energy and influence.

The manner of giving salvarsan is as important for the patient as the
correct performance of an operation, and the safeguards which surround
it are essentially the same. The drug is an extremely powerful one, more
powerful than any other known, and in the usual doses it carries with it
into the body for the destruction of the germs of syphilis many times
the amount of arsenic needed to kill a human being. If something should
go astray, the patient might lose his life as promptly as if the surgeon
or the anesthetist should make a slip during an operation. To make the
giving of salvarsan safe, the judgment, experience, and training of the
specialist are not too much to ask.

The dangers of salvarsan are easily exaggerated, and some people have a
foolish fear of it. The wonderful thing about the drug is that, with all
the possibility for harm that one might expect in it, it so seldom makes
any trouble. It is, of course, first carefully tested on animals when it
is manufactured, so that no poisonous product is placed on the market.
It is as safe to take salvarsan at the hands of an expert as it is to
take ether for an operation or to take antitoxin for diphtheria, and
that is saying a good deal. Most of the stories of accidents that go the
rounds among laymen date back to the days when first doses were too
large and made the patients rather sick for a time. Present methods and
cautions about administering the drug are such that, except for the
improvement in their condition, patients seldom know they have received
it. The first dose may light the eruption up a little, but this is only
because the drug stirs the germs up before it kills them, and
improvement begins promptly within a few hours or a day or two.

The first characteristic of salvarsan which we should bear in mind
especially, in our interest in the social aspects of syphilis, is then
the rapidity rather than the thoroughness of its action. It is a social
asset to us because it protects us from the infected person, and it is
an asset to the patient because it will set him on his feet, able to
work and go about his business, in a fraction of the time that mercury
can do it.

The efficiency of salvarsan in the cure of syphilis in the early stages
is due, first, to the large amount of it that can be introduced into the
body without killing the patient, and second, to the promptness with
which it gets to the source of trouble. In the old days, while we were
laboriously getting enough mercury into the patient to help him to stop
the invading infection, the germs marched on into his blood and through
his body. With salvarsan, the first dose, given into the blood, reaches
the germs forthwith and destroys them. There is enough of it and to
spare. Twenty-four hours later scarcely a living germ remains. The few
stragglers who escape the fate of the main army are picked up by
subsequent doses of salvarsan and mercury, and a cure is assured. There
is all the difference between stopping a charge with a machine gun and
stopping it with a single-shot rifle, in the relative effectiveness of
salvarsan and mercury at the beginning of a syphilitic infection.

     In syphilis affecting the central nervous system, salvarsan,
     modified in various ways, may be injected into the spinal canal in
     an effort to reach the trouble more directly. The method, which is
     known as _intradural therapy_, has had considerable vogue, but a
     growing experience with it seems to indicate that it has less value
     than was supposed, and is a last resort more often than anything
     else. It involves some risk, and is no substitute for efficient
     treatment by the more familiar methods. If necessary, a patient can
     have the benefit of both.

     The _luetin test_ was devised by Noguchi for the presence of
     syphilis, and is performed by injecting into the skin an emulsion
     of dead germs. A pustule forms if the test is positive. It is of
     practical value only in late syphilis, and a negative test is no
     proof of the absence of the disease. Positive tests are sometimes
     obtained when syphilis is not present. For these reasons the test
     is not as valuable as was at first thought.




Chapter IX

The Cure of Syphilis


There are few things about our situation with regard to syphilis that
deserve more urgent attention than questions connected with the cure of
the disease, and few things in which it is harder to get the necessary
coöperation. On the one hand, syphilis is one of the most curable of
diseases, and on the other, it is one of the most incurable. At the one
extreme we have the situation in our own hands, at our own terms--at the
other, we have a record of disappointing failure. As matters stand now,
we do not cure syphilis. We simply cloak it, gloss it over, keep it
under the surface. Nobody knows how much syphilis is cured, partly
because nobody knows how much syphilis there really is, and partly
because it is almost an axiom that few, except persons of high
intelligence and sufficient means, stick to treatment until they can be
discharged as cured. Take into consideration, too, the fact that the
older methods of treating syphilis were scarcely equal to the task of
curing the disease, and it is easy to see why the idea has arisen, even
among physicians, that once a syphilitic means always a syphilitic, and
that the disease is incurable.

+Radical or Complete Cure.+--In speaking of the cure of syphilis, it is
worth while to define the terms we use rather clearly. It is worth while
to speak in connection with this disease of radical as distinguished
from symptomatic cure. In a radical cure we clear up the patient so
completely that he never suffers a relapse. In symptomatic cure, which
is not really cure at all, we simply clear up the symptoms for which he
seeks medical advice, without thought for what he may develop next.
Theoretically, the radical cure of syphilis should mean ridding the body
of every single germ of the disease. Practically speaking, we have no
means of telling with certainty when this has been done, or as yet,
whether it ever can be done. It may well be that further study of the
disease will show that, especially in fully developed cases, we simply
reduce the infection to harmlessness, or suppress it, without
eradicating the last few germs. Recent work by Warthin tends to
substantiate this idea. So we are compelled in practice to limit our
conception of radical cure to the condition in which we have not only
gotten rid of every single symptom of active syphilis in the patient,
but have carried the treatment to the point where, so far as we can
detect in life, he never develops any further evidence of the disease.
He lives out his normal span of years in the normal way, and without
having his efficiency as a human being affected by it. In interpreting
this ideal for a given case we should not forget that radical methods of
treating syphilis are new. Only time can pass full verdict upon them.
Yet the efficiency of older methods was sufficient to control the
disease in a considerable percentage of those affected. There is,
therefore, every reason to believe that radical cure under the newer
methods is a practical and attainable ideal in an even higher percentage
of cases and offers all the assurance that any reasonable person need
ask for the conduct of life. It should, therefore, be sought for in
every case in which expert judgment deems it worth while. It cannot be
said too often that prospect of radical cure depends first and foremost
upon the stage of the disease at which treatment is begun, and that it
is unreasonable to judge it by what it fails to accomplish in persons
upon whom the infection has once thoroughly fastened itself.

+Symptomatic or Incomplete Cure.+--Symptomatic "cure" is essentially a
process of cloaking or glossing over the infection. It is easy to obtain
in the early stages of the disease, and in a certain sense, the earlier
in the course of the disease such half-way methods are applied, the
worse it is for patient and public. In the late stages of the disease
symptomatic cure of certain lesions is sometimes justifiable on the
score that damage already done cannot be repaired, the risk of infecting
others is over, and all that can be hoped for is to make some
improvement in the condition. But applied early, symptomatic methods
whisk the outward evidences temporarily out of sight, create a false
sense of security, and leave the disease to proceed quietly below the
surface, to the undoing of its victim. Such patients get an entirely
false idea of their condition, and may refuse to believe that they are
not really cured, or may have no occasion even to wonder whether they
are or not until they are beyond help. Every statement that can be made
about the danger of syphilis to the public health applies with full
force to the symptomatically treated early case. Trifling relapses,
highly contagious sores in the mouth, or elsewhere, are not prevented by
symptomatic treatment and pass unnoticed the more readily because the
patient feels himself secure in what has been done for him. In the first
five years of an inefficiently treated infection, and sometimes longer,
this danger is a very near and terrible one, to which thousands fall
victims every year, and among them, perhaps, some of your friends and
mine. Dangerous syphilis is imperfectly treated syphilis, and at any
moment it may confront us in our drawing rooms, in the swimming pool,
across the counter of the store, or in the milkman, the waitress, the
barber. It confronts thousands of wives and children in the person of
half-cured fathers, infected nurse-maids, and others intimately
associated with their personal life. These dangers can be effectively
removed from our midst by the substitution of radical for symptomatic
methods and ideals of cure. A person under vigorous treatment with a
view to radical cure, with the observation of his condition by a
physician which that implies, is nearly harmless. In a reasonable time
he can be made fit even for marriage. The whole contagious period of
syphilis would lose its contagiousness if every patient and physician
refused to think of anything but radical cure.

In such a demand as this for the highest ideals in the treatment of a
disease like syphilis, the medical profession must, of course, stand
prepared to do its share toward securing the best results. No one
concedes more freely than the physician himself that, in the recognition
and radical treatment of syphilis, not all the members of the medical
profession are abreast of the most advanced knowledge of the subject.
Syphilis, almost up to the present day, has never been adequately taught
as part of a medical training. Those who obtained a smattering of
knowledge about it from half a dozen sources in their school days were
fortunate. Thorough knowledge of the disease, of the infinite variety of
its forms, of the surest means of recognizing it, and the best methods
of treating it, is only beginning to be available for medical students
at the hands of expert teachers of the subject. The profession, by the
great advances in the medical teaching of syphilis in the past ten
years, and the greater advances yet to come, is, however, doing its best
to meet its share of responsibility in preparation for a successful
campaign. The combination of the physician who insists on curing
syphilis, with the patient who insists on being cured, may well be
irresistible.

+Factors Influencing the Cure of Syphilis.--Cost.+--We must admit that,
as matters stand now, few patients are interested in more than a
symptomatic cure. Yet the increasing demand for blood tests, for
example, shows that they are waking up. Ignorance of the possibility and
necessity for radical cure, and of the means of obtaining it, explains
much of the indifference which leads patients to disappear from their
physician's care just as the goal is in sight. But there is another
reason why syphilis is so seldom cured, and this is one which every
forward-looking man and woman should heed. The cure of syphilis means
from two to four years of medical care. All of us know the cost of such
services for even a brief illness. A prolonged one often sets the victim
farther back in purse than forward in health. The better the services
which we wish to command in these days, usually, the greater the cost,
and expert supervision, at least, is desirable in syphilis. It is a
financial impossibility for many of the victims of syphilis to meet the
cost of a radical cure. It is all they can do to pay for symptomatic
care in order to get themselves back into condition to work. We cannot
then reasonably demand of these patients that they shall be cured, in
the interest of others, unless we provide them with the means. In
talking about public effort against syphilis, this matter will be taken
up again. We have recognized the obligation in tuberculosis. Let us now
provide for it in syphilis.

+Factors Controlling the Cure of Syphilis--Stage, Time, Effective
Treatment.+--Three factors enter into the radical cure of syphilis, upon
which the possibility of accomplishing it absolutely depends. The first
of these concerns the stage of the disease at which treatment is begun;
the second is the time for which it is kept up; and the third is the
coöperation of doctor and patient in the use of effective methods of
treatment.

+Cure in the Primary Stage.+--It goes almost without saying that the
prospect of curing a disease is better the earlier treatment is begun.
This is peculiarly so in syphilis. In the earliest days of the disease,
while the infection is still local and the blood test negative, the
prospects of radical cure are practically 100 per cent. This is the
so-called abortive cure, the greatest gift which salvarsan has made to
our power to fight syphilis. It depends on immediate recognition of the
chancre and immediate and strenuous treatment. So valuable is it that
several physicians of large experience have expressed the belief that
even in cases in which we are not entirely sure the first sore is
syphilitic, we should undertake an abortive treatment for syphilis. This
view may be extreme, but it illustrates how enormously worth while the
early treatment of syphilis is.

+Cure in the Secondary Stage.+--The estimation of the prospect of
recovery when the secondary symptoms have appeared and the germs are in
the blood is difficult, owing to the rapid changes in our knowledge of
the disease, which are taking place almost from day to day. The patient
usually presses his physician for an estimate of his chances, and in
such cases, after carefully explaining why our knowledge is fallible and
subject to change, I usually estimate that for a patient who will
absolutely follow the advice of an expert, the prospects are well over
90 per cent good.

+The Outlook in Late Syphilis.+--After the first year of the infection
is passed, or even six months after the appearance of the secondary
rash, the outlook for permanent cure begins to diminish and falls
rapidly from this point on. That means that we are less and less able
to tell where we stand by the tests we now have.

In the later stages of the disease we are gradually forced back to
symptomatic measures, and are often rather glad to be able to say to the
patient that we can clear up his immediate trouble without mentioning
anything about his future.

The gist of the first essential, then, is to treat syphilis early rather
than late. If this is done, the prospect of recovery is better than in
many of the acute fevers, such as scarlet fever, a matter of every day
familiarity, and better, on the whole, than in such a disease as
tuberculosis. _Yet this does not mean that the men or women whose
syphilis is discovered only after a lapse of years, must be abandoned to
a hopeless fate._ For them, too, excellent prospects still exist, and
careful, persistent treatment may, in a high percentage of cases, keep
their symptoms under control for years, if not for the ordinary
life-time.

+The Time Required for Cure.+--Time is the second vital essential for
cure. Here we stand on less certain ground than in the matter of the
stage of the disease. The time necessary for cure is not a fixed one,
and depends on the individual case. Long experience has taught us that
the cure of syphilis is not a matter of weeks or months, as patients so
often expect, but of years. For the cure of early primary syphilis
("abortive" cure) not the most enthusiastic will discharge a patient
short of a year, and the conservative insist on two years or more of
observation at least. In the fully developed infection in the secondary
stage, three years is a minimum and four years an average for treatment
to produce a cure. Five years of treatment and observation is not an
uncommon period. In the later stages of the disease, when we are
compelled to give up the ideal of radical cure, our best advice to
syphilitic patients, as to those with old tuberculosis, is that after
they have had two years of good treatment, they should submit to
examination once or twice a year, and not grumble if they are called
upon to carry life insurance in the form of occasional short courses of
treatment for the rest of their days.

+Efficient Treatment.+--The third essential is efficient treatment,
about the nature of which there is still some dispute. The controversy,
however, is mainly about details. In the modern methods for treatment of
syphilis both salvarsan and mercury are used, as a rule, and keep the
patient decidedly busy for the first year taking rubs and injections,
and pretty busy for the second. The patient is not incapacitated for
carrying on his usual work. The intervals of rest between courses of
salvarsan and mercury are short. In the third year the intervals of rest
grow longer, and in the absence of symptoms the patient has more chance
to forget the trouble. Here the doctor's difficulties begin, for after
two or three negative blood tests with a clear skin, all but the most
conscientious patients disappear from observation. These are the ones
who may pay later for the folly of their earlier years.

The aim in syphilis, then, is to crush the disease at its outset by a
vigorous campaign. Not until an amount of treatment which experience
has shown to be an average requirement has been given, is it safe to
draw breath and wait to see what the effect on the enemy has been.
Dilatory tactics and compromises are often more dangerous than giving a
little more than the least amount of treatment possible, for good
measure. This is, of course, always provided the behavior of the body
under the ordeal of treatment is closely studied and observed by an
expert and that it is not blindly pushed to the point where injury is
done by the medicine rather than the disease.

+The Importance of Salvarsan.+--Salvarsan is an absolute essential in
the treatment of those early infections in which an abortive cure can be
hoped for, and in them it must be begun without a day's delay. To some
extent, the abortive cure of the disease, with its 100 per cent
certainty, will therefore remain a luxury until the public is aroused to
the necessity of providing it under safe conditions and without
restrictions for all who need it. At all stages of the disease after the
earliest it is an aid, and a powerful one, but it cannot do the work
alone, as mercury usually can. But though mercury is efficient, it is
slow, and the greater rapidity of action of salvarsan and its power to
control infectious lesions give it a unique place. The combination of
the two is powerful enough to fully justify the statement that none of
the great scourges of the human race offers its victim a better prospect
of recovery than does syphilis.

Is a cure worth while? There is only one thing that is more so, and
that is never to have had syphilis at all. The uncured syphilitic has a
sword hanging over his head. At any day or hour the disease which he
scorned or ignored may crush him, or what is worse, may crush what is
nearest and dearest to him in the world. It does it with a certainty
which not even the physician who sees syphilis all the time as his
life-work can get callous to. It is gambling with the cards stacked
against one to let a syphilitic infection go untreated, or treated short
of cure. It is criminal to force on others the risks to which an
untreated syphilitic subjects those in intimate contact with him.

+The Meaning of "You are Cured."+--How do we judge whether a patient is
radically cured or not? Here again we confront the problem of what
constitutes the eradication of the disease. In part we reckon from long
experience, and in part depend upon the refinement of our modern tests.
Repeated negative Wassermann tests on the blood over several years,
especially after treatment is stopped, are an essential sign of cure.
This must be reinforced, as a rule, by a searching examination of the
nervous system, including a test on the fluid of the spinal cord. This
is especially necessary when we have used some of the quick methods of
cure, like the abortive treatment. When we have used the old reliable
course, it is less essential, but desirable. Can we ever say to a
patient in so many words, "Go! you are cured"? This is the gravest
question before experts on syphilis today, and in all frankness it must
be said that the conservative man will not answer with an unqualified
"Yes." He will reserve the right to say to the patient that he must from
time to time, in his own interest, be reëxamined for signs of
recurrence, and perhaps from time to time reinforce his immunity by a
course of rubs or a few mercurial injections. Such a statement is not
pessimism, but merely the same deliberate recognition of the fallibility
of human judgment and the uncertainty of life which we show when we
sleep out-of-doors after we have been suspected of having tuberculosis,
or when we take out accident or life insurance.




Chapter X

Hereditary Syphilis


It seems desirable, at this point, to take up the hereditary
transmission of syphilis in advance of the other modes of transmitting
the disease, since it is practically a problem all to itself.

Syphilis is one of the diseases whose transmission from parent to child
is frequent enough to make it a matter of grave concern. It is, in fact,
the great example of a disease which may be acquired before birth. Just
as syphilis is caused only by a particular germ, so hereditary syphilis
is also due to the same germ, and occurs as a result of the passage of
that germ from the mother's body through the membranes and parts
connecting the mother and child, into the child. Hereditary syphilis is
not some vague, indefinite constitutional tendency, but syphilis, as
definite as if gotten from a chancre, though differing in some of its
outward signs.

+Transmission of Syphilis From Mother to Child.+--It is a well-known
fact that the mothers of syphilitic children often seem conspicuously
healthy. For a long time it was believed that the child could have
syphilis and the mother escape infection. The child's infection was
supposed to occur through the infection of the sperm cells of the father
with the germ of syphilis. When the sperm and the egg united in the
mother's body, and the child developed, it was supposed to have syphilis
contracted from the father, and the mother was supposed to escape it
entirely in the majority of such cases. This older idea has been largely
given up, chiefly as a result of the enormous mass of evidence which the
Wassermann test has brought to light about the condition of mothers who
bear syphilitic children, but themselves show no outward sign of the
disease. It is now generally believed that there is no transmission of
syphilis to the child by its father, the father's share of
responsibility for the syphilis lying in his having infected the mother.
None the less, it must be conceded that this is still debatable ground,
and that quite recently the belief that syphilis can be transmitted by
the father has been supported on theoretical grounds by good observers.

+Absence of Outward Signs in Syphilitic Mothers.+--The discovery that
the mother of a syphilitic child has syphilis is of great importance in
teaching us how hereditary syphilis can be avoided by preventing
infection of the mother. It is even more important to understand because
of the difficulty of convincing the seemingly healthy mother of a
syphilitic child that she herself has the disease and should be treated
for it, or she will have other syphilitic children. Just why the mother
may never have shown an outward sign of syphilis and yet have the
disease and bear syphilitic children is a question we cannot entirely
answer, any more than we can explain why all obvious signs of syphilis
are absent in some patients even without treatment, while others have
one outbreak after another, and are never without evidence of their
infection, unless it is suppressed by treatment. Probably at least a
part of the explanation lies in the fact, already mentioned, that
syphilis is a milder disease in women than in men, and has more
opportunities for concealing its identity.

+Healthy Children of Syphilitic Mothers.+--If the mother of a syphilitic
child has the disease, is it equally true that a syphilitic mother can
never bear a healthy child? It certainly is not, especially in the late
years of the disease, after it has spent much of its force. When the
multitudes of germs present in the secondary period have died out,
whether as a result of treatment or in the normal course of the disease,
a woman who still has syphilis latent in her or even in active tertiary
form, may bear a healthy child. Such a child may be perfectly healthy in
every particular, and not only not have syphilis, but show no sign that
the mother had the disease. It is in the period of active syphilis, the
three, four, or five years following her infection, that the syphilitic
mother is most likely to bear syphilitic children.

+Non-hereditary Syphilis in Children.+--Syphilis in children is not
always hereditary, even though the signs of it appear only a short time
after birth. A woman who at the beginning of her pregnancy was free from
the disease, may acquire it while she is still carrying the child as a
result of her husband's becoming infected from some outside source. The
limitation which pregnancy may put on sexual indulgence leads some men
to seek sexual gratification elsewhere than with their wives. The
husband becoming infected, then infects his pregnant wife. There are no
absolute rules about the matter, but if the mother is not infected until
the seventh month of her pregnancy, the child is likely to escape the
hereditary form of the disease. On the other hand, imagine the prospects
for infection when the child is born through a birth-canal filled with
mucous patches or with a chancre on the neck of the womb. Children
infected in this way at birth do not develop the true hereditary form of
the disease, but get the acquired form with a chancre and secondary
period, just as in later life.

+Effect of Syphilis on the Child-bearing Woman.+--What does syphilis
mean for the woman who is in the child-bearing period? In the first
place, unlike gonorrhea, which is apt to make women sterile, syphilis
does not materially reduce the power to conceive in most cases. A woman
with active syphilis alone may conceive with great frequency, but she
cannot carry her children through to normal birth. The syphilitic woman
usually has a series of abortions or miscarriages, in which she loses
the child at any time from the first to the seventh or eighth month. Of
course, there are other causes of repeated miscarriages, but syphilis is
one of the commonest, and the occurrence of several miscarriages in a
woman should usually be carefully investigated. The miscarriage or
abortion occurs because the unborn child is killed by the germs of the
disease, and is cast out by the womb as if it were a foreign body.
Usually the more active the mother's syphilis, the sooner the child is
infected and killed, and the earlier in her pregnancy will she abort.
Later in the disease the child may not be infected until well along, and
may die only at the ninth month or just as it is born. In other words,
the rule is that the abortions are followed later by one or more still
births. This is by no means invariable. The mother may abort once at the
third month, and with the next pregnancy bear a living syphilitic child.
The living syphilitic children are usually the results of infection in
the later months of the child's life inside its mother, or are the
result of higher resistance to the disease on the part of the child or
of the efficient treatment of the mother's syphilis.

+Variations on the Rule.+--It should never be forgotten that all these
rules are subject to variation, and that where one woman may have a
series of miscarriages so close together that she mistakes them for
heavy, irregular menstrual flows, and never realizes she is pregnant,
another may bear a living child the first time after her infection, or
still another woman after one miscarriage may have a child so nearly
normal that it may attain the age of twenty or older, before it is
suspected that it has hereditary syphilis. Again a woman with syphilis
may remain childless through all the years of her active infection, and
finally, in her first pregnancy, give birth to a healthy child, even
though she still has the disease in latent form herself. Still another
may have a miscarriage or two and then bear one or two healthy children,
only to have the last child, years after her infection, be stillborn
and syphilitic. The series of abortions, followed by stillborn or
syphilitic children, and finally by healthy ones, is only the general
and by no means the invariable rule.

+Treatment of the Mother.+--For the mother, then, syphilis may mean all
the disappointments of a thwarted and defeated maternity, and the
horrors of bearing diseased and malformed children. She is herself
subject to the risk of death from blood poisoning which may follow
abortion. But here, as in all syphilis, early recognition and thorough
treatment of the disease may totally transform the situation. In the old
days of giving mercury by mouth and without salvarsan, there was little
hope of doing anything for the children during the active infectious
period in the mother. Now we are realizing that even while the child is
in the womb the vigorous treatment of the mother may save the day for
it, and bring it into the world with a fair chance for useful and
efficient life. More especially is this true when the mother has been
infected while carrying the child, or just before or as conception
occurred. In these cases, salvarsan and mercury, carefully given, seem
not only not harmful to mother and child, but may entirely prevent the
child's getting the disease. For this reason every maternity hospital or
ward should be in a position to make good Wassermann blood tests,
conduct expert examinations, and give thorough treatment to women who
are found to have syphilis. There does not seem to be any good reason
why a Wassermann test should not be made part of the examination which
every intelligent mother expects a physician to make at the beginning
of her pregnancy. Such a test would bring to light some otherwise
undiscovered syphilis, and protect the lives of numbers of mothers and
children whose health and happiness, not to say life, are now sacrificed
to blind ignorance.

+Effect of Hereditary Syphilis on the Unborn Child.+--In the effect of
hereditary syphilis on the child, we see the most direct illustration of
the deteriorating influence of the disease on the race. Here again we
must allow for wide variation, dependent on circumstances and on
differences in the course of the disease. This does not, however,
conceal the tragedy expressed in the statement that, under anything but
the most expert care, more than 75 per cent of the children born with
syphilis die within the first year of life. Good estimates show that
more often 95 per cent than fewer of untreated children die. Such
figures as those of Still are not at all exceptional--of 187 children of
syphilitic parents, born or unborn, 113 were lost, whether by
miscarriage, still-birth, or in spite of treatment after they were born.
It is estimated that not more than 28 per cent of syphilitic children
survive their first year. Those that survive the first year seem to have
a fighting chance for life. Statistics based on over 100,000 cases show
that about one child in every 148 from two to twelve years of age has
hereditary syphilis. Realizing the difficulty in recognizing the disease
by examination alone, it is entirely safe to suppose that the actual
figures are probably higher. The statistics given at least illustrate
how few syphilitic children survive to be included in such an estimate.

+Moral Effect on the Parents.+--The real extent of the damage done by
the disease as a cause of death in infancy is scarcely appreciated from
figures alone. There is something more to be reckoned with, which comes
home to every man or woman who has ever watched for the birth of a child
and planned and worked to make a place for it in the world. The loss or
crippling of the new-born child jars the character and morale of the
father and mother to the root. When the object of these ideals dies,
something precious and irreplaceable is taken from the life of the
world. The toll of syphilis in misery, in desolation, in
heart-breakings, in broken bonds and defeated ideals can never be
estimated in numbers or in words.

+Course of Hereditary Syphilis in the Infant.+--The course of syphilis
in the child tends to follow certain general lines. The disease, being
contracted before birth, shows its most active manifestations early in
life. The stillborn child is dead of its disease. The living child may
be born with an eruption, or it may not develop it for several weeks or
months. It is thought by some that these delayed eruptions represent
infections at birth. Hereditarily syphilitic children are filled with
the spirochetes, the germs of the disease. They are in every tissue and
organ; the child is literally riddled with them. In spite of this it may
for a time seem well. The typical syphilitic child, however, is thin,
weak, and wasted. Syphilis hastens old age even in the strong. It turns
the young child into an old man or woman at birth. The skin is
wrinkled, the flesh flabby. The face is that of an old man--weazened,
pinched, pathetic, with watery, bleary eyes, and snuffling nose. The
mother often says that all the baby's trouble started with a bad cold.
The disease attacks the throat, and turns the normal robust cry of a
healthy infant into a feeble squawk. The belly may become enormously
distended from enlargement of the internal organs, and the rest of the
child dwindle to a skeleton. The eruptions are only a part of the
picture and may be absent, but when they occur, are quite
characteristic, as a rule, especially about the mouth and buttocks, and
do not usually resemble the commoner skin complaints of infants. It is
important to remember here that a badly nourished, sickly child with a
distressing eczema is not necessarily syphilitic, and that only a
physician is competent to pass an opinion on the matter. Syphilitic
children in a contagious state are usually too sick to be around much,
so that the risk to the general public is small. On the other hand, the
risk to some woman who tries to mother or care for some one else's
syphilitic child, if the disease is active, should be thoroughly
appreciated. Women who are not specially trained or under the direction
of a physician should not attempt the personal care of other people's
sick children.

+The Wet Nurse.+--This is also the proper place to introduce a warning
about the wet nurse. Women who must have the assistance of a wet nurse
to feed their babies should, under no circumstances, make such
arrangements without the full supervision of their physicians. There is
no better method for transmitting syphilis to a healthy woman than for
her to nurse a syphilitic child. Conversely, the healthy child who is
nursed by a syphilitic woman stands an excellent chance of contracting
the disease, since the woman may have sores about the nipples and since
the germs of syphilis have been found in the milk of syphilitic women.
The only person who should nurse a syphilitic child is its own mother,
who has syphilis and, therefore, cannot be infected. A Wassermann blood
test with a thorough examination is the least that should be expected
where any exchanges are to take place. Nothing whatever should be taken
for granted in such cases, and the necessary examinations and questions
should not give offense to either party to the bargain. Syphilis is not
a respecter of persons, and exists among the rich as well as among the
poor.

+Hereditary Syphilis in Older Children.+--Hereditary syphilis may become
a latent or concealed disease, just as acquired syphilis does. None the
less, it leaves certain traces of its existence which can be recognized
on examination. These are chiefly changes in the bones, which do not
grow normally. The shin bones are apt to be bowed forward, not sideways,
as in rickets. The skull sometimes develops a peculiar shape, the joints
are apt to be large, and so on. Syphilis may affect the mental
development of children in various ways. Perhaps 5 per cent of children
are idiots as a result of syphilis. Certain forms of epilepsy are due to
syphilitic changes in the brain. On the other hand, syphilitic children
may be extraordinarily bright and capable for their years. Some are
stunted in their growth and develop their sexual characteristics very
late or imperfectly. It is one of the wonders of medicine to see a
sickly runt of a child at fifteen or sixteen develop in a few months
into a very presentable young man or girl under the influence of
salvarsan and mercury. A few syphilitic children seem robust and healthy
from the start. The signs of the disease may be very slight, and pass
unrecognized even by the majority of physicians. Some of them may be
splendid specimens of physical and mental development, but they are
exceptional. The majority are apt to be below par, and nothing shows
more plainly the insidious injury done by the disease than the way in
which they thrive and change under treatment. Even those who are
mentally affected often show surprising benefits.

+Destructive Changes, Bones, Teeth, Etc.+--Syphilis in children, since
it is essentially late syphilis, may produce gummatous changes of the
most disfiguring type, fully as extreme as those in acquired syphilis
and resulting in the destruction or injury of important organs, and the
loss of parts of bones, especially about the mouth and nose. Certain
changes in the teeth, especially the upper incisors in the second set,
are frequent in hereditarily syphilitic children, but do not always
occur. These peg-shaped teeth are called Hutchinson's teeth. Individuals
with hereditary syphilis who survive the early years of life are less
likely to develop trouble with the heart, blood vessels, or nervous
system than are those with acquired syphilis.

+Eye Trouble--Interstitial Keratitis.+--Two manifestations of
hereditary syphilis are of obvious social importance. One of these is
the peculiar form of eye trouble which such children may develop. It is
known as interstitial keratitis, and takes the form of a gradual, slow
clouding of the clear, transparent convex surface of the eyeball, the
cornea, through which the light passes to reach the lens. While the
process is active, the child is made miserable by an extreme
sensitiveness to light, the eye is reddened, and there is pain and a
burning sensation. When the condition passes off, the child may scarcely
be able to distinguish light from dark, to say nothing of reading,
finding its way about, or doing fine work. A certain amount of the
damage, once done, cannot be repaired, although cases improve
surprisingly if the process is still active and is properly treated. The
course is slow, often a matter of years, and only too many patients do
very poorly on the sort of care they can get at home. One eye case in
every 180 has interstitial keratitis, according to reliable figures.[9]
Of 152 with this trouble, only 60 per cent recovered useful eye-sight
and the remaining 40 per cent were disabled partly or completely.
Forty-three out of 71 persons lost more or less of their capacity for
earning a living. In practically all cases it means the loss of months
or years of school between the ages of five and ten and a permanent
handicap in later life. These patients would belong in school-hospitals,
if such things existed, where they could get the elaborate treatment
that might save their eyes, and at the same time not come to a
stand-still mentally. Any chronic inflammatory eye disease in children
urgently needs early medical attention, and those who know of such cases
should do what they can to secure it for them.

    [9] Iglesheimer, quoted by Derby.

Blindness in hereditary syphilis may, of course, take the same form that
it does in the acquired disease, resulting from changes in the nerve of
sight (optic nerve). This form is entirely beyond help by treatment.

+Ear Trouble--Nerve Deafness.+--The second important complication of
hereditary syphilis is deafness. This occurs from changes in the nerve
of hearing and may be present at birth or may come on many years later.
The deaf infant is usually recognized by its failure to learn to talk,
although it may seem perfectly normal in every other way. Again, the
child may hear well at birth and deafness may come on in later life,--as
late as the twentieth year,--suddenly or gradually, and become complete
and permanent. It is often ascribed to colds or to falls and accidents
that happen to occur at the same time. If syphilitic deafness comes on
before the age of ten years, it is very apt to result in the child's
forgetting how to talk, and becoming dumb as well. It goes without
saying that children whose syphilis made them deaf at birth never learn
to talk at all, and are therefore deaf and dumb. Very little is known
about how many of the inmates of asylums for the deaf are hereditary
syphilitics, but there is reason to suspect the percentage to be rather
large. Deafness in hereditary syphilis is practically uninfluenced by
treatment.

+Accident and Injury in Hereditary Syphilis.+--It is a matter of great
importance to realize the large part played by accidents, injury, poor
health, or lowered resistance in bringing a hidden hereditary syphilis
to the surface. A child may show no special signs of the disease until
some time during its childhood it has a fall which injures or bruises a
bone or breaks a limb. Then suddenly at the place where the injury was
done a gumma or tertiary syphilitic change will take place and the bone
refuses to heal or unite or a large sore may develop which may be
operated on before the nature of the condition is realized. In the same
way a woman with hereditary syphilis may seem in perfect health, marry,
and suddenly after the birth of her first child, even as late as her
twenty-fifth year, may develop syphilitic eye trouble. It must be
realized that hereditary syphilis is as treacherous as the acquired
disease, and can show as little outward signs before a serious outbreak.
It is part of the duty of every person who suspects syphilis in his
family or who has it himself to let his physician know of it, for the
sake of the help which it may give in recognizing obscure conditions in
himself or his children.

+Marriage and Contagion in Hereditary Syphilis.+--In general it may be
said that, in the matter of marriage, persons who have hereditary
syphilis and live to adult life with good general health can, after
reasonable treatment, marry without fear of passing on the disease.
Hereditary syphilis apparently is not transmitted to the children as
acquired syphilis is. Hereditary syphilis practically is not contagious
except during the eruptions and active manifestations in infancy, such
as the nasal discharge and the other sores in the mouth and about the
genitals. As adults they can enter into the intimate relations of life
without risk. Many of them, while perhaps having positive blood tests
while the disease is active, later become negative without treatment.
Some of them even recover from the disease to the extent that they can
acquire it again, since there is no absolute immunity.

+Syphilis in Adopted Children.+--A word might well be said at this point
on the adoption of children with hereditary syphilis. In all probability
this is not a common occurrence, certain factors tending to diminish the
risk. A child adopted after its second year will not be so likely to
have the disease, since most syphilitic children die before this age is
reached. Agencies which arrange for the adoption of children are now
much more careful about the matter than formerly, and a Wassermann test
on the mother and also on the child, as well as a careful history in the
case of the mother, is frequently available. The information in regard
to the mother is quite as important as that about the child, since the
child may have a negative test while the mother's may be positive.
Children who have hereditary syphilis, even in latent form, should not
be offered for adoption, and should become a charge upon the state.
Families in which it later develops that an adopted child was syphilitic
should not, however, be needlessly alarmed for their own safety, since,
from the standpoint of infectiousness, the late forms of hereditary
syphilis are not dangerous to others. The agency from which the child
was adopted should assume responsibility for the child if the family
cannot meet the situation. The state of Michigan has been a pioneer in
this country in legislation which provides for the welfare of these
children among others. A law has been enacted making it possible to
provide for their medical treatment for an indefinite period in the
state hospital at Ann Arbor, at the cost of the state.

+Treatment of Hereditary Syphilis.+--The question of the treatment and
cure of a person with hereditary syphilis is in many respects a
different one from that in an acquired case. The foothold which the germ
has in the body in hereditary syphilis is stronger even than in an
untreated acquired case. Many of the changes produced by it are
permanent, and the prospects of completely eradicating it are
correspondingly small. On the other hand, the child who survives
hereditary syphilis has probably an enormous resistance to the disease,
which in a measure compensates for the hold which it has on him.
Treatment in hereditary syphilis becomes an extremely difficult problem
because it must in many cases be carried out during infancy, and for
that reason the coöperation of the patient cannot be secured. By
treating the mother, we now know that we can accomplish a great deal for
the unborn child. Once the child is born, its salvation will depend on
unremitting care and labor. If it is skilfully treated and kept at the
breast, it is estimated that it has even as high as ninety chances in
one hundred of surviving to a useful life. Salvarsan can be given to
even very small babies, and mercury also is employed with excellent
results. Persistence and skill are essential, and for that reason, if
possible, hereditary syphilis in active form in later childhood should
have the advantage of occasional or prolonged treatment in special
hospitals or sanitariums where the child could go to school while he is
being built up and cared for. This is not like trying to salvage
wreckage. Many syphilitic children are brilliant, and if treated before
they are crippled by the disease, give every sign of capacity and great
usefulness to the world. Welander, who was one of the greatest of
European experts on syphilis, has left himself an enduring monument in
the form of the so-called Welander homes, which have been established by
cities like Copenhagen, Berlin, and Vienna to provide for such children
the combined benefits of the school and the hospital. We cannot be too
prompt in adopting similar provision for such cases in this country.
There can be little excuse, eugenic or otherwise, for not doing the
utmost that modern medical science is capable of for their benefit.




Chapter XI

The Transmission and Hygiene of Syphilis


The problem of the control of syphilis as a contagious disease is the
least appreciated and the most important one in the whole field. It
should be the key to our whole attitude toward the disease, and once
given its rightful place in our minds, will revolutionize our situation
with regard to it. For that reason, while some repetition of what has
gone before may be unavoidable, it will be worth while to gather in one
chapter the details relating to the question of how the disease is
spread about.

Two bed-rock facts stand out as the basis for the whole discussion.
First, for practical purposes syphilis is contagious only in the primary
and secondary stages. Second, syphilis is transmitted only by open sores
or lesions whose discharges contain the germs, or by objects which are
contaminated by those discharges. Infection with syphilis by such fluids
as the blood, milk, or spermatic fluid uncontaminated by contact with
active lesions is at least unusual.

+Contagiousness in the Primary Stage.+--The chancre is always
contagious. If it is covered with a dry crust, it is, of course, less
so, but as soon as the crust is rubbed off, the germ-infested surface is
exposed and the thin, watery discharge contains immense numbers of the
organisms, especially in the first two or three weeks. This is just as
true of a chancre on the lip or chin as on the genitals. Chancres which
are in moist places, as in the mouth, or on the neck of the womb, or
under the foreskin, are especially dangerous, because the moisture keeps
the germs on the surface.

+Contagiousness in the Secondary Stage.+--In the secondary period, when
the body is simply filled with germs, one would expect the risk to be
even greater than in the primary stage. As a matter of fact, however, no
matter how many germs there are in the body, the only ones that are
dangerous to others are those that are able to get to the surface. A
syphilitic nodule or hard pimple on the hand or face is not contagious
so long as the skin is dry and unbroken over it. The sores which occur
in the moist, warm, protected places, like the mouth, on the lips, about
the genitals, and in the folds of the body, such as the thighs, groins,
armpits, and under the breasts in women, are, like the chancre, the real
sources of danger in the spread of the disease.

+Relatively Non-contagious Character of Late Syphilis.+--The older a
syphilis is, the less dangerous it becomes. It is the fresh infection
and the early years which are a menace to others. It will be recalled
that the germs die out in the body in immense numbers after the active
secondary period is over, so that when the tertiary stage is reached,
there is only a handful left, so to speak. The germs in a tertiary sore
are so few in number that for practical purposes it is safe to say they
may be disregarded, and that for that reason late syphilis is
practically harmless for others. Just as every syphilitic runs a gradual
course to a tertiary period, so every syphilitic in time becomes
non-contagious, almost regardless of treatment.

+The Time Element in Contagiousness.+--It is the time that it takes an
untreated case to reach a non-infectious stage and the events or
conditions which can occur in the interval, that perpetuate syphilis
among us. The chancre is contagious for several weeks, and few
syphilitics escape having some contagious secondary lesions the first
year. These are often inconspicuous and misunderstood. They may be
mistaken for cold sores or the lesions about the opening of the rectum
may be mistaken for hemorrhoids, or piles. The recurrence of these same
kinds of sores may make the patient dangerous from time to time to those
about him, without his knowledge. It is an unfortunate thing that the
most contagious lesions of syphilis often give the patient least warning
of their presence in the form of pain or discomfort. While they can
often be recognized on sight by a physician, it is sometimes necessary
to examine them with a dark-field microscope to prove their character by
finding the germs. It is a safer rule to regard every open sore or
suspicious patch in a syphilitic as infectious until it is proved not to
be so.

+Contagious Recurrences or Relapses.+--The duration of the infectious
period in untreated cases and the proportion of infectious lesions in a
given case vary a good deal and both may be matters of the utmost
importance. Some persons with syphilis may have almost no recognizable
lesions after the chancre has disappeared. Others under the same
conditions may have crop after crop of them. There is a kind of case in
which recurrences are especially common on the mucous or moist surfaces
of the mouth and throat, and such patients may hardly be free from them
or from warty and moist growths about the genitals during the first five
years of the disease, unless they are continuously and thoroughly
treated. Irritation about the genitals and the use of tobacco in the
mouth encourage the appearance of contagious patches. Smokers, chewers,
persons with foul mouths and bad teeth, and prostitutes are especially
dangerous for these reasons.

+Average Contagious Period.+--It is a safe general rule, the product of
long experience, to consider a person with an untreated[10] syphilis as
decidedly infectious for the first three years of his disease, and
somewhat so the next two years. The duration of infectiousness may be
longer, although it is not the rule. It must be said, however, that more
exact study of this matter since the germ of syphilis was discovered has
tended to show that the contagious period is apt to be longer than was
at first supposed, and has taught us the importance of hidden sores in
such places as the throat and vagina.

    [10] The control of infectiousness in syphilis through treatment is
    considered in the next chapter.

    [Illustration: FRITZ SCHAUDINN [1871-1906]

    (From the "Galerie hervorragender Aerzte und Naturforscher."
    Supplement to the Münchener med. Wochenschrift, 1906. J. F. Lehmann,
    Munich.)]

+Individual Resistance to Infection.+--The contagiousness of untreated
syphilis is influenced by two other factors besides the mere lapse of
time. The first of these is the resistance or opposition offered to
the germ by the person to whom the infection is carried. The second is
the feebleness of the germ itself, and the ease with which it dies when
removed from the body. In regard to the first of these factors, while
natural resistance to the disease in uninfected persons is an uncertain
quantity, it is very probable that it exists. It is certain that the
absence of any break in the skin on which the germs are deposited makes
a decided difference if it does not entirely remove the risk of
infection. A favorable place for the germ to get a foothold is a matter
of the greatest importance. When, however, it is remembered that such a
break may exist and not be visible, it is evident that little reliance
should be placed on this factor in estimating the risk or possibility of
infection.

+Transmission by Infected Articles.+--The feebleness of the germ and the
ease with which it is destroyed are its redeeming qualities. This is of
special importance in considering transmission by contact with infected
articles. Nothing which is absolutely dry will transmit syphilis.
Moisture is necessary to infection with it, and only articles which have
been moistened, such as dressings containing the discharges, and
objects, such as cups, eating utensils, pipes, common towels, and
instruments which come in contact with open sores or their discharges,
are likely to be dangerous. Moreover, even though these objects remain
moist, the spirochetes are likely to die out within six or seven hours,
and may lose their infectiousness before this. Smooth, non-absorbent
surfaces, especially of metal, are unfavorable for the germ.
Wash-basins, dishes, silverware, and toilet articles are usually
satisfactorily disinfected by hot soapsuds, followed by drying. Barbers,
dentists, nurses, and physicians who take care at least to disinfect
instruments and other objects brought into contact with patients with
carbolic acid and alcohol will never transmit syphilitic infection to
others. Toilet-seats, bath-tubs, and door-knobs, although theoretically
dangerous, are practically never so, and syphilitic infection
transmitted by them can be dismissed as all but unknown. This is in
marked contrast to gonorrhea, which in the case of little girls can be
transmitted apparently by toilet-seats. Much depends, as has been said,
on placing the germ on a favorable ground for inoculation, and the bare
skin, unless the virus is massaged or rubbed in, is certainly not a
favorable situation. Many experts do not hesitate to handle infectious
lesions with the fingers provided the skin is not broken, relying simply
on the immediate use of soap and water, and perhaps alcohol, to remove
the germ. While this may be a risk, it should, none the less, reassure
those who are inclined to an unreasoning terror of infection whenever
they encounter the disease.

+Transmission Under the Conditions of Every-day Life.+--The question of
just how dangerous the worker with foodstuffs may be to others when he
has active contagious lesions is unsettled. Recent surveys of various
types of workers have tended to show that syphilis in transmissible form
is not especially prevalent among them. The same general principle
applies here as elsewhere. The risk of infection with syphilis
increases with dirty and unsanitary conditions, and becomes serious when
there is opportunity for moist materials to be transferred to sensitive
surfaces, like the mouth, sufficiently soon after they have left the
syphilitic person for the germs to be still alive. That the real extent
of the risk is not known does not make it any the less important that
persons who have opportunity to handle materials in which this may occur
should be subject to frequent sanitary inspection. Restaurants in which
the silverware is not properly cleaned, and is used over and over at
frequent intervals, and in which there is a careless and unsanitary type
of personal service, can hardly be regarded as safe. While there is no
need for hysterical alarm over such possibilities, it is just as well to
provide for them. Crowding, close quarters, and insufficient sanitary
conveniences in stores and offices, in restaurants or tenements, provide
just the conditions in which accidental infection may occur. A gang of
men with a common bucket and drinking cup may be at the mercy of
syphilis if one member is in a contagious condition. A syphilitic might
cough into the air with little risk, since the germs would die before
they could find a favorable place to infect. But a syphilitic who coughs
directly into one's face with a mouth full of spirochetes multiplies the
risk considerably. The public towel is certainly dangerous--almost as
much so as the common drinking cup. The possibility of syphilitic
infection by cutting the knuckle of the hand against the teeth of an
opponent in striking a blow upon his mouth should not be overlooked, and
the occurrence is common enough for this type of chancre to have
received the special name of brawl, or fist, chancre.

+Accidental Syphilis in Physicians and Nurses.+--Another type of
infection ought not to go unmentioned--that to which physicians and
nurses are exposed in operating on or handling patients with active
syphilis. Before the day of rubber gloves such things were much more
common perhaps than they are now, yet they are common enough at the
present time. Most of the risk occurs in exploring or working in
cavities of the body containing infected discharges. The blood may
become infected in passing over active sores. The risk from all these
sources is so considerable that it is justifiable as a measure of
protection to a hospital staff to take a blood test on every patient who
applies for treatment in a hospital, to say nothing of the advantage
which this would be to the patient.

+Transmission by Intimate Contacts--Kissing.+--As we pass from the less
to the more intimate means of contact between the syphilitic person and
others, the risk of transmitting syphilis may be said to increase
enormously. The fundamental conditions of moisture, a susceptible
surface, protection of the germ from drying and from air, and possibly
also massage or rubbing, are here better satisfied than in the risks
thus far considered. Kissing, caresses, and sexual relations make up the
origin of an overwhelming proportion of syphilitic infection. Infections
are, of course, traceable to the nursing of syphilitic infants. It is
through these sources of contact that syphilis invades the family
especially. Many a syphilitic who realizes that he should not have
sexual relations with his wife while he has the disease in active form
will thoughtlessly infect her or his children by kissing. Kissing games
are potentially dangerous, and a classical example of this danger is
that of a reported case[11] in which a young man in Philadelphia
infected seven young girls in one game, all of whom developed chancres
on the lips or cheeks. It is no great rarity to find a syphilis dating
from a sore on the lip that developed while a young couple were engaged.
Certainly the indiscriminate kissing of strangers is as dangerous an
indulgence as can be imagined. Syphilis does not by any means invariably
follow a syphilitic's kiss, but the risk, although not computable in
figures, is large enough to make even the impulsive pause. The
combination of a cold sore or a small crack on the lip of the one and a
mucous patch inside the lip of the other brings disaster very near.
Children are sometimes the unhappy victims of this sort of thing, and it
should be resented as an insult for a stranger to attempt to kiss
another's child, no matter on what part of the body. It would be easy to
multiply instances of the ways in which syphilis may be spread by the
careless or ignorant in the close associations of family life, but
little would be accomplished by such elaboration that would not occur to
one who took the trouble to acquaint himself with the principles already
discussed.

    [11] Schamberg, J. F.: "An Epidemic of Chancres of the Lip from
    Kissing," Jour. Amer. Med. Assoc., 1911, lvii, 783.

+The Sexual Transmission of Syphilis.+--The sexual transmission of
syphilis is beyond question the most important factor in the spread of
the disease. Here all the essential conditions for giving the germ a
foothold on the body are satisfied. The genitals are especially fitted
to keep the germs in an active condition because of the ease with which
air is excluded from the numerous folds about these parts. It is
remarkable what trifling lesions can harbor them by the million, and how
completely, especially in the case of women, syphilitic persons may be
ignorant of the danger for others. Sexual transmission of syphilis is
simply a physiologic fact, and in no sense to be confounded with
questions of innocence and guilt in relation to the acquiring of the
disease. A chancre acquired from a drinking cup or pipe may be
transmitted to husband or wife through a mucous patch on the genitals
and to children through an infected mother, without the question of
innocence or guilt ever having arisen. On the other hand, chancres on
parts other than the genitals may be _acquired in any but innocent
ways_. It is impossible to be fair or to think clearly so long as we
allow the question of innocence or guilt to color our thought about the
genital transmission of syphilis. That syphilis is so largely a sexually
transmitted disease is an incidental rather than the essential fact from
the broadly social point of view. We should recognize it only to the
extent that is necessary to give us control over it--not allow it to
hold us helplessly in its grip because we cannot separate it from the
idea of sexual indiscretion. There is a form of narrow-minded
self-righteousness about these things that sets the stamp of vice on
innocent and guilty alike simply on the strength of the sexual
transmission of syphilis. In the effort to avoid so mistaken and
heartless a view, we cannot remind ourselves too often that syphilis is
a disease and not a crime, and as such must be approached with the
impulse to heal and make whole, and not to heap further misfortune on
its victim or take vengeance on him.

+Extragenital and Marital Syphilis.+--Estimates of the ratio of genital
to non-genital or so-called extra-genital infection in syphilis vary a
good deal, and are largely the products of the clinical period in the
history of the disease before the days of more exact methods of
detecting its presence. The older statistics estimate from 5 to 10 per
cent of all syphilitic infections to be of non-genital origin, while the
remaining 90 per cent are genital. As we become better able to recognize
hidden syphilis, we shall probably find that the percentage of
non-genital infections will increase.

The physician's suspicions are easily aroused by a genital sore, less so
by one on the lip or the tonsil, for example. The same thing is true of
the layman. Syphilis which starts from a chancre elsewhere than on the
genitals runs the same course and may conceal itself quite as
effectively as syphilis from the usual sources, and for that reason may
even more easily escape notice because misinterpreted at the start. It
is my personal impression that careful study of patients with syphilis,
and of those who live with them, would bring to light many overlooked
extragenital infections, especially among those who are the victims of
crowding, poor living conditions, and ignorance. Estimates on the amount
of syphilis which is contracted in marriage are apt to be largely
guesswork in the absence of reliable vital statistics on the disease.
Fournier believed that 20 per cent of syphilis in women was contracted
in marriage. So much syphilis in married women is unsuspected, and so
little of what is recognized is traceable to outside sources, that 50
per cent seems a nearer estimate than twenty.




Chapter XII

The Transmission and Hygiene of Syphilis (Continued)


THE CONTROL OF INFECTIOUSNESS IN SYPHILIS.--SYPHILIS AND MARRIAGE

+Means for Controlling Infectiousness.+--The usual method of controlling
a very contagious disease, such as scarlet fever or measles, is to put
the patient off by himself with those who have to care for him and to
keep others away--that is, to quarantine them. This works very well for
diseases which run a reasonably short course, and in which contagious
periods are not apt to recur after the patient has been released. But in
diseases such as tuberculosis and syphilis, in which contagiousness may
extend over months and years, such a procedure is evidently out of the
question. We cannot deprive a patient of his power to earn a living, to
say nothing of his liberty, without providing for his support and for
that of those who are dependent on him. To do this in so common a
disease as syphilis would involve an expenditure of money and an amount
of machinery that is unthinkable. Accordingly, as a practical scheme for
preventing its spread, the quarantine of syphilis throughout the
infectious period is out of the question. We must, therefore, consider
the other two means available for diminishing the risk to others. The
first of these, and the most important, is to treat the disease
efficiently right from the start, so that contagious sores and patches
will be as few in number as possible, and will recur as little as
possible in the course of the disease. This will be in effect a
shortening of the contagious period, and should be recognized as one of
the great aims of treatment. The second means will be to teach the
syphilitic and the general public those things which one who has the
disease can do to make himself as harmless as possible to others. This
demands the education of the patient if we hope for his coöperation, and
demands also the coöperation of those around him in order that the
pressure of public sentiment may oblige him to do his part in case he
does not do it of his own free will.

+Control of Infectiousness by Treatment--Importance of Salvarsan.+--In a
disease which yields so exceptionally well to treatment as syphilis, a
great deal can be done to shorten the contagious period. Especially is
this so when we are able to employ an agent such as salvarsan, which
kills off the germs on the surface within twenty-four hours after its
injection. When a patient is discovered to be in a contagious state, in
a large majority of cases the risk to the community which he represents
can be quickly eliminated, at least for the time being. Combining the
use of mercury and salvarsan in accordance with the best modern
standards, the actively contagious period as a whole can be reduced in
average cases from a matter of years to one of a few weeks or months.
Certainly, so far as recognizable dangerous sores are concerned,
periodic examination, with salvarsan whenever necessary, would seem to
dispose of much of the difficulty.

+Obstacles to Control by Treatment.+--There are, however, obstacles in
the way of complete control of infectiousness by treatment. For example,
one might ask whether a single negative blood test would not be
sufficient assurance that the patient was free from contagious sores. It
is, however, a well-recognized fact that a person with syphilis may
develop infectious sores about the mouth and the genitals even while the
blood test is negative. An examination, moreover, is not invariably
sufficient to determine if a patient is in a contagious state. The value
of an examination depends, of course, entirely on its thoroughness and
on the experience of the physician who makes it. It is only too easy to
overlook one of the faint grayish patches in the mouth or a trifling
pimple on the genitals. The time and special apparatus for a microscopic
examination are not always available. Moreover, contagious lesions come
and go. One may appear on the genitals one day and a few days later be
gone, without the patient's ever realizing that it was there--yet in
this interval a married man might infect his wife by sexual contact. The
patient with a concealed syphilis often lacks even the incentive to seek
examination by a doctor. It is important also to realize that when
mercury has to be the only reliance, the risk of infection cannot be
entirely controlled by treatment. Contagious sores may develop even
during a course of mercurial injections, especially in early cases. It
requires the combination of mercury and salvarsan to secure the highest
percentage of good results.

+The Five-year Rule.+--The truth of the matter is that, as Hoffmann
says, no treatment can _guarantee_ the non-infectiousness of a
syphilitic in the first five years of his disease. Time is thus an
essential element in pronouncing a person non-infectious and hence in
deciding his fitness for marriage, for example. The person with active
syphilis who has intimate relations with uninfected persons, who will
not abandon smoking or take special precautions about articles of
personal use which are likely to transmit the disease, is unsafe no
matter what is done for him. In spite of this qualifying statement it
may be reiterated, however, that good treatment with salvarsan and
mercury reduces the risk of infecting others in the ordinary relations
of life practically to the vanishing point, and of course reduces, but
not entirely eliminates, the dangers of the intimate contacts.

+Personal Responsibility of the Patient.+--If we are compelled then to
fall back to some extent upon the personal sense of responsibility of
the patient himself to fill in the gap where treatment does not entirely
control the situation, it becomes increasingly important that in the
irresponsible and ignorant, when the patient fails to meet his
obligation, we should push treatment to the uttermost in our effort to
prevent the spread of the disease. To supply this necessary treatment to
every syphilitic who cannot afford it for himself, and make it
obligatory, if need be, will be a long step forward in the control of
the disease. The educational campaign for it is well under way all over
the world, and the money and the practical machinery will inevitably
follow. We have the precedents of the control of tuberculosis, smallpox,
malaria, and yellow fever to guide us, to say nothing of a practical
system against sexual disease already in operation in Norway, Sweden,
Denmark, and Italy.

+Syphilis and Marriage.+--The problem of the relation of syphilis to
marriage is simply an aspect of the transmission of an infectious
disease. The infection of one party to the marriage by the other and the
transmission of that infection to children summarizes the social
problem. Through the intimate contacts of family life, syphilis attacks
the future of the human race.

+Estimated Risk of Infecting the Wife.+--How serious is the risk of
infecting the wife if a man should marry during the contagious period of
syphilis? This will depend a good deal on the frequency of relapses
after the active secondary stage. On this point Sperk estimated that in
1518 patients, only ten escaped relapses entirely. These were, however,
not patients that had been specially well treated. Keyes, quoted by
Pusey, estimated, on the basis of his private records, that the chances
taken by a syphilitic husband who used no special precautions to prevent
infecting his wife were twelve to one the first year in favor of
infection, five to two the second year, and one to four the third year,
being negligible after the fourth year.

+Syphilis in the Father.+--Even while we recognize the infection of
women and children as the greatest risk in marriage we should not lose
sight of the cost to society which syphilis in the father of the family
himself may entail. For such a man to be stricken by some of the serious
accidents of late syphilis throws his family as well as himself upon
society. A syphilitic infection which has not been cured not only makes
a man a poor risk to an insurance company, but a poor risk to the family
which has to look to him for support and for his share and influence in
the bringing up of the children. A sufficient number of men and women in
the thirties and forties are crippled, made dependent, or lost to the
world entirely, to make the responsibilities of the family when assumed
by persons with untreated or poorly treated syphilis a matter of some
concern, whether or not they are still able to transmit the disease to
others.

+The Time-treatment Principle and the Five-year Rule.+--In setting a
modern standard for the fitness of syphilitics for marriage it may be
said at the outset that there is little justification for making the
mere fact of a previous syphilitic infection a permanent bar in the
majority of cases. The risk of economic disaster to the parent and
wage-earner, and the risk of transmission of the disease to the partner
and the children, are both controllable by a combination of efficient
treatment and time. The man who has conformed to the best practice in
both particulars may usually marry and have healthy children. The woman
under the same circumstances need not fear that the risk of having
offspring injured by her disease is any greater than the risk that they
will be injured by any other of the unforeseen risks that surround the
bringing of a child into the world. A vast experience underlies what
might be called the time-treatment principle on which permission to
marry after syphilis should be based. It has recently been ably
summarized again, and with commendable conservatism, by Hoffmann in the
rule that a syphilitic who has been efficiently treated by modern
standards, with mercury and salvarsan, over a period of two to three
years, and who has remained free from all symptoms and signs of the
disease for two years after all treatment was stopped, including
negative blood and spinal fluid tests, may marry in from four to five
years from the beginning of his infection. Variations of this rule must
be allowed only with great conservatism, since salvarsan, on whose
efficiency many pleas for a shortening of probation have been based, is
still too recent an addition to our implements of warfare to justify a
rash dependence upon it. The abortive cure in relation to marriage is a
problem in itself, and the shortening of time allowed in such cases must
be individually determined by an expert who has had the case in charge
from the beginning, and not, at least as yet, by the average doctor.
Such a standard as this for the marriage of persons who have had
syphilis steers essentially a middle course between those who condemn
syphilitics to an unreasonable and needless deprivation of all the joys
of family life, and those who are too ready to take our conquest of
syphilis for granted and to cast to the winds centuries of experience
with the treachery of the disease.

Even while we concede the value of generations of experience with
syphilis in determining the probable risk of infection, it is a duty to
investigate thoroughly by the modern methods, such as the Wassermann
blood test, the condition of all members of a family in which syphilis
has appeared. This means, for example, that even though the husband with
syphilis may have married years after the usual period of infectiousness
has passed, his wife, though outwardly healthy, should have a Wassermann
test, and his children would be none the worse for an examination, even
though they seem normal. Syphilis is an insidious disease, a consummate
master of deceit, able to strike from what seems a clear sky. The latest
means for its recognition have already revolutionized some of our
conceptions of its dangers and its transmission. It is only common
prudence to take advantage of them in every case, to forestall even the
remotest possibility of mistake or oversight.

Where both husband and wife have had syphilis, even though both are past
the infectious stage, both should be treated, and a complete cure for
the wife is advisable before they undertake to have children. This must
mean an added burden of responsibility on both physician and patient,
and one extremely difficult to meet under existing conditions. A
reliable means of birth control used in such cases would place the
problem in women on a par with that in men, and give the physician's
insistence on a complete cure for the woman a reasonable prospect of
being needed. Where his advice is disregarded and a pregnancy results,
the woman should be efficiently treated while she is carrying the child.

+Syphilis and Engagements to Marry.+--If a five-year rule is to be
applied to marriage, a similar rule should cover the engagement of a
syphilitic to marry, and it should cover the sexual relations of married
people who acquire syphilis. It is not too much to expect that an
engaged person who contracts syphilis shall break his engagement, and
not renew it or contract another until by the five-year rule he would be
able to marry with safety.

Engagements nowadays may well be thought of as equivalent to marriage
when the question of syphilis is considered. They not infrequently offer
innumerable opportunities for intimacies which may or may not fall short
of actual sexual relations. Attention has been called to this situation
by social workers among wage-earning girls. It has been a distressingly
frequent experience in my special practice to find that the young man,
overwrought by the excitement of wooing, has exposed himself elsewhere
to infection and unwittingly punished the trustfulness of his fiancée by
infecting her with syphilis through a subsequent kiss. The publication
of banns before marriage is worth while, and unmistakable testimony as
to the character and health of the parties concerned might well be
exchanged before a wooing is permitted to assume the character of an
engagement. It is of little use to say that a Wassermann and a medical
examination should be made before marriage, when the damage may be done
long before that point is reached.

+Medical Examination for Syphilis before Marriage.+--How shall we
recognize syphilis in a candidate for marriage? The prevailing idea is
to demand a negative Wassermann test. Assuredly this is good as far as
it goes, but it is not so reliable as to deserve incorporation into law
as sole sufficient evidence of the absence of syphilis, as has been done
in one state. From what has been said, it is plain that a single
negative Wassermann is no proof of the absence of syphilis. The subject
must be approached from other angles, and when syphilis may be
suspected, the question should be decided _by an expert_. A thorough
general or physical examination is desirable, and if this reveals
suspicious signs, such as scars, enlarged glands, etc., it is then
possible to investigate the Wassermann report more thoroughly by
repeating the test, sending it to another expert for confirmation. In
some cases it may even be necessary to insist that the patient submit to
a special test, called the provocative test, in which a small injection
of salvarsan is used to bring out a positive blood test if there is a
concealed syphilis. These are, of course, measures which are seldom
necessary except in patients who have had the disease. Much depends on
the attitude of the patient toward the examination and his willingness
to coöperate. A resourceful physician can usually settle the question of
a person's fitness for marriage, and the result of a reliable
examination offers a reasonable assurance of safety.

+Laws Crippling Physicians in Such Matters.+--What shall the physician
do when confronted with positive evidence that a patient who is about to
marry has an active syphilis? It is important for laymen to understand
that the law relating to professional confidence between physician and
patient ties the hands of the physician in such a situation. For the
doctor to tell the relatives of the healthy party to such an intended
marriage that the other has active syphilis would make him subject to
severe penalties in many states for a violation of professional
confidence, or to suit for libel. Of course, if the patient has agreed
to submit to examination to determine his fitness for marriage, the
physician's path is clear, but if the condition is discovered in
ordinary professional relations, there is nothing to be done except to
try to persuade the patient not to marry--advice he usually rejects. To
this blind policy of protecting the guilty at the expense of the
innocent an immeasurable amount of human efficiency and happiness has
been sacrificed. Fortunately there are signs of an awakening. For
example, Ohio has recently amended the law so as to permit a physician
to disclose to the parties concerned that a person about to be married
has a venereal disease (Amendment to Section 1275, General Code, page
177). This is preventive legislation, as distinguished from the old
policy of locking the stable door after the horse was stolen by laws
punishing one who infects another with a venereal disease after
marriage has been contracted. Recent Supreme Court decisions (Wisconsin)
have also taken the ground that a venereal disease existing at the time
of marriage and concealed from the other party is ground for annulment
of the marriage, provided the uninfected party ceases to have marital
relations as soon as the fact is discovered.

The problem of syphilis in its relation to marriage is, of course, a
serious one. It is safe to say that it will never be completely met
except by a vigorous general public program against syphilis as a
sanitary problem. It is by no means so serious, however, that it need
lead clean young men and women to remain single for fear they will
encounter it. The medical examination of both parties before marriage,
efficiently carried out by disinterested experts, each perhaps of the
other's appointing, is the best insurance a man and woman can secure at
the present day against the risk that syphilis will mar their
happiness.[12]

    [12] The problem of gonorrhea is not considered in the framing of
    this statement.




Chapter XIII

The Transmission and Hygiene of Syphilis (Continued)


SYPHILIS AND PROSTITUTION

In taking up the consideration of the relation of syphilis to illicit
sexual relations, we must again remind ourselves that we are approaching
this subject, not as moralists, important though their point of view may
be, but for the time being as sanitarians, considering it from the
standpoint of a method of transmission of a contagious disease.

+Genital and Non-genital Syphilis in Lax Individuals.+--The prevalence
of syphilis among women who receive promiscuous attentions is enormous.
It is practically an axiom that no woman who is lax in her relations
with men is safe from the danger of the disease, or can long remain free
from it. The type of man who is a Light o' Love does not go far before
he meets the partner who has been infected by some one else. Becoming
infected himself, he passes on his infection to his next partner.
Syphilis is not so often transmitted in prostitution, open or secret, as
gonorrhea, but it is sufficiently so to make the odds overwhelmingly
against even the knowing ones who hope to indulge and yet escape. The
acquiring of syphilis from loose men or women is usually thought of as
entirely an affair of genital contacts. Yet it is notable that
extra-genital chancres are the not uncommon result of liberties taken
with light women which do not go to the extent of sexual relation. Women
who accept intimacies of men who, while unwilling to commit an outright
breach of decency, will take liberties with a woman who will accept them
have only themselves to blame if it suddenly develops that the infection
has been transmitted from one to the other by kisses or other supposedly
mild offenses against the proprieties.

+Syphilis Among Prostitutes.+--As to the prevalence of syphilis among
both public and clandestine or secret prostitutes, several notable
surveys of more or less typical conditions have been made. With the aid
of the Wassermann test much heretofore undiscovered syphilis has been
revealed. Eighty to 85 per cent of prostitutes at some time in their
careers acquire the disease.[13] About half this number are likely to
have active evidence of the disease. Thirty per cent of the prostitutes
investigated by Papee in Lemberg were in the most dangerous period--the
first to the third year of the disease. Three-fourths of these dangerous
cases were in women under twenty-five years of age--in the most
attractive period of their lives. Averaging a number of large European
cities, it was found that not more than 40 per cent of prostitutes were
even free of the outward signs of syphilis, to say nothing of what
laboratory tests might have revealed. It is more than evident that
prostitution is admirably fitted to play the leading rôle in the
dissemination of this disease. The young and attractive prostitute,
whether in a house of ill-fame, on the street, or in the more secret and
private highways and by-ways of illicit sexual life, is the one who
attracts the largest number with the most certain prospect of infecting
them.

    [13] The figures here given are based on those of Papee, Wwednesky,
    Raff, Sederholm, and others. The recently published investigations
    of the Baltimore Vice Commission showed that 63.7 per cent of 289
    prostitutes examined by the Wassermann test had syphilis. Of 266
    examined for gonorrhea, 92.1 per cent showed its presence. Nearly
    half the girls examined had both diseases and only 3.39 per cent had
    neither. (Survey, March 25, 1916, Vol. 35, p. 749.)

+Concealed Syphilis and Medical Examinations of Prostitutes.+--A number
of delusions center around the relation of open and secret prostitution
to disease. From the description of syphilis given in the foregoing
pages, it must be apparent how little reliance can be placed, for
example, on the ordinary medical examination of prostitutes as practised
in segregated districts. The difficulties of efficient examination are
enormous, especially in women. Even with the best facilities and a high
degree of personal skill, with plenty of time and laboratory help in
addition, extremely contagious syphilis can escape observation entirely,
and even the negative result of one day's examination may be reversed by
the appearance of a contagious sore on the next. Women can transmit
syphilis passively by the presence of infected secretions in the genital
canal even when they themselves are not in a contagious state. In the
same way a woman may find herself infected by a man without any idea
that he was in an infectious state. She may in turn develop active
syphilis without ever realizing the fact. Medical examination of
prostitutes as ordinarily carried out does actual harm by deluding both
the women and their partners into a false sense of security. The life
which such women lead, with the combination of local irritation,
disease, and fast living, makes them especially likely to develop the
contagious mucous patches, warts, and other recurrences, and to relapse
so often that there can be little assurance that they are not contagious
all the time.

Under such circumstances one might almost expect every contact with a
prostitute on the part of a non-syphilitic individual to result in a new
infection. The factors which interfere to prevent such wholesale
disaster are the same which govern infectiousness throughout the
disease. Local conditions may be unfavorable, even though the germs are
present, or there may be no break in the skin for the germs to enter. If
the syphilitic individual is beyond the infectious period, there may be
no dangerous lesions. Here, as all through the history of infections
with syphilis, there is an element of the unexpected, a favoring
combination of circumstances. Sometimes when infection is most to be
expected it is escaped, and conversely it seems at times that in the
"sure thing," the "safe chance," and the place where infection seems
most improbable, it is most certain to occur.


PERSONAL HYGIENE IN SYPHILIS

Syphilis is a constitutional disease, affecting in one way or another
the whole body. For that reason, measures directed to improving the
general health and maintaining the resistance of the patient at the
highest point have an important place in the management of the disease.
By his habits and mode of life a person with syphilis does much to help
or hinder his cure, and to protect or endanger those around him. For
that reason a statement of general principles may well be drawn up to
indicate what is desirable in these regards.

+A Well-balanced Life.+--First, for his own sake, a syphilitic should
live a well-balanced and simple life so far as possible. In this disease
the organs and structures of the body which are subject to greatest
strain are the ones most likely to suffer the serious effects of the
disease. Worry and anxiety, excessive mental work, long hours without
proper rest, strain the nervous system and predispose it to attack.
Excessive physical work, fatigue, exhaustion, poor food, bad air,
exposure, injure the bodily resistance. Excesses of any kind are as
injurious as deprivation. In fact, it is the dissipated, the high
livers, who go to the ground with the disease even quicker than those
who have to pinch.

+Alcohol.+--Alcohol in any form, in particular, has been shown by
extensive experience, especially since the study of the nervous system
in syphilis has been carried to a fine point, to have an especially
dangerous effect on the syphilitic. Alcohol damages not only the nervous
system, but also the blood vessels, and makes an unrivaled combination
in favor of early syphilitic apoplexy, general paresis, and locomotor
ataxia. A syphilitic who drinks at all is a bad risk, busily engaged in
throwing away his chances of cure. Even mild alcoholic beverages are
undesirable and the patient should lose no time in dropping them
entirely.

+Tobacco.+--Tobacco has a special place reserved for it as an
unfavorable influence on the course of syphilis. It is dangerous to
others for a syphilitic to smoke or chew because, more than any other
one thing, it causes the recurrence of contagious patches in the mouth.
It is remarkable how selfish many syphilitic men are on this point. In
spite of the most positive representations, they will keep on smoking.
Not a few of them pay for their selfishness with their lives. These
mucous patches in the mouth, often called "smoker's patches," predispose
the person who develops them to one of the most dangerous forms of
cancer, which is especially likely to develop on tissues, like those of
the mouth and tongue, which have been the seat of these sores.

+Sexual Relations, Kissing, Etc.--Contagious Sores.+--Sexual indulgence,
kissing, and other intimate contacts during the active stage of
syphilis, as has been indicated, directly expose others to the risk of
getting the disease. For that reason they should not be indulged in
during the first two years of the average well-treated case receiving
salvarsan and mercury by the most modern methods. Exceptions to this
rule should be granted only by the physician, and should be preceded by
careful and repeated examination in connection with the treatment. Under
no circumstances should a patient kiss or have intercourse if there is
even the slightest sore or chafe on the parts, regardless of whether or
not it is thought to be syphilitic.

+Articles of Personal Use.+--Persons with a tendency to recurrences in
the mouth or elsewhere should report to the physician any sore they may
discover and should watch for them. Persons with syphilitic sores in the
mouth or elsewhere should have their own dishes, towels, toilet
articles, shaving tools, pipes, silverware, and personal articles, and
should not exchange or permit others to use them.

+Secrecy.+--Professional secrecy is something to which the syphilitic is
most certainly entitled when it can be had without danger to the public
health. So long as a syphilitic in the contagious period carefully
observes the principles which ought to govern him in his relations to
others, his condition is his own concern. But there is one person within
the family who should, as a rule, know of his infection if it is still
in the contagious period, since it is almost impossible to secure
coöperation otherwise. No matter how painful it may be, a person with
syphilis, if advised to do so by his physician, should tell husband or
wife the true state of affairs. There is no harder duty, often, and none
which, if manfully performed, should inspire more respect. For those who
will not follow his advice in this matter the physician cannot assume
any responsibility, and is fully justified, and in fact wise, if he
decline to undertake the case.

+Re-infection.+--Since it is a common misconception, it cannot be said
too forcibly that no person with syphilis should forget that his having
had the disease does not confer any immunity, and that as soon as he is
cured he may acquire it again. It is possible, by a single exposure to
infection, to undo the whole effect of what has been done, just after a
cure is accomplished. There can be only one safe rule for infected as
well as uninfected persons--to keep away from the risk of syphilis.

+Quacks and Self-treatment.--Hot Springs.+--The temptation to take up
quack forms of treatment or to treat himself without the advice of a
physician besets the path of the syphilitic throughout the course of the
disease; an enormous number of fraudulent enterprises thrive on the
credulity of its victims. Most of them are of the patent medicine
specific type. Others, however, have a tinge of respectability and are
dangerous simply because they are insufficient and not carried out under
proper direction. Many popular superstitions as to the value of baths in
syphilis and of the usefulness of a short course of rubs with bathing,
or a "trip to the springs," are of this kind. Enough has been said in
the foregoing chapters to make it plain to any one who is open to
conviction that syphilis is no affair for the patient himself to attempt
to treat. The best judgment of the most skilled physicians is the least
that the victim owes himself in his effort to get well.

+Patient and Physician.+--For the same reasons every person who has or
has had syphilis, cured or not, or has been exposed to it, should make
it an absolute rule to inform his physician of the fact. The recognition
of many obscure conditions in medicine depends on this knowledge. For a
patient to falsify the facts or to ignore or conceal them is simply to
work against his own interests and to hinder his physician in his
efforts to benefit him.




Chapter XIV

Mental Attitudes in Their Relation to Syphilis


One's way of looking at a thing has an immense influence on what one
does about it. Obvious as this principle is in the every-day affairs of
life, it becomes still more obvious as one studies a disease and watches
the way in which different individuals react to it. The state of mind of
a few people infected with a rare condition may not seem a matter of
more than passing interest, but in a disease which is a wide-spread and
disastrous influence in human life, the sum-total of our states of mind
about it determines what we do against it and, to no small degree, what
it does to us. Syphilis as a medical problem offers comparatively few
difficulties at the present day. What blocks our progress now is largely
an affair of mental attitudes, of prejudices, of fears, or shame, of
ignorance, stupidity, or indifference. Mental strain, a powerful
influence in many diseases, is a factor in syphilis also, and the state
of mind of the patient has often almost as much to do with the success
of his treatment as has salvarsan or mercury. For that reason it is
worth while to devote a chapter to picturing in a general way the mental
side of syphilis.

+The Public Attitude Toward Syphilis.+--First of all, in order to
understand the mental state of the patient, consider once more the
attitude of the world at large toward the victim of syphilis. A few who
are frankly ignorant of the existence of the disease to start with are
unprejudiced when approached in the right way. But ninety-eight persons
in a hundred who know that there is such a disease as syphilis are alive
to the fact that it is considered a disgrace to have it, and to little
else. Such a feeling naturally chokes all but secret discussion of it.
Most of us remember the day when newspaper copy containing reference to
tuberculosis did not find ready publication. Syphilis is just crossing
this same threshold into publicity. It is now possible to get the name
of the disease into print outside of medical works and to have it
referred to in other ways than as "blood poisoning" in quack
advertisements. The mention of it in lectures on sex hygiene is an
affair of the last twenty years, and the earlier discussions of the
disease on such occasions were only too often vague, prejudiced, and
inaccurate. There are many who still believe, as did an old librarian
whom I met in my effort to reach an important reference work on syphilis
in a great public library. "We used to keep them on the shelves," he
said, "until the high school boys began to get interested, and then we
thought we would reserve the subject for the profession." Syphilis has
been reserved for the profession for five hundred years and the disease
has grown fat on it. The lean times will come when a reasonable
curiosity about syphilis can be satisfied without either shame or
secrecy by a reasonable presentation of the facts. We need the light on
this subject and the light on reserved shelves is notoriously poor. The
stigma attaching to syphilis as a disease is one of the most tragic
examples of a great wrong done to do a little right. What if there are a
few who deserve what they got? We may well ask ourselves how free we are
to cast the first stone. And why single out syphilis as the badge of
venery? The "itch" is transmitted by sexual relations too. Why not make
the itch a sign of shame? The power that has done the damage is not the
intrinsic viciousness of syphilis, but the survival of the old idea of
sexual taboo, the feeling that sex is a secret, shameful thing,
essentially unclean. To this age-old myth some one added the idea of
punishment, and brutalized our conception of syphilis for centuries. If
there were a semblance of crude, stern justice in accepting syphilis as
the divinely established punishment for sexual wrong-doing, protest
would lose half its meaning. Not only does syphilis fail to punish
justly, but there is also something savage, akin almost to the mental
attitude that makes "frightfulness" possible in war, in the belief that
it is necessary to make headway against a sexual enemy by torturing,
ruining, and dismembering men, women, and children, putting out the eyes
of the boy who made a slip through bad companionship and mutilating the
girl who loved "not wisely but too well." Only innocence pays the
spiritual price of syphilis. The very ones whose punishment it should be
are the most indifferent to it, and the least influenced by fear of it
in their pursuit of sexual gratification. I always recall with a shock
the utterance of a university professor in the days when salvarsan was
expected to cure syphilis at a single dose. He rated it as a catastrophe
that any such drug should have been discovered, because he felt that it
would remove a great barrier to promiscuous relations between men and
women--the fear of venereal disease. This is the point of view that
perpetuates the disease among us. It is this attitude of mind that
maintains an atmosphere of disgrace and secrecy and shame about a great
problem in public health and muddles our every attempt to solve it.
Those who feel syphilis to be an instrument adapted to warfare against
sexual mistakes, and are prepared to concede "frightfulness" to be
honorable warfare, will, of course, fold their hands and smugly roll
their eyes as they repeat the words of the secretary of a London Lock
hospital, "I don't believe in making it safe."[14]

    [14] Quoted by Flexner in "Prostitution in Europe."

+Syphilis as a "Disgrace" and a "Moral Force."+--If syphilis really
deterred, really acted as an efficient preventive of license, we might
have to tolerate this attitude of mind, even though we disagreed with
it. I had occasion, during a period of two years, to live in the most
intimate association with about 800 people who had syphilis--every kind
of person from the top to the bottom of the social scale. It was not a
simple matter of ordering pills for them from the pharmacy, or castor
oil from the medicine room. I had to sit beside their beds when they
heard the truth; I had to see the women crumple up and go limp; I had
to tell the blind child's father that he did it, to bolster up the weak
girl, to rebuild the wife's broken ideals, to suppress the rowdy and the
roysterer, to hear the vows of the boy who was paying for his first
mistake, and listen to the stories of the pimp and the seducer. What
made syphilis terrible to the many really fine and upright spirits in
the mass thus flung together in a common bondage? It was not the fear of
paresis, or of any other consequence of the disease. It was the torture
of disgrace, unearned shame, burnt into their backs by those who think
syphilis a weapon against prostitution and a punishment for sin. It
wrecked some of them effectually--left them nothing to live for. It
case-hardened others against the world in a way you and I can well pray
we may never be case-hardened. It left scars on others, and others
laughed it off. Hundreds of sexual offenders passed through my hands,
and in the closest study of their points of view I was unable to find
that in more than rare cases had the risk of syphilis any real power to
control the expression of their desires. Sexual morality is a complex
affair, in which the habit of self-control in many other activities of
life plays an important part. The man or woman who best deserves to be
called clean and honorable and sexually blameless has not become so
through a negative morality and an enlightened selfishness. The man who
does not have bred into him from childhood the instinct to say the
"everlasting no" to his passions will never learn to say it from the
fear of syphilis. Sexual self-control is a habit, not a reasoned-out
affair, and its foundation must rest on the rock bottom of character
and not in the muck of venereal disease.

+The Broader Outlook.+--If, then, it avails nothing in the uplifting of
our morals to treat syphilis as a disgrace, if the disease is
ineffective as a deterrent, and barbarously undiscriminating, inhuman,
and unjust as a punishment, let us in all fairness lay aside the
attitude of mind which has so hindered and defeated our efforts to deal
with it as an arch enemy to human health, happiness, and effectiveness.
In the face of all our harsh traditions it takes a good deal of breadth
of view to look on the disease impersonally, rather than in the light of
one or two contemptible examples of it whom we may happen to know. But,
after all, to think in large terms and with a sympathy that can separate
the sinner from his sin and the sick man from the folly that got the
best of him, is no mean achievement, well worthy of the Samaritan in
contrast with the Levite. To the remaking of the traditional attitude of
harsh, unkindly judgment upon those unfortunate enough to have a
terrible disease, we must look for our soundest hope of progress.

+The Mental States of Syphilitics.+--The mental outlook of the person
with syphilis is in its turn as important a factor in our campaign
against the disease as is that of the person without it. In order to
give some idea of the ways in which this can influence the situation it
may be well to sketch what might be called the four types of mind with
which one has to deal--the conscientious, the average, the
irresponsible, and the morbid. Under the morbid type are included those
persons who, without having syphilis, are in morbid fear of the disease,
or have the fixed belief that they are infected with it, even when they
are not.

+The Conscientious Type.+--Conscientious patients, speaking from the
physician's standpoint, are the product of intelligence and character
combined. Though distinctly in the minority, and usually met in the
better grades of private practice, one is often surprised how many there
are, considering the treacherous and deceptive features of the disease,
which leave so much excuse for laxity and misunderstanding on the part
of the laymen. A conscientious patient is one who is not content with
any ideal short of that of radical cure. It takes unselfishness and
self-control to go without those things which make the patient in the
infectious stage dangerous to others. For a time life seems pretty well
stripped of its pleasures for the man who may not smoke, must always
think beforehand whether any contact which he makes with persons or
things about him may subject others to risk of infection, and perhaps
must meet the misunderstanding and condemnation of others whom he has to
take into his confidence for the same purpose. An element of moral
courage and a keen sense of personal responsibility help to make the
ideal patient in this disease. To meet a treatment appointment promptly
at the same day and hour week after week, to go through the drudgery of
rubbing mercurial ointment, for example, to say nothing of the
unpleasantness of the method to a cleanly person, night after night for
weeks, takes unmistakable grit and a well-developed sense of moral
obligation. The man who has been cured of syphilis has passed through a
discipline which calls for the best in him, and repays him in terms of
better manhood as well as better health.

The physician's coöperation in the development of the necessary sense of
responsibility and the requisite character basis for a successful
treatment is invaluable. To the large majority of the victims of the
disease it is a severe shock to find out what ails them. Many of them,
without saying much about it, give up all hope for a worth-while life
from the moment they learn of their condition. Just as in the old days
the belief that consumption was incurable cost nearly as many lives as
the disease itself, by leading victims to give up the fight when a
little persistence would have won it, so among many who acquire
syphilis, especially when it is contracted under distressing
circumstances, there is a lowering of the victims' fighting strength, a
sapping of their courage which makes them an easy prey to the
indifference to cure that is so fatal in this disease. The person with
syphilis should have the benefit of all the friendly counsel,
reassurance, and moral support that his physician can give, and such
time and labor on the latter's part are richly repaid.

+The Average State of Mind.+--The average mental attitude stops
tantalizingly short of the best type of conscientiousness. Average
patients are good coöperators in the beginning of a course of treatment
or while the symptoms are alarming or obvious, but their energy leaves
them once they are outwardly cured. The average patient only too often
overrules his physician's good judgment on trivial grounds, slight
inconveniences, and temporary considerations, forgetting that cure is
what he needs more than anything else in the world. The deprivations go
hard with this type of patients, and it is difficult, almost impossible,
to persuade them to stop smoking or to abstain from sexual relations or
other contacts that are apt to subject others to risk. Average patients
will almost never remain under the care of a physician until cured. A
year, or at the most two years, is all that can be expected, and a
second or third negative blood test is usually the signal for their
disappearance. They are, of course, lost in the great unknown of
syphilis, and swell the total of deaths from internal causes of
syphilitic origin, such as diseases of the arteries and of the nervous
system. A good many have to be treated for relapses, but the amount of
infection spread by them, while of course unknown, is probably small
considering how many of them there are.

+Effect of the High Cost of Treatment.+--A factor which is extremely
influential in forcing average treatment and ideals on those who, if
opportunity were more abundant, would be conscientious about the
disease, has already been mentioned as the cost of treatment, which is
such that persons with small incomes, who are too proud or sensitive to
seek charitable aid, can scarcely be expected to meet. The cost of
salvarsan under present conditions is a burden that few can hope to
assume to the extent that modern treatment tends to require, and the
slower methods of treatment are more of a tax on the patient's courage
and determination, and less effective in preventing the danger of
infectiousness, although quite as reliable for cure. There is no more
serious problem in the public health movement against syphilis than to
get for the average man who can pay a moderate but not a large fee the
benefits of expensive and elaborate methods of recognizing and treating
a disease such as syphilis. Some practical methods of doing this will be
taken up in the next chapter.

+The Irresponsible.+--The irresponsible attitude of mind about syphilis
forms the background of the darkest and most repellent chapter in the
story of the disease. Yet we ought to confront it if we wish to master
the situation. The irresponsible person has either no regard for, or no
conception of, the rights of others where a dangerous contagious disease
is concerned, and often little conception of, and less interest in, what
is to his own ultimate advantage. Irresponsible syphilitics lack
character first and sense next. Many of them, through the gods-defying
combination of stupidity and ignorance, cannot be approached through any
channel of reason or persuasion. The only argument capable of
influencing such minds is compulsion. Others are, of course, mental
defectives with criminal and perverted tendencies. Yet it is both
amazing and discouraging to find how many irresponsibles there are in
the ordinary and even in the better walks of life. To the wilful type of
irresponsible person the transmission of a syphilitic infection is
nothing, and cannot weigh a straw against the gratification of his
desire or the pursuit of his own interest. The disease cannot teach such
people anything, and if it cannot, how can the physician? Such people
pursue their personal and sexual pleasure, marry, spread disaster around
them, and outlive it all, perhaps brazenly to acknowledge the fact.
Others, suave, attractive, agreeable, seductive, often masquerade as
respectability, or constitute the perfumed, the romantic, the elegant
carriers of disease. The proportion of ignorant to wilful
irresponsibility can scarcely be estimated. But there is little choice
between the two except on the score of the hopefulness of the latter. As
examples of the mixture of types with which a large hospital is
constantly dealing, I might offer the following at random, from my own
recollections: A milkman came to a clinic one morning with an eruption
all over his body and his mouth full of the most dangerously contagious
patches. Two of us cornered him and explained to him in full why he
should come in if only for twenty-four hours. He promised to be back
next morning and disappeared. Another, a butcher in the same condition,
put his wife, whom he had already infected, into the hospital, and in
spite of every argument by all the members of the staff, went home to
attend to his business--the selling of meat over the counter. A
lunch-room helper, literally oozing germs, was after several days
induced to come up for an examination and promised to begin treatment,
whereupon he disappeared. A college student reported with an early
primary sore. "X----," I said, "If you will pledge me your honor as a
gentleman never to take another chance and not to marry until I say you
are cured I will use salvarsan on you, which is just about as scarce as
gold now, and give you a chance for abortive cure." He pledged himself,
and six months later there was every sign that we were going to secure a
perfect result. Suddenly he failed to appear for a treatment
appointment, and I never saw him again. But I did see a letter written
to him by the clinic which showed that he had come up for the
examination with a newly acquired sore while he knew I was away--in all
probability a reinfection. He was not even man enough to face me with
his broken word. Three or four men with chancres may report in an
afternoon and leave, the clinic powerless to detain them or to protect
others against the damage they may do. One such, a Greek boy, had
exposed four different women to infection before we saw him, and only
the most strenuous efforts of the entire staff got him into the
hospital, because he had neither money nor sense. Half-witted tramps,
gang laborers, and foreigners who cannot understand a word of any other
language than Lithuanian or some other of the European dialects for
which no interpreter can be secured, pass in a steady stream through the
free clinics of large cities. The impossibility of securing even the
simplest coöperation from such patients is scarcely realized by any one
who is not called upon to deal with them face to face. Even with an
interpreter, they display the wilfulness of irresponsibility. One
Italian woman wiped her chancre, which was on her lip, with her fingers
at every other shake of the head. She was cooking for two boarders and
had two children. She did not like hospitals and was homesick and
pettish. Would she go over to the dispensary in the next block and find
out how to take care of herself? Not a bit of it. She was going home,
and she went. I saw the children later in the children's ward, both
infected with syphilis--a poor start in life. Criminal intent in the
transmission of syphilis is common enough, and the writer can think
off-hand of four or five cases in which men or women "got" their
estranged partners later in their careers.

+The Necessity for Legal Control.+--All these repulsive details have a
place in driving home a conception of the cost to society of the immoral
and irresponsible syphilitic. Syphilis is an infectious disease,
dangerous to the individual and to society. If it is rational to
quarantine a mouth and throat full of diphtheria germs, it is rational
to quarantine a mouth and throat full of syphilitic germs at least until
the germs are killed off for the time being. There can be no more excuse
for placing society at the mercy of the one than of the other.

+The Morbid Attitude of Mind: Syphilophobia.+--The morbid attitude of
mind, whether in persons who have the disease or in those who fear they
may have it, is one of the hardest the physician has to deal with. Any
one who knows anything of the disease naturally has a healthy desire to
avoid it, and if he is a victim of it, a considerable belief in its
seriousness. But certain types of persons, who are usually predisposed
to it by a nervous makeup, or who have a tendency to brood over things,
or who perhaps have heard some needlessly dreadful presentation of the
facts, become the victims of an actual mental disorder, a temporary
unbalancing of their point of view. To the victims of syphilophobia, as
this condition is called, syphilis fills the whole horizon. If they have
not been too seriously disturbed by the idea, a simple statement of the
facts does wonders toward relieving their minds. A few of them cling
with the greatest tenacity to the most absurd notions. For those victims
of the disease who are the prey of morbid anxiety the assurance that it
is one of the most curable of all the serious diseases, and that if they
are persistent and determined to get well, they can scarcely help doing
so, usually sets their minds at rest. The idea that there is a cloud of
disgrace over the whole subject, and the old-fashioned belief that
syphilis is incurable and hopeless, inflict needless torture and may do
serious damage to the highly organized sensitive spirits which it is to
society's best interest to conserve. The overconscientious syphilitic
hardly realizes that the real horrors of the disease are usually the
rewards of indifference rather than overanxiety. Persons who subject
themselves to the ordinary risks of infection which have been described
in the preceding chapters do well to be on their guard and to maintain
even a somewhat exaggerated caution. Those who do not expose themselves
need not look upon the disease with morbid anxiety or alarm. In the
relations of life in which syphilis is likely to be a factor it should,
of course, be ferreted out. But there is no occasion for panic. We need
a sane consciousness of the disease, a knowledge of its ways and of the
means of prevention and cure for the world at large. We do not need
hysteria, whether personal or general, and there is nothing in the facts
of the situation to warrant the development of such a mental attitude
either on the part of the syphilitic or of those by whom he is
surrounded. Insofar as morbid fear in otherwise normal persons is the
product of ignorance it can be dispelled by convincing them of this
fact.




Chapter XV

Moral and Personal Prophylaxis


Prophylaxis, of course, means prevention, and it has been a large part
of the purpose of the present study to deal with syphilis from the
standpoint of prevention and cure. The material of this chapter is,
therefore, only a special aspect of the larger problem.

+Repression of Prostitution.+--By the moral prophylaxis of syphilis is
meant the cultivation of such moral ideals as will contribute to the
control of a disease which is so closely associated with sexual
irregularities. Since public and secret prostitution serve as the
principal agencies for the dissemination of the disease, it follows that
anything tending to decrease the amount of disease in prostitutes, on
the one hand, or to diminish the amount of promiscuous sexual activity,
on the other, will retard the spread of syphilis. Systems based on the
first ideas, aiming rather to control the disease in public women by
inspection of their health and activities than by suppressing
prostitution, have failed because the methods of control ordinarily
practised are worthless for the detection of infectiousness. So-called
regulation has, therefore, given way very largely in progressive
communities to the second ideal of repressing or abolishing the outward
evidences of vice as far as possible. In behalf of sanitary control of
prostitution, leaving out of the question its moral aspect, it must be
admitted that Neisser, probably the greatest authority on the sexual
diseases, believed that, as far as syphilis is concerned, the use of
salvarsan as a means of preventing infection from prostitutes has never
had a satisfactory trial. In behalf of abolition it would seem that
systematic stamping-out of the outward evidences of vice, the making of
immorality less attractive and conspicuous, is, in theory at least, a
valuable means of diminishing the extent and availability of an
important source of infection.

+Educational Influences.+--To do something positive against an evil is
certainly a more promising mode of attack than to use only the negative
force of repression of temptation. Education of public opinion offers us
just such a positive mode of attack. Men and women and boys and girls
should first be taught sexual self-control even before being made aware
of the risk they run in throwing aside the conventional moral code.
Teach honor first and prudence next. The slogan of education in sexual
self-restraint is the easiest to utter and the most difficult to put
into practice of all the schemes for the control of sexual diseases. A
large part of the difficulty of making education effective arises from
one or two situations which are worth thinking over.

+Economic Forces Opposing Sexual Self-control.+--In the first place,
while continence, or abstinence from sexual relations, is a valuable
ideal in its place, it cannot be indefinitely extended with benefit
either to the individual or to the race. The instinct to reproduce is as
fundamental as the instinct of self-preservation and the desire for
food. A social order which disregards it or defies it will meet defeat.
To an alarming extent the tendency of the present economic system is to
create unsocial impulses by making the normal gratification of sexual
instinct in marriage and the assumption of the responsibility of a
family more and more difficult. The cost of living is steadily rising
without a corresponding certainty on the part of a large proportion of
young men that they can meet it for themselves, to say nothing of
meeting it for wife and children. The uncertainties of a 'job' are often
serious enough to discourage the rashest of men from depending on a
variable earning power to help him do his share for the advancement of
the race. It will be an impossible task to convince even naturally
clean-minded, healthy young men and women that they should live a life
of hopeless virtue because it is part of the divine order that they
should be so held down by hard times and small earnings as to make
marrying and having children an unattainable luxury. Continence and
clean living as preparations for decent and reasonably early marriage
and the raising of a healthy family are the highest of ideals, and ought
to be preached from every housetop. Continence as a life-long punishment
for the impossible demands of an oppressive social and economic order
gets as little attention as it deserves. First, let us make a clean
sexual life lead with greater certainty to some of the rewards that make
life worth living and we shall then have a more substantial basis for
making continence before marriage other than empty words. If every
father, for example, could say to his sons and daughters that if they
showed themselves clean men and women he would back them in an early
marriage, there would be an appreciable decrease in the amount of young
manhood which is now squandered on indecency. If every employer, or the
state itself, would give a clean marriage a preferred position in the
social and economic scale, and, by helping to meet the cost of it,
recognize in a substantial way the value to the race of a family of
vigorous children, an important factor in youthful sexual laxity would
be robbed of its power. No one will assert that such remedial proposals
are of themselves cure-alls for present evils, but they must have at
least an emphatic place in the future of moral prophylaxis.

+The Teaching of Sexual Self-control.+--First then, make the social
order such that sexual self-control yields a reward and not a
punishment. Second, teach sexual control itself, since it is one of the
fundamental means of attack on the problem of syphilis. How can such
control be taught? Information about the physical dangers of illicit
sexual indulgence is of course of value, and should be spread broadcast.
But taken by itself, the fear of disease, especially if it enters the
individual's life after the age when he has already experienced the
force of his sexual instincts, is a feeble influence. The person who has
nothing but the knowledge that he is taking great risks between him and
the gratification of his sexual desires will take the risks and take
them once too often. One cannot begin to teach the boy or girl of high
school age that sexual offenses mean physical disaster, and expect to
control syphilis. The time to control the future of the sexual diseases
is in the toddler at the knee, the child whose daily lesson in
self-control will culminate when he says the final 'No' to his passions
as a man. The child who does not learn to respect his body in the act of
brushing his teeth and taking his bath and exercise, and whose thought
and speech and temper are unbridled by any self-restraint, will give
little heed when told not to abuse his manhood by exposing himself to
filth. The prevention of syphilis by sexual self-control goes down to
the foundations of character, and has practical value only in those
whose self-control is the expression of a lifelong habit of
self-discipline bred in the bone from childhood, not merely painted on
the surface at puberty. Those who want their sons and daughters never to
know by personal experience the meaning of syphilis must first build a
foundation in character for them which will make self-control in them
instinctive, almost automatic. Knowledge of sexual matters has power
only in proportion to the strength of the character that wields it, and
on well-rounded character education, rather than mere knowledge of the
facts, the soundest results will be based.

    [Illustration: E. ROUX

    ÉLIE METCHNIKOFF [1845-1916]

    (From McIntosh and Fildes, "Syphilis from the Modern Standpoint,"
    New York, Longmans Green & Co., 1911.)]

The moral prophylaxis of syphilis is then briefly summed up in the
repression of as many of the recognized agencies for the spread of the
disease as possible; the making of continence a preparation for a normal
sex life rather than an end in itself; the control and remedying of
those influences which are making normal marriage harder of attainment;
and the development of an instinctive self-control and self-discipline
in every field of life from childhood up as the character basis
necessary to make knowledge about sexual life and sexual disease
effective.

+Personal Preventive Methods.--Continence.+[15]--There remains to be
considered what is often called the personal prophylaxis of syphilis,
meaning thereby the methods by which the individual himself can diminish
or escape the risk of infection. The first and most effective method of
avoiding syphilis is abstinence from sexual relations and intimacies
except in normal marriage with a healthy person. Although it has been
alluded to under the moral prophylaxis of syphilis, it deserves to be
reëmphasized. No consideration as to the justice or desirability of
continence and self-restraint can add anything to the simple fact that
it is _the_ way to avoid disease, and can be unhesitatingly recommended
as the standard for personal prophylaxis. In the experience of
physicians it is an axiom that disillusionment sooner or later overtakes
those who think they are exempt from this rule. Persons who discard
continence in favor of what they believe to be some absolutely safe
indulgence are so almost invariably deceived that the exceptions are not
worth considering. Although infection with syphilis is no necessary
evidence of unclean living, clean living will always remain the best
method of avoiding syphilis.

    [15] The American Social Hygiene Association, 105 W. 40th Street,
    New York City, can supply pamphlets and lists of authoritative
    publications bearing on this and related subjects.

+The Metchnikoff Prophylaxis.+--The second method of personal
prophylaxis of syphilis was developed as a result of the discovery of
Metchnikoff and Roux in 1906, that a specially prepared ointment
containing a mercurial salt, if rubbed into the place on which the germs
were deposited within a few hours (not exceeding eighteen hours, and the
sooner the better) after exposure to the risk of syphilis, would prevent
the disease by killing the germs before they could gain a foothold. This
method of protection against syphilis has been subjected to rigid tests,
with fairly satisfactory results. It has been adopted by the army and
navy of practically every country in the world, and, as carried out
under the direction of physicians and with military control of the
patient, has apparently reduced the amount of syphilitic infection
acquired in the armies and navies using it to a remarkable degree. The
method, of course, cannot assume to be infallible, but if intelligently
applied, it is one of the important weapons for the extinction of
syphilis in our hands at the present day. It fails to meet expectations
precisely in those circumstances and among those persons in whom
intelligent employment of it cannot be expected. This of course covers a
considerable number of those who acquire syphilis. What disposal an
awakened opinion will make of this knowledge remains to be seen. At the
present time it may well be doubted whether the indiscriminate placing
of it in the hands of anybody and everybody would not work as much harm
as good through ignorant and unintelligent use. This opinion is shared
by European as well as American authorities. Administered under the
direction of a physician, the Metchnikoff prophylaxis of syphilis would
undoubtedly be at its best in the prevention of the disease. For these
reasons, as well as to prevent the spread of the knowledge to those who
would be damaged by it, those interested are referred to their
physicians for a description of the method. Any one having the benefit
of it should be able to convince his medical advisor that there is good
reason why this kind of professional knowledge should be brought to bear
on his case. The ordinary methods of preventing infection by washes and
similar applications used by the "knowing ones" are most of them
worthless or greatly inferior to the Metchnikoff prophylaxis. They are,
moreover, a positive source of danger because of the false sense of
security which they create. If every person who has run the risk of
contracting syphilis should visit his physician _at once_ to receive
prophylactic treatment, the effect on syphilis at large would probably
be as good as in the army and navy. There would still be opportunity on
such occasions to bring moral forces and influence to bear on those who
would respond to them. There can be no object in withholding such
knowledge from those who are confirmed in their irregular sexual habits.
At the same time there could be few better influences thrown across the
path of one just starting on a wrong track than that exerted by a
physician of skill and character, to whom the individual had appealed to
avert the possible disastrous result of an indiscretion.




Chapter XVI

Public Effort Against Syphilis


+The World-wide Movement Against Venereal Disease.+--This chapter is
intended to give some account of the great movements now begun to
control syphilis and its fellow-diseases throughout the world. A
campaign of publicity was the starting-point of the organized attempt to
control tuberculosis, and in the same way a similar campaign has been at
the bottom of movements which now, under the pressure of the tremendous
necessities of war, are making headway at a pace that generations of
talking and thinking in peaceful times could not have brought about.
Although this country at the present writing is probably farther in the
rear than any other great nation of the world in its efforts to control
the venereal diseases as a national problem, it is fortunate in having
had the way paved for it by epoch-making movements such as those of the
Scandinavian countries, and by the studies of the Sydenham Royal
Commission on whose findings the British Government is now undertaking
the greatest single movement against syphilis and gonorrhea that has
ever been launched. For many years Germany has had a society whose roll
includes some of the greatest names in modern science, directing all its
energy toward the solution of the problem of sexual disease, and German
sentiment on these matters is developing so fast that it is difficult,
even for those in touch with such matters, to keep pace with it. In this
country progress has been much slower, hampered by peculiarities of
mental outlook and tradition very different from those which have
controlled the thought of Europe. The association of syphilis with
prostitution has been largely instrumental in putting much valuable
statistical and general knowledge of the disease into semi-private
reports and sources not available to the large mass of the thinking
public. The effect of finding the problem of syphilis invariably bound
up with discussions of the social evil has been to perpetuate in popular
thought an association which simply blocks the way to any solution of
the public health problem. While the control of prostitution will
influence syphilis, ignoring syphilis, or treating it as incidental,
will never contribute anything to the conquest of either. It is one of
the most significant features of the great movements now on foot all
over the world that they have finally adopted the direct route, and are
attacking syphilis and gonorrhea as diseases and not by way of their
association with prostitution.

The agencies in this country which are making notable efforts to push
the campaign against syphilis and gonorrhea deserve every possible
support from the thinking public. The American Social Hygiene
Association is a clearing-house for trustworthy information in regard to
the problems of sexual disease, and publishes a quarterly journal.[16]
The National Committee for Mental Hygiene and its branch societies are
also engaged in spreading knowledge of the relation of syphilis to
mental disease and degeneration. State and City Boards of Health are
active in their efforts to further the campaign, and notable work is
being done by New York City, Buffalo, Cleveland, and Rochester, New
York, both on publicity and in the provision of facilities for
recognizing and treating the diseases in question. Certain states, such
as Ohio, Michigan, and Vermont, have made steps toward an intelligent
legislative attack on different aspects of the problem. Influential
newspapers and magazines have made the idea of a campaign against these
diseases familiar enough to the public, for example, to bring a young
girl to me to ask outright without affectation that she be told about
syphilis, because she had seen the word in the paper and did not fully
understand it. The aggregate of these forces is large, and an awakening
is inevitable.

    [16] Social Hygiene, New York.

To prepare ourselves for an active and intelligent share in the
movement, we should review briefly the essential elements of a public
campaign against syphilis as they have been developed by recent
investigations and legislative experiments.

+Undesirable and Freak Legislation.+--Syphilis has had a limited amount
of recognition in law, unfortunately not always wise or timely. Freak
legislation and half-baked schemes are the familiar preliminaries which
precede the grim onset of a real attack supported by public sentiment.
Typical examples of such premature legislation may be found in the
setting up of the Wassermann test as evidence of fitness for marriage
by certain states, and in the efforts of certain official agencies to
enforce the reporting of syphilis and gonorrhea by name. Proposals to
quarantine and placard all syphilis are in the same category, though
seriously entertained by some. The plan to establish by state enactment
or municipal appropriation special venereal hospitals falls in the same
class, since it is obvious that in the present state of opinion none but
down-and-outs would resort to them. The stigma attached to them would
effectually make them useless to the very group of worth-while people
which it is to the public interest to conserve and reëducate.

+Value of Conservative Action.+--It cannot be said too often that a
reasonable conservatism should temper the ardor of reformers, or more
harm than good will be done by the collapse and failure of
ill-considered special legislation. Unified action against syphilis and
gonorrhea as public health problems is as important as unified action on
the problems of railroad control, child labor, or corporate monopoly.
For that reason it is a matter of some uncertainty how much can be
accomplished by individual states in this country in the way of
restrictive legislation, such as that controlling the marriage of
infected persons, or punishing persons who fail to carry treatment to
the point of cure. Under the direction of a national bureau or
department of health administration there is no doubt that the movement
against syphilis would advance at a much more rapid pace than with the
sporadic and scattered activities of mixed state and private agencies.

+The Essential Features of a Modern Campaign.+--The repeated sifting of
the facts which has been done in recent years by important
investigations, such as that of the Sydenham Commission in Great Britain
and the Society for Combatting Sexual Disease in Germany, and the
legislative programs already mentioned, have gradually crystallized into
fairly definite form, the undoubted essentials of a program for
controlling venereal diseases, syphilis among them. These may be
summarized as follows:

1. The provision of universally available good treatment, at the expense
of the state, if necessary, for the diseases in question.

2. The provision by the state of efficient means of recognizing the
diseases at the earliest possible time and with the greatest possible
certainty in any given case.

3. The suppression of quack practice, drug-store prescribing, and
advertising of cures for these diseases.

4. Moral and educational prophylaxis and the vigorous suppression of
prostitution.

In addition to these measures, which are common to all proposals and
working systems for the control of sexual disease, certain other
recommendations may be classed as debatable, inasmuch as they are still
under discussion and have been incorporated into some and omitted from
others. These are as follows:

1. General instruction in personal prophylaxis for the population at
large.

2. Compulsory measures and penalties obliging patients to receive
treatment and continue it until cured, regardless of their own desires
in the matter.

3. Notification or reporting of cases of sexual disease to the health
authorities.

4. Indirect legislation, as it might be called, which aims to detect
infected persons before they enter on marriage rather than at the outset
of the disease, either by releasing the physician in charge of the case
from the bond of professional confidence, or by requiring health
certificates before marriage, and which annuls marriages after infection
is discovered.

+Easily Available Treatment.+--It will be noticed that toleration of
prostitution with supervision has finally disappeared from the modern
program for the control of sexual diseases. The provision for
universally available treatment, regardless of the patient's means or
circumstances, should be thought of as the one fundamental requirement
without which no program has made even a beginning. For over a century
Denmark has provided for the free treatment of all patients with
venereal disease. The Norwegian law, essentially similar, dates from
1860. Italy a few years ago adopted a similar program, placing squarely
upon the state the responsibility of providing for the care of all
patients with venereal diseases. England has just adopted a mixed
provision which will in practice place most of the responsibility upon
the state and very little on the individual, as far as the expense of
treatment is concerned. Germany has compelled her insurance companies
to shoulder the burden, and under pressure of war is hastening matters
by invoking more and more governmental aid. The recent West Australian
Act provides that every medical officer in the pay of the state shall
treat venereal disease free of charge. In comparison with the tremendous
advances over previous indifference which such programs represent, this
country makes a poor showing. Among us, no public agency is formally
charged with any duty in the matter of preventing, recognizing, or
treating the vast amount of venereal infection that mars our national
health. Certain state boards of health are attempting to perform
Wassermann tests, and certain municipalities have well-organized
laboratories for the detection of syphilis and gonorrhea, but there are
few purely public agencies that even pretend to have a specialist in
their employ to assist in the recognition of cases and conduct the
treatment of patients who cannot afford private care. Hospital and
dispensary treatment of venereal diseases is almost entirely in
semi-private hands, and a recent investigation of clinics and
dispensaries for the treatment of syphilis and gonorrhea in New York
city, for example, showed that many of them were so poorly equipped and
run at such unreasonable hours that they were frequented only by
vagabonds, were of no value in the early recognition of syphilis, could
not administer salvarsan under conditions to which a discriminating
patient would dare to trust himself, and made no pretense at following
their cases beyond the door or discharging them from medical care as
cured. One of the largest cities in this country until a year ago had
not even a night clinic to which day workers could come, and is scarcely
awake now to the necessity for such a thing.

+Dispensary Service.+--The provision of adequate treatment and
diagnostic facilities, on a par with those which will presently cover
Europe, will mean the following things: First of all, dispensaries, and
many of them, for the identification of early cases, fully equipped with
dark-field microscopes, with record systems, and with the means for
following patients from the time they enter until they are cured. This
means nurses, it means social service workers, it means doctors with
special and not general knowledge of syphilis and gonorrhea. The
Brooklyn Hospital Dispensary is an admirable example of what such an
institution should be, but it is one where such institutions should be
numbered by dozens and by hundreds. Copenhagen, with a population less
than that of several cities in this country which have none, has seven
municipal clinics whose hours and names are prominently advertised.

+Hospitals.+--In the second place there must be hospital facilities.
They must not be venereal hospitals, but services or parts of general
hospitals, so that patients who are received into them will be protected
from stigma and comment. Pontopidan, a Danish expert, estimated that for
the care of venereal disease one hospital bed to every 2000 of
population was insufficient, and yet there are cities in this country
which do not have one bed available for the purpose to 100,000 people.
The hospital performs a peculiarly valuable function in the care of
syphilis in particular. It provides for temporary quarantine, and for
the education of the patient in his responsibility to the community when
he is discharged. Three weeks or more under hospital direction is the
best possible start for an active syphilis that is to be cured. The
privacy of a syphilitic can be protected in a hospital as successfully
as in a specialist's office, and the quality of treatment which can be
given him is distinctly better than he can obtain while out and around.
Hospitals in general have kept their doors closed to syphilis until
recently, and it is only under the pressure of a growing understanding
of what this means to the public health that they are awakening to their
duty.

+Cheap Salvarsan.+--Before a general campaign for the successful
treatment of syphilis can be made a fact, salvarsan must become, as has
already been pointed out, a public and not a private asset. It must be
available to all who need it at the lowest possible cost[17]--practically
that of manufacture--and must be supplied by the state when necessary.
The granting of patent rights which make possible the present
exploitation for gain of such vital agents in the protection of the
public health is a mistake which we should lose no time in remedying.
While salvarsan does not mean the cure of syphilis, it does mean a
large part of its control as an infectious disease. When it can be given
only to the person who can muster from five to twenty-five dollars for
each dose which he receives, it is evident that its usefulness is likely
to be seriously restricted.

    [17] The price of salvarsan before the war was $3.50 per full dose
    for the drug alone. It can be profitably marketed at less than $1.00
    per dose. The patent rights have been temporarily suspended during
    the war, and their renewal by Congress should not be permitted.

+Reduction of the Expense of Efficient Treatment.+--Free treatment for
those who cannot afford to pay is a necessary part of the successful
operation of any scheme for the control of sexual disease. But for those
who can and are willing to pay a moderate amount for what they receive,
there should be pay clinics which will bridge the gap between the rough
and ready quality and the unpleasant associations of a free dispensary,
and the expensive luxuries of a specialist's office. This is a field
which is almost virgin in this country, and which deserves public
support. There is no reason why, for a reasonable fee, the patient with
syphilis should not secure all the benefits of hospital care, the
personal attention of specially trained men, an intelligent supervision
of his case, and the benefit of coöperation between a hospital service
in charge of experts and the home doctor who must care for him during a
considerable part of the course of his disease. Provision of this sort
makes treatment both more attractive and more available to large numbers
of people whose pride keeps them away from the public provision for
charity cases, and whose limited means leave them at the mercy either of
quackery or of well-meaning but entirely inexperienced physicians.

+Value of Expert Services.+--The factor of expert judgment in the care
and recognition of syphilis is an important one, and a progressive
public policy will not neglect to provide for it. The state, municipal
or hospital laboratory which professes to do Wassermann tests should not
be in charge of some poorly paid amateur or of a technician largely
concerned with other matters, or its findings will be worthless. Every
clinic and hospital should also attach to its staff an expert consultant
on syphilis on whom it can draw for advice in doubtful cases and for the
direction of its methods of work. Every city health board which
undertakes a serious campaign against syphilis should not be satisfied
merely with doing Wassermanns, but should enlist in behalf of the public
consultation of the same grade which it expects to employ in the
solution of its traction and lighting problems, and in the management of
its legal affairs. No one would think nowadays of placing a physician in
charge of a great tuberculosis sanitarium whose knowledge of the chest
was confined to what he had learned in medical school twenty or more
years before--yet in a parallel situation one often finds the subject of
syphilis handled with as little attention to the value of expert
knowledge. Expert service is expensive, and if the state wishes to
command the whole energy of progressive men, it must be prepared to pay
reasonably well for what it gets.

+Suppression of Quacks and Drug-store Prescribing.+--The suppression of
quackery is nowhere more urgent than in the control of syphilis. Every
important legislative scheme that has come into existence in recent
years has recognized this fact. The devil may well be fought by fire,
and reputable agencies should enter the field of publicity with some of
the vigor of their disreputable opponents. The brilliant success of this
scheme was admirably illustrated by the results of the recent efforts of
the Brooklyn Hospital Dispensary, which, by replacing the placards of
advertising quacks in public comfort and toilet rooms, and running a
health exhibit on Coney Island, attracted to a clinic where modern
diagnosis and treatment were to be had an astonishing number of young
people who would have fallen victims to quacks. The evil influence of
the drug store in perpetuating the hold of syphilis and gonorrhea upon
us is just being understood. The patient with a beginning chancre, at
the advice of a drug clerk, tries a little calomel powder on the sore,
and it either "dries up" and secondary symptoms of syphilis appear in
due course, or it gets worse or remains unchanged and the patient
finally goes to a doctor or a dispensary to find that his meddling has
lost him the golden opportunity of aborting the disease. If secondaries
appear, a bottle or two of XYZ Specific, again at the suggestion of the
all-knowing drug clerk, containing a little mercury and potassium iodid,
disposes of a mild eruption, and a year or so later a marriage with
subsequent mucous recurrences and the infection of the wife signalizes
the triumph of ignorance and public shortsightedness. The health
commissioner of one of the largest and most progressive cities in this
country stated before a recent meeting of the American Public Health
Association that he had sent a special investigator to twelve
representative drug stores in his city, and that simply on describing
some symptoms, without even the ceremony of an examination, he had
received from ten of them something to use on a sore or to take for
gonorrhea. It is only justice to say that occasionally one finds drug
stores which will refer a patient to a doctor or a dispensary. Drastic
legislation to suppress this sort of malpractice is part of the program
of Great Britain, Germany, and West Australia, and we in this country
cannot too quickly follow in their steps.

+Publicity Campaign.+--The educational campaign against sexual disease
has already been discussed in theory. In close relation to it is the
question of the use of publicity methods for legitimate ends, mentioned
above. It has had a number of interesting applications in practice. The
West Australian law has taken the stand of prohibiting all advertising,
replacing the method of attracting the patient into coming for treatment
of his own free will by the method of making treatment compulsory under
heavy penalty. In this country, where compulsory legislation will be
slow of adoption, publicity methods will have a certain vogue and a
proper place. It has been of great service in the campaign against
tuberculosis and in the movements for "Better Babies" and the like. It
should never be forgotten that it is a two-edged weapon, however, and
that where a stigma exists, as in the case of sexual disease, too much
advertising of the place of treatment as distinguished from the need for
it will drive away the very people whose sensitiveness or need for
secrecy must be considered. On the other hand, the publication of
material relating to sexual diseases in the public press has not yet
reached the height of its possibilities, and should be pushed.

+Utilization of Personal Prophylaxis.+--Passing now to the debatable
elements in a public campaign, opinion about the value of personal
prophylaxis (Metchnikoff) against syphilis shows interesting variations
in different countries at the present time. English-speaking countries
hesitate over this. On the other hand, eminent German authorities, such
as Neisser and Blaschko, urged it at the outset of the present war, and
their views have apparently overcome a vigorous opposition. As a result,
the knowledge of methods of preventing venereal infection are being
spread broadcast over Germany in the hope of diminishing the inevitable
risk that will arise with the disbanding of armies after peace is
concluded, no matter how stringent the precautions taken to insure the
health of soldiers before their return to civil life. The results of
this experiment will be watched with the most intense interest by all
those familiar with the situation, and the results will be of value as a
guide for our own policy when we have had time to develop one. It is
interesting that the most radical departure in the way of legislative
provision for sexual disease, that of West Australia, takes up the
patient at the point where his infection begins and promptly places him
under penalty in the hands of a physician, but assumes no responsibility
for other than indirect prevention. The most radical of all present-day
legal measures against the disease has therefore not yet reached the
radicalism of compulsory prophylaxis as it exists in armies, or even the
radicalism of compulsory vaccination for smallpox.

+Reporting of Syphilis to Health Officers.+--The question of reporting
syphilis to health officers as a contagious disease is a good one to
raise in a meeting when a stormy session is desired. Upon this question
wide differences of opinion exist all over the world. The right of a
sick person to privacy, always deserving of consideration, becomes acute
when it touches not only his physical but his social, economic, and
moral welfare. It becomes a matter of importance to the state also when
the prospect that his secret will not be kept leads him to conceal his
disease and to avoid good public aid in favor of bad private care. It is
a question whether the amount gained by collecting a few statistics as
to the actual presence of the disease will be offset by the harm done in
driving to cover persons who will not be reported. Modified forms of
reporting sexual diseases, without name or address, for example, can be
employed without betraying a patient's identity, thus doing away with
some of the objections, and they have been in force in such cities as
New York for some time. Vermont has recently adopted a compulsory
reporting system, with the almost ludicrous result that by the figures
her population shows 0.5 per cent syphilis, when the truth probably
stands nearer 10 per cent. Much of the difficulty with reporting systems
goes back to the lack of an educated public or professional sentiment
behind them. For this reason they may be fairly placed in the category
of premature legislative experiments, and should be postponed until a
more favorable time. That this view has the sanction of students of such
problems is borne out by the recent comment of Hugh Cabot on this issue,
and by the decision of the British Royal Commission which, after careful
deliberation, decided not to recommend to the Government at the present
time any form of reporting for sexual disease. The West Australian law
recognizes the wisdom of providing the patient having sexual disease
with every safeguard for his secret provided he conforms to the
requirement of the law in the continuance of his treatment. German
sentiment is strongly against reporting, and no provision is made for it
in the civil population. On the other hand, the very complete programs
of the Scandinavian countries provide for reporting cases without names.
It is, therefore, apparent, in view of this conflict of opinion, that we
can afford to watch the experience of our neighbors a little longer
before committing ourselves to the risk of arousing antagonism over a
detail whose importance in the scheme of attack on syphilis is at best
secondary to the fundamental principles of efficient treatment and
diagnosis. There is no apparent reason why we should not be satisfied,
for the present, at least, with drawing to our aid everything which can
give us the confidence and the willing coöperation of those we want to
reach. Physicians who work with large numbers of these patients realize
that privacy is one of the details which has an attraction that cannot
be ignored.

+Compulsory Treatment.+--Compulsory provisions in the law form the
third debatable feature of a modern program against syphilis. The
Scandinavian countries have adopted it, and in them a patient who does
not take treatment can be made to do so. If he is in a contagious
condition, he can be committed to a hospital for treatment. If he
infects another, knowing himself to have a venereal disease, he is
subject, not to fine, but to a long term of imprisonment. The West
Australian law is even more efficient than the Scandinavian in the vigor
with which it supplies teeth for the bite. The penalties for violations
of its provisions are so heavy as to most effectually discourage
would-be irresponsibles. At the other end of the scale we find Great
Britain relying thus far solely upon the provision of adequate
treatment, and trusting to the enlightenment of patients and the
education of public sentiment to induce them to continue treatment until
cured. Italy has, in the same way, left the matter to the judgment of
the patient. The Medical Association of Munich, Germany, in a recent
study has subscribed to compulsory treatment along the same lines as the
West Australia act, although thus far enforcement has been confined to
military districts. The program for disbanding of the German army after
the war, however, includes, under Blaschko's proposals, compulsion and
surveillance carried to the finest details. A conservative summary of
the situation seems to justify the belief that measures of compulsion
will ultimately form an essential part of a fully developed legal code
for the control of syphilis. The reasons for this belief have been
extensively reviewed in the discussion of the nature of the disease
itself (pages 104-105). On the whole, however, the method of Great
Britain in looking first to the provision for adequate diagnosis and
treatment, and then to the question as to who will not avail himself of
it, is a logical mode of attacking the question, and as it develops
public sentiment in its favor, will also pave the way for a sentiment
which will stand back of compulsion if need be, and save it from being a
dead letter.

+Backwardness of the United States in the Movement.+--It will be
apparent, from the foregoing review of the world movement against
syphilis, and the essentials of a public policy toward the disease, that
the majority of our efforts in this direction have been decidedly
indirect. We have no national program of which we as a people are
conscious. It is all we can do to arouse a sentiment to the effect that
something ought to be done. In these critical times we must mobilize for
action in this direction with as much speed at least as we show in
developing an army and navy, slow though we are in that. To limit our
efforts to the passing of freak state legislation regulating the price
of a Wassermann to determine the fitness of a person for marriage, when
both Wassermann test itself, and Wassermann test as evidence of fitness
for marriage, are likely, under the conditions, to be absolutely
worthless, is to play penny eugenics. The move to take the gag from the
mouth of the physician when an irresponsible with a venereal disease
aims to spread his infection by marriage is at least intelligent,
preventive, even if indirect, legislation, because it acts before and
not after the event. Although at the present time we cannot boast a
single example of a complete program of direct legislation, the example
of Michigan, which is providing free hospital treatment for adults and
children with syphilis, should be watched as the first radical step in
the right direction. If war and our mobilization for defense leave us
with every hospital and dispensary and public health resource and all
the expert judgment we have available within our borders enlisted
finally in a great campaign against gonorrhea and syphilis, it will have
accomplished a miracle, though it will have done no more than war has
done for Europe. If it leaves us even with our more progressive states
committed to an expanding program of universal efficient and accessible
diagnosis and treatment, it will have conferred a blessing.

+Relation of War to the Spread of Venereal Disease.+--The frequent
reference to the relation of war to the problems of sexual disease seems
to justify a concluding paragraph on this aspect of the matter. Much of
the impetus which has carried European nations so far along the road
toward an organized attack on syphilis and gonorrhea, as has been said,
is undoubtedly due to the realization that war in the past has been the
ally of these diseases, and that a campaign against them is as essential
to national self-defense as the organization of a vast army. Conflicting
reports are coming from various sources as to the prevalence of syphilis
and gonorrhea among European troops, although hopeful indications seem
to be that troops in the field may have even a lower rate of disability
than in peace times (British figures). The most serious risks are
encountered in troops withdrawn from the front or sent home on leave,
often demoralized by the strain of the trenches. The steady rise in the
amount of syphilis in a civil population during war is evidenced, for
example, by the figures of Gaucher's clinic in Paris, in which, just
before the war, 10 per cent of patients were syphilitic; after the first
sixteen months of the war 16.6 per cent were syphilitic, and in the last
eight months, up to December, 1916, 25 per cent had the disease. There
can be no doubt that a campaign of publicity can do much to control the
wholesale spread of infection under war conditions, and we should bend
our efforts to it, and to the more substantial work of providing for
treatment and the prevention of infectiousness, with as much energy as
we devote to the other tasks which preparedness has forced upon us. The
rigorous provisions proposed for continental armies should be carefully
studied, and in no cases in which either syphilis or gonorrhea is active
should leave or discharge be granted until the infectious period is
over. Compelling infected men to remain in the army under military
discipline until cured might have a deterrent effect upon promiscuous
exposure. In addition we should create as rapidly as possible a
mechanism for keeping inactive cases under surveillance after discharge
until there can no longer be the slightest doubt as to their fitness to
reënter civil life. Observers of European conditions in the population
at large are emphatic in saying that home conditions must have as much
attention as the army, and that suppression of open prostitution, a
watchful eye on the conditions under which women are employed or left
unemployed, and the control of contributory factors, such as the liquor
traffic, must be rigorously carried out. Nation-wide prohibition will do
much to control venereal disease.[18] It is interesting and significant
that little reliance is being placed on the obsolete idea that
prostitution can be made a legitimate and safe part of army life solely
by personal prophylactic methods, or by any system of inspection of the
women concerned. It is a hopeful sign that this conception is at last
meeting with the discredit which has long been due it.

    [18] Through the effect on prostitution. A well-known and very
    intelligent prostitute, with whom this question was recently
    discussed, rated the liquor traffic first among the influences
    tending to promote prostitution.

The question has occurred to those interested in compulsory military
service as a measure of national defense as to whether the mobilization
of troops for training will favor the spread of sexual disease.
Unfortunately, there are no satisfactory figures for the civil
population showing how many persons per thousand per year acquire
syphilis or gonorrhea, to be compared with the known figures for the
onset of such infections in the army. Arguing from general
considerations, however, there seems to be no reason to suppose that the
army will show a higher proportion of infections than civilians. In
fact, there is every ground for believing that the percentage will be
lower, since the army is protected by a fairly efficient and enforceable
system of prophylaxis which is taught to the men, and they live,
moreover, under a general medical discipline which reduces the risk of
infection from other than genital sources to the lowest possible terms.
In opposition to the conception that the sexual ideals of the army are
low, it may be urged that they are no lower than those of corresponding
grades in civil life, and that hard work and rigid discipline have a
much better effect in stiffening moral backbone than the laxities of
present-day social life. In the last analysis, the making of the moral
tone of the army is in our own hands, and by putting into it good blood
and high ideals, we can do as much to raise from it a clean manhood as
by submitting that same manhood to the temptations and inducements to
sexual laxity that it meets on every street corner.

This chapter closes the discussion of syphilis as a problem for the
every-day man and woman. It represents essentially the cross-section of
a moving stream. Today's truth may be tomorrow's error in any field of
human activity, and medicine is no exception to this law of change. It
is impossible to speak gospel about many things connected with syphilis,
or to offer more than current opinion, based on the keenest
investigation of the facts which modern methods make possible. None the
less, the great landmarks in our progress stand out with fair prospect
of permanent place. The germ, the recognition of the disease by blood
test and dark field microscope, the treatment and prevention seem built
on a firm foundation. As they stand, without regard to further advances,
they offer a brilliant future to a campaign for control To that
campaign, each and every one of us can address himself with the
prospect of adding his mite of energy to a tremendous movement for human
betterment. For every man or woman to whom the word syphilis can be made
to mean, not a secret, private, shameful disease, but a great open
problem in public health, a recruit has been called to the colors. There
are no signs more hopeful of the highest destiny for humanity than those
of today which mark the transition of disease from a personal to a
social problem. Such a transition foreshadows the passing of syphilis.
In that transition, each one of us has his part. Toward that
consummation, a goal only to be won by united and stubborn assault, each
one of us can contribute the comprehension, the sympathetic support, the
indomitable determination, which make victory.




INDEX


ABORTION, syphilis as cause of, 95

Abortive cure and marriage, 127
  of syphilis, 27, 86
  salvarsan in, 73, 79, 89
  time required for, 87

Accidents, late, 45. _See also late syphilis_

Advertising in regard to treatment for syphilis, 175, 176

Alcohol, effects of, in syphilis, 137

America, backwardness of, in movement against venereal diseases, 181
  state control of venereal diseases in, 170

American Social Hygiene Association, 165
  pamphlets, 161

Antibodies in disease, 54

Antiseptics, effect of, on germ of syphilis, 27

Appearance of chancre, time elapsing before, 29

Armpits, contagious patches in, 38

Army and navy, Metchnikoff prophylaxis in, 162
  probable outlook for venereal diseases in, 184
  proposed measures relative to venereal disease in, 183
  syphilis in, 25

Arsenic in salvarsan, 71

Arteries, effect of syphilis on, 47

Australia. _See West Australia_


BABIES, hereditary syphilis in, 99

Baltimore Vice Commission, report of, 134

Baths in treatment of syphilis, 140

Bath-tubs not means of transmitting syphilis, 114

Berlin, syphilis in clerks and merchants of, 25

Birth, premature, 95

Blaschko and German sexual disease program, 177, 180
  estimate of syphilis in Berlin, 25

Blindness in hereditary syphilis, 104

Blood, Spirochæta pallida in, during secondary stage of syphilis, 35
  test for syphilis, 54. _See also Wassermann test_
  vessels, late syphilis in, 46

Board of Health, activities of, against syphilis, 165
  national, need for, 167

Body, invasion of, by germs in secondary stage of syphilis, 35

Bones in hereditary syphilis, 102
  late syphilis (gumma) in, 46
  Spirochæta pallida in, 39
  supposed effect of mercury on, 63

Bordet and Wassermann, blood test for syphilis, 14

Brain, late syphilis of, 48
  softening of, 48
Brawl chancre, 116

Breasts, contagious patches on, 38

Brooklyn Hospital Dispensary, 171
  health exhibit by, 175


CABOT, Hugh, comment on reporting syphilis, 179

Cancer following smoker's patch, 138

Chafe, chancre resembling, 30
  relation of, to infection with syphilis, 28

Chancre, 29
  and cold sores, 30
  appearance of, 30
  brawl, 116
  combined with chancroid, 30
  concealment of, by gonorrhea, 30
  contagiousness of, 109
  contracted during engagement, 117
  cure of syphilis in stage of, 85
  developed from kissing game, 117
  diagnosis of, prevented by improper treatment, 32
  ease with which overlooked, 30
  enlargement of glands near, 33
  extra-genital, from lax relations, 134
  importance of early recognition of, 31, 34
  in women, 30
  location of, 28
  of the lip, 117, 119
  on knuckle (brawl chancre), 116
  painlessness of, 30
  soft, 30. _See also chancroid_
  tertiary symptoms following, 45
  urethral, in men, 30
  variations in, 30

Chancroid, 16
  and syphilitic infection, 30
  confusion of, with syphilitic chancre, 31

Child, death of, in syphilitic miscarriages or abortion, 95
  early signs of hereditary syphilis in, 99
  effect of syphilitic eye trouble on development of, 103
  healthy, born of syphilitic mother, 94
  infection of wet nurse by syphilitic, 100
  necessity of teaching sexual self-control to, 160
  older, effect of hereditary syphilis on, 102
  transmission of syphilis from mother to, 92
  treatment of syphilis in, before birth, 97
  unborn, effect of syphilis on, 98

Child-bearing, effect of syphilis on, 95

Children, adopted, syphilis in, 106
  syphilitic, mental condition of, 101

Clap, 16.
  _See also gonorrhea_

Clinics for pay patients to secure better treatment, 173
  inadequate, for venereal disease, 170
  night, necessity for, 171

Cold sores and chancres, 30

College students, syphilis in, 25

Commission, Baltimore Vice, 134
  Sydenham Royal, 164

Complications, serious, of syphilis, 45

Compulsory treatment, state provision for, 169

Conception, influence of syphilis on, 95
  treatment of syphilis occurring in mother after, 97

Coney Island Health Exhibit, 175

Contagiousness of moist sores in syphilis, 27, 38, 110
  of secondary relapses in syphilis, 42
  syphilitic sores, 38
  of syphilis, 109. _See also infectiousness, infection, and transmission_
    and medical examination of prostitutes, 135
    control of, by salvarsan, 73, 74, 122
    detection of, by examination of patient, 123
    disappearance of, in late syphilis, 110
    duration of, in late syphilis, 112
      under treatment, 123
    effect of incomplete cure on, 83
      of local irritation on, 43
      of mercury on, 64
      of moisture on, 27, 38, 110
      of time on, 111
      of tobacco on, 138
    estimate of risk for wife, 125
    factors tending to increase, 112
    five-year rule in relation to, 124
    hereditary, 100, 105
    ignorance of, in women, 135
    impracticability of quarantine in control of, 121
    in wet nurses, 101
    inability of mercury to control, 123
    obstacles to control by treatment, 123

Continence as personal prophylaxis, 161
  economic forces opposing, 157

Copenhagen, dispensaries for treatment in, 171

Cost, economic, of mental disease due to syphilis, 51
  of living, effect of, on marriage and sexual life, 158
  of treatment, effect of, 84, 149

Cups, drinking, transmission of syphilis by, 113

Curability of syphilis, critical estimate of, 90

Cure, importance of, for the wife, 128
  incomplete or symptomatic, danger of, 82
  of early syphilis, abortive, 27, 34, 86, 127
  of hereditary syphilis, 107
  of syphilis, 124, 126, 129. _See also five-year rule_
    abortive, salvarsan in, 73, 79, 89
    complete, responsibility of the physician in regard to, 84
    effect of cost on, 84, 149
      stage of disease on, 85
    importance of, 90
    in early stage, 27, 86
    in primary stage, 85. _See also cure of syphilis, abortive_
    in secondary stage, 86, 88
    methods of determining, 90
    obstacles to, 80
    radical or complete, 80
    Wassermann test in, 58
  symptomatic, in late syphilis, 87
  time required for, 87


DARK-field examination, use of, in recognizing contagious recurrences, 111
  germ of syphilis in, 22
  importance of using, 22
  use of, in recognizing early syphilis, 33

Deafness and loss of speech due to hereditary syphilis, 104

Deaths due to hereditary syphilis, 98, 99
  due to late syphilis, 48

Denmark, free treatment of syphilis in, 169

Disgrace, syphilis and, 142, 144

Disinfection of hands, dishes, etc., by washing and disinfectants, 114

Dispensaries for syphilis in large cities, 170

Drinking of alcoholic liquors, effect of, in syphilis, 137

"Drops," 69

Drug stores and drug clerks, evil influence of, 175
  prescribing, suppression of, 168, 174

Drying, effect on germ of syphilis, 27

Dumbness (loss of speech) in hereditary syphilis, 104

Dyes, relation of, to salvarsan, 70


EARS, secondary recurrences affecting, 43

Ears, trouble in, in hereditary syphilis, 104

Eating utensils, transmission of syphilis by, 113, 115

Education and character in the control of syphilis, 160
  as means of controlling contagiousness of syphilis, 122

Ehrlich, Paul, 70

Engagements, syphilis contracted during, 117
  to marry in syphilitics, precautions in connection with, 129

England, action of, against drug stores prescribing for syphilis, 176
  provision for treatment of venereal disease in, 169
  treatment not compulsory in, 180

English-speaking countries, attitude on Metchnikoff prophylaxis in, 177

Eruptions, absence of, in serious syphilis, 46
  effect of mercury on syphilitic, 64
  in hereditary syphilis, 100
  non-syphilitic, 37
  recurrent, 42, 43
  secondary syphilitic, 36
  syphilitic, effect of salvarsan on, 74

Estimate of damage caused by syphilitic eye trouble, 103
  of frequency of relapse and recurrence in secondary syphilis, 125
  of increase of syphilis during war, in Paris, 183
  of percentage of marital syphilis, 119
  of percentage of non-genital syphilis, 119
  of prevalence of gonorrhea, 26
  of syphilis, 24, 25
  of risk of infecting wife, 125
  of syphilis in prostitutes, 134

Examination, medical, before marriage, 130
  limitations of, in detecting contagiousness, 123

Excesses, effect of, on the syphilitic, 137

Expense of treatment, effect of, 77, 84, 149

Expert advice, importance of, 32
  in secondary stage of syphilis, 86
  in pay patient clinics, 174
  services, value of, in control and
  treatment of syphilis, 173

Eye trouble in hereditary syphilis, 103
  in later life, 105
  in secondary syphilis, 36

Eyes, secondary syphilitic recurrences affecting, 43


FAMILY, economic forces working against, 158
  transmission of syphilis in, 116

Fathers of families, encouragement of early marriages by, 159
  syphilis in, 93, 126

Fiancée, non-genital chancre in, 129

First sore, 29. _See also chancre_

Fist chancre, 116

Five-year rule, 124, 126, 129
  in relation to marriage, 126

Founder's estimate of prevalence of syphilis, 24

France, increase of syphilis in, during war, 183


GAUCHER'S estimates of increase in syphilis during war in France, 183

Genital syphilis in lax individuals, 133

Genitals, contagious sores on, 38, 112
  fitness of, for harboring germs of syphilis, 118

Germ of syphilis, 40. _See also Spirochæta pallida_

Germany, action of, against drug store prescribing for syphilis, 176
  attitude on Metchnikoff prophylaxis in, 177
  compulsory treatment of venereal disease in, 180
  sentiment against reporting of venereal disease in, 179
  society for preventing sexual disease in, 164
  syphilis in, 25

Germs, behavior of, in various diseases, 40

Glands, enlargement of, in neighborhood of chancre, 33
  in chancre of the lip, 33

Gonorrhea and syphilis, measures to prevent spread from army to general
population, 183
  concealment of chancre by, 31
  confusion of, with syphilis, 13, 16, 31
  drug store treatment of, 175
  estimated prevalence of, 26
  in prostitutes in Baltimore, 134
Gonorrhea, transmission of, by toilet seats, 114

Great Britain. _See England_

Gumma, 46. _See also syphilis, late_
  effect of treatment on, 47
  nature of, 46

Gummatous infiltration in hereditary
  syphilis, 102
  in late syphilis, 46


HAITI, origin of syphilis in, 11

Hata, 70

Headaches in syphilis, 36

Health, effect of secondary syphilis on, 36
  Exhibit, Brooklyn Hospital Dispensary, 175

Hearing, disturbances of, in hereditary syphilis, 104
  in secondary syphilis, 36

Heart in hereditary syphilis, 102

Hereditary syphilis, apparently healthy children with, 101
  as cause of abortions and miscarriages, 95
    of death, 98
  blindness in, 104
  bones and teeth in, 102
  contagiousness of, 100, 105
  deafness in, 104
  early signs of, 99, 100
  effect of accident and injury in, 105
  eye trouble in, 103
  heart, blood-vessels and nervous system in, 102
  Hutchinson's teeth in, 102
  immunity in, 106
  in adopted children, state provision for care of, 106
  in infant, 99
  in unborn child, 98
  late, in older children and adults, 101
  moral costs of, 99
  non-transmission of, by marriage, 105
  treatment of, 107
    in school hospitals, 108

Hoffmann's rule for marriage of syphilitics, 124

Hospital beds, number of, needed for venereal disease, 171
  treatment for hereditary syphilis, 108

Hospitals in treating venereal disease, 171
  special venereal, 167, 171

Hot Springs in treatment of syphilis, 140

Hunter, John, 13

Husband, probability of infection of wife by, 125

Hutchinson's teeth in hereditary syphilitics, 102

Hygiene, personal, of the syphilitic, 136


IDIOCY in hereditary syphilis, 101

Immunity in syphilis, absence of, 139
  hereditary, 106

Incubation period of syphilis, 28, 29

Infection, break in skin necessary to, 28
  double, with gonorrhea and syphilis, 30
  with syphilis and chancroid, 30
  point of entry of, site of chancre, 29
  risks of, 32
  time elapsing after, before chancre appears, 29
  unsuspected risk of, 161
  with syphilis favored by moisture, 27

Infectiousness of syphilis. _See contagiousness_
  of syphilitic discharges, 28

Infiltration, gummatous, in late syphilis, 46
  in hereditary syphilis, 102

Injections, mercurial, 66

Innocence, question of, in transmission of syphilis, 118

Inoculation, favorable ground for, 114

Insane asylums, amount of syphilitic mental disease in, 50

Inunctions, advantages of, 66
  disadvantages of, 65
  mercurial, 65
  number required for cure, 66

Iodid of potash, 69

Irresponsible mental attitude in syphilis, 150, 151

Irritation, effect of, on contagious recurrences, 43

Italy, non-compulsory treatment in, 180
  provision for treatment of venereal disease in, 169


KERATITIS, interstitial, in hereditary syphilis, 103

Kernels. _See glands_

Keyes' estimate of risk of infection of wife by husband, 125

Kissing, rules governing, in syphilitics, 138
  transmission of syphilis by, 116

Knuckle chancre, 116


LATE syphilis, non-contagious character of, 110
  premature development of, 45
  prospects for cure in, 86

Latent or concealed syphilis, 22

Law, Ohio, relative to physicians and marriage of syphilitics, 131
  controlling professional confidence, 131
  crippling physician in relation to marriage of syphilitics, 131
  providing for compulsory treatment in various countries, 180

Legal control, necessity for, in irresponsible syphilitics, 153

Legislation, conservative, 167
  indirect, against venereal disease, 169
  undesirable and freak, 166

Legs in locomotor ataxia, 49

Lemberg, study of prostitutes in city of, 134

Lesion, primary. _See chancre; also sore_

Life, well-balanced, for syphilitic, 137

Lip, chancre of, glands in, 33

Liquid medicine, giving of mercury in form of, 65

Liquor, alcoholic, effect of, in syphilis, 137
  traffic, importance of abolition of, in prevention of venereal
  disease, 184

Liver, Spirochæta pallida in, 39

Locomotor ataxia, 48
  frequency of, 51
  stomach symptoms in (gastric crises), 49
  symptoms in legs, bladder and rectum, 49
  syphilitic germs in spinal cord in, 49
  treatment and prevention of, 52

London, syphilis in, 24

Luetin test, Noguchi, 79


MALARIA, comparison of, with syphilis, 62

Marriage and abortive cure of syphilis, 127
  and five-year rule, 126
  and syphilis, 125
  and Wassermann test, 130
  annulment of, for concealment of syphilitic infection, 132
  early encouragement of, by state, parents, employers, 159
  effect of economic forces on, 158
  medical examination for syphilis before, 130
  of hereditary syphilitics, 105
  of persons with syphilis, inability of physician to prevent, 131
  of syphilitics, Hoffmann's rule for, 124
  syphilis acquired in, 120

Massachusetts, syphilitic mental disease in, 51

Medical examination before marriage, 130
    in relation to syphilis, 130
  of prostitutes, 135, 136

Mental attitude in relation to syphilis, 141
    morbid, in syphilis, 153
  disease and hereditary syphilis, 101

Mental disease and syphilis, 50
  Hygiene, National Committee for, 166

Mercury, 62
  and salvarsan, combination of, in controlling contagiousness, 124
  comparative value of, 68
  deceptive value of, 64
  effect of, on syphilis, 63
  inability of, to control contagiousness, 123
  ineffectiveness of, by mouth, 65
  injections of, 66
  injurious effects of, 67
  inunctions (rubs), 65
  methods of administering, 64
  of using in treatment, 62
  misconception in regard to, 63

Metchnikoff and Roux, 14
  prophylaxis in syphilis, 162

Michigan, legislative measures against syphilis in, 182

Military service, universal, and spread of venereal disease, 184

Miscarriage and abortion, syphilis as cause of, 95
  repeated, 95

Misconceptions regarding cure of syphilis with salvarsan, 72
  syphilis in children, 100

Moisture, effect of, on contagiousness of syphilis, 27, 38, 110
  relation of, to infection with syphilis, 27, 38, 110

Moore, Noguchi and, 48

Moral problems in relation to syphilis, 18

Morality, sexual, in relation to syphilis, 18

Morals, syphilis and, 144

Morbidness in syphilitics, 153

Mother, knowledge of, in adopting a child, 106
  syphilitic, apparent good health of, 93
    period of greatest danger to child, 94
  treatment of syphilis in, 97

Mouth, administration of mercury by, 64
  contagious sores in, 38, 42. _See also mucous patches_
  effect of mercury on, 67
  late syphilis in, 47

Mucous patches, 38, 42
  cancer following, 138
  effect of salvarsan on, 74
    of tobacco in predisposing to, 43, 112
  susceptibility of prostitutes to, 136


NATIONAL Board of Health, need for, 167

Neck, enlargement of glands in, 33, 34

Neosalvarsan, 75

Nervous strain, effect of, on syphilis, 137
  system, complications, relation of, to mild secondary syphilis, 45, 46
    examination of, in determining cure of syphilis, 90
    relapses, 43
    Spirochæta pallida in, 39

New York City, clinics and dispensaries in, 170
  reporting of syphilis in, 178

Noguchi, 48
  test, luetin, 79

Non-genital syphilis, estimate of percentage of, 119
  in lax individuals, 133, 134

Notification of venereal disease. _See reporting_

Nurse, accidental infection of, with syphilis, 116
  wet, syphilis in, 100

Nursing mothers, syphilitic germs in milk of, 39
  of syphilitic child by mother, 101


OHIO, law permitting physician to prevent marriage of contagious
syphilitic person, 131

Overwork, effect of, on syphilitics, 137


PAPEE'S study of prostitution in Lemberg, 134

Paralysis, general, danger to others in, 49, 50
  estimated frequency of, 51
  mental symptoms in, 49
  of insane, 48
  syphilitic germs in brain in, 49
  treatment and prevention of, 52

Paresis, 48. _See also paralysis, general_

Paris, increase of syphilis in, during war, 183

Physician, accidental infection of, with syphilis, 116
  coöperation of, in educating syphilitic, 148
  importance of informing, in regard to syphilis, 105, 140
  inability of, to prevent marriage of persons with syphilis, 131

Physician proper person to administer Metchnikoff prophylaxis, 163

Piles, contagious sores mistaken for, 43

Pills, ineffectiveness of, in treating syphilis, 65
  mercury, 65

Pinkus' estimate of syphilis in Germany, 25

Pontopidan's estimate of number of hospitals needed for venereal
diseases, 171

Population, civil, syphilis in, 183
  general, prevention of venereal disease in, during war time, 184

Potash, iodid of, 69

Pregnancy, syphilis acquired during, 94
  treatment of mother during, 97

Prevalence of gonorrhea, estimates of, 26
  of syphilis, estimates of, 24, 25

Prevention of locomotor ataxia and general paralysis, 52
  of syphilis. _See prophylaxis_

Primary lesion. _See chancre_
  stage. _See also chancre_
    contagiousness of syphilis in, 109
    cure of syphilis in, 85

Prohibition, national, importance of, in controlling venereal disease, 184

Prophylaxis, educational, 157
  state provision for, 168
  Metchnikoff, 162
    utilization of, in public campaign, 177
  moral, of syphilis, 156

Prophylaxis, personal, of syphilis, continence in, 161
  general instruction in, 169
  in army and navy, 162
  physician proper person to administer, 163
  unsatisfactory features of, 162

Prostitutes in Baltimore, gonorrhea in, 134
  medical examination of, 135
  syphilis in, 134

Prostitution, abolition or repression of, 156, 157
  and syphilis, 18, 133
  clandestine, risks of, 136
  effects of liquor traffic on, 184
  regulation of, 156

Psoriasis, confusion of, with syphilitic eruptions, 37

Public Health, syphilis as problem of, 18
  Service, United States, estimates of prevalence of syphilis, 24
  opinion about syphilis, 141
  sentiment and reporting of syphilis to health officers, 178

Publicity, campaign for, 176


QUACKS, suppression of, 168, 174
  treatment of syphilitics by, 140

Quarantine and freak legislation, 167
  compulsory, for irresponsible syphilitics, 153
  limitations of, in controlling spread of syphilis, 121
  temporary, for syphilis, in hospitals, 172

Quiescent period following entry of germ, 28


RAILROAD MEN, locomotor ataxia and general paralysis in, 50

Rash. _See eruption_

Recurrences, contagiousness of, 111
  estimated frequency of, in secondary syphilis, 125
  in secondary stage, 42, 43

Re-infection with syphilis, 139

Relapses, contagious, in syphilis, 42
  frequency of, in secondary stage, 125
  in nervous system, 43

Reporting of syphilis, attitude of various countries on, 179
  to health officers, 178

Resistance of body to syphilis, 29, 107, 112

Rest, need of, in syphilis, 137

Restaurants, risk of transmitting syphilis under conditions found in, 115

Rheumatism, symptoms resembling, in secondary syphilis, 36

Ricord, founder of modern syphilology, 13

Rub, mercurial. _See inunction_

Rule, five-year, 124, 126, 129
  for marriage of syphilitics. _See marriage_
  for personal hygiene of syphilitics, 136
  governing miscarriage and abortion due to syphilis, 96
  sexual relations in syphilitics, 138
  variations on, in hereditary syphilis, 96


SALIVA, syphilitic germs in, 38

Salvarsan, accidents due to, 78
  action of, in syphilis, 73
  and abortive cure, 73, 79, 89
  and mercury, comparative value of, 68, 89
    in pregnancy, 97
  animal tests on, 71
  arsenic in, 71
  as a social asset, 78
  cheap, vital importance of, 172
  combination of arsenic and dye, 70, 71
  correct administration of, 77
  discovery of, 70
  effect of first dose, 78
    of insufficient treatment with, 76
    on mucous patches, 74
  expense of treatment with, 76
  importance of, in controlling contagiousness of syphilis, 73, 74, 122
  in treatment, 89
  in control of syphilis in prostitutes, 157
  methods of giving, 75
  misconceptions regarding cure by single dose, 72
  need for governmental control, 77
  patent rights on, 172
  preliminary tests of, on man, 71, 72
  price of, 172
  repeated doses, 76
  use of, does not justify relaxation of rules for marriage, 127
  value of, in syphilis, 73

Scandinavian countries, compulsory treatment of venereal disease in, 180
  free treatment of venereal diseases in, 169
  provision for reporting venereal disease in, 179

Scars following gummatous changes, 46

Schaudinn and Hoffmann, 14, 22

School-hospitals for hereditary syphilis, 108

Secondary stage of syphilis, 35
  contagious relapses in, 42
  contagiousness in, 110
  cure in, 86
  eye trouble in, 36
  headaches in, 36
  loss of weight in, 36
  problems of, 42
  rash (eruption) in, 36
  rheumatic pains in, 36
  severe, 36
  spontaneous disappearance of symptoms, 39
  time required for cure, 88

Secrecy, professional, right of syphilitics, 139
  right of syphilitic, in connection with reporting of disease, 178

Self-control. _See sexual self-control_

Self-deception in regard to risk of infection, 161

Self-treatment in syphilis, 140

Semen, Spirochæta pallida in, 39

Sexual characteristics of syphilitic children, 102
  morality, development of, 145
  relations, abstinence from, economic influences opposing, 158
  of syphilitics, rules governing, 129, 138

Sexual relations, transmission of syphilis by, 117
  self-control, economic forces opposing, 157
  teaching of, 159
  transmission of syphilis, question of guilt or innocence, 118

Silverware, transmission of syphilis by, 115

Single dose cure of syphilis with salvarsan, 72

"606." _See salvarsan_

Skin, recurrences of secondary eruption in, 43
  unbroken, importance of, in preventing contagiousness of eruptions, 38

Sleeping sickness, 70

Smoker's patches, 138

Smoking (tobacco) in syphilis, 138

Snuffles in hereditary syphilis, 100

Social evil and syphilis, 165. _See also prostitution_
  problem of syphilis, 15

Soft ulcer or sore, 16. _See also chancroid_

Soldiers, syphilis and gonorrhea among, in present war, 183

Sore throat in secondary syphilis, 38

Sores, contagious, effect of salvarsan on, 74
    in prostitutes, 136
    in syphilis, 38
    transitory character of, 123
  contagiousness of moist, 27, 38, 110
    of open, 109
  on nipples in wet nurses, 101
  primary. _See chancre_
  soft, 16. _See also chancroid_
  tertiary. _See syphilis, late, gumma_

Sperk's estimate of frequency of relapse in secondary stage, 125

Spirochæta pallida, 27
  average life of, on objects outside body, 113
  destruction of, in body, 39
  discovery of, 14, 22
  distribution of, in internal organs, 39
  effect of antiseptics on, 27
    of drying on, 27
    of salvarsan on, 74
  growth of, 27
  in brain, in general paralysis of insane, 48
  in hereditary syphilitic children, 99
  in late syphilis, 45
  in lymph-glands, 34
  in secondary syphilitic eruptions, 38
  in spinal cord, in locomotor ataxia, 49
  invasion of body by, in secondary stage, 35
  low vitality of, 27
  mode of entry into body, 28
  sensitizing of body to, 39
  strains or type of, 40
  variations in behavior of, in different persons, 40

Spleen, Spirochæta pallida in, 39

Stage of syphilis, relation of, to curability, 82
  secondary, of syphilis, 35. _See also secondary stage; secondary
  syphilis; contagiousness; transmission; and Spirochæta pallida_

Stage, tertiary, of syphilis, 45. _See also syphilis, late_

State, encouragement of early marriage by, 159
  provision of, for recognition and treatment of syphilis, 168

Stigma attaching to syphilis, harm done by, 143
  of syphilis, effect of, on venereal hospitals, 167

Still birth, relation of syphilis to, 96

Still's statistics on death from hereditary syphilis, 98

Stomach in locomotor ataxia, 49

Sweat-glands, absence of Spirochæta pallida in, 39

Sydenham Royal Commission, 164
  views on reporting of venereal disease, 179

Symptomatic cure in late syphilis, 87

Symptoms, absence of, in syphilis, 23
  constitutional, of secondary syphilis, 36

Syphilis, absence of immunity in, 139
  accidental, in physicians and nurses, 116
  acquired, in children, 95
    in marriage, 119
  action of mercury in, 63
    of salvarsan in, 74
  active, relation of, to miscarriages and abortion, 96
  adequate dispensary service for treating, 171
  ageing effect of, in child, 99
  and civil population, 183
  and engagements to marry, 129

Syphilis and marriage, 125
  and mental disease, 50
  and prostitution, 18, 133
  and public prejudice, 141
  and sexual problems, 18
  and war, 183
  as cause of death in children, 98
    of miscarriages and abortion in women, 95
  as public health problem, 18
  as social problem, 15
  blood test for, 54
  broader outlook concerning, 146
  comparison of, with malaria, 62
  compulsory treatment of, 180
  concealed forms of, 23
  concealment of, by gonorrhea, 30
  confusion of, with gonorrhea, 13, 16, 31
  problem of, with various issues, 16, 17, 165
  congenital, 94. _See also syphilis, non-hereditary_
  constitutional symptoms of, 36
  contagiousness of, in secondary stage, 110
  course of, summary, 52
  cure of, 90
  danger from irresponsible persons infected with, 150
  deaths from, 48
  definition of, 21
  diminishing virulence of, 12
  early, methods of recognizing, 32
  educational prophylaxis of, 157
  epidemic of, in sixteenth century, 11
  eruption in secondary stage, 36
  essentials of campaign against, 168
  false silence in regard to, 15
  five-year rule regarding contagiousness, 124, 126, 129
  freak legislation in regard to, 166
  guilt or innocence in transmission, 118
  harm done by stigma attaching to, 143
  hereditary, 92
    accident and injury in, 105
    contagiousness of, 100, 105
    destructive changes in, 101, 102
    early signs of, in children, 99, 100
    late signs of, 101
    mental symptoms in, 101
    of eye, 103
    treatment of, 107
  history of, 11
  importance of prohibition in controlling, 184
  important advances in knowledge of, 17
  in adopted children, 106
  in British working men, 24
  in families, detection of, by Wassermann test, 128
  in father or mother of family, 92, 93, 126
  in men who have only had gonorrhea, 31
  in prostitutes, 134
  in United States, estimates of, 26
  in wet nurses, 100, 101
  inability of physician to prevent marriage of persons with, 131
  incomplete cure of, 82
  influence of, on progress of mediæval medicine, 13
  innocent, in fiancée, 129
    suffering of, caused by, 19
  late, attributable to insufficient salvarsan treatment, 73
    curability of, 86
    destructive effect of, 47
    in nervous system, 48
    most serious forms of, 47
    seriousness of, 45
    tissue changes in (gumma), 46
  measure to prevent spread of, from army to general population, 183
  medical examination for, as means of detecting contagiousness, 123
    of prostitutes for, 135
  mental attitudes in relation to, 141
  Metchnikoff prophylaxis of, 162
  mild, dangers of, 41
    relation to complications in nervous system, 45
  mistaken conceptions of, 13
  moral prophylaxis of, 156
  morbid fear of, 154
  non-genital, 28
    or extra-genital, 119
  obstacles to control of contagiousness of, 123
    to social control of, 141
  passive, transmission of, by prostitutes, 135
  personal hygiene of, 136
  prevalence of, 23
    in lax individuals, 133
  prevention of, by sexual self-control, 159
  public attitude toward, 141
  quacks and self-treatment in, 140
  radical or complete cure, 80
  reinfection with, 139
  relation of mouth and tongue cancers to, 138
  reporting of, to health officer, 178
  risk of acquiring, from prostitutes, 136
    of infecting wife with, 125
  secondary, cure of, 86
    time required for cure of, 86
  sexual transmission of, 117
  stages of, 26
  state provision for treatment of, in Denmark, Norway, Italy,
    England, Germany, West Australia, 168, 169
  tertiary, 45
  transmission and hygiene of, 109
    by kissing, 116
    to and by wet nurse, 100, 101
  treatment of, 60
    at Hot Springs, 140
    with salvarsan, 75
  unnoticed manifestations of, 41
  variations in course of, in different persons, 41
  Wassermann test for, 54
  world movement against, 164

Syphilitic, average type of, 148
  child, nursing of, by mother, 101
  ideal conscientious type of, 147
  irresponsible types of, 151
  morbid mental states, 153
  personal hygiene of, 136
  should tell physician he has disease, 140
  rule governing care of personal articles used by, 139
  rules governing kissing in, 138
  sexual relations in, 138
  well-regulated life for, 137

Syphilophobia, 153


TABES dorsalis, 48. _See also locomotor ataxia_

Taboparesis, 50

Teeth, effect of mercury on, 63, 67
  (Hutchinson's), in hereditary syphilis, 102

Tertiary stage, 45

Test for syphilis in blood, 54. _See also Wassermann test_
  Noguchi, luetin, 79

Throat, contagious sores in, 38

Time treatment principle in relation to marriage, 124, 126, 129

Tobacco, effect of, in syphilis, 43, 112, 138

Toilet seats not means of transmitting syphilis, 114
  transmission of gonorrhea by, 114

Tongue and tonsils, contagious sores on, 42
  cancer of, following contagious mucous patches, 138

Towels, transmission of syphilis by, 113, 115

Transmission of syphilis by dishes, etc., effect of washing and
disinfection on, 114
  by infected articles, 113
  by kissing, 116
  by sexual contact, 117
  effect of treatment on risk of, 124
  from father to mother, 93
  from mother to child, 92
  increased risk of, in tobacco users, 138
  medical examination in prevention of, 123
  not by door-knobs, bath-tubs, or toilet seats, 114
  passive, by prostitutes, 135
  personal responsibility in, 124 to wife, 125
  under conditions of crowding and bad sanitation, 115
    of everyday life, 114
  unlikely in marriage of hereditary syphilitics, 105

Treatment, intraspinal, in syphilis of nervous system, 79
  lack of effect of, on deafness in hereditary syphilis, 104
  obstacles to control of contagiousness of syphilis, 123
  of chancre may prevent recognition, 32
  of syphilis, 60
    advertising in regard to, 176
    backwardness of this country in public provision for, 170
    by drug clerks, 175
    by quacks, 140
    compulsory, 180
    control of contagiousness, 122, 124, 126
    dispensary service necessary for, 171
    efficient, 88
    expense of, 76, 173
    expert advice in, 174
    hospitals in, 171
    importance of salvarsan in, 89
    in pay-patient clinics and hospitals, 173
    necessity for cheap salvarsan in, 172
    various state provisions for, 168, 169
    Wassermann test in, 57
    with salvarsan and mercury combined, 89
  specific methods of, 60

Troops, syphilis and gonorrhea in, 182


UNITED STATES. _See America_


VEDDER'S estimate of prevalence of syphilis, 25

Venereal disease, 16
    and marriage, annulment of, 132
    effect of universal military service on, 184
    European and American provision in regard to care of, 169, 170
    importance of national prohibition in controlling, 184
    proposed military measures in connection with, 183
    relation of war to spread of, 182
    world-wide movement against, 164
  hospitals and freak legislation, 167

Vermont, reporting of syphilis in, 178

Vice Commission, Baltimore, syphilis in prostitutes, 134

Virulence of syphilis in 15th and 16th centuries, 12

Vomiting in locomotor ataxia, 49


WAR, control of venereal diseases during, 183, 184

War, relation of, to spread of venereal disease, 182

Warts, contagious syphilitic, 42

Washing, effect of, on transmission of syphilis by dishes, 114

Wassermann test, 54
  as evidence of fitness to marry, 130
  difficulties of, 55
  effect of mercury on, 67
    of treatment on, 58
  factor of error in, 56
  importance of expert performance of, 174
    to pregnant mother, 97
  in connection with adoption of children, 106
  in determining cure of syphilis, 58, 90
  in family where one member is syphilitic, 128
  in freak legislation, 167
  in late hereditary syphilis, 106
  in syphilitic mothers, 93
  negative, development of infectious sores in spite of, 123
    meaning of, 56
  on spinal fluid, 59
  persistently positive, 58
  positive, meaning of, 56
  practical details concerning, 59
  provocative, 130
  use of, in recognizing early syphilis, 33

Weight, loss of, in secondary recurrences, 43
  in secondary syphilis, 36

Welander homes for hereditary syphilis, 108

West Australia, action of, against drug stores prescribing for
syphilis, 176
  attitude of, on personal Metchnikoff prophylaxis, 177
  compulsory treatment of syphilis in, 180
  state provision of, for treatment of venereal diseases, 170

Wet nurses, syphilis in, 100

Wife, importance of cure for, 128
  infection of, by husband during pregnancy, 94
  risk of infecting, 125

Williams, syphilis and mental diseases, statistics on, 50

Womb, chancre on neck of, 30

Women, child-bearing, effect of syphilis on, 95
  employment of, in connection with problem of controlling venereal
    diseases in war times, 184
  miscarriages and abortions in, due to syphilis, 95
  syphilis in lax, 133

Worry and anxiety, effect of, on syphilitic, 137




Transcriber's Note

The following variably hyphenated words have been left as in the text.

  Everyday       Every-day
  everyday       every-day
  extragenital   extra-genital
  lifelong       life-long
  lifetime       life-time
  makeup         make-up
  newborn        new-born

All bold text has been surrounded by + symbols.

A List of Illustrations has been added to the text of the file.






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