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.
 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.
The Treatment of Syphilis (Continued)
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.
(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.
The Cure of Syphilis
There are few things about our situation with regard to syphilis that deserve more urgent attention than questions connected with the cure of the disease, and few things in which it is harder to get the necessary cooeperation. On the one hand, syphilis is one of the most curable of diseases, and on the other, it is one of the most incurable. At the one extreme we have the situation in our own hands, at our own terms—at the other, we have a record of disappointing failure. As matters stand now, we do not cure syphilis. We simply cloak it, gloss it over, keep it under the surface. Nobody knows how much syphilis is cured, partly because nobody knows how much syphilis there really is, and partly because it is almost an axiom that few, except persons of high intelligence and sufficient means, stick to treatment until they can be discharged as cured. Take into consideration, too, the fact that the older methods of treating syphilis were scarcely equal to the task of curing the disease, and it is easy to see why the idea has arisen, even among physicians, that once a syphilitic means always a syphilitic, and that the disease is incurable.
Radical or Complete Cure.—In speaking of the cure of syphilis, it is worth while to define the terms we use rather clearly. It is worth while to speak in connection with this disease of radical as distinguished from symptomatic cure. In a radical cure we clear up the patient so completely that he never suffers a relapse. In symptomatic cure, which is not really cure at all, we simply clear up the symptoms for which he seeks medical advice, without thought for what he may develop next. Theoretically, the radical cure of syphilis should mean ridding the body of every single germ of the disease. Practically speaking, we have no means of telling with certainty when this has been done, or as yet, whether it ever can be done. It may well be that further study of the disease will show that, especially in fully developed cases, we simply reduce the infection to harmlessness, or suppress it, without eradicating the last few germs. Recent work by Warthin tends to substantiate this idea. So we are compelled in practice to limit our conception of radical cure to the condition in which we have not only gotten rid of every single symptom of active syphilis in the patient, but have carried the treatment to the point where, so far as we can detect in life, he never develops any further evidence of the disease. He lives out his normal span of years in the normal way, and without having his efficiency as a human being affected by it. In interpreting this ideal for a given case we should not forget that radical methods of treating syphilis are new. Only time can pass full verdict upon them. Yet the efficiency of older methods was sufficient to control the disease in a considerable percentage of those affected. There is, therefore, every reason to believe that radical cure under the newer methods is a practical and attainable ideal in an even higher percentage of cases and offers all the assurance that any reasonable person need ask for the conduct of life. It should, therefore, be sought for in every case in which expert judgment deems it worth while. It cannot be said too often that prospect of radical cure depends first and foremost upon the stage of the disease at which treatment is begun, and that it is unreasonable to judge it by what it fails to accomplish in persons upon whom the infection has once thoroughly fastened itself.
Symptomatic or Incomplete Cure.—Symptomatic "cure" is essentially a process of cloaking or glossing over the infection. It is easy to obtain in the early stages of the disease, and in a certain sense, the earlier in the course of the disease such half-way methods are applied, the worse it is for patient and public. In the late stages of the disease symptomatic cure of certain lesions is sometimes justifiable on the score that damage already done cannot be repaired, the risk of infecting others is over, and all that can be hoped for is to make some improvement in the condition. But applied early, symptomatic methods whisk the outward evidences temporarily out of sight, create a false sense of security, and leave the disease to proceed quietly below the surface, to the undoing of its victim. Such patients get an entirely false idea of their condition, and may refuse to believe that they are not really cured, or may have no occasion even to wonder whether they are or not until they are beyond help. Every statement that can be made about the danger of syphilis to the public health applies with full force to the symptomatically treated early case. Trifling relapses, highly contagious sores in the mouth, or elsewhere, are not prevented by symptomatic treatment and pass unnoticed the more readily because the patient feels himself secure in what has been done for him. In the first five years of an inefficiently treated infection, and sometimes longer, this danger is a very near and terrible one, to which thousands fall victims every year, and among them, perhaps, some of your friends and mine. Dangerous syphilis is imperfectly treated syphilis, and at any moment it may confront us in our drawing rooms, in the swimming pool, across the counter of the store, or in the milkman, the waitress, the barber. It confronts thousands of wives and children in the person of half-cured fathers, infected nurse-maids, and others intimately associated with their personal life. These dangers can be effectively removed from our midst by the substitution of radical for symptomatic methods and ideals of cure. A person under vigorous treatment with a view to radical cure, with the observation of his condition by a physician which that implies, is nearly harmless. In a reasonable time he can be made fit even for marriage. The whole contagious period of syphilis would lose its contagiousness if every patient and physician refused to think of anything but radical cure.
In such a demand as this for the highest ideals in the treatment of a disease like syphilis, the medical profession must, of course, stand prepared to do its share toward securing the best results. No one concedes more freely than the physician himself that, in the recognition and radical treatment of syphilis, not all the members of the medical profession are abreast of the most advanced knowledge of the subject. Syphilis, almost up to the present day, has never been adequately taught as part of a medical training. Those who obtained a smattering of knowledge about it from half a dozen sources in their school days were fortunate. Thorough knowledge of the disease, of the infinite variety of its forms, of the surest means of recognizing it, and the best methods of treating it, is only beginning to be available for medical students at the hands of expert teachers of the subject. The profession, by the great advances in the medical teaching of syphilis in the past ten years, and the greater advances yet to come, is, however, doing its best to meet its share of responsibility in preparation for a successful campaign. The combination of the physician who insists on curing syphilis, with the patient who insists on being cured, may well be irresistible.
Factors Influencing the Cure of Syphilis.—Cost.—We must admit that, as matters stand now, few patients are interested in more than a symptomatic cure. Yet the increasing demand for blood tests, for example, shows that they are waking up. Ignorance of the possibility and necessity for radical cure, and of the means of obtaining it, explains much of the indifference which leads patients to disappear from their physician's care just as the goal is in sight. But there is another reason why syphilis is so seldom cured, and this is one which every forward-looking man and woman should heed. The cure of syphilis means from two to four years of medical care. All of us know the cost of such services for even a brief illness. A prolonged one often sets the victim farther back in purse than forward in health. The better the services which we wish to command in these days, usually, the greater the cost, and expert supervision, at least, is desirable in syphilis. It is a financial impossibility for many of the victims of syphilis to meet the cost of a radical cure. It is all they can do to pay for symptomatic care in order to get themselves back into condition to work. We cannot then reasonably demand of these patients that they shall be cured, in the interest of others, unless we provide them with the means. In talking about public effort against syphilis, this matter will be taken up again. We have recognized the obligation in tuberculosis. Let us now provide for it in syphilis.
Factors Controlling the Cure of Syphilis—Stage, Time, Effective Treatment.—Three factors enter into the radical cure of syphilis, upon which the possibility of accomplishing it absolutely depends. The first of these concerns the stage of the disease at which treatment is begun; the second is the time for which it is kept up; and the third is the cooeperation of doctor and patient in the use of effective methods of treatment.
Cure in the Primary Stage.—It goes almost without saying that the prospect of curing a disease is better the earlier treatment is begun. This is peculiarly so in syphilis. In the earliest days of the disease, while the infection is still local and the blood test negative, the prospects of radical cure are practically 100 per cent. This is the so-called abortive cure, the greatest gift which salvarsan has made to our power to fight syphilis. It depends on immediate recognition of the chancre and immediate and strenuous treatment. So valuable is it that several physicians of large experience have expressed the belief that even in cases in which we are not entirely sure the first sore is syphilitic, we should undertake an abortive treatment for syphilis. This view may be extreme, but it illustrates how enormously worth while the early treatment of syphilis is.
Cure in the Secondary Stage.—The estimation of the prospect of recovery when the secondary symptoms have appeared and the germs are in the blood is difficult, owing to the rapid changes in our knowledge of the disease, which are taking place almost from day to day. The patient usually presses his physician for an estimate of his chances, and in such cases, after carefully explaining why our knowledge is fallible and subject to change, I usually estimate that for a patient who will absolutely follow the advice of an expert, the prospects are well over 90 per cent good.
The Outlook in Late Syphilis.—After the first year of the infection is passed, or even six months after the appearance of the secondary rash, the outlook for permanent cure begins to diminish and falls rapidly from this point on. That means that we are less and less able to tell where we stand by the tests we now have.
In the later stages of the disease we are gradually forced back to symptomatic measures, and are often rather glad to be able to say to the patient that we can clear up his immediate trouble without mentioning anything about his future.
The gist of the first essential, then, is to treat syphilis early rather than late. If this is done, the prospect of recovery is better than in many of the acute fevers, such as scarlet fever, a matter of every day familiarity, and better, on the whole, than in such a disease as tuberculosis. Yet this does not mean that the men or women whose syphilis is discovered only after a lapse of years, must be abandoned to a hopeless fate. For them, too, excellent prospects still exist, and careful, persistent treatment may, in a high percentage of cases, keep their symptoms under control for years, if not for the ordinary life-time.
The Time Required for Cure.—Time is the second vital essential for cure. Here we stand on less certain ground than in the matter of the stage of the disease. The time necessary for cure is not a fixed one, and depends on the individual case. Long experience has taught us that the cure of syphilis is not a matter of weeks or months, as patients so often expect, but of years. For the cure of early primary syphilis ("abortive" cure) not the most enthusiastic will discharge a patient short of a year, and the conservative insist on two years or more of observation at least. In the fully developed infection in the secondary stage, three years is a minimum and four years an average for treatment to produce a cure. Five years of treatment and observation is not an uncommon period. In the later stages of the disease, when we are compelled to give up the ideal of radical cure, our best advice to syphilitic patients, as to those with old tuberculosis, is that after they have had two years of good treatment, they should submit to examination once or twice a year, and not grumble if they are called upon to carry life insurance in the form of occasional short courses of treatment for the rest of their days.
Efficient Treatment.—The third essential is efficient treatment, about the nature of which there is still some dispute. The controversy, however, is mainly about details. In the modern methods for treatment of syphilis both salvarsan and mercury are used, as a rule, and keep the patient decidedly busy for the first year taking rubs and injections, and pretty busy for the second. The patient is not incapacitated for carrying on his usual work. The intervals of rest between courses of salvarsan and mercury are short. In the third year the intervals of rest grow longer, and in the absence of symptoms the patient has more chance to forget the trouble. Here the doctor's difficulties begin, for after two or three negative blood tests with a clear skin, all but the most conscientious patients disappear from observation. These are the ones who may pay later for the folly of their earlier years.
The aim in syphilis, then, is to crush the disease at its outset by a vigorous campaign. Not until an amount of treatment which experience has shown to be an average requirement has been given, is it safe to draw breath and wait to see what the effect on the enemy has been. Dilatory tactics and compromises are often more dangerous than giving a little more than the least amount of treatment possible, for good measure. This is, of course, always provided the behavior of the body under the ordeal of treatment is closely studied and observed by an expert and that it is not blindly pushed to the point where injury is done by the medicine rather than the disease.
The Importance of Salvarsan.—Salvarsan is an absolute essential in the treatment of those early infections in which an abortive cure can be hoped for, and in them it must be begun without a day's delay. To some extent, the abortive cure of the disease, with its 100 per cent certainty, will therefore remain a luxury until the public is aroused to the necessity of providing it under safe conditions and without restrictions for all who need it. At all stages of the disease after the earliest it is an aid, and a powerful one, but it cannot do the work alone, as mercury usually can. But though mercury is efficient, it is slow, and the greater rapidity of action of salvarsan and its power to control infectious lesions give it a unique place. The combination of the two is powerful enough to fully justify the statement that none of the great scourges of the human race offers its victim a better prospect of recovery than does syphilis.
Is a cure worth while? There is only one thing that is more so, and that is never to have had syphilis at all. The uncured syphilitic has a sword hanging over his head. At any day or hour the disease which he scorned or ignored may crush him, or what is worse, may crush what is nearest and dearest to him in the world. It does it with a certainty which not even the physician who sees syphilis all the time as his life-work can get callous to. It is gambling with the cards stacked against one to let a syphilitic infection go untreated, or treated short of cure. It is criminal to force on others the risks to which an untreated syphilitic subjects those in intimate contact with him.
The Meaning of "You are Cured."—How do we judge whether a patient is radically cured or not? Here again we confront the problem of what constitutes the eradication of the disease. In part we reckon from long experience, and in part depend upon the refinement of our modern tests. Repeated negative Wassermann tests on the blood over several years, especially after treatment is stopped, are an essential sign of cure. This must be reinforced, as a rule, by a searching examination of the nervous system, including a test on the fluid of the spinal cord. This is especially necessary when we have used some of the quick methods of cure, like the abortive treatment. When we have used the old reliable course, it is less essential, but desirable. Can we ever say to a patient in so many words, "Go! you are cured"? This is the gravest question before experts on syphilis today, and in all frankness it must be said that the conservative man will not answer with an unqualified "Yes." He will reserve the right to say to the patient that he must from time to time, in his own interest, be reexamined for signs of recurrence, and perhaps from time to time reinforce his immunity by a course of rubs or a few mercurial injections. Such a statement is not pessimism, but merely the same deliberate recognition of the fallibility of human judgment and the uncertainty of life which we show when we sleep out-of-doors after we have been suspected of having tuberculosis, or when we take out accident or life insurance.
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. 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.
 Iglesheimer, quoted by Derby.
Blindness in hereditary syphilis may, of course, take the same form that it does in the acquired disease, resulting from changes in the nerve of sight (optic nerve). This form is entirely beyond help by treatment.
Ear Trouble—Nerve Deafness.—The second important complication of hereditary syphilis is deafness. This occurs from changes in the nerve of hearing and may be present at birth or may come on many years later. The deaf infant is usually recognized by its failure to learn to talk, although it may seem perfectly normal in every other way. Again, the child may hear well at birth and deafness may come on in later life,—as late as the twentieth year,—suddenly or gradually, and become complete and permanent. It is often ascribed to colds or to falls and accidents that happen to occur at the same time. If syphilitic deafness comes on before the age of ten years, it is very apt to result in the child's forgetting how to talk, and becoming dumb as well. It goes without saying that children whose syphilis made them deaf at birth never learn to talk at all, and are therefore deaf and dumb. Very little is known about how many of the inmates of asylums for the deaf are hereditary syphilitics, but there is reason to suspect the percentage to be rather large. Deafness in hereditary syphilis is practically uninfluenced by treatment.
Accident and Injury in Hereditary Syphilis.—It is a matter of great importance to realize the large part played by accidents, injury, poor health, or lowered resistance in bringing a hidden hereditary syphilis to the surface. A child may show no special signs of the disease until some time during its childhood it has a fall which injures or bruises a bone or breaks a limb. Then suddenly at the place where the injury was done a gumma or tertiary syphilitic change will take place and the bone refuses to heal or unite or a large sore may develop which may be operated on before the nature of the condition is realized. In the same way a woman with hereditary syphilis may seem in perfect health, marry, and suddenly after the birth of her first child, even as late as her twenty-fifth year, may develop syphilitic eye trouble. It must be realized that hereditary syphilis is as treacherous as the acquired disease, and can show as little outward signs before a serious outbreak. It is part of the duty of every person who suspects syphilis in his family or who has it himself to let his physician know of it, for the sake of the help which it may give in recognizing obscure conditions in himself or his children.
Marriage and Contagion in Hereditary Syphilis.—In general it may be said that, in the matter of marriage, persons who have hereditary syphilis and live to adult life with good general health can, after reasonable treatment, marry without fear of passing on the disease. Hereditary syphilis apparently is not transmitted to the children as acquired syphilis is. Hereditary syphilis practically is not contagious except during the eruptions and active manifestations in infancy, such as the nasal discharge and the other sores in the mouth and about the genitals. As adults they can enter into the intimate relations of life without risk. Many of them, while perhaps having positive blood tests while the disease is active, later become negative without treatment. Some of them even recover from the disease to the extent that they can acquire it again, since there is no absolute immunity.
Syphilis in Adopted Children.—A word might well be said at this point on the adoption of children with hereditary syphilis. In all probability this is not a common occurrence, certain factors tending to diminish the risk. A child adopted after its second year will not be so likely to have the disease, since most syphilitic children die before this age is reached. Agencies which arrange for the adoption of children are now much more careful about the matter than formerly, and a Wassermann test on the mother and also on the child, as well as a careful history in the case of the mother, is frequently available. The information in regard to the mother is quite as important as that about the child, since the child may have a negative test while the mother's may be positive. Children who have hereditary syphilis, even in latent form, should not be offered for adoption, and should become a charge upon the state. Families in which it later develops that an adopted child was syphilitic should not, however, be needlessly alarmed for their own safety, since, from the standpoint of infectiousness, the late forms of hereditary syphilis are not dangerous to others. The agency from which the child was adopted should assume responsibility for the child if the family cannot meet the situation. The state of Michigan has been a pioneer in this country in legislation which provides for the welfare of these children among others. A law has been enacted making it possible to provide for their medical treatment for an indefinite period in the state hospital at Ann Arbor, at the cost of the state.
Treatment of Hereditary Syphilis.—The question of the treatment and cure of a person with hereditary syphilis is in many respects a different one from that in an acquired case. The foothold which the germ has in the body in hereditary syphilis is stronger even than in an untreated acquired case. Many of the changes produced by it are permanent, and the prospects of completely eradicating it are correspondingly small. On the other hand, the child who survives hereditary syphilis has probably an enormous resistance to the disease, which in a measure compensates for the hold which it has on him. Treatment in hereditary syphilis becomes an extremely difficult problem because it must in many cases be carried out during infancy, and for that reason the cooeperation of the patient cannot be secured. By treating the mother, we now know that we can accomplish a great deal for the unborn child. Once the child is born, its salvation will depend on unremitting care and labor. If it is skilfully treated and kept at the breast, it is estimated that it has even as high as ninety chances in one hundred of surviving to a useful life. Salvarsan can be given to even very small babies, and mercury also is employed with excellent results. Persistence and skill are essential, and for that reason, if possible, hereditary syphilis in active form in later childhood should have the advantage of occasional or prolonged treatment in special hospitals or sanitariums where the child could go to school while he is being built up and cared for. This is not like trying to salvage wreckage. Many syphilitic children are brilliant, and if treated before they are crippled by the disease, give every sign of capacity and great usefulness to the world. Welander, who was one of the greatest of European experts on syphilis, has left himself an enduring monument in the form of the so-called Welander homes, which have been established by cities like Copenhagen, Berlin, and Vienna to provide for such children the combined benefits of the school and the hospital. We cannot be too prompt in adopting similar provision for such cases in this country. There can be little excuse, eugenic or otherwise, for not doing the utmost that modern medical science is capable of for their benefit.
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 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.
 The control of infectiousness in syphilis through treatment is considered in the next chapter.
(From the "Galerie hervorragender Aerzte und Naturforscher." Supplement to the Muenchener med. Wochenschrift, 1906. J. F. Lehmann, Munich.)]
Individual Resistance to Infection.—The contagiousness of untreated syphilis is influenced by two other factors besides the mere lapse of time. The first of these is the resistance or opposition offered to the germ by the person to whom the infection is carried. The second is the feebleness of the germ itself, and the ease with which it dies when removed from the body. In regard to the first of these factors, while natural resistance to the disease in uninfected persons is an uncertain quantity, it is very probable that it exists. It is certain that the absence of any break in the skin on which the germs are deposited makes a decided difference if it does not entirely remove the risk of infection. A favorable place for the germ to get a foothold is a matter of the greatest importance. When, however, it is remembered that such a break may exist and not be visible, it is evident that little reliance should be placed on this factor in estimating the risk or possibility of infection.
Transmission by Infected Articles.—The feebleness of the germ and the ease with which it is destroyed are its redeeming qualities. This is of special importance in considering transmission by contact with infected articles. Nothing which is absolutely dry will transmit syphilis. Moisture is necessary to infection with it, and only articles which have been moistened, such as dressings containing the discharges, and objects, such as cups, eating utensils, pipes, common towels, and instruments which come in contact with open sores or their discharges, are likely to be dangerous. Moreover, even though these objects remain moist, the spirochetes are likely to die out within six or seven hours, and may lose their infectiousness before this. Smooth, non-absorbent surfaces, especially of metal, are unfavorable for the germ. Wash-basins, dishes, silverware, and toilet articles are usually satisfactorily disinfected by hot soapsuds, followed by drying. Barbers, dentists, nurses, and physicians who take care at least to disinfect instruments and other objects brought into contact with patients with carbolic acid and alcohol will never transmit syphilitic infection to others. Toilet-seats, bath-tubs, and door-knobs, although theoretically dangerous, are practically never so, and syphilitic infection transmitted by them can be dismissed as all but unknown. This is in marked contrast to gonorrhea, which in the case of little girls can be transmitted apparently by toilet-seats. Much depends, as has been said, on placing the germ on a favorable ground for inoculation, and the bare skin, unless the virus is massaged or rubbed in, is certainly not a favorable situation. Many experts do not hesitate to handle infectious lesions with the fingers provided the skin is not broken, relying simply on the immediate use of soap and water, and perhaps alcohol, to remove the germ. While this may be a risk, it should, none the less, reassure those who are inclined to an unreasoning terror of infection whenever they encounter the disease.
Transmission Under the Conditions of Every-day Life.—The question of just how dangerous the worker with foodstuffs may be to others when he has active contagious lesions is unsettled. Recent surveys of various types of workers have tended to show that syphilis in transmissible form is not especially prevalent among them. The same general principle applies here as elsewhere. The risk of infection with syphilis increases with dirty and unsanitary conditions, and becomes serious when there is opportunity for moist materials to be transferred to sensitive surfaces, like the mouth, sufficiently soon after they have left the syphilitic person for the germs to be still alive. That the real extent of the risk is not known does not make it any the less important that persons who have opportunity to handle materials in which this may occur should be subject to frequent sanitary inspection. Restaurants in which the silverware is not properly cleaned, and is used over and over at frequent intervals, and in which there is a careless and unsanitary type of personal service, can hardly be regarded as safe. While there is no need for hysterical alarm over such possibilities, it is just as well to provide for them. Crowding, close quarters, and insufficient sanitary conveniences in stores and offices, in restaurants or tenements, provide just the conditions in which accidental infection may occur. A gang of men with a common bucket and drinking cup may be at the mercy of syphilis if one member is in a contagious condition. A syphilitic might cough into the air with little risk, since the germs would die before they could find a favorable place to infect. But a syphilitic who coughs directly into one's face with a mouth full of spirochetes multiplies the risk considerably. The public towel is certainly dangerous—almost as much so as the common drinking cup. The possibility of syphilitic infection by cutting the knuckle of the hand against the teeth of an opponent in striking a blow upon his mouth should not be overlooked, and the occurrence is common enough for this type of chancre to have received the special name of brawl, or fist, chancre.
Accidental Syphilis in Physicians and Nurses.—Another type of infection ought not to go unmentioned—that to which physicians and nurses are exposed in operating on or handling patients with active syphilis. Before the day of rubber gloves such things were much more common perhaps than they are now, yet they are common enough at the present time. Most of the risk occurs in exploring or working in cavities of the body containing infected discharges. The blood may become infected in passing over active sores. The risk from all these sources is so considerable that it is justifiable as a measure of protection to a hospital staff to take a blood test on every patient who applies for treatment in a hospital, to say nothing of the advantage which this would be to the patient.
Transmission by Intimate Contacts—Kissing.—As we pass from the less to the more intimate means of contact between the syphilitic person and others, the risk of transmitting syphilis may be said to increase enormously. The fundamental conditions of moisture, a susceptible surface, protection of the germ from drying and from air, and possibly also massage or rubbing, are here better satisfied than in the risks thus far considered. Kissing, caresses, and sexual relations make up the origin of an overwhelming proportion of syphilitic infection. Infections are, of course, traceable to the nursing of syphilitic infants. It is through these sources of contact that syphilis invades the family especially. Many a syphilitic who realizes that he should not have sexual relations with his wife while he has the disease in active form will thoughtlessly infect her or his children by kissing. Kissing games are potentially dangerous, and a classical example of this danger is that of a reported case 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.
 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.
The Transmission and Hygiene of Syphilis (Continued)
THE CONTROL OF INFECTIOUSNESS IN SYPHILIS.—SYPHILIS AND MARRIAGE
Means for Controlling Infectiousness.—The usual method of controlling a very contagious disease, such as scarlet fever or measles, is to put the patient off by himself with those who have to care for him and to keep others away—that is, to quarantine them. This works very well for diseases which run a reasonably short course, and in which contagious periods are not apt to recur after the patient has been released. But in diseases such as tuberculosis and syphilis, in which contagiousness may extend over months and years, such a procedure is evidently out of the question. We cannot deprive a patient of his power to earn a living, to say nothing of his liberty, without providing for his support and for that of those who are dependent on him. To do this in so common a disease as syphilis would involve an expenditure of money and an amount of machinery that is unthinkable. Accordingly, as a practical scheme for preventing its spread, the quarantine of syphilis throughout the infectious period is out of the question. We must, therefore, consider the other two means available for diminishing the risk to others. The first of these, and the most important, is to treat the disease efficiently right from the start, so that contagious sores and patches will be as few in number as possible, and will recur as little as possible in the course of the disease. This will be in effect a shortening of the contagious period, and should be recognized as one of the great aims of treatment. The second means will be to teach the syphilitic and the general public those things which one who has the disease can do to make himself as harmless as possible to others. This demands the education of the patient if we hope for his cooeperation, and demands also the cooeperation of those around him in order that the pressure of public sentiment may oblige him to do his part in case he does not do it of his own free will.
Control of Infectiousness by Treatment—Importance of Salvarsan.—In a disease which yields so exceptionally well to treatment as syphilis, a great deal can be done to shorten the contagious period. Especially is this so when we are able to employ an agent such as salvarsan, which kills off the germs on the surface within twenty-four hours after its injection. When a patient is discovered to be in a contagious state, in a large majority of cases the risk to the community which he represents can be quickly eliminated, at least for the time being. Combining the use of mercury and salvarsan in accordance with the best modern standards, the actively contagious period as a whole can be reduced in average cases from a matter of years to one of a few weeks or months. Certainly, so far as recognizable dangerous sores are concerned, periodic examination, with salvarsan whenever necessary, would seem to dispose of much of the difficulty.
Obstacles to Control by Treatment.—There are, however, obstacles in the way of complete control of infectiousness by treatment. For example, one might ask whether a single negative blood test would not be sufficient assurance that the patient was free from contagious sores. It is, however, a well-recognized fact that a person with syphilis may develop infectious sores about the mouth and the genitals even while the blood test is negative. An examination, moreover, is not invariably sufficient to determine if a patient is in a contagious state. The value of an examination depends, of course, entirely on its thoroughness and on the experience of the physician who makes it. It is only too easy to overlook one of the faint grayish patches in the mouth or a trifling pimple on the genitals. The time and special apparatus for a microscopic examination are not always available. Moreover, contagious lesions come and go. One may appear on the genitals one day and a few days later be gone, without the patient's ever realizing that it was there—yet in this interval a married man might infect his wife by sexual contact. The patient with a concealed syphilis often lacks even the incentive to seek examination by a doctor. It is important also to realize that when mercury has to be the only reliance, the risk of infection cannot be entirely controlled by treatment. Contagious sores may develop even during a course of mercurial injections, especially in early cases. It requires the combination of mercury and salvarsan to secure the highest percentage of good results.
The Five-year Rule.—The truth of the matter is that, as Hoffmann says, no treatment can guarantee the non-infectiousness of a syphilitic in the first five years of his disease. Time is thus an essential element in pronouncing a person non-infectious and hence in deciding his fitness for marriage, for example. The person with active syphilis who has intimate relations with uninfected persons, who will not abandon smoking or take special precautions about articles of personal use which are likely to transmit the disease, is unsafe no matter what is done for him. In spite of this qualifying statement it may be reiterated, however, that good treatment with salvarsan and mercury reduces the risk of infecting others in the ordinary relations of life practically to the vanishing point, and of course reduces, but not entirely eliminates, the dangers of the intimate contacts.
Personal Responsibility of the Patient.—If we are compelled then to fall back to some extent upon the personal sense of responsibility of the patient himself to fill in the gap where treatment does not entirely control the situation, it becomes increasingly important that in the irresponsible and ignorant, when the patient fails to meet his obligation, we should push treatment to the uttermost in our effort to prevent the spread of the disease. To supply this necessary treatment to every syphilitic who cannot afford it for himself, and make it obligatory, if need be, will be a long step forward in the control of the disease. The educational campaign for it is well under way all over the world, and the money and the practical machinery will inevitably follow. We have the precedents of the control of tuberculosis, smallpox, malaria, and yellow fever to guide us, to say nothing of a practical system against sexual disease already in operation in Norway, Sweden, Denmark, and Italy.
Syphilis and Marriage.—The problem of the relation of syphilis to marriage is simply an aspect of the transmission of an infectious disease. The infection of one party to the marriage by the other and the transmission of that infection to children summarizes the social problem. Through the intimate contacts of family life, syphilis attacks the future of the human race.
Estimated Risk of Infecting the Wife.—How serious is the risk of infecting the wife if a man should marry during the contagious period of syphilis? This will depend a good deal on the frequency of relapses after the active secondary stage. On this point Sperk estimated that in 1518 patients, only ten escaped relapses entirely. These were, however, not patients that had been specially well treated. Keyes, quoted by Pusey, estimated, on the basis of his private records, that the chances taken by a syphilitic husband who used no special precautions to prevent infecting his wife were twelve to one the first year in favor of infection, five to two the second year, and one to four the third year, being negligible after the fourth year.
Syphilis in the Father.—Even while we recognize the infection of women and children as the greatest risk in marriage we should not lose sight of the cost to society which syphilis in the father of the family himself may entail. For such a man to be stricken by some of the serious accidents of late syphilis throws his family as well as himself upon society. A syphilitic infection which has not been cured not only makes a man a poor risk to an insurance company, but a poor risk to the family which has to look to him for support and for his share and influence in the bringing up of the children. A sufficient number of men and women in the thirties and forties are crippled, made dependent, or lost to the world entirely, to make the responsibilities of the family when assumed by persons with untreated or poorly treated syphilis a matter of some concern, whether or not they are still able to transmit the disease to others.
The Time-treatment Principle and the Five-year Rule.—In setting a modern standard for the fitness of syphilitics for marriage it may be said at the outset that there is little justification for making the mere fact of a previous syphilitic infection a permanent bar in the majority of cases. The risk of economic disaster to the parent and wage-earner, and the risk of transmission of the disease to the partner and the children, are both controllable by a combination of efficient treatment and time. The man who has conformed to the best practice in both particulars may usually marry and have healthy children. The woman under the same circumstances need not fear that the risk of having offspring injured by her disease is any greater than the risk that they will be injured by any other of the unforeseen risks that surround the bringing of a child into the world. A vast experience underlies what might be called the time-treatment principle on which permission to marry after syphilis should be based. It has recently been ably summarized again, and with commendable conservatism, by Hoffmann in the rule that a syphilitic who has been efficiently treated by modern standards, with mercury and salvarsan, over a period of two to three years, and who has remained free from all symptoms and signs of the disease for two years after all treatment was stopped, including negative blood and spinal fluid tests, may marry in from four to five years from the beginning of his infection. Variations of this rule must be allowed only with great conservatism, since salvarsan, on whose efficiency many pleas for a shortening of probation have been based, is still too recent an addition to our implements of warfare to justify a rash dependence upon it. The abortive cure in relation to marriage is a problem in itself, and the shortening of time allowed in such cases must be individually determined by an expert who has had the case in charge from the beginning, and not, at least as yet, by the average doctor. Such a standard as this for the marriage of persons who have had syphilis steers essentially a middle course between those who condemn syphilitics to an unreasonable and needless deprivation of all the joys of family life, and those who are too ready to take our conquest of syphilis for granted and to cast to the winds centuries of experience with the treachery of the disease.