John H. Stokes.

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The Third Great Plague

A Discussion of Syphilis
for Everyday People


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

Published, November, 1917

Copyright, 1917, by W. B. Saunders Company

Reprinted July, 1918

Reprinted February, 1920



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

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






The Prevalence of Syphilis 24
The Primary Stage 26

The Secondary Stage 35

Late Syphilis (Tertiary Stage) 45


General Considerations 60
Mercury 62

Salvarsan 70




The Control of Infectiousness in Syphilis 121
Syphilis and Marriage 125

Syphilis and Prostitution 133
Personal Hygiene of Syphilis 136






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

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