John H. Stokes.

The Third Great Plague A Discussion of Syphilis for Everyday People online

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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

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

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

+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

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

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

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

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

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

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

Chapter X

Hereditary Syphilis

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

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

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

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

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

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

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

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

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

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

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

+Course of Hereditary Syphilis in the Infant.+ - The course of syphilis
in the child tends to follow certain general lines. The disease, being
contracted before birth, shows its most active manifestations early in
life. The stillborn child is dead of its disease. The living child may
be born with an eruption, or it may not develop it for several weeks or
months. It is thought by some that these delayed eruptions represent
infections at birth. Hereditarily syphilitic children are filled with
the spirochetes, the germs of the disease. They are in every tissue and
organ; the child is literally riddled with them. In spite of this it may
for a time seem well. The typical syphilitic child, however, is thin,
weak, and wasted. Syphilis hastens old age even in the strong. It turns
the young child into an old man or woman at birth. The skin is
wrinkled, the flesh flabby. The face is that of an old man - weazened,
pinched, pathetic, with watery, bleary eyes, and snuffling nose. The
mother often says that all the baby's trouble started with a bad cold.
The disease attacks the throat, and turns the normal robust cry of a
healthy infant into a feeble squawk. The belly may become enormously
distended from enlargement of the internal organs, and the rest of the
child dwindle to a skeleton. The eruptions are only a part of the
picture and may be absent, but when they occur, are quite
characteristic, as a rule, especially about the mouth and buttocks, and

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Online LibraryJohn H. StokesThe Third Great Plague A Discussion of Syphilis for Everyday People → online text (page 6 of 13)