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do not usually resemble the commoner skin complaints of infants. It is
important to remember here that a badly nourished, sickly child with a
distressing eczema is not necessarily syphilitic, and that only a
physician is competent to pass an opinion on the matter. Syphilitic
children in a contagious state are usually too sick to be around much,
so that the risk to the general public is small. On the other hand, the
risk to some woman who tries to mother or care for some one else's
syphilitic child, if the disease is active, should be thoroughly
appreciated. Women who are not specially trained or under the direction
of a physician should not attempt the personal care of other people's
sick children.

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

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

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

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

[9] Iglesheimer, quoted by Derby.

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

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

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

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

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

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




Chapter XI

The Transmission and Hygiene of Syphilis


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

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

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

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

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

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

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

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

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

[Illustration: FRITZ SCHAUDINN [1871-1906]

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

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

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

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


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