The Third Great Plague Part 4

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 ident.i.ty.

+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 mult.i.tudes 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 s.e.xual indulgence leads some men to seek s.e.xual 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-ca.n.a.l 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 Wa.s.sermann 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 Wa.s.sermann 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 ill.u.s.tration of the deteriorating influence of the disease on the race. Here again we must allow for wide variation, dependent on circ.u.mstances 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 ill.u.s.trate 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 b.u.t.tocks, 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 pa.s.s 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 a.s.sistance of a wet nurse to feed their babies should, under no circ.u.mstances, 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 Wa.s.sermann 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 s.e.xual 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 pa.s.s 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--Interst.i.tial Kerat.i.tis.+--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 interst.i.tial kerat.i.tis, and takes the form of a gradual, slow clouding of the clear, transparent convex surface of the eyeball, the cornea, through which the light pa.s.ses 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 pa.s.ses 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 interst.i.tial kerat.i.tis, 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 pa.s.sing 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 Wa.s.sermann 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 a.s.sume 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 cooperation 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 att.i.tude 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 repet.i.tion 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 b.r.e.a.s.t.s 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 r.e.c.t.u.m 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 prost.i.tutes 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 v.a.g.i.n.a.

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

[Ill.u.s.tration: FRITZ SCHAUDINN [1871-1906]

(From the "Galerie hervorragender Aerzte und Naturforscher."

Supplement to the Munchener 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 quant.i.ty, 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-k.n.o.bs, 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 ma.s.saged 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, rea.s.sure 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 pa.s.sing 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.