The Third Great Plague Part 3

[Ill.u.s.tration: PAUL EHRLICH [1854-1915]

(From "Year Book of Skin and Venereal Diseases," 1916, vol. ix.

"Practical Medicine Series," Year Book Publishers, Chicago.)]

The poison which had already been shown to be especially effective in killing germs like those of syphilis was a.r.s.enic. The problem was to get a.r.s.enic into such a combination with other chemical substances that it would lose its poisonous quality for man, but still be poisonous for the spirochete of syphilis. Ehrlich and Hata began to make chemical compounds of a.r.s.enic in the laboratory with chemical substances like the dyes. As the compounds grew more complex they were tested on animals and some of them found to have the qualities for which their inventors were searching. Some of them are even used at the present time in the treatment of certain diseases. The six hundred and sixth compound in this series, when tested on syphilitic animals, was found to be extraordinarily efficient in killing the germ of syphilis, even when used in quant.i.ties so small as not to injure the animal. Among other things, there could be no better example of the importance of animal experiment in medicine. If the cause of syphilis had not been known, and the disease not given to animals, the discovery of salvarsan might never have been made. After extensive experiments on syphilitic rabbits, which showed that the drug could be given safely in amounts large enough to cure the animal at a single dose, it was tried on man, two physicians, Drs. Hoppe and Wittneben, volunteering for the test. When it was found that the drug did them no harm, it was used on syphilitic patients for the first time. As soon as its remarkable effect on the disease in them was fully established, Ehrlich announced the discovery before the medical society of Magdeburg, and the results were published in one of the most important of the German medical journals. Ehrlich then sent out from his own laboratory several thousands of doses of the new drug to all the princ.i.p.al clinics and large hospitals of the world for an extended trial. It was not until the results of this trial became apparent that he permitted its manufacture on a commercial scale. There could scarcely be a more ideal way of introducing a new form of treatment than the one adopted by Ehrlich, or one better surrounded by all the safeguards that conservatism could suggest.

+The Mistaken Conception of "Single Dose Cure."+--In the light of his experience with salvarsan in animals, Ehrlich hoped to accomplish the cure of syphilis in man by a single dose of the new drug, as he had been able to cure it in rabbits. All the earlier use of salvarsan in the treatment of syphilis was carried out with this idea in view, and the remarkable way in which the symptoms vanished before the large doses used encouraged the belief that Ehrlich's ideal for it had been fulfilled. But it was not long before it was found that syphilis had a stronger hold on the human body than on animals, and that patients relapsed after a single dose, either as shown by the blood test or by the reappearance, after varying intervals, of the eruption or other symptoms of the disease. Unfortunately, the news of the discovery of salvarsan, and with it Ehrlich's original idea that it would cure syphilis by a single dose, had gotten into the newspapers. Numbers of syphilitics treated with it have been deceived by this notion into believing themselves cured. In those whose symptoms came back in severe form, the trouble was, of course, found out. But there are at the present time, undoubtedly, many persons who received a single dose of salvarsan for a syphilis contracted at this time, and who today, having never seen any further outward signs of the disease, believe themselves cured, when in reality they are not. In the next twenty years the introduction of salvarsan will probably result in a wave of serious late syphilis, the result of cases insufficiently treated in the early days of its use. It was not long before it was found that not one but several doses of salvarsan were necessary in the treatment of syphilis, and soon many physicians of wide experience began to call in mercury again for help when salvarsan proved insufficient for cure. At the present time the use of both mercury and salvarsan in the treatment of the disease is the most widely accepted practice, and seems to offer the greatest a.s.surance of cure.

+The Value of Salvarsan.+--Salvarsan has done for the treatment of syphilis certain things of the most far-reaching importance from the standpoint of the interests of society at large. It has first of all made possible the control of the _contagious_ lesions of the disease.

Secondly, as was said before, it has made possible the cure of the infection in the primary stage, before it has spread from the starting-point in the chancre to the rest of the body. To understand how it accomplishes these results it is important to understand its mode of action.

+The Action of Salvarsan.+--It will be recalled that Ehrlich planned salvarsan to kill the germs of syphilis, just as quinin kills the germs of malaria. It was intended that when the drug entered the blood it should be carried to every part of the body, and fastening itself on the spirochetes, kill them without hurting the body. This is seemingly exactly what the drug does, and it does it so well that within twenty-four hours after a dose of it is given into the blood there is not a living germ of syphilis, apparently, in any sore on the body. If the same thing happened in all the out-of-the-way corners of the body, the cure would be complete. The natural result of removing the cause of the disease in this fas.h.i.+on is that the sores produced by it heal up.

They heal with a speed and completeness that is an even greater marvel than the action of mercury. The more superficial the eruption, the quicker it vanishes, so that in the course of a few days all evidence of the disease may disappear. This is especially true of the grayish patches in the mouth and about the genitals, which have already been described as the most dangerously contagious lesions of syphilis. It is evident, therefore, that to give salvarsan in a case of contagious syphilis is to do away with the risk of spreading the disease in the quickest and most effective fas.h.i.+on. It is as if a person with scarlet fever could be dipped in a disinfecting bath and then turned loose in the community without the slightest danger of his infecting others. How much scarlet fever would there be if every case of the disease could be treated in this way? There would be as little of it as there now is of smallpox, compared to the wholesale plagues of that disease which used to kill off the population of whole towns and counties in the old days.

If we could head off the crops of contagious sores in every syphilitic by the use of "606," syphilis in the same way would take a long step toward its disappearance. It is not a question, in this connection, of curing the disease with salvarsan, but of preventing its spread, and in doing that, salvarsan is one of the things we have been looking for for centuries.

+The Treatment of Syphilis With Salvarsan.+--Salvarsan, the original "606," was improved on by Ehrlich in certain ways, which make it easier for the ordinary physician to use it. The improved salvarsan is called neosalvarsan ("914") and has no decided advantages over the older preparation except on the score of convenience. Both salvarsan and neosalvarsan are yellow powders, which must be manufactured under the most exacting precautions, to prevent their being intensely poisonous, and must be sealed up in gla.s.s tubes to prevent their spoiling in the air. They were formerly administered by dissolving them or by mixing with oil and then injecting them into the muscles, much as mercury is given by injection. At the present time, however, the majority of experts prefer to dissolve the drug in water or salt solution and to inject it into the blood directly, through one of the arm veins. There is very little discomfort in the method, as a rule--no more than there is to the taking of blood for a blood test. At the present time the quant.i.ty of the drug injected is relatively small for the first injection, growing larger with each following injection. The intervals between injections vary a good deal, but a week is an average. The number of injections that should be given depends largely on the purpose in view. If the salvarsan is relied on to produce a cure, the number may be large--as high as twenty or more. If it is used only to clear up a contagious sore, a single injection may be enough for the time being.

But when only a few injections are used, mercury becomes the main reliance, and a patient who cannot have all the salvarsan he needs should not expect two or three doses of it to produce a cure. The publicity which has been given to this form of treatment has led many patients to take matters into their own hands and to go to a physician and ask him to give them a dose of salvarsan, much as they might order a highball on a cold day. The physician who is put in a position like this is at a disadvantage in caring for his patient, and the patient in the end pays for his mistaken idea that he knows what is good for himself.

The only judge of the necessity of giving salvarsan, and the amount and the frequency with which to give it, is the expert physician, and no patient who is wise will try to take the thing into his own hands. There are even good reasons for believing that the patient who is insufficiently treated with salvarsan is at times worse off than the patient who, unable to afford the drug at all, has had to depend for his cure entirely on mercury.

It is one of the tragedies of the modern private practice of medicine that the physician has so often to consult the patient's purse in giving or withholding salvarsan, and for that reason, except in the well-to-do, it is seldom used to the best advantage. Such a drug, so powerful an agent in the conservation of the public health, should be available to all who need it in as large amounts as necessary, without a moment's hesitation as to whether the patient can afford it or not. It is not too much to urge that private patent rights should not be allowed to control the price and distribution of such a commodity to the public.

Upon the payment of suitable royalties to the inventor the manufacture of such a drug should be thrown open to properly supervised compet.i.tion, as in the case of diphtheria ant.i.toxin, or be taken over by the Government and distributed at cost, at least to hospitals. To bring about such a revision of our patent law every thinking man and woman may well devote a share of personal energy and influence.

The manner of giving salvarsan is as important for the patient as the correct performance of an operation, and the safeguards which surround it are essentially the same. The drug is an extremely powerful one, more powerful than any other known, and in the usual doses it carries with it into the body for the destruction of the germs of syphilis many times the amount of a.r.s.enic needed to kill a human being. If something should go astray, the patient might lose his life as promptly as if the surgeon or the anesthetist should make a slip during an operation. To make the giving of salvarsan safe, the judgment, experience, and training of the specialist are not too much to ask.

The dangers of salvarsan are easily exaggerated, and some people have a foolish fear of it. The wonderful thing about the drug is that, with all the possibility for harm that one might expect in it, it so seldom makes any trouble. It is, of course, first carefully tested on animals when it is manufactured, so that no poisonous product is placed on the market.

It is as safe to take salvarsan at the hands of an expert as it is to take ether for an operation or to take ant.i.toxin for diphtheria, and that is saying a good deal. Most of the stories of accidents that go the rounds among laymen date back to the days when first doses were too large and made the patients rather sick for a time. Present methods and cautions about administering the drug are such that, except for the improvement in their condition, patients seldom know they have received it. The first dose may light the eruption up a little, but this is only because the drug stirs the germs up before it kills them, and improvement begins promptly within a few hours or a day or two.

The first characteristic of salvarsan which we should bear in mind especially, in our interest in the social aspects of syphilis, is then the rapidity rather than the thoroughness of its action. It is a social a.s.set to us because it protects us from the infected person, and it is an a.s.set to the patient because it will set him on his feet, able to work and go about his business, in a fraction of the time that mercury can do it.

The efficiency of salvarsan in the cure of syphilis in the early stages is due, first, to the large amount of it that can be introduced into the body without killing the patient, and second, to the promptness with which it gets to the source of trouble. In the old days, while we were laboriously getting enough mercury into the patient to help him to stop the invading infection, the germs marched on into his blood and through his body. With salvarsan, the first dose, given into the blood, reaches the germs forthwith and destroys them. There is enough of it and to spare. Twenty-four hours later scarcely a living germ remains. The few stragglers who escape the fate of the main army are picked up by subsequent doses of salvarsan and mercury, and a cure is a.s.sured. There is all the difference between stopping a charge with a machine gun and stopping it with a single-shot rifle, in the relative effectiveness of salvarsan and mercury at the beginning of a syphilitic infection.

In syphilis affecting the central nervous system, salvarsan, modified in various ways, may be injected into the spinal ca.n.a.l in an effort to reach the trouble more directly. The method, which is known as _intradural therapy_, has had considerable vogue, but a growing experience with it seems to indicate that it has less value than was supposed, and is a last resort more often than anything else. It involves some risk, and is no subst.i.tute for efficient treatment by the more familiar methods. If necessary, a patient can have the benefit of both.

The _luetin test_ was devised by Noguchi for the presence of syphilis, and is performed by injecting into the skin an emulsion of dead germs. A pustule forms if the test is positive. It is of practical value only in late syphilis, and a negative test is no proof of the absence of the disease. Positive tests are sometimes obtained when syphilis is not present. For these reasons the test is not as valuable as was at first thought.

Chapter IX

The Cure of Syphilis

There are few things about our situation with regard to syphilis that deserve more urgent attention than questions connected with the cure of the disease, and few things in which it is harder to get the necessary cooperation. On the one hand, syphilis is one of the most curable of diseases, and on the other, it is one of the most incurable. At the one extreme we have the situation in our own hands, at our own terms--at the other, we have a record of disappointing failure. As matters stand now, we do not cure syphilis. We simply cloak it, gloss it over, keep it under the surface. n.o.body knows how much syphilis is cured, partly because n.o.body knows how much syphilis there really is, and partly because it is almost an axiom that few, except persons of high intelligence and sufficient means, stick to treatment until they can be discharged as cured. Take into consideration, too, the fact that the older methods of treating syphilis were scarcely equal to the task of curing the disease, and it is easy to see why the idea has arisen, even among physicians, that once a syphilitic means always a syphilitic, and that the disease is incurable.

+Radical or Complete Cure.+--In speaking of the cure of syphilis, it is worth while to define the terms we use rather clearly. It is worth while to speak in connection with this disease of radical as distinguished from symptomatic cure. In a radical cure we clear up the patient so completely that he never suffers a relapse. In symptomatic cure, which is not really cure at all, we simply clear up the symptoms for which he seeks medical advice, without thought for what he may develop next.

Theoretically, the radical cure of syphilis should mean ridding the body of every single germ of the disease. Practically speaking, we have no means of telling with certainty when this has been done, or as yet, whether it ever can be done. It may well be that further study of the disease will show that, especially in fully developed cases, we simply reduce the infection to harmlessness, or suppress it, without eradicating the last few germs. Recent work by Warthin tends to substantiate this idea. So we are compelled in practice to limit our conception of radical cure to the condition in which we have not only gotten rid of every single symptom of active syphilis in the patient, but have carried the treatment to the point where, so far as we can detect in life, he never develops any further evidence of the disease.

He lives out his normal span of years in the normal way, and without having his efficiency as a human being affected by it. In interpreting this ideal for a given case we should not forget that radical methods of treating syphilis are new. Only time can pa.s.s full verdict upon them.

Yet the efficiency of older methods was sufficient to control the disease in a considerable percentage of those affected. There is, therefore, every reason to believe that radical cure under the newer methods is a practical and attainable ideal in an even higher percentage of cases and offers all the a.s.surance that any reasonable person need ask for the conduct of life. It should, therefore, be sought for in every case in which expert judgment deems it worth while. It cannot be said too often that prospect of radical cure depends first and foremost upon the stage of the disease at which treatment is begun, and that it is unreasonable to judge it by what it fails to accomplish in persons upon whom the infection has once thoroughly fastened itself.

+Symptomatic or Incomplete Cure.+--Symptomatic "cure" is essentially a process of cloaking or glossing over the infection. It is easy to obtain in the early stages of the disease, and in a certain sense, the earlier in the course of the disease such half-way methods are applied, the worse it is for patient and public. In the late stages of the disease symptomatic cure of certain lesions is sometimes justifiable on the score that damage already done cannot be repaired, the risk of infecting others is over, and all that can be hoped for is to make some improvement in the condition. But applied early, symptomatic methods whisk the outward evidences temporarily out of sight, create a false sense of security, and leave the disease to proceed quietly below the surface, to the undoing of its victim. Such patients get an entirely false idea of their condition, and may refuse to believe that they are not really cured, or may have no occasion even to wonder whether they are or not until they are beyond help. Every statement that can be made about the danger of syphilis to the public health applies with full force to the symptomatically treated early case. Trifling relapses, highly contagious sores in the mouth, or elsewhere, are not prevented by symptomatic treatment and pa.s.s unnoticed the more readily because the patient feels himself secure in what has been done for him. In the first five years of an inefficiently treated infection, and sometimes longer, this danger is a very near and terrible one, to which thousands fall victims every year, and among them, perhaps, some of your friends and mine. Dangerous syphilis is imperfectly treated syphilis, and at any moment it may confront us in our drawing rooms, in the swimming pool, across the counter of the store, or in the milkman, the waitress, the barber. It confronts thousands of wives and children in the person of half-cured fathers, infected nurse-maids, and others intimately a.s.sociated with their personal life. These dangers can be effectively removed from our midst by the subst.i.tution of radical for symptomatic methods and ideals of cure. A person under vigorous treatment with a view to radical cure, with the observation of his condition by a physician which that implies, is nearly harmless. In a reasonable time he can be made fit even for marriage. The whole contagious period of syphilis would lose its contagiousness if every patient and physician refused to think of anything but radical cure.

In such a demand as this for the highest ideals in the treatment of a disease like syphilis, the medical profession must, of course, stand prepared to do its share toward securing the best results. No one concedes more freely than the physician himself that, in the recognition and radical treatment of syphilis, not all the members of the medical profession are abreast of the most advanced knowledge of the subject.

Syphilis, almost up to the present day, has never been adequately taught as part of a medical training. Those who obtained a smattering of knowledge about it from half a dozen sources in their school days were fortunate. Thorough knowledge of the disease, of the infinite variety of its forms, of the surest means of recognizing it, and the best methods of treating it, is only beginning to be available for medical students at the hands of expert teachers of the subject. The profession, by the great advances in the medical teaching of syphilis in the past ten years, and the greater advances yet to come, is, however, doing its best to meet its share of responsibility in preparation for a successful campaign. The combination of the physician who insists on curing syphilis, with the patient who insists on being cured, may well be irresistible.

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

+Factors Controlling the Cure of Syphilis--Stage, Time, Effective Treatment.+--Three factors enter into the radical cure of syphilis, upon which the possibility of accomplis.h.i.+ng 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 cooperation of doctor and patient in the use of effective methods of treatment.

+Cure in the Primary Stage.+--It goes almost without saying that the prospect of curing a disease is better the earlier treatment is begun.

This is peculiarly so in syphilis. In the earliest days of the disease, while the infection is still local and the blood test negative, the prospects of radical cure are practically 100 per cent. This is the so-called abortive cure, the greatest gift which salvarsan has made to our power to fight syphilis. It depends on immediate recognition of the chancre and immediate and strenuous treatment. So valuable is it that several physicians of large experience have expressed the belief that even in cases in which we are not entirely sure the first sore is syphilitic, we should undertake an abortive treatment for syphilis. This view may be extreme, but it ill.u.s.trates 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 pa.s.sed, or even six months after the appearance of the secondary rash, the outlook for permanent cure begins to diminish and falls rapidly from this point on. That means that we are less and less able to tell where we stand by the tests we now have.

In the later stages of the disease we are gradually forced back to symptomatic measures, and are often rather glad to be able to say to the patient that we can clear up his immediate trouble without mentioning anything about his future.

The gist of the first essential, then, is to treat syphilis early rather than late. If this is done, the prospect of recovery is better than in many of the acute fevers, such as scarlet fever, a matter of every day familiarity, and better, on the whole, than in such a disease as tuberculosis. _Yet this does not mean that the men or women whose syphilis is discovered only after a lapse of years, must be abandoned to a hopeless fate._ For them, too, excellent prospects still exist, and careful, persistent treatment may, in a high percentage of cases, keep their symptoms under control for years, if not for the ordinary life-time.

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

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

The aim in syphilis, then, is to crush the disease at its outset by a vigorous campaign. Not until an amount of treatment which experience has shown to be an average requirement has been given, is it safe to draw breath and wait to see what the effect on the enemy has been.

Dilatory tactics and compromises are often more dangerous than giving a little more than the least amount of treatment possible, for good measure. This is, of course, always provided the behavior of the body under the ordeal of treatment is closely studied and observed by an expert and that it is not blindly pushed to the point where injury is done by the medicine rather than the disease.

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

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

+The Meaning of "You are Cured."+--How do we judge whether a patient is radically cured or not? Here again we confront the problem of what const.i.tutes 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 Wa.s.sermann tests on the blood over several years, especially after treatment is stopped, are an essential sign of cure.

This must be reinforced, as a rule, by a searching examination of the nervous system, including a test on the fluid of the spinal cord. This is especially necessary when we have used some of the quick methods of cure, like the abortive treatment. When we have used the old reliable course, it is less essential, but desirable. Can we ever say to a patient in so many words, "Go! you are cured"? This is the gravest question before experts on syphilis today, and in all frankness it must be said that the conservative man will not answer with an unqualified "Yes." He will reserve the right to say to the patient that he must from time to time, in his own interest, be reexamined for signs of recurrence, and perhaps from time to time reinforce his immunity by a course of rubs or a few mercurial injections. Such a statement is not pessimism, but merely the same deliberate recognition of the fallibility of human judgment and the uncertainty of life which we show when we sleep out-of-doors after we have been suspected of having tuberculosis, or when we take out accident or life insurance.

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 pa.s.sage 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 const.i.tutional 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 ma.s.s of evidence which the Wa.s.sermann 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.