Even while we concede the value of generations of experience with syphilis in determining the probable risk of infection, it is a duty to investigate thoroughly by the modern methods, such as the Wassermann blood test, the condition of all members of a family in which syphilis has appeared. This means, for example, that even though the husband with syphilis may have married years after the usual period of infectiousness has passed, his wife, though outwardly healthy, should have a Wassermann test, and his children would be none the worse for an examination, even though they seem normal. Syphilis is an insidious disease, a consummate master of deceit, able to strike from what seems a clear sky. The latest means for its recognition have already revolutionized some of our conceptions of its dangers and its transmission. It is only common prudence to take advantage of them in every case, to forestall even the remotest possibility of mistake or oversight.
Where both husband and wife have had syphilis, even though both are past the infectious stage, both should be treated, and a complete cure for the wife is advisable before they undertake to have children. This must mean an added burden of responsibility on both physician and patient, and one extremely difficult to meet under existing conditions. A reliable means of birth control used in such cases would place the problem in women on a par with that in men, and give the physician's insistence on a complete cure for the woman a reasonable prospect of being needed. Where his advice is disregarded and a pregnancy results, the woman should be efficiently treated while she is carrying the child.
Syphilis and Engagements to Marry.—If a five-year rule is to be applied to marriage, a similar rule should cover the engagement of a syphilitic to marry, and it should cover the sexual relations of married people who acquire syphilis. It is not too much to expect that an engaged person who contracts syphilis shall break his engagement, and not renew it or contract another until by the five-year rule he would be able to marry with safety.
Engagements nowadays may well be thought of as equivalent to marriage when the question of syphilis is considered. They not infrequently offer innumerable opportunities for intimacies which may or may not fall short of actual sexual relations. Attention has been called to this situation by social workers among wage-earning girls. It has been a distressingly frequent experience in my special practice to find that the young man, overwrought by the excitement of wooing, has exposed himself elsewhere to infection and unwittingly punished the trustfulness of his fiancee by infecting her with syphilis through a subsequent kiss. The publication of banns before marriage is worth while, and unmistakable testimony as to the character and health of the parties concerned might well be exchanged before a wooing is permitted to assume the character of an engagement. It is of little use to say that a Wassermann and a medical examination should be made before marriage, when the damage may be done long before that point is reached.
Medical Examination for Syphilis before Marriage.—How shall we recognize syphilis in a candidate for marriage? The prevailing idea is to demand a negative Wassermann test. Assuredly this is good as far as it goes, but it is not so reliable as to deserve incorporation into law as sole sufficient evidence of the absence of syphilis, as has been done in one state. From what has been said, it is plain that a single negative Wassermann is no proof of the absence of syphilis. The subject must be approached from other angles, and when syphilis may be suspected, the question should be decided by an expert. A thorough general or physical examination is desirable, and if this reveals suspicious signs, such as scars, enlarged glands, etc., it is then possible to investigate the Wassermann report more thoroughly by repeating the test, sending it to another expert for confirmation. In some cases it may even be necessary to insist that the patient submit to a special test, called the provocative test, in which a small injection of salvarsan is used to bring out a positive blood test if there is a concealed syphilis. These are, of course, measures which are seldom necessary except in patients who have had the disease. Much depends on the attitude of the patient toward the examination and his willingness to cooeperate. A resourceful physician can usually settle the question of a person's fitness for marriage, and the result of a reliable examination offers a reasonable assurance of safety.
Laws Crippling Physicians in Such Matters.—What shall the physician do when confronted with positive evidence that a patient who is about to marry has an active syphilis? It is important for laymen to understand that the law relating to professional confidence between physician and patient ties the hands of the physician in such a situation. For the doctor to tell the relatives of the healthy party to such an intended marriage that the other has active syphilis would make him subject to severe penalties in many states for a violation of professional confidence, or to suit for libel. Of course, if the patient has agreed to submit to examination to determine his fitness for marriage, the physician's path is clear, but if the condition is discovered in ordinary professional relations, there is nothing to be done except to try to persuade the patient not to marry—advice he usually rejects. To this blind policy of protecting the guilty at the expense of the innocent an immeasurable amount of human efficiency and happiness has been sacrificed. Fortunately there are signs of an awakening. For example, Ohio has recently amended the law so as to permit a physician to disclose to the parties concerned that a person about to be married has a venereal disease (Amendment to Section 1275, General Code, page 177). This is preventive legislation, as distinguished from the old policy of locking the stable door after the horse was stolen by laws punishing one who infects another with a venereal disease after marriage has been contracted. Recent Supreme Court decisions (Wisconsin) have also taken the ground that a venereal disease existing at the time of marriage and concealed from the other party is ground for annulment of the marriage, provided the uninfected party ceases to have marital relations as soon as the fact is discovered.
The problem of syphilis in its relation to marriage is, of course, a serious one. It is safe to say that it will never be completely met except by a vigorous general public program against syphilis as a sanitary problem. It is by no means so serious, however, that it need lead clean young men and women to remain single for fear they will encounter it. The medical examination of both parties before marriage, efficiently carried out by disinterested experts, each perhaps of the other's appointing, is the best insurance a man and woman can secure at the present day against the risk that syphilis will mar their happiness.
 The problem of gonorrhea is not considered in the framing of this statement.
The Transmission and Hygiene of Syphilis (Continued)
SYPHILIS AND PROSTITUTION
In taking up the consideration of the relation of syphilis to illicit sexual relations, we must again remind ourselves that we are approaching this subject, not as moralists, important though their point of view may be, but for the time being as sanitarians, considering it from the standpoint of a method of transmission of a contagious disease.
Genital and Non-genital Syphilis in Lax Individuals.—The prevalence of syphilis among women who receive promiscuous attentions is enormous. It is practically an axiom that no woman who is lax in her relations with men is safe from the danger of the disease, or can long remain free from it. The type of man who is a Light o' Love does not go far before he meets the partner who has been infected by some one else. Becoming infected himself, he passes on his infection to his next partner. Syphilis is not so often transmitted in prostitution, open or secret, as gonorrhea, but it is sufficiently so to make the odds overwhelmingly against even the knowing ones who hope to indulge and yet escape. The acquiring of syphilis from loose men or women is usually thought of as entirely an affair of genital contacts. Yet it is notable that extra-genital chancres are the not uncommon result of liberties taken with light women which do not go to the extent of sexual relation. Women who accept intimacies of men who, while unwilling to commit an outright breach of decency, will take liberties with a woman who will accept them have only themselves to blame if it suddenly develops that the infection has been transmitted from one to the other by kisses or other supposedly mild offenses against the proprieties.
Syphilis Among Prostitutes.—As to the prevalence of syphilis among both public and clandestine or secret prostitutes, several notable surveys of more or less typical conditions have been made. With the aid of the Wassermann test much heretofore undiscovered syphilis has been revealed. Eighty to 85 per cent of prostitutes at some time in their careers acquire the disease. About half this number are likely to have active evidence of the disease. Thirty per cent of the prostitutes investigated by Papee in Lemberg were in the most dangerous period—the first to the third year of the disease. Three-fourths of these dangerous cases were in women under twenty-five years of age—in the most attractive period of their lives. Averaging a number of large European cities, it was found that not more than 40 per cent of prostitutes were even free of the outward signs of syphilis, to say nothing of what laboratory tests might have revealed. It is more than evident that prostitution is admirably fitted to play the leading role in the dissemination of this disease. The young and attractive prostitute, whether in a house of ill-fame, on the street, or in the more secret and private highways and by-ways of illicit sexual life, is the one who attracts the largest number with the most certain prospect of infecting them.
 The figures here given are based on those of Papee, Wwednesky, Raff, Sederholm, and others. The recently published investigations of the Baltimore Vice Commission showed that 63.7 per cent of 289 prostitutes examined by the Wassermann test had syphilis. Of 266 examined for gonorrhea, 92.1 per cent showed its presence. Nearly half the girls examined had both diseases and only 3.39 per cent had neither. (Survey, March 25, 1916, Vol. 35, p. 749.)
Concealed Syphilis and Medical Examinations of Prostitutes.—A number of delusions center around the relation of open and secret prostitution to disease. From the description of syphilis given in the foregoing pages, it must be apparent how little reliance can be placed, for example, on the ordinary medical examination of prostitutes as practised in segregated districts. The difficulties of efficient examination are enormous, especially in women. Even with the best facilities and a high degree of personal skill, with plenty of time and laboratory help in addition, extremely contagious syphilis can escape observation entirely, and even the negative result of one day's examination may be reversed by the appearance of a contagious sore on the next. Women can transmit syphilis passively by the presence of infected secretions in the genital canal even when they themselves are not in a contagious state. In the same way a woman may find herself infected by a man without any idea that he was in an infectious state. She may in turn develop active syphilis without ever realizing the fact. Medical examination of prostitutes as ordinarily carried out does actual harm by deluding both the women and their partners into a false sense of security. The life which such women lead, with the combination of local irritation, disease, and fast living, makes them especially likely to develop the contagious mucous patches, warts, and other recurrences, and to relapse so often that there can be little assurance that they are not contagious all the time.
Under such circumstances one might almost expect every contact with a prostitute on the part of a non-syphilitic individual to result in a new infection. The factors which interfere to prevent such wholesale disaster are the same which govern infectiousness throughout the disease. Local conditions may be unfavorable, even though the germs are present, or there may be no break in the skin for the germs to enter. If the syphilitic individual is beyond the infectious period, there may be no dangerous lesions. Here, as all through the history of infections with syphilis, there is an element of the unexpected, a favoring combination of circumstances. Sometimes when infection is most to be expected it is escaped, and conversely it seems at times that in the "sure thing," the "safe chance," and the place where infection seems most improbable, it is most certain to occur.
PERSONAL HYGIENE IN SYPHILIS
Syphilis is a constitutional disease, affecting in one way or another the whole body. For that reason, measures directed to improving the general health and maintaining the resistance of the patient at the highest point have an important place in the management of the disease. By his habits and mode of life a person with syphilis does much to help or hinder his cure, and to protect or endanger those around him. For that reason a statement of general principles may well be drawn up to indicate what is desirable in these regards.
A Well-balanced Life.—First, for his own sake, a syphilitic should live a well-balanced and simple life so far as possible. In this disease the organs and structures of the body which are subject to greatest strain are the ones most likely to suffer the serious effects of the disease. Worry and anxiety, excessive mental work, long hours without proper rest, strain the nervous system and predispose it to attack. Excessive physical work, fatigue, exhaustion, poor food, bad air, exposure, injure the bodily resistance. Excesses of any kind are as injurious as deprivation. In fact, it is the dissipated, the high livers, who go to the ground with the disease even quicker than those who have to pinch.
Alcohol.—Alcohol in any form, in particular, has been shown by extensive experience, especially since the study of the nervous system in syphilis has been carried to a fine point, to have an especially dangerous effect on the syphilitic. Alcohol damages not only the nervous system, but also the blood vessels, and makes an unrivaled combination in favor of early syphilitic apoplexy, general paresis, and locomotor ataxia. A syphilitic who drinks at all is a bad risk, busily engaged in throwing away his chances of cure. Even mild alcoholic beverages are undesirable and the patient should lose no time in dropping them entirely.
Tobacco.—Tobacco has a special place reserved for it as an unfavorable influence on the course of syphilis. It is dangerous to others for a syphilitic to smoke or chew because, more than any other one thing, it causes the recurrence of contagious patches in the mouth. It is remarkable how selfish many syphilitic men are on this point. In spite of the most positive representations, they will keep on smoking. Not a few of them pay for their selfishness with their lives. These mucous patches in the mouth, often called "smoker's patches," predispose the person who develops them to one of the most dangerous forms of cancer, which is especially likely to develop on tissues, like those of the mouth and tongue, which have been the seat of these sores.
Sexual Relations, Kissing, Etc.—Contagious Sores.—Sexual indulgence, kissing, and other intimate contacts during the active stage of syphilis, as has been indicated, directly expose others to the risk of getting the disease. For that reason they should not be indulged in during the first two years of the average well-treated case receiving salvarsan and mercury by the most modern methods. Exceptions to this rule should be granted only by the physician, and should be preceded by careful and repeated examination in connection with the treatment. Under no circumstances should a patient kiss or have intercourse if there is even the slightest sore or chafe on the parts, regardless of whether or not it is thought to be syphilitic.
Articles of Personal Use.—Persons with a tendency to recurrences in the mouth or elsewhere should report to the physician any sore they may discover and should watch for them. Persons with syphilitic sores in the mouth or elsewhere should have their own dishes, towels, toilet articles, shaving tools, pipes, silverware, and personal articles, and should not exchange or permit others to use them.
Secrecy.—Professional secrecy is something to which the syphilitic is most certainly entitled when it can be had without danger to the public health. So long as a syphilitic in the contagious period carefully observes the principles which ought to govern him in his relations to others, his condition is his own concern. But there is one person within the family who should, as a rule, know of his infection if it is still in the contagious period, since it is almost impossible to secure cooeperation otherwise. No matter how painful it may be, a person with syphilis, if advised to do so by his physician, should tell husband or wife the true state of affairs. There is no harder duty, often, and none which, if manfully performed, should inspire more respect. For those who will not follow his advice in this matter the physician cannot assume any responsibility, and is fully justified, and in fact wise, if he decline to undertake the case.
Re-infection.—Since it is a common misconception, it cannot be said too forcibly that no person with syphilis should forget that his having had the disease does not confer any immunity, and that as soon as he is cured he may acquire it again. It is possible, by a single exposure to infection, to undo the whole effect of what has been done, just after a cure is accomplished. There can be only one safe rule for infected as well as uninfected persons—to keep away from the risk of syphilis.
Quacks and Self-treatment.—Hot Springs.—The temptation to take up quack forms of treatment or to treat himself without the advice of a physician besets the path of the syphilitic throughout the course of the disease; an enormous number of fraudulent enterprises thrive on the credulity of its victims. Most of them are of the patent medicine specific type. Others, however, have a tinge of respectability and are dangerous simply because they are insufficient and not carried out under proper direction. Many popular superstitions as to the value of baths in syphilis and of the usefulness of a short course of rubs with bathing, or a "trip to the springs," are of this kind. Enough has been said in the foregoing chapters to make it plain to any one who is open to conviction that syphilis is no affair for the patient himself to attempt to treat. The best judgment of the most skilled physicians is the least that the victim owes himself in his effort to get well.
Patient and Physician.—For the same reasons every person who has or has had syphilis, cured or not, or has been exposed to it, should make it an absolute rule to inform his physician of the fact. The recognition of many obscure conditions in medicine depends on this knowledge. For a patient to falsify the facts or to ignore or conceal them is simply to work against his own interests and to hinder his physician in his efforts to benefit him.
Mental Attitudes in Their Relation to Syphilis
One's way of looking at a thing has an immense influence on what one does about it. Obvious as this principle is in the every-day affairs of life, it becomes still more obvious as one studies a disease and watches the way in which different individuals react to it. The state of mind of a few people infected with a rare condition may not seem a matter of more than passing interest, but in a disease which is a wide-spread and disastrous influence in human life, the sum-total of our states of mind about it determines what we do against it and, to no small degree, what it does to us. Syphilis as a medical problem offers comparatively few difficulties at the present day. What blocks our progress now is largely an affair of mental attitudes, of prejudices, of fears, or shame, of ignorance, stupidity, or indifference. Mental strain, a powerful influence in many diseases, is a factor in syphilis also, and the state of mind of the patient has often almost as much to do with the success of his treatment as has salvarsan or mercury. For that reason it is worth while to devote a chapter to picturing in a general way the mental side of syphilis.
The Public Attitude Toward Syphilis.—First of all, in order to understand the mental state of the patient, consider once more the attitude of the world at large toward the victim of syphilis. A few who are frankly ignorant of the existence of the disease to start with are unprejudiced when approached in the right way. But ninety-eight persons in a hundred who know that there is such a disease as syphilis are alive to the fact that it is considered a disgrace to have it, and to little else. Such a feeling naturally chokes all but secret discussion of it. Most of us remember the day when newspaper copy containing reference to tuberculosis did not find ready publication. Syphilis is just crossing this same threshold into publicity. It is now possible to get the name of the disease into print outside of medical works and to have it referred to in other ways than as "blood poisoning" in quack advertisements. The mention of it in lectures on sex hygiene is an affair of the last twenty years, and the earlier discussions of the disease on such occasions were only too often vague, prejudiced, and inaccurate. There are many who still believe, as did an old librarian whom I met in my effort to reach an important reference work on syphilis in a great public library. "We used to keep them on the shelves," he said, "until the high school boys began to get interested, and then we thought we would reserve the subject for the profession." Syphilis has been reserved for the profession for five hundred years and the disease has grown fat on it. The lean times will come when a reasonable curiosity about syphilis can be satisfied without either shame or secrecy by a reasonable presentation of the facts. We need the light on this subject and the light on reserved shelves is notoriously poor. The stigma attaching to syphilis as a disease is one of the most tragic examples of a great wrong done to do a little right. What if there are a few who deserve what they got? We may well ask ourselves how free we are to cast the first stone. And why single out syphilis as the badge of venery? The "itch" is transmitted by sexual relations too. Why not make the itch a sign of shame? The power that has done the damage is not the intrinsic viciousness of syphilis, but the survival of the old idea of sexual taboo, the feeling that sex is a secret, shameful thing, essentially unclean. To this age-old myth some one added the idea of punishment, and brutalized our conception of syphilis for centuries. If there were a semblance of crude, stern justice in accepting syphilis as the divinely established punishment for sexual wrong-doing, protest would lose half its meaning. Not only does syphilis fail to punish justly, but there is also something savage, akin almost to the mental attitude that makes "frightfulness" possible in war, in the belief that it is necessary to make headway against a sexual enemy by torturing, ruining, and dismembering men, women, and children, putting out the eyes of the boy who made a slip through bad companionship and mutilating the girl who loved "not wisely but too well." Only innocence pays the spiritual price of syphilis. The very ones whose punishment it should be are the most indifferent to it, and the least influenced by fear of it in their pursuit of sexual gratification. I always recall with a shock the utterance of a university professor in the days when salvarsan was expected to cure syphilis at a single dose. He rated it as a catastrophe that any such drug should have been discovered, because he felt that it would remove a great barrier to promiscuous relations between men and women—the fear of venereal disease. This is the point of view that perpetuates the disease among us. It is this attitude of mind that maintains an atmosphere of disgrace and secrecy and shame about a great problem in public health and muddles our every attempt to solve it. Those who feel syphilis to be an instrument adapted to warfare against sexual mistakes, and are prepared to concede "frightfulness" to be honorable warfare, will, of course, fold their hands and smugly roll their eyes as they repeat the words of the secretary of a London Lock hospital, "I don't believe in making it safe."
 Quoted by Flexner in "Prostitution in Europe."
Syphilis as a "Disgrace" and a "Moral Force."—If syphilis really deterred, really acted as an efficient preventive of license, we might have to tolerate this attitude of mind, even though we disagreed with it. I had occasion, during a period of two years, to live in the most intimate association with about 800 people who had syphilis—every kind of person from the top to the bottom of the social scale. It was not a simple matter of ordering pills for them from the pharmacy, or castor oil from the medicine room. I had to sit beside their beds when they heard the truth; I had to see the women crumple up and go limp; I had to tell the blind child's father that he did it, to bolster up the weak girl, to rebuild the wife's broken ideals, to suppress the rowdy and the roysterer, to hear the vows of the boy who was paying for his first mistake, and listen to the stories of the pimp and the seducer. What made syphilis terrible to the many really fine and upright spirits in the mass thus flung together in a common bondage? It was not the fear of paresis, or of any other consequence of the disease. It was the torture of disgrace, unearned shame, burnt into their backs by those who think syphilis a weapon against prostitution and a punishment for sin. It wrecked some of them effectually—left them nothing to live for. It case-hardened others against the world in a way you and I can well pray we may never be case-hardened. It left scars on others, and others laughed it off. Hundreds of sexual offenders passed through my hands, and in the closest study of their points of view I was unable to find that in more than rare cases had the risk of syphilis any real power to control the expression of their desires. Sexual morality is a complex affair, in which the habit of self-control in many other activities of life plays an important part. The man or woman who best deserves to be called clean and honorable and sexually blameless has not become so through a negative morality and an enlightened selfishness. The man who does not have bred into him from childhood the instinct to say the "everlasting no" to his passions will never learn to say it from the fear of syphilis. Sexual self-control is a habit, not a reasoned-out affair, and its foundation must rest on the rock bottom of character and not in the muck of venereal disease.
The Broader Outlook.—If, then, it avails nothing in the uplifting of our morals to treat syphilis as a disgrace, if the disease is ineffective as a deterrent, and barbarously undiscriminating, inhuman, and unjust as a punishment, let us in all fairness lay aside the attitude of mind which has so hindered and defeated our efforts to deal with it as an arch enemy to human health, happiness, and effectiveness. In the face of all our harsh traditions it takes a good deal of breadth of view to look on the disease impersonally, rather than in the light of one or two contemptible examples of it whom we may happen to know. But, after all, to think in large terms and with a sympathy that can separate the sinner from his sin and the sick man from the folly that got the best of him, is no mean achievement, well worthy of the Samaritan in contrast with the Levite. To the remaking of the traditional attitude of harsh, unkindly judgment upon those unfortunate enough to have a terrible disease, we must look for our soundest hope of progress.
The Mental States of Syphilitics.—The mental outlook of the person with syphilis is in its turn as important a factor in our campaign against the disease as is that of the person without it. In order to give some idea of the ways in which this can influence the situation it may be well to sketch what might be called the four types of mind with which one has to deal—the conscientious, the average, the irresponsible, and the morbid. Under the morbid type are included those persons who, without having syphilis, are in morbid fear of the disease, or have the fixed belief that they are infected with it, even when they are not.
The Conscientious Type.—Conscientious patients, speaking from the physician's standpoint, are the product of intelligence and character combined. Though distinctly in the minority, and usually met in the better grades of private practice, one is often surprised how many there are, considering the treacherous and deceptive features of the disease, which leave so much excuse for laxity and misunderstanding on the part of the laymen. A conscientious patient is one who is not content with any ideal short of that of radical cure. It takes unselfishness and self-control to go without those things which make the patient in the infectious stage dangerous to others. For a time life seems pretty well stripped of its pleasures for the man who may not smoke, must always think beforehand whether any contact which he makes with persons or things about him may subject others to risk of infection, and perhaps must meet the misunderstanding and condemnation of others whom he has to take into his confidence for the same purpose. An element of moral courage and a keen sense of personal responsibility help to make the ideal patient in this disease. To meet a treatment appointment promptly at the same day and hour week after week, to go through the drudgery of rubbing mercurial ointment, for example, to say nothing of the unpleasantness of the method to a cleanly person, night after night for weeks, takes unmistakable grit and a well-developed sense of moral obligation. The man who has been cured of syphilis has passed through a discipline which calls for the best in him, and repays him in terms of better manhood as well as better health.
The physician's cooeperation in the development of the necessary sense of responsibility and the requisite character basis for a successful treatment is invaluable. To the large majority of the victims of the disease it is a severe shock to find out what ails them. Many of them, without saying much about it, give up all hope for a worth-while life from the moment they learn of their condition. Just as in the old days the belief that consumption was incurable cost nearly as many lives as the disease itself, by leading victims to give up the fight when a little persistence would have won it, so among many who acquire syphilis, especially when it is contracted under distressing circumstances, there is a lowering of the victims' fighting strength, a sapping of their courage which makes them an easy prey to the indifference to cure that is so fatal in this disease. The person with syphilis should have the benefit of all the friendly counsel, reassurance, and moral support that his physician can give, and such time and labor on the latter's part are richly repaid.
The Average State of Mind.—The average mental attitude stops tantalizingly short of the best type of conscientiousness. Average patients are good cooeperators in the beginning of a course of treatment or while the symptoms are alarming or obvious, but their energy leaves them once they are outwardly cured. The average patient only too often overrules his physician's good judgment on trivial grounds, slight inconveniences, and temporary considerations, forgetting that cure is what he needs more than anything else in the world. The deprivations go hard with this type of patients, and it is difficult, almost impossible, to persuade them to stop smoking or to abstain from sexual relations or other contacts that are apt to subject others to risk. Average patients will almost never remain under the care of a physician until cured. A year, or at the most two years, is all that can be expected, and a second or third negative blood test is usually the signal for their disappearance. They are, of course, lost in the great unknown of syphilis, and swell the total of deaths from internal causes of syphilitic origin, such as diseases of the arteries and of the nervous system. A good many have to be treated for relapses, but the amount of infection spread by them, while of course unknown, is probably small considering how many of them there are.
Effect of the High Cost of Treatment.—A factor which is extremely influential in forcing average treatment and ideals on those who, if opportunity were more abundant, would be conscientious about the disease, has already been mentioned as the cost of treatment, which is such that persons with small incomes, who are too proud or sensitive to seek charitable aid, can scarcely be expected to meet. The cost of salvarsan under present conditions is a burden that few can hope to assume to the extent that modern treatment tends to require, and the slower methods of treatment are more of a tax on the patient's courage and determination, and less effective in preventing the danger of infectiousness, although quite as reliable for cure. There is no more serious problem in the public health movement against syphilis than to get for the average man who can pay a moderate but not a large fee the benefits of expensive and elaborate methods of recognizing and treating a disease such as syphilis. Some practical methods of doing this will be taken up in the next chapter.
The Irresponsible.—The irresponsible attitude of mind about syphilis forms the background of the darkest and most repellent chapter in the story of the disease. Yet we ought to confront it if we wish to master the situation. The irresponsible person has either no regard for, or no conception of, the rights of others where a dangerous contagious disease is concerned, and often little conception of, and less interest in, what is to his own ultimate advantage. Irresponsible syphilitics lack character first and sense next. Many of them, through the gods-defying combination of stupidity and ignorance, cannot be approached through any channel of reason or persuasion. The only argument capable of influencing such minds is compulsion. Others are, of course, mental defectives with criminal and perverted tendencies. Yet it is both amazing and discouraging to find how many irresponsibles there are in the ordinary and even in the better walks of life. To the wilful type of irresponsible person the transmission of a syphilitic infection is nothing, and cannot weigh a straw against the gratification of his desire or the pursuit of his own interest. The disease cannot teach such people anything, and if it cannot, how can the physician? Such people pursue their personal and sexual pleasure, marry, spread disaster around them, and outlive it all, perhaps brazenly to acknowledge the fact. Others, suave, attractive, agreeable, seductive, often masquerade as respectability, or constitute the perfumed, the romantic, the elegant carriers of disease. The proportion of ignorant to wilful irresponsibility can scarcely be estimated. But there is little choice between the two except on the score of the hopefulness of the latter. As examples of the mixture of types with which a large hospital is constantly dealing, I might offer the following at random, from my own recollections: A milkman came to a clinic one morning with an eruption all over his body and his mouth full of the most dangerously contagious patches. Two of us cornered him and explained to him in full why he should come in if only for twenty-four hours. He promised to be back next morning and disappeared. Another, a butcher in the same condition, put his wife, whom he had already infected, into the hospital, and in spite of every argument by all the members of the staff, went home to attend to his business—the selling of meat over the counter. A lunch-room helper, literally oozing germs, was after several days induced to come up for an examination and promised to begin treatment, whereupon he disappeared. A college student reported with an early primary sore. "X——," I said, "If you will pledge me your honor as a gentleman never to take another chance and not to marry until I say you are cured I will use salvarsan on you, which is just about as scarce as gold now, and give you a chance for abortive cure." He pledged himself, and six months later there was every sign that we were going to secure a perfect result. Suddenly he failed to appear for a treatment appointment, and I never saw him again. But I did see a letter written to him by the clinic which showed that he had come up for the examination with a newly acquired sore while he knew I was away—in all probability a reinfection. He was not even man enough to face me with his broken word. Three or four men with chancres may report in an afternoon and leave, the clinic powerless to detain them or to protect others against the damage they may do. One such, a Greek boy, had exposed four different women to infection before we saw him, and only the most strenuous efforts of the entire staff got him into the hospital, because he had neither money nor sense. Half-witted tramps, gang laborers, and foreigners who cannot understand a word of any other language than Lithuanian or some other of the European dialects for which no interpreter can be secured, pass in a steady stream through the free clinics of large cities. The impossibility of securing even the simplest cooeperation from such patients is scarcely realized by any one who is not called upon to deal with them face to face. Even with an interpreter, they display the wilfulness of irresponsibility. One Italian woman wiped her chancre, which was on her lip, with her fingers at every other shake of the head. She was cooking for two boarders and had two children. She did not like hospitals and was homesick and pettish. Would she go over to the dispensary in the next block and find out how to take care of herself? Not a bit of it. She was going home, and she went. I saw the children later in the children's ward, both infected with syphilis—a poor start in life. Criminal intent in the transmission of syphilis is common enough, and the writer can think off-hand of four or five cases in which men or women "got" their estranged partners later in their careers.
The Necessity for Legal Control.—All these repulsive details have a place in driving home a conception of the cost to society of the immoral and irresponsible syphilitic. Syphilis is an infectious disease, dangerous to the individual and to society. If it is rational to quarantine a mouth and throat full of diphtheria germs, it is rational to quarantine a mouth and throat full of syphilitic germs at least until the germs are killed off for the time being. There can be no more excuse for placing society at the mercy of the one than of the other.
The Morbid Attitude of Mind: Syphilophobia.—The morbid attitude of mind, whether in persons who have the disease or in those who fear they may have it, is one of the hardest the physician has to deal with. Any one who knows anything of the disease naturally has a healthy desire to avoid it, and if he is a victim of it, a considerable belief in its seriousness. But certain types of persons, who are usually predisposed to it by a nervous makeup, or who have a tendency to brood over things, or who perhaps have heard some needlessly dreadful presentation of the facts, become the victims of an actual mental disorder, a temporary unbalancing of their point of view. To the victims of syphilophobia, as this condition is called, syphilis fills the whole horizon. If they have not been too seriously disturbed by the idea, a simple statement of the facts does wonders toward relieving their minds. A few of them cling with the greatest tenacity to the most absurd notions. For those victims of the disease who are the prey of morbid anxiety the assurance that it is one of the most curable of all the serious diseases, and that if they are persistent and determined to get well, they can scarcely help doing so, usually sets their minds at rest. The idea that there is a cloud of disgrace over the whole subject, and the old-fashioned belief that syphilis is incurable and hopeless, inflict needless torture and may do serious damage to the highly organized sensitive spirits which it is to society's best interest to conserve. The overconscientious syphilitic hardly realizes that the real horrors of the disease are usually the rewards of indifference rather than overanxiety. Persons who subject themselves to the ordinary risks of infection which have been described in the preceding chapters do well to be on their guard and to maintain even a somewhat exaggerated caution. Those who do not expose themselves need not look upon the disease with morbid anxiety or alarm. In the relations of life in which syphilis is likely to be a factor it should, of course, be ferreted out. But there is no occasion for panic. We need a sane consciousness of the disease, a knowledge of its ways and of the means of prevention and cure for the world at large. We do not need hysteria, whether personal or general, and there is nothing in the facts of the situation to warrant the development of such a mental attitude either on the part of the syphilitic or of those by whom he is surrounded. Insofar as morbid fear in otherwise normal persons is the product of ignorance it can be dispelled by convincing them of this fact.
Moral and Personal Prophylaxis
Prophylaxis, of course, means prevention, and it has been a large part of the purpose of the present study to deal with syphilis from the standpoint of prevention and cure. The material of this chapter is, therefore, only a special aspect of the larger problem.
Repression of Prostitution.—By the moral prophylaxis of syphilis is meant the cultivation of such moral ideals as will contribute to the control of a disease which is so closely associated with sexual irregularities. Since public and secret prostitution serve as the principal agencies for the dissemination of the disease, it follows that anything tending to decrease the amount of disease in prostitutes, on the one hand, or to diminish the amount of promiscuous sexual activity, on the other, will retard the spread of syphilis. Systems based on the first ideas, aiming rather to control the disease in public women by inspection of their health and activities than by suppressing prostitution, have failed because the methods of control ordinarily practised are worthless for the detection of infectiousness. So-called regulation has, therefore, given way very largely in progressive communities to the second ideal of repressing or abolishing the outward evidences of vice as far as possible. In behalf of sanitary control of prostitution, leaving out of the question its moral aspect, it must be admitted that Neisser, probably the greatest authority on the sexual diseases, believed that, as far as syphilis is concerned, the use of salvarsan as a means of preventing infection from prostitutes has never had a satisfactory trial. In behalf of abolition it would seem that systematic stamping-out of the outward evidences of vice, the making of immorality less attractive and conspicuous, is, in theory at least, a valuable means of diminishing the extent and availability of an important source of infection.
Educational Influences.—To do something positive against an evil is certainly a more promising mode of attack than to use only the negative force of repression of temptation. Education of public opinion offers us just such a positive mode of attack. Men and women and boys and girls should first be taught sexual self-control even before being made aware of the risk they run in throwing aside the conventional moral code. Teach honor first and prudence next. The slogan of education in sexual self-restraint is the easiest to utter and the most difficult to put into practice of all the schemes for the control of sexual diseases. A large part of the difficulty of making education effective arises from one or two situations which are worth thinking over.
Economic Forces Opposing Sexual Self-control.—In the first place, while continence, or abstinence from sexual relations, is a valuable ideal in its place, it cannot be indefinitely extended with benefit either to the individual or to the race. The instinct to reproduce is as fundamental as the instinct of self-preservation and the desire for food. A social order which disregards it or defies it will meet defeat. To an alarming extent the tendency of the present economic system is to create unsocial impulses by making the normal gratification of sexual instinct in marriage and the assumption of the responsibility of a family more and more difficult. The cost of living is steadily rising without a corresponding certainty on the part of a large proportion of young men that they can meet it for themselves, to say nothing of meeting it for wife and children. The uncertainties of a 'job' are often serious enough to discourage the rashest of men from depending on a variable earning power to help him do his share for the advancement of the race. It will be an impossible task to convince even naturally clean-minded, healthy young men and women that they should live a life of hopeless virtue because it is part of the divine order that they should be so held down by hard times and small earnings as to make marrying and having children an unattainable luxury. Continence and clean living as preparations for decent and reasonably early marriage and the raising of a healthy family are the highest of ideals, and ought to be preached from every housetop. Continence as a life-long punishment for the impossible demands of an oppressive social and economic order gets as little attention as it deserves. First, let us make a clean sexual life lead with greater certainty to some of the rewards that make life worth living and we shall then have a more substantial basis for making continence before marriage other than empty words. If every father, for example, could say to his sons and daughters that if they showed themselves clean men and women he would back them in an early marriage, there would be an appreciable decrease in the amount of young manhood which is now squandered on indecency. If every employer, or the state itself, would give a clean marriage a preferred position in the social and economic scale, and, by helping to meet the cost of it, recognize in a substantial way the value to the race of a family of vigorous children, an important factor in youthful sexual laxity would be robbed of its power. No one will assert that such remedial proposals are of themselves cure-alls for present evils, but they must have at least an emphatic place in the future of moral prophylaxis.
The Teaching of Sexual Self-control.—First then, make the social order such that sexual self-control yields a reward and not a punishment. Second, teach sexual control itself, since it is one of the fundamental means of attack on the problem of syphilis. How can such control be taught? Information about the physical dangers of illicit sexual indulgence is of course of value, and should be spread broadcast. But taken by itself, the fear of disease, especially if it enters the individual's life after the age when he has already experienced the force of his sexual instincts, is a feeble influence. The person who has nothing but the knowledge that he is taking great risks between him and the gratification of his sexual desires will take the risks and take them once too often. One cannot begin to teach the boy or girl of high school age that sexual offenses mean physical disaster, and expect to control syphilis. The time to control the future of the sexual diseases is in the toddler at the knee, the child whose daily lesson in self-control will culminate when he says the final 'No' to his passions as a man. The child who does not learn to respect his body in the act of brushing his teeth and taking his bath and exercise, and whose thought and speech and temper are unbridled by any self-restraint, will give little heed when told not to abuse his manhood by exposing himself to filth. The prevention of syphilis by sexual self-control goes down to the foundations of character, and has practical value only in those whose self-control is the expression of a lifelong habit of self-discipline bred in the bone from childhood, not merely painted on the surface at puberty. Those who want their sons and daughters never to know by personal experience the meaning of syphilis must first build a foundation in character for them which will make self-control in them instinctive, almost automatic. Knowledge of sexual matters has power only in proportion to the strength of the character that wields it, and on well-rounded character education, rather than mere knowledge of the facts, the soundest results will be based.
(From McIntosh and Fildes, "Syphilis from the Modern Standpoint," New York, Longmans Green & Co., 1911.)]
The moral prophylaxis of syphilis is then briefly summed up in the repression of as many of the recognized agencies for the spread of the disease as possible; the making of continence a preparation for a normal sex life rather than an end in itself; the control and remedying of those influences which are making normal marriage harder of attainment; and the development of an instinctive self-control and self-discipline in every field of life from childhood up as the character basis necessary to make knowledge about sexual life and sexual disease effective.
Personal Preventive Methods.—Continence.—There remains to be considered what is often called the personal prophylaxis of syphilis, meaning thereby the methods by which the individual himself can diminish or escape the risk of infection. The first and most effective method of avoiding syphilis is abstinence from sexual relations and intimacies except in normal marriage with a healthy person. Although it has been alluded to under the moral prophylaxis of syphilis, it deserves to be reemphasized. No consideration as to the justice or desirability of continence and self-restraint can add anything to the simple fact that it is the way to avoid disease, and can be unhesitatingly recommended as the standard for personal prophylaxis. In the experience of physicians it is an axiom that disillusionment sooner or later overtakes those who think they are exempt from this rule. Persons who discard continence in favor of what they believe to be some absolutely safe indulgence are so almost invariably deceived that the exceptions are not worth considering. Although infection with syphilis is no necessary evidence of unclean living, clean living will always remain the best method of avoiding syphilis.
 The American Social Hygiene Association, 105 W. 40th Street, New York City, can supply pamphlets and lists of authoritative publications bearing on this and related subjects.
The Metchnikoff Prophylaxis.—The second method of personal prophylaxis of syphilis was developed as a result of the discovery of Metchnikoff and Roux in 1906, that a specially prepared ointment containing a mercurial salt, if rubbed into the place on which the germs were deposited within a few hours (not exceeding eighteen hours, and the sooner the better) after exposure to the risk of syphilis, would prevent the disease by killing the germs before they could gain a foothold. This method of protection against syphilis has been subjected to rigid tests, with fairly satisfactory results. It has been adopted by the army and navy of practically every country in the world, and, as carried out under the direction of physicians and with military control of the patient, has apparently reduced the amount of syphilitic infection acquired in the armies and navies using it to a remarkable degree. The method, of course, cannot assume to be infallible, but if intelligently applied, it is one of the important weapons for the extinction of syphilis in our hands at the present day. It fails to meet expectations precisely in those circumstances and among those persons in whom intelligent employment of it cannot be expected. This of course covers a considerable number of those who acquire syphilis. What disposal an awakened opinion will make of this knowledge remains to be seen. At the present time it may well be doubted whether the indiscriminate placing of it in the hands of anybody and everybody would not work as much harm as good through ignorant and unintelligent use. This opinion is shared by European as well as American authorities. Administered under the direction of a physician, the Metchnikoff prophylaxis of syphilis would undoubtedly be at its best in the prevention of the disease. For these reasons, as well as to prevent the spread of the knowledge to those who would be damaged by it, those interested are referred to their physicians for a description of the method. Any one having the benefit of it should be able to convince his medical advisor that there is good reason why this kind of professional knowledge should be brought to bear on his case. The ordinary methods of preventing infection by washes and similar applications used by the "knowing ones" are most of them worthless or greatly inferior to the Metchnikoff prophylaxis. They are, moreover, a positive source of danger because of the false sense of security which they create. If every person who has run the risk of contracting syphilis should visit his physician at once to receive prophylactic treatment, the effect on syphilis at large would probably be as good as in the army and navy. There would still be opportunity on such occasions to bring moral forces and influence to bear on those who would respond to them. There can be no object in withholding such knowledge from those who are confirmed in their irregular sexual habits. At the same time there could be few better influences thrown across the path of one just starting on a wrong track than that exerted by a physician of skill and character, to whom the individual had appealed to avert the possible disastrous result of an indiscretion.
Public Effort Against Syphilis
The World-wide Movement Against Venereal Disease.—This chapter is intended to give some account of the great movements now begun to control syphilis and its fellow-diseases throughout the world. A campaign of publicity was the starting-point of the organized attempt to control tuberculosis, and in the same way a similar campaign has been at the bottom of movements which now, under the pressure of the tremendous necessities of war, are making headway at a pace that generations of talking and thinking in peaceful times could not have brought about. Although this country at the present writing is probably farther in the rear than any other great nation of the world in its efforts to control the venereal diseases as a national problem, it is fortunate in having had the way paved for it by epoch-making movements such as those of the Scandinavian countries, and by the studies of the Sydenham Royal Commission on whose findings the British Government is now undertaking the greatest single movement against syphilis and gonorrhea that has ever been launched. For many years Germany has had a society whose roll includes some of the greatest names in modern science, directing all its energy toward the solution of the problem of sexual disease, and German sentiment on these matters is developing so fast that it is difficult, even for those in touch with such matters, to keep pace with it. In this country progress has been much slower, hampered by peculiarities of mental outlook and tradition very different from those which have controlled the thought of Europe. The association of syphilis with prostitution has been largely instrumental in putting much valuable statistical and general knowledge of the disease into semi-private reports and sources not available to the large mass of the thinking public. The effect of finding the problem of syphilis invariably bound up with discussions of the social evil has been to perpetuate in popular thought an association which simply blocks the way to any solution of the public health problem. While the control of prostitution will influence syphilis, ignoring syphilis, or treating it as incidental, will never contribute anything to the conquest of either. It is one of the most significant features of the great movements now on foot all over the world that they have finally adopted the direct route, and are attacking syphilis and gonorrhea as diseases and not by way of their association with prostitution.
The agencies in this country which are making notable efforts to push the campaign against syphilis and gonorrhea deserve every possible support from the thinking public. The American Social Hygiene Association is a clearing-house for trustworthy information in regard to the problems of sexual disease, and publishes a quarterly journal. The National Committee for Mental Hygiene and its branch societies are also engaged in spreading knowledge of the relation of syphilis to mental disease and degeneration. State and City Boards of Health are active in their efforts to further the campaign, and notable work is being done by New York City, Buffalo, Cleveland, and Rochester, New York, both on publicity and in the provision of facilities for recognizing and treating the diseases in question. Certain states, such as Ohio, Michigan, and Vermont, have made steps toward an intelligent legislative attack on different aspects of the problem. Influential newspapers and magazines have made the idea of a campaign against these diseases familiar enough to the public, for example, to bring a young girl to me to ask outright without affectation that she be told about syphilis, because she had seen the word in the paper and did not fully understand it. The aggregate of these forces is large, and an awakening is inevitable.
 Social Hygiene, New York.
To prepare ourselves for an active and intelligent share in the movement, we should review briefly the essential elements of a public campaign against syphilis as they have been developed by recent investigations and legislative experiments.
Undesirable and Freak Legislation.—Syphilis has had a limited amount of recognition in law, unfortunately not always wise or timely. Freak legislation and half-baked schemes are the familiar preliminaries which precede the grim onset of a real attack supported by public sentiment. Typical examples of such premature legislation may be found in the setting up of the Wassermann test as evidence of fitness for marriage by certain states, and in the efforts of certain official agencies to enforce the reporting of syphilis and gonorrhea by name. Proposals to quarantine and placard all syphilis are in the same category, though seriously entertained by some. The plan to establish by state enactment or municipal appropriation special venereal hospitals falls in the same class, since it is obvious that in the present state of opinion none but down-and-outs would resort to them. The stigma attached to them would effectually make them useless to the very group of worth-while people which it is to the public interest to conserve and reeducate.
Value of Conservative Action.—It cannot be said too often that a reasonable conservatism should temper the ardor of reformers, or more harm than good will be done by the collapse and failure of ill-considered special legislation. Unified action against syphilis and gonorrhea as public health problems is as important as unified action on the problems of railroad control, child labor, or corporate monopoly. For that reason it is a matter of some uncertainty how much can be accomplished by individual states in this country in the way of restrictive legislation, such as that controlling the marriage of infected persons, or punishing persons who fail to carry treatment to the point of cure. Under the direction of a national bureau or department of health administration there is no doubt that the movement against syphilis would advance at a much more rapid pace than with the sporadic and scattered activities of mixed state and private agencies.
The Essential Features of a Modern Campaign.—The repeated sifting of the facts which has been done in recent years by important investigations, such as that of the Sydenham Commission in Great Britain and the Society for Combatting Sexual Disease in Germany, and the legislative programs already mentioned, have gradually crystallized into fairly definite form, the undoubted essentials of a program for controlling venereal diseases, syphilis among them. These may be summarized as follows:
1. The provision of universally available good treatment, at the expense of the state, if necessary, for the diseases in question.
2. The provision by the state of efficient means of recognizing the diseases at the earliest possible time and with the greatest possible certainty in any given case.
3. The suppression of quack practice, drug-store prescribing, and advertising of cures for these diseases.
4. Moral and educational prophylaxis and the vigorous suppression of prostitution.
In addition to these measures, which are common to all proposals and working systems for the control of sexual disease, certain other recommendations may be classed as debatable, inasmuch as they are still under discussion and have been incorporated into some and omitted from others. These are as follows:
1. General instruction in personal prophylaxis for the population at large.
2. Compulsory measures and penalties obliging patients to receive treatment and continue it until cured, regardless of their own desires in the matter.
3. Notification or reporting of cases of sexual disease to the health authorities.
4. Indirect legislation, as it might be called, which aims to detect infected persons before they enter on marriage rather than at the outset of the disease, either by releasing the physician in charge of the case from the bond of professional confidence, or by requiring health certificates before marriage, and which annuls marriages after infection is discovered.
Easily Available Treatment.—It will be noticed that toleration of prostitution with supervision has finally disappeared from the modern program for the control of sexual diseases. The provision for universally available treatment, regardless of the patient's means or circumstances, should be thought of as the one fundamental requirement without which no program has made even a beginning. For over a century Denmark has provided for the free treatment of all patients with venereal disease. The Norwegian law, essentially similar, dates from 1860. Italy a few years ago adopted a similar program, placing squarely upon the state the responsibility of providing for the care of all patients with venereal diseases. England has just adopted a mixed provision which will in practice place most of the responsibility upon the state and very little on the individual, as far as the expense of treatment is concerned. Germany has compelled her insurance companies to shoulder the burden, and under pressure of war is hastening matters by invoking more and more governmental aid. The recent West Australian Act provides that every medical officer in the pay of the state shall treat venereal disease free of charge. In comparison with the tremendous advances over previous indifference which such programs represent, this country makes a poor showing. Among us, no public agency is formally charged with any duty in the matter of preventing, recognizing, or treating the vast amount of venereal infection that mars our national health. Certain state boards of health are attempting to perform Wassermann tests, and certain municipalities have well-organized laboratories for the detection of syphilis and gonorrhea, but there are few purely public agencies that even pretend to have a specialist in their employ to assist in the recognition of cases and conduct the treatment of patients who cannot afford private care. Hospital and dispensary treatment of venereal diseases is almost entirely in semi-private hands, and a recent investigation of clinics and dispensaries for the treatment of syphilis and gonorrhea in New York city, for example, showed that many of them were so poorly equipped and run at such unreasonable hours that they were frequented only by vagabonds, were of no value in the early recognition of syphilis, could not administer salvarsan under conditions to which a discriminating patient would dare to trust himself, and made no pretense at following their cases beyond the door or discharging them from medical care as cured. One of the largest cities in this country until a year ago had not even a night clinic to which day workers could come, and is scarcely awake now to the necessity for such a thing.
Dispensary Service.—The provision of adequate treatment and diagnostic facilities, on a par with those which will presently cover Europe, will mean the following things: First of all, dispensaries, and many of them, for the identification of early cases, fully equipped with dark-field microscopes, with record systems, and with the means for following patients from the time they enter until they are cured. This means nurses, it means social service workers, it means doctors with special and not general knowledge of syphilis and gonorrhea. The Brooklyn Hospital Dispensary is an admirable example of what such an institution should be, but it is one where such institutions should be numbered by dozens and by hundreds. Copenhagen, with a population less than that of several cities in this country which have none, has seven municipal clinics whose hours and names are prominently advertised.
Hospitals.—In the second place there must be hospital facilities. They must not be venereal hospitals, but services or parts of general hospitals, so that patients who are received into them will be protected from stigma and comment. Pontopidan, a Danish expert, estimated that for the care of venereal disease one hospital bed to every 2000 of population was insufficient, and yet there are cities in this country which do not have one bed available for the purpose to 100,000 people. The hospital performs a peculiarly valuable function in the care of syphilis in particular. It provides for temporary quarantine, and for the education of the patient in his responsibility to the community when he is discharged. Three weeks or more under hospital direction is the best possible start for an active syphilis that is to be cured. The privacy of a syphilitic can be protected in a hospital as successfully as in a specialist's office, and the quality of treatment which can be given him is distinctly better than he can obtain while out and around. Hospitals in general have kept their doors closed to syphilis until recently, and it is only under the pressure of a growing understanding of what this means to the public health that they are awakening to their duty.
Cheap Salvarsan.—Before a general campaign for the successful treatment of syphilis can be made a fact, salvarsan must become, as has already been pointed out, a public and not a private asset. It must be available to all who need it at the lowest possible cost—practically that of manufacture—and must be supplied by the state when necessary. The granting of patent rights which make possible the present exploitation for gain of such vital agents in the protection of the public health is a mistake which we should lose no time in remedying. While salvarsan does not mean the cure of syphilis, it does mean a large part of its control as an infectious disease. When it can be given only to the person who can muster from five to twenty-five dollars for each dose which he receives, it is evident that its usefulness is likely to be seriously restricted.
 The price of salvarsan before the war was $3.50 per full dose for the drug alone. It can be profitably marketed at less than $1.00 per dose. The patent rights have been temporarily suspended during the war, and their renewal by Congress should not be permitted.
Reduction of the Expense of Efficient Treatment.—Free treatment for those who cannot afford to pay is a necessary part of the successful operation of any scheme for the control of sexual disease. But for those who can and are willing to pay a moderate amount for what they receive, there should be pay clinics which will bridge the gap between the rough and ready quality and the unpleasant associations of a free dispensary, and the expensive luxuries of a specialist's office. This is a field which is almost virgin in this country, and which deserves public support. There is no reason why, for a reasonable fee, the patient with syphilis should not secure all the benefits of hospital care, the personal attention of specially trained men, an intelligent supervision of his case, and the benefit of cooeperation between a hospital service in charge of experts and the home doctor who must care for him during a considerable part of the course of his disease. Provision of this sort makes treatment both more attractive and more available to large numbers of people whose pride keeps them away from the public provision for charity cases, and whose limited means leave them at the mercy either of quackery or of well-meaning but entirely inexperienced physicians.
Value of Expert Services.—The factor of expert judgment in the care and recognition of syphilis is an important one, and a progressive public policy will not neglect to provide for it. The state, municipal or hospital laboratory which professes to do Wassermann tests should not be in charge of some poorly paid amateur or of a technician largely concerned with other matters, or its findings will be worthless. Every clinic and hospital should also attach to its staff an expert consultant on syphilis on whom it can draw for advice in doubtful cases and for the direction of its methods of work. Every city health board which undertakes a serious campaign against syphilis should not be satisfied merely with doing Wassermanns, but should enlist in behalf of the public consultation of the same grade which it expects to employ in the solution of its traction and lighting problems, and in the management of its legal affairs. No one would think nowadays of placing a physician in charge of a great tuberculosis sanitarium whose knowledge of the chest was confined to what he had learned in medical school twenty or more years before—yet in a parallel situation one often finds the subject of syphilis handled with as little attention to the value of expert knowledge. Expert service is expensive, and if the state wishes to command the whole energy of progressive men, it must be prepared to pay reasonably well for what it gets.
Suppression of Quacks and Drug-store Prescribing.—The suppression of quackery is nowhere more urgent than in the control of syphilis. Every important legislative scheme that has come into existence in recent years has recognized this fact. The devil may well be fought by fire, and reputable agencies should enter the field of publicity with some of the vigor of their disreputable opponents. The brilliant success of this scheme was admirably illustrated by the results of the recent efforts of the Brooklyn Hospital Dispensary, which, by replacing the placards of advertising quacks in public comfort and toilet rooms, and running a health exhibit on Coney Island, attracted to a clinic where modern diagnosis and treatment were to be had an astonishing number of young people who would have fallen victims to quacks. The evil influence of the drug store in perpetuating the hold of syphilis and gonorrhea upon us is just being understood. The patient with a beginning chancre, at the advice of a drug clerk, tries a little calomel powder on the sore, and it either "dries up" and secondary symptoms of syphilis appear in due course, or it gets worse or remains unchanged and the patient finally goes to a doctor or a dispensary to find that his meddling has lost him the golden opportunity of aborting the disease. If secondaries appear, a bottle or two of XYZ Specific, again at the suggestion of the all-knowing drug clerk, containing a little mercury and potassium iodid, disposes of a mild eruption, and a year or so later a marriage with subsequent mucous recurrences and the infection of the wife signalizes the triumph of ignorance and public shortsightedness. The health commissioner of one of the largest and most progressive cities in this country stated before a recent meeting of the American Public Health Association that he had sent a special investigator to twelve representative drug stores in his city, and that simply on describing some symptoms, without even the ceremony of an examination, he had received from ten of them something to use on a sore or to take for gonorrhea. It is only justice to say that occasionally one finds drug stores which will refer a patient to a doctor or a dispensary. Drastic legislation to suppress this sort of malpractice is part of the program of Great Britain, Germany, and West Australia, and we in this country cannot too quickly follow in their steps.
Publicity Campaign.—The educational campaign against sexual disease has already been discussed in theory. In close relation to it is the question of the use of publicity methods for legitimate ends, mentioned above. It has had a number of interesting applications in practice. The West Australian law has taken the stand of prohibiting all advertising, replacing the method of attracting the patient into coming for treatment of his own free will by the method of making treatment compulsory under heavy penalty. In this country, where compulsory legislation will be slow of adoption, publicity methods will have a certain vogue and a proper place. It has been of great service in the campaign against tuberculosis and in the movements for "Better Babies" and the like. It should never be forgotten that it is a two-edged weapon, however, and that where a stigma exists, as in the case of sexual disease, too much advertising of the place of treatment as distinguished from the need for it will drive away the very people whose sensitiveness or need for secrecy must be considered. On the other hand, the publication of material relating to sexual diseases in the public press has not yet reached the height of its possibilities, and should be pushed.
Utilization of Personal Prophylaxis.—Passing now to the debatable elements in a public campaign, opinion about the value of personal prophylaxis (Metchnikoff) against syphilis shows interesting variations in different countries at the present time. English-speaking countries hesitate over this. On the other hand, eminent German authorities, such as Neisser and Blaschko, urged it at the outset of the present war, and their views have apparently overcome a vigorous opposition. As a result, the knowledge of methods of preventing venereal infection are being spread broadcast over Germany in the hope of diminishing the inevitable risk that will arise with the disbanding of armies after peace is concluded, no matter how stringent the precautions taken to insure the health of soldiers before their return to civil life. The results of this experiment will be watched with the most intense interest by all those familiar with the situation, and the results will be of value as a guide for our own policy when we have had time to develop one. It is interesting that the most radical departure in the way of legislative provision for sexual disease, that of West Australia, takes up the patient at the point where his infection begins and promptly places him under penalty in the hands of a physician, but assumes no responsibility for other than indirect prevention. The most radical of all present-day legal measures against the disease has therefore not yet reached the radicalism of compulsory prophylaxis as it exists in armies, or even the radicalism of compulsory vaccination for smallpox.
Reporting of Syphilis to Health Officers.—The question of reporting syphilis to health officers as a contagious disease is a good one to raise in a meeting when a stormy session is desired. Upon this question wide differences of opinion exist all over the world. The right of a sick person to privacy, always deserving of consideration, becomes acute when it touches not only his physical but his social, economic, and moral welfare. It becomes a matter of importance to the state also when the prospect that his secret will not be kept leads him to conceal his disease and to avoid good public aid in favor of bad private care. It is a question whether the amount gained by collecting a few statistics as to the actual presence of the disease will be offset by the harm done in driving to cover persons who will not be reported. Modified forms of reporting sexual diseases, without name or address, for example, can be employed without betraying a patient's identity, thus doing away with some of the objections, and they have been in force in such cities as New York for some time. Vermont has recently adopted a compulsory reporting system, with the almost ludicrous result that by the figures her population shows 0.5 per cent syphilis, when the truth probably stands nearer 10 per cent. Much of the difficulty with reporting systems goes back to the lack of an educated public or professional sentiment behind them. For this reason they may be fairly placed in the category of premature legislative experiments, and should be postponed until a more favorable time. That this view has the sanction of students of such problems is borne out by the recent comment of Hugh Cabot on this issue, and by the decision of the British Royal Commission which, after careful deliberation, decided not to recommend to the Government at the present time any form of reporting for sexual disease. The West Australian law recognizes the wisdom of providing the patient having sexual disease with every safeguard for his secret provided he conforms to the requirement of the law in the continuance of his treatment. German sentiment is strongly against reporting, and no provision is made for it in the civil population. On the other hand, the very complete programs of the Scandinavian countries provide for reporting cases without names. It is, therefore, apparent, in view of this conflict of opinion, that we can afford to watch the experience of our neighbors a little longer before committing ourselves to the risk of arousing antagonism over a detail whose importance in the scheme of attack on syphilis is at best secondary to the fundamental principles of efficient treatment and diagnosis. There is no apparent reason why we should not be satisfied, for the present, at least, with drawing to our aid everything which can give us the confidence and the willing cooeperation of those we want to reach. Physicians who work with large numbers of these patients realize that privacy is one of the details which has an attraction that cannot be ignored.
Compulsory Treatment.—Compulsory provisions in the law form the third debatable feature of a modern program against syphilis. The Scandinavian countries have adopted it, and in them a patient who does not take treatment can be made to do so. If he is in a contagious condition, he can be committed to a hospital for treatment. If he infects another, knowing himself to have a venereal disease, he is subject, not to fine, but to a long term of imprisonment. The West Australian law is even more efficient than the Scandinavian in the vigor with which it supplies teeth for the bite. The penalties for violations of its provisions are so heavy as to most effectually discourage would-be irresponsibles. At the other end of the scale we find Great Britain relying thus far solely upon the provision of adequate treatment, and trusting to the enlightenment of patients and the education of public sentiment to induce them to continue treatment until cured. Italy has, in the same way, left the matter to the judgment of the patient. The Medical Association of Munich, Germany, in a recent study has subscribed to compulsory treatment along the same lines as the West Australia act, although thus far enforcement has been confined to military districts. The program for disbanding of the German army after the war, however, includes, under Blaschko's proposals, compulsion and surveillance carried to the finest details. A conservative summary of the situation seems to justify the belief that measures of compulsion will ultimately form an essential part of a fully developed legal code for the control of syphilis. The reasons for this belief have been extensively reviewed in the discussion of the nature of the disease itself (pages 104-105). On the whole, however, the method of Great Britain in looking first to the provision for adequate diagnosis and treatment, and then to the question as to who will not avail himself of it, is a logical mode of attacking the question, and as it develops public sentiment in its favor, will also pave the way for a sentiment which will stand back of compulsion if need be, and save it from being a dead letter.