stokes 
?o~day*s '.'crld ” nobler in Disease 
Prevention. To-day’s World Problem in Disease 
Prevention -r- 
A NON-TECHNICAL DISCUSSION OF SYPHILIS 
AND GONORRHCEA 
. By 
JOHN H. STOKES, A.B., M.D., 
Ml 
Chief of the Section of Dermatology and Syphilology, 
The Mayo Clinic, Rochester, Minnesota, U.S.A. 
Associate Professor of Medicine, Mayo Foundation Graduate School, 
University of Minnesota. 
OTTAWA 
F. A. ACLAND 
PRINTER TO THE KING’S MOST EXCELLENT MAJESTY 
1923 
51807—1 This booklet was written by Dr. John H. Stokes as a patriotic service and 
and was given to the U.S. Public Health Service for publication and 
distribution to those interested in the Government’s program for 
Venereal Disease Control, being carried on in co-operation with the 
various State Boards of Health. 
Copyright 
John H. Stokes 
1919 . 
(The Canadian Department of Health is authorized to use this book in its 
venereal control work without the payment of royalty.) FOREWORD 
This book written by Dr. Stokes, presents the facts concerning Syphilis 
and Gonorrhoea in a clear common-sense manner, without exaggeration; 
tells the true story as to causes and results and shows the way of applying 
our present knowledge to combat the disease. The book was written for 
the socially minded and public spirited layman, and is not to be regarded 
as a medical text, although it has an appeal to the physician equally with 
the social worker, the clergyman, the educator and the leaders of the busi- 
ness and professional world. 
It seems desirable to place this work in the hands of the Medical 
Profession of Canada and Dr. Stokes has kindly given his permission 
to publish a limited edition for such distribution. This Department desires 
to express its thanks to Dr. Stokes, who owns the copyright of the book 
for allowing this publication. 
This being a limited edition, further copies are not available for 
general distribution. 
Department of Health, Ottawa, Canada, 1920. 
51807—11 INTRODUCTION 
Major Wilbur A. Sawyer, of the United States Medical Corps, in the 
United States introduction says in part: 
“ The years of the great war have brought a sharp awakening of the 
American people to the need for facing the greatest present-day problem of 
public health. Almost over night we seem to have changed from a nation 
with its eyes shut and its ears stopped into a country alert, interested, and 
on the road to the full accomplishment of what had hitherto been declared 
impossible. 
“ In endless repetition the advocates of the doctrine of laissez faire 
have told us of the antiquity of prostitution and of the certainty that it 
would be with us forever in undiminished prevalence. They have said like- 
wise that syphilis and gonorrhoea and chancroid—that group called venereal 
diseases because of their commonest method of transmission—would never 
come under public health control, because they were “secret” diseases 
and u different from other diseases.” Therefore, the sufferer must be left 
undisturbed, to spread disease to others and to decay in self-neglect, unless 
chance information or intuition made him seek and appreciate the advice 
of a conscientious and skilled physician. 
“ Under the system of the past the physician could treat the patient 
as little or as much as he saw fit, and be accountable to no one for the 
protection of society against the refactory or careless patient. The patient, 
on the other hand, could stop his treatment and ignore precautions against 
the exposure of others whenever the whim seized him. Up to the time of 
the war, the American health officer, with his brilliant record for conquering 
such lesser evils as yellow fever, typhoid fever, small pox and malaria, felt 
that the venereal diseases were entirely out of his field. He accepted the 
dictum that they were “ different.” As a result, venereal diseases main- 
tained their prevalence and the cases were not even counted. Society paid 
for its neglect in wrecked homes, childless marriages, invalidism, blindness 
and insanity. And still venereal diseases were “ different.” 
“ Out of the war, along with all the suffering and destruction, has 
come much good. One benefit has been a change of this attitude and the 
creation of an American plan for banishing the vast amount of ill-being 
and pain and death caused by venereal diseases. This American plan is 
an entirely new concept. It is not new in any one part, but new in its 
combination of all the consistent, worth-while methods, and new in that it 
squares with the highest American standards of upright living. And it is 
sound in its sociology as well as in its preventive and curative medicine. 
“ If the American plan is to live and develop steadily into a better 
and still more effective plan of the future, the people of America must 
understand it. The silence of the leaders must be broken and their mouths 
must utter the truth with understanding. The lawyer and the statesman, 
the teacher and the clergyman, need more than the selected data which are 
scattered about with popular propaganda. They should have ready access 
to those fundamental facts about venereal disease on which successful 
methods of control must rest. To present these facts Dr. Stokes has pre- 
5 6 
pared this book. To make them widely available the United States Public 
Health Service has published a large edition and is sending it out to the 
teachers and leaders of the people—particularly the clergymen with their 
wonderful opportunities for warning, comforting, and advising. 
“ The plan was horn with the war. Those high in authority were 
prompt to see the need to forestall the debauching and disease-breeding 
conditions which were wont to arise in the neighbourhood of camps and 
follow in the trail of armies. 
“ The problem was attacked with vigor. Commissions on Training 
Camp Activities were established by the War and Navy Departments. They 
co-operated with the Surgeons General of the Army and Navy and Public 
Health Service in keeping conditions wholesome around the camps and 
training stations. Liquor and prostitution were suppressed in wide zones 
around places of training. Red-light districts were closed. Healthful recre- 
ation was made possible in town and in camps. Athletics, books, music, and 
dances were arranged for. The life of the soldier was made as normal as 
camp life and rigorous training would allow. 
“ But this was not all. The soldier himself was taught the dangers 
of venereal diseases and the advantages of a continent life, through 
lectures, exhibits, stereopticon slides, and most vividly by motion pictures. 
u The civilians living near army camps and in communities engaged in 
war industries were bombarded with appeals for co-operation, and they 
usually gave it unstintingly. Clinics were established and hospital beds 
provided for the treatment of venereal diseases, even under quarantine when 
that was necessary to protect the public health. The United States Public 
Health Service and the Red Cross maintained venereal disease clinics in 
extra-cantonment areas for the purpose of cutting down the incidence of 
venereal disease by curing the sick, and in this way reducing the health- 
hazard of the soldiers. 
“ For soldiers who had become infected, or who had been exposed, 
prompt and efficient treatment was provided by the army. Soldiers in 
infectious stages of venereal diseases were kept in camp as an added pro- 
tection to the civilian community. 
“ In these ways much disease was prevented, but the draft army soon 
provided some revealing figures that called for different efforts. It was 
found that most of the cases of venereal diseases among our soldiers were 
contracted before the men came into camp. In fact, over five-sixths of 
the venereal disease treated in the army in America up to the time of the 
armistice was acquired before the boys put on the uniform. This evidence 
showed that the environment of the home town was more dangerous to 
the health of young men of draft age than the carefully guarded surround- 
ings of the camp. 
“ And then began the fight to protect the soldier of anticipated future 
drafts. The campaign had to be carried to all communities, whether or 
not they were near army camps. State Doards of health widened their 
activities. Congress recognized the problem and created a Division of 
Venereal Diseases in the Public Health Service, and also an Inter-Depart- 
mental Social Hygiene Board to correlate the venereal disease work of 
the War, Navy, and Treasury Departments. Over four million dollars were 
appropriated to carry out measures for control by the government and to 
assist the states in financing the work being initiated by their boards of 
health. 7 
“ Under the leadership of the new division of the Public Health 
Service, further developments were rapid. Nearly all the states made 
venereal disease reportable, with due precautions for secrecy in the interests 
of the patient. There developed a widespread movement for the establish- 
ment of clinics in which the best of treatment could be made available to 
the many who need it but cannot afford the high cost of the prolonged 
treatment necessary for the cure of syphilis and chronic gonnorrhoca. 
“ With all these measures aimed at disease prevention, there has been 
arising a feeling of sympathy for those who are suffering from venereal 
disease. A deep-rooted and unreasoning antagonism is being replaced by 
understanding and a desire to help. Social service by trained workers is 
bringing to the clinics people who are diseased, following up those who 
have dropped from view before their cure was completed, and offering hope 
of health to the infected families and associates. Experts in constructive 
institutional work are taking up the task, persons experienced in dealing 
with those who require restraint and training and encouragement, as well 
as medical care. And throughout it all there has been a hopeful optimism 
not often seen among those who deal so often with the degenerate and the 
prostitute. 
“ The prevalence of venereal disease among soldiers in the United 
States and in the expeditionary forces has been very low, much lower than 
had been expected on the basis of the earlier experiences of other armies 
in the conflict. In addition to the prevention of new cases of venereal 
disease, the amount of venereal disease in the army was reduced by the 
treatment of many thousands of men who had contracted their disability 
in civil life and would have continued to spread infection if released from 
the army untreated. 
“ What was done to keep the soldier fit should be done year in and year 
out for the health, efficiency, and well-being of every young man and young 
woman of America. They must be taught, guided and protected, not only 
through individual attention, but especially by the correction of vicious 
influences in the community and the creation of an environment which 
is wholesome and stimulating to better living. The war has furnished a 
successful demonstration. May its lessons not be forgotten. 
“ Under the leadership of the Public Health Service the state boards 
of health are working and planning for venereal disease control. People 
are organizing in many communities to resist any attempts of the tender- 
loin influence to bring back the old conditions of vice recognized and disease 
rampant. 
“ The first duty of all who wish to take a hand in the fight is to inform 
themselves so that they may lead and help others intelligently. And this 
brings me again to the volume which Dr. Stokes has prepared, not so 
much for the benefit of the readers themselves as for the welfare of the 
much larger body which will be influenced through their words, example, 
and direct assistance. 
“Venereal diseases have at last recognized as prevalent, 
destructive and preventable. They have been brought into the open and 
they cannot stand the light.” 
The introduction to the American edition as written by Major Wilbur 
A. Sawyer, is so applicable in many ways to Canada, that it seems out of 
place to detract therefrom by duplication. 8 
To the well informed Canadian reader repetition is unnecessary and 
the general public will find in the brochure of Dr. Stokes such a treasury 
of ideas, thoughts and practical applications that they are confidently 
recommended for serious perusal with the hope that they may find early 
and practical application in the crusade against venereal disease to which 
Dr. Stokes’ efforts have been so well and ably directed. 
With grateful acknowledgement to the author for the courtesy extended 
for the publication of this Canadian edition. 
John A. Amyot, 
Deputy Minister, 
Department of Health. CONTENTS 
PAGE 
Foreword 3 
Introduction 6 
Author's Preface 16 
PART I. 
THE NATURE OF THE GENITAL INFECTIONS. 
Chapter I—The Source of the Genital Infections. 
The Genital Infection Defined 19 
General Principles of Transmission of the Genital Infections 19 
Intimate Contact and Moisture Necessary 20 
Individual Resistance, Peculiarities of the Germs 20 
Chapter II—The Genital Sore. 
Antiquated Distinctions Between Syphilitic and Chancroidal Sores 22 
Modern Methods for Recognizing Early Syphilis 22 
Early Examination and No Previous Treatment 23 
The Microscopic Examination is Essential 23 
Reassurance for the Timid 24 
The True Chancroid 24 
PART II. 
GONORRHCEA. 
Chapter I—History, Cause and Prevalence. 
Gonorrhoea a Localized, Resistant Infection . 27 
The History of Gonorrhoea 27 
The Gonococcus, the Cause of Gonorrhoea 28 
The Microscope Essential In the Treatment of Gonorrhoea. 28 
The Prevalence of Gonorrhoea 29 
Gonorrhoea in Men 29 
Gonorrhoea in Women 30 
Chapter II—Gonorrhoea in Men. Symptoms, Tests for Infectiousness. 
Acute and Chronic Gonorrhoeal Inflammation 31 
The Course of Acute Gonorrhoea in the Male 32 
Posterior Gonorrhoea and the Genital Complications 32 
Causes and Complications of Chronic or Persistent Gonorrhoea 32 
Stricture . . . . 33 
Relapses and Flare-Ups: “Gleet” or "Morning Drop” 33 
Chronic Gonorrhoea of the Prostate and Urethal Glands 33 
Tests for Chronic Urethritis, etc 34 
Morbid Fear of Gonorrhoea. 34 
Gonorrhoeal Nervous Prostrations 34 
9 10 
PAG* 
Chapter III—Systemic Gonorrhcba and Gonorrhoea in Women and Children. 
Reasons for the Greater Seriousness of Gonorrhoea in Women 35 
Course of Genorrhoeal Infection in Women 36 
Gonorrhoea and Pregnancy 36 
Gonorrhoeal Child-Bed Fever and Sterility 36 
“Pelvic Inflammatory Disease” 37 
Concealed or Latent Gonorrhoea in Certain Glands 37 
Systemic Gonorrhoea; Rheumatism, etc 38 
Gonorrhoea of the Eye (Gonorrhoeal Opthalmia) 38 
Prevention of Gonorrhoeal Blindness 39 
Gonorrhoeal Inflammation of the Genitals in Girl Children 39 
Vulvo-Vaginitiis in Hospitals.. 39 
Chapter IV—Treatment and Hygiene of Gonorrhoea. 
The Difficulties of Treatment.... - 41 
Local and General Measures Employed 41 
The Patient’s Co-operation 41 
The Treatment of Chronic Gonorrhoea 42 
The “ Bad Cold ” Lie, Fakes, Drug Stores and Quacks 42 
Treatment of Gonorrhoea In Women... 43 
The Obstinacy of Chronic Gonorrhoea in Women 44 
The Abortive or Suppressive Treatment of Gonorrhoea 44 
Hygiene of Gonorrhoea 44 
Chapter V—The Cure of Gonorrhoea. Gonorrhoea and Marriage. 
Gonorrhoea is Usually Curable 46 
The Carrier of Infection the Real Danger 46 
Modern Tests for Determining Infectiousness and Cure 47 
Gonorrhoeal Childlessness in Men and Women 47 
A Child Unborn 48 
Gonnorhoea and the Medical Examination Before Marriage. 48 
Protection of the Fianc&e 49 
Protection of the Pregnant Woman Against Gonorrhoea 49 
A Warning in Regard to Double Marital Infection 50 
Remediable Weakness of the Existing Situation 50 
SYPHILIS. 
Chapter I—History, Cause and Prevalence of Syphilis. 
The Origin of the Name 55 
Syphilis, a Master Disease 55 
The Historical Aspects of Syphilis 56 
The New Knowledge of Syphilis 57 
The discovery of the Germ and the Transmission of Syphilis to Animals.. 57 
The Spirochgeta Pallida and its Recognition in Early Syphilitic Sores.. 67 
The Prevalence of Syphilis 58 
Chapter II—The Course of Syphilis—Primary and Secondary Stages. 
The Stages of Syphilis 60 
The Primary or Localized Stage—The Chancre 60 
Cure in the Early Stage (Abortive Cure) 61 
Difficulties in Recognizing a Syphilitic Chancre 61 
The Spread of the Germs from the Chancre to the Body 62 
The Generalized or Secondary Stage 63 
Syphilitic Eruptions and Their Variations; Common Misconceptions.... 63 
Syphilitic Eruptions and the General Public 63 
The Dangerous Contagious Manifestations of Secondary Syphilis 63 
The Constitutional Effects of Secondary Syphilis; Symptomless Syphilis. 64 
PART III. 11 
PAGE 
Chapter III—Recurrent, Inactive and Late Syphilis. 
Latent, Obscure or Silent, and Recurrent Syphilis * 65 
Contagious Recurrences and Inefficient Treatment 65 
Silent or Latent Syphilis and Late Complications 66 
Late Syphilis—Premature Old Age and Gummatous Change 66 
The Hopeful Side of Late Syphilis . 67 
Late Syphilis of the Nervous System—Locomotor Ataxia and General 
Paralysis 68 
Late Syphilis is Preventable and Treatable 68 
Chapter IV—Modern Tests for the Recognition of Syphilis. 
Laboratory Tests vs. Medical Examination in Syphiiology 69 
The Wassermann Blood Test for Syphilis 69 
Personal Equation and Interpretation in the Wasserman Test 70 
The Positive Wasserman Test 71 
The Negative Wasserman Test 71 
Effect of Treatment on the Blood Test 71 
The General Medical Examination Essential 72 
Spinal Fluid Tests 72 
Chapter V—Hereditary Syphilis. 
Effect of Syphilis on the Race 74 
The Syphilitic Mother 74 
Mode of Infection of the Child 74 
Treating the Mother May Protect the Unborn Child 75 
Effect of Inherited Syphilis on the Child 76 
Symptoms of Syphilis in the New-Born 76 
Late Effects of Inherited Syphilis; Imbecility, Eye and Ear Trouble.... 76 
Heriditary Syphilis and the Third Generation 76 
Public Responsibility in Hereditary Syphilis 77 
Chapter VI—The Treatment of Syphilis. 
The Treatment of Syphilis with Mercury 78 
The Discovery of Arsphenamine—Ehrlich’s " 606 ”...., 79 
Mercury Does not Control Contagiousness 79 
The Commercial Status of Arsphenamine 80 
The Fallacy of the One-Dose Cure 81 
The Action of Arsphenamine 81 
Chapter VII—The Cure of Syphilis. 
What is Adequate Treatment? 82 
An Interpretation of the Cure of Syphilis 82 
The Time Factor in Cure 83 
Determination of the Pact of Cure.. 83 
Treatment of Hereditary Syphilis 83 
Chapter VIII—Public and Personal Hygiene of Syphilis. 
Summary of Facts Regarding Contagiousness 85 
Non-Genital Syphilis 85 
The Engagement Chancre 85 
Genital Transmission of Syphilis 86 
Duration of Contagiousness. Effect of Tobacco, Dirt, etc 86 
Arsphenamine in the Control of Contagiousness in Syphilis. 86 
Personal Responsibility in the Transmission of Syphilis 87 
Chapter IX—Syphilis and Marriage. 
Syphilis and the Medical Examination before Marriage 88 
Responsibility of the Church 89 
Responsibility of the Medical Profession 89 
Summary of the General Outlook 89 PART IV. 
12 
THE SOCIAL, PSYCHOLOGIC, AND ECONOMIC BACKGROUND OF 
SYPHILIS AND GONORRHCEA. 
PAGE 
Chapter I—The Public Viewpoint. 
The Inertia of Public Opinion 93 
An Analysis of Current Misconceptions 93 
Public Ignorance of the Facts 94 
Confusion with the Problem of Prostitution 94 
Exaggerated Notions about Contagiousness 95 
The Fallacy of Believing Fear a Deterrent 96 
A Positive Idealism Necessary 96 
"I Thank Thee That I am not as Other Men Are ” 96 
Syphilis and Gonorrhoea as “Frightfulness” 97 
Chapter II—Normal Ideals of the Sex Life—Abnormal Checks on 
Marriage. The Trend of the Times to Laxity—The Influence of 
the War. 
The Changing Trend of Sex Ideals 98 
The Normality of Sex Ideals 98 
Growing Need for a Bulwark of Moral Ideals 98 
Remediable Obstacles and Factors of Error in Marriage 99 
Training in the Ideals and Practicalities of Marriage 99 
Marriage and Industrial Dependence 99 
The Effect of Failure on Marriage Ideals 100 
Marriage and the Economic Treadmill 100 
The Tendency of Sex Life to Crudity of Expression 101 
The Trend Toward Sexual Laxity; Decadence of Chaperonage 101 
Contributions Made by the War to Sex Problems 102 
Chapter III—The Economic Background of Syphilis and Gonorrhcea 
—Prostitution—Alcoholism and the Genital Infections—Other 
Forms of Commercial Exploitation. 
The Dollars and Cents Aspect 103 
Cost of Treatment as an Element in the Campaign 103 
Commercialization of the Sex Impulse 104 
Syphilis and Gonorrhcea in Prostitutes 104 
The Medical Examination of Prostitutes 105 
Syphilis in the Lax and Indiscrit 106 
Unsocial Sexual Relations Cannot be Made Safe 106 
The Struggle Against Prostitution; Regulations, Repression, Legal 
Measures 106 
State Care of Delinquent Girls 107 
The Fundamental Principle 107 
Alcoholism and the Acquiring of Syphilis and Gonorrhoea.. 107 
Physiologic Effects on Persons Already Infected. 108 
Other Phases of Commercial Exploitation of Sex; the Stage, Books, 
Clothes, etc 108 
Chapter IV—Moral and Educational Prophylaxis of Syphilis and 
Gonorrhcea—Problems and Methods of Sex Education. 
Morale and the Sexual Life 109 
Positive Idealism and Idealistic Expression 109 
Altruistic Outlets for Sexual Energy 109 
The Fundamental Inhibitions ; Sound Character as a Basis of Self Control 110 
Teach the Child 110 
Virginity is only Half the Problem Ill 
Home, Protection and the Work Outlet in Sex Education... Ill 
Value of Sex Instruction Ill 13 
PAGE 
Methods of Technic of Sex Instruction 112 
Companions and Book 113 
Good Sportsmanship and Hardy Living 113 
The Time for Plain Pacts 113 
Visual, Graphic and Personal Teaching; the Speaker 113 
Chapter V—The Public Health Control and Personal Prophylaxis 
of Syphilis and Gonorrhoea. 
The Public Health Control of Syphilis ar 1 Gonorrhoea. 115 
The Church and the Problem 115 
The New Responsibilities of the Medical Profession 115 
Hospitals and the Problem 116 
The Press and the Problem. 116 
Laws and Law Enforcement; Compulsory Treatment 117 
The Reporting of Syphilis and Gonorrhcea to Health Officers 118 
Legislation Needed on Medical Profession Confidence 119 
Personal Prophylaxis; Continence 119 
The Medical Prevention of Syphilis and Gonorrhcea 119 
Conclusion 120 AUTHOR’S PREFACE. 
In the past fifty years the socialization of medicine has paralleled the 
centralization of commerce and the organization of labour. It is no longer 
possible for the individual physician to maintain the isolation and the 
arbitrary powers and responsibilities which were his in primitive times. 
The advance of both the art and the science of medicine has compelled the 
development of partnerships and group practice, in which the knowledge 
of one man supplements the lacks of another, to the advantage of the sick 
for whom and upon whom they work. As this idea of co-operative effort 
develops within medicine itself, a new form of relationship in the main- 
tenance of human welfare appears upon the horizon. A partnership 
between intelligent and well informed public opinion and the physician as 
leader is the logical ultimate expression of the trend of the times. Medicine 
is beset with problems whose solution is impossible except by ithe widest 
co-operation and the broadest understanding imaginable. The physician 
as a leader acting alone is helpless. It was said of the Roman legion 
that its tremendous effectiveness as against the phalanx was due to the 
fact that every man in it was an accomplished warrior who could, if alone, 
give admirable account of himself. To make every intelligent man, 
woman and child a legionary in the organization of the public health, some 
of the knowledge so long sedulously kept as the property of the profession 
of medicine must be imparted to the rank and file. 
One by one the greatest scourges of the race are succumbing to this 
new strategic method. Malaria and yellow fever are giving way not alone 
before the advance of medical knowledge, but also before the popularizing 
of that knowledge which makes every-day people intelligent co-operators 
in the campaign. Tuberculosis mortality is falling, not alone because of 
new conceptions in its treatment, but because of the tremendous force of 
public knowledge and sentiment. In time the same fate will await cancer, 
syphilis and gonorrhoea. 
Syphilis and gonorrhoea perhaps more than any other of the great 
plagues which scourge humanity, need the new strategic method. Medically 
we are armed to the teeth against them. All the paraphernalia of battle 
is at hand. Against these two diseases we can move with irresistible 
force on the dawn of the day of human enlightenment. That dawn is 
very near. Once we can open the eyes of the every-day man and woman 
to see the enemy ae he is, his course is run. 
There is no device known to a cruel, unscrupulous and implacable 
opponent which has not been used against us by the twin scourges. They 
have crept into our houses and murdered the innocent and the helpless. 
They have appeared to many a sincere well-wisher of mankind not in their 
true semblance of brutal, wanton and savage mutilators and destroyers, 
15 16 
but in the disguise of wellwishers, guardians of the moral life, painful 
but just chasteners of iniquity. Many a sincere but uninformed or un- 
thinking man or woman has shuddered to think that these things must 
be, and yet feared to protest against them, refused even to know about 
them lest with one horror removed or explained away, they should confront 
a worse one. We have lived the nightmare of one who dreams that his 
awakening will be his death, and dares not open his eyes. 
Syphilis and gonorrhoea are not what public misconception makes them. 
Quietly and dispassionately examined, they can be easily seen to be no 
more disreputable than other disease enemies of the race. They have like- 
wise no supernal power or commission. They are no more repellent to 
the senses than many another ailment. There is nothing in their origin 
which gives us cause to refuse to know about them. In fact, an under- 
standing of them is the more obligatory upon us because they undermine 
and attack the citadel of life itself. The clothing of mysterious words and 
allusions, of shame-fast silence, of false disgrace, of painted horror thaJt 
surrounds them is their cloak of darkness which protects them from the 
vengeance we would visit on intimate and secret enemies. Like murderers 
who mingle with the crowd upon the very scene of their crime, syphilis 
and gonorrhoea stand so near to us tha*t although they have attacked our 
very germ plasm and our physical immortality, we have not known them 
for what they are. 
The movement for a new jconception of these two diseases, which will 
make the common man a legionary, and will enlist against syphilis and 
gonorrhoea all the force of an enlightened public sentiment, begins with 
a choice of words. The armour of the third and fourth great plagues is 
words. For generations syphilis and gonorrhoea have been called venereal, 
until the mere use of the term throws a cloak of odium over any subject 
to which it is attached. People are .afraid of it, afraid of being shocked, 
afraid of being besmirched, of having the loathsome thrust upon them. 
And all this repulsive connotation, wholly uncalled for as it is, plays into 
the hand of syphilis and gonorrhoea. Labels that attract lead us to 
scrutinize the object. Labels that repel, turn away (our gaze and foster 
ignorance. Much of our public attitude toward syphilis and gonorrhoea, 
our false modesty and mistaken shame, our ultra-sexual point of view, is 
the product of false labelling. To look at syphilis and gonorrhoea with 
the verbal veil withdrawn is not to turn to stone before the Medusa gaze, 
but to be inspired to dash at the monster and demolish lit. To withdraw 
the veil and permit people to face the facts, is the first function of a public 
health movement against the “ diseases of vice.” 
A dispassionate and calm analysis; good Anglo-Saxon words; the 
simple dignity of truth-telling; iteration and reiteration, will yet awaken a 
sleeping public thought to the enemy within our gates. 
John H. Stokes. PART I. 
THE NATURE OF THE GENITAL INFECTIONS. 
51807—2 
17 CHAPTER 1. 
The Source of the Genital Infections. 
The Genital Infections Defined.—There are more than merely psycho- 
logical grounds for avoiding the tendency to group the four so-called 
“ venereal diseases,” syphilis, gonorrhoea, chancroid and gangrenous 
balanitis, together under a single head. The history of these four infec- 
tions is rich in examples of the retarding effect on knowledge, of a prema- 
ture inclusion in one conception of several different ailments merely because 
of the accident of their beginning on the same part of the body. To be 
sure, syphilis, chancroid and gangrenous balanitis begin as sores. Yet 
the latter two of the sores have ahead of them when they appear, only a 
brief and usually a trivial history. Prompt and complete recovery, with- 
out any more than local damage to the genitals, is the rule. The first 
sore of syphilis, on the other hand, has, from the moment of its appearance, 
a significance which reaches potentially into every tissue of the patient’s 
body and into every hour of his succeeding days and years. It reaches 
beyond him into the lives of his intimates and his friends, into his career 
and all that it may touch, and through the children that may or may not 
be his, it lays hands upon the future of the race. Gonorrhoea, instead of 
beginning as a sore, begins as a discharge of pus from the canal through 
which the urine flows, or in women often as an inflammation of some 
deeper portion of the genital tract. In the large majority of cases its 
field of action is local, the damage that it doe3 the race being inflicted 
mainly through its power to injure and incapacitate the structures that 
create and bring children into the world. Syphilis in the overwhelming 
proportion of cases carries consequences for the individual that have a 
quality of seeming remoteness, a potential gravity and an element of sur- 
prise which make it stand alone among all human ailments. Between 
the tiny genital sore and the doddering victim of syphilitic insanity there 
is a vast gulf of alarms and tragic possibilities. Gonorrhoea is more of 
an inch-by-inch disease, less versatile and less dramatic than syphilis, and 
in proportion to its wider distribution, perhaps less inexorable and 
implacable. It is none the less a tenacious, stubborn and mean-spirited 
foe. 
It will be worth while to bear in mind that for the broader outlook, 
the genital diseases are really only two in number—syphilis and gonor- 
rhoea. Chancroid and gangrenous balanitis are incidents in the diagnosis 
of syphilis. Gonorrhoea is a wholly different problem from every point 
of view. There is no longer any need to speak of the venereal diseases. 
If we must choose two words, let it be the two that have the ring of frank- 
ness and the grace of simplicity and directness—syphilis, gonorrhoea. 
General Principles of Transmission of Genital Infections.—Certain 
fundamental facts apply no less to syphilis, gonorrhoea, and their satellites, 
chancroid and gangrenous balanitis, than to such diseases as diphtheria, 
tuberculosis and pneumonia. All of them are infections, each produced 
by its own specific germ. They are transmitted by the physical contact 
51807—2§ 
19 20 
of the well person with some intermediate object, or with some part of the 
body of the sick one, on which are present the germs causing the disease 
in question. If there are germs of syphilis in the mouth, contact with 
the mouth or with objects containing secretions from the mouth will 
give the disease to a healthy person. The transmission of disease by inter- 
mediate objects is dependent upon the length of time and the conditions 
under which the germ in question can live outside of the body. Unless 
the germ is carried in droplets of saliva, as sometimes happens in certain 
diseases, there is no vague blowing about of the poisonous agent in mys- 
terious ways from place to place. The contact is physical, the infection 
by actual transfer of germs. 
Individual Resistance, Peculiarities of the Germs.—A third factor 
enters into the transmission of infections, in addition to the infected body, 
and the intermediate article carrying the germs. This is the so-called 
resistance of the well person—his ability to fight off germs that try to gain 
a foothold on him. While this is a large factor in protecting well people 
from certain diseases, it plays a little understood but probably very minor 
role in protecting healthy persons from syphilis, gonorrhoea, and chancroid. 
To these diseases practically everybody seems to be susceptible—at least 
everybody can acquire them, although in some the infection may run a 
milder course than in others. The great factor which, in the last analysis, 
protects humanity from the practically universal spread of syphilis and 
gonorrhoea is not the virtue and chastity of some as distinguished from 
the viciousness of others, although, to be sure, foolhardy exposure increases 
the risk of acquiring these as much as any other infection—it is essentially 
the biological characteristics of the germs themselves that save us. Syphilis 
and gonorrhoea are genital diseases, but not because some far-seeing power 
set them as watch-dogs at the gate of righteousness. They are transmitted 
by sexual intercourse and by intimate contacts between person and person 
(not necessarily man and woman) because, like the homely potato, the 
germs of these diseases need a certain soil on which to grow. These germs 
are vegetables, so to speak, and if the conditions can be made unfavourable 
for them at the spot on which they are planted, no amount of vice and 
immorality connected with the planting can persuade them to grow. Corre- 
spondingly, innocence, virtue and ignorance have no power to retard their 
growth upon the parts of the body where they find conditions favourable. 
The absence of air in the genital tract of a saint is as favourable to the 
growth of the germ of syphilis as in that of a sinner. It makes not an 
iota of difference whether the cause is just or unjust, the victim innocent 
or besmirched. No one would go so far as to say that collateral habits 
of drunkenness, uncleanliness and bad living such as are prevalent among 
the vicious, do not favour infection with these as with all other contagious 
diseases. But there is no connection so direct as to justify the title of 
venereal as applied to any disease to mark it as a punishment for sin. 
Intimate Contact and Moisture Necessary.—For the transmission of 
syphilis and gonorrhoea in general, intimate contacts between moist sur- 
faces are essential. Intimate contact between the male and female genitalia, 
however, is in no wise essential. A syphilitic chancre on the cheek from 
an infected razor cut, or gonorrhoea in infants from contact with an infected 21 
diaper is just as much syphilis or gonorrhoea as the sexually transmitted 
type that so completely occupies the horizon of popular misconception. Dry 
materials do not transmit these diseases, nor does infection with them tend 
to follow invariably upon casual contacts. The germ of gonorrhoea will 
not grow as a rule upon the skin, while that of chancroid will, and that of 
syphilis may if the conditions are otherwise favourable. Door knobs, the 
walls of rooms, linen and blankets that have been washed, for example, do 
not harbour them. Mild antiseptics usually destroy them. Yet there is 
about them, and about the germ of syphilis especially, an uncanny 
versatility. Only too often, where every precaution has been taken they 
manage to get a foothold through some trivial slip, and where they are 
least expected, they appear. In fact, it is too often those ignorant of facts 
and risks alike who are betrayed in the sacred intimacies of life, instead of 
in its unworthy moments. The human genital infections are parts of a 
biological problem, not a moral issue. Dourine, a disease of the horse 
which, while caused by another germ than syphilis, has a remarkable resem- 
blance to it in its manifestations and its sexual transmission, can hardly 
be conceived of by any reasonable person as a special device for guarding 
that animal’s moral life. Yaws, the twin brother of syphilis in man, a 
tropical disease so like it in every respect, even to the germ causing it, that 
it might almost be called syphilis, has not developed the unsavoury reputa- 
tion of a “ venereal ” disease. Larger considerations such as these soon 
disabuse even the prejudiced of the idea that there is moral value in the 
genital infections and that they are needed to safeguard us from license. 
They are dangerous contagious diseases. Their value to mankind as a 
source of inspiration and uplift is nil. Their cost in undeserved wretched- 
ness, in innocence put to torture, in physical and spiritual degradation, is 
immeasurable. An enlightened conception of duty to the public health 
demands that we blot them out. CHAPTER II. 
The Genital Sore. 
Chancroid, and gangrenous balanitis, are mere appendages of the prob- 
lem of syphilis, and derive practically all of their significance from the fact 
that being sores on the genitals, they may conceal beneath a seemingly 
harmless exterior, a much graver infection. Syphilis begins with a pimple, 
ulcer or sore at the point where the germs enter the body. While it has 
long been recognized that mixed infections with chancroid and syphilis 
could occur, it was not until the discovery in 1905 of the germ causing 
syphilis that a reliable and widely applicable method of distinguishing a 
syphilitic from a chancroidal sore by the microscope was developed. This 
will be more fully discussed in connection with syphilitis. 
Antiquated Distinctions between Syphilitic and Chancroidal Sores.— 
Physicians of the older school, and unfortunately too many younger men, 
have been taught an elaborate lore or diagnostic system for distinguishing 
chancroid from chancre (syphilis) on the score of the appearance of the 
ulcer alone. By this method, of course, typical text-book picture chancres 
may be recognizable, but in general it may be said that the first sore of 
syphilis is quite as often unlike the pictures in books, as it is like them. 
The effort to distinguish the two by their appearance has in general done 
vastly more harm than good, since innumerable syphilitic sores have been 
mislabelled chancroids by victims who have picked up a little half-know- 
ledge on the matter, and by physicians not familiar with the very large 
margin of error in such judgments. It may be absolutely impossible to 
distinguish the sore marking the beginning of syphilis from any one of the 
half-dozen other types of sores which may appear upon the genitals. 
“ Hair pimples,” “ warts,” “ chafes,” the bites of the itch mite, the blisters 
of a “ cold sore,” the plainest and most undoubted chancroid that ever was, 
may each and every one be the first sore of syphilis. When a sore of any 
description appears upon the genitals of a person who has had sexual 
intercourse or intimate contact with another, the first problem of the 
physician is to prove that that sore is not syphilitic. 
Modern Methods for Recognizing Early Syphilis.—There are only two 
ways of proving that a sore is not the beginning of syphilis. The first of 
these is failure to find the germ of syphilis after repeated careful examina- 
tions with the microscope. The second is repeatedly to test the blood of 
the patient for evidence of syphilis through a period of not less than three 
months from the time the sore first appeared. The second of these pro- 
cedures is never to be made a substitute for the first, since a sore can be 
proved to be a chancre, the beginning of syphilis by microscopic examina- 
tion, long before it can be proved to be such by the blood test. Neither is it 
permissible to substitute mere waiting for a “breaking out” or eruption 
to develop, since the blood test usually becomes positive first, and the 
eruption may be so trifling as to be overlooked or misunderstood. In the 
modern treatment of syphilis, hours count, and to lose them by waiting for 
22 23 
a blood test to show the disease because one is too ignorant, indifferent or 
inexperienced to find the germ itself in the secretions from the sore, is 
fast becoming criminal negligence. 
Early Examination and No Previous Treatment.—In order to make it 
possible to prove the nature of a sore by microscopical examination, and 
the finding of the germ, two things are absolutely essential in addition to 
the necessary equipment and knowledge on the part of the doctor. The 
first is that the sore shall have had no treatment of any hind, whether 
applied to the sore, or given to the patient internally. The second element 
is time. The sore must be seen early. The germs of syphilis are fragile 
and yet tremendously tenacious. A little dusting powder of almost any 
kind, a wash even of boric acid, may kill or drive them from the surface of 
the sore. But in the deeper tissues, where they are much harder to reach 
and may not be found at all, they may continue to thrive. The sore may 
even heal over above them, and the patient yet develops syphilis. If the 
sore has not been treated, all that is necessary to obtain them is to clean 
off the surface with gauze or scrape it very lightly, and the serum that 
comes out will swarm with them. It is safe to say that every year tens of 
thousands of men unknowingly throw away a one hundred per cent pos- 
sibility of being cured of syphilis by listening to some friend who advises 
them to “ dry it up with calomel powder,” or by accepting the ever ready 
advice of Joe the drug clerk at the Fixall Store, only to find a few weeks or 
a few years later that the disease has them by the throat. Too often the 
doctor himself is the man who “burnt it off” and let it go at that, or 
allowed the patient to believe that healing means “chancroid” and not 
syphilis. Emphasis, too, must be laid upon the word repeated, wherever ,-t 
occurs. Repeated microscopic examinations, three or four—repeated blood 
tests, so as to catch the first signs of the disease in the blood, are part of the 
modem requirements. Their expense is trifling compared with the expense 
of the additional months and years of treatment and the increased risks 
that delay in recognition of a syphilitic infection entails. 
The Microscopic Examination is Essential —Let it be said again, 
that there is no way of describing or picturing chancroid and gangrenous 
balanitis which can exclude the possibility of their being the beginning of 
syphilis. Whether the sore is hard or soft, single or many, painful or 
painless, pinhead or silver dollar size, the day is passed when physician 
or layman can look at it, pinch it, feel the kernels or glands in the groin 
and dramatically say the fateful word that brings joy or lamentation 
“ chancroid ” or “ syphilis.” No patient should be content with such an 
examination, or with the innumerable names such as “ chafe,” “ cold sore,” 
or the laugh an'd “pooh-pooh” which may be offered him by friend or 
doctor as a reassurance. Experts may occasionally be able to judge cases 
on their merits and decide without examination tha't a group of blisters 
on the genitals of a man or woman who has not had sexual contact is not 
syphilis. But in general the less leewtay the better and the more unvary- 
ingly the patient demands and the physician carries out the proper micro- 
scopical examination of genital sores, followed by the repeated testings of 
the blood if the germs are not found, the more syphilis will be recognized 24 
in time for cure and the fewer men will have the experience so dis- 
tressingly common in these days, of finding that p mere label like 
“ chancroid,” glossed over the syphilis that wrecked them when they 
reached their prime. The public has a duty in demanding service of this 
type from the medical profession, quite as much as the profession has a 
duty in furnishing it, and the pressure of a public conception of what the 
doctor ought to do in such a case will hasten .the day when the doctor will 
be ready and able to do it. 
Reassurance for the Timid.—Positive statements like the foregoing, 
true though they may be, have a trick of upsetting the nervous and timid, 
usually those for whom the admonitions are least intended. For the 
benefit of such, let it be said that the presumption of syphilitic infection 
is proportional in some degreo to the amount of exposure, and that men 
and women who are continent are not at all likely to develop genital sores 
or gonorrhoea from the many harmless outside contacts with toilets, door 
knobs, .bathtubs and people which nervous persons are inclined to fear. 
The True Chancroid.—A true chancroid, or a gangrenous balanitis, 
in spite of the relative insignificance into which it subsides, once the 
question of a syphilitic element is eliminated, can none the less be an 
exciting and highly disagreeable affair. Little sympathy need be wasted 
on the average chancroid, or on any gangrenous balanitis, since they are 
both distinctly venereal in the overwhelming majority of cases,1 and 
filthily so at that. While the average chancroid runs the course of an 
infected ulcer, which under proper treatment becomes clean and heals 
with only a small amount of scarring, small chancroids especially have a 
habit of sending infection up into the kernels of the groin, which swell, 
become intensely painful and usually have to be lanced—a “ bubo,” as 
this complication is called. Larger chancroids leave ineradicable labels an 
the form of loss of (tissue and scarring as reminders. The common chan- 
croid often, and gangrenous balanitis almost always, show a tendency to 
spread. A little unwise interference, and often no apparent cause, is 
sufficient to make them violent. Such a “ phagedenic ” or devouring 
chancroid may :in a few hours leave the testicles hanging by shreds, the 
remainder of the genitalia nothing but ragged bloody stubs, and not 
content with this, will march up on to the abdomen, melting everything 
before it. Gangrenous balanitis produces equally horrible mutilations 
The chancroid certainly lacks nothing in physical characterictics when 
once aroused to make it a means of employing fear for educational 
purposes. Its treatment in serious cases, too, causes physical agony that 
comes as near the German conception of frightfulness as any single 
experience vouchsafed a human being in peaceful life. Even in the 
serious, mutilating chancroids, in which, when .the patient is first seen, 
conditions are such that no microscopical examination for the germs can 
be made with any hope of success, the ever present possibility of an 
underlying syphilis must mot be overlooked, and the patient cannot be 
regarded as well until blood tests taken as late as four months after the 
infection have shown he does not have syphilis. 
i There seems to be a type of gangrenous ulcer of the genitals which is non- 
venereal, and there are forms of genital ulceration in women (ulcus acutum 
vulvas) which have no connection with chancroidal infection and yet closely 
resemble it. PART II. 
GONORRHOEA. 
25 CHAPTER I. 
History, Cause and Prevalence. 
Gonorrhoea a Localized Resistant Infection.—We pass now from the 
prelude of the .local “phase *of genital infections to the consideration of two 
,of the greatest modern (problems in disease. Of the two, gonorrhoea pre- 
sents the more depressing picture. Its enormous prevalence and the 
terrible and tragic costs which it entails upon uncomprehending mankind, 
give it a leading place among the scourges of the race. Its bulldog 
obstinacy, and slowness of response to treatment, its ability to baffle every 
resource brought against it, and its trickery, seem to give it all the 
attributes of an evil personality. Curable to be sure, and usually cured 
under prolonged skilful direction, we are not wholly able to lay our hands 
on the factors that make success in its treatment. “Nature” seems to 
.bear too large .a hand, and medical skill to have too little power to give 
work with the disease the fascination there is in treating syphilis. There 
is little of the dramatic about its treatment. Dogged persistence on the 
part of the doctor and a liberal share of knowledge as to what not to do as 
well as what to do, with a co-operation from the patient which is rarely 
forthcoming, constitute the essentials of the [medical management. 
Gonorrhoea, is an infection due to a germ which on its appropriate 
tissue soil produces inflammation and the formation of pus or matter. 
It is essentially a local disease of the genital tract in both the male and 
the female. It may extend to the body as a whole in a limited percentage 
of cases, .causing usually, however, only a restricted range of symptoms. 
The germ of gonorrhoea thrives upon certain tissues in addition to those 
of the genital tract, notably those of the conjunctiva of the eye. Gonor- 
rhoeal inflammation of the eye or gonorrhoeal ophthalmia in childhood is 
so common and so terrible a disease as to deserve to rank as a (scourge in 
itself alone. 
The History of Gonorrhoea.—Gonorrhoea is a disease of ancient 
lineage.. In the Brugsch papyrus attributed to the year 1350 B.C., there 
appear among the Temnants of an Egyptian system of medical practice, 
references to symptoms and treatment which would seem almost certainly 
to apply to gonorrhoea. Jean Astruc described it in 1736. The disease 
emerges from the obscurity of the Middle Ages in time to be confused 
with syphilis by such men as Paracelsus, *a misconception whlich persisted 
through the next three centuries and did much to retard the progress ,of 
knowledge. Morgagni during the early eighteenth century gave an 
account of the complications of gonorrhoea, which, in view of the mis- 
conceptions of his time, was remarkable for its insight and completeness. 
In the late eighteenth century the immense influence of John Hunter 
gave renewed impetus to the already existing misconceptions of the rela- 
tions between syphilis and gonorrhoea. With commendable but unfortunate 
courage he innoculated himself with the pus from a patient with 
gonorrhoea. It happened that the patient, as we know now, had syphilis also, 
27 28 
and Hunter developed, not gonorrhoea, but syphilis. He believed from 
this experiment that the two were identical and the weight of his medifoal 
authority was such that it took another generation under the leadership 
of the great Frenchman, Ricord, to set the matter right. While Rollet 
in the middle of the nineteenth century had insisted upon the special 
identity of gonorrhoea, it remained for Neisser the famous urologist and 
syphilographer of Breslau, to identify, in 1879, the true cause of gonor- 
rhoea. With this discovery—one of the really great facts in the history 
of medicine—the modern methods for the recognition of the disease in 
early, quiescent and obscure cases were developed, and the miscroscope 
assumed control over the field in precisely the way that it did later in 
early syphilis. The discovery of the germ did not, however, give the 
cue for the brilliant triumphs in treatment that were made possible in 
syphilis by the recognition of the spirochaete or spiral germ which causes 
that disease. The non-transmissibility of gonorrhoea 'to animals has 
decidedly increased the difficulties of its study, and has probably delayed 
the progress of knowledge on treatment as much as the treatment of 
syphilis has been advanced by the fact that it, unlike gonorrhoea, can be 
given to certain animals on whom it is possible to carry out experimental 
work. 
The Gonococcus, the Cause of Gonorrhoea.—The gonococcus of Neisser, 
as the germ of gonorrhoea is called, is one of a type of round or spherical 
germs known as the cocci, which include among their numbers such 
common enemies of humanity as the pus germs that produce boils and 
abscesses, and the germs of pneumonia and of spinal meningitis. In fact 
the gonococcus seems to bear a striking resemblance to the pneumococcus 
and the meningococcus both in appearance and in the reactions which it 
sets up in the body tissues. Pus, which is made up of the white cells of 
the blood that constitute our first line of defense against certain germs, is 
usually produced in abundance by a gonococcal invasion during its early 
or acute stages. Gonococci are very minute, and can be found in the pus 
only by the higher powers of the microscope, after it has been stained with 
certain dyes. The germs are incapable of motion and lie either free in 
the pus, or more often inside the bodies of white blood cells that have 
devoured them in their struggle against the invaders. In the latter 
situation they usually occur in pairs, flattened somewhat against each 
other into what looks for all the world like a coffee-bean. Three of the 
characteristics of the gonococcus provide the quickest and on the whole, 
most reliable method of identifying the germs in recognizing or treating 
the disease: (1) their reaction to a certain method of staining (Gram 
stain) in which the gonococcus does not take the stain .itself but takes a 
“contrast stain,” while the other germs of similar appearance take the 
original stain, (2) their presence within the white blood cells, (3) their 
typical coffee-bean shape. Gonococci can be grown on certain culture 
media in glass tubes, but this method of identifying them is of secondary 
importance except in special cases. 
The Microscope Essential in the Treatment of Gonorrhoea.—Gonor- 
rhoea can only be positively identified by the physician after a micro- 
scopic examination and it is the presence or absence of the germ when 29 
looked for in the way described that determines whether or not a patient 
who has had gonorrhoea, is well or still has the disease. Realizing his, 
it at once becomes apparent that the same principle applies to the direction 
of gonorrhoea that applies to syphilis. It cannot be said too often or 
emphatically that the finding of the germ by the microscope is the 
essential point in the game both before and after treatment. The patient 
who does not have the benefit of such examinations or who does not abide 
by their outcome, places himself voluntarily or through ignorance at the 
mercy of medical practice little better than that of the Dark Ages. The 
physician who diagnoses and treats gonorrhoea without the use of the 
microscope never knows when his patient is free from the infection. Such 
a physician may be directly responsible for all the disastrous sequels to an 
uncured gonorrhoea that may develop in any one who is so unfortunate as 
to entrust himself- to his care. 
The Prevalence of Gonorrhoea.—The real significance of gonorrhoea 
will be better appreciated, if before taking up its symptoms, some figures 
are offered to show the magnitude of the problem. It should be 
remembered that most of these figures are estimates, based to be sure on 
large experience, but lacking the assured correctness of properly gathered 
statistics. Accurate vital statistics on a disease such as gonorrhoea which 
has always been concealed as a secret and shameful thing, are, of course, 
in their infancy. The new point of view toward the disease as a public 
health problem will in time lead to definite understanding of its pre- 
valence. 
There is a distinction to be emphasized between the number of persons 
who have active gonorrhoea in a population or a class at a given time, and 
the percentage of persons who have had it. The statistics are modified by 
the fact that since gonorrhoea is curable and no immunity is conferred by 
an attack, one person may have it a number of. times. Another element 
of inaccuracy is introduced into the figures by the ability of a gonorrhoea 
to remain latent for considerable periods, only to flare up like a new 
attack on suitable provocation. 
Gonorrhoea in Men.—Probably the highest single estimate of the pre- 
valence of gonorrhoea is that of Noeggerath, which was made before the 
discovery of the germ by Neisser. He estimated that 80 per cent of all 
men had or had had gonorrhoea—figures which are now generally accepted 
as too high. Morrow, and Forcheimer, on the basis of a large experience 
with conditions in the United States, propose figures varying from 51 to 
60 per cent of the adult male population as having had the disease. 
Forcheimer further states that 20 per cent of those infected have acquired 
the disease before their twenty-first year, more than 60 per cent before their 
twenty-fifth year, and more than 80 per cent before their thirtieth year is 
passed. Equally large estimates are given by various well-informed 
Europeans, notably German observers, such as Blaschko, Erb, and Pinkus. 
Getting at the matter indirectly, figures drawn from recent army experi- 
ence indicate that gonorrhoea is from four to five times as prevalent as 
syphilis. A very widely accepted conservative estimate of the prevalence 
of syphilis is 10 to 13 per cent of the adult male population, so that a 
possible prevalence rate for gonorrhoea of from 40 to 60 per cent is not 30 
unreasonable. Estimates of the amount of active gonorrhoea acquired by 
a large group of men in a given time can be obtained from the reports of 
the Surgeon General of the United States Army. In 1907, under an 
inadequate system of examination, the admission rate (proportion of men 
admitted to sick list) for gonorrhoea, was about 12 to 13 per cent of the 
enlisted personnel. In the army the percentage has fallen steadily to 
between 5 and 6 per cent in 1915-16, owing to the efficiency of prophylactic 
or preventive methods introduced since 1911. The male civil population, 
which is not protected by the safeguards that surround the army, probably 
has a prevalence approaching the army rates during our recent mobili- 
zation. Chronic gonorrhoea often escapes inclusion in statistical esti- 
mates, because it is not brought to the attention of physicians or medical 
officers. 
Gonorrhoea in Women.-—Gonorrhoea is estimated to be sixteen times as 
prevalent in men as in women on the basis of statistics which cannot, 
however, be accepted as conclusive. The lowest estimate quoted and one 
which is undoubtedly too low is probably that of Erb, who maintained a 
number of years ago, that only 5 per cent of four hundred women whose 
husbands had had gonorrhoea, acquired the disease themselves. No direct 
estimates of value exist, relative to prevalence in women, but an indirect 
conception may be obtained from the fact that 50 per cent of absolute 
and one-child sterility is due to gonorrhoea in women. The percentage 
of gonorrhoea in women varies largely with their social status. Among 
the most refined types of unmarried women and girls it is probably negli- 
gibly small. Of the pregnant women in the public hospitals of ia number 
of Continental cities, 20 to 25 per cent were said to have had gonorrhoea. 
Prostitutes, professional or occasional, nearly all have it. The estimated 
prevalence of the disease in these types ranges from 70 to 95 per cent, as 
determined by various vice investigations, and by studies of delinquent 
women, such as that of Haines, who found percentages ranging from 
75.7 to 9*8.2 in 500 cases. 
It must be more than apparent, in spite of the obvious difficulty in 
interpreting figures which contain so large an element of speculation, that 
gonorrhoea offers to the sanitarian a problem of the first magnitude. It is 
in very fact, one of the commonest of all significant diseases. It wholly 
outranks the large majority of contagious infections such as scarlet fever, 
smallpox and diphtheria, and even runs a close second to measles, the most 
contagious disease that affects mankind. CHAPTER II. 
Gonorrhoea in Men. Symptoms, Tests for Infectiousness. 
For convenience gonorrhoea as a disease may be described as it appears 
in men, in women and in children. It should not be forgotten that while 
there are differences between the three types, the same principles underlie 
the process as a whole. The differences are more largely due to differences 
in anatomical structure than to any other factor. 
Acute and Chronic Gonorrhoeal Inflammation.—Gonorrhoea, as has 
been pointed out, is an inflammation. Like every disease in which inflam- 
mation plays an important part, it tends to pass through two stages—an 
acute or active early stage and a late, slowly progressive, inactive or 
chronic stage. If the acute stage of the inflammation is sufficiently violent, 
that is, if the body puts up a big enough fight, the germs may be so rapidly 
destroyed that a chronic state may be avoided altogether. On the other 
hand, if the body for any reason does not acutely resent the invasion or 
if something is lacking in its fighting mechanism or again if something is 
done to weaken its defensive powers during the acute stage, the germs are 
not killed off but manage to retain a foothold for a long time. The effect 
of their habitual presence is in a certain sense to make the body tolerant 
of or indifferent to them. It may grow weary of the fight, so to speak, 
and ceases to put up an active opposition. There is also, perhaps, a differ- 
ence between individual families or strains of the gonococcus, in the matter 
of ability to adapt themselves to the conditions which they meet in their 
host. Precisely as an invading army endeavours as rapidly as possible 
to convert the strategy of war into the strategy of diplomacy and peaceful 
infiltration, so a really clever and adaptable germ alters its tactics enough 
to persuade the body in the coarse of time to put up with the inconvenience 
of its presence. With this process of getting accustomed the infection 
passes from an acute to a chronic phase. If the germ is sufficiently adapt- 
able this chronic phase soon becomes so inconspicuous that the patient 
loses sight of it altogether. A draw or truce occurs between invader and 
invaded,which is by no means a victory for the body or “ cure.” Unless 
something happens to disturb the balance of the draw by weakening the 
body or stirring up the germ and provoking a “ flare-up,” a draw or 
chronic state may go on for months, or even several years before the infec- 
tion dies out. On the other hand, it should not be supposed for a moment 
that the germs which are present in a chronic infection have lost their 
power to spread the disease. Many persons carry about with them the 
germs of pneumonia in the nose and throat. Only a few, however, have 
pneumonia as. a result. In the same way in the chronic phase of the 
gonorrhoeal inflammation, many persons may carry around the germs in 
their genital tracts without showing any active symptoms. As soon, 
however, as the germ is transferred from a person in whom it is being 
held in check to a new soil in a healthy person, it promptly sets up a new 
acute process fully as violent as that which originally developed in the 
carrier. 
31 32 
The Course of Acute Gonorrhoea in the Male.—In order to appreciate 
the successive possibilities in the struggle between the gonococcus and 
the body it is necessary to recall the anatomy of the parts involved. In 
the man the secretions containing the germs enter the opening through 
which the urine escapes and the first sign of the beginning inflammation 
appears at this point within a day or a week after they have gained a foot- 
hold. The symptoms are prickling followed by burning in the urinary 
canal with burning and pain on urination. There is considerable redness 
and swelling of the affected parts and the discharge of a thick, yellow pus 
from the urinary canal. In this pus enormous numbers of the gonococci 
can be found. The inflammation progresses backward along the urinary 
canal and in from 40 to 80 per cent of the cases manages to travel back 
the entire length of the canal into what is called the posterior urethra. 
The condition is then spoken of as a “ posterior ” gonorrhoea. 
Posterior Gonorrhoea and the Genital Complications.—Posterior gonor- 
hoea is a highly undesirable complication of the disease. When the 
inflammation extends this far, new and very painful symptoms usually 
develop. Furthermore, into the deeper part of the urinary canal near the 
base of the bladder open the canals which lead from the reproductive 
organs. If in a “ posterior gonorrhoea ” for any reason the germ succeeds 
in travelling downward through these canals leading into the epididymis, 
a structure connected with the testicle, in which the male cells mature, 
it has done more than merely invade the man’s tissues. It has invaded 
his future and his personal immortality. The inflammatory process which 
then develops, if it involves both testicles or their appendages, while it 
may not cost him his sexual powers, will be likely, then and there, to des- 
troy his power to father a child. When the inflammatory process which 
is evidenced by swelling and pain in the testicles, dies out or becomes 
quiescent, the man may never think of it again. In the later years of his 
life he wonders, not always with good grace, why his healthy wife has no 
Children, as he listens to the clatter of the shoe heels of adopted youngsters 
on his stairs. Sterility is by no means a feminine monopoly and is only 
too often the heritage of masculine “ posterior gonorrhoea.” 
Causes and Complications of Chronic or Persistent Gonorrhoea.—To 
describe all the symptoms of acute gonorrhoea in the male would crowd out 
other considerations of greater importance here. The average duration 
of the acute phase of the infection is about eight to twelve weeks. The 
discharge and active inflammatory symptoms and the burning on urination 
gradually subside. The painful erections, commonly known as chordee, 
also disappear. If, however, the smooth progress of the case has been 
interfered with by the patient’s disobeying instructions or through his 
attempt to treat himself, or again, through the ministrations of an inex- 
perienced or unskilled medical adviser, the acute phase results not in 
recovery but in chronic or persistent gonorrhoea. In spite of the best 
possible care a small percentage of acute cases will become chronic. It is 
exceedingly important, however, since there are so many seemingly dis- 
couraging features about the entire situation with respect to gonorrhoea, 
to emphasize here and again, the very favourable outlook for complete 
cure in the large majority of intelligently managed cases of gonorrhoea. 33 
Complications and chronicity with delay in cure and prolonged infectious- 
ness are not the fate of every patient who acquires the disease. They are 
the penalty of negligence, ignorance, and indifference in the overwhelming 
proportion of cases. The outlook in the treatment of the disease can be 
brightened in exactly the proportion that these unfavourable factors can 
be eliminated by raising the standard of public comprehension, by devel- 
oping the personal co-operation of the patient, and by contributing to 
the efficiency of medical care. 
Stricture.—A chronic posterior gonorrhoea is an unfortunate com- 
plication from the standpoint of the man’s future and of the public health. 
If the inflammation in the urinary canal itself persists, small ulcers are 
apt to form and these in turn on healing leave scars which shrink, reducing 
the diameter of the canal. Such a condition is called stricture. A stricture 
inferferes with the passage of urine and predisposes the patient to compli- 
cations attendant upon the infection of his bladder by other germs, and 
the passage of that infection upward through the duct which leads from 
the kidney to the bladder with resulting infection of the kidney. The 
last-mentioned complication is, however, unusual. Prompt treatment as 
soon as any obstruction in the stream develops will prevent any complica- 
tions. 
Relapses and Flare-ups; “Gleet” or “Morning Drop”—In most 
chronic posterior gonorrhoea active inflammation disappears, and the patient 
may believe he is well. From time to time, however, usually under the 
influence of alcohol or sexual indulgence, there may be a flare-up and a 
fresh discharge of pus of briefer duration than the original attack. This 
the patient may mistake for a new infection, easily cured. The continuity 
of the process between flare-ups is, however, evidenced by the persistence 
of a very slight discharge in the form of a drop or two of a sticky fluid 
which appears at the urinary opening usually in the morning on arising. 
This is the condition commonly known as gleet, or “morning drop,”, and 
in this drop of discharge which the French have sardonically christened 
“ la goutte militaire,” gonococci can usually be found. Gonorrhoea in this 
stage is not one whit less dangerous to others than is the acute infection. 
In fact, it is vastly more dangerous because when the patient reaches this 
stage he usually discards the restraints as to sexual indulgence which have 
been put upon him by the physician, with the result that he promptly 
infects his partner if she be not already infected. In the sociology of the 
disease “gleet” is its most important stage. 
Chronic Gonorrhoea of the Prostate and Urethral Glands.—The factors 
which make a chronic gonorrhma of the type described an obstinate and 
serious affair are easily understood. The urinary canal or urethra is lined 
with innumerable tubular mucous glands and pockets. Once the gonococci 
have invaded them in the march of the acute infection upward and back- 
ward through the canal and have gained the truce which chronicity repre- 
sents, every resource in treatment may fail to dislodge them. The only 
outlook may be for them to die out of themselves, although modern methods 
with the use of instruments offer a better outlook than formerly. The 
prostate gland, a large gland which surrounds the posterior urethra at the 
51807—3 34 
point where it passes'into the bladder, and which is practically always 
involved in posterior gonorrhoea, has a structure which makes it a atrong- 
hold for the gonococcus in chronic cases. Chronic infection of the prostate 
gland often keeps the victim under the weather for long periods and 
threatens him while it persists, with the risk of having the gonorrhoeal 
infection spread through his blood to his joints (rheumatism) and other 
parts of the body. The discharge from both of these types of glands forms 
a part of the semen and thus maintains for long periods the risk of infec- 
tion in sexual intercourse. 
Tests for Chronic Urethritis, etc.—Chronic inflammation of the urethra 
may finally pass into a state in which it is apparently innocuous so far as 
the transmission of gonorrhoea is concerned. It is, however, a difficult 
matter to tell a patient when such a condition is reached. The examination 
of a patient with chronic urethritis for evidence of a persistent gonor- 
rhoeal infection involves not only the microscopic examination of the gleetv 
discharge for gonococci, but also an examination of the secretions of the 
prostate gland, which may harbor the germs after they have disappeared 
from the rest of the tract. This is accomplished by staining and examining 
the shreds which appear in the urine in cases of inflammation of the 
prostate. In some cases it may be desirable to massage the prostate gland 
with the finger through the rectum, and examine the urine after the dis- 
charge or secretion has been forced out into the urinary canal in this way. 
In order to determine whether a persistent discharge is due to gono- 
coccus infection or whether a gonorrhoea is cured or not, it may be neces- 
sary to excite a fresh discharge by irritation of the urinary canal by the 
injection of a strong solution, or otherwise. This new discharge will con- 
tain cells from the glands and mucous membrane of the urinary canal. 
In these cells the gonococci can be found by the microscope if they are the 
cause of the persistent discharge, or if the case is not cured. 
Morbid Fear of Gonorhcea.—The “ morning drop ” and “ clap threads ” 
in the urine, while, of course, of superlative importance in the proper esti- 
mation of the condition of a man who has had gonorrhoea, occasionally 
furnish a nervous person with a cause for morbid worry which is out of 
proportion to their significance in his particular case. The wise course for 
a patient who is inclined to worry about floating objects or stringy mucus 
in his urine, or a drop of discharge at the urinary opening in the morning, 
whether or not he has had gonorrhoea, is to proceed to the very best specialist 
available, and place himself unreservedly in his hands and accept his 
assurances as final. 
Gonorrhoeal Nervous Prostrations.—Gonorrhoea, perhaps because it 
involves structures so intimately associated with the nervous system and so 
richly supplied with nerves, gives rise to a peculiar mental and physical 
depression in from 5 to 10 per cent of its victims, a post-gonorrhoeal nervous 
prostration or neurasthenia, which drives them from pillar to post, seeking 
relief for weakness, vague pains, and inability to gather themselves together 
or to work. These symptoms are to be regarded essentially as after effects, 
and not as evidence that the gonococcus is undermining the patient’s man- 
hood. CHAPTER III. 
Systemic Gonorrhoea and Gonorrhoea in Women and Children 
Gonorrhoea in women is the most embittering and tragic aspect of the 
disease. The overwhelming proportion of infections are innocent. A 
man has a chance, at least, to know what ails him. The woman, in the 
existing state of popular and even medical sentiment, is lied to at every 
turn of the way. Gonorrhoea is a serious enough disease in men; in women 
it may be a disaster. Gonorrhoea is usually cured in men. In women, 
while the disease if taken in time is curable, the problem is much more 
difficult. In women in general gonorrhoea may run, on the one hand, a 
course so mild that although virulently infectious, the woman may never 
realize she has the disease; on the other hand, it may reduce her almost 
at once to a pitiable invalidism, or cost her her life. 
Reasons for the Greater Seriousness of Gonorrhoea in Women.—The 
greater seriousness and obstinacy of gonorrhoea in women is explainable on 
comparatively simple anatomical and physiological grounds. The woman’s 
urinary system is simpler than the man’s so that the full force of the infec- 
tion is rarely felt here. Inflammation of the urethra and bladder may 
occur and are usually attributed to a “ cold.” The usual rule, however, is 
for it to fall with full force upon her sexual organs. The man’s sexual 
organs are largely on the outside, so to speak—that is, outside the abdominal 
cavity. The woman’s, while theoretically outside, open into the abdominal 
cavity at the mouth of the tube that carries the eggs from the ovary into 
the womb. A discharge of infected semen thus carries the enemy to her 
very vitals. It should be realized, however, in describing the complications 
of gonorrhoea in women, that by no means every woman who is infected 
progresses step by step to the worst possible outcome. It is a notable fact 
that many women who acquire the disease have so few symptoms from it 
that they never realize that they are infected and do not seek medical 
advice. The condition may only be recognized incidentally in the course 
of other examinations. Such cases are a public health problem rather than 
a personal medical one. Not every case of gonorrhoeal infection in a women 
results in sterility, or necessitates radical operations. On the other hand, 
there can be nothing gained by attempting to gloss over the dark side of 
the situation. While one may rejoice that many escape the worst, it is 
impossible to ignore the fact that enough women are wrecked by gonorrhoea 
in one way or another to maintain an entire specialty in medicine— 
gynaecology, which would become relatively a side issue in surgery if the 
effects of gonorrhoeal pelvic inflammation and of abortion or miscarriage 
could be eliminated. Few have been found to dispute the opinion of 
Noeggerath, who first recognized gonorrhoea in women as a definite and 
distinct condition, when he stated that 80 to 90 per cent of pelvic inflam- 
matory disease and 50 per cent of absolute and one-child sterility in women 
is due to gonorrhoea. 
51807—31 
35 36 
Course of Gonorrhoeal Infection in Women.—The successive stages and 
possibilities in a gonorrhoeal infection in the woman may be described as 
follows, always bearing in mind the fact that the process may stop so far 
as the patient is concerned, at any of the stages mentioned, and become 
arrested or chronic or may even die out of itself. It is the tremendous 
uncertainty attaching to the course of the disease and its outcome that 
makes it so important to understand all its activities. 
In a variable percentage of cases the first symptoms may be from the 
urinary canal and bladder, as in men, but usually less severe. Not infre- 
quently an abscess may form in a gland at the opening of the vagina. 
When the gonococci in their ascent gain entrance to the genital tract 
and infect the neck of the womb (cervix), a discharge of mucus and pus 
from the vagina occurs, which is usually called leucorrhoea, or u whites.” 
It should be emphatically stated, however, that not all leucorrhoea is due 
to gonorrhoea. In many cases, with the first menstrual period after infec- 
tion, gonorrhoea of the neck of the womb or the vagina is likely to be fol- 
lowed by infection of the womb itself, and then of one or both of the tubes 
that lead from the ovary to the womb. These tubes open, as has been said, 
into the abdominal cavity. A gonorrhoeal inflammation of a tube gives 
rise to symptoms suggesting an attack of appendicitis, although, of course, 
it may occur on the left as well as on the right side. Tubal inflammation 
usually results in the closure of the abdominal opening if both tubes are 
affected so that eggs can no longer pas3 down to the womb, and the woman 
becomes sterile. If both ends of either tube are closed, pus usually collects, 
forming a “ pus tube,” which may become chronic without rupturing, and 
usually has to be removed by operation. In severe gonorrhoeal infections all 
the steps described above may occur in rapid succession and the inflamma- 
tion may then extend from the abdominal opening of the tube into the 
abdomen itself. The woman thereupon develops what is called peritonitis, 
an inflammation of the lining membrane of the abdominal cavity, a com- 
plication of the utmost gravity and occasionally fatal in its outcome. 
Gonorrhoea and Pregnancy.—For the woman with gonorrhoea, preg- 
nancy greatly increases the risk of a spread of her infection and an exag- 
geration of all its manifestations. If the tubes carrying the egg 
to the womb have been distorted by a gonorrhoeal inflammation, but not 
closed, the fertilized egg may be caught in a pocket without reaching the 
womb, and the woman thus develops the child in the tube or the abdominal 
cavity. Such an accident may, of course, result at times from non- 
gonorrhoeal changes in the tubes. Tubal or extra-uterine pregnancy, 
so-called, may, if not quickly recognized and operated upon, result in the 
death of the mother from internal haemorrhage following rupture of the 
pregnant tube. If by any chance the child develops far enough, the condi- 
tion of the organs in the abdominal cavity baffles description, and operative 
interference has little prospect of success. Any woman who notices that 
she continues to bleed after she believes herself pregnant, either irregularly 
or at the time when her menstrual periods would ordinarily be due, ought 
to have a thorough examination for the possibility of tubal pregnancy. 
Gonorrhoeal Child-Bed Fever and Sterility.—In a woman with an 
acute, active gonorrhoea whose tubes and womb are still normal, so that 37 
she can become normally pregnant, the delivery of the child opens the way 
to some of the most disastrous complications of the disease. After the 
passage of the child the womb is literally raw and bleeding, and the way 
is open (for infection to get a start) through the lowered resistance of the 
tissues, which is impossible under normal conditions. The gonococci in 
the neck of the womb seize the opportunity, in company with other germs, 
to make a whirlwind charge, and within a few days, or, perhaps, a few 
hours, the mother may be dead of “ child-bed fever.” While not all such 
patients die, those who survive are likely to be hobbling, painwracked 
cripples until a radical operation relieves them of all the damaged struc- 
tures. Pregnancy in a woman with chronic, as distinguished from acute 
gonorrhoea, is one of the chief predisposing causes of inflammation of the 
tubes and subsequent sterility. The pregnancy gives the woman a chance 
to have one child, but she never has another. This constitutes the so-called 
one-child sterility already referred to. That not all one-child sterility is 
due to gonorrhoea must be borne in mind by critical inspectors of genea- 
logical trees. 
" Pelvic Inflammatory Disease—Pelvic inflammatory disease is a 
general term employed to describe the condition following an extension 
of the gonorrhoea from the more external female parts upward into the 
structures of the lower abdomen. Pus tubes, for example, are a phase of 
pelvic inflammatory disease. If the germ escapes through the wall of 
inflammation thrown up by the body against it, and gets into the surround- 
ing tissues., every part and structure in the neighbourhood are involved 
in the fight, and intestines, omentum, and womb are matted together 
around an abscess that may later burst or be opened through the genital 
canal (vagina) or even the rectum. The treatment in cases of this type 
must often be the operation euphoniously called “ hysterectomy plus 
bilateral salpingo-oophorectomy ” or “ pan-hysterectomy.” After it the 
woman is usually told that a piece of one ovary was left (as it often is) 
so that she can still feel she is a woman, since that is all the evidence of 
the fact that she will ever have from that time on, except that she will 
continue to wear skirts. For the benefit of her husband they leave her 
a vagina; for the benefit of herself, perhaps, a piece of ovary. To hear 
such a woman, so defenceless-looking in her braided hair and ether jacket, 
whisper timidly as they wheel her, uncomplaining up to the operating 
table: “ I do hope theyTl fix me so I can have a baby”; to see the skin and 
muscles gape before the sweep of the knife; to think that woman’s thoughts 
for her, through an hour of ether haze and hushed comment and the 
peculiar sibilant click of hemostats as the surgeon does his uttermost to 
cobble up the wreckage and save her hope; finally in despair he begins 
the quick swinging practised movements that mean it all must go; and then 
to see her again a week later, after they have told her the ovary story, is 
an experience to make the hardest turn away his face. 
Concealed or Latent Gonorrhoea in Certain Glands.—Gonorrhoea 
regardless almost of the part of the genital tract in which the germ is 
deposited, seldom fails to invade certain glands, called Bartholin’s and 
Skene’s glands, which lie at the entrance of the vagina, and correspond to 
certain deep glands lying beside the male urethra. Few women whose 38 
married life begins with an abscess at the opening of the genital canal 
are told they have gonorrhoea, although this is one of its characteristic 
beginnings. In these glands, even if abscesses do not form, the gonococcus 
may remain latent for long periods. The secretion from them is dis- 
charged upon the mucous membrane of the vaginal opening before and 
during intercourse, and though there may not be a living gonococcus in the 
canal, the woman may be free from leucorrhoeal discharge, and in other 
respects seem healthy, there will be gonococci enough here to infect an 
army. An examination for gonorrhoea in the woman which fails to include, 
besides a microscopic study of a smear from the urinary canal and the 
neck of the worm (cervix), smears from Bartholin’s glands, overlooks 
entirely one of the strongholds of the infection. 
Systemic Gonorrhoea, Rheumatism, etc.—The description of gonor- 
rhoea in both men and women has thus far been that of a genital infection. 
The invasion of the body as a whole by the gonococcus may be said to be 
rare, but serious. About one case in a hundred is thus affected and men 
more often than women. While the iris of the eye, the heart, the skin, 
the nervous system and other structures may be affected, these accidents 
are rare. The commonest systemic complication is involvement of the 
joints in the form of gonorrhoeal rheumatism. Gonorrhoeal rheumatism 
is a chronic and resistant disease which sometimes, although not usually, 
produces permanent crippling. Though it may come on early in the infec- 
tion, many cases are due especially in men to the persistence of the disease 
in such structures as the prostate gland and the seminal vesicles, from 
which the germs escape into the blood, to be carried to other parts of the 
body. 
Gonorrhoea of the Eye (Gonorrhoeal Opthalmia).—Under this head 
is included the form of gonorrhoea of the eye already spoken of as gonor- 
rhoeal opthalmia, which while it can and does occur in adults, is over- 
whelmingly more common in children. The very first word that should be 
said about gonorrhoea of the eye is that it can be prevented. The next 
word is, that if not prevented, it will probably cause blindness. Increasing 
knowledge of the first fact has diminished but by no means done away with 
the importance of the second. Gonorrhoeal ophthalmia is a disease of the 
innocents. The usual time of infection is in the passage of the child down 
the infected birth-canal of the mother. The bare thought of a little chubby 
child’s bright eyes being ground through the filthy pus of a “ clap ” sickens 
a decent man. Yet this is exactly what happens, and its mother, all unknow- 
ingly, is made the doer of it. Usually within twenty-four hours after 
birth, if a preventive has not been used, pus begins to form in the eyes, 
and with almost lightning-like rapidity the clear, bright cornea of the eye 
ulcerates, under the swollen, pus-filled lids, breaks through, and lens and 
all collapse into the opening. When the process subsides, the baby is 
blind. The mere statement that one-third of the blindness in asylums and 
one-half the blindness dating from birth is due to gonorrhoea of the eye 
conveys no impression whatever of the tragedy. One has to see one 
of these little children, rocking back and forth in a railed-in chair, waving 
its hand between face and window because that flickering of the finger 
shadows across the twilight is all it will ever know of more than half of 39 
life, one has to see this thing, and watch the baby groping about on the 
floor and gurgling as it feels of your shoe-strings, really to know in the 
soul of him, what gonorrhoea means. 
Prevention of Gonorrhoeal Blindness.—The prevention of gonorrhoea 
of the eye is accomplished by the use of a one per cent solution of silver 
nitrate, which is dropped into the eyes immediately after birth. In the 
vast majority of civilized countries this is now a universal and legally 
compulsory practice. It is required by most of our states, and it should 
be done on every baby born into the world, no matter what its parentage. 
The necessary medicine and directions for carrying out this protective 
measure can be obtained from any state board of health. The universal 
observance of this preventive measure will in time banish from the earth 
the gonorrhceal blindness that begins in infancy. 
A certain amount of ocular gonorrhoea is due to accidental inocula- 
tion and to carelessness, and for this reason the care of the eyes is the 
first thing in regard to which a physician instructs his gonorrhoeal patient. 
Gonorrhoeal blindness may of course occur in children after birth, as a 
result of their becoming infected by handkerchiefs and articles of per- 
sonal use from adults who have the disease. Special precautions about 
nurse maids, and in hospitals, about visitors, are essential. Sometimes 
in the form of gonorrhoea known as vulvo-vaginitis, described below, the 
child may infect its eyes from its own discharges. Such complications are 
especially likely to occur under conditions of crowding and bad hygiene. 
If treatment of gonorrhoea of the eye is begun immediately after its onset 
and is expertly carried out in a hospital by skilled doctors and nurses, 
it may be prevented from going on to total blindness. 
Gonorrhceal Inflammation of the Genitals in Girl Children.—Gonor- 
rhoeal vulvo-vaginitis is an elaborate Latin and Greek name for the most 
pathetic of all the tragedies to which womankind is subjected by this 
disease. Little girl children for some reason are extremely susceptible to 
the gonococcus. If it is deposited upon the external genitals from the 
fingers of a nurse, from a soiled or infected diaper, from an infected toilet 
seat or bed-pan, or in the passage of the child through its mother’s birth- 
canal, it sets up immediately a gonorrhceal inflammation which, however, 
rarely extends up the genital tract as in an adult woman. Its usual dura- 
tion even under skilled treatment is years instead of months. No child 
having it should be allowed to leave an isolation hospital, for it is extremely 
contagious. It spells the end of the child’s education unless there happen 
to be special classes held for such cases, as in some of the larger hospitals, 
since no child with it should be in school. It may mean the same thing 
for their life work, for their health and for their hopes of having children, 
that it does for their mothers. 
Vulvo-vaginitis in Hospitals.—Gonorrhoeal vulvo-vaginitis is a scourge 
of infant hospitals, and asylums, and also of all places where children are 
crowded into close and undiscriminating contact with adults, as when 
they sleep in the same beds with them, for example. So dangerous is it 
that no well-regulated public hospital admits any Child, regardless of its 
antecedents, to a children’s ward, without a smear of the genital secretions. 40 
Conversely the appearance of gonorrhoeal vulvo-vaginitis on a hospital ward 
is a reflection on some one, and should cause the physician and the nurses 
in charge many painful hours of self-inquiry. No better example of the 
savage heartlessness of the type of human being to whom “ venereal ” disease 
is outside the pale of consideration, can be imagined, than that furnished 
by an instance in which several little girls with hereditary syphilis in one 
of the largest, charity hospitals in this country were knowingly placed in 
a ward with vulvo-vaginitis cases because gonorrhoea and syphilis are both 
“ venereal ” diseases. In spite of the protests of the physician the little 
syphilitic girls who had had some chance for recovery from the syphilis, 
were ruined as effectually as if they had been raped, by being made to add 
the vulvo-vaginitis to their woes. The eccentricities of “ Kultur ” have 
indeed little to offer us that is not already in our midst, in the persons, the 
methods and the ideals of those who place the victims of “venereal 
diseases ” outside the dictates of mercy and justice, because their ailments 
are “ punishments for sin and badges of disgrace.” CHAPTER IV. 
Treatment and Hygiene of Gonorrhoea. 
The Difficulties of Treatment.—The treatment of gonorrhoea bears the 
earmarks unfortunately familiar in more than one field of medical 
practice, in that many methods and a host of remedies mean doubtful 
ground. Nearly every expert in the management of the disease has his 
own peculiar way of going about it. General principles are recognized, 
to be sure, but they lack specificity, as we say. That is, no one or two 
remedies or methods can be certain of producing results in the over- 
whelming proportion of patients as is the case for example, in syphilis. 
No epoch-making achievements in the treatment of gonorrhoea seem to 
have been recorded in recent years, although on the whole there has been 
a persistent improvement in methods and results. The growing appreci- 
ation of the importance of the microscope in the control of treatment is a 
signal advance. At times it seems as if the rather sordid peculiarities 
of the disease, the difficulty of getting the patient’s co-operation when it is 
so vital to a successful issue, the lack of the spectacular, the tendency to 
obstinacy and chronicity, and the brilliant triumphs in the related field of 
syphilis had, in an indefinite way, deflected interest from a field in which 
compensations are few and the labour often out of proportion to the 
rewards. Yet nothing is becoming more apparent than that intelligent 
treatment of a gonorrhoea is an essential to its cure, and should be 
adequately provided for in the interest of the public health alone, to say 
nothing of the patient himself., It rests with the future to devise means to 
bring home the importance of adequate care of gonorrhoea and a more 
pressing sense of responsibility in regard to it, first to the public, and then 
perhaps to the medical profession. 
Local and General Measures Employed.—In general an acute gonor- 
rhoea is approached by the use of local injections of various drugs into 
the infected canal, and in gonorrhoea of the urinary tract by the admin- 
istration of medicines by mouth which when excreted by the kidneys and 
passed out through the urine, have a favourable influence upon the 
structures involved. Preparations containing silver have a long estab- 
lished reputation for local use. The action of many of the drugs i3 less 
that of a means of killing the gonococcus than a means of making the soil 
unfavourable for it. In addition to this active medication, the diet of 
the patient calls for careful regulation, sexual excitement must impera- 
tively be avoided, rest is usually essential for a time while the process is 
at its height, and alcohol, always particularly vicious in its effect on acute 
gonorrhoea, must be absolutely abstained from. 
The Patient's Co-operation.—It is one of the struggles of the physician 
who treats gonorrhea to secure from his patient 'by a combination of 
cajolery and threats, the unquestioning, prolonged obedience to orders 
which the cure of a gonorrhoea requires. In fact, it is the patient rather 
41 42 
than the physician who is usually responsible for failure and a chronic 
resistant infection. To this factor of reliability which so many gonor- 
rhoeal patients lack either because of their youth, their ignorance and 
inexperience or their character make-up, add the expense of treatment 
and the length of time involved in the management of obstinate cases, 
and it is small wonder that even a reasonably efficient free dispensary in a 
city such as New York is obliged to admit that more than 70 per cent 
of its cases of gonorrhoea pass through its hands unbenefited, and usually 
make only one visit. The man with a gonorrhoea appeals to every one as 
a “ floater,” and he inevitably tends to respond to zero in expectations by 
zero in co-operation and fulfilment. That the traditional irresponsibility 
of the patient with gonorrhoea is all one-sided is, of course, a mistake. Just 
as in syphilis, the ability to hold patients voluntarily to treatment depends 
at least in part upon the physician, and upon the confidence, response 
and co-operation he is able to inspire in those he treats. Little enough 
of human kindliness and consideration is extended to the vast mass of 
victims of gonorrhoea. A dispensary “ mill ” in which a patient’s 
enthusiasm for cure is allowed to leak out in the jostle of a basement 
line-up and any signs of persistence he may show, meet with an exceedingly 
impersonal reception or actual rebuff in the form of a sour-visaged inti- 
mation that he is a nuisance, trying to get something for nothing, is no 
place to encourage cures of an obstinate and refractory disease. The 
injection of a little of the human element into the situation, as so 
brilliantly exemplified in the pioneer methods of the Brooklyn Hospital 
Dispensary has a wonderful effect in bringing the value of effective treat- 
ment home to the man with gonorrhoea making him swear by it. 
Treatment of Chronic Gonorrhoea.—The treatment of chronic as 
distinguished from acute gonorrhoea in men is a problem of wide variabi- 
lity, and may call for superlative skill. The seat of the inflammatory 
process whether in urinary canal, prostate gland, or seminal vesicle, must 
be identified by careful tests, and then treatment directed to the place 
where the disease maintains its foothold. Massage of the prostate gland, 
injections of vaccines made from dead germs to teach the body to fight 
the living ones, skilful instrumental applications of medicines to points 
deep in the urinary system, stretching or cutting of strictures, and similar 
treatment form a group of procedures which, while of greit interest to 
the genito-urinary surgeon, offer the patient a much less agreeable prospect. 
The ounce of prevention in gonorrhoea, first, last, and all the time, is 
worth many tons of cure. 
The “Bad Cold” Lie, Fakes, Drug Stores and Quacks.—One of the 
great obstacles to the treatment of gonorrhoea is an ancient lie expressed 
in the now hackneyed quotation of a current remark, “A dose of clap 
is no worse than a bad cold.” This monumental falsehood is at last being 
nailed by the combined efforts of medical profession and laity, city, stato 
and nation. With such an impression of the disease dinned into his ears 
by tradition and associates it is little wonder that the young man of the 
average type finds the restrictions and exactions of treatment irksome. 
It is little wonder also that he falls an easy prey to all sorts of quackery 
and to the wiles of Jimmy the drug clerk, who is always “ there ” with the 43 
right thing to take “ to dry up a dose ” and has no unpleasant ideas about 
the “ water wagon ” and avoiding sexual relations while the cure is 
going on. Of course the boy who “ falls for ” this stuff wakes up with a 
jolt some day, and crawls to some doctor’s office with a chronic urethritis 
that may never clear up entirely, and a prostatitis and vesiculitis that 
have snuffed his chances for all that makes his later life what it ought to 
be. There are no superlatives adequate to describe the human vermin 
that thrive on this sort of thing. Among them must be reckoned not 
alone the advertising quack and the men’s specialist, but those commercial 
concerns which make and market, and those drug stores which permit upon 
their shelves the innumerable “ specifics ” for the self-cure of gonorrhoea 
and “gleet,” whose alluring promises appear upon the walls of every bar 
and toilet room. The “ clap doctor,” with his waving hair and the fatherly 
look and voice, is still with us. He is the man who plucks the inex- 
perienced boy of the last cent he can beg, borrow or steal, and then turns 
him out with the words, “That morning drop means nothing; you are 
cured.” Hot far removed from his level, to our shame be it said, is that 
type of physician, fortunately becoming more and more rare, whose con- 
ception of the cure of gonorrhoea ends with “ drying it up,” and whose 
ignorance of the miscroscope and all the modern tests for cure is only 
equalled by his scorn of them. 
Treatment of Gonorrhoea in Women.—The treatment of gonorrhoea in 
women is too often a problem of peculiar obstinacy. The mildness of the 
early symptoms in one group of cases never brings them to medical atten- 
tion until the outlook for cure is almost nil. Even when definite symptoms 
appear they are usually misinterpreted into the terms so often used by 
profession and laity, to conceal the facts; “ cold ” on the bladder, with 
frequent urination; “ leucorrhoea,” “ abscess ” following the first sexual 
relations after marriage; “ appendicitis,” when after the first menstruation, 
the gonococcus sets up an inflammation in the tubes; and “ child-bed 
fever ” perhaps if the ascent of the infection is delayed until after the 
first child is born. While douches and washes are needed in the treat- 
ment of gonorrhoea in the woman, their unskilful use by the patient in the 
self-treatment of a “ leucorrhoea ” often does no more than reduce the 
infection to latency without cure. The neck of the womb, the womb itself 
and the tubes, as well as the glands that lie at the opening of the vagina, 
are out of reach of such methods. Skilful instrumentation and prolonged 
local treatment with surgical measures are usually necessary. Much of 
the surgery that follows the ascent of a gonorrhoea into the upper genital 
tract in a woman is a treatment of consequences rather than of the 
disease itself, since the germs may have died out, as in an old pus-tube 
for example. Acute gonorrhoea, invading the abdomen with the symptoms 
of peritonitis often can only be treated by waiting for nature to wall the 
process off, since to cut in upon it while it is active is to spread the infec- 
tion all over the abdomen, with a fatal result. These are the cases of 
“ honey-moon appendicitis ” that many a pale, drawn-faced girl can tell 
of, always ending with that unconscious but no less flagrant indictment 
of the man and of our social order, “ I was always so well until I married.” 
There is no chivalry about gonorrhoea. Upon the woman, on whom life 
at best bestows the larger share of pain, it inflicts the crowning ignominies 44 
and deprivations. Yet this, many good people would persuade us, is our 
ally; “clap,” the sturdy guardian of our moral life. 
The Obstinacy of Chronic Gonorrhoea in Women.—At best, then, the 
disease offers women a less satisfactory outlook than it does men. Its 
effects and their treatment are too often finalities, sealed with the loss of 
parts and functions that can never be replaced. The seriousness for society 
of the chronicity and inveterate tendency to relapse that characterize 
feminine gonorrhoea can best be appreciated in dealing with those women 
who are the reservoir supplying it to the world at large, prostitutes, public 
or secret. It is a conservative estimate that 75 to 90 per cent of them 
have the disease. Haines found that after gonorrhoea had persisted four 
to six months without treatment, it required ten to twelve months of 
systematic care, such as it would be out of the question for any but the 
wealthy to afford in private life, before the symptoms disappeared and the 
baeteriologic examination became negative. The significance of such a 
statement for the girl who through a misfortune or a false step acquires 
the disease, stands out on the face of it. Stockman, quoted by Af Heurlin, 
found that in nearly half (46 per cent) of 500 women, gonococci could still 
be found on examination months after the patient had been dismissed as 
cured. It cannot be said too forcibly that there are no clinical signs such 
as a leucorrhoeal discharge, etc., by which gonorrhoea in a woman can be 
unvaryingly recognized or the fact of her cure determined. The micro- 
scope and the judgment of the expert both in treatment and the determina- 
tion of cure are the courts of last resort. 
The Abortive or Suppressive Treatment of Gonorrhoea.—No discussion 
of the treatment of gonorrhoea in men or women is complete without men- 
tion of the so-called abortive or suppressive treatment of the disease, 
which is essentially an attempt to cure or arrest it before it has a chance 
to extend into the deeper structures. It deserves mention as much for 
what it will not do, as for what it will. It may be said in a general way, 
that it will not work at the hands of the patient himself, though many try 
it, nor yet of a physician, who, while perhaps skilled enough in other 
ways, is an amateur or out of date in the treatment of gonorrhoea. It 
may also be said, that the attempt of the patient to abort a gonorrhoea 
with any of the strong injections which he may obtain from officious drug 
clerks and friends, is likely not only to fail to cure, but will probably make 
the ensuing infection very much more serious than it would have been, 
and perhaps make it chronic and unmanageable where in the ordinary 
course of events with average management there would have been a com- 
plete recovery. To get the benefit of an abortive treatment, the patient 
should be in the hands of an expert within twenty-four hours after the 
first burning and itching around the urinary opening, and the first signs 
of discharge appear. For the patient to delay matters, to meddle on his 
own account or to seek unskilled advice is to fail and perhaps to fail 
disastrously. 
Hygiene of Gonorrhoea.—So much has been said about the import- 
ance of the patient’s co-operation in the management and cure of 
gonorrhoea, that it seems worth while to point out the cardinal essentials. 45 
1. Avoidance of excessive exercise during the acute stage. Patients 
should especially avoid much walking, and dancing is flatly forbidden. 
2. The use of alcohol is exceedingly dangerous. The man who exposes 
himself to gonorrhoea when he has been drinking runs a double risk of 
getting the disease. The man who drinks after he has gonorrhoea runs a 
triple risk of keeping the disease. One of the old-time tests for the cure 
of a gonorrhoea used to be that of seeing whether the discharge would start 
up again after a “ souse.” 
3. Much water, tea, and coffee, should be drunk to flush the kidneys. 
Spicy foods or spicy drinks, such as ginger ale, are not to be used. 
4. Sexual intercourse during acute gonorrhoea is usually not desired 
by the patient. It is when the acute symptoms subside that the danger 
comes. To have sexual intercourse after the acute stage while a gonorrhoea 
is clearing up or before it is completely cured, is a criminal act, and will 
moreover start a new attack with serious complications. Sexual excite- 
ment without intercourse is likely to have the same effect. 
5. Acute gonorrhoea is contagious. Although the germs die out on 
dry surfaces, they can be transmitted by the discharges as long as they 
are moist. The strictest care in not touching persons or objects or carry- 
ing the hands to the face or eyes until they are washed and disinfected, 
and in not allowing others to use toilet and personal articles, including 
syringes which belong to the patient, are all essential. A patient with 
acute gonorrhoea should not use a common bath-tub, or sleep with others, 
or infect the toilet seat by contact. If there are children in house 
all precautions should be redoubled. CHAPTER Y. 
The Cure of Gonorrhoea. Gonorrhoea and Marriage. 
Gonorrhoea is Usually Curable.—With proper care the large majority 
of both men and women who acquire gonorrhoea can recover completely. 
The problem of gonorrhoea from the standpoint of public health is less 
that of ultimate cure, than that of prolonged infectiousness. Precisely 
what percentage of cases is ultimately cured cannot be stated in statistical 
form at the present day since so much of the disease never even gets to the 
attention of those in position to estimate, much less record, its frequency. 
It is certainly very large. It must be apparent that an infection which 
is as effective as gonorrhoea in producing childlessness, must have had 
some check upon its career, or it would long ago have extinguished the 
race. This check is the almost spontaneous tendency which the disease 
exhibits, to run its course and get well. If actual and apparent cure were 
identical, and an acute gonorrhoea really ended with the cessation of gross 
signs and symptoms, the situation would be relatively simple from the 
public health standpoint. It is, as has been said, the chronic phase of the 
disease and the long duration of the infectiousness of it in cases in which 
the process seems to be no longer active that perpetuate its hold upon 
us. With reference to the duration of this infectiousness Keyes estimates 
that the average persistence of the germs of gonorrhoea in the male urinary 
canal is six months and persistence over eighteen months is exceptional. 
He states that he has not known a gonorrhoea to remain potentially virulent 
more than two or three years—although he believes this proves the possi- 
bility of indefinite infectiousness in some cases. In women, while the 
patients usually recover in a few months (Keyes) the exceptions are of 
more indefinite duration, harder to recognize, and more difficult to treat. 
Ho one is willing to set a limit on the period of a woman’s infectiousness, 
and conservative observers have the greatest hesitancy in naming a time 
at which woman may regard herself as cured and no longer capable of 
transmitting the disease. 
The Carrier of Infection the Beal Danger.—The fact that it is not its 
incurability, then, so much as the activity of carriers of infection, which 
perpetuates gonorrhoea, points the way to effectual control. So long as 
individual caprice rather than respect for the public health governs the 
treatment situation and makes most cases carriers for considerable periods 
before cure occurs, we can expect no encouraging change in the picture. 
When dispensary patients can make one visit and disappear, when private 
cases vanish as soon as the discharge “ dries up,” when thousands of cases 
never have more skilful care than that afforded at the corner drug store, 
it is immaterial whether gonorrhoea is curable or not, since so much of 
it is permitted to move through ordinary life without let or hindrance. 
Education of the public, not to the curability, about which they already 
have an unwarranted optimism, but to the prolonged infectiousness, the 
difficulties of the treatment, the obstinacy of the disease, will be more 
46 47 
likely to provoke action. Once the public grasps the situation, cure will 
become compulsory and therefore attainable in nearly every case, and 
carriers, intentional or unintentional, will be isolated as far as opportun- 
ities to transmit gonorrhoea are concerned, with the thoroughness with 
which typhoid and diphtheria carriers are to-day. 
Modern Tests for Determining Infectiousness and Cure. The modern 
tests for the identification of gonorrhoea in a doubtful case and the tests 
to determine its cure should be summarized because one of the surest ways 
to bring about their general adoption is to familiarize the public with what 
to expect of those who treat the disease, and incidentally, what must be 
provided for, in a public movement against it. The detection of an acute 
early gonorrhoea while sometimes possible without the microscope, should 
usually be made with it by recognizing the germ in the discharge. A 
point of great importance, often overlooked, is that every patient with a 
discharge from the urinary canal, gonorrhoeal or otherwise, should be 
examined for coincident evidence of the presence of syphilis, since an 
unknown but probably surprising percentage of gonorrhoeas mask the begin- 
ning of syphilis. In chronic gonorrhoea, the microscope becomes even more 
important, in the examination of shreds in the urine after massage of the 
prostate gland or other special manipulations, in cases of “ morning drop,” 
etc. A single examination is not sufficient to show the absence o<f the 
disease especially in women and three or four examinations or even more 
may be needed. In women more than in men, the absence of a discharge 
or leucorrhcea is no evidence of the absence of the disease. Its stronghold 
is in the glands and these must be searched, sometimes with the aid of 
special instruments, in cases in which there is reason to doubt ordinary 
findings. Sometimes it is necessary to try to grow the germs to prove 
they are gonococci. There exists also a blood test for the presence of 
gonorrhoea, recently devised, which rests upon principles similar to those 
governing the blood test in syphilis, to be described later. The blood test, 
while new, seems to be gaining ground as a valuable means of recognizing 
cases in patients that otherwise seem to be well. Among all these elabora- 
tions and technical details, use of the microscope stands out conspicuously. 
Any agency—from the clap-quack and drug clerk through the dispensary 
to the licensed practitioner of medicine—which is treating gonorrhoea 
without the use of the miscroscope, is playing a gambling risk against the 
patient, trading on luck, and contributing directly, without excuse or 
extenuation, to the aid and comfort of the enemy. 
Gonorrhoeal Childlessness in Men and Women.—Much that should be 
summarized under this head has been suggested in the foregoing discussion. 
In men, gonorrhoea, aside from the risk of infecting the wife which exists 
in an uncured or latent case, unfits a certain percentage for marriage 
through the effect of the inflammatory process on the sperm or male sexual 
elements, and the duets or tubes through which they pass. Sterility in the 
husband is variously estimated as responsible for from 17 to 25 per cent 
of childless marriages. It should be understood that the ability to have 
sexual relations may exist in sterility. It is the failure of the relation 
to result in pregnancy that constitutes the sterility for which the gono- 
coccus is responsible. It is one of the supreme ironies of fate to have 48 
the woman in a childless marriage appear before the physician, ready to 
submit herself to every manner of procedure, including even serious opera- 
tions, in the hope of curing a sterility for which the husband is respon- 
sible, while he, as Morrow says, goes about “ inflated with a sense of his 
own virility.” Such charges of sterility in the wife, for which the husband 
is directly or indirectly responsible, have formed the basis of separations 
and even of actions for divorce. Fortunately it has now become well 
understood by the medical profession that proper examination of the 
husband to prove that he has living active male elements is essential as 
the first move in determining the cause of a sterility. Yet it should not 
be imagined that all male sterility is due to gonorrhoea. For example, 
Simmonds estimates that 61 per cent of alcoholics are sterile. Moreover, 
it must never be forgotten that the reproductive function is one of the 
most complicated of physico-chemical mechanisms, and a marriage may 
be childless even in the face of the entire good health of husband or wife. 
The layman’s snap judgment on the presence of gonorrhoea in a childless 
couple therefore has at least an even chance of being wrong instead of 
right. Certain forms of sterility in the man due to the effects of gonor- 
rhoea, are not incurable, the outlook depending somewhat on whether active 
male cells exist or not. 
A Child Unborn—The burden of gonorrhoea in marriage falls over- 
whelmingly upon the woman. While some men are the unfortunate 
victims of their wives’ infection the rule usually works the other way. 
Estimates of the percentage of men who transmit their gonorrhoeas to their 
wives vary widely from 5 to 45 per cent. Aside from the invalidism 
already discussed, for which gonorrhoea is responsible in marriage, its 
influence on the perpetuation of the race is, as such, exceedingly serious. 
As previously noted, about 50 per cent of all absolute and one-child 
sterility is due to gonorrhoea, and of this sterility, 75 per cent is the result 
of gonorrhoea transmitted to the woman by her husband. The loss to the 
good of the world which an unborn child represents is in no sense to be 
measured by its mere place in a numerical series, large though this be. 
In no trivial sense, the child is the personal immortality of its bearers 
and of the race. A child unborn is a defeated purpose and a bond 
unbound. Being unborn is more costly even than death, since the experi- 
ences of childbirth and death are at least part of that discipline without 
which man and wiffe rarely reach the full development of their character 
and personality. The woman who through gonorrhoea has not known the 
bearing and rearing of a child carries an inevitable and tragic handicap— 
she is indeed the victim of an unfulfilment whose poignancy can never be 
subjected to mere statistical estimation. 
Gonorrhoea and the Medical Examination Before Marriage.—The pro- 
tection of marriage from the effects of gonorrhoea is one of the critical 
eugenic problems of our time. It is beset by difficulties which are part 
and parcel of the status of the genital infections in our social order, and 
of the medical problems involved in the recognition of gonorrhoea itself. 
It may be said to begin with, that so long as public sentiment does not 
compel the revocation of the laws in force in most states which oblige the 
physician to remain silent under the so-called bond of professional con- 49 
fidence while selfish and irresponsible men or women, knowing themselves 
to be in an infectious state, or indifferent to the question, deliberately 
marry healthy partners, a certain amount of marital infection will 
persist. Such a revision of the law is among the first essentials of any* 
attempt to control carriers of the disease. On the other hand, the gonor- 
rhoea transmitted in ignorance by inadequately treated and uncured cases 
is a much larger part of the problem, which will only be fully done away 
with through the reform of the whole situation, which public enlighten- 
ment will bring. Medical examination before marriage, while it has not 
yet reached the status in public sentiment and law which it deserves, is 
a powerful weapon against every type of gonococcus carrier. It is true 
that the result of such an examination is less trustworthy in women than 
men, since an antiseptic douche can conceal the actual status of the case; 
nevertheless repeated examinations properly carried out can often demon- 
strate the infection if present. Widows, particularly childless ones, no 
matter what their personal character, and non-virgin women, are legiti- 
mate objects of medical suspicion. It is true that in isolated cases no 
satisfactory conclusion can he reached, although such cases are rare 
exceptions. Medical examination of men is irksome to physician and 
patient, but capable of more trustworthy results. While urination 'before 
examination may wash away a morning drop, massage of the prostate 
gland in the office, followed by a so-called two-glass test and microscopic 
examination will usually identify a gonococcus carrier, and examination 
of the urinary canal with an instrument called the endoscope may yield 
findings that point toward the persistence of an infection. The mere 
absence of discharge in a man who has had a comparatively recent 
gonorrhoea is never to be trusted as evidence of fitness to marry. Neither 
is the cursory looking over too often given such cases, to be regarded as 
satisfactory. The development of the blood test for gonorrhoea may offer 
a valuable aid, but one whose status is as yet not fully determined. Every 
man who has had a gonorrhoea—and this it will be recalled includes about 
50 per cent of all men—should be willing to submit to thorough examin- 
ation by an expert chosen by the family of his fiancee, as an evidence of 
his moral as well as physical fitness to become her husband. The com- 
pleteness of the examination should be left to the expert’s judgment. 
Protection of the Fiancee.—When gonorrhoea complicates an engage- 
ment, as it too often does, there is only one principle to follow; postpone- 
ment until a cure has been effected, and that, a cure determined by the 
microscope and time, and not by the patient’s impatience and desires. 
Here again a new conception of the physician’s higher obligation to society 
will allow him to state the facts to the healthy person if the infected 
individual shows an intention to marry before he is cured, a form of 
forced control of the situation that is too often the only way of aiding 
the woman. These occurrences are anything but remote, as any expert 
can attest, and until they are dealt with, the problem of gonorrhoea in 
marriage will remain unsolved. 
Protection of the Pregnant Woman against Gonorrhoea.—The serious- 
ness of pregnancy as a complication of gonorrhoea demands special medical 
measures, both for the sake of the mother, and of the child. The examina- 
51807—4 50 
tion of women who have such symptoms as “ vaginal abscess,” burning 
urination, leucorrhoea and abdominal pain soon after marriage or during 
pregnancy, and of unmarried mothers especially, for evidence of gonorrhoea, 
is of the utmost importance. The examination should be made early in 
the pregnancy if possible to allow for painstaking and systematic treat- 
ment before the birth of the child. The life-saving value of such a measure 
is so great that it should under no circumstances be neglected. 
A Warning in regard to Double Marital Infection.—It should not be 
forgotten, as an explanation of more than one embarrassing or tragic 
situation, that the fact that a man and wife live together or have sexual 
relations without showing evidence of gonorrhoeal infection may be due 
to the simple fact that both have it, albeit in a mild or quiescent form. 
The separation of the parties to such a marriage or liaison leaves two 
sources of infection free to communicate their ailment to others, the more 
easily because, having failed to note any evidence that they had infected 
each other, they would believe themselves to be normal. Similarly, the 
treatment of one party to a marriage for gonorrhoea calls for the examina- 
tion and treatment of the other, since it is only under the rarest of con- 
ditions that one has the disease without the other, or that the one can be 
cured while subject to repeated risk of re-infection by the other. 
Remediable Weaknesses of the Existing Situation.—This completes 
for the time being the consideration of the medical aspects of gonorrhoea 
which affect its status in a public health campaign against diseases of 
sexual origin. Age-long underestimation of its seriousness has become part 
and parcel of common thought, and only prolonged and persistent effort 
at re-education will finally give the disease the place it deserves in the 
public mind side by side with syphilis, tuberculosis and cancer, as one of 
the four greatest surviving plagues of the human race. This undeveloped 
public sentiment is coupled with a medical handicap that is yet to be over- 
come. Slowness and some uncertainty in treatment, the absence of the 
spectacular, and the unfamiliarity of the medical profession with certain 
new and vitally important methods for the recognition of the disease in 
active and in latent, though still contagious cases, deprive a campaign 
of some of the dash and brilliancy possible in syphilis, but form no insur- 
mountable obstacles. Too few great minds, it would almost seem, have 
made the biology, the physiology, the chemistry of the gonococcus, and 
the body which it invades, their life-work. Throughout this field, as 
throughout all fields of medicine, the temporizing, hand-to-mouth treat- 
ment of consequences rather than causes has held the centre of attention. 
An expenditure of effort and brain-power equal to that which has been 
lavished on the results and the wreckage of gonorrhoea, if expended upon 
its early stages on the control of its carriers, and on its prevention, would, 
within a generation or two, lead to new knowledge that should reduce 
it to a position of minor importance in the ranks of disease. It is not the 
association of gonorrhoea with a moral issue such as that of prostitution 
which maintains its foothold. It is our own refusal in the past to deal 
with it radically as a dangerous infectious disease wherever it may be 
found. The fact deserves re-emphasizing, that in spite of its peculiar 
obstinacies, in spite of the lack of dramatic and rapidly effective methods 51 
of attack, continued insistence upon the contagiousness of gonorrhoea, 
determined focusing of every effort against it, upon its transmissible stage 
and upon its transmitter, can even to-day remake our point of view, and 
begin the abolition of the disease. When gonorrhoea is universally under- 
stood to be almost as common as measles and more terrible than smallpox 
—a disease which thrives on lies and cowardly silence—the way will open 
for a new public health. 
51807—41 PART III. 
SYPHILIS. 
58 CHAPTER I. 
History, Cause and Prevalence of Syphilis.1 
The Origin of the Name.—Syphilis, vulgarly spoken of as “ pox ” 
and “ blood disease,” is one of the most remarkable diseases which alfects 
the human race. The name, over which so many victims have stuttered, 
means “ a lover of swine,” and was first applied to the disease following 
the appearance of a poem by Fracastor2 in 1530, in which a dramatic recital 
of the symptoms was given as they appeared in the person of the principal 
character, Syphilis, a swine-herder, who became infected. The word has 
no more horrifying or disgraceful significance than would the name “ Job,” 
if used as a modern term for boils, with which that Biblical character was 
afflicted. 
Syphilis, a Master Disease.—Syphilis, like gonorrhoea, is an infection 
caused by a specific and definite germ. It is a master disease, the peer, 
and indeed the superior of tuberculosis, the great “ white plague ” in the 
wide range of its influence over the fate of mankind, present and future. 
There is not a tissue or a structure of the body which syphilis cannot 
affect, nor is there an aspect of the entire science of medicine in which it 
will not be encountered. Sir William Osier coined the famous phrase 
which for all time expresses the relation of syphilis to medicine, “ Know 
syphilis in all its manifestations and relations, and all other things clinical 
will be added unto you.” No lane is so long that one may not find syphilis 
at its turning. The disease has changed the destiny of mankind upon the 
earth. If it should cease at this moment to be transmitted, its effects would 
not disappear from the world within two and perhaps three generations. 
Few indeed of living human beings can boast an ancestry free from its 
remote effects. 
It is not strange, therefore, that a disease of which such statements 
can be made, should have challenged the most intense interest, and should 
have drawn to its investigation and to the problem of its treatment many 
of the ablest minds of medicine and the sciences upon which medicine is 
founded. There is about it a dramatic quality that one feels the lack of 
in gonorrhoea. Infinitely clever, infinitely versatile, even a little inclined 
to chivalry in that the disease is in general less severe in women than in 
men, syphilis is an opponent worthy of the subtlest resource, the most 
1 Three discussions of syphilis are available to the general reader. They are: 
1. Pusey, W. A.: Syphilis as a modern problem. Am. Med. Assn., Chicago, 
1915. An eminently readable discussion, containing a large col- 
lection of important facts. 
2. Vedder, Col. E. B.: Syphilis and public health. Philadelphia, Lea & 
Febiger, 1918, 315 pp. This is a monumental, but not over-technical, 
presentation of every phase of the subject. 
3. Stokes, J. H.: The third great plague: A discussion of syphilis for every- 
day people. Philadelphia, Saunders, 1917, 204 pp. This book is 
written primarily from the standpoint of the patient and those who 
come in contact with him. 
2 Fracastor, H.: Syphilis, sive morbus gallicus. Verona, 1530. 36 1, 
55 56 
indomitable determination. The seeming triviality of its onset, its extra- 
ordinary skill as a dissembler, the silent but none the less terrible march 
of the invading host of spiral germs from their point of invasion through 
the blood to every structure of the body, the long years of silent, evil 
and yet wonderfully skilful work they do under an outward aspect of 
good health; the variety of ailments to which syphilis can give rise, and 
yet the dramatic, the almost astounding effectiveness of proper treatment, 
make it decidedly unique. It is little wonder that Fracastor felt impelled 
to describe it in poetry, for bizarre though the conception may seem, 
syphilis is an artist, a craftsman in evil beside whom Machiavelli and 
Cesare Borgia were bunglers and dealers in crudity. To the appreciation 
of its course and its history it is not amiss to bring a little of the spirit 
of the artist, in order to understand the workings of this masterpiece of 
evil, this most gifted of all the unholy fellowship of devil’s aides. It is 
this touch of knightliness that lifts the story of syphilis from the sordid 
into the field of romance. 
The Historical Aspects of Syphilis.—Syphilis has a peculiar history. 
There is, of course, room for argument as to its antiquity and its origin, 
and it is scarcely possible as yet to regard the question as closed. But 
the conception of the so-called American source of the infection seems to 
be obtaining a wider and wider acceptance. In accordance with this view, 
it would appear that instead of having the universality of gonorrhoea, 
syphilis was suddenly laid upon the doorstep of an unsuspecting world by 
the sailors of Columbus in 1493, upon their return from the Island of Haiti, 
in which the disease was known, and where they had acquired it. Whether 
or not it had existed in the old world prior to this time, certain it is 
that from the time of this fresh importation it took on new life. During 
the sixteenth and seventeenth centuries an epidemic of the disease swept 
over the continent of Europe, which, for virulent frightfulness and spec- 
tacular horrors totally eclipsed anything seen except in the rarest of cases 
in these days. The combined aid of armies and voyagers carried it appar- 
ently into every corner of the habitable earth. Medicine, still enchained 
by the lethargy of the Middle Ages, was jolted into life by the whirlwind 
of disaster. On every side the ablest minds the art could muster bent 
themselves to the problem. Clinical knowledge of the symptoms of 
syphilis sprang into existence with a rapidity scarcely to be equalled for 
a time by progress in any other field of medicine. We have noted already 
the confusion with gonorrhoea fathered by John Hunter and later set 
right by Ricord. With the work of the latter, and of Diday, both French- 
men, and that of their disciples, the modem conceptions of the disease 
came one by one into being, so that by the end of the nineteenth century 
there lay ready for the fertilizing power of laboratory research, a rich 
field of knowledge of the human aspects of the disease. Syphilis itself, 
after the violence of its epidemic phase, seemed to subside into the subtle 
and malevolent cleverness we know so well to-day. Instead of descending 
upon the victim as a thunderbolt, literally dissolving him bone and body 
into a mass of carrion, it now expresses itself less luridly but none the less 
effectively in the form of grave diseases of the heart and kidneys, in 
death from impairment of the great blood vessels, in damage to sight and 57 
hearing, in loss of the power to move through the death of nerves, in 
snuffing out of the mind itself. 
The New Knowledge of Syphilis.—In the later years of the nineteenth 
century, a change long prepared for and foreshadowed came over the whole 
face of medicine. The sciences upon which the art must always rest for 
the foundation of its advance, had come into existence, and grew under 
the genius of men like Pasteur, the founder of bacteriology, into a 
fountain-head of inspiration and new knowledge. With almost miraculous 
suddenness the whole aspect of our knowledge of syphilis changed with 
the changing situation in medicine. One epochal discovery trod the heels 
of another in the decade from 1900 to 1910. The whole fabric of the new 
science of syphilology was welded together by men whose labours deserve 
Homeric words of praise. iSchaudinn and Hoffmann, Metchnikoff, Roux, 
Bordet, Wasserman, Ehrlich, Hata, unassuming men drawn from all the 
great intellectual sources of human life, carrying on their labours in the 
seclusion and quiet of laboratories, were none the less the peers of the 
fellow-workers of Vulcan, who in the heart of a volcano, forged the armour 
of the gods. To the tremendous constructive brain-power of these men, 
the grasp that Ehrlich and Hata had of the chemistry of arsenic and the 
biology of the germ of syphilis, the eyesight and experience of Schaudinn 
who could see in the germ he discovered, with the ordinary lenses of the 
microscope, structures that lesser men can barely see to-day with the 
artificial aids he despised or did not have—to these men we do homage in 
the mere mention of the new knowledge of syphilis. “ Though they be 
not sought for in the council of the people, nor be exalted in the assembly,” 
they have re-made the destiny of man upon the earth. 
The Discovery of the Germ and the Transmission of Syphilis to 
Animals—Few more important occurrences could be imagined than the 
identification on April 5, 1905, by Schaudinn and Hoffmann, the former a 
zoologist and the latter a syphilologist, of the germ which is now practically 
universally accepted as the cause of syphilis. Innumerable germs had 
been suspected before this, but had failed to stand critical study. The 
identification of syphilis as an infection and the recognition of its cause 
combined with the proof furnished by Metchnikoff and Boux that it could 
be transmitted to certain animals and could therefore be studied experi- 
mentally, furnished the groundwork upon which rests the whole fabric 
of the modern recognition and treatment of the disease. Hot that syphilis 
was not recognized before, or that its treatment had not met with a measure 
of success. But the identification of the germ in the very first sore of the 
disease makes possible a prospect of complete cure that is incomparably 
greater than anything the older knowledge could offer. The transmission 
of the disease to animals made possible the invention of the synthetic 
compound of arsenic known as “ 606 ” by Ehrlich, which produces radical 
effects upon the disease in all its stages, and controls its contagiousness 
in a way that alters our whole outlook upon it as a problem in public 
health. 
The Spirochaeta Pallida and its Recognition in Early Syphilitic 
Sores.—The germ of Syphilis is called the Spirochaeta pallida/ the first 
i A number of investigators consider “treponema pallidium” the proper term. 58 
word describing its corkscrew shape, and the second the extreme diffi- 
culty with which it can he stained with dyes to make it visible. It is 
exceedingly minute, and is best observed in the living state, whea freshly 
taken from the secretions of certain syphilitic sores, the study being made 
under the highest powers of the microscope, with the aid of a special 
instrument called the “ dark field,” which shows the germs in a beam of 
reflected light, much as motes appear in a sunbeam in a darkened room. 
It is also possible to use stains as in the case of the gonococcus, though 
they are less satisfactory. The germ of syphilis has been so recently dis- 
covered, and the subject of syphilology in general has been so poorly 
taught in medical schools of the past generation that many men called 
upon to deal with syphilis to-day have little or no conception of the 
importance of the germ in the recognition of the disease in the living 
patient, and too often have never seen it or learned how to find it when 
occasion demands. Yet it is not too much to say that the time has come 
when the ability to find the Spirochseta pallida in certain sores, especially 
the early ones of syphilis, and the mechanical equipment for doing it, are 
absolutely prerequisite to professional fitness to diagnose or treat the 
disease. British naval medical officers in the first year of the war, showed 
for example, that of 671 men with venereal sores, 63-4 per cent were 
recognized at once as syphilitic by the use of the dark field and only 13-9 
per cent were later found to be syphilitic by subsequent blood tests. When 
we recall that in 1911 only about 14 per cent of early syphilis in the 
United States army was recognized during the stage of the first sore or 
chancre, and in 1915 only 22 per cent, we can appreciate the immense 
advance made possible through the newer methods, by which it is safe to 
say no less than 30 per cent of all syphilitics seen in the stage of the first 
sore can be recognized and given the 100 per cent chance for cure. No 
physician, and no hospital or dispensary which is not equipped to identify 
the germ of syphilis or is unwilling to see that the patient gets the benefit 
of such knowledge elsewhere if it is called for by the nature of his case, 
has any business to pretend to deal with early syphilis. The statement 
seems radical, yet upon its literal acceptance depends more than half of 
our hope of future progress based on early and complete cure. 
The Prevalence of Syphilis.1—Before considering the nature of the 
disease itself, a few words should be said about its prevalence. Here again, 
as in the case of gonorrhoea, estimates rather than exact statistics must be 
largely drawn upon. It should be recalled that a large amount of syphilis 
goes about unrecognized in the ordinary course of events, until some of 
its effects appear, or an incidental ailment brings the patient into the 
hands of some one who applies the modern tests. So greatly has the blood 
test for syphilis increased our power to recognize the disease that the older 
figures have lost much of their value. Yet even these based in the vast 
personal experience of men like Fournier, estimated the percentage of 
syphilis among the adults of large cities like London and Paris as from 
10 to 13 per cent. A survey of British working men seemingly in good 
i Those especially Interested in this question, and all public health officers, 
should read the remarkably complete presentation of this subject by Col. E. B. 
Vedder In “Syphilis and public health," loc. cit. 59 
health, made by Collie, showed 9 per cent to have syphilis. Class varia- 
tions and age are a large factor in estimating the prevalence of the dis- 
ease, and no consideration is complete which omits them. For example, 
Vedder came to the conclusion that 20 per cent represented a fair average 
for the amount of syphilitic infection among young men who enlist in 
the army, and that among men representing the grade which applies for 
commissions, trains at West Point or enters our colleges, 2 to 5 per cent 
is the approximate prevalence. Among hospital patients estimates range 
from 10 to 20 per cent, based, however, quite largely upon the blood test 
rather than upon combined blood test and medical examination, which 
invariably results in a higher figure. Among young women Vedder esti- 
mates that the percentage fluctuates between 3 and 20 per cent depending 
on age, marital condition, social status, etc. Among private patients from 
10 to 20 per cent have syphilis, among children 3 to 10 per cent. Among 
negroes in apparent health, the percentage varies from 25 to 30 per cent, 
among the sick from 40 to 50 per cent. Among criminals the range is 
from 20 to 40 per cent, among the insane (male whites) 20 to 35 per cent, 
among prostitutes from 50 to 100 per cent. There are some notable 
national figures, especially those for parts of Russia, in which it was 
estimated that 95 per cent of the peasant population had the disease. 
While such spectacular estimates can have no general significance, they 
suggest the extent of the problem in nations with a low physical and mental 
standard of living. Estimates for the continental countries such as 
Germany and France do not differ materially from those quoted for the 
United States. The question as to whether or not syphilis is on the 
increase is one difficult of determination, since the newer methods of 
recognizing the disease are creating an impression of increase which may 
be more apparent than real. Pusey believes that on the whole there is 
no evidence to show that it is becoming more prevalent than in the past. 
It needs no comment to carry home the meaning of these figures to 
every thinking man and woman. Nothing could more effectively shatter 
the notion that syphilis is the heritage of the unfavoured few, the trophy 
of debauch, the sign-manual of the down-and-out. Syphilis is one of the 
most widespread of all infectious diseases. Its victims are numbered in 
millions, not in hundreds. Not a man lives, or a woman, who does not 
elbow it every day, whose house has not seen its entry and departure, 
who may not a.t any hour have his name added to the rolls. While to be 
sure there are variations in the nearness or remoteness of the risk, never 
does it become so distant that any one of us can sit by and say in smug 
unconcern, “ This is not my affair.” While it is not so prevalent as 
gonorrhoea, it may beset us perhaps in disguise, and but too often in 
dangerous contagious form, in those unsuspecting hours when we believe 
ourselves at ease among our friends. Syphilis is too cunning a craftsman 
in evil to permit the limitation of his labours to the few. CHAPTER II. 
The Course of Syphilis—Primary and Secondary Stages. 
The Stages of Syphilis.—A knowledge of the course of syphilis and 
the effect produced by the germ upon the body is essential to any com- 
prehension of the problem in public health which it presents. Reference 
has already been made to the fact that it can affect any portion of the 
body and in such a variety of ways as to make its manifestations almost 
synonymous with the whole field of medicine itself. There is indeed 
scarcely a known condition due to other causes which syphilis cannot 
passably imitate. The conventional division of the disease into stages 
has also been foreshadowed in the preceding discussion. The usual terms 
for these stages are primary, secondary and tertiary. They are arbitrary 
divisions based on time rather than on the course and peculiarities of the 
disease. A more rational grouping would be into an early local, a gener- 
alized or disseminate stage, a stage of recurrences and latency, and finally 
so-called late syphilis, including what was formerly spoken of as quarter- 
nary syphilis of the nervous system—that is locomotor ataxia and general 
paralysis of the insane. These divisions while taking account of time, 
are also based upon the behaviour of the germ and the reaction of the 
body to its invasion. 
The Primary or Localized Stage—The Chancre.—Early local or prim- 
ary syphilis covers essentially the period from the appearance of the first 
sore, to the time when the germs spread to all parts of the body. The 
germ of syphilis gains entrance to the body usually through an abrasion 
or wound in the skin or the thin, moist, red mucous surfaces. This 
abrasion may be so small that it is only visible under the microscope, so 
that the seeming wholeness of the skin or mucous surfaces is no evidence 
whatever that the germ has not found an entrance. When the Spirochseta 
pallida enters the body it remains for some time at the place where it 
gained entrance, the germs multiplying and setting up in the surrounding 
tissues a reaction which is essentially a mild chronic inflammation. In 
an infection with the gonococcus there is at least a passable fight, and 
that quite promptly. The spirochsete of syphilis on the other hand arouses 
much less opposition, unfortunately, and has a correspondingly greater 
opportunity to gain a foothold. From the time the germ enters the body 
until the first signs of a sore or reaction appear a period of several days 
to several weeks may elapse, in which the patient has no idea of the 
danger he is in. If he knew himself to be infected, this so-called period 
of incubation would be the ideal time in which to take strong treatment, 
since the germs could be killed off with comparative ease. In cases where 
a person is known to have been exposed, it is in fact becoming good prac- 
tice to forestall the apperance of any sore by treating him on the chance 
that one will develop. The patient, however, does not usually discover 
his situation until a small lump, a chafe, or an actual ulcer appears at 
the place where the germs entered. This sore is the first outspoken evid- 
60 61 
enee of syphilis and is called the chancre (pronounced shan-ker) or 
primary lesion. During the first few days of its appearance, the over- 
whelming majority of the germs of the disease are in it and in its imme- 
diate neighbourhood. They have not as yet spread to any significant 
extent to other parts of the body. Their presence makes the discharges 
from the chancre extremely contagious and dangerous for others. But 
from the patient’s standpoint the fact that they are still in one place and 
have not as yet invaded the body makes this the golden moment for cure. 
Cure in the Early Stage (Abortive Cure).—The patient is warned 
by the sore that there is something wrong, if he knows enough to take it 
seriously. If the germs are immediately found by the dark field micro- 
scope aiffl powerful doses of the newer drugs such as “ 606 ” are given 
directly into his blood before the spread of the germs takes place, the 
process is stopped before it has started so to speak, all the germs can 
be killed off, and a complete and rapid cure results. This curing of the 
disease in the earliest days of the primary lesion is called “ abortive ” 
cure. It should be reiterated that this is only possible in the earliest days, 
almost the earliest hours of the visible chancre. No test of the blood will 
prove the presence of the disease at this time, for once the blood shows 
it, the chance for abortive cure is gone. Abortive cure is one of the great 
hopes of humanity in its battle against syphilis. The need for it should 
be preached from house tops, as was the outdoor treatment of tuberculosis. 
While its use is still in its infancy, we have good reason to believe that 
if it could be applied throughout the world in conjunction with social 
and educational as well as medical preventive measures, syphilis could 
be wiped out as completely as malaria can be by the extermination of the 
mosquito. 
Just when the opportunity for abortive cure ends cannot be deter- 
mined as yet by any means that we know. One thing is sure—abortive 
treatment cannot begin too soon and it can easily be too late. The first 
four to ten days of a sore seen from its very beginning represent the best 
guess as to the upper limit of time in which it is possible to obtain an 
abortive result. 
Difficulties in Recognizing a Syphilitic Chancre.—Emphasis has 
already been placed on the fact that there is no reliable way of telling from 
its appearance whether a genital sore is a chancre or not. The microscope 
is the first resort. Chancres may be of any size and appearance, and may 
develop anywhere. It is even believed that they may be altogether absent 
and the patient still acquire syphilis. It is not a rare thing for a chancre 
to occur inside the canal through which the urine passes or just at the 
opening and to be masked by the discharge of a gonorrhoea acquired at 
the same time. In women it may develop in the vagina or on the neck 
of the womb. Many intelligent and entirely truthful patients with 
syphilis can give no account whatever of a chancre though they admit 
having had gonorrhoea. Still others, women especially, can give no account 
of either syphilis or gonorrhoea, and yet they have syphilis. It has been 
estimated that as high as 40 per cent of men and 60 per cent of women 
having syphilis are not aware of the onset of their infection as such, or 
have forgotten its trivial beginnings. It cannot be too strongly said that 62 
n chancre may be so small, so unobtrusive, so painless, so well concealed 
in some fold of skin or mucous membrane that even an intelligent and 
observing patient will wholly overlook it. Add to these overlooked infec- 
tions the innumerable misinterpretations of chancres which are dubbed 
“ chancroids,” “ soft sores,” “ chafes,” cold sores, etc., and the real wonder 
becomes, not that so much early syphilis goes unrecognized, but that any 
of it is recognized at all. In women especially, as already intimated, the 
opportunities for a chancre to pass unnoticed are much greater than in 
men. The genitalia are less accessible, and the chancre can occur for 
example on the neck of the womb or in the vagina without the victim’s 
ever realizing the fact or being aware that she is in an infectious condition. 
It is indeed a rarity for women to have an infection recognized in the 
primary stage and for them therefore the outlook for abortive cure based 
on the identification of the primary lesion is vanishingly small. Aside 
from these few cases which can be treated on the knowledge that they 
have been exposed even though no chancre can be found, the problem 
of controlling syphilis by the treatment of women will largely resolve 
itself into putting a stop to their infectiousness as soon as the disease 
has developed far enough to be recognized by other signs. 
The Spread of the Germs from the Chancre to the Body.—From the 
chancre or primary lesion, if nothing is done to stop the progress of the 
disease, the germs of syphilis travel by way of the lymph channels at first, 
to the nearest set of glands or kernels, where they provoke a reaction 
which shows itself as a local swelling. A marked swelling of the kernels 
or glands in the neck or under the jaw, coming on rather rapidly, with a 
very sore throat or a sore on the lip, should at once arouse the suspicion 
that the sore is a chancre. When the chancre occurs on the genitals the 
swelling is less characteristic, and more likely to occur with other types of 
infections. The invasion of the lymph glands is the last phase of the 
primary stage, and indeed when it becomes definite the local period of 
syphilis is over. When the lymph glands have ceased to serve as a defence, 
a sudden change in the whole aspect of the disease occurs. The germs 
abruptly get into the blood stream in enormous numbers, and are carried 
forthwith to every single structure in the body. While a few germs may 
have entered the blood before the grand attack, the sudden rush is an 
attack in force, a “Big Push” which places the patient.once and for 
all beyond the reach of the abortive, hundred per cent cure. The infection 
has now become generalized, as we say, and syphilis is a constitutional 
disease from that moment. While the germs of gonorrhoea gain access 
to the blood in occasional cases and produce symptoms, syphilis differs 
from gonorrhoea in that this invasion is invariable, and that owing to the 
peculiarities in the germ, it involves consequences vastly more serious 
and far reaching than those of systemic gonorrhoea. 
Author’s Footnote: Since the original text of this and several subsequent 
passages referring to the generalization of the syphilitic infection, was written, 
animal experimental evidence has developed to show that the generalization or 
spread of the infection through the body occurs not infrequently within a few 
hours after inoculation, and that spirochetes may be found in the blood stream 
and in various organs even before any visible signs of reaction in the form of a 
chancre appears at the point of entry. Accordingly the distinction drawn between 
the primary and the secondary stages of syphilis so far as treatment is concerned 
is even more artificial and of more doubtful significance than was at first supposed. 63 
The Generalized or Secondary Stage.—The generalization of the 
infection, which usually occurs from the first to the fourth week after the 
appearance of the chancre, marks the beginning of the secondary stage. 
Before anything appears the patient may have premonitions of trouble 
in the form of headaches, a drop in weight and a feeling of being under 
the weather. Then in the large majority of cases the thing which con- 
stitutes syphilis in popular imagination occurs. The patient usually 
u breaks out ” with some kind of skin eruption which on account of the 
wide distribution of the germs tends to be general over the body. 
Syphilitic Eruptions and Their Variations; Common Misconceptions. 
—Syphilitic secondary eruptions are comparable to many other eruptions 
in skin diseases. They take on the widest varieties of forms, ranging from 
a few faint pink spots in the armpits and flanks, which the patient may 
not even see, to great, round, punched out ulcers that may riddle his skin 
like a burst of shrapnel. The recognition of syphilitic secondary eruptions 
is at times none too easy a matter for the expert and it may be a bugbear 
for the average doctor. If it is hard for him, it is apparent that no layman 
has any business to take upon himself the task of deciding the matter. 
The arrogant self-sufficiency with which occasional persons will set them- 
selves to wreck the lives of unfortunates with skin diseases on a non- 
medical decision that they have some “ bad disease ” is one of the wonders 
of that combination of stupidity and ignorance against which the gods 
themselves fight in vain. Persons with psoriasis especially, a harmless 
but disfiguring affair, are subject to cruel and scandalous mis judgments 
from this source. The author has known ministers to all but lose wife, 
church and reputation through the unprincipled activities of the amateur 
dermatologists in their congregations. There can be but one honourable 
course for an outsider to pursue when confronted with an eruption on the 
person of friend or acquaintance. If it is any of the outsider’s business, 
let him frankly ask the friend for a statement from his medical adviser 
or advise him to carry such a statement about with him. If it is not 
the outsider’s business, let him keep silent. 
Syphilitic Eruptions and the General Public.—Fortunately two con- 
siderations minimize the importance of syphilitic skin eruptions for the 
general public. In the first place, they are practically never contagious 
when on the free skin of the body or the face. It is only when some 
of the bumps occur in moist spots such as the armpits or the groins, where 
their tops can be rubbed off, that the germs get an opportunity to escape. 
Even in such cases the damage can only be done to those who come into 
intimate contact with the body or the moist underclothing of the syphilitic. 
No dry, unbroken skin surface transmits the disease. In the second place, 
a syphilitic skin eruption if prominent enough to draw the public eye 
sends the person at once for treatment, with the result that it is usually 
rapidly cleared up. 
The Dangerous Contagious Manifestations of Secondary Syphilis.— 
Secondary syphilis is, however, accompanied by outbreaks which are full 
of danger for others, and the danger is the greater because it is the danger- 
ous sores which are usually hardest to recognize or least suspected of 
having any connection with the disease. Secondary syphilis shows a 64 
marked tendency to involve the throat and mouth, and the moist surfaces 
in and about the genital tract in both men and women. The biological 
reason is apparent enough. Here the germs find the ideal combination 
of moisture and an absence, or comparative absence of air. The constant 
friction and motion to which such surfaces are subject in walking, talking, 
etc., soon rubs the tops off the spots in which the germs have gathered, 
and releases them by millions. The spot becomes covered with a thin 
greyish membrane, forming the so-called mucous patch, which with its 
brother, the flat wart or condyloma, is by all odds the most dangerous 
sore, produced by syphilis. Mucous patches are practically painless. A 
throat may be literally plastered with them from side to side and the 
patient complain of no inconvenience, or only a slight soreness or dis- 
comfort. There may be none in the throat but one or two of them may 
appear on the under side of the lip opposite the gum or at the angles 
of the mouth, ready to spread spirochgetes over dishes, pipes, dental instru- 
ments, the lips of children or adults, the faces and fingers of doctors 
operating on and examining the mouth, the thermometer with which the 
nurse takes the temperature. They may not be, and indeed too often are 
not, seen by the busy or hurried doctor, and certainly not by the patient, 
by uninitiated friends and outsiders, or by unsuspecting wife and children. 
Similar spots and patches appear about the genitals, but here on account 
of irritation they are inclined, especially in women, to grow into peculiar 
flat warts, or condylomas. Growing about the opening of the rectum 
they are often mistaken for “ piles.” Of all the sores that syphilis can 
produce there is nothing so rich in the germs as the flat wart or condy- 
loma. Hot being sensitive they easily pass unnoticed, and one of them 
can infect an army. 
The Constitutional Effects of Secondary Syphilis; Symptomless 
Syphilis.—It should not be supposed that the activities of secondary 
syphilis are limited to the skin and the mucous surfaces of mouth and 
genitals. The spread of the germs 'by the blood enables it to affect in 
some degree all parts of the body. But there is a definite tendency on the 
part of certain strains or breeds of the Spirochseta pallida to affect some 
parts more than others. Some patients develop the violent headaches of 
syphilitic meningitis and nerve paralysis of various types. Others have 
inflammation in the eyes, still others develop bone and joint pains and 
swellings that too often pass as “ rheumatism.” Some have thinning of 
the blood (ansemia) and marked loss in weight. But the most serious 
thing about it all is that many develop almost no symptoms, and occasion- 
ally some of them even say they feel in better health. Half the persons 
with secondary syphilis would never have their attention attracted to their 
condition by their symptoms. It is indeed true that those who have a 
severe secondary syphilis are fortunate, since only too large a share of the 
victims pass untreated to the late stages through failure to realize that 
anything much ails them. Treatment in the late stage cannot make good 
damage that delay through ignorance has made possible. CHAPTER III. 
Recurrent Inactive and Late Syphilis. 
The secondary or generalized stage of syphilis termintes in a remark- 
able way. The billions of germs that swarm through the body when the 
secondary stage is at its height, through some remarkable development of 
the patient’s bodily resistance, die out whether the patient is treated or not, 
until comparatively few remain. But in their dying they have left behind 
a legacy that reaps disaster for the victim of the disease in his later years. 
The body has in some way become sensitive to the few germs that remain, 
and as the disease progresses, reacts to their presence in a far more serious 
way than it does in the earlier stages. Syphilis in the early local and in 
the generalized or secondary stage is one of the mildest of all the serious 
infections. In its late stage it becomes one of the gravest diseases known. 
Latent, Obscure or Silent, and Recurrent Syphilis.—The transition 
from secondary to late syphilis is not abrupt, nor embraced with a definite 
period of time. Late manifestations may appear before the chancre has 
thoroughly healed in some cases. But as a rule they are preceded by a 
period of latency, which may last from a few weeks or months to sixty 
years or more. In this long period of latency, in which the patient is 
seldom reminded of the existence of his infection, appear the so-called 
recurrences which make him a danger to his fellows. From time to time, 
perhaps, from some focus or hiding place in the body, it would seem as if 
fresh showers of germs may be discharged into the blood. When these 
affect the constitutional condition the patient may note a loss in weight 
and feel under the weather, have some aches and pains, and recover. 
Sometimes minor eruptions appear on the skin, usually inconspicuous and 
not noticed by the patient, but highly significant to the experienced 
physician. 
Contagious Recurrences and Inefficient Treatment.—When recurrences 
affect the mucous membranes and the genital tract they have the most 
alarming meaning for the public at large. They usually take the. form 
of mucous patches and condylomas, and are generally either not noticed 
by the patient or are misinterpreted as cold sores, piles, canker sores, 
smoker’s patches, etc. They siwarm with the germs of syphilis, and 
because unsuspected, are doubly effective in transmitting the disease to 
others. Often in the stage of recurrence, sores which are not essentially 
syphilitic will contain the germs of the disease, especially ordinary cold 
sores (herpes) about the lips and genitals. It is not difficult to grasp the 
fact that a patient who thinks himself well, or does not know that he had 
the disease, when armed with an equipment of mucous membrane recur- 
rences of whose presence he is not aware, is an unconscious engine of 
destruction scarcely inferior to a baby handling dynamite. Many an 
infection in and out of marriage and in the ordinary course of life owe? 
itself to these fleeting recurrences in syphilitics who, either in the natural 
51807—5 
65 66 
course of events or after a little treatment, recovered from their outspoken 
secondary manifestations. They are the Nemesis for the world at large, 
of inadequate treatment. Treatment enough to clear up a secondary 
eruption is not sufficient to prevent recurrences.. In fact it is in precisely 
these cases that the recurrence is the greatest menace, since it catches 
patient and doctor off his guard. I have known patients, giving a frank 
history of syphilis and of a fair amount of modern treatment but not 
enough to be examined at the hands of unusually competent general 
diagnosticians and with normal or negative blood tests be passed as all 
right. Within twenty-four hours after, I have found the Spirochseta 
pallida in a mucous patch on the tonsil, which had appeared literally over 
night. The patient, absolutely unaware of its presence and secure in the 
assurances of his physician of the day before to the effect that he was well, 
could scarcely be persuaded that he was not the victim of a hoax. 
Silent or Latent Syphilis and Late Complications.—If one adds to the 
obscure and frequently overworked early signs of syphilis a latent period 
covering from ten to twenty years in which absolutely nothing may warn 
the patient of the fate that awaits him, it is easy to understand the almost 
mind-destroying shock which temporarily wrecks the courage and morale 
of those who in the prime of life, have to be told that the trouble with the 
stomach, or the pain in the chest, or the dimming eyesight and unsteady 
feet means the syphilis of their youth. 
“Why, man, it can’t be—I never had a thing the matter with me in 
my life—never had a sore or breaking out, never even had a dose of “ clap.” 
Why I haven’t had to call a doctor for twenty years, until this came on. 
It just can’t be.” 
“You took your chances with the rest when you were a young fellow, 
didn’t you, old man?” 
“Yes, I suppose I did, but I’ve never been outside the family, since I 
married, doctor; always prided myself on being clean, and yet you can tell 
me this.” 
“It was somewhere along in there before you married, old man, even 
if you didn’t know it. Better bring the wife and kiddies up to see me, too. 
Let’s see, she had two miscarriages, didn’t she?” 
And so the whole wretched story comes out in dialogue, each a varia- 
tion upon the great central theme of the latent period of syphilis. 
Late Syphilis—Premature Old Age and Gummatous Change.—Two 
changes characterize the activities of late syphilis in the body. One of 
these is the induction of premature old age, so to speak, by the slow con- 
version of active tissue into thickened, hardened, fibrous scar. The other 
is the process known as gummatous infiltration, which consists in the re- 
placement of normal structure by a kind of tumour-like growth of shoddy 
tissue, which, being of low vitality, breaks down or ulcerates, leaving a 
hole to be filled in its turn also, by a scar. The aging effects of syphilis are 
most apparent in the blood vessels and in structures like the heart, in 
which long-standing slight inflammation produces a hardening, and loss of 
elasticity, a toughening and thickening that finally impairs their power to 
do their work. Premature old age of the arteries, early arteriosclerosis, is 
common, and quite often, though not always, due to syphilis. Gummatous 67 
changes may affect almost any structure of the body. Since the destruction 
done by gumma formation is permanent and the tissue lost can only be re- 
placed by scar, it is a matter of the utmost import where the gummatous 
change occurs. Gummas of the skin and bones, especially about the face, 
are hideous and disfiguring, but the loss of a feature or two, the caving in 
of a nose or a hole in the roof of the mouth, is really a cheap escape in late 
syphilis. The damage to the goods in this case involves the package only, 
so to speak. But gummatous replacement of parts of important organs 
such as the liver or the walls of blood vessels, large and small; of the tissues 
of the nervous system which never regenerate once they die, strikes at es- 
sentials. As an illustration of the often unsuspected effects of such changes 
a weak spot in the wall of the lenticulostriate artery, a minute blood-vessel 
in the brain, so often involved in late syphilis, spells early apoplexy for the 
one whose disease takes this form. As one passes through the wards and 
rooms of great hospitals one meets in tragic succession the man whose 
wheezing breath and swollen limbs and pounding heart betray the work 
of the Spirochseta pallida upon the valves of the heart, and at the base and 
in the walls of the aorta, the great artery that carries the blood to the body; 
the man whose yellow weazened pallor, bony chest, and enormous swollen 
abdomen spells late syphilis of the liver; the fine young fellow with the dark 
expressive but sightless eyes who has gone the way of “primary optic atro- 
phy.” That thin broken woman and those forlorn weeping children bowed 
beside the unconscious father whose loud puffing breathing can be heard all 
along the corridor, are brought to that death-bed by the work of late syphilis 
upon the kidney—“chronic Bright’s disease” in one of its many forms. The 
man whose feet flop wildly as he claws the arms of his wheel-chair at your 
command to rise—the wobbling, doddering fellow yonder, whose foolish 
fatuous smile and trembling flabby lips and food-stained waistcoat marie 
him as having softening of the brain, are part of the picture of late syphilis 
at headquarters, among the intricate mechanisms of the nervous system. 
The Hopeful Side of Late Syphilis.—No picture of late syphilis is a 
just one, however, which does not end in reassurance. Some unaccountable 
peculiarity of the germ or of the personal resistance of the patient intervenes 
to save many patients with syphilis from the most distressing complica- 
tions of the disease. Syphilis is equally adept in the role of the lion and of 
the lamb. On the one hand a gummatous tumour of the brain may carry 
off a young fellow within a year of his primary lesion—on the other hand 
an aged veteran of the Civil War, may after a latent period of more than 
sixty years, show a trivial little crusted sore or a few small lumps in the 
skin as the sole remaining evidence of an infection that he never knew he 
had had, and which never was treated. It is impossible in the present state 
of knowledge to estimate the percentage of persons who having acquired 
the disease, later suffer from serious late accidents. All that can safely 
be said is that as our means of detecting syphilis in the blood, and in the 
tissues and organs both during life and after death become more accurate, 
our conception of the really tremendous role of this disease in human dis- 
ability and physical deterioration grows. One thing is certain: if only 
50 per cent of the patients who contract syphilis, die, or are crippled with 
its late complications, it ranks easily as one of the most formidable of foes 
51807—51 68 
—an enemy that no thinking human being would invite within his camp 
on the chance that lion might prove lamb. 
Late Syphilis of the Nervous System—Locomotor Ataxia and General 
Paralysis.—The prevalence of locomotor ataxia and of general paralysis of 
the insane needs a special word. Locomotor ataxia is a form of creeping 
paralysis of the spinal cord which affects the limbs and the nerves to the 
bladder usually first, but also involves the eyes, and the nerve supply to 
other structures, including the stomach. General paralysis of the insane or 
softening of the brain is a progressive and invariably fatal form of mental 
and physical degeneration which converts the victim from a normal indi- 
vidual into an imbecile and a skeleton before his death. These two diseases 
constitute to the partly informed public and to victims of syphilis, the over- 
whelming horror of their outlook. The belief that all syphilitics are doomed 
creatures, certain to lose the use of their limbs or their mental faculties is, 
however, wholly wrong. It is not at all improbable that as high as 10 or 
15 per cent of syphilitics show changes in the nervous system which are due 
to the disease, but in many cases these changes do not progress, and may 
even fail to attract attention. Estimates of the prevalence of these two 
diseases vary from 1 to 6 per cent of the total number who acquire syphilis, 
figures which make it evident they are by no means the inevitable termina- 
tion of a syphilitic infection. Persons with syphilis are predisposed to 
these complications by bad habits of living as well as peculiarities in the 
germ and the resistance of the patient, so that much can be done by the 
syphilitic himself to escape the fate they bear. 
Late Syphilis is Preventable and Treatable.—Another word of reassur- 
ance must accompany any discussion of late syphilis. It is both prevent- 
able, and treatable. While both these points will be better understood after 
the discussion of treatment in general, it may be emphasized here, that 
adequate, skilled modern treatment can reduce the danger of developing the 
late complications of the disease, almost to the vanishing point. In fact, 
the mortality of only moderately well treated syphilis is much lower than 
that of most serious diseases. The ability of good treatment in the latent 
period, largely to forestall the real terrors of the disease, even in cases which 
have been recognized comparatively late, offers abundant hope to the victims 
in this generation. Even in still later cases which show the unmistakable 
signs of serious changes in important organs and in the nervous system, a 
prompt resort to systematic measures may repair a good deal of damage and 
fight off the enemy for an average lifetime. But even while we recall the 
hope for the victims let us never forget that the real strategy in our battle 
with syphilis must be that of prevention, and that the abortive cure, and 
early systematic treatment have a worth that no amount of scientific patch- 
ing and repair work can ever claim. The treatment of the chancre in the 
first few days of its existence is the treatment of meningo-encephalitis and 
tabes dorsalis, of cirrhosis of the liver, of syphilitic myocarditis and coron- 
ary sclerosis, of aortitis and aneurism, of primary optic atrophy and 
internal ear deafness and all that roll call of strange names which blaze the 
path of syphilis across the field of medicine. CHAPTER IV. 
Modern Tests for the Recognition of Syphilis. 
Laboratory Tests vs. Medical Examination in Syphilology.—In a broad 
way it may be said that the criterion which distinguishes the medicine of 
the past from that of the present, is the dominance of the laboratory in 
the modern recognition and treatment of disease. In no field has this 
revolutionary power done its work more thoroughly or to greater advan- 
tage than in the field of syphilis. Fifteen years have seen the entire situa- 
tion with respect to the disease transformed almost beyond recognition 
as compared with a generation ago. In this transition four landmarks 
stand out conspicuously as mileposts in the general advance. 
The first was reached when Wassermann, Neisser and Bruck announced 
in 1904 the successful application to the diagnosis of syphilis, of a test 
made upon the blood of the patient. This test is based upon the work of 
two French investigators, Bordet and Gengou, and has wide applicability 
outside of the immediate field of syphilis, although in no disease has its 
service been more gratifying or more spectacular. The blood test for 
syphilis is now quite generally known as the Wassermann test. The second 
landmark of progress, in chronological order, is the discovery of the germ 
causing the disease, by Schaudinn and Hoffmann in 1905. The tremendous 
significance of this discovery for the recognition of syphilis in the earliest 
days of its onset, when radical and complete cure is possible, cannot be 
overestimated. The method of its application in the use of the darkfield 
microscope has already been discussed. It has a third field of usefulness 
which bids fair to grow into greater prominence with time—the identifi- 
cation of the germ in the tissues of the body after death. This will serve 
as the ultimate check upon our conceptions of the curability and the real 
prevalence of the disease. In fact, it is the identification of the Spirochseta 
pallida in the tissues of the brains and spinal cords of patients dying of 
general paralysis and locomotor ataxia, by Noguchi and Moore in 1913, 
that first proved beyond reasonable doubt, the syphilitic nature of these 
complications. From the first landmark, the Wassermann test, as applied 
to the study of the nervous system, has arisen a third valuable diagnostic 
aid, the study of the spinal fluid in syphilis as a means of recognizing early 
invasion of the nervous system by the germ. The fourth contribution to 
modern warfare against the disease based on the discovery of the germ, 
is the development of the drug known as “ 606,” dimethyl-diamino-arseno- 
benzol-dihydrochloride, which is a vital part of our modern programme for 
the control of infection and the early cure of the disease. 
The Wassermann Blood. Test for Syphilis.—The Wassermann blood test 
for syphilis is based upon the general observation that when the body is 
invaded by certain germs, it develops a defensive mechanism which takes 
the form of the appearance in the blood of substances that poison or cripple 
the invaders, or in some less definite way, make conditions unfavourable 
for them. In the case of certain diseases, the relation between the invading 
69 70 
germ, such as the diphtheria bacillus, and the substance produced by the 
body for defensive purposes, is obvious and direct. The antitoxin of diph- 
theria combines with and destroys the poison of the diphtheria germ, as 
one chemical combines with another, to neutralize it. On the other hand, 
in certain other germ diseases the body’s method of attack is less obvious 
and simple. The finding in the blood of substances known to bear a fixed 
relation to the presence of certain disease germs in the body serves as a 
means of identifying the disease in a particularly doubtful case. An 
analogy to the employment of blood tests in the detection of disease might 
be found by picturing the physician in the situation of a deaf, dumb and 
blind man wandering across a field of battle. Knowing that mustard gas 
is used in modern warfare, he would, upon getting a whiff of it, infer that 
he was near or upon the scene of a battle. It is, of course, possible, how- 
ever, that he might instead be near the laboratory of a chemical works 
where the gas was being made. When he identifies the gas by his sense of 
smell, he must go through a course of reasoning, brief though it may be, 
in which he will estimate the chance of being misled by the fact that the 
gas may be in a laboratory and not on the field of battle. Being deaf, he 
cannot hear, but he may feel the ground heave beneath his feet, and feel 
the air tremble with the detonations of guns. Correlating these additional 
impressions he will further be convinced that he is not in a laboratory, 
but at the scene of a gas attack on the field of battle. Precisely such a 
complex chain of reasoning applies to the recognition of a disease by a 
blood test. The spirochaete of syphilis, under certain conditions in the 
animal body, produces changes which manifest themselves by the presence 
of certain substances in the blood. These substances are not antitoxins or 
chemicals which react directly with the germ. They may even be the pro- 
ducts discharged into the blood by the death of the germs in their fight 
with the body. But under certain conditions, which constitute the limita- 
tions of accuracy of the test, the presence of these substances shows the 
germs of syphilis to be present. Precisely as in the case of the man who 
smells mustard gas, it is necessary for us after proving their presence to 
reason whether or not some factor may not be obscuring the test by con- 
cealing the expected substance when it should be there, or to decide whether 
it is not there for some other reason than because syphilis is present. Both 
these factors enter into the accuracy of the blood test for syphilis, and into 
the interpretation of the information which it gives us. In other words, 
the finding of syphilitic substances in the blood of a person is simply one 
factor in the chain of reasoning which must be carried through in every 
case before we can say positively that the presence of those substances 
means the person has syphilis. Under these circumstances it is apparent 
that the test falls far short of infallibility, and that a blunder in the 
reasoning of the doctor who interprets it, or a gap in his experience is 
quite as important in making the test worthless as is an actual error in its 
performance. 
Personal Equation and Interpretation in the Wassermann Test.—The 
mechanism of the Wassermann test is too complex for the comprehension 
of the average layman without an amount of detailed discussion that would 
be out of place here. It may be said of it in general, and in fact of every 
complement fixation reaction as this type of test is called, whether in 71 
syphilis, gonorrhoea, tuberculosis or elsewhere, that its accuracy depends 
upon the technical skill, experience, and judgment of the one who per- 
forms it. Wassermann tests are constantly being performed which are 
valueless and the destinies of human beings are being decided on laboratory 
evidence which is not worth the paper on which the report is written. On 
the other hand, the Wassermann test, performed by an expert of large 
experience and high standing, and interpreted to the patient by a physician 
who knows syphilis, is one of the most valuable tests in medicine, and has 
a margin of error that is very small. Between these two extremes, one 
finds in actual practice every conceivable grade of understanding and mis- 
understanding, of efficiency and worthlessness. 
The Positive Wassermann Test.—When the Wassermann test on the 
blood shows the presence of the disease, it is spoken of as positive, usually 
strongly positive. When it does not show the presence of the disease, it is 
spoken of as negative. “ Doubtful ” usually means a test of no value either 
way. Certain well-defined limits are set upon the value of the Wassermann 
test in the recognition of the presence of syphilis. First of all, the test 
may be positive, but is rarely so, in other diseases in temperate climates. 
In the tropics a rather common disease called “ yaws ” gives a positive 
Wassermann test. The margin of error on the positive side is small—in 
other words, a competently performed Wassermann test in the temperate 
zone, if positive, means syphilis in 95 to 98 per cent of cases. On the other 
hand, the situation is radically different with the negative test. 
The Negative Wassermann Test.—A negative Wassermann test even 
when technically correct does not prove the absence of syphilis. A 
negative test while rare in secondary syphilis occurs naturally in as high 
as 35 per cent of syphilitics in the later stages of the disease, and in all 
syphilitics during the first few days of the primary sore, at which time the 
precious hope for radical or abortive cure exists. Therefore a doctor who 
depends on the Wassermann test to tell him when he is dealing with 
syphilis, will miss all of his cases at the time when the prospect of curing 
them is at its best, and will miss a liberal percentage of them late in the 
disease when it is vitally important they be recognized before the damage 
has gone too far for recovery. 
Effect of Treatment on the Blood Test—Treatment for syphilis has 
the power to make a positive Wassermann test negative. The amount of 
treatment needed to make a positive test negative may be much, or 
exceedingly little. Unless treatment in a patient with syphilis has been 
carried to the point which experience has shown us is necessary for arrest 
or cure, the test may not remain negative. It may become positive again 
within a few weeks or months after treatment is stopped. Even if it does 
remain negative the disease may go on working just the same. A Wasser- 
mann test may be negative on the blood for years, and the patient die of 
syphilitic heart disease or of changes in his nervous system. A Wasser- 
mann may become negative on the blood for a few months after insufficient 
treatment, and the patient then marry, only to infect his wife while his own 
blood still remains negative. The germs of syphilis can be taken from a 72 
mucous patch on the lip of a patient while his blood test is negative. They 
can even be grown from his blood while his blood shows no signs of 
syphilis that a Wassermann test will detect. When all this unescapable 
evidence of the shortcomings of the negative Wassermann test is taken into 
account, one may well ask, of what use is it anyhow. In reply to this 
question, only one thing can be said. One negative or two negative Wasser- 
mann blood tests mean nothing at all. In the presence of a reason for 
suspecting the disease, only a series of negative tests can mean anything as 
a proof of its absence. In a patient treated for syphilis, the series of 
negative tests must extend consistently over months and years, and even 
then it is not trustworthy unless the most searching examination of every 
accessible structure of the body shows that the disease is not in hiding. 
The Wassermann blood test for syphilis has no infallibilities. It is merely 
a part of a chain of reasoning, and its value is dependent not only upon the 
skill of the performer, but upon that of the reasoner. 
The General Medical Examination Essential.—With this proviso, the 
sypnilis of the examining room again claims its place, so long threatened 
by the syphilis of the laboratory. An opinion as to whether or not a 
person has syphilis, or having had it, has recovered, cannot be based upon 
a blood lest. It depends in the last analysis upon what the physician who 
renders the opinion, knows about every aspect of syphilis. So few and far 
between are the men who know the ramifications and intricacies of the 
disease, that critical judgments can best be rendered by a group of 
physicians, perhaps under the leadership of one who has made the disease 
a special and lifelong study. In other words, the eye specialist and the 
ear specialist, the expert on diseases of the nervous system and the clinician 
who knows the heart, the specialist on the diseases of the bones, the expert 
on the skin, each may have his place beside the laboratory man with his 
dark field and Wassermann test. No one of them can, without presumption, 
claim that his assertion that there is no sign of syphilis in the particular 
part of the body which he knows, proves there is none elsewhere in the 
system. To laboratory methods we must concede almost unqualified title 
to first place in the recognition of syphilis by the finding of the germ in 
the chancre, in recurrent sores on mouth and genitals, and in the confirma- 
tion of the presence of syphilis in the secondary stage, when the Wasser- 
mann test well performed is positive in practically one hundred per cent of 
cases. To clinical facts as ascertained by a careful general physical exami- 
nation we must, however, as the last resort look for final judgment where 
the laboratory tests are disappointing or inconsistent. 
Spinal Fluid Tests.—The examination of the spinal fluid by the aid 
of the Wassermann test has developed rapidly in importance in recent 
years. The spinal fluid is a watery clear liquid that surrounds and 
supports the brain and spinal cord inside the skull and spinal column, 
acting as a sort of water cushion to protect them against shock. This 
fluid, in syphilitic disease of the nervous system, undergoes changes which 
prove the presence and help to identify the seriousness and extent of the 
damage done by the disease in the tissues of the nervous system, even when 
all other signs fail or leave one puzzled as to what is going on. The 
testing of the spinal fluid is often a necessary adjunct to the blood test in 73 
settling the question of the presence or absence, or the cure of syphilis, and 
as such it will attain to constantly greater usefulness. 
Both the Wassermann blood test and the examination of the spinal 
fluid are at their best when performed by hospitals and by groups of 
specialists who have the means at hand to make them properly and interpret 
them correctly to the patient. The drawing of blood for the Wassermann 
test is a trifling matter, and can be done by almost anyone. The popularity 
of the test has made many physicians uncritical in regard to it, and has 
encouraged the growth of laboratories whose tests have all the faults and 
inaccuracies which the peculiarities of the Wassermann reaction make 
possible. Until the situation is finally standardized, perhaps by Govern- 
ment control, the Wassermann test will be abused and misinterpreted. The 
soundest advice that in the present state of knowledge can be given one 
who has reason to ask himself if he has syphilis, is “ to seek expert medical 
advice,” rather than “to have a Wassermann taken.” CHAPTER V. 
Hereditary Syphilis. 
Effect of Syphilis on the Race.—We must now take up an aspect of 
syphilis which makes it all but unique among diseases, namely, its trans- 
mission to the second generation. Gonorrhoea affects the future of the race 
by making men and women childless. Syphilis affects the race by destroying 
outright 75 per cent of the children of syphilitic parents before they are 
born or during the first year of life, and by crippling or weakening a con- 
siderable proportion of those who survive. Gonorrhoea as such is not trans- 
missable to the child before birth. On the other hand, syphilis is more often 
transmitted in this way than otherwise, and when so transmitted is not mere 
constitutional inferiority, but syphilis, as definite and actual as if acquired 
with a chancre and secondary period during later life. 
The Syphilitic Mother.—A very large body of evidence, much of which 
has come into existence since the Wassermann test was devised, has shown 
that in the great majority of cases, syphilis is transmitted to the child by 
its mother, rather than by its father. This means that the role of the 
father, if he be responsible, is in the infection of the mother. It is only 
fair to say that this question of paternal transmission is not wholly settled, 
and that there are able men who believe that the father can be responsible 
for the infection of the unborn child without infecting the mother. It is, 
however, the general opinion that a child syphilitic at birth, means a mother 
with syphilis, whether or not she shows outward signs. In fact, the mother 
sometimes shows no signs of the disease to either examination or blood test, 
a condition theoretically explained by her having developed a form 
of immunity through carrying the child. The presumption, however, is 
that she has the disease and should therefore be treated for it. 
Mode of Infection of the Child.—Children may acquire syphilis before 
birth, through the transfer of the germs from the body of the mother to the 
blood of the child, through the placenta, the structure which connects the 
child with the wall of the womb. If the child acquires syphilis through 
the mother’s blood within the first three months after conception it is 
almost certain to die and the body be expelled, constituting an abortion or 
miscarriage. If it acquires syphilis from the third to the seventh month, 
it may survive for a time, but is likely to be born prematurely and very 
probably dead. If it is not infected until after the seventh month of pren- 
atal life, it will probably be born alive, although it may die later of the 
disease. The time after conception that a child in the womb is likely to 
be infected varies to a certain extent with the activity and age of the 
mother’s infection. If she has been recently infected, and there are still many 
germs in her body and frequent showers of them circulating in her blood, 
the child has almost no chance of escape. The result is miscarriage or 
abortion, repeated again and again whenever the woman becomes pregnant. 
Some of these abortions occur so early that the woman may think she is 
74 75 
simply suffering from irregular menstruation. As the mother’s infection 
becomes older and less virulent, the child is not infected until later in the 
pregnancy, or may even escape altogether. It may die if infected, resulting 
in a still birth, or it may live and show its first signs in the first few months 
after birth. Again, it may live, seem in fair health, and show no signs of 
the disease until it is from five to ten years old. A few cases do not show 
any signs until much later, even as old as twenty-five years. 
Treating the Mother May Protect the Unhorn Child.—No fixed rule 
applies to the birth of syphilitic children from a mother who has the disease, 
although usually a series of abortions is followed by a still birth or two and 
finally bv living but syphilitic children, as the activity of the mother’s 
infection subsides. A syphilitic mother whose disease has been temporarily 
reduced to inactivity by treatment in the later stages may give birth to an 
entirely healthy child, and women who still have active syphilis may 
occasionally have children who escape. Even a woman who is in the 
secondary stage of syphilis, whose pregnancy is recognized in time may 
apparently give birth to a healthy child if she is intelligently and 
systematically treated for syphilis herself all during the period she is 
carrying the child. Once again, a woman who acquires syphilis just before 
the child is to be born, and who has a chancre or mucuous patches on the 
neck of the womb or in the vaginal birth canal, may give birth to a healthy 
child whom she infects as she brings it into the world. This variety of 
syphilis in children is comparable to birth infection with gonorrhoea and is 
true congenital as distinguished from uterine syphilis. It runs the same 
course as the adult form, with a chancre, often on the navel, and a 
secondary eruption as in the acquired case. 
Effect of Inherited Syphilis on the Child.—Uterine syphilis in the 
child gives rise to changes in its body which are more profound than those 
which occur from the acquired form. The child being literally filled with 
the germs as it is coming into being, is distorted to some extent by the 
disease. Changes in the bones, in the teeth, and in the internal organs 
occur which have much in common with late syphilis. But if the child 
does not die outright before or within a year or two after birth, the inti- 
mate association of its body cells with the germs gives them, paradoxically, 
an advantage. Such children must have a high resistance or they would 
die. For this reason, children with uterine syphilis after the first high 
mortality, have an excellent fighting chance, which if reinforced hy intelli- 
gent treatment, may permit them to develop into practically normal men 
and women. 
Symptoms of Syphilis in the New-Born.—Children with syphilis who 
are born alive, sometimes seem outwardly normal at birth. Quite a 
number of them die, however, soon after birth from convulsions and other 
internal ailments. As a rule, however, the syphilitic child presents at 
birth a striking example of the power of the germ of syphilis to age the 
human body. The child looks weazened, withered, so to speak, at the root. 
The face suggests a little old man, the child is under size, and within a few 
days or weeks of birth begins to show outspoken signs of the disease in the 
form of “ snuffles ” or running nose, often taken for a cold, and changes in 76 
vocal mechanism which convert the normal cry into a squawk. Skin 
eruptions, especially large blisters, mucous patches, and large sores may 
appear, and unless treated, the child rapidly declines. Extraordinary 
variations in the picture presented by syphilis in the child may occur. Not 
every child with a skin rash and a feeble cry is syphilitic. On the other 
hand, it is a wise caution that sends the mother or the woman in charge of 
sickly children to the doctor when something abnormal develops, and it is 
a wiser caution that keeps healthy women from meddling with others’ sick 
children until they are properly advised by a competent physician. A 
caution may well be given here also with reference to the wet nurse, who 
should never take up the care of a child except under the direction of an 
expert physician who can protect her from the risk of nursing a syphilitic 
baby who will promptly transmit the disease to her. Vice versa there is 
no better way to infect a well baby than to give it to a syphilitic woman to 
nurse. Fortunately the best modern technic, which simply draws the 
woman’s milk and feeds it to the baby after proper sterilization will reduce 
the risk of such transmission of the disease. There is no better evidence 
that the mother of a syphilitic child has syphilis, than the fact that she 
cannot acquire it from her own nursing baby even though the baby has a 
mouth full of mucous patches. 
Late Effects of Inherited Syphilis; Imbecility, Eye and Ear Trouble.— 
Uterine syphilis in older children may repeat the course of syphilis acquired 
in adult life, even to the development of juvenile locomotor ataxia and 
general paresis. On the other hand, it has some distinctive features. About 
five per cent of children who are idiotic are so because of syphilis. Many 
syphilitic children show distinctive changes in the teeth and certain bones, 
which can be recognized even though the Wassermann test may be and 
frequently is negative. While the large majority of syphilitic children are 
below par physically, it often seems as if they had a precocious mental 
development not unlike that seen with rickets, which makes them by no 
means degenerates, but valuable assets in human life once their infection 
is brought under control by treatment. Heredo-syphilitic children are 
subject to a peculiar type of eye trouble, called interstitial keratitis, which 
clouds the cornea or glassy part of the eye so that not over 60 per cent 
of the cases which have it recover with vision unimpaired. Many of these 
children lose their ability to earn a living and become burdens upon the 
family, the community and the state. A few children are made totally 
blind by syphilitic changes in the nerve of sight. A similar but much com- 
moner type of change occurs in the nerve of hearing, resulting in total and 
irremediable deafness. In the infant it is recognized by the child’s failure 
to learn to speak, and if it develops before the tenth year the child i9 likely 
to become dumb, either because it does not learn or forgets how to talk. The 
inmates of deaf and dumb asylums and schools present in all probability a 
high proportion of heredo-syphili tics, although just what proportion is not 
known. 
Hereditary Syphilis and the Third Generation.—One or two additional 
points deserve mention. Hereditary syphilis in the strict sense is probably 
not transmitted to offspring—that is the children of hereditary syphilitics 
do not have abortions and give birth to syphilitics as do their parents. On 77 
the other hand, there is room for disagreement on this point, and able men 
again believe that the germ may be handed on for more than two genera- 
tions. It is generally conceded that a tendency to constitutional inferiority 
appears in the children of parents who have severe forms of hereditary 
syphilis. Those who have hereditary syphilis in mild form, however, may 
if efficiently treated, give birth to healthy children. 
Public Responsibility in Hereditary Syphilis.—'Syphilis in adopted or 
orphaned children should be much more a matter of concern on the part of 
the state than it is. Careful Wassermann tests on mother, father and 
child should be available in every baby offered for adoption, and the risk 
of a concealed infection will be diminished if, where there is doubt, 
adoption is deferred until after the second year. Children who prove 
early or later in their lives, to have the disease, should not be offered for 
adoption, but should be cared for and treated by the state. The con- 
tagiousness of hereditary syphilis and its treatment will be discussed in 
connection with these aspects of the disease as a whole. CHAPTER VI. 
The Treatment of Syphilis. 
From the standpoint of treatment, as in other ways that have been 
mentioned, syphilis occupies a distinctive place in the hierarchy of disease. 
In the domain of general medicine there is a small group of ailments whose 
successful treatment presents the dramatic and spectacular quality that 
makes surgery, for instance, so attractive to the majority of physicians. 
Malaria is the oldest member of this group. The control of malaria by 
quinine is a medical miracle which never loses its power to astonish 
because it is so familiar. In the same way, the control of syphilis by the 
drugs both ancient and modern which are used against it, contains all the 
dramatic elements that add zest to the work of him who treats it and give 
hope to those who look for its ultimate extermination. The treatment of 
syphilis has what the treatment of gonorrhoea lacks, weapons whose efficiency 
stands all but unrivalled in the practice of the healing art. 
The Treatment of Syphilis with Mercury.—Mercury throughout the 
five centuries intervening since the wholesale spread of syphilis over the 
world has sustained much the same relation to the disease that quinine has 
to malaria. The ability of this drug to cause the outward signs of the 
disease to vanish was early recognized; and its wholesale and over- 
enthusiastic use for a time threatened to retire it to obscurity rather than 
to develop its effectiveness. Mercury is a poison, and gives rise to 
symptoms at times only less serious than the disease itself. In fact it 
acts only by being more poisonous for the germs than for the tissues of the 
body itself. For that reason its proper use was only slowly developed, and 
its limitations are set, not so much by the fact that more would not kill 
spirochaetes more effectively, but that more might kill the patient. While 
the action of the drug in the body is usually thought of as directly upon 
the germs, it seems very probable that while this element is of course 
important, mercury is even more effective in stimulating the body to make 
its own fight. For that reason it occupies a unique and indispensable 
place in the management of the disease. 
Mercury is given in syphilis in a variety of ways. In all cases it is 
the metal itself, or its salts that is used. Mercury taken by mouth as pills 
or solutions of its salts attained intense popularity among the French school 
of syphilologists, but has now been shown to be good enough for glossing 
over external signs, but of little real effect in bringing about a cure. 
Especially in the early stages of the disease, when we stake everything upon 
the hope of early and complete results, mercury by mouth is an anachronism 
and a snare. It has had a most unfortunate popularity among the past 
generation of physicians, and many a man who develops serious signs of 
late syphilis in later life owes his plight to his doctor’s prescription of 
mercurial pills in the days of his chancre. Pills have their place, un- 
doubtedly, but their field of effective action is very limited. Mercury is 
78 79 
also given by injection of various salts under the skin or into the muscles 
at various intervals, from which tissues the drug is absorbed into the 
blood. This form of treatment, often spoken of as German, has many 
advantages, and in the hands of the expert has a high degree of efficiency. 
Mercury is also given by incorporating the metal with a grease or salve 
and rubbing it into the skin from which it is absorbed in part directly and 
in part through the lungs from evaporation and inhalation. This method 
known as the inunction, is in the opinion of many syphilographers the 
method par excellence for administering mercury in the treatment of 
syphilis. It has the disadvantage of seeming dirty and smudgy and thus 
offensive to particular patents. But for the certainty of its action, and its 
ability to combine high doses with minimum ill effects, it stands un- 
rivalled, and only fails to attain its highest usefulness through objections 
based on trivial annoyances rather than on the actual best interests of the 
patient. 
Mercury Does Not Control Contagiousness.—The technic of the treat- 
ment of syphilis with mercury, the times and ways and reasons for its em- 
ployment cannot be discussed here. Its intelligent use is perhaps even 
more than in the case of quinine in malaria, an art in which a true expert- 
ness may be developed. The last five years of the practice of syphilology 
have only served to raise mercury in the estimation of discriminating ob- 
servers. Monumental though the progress made possible by Ehrlich’s dis- 
covery of salvarsan (“606”) has been, the new drug has not displaced its 
older brother as an esential in the cure of syphilis. The one great defect 
of mercury from the standpoint of the public health is its inability to con- 
trol contagiousness. A patient receiving it by the most vigorous methods 
known may none the less in the early, contagious stages of the disease 
develop recurrent sores in the mouth and elsewhere, which make him a 
danger to others. It is precisely this lack in the older methods of treating 
syphilis, which “606” supplies, and it is this combination of qualities 
obtained by the use of both drugs which justifies the statement that 
no man to-day treats syphilis effectively who does not use both “606” and 
mercury. 
The Discovery of Arsphenamine—Ehrlich’s “ 606.”—The story of the 
discovery of arsphenamine (salvarsan) as it is now called in the United 
States, is a chapter in the romance of scientific discovery of which only 
a glimpse is possible here. Arsphenamine is the American technical name 
for the substance known as Ehrlich’s “606” which was later patented in 
Europe and the United States under the name of salvarsan. Arsphenamine 
is a compound of arsenic with substances derived from benzol, the chemical 
agent which forms the basis of modern organic chemistry. It is to all 
intents and purposes a dye. Certain dyes are poisonous. The action of 
arsphenamine upon the germs of syphilis is based upon Ehrlich’s realiza- 
tion that if a poisonous dye or stain could be found which would pick out 
and attach itself to the spirochsete of syphilis and poison iit without doing 
the same thing for the cells of the human body, a means might be found to 
kill the germ directly in the tissues and the blood. This selective affinity 
of dyes for certain tissues or for certain germs is, of course, familiar in 
medicine, but Ehrlich’s application of it to the problem of syphilis was 80 
unique and was said to have been inspired by the effect of trypan red, a 
special dye, upon germs related in some respects to those of syphilis. After 
prolonged experimentation, Ehrlich and his Japanese collaborator, Hata, 
with the co-operation of the chemist Bertheim, succeeded after 606 attempts 
(hence the name “606”) in producing the substance dimethyl-diamino- 
arsenobenzol-dihydrochloride, which was found by animal experiment to be 
able to pick out and kill the spirochsete of syphilis in the blood and tissues 
without appreciably injuring the infected animal. It is not too much to say, 
incidentally, that had the germ of the disease not been discovered by Schau- 
dinn and Hoffmann, and the transmissibility of the disease to animals de- 
monstrated by Metchinkoff and Roux, the work of Ehrlich would probabl.y 
have been neither inspired nor carried out. Nothing better illustrates the 
cosmopolitan status of scientific progress or the interdependence of scientific 
men upon one another, regardless of race or nationality, than the modern 
advances in the knowledge of syphilis. Nor is it possible to conceive a better 
justification of experimental work on animals than that afforded by the 
results and the combined efforts of these scientists. 
The Commercial Status of Arsphenamine.—After a long series of care- 
ful experiments to determine its efficiency and freedom from danger, 
Ehrlich finally announced the discovery of “606” to the world in December, 
1910, and turned the formula over to a German firm for the manufacture 
and marketing of the drug on a commercial scale. In accordance with the 
accepted custom in Germany, the drug and every detail of its manufacture 
were carefully protected by patents in all countries. The tragic but little 
appreciated result was that long after the legitimate claims of the inventor 
had been satisfied, and in this particular Ehrlich was most unselfish, this 
drug, so precious a necessity to the world, remained a private monopoly, 
exploited at a price that placed it out of the reach of the poor except as 
charity made provision for it, and restricted in its usefulness by merely 
dollar considerations. It required the commanding necessities of the war 
to bring these facts to light, and to open the way for competition to increase 
its accessibility. In practically all important countries, the drug is now 
being manufactured under government license and a variety of names. In 
the United States the short-sighted stringency of the patents for a time 
prevented the open manufacture of the drug after the English blockade cut 
off German exports. The monopoly and the high prices continued and 
there was a prolonged period when the medical profession and the sick of 
this country were virtually deprived of what should under a more enlight- 
ened public policy have been cheap and abundant. The drug was even for 
a time imported from Germany by submarine in the effort to maintain 
control of the parents. Finally, after the declaration of war with Germany, 
action became imperative. The Adamson Act was then passed, providing 
incidentally for the manufacture of arsphenamine by American firms of 
demonstrated competence, under federal license. This has placed the United 
States for the time being on the same basis as European nations. The 
tremendous profits reaped by the German monopoly are apparent from the 
fact that the price promptly fell from $4.50 to $1.25 per dose. The restora- 
tion of ante-bellum prices for raw materials could greatly reduce even this 
figure. It must not be forgotten that the present satisfactory situation is 
for the duration of the war only, and that public opinion back of a fund- 81 
amental revision of our patent laws is necessary to make the change per- 
manent. It is not too soon to begin to impress upon American legislators 
in unmistakable fashion, that ideas and substances capable of altering the 
history of the race through their influence on public health and welfare, 
cannot remain private monopolies and reap exorbitant profits for owners 
and exploiters after the reasonable claims of the inventor are satisfied. 
The Fallacy of the One-Dose Cure.—Arsphenamine was introduced 
into medicine with an initial fallacy due to its extreme effectiveness in 
animals, and the spectacular character of its action on syphilis in man. 
Ehrlich hoped that it would accomplish a cure of the disease in a single 
dose. This idea, now fully understood to be erroneous, gained an unfor- 
tunate publicity which will in the course of the next decade result in a 
good deal of late syphilis in patients whose early signs were cleared up but 
whose disease was not cured, by the single injection which they received. 
The Action of Arsphenamine.—Arsphenamine is given in a variety of 
ways, the most widely used being direct injection of a solution of it into 
the blood through a vein. It combines in some way with the tissues of the 
body and the elements of the blood, and the combination, apparently, is 
deadly for the germs, but almost harmless, in the doses used, for the human 
body. The effect is quite miraculous. Within twenty-four hours after a 
single injection, not a spiroehsete can be obtained from any lesion of the 
body, although mucous patches and condylomas may have swarmed with 
them before the treatment. In the same way arsphenamine is able to wipe 
a syphilitic eruption from the skin almost as a wet sponge cleans the school- 
boy’s slate. Its effect therefore is to control contagiousness with incom- 
parable efficiency, and to produce spectacular and rapid symptomatic 
results. It requires repeated injections to make the effects lasting, however, 
and mercury must be invoked for final cure. 
The value of arsphenamine has one qualification from the patient’3 
standpoint. Too little of it may be worse than none at all, and may bring 
on gummatous changes before the secondary period is well over, this 
through certain peculiarities in the immunological mechanism of syphilis. 
If the administration of mercury requires *a refined therapeutic judgment, 
the management of arsphenamine treatment of a patient requires even 
more, and too much or too little may lead to unforseen consequences. The 
administration of the drug at competent hands is not dangerous, but must 
be surrounded with precautions established by experience. Modifications of 
the original Ehrlich “606”, particularly “914”, or neoarsphenamine, are 
used, but the detail of their employment has no place in this discussion. 
51807—6 CHAPTER VII. 
The Cure of Syphilis. 
What is Adequate Treatment?—The adequate treatment of syphilis, by 
whatever means it may be approached, is not a matter of days or weeks, 
but of months and years. In this simple statement lies four-fifths of the 
problem of the disease in personal and social life. The hold of the Spiro- 
chaeta pallida upon the human body, once it is established, in the over- 
whelming majority of cases cannot be broken except by wearing it out, so 
to speak. Nothing is easier to control than syphilis so far as many of the 
symptoms are concerned. A few pills, even, may make a new man of many 
a wreck. But nothing is more inexorable or more unexpected in its “ come- 
back.” Inadequate treatment carries more than the danger of a failure 
to cure. It makes possible under an outward aspect of calm, the recurrence 
of infectious lesions, the transmission of the disease to others, and the 
progress of the disease in the internal structures, under a skin kept clean 
and whole by half-way measures. Just what constitutes adequate treat- 
ment can only be determined in the individual case. It may be safely 
said that the three or four injections of arsphenamine and a few mercurial 
injections or rubs which many patients get, is not adequate. One or two 
negative Wassermann tests are no measure of adequacy, popular though 
this fallacy is. Our last resort must often be the old rules of thumb which 
still retain a place in the management of the disease that cannot be shaken 
by any of the epochal discoveries of the last twenty years. In fact some 
of the most recent work on syphilis is tending to show that what even a 
good deal of treatment accomplishes is simply a reduction of the infection 
to harmlessness, rather than a cure signalized by the killing off of all 
germs. 
An Interpretation of the Cure of Syphilis.—In the face of such con- 
siderations, it is becoming increasingly difficult to tell the patient just, what 
cure means and what will secure it. It should in general be understood 
that for all practical purposes, cure means lifelong freedom from all 
symptoms and signs of the disease, and no risk of transmission to others, 
hereditarily or directly. Even abortive cure, to which we pin our hopes, 
still contains a liberal admixture of faith, which only the clarifying 
influence of time can justify or discredit. To tell a man with a four-day - 
old primary lesion that six months of treatment will cure him is near-folly 
—to tell him that a year will do it is rash, to tell him that two years will 
see him well, is to enter the borders of conservatism. In the fully developed 
secondary case, not only are two and perhaps three years of systematic 
treatment necessary, but there must be a succeeding period of probation 
before cure is confirmed in which the patient must show no signs of the 
disease, not only to the Wassermann test, but to a variety of other 
examinations intended to reach all the structures that syphilis is known to 
affect. This advances the average period of time before the pronouncing 
82 83 
of a cure in a fully developed case in the secondary stage, to five years 
from the time treatment was begun. All that can be said of a cure thus 
carried out, is that its value while not absolute, is borne out by the over- 
whelming mas® of human experience with the disease. The risk of per- 
sistence of a syphilis after these demands have been satisfied is comparable 
to the risk of death that is inseparable from the mere fact of living. So 
far as our human fallibility allows, we say that the average man who has 
had a fully developed secondary syphilis treated by the most modern 
methods for three years, and has been free from every symptom and sign 
for two years after all treatment is stopped, has returned to the class of 
insurable risks. He is less likely to have a relapse than he is to fall from 
the top of a building or be hit by an automobile rounding a corner. 
The Time Factor in Cure.—Time is a vital factor in the treatment of 
syphilis, and the time at which treatment is begun is no less so than the 
time for which it is continued. Abortive cure depends on time and the 
recognition of the germ. Similarly the outlook on late syphilis once past 
the secondary stage depends on the age of the infection and the damage 
already done. In late syphilis of the nervous system and of important 
organs, we do not speak of cure, rather of arrest and the reinforcement of 
the patient’s resistance from time to time by treatment, until he shall have 
lived out his days. Just at what moment in the life history of an infection 
the bright outlook of primary and secondary syphilis passes over into the 
less hopeful prospect of late syphilis can be decided only in the individual 
case and by the conservative instinct of the syphilographer. Personally, 
the author believes the disease to be curable in its earlier stages, but does 
not encourage any patient to cast all caution to the winds and rely 
implicitly on a dramatic word of final release—“you are cured.” Occasional 
expert observation through life for the person who has had syphilis has 
the same value that it has in tuberculosis, as an insurance against the 
fallibility of human judgment. 
Determination of the Fact of Cure.—The answering of the question 
“ Am I cured of syphilis,” like the settlement of the question of the cure 
of gonorrhoea, is often a matter for experts. The first essential of proof is 
a series of negative blood tests covering a period of from one to two 
years. Many syphilographers believe that a special series of tests called 
a “ provocative ” should be carried out. This consists in taking blood tests 
at various intervals within a month after an injection of arsphenamine 
(“ 606 ”). It is increasingly the belief of men who see a great deal of 
late syphilis that no case should be discharged from medical care without 
an examination of the spinal fluid by an expert, since syphilis of the ner- 
vous system may remain concealed for years before the outbreak, and only 
be recognized during the latent period by the testing of the spinal fluid. 
An examination to prove the cure of syphilis should also extend into every 
nook and corner of the body, with tests of the eyes, the ears, and other 
important structures by specialists competent to pass an opinion upon 
them. Only by this apparantly needless precaution is it possible to reduce 
the chance of a mistaken or premature decision. 
Treatment of Hereditary Syphilis.—The treatment of hereditary 
syphilis is in many respects a much more hopeful matter than a considera- 
51807—6J 84 
tion of the nature of the disease suggests. Children who survive it are 
aided by a resistance that is an invaluable asset. If systematic intense 
measures could be applied to every mother who has syphilis, while she 
is carrying the child, we would witness an immediate and surprising 
decrease in the transmission of the infection to offspring. So effective is 
this treatment of the mother before the birth of the child that it is the 
bounden duty of every physician called upon to deal with pregnant women, 
to be familiar with the essentials of syphilology and to secure for those 
under his care proper expert investigation and treatment if the findings 
show the presence of the disease. If the new-born child has syphilis, its 
preservation depends upon constant unremitting care combined with skilled 
treatment. The baby must be nursed by the mother. In older children the 
treatment of the complications of hereditary syphilis becomes a problem 
for the state. The successful treatment of interstitial keratitis, for 
example, may call for months in the hospital and may delay the child’s 
education enough to damage permanently its social efficiency and waste 
its mental powers. The Scandinavian countries, through the influence 
of the great syphilographer Weylander, treat these children in special 
school-hospitals, or homes, with really wonderful results. Few experiences 
are more gratifying to the expert than to transform the little shrunken 
body with its bowed head and aching, red, and all but sightless eyes, into 
robust and laughing youth. The State of Michigan is conspicuous in this 
country in its provision for the care of children who can be benefited by 
medical treatment, those with hereditary syphilis among the number. CHAPTER VIII. 
Public and Personal Hygiene of Syphilis. 
Summary of Facts Regarding Contagiousness.—We have now reached 
the point where it is possible to summarize the problem of syphilis as it 
concerns personal and public health. Syphilis is a contagious infection. 
For practical purposes, it is a danger to others only during the primary 
stage, the secondary stage, and such part of the latent period as may be 
marked by the recurrence of contagious lesions about the mouth and 
genitals. Any syphilitic lesion in the stages named is dangerous if it is 
moist. The sores of late syphilis, occurring as they do after the larger 
part of the germs have died off in the body, are not dangerous. In fact, it 
may be said of syphilis in general that danger is inversely proportional to 
glare and conspicuousness. There move among us every day persons with 
dangerous syphilitic lesions, for whom we would never think to turn aside; 
though we would shun one who had a harmless “ running sore ” as if he 
were a leper. Categorically, the important principles governing the trans- 
mission of syphilis may be summarized as follows: 
The disease is transmitted only by the transfer of the germs. Personal, 
immediate contact with an infectious sore or lesion stands first and fore- 
most in the spread of the disease. The germs of syphilis cannot live long 
away from the body, or in the presence of air. They are killed at once by 
drying. They are not distributed about by objects that have only remote 
contact with syphilitics, such as furniture, door knobs, bath tubs, and even 
toilet seats. The dangerous articles are instruments recently used, articles 
that are put in the mouth, such as silverware, cups, pipes, etc., clothing or 
dressings moist with discharges. Germs of syphilis deposited on foreign 
objects, die at once on contact with so weak an antiseptic as soap and 
water. The washing of all personal articles in hot soap suds effectually 
sterilizes them so far as this disease is concerned. 
Non-genital Syphilis.—Syphilis is non-genital—that is, the primary 
sore occurs elsewhere than on the genitalia in from 5 to 10 per cent of all 
cases. These are older figures, and a greater expertness in recognizing the 
early onset of the disease will increase the amount of non-genital syphilis 
recognized. Physicians and nurses, and also members of families in which 
there is a careless syphilitic, or in which there is crowding and bad hygiene 
are conspicuous victims of this mode of acquiring the disease. It is said 
that in parts of Russia, genital infection is the exception, and non-genital 
the rule, and the same observation was made by Tullidge in connection with 
Austrian troops in the war. The chancre may appear on the lip, the 
tongue, the tonsil, the eye, the finger, the nipple or any other part of the 
body, even to the septum of the nose and the palm of the hand. 
The Engagement Chancre.—An important phase of extragenital 
syphilis is the syphilis of intimate non-genital contacts—kissing and 
caresses. Into this group fall the engagement chancre on the lips of the 
85 86 
young girl whose fiance acquired his infection by resorting to some other 
woman for the relief of the excitement of his courtship; the chancres on 
the eyelids, the lips and the cheeks of children from the kisses of infected 
parents or brothers and sisters, or from strangers; the chancres of the finger 
that are acquired in other than innocent ways. 
Genital Transmission of Syphilis.—The genital transmission of 
syphilis covers from 80 to 90 per cent of all cases, according again to older 
figures. About 50 per cent of the infections of married women have 
seemed to me to be contracted in marriage, though Fournier gave 20 per 
cent as his estimate. The physiological reasons for the importance of 
genital transmission have been discussed. No person who dispassionately 
reviews the facts can long cherish the belief that guilt or innocence has 
any part in the developments of the peculiar habits of the Spirochaeta 
pallida, or maintain that the innocent and loyal wife or husband or the 
unknowing, unoffending child should be besmirched by our prurience 
simply because the organism is an anerobe of low vitality, requiring special 
conditions for its growth. 
Duration of Contagiousness. Affect of Tobacco, Dirt, Etc.—The 
average syphilitic infection, untreated, must be rated as contagious for a 
period of at least five years from its onset. Lapse of time with progress 
toward the non-contagious tertiary or late stage, sooner or later disposes 
of the public menace of every syphilitic. This is scant consolation, 
however, when it is recalled that the contagious periods of the diseases of 
children, for example, seldom occupy the number of days or weeks that 
syphilis does years. The contagiousness of syphilis is increased by any- 
thing which tends, as do tobacco, dirt and irritation, to produce moist 
recurrences about the mouth and genitals. The contagiousness of syphilis 
is diminished, and the danger period shortened, by modern treatment. 
Arsphenamine in the Control of Contagiousness in Syphilis.—Any 
device or remedy which shortens the contagious period of an infection, has 
life-saving value. In this class we must place arsphenamine, whose ability 
quickly to destroy the germs of syphilis in contagious sores is one of the 
most brilliant contributions to the modern campaign against the disease. 
Quarantine for syphilis, as it is practised in other contagious diseases, is 
impracticable, and fortunately it has at last become unnecessary. A 
twenty-four hour stay in a hospital with a single injection of “ 606 ” does 
away for the time being with the need of it. It should never be forgotten, 
however, that it is a short-sighted policy which provides only enough 
arsphenamine to temporarily destroy the germs. Such a policy inflicts 
deliberate injury upon the patient by exposing him to the risk of dangerous 
complications, and does not protect the public from his relapses any more 
effectively than the old-time use of mercury. Every case must be adequately 
treated from the broad standpoint, as syphilis, not from the narrow point 
of view of merely reducing contagiousness for the time being. By 
adopting the former standard, and backing it with our dollars and our 
laws, we will best serve both the interests of the public and those of the 
patient himself. Good all-around treatment with salvarsan and mercury, 
while it can never unconditionally guarantee the non-infectiousness of a 87 
syphilitic, least of all in the intimacies of life, can none the less reduce the 
risk in ordinary relations practically to the vanishing point. 
Personal Responsibility in the Transmission of Syphilis —There enters 
into the control of syphilis as a contagious disease, the same problem of 
personal responsibility which appears in gonorrhoea. In those who are 
ignorant, the transmission of syphilis to others goes on unawares; in those 
who are indifferent, the risk of infecting others is ignored—sometimes 
even deliberately recognized and employed as a means of vengeance. The 
extent of irresponsibility in the transmission of the disease is large, and 
it bears no direct relation to the supposed intelligence of the person who 
transmits the disease. I have known Croatian labourers who barely 
understood the words in which they were addressed, to take precautions to 
protect others which conformed to an ideal code of unselfish consideration. 
On the other hand, I have had trained nurses, infected in illicit sexual 
relations, leave my consulting room after the most explicit instruction as 
to the danger for others, and marry healthy partners before they were 
non-infectious. The transmission of syphilis is too often dependent on a 
character factor which no amount of treatment can reach. The rapidly 
developing modern public health programme for the control of genital 
infections is fortunately taking account of this phase of the problem, and 
is placing the irresponsible syphilitic within the grasp of the law. 'Syphilis 
gives even the conscientious patient all too few reminders of his duty. A 
little treatment, and everything, including the patient, vanishes. I 
remember in my own dispensary days the signal that marked the intention 
of many a patient to pronounce himself cured and disappear. A basket 
of tomatoes, or some fruit, or a box of cigars would appear on the window 
sill, and then there would be a vacancy in the treatment line, perhaps all 
that was left to symbolize the value of hours of as ardent persuasion on 
my part and as complete a good will as ever glorified an evangelist pleading 
for a lost soul. Now with the plenary powers of the police and the 
searching eye of the social worker to aid, the old-time shrug and “ What’s 
the use?” that was our only resort in our struggle with irresponsibility, 
has lost its sardonic meaning. A great deal of syphilis can be held to 
treatment and to a hygiene which protects others, through the personal 
effort of the physician. That part of it which declines the voluntary 
assumption of its responsibility must be forced, and forced it will be. CHAPTER IX. 
Syphilis and Marriage. 
The fitness for marriage of a person who has had syphilis must be 
judged by two criteria. It is a matter of some importance that the non- 
infectious marital partner be able to measure up to the social responsibi- 
lities of marriage. Williams1 showed for example, in an investigation of 
100 men dying in Massachusetts of syphilitic insanity that 78 women and 
109 children were thrown upon society without the protection of a wage- 
earner, the state paid $39,312 for the care of the men alone, and ten of 
them represented a financial loss of $212,248. It is therefore usually 
inadvisable for patients exhibiting serious late complications which are 
likely to incapacitate them, to marry, even though there is no risk of trans- 
mitting the disease, unless the partner knowingly assumes the risk of having 
an invalid on his hands. Patients in the infectious stage of the disease 
should be governed by the so-called Hoffman or five-year rule, which 
is practically identical with the standard for cure in the fully developed 
case of secondary syphilis. There is a tendency on the part of a few 
observers to let down the bars on the strength of the effectiveness of modern 
treatment. In the opinion of conservative syphilologists, however, this 
relaxation is premature. It is safe to say that there is no longer any 
justification for the prolonged restrictions covering most , of a life time, 
advocated by men of the past generation, like Fournier, whose experience 
was affected by the relative inefficiency of the methods of treatment then 
employed. It must be emphatically stated that the same rule should 
apply to the engagement to marry that applies to marriage itself. The 
American engagement is a period of informality and intimacy which may 
even be synonymous with the most intimate contact. Ho person having 
the welfare of a young girl in charge is justified in permitting her to 
enter upon an engagement, or intimacies approaching it, that cannot be 
thought of as terminating in marriage. The careful investigation of the 
actual or potential fiance is the only way to avoid the all too frequent lip 
and tonsillar chancre in trusting girls. 
Syphilis and the Medical Examination Before Marriage.—From the 
syphilologic standpoint the determination of the fitness of a person who 
presents himself for medical examination before marriage offers problems 
not unlike those which beset the examination of gonorrhoea. The value 
of the certification must depend to no small extent upon the status of the 
examiner as an expert on syphilis. If he knows so little about the disease 
as to be content with a single negative Wassermann test, which by the 
way is the favourite legislative sop to public sentiment on this matter, his 
opinion will be worth exactly nothing. A thorough physical examination 
is necessary, an honest history from the patient, some acquaintance with 
1 Williams, F. E.: Relation of alcohol and syphilis to mental hygitne. Am. 
Jour. Pub. Health, 1916, vi, 1272. 
88 89 
his family tree and traditions, and repeated confirmatory tests upon the 
blood. If there seems ground for suspicion, the complete procedure for 
determining the fact of cure may be undertaken with its “ provocative ” 
blood test, examination of the eye, ear and nervous system, and of the 
spinal fluid. It is obvious that this is, in the vernacular, “ a large order,” 
and will not attain to popularity without a prolonged and vigorous 
educational campaign. The physical fitness of candidates for marriage 
should be the occasion for an all-around family conference on both sides, 
with seats at the conference table for both the medical expert and the 
minister. The laws which govern professional medical confidence, and 
protect the secrets of rascals should on this occasion be adjourned, as they 
are now in the progressive State of Ohio for example.”1 
Responsibility of the Church.—The church has, I believe, a little 
appreciated and much needed power in this matter. In these days it 
takes a man or woman of more than ordinary force and determination to 
brave the inertia of popular silence, distrust and misconception, and insist 
that the one he or she loves and trusts, shall be appraised on the score of 
physical fitness for the relation into which they shall enter. The vigorous 
and determined stand of the clergy in support of physical examination of 
candidates for the religious ceremony will go far to bolster the timid and 
spread the new conception of responsibility. The author had the experi- 
ence of seeing the photograph of a partially treated patient and his bride 
appear in the pages of a supposedly progressive newspaper. On reading the 
paragraph accompanying it, he found that this enterprising journal had 
furnished even the officiating minister who made this marriage possible. 
All that remained for him to do was to pray that the arsphenamine he had 
injected so long as the patient chose to continue treatment, would do double 
duty. How much better would it have been, and how much more pro- 
gressive, if the minister who unknowingly contributed to this consummation 
had swung his influence against the snap-shot marriage and avoided even 
the semblance of acting as a stool pigeon to an irresponsible. The church 
has a mission here which it cannot long neglect. 
Responsibility of the Medical Profession.—The medical profession 
must in its turn bear its share of the blame for marriages consummated 
after inadequate tests. “ But the doctor told me I was well—he said 
my blood was clean” (Wassermann negative) is an all too familiar cry 
from fathers when examination of mother and child shows the presence 
of the disease. Until, for one thing, the newer standards for the detection 
and cure of syphilis have become the common property of the medical 
profession, or the care of the disease is concentrated on the hands of 
experts, it will be futile to expect striking results from the medical exam- 
ination of candidates for marriage. 
Summary of the General Outloolc.—The extinction of syphilis is a 
consummation in public health which has more prospect of concrete 
fulfilment than in the case of any other of the four great modem plagues. 
Tuberculosis, while a disease of known cause, lacks the means for such 
effective treatment and control of contagion as are available in syphilis. 
1 Amendment to Section 1275, General Code, p. 177. 90 
Cancer is still shrouded in obscurity—of unknown cause, of terrific 
fatality, definitely remediable only in its earliest stages, little understood 
as to its prevention. Gonorrhoea, preventable, but with its long period 
of uncontrolled infectiousness and train of complications following upon 
a neglect which the disease itself encourages in every possible way, lacks 
also the striking, the effective, the specific cure. Syphilis alone of the 
four is at our mercy. A method of prevention to be discussed later, whose 
efficiency is very high; methods of treatment which bid fair to cure nearly 
every case taken in time; methods of recognition in the form of blood 
and other tests which have some of the smallest margins of error in 
medicine; control of contagiousness which is more absolute, immediate 
and effective than the most rigorous quarantine, all point to possibilities, 
whose realization is only a matter of time. A matter of time, and of 
public education—for nothing stands out more clearly than the fact that 
our refusal, not our inability to control, explains the existing situation. 
Free, abundant, effective early treatment and preventive measures, with 
compulsion where necessary, will from the medical side, enable us to hold 
the situation in the hollow of the hand. That the medical solution shall 
be touched with idealism and inspired by great principles, must be our 
next concern. PART IV. 
THE SOCIAL, PSYCHOLOGIC, AND ECONOMIC 
BACKGROUND OF SYPHILIS AND 
GONORRHOEA. 
91 CHAPTER I. 
Every bodily ailment has its social and psychologic background—a 
fact that physicians themselves are often only too prone to forget, or to 
ignore under the mistaken belief that such detachment is an essential 
part of the scientific point of view. No presentation of the subject of 
syphilis and gonorrhoea can lay any claim to breadth or completeness which 
does not point out at least the principal factors in human nature and the 
social order that underlie the powerful hold that these diseases have upon 
the race. 
The Inertia of Public Opinion.—The medical consultant on the 
genital infections must have the spirit of a pioneer and aim to mould 
public opinion. Too often he is thought of as a devil’s porter, busy throw- 
ing wide the gates. About him there seems at times to lie a vast, and 
occasionally a vociferous wilderness of ignorance, prejudice and distrust. 
More to be feared than outspoken aversion and contempt, is, too, a certain 
silent, veiled, but peculiarly intense and irrational hostility which some- 
times marks the thought of those who are otherwise intelligent and culti- 
vated people, on the question of what to do with, and for, the syphilitic 
and the man or woman with gonorrhoea. The physician himself, to whom 
no sickness should be alien or deserving of less than his best, too often 
feels that syphilis and gonorrhoea are in a class by themselves and leaves 
them coldly to the exploitation of quackery and incompetence. His 
attitude is simply a reflex of the public thought. It still takes a measure 
of hardihood, ev?n in this comparatively enlightened day to permit one’s 
name to become sy aonymous in a locality with a tratficker in the unmen- 
tionable, the dubious shepherd of black sheep. Yet after all there is some- 
thing to inspire in the work. Those who can bring to the care of the 
modern venereal leper the spirit of a Father Damien will have a real 
mission. There are few who reap more generously the rewards of gratitude 
and whole-hearted fellowship than those who are able to appreciate and 
lighten the trials of that portion of the sick whom public misunderstanding 
condemns without a hearing. False tradition is not adamant. For those 
who attempt without cynicism and with adequate special knowledge to 
illuminate the problem of sex diseases it seems as if there must exist an 
actual and definite public need, and a promise of public comprehension 
and response. 
The state of public opinion on syphilis and gonorrhoea can best be 
appreciated by an effort at critical analysis. It has a definite psychology. 
The inertia that seems to characterize it is not hopeless. It can be traced 
to a half dozen or so of more or less conflicting and inhibitive points of 
view. To attack and demolish or to reconstruct these individual miscon- 
ceptions is to convert the heathen and uphold the larger gospel " Solus 
populi supremo lex." 
An Analysis of Current Misconceptions.—My own experience with 
the psychological problem has led me to summarize the basis of this long- 
standing public indifference and antagonism under the following heads: 
The Public Viewpoint. 
93 94 
1. Ignorance of the facts in regard to the tremendous prevalence and 
wide distribution of syphilis and gonorrhoea. Yery few people possess 
the special knowledge to convince them* that these diseases cannot be 
evidence of inherent disreputability and viciousness, or the property of any 
special class. 
2. Confusion of the issue with the problem of commercialized 
prostitution. 
3. Exaggerated notions of the contagiousness of syphilis and gonoi 
rhoea, especially the former. 
4. The belief that the horrors of syphilis and gonorrhoea have moral 
value—that they act as deterrents to sexual license. 
5. Pharisaical self-righteousness. 
6. The belief that syphilis and gonorrhoea are well-deserved punish- 
ments visited upon offenders against moral and natural laws. 
Public Ignorance of the Facts.,—Public ignorance of the facts is an 
outstanding and basic factor. Even highly trained, cultivated and well- 
informed people, not excluding from that number physicians of wide 
experience, still cherish the lingering belief that syphilis is largely, and 
gonorrhoea almost entirely, a proof of moral degradation and the property 
of down-and-outs. If sexual longings and illicit gratifications were limited 
to a few, and if absolute sexual regularity were the only proof of sound 
character, the bulk of humanity would have to be classed as vicious and 
degraded. It is not cynicism that prompts the syphilographer to urge 
the dropping of all social distinctions in the survey of the situation in 
his field. It is a far more sordid cynicism that can believe so ill of human 
nature as to hold that because 60 per cent of men have had gonorrhoea, 
60 per cent of men are outside the pale of decency and honour. It is 
equally impossible to believe that vileness clings to one in five adults with 
syphilis while the remaining four with Wassermann negative passports, 
enter the gates of social respectability. Distinctions based on social status 
and class are irrational and unfounded to one who meets the situation day 
in and day out. For one thing they have a reflex effect that interferes 
with the medical diagnosis of the disease. How many carefully performed 
and accurate positive Wassermann tests does it take to establish the 
presence of syphilis? Far from being a purely medical question as the 
syphilologist would insist, the public and even physicians, too often believe 
it is a social one. One positive test will usually convict a labourer over 
his own denial, two may indict a railroad president or a banker, but I 
have known three to be insufficient to satisfy a clinician of the “ guilt ” 
of a minister. To one who knows even the preliminaries of his subject, 
such situations would be laughable were it not for the tragic blindness 
they imply. This illustration, harsh though it is, exemplifies the ever- 
present fallacy in all public thought about syphilis and gonorrhoea—the 
uncritical injection of moral issues and class distinctions into the problem. 
To the critical judgment, syphilis and gonorrhoea have, of course, their 
moral phase, precisely as they have an economic or an ethical or a social 
or a medical phase; but the effort to mix the standards of moral judgment 
with the medical issues of detection and treatment of the two diseases 
persistently befuddles thought and blocks the waiting forces of progress. 
Confusion with the Problem of Prostitution.—The second fallacy is 
the confusing of the problem of the genital infections with that of 
commercialized vice. To this, the false and misleading label “ social evil ” 95 
and its twin sister “social diseases” have contributed liberally. The 
situation is essentially that of mistaking the part for the whole. No one 
would seek to deny that commercialized vice is a large factor in the dis- 
tribution of syphilis and gonorrhoea. Medically speaking, it can be thought 
of as the intermediate host or carrier of the Spirochseta pallida just as the 
mosquito is host for the malarial parasite. No rational public action 
against malaria neglects the destruction of the mosquito and the swamps 
in which it breeds. Yet is that any reason why we should ignore mosquito 
netting to prevent its access to the body, or quinine to destroy the germ when 
once it enters the blood ? Point for point, the rational outlook on syphilis 
should match that on malaria. Because we have indeed found it unex- 
pectedly difficult and perhaps impossible totally to destroy the prostitution 
host, is that an intelligent argument against the use of preventatives upon 
those who have been exposed to danger of acquiring syphilis and gonorrhoea, 
or of curatives on those who have become infected? No clear-thinking 
man or woman who is familiar with the problem expects the immediate 
extinction of all mosquitoes or all prostitutes. Yet no clear thinker 
expects this difficulty to block all advance, and no forward-looking mind is 
willing to see the day of racial health and soundness of mind and body 
delayed indefinitely by it. Military strategy under Marshal Foch has 
taught us that many blows and many points of attack make victory. It 
is German obtuseness in a public health campaign against syphilis and 
gonorrhoea to push away in shortsighted doggedness at the obstacles in the 
fields of prostitution, to the exclusion of all other forms of effort. An 
offensive which covers the other strategic points as well, carries a much 
larger prospect of success. 
Exaggerated Notions About Contagiousness.—Exaggerated notions 
about the contagiousness of syphilis and gonorrhoea have performed to 
some extent for these diseases, though to a less degree, the disservice that 
they have for leprosy. In leprosy the issue has been less productive of 
tragedies because of the comparative rarity of the disease. In syphilis 
because the disease is so much more common, false notions have worked 
deep and embittering injustice. Some of the situations have, however, 
the merciful quality of being ludicrous. The development of hospital 
services for the treatment of the disease is replete with anecdotes that 
there is no space to repeat. I have known eminent medical gentlemen to 
wash their hands with almost hysterical eagerness after touching my door 
knob, or after the presentation of one of my cases in a clinic; and nurses 
and office assistants joining my staff to be the recipients of condolences 
from friends and tearful protests from relatives; the supposedly well- 
informed heads of training schools to refuse me nurses when, without their 
realizing it, I have identified for them repeatedly the dangerously con- 
tagious syphilis which they were unconsciously nursing in their wards and 
in their finest private rooms. Of the uninformed we, of course, expect 
such blunders. That similar types of thinking are still prevalent among 
the flower of the profession is only a tribute to the super-darkness that 
surrounds us. We who are labourers in this field, look forward to the day 
when toilet and bath, door knob, effluvium and invisible contagion will 
retreat from the foreground of the public thought and give place to rational 
comprehension of the bacteriology, the hygiene and the epidemiology of 
syphilis and gonorrhoea. 96 
The Fallacy of Believing Fear a Deterrent.—‘With the fourth element 
in public misconception we enter a field for thought. The belief is 
exceedingly common that the fear of acquiring syphilis or gonorrhoea, if 
widely enough spread, will deter those who would otherwise seek unsocial 
sexual gratification. No unequivocal answer to the argument can be 
offered. On one side of the question, however, it can be given as the 
experience of many workers in this field, myself among the number, that 
the popular impression is a delusion. As a student of this question for a 
number of years, and at times a speaker upon it, I have been unable to 
convince myself that fear stands effectively between a man and the 
gratification of his sexual desire. Of the many fairly well-informed sexual 
offenders that have passed through my hands, I can scarcely recall one 
who did not believe himself skilful enough to evade trouble, or the 
possessor of some talismanic key to a situation or who did not go ahead, 
risk or no risk, in response to imperious desire. It is not cynicism to 
rate the efficacy of horror so low. Horror is cheap, and makes a feeble and 
unworthy substitute for ideals. A reasonably brisk talker with coloured 
lantern slides can pile horror on horror until it bulges from the windows 
and through the doors, and the pause between impressive sentence and 
impressive sentence is punctuated by the collapse of the weaker members 
of the crowd. During the next few months after such a presentation the 
observer behind the lines meets distracted members of the audience in the 
consulting room and wrestles with them to undo the damage inflicted by 
a mode of approach that did not prevent subsequent infection, but simply 
superimposed upon it, nervous prostration. Knowledge of disastrous con- 
sequences, and fear of syphilis particularly, is now an old story to quite a 
number of young men. Medical students, who know all about it, have no 
monopoly of virtue. iSyphilis and gonorrhoea have long officiated in the 
role of moral policeman. They have never shown evidence of enough 
efficiency in the form of a reduction of the rate of exposure to justify their 
tremendous cost to the world. 
A Positive Idealism Necessary—'Bishop Lawrence in one of his 
addresses1 touched the vital point in fear as a deterrent. In a day when 
the Christian church is at last learning the virtues of a positive idealism 
and has ceased to preach hell as a means toward heaven, it is a tawdry 
morality that would found the new moral responsibility in sexual life 
upon fear. It is a degrading and unworthy monogamy whose slogan is only 
prudence, and whose bulwark of defence consists of the pitifully broken 
and twisted human wreckage, the shorn innocence, the dismembered 
helplessness piled up by syphilis and gonorrhoea in the masquerade of 
spiritual defence. On honour and social responsibility and not on en- 
lightened cowardice will be squarely placed the burden of the sex ethics of 
the future. 
I Thank Thee That I Am Not as Other Men Are.”—A certain Phari- 
saical self-righteousness underlies too much of our public thought about 
syphilis and gonorrhoea. “ Diseases of vice.” “ the underworld,” “ such 
patients,” “that kind of work,” represent types of thought that are tinged 
with it. Like the “erring brother” type of missionary spirit, it defeats 
i Social Hygiene, 1918, 12, 317. 97 
itself. Nothing was ever gained by undiscriminating “sob stuff” of the 
“fallen woman” order. It has been my personal duty, and often my privi- 
lege to know the intimacies of the lives of many types of victims of the 
genital infections, and I have yet to meet a “fallen woman.” Some of them 
are mentally abnormal, some of them tough, the women tougher than the 
men sometimes, but at bottom a curious streak of the square deal still 
persists. Through all their wobblings and gropings, their weakness and 
blindness, their egregious vanity and towering egotism, their unsocial 
minds and spineless irresponsibilities, there still moves something which 
makes them human. With many of them their condition is a sickness, not 
a vice. They cling to friendship pathetically, honour can move them, and 
love may lead them when honour fails. There is no man or woman of 
grace and distinction who need feel that an acknowledgment of brother- 
hood with these will precipitate one from the heights. It is not necessary 
in the exercise of a larger charity to swing to the extreme of maudlin 
-entimentality. After all, thinking men and women can ask themselves 
the really fundamental question about their attitude toward syphilis and 
gonorrhoea: “Do I think myself holier than thou ?” Christ laid the simple 
foundations of a noble ethic in His word to the woman taken in adultery, 
“Neither do I condemn thee—go, and sin no more.” 
Syphilis and Gonorrhoea as “ Frightfulness —And in the final group 
of obstructionists we number that fellowship of the apostles of frightful- 
ness who believe that syphilis and gonorrhoea are punishments for sin. 
To these, the “ Gott-strafers,” we owe a truly fiendish conception of the 
two diseases, that of disgrace and stigma. The mother on her deathbed, 
dying of gonorrhoeal puerperal sepsis while two nurses and a doctor fight 
for the baby’s eyes, is disgraced. The boy with a chancre who came in to 
offer himself as a subject for experiment, if it cost him his life—he had 
been filled up with liquor by companions, and infected—he is disgraced. 
There is the mother, half her children in the grave, a third of the rest in 
hospital and asylum, taking in washings to hold the family together and to 
fill the place of the husband who died. Her twisting face, and shaking 
chin, and catching throat beg you to tell her she has a fatal cancer rather 
than “ the bad disease ”—yes, she is disgraced, too. And there is the girl 
who trusted him, and, too, the boy who trusted her, and the man who in 
an hour of loneliness met folly once—the “Gott-strafers” lump them all in 
Limbo with the stage-door Johnny and the hotel tout, the cop who takes 
his pay in trade, the pimp and the professional seducer. Leaving the 
humanity of it out of the question and speaking medically the crushing 
effect of the sense of disgrace breaks many a patient whom the disease 
would scarcely touch. And it is not the patient who deserves it, that 
meets this fate. The hardened, the vicious, laugh it off as part of the 
hazard of the game. It is the innocent, the sensitive, the timid, the 
shrinking, the child-like who are crushed. Analysis again comes to our 
rescue. Syphilis and gonorrhoea have all the characteristics of the famous 
German frightfulness. They make no pretence of discrimination between 
innocent and guilty. They are non-educative and non-reformatory. They 
murder non-combatants. They inflict barbarities which for refined 
atrociousness can put the best efforts of kultur into the background. They 
are indeed worthy of the “ Gott-strafe ” mind, which adopts them as 
punishments for sin. 
51807—7 CHAPTER II. 
Normal Ideals of the Sex Life. Abnormal Checks on Marriage. The 
Trend of the Times to Laxity. The Influence of the War. 
The Normality of Sex Ideals.—The day of calmer thinking, less 
prurience, fetichism and taboo, will see a reconstruction of our conceptions 
of the sexual life. The instinct to reproduce has as great a normality, as 
high a title to consideration and intelligent adjustment as does the passion 
for enough to eat, which is simply an expression of the metabolic needs 
of the protoplasm of which we are made. The tendency to strain at sexual 
gnats and swallow commercial, ethical and political camels is as common 
as it is alternately laughable and tragic. Fundamental principles of 
equity, justice, mercy and unselfishness underlie this part of our lives 
as truly as they do the dealings in our courts of law, our business organi- 
zations, our hospitals, our social settlements. The future is in the hands 
of those who can read into the heretofore distorted and primitive narrow- 
ness, the prurient self-consciousness of society about sex, a broader and 
more generous interpretation. It is equally in the hands of those who can 
balance a liberal tendency with far-sighted idealism, who can temper 
generosity with fairness and freedom with responsibility. 
The Changing Trend of Sex Ideals.—The student of the sexual life in 
its relation to problems of public health cannot escape a sense of impending 
great revisions. Murmurings and intimations float about, social investi- 
gations from time to time give definite shape to impressions. No one 
would be so rash as to predict the cataclysmic, but it is hard to avoid the 
belief that reconstruction is on us whether we will or not. Moral codes 
that are ultrabiologic will plunge us into muck. On the other hand, moral 
codes that consist of a thin, attenuated and bloodless idealism which would 
convert the sexual relation from a love expression into a stock-breeder’s 
device for the fertilization of the human female, have an even smaller 
chance of shaping our future. It must be a primary aim of any move- 
ment, public health, ethical or whatnot, if it deals with sex, to combine 
ideals and practicality into a standard of conduct which best expresses the 
fundamental and all-inclusive principles of love, honour, and responsibility. 
Crowing Need for a BulwarJc of Moral Ideals.—The need for con- 
sidering the future of sex ethics carries with it the demand for a frank 
analysis of our present situation. The prevention of syphilis and 
gonorrhoea will have direct effect in throwing human sexual life back upon 
its ethical essentials. If disease wrere to be removed from the field of 
“accidents” and what little preventive influence it possesses were to 
cease to be, then moral standards would take their true places, as the only 
real character-forming bulwark between the social order and unrestrained 
gratification of sex impulses. But in the last analysis, the hold of such 
moral standards upon the race will be proportional, not to the depth of the 
social frown which punishes their violation, but to their inherent nobility. 
98 99 
reasonableness and justice. It is at least good policy to believe that a 
self-enforcing sexual moral code will rest primarily upon such a foundation. 
Only by so doing can it hope to appeal to a sufficiently large body of 
humanity to make social disapproval of unsocial behaviour effective. The 
first necessity for the development of such a code is a consciousness of the 
weaknesses of the existing system. 
Remediable Obstacles and Factors of Error in Marriage.—Marriage, 
the accepted convention for the gratification of the human sexual impulse 
and its utilization as an inspirational force, has not yet reached its ulti- 
mate perfection. It is urged as an outlet for the sexual ardour of young 
men and young women. Under existing conditions it has too high a 
margin of error for a scientific method, too large a factor of wastage for 
an efficient piece of economic machinery. It is, of course, no reproach 
upon an ideal such as we cherish for marriage to say that it is high. Any 
reproach comes in allowing its institutional expression to be so beset with 
obstacles and factors of error that it becomes unattainable, or a punish- 
ment and a discipline rather than a compensation, an outlet, and a worthy 
expression of human nature. In the same way, continence, as a sex ideal 
for the unmarried, is invaluable in preparation for normal marriage. Yet 
there are those who seem to feel that as a mean9 of keeping worth-while 
men and women unfulfilled and childless because of the impossible demands 
of an oppressive social order, it deserves even les9 attention than it gets. 
Between these two extremes there lies a middle course, dictated by a com- 
bination of idealism and common sense. The idealism is summed up in 
the words love, honour, responsibility. No institution or code which 
adequately translates all three into practice need be distrusted. Common 
sense consists in the recognition of the fact that a social order which offers 
neither training nor‘inducement for its authorized sexual practice; which 
makes it economically prohibitive and unattainable in one way or another 
for a liberal percentage of common humanity and makes it acutely painful 
and punitive for another portion, must revise its methods or meet disaster. 
• 
Training in the Ideals and Practicalities of Marriage.—It is worth 
while to be briefly enumerative of certain aspects of the problem of 
increasing the practicality of the conventional sexual life, in order to 
inspire those who have the opportunity to think and speak to thought and 
speech. In the first place, only in indirect ways are the idealism of 
marriage and the ways of making those ideals practical, taught to children. 
If marriage is to constitute the whole outlet for an instinct as fundamental 
as the securing of food, it should be taught with the same assiduity and 
even greater skill and foresight than goes into the learning of a life-work. 
Not only should girls learn its economics, but they should learn its theory, 
its ethics, its arts. Boys should learn side by side with the business train- 
ing of the paper route, and the physical training of the gymnasium, the 
disciplinary give and take, the chivalrous gentleness that fits them to be 
fathers and husbands. 
Marriage cmd Industrial Dependence.—As long as marriage spells 
economic slavery, it will be an unworthy expression of human ideals. 
If it cannot be made to appeal to the healthy-minded woman of the future 
51807—7* 100 
on other than economic grounds it lacks something. If the woman feels 
that marriage is a descent into domestic drudgery from an elevation of 
industrial independence she will not be long in finding a way to combine 
the independence of industry with marriage minus drudgery. What such 
a combined institution might be, it is impossible to predict. In many 
talks with different types of women the author has received impressions of 
the future varying from a liaison for sexual pleasure to virtually sexless 
business partnerships, and platonic friendships. These, of course, repre- 
sent extremes. There is no question, however, that the “ meal-ticket ” 
hold of feminine economic dependence in marriage is slipping, and with 
it will go a force for which an adequate substitute in idealism will have to 
be found. Where it is lacking, an ill-judged union will end ih speedy 
separation, and the creation of two sexual appetites to be satisfied instead 
of one, since sexual experience when once had, tends to break down the 
bonds of self-restraint. Stringent divorce laws will have less than their 
oresent trifling effect in .controlling the situation, since the refusal ‘of 
divorce where both sides are independent merely serves as a means of 
inciting to clandestinism and concubinage. 
The Effect of Failure on Marriage Ideals.—The unsuccessful marriage 
oer se has probably no more effect under existing conditions in deterring 
others from marrying than has fear in preventing sexual indulgence. 
Again each pair believes itself possessed of a talismanic key to the situ- 
ation. Yet in the end, the high percentage of blighted unions has an 
unfavourable effect upon the conventional form of sexual expression. One 
sees what appears to be an increasing tendency to ‘Try it out,” which must 
be considered and aligned with the future of the sexual life. My own 
impressions have, for instance, repeatedly confirmed the observations of 
Woods and Kennedy1 among working girls and men, upon the growing 
popularity of an unofficial form of sexual union, a liaison which may or 
may not end in marriage, according to the inclination of the parties or the 
incidence of a complication such as pregnancy. The vogue and the 
rationale of such a trial marriage should be the object of careful social 
study, with a view to ascertaining its idealistic basis, which is often 
higher than rigorous convention admits, and to diverting it into social 
channels. As a distinguished landscape architect once remarked to a 
college group apropos of the laying out of paths between buildings on a 
campus “ we watch the movements of the students across the grounds and 
allow them to influence to some extent the lines along which we lay 
cement.” A similar attitude, always properly guarded, has its place in 
determining the institutional future of human sexual life. 
Marriage and the Economic Treadmill.—Economic obstacles are a 
grave menace to the future of marriage as the solution of the problem of 
human sexual relations. The almost cynical indifference of the state to 
one of the most vital of human functions and one which more than any 
other involves its own perpetuation is one of the social anomalies of our 
times. Apart from using the portal of entry into marriage as a fee- 
l Woods, R., and Kennedy, A.: Young working girls. Evidence of 2,000 social 
* workers. Boston, Houghton, 1913. Price, $1.00. 101 
collecting mill, and barring the exit from many a spiritual catastrophe, the 
state gives the relation minimal attention. Marriage in these days 
depends too much on being able to meet the extortionate cost of living for 
two and the children, and too little on physical or spiritual fitness for the 
perpetuation of the race. In some way an equitable basis must be found 
for making the raising of a family an industry, with adequate rewards 
proportionate to its success. The special worker with the genital infec- 
tions has more than enough opportunity to appreciate the force of the 
answer he gets from likely young men in response to his question, “ Why 
don’t you marry?” A statement of earning capacity and the response 
“ Would you ask a girl to marry you on that much, in these days?” is only 
too often answered by a reluctant “ No.” Early marriage of all things is 
the most completely out of harmony with the existing economic order, 
while it seems the only available solution within existing conventions, of 
the problem of sexual life. When a man’s sexual ardor and value are 
greatest, he should marry; but to do so, too often chains himself and the 
girl to the treadmill of economic bondage. The advice has so little of 
practicality in it under present conditions that those who undertake to 
follow it to-day are regarded as painfully and even questionably romantic. 
They are certainly not de rigeur, and have a place as objects of com- 
miseration. Until the father believes the son’s and daughter’s successful 
and reasonably early marriage to be fully as significant as a college com- 
mencement, and is willing to provide for it; until the state subsidizes 
healthy motherhood and childhood substantially, without waiting for 
parentage to be crowned with widowhood; until we realize that to talk 
marriage as a sexual solution and then postpone it, is to deal in farce, the 
problem of an adequate sexual life as a protection against unsocial gratifi- 
cations remains unsolved. 
The Tendency of Sex Life to Crudity of Expression.—It is the fashion 
in these days to rend, not lift the veil. By this phrase I mean to put 
a hopeful construction on the modern habit, not yet at its climax, of 
making sexual issues the currency of everyday thought and speech. We 
have seen the period of irrational silence and restraint. We are moving, 
it seems to me, with equal certainty upon the period of over-expression. 
The tendency to think, to talk, to read sex problems on every side creates 
an impression that everybody acts them, that there is a trend of the times 
to license. While some of the trouble is mere noise and some is simply 
uncouchness, there is a noticeable abandonment of the dignity which 
should mark a new idealism and guard its translation into practice. Of 
course, we want no more whispers, no more lies, false names, wriggling and 
squeamish prudishness. But force is not incompatible with dignity, and 
frankness with a discriminating choice of words. More than one ardent 
spirit has been chastened by the appreciation that he might have spread 
the new knowledge better if he had done it less crudely. That the truth 
needs lucidity rather than expletives is a maxim that the ablest thinker 
on sex questions can afford to recall. 
The Trend Toward Sexual Laxity; Decadence of Chaperonage.—To 
my mind, much of the real trend of the times to sexual laxity as dis- 
tinguished from mere noise, lies in the decadence of home influence, as 102 
illustrated, let us say, by the decline of chaperonage. We forget so easily, 
as I shall take occasion to say again, that knowledge per se is little pro- 
tection unless reinforced 'by judgment. The home must in childhood and 
adolescence, supply judgment. No one can read and see verified in daily 
life such a series of thumb-nail sketches as Kauffman’s “ Girl That Goes 
Wrong,”1 without realizing that there is no substitute for the guardianship 
of experience over the rashness, the impulse and the unsophistication of 
youth. Such guardianship, without being tyrannical, must extend to many 
little things, which the relaxations of our day regard as trivial. In con- 
versation with a noted prostitute, herself a woman of more than average 
cultivation and insight, she rated the young girl’s ha'biit of dining out 
unchaperoned with men as one of the most potent contributing factors to 
illicit sexual experience. In the same class go the unsupervised automobile 
jaunt, and the activities of the taxi-cab, which are writing a new chapter 
into the sexual history of the day. There is little time for mention of 
more than principles, though each observer can discover a new illustration 
for himself. The same point stands out through all of them. The 
decadence of adult oversight for boys and girls alike, is throwing back 
upon the most ardent, least sophisticated, least experienced and therefore 
least competent period of life, sex decisions of more than vital moment to 
the race. 
Contributions Made by the War to Sex Problems.—Upon problems of 
sexual conduct the war has already shown evidence of four important 
influences. The first of these is the full-fledged entry of women upon the 
stage of industry and economic independence. As I have already inti- 
mated, profound modification of the relation of husband and wife may 
result from it. The second influence may come through the general 
spread of knowledge on medical means of preventing syphilis and 
gonorrhoea. Millions of men, literally, have been educated to it by army 
methods, and broadcast public teaching on the subject has been carried 
out in Italy and Germany at least. Whether or not there shall be a 
medical prevention of the genital infections has ceased to he a matter for 
discussion. It is here, and the next problem is its proper utilization and 
control. The knowledge is good, but again, its application needs judgment 
and must be begun before the flood of it engulfs us. The third influence 
comes through the tremendous contributions of the war to the idealistic 
solution of sex problems. The questions of the efficiency of intelligent sex 
education, of the repression of vice, of the ability to keep up sexual morale 
by indirect influences such as recreation and the increasing of the livable- 
ness of life, are settled past all dispute. The fourth influence is being 
exerted through the awakening of the world from lethargic indifference to 
a sense of public duty in connection with sexual issues. The spectacle of 
governments bending their energies to the solution of the problem of 
syphilis and gonorrhoea would astonish our great grandfathers no less than 
would the electric motor, the locomotive and the wireless telegraph. 
1 Kauffman, R. W.: The girl that goes wrong. New York, Moffat, Yard, 1911 CHAPTER III. 
The Economic Background of Syphilis and Gonorrhoea. Prostitution. 
Alcoholism and the Genital Infections. Other Forms 
of Commercial Exploitation. 
The Dollars and Cents Aspect.—In the earlier days of the campaign 
against tuberculosis, some very ingenious methods were resorted to in 
order to impress the public with the fabulous losses in actual dollars and 
cents, occasioned by this disease. No comprehensive figures are at present 
available for syphilis and gonorrhoea. Most of the evidence bearing upon 
the economic cost of syphilis is buried among the statistics of insane 
hospitals and pauper institutions. Only occasional glimpses can be had, 
which indicate the enormous wastage which they cause. Williams 
estimated, it will be recalled, that ten men insane from syphilis represented 
a net loss based on life expectancy of $212,248 in earning capacity, and 
a cost to the state of Massachusetts of $39,3lU2. According to the census 
of 1910 there were 180,000 insane persons in the United States. Estimat- 
ing 12 per cent of insanity to be due to syphilis and the experience of 
Massachusetts to be applicable to the country as a whole, the economic 
loss in earning capacity and cost of care on the score of a single item in 
the total bill of only one of the genital infections, would approximate 
$467,000,000. If insanity, a relatively uncommon complication of syphilis, 
can alone cost more than a half billion dollars, the cost of illness and 
death from other and equally grave complications, such as heart and 
kidney disease, blindness, deafness, paralysis due to nervous change, when 
added together, will total figures that take rank beside the stupendous 
costs of war. These are estimates of the cost of consequences. The wast- 
age of money spent on ineffective treatment, on the maintenance of hos- 
pitals and dispensaries, on medical fees, and through reduction of 
efficiency without absolute crippling and death, is beyond the reach of 
comprehension. 
Current legislative appropriations which provide for little more than 
scratching the surface of the problems of prevention, vary from $60,000 
to $100,000 in certain states, to the $2,700,000 provided for one year’s 
work on the part of the national government. In 1914 it was estimated 
that $400,000 would merely provide salvarsan for the British, without any 
consideration of the cost of giving it. The United States Navy on a 
single invoice of salvarsan paid a bill of $17,000. Sums such as 
could in the aggregate within a generation make an appreciable showing 
on the part of one disease, even as against the colossal figures of war 
finance. 
Cost of Treatment as an Element in the Campaign.—The cost of the 
treatment of syphilis or gonorrhoea is a practical issue of the first magni- 
tude in a public health campaign. Modern treatment of either of these 
diseases calls for prolonged medical attention, and in the case of syphilis, 
especially, for expensive drugs and tests. The expert, who is best fitted 
103 104 
to cope with them, is an expensive man, who has had one of the long and 
costly trainings so characteristic of medicine of to-day. Few patients 
of moderate means are adequately treated for a secondary syphilitic 
infection for less than $500. With complications in either gonorrhoea 
or syphilis the cost rises rapidly and wTith the increasing capacity which 
many of them involve, the ability of the patient to pay for good sendee 
rapidly declines. Again, the large majority of infections are acquired 
early in life, before the victim has reached an earning capacity which 
will enable him to cope with the situation. The result is that he neglects 
it, and loses the opportunity for cure for which in later years, as success- 
ful merchant, banker, public official, he would give all he has. So 
significant is the cost factor in the public health problem of syphilis and 
gonorrhoea, that it is now universally recognized as wise policy for the 
State to provide free treatment for every patient who cannot meet the 
expense. The provision of such treatment should include the services of 
adequately trained men. The sooner the State commits itself to a 
policy of expert service in the genital infection field, the sooner will 
results appear. It is scarcely to be imagined that highly special know- 
ledge of this subject will be found behind every doctor’s name plate. It 
is also a gross injustice to expect men who have met the expense of a 
training fully as prolonged and costly as that of the traction and lighting 
experts and legal counsel for which a city pays so lavishly, to serve with 
inadequate compensation in hospitals and dispensaries. iSuch a system 
in connection with medical schools and public medical facilities leads to 
worthless service and to forms of graft no less obnoxious than thosi of 
politics. Until medical schools and hospitals are prepared to place the 
care of syphilis and gonorrhoea in the hands of properly qualified and 
paid experts, who receive appropriate recognition, for their ability as 
teachers and physicians, a most important field of progress against these 
diseases will remain closed. 
Commercialization of the Sex Impulse.—A powerful, constantly exerted 
force in human affairs will inevitably be subjected to commercial exploita- 
tion, precisely like a source of physical energy such as water-power. 
Powerful influence will be brought to bear to meet an existing demand, 
and to create new demand.. -Simple economic laws like these govern the 
relation of prostitution to the sex life. The relation has no secrets and 
few mysteries. Take the money out of it and from behind it, and it loses 
a large part of its hold on the world. Similarly the relation of alcoholism 
to prostitution and through it, to syphilis and gonorrhoea, is a phase of 
commercial exploitation of the sex impulse, the simple selling of a means 
to promote hilarity and take off the moral brakes. These two factors in 
the public health problem of syphilis and gonorrhoea are so important that 
their fundamentals must be considered here. 
Syphilis and Gonorrhoea in Prostitutes.—Sexual relations between 
men and women of easy virtue constitute the ultimate source of the over- 
whelming proportion of infections with syphilis and gonorrhoea. There is 
on the whole little evidence to show that clandestine differs markedly from 
public prostitution in its ability to infect the patron. In fact the throwing 
of false security such as that of medical examination and registration 105 
about the better organized public types, serves to make them more rather 
than less dangerous.1 Repeated careful surveys of the situation have 
brought out with striking definiteness the percentage of infection which 
exists among prostitutes.2 Gonorrhoea is present in approximately 75 to 90 
per cent and syphilis in 60 to 80 per cent of those to whom promiscuous 
sexual exposure is habitual. Papee showed that 30 per cent of the prosti- 
tutes in a typical city (Lemberg) were in the first to third year of a 
syphilitic infection—that is in its most contagious period. Through every 
investigation there stands out the fact that three-fourths of the dangerous 
cases are sexually in the most attractive period of their lives—under 
twenty-five years of age.3 The number of men who may be subjected to 
risk of infection by a single woman seems incredible. Conservative Ger- 
man estimates during the war placed the activities of a prostitute at forty 
exposures per day, and Exner cites a case on the Mexican border where a 
woman with active syphilitic lesions subjected 120 men to exposure in 
two days. With syphilis and gonorrhoea so overwhelmingly prevalent it is 
difficult to understand why every exposure with a prostitute, public or 
private, does not result in infection. The explanation involves a com- 
bination of chance, presence or absence of contagious lesions, the stage of 
the prostitute’s infection, and the presence or absence of favouring con- 
ditions in the partner such as abrasions, uncleanliness, etc. 
The Medical Examination of Prostitutes.—The general description of 
the medical aspects of syphilis and gonorrhoea makes it apparent why the 
prevention of infection in prostitution by such measures as the medical 
examination of women has proved a failure under the conditions of 
ordinary life. A woman may be a passive carrier of infection from a 
previous partner without herself showing evidence of the disease. Ex- 
amination of men is therefore as much in order as that of women. The 
entire intent and purpose of a medical examination for gonorrhoea can be 
easily evaded in the majority of instances by a clever prostitute. The 
examination for both diseases to be even partially effective calls for 
laboratory equipment and special skill not usually available, and for 
time, which officials making such examinations do not have. The result 
of a negative examination on one day may be reversed on the next by the 
appearance of a flare-up or a contagious lesion of which the patient herself 
may be unaware. It is true that so far as the prevention of syphilis 
particularly is concerned, there are measures which have never been 
employed on prostitutes which may have greater value than those used 
heretofore. The question arises, however, whether such measures can ever 
be brought to a pitch of efficiency wdiich will make them even medically 
speaking as effective as a vigorous policy of suppressing and crushing out 
all prostitution -wherever it can be reached. 
1 Jolivet found in a recent survey that 52 per cent of 100 soldiers had been 
infected by registered, 48 per cent by clandestine prostitutes. 
2 Baltimore Vice Commission. Survey, March 25, 1916, 749. 
3 Philadelphia Municipal Court Reports, for 1916, for example (p. 260) show 
that 150 of 214 girls entered prostitution between the ages of twenty and twenty- 
four. 106 
Syphilis in the Lax and Indiscreet.—‘Syphilis in particular does not 
wait for sexual intercourse in order to attack the lax and careless. Those 
who permit liberties to be taken with their persons in the form of kissing 
and caresses which do not go to the point of actual sexual relations, are 
subject to a risk of infection which is larger than is generally realized. 
This risk is doubled by the mistaken belief of both parties that by 
indulging in mild offences they escape the dangers of an outright breach of 
decency. 
Unsocial Sexual Relations Cannot he Made Safe.—On the whole it is 
a conservative judgment that no device exists by which unsocial sexual 
relations can be made safe from the standpoint of genital infection. It is 
difficult to believe that the attainment even of maximum efficiency in their 
public health control will totally do away with syphilis and gonorrhoea. 
They will remain the heritage of lust. It is axiomatic that the quintessence 
of caution, the most highly specialized instinct of the “ knowing one ” for 
the “ safe chance ” sooner or later goes astray. Where infection has been 
most carefully ruled out, or is least suspected, there it occurs. 
The Struggle Against Prostitution; Regulation, Repression, Legal, 
Measures.—It is, of course, impossible in a study of this kind to discuss at 
length the methods of attack upon prostitution as the carrier of syphilis 
and gonorrhoea. The older conception that the situation was hopeless has 
no foundation in fact. The control of the more intangible and clandestine 
types of unsocial sexual relations is a problem in morals, psychology and 
economics. The control of commercialized vice which is probably the 
larger factor of the two is a matter of public administration and the 
systematic and determined employment of repressive force. Regulation 
of prostitution, in effect an attempt to herd it together and control it by 
systems of inspection and registration is of long standing on the Continent, 
and during the war was a part of the accepted policy of certain of the 
belligerents. The plan has innumerable weaknesses, apart from its con- 
temptibility as an expedient. Policies of toleration and regulation are 
giving way before repression or abolition, which consists in the systematic 
stamping out of vice wherever it can be found. To the United States 
belongs the distinction of demonstrating in connection with the military 
and naval policy of this war, that repression is not only the only 
respectable, but by all odds the most highly efficient policy which a com- 
munity or a nation can adopt. The most effective implements in civil 
life against commercialized vice are those which separate the commercial 
and the vice by attacking the former. As soon as organized prostitution 
ceases to be a paying proposition, it begins to dwindle in influence and 
extent. The removal of the pernicious influence of the liquor traffic which 
reaps enormous profits from organized prostitution, has had remarkable 
effect. A very ingenious and effective legal instrument exists for making 
commercialized prostitution unprofitable. This is known as the injunction 
and abatement law, and its mode of action consists in tying up property 
both real and personal, which can be shown to be used for immoral 
purposes. It is so effective that one vigorous application will put an 
entire red light district out of business, and the law can then be employed 
in ferreting out and crushing the sporadic and scattered activities which 
follow it. 107 
State Care of Delinquent Girls.—A measure directed against prosti- 
tution whose importance has repeatedly impressed me, is the proper 
provision by the State for the care of mentally or morally deficient girls, 
who through weakness and lack of moral sense and backbone rather than 
viciousness are led into prostitute careers. Many such patient® are 
encountered in the course of medical consultation work, and the problem 
as to what to do with them has had deplorably little attention. Industrial 
schools do them no good, since the difficulty is inherent and cannot always 
be trained away. They are not insane or imbecile, and hence cannot be 
committed to the average asylum. The influence of every one interested 
in the movement against genital infections should be enlisted in trying to 
secure farm colonies for these types, where they can be under custodial 
care for life. 
The Fundamental Principle.—One principle stands out sharply from 
all the rest. Regardless of whether the relations between the sexes have 
reached or will ever reach a final adjustment, it can be unqualifiedly said 
that commercialized prostitution is wrong and must go. Every self- 
respecting man or woman can without a moment’s hesitation cast his 
influence on the side of repression. 
Alcoholism and the Acquiring of Syphilis and Gonorrhoea.—Alcohol 
has two important influences on the spread of syphilis and gonorrhoea. It 
puts people in a state of mind to get infected, and it decreases their 
resistance and systematically injures them once they are infected. 
Estimates of the proportion of men infected while under the influence of 
liquor vary from 30 to 80 per cent (Riggs). The physiological action 
of the drug, even when taken short of intoxication, is to take off the 
brakes, remove the inhibitions, so that acts which an individual could not 
perform in a normal state without losing his self-respect, become matters 
of course under alcohol. Befuddlement and confusion further add to the 
effect by making the individual not only rash but undiscriminating, so that 
he will assume risks which he would have avoided if he had been in 
possession of his faculties. A drunken man not only can be betrayed into 
any sort of situation, but is powerless to take any measures to prevent 
infection until too late. That no amount of cultural tradition avails 
against a few drinks is abundantly evidenced by the downfall of many a 
splendid college man. The influence of alcohol upon girls and women is 
no less dangerous. The wine-list on the back of a cafe menu is responsible 
for the tragic ending of many a seemingly innocent supper. If alcohol 
could be absolutely excluded from every point of social contact between 
men and women, there would be an immediate drop in the incidence of 
syphilis and gonorrhoea. The influence of alcohol in promoting sexrual 
indiscretion has been exploited without scruple by the liquor interests of 
the world, and furnishes alone an adequate reason for their extinction. 
Kneeland’s astonishing presentation of the relation between commercial 
alcohol and commercial vice is classical and should be read by every adult1 
i Kneeland, George J.: Commercialized Prostitution and the Liquor Traffic. 
Social Hygiene. 1916, ii, 69-90. 
Clark, Walter (Field Secretary of the American Social Hygiene Association) : 
Prostitution and Alcohol. Social Hygiene, 1917, iii, 75-90. 10S 
Physiologic Effects on Persons Already Infected.—The physiologic 
effect of alcohol upon the gonorrhoeic has been mentioned. It makes 
infection easier, and it promotes relapse in the acute stage. Upon the 
syphilitic the influence of the drug seems to be mainly upon the nervous 
system. The combination of alcohol and syphilis tends sharply toward 
locomotor ataxia and general paresis, and toward serious involvement of 
the kidneys, the 'blood vessels and the liver. A syphilitic who drinks is 
predisposed to danger from treatment as well as disease, and on the whole 
deserves little consideration unless he stops. 
Other Phases of Commercial Exploitation of Sex; the Stage, Boohs, 
Clothes, etc.—'Commercialization of the sex impulse extends to other fields 
than those of alcoholism and prostitution. The filthy picture industry and 
other grossly indecent activities still thrive. Less flagrantly but still 
regrettably, the moving picture theatre, the legitimate stage, books, and 
clothes, all reflect the eagerness to coin sex curiosity and sex desire into 
cash. While it is scarcely necessary to be Comstockian in repression of 
every aspect of the nude, there can be no escape from the fact that the 
vogue of “ leg shows,” suggestive gesture and dancing, risque plays and 
peek-a-boo garments is inspired by something more than a return to 
appreciation of the Grecian in art. It perceptibly raises the tempo of 
sex life, and cannot be dismissed as negligible by the student of sexual 
morale. While we need not become fanatics, it is unwise to ridicule 
jnqualifiedly those who speiak on the side of caution in these things. 
The trend is there, and best recognized for good or ill, rather than veiled 
under an assumed, because convenient broadmindedness. If eroticism 
is to be the trend of the times, perhaps well and good. It may be that 
nature is thus asserting herself in the struggle against modern economic 
checks upon the sexual life. But profitable eroticism has no excuse for 
being. 
We return then to the point at which we began. Every act and every 
industry which makes a dollar out of the stimulation of sex impulses 
deserves the closest scrutiny and the most persistent supervision from 
those intent on sexual idealism. It plays with fire. CHAPTER IV. 
Moral and Educational Prophylaxis of Syphilis and Gonorrhcea. 
Problems and Methods of Sex Education. 
Morale and the Sexual Life.—It has taken the war to demonstrate the 
extraordinary efficiency of morale in every phase of struggle. In the 
sexual life no less than on the field of battle, it is paramount. A high 
morale has an efficiency as a preventative of syphilis and gonorrhoea in 
comparison with which even the triumphs of medical prophylaxis take 
second place. The conservation and the development of morale in the 
sexual life, therefore, becomes not a mere side-issue, but a first duty. Four 
fundamental factors contribute to a high standard of sexual morale. These 
are: a positive as distinguished from a merely negative or prohibitive 
idealism; numerous effective and clean outlets for the energy of the sex 
impulse and the ideals that it underlies; certain fundamental habit 
inhibitions; the teaching of the young child, not the adolescent or the 
adult, the character basis for a healthy sex life. 
Positive Idealism and Idealistic Expression.—“ Elan,” that vivid 
French word to express the ardour and exultation of battle, is a product 
of the attack, rather than of defence. A man may stubbornly but without 
enthusiasm, defend himself from temptation. But give the force behind 
the temptation something positive to work for and it is transformed into 
inspiration. For example, “Thou shalt not covet thy neighbour’s wife,” 
and “ thou shalt not commit adultery,” have force, to be sure, but they 
lack as principles the breadth and the effectiveness of the positive in- 
junction which embraces all that either of them could mean, “ Thou shalt 
love thy neighbour as thyself.” The sexual life of humanity needs 
inhibitions to be sure—but too often the negations have been substituted 
for the outlets and expressions, and dwarfing without ennoblement has been 
the result. To the effect of lifelong repression and inhibition of sex 
expressions and yearnings much of the barrenness of many a withered 
marriage has been due. It is an essentially evolutionary and stimulating 
view of the possibilities of the sexual life which teaches a self-control that 
expresses itself in noble action rather than in the negative virtue of 
frigid ultra-restraint. To teach sexual morale as a thing which can 
and should be an expression of one’s best, not an inhibition of one’s 
worst, is to teach it dynamically and synthetically, and to enlist in the 
cause all the upward tendency of the race. 
Altruistic Outlets for Sexual Energy.—If a high sexual morale is to 
be a form of enlightened expression rather than suppression it is necessary 
to plan altruistic outlets. One’s lower centres in a state of physical health 
take care of our impulse to physical expression. What the vast body of 
men and women need to have insistently shown them, is the fact that 
there are indirect expressions of the sexual instinct which will enrich both 
themselves and the world. Few passionate but controlled souls escape the 
109 110 
learning of this lesson. More could be taught it, if there were more 
teachers and the teaching were begun earlier. The woman who in default 
of marriage and children, mothers the family of another; the nurse whose 
care of the sick has all the tenderness of the love of woman for man and 
mother for child, are examples of it. The man who builds into the fabric 
of a great lifework the love of the woman he cannot have or never met, 
is a less familiar but no less needed type. Gospel of this sort seems some- 
times far removed from the sordid details of this or that wreck we know 
of, and yet it is fundamental and vital, and analysis leads us to it again 
and again. The torrent of obscenity which belches from the mouth of a 
brickyard paddy has at least the latent energy of sewage. If as a child 
he had been taught a different mode of expression for that same force, 
he might have been a power for good as a man. Outlets, physical and 
spiritual, for the energy of the sexual life, are part of the essential mech- 
anism for the preservation of its morale. 
The Fundamental Inhibitions; Sound Character as a Basis of Self- 
Control.—An unqualifiedly positive and expressive philosophy in the sex 
life would' be, of course, overbalanced. There must be fundamental inhibi- 
tions. The “ Everlasting No ” in the sexual life must be bred in the bone, 
not merely put on as a garment. It is moreover, a habit, not an enlightened 
rationalism. The man to whom the physical degradation of resort to a 
prostitute for sexual relief is impossible, is not the product of the logic 
of the situation, or its fears. He is physically incapable of an act that 
runs counter to the instincts of cleanliness bred in him with tooth-brush 
and soap, as well as the more spiritual forms of cleanliness expressed in 
the straight-forward eye and the ring of sincerity and honesty in the 
voice. The strongest safeguard against syphilis and gonorrhoea which 
a man or woman can have is not knowledge of risks of infection or 
familiarity with means of avoiding them, but sound character. The type 
of personality that loves its neighbour as itself, that lives rather than talks 
the square deal, that is tender, chivalrous, loyal, and generous, possesses 
a margin of sexual safety for which there is no prophylactic substitute. 
Make a man first; teach him honour, make his word his bond, his first 
thought for the other fellow—then let him love, and there will be little 
cause for fear. 
Teach the Child.—A foundation of the type I have described is laid 
at only one time in life—in childhood. If sexual morale depends on 
character, it is folly to try to paint it on the surface at puberty. Those 
who have tried their hand at reconstruction in adults likewise appreciate 
the futility of trying to mould the hardened clay of the sexual experience 
of later life. If we are to grasp the opportunity to create a sexual idealism 
we must teach it to the children. The opportunity often comes in my 
experience, by utilizing those who have suffered themselves, and will take 
the steps that save their children from a similar fate. The mother who has 
been infected, or who has had the opportunity to see at first hand the 
experience of another, makes an able ally. Projects for the reformation 
of the adult sexual offenders of our own generation require a superlative 
and in the end usually a futile evangelism. If we are to reconstruct, it 
must be through our children. Ill 
Home, Protection and the Worh Outlet in Sex Education.—Sound 
sex education is a highly complex affair. It demands the intelligent 
employment of recreation, of discipline, of hard work, of responsibility, 
even of hardship, as means to an end. The scene par excellence for the 
play of these forces upon the child is home. No system of schooling, no 
formal method of training will ever he an adequate substitute for the right 
kind of a family life. To remedy a defect or find a cause in a sexual 
blunder, go back to the home and the family. The child who is insolent 
and disobedient, the boy who is unsportsmanlike, who has an allowance he 
does not earn, the wilful, pert girl with skirts too short and hair too 
high, the youth with silk hose, and cigarette hanging from his lips, owner 
of an automobile when he should he mastering the wheelbarrow, are feeders 
of the mill of sexual catastrophe. Unsupervised companionship between 
boys and girls, idle evenings, personal familiarities and especially physical 
contacts between the sexes, seem outwardly harmless, but they are the 
starting points of trouble. It should not take a medical expert in syphilis 
or gonorrhoea to appreciate that it is not a cold old-maidishness but simple 
common sense which throws protection around young girls, and keeps 
young fellows busy striving, studying and working instead of philandering. 
Protection and the work outlet should come into play early. Few men who 
can look back with frankness upon their boyhood and school days really 
believe that sexual activity begins with puberty, or that sexual stimulants 
such as dancing and tete-a-tetes, can he allowed full play untempered with 
judgment, if we are really to take our sex standards seriously. 
Virginity is only Half the Problem.—The object of a successful teach- 
ing of sexual morale i3 not merely to marry virgin women to virgin men. 
Pre-marital continence is only one phase of the problem. Many a mother 
heaves a sigh of relief when she has her daughter safely married off, 
forgetting that there are wolves within as well as without the fold, though 
perhaps of a different stripe. The man or woman whose whole sexual 
training has been concentrated on virginity and suppression can be as 
hopeless an impossibility in a workable sexual career as a Light o’ Love. 
To this side of the problem, by all odds the more difficult of the two, little 
thought has been devoted. Inhibitions may make the virgin, but it takes 
dynamic idealism, some power of expression, and physical fitness to make 
the successful father and mother, husband and wife. To this dynamic 
idealism all the variegated experiences of living—those gained in work, 
in recreation, in hardship, and in adversity, contribute the gifts which 
make achievement. It is our double duty to see that our children do not 
lack their share of these essential aids. 
Value of Sex Instruction.—Education in the facts of the sexual life 
is to many the stone of stumbling in modern ideals for a higher sexual 
morale. Opinion on the correct technic of such teaching is in the making. 
The actual value of education in sex matters is, however, fairly well 
settled. For example, Riggs, at the Norfolk Naval Training Station, was 
able by purely educational methods, to reduce the percentage of sexual 
exposure in a large body of men, from 126.7 per cent to 38.6 per cent 
in a period of two and one-half years. Ninety per cent of 676 college men 
in a special survey estimated that they had been benefited by sex instruc- 112 
tion received from wholesome sources. On the other hand, 79 per cenx 
of 690 college men who had received their first information from other 
boys and girls and miscellaneous sources, estimated the effect to have been 
bad. As between the taught and the untaught the difference is so striking 
as to justify even the timid in making an effort to instruct those to 
whom they owe a duty. 
Methods and Technic of Sex Instruction.—Impressions of the methods 
and technic of sex instruction may be briefly summarized as follows. The 
age at which children begin to acquire first impressions of sex is much 
less than is commonly supposed, and much earlier than the age of the 
official attempts to impart information. The estimated age of first sexual 
impressions in a large survey was 9.6 years, the age at which wholesome 
instruction was first received 15.5 years. The sex education of children as 
such must therefore be begun much earlier than puberty, as previously 
pointed out. If the parent frankly confronts the first questions asked 
by the child and answers them simply, truthfully and directly, without 
too much detail, the simplicity of the child and the entire absence of the 
selfconsciousness of puberty will make the situation easier to manage 
thereafter. The child should be repeatedly impressed with the fact that 
the source of information on such matters is the father and mother, not 
friends and companions, and that the subject is never to be discussed 
outside. Emphasis on the impersonal and larger aspects of sex is essential. 
Children respond well, in my experience, to explanations of honourable 
conduct toward each other. The physical side should be biologized at first 
by the use of plants and other animals, but to be effective it must always 
come back to human beings, although an excessive literalism is to be 
avoided. While corn and tiger lilies and other examples from real life 
are valuable, pictures of human anatomy are generally conceded to be 
undesirable because too suggestive. The choice of words is the most 
embarrassing problem to the untrained. It can be overcome to no small 
extent by reading some of the literature illustrating methods of approach, 
which is obtainable from accredited sources at the present time.1 During 
the earlier years of a child’s life it should be taught personal cleanliness, 
learn not to meddle with the genitalia, and acquire a profound respect 
for these parts, which little children learn well on repeated insistence. 
If children are found to have made a false start, it is the height of folly 
to resort to fear or threats. Both of them drive the child violently in 
upon himself, and in the case of masturbation especially, lead to mental 
states infinitely worse than the original trouble. In the earlier years 
is laid the whole foundation of the intimate friendliness between parent 
and child which will draw the two together and make the child approach- 
able during the transitions and self-consciousness of puberty. The parent 
must play an active part and move toward the child, not wait for the latter 
to approach him. It is surprising how easily satisfied a child’s curiosity 
is, and how often vicious information comes to him gratuitously, and not 
of his own seeking. 
i A written request for booklets, or teaching material, addressed to the 
United States Public Health Service, 228 First Street, N.W., Washington, D.C., with 
a statement of the age, sex, and social status of the persons concerned, will receive 
a prompt response. 113 
Companions and Books.—The companionships of a child must be 
closely watched, and this not by watching the companion alone, hut hy 
watching his parents, and estimating the type and degree of their influence. 
A boy whose father and mother let him grow up as a weed has a surprising 
capacity for imparting weedy characteristics to the better stock of the 
neighbourhood. Older boys are a particular danger, and unsupervised 
walks and absences with older boys are often fully as dangerous to sexual 
integrity as later unchaperoned contact between the two sexes. A boy’s 
first lessons in his relation to girls should take the form of chivalric regard 
for mother and sister, and the cultivation of his protective instinct for 
them. To make it part and parcel of a boy’s creed that he who harms a 
woman is a cad and a bum sport as well as a coward is to build up insurance 
for clean living. Books, too, have no small influence on adolescent sex 
ideals. A course of the sentitmentalistic mush too easily available to 
unguided boys and girls has paved the way to many a premature emotional 
crisis and sexual disaster. 
Good Sportsmanship and Hardy Living.—Woodsmanship, as among 
the Boy Scouts, vigorous exercise, forms of activity involving team play, 
teach fundamental ideals of sportsmanship and the square deal, and have 
a vital place. The leaders in these movements should be selected with the 
utmost care, on a basis of personal character and not on that of mere 
craftsmanship. The foulest mouth and the vilest personality I have ever 
met in a variegated experience was that of the much prized captain, 
athletic idol and all-American star of the football team of a great univer- 
sity. Athletics for its own sake breeds dangerous types of personality. 
The so-called amateur ideal of training to a pitch whose height only 
serves to emphasize the fall when training breaks, has no place in the 
kind of sportsmanship that develops sexual morale. 
The Time for Plain Facts —(Syphilis and gonorrhoea should not be 
mentioned to children. It is my personal belief that the essential facts 
of the carrying of sperm to egg cell in the human being, told in purely 
impersonal language and devoid of detail can be given to both boys and 
girls just before puberty. Information of this sort to be protective must 
not, however, be too vague. Girls for example, can be warned to make 
boys keep “hands off” and boys similarly, enjoined against caressing and 
handling girls. The pubescent boy or girl can then be told if the situation 
seems threatening, about the genital infections. Much depends on the 
individual. In general such knowledge comes best, I believe, between the 
fifteenth and the eighteenth year. While sexual experience occasionally 
occurs soon after the twelfth year, a sound foundation in character and 
elementary training will make any restraining influence that fear can 
lend unnecessary until maturity is well established. The importance of 
seeing that every girl at this time understands the physiology of menstru- 
ation and every boy understands the seminal emission and is put on his 
guard against quacks, cannot be over-emphasized. 
Visual, Graphic and Personal Teaching; the Speaker.—War experi- 
ence has definitely demonstrated the superiority of visual, graphic and 
personal methods of teaching over books, leaflets and other forms of 
51807—8 114 
printed matter. None the less the latter must be resorted to and have an 
important place. Visual methods call for discretion. Skilfully prepared 
exhibits of the poster type are effective,1 especially when accompanied by 
facilities for free private medical advice—a fact which quacks have long 
used as a drawing card. Bulk methods of verbal teaching of sexual facts 
to younger people are to be discountenanced. Very few speakers have 
shown themselves able to handle them. Munger, in the Navy, had oppor- 
tunity to observe its undersirability and relative ineffectiveness. It is 
impossible to strike a tone that fits all ages or types even in a one-sex 
audience under eighteen years of age. It is vital in these matters that 
the speaker be en rapport, and a giggle is enough often to mar the situ- 
ation. Amateurs should not practice upon audiences. Before older 
groups a forceful and well-informed speaker can dominate the situation. 
The presentation of sex material in lectures is an art in which many are 
called but few chosen. The most powerful and effective speakers I have 
heard have combined a commanding personality with the ability to express 
themselves in the vernacular. In other words, they have possessed the 
qualities of popular leadership. The fault of many lecturers is their 
tendency to talk from above down, to be too vague and to indulge in 
pedantry, bathos, or sesquipedalian verbiage. It is possible to give an 
unforgettable talk on sex ideals without direct reference to the Deity, or 
to vice and sin. There is that in clean living, good sportsmanship and the 
square deal for women, that instinstively appeals to red-blooded men, and 
its application to the sexual life is more often obscured than furthered by 
turgid rhetoric. 
i Osborne, F. J.: A health exhibit f r men. An educational exhibit on venereal 
disease control and prevention presented at Coney Island by the New York Social 
Hygiene Society, Social Hygiene, 1916-17, iii, 27-49. CHAPTER V. 
The Public Health Control and Personal Prophylaxis of Syphilis! 
and Gonorrhoea. 
The Public Health Control of Syphilis and Gonorrhoea.—Public 
health control of the genital infections is meant to include those elements 
wVch organized public health work contributes directly to the campaign 
against these diseases. As legitimate parts of public health activity we 
must rate the systematic suppression of temptation to indecency involved 
in the abolition of prostitution, and the extinction of the liquor traffic. 
No attempt to control syphilis and gonorrhoea deserves serious consider- 
ation until it has a thoroughly organized and uncompromising policy with 
reference to these two factors. The gross stimulation of sexual impulses 
must go. This and other essentials of a public health campaign against 
syphilis and gonorrhoea are admirably illustrated in the policy of the 
United States Government as outlined by Major Sawyer, and need not be 
duplicated here. 
The Church and the Problem.—Attention has already been called to 
a point of contact between the church and the problem, which deserves 
re-emphasizing; that is, the influence of the former over the solemnization 
of marriage. Few obligations seem more obvious than that the institution 
which stands determinedly for the inviolability of this moral and social 
bond should feel a direct sense of obligation in determining the fitness of 
those who enter into it. The clergyman and the priest are exercising 
their highest function in company with the physician and the parent 
when they feel toward the marriages of their parishioners a sense of 
responsibility greater than that attached to any other duty which they 
may perform. If they feel that sense of responsibilty, the marrying 
parson and the ecclesiastical marriage mill will cease to exist. A closer 
guardianship of the entrance into marriage will obviate the necessity for 
so much emphasis on divorce, inasmuch as the permanence of the bond 
is directly proportional not to penalties placed on its violation, but to the 
wisdom that presided when it was entered into. 
The New Responsibilities of the Medical Profession.—The awakening 
with respect to syphilis and gonorrhoea will place new responsibilities 
upon the medical profession, to which attention has been directed from 
time to time in this study. 
The existing situation is not satisfactory. It is unsatisfactory, not 
because the physician does not feel the need for better things and does not 
seek them, but because better things have not been available. To know 
syphilis and gonorrhoea one must be taught, and taught not by men to 
whom the subject is incidental drudgery, but by enthusiasts. Such men 
have formed no part of the staff of the medical schools of the past. 
Even to-day the number of schools which are teaching syphilis and 
gonorrhoea with the energy that their place in medicine and public health 
115 116 
deserves, can be numbered on the fingers of one hand. An unfortunately 
large proportion of the medical profession are thus attempting to work 
with a modern situation using tools that compare in effectiveness with 
the stone hammers and knives of paleolithic man. Gonorrhoea lags in the 
background not alone because of its inherent peculiarities as a disease, 
but because a combination of adverse circumstances has kept enthusiasm 
about it at a low ebb, and teachers and fighters correspondingly scarce and 
ill-trained. 
Hospitals and the Problem.—Conspicuous examples of medical philis- 
tinism of the type that obstructs progress in this field can be found in the 
attitude taken toward syphilis and gonorrhoea by hospitals. While syphilis 
is not a quarantinable disease throughout its whole course, a person with 
active contagious syphilis has no business at large in the community until 
he is temporarily sterilized by arsphenamine. A very brief stay in 
hospital provides the needed opportunity. Many of the complications of 
gonorrhoea respond rapidly to bed treatment, with the avoidance of chron- 
icity and prolonged contagiousness. Many other reasons exist why there 
should be regular provision in general hospitals for the care of patients 
with syphilis and gonorrhoea. Estimates based on large experience call 
for one hospital bed for these diseases to each 2,000 population in order 
to provide for their modern treatment. The actual state of affairs in 
our large cities comes nearer one bed to 10,000 population. The explan- 
ation appears to lie simply in the mediaeval attitude of boards of trustees 
and hospital administrators toward the diseases, plus the belief that in 
the existing state of public sentiment their proper care is “ not feasible.” 
That it is eminently feasible, is demonstrated by the fact that probably 
the best-considered and yet most conservative modern programme against 
syphilis and gonorrhoea in the world, that of the Sydenham Commission 
in Great Britain, embodies it and is putting it into practice. In this 
country a mere half-dozen or so of hospitals and clinics have recognized 
the place of thi3 work in the future of medicine and are operating com- 
plete hospital and dispensary services under the direction of experts. 
Two details it is important to remember. In the first place special 
venereal ho*spitals treating syphilis and gonorrhoea alone are not effective 
in meeting the general problems, because patients, sharing the public 
prejudice, feel themselves disgraced by resorting to a place the mere attend- 
ance upon which constitutes a label. In the second place the need for 
hospital care for the victims of the genital infections is not limited to 
the down-and-outs who are now the best provided for. It would be difficult 
to find a hospital of any size so discriminating in its patronage that it 
has no need for beds to treat syphilis and gonorrhoea. There is no city 
of 25,000 or over whose hospital would not be performing a public service 
of the first magnitude by taking the lead in the development of modern 
facilities for the care of genital infections. Public demand for such 
facilities combined with the demonstration that it is not only a duty, but 
profitable to furnish them, will in the end convert the obstructionists. 
The Press and the Problem.—The problem of how to bring authentic, 
effective and yet properly guarded information on the genital infections 117 
to public attention through the medium of newspapers, magazines and 
other influential organs of public opinion is an important one. Such a 
means of making even a few truth-telling words and names common know- 
ledge, is of the greatest service. To be effective I believe the following 
principles should be followed. First, the information must have the sanc- 
tion of a central authoritative source, which can standardize it and give 
it a positive quality. All through the medical field of the genital infec- 
tions there are seeming contradictions and variations in method and 
opinion which are extremely confusing to the uninitiated. When doctors 
disagree, the unfortunate layman, lacking the power to interpret, is thrown 
into perplexities which leave him in doubt as to whether there is such a 
thing as real knowledge on the subject. The point over which the dis- 
agreement occurs may be trivial, and the wrangle purely scholastic, but 
it breaks down the confidence in leadership which promotes effective 
public action. Other obvious requirements of a written propaganda are 
the judicious but not vulgar use of the vernacular, precisely as in lectures, 
and the avoidance of technicality. Written material on health matters 
should not attempt to deal with treatment except to outline general prin- 
ciples and minimum requirements. If it does more than this, it belongs 
on the same plane as the practice of medicine by correspondence, which 
can become an insidious and vicious form of quackery to which the 
columns of many newspapers subscribe even while they ostensibly exclude 
untrustworthy and disreputable medical advertising. Printed propaganda 
must steer between the tendency to over-emotionalism that paints up 
genital infections and hangs them in a verbal gallery of horrors, and the 
dry-as dust presentation of medical facts. It should never be forgotten, 
that in print there is no human voice, no compelling eye, no sharp incisive 
gesture that drives a point home to an intent audience. The vivid and 
dramatic in life, unskilfully managed, too often sounds like “ sob-stuff ” 
on paper, and a tension and tone that can be safely carried, man to man, 
fails of effect when mixed with ink. I think too, that writing on medical 
subjects is a form of special pleading which should so far a3 possible be 
directed at a specific audience. The effort to make material of this kind 
into a single-standard literary pabulum that all who run may read, makes 
it effective only for the middle third of the world audience, affronts the 
intelligence of the upper portions and flies over the heads of the lower 
portions. Italicizing and soarehead typography, too, while they may, like 
the loudly printed handbills, draw a crowd, detract in the end from the force 
of the presentation by robbing it of dignity. Where force of this sort must 
be evoked it should be exerted personally and not in print. I believe, too, 
that convincing material for a medical propaganda can best be written by 
those whose special experience and enthusiam make their thumb-nail 
graphic touches true to life. Much of the literature on sex questions is 
flabby. It seems to lack genuineness because it is abstract. It is the 
specific instance, told with the art of the raconteur, and a proper touch on 
lights and shadows, that etches in the image which inspires action. 
Laws and Law Enforcement; Compulsory Treatment.—It is worth 
while to say a word or two on the need for new laws and law enforcement 
m the modern campaign against syphilis and gonorrhoea, since the 
influence of intelligent men and women can go far toward shamng such 118 
legislation, and the creating of the sentiment which sustains it. The 
rapid progress made during the war has brought certain issues into the 
realm of certainties which would have remained only possibilities for 
many years in times of peace. To have syphilis or gonorrhcea, has sud- 
denly ceased to be a private affair, and has become one of public concern. 
The first evidences of this change of viewpoint is found in the fact that 
syphilis and gonorrhoea are becoming reportable diseases, like measles or 
scarlet fever. The second evidence is that it is no longer a matter of 
individual option with the patient whether he will be treated or not. He 
must be treated, and he must be treated not only until he is not contagious, 
but until he is cured. The entry of this compulsory element into the 
management of syphilis and gonorrhcea will be welcomed by every phy- 
sician who has had special experience with these diseases and has the 
interests of the public at heart. The constant menace of irresponsibility 
can scarcely be appreciated by those who have not had to deal with it 
under the conditions of special and dispensary practice. The ignorantly 
and the wilfully irresponsible form a large factor in the spread of both 
syphilis and gonorrhoea. No amount of personal good will on the part 
of the physician, no amount of free and available treatment, suffices to 
secure the co-operation of some types. Perfectly possessed of all their 
faculties, they will leave the consulting room with fervid assurance of 
good intention, to disappear as completely as if they had stepped off the 
horizon. Among the ignorant and foreigners the problem becomes acute. 
I have seen nurse, interpreter and doctor working to persuade a man with 
a mouth and throat full of syphilitic germs, talking in relays, gesticu- 
lating, arguing, their faces running the gamut of emotions from good 
will to the hopeless anger of defeat, and seen the irresponsible and 
unprincipled carrier of the disease close the conversation by turning on 
his heel and sauntering from the room without a word. The power to 
press a button and have that man arrested at the door would have seemed 
God-given at that moment. There is as great a need for legal compulsion 
hack of the control of syphilis and gonorrhoea, as there is behind the 
prevention of crime. 
The Reporting of Syphilis and Gonorrhoea to Health Officers.--The 
reporting of cases of syphilis and gonorrhcea to the public health authori- 
ties is at present carried out in modified form in a number of states in 
this country. The measure is a rational one, contributing information 
of some value and at the same time doing much to educate patient and 
public in the contagiousness of the infections concerned. As a means 
of controlling irresponsibles it is absolutely essential. Systems of the 
type of the West Australian, do not require reporting by name unless 
the patient shows himself disposed to neglect treatment and thus subject 
others to risk. An unaccountable prejudice even against this form of 
impersonal reporting exists although it must be admitted that the opposi- 
tion too often comes from the type of medical man whose methods and 
ideals are a generation old, wrho cannot give arsphenamine and therefore 
does not believe in it, and who feels that a contagious disease is the 
private property of the owner and may be obtained from him on the 
ancient principle of caveat emptor. A public which is concerned for its 119 
own protection will first see that every infected person who is so dis- 
posed will be able to secure the best modern treatment without regard 
to his means or lack of them. Having fulfilled its duty in this regard, 
it will be justified in demanding that all infected persons, regardless of 
personal vagaries and desires, shall be treated, and that if they show 
themselves inconsiderate of the welfare of others, they shall feel the force 
of the law. 
Legislation Needed on Medical Professional Confidence.—A necessary 
corollary to all progressive legislation on such matters is a provision 
which unbinds the tongue of the physician1 where infection is about to 
be transmitted, and even punishes him as an accessory to a crime if he 
fails to do his duty in making the facts known to the proper persons. 
Personal Prophylaxis; Continence.—The so-called personal prophy- 
laxis of genital infections is the final consideration in a discussion of 
the prevention of these diseases. Personal prophylaxis includes those 
things which the individual can himself do to avoid acquiring gonorrhoea 
or syphilis. The standard of personal prophylaxis is abstinence from 
sexual relations and personal intimacies except in normal marriage with 
a healthy person. It has no substitutes, and no competitors. 
The Medical Prevention of Syphilis and Gonorrhoea.—The medical 
prophylaxis of the genital infections rests upon a discovery by Metchni- 
koff, Roux and Maisonneuve in 1906, that a properly prepared medicinal 
ointment containing certain mercurial salts, if rubbed into the place 
where the germs of syphilis had been deposited, within a few hours after 
exposure, was able to prevent the development of a chancre by killing 
them before they could gain a foothold. This method has been found 
to have a certain amount of efficiency in the prevention of gonorrhoea 
also, but it has been discarded for this purpose in favour of the use of 
certain injections into the urethral canal. The combined prophylaxis of 
syphilis and gonorrhoea was rapidly adopted into all the armies of the 
world following a series of rigorous tests, and has demonstrated a 
remarkable degree of efficiency, which has been increased by the reali- 
zation that to be of the greatest service it must be administered within an 
hour after exposure, and be given by a specially trained attendant under 
medical supervision. Medical prophylaxis is not infallible. Even when 
rigorously carried out it offers no protection against the grave risks of 
extra-genital infection. Its percentage of failure is highest precisely 
where the risk of infection is greatest, among those who cannot exercise 
intelligence in its application. Then, too, apparently trifling variations 
upon the standard methods often render it ineffective, a fact which accords 
with the familiar experience of physicians as to the uselessness of the 
average attempt of a knowing patient to avoid infection by washes and 
similar applications. The prophylaxis of syphilis and gonorrhoea will 
to some extent become common knowledge as a result of the wholesale 
spread of such information through army service. This does not alter 
the fact that to be at its best it must remain under the control of the 
1 As in the State of Ohio. 120 
medical profession. If every person who has been exposed to the risk of 
syphilis or gonorrhoea could be persuaded to report within an hour to a 
competent physician to receive effective prophylactic treatment, the pre- 
valence of the disease concerned would be enormously reduced. It re- 
mains for the individual physician to adopt the standard of personal 
relation to the problem of prevention so ably set forth in the Manual1 
used by the United States Army Medical Corps. As an opportunity to 
give a few words of sound advice, to encourage a new clean point of view, 
to bring home a great moral principle, the moment when a young man 
appeals for rescue from the possibly disastrous results of an indiscretion 
has few equals in the practice of medicine. 
Conclusion.—This chapter closes the study of the modern problem 
of syphilis and gonorrhoea. It has been the aim of the discussion to 
present the facts bearing on these diseases not alone as a medical issue 
for medical men, but as a problem in human nature and in the moral 
strength and weakness of the social order, in whose solution each and 
every one of us has his part. Though we may be spared the actual 
miseries of the sick, their pain must now be our pain, their struggle our 
struggle. Their defeat and death are symbols of our own futility. Only 
by such a socialization of our point of view toward the public health can 
we hope to advance beyond our present outlook and effectiveness. With 
the movement against germs and bodily disease must go a will to right 
spiritual wrong, an idealism for the body which is incomplete without the 
perfection of the soul. If we see the two as one, we have made the first 
step. If we as a race can feel our brothers’ sickness as our own, their 
lacks our lacks, their triumph in flesh and spirit, our triumph, there is 
in us the stuff of destiny and there awaits us a future without finite limit. 
iA manual of treatment of venereal disease. Chicago, Am. Med. Assn., 1917, 
100 pp. This manual revised for use of civilian physicians and issued by the 
United States Public Health Service, 1919.