REFERENCE ROOM. LOCKT CASF Book -.S^gg. ^^^v^^ie ^i^^ m^^^^^ ^^^M DI5TRICTffC0LV/ABlA G^A^L* SYPHILIS OF THE INNOCENT A Study of the Social Effects of Syphilis on the Family and the Community With 152 Illustrative Cases Made under a Grant from the United States Interdepartmental Social Hygiene Board HARRY C. SOLOMON, B.S., M.D. n Chief of Therapeutic Research, Boston, Psychopathic Hospital Instmotor in Psychiatry and Neuropathology, Harvard Medical School AND MAIDA HERMAN SOLOMON, A.B., B.S. Besearch Social Worker, Boston Psychopathic Hospital, Boston WASHINGTON UNITED STATES INTERDEPARTMENTAL SOCIAL HYGIENE BOARD 1922 cVpjl rMNCE RQOMt DOCKT CASE Copy z Copyright, 1922, by Haery C. Solomon fty Transfer p, C. WW* L cc © a .5 * ale o* 1 si 11 £ a o . CD 09 pq Cm Ps O 02 -4_> CO O CO — in d is ea X X 9 «D © ~ ^ 03 ■= ~ lis -o c — © — r -^ OQ 5- o O c3 ^ a> 2 o ao pj +2 +j cu <; 33 o O O K .- ^ "^ ^ H3 ^ i-h o ^ ^ 4J ond S .2 o "5 r^ .X ">3 — i ¥ O as . a v m o h a ^ g .9 -« »- -M S cfi to !> o o p,Ph ^ g &H ni) ro ^ £ a -3 f> - T3 ^ ^» 02 ^^J » -^ o o cS S O c C>2 > > p. © 03 > M ^ 5 § THE MATE 19 The larger number of male syphilitica is due in part to the double standard of morality and to the more indiscriminate sexual relations of men. While one syphilitic man will prob- ably not infect a great number of women, the victims of one syphilitic prostitute may be legion. If it were not for the relatively large number of women who acquire syphilis in marriage the proportion of male to female syphilitics would be even larger than it is. Conjugal Syphilis. — The danger of contagion is directly proportional to the infectivity of the disease as it exists in the contaminated party. Syphilis may be acquired by an indi- vidual prior to or after marriage. In either case the mate is exposed to infection. When syphilis is transmitted from husband to wife or wife to husband it is called conjugal syphilis. We are not able to find the date when conjugal syphilis was first recorded, but the early literature on syphilis refers to the matter. More Frequent among Women; Blaisdell 5 s Study. — As men more often acquire syphilis before marriage the mate who acquires syphilis in marriage is more often the woman. Thus one finds more single than married syphilitic men and more married than single syphilitic women. This is shown by Blaisdell, 1 who has studied a series of 500 consecutive cases of adult syphilis. He reports the civil condition as follows : 236 single men, 98 married men, 35 single women, 131 married women. In the male group there were more than twice as many single as married men, while there were practically four times as many married as single women. The danger to wives as shown by this study is even greater than would appear. The syphilitic men were young. Seventy-two per cent had contracted syphilis before their thirtieth year. Sixty-three per cent had early or secondary syphilis. An average of 70 per cent made less than five visits to the clinic and hence had insufficient treatment. The danger to the wives and children of the married men can be visualized. Many of l Blaisdell, J. H., The Menace of Syphilis of To-day to the Family of To- morrow, Boston Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 1916, pp. 18-19. 20 SYPHILIS OF THE INNOCENT the unmarried will undoubtedly marry uncured and infect their wives. Case 1} George Swallow acquired syphilis one year before his marriage. He had a small amount of treatment, insufficient to pro- tect his wife, who acquired syphilis from him. It must always be remembered that not every case of syphilis in a married woman means an innocent infection. Case 2. Norma Blaine acquired syphilis when about 17 years of age. Before her marriage she was sexually immoral and had had a miscarriage. At 35 she developed general paresis. Her husband to whom she had been married eleven years showed no clinical or labora- tory evidence of syphilis. Further Statistics on Syphilis in Women (Tables 3, 4, 5). — The accompanying tables (3, 4, and 5) give further statistics on how many women with syphilis are married or single, how many married women acquire the disease from their husbands, or otherwise. Table 3. Comparative Statistics of Syphilis in Married and Single Women Clinic Total Syph- ilitic Fe- males Single Married Married, Acquiring Syphilis from Husband No History of Source of Infection No. No. P. C. No. P. C. No. P. C. No. P. C. Fournier Cases, Paris 1 842 366 (2 43.5 56 status 220 unknot 26.1 n)- 164 74.5 Bulkley Cases, New York* 131 23 17.6 10S 82.4 54 50.0 Blaisdell Cases, Boston Dispensary, Boston* 166 35 21.0 131 79.0 Psychopathic Hospital, Boston 102 24 23.8 78 76.2 18 5 (prob 23.1 6.47 ably) 35 44.8 i Fournier. A., Treatment and Prophylaxis of Syphilis, English translation, New York, Rebman & Co., pp. 348-351. 2 Bulkley, L. D., Syphilis in the Innocent, New York, Bailey & Fairchild, 1898, p. 28. 3 Blaisdell, J. H.. The Menace of Syphilis of To-day to the Family of To- morrow, p. 19. i The names assigned to the cases are fictitious and chosen to suggest race or descent. THE MATE 21 Table 4. Further Analysis of Psychopathic Hospital Cases as to Sources of Syphilis among Married Women Syphilitic Females Acquired Innocently Possibly Acquired Innocently Acquired througb Immorality Probably Acquired through Immorality No Definite History, Apparently Moral No. P. C No. P. C. No. P. C No. P. C No. P. C. No. P. C. Married 78 100 18 23.1 5 6.4 20 25.7 35 44.8 Single 24 100 1 4.2 3 12.4 16 66.7 4 16.7 Table 5. Comparison of Syphilis in the Mate When Original Patient is Male or Female Mate, Positive Wassermann Reaction Mate, Doubtful Wassermanx Reaction Mate, Negative Wassermann Reaction Total Cases No. P. C. No. P. C No. j P. C. No. Original Patient, Male 6 14.2 3 7.1 33 78.7 42 Original Patient, Female 21 50.0 4 9.6 17 40.4 42 Total Mates 27 32.1 7 8.4 50 59.5 84 Number of Married Syphilitic Women. — Alfred Founder made a careful study of his private cases. He showed that of 842 women who derived syphilis from sexual contact 366 belonged to the demimonde, 256 were of unknown social status, and 220 were married; that is, only 26 per cent were defi- nitely known to be married. These figures are based upon Paris material and hence are probably not valid for the United States. Bulkley found in an analysis of the civil status of syphilitic women in New York that 82.4 per cent were married, while Blaisdell found 79 per cent of his Boston Dispensary cases were married. We have found that among 102 syphil- itic women at the Psychopathic Hospital in Boston 78 or 76.2 per cent were married. It would seem fair to assume that in the United States about 75 per cent of syphilitic women are married. Source of Infection in Married Women. — As has been stated above, it does not follow that because a woman who has syphilis is married that she was infected by her husband. Founder's analysis shows that 74.5 per cent of his syphilitic 22 SYPHILIS OF THE INNOCENT married women acquired the disease from their husbands, Bulkley could show this in 50 per cent of his cases, and we found that 23.1 per cent of our cases certainly, and 6.4 per cent additional probably, acquired syphilis in marriage, while in 44.8 per cent of our cases it was not possible to determine this point. A further analysis of our 102 cases of syphilis in women (78 married, 24 single) showed that 25.7 per cent of the mar- ried women were immoral, as contrasted with 66.7 per cent of the single women, and that, whereas 23.1 per cent of the mar- ried women had acquired the disease innocently (from hus- bands or extragenitally) only 4.2 per cent of the single women were definitely innocent victims. The 44.8 per cent of the mar- ried women about whom we could not definitely determine the source of infection were apparently strictly moral and in some instances the husband was known to have syphilis. Conse- quently, the number of innocent infections among the married women must be much greater than the figure given (23.1 per cent) would indicate. We may, therefore, conclude that most married women with syphilis have contracted it innocently and per contra only a minority of the single women can be classed as examples of innocent infections. High Percentage of Syphilitic Mates of Syphilitic Women. —Table 5 gives a comparison of the amount of syphilis in the mate considered from the standpoint of whether the orig- inal patient was male or female. Of the original group of 78 syphilitic women, it was possible to examine the husbands of 42. For purposes of comparison, therefore, a random group of 42 syphilitic men whose wives had been examined were chosen. It was found that whereas only 14 per cent of the wives of these male syphilitics gave evidence of syphilis, 50 per cent of the husbands of the women syphilitics were syphil- itic. This difference in percentage lends weight to the ideas that syphilis is more frequently acquired by men outside of marriage than by women, and that much female syphilis is marital in origin. Assuming that a high percentage of female syphilitics have acquired syphilis from their husbands, one would expect a large percentage of the husbands of female THE MATE 23 sypliilitics to be syphilitic. In our group this was true of 50 per cent. On the other hand, assuming that most men acquire syphilis a considerable period before marriage, then a rela- tively small percentage will infect their wives. We find in the group of Table 5 that in this case 14 per cent of the wives were syphilitic. Thus it is seen that the figures are in accord with our two assumptions. Approximate Percentage of Female Syphilis Acquired through Marriage. — On the basis of the preceding figures of Fournier, Bulkley, and the Psychopathic Hospital, calcula- tions were made to determine what percentage of all syphil- itic women (married and single) have acquired syphilis through marriage. Fournier found that one in every five syphilitic women acquired syphilis in marriage. The Psycho- pathic figures are identical with Fournier 's, while from Bulk- ley 's material it appears that one in every three women with syphilis was maritally infected. Extramarital Infection Acquired by Men Before and After Marriage. — In considering syphilis among wives it is of inter- est to know whether the husband acquired syphilis before or after marriage. Fournier 1 shows by an examination of 312 cases that the first is much more frequent. In 218 cases the woman was contaminated by a man who acquired syphilis before marriage, in 94, after marriage. Stated differently, of 100 women contaminated in marriage 70 owe their infection to a syphilis acquired by their husbands before marriage, as against 30 infected by syphilis acquired by their husbands after marriage. Undoubtedly more Frenchmen than Americans are unfaith- ful to their wives owing to Continental customs. Thus, prob- ably 80 to 90 per cent of American husbands who contaminate their wives versus the 70 per cent of French husbands acquired the infection before marriage. Thibierge 2 shows that the war conditions in France, neces- 1 Fournier, A., La Syphilis des Honnetes Femmes, Bulletin de 1 'Academie de medecine (Seances du 2 et du 9 Octobre 1906) pp. 2-3. 2 Thibierge, G., Syphilis and the Army, London, University of London Press, Ltd. 1918, p. 280. / 24 SYPHILIS OF THE INNOCENT sitating the long absence from home, either in the army or in the munition works, resulted in a laxity of morals, so that there was considerable extramarital intercourse followed by an increase in the number of syphilitic infections. When the husband returned home on leave or permanently many wives were infected. Although the precautions taken by the Amer- ican army made the rate of syphilitic infection very low, there is evidence 1 to show that many infected soldiers received only enough treatment to render them noncontagious for the time being and not enough sound advice on how to act when the delayed secondaries appeared so that they could receive treatment and their families be protected. Syphilis and Marriage. — When syphilis is acquired by one of a married pair living in the married state, the chance of the mate escaping infection is very small. This follows from the general rule that the earlier stages of syphilis are the most contagious. Vedder 2 quotes M. Dechambre as stating that "syphilis is divided among husband and wife like the daily bread.' ' The question of when a syphilitic can many without danger to the mate depends on three things: the age of the infection, the amount and sort of treatment, and the kind of lesions shown. A certain number of years must elapse before a syphilitic can safely marry, and this time factor is interwoven with that of the adequacy of his treatment. Fournier 3 found that of 142 women infected by their husbands, 37 husbands had been syphilitic for a period varying from a few weeks to a year, 31 from a year to two years, and 30 from two to three years. Hence 98, or two thirds of the total, had had syphilis less than three years when they married. As all these men infected their wives, the conclusion is that many syphilitics marry too soon after infection. There is a good deal of vari- ance of opinion among authorities as to the exact time limit and just what constitutes good treatment. 1 Collins, H. G., Syphilis in the Innocent, Journal of the Kansas Medical Society, vol. xxi, no. 1, January, 1921, p. 7. 2 Vedder, op. cit., p. 137, quotes M. Dechambre. 3 Fournier, La Syphilis des Honnetes Femines, quoted by Vedder, p. 138. THE MATE 25 It must be emphasized that even after having satisfied the first two prerequisites to marriage, there is still the third point to be considered, namely, the contagiousness of the type of lesion any given individual may develop. It may be stated that most conjugal syphilis is transmitted by the chancre or early secondary lesions. The consideration of a syphiliticus right to marriage will be discussed in more detail in the chapter called ' ' The Family. ' ' Marriage Soon After Infection as Cause of Conjugal Syphilis; No Treatment. — The most frequent cause of con- jugal syphilis is marriage within the first year or so after a person has acquired syphilis. The chances of the mate's being infected are especially great in those cases where the syphilitic has not had treatment. Case 3. Alice Shelley appeared at the hospital in the early sec- ondary period of syphilis. A few weeks prior she had had a still- born child. She had been married about ten months and a few months after her marriage developed a chancre and skin lesions. Her husband admitted that he had acquired syphilis a year before his marriage and had not been treated. Though an early marriage without treatment is prone to cause conjugal infection, this is not an inevitable result. It is possible, though probably rare, for the mate to escape. Case 4. Etta Prince acquired syphilis at eighteen and received no treatment. She married after one year and her husband when ex- amined three years later was free from syphilis. Inadequate Treatment. — Inadequate treatment is often taken by a syphilitic before marriage. This has the effect of giving false confidence to the patient. Where marriage takes place during the early stages, the mate is very likely to be- come infected. Case 5. John Collins developed a chancre when a young man. He received local treatment for ten to fifteen days. This, of course, was entirely inadequate either as treatment of his syphilis or to make him noncontagious to others. He married a few months after the disap- pearance of the primary lesion. As was to be expected, the wife be- came infected and gave birth to a syphilitic child. / 26 SYPHILIS OF THE INNOCENT Marriage Long After Infection and Escape of the Mate. — As time goes on syphilis becomes less contagious. Thus, after several years a patient may no longer be a source of danger to others. This is true even when the patient receives no treatment. When syphilitics marry five to twenty years after the infection, their mates frequently remain entirely free from the disease. Case 6. Frances Brown contracted syphilis at the age of 18. She was engaged at the time, and infected her fiance. Almost immediately after, she became infatuated with another young man whom she married a week later. She lived with him for six months during which time he also contracted syphilis from her, and left her. A few months later she had a child which was born in a frightful condition and died immediately. In a span of four years, this girl had contracted syphilis herself, infected both fiance and husband, and had given birth to a dead syphilitic child. In the fifth year after her infection with syphilis, she bore an illegitimate child. She then lived with the father of this child as his wife and had five other illegitimate children. She appeared at the hospital at the age of 32. She had never been treated and showed a positive Wassermann. Her six illegitimate children were examined; none of them were syphilitic. There is no history of the father of the children having contracted syphilis from her, though the two men who had lived with her in the early stages of the disease both became syphilitic. Importance of Treatment. — Early adequate treatment is of great importance from the standpoint of the spread of the disease. This is particularly true when arsphenamin is used. A few injections of arsphenamin can do a great deal to lessen contagiousness. Even though treatment is not sufficient to cure the patient, it may suffice to render his condition non- contagious to others. A patient who has received active anti- syphilitic treatment in the first few weeks of the disorder may even marry during the first year and not transmit the disease to his mate. This is taking an undue risk, however, and should never be advocated. For our present purpose it might be stated that when a period of five years or more has elapsed since the date of the THE MATE 27 primary stage the danger to the mate is minimal. This danger is further decreased by treatment. When treatment has been intensive and continued, the period may be lessened at the discretion of the doctor. Marriage Long After Infection and Infection of Mate. — All rules concerning syphilis must be considered as general and not necessarily applicable to any particular case. Thus a person may be infected by a syphilitic who has acquired syphilis many years prior to marriage. The infections occur- ring late in the disease are largely dependent on the occur- rence of superficial lesions containing treponemata. Such lesions may occur in a patient who has had considerable treat- ment but not enough to cure the disease, and the patient may then infect the mate. Case 7. A case is reported from the clinic of Dr. Max Joseph * of a man who married eight years after acquiring syphilis. The wife was infected. The man, who was in the late stage of the disease, had mucous patches which probably explained the infection of the wife. Case 8. Finger 2 reports a man who acquired syphilis in 1888. He married eight years later having had mercurial treatment in the meantime. Four months after the marriage the wife developed a chancre. The husband on examination was found to have papular syphilides of the glans and prepuce of the penis. Variation in Probabilities of Conjugal Infection When Mar- riage Occurs 3-5 Years After Infection. — While marriage to a syphilitic many years after the disease is acquired, is rela- tively safe, and marriage early in the course of the disease is highly dangerous, it is not possible to give any definite state- ment as to the probability of conjugal infection in marriages contracted from three to five years from the date of the initial lesion. In this period, neither very late nor very early, the disease is transmitted in some cases, while in others, the mate escapes. lBuba, Die Contagiositatsdauer der Syphilis, Inaugural Dissertation, Leipzig, 1905, quoted by Vedder, p. 113. 2 Finger, Wann Diirfen Syphilitische heiraten, Heilkunde, Wien, 1897, vol. i, p. 351, quoted by Vedder, p. 113. 28 SYPHILIS OF THE INNOCENT Case 9. George Carpenter was seen at the clinic at the age of 32. He acknowledged contracting syphilis when 16 years of age. He had treatment at that time for about three months and off and on ever since. Four years after the infection he married. The first pregnancy resulted in a stillbirth. He had two living children both of whom were syphilitic as was his wife. All three were under treatment. Case 10. William Baldwin also married four years after he ac- quired syphilis. He had had treatment for seven or eight months following the appearance of his chancre, but this was chiefly in the form of mercury by mouth. This treatment was inefficient as far as he was concerned and he developed late symptoms. His wife, how- ever, was not infected. One must be on guard about viewing all cases of syphilis which occur in both husband and wife as instances of conjugal syphilis, and attempting to place the blame on one for the disease of the other. It is always quite possible for both husband and wife to have acquired syphilis outside of marriage. Case 11. Three months after his marriage, Harry Coffin showed symptoms of general paresis. His wife was examined and found to be syphilitic. However, she did not have symptoms of early syphilis, such as would be expected if she had been infected during the three months of her marriage. Furthermore it is quite certain that a patient with paresis without superficial lesions is not contagious. On the other hand it was not possible for Harry to have acquired his syphilis from his wife. It is, therefore, obvious that in this case each acquired syphilis independently before marriage. Probable Date of Conjugal Infection. — Having seen that conjugal infections occur, attention may be turned to the ques- tion of how long after marriage the infection is likely to take place. Fournier 1 show r s that of 572 syphilitic women, 81 or over 14 per cent contracted syphilis from their husbands dur- ing the first days of marriage. In 153 cases Fournier gives the following dates for contagion: The first month after marriage 10 The second month after marriage 26 The third month after marriage 20 i Fournier, A., Syphilis et Mariage, Paris, G. Masson, 1880, quoted by Vedder, p. 137. THE MATE 29 The fourth and fifth months after marriage 7 The sixth month after marriage 1 During the first months of marriage (without more precision) 53 Second part of the first year 13 Second year 9 Third year 3 Fourth year. . 3 Fifth year. .' 2 Sixth year 2 Seventh year 2 Eighth year 1 Ninth year 1 Total 153 Eighty-six per cent of the infections occurred in the first year after marriage, the vast majority (90 per cent) of these in the first six months. These figures seem to indicate that there is about one chance in seven of being infected after the first year. Keyes 1 studied the records of private patients who married without taking any particular precautions although they were actively syphilitic. He drew the following conclusions: Wife infected first year of disease, chances 12 to 1 Wife infected second year of disease, chances 5 to 2 Wife infected third year of disease, chances 1 to 4 Wife infected fourth year of disease, almost no chance Wife infected fifth year of disease, 2 cases Cause of Conjugal Contamination. — The reasons persons are contaminated in marriage are various. Some syphilitics are unaware that they have contracted syphilis. They may have a small and unnoticed chancre with no obvious second- ary lesions and may marry in all innocence. Others know that they -have had the disease but are not cognizant of the dangers to the mate. These are the ignorant and uninformed, who it is hoped will diminish in number when the various modern educational methods have been in vogue for some time. Though education will probably not prevent people from running the risks of acquiring syphilis it may arouse i Pusey, W. A., Syphilis as a Modem Problem, Chicago, American Medical Association, 1915, p. 99, quotes Keyes. 30 SYPHILIS OF THE INNOCENT more caution in taking the risk of harming a mate and chil- dren. Many syphilitics are conscious of the general possi- bilities of infecting their mates but feel confident that they can run the risk with impunity. This confidence may be based on a superabundance of faith in someone 's judgment, on per- mission granted by a doctor who does not know all the facts, on an indifferent attitude towards possible future dangers, or on pure callousness. This last attitude is fortunately rare. As an example one may quote the following paragraph from Fournier: 1 A man came to rue and asked me if he could marry. Recognizing his contagions state, I forbade it. Then naturally he married. Three months later he came to me repentant, asking my care for his wife Avhom lie had infected. "At least," said I, "You will save yourself a new unhappiness and do everything you can to avoid having chil- dren. ' ' Naturally a few months later his wife was pregnant. ' ' There remains only one more thing for you to do, " I added, ' ' and that is to give your child to a wet nurse if it comes into the world alive. ' ' Well, it was complete, because the wet nurse did not fail to be infected by him. Importance of Examination of Mate of Syphilitic. — Syphilis acquired in marriage does not differ in its results from syphilis acquired outside of marriage. It is, however, more likely to go unnoticed. A person taking the risks of promiscuous sexual relations is likely to be on the lookout for symptoms of syphilis or gonorrhea. This is not true in the case of the mar- ried person. In women, especially, the symptoms of syphilis are likely to be overlooked. Many times a patient will go through a long period of life with latent syphilis without noticeable symptoms. In most cases, however, the disease shows itself later in the form of a serious disorder. Early recognition, or recognition during the latent period, offers the opportunity to apply therapy and thus prevent serious con- ditions. It is for this reason that the examination of the mate of every syphilitic is urged. Types of Manifestation in Husband and Wife — Same. — The manifestations of syphilis may be the same in husband and l Fournier, A., La Syphilis des Honnetes Fernnies, p. 13. THE MATE 31 wife. Thus, in both, the disease may appear to be latent and only be recognized as the result of the Wassermann test. 1 Or both may have the same very serious manifestations such as involvement of the central nervous system. Case 12. James Billings was brought to the hospital because of delirium tremens. A routine Wassermann test was positive. The wife was then examined and she also had a positive Wassermann re- action though neither showed any other signs of active syphilis. Case 13. Edward Flint acquired syphilis after he was married, and infected his wife. Twelve years later he came to the hospital in an advanced stage of nervous system syphilis. His wife was examined and was also found to have syphilis of the central nervous system. It is pleasing to be able to report improvement of the wife under treatment. Types of Manifestations in Husband and Wife — Different. — In many cases the disease manifestations may be quite dif- ferent in husband and wife. When the effects are more seri- ous in the person who originally acquired syphilis one is inclined to feel that there is more justice than when the inno- cent member of the pair suffers seriously while the one who was to blame escapes without grave results. Not infrequently a mate will develop heart disease, vascular disturbance, or central nervous system symptoms while the one who acquired syphilis originally remains without symptoms other than a positive Wassermann reaction. Case 14. Howard Lincoln developed a hemiplegia due to syphilitic vascular disease during the first year of his syphilis. The wife was found to have been infected but was symptom-free. She was given antisyphilitic treatment and at the end of four years of treatment her Wassermann test became negative. Case 15. Louis Morse after the death of his first wife acquired syphilis. He married again in a short time and his wife was infected by him. She developed general paresis and died from the disease. Mr. Morse developed no very grave results. After his wife's illness he received treatment and it is likely that he will not have any further trouble. l Throughout, when we speak of a positive or negative Wassermann reaction we do not, of course, refer to a single test, but to a repeated series giving a consistent result. 32 SYPHILIS OF THE INNOCENT Frequency of Syphilis in Both Man and Wife; Psycho- pathic Hospital Study. — How frequently is syphilis found in both man and wife! To answer this and related questions a study was made of the families of 555 syphilitics who were in the late stages. This group included patients with visceral syphilis, latent syphilis, and involvement of the nervous system. TABLE 6. AMOUNT OF CONJUGAL SYPHILIS BY WASSERMANN SURVEY OF MATES OF 555 SYPHILITICS Number Total mates examined 336 Wassermann reaction positive 98 29.2 Wassermann reaction doubtful 7 2.1 Wassermann reaction negative 231 68.7 Of this group of 555 patients it was possible to get Wasser- mann tests on the mates of 336. Of these 336 mates, 98 or 29.2 per cent gave positive Wassermann reactions and 7 or 2.1 per cent gave doubtful reactions. It may therefore be stated that approximately 30 per cent of the mates were syphilitic. A few words may be said in order to explain the use of the Wassermann reaction in this study as the criterion of the presence of syphilis. It is a comparatively definite standard. While recognizing that many cases of syphilis do not give positive Wassermann reactions, it seemed that for statistical purposes it would be more accurate than a diagnosis made from clinical evidence alone, where there is bound to be a variation due to the individual equation of different exam- iners. As some cases of syphilis may have been missed, it would seem quite justifiable to state that at least 30 per cent or almost one out of every three of the 336 mates of syphilitic patients examined had syphilis. Thus, the mates of syphilitics offer a fertile field for the discovery of syphilis. How many of the syphilitic mates acquired syphilis in mar- riage and are therefore to be considered as cases of innocent syphilis, is not shown in this study. However, it may be assumed on the basis of our earlier analysis, that in the major- ity of the cases the husband acquired syphilis outside of mar- riage and infected his wife. Per contra, in a few cases the THE MATE 33 wife was probably at fault and infected her husband; while in a very small percentage of cases each mate acquired syphilis independently outside of marriage. It is perfectly safe to assume, however, that the majority of the women considered in this study were infected by their husbands. Mate Usually Unaware of Infection. — As already men- tioned, one of the unfortunate aspects of syphilis acquired conjugally is that it is so often unrecognized until the late and serious manifestations have occurred. That most of the women in this group were unaware of having syphilis is shown by the following analysis : of the 98 syphilitic mates who had positive Wassermann reactions, 54 were women whom we were able to question as to their awareness of having syphilis. All knowledge was denied by 44 or 81.5 per cent of the women while only 10 or 18.5 per cent knew they had the disease. Possible Methods of Preventing Conjugal Infection. — Pre- marriage examination of every applicant for a marriage license, if such an examination could be thorough instead of superficial, might prevent some syphilitic marriages. If it did not accomplish this, it would at least indicate to the infected person that he or she was still syphilitic and ought to have the future mate under a doctor's supervision so that if syphilis developed later it might be cared for immedi- ately. The aim of all examinations is"' to get at the disease early, before it has made much headway. The only way to accomplish this in syphilis is to examine suspected cases even though symptom-free. This would mean that the mates of all syphilitics should be examined. Every doctor should make a strenuous effort to accomplish this examination, in private cases as well as in all syphilis clinics, All institutions such as hospitals, prisons, pauper institutions and the like should take a routine Wassermann test on all their inmates and when possible follow this up by an examination of the mates of the syphilitics. Unfortunately, such examinations are by no means routine throughout the country. Fresh evi- dence is constantly brought to light by the discovery of a syphilitic mate through the routine Wassermann test in one 34 SYPHILIS OF THE INNOCENT hospital, while this same person has been at various other institutions previously without a suspicion of syphilis. Although the examination of the mate cannot prevent the acquiring of syphilis, by making early diagnosis possible and leading to treatment many of the later and more dreaded mani- festations can probably be prevented. One ? s sense of propor- tion must not be lost. Sad as are the cases of innocent women who are infected in marriage, we must remember that all women who marry syphilitic men do not acquire syphilis. The reasons for their escape are the converse of the reasons why other women acquire syphilis. The husbands either had good treatment or waited a long time before marrying or were very careful if they developed any secondary lesions. Some of the women might even be immune to the disease. Of the mates quoted in Table 6, 70 per cent escaped infection either by pure luck or proper care. It is well not to count at all on the former. Even the latter cannot insure safety, although naturally favoring it. Importance of the Conjugal Syphilis Problem. — From what has been said above it may be concluded that any campaign for the prevention of syphilis must take into consideration the matter of marriage. Whatever may be one's opinion about a syphilitic's right to marry or when he may do so, the fact remains that a large number cf syphilitics do marry and in many instances the mate is infected. Whatever laws are invoked in the future to reduce the risk of marital infection, the problem of conjugal syphilis will be with us for a long time to come and it is our special duty to consider and help these innocent victims of syphilis. Necessity of Examining Mates of Syphilitics. — In consider- ing our figure of a rate of 30 per cent of infection among mates it should be emphasized that in practically every instance, the original patient when first seen by us was in a late stage of the disease. Thus, in the cases in which the mate was infected in marriage, the infection had taken place a long period prior to the time our diagnosis was made. It is also implied that most of these patients probably had some medical inspection THE MATE 35 during this long period, but in very few instances had a diag- nosis of syphilis been made or treatment instituted. Practi- cally everyone recognizes the contagiousness of the early stages of syphilis, and if a married person appears for treat- ment at this period, attention will probably be directed also to the mate. This is by no means so frequently done when the patient comes under medical care at a time far removed from the date of infection. If one is to do justice to the problem and the individuals concerned, it is necessary to examine the mate whether syphilis was acquired a short or a long time prior to the date of examination. REFERENCES Blaisdell, J. H., Menace of Syphilis of To-day to the Family of To-morrow, Boston Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 1916. Bulkley, L. D., Syphilis in the Innocent, New York, Bailey and Fairehild, 1898. Collins, H. G., Syphilis in the Innocent, Journal of the Kansas Medical Society, vol. xxi, no. 1, Jan., 1921. Day, A. B. and McNitt, W., Incidence of Syphilis as Manifested by Routine Wassermann Reaction on 2925 Hospital and Dispensary Medical Cases. Transactions of the Association of American Physicians, Philadelphia, xxxiv, 1919. Fournier, A., La Syphilis des Honnetes Femmes. Bulletin de l'Academie de medecine (Seances du 2 et du 9 Oct., 1906). , Treatment and Prophylaxis of Syphilis, English translation, New York, Rebman and Co. Pusey, W. A., Syphilis as a Modern Problem. Chicago, American Medical As- sociation, 1915. Report of the Commission to Investigate the Extent of Feeble-mindedness, Epilepsy, and Insanity and Other Conditions of Mental Defectiveness in Michigan, 1915. Royal Commission of Venereal Diseases, Final Report of the Commissioners, London, 1916. Salmon, T. W., General Paralysis as a Public Health Problem, Proceedings of the American Medico-Psychological Association, Seventieth Annual Meeting, Baltimore, Maryland, May 26-29, 1914. Thibierge, G., Syphilis and the Army, London, University of London Press, Ltd., 1918. Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lee and Febiger, 1918. CHAPTER III THE CHILD Congenital Syphilis; Date of Recognition. — The saddest aspect of syphilis is that it is transmitted to the second genera- tion. The child of a syphilitic may be born into the world with the Treponema pallidum in his body and thus be handi- capped through life. Like the adult who acquired syphilis, he may suffer any of its results. The transmission of syphilis from syphilitic parents to their children was recognized very soon after syphilis was known in Europe. As early as 1498 Gaspard Torella 1 mentioned the existence of syphilis in new- born infants "propter mammas infectas." Paracelsus, 1 in 1529, was the first to note its hereditary character: "fit morbus hereditarius et transit a patre ad filium." In the last of the eighteenth century Stoll, Planck, Von Rosenstein, and Sanchez 2 described syphilis hereditaria and syphilis heredi- taria tarda. Connotation of Terms "Congenital" and "Inherited." — When a child has acquired syphilis before or at birth he is said to have congenital or hereditary syphilis. There is con- siderable confusion in the usage of these terms and not all authors apply them in the same sense. Nonne 3 says that scientifically the term congenital rather than inherited syphilis should be used. The difference lies in the fact that con- genital syphilis is a condition in which the infection of the fetus occurs in utero through the agency of the treponema, while by the term inherited syphilis we would mean that in some way the germ-plasm of either parent had become affected 1 Diday, P., A Treatise on Syphilis in New-born Children and Infants at the Breast, translated by G. Whitley, London, New Sydenham Society, 1859, p. 8. 2 Pusey, W. A., Syphilis as a Modern Problem, Chicago, American Medical Association, 1915, p. 23. 3 Nonne, M., Syphilis und Nervensystem, Dritte Neubearbeitete Auflage, Berlin, Verlag von S. Karger, 1915, pp. 690-1. 36 THE CHILD 37 by the treponemal toxins. That is, without direct infection of the offspring, changes would have been wrought in its development. There are two varieties of this so-called inheritance of the infection: The infection may be carried through the placenta, or the organism may be directly bound to the germ cell. These two modes of infection have been called placental and germinal. We shall apply the term congenital syphilis to those cases in which the infection of the offspring occurred prior to or during birth. It will always mean in our usage that a direct transference of the treponema from parent to child took place at some period between conception and the child's existence independent of the body of the mother. The term hereditary syphilis will be used in a narrow and restricted sense referring to changes in the offspring due not to active and direct infection but to germinal defects caused by parental syphilis. Effects of Syphilis on Childbearing — The effects of syphilis on childbearing are several and vary in severity. Sterility, abortions, miscarriages, stillbirths, and syphilitic living progeny result from parental syphilis. As an illustration of what syphilis may do to the progeny the following case is given : Case 16. Emil Lachine was a druggist by trade and on acquiring syphilis thought he could treat himself. That his treatment was inadequate was shown by the fact that he infected his wife. He again attempted therapy by giving her pills and nostrums. She was not cured, however, and many years later bad syphilitic liver disease. The effect of syphilis on the next generation is quite significant. The first pregnancy was terminated by a miscarriage; the second one reached term but the child lived only five weeks. The third and fourth pregnancies were productive of boys who were seen by us at the respective ages of 19 and 15 years. Both showed numerous signs of congenital syphilis, were deficient mentally, and had defective vision. The younger child was also deaf. The fifth pregnancy re- sulted in a child who died at five weeks. The result of the sixth pregnancy was a child who was apparently normal and non-syphilitic when seen at 11 years of age. The seventh pregnancy produced a child who died at nine months. In this syphilitic family the fruition 38 SYPHILIS OF THE INNOCENT of seven pregnancies was three children, two definitely feeble-minded, with defective vision and physical inferiority, and only one normal child. Problem of Paternal Transmission. — Having recognized the existence of the problem of congenital syphilis, it is expedient to consider the part played by one or both parents in the trans- mission of the disease. There is a divergence of opinion amongst leading authorities as to whether a syphilitic child can be born of a non-syphilitic mother. Can the father trans- mit syphilis directly to his child without infecting the mother? It should be explained that the placenta is commonly sup- posed to be a rather perfect filter which separates the fetus from the mother. On this supposition it would be possible for treponemata to circulate in the blood of either the mother or the fetus without infecting the other. To believe in the paternal transmission of syphilis without infection of the mother it must be supposed that the impregnating sperm carries a treponema into the uterus of the mother and attaches itself to the impregnated ovum, which is then sealed off, as it were, from the maternal organism. Treponemata arising from this original sperm-borne treponema would multiply in the fetus while the mother would remain free from syphilis. This view of the paternal transmission of syphilis was held quite generally until a comparatively few years ago. Diday 1 and Eicord, 2 writing in the middle of the nineteenth century 7- , thought it quite possible for the mother of a syphilitic child to be non-syphilitic. Nonne, 3 at the beginning of the twen- tieth century, says that a woman can conceive a child by a syphilitic man without herself becoming infected by syphilis, and the fetus is then made syphilitic only by the father. More recent syphilologists tend to think that the mother must be infected in order that a child have true congenital syphilis. This matter has not been entirely settled. Ideas concerning syphilis have been materially influenced 1 Diday, op. cit., p. 8. 2 Ricord, Lectures on Venereal and Other Diseases, translated by V. de Meric, Philadelphia, 1849. 3 Nonne, op. cit., p. 692. THE CHILD 39 by knowledge of the treponema and the Wassermann test obtained in the last sixteen years. Realizing that syphilis very frequently runs a latent course during many years, espe- cially in women, it is seen that the mother of a syphilitic child may have syphilis herself, but be symptom-free. Jeans 1 took a Wassermann test on 85 mothers of syphilitic children. The Wassermann reaction was positive in 73 or 85.9 per cent. If a positive Wassermann reaction is to be accepted as denoting syphilis it would mean that at least 85.9 per cent of these mothers were syphilitic, although many of them showed no other signs or symptoms of the disease. But not every syphil- itic will give a positive Wassermann reaction. Of the twelve mothers whose reactions were negative, several showed signs of having had syphilis. This survey of Jeans therefore shows that the vast majority of syphilitic children have syphilitic mothers. It does not prove, however, that pure paternal transmission is impossible. Nonne 2 speaks of wives of paretics and tabetics (i.e. wives of syphilitics) giving birth to syphilitic children although they themselves were entirely free from evidence of syphilis including negative Wassermann tests. Dealing with this matter purely argumentatively it has been explained that such cases are instances of " burnt out syphilis' ' or " Wasser- mann negative syphilis.' ' Some modern authorities are so dogmatic in the feeling that every syphilitic child must have a syphilitic mother, that they advocate antisyphilitic treatment for such mothers although they show no clinical or serological signs of syphilis. Our own experience agrees with the foregoing of Jeans; namely, that in most cases the mothers of syphilitic children, although frequently without obvious physical symptoms of syphilis, have positive Wassermann reactions. Case 17. Ralph Jackson was a congenital syphilitic. His mother was apparently well but on examination showed a positive Wasser- mann reaction. There are, however, a few instances where all signs and i Jeans, P. C, Familial Syphilis, American Journal of Diseases of Children, vol. xi, no. 1, Jan., 1916, pp. 11-19. 2 Nonne, op. cit., p. 693. 40 SYPHILIS OF THE INNOCENT symptoms of syphilis including the Wassermann reaction, are absent. In a study of 33 mothers of 49 syphilitic children (see page 90) we were able to examine 25 (3 were dead, 5 not secured for examination). Twenty (80 per cent) had a posi- tive Wassermann reaction, 1 (4 per cent) a doubtful Wasser- mann reaction, and 4 (16 per cent) a negative Wassermann reaction. Case 18. Jacob Frank was an attractive lad of 10 years of age. His great drawback was stuttering. He stuttered so badly that he could hardly be understood. It interfered with his school work which was otherwise excellent. It was on this account that he sought help at the clinic. Physically, the boy was practically perfect. He had had no debilitating disease and had always enjoyed good health. He was the oldest of three children; there had been no further preg- nancies. The father and mother were both reported to be in good health. There was nothing in the appearance or physical findings to make one suspect congenital syphilis, and yet the routine Wasser- mann reaction on Jacob was positive. This was true on numerous repetitions which were made while he was under treatment. The father was interviewed and denied any syphilitic infection. However, his Wassermann was also positive. Upon learning this, he was ready and even overanxious to have treatment, which led to the suspicion that he knew of his infection. The mother was also examined. She showed no signs of a luetic infection nor did she give any history that was suggestive. A repetition of blood tests was entirely negative in her case. The second child in the family was 6 years old. Like Jacob, he was a fine healthy specimen. His Wasser- mann was reported as doubtful. The third child, 3 years old, was again a perfectly normal boy who was not tested. Our conclusion on the question of the transmission of syphilis from father to child without the acquisition of syphilis by the mother is that it is a possibility but that if it occurs at all, it occurs but rarely. In a high percentage of cases the mother of a congenital syphilitic is herself syphilitic, therefore the question of treatment should be considered in each case. Further investigation, however, will be necessary before it is possible to give a categorical answer to the question. From the practical standpoint of handling the disease it is necessary to suspect syphilis in both parents of a congenital THE CHILD 41 syphilitic. As shown by Jeans, 1 the chances of the mother's being syphilitic are more than 85 per cent. If the mother is syphilitic it is likely that the father is also, either having infected the mother or, what is less frequent, having been infected by her. Therefore, when confronted by a case of congenital syphilis it behooves the physician or clinic to make arrangements for the examination of the parents. Apparent Immunity of Mother of Syphilitic Child; Colles* Law. — At the time when belief in the doctrine of paternal transmission was prevalent it was noted that after the mother had given birth to a syphilitic child she never became infected by the child whom she nursed and handled, although another person, a nurse, was likely to become contaminated. This led Colles in 1837 to formulate the dictum which is now known as Colles' law, to the effect that when a non-syphilitic woman gives birth to a syphilitic child she is immune from infection by the child, although the child may infect another person. In view of the evidence of the Wassermann findings we agree with most current opinion that the mother is not infected by the syphilitic child because she is already syphilitic. Case 19. Merton Winship at the age of 10 had the definite mark- ings of congenital syphilis. His father was dead, but his mother was living. She was in good health and said she had never been really ill. She disclaimed any symptoms past or present, suggestive of syphilis. Physical examination disclosed no signs indicating that she was or had been syphilitic. This mother would seem to exemplify the law of immunity that a healthy mother giving birth to a syphilitic child is not infected by the child. A positive Wassermann reaction on her blood led to the conclusion that she was really syphilitic but had manifested no other signs up to that time. Although the vast majority of mothers who give birth to syphilitic children are apparently syphilitic, as demonstrated by physical signs or the Wassermann test, there are a few who show no evidence of syphilis. These mothers would bet- ter exemplify Colles' law, and it is upon evidence furnished by such cases that some authorities sponsor it. l Jeans, loc. cit., p. 11. 42 SYPHILIS OF THE INNOCENT Case 20. Leon Shephard was 9 years of age when first seen by us. He was defective mentally, being classified as feeble-minded. He showed a moderate degree of hydrocephalus, and a strabismus which was said to date from the age of one year. At 3 he had had convul- sions. His blood and spinal fluid Wassermann reactions were positive. There had been one pregnancy preceding the birth of Leon which eventuated in a child who died at 3 months. Later the mother had had a miscarriage. The mother herself was quite free of any physical or laboratory signs pointing towards syphilis. Apparent Immunity of Healthy Offspring" of Syphilitic Mother; Prof eta's Law. — A rule of immunity relating to the child which is somewhat similar to Colles' law was set forth in 1805 by Giuseppe Profeta, namely, that an apparently healthy offspring of a syphilitic mother could be nursed by its mother or a syphilitic wet nurse and yet not be infected. Profeta 's conception was that these children were non-syphil- itic and immune to syphilis. There are two other explana- tions possible. First, the child may really be syphilitic though symptom-free. Many congenital syphilitics are symptom-free from birth until a number of years have elapsed when they are diagnosed by aid of the Wassermann reaction or later symptoms. These cases would not, of course, acquire syphilis from their mothers or from syphilitic wet nurses. Thus, although they may seem to bear out Prof eta's law in fact, they do not support his theory of immunity. Cose 21. Amelia Borgesi was a healthy, bright girl of 14. Her past history was not significant, her development having been normal in every way. Her mother as well as her father was syphilitic. Amelia, in spite of her negative history and the absence of all symp- toms or stigmata, had a consistently positive Wassermann reaction. In the second place, the mother's syphilis may be of long standing and no longer contagious. There are those who hold that all children of syphilitic mothers should receive treatment. This seems to us an extreme view, but it may be justifiable if one recalls that cases of interstitial keratitis, for instance, may show T their first symptoms in late adolescence in patients, until then, apparently non-syphilitic. In this connection we studied a group of 236 syphilitic women. Was- THE CHILD 43 sermann tests and clinical examinations were made on the children. Out of 142 children who were examined 39 or 27.5 per cent were syphilitic. The remaining' 103 or 72.5 per cent showed no signs or symptoms of syphilis. In view of these findings we feel that it would be extreme to treat all the chil- dren of syphilitic mothers. Our conviction is that a syphilitic woman may, and frequently does, give birth to healthy non- syphilitic children. This usually occurs late in her disease. Case 22. Mrs. Yogel had been unable to bring a child to term. She was found to be syphilitic, with the serology and the sympto- matology of nervous system involvement. After having antisyphilitic treatment, she gave birth to a child who seemed normal in all ways and who had a negative TVassermann reaction. The mother, who still showed signs and symptoms of syphilis nursed and cared for the child without its becoming infected. Although the mother was suffer- ing from syphilis she was noncontagious, both because a number of years had elapsed since she herself had been infected and because of antisyphilitic treatment. Conditions Accounting for Congenital Syphilis. — If pure paternal transmission is left out of consideration because its possibility is not thoroughly established, it may be stated that there are three situations which account for congenital syphilis. (1) The mother may have contracted syphilis from the child's father before or at the time of conception. In this case the child is the offspring of two syphilitic parents. (2) The mother may have syphilis and transmit it to her child while the father remains syphilis-free. (3) The mother may become infected during pregnancy and infect the fetus during gesta- tion or at the time of birth. Here the mother may have con- tracted syphilis from the father, from extramarital or from extragenital infection. In the second and third contingen- cies, the syphilis of the child is directly related only to the mother. However, as far as is known, the results are no different if both parents are syphilitic or if only one parent is so affected at the time of conception. In any case, the child's syphilis is innocently acquired. The following cases illustrate the three methods of infection of the child : 44 SYPHILIS OF THE INNOCENT Case 23} married two years after he had contracted syphilis. He had had treatment for only a very short period at the beginning of his infection. Five years after the marriage both the man and his wife had strongly positive Wassermann reactions, al- though they showed no other symptoms of the disease. There were two children born of this marriage, a boy who at three years of age showed the signs of congenital syphilis, and a girl who had died at ten days of age, and is said to have had an exfoliation of the skin and to have turned black. She was probably syphilitic. The mother had been married previously and in her former marriage had five children, all of whom were living and well. In this family the syphilis acquired by the man was transmitted to his wife and then two syphilitic children were born. Case 24. Richard Shoemaker was a congenital syphilitic whose syphilis was diagnosed a few weeks after his birth. The parents were not examined until nine years later, at which time the mother had a positive Wassermann reaction and the father had a negative reaction and showed no signs or symptoms of syphilis. It is not possible to state absolutely definitely that the father had not been syphilitic but there was no evidence that he had had syphilis. This would well illustrate the possibility of congenital syphilis acquired through the mother while the father remained uninfected. Case 25. Jeans 2 reports two families in which the women were infected by their first husbands and married a second time without infecting their second husbands, although they continued to bear syphilitic children. Case 26. 1 While was pregnant with her third child her husband contracted syphilis from a prostitute and infected her. The child when seen at six months of age was easily diagnosed con- genital syphilitic. Two children born before the infection were en- tirely free of any signs of syphilis so that it may be concluded that the third child had acquired syphilis in utero, due to the infection of the mother while pregnant. i Blaisdell, J. H., The Menace of Syphilis of To-day to the Family of To- morrow, Boston, Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 1916, pp. 7-13. 2 Jeans, loc. cit., pp. 11-19, THE CHILD 45 Different Manifestations in Parents and Children. — The severity of parental syphilis has no relation to the severity of the congenital syphilis. One finds parents who have had very grave symptoms whose children have only slight mani- festations or none at all; on the other hand, the children may be great sufferers while the parents show little besides a positive Wassermann reaction. Case 27. Adelaide Price had general paresis, the severest form of syphilis. Her son was a healthy, stalwart lad of about 20 who had never suffered any symptoms suggestive of syphilis and who would have been considered free from the disease but for a positive Wasser- mann reaction. Case 28. Jennie Bradford presents the opposite situation from the preceding family. The father and mother were well. The diagnosis of syphilis in the mother was reached because of a positive Wasser- mann reaction found after the discovery of the disease in her two children. Both daughters had juvenile paresis, with paralysis and dementia and were certain to eventuate in early death. The Attenuation of the Virus with Time; Kassowitz's Law. — An important law concerning transmission of syphilis to the second generation was formulated by Kassowitz in 1876. According to this law, the more distant the date of the infec- tion the more attenuated is the virus and the less evil are the effects on the children. For example, following the infection there may be a period of sterility. Pregnancies may then occur, which end in early abortion at from one to three months. Later pregnancies may lead to miscarriages at from four to seven months. Then a child may be born dead at term, fol- lowed by a living syphilitic child. The next child may show fewer manifestations of syphilis and after a time children may be born free of any sign of syphilis. This law is not likely to be fully exemplified in any given case, but repre- sents a general tendency for the earlier pregnancies to show more syphilitic effects than the later ones. We have made a study of 50 families in which syphilis occurred. No single case ran the entire gamut of possibilities. It was rather fre- quent, however, to find the severer disasters occurring first and the later results to be less serious. 46 SYPHILIS OF THE INNOCENT Case 29. Patrick O'Brien. Father — syphilitic. Mother — syphilitic. 1. Girl died at nine months of syphilis. 2. Stillbirth. 3. Boy, 16, congenital syphilis with interstitial keratitis. 4. Boy, 13, apparently normal with a negative Wasser- mann reaction. Case 30. Mary Flynn. This family illustrates Kassowitz's law from the Wassermann standpoint. The father and mother were syphilitic. The four oldest children had positive blood Wassermann reactions. The next two children had doubtful Wassermann reactions, and the two youngest had negative Wassermann reactions. Jeans 1 says that in 69 of the families studied in which the order of pregnancies was ascertained and all of the living children examined, 44 families followed the rule in a general way although they varied more or less. "In no case was there a complete reversal of the rule, but in one family there was first a non-syphilitic child, then a negative child with a positive Wassermann, followed by seven stillbirths and then a living birth in which the child was actively syphilitic. Non- syphilitic children were interspersed between syphilitic chil- dren in seven instances in five families. For the most part the variation from the rule consisted of abortions following living syphilitic children, so that in a large measure in these 25 irregular families Kassowitz's rule was followed." An analysis of any large group of syphilitic families will show similar variations from Kassow r itz's law. Among our own cases the following variations were noted among others: In several families there was one type of difficulty only, such as a series of four miscarriages, three children born alive but syphilitic. Frequently the syphilitic children preceded rather than followed the accidents to pregnancies. A long period of sterility was at times follow-ed by the birth of a normal child. In one case the first children were syphilitic, and were followed by a nonsyphilitic child, an accident to pregnancy and another nonsyphilitic child. At times the entire order seemed to be reversed as in the following cases: l Jeans, loc. cit. THE CHILD 47 (1) Accident to pregnancy, non-syphilitic child, accident to preg- nancy, syphilitic child, accident to pregnancy, syphilitic children. ( (2) Syphilitic child, non-syphilitic children, syphilitic child, acci- dent to pregnancy. An interesting case was reported by the Boston Dispensary, 1 in which every other child of five was actively syphilitic beginning with the first. The intervening two children were thoroughly examined but showed no clinical or laboratory evidence of syphilis. The question of twins is pertinent in this connection. One would expect both of the twins to be syphilitic or non-syphil- itic. Post 2 reports two sets of twins, all syphilitic. Various cases have been reported in which one only was syphilitic. Still 3 reports a case of twins, one of whom died at the age of seven months of syphilis. The fellow twin was apparently healthy. Sir Herman Weber 4 notes an instance in which a syphilitic mother bore twin children, one of whom suffered with characteristic symptoms of congenital syphilis and died at the age of eleven weeks of diarrhea, while the other remained perfectly healthy. Goldenberg 5 reports one syphil- itic and one non-syphilitic twin. DaCosta and Van der Valk 6 report triplets of syphilitic parentage, one of whom died at three weeks without any signs of syphilis, one at three years showed obvious signs, and the third child developed normally. Results of Parental Syphilis — Sterility and Accidents to Pregnancies. — Irrespective of the order of syphilitic accidents to pregnancies, it is important to keep in mind the various difficulties which may be attributable to parental syphilis before the birth of a living syphilitic child. Sterility is com- mon in syphilitic families, although it is impossible to show an 1 Boston Dispensary ease reported at a meeting. 2 Jeans, P. C, A Review of the Literature of Syphilis in Infancy and Child- hood, American Journal Diseases of Children, vol. 20, no. 1, July, 1920, p. 58,. quotes Post, American Journal Diseases of Children, vol. 12, Oct., 1916, p. 364. 3 Still, G. F., Congenital Syphilis. (System of Syphilis, vol. I), 2nd edition, London, 1914, p. 287. 4 Still, loc. cit., quotes Sir Herman Weber, p. 287. 5 Jeans, loc. cit., p. 58, quotes Goldenberg in discussion of Wile, J., Cutaneous Diseases, vol. 34, Sept., 1916, p. 645. 6 Jeans, loc. cit., p. 58, quotes DaCosta and Van der Valk, TJrologic and Cutaneous Beview, vol. 23, March, 1919. p. 159. 48 SYPHILIS OF THE INNOCENT absolute percentage due to syphilis alone. Although, abor- tions, miscarriages, and stillbirths occur in non-syphilitic families from various causes, the number in syphilitic fami- lies exceeds the normal incidence. These two points will be taken up in detail in the chapter, "The Family," where the results of syphilis on the family as an entity will be shown by a recent study 1 of 555 syphilitic families at the Boston Psychopathic Hospital. It is sufficient here to note briefly that this study demonstrates that between one third and one fourth of the syphilitic parents never give birth to a living child. This is to be compared with the study of a similar group of New England families which gives only one tenth as being childless. More than one third of the families of syphil- itics had accidents to pregnancies. One fifth of the pregnan- cies were abortions, miscarriages, and stillbirths, as compared with less than one tenth of the pregnancies in non-syphilitic families. Syphilis thus destroys children before they have a chance to compete with life. Infant or Early Deaths. — Opinions differ as to the viability of children born alive in syphilitic families. It is generally supposed that syphilis is a frequent cause of infant deaths. Jeans 2 found that 22.7 per cent of the children born alive in 100 families were dead at the time of examination. Post 3 in a small group of 30 families gives the percentage as 38.1. Julien 4 found that of 162 children born alive, 42.6 per cent died. In the families with congenital syphilitica or of known syphilitic mothers the percentage varies from 19.5 (Veeder 5 ) and 27.6 (Harmon 6 ) to 71.3 (Pileur 7 ). We thus see a varia- 1 Solomon, H. C. and M. H., The Effects of Syphilis on the Family of Syphi- litics Seen in the Late Stages, Social Hygiene, vol. vi, no. 4, Oct., 1920, pp. 469-487. 2 Jeans, P. C, Syphilis and Its Relation to Infant Mortality, American Journal of Syphilis, vol. iii, no. 1, Jan., 1919. 3 Jeans, loc. cit., quotes Commisky, American Journal of Obstetrics, lxxiii, 1916, p. 676, who quotes Post. 4 Jeans, loc. cit., quotes Holt : Diseases of Infancy and Childhood, D. Appleton and Co., 1916, p. 1126, who quotes Julien. 5 Veeder, B. S., Hereditary Syphilis in the Light of Recent Clinical Studies, American Journal Medical Sciences, clii, 1916, p. 25. 6 Harmon, Bishop, Final Report of the Commissioners : Report of the Com- mission on Venereal Diseases, London, 1916, p. 149. 7 Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea and Febiger, 1918, p. 144, quotes Pileur. THE CHILD 49 tion of from 19.5 to 71.3 per cent with a mean percentage between 27.6 and 38.1. It is not stated how many of these deaths were during infancy or later. In onr study of 555 families it is probable that many of the children who had died before examination were syphilitic, yet our figures for deaths are no greater than those found in non-syphilitic families. A review 1 of our statistics shows that at the time of examination approximately 20 per cent of the children who had been born alive had died. This agrees almost exactly with the figures given by the United States Life Table for 1910, 2 which shows that slightly more than 20 per cent of the children born into the world do not reach the age of 18. We were able to obtain the age of death of 44 children in our group/ Of these, all but one died under the age of 18, and this one died at the age of 19, so that it may be stated that these figures are absolutely comparable. Consid- ered from the standpoint of infant mortality, it is found that the infant mortality of the group born in our syphilitic fami- lies is less than that found in the Massachusetts Census (1915) which gave the infant mortality rate as 131 and 134 per thou- sand, respectively. The infant mortality rate in our group was 124 per thousand. These figures are of considerable interest in showing that the infant mortality rate and the deaths of children under 18 years of age do not vary greatly in the families of the late syphilitic as seen in the clinic, from the mortality as found in the community. Wirz 3 on the other hand quotes Pfaundler as showing that only 43 per cent of the children born living of syphilitic par- ents reach the age of 10, while the normal percentage is 69 per cent. This would indicate that the death-rate from syphilis in the early years is greater than the normal rate. In spite of this we conclude from our findings that the infant death-rate from syphilis is not abnormally high except that, when added to the other effects of syphilis on the children of syphilitics, the deaths reduce the number of living and 1 Solomon, H. C. and M. H., loc. eit., p. 482. 2 Bureau of the Census, Department of Commerce, Washington, Government Printing Office, 1916, p. 16. 3 Jeans, Amer. Jmr. Dis. Children, July, 1920, p. 56, quotes Wirz, Ztschr. f. Kinderh. 19:189 (July), 1919, who quotes Pfaundler. 50 SYPHILIS OF THE INNOCENT healthy children below the norm for any family. Of course in any given case an infant death may well be ascribed to syphilis. Case 31. Margaret Miles was a syphilitic woman of 37. She seemed unable to bear any children who could live. In addition to two miscarriages, she bore five children who died in their first year. Congenital Syphilis — Incidence in General Child Population — Tables 7, 8, 9. — The last but probably most important aspect of the effect of syphilis on the offspring is the congen- ital syphilitic — the child who has weathered the very earliest consequences but is a syphilitic as surely as his parents. As in all statistics of general incidence, it is difficult to secure satisfactory figures for the number of children who are syphil- itic. The incidence of congenital syphilis may be considered from two viewpoints : first, the incidence in the general child population, and second, among the offspring of syphilitic parents. Some idea of the general incidence of congenital syphilis may be gained by a study of groups of children. Table 7 gives the incidence of syphilis as shown by Wasserraann sur- veys in eight children's hospitals and clinics. These figures are open to some criticism. Clinic and hospital cases are, of course, selected material since they represent unhealthy chil- dren drawn largely from the poorer classes of the community. As mentioned before, the Wassermann survey is never an accu- rate method of determining syphilis, congenital or acquired, but has the value of being relatively standardized and is fairly satisfactory for statistical purposes, as the errors due to false positives and false negatives tend to cancel each other. In the surveys given in Table 7, 3185 children, divided among eight groups, were submitted to routine Wassermann tests and 5.2 per cent were found to have a positive reaction, indi- cating that syphilis was present in one out of 20 children. The percentages in these eight groups vary from 21.9 per cent at Bellevue Hospital in New York to 1.7 per cent at the New England Hospital for Women and Children in Boston. The variation between the highest and lowest figures is a very good warning of the care that must be used in draw- ing general conclusions from specific investigations. This cannot be emphasized too much. The percentages obtained THE CHILD 51 by ns in analyzing the figures of the two Boston hospitals, New England Hospital for Women and Children and the Boston Floating Hospital, are in point. These figures are 1.7 per cent and 10 per cent. The children at the New England Hospital for Women and Children are on the whole from a class of higher financial rating and are less severely ill than those making up the patients of the Floating Hospital. Fur- ther, in the New England Hospital for Women and Children group are some new born infants whose Wassermann reactions would not be positive. These factors undoubtedly explain in part the variation in percentages. We can only conclude from a consideration of the figures given in the table that it is impossible to give a figure on the incidence of congenital syphilis at this time. The best we can do is to state that in hospital groups the incidence of congenital syphilis as shown by the Wassermann reaction is greater than 1.7 per cent and less than 22 per cent, and that it is probably about 5 per cent. The diagnosis of congenital syphilis based on clinical symp- toms excluding the Wassermann reaction cannot be consid- ered so accurate as when this test is the basis of the diagnosis. The only chance of correctly diagnosing congenital syphilis clinically is when the child has unmistakable stigmata or active symptoms at the moment of examination. In Table 8 figures are given from several sources on the incidence of congenital syphilis, based upon clinical diagnosis alone. The percentages in these studies vary from 0.6 per cent to 3.3 per cent, with an average of 0.9 per cent. That the figures given in Table 8 vary from those of Table 7 merely adds to the difficulty of giving an adequate estimate of the incidence of congenital syphilis. If any further proof is needed to show how badly situated one is in this regard, it is given in Table 9, where the figures of a Wasser- mann survey of four groups of children vary from per cent to 33.9 per cent positive reactions. To make matters worse, the investigators who made the study at the New Orleans Foundling Asylum found no children having a positive Was- sermann reaction but made a diagnosis of syphilis in 83.9 per cent of the cases based upon the luetin reaction plus clinical findings. The futility of attempting to be explicit in the present stage of our information needs no comment. 52 SYPHILIS OF THE INNOCENT Table 7. Incidence of Congenital Syphilis as Shown by Wasser- mann Surveys of Children's Clinic Group Clinic Number of Children Positive Wassermann Reaction Doubtful Wassermann Reaction Negative Wassermann Reaction No. P. C. No. P. C. No. P. C. Bellevue Hospital, New York 1 191 42 21.9 18 9.4 131 68.6 New England Hospital for Women and Children, Boston 2 175 3 1.7 1 .6 171 97.7 Floating Hospital, Boston 3 110 11 10.0 2 1.8 97 88.2 England* 6 331 33 10.0 14 4.0 284 86.0 Germany 6 * 236 8 3.3 Brooklyn, N. Y.» • 1074 34 3.2 University of California Hospital, California 10 890 26 2.9 New York'i « 178 11 6.1 Total 3185 168 5.2 1 Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea and Febiger, 1918, p. 55, quotes Dr. William F. Snow. 2 New England Hospital for Women and Children. Tests by Massachusetts State Department of Health. Compilation by H. C. Solomon, Boston, Mass. 3 Floating Hospital, Boston. Tests by Massachusetts State Department of Health. Compilation by H. C. Solomon, Boston, Mass. 4 Random cases. 6 Browning, Investigations on Syphilis as Affecting the Health of the Com- munity, British Medical Journal, vol. i, 1914, p. 77, quoted by Vedder, p. 44. 6 Nursing children. 7 Epstein, Ueber die Bedeutung der Wassermannschen Reaktion in der Sauglingsfiirsorge, Praeger med. Wchnschr., vol. 38, 1913, p. 621, quoted by Vedder, p. 36. 8 Newborn babies. Many congenital syphilitics do not give a positive Wasser- mann reaction at birth. 9 Jeans, loc. cit., American Journal of Syphilis, vol. iii, no. 1, Jan., 1919, quotes Commisky, American Journal of Obstetrics, vol. 73, 1916, p. 676. io Whitney, A Statistical Study of Syphilis, Journal of the American Medical Association, vol. 65, 1915, 1896, quoted by Vedder, p. 61. 11 Children without signs of syphilis. Five proved to be syphilitic and two possibly. Random cases. 12 Holt, The Wassermann Reaction in Hereditary Syphilis in Congenital De- formities and in Various Other Conditions in Infancy, American Journal Diseases of Children, vol. 6, 1913, p. 168, quoted by Vedder, 'p. 72>. THE CHILD 53 Table 8. Incidence of Congenital Syphilis as Shown by Clinical Findings in Children's Clinic Group Clinic Number of Individuals Positive Wassermann Reaction No. P. C. King's College, England 1 4830 29 .6 Budapest, Children's Clinic 2 106407 720 .66 Children's Polyklinik, Berlin 3 28000 254 .9 Berlin 4 6 17282 186 1.07 Germany 6 17448 207 1.18 Hospital for Sick Children, England 7 12000 250 2.5 Children's Memorial Hospital, Chicago 8 695 23 3.3 Southern Clinic 9 10 225 7 3.1 Total 186887 1676 .89 1 Still. G. E., Congenital Syphilis, London, (System of Syphilis, vol. i), second edition, 1914, p. 290. 2 Pusey, op. cit., quotes Vas, p. 70. 3 Heller, Die Hauflgkeit der Hereditaren Syphilis in Berlin, Bed. Jclm. Wchnschr. xlvi, 1909, p. 1315, quoted by Vedder, p. 36. 4 Nursing children. 5 Griffith, J. P. C, The Diseases of Infants and Children, Philadelphia, Saunders, 1919, quotes Fruhinholz, p. 562, Eev. d'Hyg. et de med. inf., vol. ii, no. 1, 1903. 6 Heller, quotes Von Cassel, quoted by Vedder, p. 36. 7 Still, G. F., op. cit,, quotes R. J. Lee, vol. i, p. 290. 8 Churchill and Austin, Frequency of Hereditary Syphilis, American Journal Diseases of Children, vol. 12, 1916, p. 355, quoted by Vedder, p. 72. 9 White children only. io Moore, Hereditary Syphilis in the Negro Race, Southern Medical Journal, vol. 8, 1915, p. 946, quoted by Vedder, p. 91. 54 SYPHILIS OF THE IXXOCEXT Q o m cu P o 03 O 3 w S < Eh S z o Q c w K Q 5 OS - pq EH < Eh < Q B > Eh a « « B Eh Routine Wassermann and luetin tests. 74.5% of cases showed positive luetin; 9.43% showed clinical findings. Conclusion is that 83.96% are syphilitic. g 0) d 00 CO o 00 35 o « a 6 o - 6 2 o »o 8 ill rs <" ^ d o co CO OS CO CO 00 © o o 00 CO Tf o o o o CO 0. & O « O o s s -< "a: g a CO o Ct> B _o 3 '"§ 3 bfl G % a S m I a 3 O ax '3 O 1 ■a qq s a O T5 3 -5 O O OO & 3 O Li O >> -a 1 .3. 3 P O s Oh «2 CD cS rn d Sh g rr CD f=i ^ 23 T3 ^ ^3 Pi I— 1 O 03 '3 O Jh s Ph O -»j N s •» ^ rC II M O bJD a s O >h rrt .2 =3 a c-j S s *H 31 n3 H- 3 « 03 OS £ 1 T—l ,rtri id O O CM O © oo u H-3 M J-SS ^ A ^ Si ^g: rt> goo CO S>»2-5 Z< > « 13 S r-H CS r^ > O ^ ?-l S « 3! ce CD pq H > bx) -X o © o O ^> 9 o fl t- ^ ■< s « H Z 00 OJ c c ob E tt ej 1 CJ _g "5 o pi d o 6 o o o Ph el '43 o fcU cogE C r; to ° « 2 "-Jo c3 « §p1^ B§"-S S 6 5 c ^PS oc o3_ 03 0J C c £ as 09 00 1 e 3 O Pi a c OS 1 DO i OB 3 O PC a OJ E o as IE *■* o« Ph en "o £ 1 c3 oc ° £ o 2 1^ fcf o P c "o +> 9 £P^ $ a 03 B 1 03 OS o P. c — c 1« ©+> li — OJ Ph ^ I.s o-«3 ^§ 09 - ^ s i- S-l s d as o as IE 3 09 09 «- a> s a s OJ C3 EE 11 09 03 £ a) S.9 O g* +» 00 5 ry; i X OJ g -a OJ 2 s ^§ X' o3 J£ ag ^?0J ■•* d 09.3 0-5 ^ i e V d Ph' oc CO co oc CO CD d OS B OS OS d 00 6 z CD CO CO CO CM ID CD CO . . c! * fc ^ 1 h §£^ d Ph CM ■* OJ C5 - o3 S w £ o o ro O O j>> 3 o o ffl .2 '.£ 3 -is cs CD OJ DO 03 "G OS C ie .E IS 09 03 o ca oc Id 1 n 1" C 2 00 o PQ 1 w o 0) o o c >* 'S o K a k R c >. 9 PQ o -3 >. a .-3 fi bC It M Ph S as". £•£ c =s t. o a« •Is « I! S3 C 3 1 c IE U ^c" 'E O >, o a 03 c H>> 09 c3 "a3 PQ 1 a 09 O w >. ■3 OJ 13 OJ 00 CJ* >> '3 03 3 c- 100 SYPHILIS OF THE INNOCENT r> --=. CO « s ft <-> J3 e 5 a «r "3 • "fn rL <» +3 S>s I § I a I :• . s l 2 C Oi DC c . •— ! © § I d § i I a £& 5 ** ^ .,?>>.££ c3 © .2 r-T cb 3 .2 r ~ l +? I * § 1 3 £ ^ O fc c * C 000 s 3J ^| to — '£ _ © ' — IE ^ T3 ° w ft o 5 Is © ~ft © oo Ig ft .£ U a a< c H3 .£* ""3 r3 *^ fen *- ^ 5 ~ I * B h I ! Ill b = ! l « I I i £* I -si* 1*8 * is of | % || s sS I § 1 ' s 1 = § is a is ee cS -^ 2 ft % "d . ® ^^ - g I 5 Its i- * iif s g * i i e -g «s" | « : p.| £! !d ~ ^ -. iTJ © _ £ S .9. *> ai ti oM d ^""3.2 o-^c6 -^o g a --^^ P^;p c P P^^.^mS . ^i i— i ^ ^ TO C3 o pc £ oa ft ^ THE CHILD 101 It is seen that a syphilitic woman is a menace to her child and that treatment is of the utmost importance. If a woman is in an actively contagions stage of syphilis and is a menace to others besides her child, she can, in states which have com- pulsory treatment laws for contagious persons, be forced to take treatment. Unfortunately, there are no laws to compel a noncontagious syphilitic pregnant woman to take treatment although she is infective to the fetus, and although the child, if born syphilitic, will be contagious for a time to any who come in close association with it. At the present time moral suasion seems to be the only and often ineffectual means of meeting the situation. Case 72. Patrick O'Brien's family (see Case 28) illustrates what may happen in syphilitic families when treatment is not given. In this typical syphilitic family only one member out of six escaped the infection. Syphilis was discovered in this family when the first child was born. The mother was not put under treatment. Had this been done the history of the family might have been entirely different. In such a family one has to consider not only the actual effect of syphilis as a disease but its social discomforts. The mother has had to take the syphilitic boy to hospitals for treatment over a period of sixteen years. This has been a difficult and costly precedure on her part as she has had to bear a large share of the burden of the family 's support. Case 73. 1 The history of the Charles family is very instructive. The father and mother both had ' ' sores, ' ' probably chancres, which re- ceived local treatment only. Their first child was stillborn and the second child died of hemorrhage of the cord. Before the death of the second child, the parents reported to the hospital for treatment but refused to continue despite all the efforts made by the social worker. Two years later their fourth child was brought to the hospital and found to be syphilitic. The third child had died at the age of three weeks. When the diagnosis was made on the fourth child and treat- ment instituted, the parents agreed to undergo systemic treatment themselves. How much better if they had followed advice and had done this earlier. One always has to reckon with the individual equation of the parents. Education and a thoroughly good system of follow-up are necessary in these cases. Case 74. Inadequate treatment of the mother may be of very little value as is shown by the history of the O'Rourke family. The hus- l Children's Hospital, Boston. 102 SYPHILIS OF THE INNOCENT band acquired syphilis before marriage. Soon after marriage the mother became pregnant and during this pregnancy she showed signs of the secondary stage of syphilis but received no treatment. The child was born dead. For six months she took some treatment which consisted chiefly of mercury by mouth. She soon became preg- nant again and discontinued her treatment. The child was born alive but lived only seven days. She again became pregnant and this time took treatment during the entire pregnancy. The child was born at full term and lived, although it had a positive Wassermann reaction. During the next pregnancy she again took some treatment and the child again was born at term but was actively syphilitic and developed nervous system involvement. Case 75. Rose DeMarino was a young woman of 27 years of age when she came under observation. The husband acknowledged hav- ing had syphilis twelve years ago and two years prior to his marriage. Mrs. DeMarino had a positive Wassermann reaction. After four miscarriages she was treated by mercurial inunctions. She then gave birth to four living children, the oldest of whom, however, was a con- genital syphilitic. The result of the untreated syphilis in the mother was four miscarriages. After treatment she gave birth to four living children and it is to be presumed that because of the inadequacy of the treatment the first child had congenital syphilis. Probably had treatment been more active this child would also have been free of signs of syphilis as were the three children born later. Case 76. When Mrs. Smith was five months pregnant it was found that she had syphilis. Discovery was made through examining the families of syphilitic patients at the hospital, her husband being a patient with general paresis. She was immediately put under anti- syphilitic treatment and the child when born was found to be quite healthy and showed no signs or symptoms of congenital syphilis. A second child born later was also free from evidence of syphilis. Question of Treatment of Apparently Well Children of Syphilitic Parents. — We may now turn to the question of the treatment of a congenital syphilitic after birth. Should one consider the offspring of all syphilitic parents as syphilitic and treat them on this basis? Certainly one should suspect children of syphilitics of having syphilis and examine them with the utmost care. Attention has already been called to the paint of view of some syphilologists who believe that the THE CHILD 103 children of syphilitic parents should be treated irrespective of whether they show definite signs or symptoms. Thus, Browning and McKenzie 1 say that "a positive Wassermann reaction in either parent of a seemingly healthy infant is an indication for the treatment of the child also, and this is espe- cially the case if the mother reacts positively. ' ' This is an extreme point of view and is hardly in keeping with the advice of some of the older syphilologists, as Jonathan Hutchinson and Fournier, who, as a result of many years of experience, felt that many syphilitics give birth to perfectly normal healthy children. Observation over a period of years has shown that many offspring of syphilitic parents never develop any debilitating condition which may be related to an active spirochetosis. Thus we feel that treatment is not indicated for those offspring who show neither stigmata nor symptoms, but rather that they should be kept under close observation. It is, of course, possible, if one does not treat all the offspring of syphilitic parents, that a certain number of children who have apparently been free from the disease will develop late symptoms. That is, children who have shown no signs or symptoms during a period of years may later develop some syphilitic disorder. It is not probable, however, that this will occur with any great frequency, and for practical pur- poses it would seem safer not to treat children who show nothing either in the way of stigmata, symptoms, or laboratory findings suggestive of the disease. Treatment in Infancy and Early Childhood; Prognosis. — If one does not hold to the view that all offspring of syphilitic parents, or particularly of syphilitic mothers, should be treated, then the basis for treatment must be stigmata or symptoms of the disease. It is obvious that a syphilitic infant should receive treatment from the earliest possible moment. The attempt should always be made to treat a syphilitic child before the appearance of symptoms such as interstitial kera- titis, deafness, or other manifestations. This is quite possible in those cases in which symptoms appear late. When, how- i Browning, C. H. and McKenzie, Recent Methods in the Diagnosis and Treat- ment of Syphilis, Philadelphia, Lea and Febiger, 1912, p. 111. 104 SYPHILIS OF THE INNOCENT ever, the symptoms appear in the first weeks of life, all atten- tion must be directed toward treating the symptoms. Where treatment is instituted early some very successful results may be obtained. The children who have severe early symptoms such as pemphigus and marasmus often improve very rapidly under antisyphilitic treatment. Case 77. Helen Morrison was five weeks old when she was first seen. She was covered with a rash which made the diagnosis of congenital syphilis possible at first sight. She was a poor little undernourished baby. She was taken into the hospital and with good care and anti- syphilitic treatment made marked improvement. After the open lesions were healed and the child no longer was considered contagious she was placed by a child-placing agency in a foster home, the foster parents understanding the conditions of the case. At the age of thirteen months this little lady was very precocious. She had a vocabulary of a number of words and was walking. She was a pretty little child, showing no stigmata. She was still small, weighing only fourteen pounds, but had gained considerably in the previous few months, and by the aid of proper hospital and medical treatment com- bined with good social service care she was showing every indication of good health and good mental development. An early diagnosis of syphilis in children is, therefore, of very great importance. As has been seen, the diagnosis of congenital syphilis is based chiefly upon stigmata, symptoms, and history of the child, supplemented by family history and examination. It would seem fair to state that every child who shows either definite stigmata of congenital syphilis or symptoms of the disease or a combination of both, should have treatment. We would hold that every child with defi- nite stigmata which make a diagnosis of congenital syphilis certain should have treatment whether or not symptoms are present. Thus, Hutchinsonian teeth in a child of syphilitic parentage is rather definite evidence that syphilis has caused some change in the organism and that the child should receive treatment, though he has shown no other signs of the activity of the disease. The Wassermann reaction is one of the most important symptoms of congenital syphilis, yet a negative Wassermann reaction is of no more significance than the absence of other signs or symptoms of syphilis. Where there THE CHILD 105 is evidence that congenital syphilis is present, a negative Wassermann reaction has no real bearing on the question of treatment. It must be thoroughly recognized that in con- genital syphilis, as in the acquired form, there may be long periods of apparent latency in which no symptoms, with the possible exception of the Wassermann reaction, appear. When the Wassermann reaction is consistently positive, the evidence that syphilis is present in an active form is weighty enough to demand radical treatment. Both logic and experience seem to show that later manifestations may be prevented by the treatment of children who have a positive Wassermann reac- tion but no other symptoms of the disease. It is, of course, difficult to say this with great definiteness, as one is here deal- ing with the subject of preventive medicine. If no symptoms develop one is never able to say that they would have devel- oped if treatment had not been given. Preventive therapy is never startling, as it offers no brilliant pictures. A vast amount of experience will be necessary to show just how much can be accomplished by the treatment of congenital syphilitics who are free from symptoms. The experience at hand, however, seems to justify the value of thorough treatment. Often when congenital syphilitics are treated and relieved of present symptoms one cannot give an entirely good prog- nosis or the assurance that no later symptoms will develop. Cases of interstitial keratitis or other late manifestations may appear in children who have been well treated. In other words, we have no definite cure for all cases of congenital syphilis. Without much question, the number of symptoms may be very markedly decreased by treatment. The great difficulty in the amassing of facts concerning the value of treatment in congenital syphilis is due to the difficulty in following cases over a long period of years. The value of a well-run follow-up service is nowhere greater than in this field. All the evidence we have at the present time goes to show the great good that can be accomplished by the treatment of con- genital syphilis. This is certainly obvious in the results that are obtained in the treatment of the earlier manifestations, and as one can remove symptoms it is most probable that one can be successful in preventing them. The most satisfactory 106 SYPHILIS OF THE INNOCENT effect of treatment of a congenital syphilitic is seen in the general constitutional improvement. Children who are feeble, weak, and poorly developed, will often begin to show immedi- ate improvement upon the administration of adequate early treatment. After many years have elapsed and the organism has secured a definite footing in the deeper structures of the body and has succeeded in thriving despite the resistance of the patient, results are often much more difficult to obtain. Thus, in interstitial keratitis, a condition in which relatively non-vascular regions of the eye are involved, the effects of treatment are not nearly so brilliant. Certainly one does not obtain the magical results that are shown in the treatment of many other types of lesion. There are some oculists who are not very enthusiastic about the systemic treatment and its results on the eye condition. Such treatment even in inter- stitial keratitis seems gradually to be winning more esteem. Thus Posey 1 says that the outcome of a case of interstitial kera- titis in which the individual is given thorough antisyphilitic treatment should be better than in those which are not thus treated. Scarring, which interferes with vision, is apparently considerably reduced when treatment is thorough and ade- quate, and the tendency to recurrence of the difficulty is greatly reduced. In certain of the severe late nervous system mani- festations, such as juvenile paresis and nerve deafness, the results are not good. In these conditions, however, we are dealing with a situation which is entirely identical with that found in acquired syphilis, and the treatment should not be considered any more discouraging than that of cases of acquired syphilis in adult life where treatment has been too long delayed. Type of Treatment. — The type of treatment that a congen- ital syphilitic should receive is something that cannot be laid down in dogmatic fashion. This is also true in regard to treatment of syphilis in general. Individual conditions make different methods of treatment advisable, and the ideas of different syphilologists demand variations in the regimen of treatment. In the days before the introduction of arsphen- i Posey, Hygiene of the Eye, Philadelphia, Lippincott, 1918. pp. 164-168. THE CHILD 107 ainin, fairly good results were obtained by the use of mercury over a period of a great many years. Mercury by mouth has its chief value in cases of congenital syphilis, and many excel- lent results have been obtained by the feeding of mercury and chalk to syphilitic infants. Hochsinger 1 gives some interest- ing figures on the chances of ultimate recovery in a series of cases of congenital syphilis treated before the days of arsphenamin. Of 263 cases under observation from four to twelve years, 79 died. One hundred and twelve had symptoms (not always syphilitic) and 72 were free from symptoms of any kind. Because of the good results that may be obtained by the use of mercury in the treatment of congenital syphilis it becomes obvious that one must use this drug in practically every case, although other forms of medication may be added. Arsphenamin produces some excellent results and may be used from the very early days of life. Clinical experience seems to show that lives of seriously ill syphilitic infants may be saved by the early administration of arsphenamin. The treatment of the nursing mother may also have some valuable therapeutic effects upon the child. This, however, does not seem to be nearly as effective as the introduction of the drugs directly into the system of the child. A combination of mer- cury and arsphenamin is probably the best method. Potas- sium iodide has its place in the treatment of congenital syphilis as well as in acquired syphilis. The treatment of congenital syphilis must be continued over a period of many years. It is doubtful if there is any exception to this state- ment. Certainly conservative judgment indicates that one must continue treatment for a long period if one wishes to be sure of results. What has been said about the type of treatment of the infant holds equally for congenital syphilitics whose treatment begins later in life. The combination of arsphenamin and mercury is also indicated over a period of years. It should be emphasized that a negative Wassermann reaction obtained during treatment is not an indication that the child is cured of syphilis. Treatment should be persistent despite nega- i Griffith, op. cit., p. 578. quotes Hochsinger, Ergebn. d. inn. Med. u. Kinderh.. vol. 6, 1910, p. 125. 108 SYPHILIS OF THE INNOCENT tive Wassermann reactions. It goes without saying that a positive Wassermann reaction is evidence that cure has not been effected. By a continuation of treatment over a period of years it is often possible to obtain a condition in which no symptoms of syphilis appear and in which the Wassermann reaction becomes and remains negative. Advantages of Hospital Schools. — The necessary care and hygiene of syphilitic children, which is equal in importance to the administration of antisyphilitic remedies, often cannot be properly given if the child remains at home. It is also difficult to secure the parents' cooperation for a long con- tinued period of out-patient treatment. When a child has active symptoms it is, at times, possible to obtain a place for him in the hospital where treatment can be carried out to better advantage ; but when the active symptoms have disap- peared this is no longer practical. Frequently the child is in such a condition that it is impossible for him to attend the ordinary schools. This is true of many children with inter- stitial keratitis and other eye conditions, deafness, difficulty with locomotion, and the like. Stokes 1 suggests that these difficulties could be remedied if the plan of Welander, the Scandinavian, were copied in America. Welander established hospital schools where children could secure antisyphilitic treatment, excellent care, and education, simultaneously. Baize 2 says that the child enters the hospital school early and receives regular treatment for at least three years. Under these conditions the child receives steady prolonged treatment as well as education, which is impossible in out-patient clinics or hospital wards. The hospital schools have a special medi- cal personnel, with special methods of treatment adapted to children of different ages, proper hygiene, and educational courses for the children of school age. The Journal of the American Medical Association reviews Mtiller's and Singer's 3 i Stokes, J. H., The Third Great Plague, Philadelphia and London, W. B. Saunders, 1917, p. 108. 2 Baize, F., Asylums for Children with Inherited Syphilis, Bulletin de I'Academie de Medecine, Paris, vol. 81, June 17, 1919, p. 811. 3 Miiller and Singer, Fate of Syphilitic Children, Archiv fur Kinderheillcunde, Stuttgart, May 17, 1919, vol. 67, nos. 3 and 4 (reviewed in the American Medical Association Journal). THE CHILD 109 results from such hospital schools in Germany, where they were started in 1909. Eighty-four of the children had been in the schools from two to ten years. Better results appar- ently were obtained by their prolonged treatment under the hospital conditions than by any other means. It must be remembered that the aim of treatment of early and late congenital syphilitics, those with little damage done and those in a serious condition, is to minimize the social handicap of the congenital syphilitic and to allow him to take his place in the everyday world. Time, only, can tell how far we have progressed towards accomplishing this end, but that we have gone a considerable distance in this direction is certain, and that we can go much further is probable. REFERENCES Adams, J., Pregnancy and Latent Syphilis. Result of Three Years' Treatment of Syphilitic Mothers and Babies, The Lancet, vol. ii, Nov. 13, 1920. Atwood, C. E., Idiocy and Hereditary Syphilis, Journal of the American Medical Association, vol. 55, Aug. 6, 1910. Balze, F., Asylums for Children with Inherited Syphilis, Bull, de VAcad. de med., Paris, vol. 81, June 17, 1919. Bazeley and Anderson, Mental Features of Congenital Syphilitics, Boston Medical and Surgical Journal, vol. 173, no. 26, Dec. 23, 1915. Blaisdell, J. H., The Menace of Syphilis of To-day to the Family of To- morrow, Boston Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 1916. Browning, C. H. and McKenzie, Becent Methods in the Diagnosis and Treat- ment of Syphilis, Philadelphia, Lea and Febiger, 1912. Bulkley, L. D., Syphilis in the Innocent, New York, Bailey and Fairchild, 1898. Bureau of the Census, Department of Commerce, Washington, Government Printing Office, 1916. Charcot, M., Clinique des Maladies du Systeme Nerveux, Paris, Veuve Babe et Cie, 1892. DeBuys, L. R. and Maude Loeber, Study in a Foundling Institution to De- termine the Incidence of Congenital Syphilis, Journal of the American Medical Association, Oct. 4, 1919. Derby G. and C. B. Walker, Interstitial Keratitis of Luetic Origin, Transac- tions of the American Ophthalmological Society, 1913. Diday, P., A Treatise on Syphilis in New-lorn Children and Infants at the Breast, translated by'G. Whitley, London, the New Sydenham Society, 1859. Fournier, A., La Syphilis Hereditaire Tardive, Paris-, G. Masson, 1896. , Treatment and Prophylaxis of Syphilis, English translation of the second edition, revised and enlarged by C. F. Marshall, American edition revised and corrected with an appendix by George M. Mackee, New York, Rebman. Freud, S., Three Contributions to the Sexual Theory (Brill's translation), Nervous and Mental Disease Publishing Co., 1910. 110 SYPHILIS OF THE INNOCENT Griffith, J. P. C, The Diseases of Infants and Children. Philadelphia. Saunders, 1919. Habermann, Hereditary Syphilis, Journal of the American Medical Association, vol. 64, no. 14, April 3, 1915. Haines, T. H., Incidence of Syphilis Among Juvenile Delinquents, Journal of the American Medical Association, vol. 66, no. 2, 1916. Hochsinger, Die gesundheitlichen Lebenschicksale, Wiener Iclmische Wochen- schrift, vol. 24, June 16, 1910. Infant Mortality Series, no. 3, Children's Bureau Publication, no. 9, Washing- ton, D. C, 1915. Jeans, P. C, A Review of the Literature of Syphilis in Infancy and Childhood, American Jmirnal of Diseases of Children, vol. 20, no. 1, July, 1920. , Cerebrospinal Involvement in Hereditary Syphilis, American Journal of Diseases of Children, vol. 18, no. 3, Sept., 1919. , Familial Syphilis. American Journal of Diseases of Children, vol. xi, no. 1, Jan., 1916. , Syphilis and Its Relation to Infant Mortality, American Jmirnal of Syphilis, vol. 3, no. 1, Jan., 1919. and E. Butler, Hereditary Syphilis as a Social Problem, American Journal of Diseases of Children, vol. 9, no. 5, Nov., 1914. Kingery, L. B., A Study of the Spinal Fluid in Fifty-two cases of Congenital Syphilis, Journal of the American Medical Association, vol. 76, no. 1, Jan. 1, 1921. Kolmer, Prenatal Syphilis, with a Plea for its Study and Prevention, Ameri- can Journal of Diseases of Children, vol. 19, no. 5, May, 1920. Kraepelin, E., Psychiatrie, eighth edition, Leipzig, vol. iii, 1913. Lucas, W. P., Contributions to the Neurology of the Child. II. Note on the Mortality and the Proportion of Backward Children in Cases of Congenital Syphilis Followed Subsequent to Hospital Treatment, Boston Medical and Surgical Journal, Feb. 29, 1912, Aug. 29, 1912, Sept. 4, 1913. , Study for Massachusetts Society for Sex Education. Unpublished. MtiLLER and Singer, Fate of Syphilitic Children, Archiv fur Kinderheilkunde, Stuttgart, May 17, 1919, vol. 67, nos. 3 and 4 (reviewed in the Journal of the American Medical Association). Newcomer, H. S., et al., One Aspect of Syphilis as a Community Problem, American Journal of Medical Sciences, vol. 158, Aug., 1919. Nonne, M., Syphilis and Nervensystem, Dritte neubearbeitete Auflage, Berlin, Verlag von S. Karger, 1915. Plaut and Goring, L T ntersuchungen an Kindern und Ehegatten von Paralytiken, Miinchener medisinische Wochenschrift, vol. 58, no. 37, Sept. 12, 1920. Posey, Hygiene of the Eye, Philadelphia, Lippincott, 1918. Pusey, W. A., Syphilids as a Modern Proolem, Chicago, American Medical As- sociation, 1915. Ricord, Lectures on Venereal and other Diseases, translated by V. de Merie, Philadelphia, 1849. Report of the Commission on Venereal Diseases, Final Report of the Com- missioners, London, 1916. Solomon, H. C. and M. H., The Effects of Syphilis on the Family of Syphilitic* Seen in the Late Stages, Social Hygiene, vol. vi, no. 4, Oct., 1920. Still, G. P., Congenital Syphilis, System of Syphilis, second edition, London, vol. 1, no. 1, 1914. THE CHILD 111 Stokes, J. H., The Third Great Plague, Philadelphia and London, W. B. Saunders, 1917. , To-day's World Problem in Disease Prevention, Issued by the U. S. Public Health Service, Treasury Department, Washington, D. C. Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea and Febiger, 1918. Veeder, B. S. 3 Hereditary Syphilis in the Light of Recent Clinical Studies, American Journal of the Medical Sciences, vol. clii, 1916. Williams, J. W., Significance of Syphilis in Prenatal Care and in the Causation of Fetal Death, Bulletin of the Johns Hopkins Hospital, vol. 31, May, 1920. ■d a CHAPTER IV THE FAMILY Syphilis as a Family Disease. — It is important to remember that syphilis not only affects the mate and offspring as indi- viduals but also as members of a family group. Syphilis threatens the stability of family life, whether it enters early or late, whether it strikes one member or all members. It is a disease which once having attacked a family affects its social and economic life as well as the health of the individual mem- bers. The entire family morale may be weakened by over- fear of infection or callousness; by attaching too much or too little importance to future difficulties; by exaggerating or minimizing any changes in the home situation. The economic status of the family, its industrial level, and standard of living are often affected. The community, a network of families, then bears part of the economic burden. Statistics on Incidence in Families. — In our study of 555 families of syphilitics 1 given in the preceding chapters, we have shown statistically the specific results on the mate and child. Further figures from the study give the effects of syphilis with the family rather than the individual as a unit. For purposes of comparison with our tables we have inserted wherever possible similar figures from other authors. Families in Which Positive Wassermann Reaction Ap- peared. — The tables on familial syphilitic involvement include five tables from our study and two tables compiled from studies by other authors. Table 17 shows the number of fami- lies in which some member aside from the original patient had a positive Wassermann reaction. Of the 191 families in which all members were examined, a positive Wassermann reaction l Solomon, H. C. and M. H., The Effects of Syphilis on the Families of Syphilitics Seen in the Late Stages, Social Hygiene, vol. vi, no. 4, Oct., 1920. 112 THE FAMILY 113 occurred in 30 per cent, whereas, in the 364 families in which every member was not examined, it occurred in but about 19 per cent. The difference in percentage may be accounted for by the fact that in the group in which not all members were examined (364) a larger or smaller number of the unexamined might have shown a positive Wassermann reaction, while the all-examined group (191) was, of course, unconsciously selected according to the ease with which members could come in, size of families, etc. It follows however, that somewhere between 19 per cent and 30 per cent would be the correct figure if every member of the original group of 555 families had been examined; that is, it would undoubtedly be higher than 19 per cent and less than 30 per cent. In the larger group (555), a positive Wassermann reaction occurred in 22.8 per cent of the families. This figure of 22.8 per cent which would probably be close to the correct figure had all members been examined, is typical of what may be expected in any clinic dealing with late syphilitics when an effort is made to bring the spouse and children of syphilitic patients to the clinic for examination. Families with no Children. — Table 18 is concerned with the percentage of families in which no living children were born. The families in which no successful pregnancies oc- curred may be divided into families which were entirely sterile, and those in which pregnancies occurred which never came to successful fruition. The tables dealing with the total 555 families may be considered as giving the correct per- centage for this study, which is based upon history. It was found that 29.7 per cent of the families did not give birth to living children, 23 per cent being entirely sterile, and 6.7 per cent having unsuccessful pregnancies. It must be borne in mind that we are not here dealing with the question of acci- dents to pregnancies as such, but merely with the number of childless families. Not all of the sterile or childless mar- riages can be definitely traced to syphilis. Gonorrhea, pelvic deformities, mismating, and the like, may account for much of it. However, if we compare this figure of 29.7 per cent 114 SYPHILIS OF THE INNOCENT TABLES SHOWING FAMILIAL -191 Families in Which Evert Living Member Was Examined Class General Paresis Cerebro- spinal Syphilis Nervous system not involved Total TABLE 17 FAMILIES IN WHICH No. P.C. No. P.C. No. P.C. No. P.C. 150 37 2 100.0 25.1 1.4 9 4 100.0 50.0 32 8 4 100.0 28.5 14.3 191 49 6 100.0 Families with positive Wassermann in one member Families with positive Wassermann in more than 26.7 3.3 Total families with positive Wassermann in one or more members 39 26.5 4 50.0 12 42.8 55 30.0 TABLE 18 FAMILIES WITH No. P.C. No. P.C. No. P.C. No. P.C. 150 53 9 100.0 35.3 6.0 9 1 1 100.0 11.1 11.1 32 11 6 100.0 34.4 18.7 191 85 16 100.0 Families with no pregnancies 34.0 Families with no children, but with abortions, mis- 8.4 62 41.3 2 22.2 17 53.1 81 42.4 TABLE 19 BIRTH-RATE AND No. P.C. No. P.C. No. P.C. No. P.C. 150 75 1.33 1.06 100.0 50.0 9 6 1.89 1.44 100.0 66.7 32 13 1.29 .94 100.0 40.6 191 94 1.35 1.06 100.0 50.0 Families with living children Average number of living children per family TABLE 20 FAMILIES WITH DEFECTS No. P.C. No. P.C. No. P.C. No. P.C. Total families 150 53 9 8 24 100.0 35.3 6.1 5.3 16.0 9 1 1 2 100.0 11.1 11.1 22.3 32 11 6 4 3 100.0 34.4 18.8 12.5 9.3 191 65 16 12 29 100.0 Families with no pregnancies 34.0 Families with no children, but with abortions, mis- carriages, or stillbirths . 8.4 Families with positive Wassermann reaction in children 6.3 Families with non-syphilitic children, but accidents to pregnancies 152 Total families with defects as to children 94 56 62.7 37.3 4 5 44.5 55.5 24 8 75.0 25.0 122 69 63-9 Total families with no defects as to children 36-1 Total 150 43 100.0 28.6 9 3 100.0 33.3 32 8 100.0 25.0 191 54 100.0 Families with no defect as to children or Wasser- mann reaction in spousef 28-2 TABLE 21 FAMILIES WITH No. P.C. No. P.C. No. P.C. No. P.C. 150 97 35 100.0 64.7 36.0 9 8 3 100.0 88.9 37.5 32 21 12 100.0 65.6 57.1 191 126 50 100 Families with pregnancies Families in which abortions, miscarriages, and still- births occurred^ 66.0 39.7 * There are a few families in which there was neither living spouse nor child, nancies is discussed (Table 18) but not in the Wassermann reaction percentages t These percentages were taken on the total families although there were a few there was no living spouse to examine. The assumption was that the spouse was t These percentages were taken on families with pregnancies. THE FAMILY 115 SYPHILITIC INVOLVEMENT B — 364 Families in Which One or More Members Besides the Patient was Examined C — 555 Families, Total of A and B General Paresis Cerebro- spinal Syphilis Nervous system not involved Total General Paresis Cerebro- spinal Syphilis Nervous system not involved Total POSITIVE WASSERMANN REACTION APPEARED No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. 192 36 8 100.0 19.6 4.3 48 2 3 100.0 4.3 6.4 124 12 6 100.0 10.0 5.0 364 50 17 100.0 14.3 4.8 342 73 10 100.0 22.0 3.0 57 6 3 100.0 10.9 5.5 156 20 10 100.0 13.5 6.8 555 99 23 100.0 18.5 4.3 44 23.9 5 10.6 18 15.0 67 19.0 83 25.0 9 16.4 30 20.3 122 22.8 NO CHILDREN No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. 192 34 8 100.0 17.7 4.2 48 8 4 100.0 16.7 8.3 124 21 9 100.0 16.9 7.3 364 63 21 100.0 17.3 5.7 342 87 17 100.0 25.4 5.0 57 9 5 100.0 15.8 8.8 156 32 15 100.0 20.5 9.6 555 128 37 100.0 23.0 6.7 42 21.9 12 25.0 30 24.2 84 23.0 104 30.4 14 24.6 47 30.1 165 29.7 AVERAGE NUMBER OF LIVING CHILDREN PER FAMILY No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. 192 145 2.32 1.90 100.0 75.5 48 33 2.96 2.45 100.0 68.6 124 80 2.34 1.75 100.0 64.5 364 258 2.41 1.92 100.0 70.9 342 220 1.89 1.53 100.0 64.3 57 39 2.79 2.28 100.0 68.4 156 93 2.12 1.58 100.0 59.6 555 352 2.05 1.62 100.0 63.4 AS TO CHILDREN OR WASSERMANN REACTION IN SPOUSE No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. 192 34 100.0 17.7 48 8 100.0 16.7 124 21 100.0 16.9 364 63 100.0 17.3 342 87 100.0 25.5 57 9 100.0 15.8 156 32 100.0 20.5 555 128 100.0 23.0 8 4.2 4 8.3 9 7.2 21 5.8 17 5.0 5 8.8 15 9.7 37 6.7 15 7.8 1 2.1 8 6.5 24 6.6 23 6.7 1 1.7 12 7.7 36 6.5 38 19.8 16 33.3 24 19.4 78 21.4 62 18.1 18 31.6 27 17.3 107 19.3 95 97 49.5 50.5 29 19 60.4 39.6 62 62 50.0 50.0 186 178 51.1 48.9 189 153 55.3 44.7 33 24 57.9 42.1 86 70 55.2 44.8 308 247 55.5 44.5 192 100.0 48 100.0 124 100.0 364 100.0 342 100.0 57 100.0 156 100.0 555 100.0 64 33.3 17 35.4 49 39.5 130 35.7 106 31.0 20 35.1 57 36.5 183 30.3 ACCIDENTS TO PREGNANCIES No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. 192 158 50 100.0 82.3 31.6 48 40 19 100.0 83.3 47.5 124 103 37 100.0 83.1 35.9 364 301 106 100.0 82.7 35.2 342 255 85 100.0 74.6 33.3 57 48 22 100.0 84.2 46.0 156 124 49 100.0 79.5 39.5 555 427 156 100.0 76.9 36.5 These are included in the total number of families when the subject of preg- nable 17). families in which the children were non-syphilitic as far as known but in which non-syphilitic. 116 SYPHILIS OF THE INNOCENT - M o 02 3 K- - pq < r^ r^ o o OS r; Ph o 6 CN» 00 00 00 b o o . . cw rH CO o 00 £ 8 CO a o o u o ? d «o 00 00 !C . CO *" _ U o tH eu s 6 fc ■* t^ CO 15 ffl 139 3£ ft w 5 § £ s M 3 _ P3 _« ft a H 03 p PC! ft 02 a « • a ft 5> iH OS 3 * ■^ "5s o O DENTS TO PREGNANCIES B — 364 Families in Which one or More Members Besides the Patient Was Examined C — 555 Families, Total of A and B General Paresis i Cerebro- spinal Syphilis Nervous system not involved Total General Paresis Cerebro- spinal Syphilis Nervous system not involved Total MISCARRIAGES, AND STILLBIRTHS TO PREGNANCIES No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C 536 100.0 185 100.0 369 100.0 1090 100.0 799 100.0 208 100.0 425 100.0 1432 100.0 7 69 \ 15] 17.0 °1 40 3j 23.2 6 H 11 J 21.4 81 176 } 29 j 19.5 14] 119 \ 21 j 19.2 1 11 23.6 21 79 ^ 13 j 22.0 16] 241 \ 40 J 20.7 2.79 3.85 2.98 2.99 2.34 3.65 2.72 2.58 LIVE BIRTHS AND STILLBIRTHS No. P.C. No P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. 445 15 3.37 100.0 142 3 2.11 100.0 290 11 3.79 100.0 877 29 3.31 100.0 645 21 3.25 100.0 159 6 3.80 100.0 331 13 4.00 100.0 1135 40 3.52 100.0 as Shown by Other Clinics Hoch- SINGER8 FOTTRNIER» Raven 10 NONNE 11 Hoch- SINGER 12 1 Tarnier 13 COUTTS" PlLETJR 15 FOURNIER 1 * No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No P.C. No. P.C. 134 100 90 82 67 42 569 100.0 200 100.0 350 100.0 319 100.0 266 100.0 90 100.0 1102 100.0 414 100.0 167 100.0 253 44.4 140 70.0 101 28.9 85 26.6 124 46.6 56 62.0 376 34.1 154 37.2 145 86.8 4.25 2.0 4.26 3.89 3.98 2.14 9 Gow, W. J., Syphilis in Obstetrics, System of Syphilis, second edition.. London, Frowde, Hodder and Stoughton, vol. 2, 1914. pp. 354-5, quotes Fournier. io Habermann, op. cit., quotes study of Nonne material by Raven. 11 Nonne, op. cit., p. 403. 12 Hochsinger, K., Die gesundheitlichen Lebensschicksale erbsyphilitischer Kinder, Wiener Tdinisclie Wochensohrift, no. 24, June 16, 1910, p. 882. 13 Bartlett, op. cit., p. 159, quotes Tarnier. 14 Coutts, Infantile Syphilis, Lancet, vol. i, 1896, p. 971. lsVedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea and Febiger, 1918, p. 144, quotes Pileur. 16 Fournier, A., Syphilis et Manage, Paris, G. Masson, 1880, p. 73. 120 SYPHILIS OF THE INNOCENT syphilitic. Our figures are not entirely comparable with others that have been quoted which are often obtained in a gynecological or obstetrical clinic where only families of pa- tients with evidence of syphilis are considered or where other methods of selection are used. Figures given in the literature (Table 22) as to the amount of sterility occurring in syphilitic families vary from 4.1 per cent 1 to 75 per cent 2 with many intermediate percentages. Birth-rate. — In Table 19, we deal with the birth-rate and average number of living children per family. Here again this information is obtained from history, and therefore the percentages of the 555 families can be considered. Of these 555 families, 352 families, or 63.4 per cent had living children. The average birth-rate per family was 2.05, and the average number of living children per family at the time of the in- vestigation was 1.62. For purposes of comparison, we give an average birth-rate of 3.8 for Rhode Island, taken from the United States Census report (Table 23) as typical for New England. This figure is almost twice that found in our group of syphilitic families. In other words, the number of children born in this group of syphilitic families is prac- tically one half of that found in the same type of population taken at random. It is thus obvious that syphilis plays a large part in the matter of race suicide. Louis Dublin 3 states that it requires an average of nearly four children per family to make a new generation as large as the old. The average of 2.05 births per family in our group of syphilitic families means a loss in population. Families Free from Syphilitic Defect. — Table 20 shows the number of families with syphilis in the spouse and defects as to children, and illustrates how few families among the syphilitic group are free from some defect or other which might be traced to syphilis. The compilation shows that only 44.5 per cent of these families gave no history of sterility, abortions, miscarriages, stillbirths, or syphilitic children. If dead children had been considered among the foregoing ill i Jamieson, loc. cit. 2 Haskell, op. cit., page 892. 3 Dublin, L., Birth Control, Social Hygiene, toI. Ti, no. 1, Jan., 1920, p. 7. THE FAMILY 121 results involving the second generation, the percentages of families free from defects as to children would be even lower. It is fair to assume that in some instances early pregnancies resulted in syphilitic children who died young. As we had no definite way of demonstrating this, we have left the possibility out of consideration entirely and assumed that the dead chil- dren were not syphilitic. Only 30.3 per cent of all the families were free both from defect in the production or nature of off- spring and from syphilis in the spouse. In other words, less than one third of our entire group of 555 families should be considered as definitely free from syphilis or defect possibly due to syphilis. Families with Accidents to Pregnancies. — The number of families with accidents to pregnancies is shown in Table 21. Of the 555 families, only 427 had any pregnancies. Of these 427 families, abortions, miscarriages, or stillbirths occurred in 156 families, or 36.5 per cent. This means that more than one third of the women who became pregnant had abortions, miscarriages, or stillbirths. The number of pregnancies which resulted unfortunately, irrespective of the number of families in which they occurred is also of interest. Table 27. Accidents to Pregnancies and Average Pregnancies Per Family in Non-syphilitic Families SOUKCE8 Children's Bureau Figures on 1491 Married Mothers of Babies Born IN 1911 IN Johnstown, Pa. 1 Jeans' Families Showing No Obvious Syphilis 2 Harmon; Poor Families, Known Cases of Syphilis Excluded 3 No. P. C. No. P. C. No. P. c. Total families 1491 200 150 Total pregnancies *5808 100.0 886 100.0 826 100.0 Total accidents to preg- nancies 445 7.7 88 9.9 78 9.4 Average pregnancies per family 3.88 4.43 5.50 * There "were 63 plural births, hence total pregnancies here represent total issue plus abortions, miscarriages, and stillbirths. i Infant Mortality Series, loc. cit. 2 Jeans and Butler, loc. cit. 3 Harmon, op. cit., p. 149. 122 SYPHILIS OF THE INNOCENT Table Showing Percentage of Syphilis in Class -191 Families in Which Evert Living Member was Examined General Paresis Cerebro- spinal Syphilis Nervous I system not ' involved ! Total TABLE 28 THE AMOUNT Total individuals examined Total individuals negative. . Total individuals doubtful. . Total individuals positive . . No. P.C. No. P.C. No. P.C. No. 302 100.0 21 100.0 58 100.0 381 249 82.5 17 81.0 38 65.5 304 7 2.3 2 3.5 9 46 15.2 4 19.0 18 31.0 68 P.C. 100.0 79.8 2.4 17.8 Percentage of Accidents to Pregnancies.— Table 24 presents the number of abortions, miscarriages, and stillbirths, com- pared to the total number of pregnancies. In the entire group of families (555) there were 1432 pregnancies. Two hundred and ninety-seven, or 20.7 per cent of these pregnancies re- sulted in abortions, miscarriages, or stillbirths. Of course, all the accidents to pregnancies in these families were not due to syphilis, as they occur not infrequently in non-syphil- itic families. Jeans 1 (Table 27) in an analysis of 200 families showing no obvious signs of syphilis, found accidents to pregnancies occurring in 9.9 per cent of a total of 886 preg- nancies. Harmon 2 states that in 150 poor families, exclusive of any known cases of syphilis, there were 826 pregnancies, with 78 or 9.4 per cent, resulting in a failure to produce a living child. In the Johnstown study 1491 married mothers had a total of 5808 pregnancies, which were unsuccessful in 7.7 per cent of the cases. This seems to indicate rather definitely that accidents to pregnancies are about twice as frequent in the known syphilitic families as in those which 1 Jeans and Butler, op. cit., p. 330. 2 Harmon, loc. cit. THE FAMILY 123 Spouses and Children by Wassermann Survey B — 364 Families in Which One or More Members Besides the Patient Was Examined C — 555 Families, Total of A and B General Paresis Cerebro- spinal Syphilis Nervous system not involved Total General Paresis Cerebro- spinal Syphilis I Nervous system not 1 involved Total OF SYPHILIS IN ALL INDIVIDUALS EXAMINED No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. 217 100.0 59 100.0 101 100.0 377 100.0 519 100.0 80 100.0 159 100.0 758 100.0 161 74.2 52 88.1 73 72.3 286 75.9 410 79.0 69 86.3 111 69.8 590 77.8 4 1.8 2 3.4 1 1.0 7 1.9 11 2.1 2 2.5 3 1.9 16 2.1 52 24.0 o 8.5 27 26.7 84 22.3 98 19.0 91 11.2 45 28.3 152 20.1 are considered in a routine procedure. The average number of pregnancies per family in our group of 555 families was 2.58, which is distinctly lower than that given in the studies just mentioned. The average number of pregnancies per family in the study made by Jeans was 4.43; in that of Har- mon, 5.5; and in the Johnstown study, 3.88. Ratio of Stillbirths to Live Births. — Table 25 presents the ratio of stillbirths to live births. There were 40 stillbirths as compared with 1135 live births, giving a ratio of 3.52 stillbirths to 100 live births. This ratio does not differ greatly from that obtained in community surveys. Thus, the average number of stillbirths per 100 live births for Boston, Massa- chusetts, in the years 1891-1919 inclusive is 3.79. The figure given by Dempsey 1 for Brockton, Massachusetts, is 3 still- births per 100 live births; for Johnstown, Pennsylvania, 4.5; i Dempsey, Infant Mortality: Results of a Field Study in Brockton, Massa- chusetts, Children's Bureau, United States Department of Labor, series no. 8, Bureau Pub., no. 37, p. 19. 124 SYPHILIS OF THE INNOCENT for Manchester, New Hampshire, 4.8; for Saginaw, Michigan, 3.3; for New Bedford, Massachusetts, 2.8; and the average for these five cities is 3.8. In other words, it would seem that there was no particular difference in the stillbirth ratio in the 555 syphilitic families from that found in the general community. We may therefore conclude that whereas the incidence of abortions and miscarriages is very much higher in our syphilitic group than in the general unselected groups of families, the incidence of stillbirths is approximately the same in both groups. Percentage of Syphilitic Individuals. — The number of syphilitic individuals found in the families of these syphil- itics has been shown for the mate and child separately. In Table 28 we give the figures for both combined. The incidence of the positive Wassermann reaction is shown to vary between 17.8 per cent (191 families) and 22.3 per cent (364 families). Seven hundred and fifty-eight indi- viduals in all were examined. Of these, 20.1 per cent gave a positive Wassermann reaction, whereas 2.1 per cent gave a doubtful reaction. This would seem to represent fairly ac- curately for general purposes, in a routine series of mates and children of the late syphilitic patient, the number of in- dividuals who will give a positive or doubtful Wassermann reaction. Comparison of Families of Syphilitics with Different Mani- festations of the Disease. — In the discussion which has pre- ceded, no consideration has been given to differences occurring in the three divisions of syphilitic cases which we have offered, namely, general paresis, cerebrospinal syphilis, and syphilitic cases in which the central nervous system is not involved. This comparison is given in Table 29. THE FAMILY 125 < z a i 02 > I* ^ of o cu £ ac Oh 3 O a o P 02 fflffl So it iO O *0 j ?3 ft 0£ 3 a > §So «^a >7 aa.5 an d co d CM 8 d IO 55.2 44.8 30. 5 US 0) co noon MCOCN o 6 Z- • 00 ■CNiO : : : •CN d 8 a *~ 3"£ d d BO d • • CD i>d d iO-- ddd CN • d • 6 Z :| : i •O5C0 ■00 IO ••* ■CO •d IQ CO « o ess » « 3 a jq ? sag fe a5 Si* ■p* pq ga-g 45-2 > ^ >,-t3 on d o d L ? : : co oo >o do d om CO OS d CO t>OCO do'-* CMCOtN ■* • Z •cot> •00 •OS d d d_2 "S.S-S * ST >> O 02 d - d O d 00 • • d • ■ TJHCO •* OO iO coco co •* lOCOi-l drt< « a a a > fc K «< EH s^ a as Is S » _■ ° 2 2x> 3 a oj 72 d Ph 00 d d CO • • d •' •' oo o ifito d NN (N LO ocoeo i-i d co COCOCN 00 • d ' (N d z • OS'* •CNC5 •iO •t>- i-H o OS a =3-a ^3 0-3 05-3 C, 3"* d Ph O d d 1> • d • • CO 0"-0 CO rhd CO T}C0 o dt>.' d COCO (M o d CO MtNCO ddd O ; CM = z : •coco •coo •CO •I> 8 d a i 3 1 o o o B a 03 £ =3 O a ,3 •r< X, * a. gt S a <- "3 5 1= e P 3 c 1 r. a "£ B H 1 = ;> m 1 E a I - 45 "r d > 1 1 P e | d 1 ;> aj B r 1 < a a d - DO 03 e a -: « 1 a X ~ += '/. 03 X o E; — C '5 (23 i- 99 ■f. 03 S: O a la u o 03 03 02 O ffl — . % = la 'il — a 53 OQ O efl .2 S S 0Q a ,o o o3 oj -< f - O s ^^ £ o •HJ ^d | 1 £ X > X = g a, 1 p - = c 2 T ,0 1 1 a d :- < r ~ 'e c - c 6 1 2 X P s < 1 - - m I 3 = B c | > < a — 15 > i S3 CO — £ .-= ^? 0. — - z 126 SYPHILIS OF THE INNOCENT This table indicates that there is only a slight difference in the proportion of difficulties that may be found in the three groups. The number of cerebrospinal syphilitics occurring in the families in which all were examined (191) is so small that this group is not valuable for this particular aspect of the study. Considering the other two groups (364 and 555), there are a few facts which stand out conspicuously. There is no one of these three types of syphilis that does not produce its effect upon the family. There is some differ- ence in the percentage figures given under the three groups. In a general way the Wassermann survey shows a smaller number of positive Wassermann reactions in the mates and children of the patients who had cerebrospinal syphilis, while on the other hand, more families in this group showed acci- dents to pregnancies. There is very little difference in the percentages obtained in the families of patients who had gen- eral paresis and those without involvement of the nervous system. The variation that does occur is apparently within the ordinary limits of variation of a finite group. It may therefore be stated that in a general way the difference in the effect of syphilis upon the mates and offspring of persons suffering from syphilis of the nervous system and of those suf- fering from syphilis which does not involve the nervous system is not sufficient to be of any great importance; the same types of difficulty occur with a frequency that does not greatly vary. The problems of syphilis from the familial standpoint are practically the same whatever course the syphilis may take in the individual patient. Importance of Methods of Selecting Families in Studies of Incidence. — Any marked difference between our figures and those reported in the literature is probably due to a conscious or unconscious selection in other studies. The discrepancies due to basing figures on a selected group are shown by a com- parison of the data of our unselected 555 families with that found in the selected group of 236 syphilitic mothers (see Chap. 3, page 56). Thus, in the 236 families with syphilitic mothers, 95, or 40.2 per cent were childless, as compared with 29.7 per cent childless marriages in the entire 555 families. The amount of actual sterility did not yslyj greatly. Of the THE FAMILY 127 236 mothers, 24.5 per cent were sterile, as compared with 23 per cent in the total group (555). On the other hand, 15.7 per cent of the syphilitic women had abortions, miscarriages, or stillbirths, and no children born alive, as compared to 6.7 per cent of the larger group (555). In the group composed of syphilitic mothers, the birth-rate was 1.84 and the average number of living children per family 1.33. In the entire group (555) the birth-rate was 2.05 and the average number of living children per family, 1.62. In the group of 236 fami- lies, 27.5 per cent of the children examined gave a positive Wassermann reaction as compared to the 12.8 per cent in the larger group of 555 families. The comparison throughout is given in tabular form: Table 30 236 Families in Which the Mothek Gave a Positive Wassermann Reaction Total Group of 555 Families in Which One or Both Parents Gave a Positive Wassermann Reaction (Includes Group op 236 Families) No. P. C. No. P. C. Families with positive Wassermann reaction in children 23 9.7 36 6.5 Families with no pregnancies 58 24.5 128 23.0 Families with no children, but with abortions, miscarriages, and still- births 37 15.7 37 6.7 Families with no children 95 40.2 165 29.7 Families in which abortions, mis- carriages and stillbirths occurred 93 52.2 156 36.5 Birth-rate 1.84 2.05 Average number of living children per family 1.33 1.62 Total pregnancies 632 100.0 1432 100 Accidents to pregnancies 198 31.3 297 20.7 Average number of pregnancie sper family 2.68 2.58 Children examined 142 100.0 423 100.0 Children positive 39 27.5 54 12.8 128 SYPHILIS OF THE INNOCENT Summary of Familial Effects of Syphilis. — A summary of our findings in this study of a consecutive series of the families of late syphilitics shows : 1. The family of the late syphilitic abounds with evidence of syphilitic damage. 2. At least one fifth of the families of syphilitics have one or more syphilitic members in addition to the original patient. 3. Between one third and one fourth of the families of syphilitics have never given birth to a living child. This is much larger than the percentage obtained from the study of a large group of New England families taken at random. Here it is shown that only one tenth were childless. 4. More than one third of the families of syphilitics have accidents to pregnancies, namely, abortions, miscarriages, or stillbirths. 5. The birth-rate in syphilitic families is 2.05 per family; whereas the birth-rate in the New England families mentioned above is 3.8 per family or almost twice as high. 6. Over one half of the families show defects as to children (steril- ity, accidents to pregnancies, and syphilitic children). 7. Only one third of the families show no defect as to children or Wassermann reaction in spouse. 8. About one fifth of the individuals examined show a positive Wassermann reaction ; more of these are spouses than children. 9. Between one fourth and one third of the spouses examined show syphilitic involvement. 10. Between one in twelve and one in six of the children examined show syphilitic involvement. 11. One fifth of all children born alive in syphilitic families were dead at the time the families were examined. This does not differ materially from the general average in the community. 12. One fifth of the pregnancies are abortions, miscarriages, or stillbirths, as compared with less than one tenth of the pregnancies in non-syphilitic families. 13. The average number of pregnancies per family is 2.58 com- pared with 3.88, 4.43, and 5.51 in non-syphilitic families. 14. There are 3.52 stillbirths per 100 live births in the syphilitic families, as compared with the 3.79 reported by the Massachusetts Census study of non-syphilitic families. This shows no very marked difference. 15. A syphilitic is a syphilitic, whether his disease is general paresis, cerebrospinal syphilis, or visceral syphilis without involve- ment of the central nervous system, and the problems affecting his family are the same in any case. THE FAMILY 129 Severe Effects of Familial Involvement. — The whole story of the effect of syphilis on the family cannot be told by statistics, although these indicate the great frequency with which syphilis acquired by an individual permeates his family. The toll of syphilis is enormous in some families; in others the amount of damage may be very slight. In fact, as has already been shown, in many instances a syphilitic does not infect his family. There are all gradations in the amount of involvement that may occur, from the families in which there is no familial infection to those in which every member shows definite syphilitic disease. Case 78. Sally McNutt. Father, Wasserraann reaction negative. Mother, Wassermann reaction positive. Pregnancies. 1. Miscarriage, 2 months. 2. Mary, juvenile paretic. 3. Miscarriage, 3 months. 4. Congenital syphilitic. 5. Congenital syphilitic. 6. 7, 8. Miscarriages. In this family both the father and mother denied venereal infec- tion but the examination of the mother gave definite evidence that she was syphilitic. There were eight pregnancies resulting in five mis- carriages and three syphilitic children, the oldest of whom at the age of 12 was in an advanced stage of juvenile paresis. The other two children were congenital syphilitics who may have serious difficulties later in life. Case 79. Syphilis was discovered in the Flynn family when the father of the family was in the forties. He had syphilis of the throat which led to his death. An examination of the family showed the following : Father, 40— Syphilitic throat. Mother, 42 — Syphilis (Wassermann positive) . Pregnancies. 1. Son, 18 — Syphilis (Wassermann positive), epilepsy. 2. Son, 16 — Syphilis (Wassermann positive). 3. Son, 15 — Syphilis (Wassermann positive). 4. Daughter, 10 — Syphilis (Wassermann positive). 130 SYPHILIS OF THE INNOCENT 5. Daughter, 8 — Wassermann doubtful. 6. Son, 7 — Wassermann doubtful. 7. Daughter, 5 — Wassermann negative. 8. Daughter, 3 — Wassermann negative. Case 80. Mazzocca family. Father, alcoholic, dead. Mother, poor health, Wassermann positive. Pregnancies. 1. Boy, dead, (11 months) diphtheria. 2. Boy, dead, (18 months) scarlet fever. 3. Boy, dead, (22 years) tuberculosis. 4. Boy, dead, (20 years) pneumonia. 5. Patient 18, juvenile paresis. 6. Girl 16, syphilitic bone disease; interstitial keratitis. 7. Stillbirth (8 months). 8. Girl, dead, (14 months) meningitis. 9. Miscarriage (3 months). The toll of syphilis in the Mazzocca family was a syphilitic mother whose nine pregnancies resulted in two living syphilitic children and seven who never came to term or who died after birth. Case 81. The history of the Jones family shows the destructive effects of syphilis on the progeny. The mother when about 41 years of age was put under treatment for syphilis. It was not possible to induce the father to have an examination. The results of the pregnancies are as follows : 1. Stillbirth. 2. Girl, 17, congenital syphilis, epilepsy, and feeble-mindedness. 3. Boy, dead, (4 months). 4. Boy, dead, (6 months) convulsions. 5. Boy, dead, 2 days. 6. Boy, 14, mental retardation, not examined for syphilis. 7. Boy, 6, physical examination and Wassermann reaction negative. 8. Boy, dead, (4 months). 9. Girl, (8 months). Marked malnutrition; under treatment for congenital syphilis. The mother is again pregnant. Thus out of nine pregnancies there is only one child who is normal as far as known. THE FAMILY 131 Case 82. Moses Bornstein. Father. Syphilitic. Mother, 43 — Cerebrospinal syphilis. Died at 45. Pregnancies. 1. Son, 19 — Juvenile paresis. Died at 23. 2. Son, 17 — Ruptured aneurysm. Died at 20. 3. Son, 16 — Achondroplasia. 4. Son, 14 — Caries of the spine. 5. Son, 11 — Stigmata of congenital syphilis. 6. Infant, died shortly after birth. 7. 8. Stillbirths. Case 83. John Friedreich. Familial Syphilis Father C? died of Syphilis Mother 9 Syphilitic after birth of first child husband contracted syphilis and infected wife. 9 dead miscarriage Case 84. Fred Klein. 9 i Father acquired ; syphilis and infected wife. d 1 o C? C? Normal Normal Normal at birth dead congeni- dead still- acquired syphilis at tal at birth from mother and 6 syphili- 5 developed cerebro- weeks tic years spinal syphilis 136 SYPHILIS OF THE INNOCENT Different Effects of Syphilis on Different Members of Family. — When syphilis has entered and spread through the family its effects on the various members may be quite similar or quite different. We have already called attention to the Kassowitz law which states that there is a tendency for the virus to become weaker with time and that the children born later are likely to have milder forms of involvement than those born earlier, or indeed, may escape the infection entirely. There is, of course, no definite rule and as Fournier puts it, "Each person makes his syphilis according to his image — the soil is more important than the seed. ' ' Case 97. The different effects that syphilis produces on members of a family are shown by the Tennyson family. The mother had latent syphilis. The father was dead, cause unknown. The two older chil- dren, aged 16 and 9, were apparently healthy. The third child, a girl, aged 8, had certain mild stigmata of congenital syphilis and a strongly positive Wassermann reaction. Her younger sister aged 6y 2 was also a congenital syphilitic who had involvement of the central ner- vous system the symptoms of which made their appearance follow- ing a fall at the age of 5. She had deteriorated mentally and had a spastic paraplegia. A younger brother aged 4 was apparently well and had a negative Wassermann reaction, and the youngest child died at the age of 9 weeks. Case 98. There were two children in the Sanzi family. The elder was a girl of six who showed a positive Wassermann reaction as the only symptom of her syphilis. A young brother aged 4 was a restless whining idiot, whose condition was very probably the result of his congenital syphilis. In this case the younger child was much more seriously damaged by the syphilis than his older sister. Same Effects an Different Members. — Modern experience and experimentation give evidence that there are strains of spirochetes which seem to have predilections for certain tissues. This shows up most plainly in cases of central nervous system involvement. There are numerous instances where mother, father, and children all show central nervous system syphilis. Case 99. The Rossini family is especially instructive in showing the tendency of syphilis to infect the central nervous system of differ- THE FAMILY 137 ent individuals in the same family. The fact that Mr. Rossini de- veloped the symptoms of general paresis at the age of 33, first brought this family into consideration as syphilitic. His wife, who was 29 years of age, had definite evidence of syphilis of the central nervous system as shown by the physical symptoms and laboratory tests. There had been seven pregnancies and there were seven living chil- dren. The oldest, Mary, was 13 years of age at the time that syphilis was discovered in the family. She had a positive blood and spinal fluid showing an involvement of the central nervous system. She was feeble-minded, rating 6 years and 8 months on the psychometric scale while her actual age was 12. The second child was seen when he was 10 years of age. His blood and spinal fluid were both negative and he rated 8 years and 8 months. He was a very difficult child and was sent to a reform school for truancy. The third child at 8 had a posi- tive Wassermann reaction in the blood but his spinal fluid was nega- tive except for a very mild change in the gold reaction. The fourth child also had a positive blood Wassermann and his spinal fluid showed a moderately positive syphilitic gold reaction but otherwise was negative. He was committed to a school for the feeble-minded. The next two children had negative blood Wassermann reactions; the spinal fluid was not examined. They seemed to be fairly bright children. The last child was a baby of 8 months who was not ex- amined. In this family both the father and mother had definite neurosyphilis. The oldest child showed involvement of the central nervous system, the following child apparently escaped involvement while the next two children showed some evidence of involvement of the nervous system as far as could be proved by the colloidal gold test. Case 100. Gridley Ringer was brought to the clinic at the age of 15 because he could not get along in school and was obviously de- mented. An examination showed definite evidence of congenital syphilis. He had a characteristic Olympic brow, Hutchinsonian teeth, and the scars of old rhagades at the corners of his mouth. He showed a high degree of dementia and his blood and spinal fluid gave the characteristic tests of paresis. The history showed that his birth was preceded by two miscarriages, one of which was induced and the other spontaneous. During his infancy he was troubled a great deal with ' ' eczema. ' ' Shortly after being seen he had a number of shocks which finally led to his death at the age of 15. The father acknowl- edged a syphilitic infection 26 years previously, that is, about ten years before the birth of the child. He said, however, "It did not get into my system. I have been perfectly well ever since." Ques- tioning, however, disclosed the fact that he had been suffering with 138 SYPHILIS OF THE INNOCENT " rheumatism ' ' for the past six months. A physical examination con- firmed by the laboratory tests brought to light that he had locomotor ataxia. His wife, the mother of Gridley, said she was in perfectly good health. Her one complaint was deafness. An examination showed that she was suffering from a disease of the auditory nerve. It was almost certain that this was the result of the syphilitic infec- tion. In this family, then, we have three members, all of whom showed disorder of the nervous system as a result of syphilis. Necessity of Familial Examination. — The damage done to the families of syphilitics has been demonstrated above statis- tically and by illustrative cases. The only way of finding whether syphilis is present is to examine the various members of the family for evidence of acquired or congenital syphilis. This means that when a syphilitic patient is discovered, whether he is in an early or late stage, the examination of all the other members of the family — husband and wife, and in the case of a congenital syphilitic, brothers and sisters — is indicated. Examination Discloses Active Syphilis. — The chief reason for examining the family is to find out if anyone else besides the patient is suffering from active syphilis and is in urgent need of treatment for his own sake as well as for others. Not only when the parent has a recent syphilis is there danger of familial infection by intercourse or contact, but also when a mature son or daughter living in close family communion acquires syphilis. Here family examination is advisable to discover cases of infection spread by accidental contact such as is likely to occur in family life. A typical case of such spread is Case 68 (Chap. 3, page 87), where the younger brother was probably infected by sleeping in the same bed with his syphilitic older brother. The brother was treated but no family examination was made and the young brother's infection was not discovered until he had developed a fatal syphilitic disease. Examination Discloses Latent Syphilis. — Next in impor- tance in the family examination is the discovery of latent un- suspected syphilis. The syphilitic arrives at a clinic anywhere THE FAMILY 139 from a few days to many years after infection, and often mem- bers of the family are syphilitic although they are not aware of it. Examination affords the opportunity of giving warning* of future dangers and of instituting immediate treatment. Case 101. Giuseppe Nigro, aged 75, thought he was worth a million dollars, threatened the life of his wife and children, and caused diffi- culty in a general hospital where he was brought for treatment. He was found to be suffering from tabo-paresis and was committed to a state hospital where he died in a short time. He acknowledged syph- ilis of many years duration for which he had had no treatment. On account of language difficulty and his mental condition, he gave very little family history. At this period there was no follow-up of syph- ilitic cases at the hospital and no examination of the family was made. Three years later, the patient's daughter was admitted to the hospital in a confused and deluded state, a condition precipitated by influenza, but which probably occurred on the basis of con- genital syphilis. She showed very characteristic features, including Hutchinsonian teeth, on which a definite diagnosis of congenital syphilis could be made. Her blood Wassermann reaction was positive. Examination of the mother showed that she likewise was syphilitic. Treatment of both mother and daughter was instituted. In the course of a few months the girl had recovered as far as her mental symptoms were concerned and she was able to take up her work in the com- munity. After a short time she married and became pregnant. If the family had been followed up and examined three years previously when the father was found to have syphilis, treatment could have been undertaken at that time, and it is quite possible that the daugh- ter 's difficulty might have been avoided. Case 102. Patrick O'Halloran came to the hospital because of an alcoholic debauch ending in delirium tremens. In a routine examina- tion it was found that he was syphilitic and for this reason his family was brought into the hospital for examination. The wife showed no evidence of syphilis, but the oldest son, 17 years of age, had a posi- tive Wasserniann reaction and there was a history that he had had some eye difficulty when he was a youngster which it seemed prob- able was interstitial keratitis. Under the circumstances, treatment was urged for Patrick, Jr. but the idea was scouted by the parents as well as by himself. It was insisted that he was quite well and that there could be nothing the matter with him, so the case was lost by default. Six years later we again ran across Patrick at the age of 23. He was 140 SYPHILIS OF THE INNOCENT almost completely deaf, due to bilateral lesions of the auditory nerve. This condition had been progressive for the past four years and only at the time when he became almost completely deaf was the much needed antisyphilitic therapy begun. It is quite probable that had treatment been instituted six years previously, that is before the beginning of the changes in his auditory nerves, his deafness might have been prevented. The family examination disclosed the problem but lack of the patient's cooperation prevented anything from being done. A case of this sort shows the value of treating congenital syph- ilitics even though symptom-free. It further indicates the value of making strenuous efforts to overcome the uncooperative attitude of some individuals. Incidence of Unsuspected Syphilis Disclosed by Examina- tion. — The value of examining families of known syphilitics to discover the unsuspected cases is shown by the following study of 100 families in which at least one other member besides the original patient was syphilitic. No. p. c. Eelatives with syphilis diagnosed at Psychopathic Hospital through family examination 112 72.7 Relatives with syphilis diagnosed elsewhere 42 27.3 Total syphilitic relatives 154 100 . Of the 112 diagnosed at the Psychopathic Hospital 112 100.0 Fathers Symptom free 18 Tabetics 2 Neurosyphilitics 2 22 19.6 Mothers Symptom free 47 General paretics 1 Neurosyphilitics (not tabetics) .... 3 Other symptoms 2 53 47.4 Children Symptom free 28 Neurosyphilitics 1 Defect in sight 3 Defect in hearing 1 Other symptoms 4 37 33.0 THE FAMILY 141 No. P. C. Of those diagnosed elsewhere 42 100 . Fathers Symptom free 8 19.0 Mothers Symptom free 11 General paretics 1 12 28.6 Children Symptom free 20 Defect in sight 2 22 52.4 It is especially significant to note that of the 154 who were found to be syphilitic, 72.7 per cent had no idea of their syphilis until it was discovered as a result of the family examination. The greater percentage of these patients (83 per cent) were in a stage of syphilis in which they were not suffering from any definite symptoms, which of course, is a favorable time to make a diagnosis. A complete examination of the entire family has the advantage of giving a clean bill of health to the uninfected. Often the wife of a syphilitic patient is cognizant of the pos- sibility of infection and it is only fair to her to confirm or disprove this idea as soon as possible. Moreover in the case of some future disease it will be a great aid to the physician to have this information at hand. Methods of Examination; History. — The methods of dis- covery of familial syphilis are the same as those employed in the detection of the infection in the individual, discussed in the previous chapter. The examination is incomplete with- out a history of the individual and the family, physical ex- aminations, and tests on the blood and spinal fluid. In spite of the value and importance of a history one must be very cautious of drawing any very far-reaching conclusions from some histories given by the patient or relative who may be consciously prevaricating or may not know the true facts. Case 103. An example of the inaccuracy of histories is given by the case of Mrs. Price who developed general paresis at the age of 40. The husband gave a history that the patient's father had contracted syphilis and infected his wife. We might draw the conclusion that the patient was a congenital syphilitic. The husband denied any his- 142 SYPHILIS OF THE INNOCENT tory of syphilis on his own part. The examination showed that he had a positive Wassermann reaction as did the only living son. As a matter of fact, the mother was not a congenital syphilitic and the husband 's history was in no way reliable. Clinical Examination and Wassermann Test. — The clinical examination is of the utmost importance and cannot be super- seded by the Wassermann test alone. The Wassermann test, however, is of the greatest service and if properly performed, controlled, and interpreted, is an essential. When the Wasser- mann test is performed routinely in hospitals, prisons, reform schools, other institutions, and private practice, it aids in picking out cases that might otherwise be unsuspected and thus makes for early and preventive treatment. A knowledge of the limitations of the Wassermann reaction is most important if "one is going to do justice to the test. It must be recognized in the first place that many syphilitics give negative Wassermann reactions. For example, early syphilitics often have negative W^assermann reactions. About 40 per cent of the cases of tabes have negative Wassermann reactions in the blood. It follows, therefore, that one must not rule out syphilis merely upon a negative result of a Was- sermann test. Before accepting a positive Wassermann re- action as evidence of syphilis it should be confirmed either by definite clinical findings or by a repetition of the test with similar results. Statistics based upon the Wassermann test are accurate within the limits of the test. As we have noted, the false negatives and false positives tend to correct each other, and often where these corrections are not absolute, the relative results are sufficiently correct for purposes of com- parison. However, in dealing with an individual the matter is entirely different because in this case any error means an error of 100 per cent for the particular person. If the clinical evidence is sufficiently strong, one may make the diagnosis of syphilis in spite of a negative reaction. Case 104. 1 The value of the routine Wassermann both for the pa- tient and for the discovery of familial syphilis is well illustrated in the case of Janet Gibbons. At the age of 6 she developed a syphilitic l Children 's Hospital, Boston. THE FAMILY 143 nasopharyngitis and interstitial keratitis. At this time the mother was examined and also found to be syphilitic. Delving into the his- tory of the case it was found that the child had been at the hospital five years previously when a diagnosis of osseous tuberculosis had been made. At that time a routine Wassermann test was not the rale and as she had no definite evidence of syphilis this diagnosis had not been made. If her condition had been discovered at that time by means of the Wassermann reaction, as it undoubtedly would have been, had routine Wassermann tests been in force, treatment might then have been instituted and the later difficulties perhaps prevented. Case 105. A negative Wassermann test on the blood must often be supplemented by a test of the spinal fluid. Mrs. Gulesian was the wife of a syphilitic. The routine Wassermann test was negative but she complained of a loss of memory, feeling weak, etc. A lumbar puncture resulting in positive findings showed that she was suffering from an unsuspected syphilis of the nervous system. Case 106. One may be led astray if he depends upon the results of the Wassermann reaction. Harry Congiano was a deaf-mute boy 4% years of age. His Wassermann reaction was reported as positive. There were no other signs or symptoms that were definitely syphilitic. An examination of the cerebrospinal fluid showed that it was entirely negative. The Wassermann reaction was repeated on several instances and always found to be negative. The mother was also examined. She showed no signs or symptoms of syphilis and her Wassermann reaction was negative on two occasions. It seems that there can be very little doubt that the report of a positive Wassermann reaction on Harry was a mistake. Case 107. A similar false positive Wassermann reaction is shown in the case of Mrs. Davis's child. Mrs. Davis was brought to the hos- pital because of fainting spells. Her Wassermann reaction was re- ported as doubtful. Almost simultaneously her fourth child, a girl of 12, came to the out-patient department. She was a poorly nourished child who had never been very healthy. Her Wassermann reaction on the blood was positive. The doubtful reaction in the case of the mother and the positive reaction in the case of the child, along with the other symptoms, led one to suspect syphilitic involvement. It should be noted, however, that none of the other symptoms were definitely syphilitic or sufficiently suggestive in themselves to allow a diagnosis of syphilis to be made. The history of this case was en- tirely negative as far as syphilis was concerned. There had been six pregnancies, all terminating successfully, the last one resulting 144 SYPHILIS OF THE INNOCENT in twins. All the children were living and ranged in age from 19 years to one year. With the exception of the oldest boy, who was living away from home, they were all examined. They showed nothing suggestive of syphilis and had negative Wassermann reactions. The same was true of the father. The examination of the mother's cere- brospinal fluid was entirely negative as was the Wassermann reac- tion in the blood on repetition. Several further Wassermann tests on Anna were also negative. We must assume that the positive Was- sermann reaction originally obtained was due to some error. All doubtful tests should be repeated, as the following case indicates : Case 108. Three-year-old Pierre Nevers was examined as one of the children of a syphilitic. He was symptom-free except for a doubtful Wassermann reaction. The oldest child had a negative reaction and the second child was doubtful. Although the effort was made to re- peat the tests the mother proved uncooperative and the case was dropped. Five years later the mother brought Pierre in for anti- syphilitic treatment, a positive Wassermann reaction having been obtained at another hospital. Thus five years of possibly valuable treatment were lost through the delay in diagnosis. At times it is very difficult to get a consistent result with the Wassermann test. Case 109. The following series of tests on husband and wife show how difficult it may be to draw any conclusions. (Angelo family.) 1 2 3 4 5 6 7 8 9 10 11 12 13 Woman aged 27 1 * — — — I ? + + — + — =• Husband, aged 34 ? ? ? ? ? — — ? — — — * Unsatisfactory. Case 110. Julia Wilson was 6 years of age when first examined. Her father was a general paretic. Examination of the mother showed no signs of syphilis. Her Wassermann reaction was negative. Julia was not a very strong healthy child but did not show any definite syphilitic symptoms. The first Wassermann test was negative and the second one was positive. Several others in the following two years were negative. She had a sister, Ethel, one year her junior, who again showed no definite symptoms of syphilis. Her first Wassermann re- action was positive, a repetition was doubtful, and the succeeding tests were negative. THE FAMILY 145 Provocative Treatment. — At times a syphilitic patient who gives a negative Wassermann reaction may show a positive reaction after treatment with arsphenamin. Treatment given for this purpose is known as provocative treatment and the reaction is spoken of as a provoked reaction. Case 111. Florence Jones developed interstitial keratitis at the age of 8 and had a positive Wassermann reaction. Her mother was examined and showed no definite evidence of syphilis and had a nega- tive Wassermann reaction. Nevertheless, it was felt that she prob- ably was syphilitic. She was given a provocative treatment and her Wassermann reaction became positive. Objections to Familial Examination — Technique of Secur- ing- Examination. — One of the objections that is often offered to the examination of other members of the family is that the discovery of syphilis in the family is likely to lead to marital discord. The remark is made over and over again that it is very dangerous because if a woman learns that her husband has syphilis the family will be broken up. In our seven years of experience we have found that this is not true. In many instances it is not even necessary to make it entirely clear what the trouble is in which one is interested. If syphilis is not found in the relative it is perfectly reason- able not to discuss the matter further. If syphilis is found, of course, it is essential to come out clearly and distinctly with the facts. However, by putting the discussion upon a medical basis and giving the individuals a proper understand- ing of the facts, family discord can be avoided. The only situation where there need be any worry in this regard is in those families in which the mate is on the point of separation and is only looking for some excuse to take the case to court. In such instances silence and avoidance of the possibility of becoming involved in the family difficulties is probably the part of discretion. ' When the family must be told that one is looking for syphilis or the patient must be notified that he is syphilitic, the question that constantly recurs is whether or not the social worker should break the news. It is our feeling that only in exceptional cases should anyone but the doctor actually 146 SYPHILIS OF THE IXXOCENT in charge of the case take this upon himself. It is the doctor's privilege and duty to inform a patient about his disease whether it be tuberculosis, nephritis, or syphilis, and in most cases no one can do this as well as the doctor whom the patient considers especially versed in the handling of disease. On the other hand, there are many instances where the contact between the social worker and the patient is so close and the latter has so much confidence and regard for the worker that it can best be discussed by the patient and social worker. It may be advisable for the social worker to give this informa- tion when a syphilitic patient or relative refuses to come to the clinic and talk with the doctor. This, however, should not be the general rule, but should apply only to those excep- tional cases in which, in the opinion of both the doctor and social worker, it is advisable. In many cases, after the doctor has explained the condition to the patient and family, the social worker can be of the utmost assistance in completing the understanding of what the doctor has already said. Such a service on the part of the social worker is often more effec- tive than would be the unaided effort of the doctor. Experience has proved that in family examination the assistance of a well-organized social service department is essential. Any deviation from absolute systematic endeavor is almost valueless, and haphazard methods will result in failure to discover a large number of syphilitics. Typical Machinery for Examination at Boston Psycho- pathic Hospital — Difficulties and their Solutions. — The proper facilities and machinery for family examination are offered by many clinics and hospitals to-day. At our clinic at the Boston Psychopathic Hospital, the members of the family of every syphilitic patient who comes to the hospital or to the out-patient department are asked to report for examina- tion, and if it is considered necessary, for treatment. It makes no difference whether the original patient is in a con- tagious state or not, whether he is in the early or late phases of the disease, or whether he is a congenital syphilitic. Of course, the examination of the families of syphilitics should be made immediate]y after the infection. Unfortunately this THE FAMILY 147 is done all too infrequently so that even though a patient is seen many years after his infection and in a state which is no longer contagious, it must be remembered that he may have been married at the time when he was very contagious. The work in cooperative cases is simple. Many clinic patients, however, are ignorant and poorly informed. Neither they nor their relatives understand the significance of the disease or see any relation between the disease of the patient and the examination of his family. The task of educating the family to the point of allowing the examination is often hampered by language difficulties. If the difficulty is due to lack of information it is important that the family be told why the examination is desired. Other individuals are irresponsible and though well understanding the significance of the ex- amination do not care to know whether they are infected or not. Very often those families who offer the most difficulty at the start, with a sufficient amount of persistence become the most cooperative. Case 112. Robert Clairinont came to the out-patient department when he was 13 years of age, because he was nervous, unmanageable, irritable, and was not getting along well in school. Examination showed that he was a congenital syphilitic. Treatment was pre- scribed for Robert and the mother cooperated with this suggestion. When it came to the examination of herself and the other children she refused. She said that they were healthy and that there was no need to examine them. Unfortunately she was not only ignorant but was also bad-tempered and pugnacious. On account of her ignorance it was not possible to go into frank detail as to the real situation. Syph- ilis would have meant only a reflection on the morality of herself and her husband, and as we found out later, argument with her would have had little avail. It was therefore necessary to compromise and get Robert well started on treatment ; finally, after sufficient time, it became possible to induce the mother to be examined. A rather interesting experiment was made in St. Louis as early as 1914 by Dr. Jeans 1 of the Children's Hospital, in an endeavor to examine uncooperative families. The support of l Jeans and Butler, op. cit., p. 329. 148 SYPHILIS OF THE INNOCENT the juvenile court was enlisted to such a degree that in the uncooperative cases, if one child was a congenital syphilitic, the family was brought before the court who urged the parents to have the rest of the children examined. The court had no legal power to enforce examination, but this was rarely understood by the family. This procedure seems to have worked well in this one locality but it could hardly be recom- mended to other districts, for when a person is symptom- free and not in a contagious state he is likely to realize the lack of power of any court to enforce an examination. Of course, the influence of the court is likely to be more effective than that of the social worker and doctor in showing a recalcitrant person that an examination is really considered important. Circumstances in the family may make it very difficult for members to report to the clinic for examination. They may live a great distance and be unwilling to take the time or go to the expense of reporting. The family may be large and a mother may be unable to bring children or have no one with whom to leave them at home. A man or woman may be unable to leave work in order to come to the clinic. There are various ways in which most of these difficulties may be overcome. Where the doctor is interested and uses his authority and persuasive powers and where the social worker is willing to put effort and ingenuity into urging her cases to report, results are usually fairly good. An early morning clinic or an evening clinic for working people helps solve the difficulty that arises from the loss of time as does the more modern attitude of employers who show a willing- ness to allow their employees to take time off for medical care. The following table shows the success at the Psychopathic Hospital in following for examination the family of every syphilitic. It is seen that in 74.3 per cent of the families some member reported. Of the total relatives desired for examina- tion 78 per cent reported to the clinic. THE FAMILY 149 Table 31. Families— 1916 to 1919 No. P. C. Families desired for examination 460 100 . Reported 342 74.3 Failed to report 118 25 . 7 Relatives Relatives desired for examination 935 100 . Examined 632 67.6 Came but examination not advised 99 10.6 Unable to report, good reason 90 9.6 Refused examination 23 2.5 Not located 91 9.7 Comparison of Difficulties of Family Examination by Private Doctor or Clinic. — The difficulty of family examina- tion is probably much greater for the private than for the clinic physician. The doctor often fears that if he presses the point of family examination against the wishes of his patient the latter will be so antagonized that he himself stops his much needed treatment. Further, there is the feeling that to a certain extent the private patient's relationship to the doctor is a business one. He pays the doctor to render certain service which does not include treating the family and because he does pay he feels that he has certain rights and privileges. On the other hand, the clinic patient pays little or nothing and the doctor need have no compunction about going into the family to find more patients for whose treatment he is to receive no recompense. In addition, the private doctor rarely has the facilities for follow-up such as are offered in a hospital clinic and social service department. And the most important deterrent of all is the question of medical secrecy. That information obtained by a physician in his professional capacity is a secret not to be divulged is shown in the oath of Hippocrates, formerly administered to all physicians: Whatever in connection with my professional practice or not in con- nection with it I see or hear in the life of men which onght not to be spoken of abroad, I will not divulge as reckoning that all such should be kept secret. "While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art respected by all men in all times, but should I trespass and violate this oath, may the reverse be my lot. 150 SYPHILIS OF THE INNOCENT These difficulties of the private doctor seem to be a recom- mendation in favor of state medicine so that the well-to-do may get as good service as the poor. Necessity of "Follow-Up" for Treatment Cases. — After a person is brought to the clinic for examination and found to be syphilitic, results can be obtained only after a considerable course of treatment. Many years of experience have shown that syphilitic patients are usually prone to discontinue treat- ment before they are cured unless steps are taken to insist on their return to the clinic. Here again, the efforts of the social worker through a follow-up system are invaluable. The past inadequacy of treatment without such a system is shown by Blaisdell's study 1 at the Boston Dispensary before a follow-up system was established. Four hundred and fifty- one new cases (July 1913- June 1914) were studied. One hun- dred and sixty-four were primary or early secondary cases, 136 secondary, 107 late, and 44 congenital. Twenty-eight per cent came but once ; 70 per cent came less than five times, an insufficient number of times to relieve even the presenting symptoms; only 9 per cent came more than eight times. The attendance of these 451 patients was analyzed to see how many visits would have been required for good treatment. It was found that as a group they actually paid only 29.4 per cent of the necessary visits for minimum good treatment. A study 2 of the Boston City Hospital Clinic in 1919 before and after a follow-up system was instituted is self-ex- planatory : A small preliminary study was made of the records of the patients with a diagnosis of syphilis who attended the clinic from March, 1918, to September, 1918, with a view of determining' the regularity of at- tendance. It was found that 116 patients in all attended the clinic during this time, 24 reportable (first and second stages) and 92 non- reportable (tertiary) cases; that 20 per cent had made only one visit, and that 80 per cent had not received adequate treatment, having dropped out after the fifth visit. i Blaisdell, J. H. The Menace of Syphilis to the Clean Living Public. Boston Medical and Surgical Journal, vol. clxxii, no. 4, April 1, 1915, pp. 476-483. 2 Department of Medical Social Work, Boston City Hospital, Feb. 1, 1918- Jan. 31, 1919, Boston. THE FAMILY 151 A simple follow-up system was then started by means of which every syphilis patient was kept track of. At the end of five months, a second study was made of the group attending the clinic from Sep- tember 1, 1918, to January 30, 1919, with the following results: Number of Syphilis Patients in Clinic 181 Keportable Cases (Infectious) 59 Non-reportable k ( Non-infectious) 122 Of these 13, or 7 per cent had made one visit only; 32, or 18 per cent had dropped out after making five visits. The remaining 135, or 75 per cent were under treatment, while 14 per cent had been transferred to night clinics or other state clinics, and were reported as under treatment. The contrast of the 75 per cent under active treatment as against the 80 per cent who failed to receive adequate treatment sufficiently demonstrates the value of a medical social follow-up system. A more recent investigation 1 in New York City of 14 institu- tions treating venereal diseases shows that the follow-up of patients for treatment is still inadequate in spite of its well- known necessity. The sanitary code in New York requires a follow-up system. However, five of the 14 clinics had no follow-up at all, six used postal cards to some extent, and only three institutions were assisted by social workers in finding the cases who failed to respond to letter. As a result of this inadequate follow-up, the duration of treatment is shortened. In over 57 per cent of the records chosen at random, the patients had been under treatment less than six months and only 19.8 per cent had had treatment for more than a year. Half of the patients had made less than 14 visits to the clinic. A further indication of inadequacy of attendance is in the records. There was no mention of patients discharged. All patients, even Wassermann negative cases had left before a formal discharge. At the meeting of the All- America Conference on Venereal Diseases, in Washington, December, 1920, it was definitely stated that a follow-up system and social w r orker were essen- tials of every modern, well-run, syphilitic clinic. i Lewinski-Corwin, E. H., Venereal Disease Clinics, Social Hygiene, vol. 6, no. 3, July, 1920, p. 341. 152 SYPHILIS OF THE INNOCENT Difficulties of ' 'Follow-up" for Treatment — Solutions. — There are attendant difficulties in a follow-up system for treatment, similar to those mentioned under family examina- tion. Often there seems to be a likelihood that a contagious case will not receive treatment. Here the social worker can often be the means of forcing treatment, thereby reducing the chances of innocent familial syphilis. Case 113. The Massachusetts General Hospital 1 reports the case of a 9-year old girl who comes to the hospital with an accidental primary lesion of syphilis on the lip, the source of infection being unknown. The family had previously been known to the clinic when a boy of 13 had interstitial keratitis, and the mother a positive blood Wassermann. At the time an effort was made to treat these two members of the family, but there was absolutely no cooperation. The little girl had not then acquired syphilis. In view of the past ex- perience with the family and because the mother failed to carry out her part, the case was taken to court and the child was forced to re- port to the clinic. Without the medical social worker this child would probably never have received adequate treatment. A contagious patient often gives the wrong address. The Boston Dispensary has* devised an immediate method of meeting such a situation for gonorrhea patients. The day the patient makes his first visit a letter is sent out to the address given. The clinic has taken a mail box so that if the patient is not at the address it is returned to the box and to the social worker without delay. In this way before the patient returns for the next visit the clinic has a check-up on his address. When a contagious case drops treatment before he is non- contagious, in communities with a reporting law he can be reported by name to the board of health, which urges treat- ment. The Boston Department of Health 2 reports much difficulty in following the cases whose treatment has lapsed . . . either because of the deliberate efforts on the part of such patients to conceal their identity or because of carelessness on the 1 Lewis. Ora M., Medical Social Service as a Factor in Protective Work, National Conference of Social Work, New Orleans, April, 1920. 2 Monthly Bulletin of the Boston Health Department, Boston, Oct., 1919, pp. 127-128. THE FAMILY 153 part of such patients or of the various agencies charged with the duty of making and transmitting records and reports with respect to them. The most important obstacles that serve to defeat the efforts of the local health department are: the fictitious names given by patients; fictitious addresses; fictitious names and addresses; the as- suming by the patient of the name or address, or both of some other person; changes in the addresses of patients, denials by persons visited of identity with the patients, and claims that the patients have merely assumed the names of the persons interviewed; claims that the patients are at the time of the inspector's call at work elsewhere than at the addresses reported ; and claims by patients that they have either never suffered from the diseases charged against them or that they have been cured. Some idea of the difficulties encountered in this work may be gathered from the fact that out of 196 cases under investigation by the department in October, 1919, only 44 cases were located. Eighty cases could not be found after diligent effort, and further search was abandoned. Three, it was definitely learned, had moved out of the city. At the close of the month 69 cases were still under investigation. A full-time investigator was then appointed to devote his entire time to the search for such patients. He was able to find many patients who had escaped discovery by the routine medical inspection. . . . Of 175 men referred to him ... 66 were found and proper action taken. All of these patients, but for the availability of the investigator for this special duty, would have escaped dis- covery, and in the absence of such information and advice as the in- vestigator was able to give them, and such pressure as he was able to bring upon them, would presumably have continued as lapsed cases, with grave likelihood of disaster to themselves, to their families, and to the public generally. Unfortunately in many localities the health department has no real power of enforcement. In St. Louis 1 however, the health department has the actual power to compel these cases to take treatment. Although by law only the clinic number is given to the board of health, the board of health and social l Weiss, R. S. and A. H. Conrad, The Medical and Social Care of Syphilis at the Washington University Dispensary, American Journal of Syphilis, voL iv, no. 2, April, 1920, p. 253. 154 SYPHILIS OF THE INNOCENT worker cooperate so that all contagious cases sent to the municipal clinic are reported directly by name and address. If these patients do not appear, the board of health notifies the police department which brings them to the clinic. Many parents are not sufficiently interested to have their children treated and at times all efforts to persuade them fail. St. Louis 1 again meets this difficulty in a rather unusual manner. The court took the stand that parents must give satisfactory evidence that a luetic child was being treated somewhere. An officer of the juvenile court at the suggestion of the hospital worker visited the home saying that unless the child were treated the parents would be brought into court. The bare statement that the child was being treated elsewhere was not considered and the juvenile court took the responsibility of placing the burden of proof on the parents. The parents saw that treatment would be enforced and preferred to acquiesce than to have the nature of the child's disease brought before the court. It is interesting that this method was used in cases in which the Wassermann reaction was the only symptom, as well as in contagious cases. A case is given by the authors in which a young mother refused treatment for an apparently well twenty-seven months' old baby. It was made a court case and the judge forced the mother to continue treatment for the baby in spite of the fact that there were no apparent symptoms. Oftentimes treatment is refused on account of its cost. The situation still remains unsolved in many states. The question of payment for treatment was formerly acute in Massachusetts when salvarsan was expensive and the clinics had only a small supply for free distribution. At the present time the Massachusetts State Department of Health is manufacturing arsphenamin (salvarsan) for free distribution to authorized clinics. It is thus possible to treat a great many persons either without cost or at a very low rate. The decision on payment for treatment really should rest in the hands of the social worker. She should investigate the financial condition when necessary and should have the privilege of deciding who should pay nothing, who should pay on the instalment plan, l Jeans, and Butler, op. cit. THE FAMILY 155 who should be aided by any of the outside agencies, and who should entirely pay for his own treatments. The treatment of the neurosyphilitic is a difficult question on account of the necessity for steady treatment over a period of years. It is practically true that once a patient, a patient almost for life. Moreover, many of these patients are below the normal in mental capacity and do not understand the situation thoroughly. They must constantly be persuaded of the value of treatment and the oftentimes impatient family must be inculcated with a sympathetic attitude towards the prolonged treatment. Cooperation with outside agencies which have well established relations with the patient often helps to keep him faithful to treatment. An examination of current treatment cases at the Psychopathic Hospital clinic showed that 40 per cent reported regularly without any special reminder other than general urging at the clinic. Thirty per cent needed letters and special clinic interviews. Thus 70 per cent re- ported regularly, leaving 30 per cent who reported irregularly in spite of letters and interviews. These recalcitrant active treatment cases as well as the cases whose treatment lapsed because they left town, moved, or refused more treatment were studied to see, first, what efforts were actually made by the social worker to avoid the irregularity or the loss to the clinic; and second, what might have been done. All patients were written to, telephoned, or visited. Often relatives were urged to cooperate and at times different visitors were tried on the same case. It was found that arguments often success- ful with other cases failed in these. The following points were made: 1. The bad effects (physical and mental) of cessation of treatment. 2. The good effects of continuous treatment (a start in life to a child, the possibility of a wife's bearing healthy children, the more rapid ending of the patient's treatment). 3. The death of a relative from the same disease, as a warning. 4. No job was worth giving up treatment. 5. Lack of symptoms not indicative of health. Decision of when cured ought to remain with the doctor. 6. The doctor's and social worker's time was wasted if the patient did not cooperate until the end of treatment. 7. If treatment was discontinued, return to state hospital probable. 156 SYPHILIS OF THE INNOCENT Suggestions as to what might have been done in any given case follow: 1. More visits, fewer letters. 2. Home interviews with patient, not messages through relative. 3. Immediate follow-up when a new worker comes. 4. More frequent telling the family of the nature of the disease (in the ease of children). 5. Closer contact with the home, relatives, and employer (question of intensive investigation). 6. More rapid follow-up of lapsing cases. 7. Frequent demand for change of address. 8. More frequent and earlier efforts to locate lost cases. 9. Securing transportation for cripples and children. Difficulty of " Follow-up' ' of Private Patient. — Here again, as in the family follow-up, the follow-up of the private patient for treatment is a difficult problem. Case 114. Mr. Farrar Was a man of education and large financial success. He was rather a high type of individual. He was sent in consultation by his doctor for skin lesions and mucous patches. A history of syphilis in youth was obtained from him. The lesions were typical and the Wassermann reaction was positive. As usual in such cases, the disappearance of the lesions was almost miraculous under treatment. While under treatment, he stated that his daughter, a girl of 8, had recently had a mastoid operation, and that the bone was not healing well. This preyed upon his mind until finally he told the doctor who did the operation that he had had syphilis and won- dered if that had any relation to the difficulty with healing the bone lesion. The aurist was of the opinion that it might, and suggested that the little girl be examined. Mr. Farrar then began to worry that his wife would find out that there was something the matter with the girl, and finally decided that he would not have her examined for syphilis, but took her to another aurist. Finally the bone did heal, and nothing was done about the daughter. Shortly, thereafter, he also discontinued his treatment, although warned by his physician that he was not cured. His family physician, who was also a friend, tells the story that he knew him when he acquired his syphilis. At that time he took a very small amount of treatment from a quack, and refused to receive any other treatment. A couple of years later, he decided to get married. When his family doctor and friend heard of this he went to him and told him that he had no right to marry, THE FAMILY 157 at least until a longer period had elapsed, and he had received more efficient treatment. The physician adds that the patient became quite indignant, and their relations became somewhat strained. The patient proceeded to get married. Everything- apparently went well, until the skin and mucous lesions appeared, and the patient went back to his old and true doctor friend who then sent him for proper treatment. Had this situation obtained with a clinic patient, the social service department would have put in a considerable amount of effort and probably would have succeeded in getting the child examined as well as the wife, and there is good reason to believe that the patient would not have been allowed to discontinue treatment when he was not cured. This case also shows: first, that it is the intelligent as well as the ignorant, who refuse to take the advice of conscientious and efficient physicians; and second, the mental torture that a man may suffer for years. To do such work and to do it satisfactorily and successfully, an efficient social worker is essential. A mere clinic clerk cannot accomplish all that is required. The social worker must have a good knowledge of case work technique, and an understanding of the problems of syphilis. Above all this, she must be level headed and must be able to handle people and situations with tact and judgment. Especially important is the correct mental attitude towards syphilis. No worker with a trace of the moralistic point of view can be successful in handling either the syphilitic or his family. An impersonal attitude towards the sensational features often present in syphilitic cases is essential. A third requisite is lack of fear of acquiring the disease. No person who is constitutionally timid or apprehensive should attempt to deal with contagious syphilis. Effects of Syphilis on Social and Mental Life — Atmosphere of the Home. — For a complete understanding of the part played by syphilis in the family one must not only consider its physical effect on patients and their families, and the importance of early diagnosis and continuous treatment, but one must also view the disease from the standpoint of the effect that it has upon the ideas, emotions, and the social life of the individuals concerned. The atmosphere of the family life may be markedly tainted through the ideas that are 158 SYPHILIS OF THE INNOCENT engendered concerning the possible effects of syphilis. Late attacks of conscience are extremely frequent, and as a result of the brooding of the man or woman the whole surroundings may become poisoned. Probably there is no disease which is more likely to lead to phobias than is syphilis. Thoughts of infecting the spouse and of transmitting the disease to the children are likely to keep cropping up again and again. Each time a child is ill, the possibility that the disorder is due to syphilis may enter the parent's mind. Many persons become exceedingly morbid just because they know they have the disease. In those cases where the fear has not developed into a form of pathological phobia, a thorough examination of the family or the individual will often be quite sufficient to straighten out the patient's ideas, but when the phobia has become deep-set and harassing, the situation is much more difficult and will usually need a considerable amount of psychotherapy to alleviate it. Case 115. Alice Shelley came to the hospital after a hysterical at- tack. She was very much depressed and said, "The doctors say my blood is bad, I have a germ in me, it killed my baby boy, they say the poison is in my blood, they say I got it from my husband." The patient was a girl of 19 and had been married about a year. A few months before coming to the hospital she had been delivered of a still- born child. When she was six months pregnant she had developed a chancre, followed by a skin eruption, but she received no treatment. Her husband admitted having acquired syphilis one year previous to marriage. He had never been treated and claimed that no physician had told him that he could not marry. The patient had always been perfectly well until acquiring syphilis. There is every reason to suppose that if she had not become syphilitic she would have remained perfectly healthy and would have borne normal children. However, following the birth of a dead child and the psychic trauma which resulted from this and from the recognition of what was wrong with her, she changed from being a happy, easy-going person to one full of fears, doubts and worries. She felt that she was unable to work, and was afraid to leave the house for fear she would collapse. Upon ex- amination it was found that she had a mild involvement of the central nervous system. Her syphilitic symptoms rapidly cleared up under treatment but she continued to suffer with psychasthenic symptoms which stand a good chance of influencing the remainder of her life. THE FAMILY 159 Different Reactions of Different Patients. — It is thus neces- sary to evaluate the individual equation of each patient. Some patients are more unfavorably influenced by insistence on the severity of the disease and the necessity of prolonged treatment than by the disease itself. Care must be exercised in dealing with sensitive individuals to prevent them from developing the feeling that the situation is entirely hopeless and that they will never be well again. Case 116. When seen in the clinic, Mrs. Flower was a pathetic picture. Tears were in her eyes every few seconds. Physically, she was quite an attractive woman of twenty-seven years of age, who gave the following story : Some seven years previously, she claims to have been raped. As a result, she developed both gonorrhea and syphilis. She immediately underwent treatment, but apparently developed a salpingitis necessitating operative intervention, since which she had never felt quite comfortable. She had received good antisyphilitic treatment from the time of her secondary symptoms. After a couple of years she married. She did not tell her husband of the condition until after marriage, when she found that it was impossible to keep her secret longer. As far as can be learned from the patient, this caused no marital difficulty. The husband was examined, and showed no evidence of syphilis. However, the patient continued to worry about herself, and after a year or two applied to the clinic for exami- nation as to her own condition. It was found that her Wassermann reaction was positive. She was put under treatment, and in a short time the Wassermann test was negative. However, she was kept un- der observation and just previous to the visit recorded above, the test had come back weakly positive. This entirely upset her. She was unable to sleep nights, her appetite was poor, she worried about her- self and cried a great deal. Her husband at the same time was launching out into new financial endeavors and having some difficul- ties. She felt that she ought to do some work to assist, but was in- capable of it on account of her various worries, pains, and aches. There was no question but that the patient had allowed herself to fall into a neurasthenic condition. As far as the disease itself was concerned, the chief sequel was sterility and this was probably the re- sult of gonorrhea rather than of syphilis. However, the other factor of importance was her poor mental condition. She stated that the greatest blow of all was when the latest test was reported as weakly positive. It would seem that more harm was done the patient in this case by retesting and following her so carefully than would have been 160 SYPHILIS OF THE INNOCENT done had she been allowed to continue through life without as adequate medical attention. It is probable that with the amount of treatment already received, no further symptoms would have occurred, and she would have been a much more useful member of society. This is a very difficult condition to discuss. Every individual case has to be considered according to the mental attitude of the patient. Not only w T as her mental condition an affliction to the patient, but equally so to her husband who not only was deprived of the assistance that he might have received from a well wife, but furthermore, had a wife who was constantly worried, unhappy, and an unpleasant companion. Effect on Mental Life of Wife and Mother. — The mental life of the wife and mother is especially likely to become affected by syphilis either in herself or in any member of the family. If she herself is syphilitic she runs a chance of repeated acci- dents to pregnancies, which not only means an unnecessary and fruitless physical strain but may lead to mental depres- sion, and is very likely to produce the unhappiness of child- lessness. Her mental condition may be lowered by the keen realization of the meaning of the infection of husband or chil- dren even though she be free of worry about herself. She may imagine that one or all of the possible future horrors of syphilis are to descend on her family. The worry about a congenitally syphilitic child may be terrific, and there is noth- ing more pathetic than the vain hope for improvement of a defective congenital syphilitic. This constant w^ear and tear is hardly calculated to make a satisfactory home environment. Case 117. A diagnosis of congenital syphilis was made on Richard Shoemaker when he was a few weeks old and treatment was at once started. He was backward in development both physically and men- tally. Despite treatment he did poorly and at the age of 8 became unable to walk and began to deteriorate mentally. At 10 he presented a picture of juvenile paresis. For ten years the mother had been caring for the child whom she knew to be syphilitic. In early years she was hopeful of his mental and physical development and it was not until he was 8 years old that she really lost all hope. When there is not a complete understanding between the husband and wife or when the situation is not well handled, knowledge of syphilis may lead to estrangement. This is especially true in those cases w T here a great deal of suffering has been caused by a group of miscarriages or the birth of THE FAMILY 161 frail congenitally syphilitic children. The trouble likely to result from a knowledge of syphilis can be very much min- imized when the matter is told in a careful and scientific man- ner. When the knowledge is accidental, difficulties are more prone to arise from the many prejudices that are commonly held by laymen to-day. Nursing Care as Disturbance to Family Life. — The actual physical care demanded by the members of a syphilitic family may cause a disturbance in the normal routine of family life. One syphilitic child may be such a burden that the other children suffer in care and attention. Constant visits for the treatment of a congenital syphilitic may mean that other children in the family are neglected. This becomes an impor- tant matter in poor families. The problem of the care of a congenital syphilitic is not limited to early childhood. It may extend from the days of adolescence to manhood. Interstitial keratitis, effusions of the knee, and other acute manifestations may necessitate a great deal of care. Feeble-mindedness, blindness, deafness, and the like may make children dependent for all time upon their parents and relatives. A paralyzed or bedridden man, a tabetic who not only cannot go about with- out assistance but who may suffer untold pain, an irritable or unreasonable paretic, add materially to the nervous tension in a family as well as increase the burden of care. Effect of Financial Difficulties on Home Life — Temporary Incapacitation. — The financial situation of the family may be seriously affected by syphilis. Temporary incapacitation of the wage earner in the early stages of syphilis leads to finan- cial loss in families of border-line economic status. Conta- gious patients rarely take time from work for hospital care, but ideally, hospitalization should be insisted on both for the rapid cure of the patient and his sterilization as a focus of infection. If it is carried out there is a chance that employ- ers might object and discharge the employee. Miss Lewis 1 i Lewis, O. M., et al., A Clinic Studies Itself, Hospital Social Service, vol. iii, no. 1, Jan., 1921, p. 75. 162 SYPHILIS OF THE INNOCENT cites the case of a girl who lost her job after hospitalization. The store doctor was willing to accept her as noncontagions, but the employment manager felt that anyone with a diagnosis of syphilis was socially a danger. The girl happened to have an extragenital, innocent infection. Industrial Decline. — The patient who has been temporarily absent from a job soon returns after treatment. Whether he is to have later financial loss depends on the adequacy of his treatment and his individual reaction to the disease. If the disease is uncured, it will probably appear again in later life in a more incapacitating form. Industrial decline is often a concomitant to a long-standing syphilis. Case 118. A striking example of industrial decline is that of Theo- dore Clarke. From a mining engineer who earned $300 per month and maintenance, he became a beggar who secured his subsistence from garbage cans. The entire cause of his decline in economic ability was a poorly treated syphilis the effects of which became mani- fest ten years after the disease was acquired. Case 119. George Powers had acquired syphilis five years pre- viously. His work record for these five years showed that he was a plumber by trade, earning a good wage, and considered an efficient workman by all his employers. Four years after his infection, how- ever, symptoms of nervous system syphilis appeared. The quality of his work markedly declined. Instead of high-grade mechanical work, he did odd laboring jobs and finally no work at all. Permanent Incapacitation. — Late manifestations of the dis- ease may entirely handicap the bread winner. Many a man who is incapacitated in the prime of his life by cardiovascular disease, by cirrhosis of the liver, by tabes, or by general paresis, becomes incapable of self-support and a serious drag upon his family. The expenses incidental to care may entirely ruin the family. The savings of many years may be used up and the family left destitute. Unless the family is well-to-do, someone — children, relatives, private or public charities — must aid in the care of the family. Case 120. Ernest Bloomfield was a tabetic of 42 who suffered severe pains. He was subject to gastric crises, attacks which made regular THE FAMILY 163 employment impossible, and reduced him to a state of irritability which made the family life extremely unpleasant. He was unable to ply his trade, that of a baker, and held odd jobs when he felt well enough. The family's support was the son-in-law's wage supple- mented by charitable aid. Case 121. James Pratt had always been a hard-working artisan, thoroughly competent and able to keep himself and family in fair circumstances in addition to putting aside a little money. When shortly past 50 he began to be bothered with shortness of breath to such an extent that he had to give up work. Examination showed that he had a very much enlarged heart with aortic insufficiency. This was of syphilitic etiology. Under antisyphilitie treatment and cardiac stimulants, the patient was kept quite comfortable but was unable to return to his work. At the end of some months he came to the clinic much distressed, saying that he had used up practically all of his savings, that he no longer had funds on which to live, and that he would have to go to work to support himself and his family. It was obvious, however, that his condition was such that he could not take up any arduous occupation and he was practically incapacitated as a money earner. The solution of the problem lay between depend- ing upon the work of the wife and charity of the relatives, or resi- dence in a public institution for the chronically ill. Financial Difficulties of Paretics. — Probably no one of the late manifestations of syphilis causes more varied financial difficulties than general paresis, which is the most frequent mental disorder due to syphilis and which is the late mani- festation of between 2 and 3 per cent of all patients infected with syphilis. The general paretic, particularly in the early stages of his disorder, is likely to commit many indiscretions of conduct. The grandiose paretic is apt to contract many debts which he is incapable of meeting or which may tax his competency, large or small, to the limit. His family or rela- tives may then have to struggle to make good his promises and may be left destitute. Case 122. Edward Smith was a traveling salesman in the late twenties. He was married and had just established a good home. He was making a fair salary and had managed to save a few hundred dollars. At this time mental symptoms of general paresis made their appearance and Mr. Smith became quite convinced that he was very 164 SYPHILIS OF THE INNOCENT wealthy. He began to live as though his dreams were reality and in a couple of weeks he had not only spent all the money that he had accumulated in the course of years, but had acquired a number of debts which he was unable to meet, and by the time he was placed in a hospital his wife was left penniless. The actions of a paretic may be such as to lead to much embarrassment or even disgrace to the family. A hitherto respected member of the community may begin to drink and carouse and acquire anything but an honorable name. A man who has always been noted for his honesty may start pilfering and become entangled in the meshes of the law. Case 123. Laurence Gardina was arrested by the detective of the firm where he had worked for many years. He was accused of break- ing windows in the store and appropriating money. It seemed that when customers paid for their purchases he had the checks made out to him instead of to the company, and deposited a hundred dollar check to his own account. He also made mistakes in his work, sending orders to wrong addresses and selling food at too low a price. After his arrest he was sent to jail, where it was found that he had mental trouble. The hospital diagnosis was a typical case of general paresis. Poor judgment is one of the very early symptoms of general paresis. It may show itself in a great variety of ways. The personal and family life may disclose this factor or it may be particularly evident in business affairs, where lack of acumen brings disaster not only upon the sufferer but upon his family and business associates. Case 124. Thomas Walpole had never been a very prosperous man, but had supported his wife and been engaged in various moderately successful business deals. About 15 years previous to admission to the hospital he went into the real estate business which consisted largely of leasing and selling hotel property. He was particularly interested during the last few years in exploiting a beach hotel. He spent all his time in rebuilding the hotel and getting it ready to start business. The hotel had been open only a few weeks when it burned down. No insurance had been placed on the hotel and a fairly large amount of money was lost. After this, the patient was not able to reestablish himself in the real estate business. He was badly dis- couraged and worried about his property. THE FAMILY 165 His wife at the time when the patient's business started to decline, supported the family by doing decorating for undertakers. When the patient entered the hospital with a diagnosis of syphilis, she was the main support of the household. After several months as an out- patient, Mr. Walpole was committed to a state hospital leaving his wife to support herself. Broken Home. — Closely bound up with the financial situ- ation is the problem of the broken home. Only too often the incapacity of the wage earner or his mate leads to a dissolu- tion of family life. The most unfortunate aspect is that this result of syphilis is no respecter of good homes or bad homes, happy marriages or unhappy marriages. The early death of a wife or husband may lead to the ruin of the home. Again paresis, one of the most virulent of the forms of late syphilis, is a frequent cause of early death. Its morbidity and mortality rate are almost equal. Dr. Salmon 1 has shown that one in nine of the 6909 men and one in thirty of the 5099 women who died between the ages of 40 and 60 in New York in 1913 died from general paresis. These men and women in the best years of their lives drop out as pro- viders and also as active influences in the family for home or character building. An only too common occurrence is that the wife must carry the burden of supporting the home after the husband's death. Of interest here is the fact that life insurance companies to-day refuse to insure a known syphilitic on the ground that he is a poor risk and likely to die early. It is to be noted that the records of the Gotha Life Insurance Company, England, 2 show that the mortality among syphilitics between the ages of 36 and 50 is well-nigh double the average rate, and other insurance records show the mortality at all ages to be at present about 30 per cent in excess of the average. Because of this, the families need even more protection. In many states, as in Massachusetts, there is public provision for aid to women who are widowed or whose husbands are public 1 Salmon, T. W., General Paralysis as a Public Health Problem, Proceedings of the American Medico-Psychological Association, 70th Annual Meeting, Balti- more, Md., May 26-29, 1914, p. 180. 2 Harmon, op. cit., p. 155. 166 SYPHILIS OF THE INNOCENT charges, yet there are many cases in which a woman prefers to work and support her children in a home of her own choos- ing. Sometimes she boards them with relatives, other times she sends them to a school. The point is that because of her work she cannot keep them at home. A state hospital commitment, especially of a woman, often means the breaking up of a home. This again occurs in the prime of life, when both parents are especially needed. An examination of the ages of the first admissions of 755 paretics at the Psychopathic Hospital showed that the largest per- centage, 40 per cent of the total number, occurred between the ages of 31 and 40. Case 125. Giuseppe Frascati infected his wife. Six years after- wards she developed neurosyphilis which rendered her ineffective both as a housekeeper and homeinaker. She was committed to a state hos- pital with the result that her husband who was unable to supervise his child of 9 in the home, placed him out through the agency of a children 's society. Case 126. Luigi Sylvestri entered the out-patient department of the Massachusetts General Hospital when he was 41 years of age. He had been a concrete construction worker for a number of years but of late had been unable to do his work because of shortness of breath and pain in his chest. Examination disclosed the fact that he had a cardiac aneurysm and aortic insufficiency. His general condition re- sulting from these disorders was such that it was quite impossible for him to do any work whatever and it was not even good for him to be up and about. A very frequent cause of a condition such as the patient had is syphilis, and this proved to be so in his case. The pa- tient was married and had three children aged five, three, and two years respectively. Examination disclosed that all were infected with syphilis, and it became necessary for the entire family to undergo treatment. The patient, being a laborer and out of work, had no funds on which to keep the family. It became necessary therefore, to apply to Mothers' Aid for financial assistance but the amount allowed by the State for such purposes was insufficient to keep the family and offer bed care to the patient so that hospitalization became necessary for him. As such hospitalization meant a state institution and separa- tion from his family the patient objected. An attempt was made to supply extra funds from other charities in order to keep the family together and give the patient the care which was needed. This was THE FAMILY 167 only a temporary makeshift, however, and the final solution had to be hospitalization for the patient, breaking up of the family unit, and charitable aid to the family. Statistical Studies of Social Difficulties in Patients with Syphilitic Mental Disease. — We recently reviewed 32 cases of syphilitic mental disease worked on intensively by the social service of the Psychopathic Hospital, with the aim of finding out which of these social difficulties were paramount in cases of syphilis of the nervous system requiring social care. Half of the married cases had some kind of family or marital diffi- culty varying from assault, threats, and jealous suspicions to definite estrangement, desertion, and non-support. Fifty per cent of these disorders affected the mate only and might be summed up under various degrees of marital discord. In the other 50 per cent the family unit was broken by desertion of wife, separation or estrangement from wife or children or both. The economic difficulties of the late syphilitic might well account for these discords in familial life. A decline in indus- trial capacity arising from a chronic inefficiency was manifest in some cases studied, others were temporarily incapacitated. On the one hand, these disorders led to inability to support a family; on the other, to employment difficulties. Thus, we found dependence on wife, relatives, and charity for support due to insufficient or lack of any income and a growing num- ber of debts. Considered statistically, we found that in the 32 cases, 23 failed to adjust themselves to a competitive industrial world. Eecognizing the special frequency with which these eco- nomic difficulties arise in the families in which the bread- winner develops paresis, a more intensive study was made of the economic status of 41 married male paretics, the details of which are published elsewhere. 1 The conclusions, how- ever, may be considered here. It was found that in a normal self-supporting group of families, the entrance of paresis pro- duces the following effects: l Solomon, H. C. and M. H. A Study of the Economic Status of Forty-One Paretic Patients and Their Families, Mental Hygiene, vol. v, no. 3, July, 1921, pp. 556-565. 168 SYPHILIS OF THE INNOCENT 1. Over one half of the patients were receiving normal salaries at the time of admission to a state hospital. 2. Two thirds, however, showed a decline in working capacity. 3. The duration of this decline varied from one month to two years. 4. In spite of this decline most of the patients were not discharged, especially by firms with whom they had worked for years. 5. About one half were irregular at work or changed jobs frequently but only a few changed to less skilled labor. 6. About one half gave a medical cause for finally leaving work while one half gave an industrial cause. 7. Very few were out of work for a long time before admission. 8. Although the wages were not markedly decreased nor the patient out of work for a long time before admission, the eating up of savings followed by the sudden cutting off of the income shows that almost one half of the wives went to work because of the patients' illness, three fourths of them working outside the home. 9. Of 39 children whose mothers worked outside the home, 30 were under 14 and had to be cared for by other relatives. 10. There was no increase in the number of children working, though some children already working had to assume heavier burdens than normally. 11. Only a few families were forced to place out children. 12. Two thirds of the families received permanent aid because of the commitment of the patient. This aid was from public and private agencies and relatives. 13. At the time of the investigation, three fourths of the families had less income than when the patient left work. Syphilis and Marriage. — In view of the effect of syphilis on the physical, mental, and social life of the family, further consideration of a syphilitic 's right to marry is important. The question is one that has produced much difference of opinion. For those who believe that syphilis is always an incurable disease, and that the offspring of any individual who has had syphilis are likely to be tainted, it follows, of course, that a syphilitic can never marry. Although, there are a number of syphilologists who hold this point of view, we agree with the majority, who feel that under certain cir- cumstances a syphilitic may marry with safety to his mate and children. The point to decide is when a syphilitic is no longer contagious. THE FAMILY 169 Opinions of Various Authorities as to Marriage of a Syphil- itic. — The discovery of the Wassermann reaction in 1906 and the introduction of arsphenamin treatment in 1909 have modified the ideas of many regarding the question of mar- riage, so that one must consider the opinions antedating and succeeding these diagnostic and therapeutic discoveries. Dr. Edward B. Vedder 1 has quoted Finger's conclusions, which were written in 1896 and which may be taken as representative of late nineteenth century German opinion: 1. While untreated syphilis may lose its contagiousness and power of hereditary transmission, yet in numerous cases these powers may be retained for years, 2. Systemic treatment shortens the contagious period so that at the end of four or five years the danger to the wife and children is small in the majority of cases. 3. Experience shows, however, that in the most carefully treated cases a small fraction may retain the capability of transmitting the in- fection for 14 or 15 years, or even longer. 4. It follows, therefore, that no definite rule can be deduced that will always be satisfactory. The minimal conditions for marriage as outlined by Finger are given as follows: 1. A mild normal course of the disease. Severe visceral syphilis and malignant syphilis are excluded. 2. An interval of at least five full years between infection and marriage. 3. An interval of three years from the last syphilitic manifestation to marriage, with careful observation to determine the existence of slight erosions and other symptoms. 4. A correspondingly systematic treatment of the disease. 5. An energetic mercurial treatment just before the marriage. 6. It is the duty of the physician to warn the patient that mar- riage may not be absolutely safe. That he must watch for small erosions on the genitalia or in the mouth that may infect his wife. The family physician should know the facts so that he can watch both the wife and children, and afford prompt treatment should it become necessary. i Vedder, op. eit., p. 206. 170 SYPHILIS OF THE INNOCENT French opinion of this period is best represented by Four- nier, 1 who formulated the rules which have influenced the entire world: 1. Absence of actual specific lesions. 2. Advanced age of the infection. 3. Certain period of absolute immunity following the last specific manifestations. 4. Non-menacing character of the disease. 5. Sufficient specific treatment. Pusey 2 gives the following views as among the representa- tive opinions at the beginning of the twentieth century: Taylor: If the treatment is thorough, marriage is safe for a syphilitic man two and a half years after infection. Keyes: If during the last two years there has been no treat- ment and no symptoms, marriage is safe after five years. Morrow: If the treatment has been sufficient, if the patient has been without symptoms for 18 months, and if four years have elapsed since the infection, marriage is safe. Pusey quotes Gennerich and Hoffman as representative of present-day conservative opinions. Gennerich believes mar- riage may be permitted after two years of vigorous treatment if the Wassermann reaction is negative and there have been no relapses. Hoffman believes in the old rule that if a patient has had good treatment and has been symptom-free for two years he may safely marry three to five years after infection. Dr. Vedder 3 gives a modified form of Finger's views as his opinion: 1. A mild course of the disease. 2. An efficient course of treatment with both salvarsan and mercury in accordance with the best practice in the treatment of syphilis. 3. An interval of at least four full years between infection and marriage. 1 Fournier, op. cit., p. 91. 2 Pusey, W. A. Syphilis as a Modern Problem, Chicago, American Medical Association, 1915, p. 99. 3 Vedder, op. cit., p. 209. THE FAMILY 171 4. An interval of three years from the last syphilitic mani- festation to marriage, with careful observation to determine the existence of symptoms. 5. A negative Wassermann reaction just before marriage, best confirmed by a test at a second laboratory to ensure accuracy. Browning and Watson 1 feel that marriage should not take place until after two years of vigorous treatment, and then only if there are no lesions six months after the end of treat- ment. If the Wassermann reaction is positive after the two years, more treatment must be given. Marriage can then take place even if the Wassermann reaction is still positive, but both husband and wife should be treated. Typical of modern French opinion is the report of a 1920 commission appointed to study the question of the marriage of syphilitics. 2 The conclusion was that if the patient were seen and treated before the reaction became positive or before he manifested any secondary reactions and he remained free from positive serology and secondary manifestations dur- ing the first year, it was safe for him to marry at the end of two years. On the other hand, if he were seen after the sero- logical reaction became positive or he showed secondary symp- toms, intensive treatment was necessary for two years, but if at the end of that time all the tests were negative it would be safe for him to marry, two years having passed since his infection. If, in the latter case, the serological reaction remained positive it was considered safe for the patient to marry if he were a man and if his spinal fluid were normal. On the other hand, if in spite of treatment the spinal fluid were positive, the physician was urged to exercise great care in ad- vising marriage. Marriage was considered safe if, after treat- ment, the spinal fluid became negative and remained so for several years. Obvious signs of nervous system syphilis were considered a definite bar to marriage and physicians were i Browning, C. H. and D. Watson. Venereal Diseases; a Practical Handbook for Students. With an introduction by Sir John Bland-Sutton. New York, Oxford University Press, 1919, p. 120. 2 Report of a Commission for the Study of the Question of the Marriage of Syphilitics. Bulletin Societe francaise de dermatologie et de syphilologie, 1920, p. 233, translated in Venereal Diseases, by Ormsby and Mitchell, Practical Medicine Series, Chicago, vol. vii, 1920, p. 169. 172 SYPHILIS OF THE INNOCENT warned to be careful about advising marriage if the patient was an old syphilitic who could not give a good account of the date of infection or the amount of treatment. Stokes 1 believes that contagious patients should be gov- erned by the Hoffman five-year rule, which is almost "identi- cal with the standard of cure in the fully developed case of secondary syphilis/ ' He does not feel that conservative syphilologists should shorten the period because of modern treatment by salvarsan. Pusey 2 points out that the time when it is safe for a man to marry without danger of infecting his wife, and hence his children, depends on the duration and frequency of the relapses in secondary syphilis. He considers tertiary syphilis practically noncontagious. In cases which are poorly treated or not treated at all relapses are more frequent. He quotes Sperk, who in 1518 cases of secondary syphilis among prosti- tutes found relapses in all but 10. Lewin, in 6000 cases treated with sublimate injections, found 40 to 45 per cent relapses; Linden, in cases treated with calomel injections, had relapses in 30 per cent of his cases. Gennerich, in treating army men with mercury and salvarsan, reduced the number of relapses to 5 per cent. Thus, the matter of relapses seems to depend on adequate, early treatment. Pusey thinks that contagious lesions are rarely found after three years, and almost never after five. Fournier 3 observed 643 late secondaries in 19,000 cases. Statistics 4 have been compiled showing the duration of the secondary period. In 1000 cases from Tarnowski's clinic observed for ten years, the last lesions developed within the first five years in 802 persons; within the second five years in 167 persons ; within the third five years in 26 persons ; and within the fourth five years in 5 persons. Thus the older the infection, the less frequent are secondary lesions. 1 Stokes, J. H. To-day's World Problem in Disease Prevention, Washington, D. C, United States Public Health Service, Treasury Department, p. 98. 2 Pusey, op. cit., p. 95. 3 Fournier, A. La Syphilis des Honnetes Femmes, extrait du Bulletin de l'Academie de rnedecine, Seances du 2 et du 9 Oct. 1906. 4 Tschistjakow, Die Condylomatose Periode der Syphilis, Inaugural Disserta- tion, St. Petersburg, 1894, quoted by Vedder, p. 113. THE FAMILY 173 The final word from America to date is given in the con- clusions of the All-America Conference on Venereal Diseases, December, 1920 1 1 Resolved, That with reference to the eligibility for marriage of the individual who has or has had syphilis the following medical considerations apply: 1. The eligibility for marriage of the person who has or has had syphilis depends in the main upon the possibility of his transmitting the disease. 2. The impossibility of absolutely determining by arbitrary rule the limits of infectivity in all cases has been admitted. 3. The problem may be more difficult of solution in women than in men, owing to the paucity of clinical and laboratory evi- dence of the disease in the former. 4. The clinical experience of many years has justified, as rea- sonably safe, the following fundamental requirements: (a) Three years of effective treatment. (b) Two additional years of freedom from all signs and symp- toms of the disease, under medical observation. 5. It is recognized that special types of cases may call for special interpretation, which, however, in all cases should be founded on the basic principles of effective treatment and pro- longed painstaking observation for signs of recurrent or active syphilis. 6. In view of the inevitable element of uncertainty, however small, the prospective marital partner of a person who has or has had syphilis should be informed before marriage of the status of the case. 7. Medical examination to establish the presence or absence of syphilis before marriage should include not merely a blood Was- sermann test but an examination, clinical and serologic, of the entire body. If evidence of a previous or probable syphilitic in- fection presents, such examination should be especially searching, may include a period of observation, and should be interpreted by an expert. It is evident that all these opinions allow a great latitude in the interpretation of the term "noncontagious." It is also clear that the time element is brought in as a more important i Resolutions of All- America Conference on Venereal Diseases, Public Health Eeports, vol. 36, no. 28, July 15, 1921, p. 1063. 174 SYPHILIS OF THE INNOCENT factor than a negative Wassermann reaction. There are many cases which, despite the most intensive treatment, continue to have positive Wassermann reactions in the blood. Despite this fact, many of these patients may be considered as probably noncontagious, and from that standpoint, fair risks for mar- riage. Unfortunately, many lawmakers feel that a negative Wassermann reaction is the most important point in an exam- ination for syphilis. Besides the difference which personal interpretation and technique make in evaluating any Wasser- mann reaction, there is the danger that satisfaction with a negative Wassermann reaction will mean that some early cases of syphilis as well as some cases of neurosyphilis will escape the doctor's notice. Case 127. What may result from relying on a negative Wasser- mann reaction is shown by the case of Max Goldstein. As the hus- band of a general paretic he was examined and found to have an early neurosyphilis for which he underwent treatment. He was anxious to remarry shortly after the death of his wife. He was urged against this by the hospital physicians on the ground that he was a poor risk for marriage. He had had a great many positive Wassermann reac- tions as well as some negative Wassermanns. In view of his desire to marry he went to a physician who sent a sample of his blood to a laboratory for a Wassermann test which was reported negative. On this ground he felt justified in marrying and refused to return to the clinic for treatment. The Wassermann test on the blood was of ab- solutely no value in this case as the patient was a neurosyphilitic. Al- though there was no danger of familial infection the patient was a poor economic risk. Legislation Regarding Syphilis and Marriage. — In recent years there has been considerable advance in legislation in the United States regarding syphilis and marriage, due, no doubt, to the increased publicity given to the question. These laws are interesting: first, from the point of view of syphilis as a bar to marriage, and second, as the means of making the marriages void. The following 17 states have provisions relating to venereal disease as a bar to marriage i 1 l Office of the Surgeon General, Division of Venereal Diseases. THE FAMILY Alabama North Carolina Vermont Indiana North Dakota Virginia Maine Oklahoma Washington Michigan Oregon Wisconsin New Jersey Pennsylvania Wyoming New York Utah 175 The general aim of the laws is to prevent the marriage of infected persons. How this purpose is carried out can best be shown by an examination of some of the laws. Some states merely prohibit the marriage of persons who know they have a venereal disease. For instance, Michigan forbids the mar- riage of a person with a venereal disease, but does not offer any provisions for enforcement or penalties for disregarding the law. In other states nothing further is demanded than a state- ment from both applicants under oath that they are free from a venereal disease or that they have no transmissible, un- cured, or contagious disease. For example: The New York law makes it the duty of the town or city clerk, before issuing a marriage license, to secure a statement from each of the parties to the marriage in the following words : "I have not to my knowledge been infected with any venereal disease, or if I have been so infected within five years I have had a laboratory test within that period which shows that I am now free from infection from any such disease." 1 In Pennsylvania one need only state that one is free from any i i communicable ' ' disease, while in Washington this is only required for the male applicant. 2 Alabama, North Dakota, Wisconsin, and Oregon provide for a medical certificate. Alabama's law of 1919 reads: No license may be issued to a person who fails to present to the issuer a certificate by a licensed physician setting forth freedom from venereal diseases so nearly as can be determined by a thorough exam- ination and by the application of the recognized clinical and labora- tory tests of scientific research, when in the discretion of the examin- i Venereal Disease Legislation, Public Health Reports, Jan. 18, 1918. 2 Social Hygiene Legislation Manual, 1921, Publication 312, American Social Hygiene Association. 176 SYPHILIS OF THE INNOCENT ing physician such clinical and laboratory tests are necessary. All males within 15 days prior to application for a license shall be exam- ined. No marriage shall be entered into in any manner whatsoever without the male party shall have first submitted to the ante-nuptial examination referred to . . . and having with him a certificate from such physician of his freedom from such diseases. 1 Wisconsin's statute of 1917 reads: . . . within 15 days prior to the application all male applicants must be examined for venereal disease by a physician licensed to practice in Wisconsin or in the state in which the applicant resides, and must file with the clerk the physician's certificate showing that the applicant is free from such disease. Any person who has been afflicted with gonorrhea or syphilis must file a certificate from the designated state laboratory showing that such person has been examined and is not in a communicable stage of the disease. Although a licensed physician must state that every appli- cant is free from venereal disease, there is, unfortunately, no mechanism provided to avoid the certificate of the ignorant doctor who is satisfied with a negative Wassermann reaction as evidence of freedom from syphilis. Nor when there is a suspicion of syphilis is there any means of securing a thor- ough medical examination consisting of a history of the pa- tient and family, thorough physical examination, repeated blood tests, and examination of the spinal fluid. Indiana, Maine, Michigan, New Jersey, Vermont, and Oklahoma go further. It is a misdemeanor (in the case of Oklahoma, a felony) for persons with a venereal disease to marry, while in Maine it is a misdemeanor for persons with syphilis to marry. The New Jersey law, March 14, 1917, reads : 1. Any person, who knowing himself or herself to be infected with a venereal disease, such as chancroid, gonorrhea, syphilis, or any of the varieties or stages of such diseases has sexual intercourse, shall be guilty of a misdemeanor. l Hall, F. S. and E. W. Brooke, American Marriage Laws in Their Social Aspects, New York, Russell Sage Foundation, 1919. THE FAMILY 177 An interesting point here is that "any variety or stage' ' is considered in the law, irrespective of whether it is con- tagious or not. This is an example of how an otherwise good law can go too far by being too inclusive. The law might be used to include noncontagious, symptom-free, latent syphilis which "varieties" are not dangerous through intercourse. Provision is often made for penalties if the marriage is consummated in spite of the existence of the contagion. Thus Oklahoma, in senate bill No. 43, Section 3, demands: . . . any person who shall, after becoming an infected person and before being discharged and pronounced cured by a reputable physician in writing, marry any other person, or expose any other person by the act of copulation or sexual intercourse to such venereal disease or to liability to contract the same, shall be guilty of a felony and upon conviction shall be punished by confinement in the penitentiary for not less than one year or not more than five years. Michigan, Vermont, and Maine laws apply this to syphilis specifically. Michigan's penalty in 1915 reads: Marriage by a person with syphilis or gonorrhea is deemed a felony and is punishable by a fine of from $500 to $1000, or imprisonment for not more than five years, or both, and it is provided that in such prosecution, the husband or wife may be examined as witness against each other, whether they consent or not, and that any physician who attended the defendant shall be compelled to testify. 1 Vermont, 1915, provides: A person who, having been told by a physician that he or she was infected with gonorrhea or syphilis, marries, without assurance and certification from a legally qualified practitioner of medicine and surgery that he or she is free from gonorrhea or syphilis, shall be fined not more than $500 or imprisoned not more than two years. 1 Maine passed in 1919 an act relating to the marriage of per- sons having syphilis: Sec. 1. No person having syphilis shall marry until he has a certificate from the attending physician or physicians that he is cured l Hall and Brooke, loc. cit. 178 SYPHILIS OF THE INNOCENT of syphilis. The state board of health is hereby empowered to make regulations prescribing the methods to be employed in diagnosticating said disease. Sec. 2. Every physician shall keep a record of all cases of syphilis that come under his observation and care, and shall use reasonable means to ascertain the intentions of syphilitic patients as to marriage. The physician shall -warn said patient of the legal, moral, and physical evils of marriage contracted by them. If the physician learns that a patient as aforesaid has filed intentions of marriage as required by law, or if the physician believes that the patient as aforesaid intends to marry, the physician shall notify the local board of health or the health officer in the town or city in which the patient resides, who are hereby empowered to notify the other party to the intended marriage. Sec. 3. Any person failing to comply with the provisions of sec- tions one and two and any physician making a certificate as aforesaid falsely shall be punished by imprisonment for not less than three months nor more than one year or by a fine of not more than five hundred dollars or less than two hundred dollars, or both. Municipal and police courts and trial justices shall have jurisdiction of the above concurrently with superior and supreme judicial courts. . . . The following states make the marriage of persons with venereal disease void: 1 Connecticut Maine Rhode Island District of Columbia Massachusetts South Carolina Georgia Michigan Utah Illinois Minnesota West Virginia Kentucky Nebraska o J Other states have recently passed statutes making venereal disease a ground for annulment as for instance, Indiana, North Dakota, Pennsylvania, and Washington. States which do not have specific laws have recently an- nulled marriages, granted separations or specific damages, on other grounds. The marriage of a syphilitic has been annulled recently in the United States on the basis of fraud. In a recent Kansas case, the wife discovered the day after marriage that her hus- band was syphilitic. She was unable to obtain a divorce for a year but the marriage was annulled on the ground that the l Social Hygiene Legislation Manual, loc. cit. THE FAMILY 179 husband was not physically fit to enter into marriage rela- tions and that the marriage was fraudulent. 1 The case is also cited where a separation was granted on the ground of cruel treatment. In this case the wife acquired gonorrhea and syphilis from her husband. (Louisiana, 1912.) In a New Jersey case, 1914, the admission of a defendant in a divorce proceeding to members of his family that he had given his wife the disease if sustained by corroborating cir- cumstances was sufficient ground for granting the decree. The Supreme Court of North Carolina, 2 recently affirmed . . . a judgment in favor of a wife who asked for actual and punitive dam- ages because . . . her husband contracted a venereal disease and "took advantage of his marital relation with said plaintiff and in- fected her with said vile and loathsome disease." . . . The jury assessed the plaintiff's damages at $10,000. ... It was held that no principle of justice can maintain . . . that a debauchee can marry a virtuous girl . . . keep up his intercourse with lewd women, contract . . . venereal disease, communicate it to his wife . . . and ruin her physically for life . . . yet be ex- empted from all liability by the assertion that he and his wife are one, and that he being that one, he owes no duty to her of making reparation to her for the gross wrong that he has done her. The value of these laws might be questioned as they do not entirely cover the ground in content or means of carrying them out. Their fallacies have been pointed out by a recent survey of some "eugenic" marriage laws. 3 Here the Wiscon- sin law is taken as an example of the most effective modern legislative effort. The writer believes that although the direct effect of the law has been wholesome its value is mostly moral and educational. The weaknesses in the practice of the law are given as follows: 1 Mimeogram, Aug., 192-0, U. S. Interdepartmental Social Hygiene Board, pp. 7-9. 2 Journal of the American Medical Association, vol. 76, no. 4, Jan. 22, 1921, p. 265. 3 Roloff, B. C, The "Eugenie" Marriage Laws of Wisconsin, Michigan, and Indiana, Social Hygiene, vol. vi, no. 2, April, 1920, pp. 230-238. 180 SYPHILIS OF THE INNOCENT 1. The tendency, which thus far has not been successfully checked, of couples who desire to evade the provisions of the Wisconsin law, to be married in neighboring states. These states either have no "evasion" act to prevent this practice (e. g., Michigan) or their officials, reaping a harvest of fees by reason of the exodus, wink at the evasion (e. g., Illinois). 2. The failure to include in the ' ' eugenic ' ' section the require- ment that a medical certificate shall be furnished by the female as well as the male. 3. The likelihood that the present simple requirement of an examination by a licensed physician is in no wise a guarantee that the applicant is free from venereal disease, a fact admitted by leading physicians within and without the state. 4. The ease with which (owing to the 15 days' grace between the application for a license and the 30 days' grace between the issuance of the license and the solemnization of the marriage) the purpose of the act may be avoided by the young man who goes out for "one last celebration" before the wedding, and acquires syphilis or gonorrhea subsequent to the medical examination. The following suggestions have been made as a method of improving these laws: 1. The adoption and enforcement by all states concerned of the standard "Marriage Evasion Act" recommended by the Con- ference of Commissioners on Uniform State Laws. Illinois and Wisconsin already have substantially this act. But . . . there is a difference of opinion among legal authorities in Wis- consin, and definite decision and interpretation are needed to validate the law. Michigan needs such a law. And a strict holding to account of the officials of these states by the local district or prosecuting attorneys is essential. 2. A "eugenic" certificate should be required of the female as well as the male. The difficulty of developing the details of such a provision is admitted, as well as the need to guard against its abuse. That such examination for women should be performed by women physicians is believed by many to be essential to the success of such an act. 3. The difficulties in the way of obtaining a reliable cure for women afflicted with gonorrhea are well known to medical men. Although the refinement of laboratory tests for syphilis and gonorrhea is by no means complete, yet in the hands of experts THE FAMILY 181 they are the best available means of diagnosis, and without them the whole issue remains vague and uncertain.. Laboratory tests were originally part of the Wisconsin law, but the requirement was repealed because of the apparent hardship to applicants. I cannot help but voice the opinion that laboratory tests should be restored as part of the examination. 4. The obvious remedy for the situation outlined in paragraph 4 under defects would be to require the examination to take place within a shorter time previous to the solemnization of the marriage — say five days. This would not solve the problem entirely, but would at least serve to reduce the number of premarital infections. In spite of the inadequacy of even the best laws it would seem that the efforts of all individual states must be of value. Just as prohibition and woman suffrage became national amendments, due partially to the local interest in wet and dry states and in suffrage and anti-suffrage states, so it is pos- sible that these unrelated so-called "eugenic'' marriage laws may lead to uniform national laws. Importance of Physician's Influence Regarding Marrying of Syphilitics. — In considering the law as a means of pre- venting family infection one cannot ignore the important per- sonal influence of the physician upon the whole situation. A man or woman who has had syphilis deserves a thorough examination by a competent physician before marriage. It is the duty of the family physician to make such an examina- tion himself or if there is any question of the diagnosis to send the patient to a syphilologist for final decision. It is not only essential for the physician to establish the degree of safety with which a patient can marry but if the patient insists on marriage and there is any danger the physi- cian should inform the other party. Here again the oath of Hippocrates is often invoked. It seems clear to us, however, that the physician has a greater duty to the community — represented by the future mate and children — than he has to the individual. A warning of future possibilities is the due of every person who is to marry a syphilitic as well as of every syphilitic who intends to marry a non- syphilitic per- 182 SYPHILIS OF THE INNOCENT son. Not only generalities but definite points must be brought out, such as: the danger of moist and open lesions; the pos- sible infection of the fetus by the wife even though she is without obvious lesions; the fact that symptom-free does not mean disease-free; the necessity of long and regular treat- ment, and the chances of involvement of the visceral, vascular, and nervous systems and of resulting incapacity. Case 128. The social complication appeared in this case when we received a letter from Mark Cochrane 's fiancee, asking us what was the matter with him and whether she could marry him. She said that he told her he had a "nervous breakdown." The patient, a young man of 28, had had a chancre six years previous. Although he had been treated and had been under care for a year, he had devel- oped an early paresis with considerable mental deterioration. He could marry without danger of infecting his wife, but he could in no way make an adequate husband. He had not been earning a living for over a year, and could not support a family. He needed oversight on account of his spells of unconsciousness and would undoubtedly deteriorate more and more during the next few years. We felt entirely justified, after urging the patient to tell his fiancee the truth, in going over the situation thoroughly with her, so that she might have all the facts on which to base a judgment. Legal Attitude Towards Physicians and Medical Secrecy. — An indication that the legal attitude towards physicians is changing, is given in the above marriage laws which demand a health certificate. The implication of such laws is that the doctor, by refusing to sign a certificate, discloses syphilis and stops the marriage. However, most of the existing laws as to libel and professional confidence do not give much free- dom to the physician. Wigmore 1 says "protection is not ex- tended to medical persons in regard to information which they have acquired confidentially by attending in their pro- fessional character.' ' Wigmore, however, does not believe that medical testimony should be a privileged communication as it is too important and decisive. More and more in recent years jurisdictions have revoked this privilege. For example, l Wigmore, J. H., Treatise on the Law of Evidence, by Simon Greenleaf, revised by J. H. Wigmore, Boston, Wile and Brown, 1899. THE FAMILY 183 Ohio 1 in 1915 made a certain provision for physicians to ex- pose facts to interested persons. Section 1275. The State Medical Board may refuse to grant a cer- tificate to a person guilty of . . . grossly unprofessional or dis- honest conduct. . . . The words "grossly unprofessional or dishonest conduct ' ' as used in this section are hereby declared to mean : Second, The willful betrayal of a professional secret. But a physi- cian, knowing that one of the parties to a contemplated marriage has a venereal disease, and so informing the other party to such contem- plated marriage, or the parent, brother, or guardian of such other party, shall not be held to answer for betrayal of a professional secret, nor shall such physician be liable in damages for truthfully giving such information to such other party, or the parent, brother, or guardian of such other party. Other state laws support this position even more positively : The Maine act requires physicians, under penalty, to notify the local health officer if an infected patient intends to marry, and the health officer is empowered to notify the other party. In the public interest the physician is not only permitted to disregard what had hitherto been considered a professional secret, but it is made his duty to do so. 2 The English situation has been summed up by the Koyal Commission on Venereal Diseases: 3 The difficulty of communicating with or warning the future bride, or her parents or other persons in a position to influence her action, is twofold. We are informed by many witnesses that it might be regarded as a breach of professional confidence. There is also the possibility of the medical practitioner being sued or prosecuted. There is no doubt that to assert to a third person that any one is suffering from a venereal disease is, if in writing, a libel, or if by word of mouth, a slander. The witnesses who have dealt with the difficulty thus created have somewhat magnified its extent ; for in a civil action against a medical practitioner, proof of the truth of the defamatory i Worthington, G. E., Developments in Social Hygiene Legislation, from 1917 to September 1, 1920, American Social Hygiene Association, Publication Ko. 313, p. 569. 2 Venereal Disease Legislation, Public Health 'Reports, loc. cit. 3 Royal Commission on Venereal Diseases, op. cit., pp. 56-7. 184 SYPHILIS OF THE INNOCENT words affords a complete defence; and in criminal proceedings, if the jury should find that the defamatory words were true in substance and in fact, and also that it was for the public benefit that the matters charged should be published, the defendant would be entitled under Lord Campbell's Act to judgment in his favour. In a case, therefore, where there can be no reasonable doubt as to the accuracy of the diagnosis, a medical practitioner would be in a secure position so far as the result of the trial is concerned, though it must be admitted that the award of costs to him would usually be a very inadequate com- pensation for the loss of time and for the trouble caused even by a successful defence. But in some cases, e. g\, where he has simply expressed his opinion that the intending husband is "not cured' 7 or 1 ' is not yet in a condition to make it safe for him to marry, ' ' it might be dangerous for him to take on himself the burden of justifying, since a doubtful or speculative issue would then be raised. This point of medical secrecy arose in London recently 1 when a physician was called in a divorce case to give evidence that he had treated the wife for syphilis. Adultery had been proved but cruelty had also to be proved by the woman. The physician brought a letter from his hospital saying that absolute secrecy was enjoined on the physician. The judge ruled that evidence should be given on the ground of justice. This is an advanced and not entirely universal point of view. Many English physicians objected to "giving away" their patients and felt that such a policy would lower the attend- ance at venereal clinics. In this chapter an attempt has been made to show how syphilis affects the family unit. Syphilis acquired by the unmarried tends to lower the marriage rate, as many a syph- ilitic feels he has no right to marry. If syphilis does not pre- clude the right to marriage, it should postpone the date con- siderably. When a syphilitic marries or a married person acquires syphilis the whole family becomes implicated. The possibilities of marital infection, sterility, accidents to preg- nancies, stillbirths, and congenitally syphilized children are to be considered. The whole structure of family life may be changed. Illness of the individual members of the family i Journal of the American Medical Association, vol. 74, no. 9, Foreign Cor- respondence, Feb. 28, 1920, p. 614. THE FAMILY 185 affects the other members. Disabilities, frequent in middle life at a time when efficient parents are most necessary, lead to much hardship for the entire family. The frequency of the disease as a family problem is so great that it may be thought of as the general rule. This would lead to the practical plan of considering the family of every syphilitic and make for a thoroughgoing medical and social investigation. REFERENCES Bartlett, F. H., Effect of Venereal Disease on Infant Mortality. American Journal of Syphilis, vol. ii, no. 1, Jan., 1918. Blaisdell. J. H., The Menace of Syphilis to the Clean Living Public, Boston Medical and Surgical Journal, vol. clxxii, no. 4, April 1. 1915. , The Menace of Syphilis of To-day to the Family of To-morrow, Boston Medical and Surgical Journal, vol. clxxv, no. 1. July 6, 1916. Browning. C. H., and D. Watson, Venereal, Diseases: A Practical Handbook for Students, with an introduction by Sir John Bland-Sutton, New York, Oxford University, 1919. Dempset, Infant Mortality, Results of a Field Study in Brockton, Mass. Children's Bureau, U. S. Department of Labor, Series No. S, Bureau Publication No. 37. Department of Medical Social Work, Boston City Hospital, Feb. 1, 191 8- Jan. 31, 1919. Dublin, L., Birth Control, Social Hygiene, vol. vi, no. 1, Jan., 1920. Fournier, A., La Syphilis des Honnetes Femmes, extrait du Bulletin de 1'Academie de Medecine, Seances du 2 et 9 Oct., 190(3. . Syphilis et Marwge, Paris, G. Masson, 1880. Gow, W. J., Syphilis in Obstetrics {System of Syphilis, vol. ii), second edition, London, Frowde, Hodder, and Stoughton, 1914. Habermann, J. V., Hereditary Syphilis. Journal of the American Medical As- sociation, vol. 64, no. 4, 1915. Hall, F. S. and E. W. Brooke, American Marriage Laics in Their Social Aspects, New York, Eussell Sage Foundation, 1919. Harmon, B., The Effects of Venereal Disease of the Parents on the Children: especially in relation to the production of blindness, Report of the Com- mission on Venereal Diseases, Final Be port of the Commissioners, London, 1916. Haskell, R. H., Familial Syphilitic Infection in General Paresis, Journal of the American Medical Association, vol. Ixiv, no. 11, March 13, 1915. Hill, J. A., Comparative Fecundity of Women of Native and American Parentage in the United States of America, Boston, American Statistical Association, Dec, 1913. Hochsinger, K., Die gesundheitlichen Lebenschicksale erbsyphilitischer Kinder, Wiener Minische Wochenschrift, no. 24, June 16, 1910. Infant Mortality Series, No. 3, Children's Bureau Publication No. 9, Washington, D. C, 1915. Jamieson, R. C, Syphilis in Detroit as an Economic and Social Factor, Ameri- can Journal of Syphilis, vol. ii, no. 3, 1918. Jeans, P. C, Svphilis and Its Relation to Infant Mortality, American Journal . of Syphilis, vol. iii, no. 1, Jan., 1919. 186 SYPHILIS OF THE INNOCENT Jeans and E. Butler, Hereditary Syphilis as a Social Problem, American Journal Diseases of Children, vol. 8, Nov., 1914. Journal of the American Medical Association, vol. 74, no. 9, Foreign Correspon- dence, Feb. 28, 1920. Journal of the American Medical Association, vol. 76, no. 4, Jan. 22, 1921. Kraepelin, E., Psychiatrie, 8th edition, vol. ii, Leipzig, Johann Ambrosius Barth, 1913. Lewinski-Corwin, E. Venereal Disease Clinics, Social Hygiene, vol. vi, no. 3, July, 1920. Lewis, Ora M., Medical Social Service as a Factor in Protective Work, National Conference of Social Work, New Orleans, April, 1920. Lewis, O. M., et al., A Clinic Studies Itself, Hospital Social Service, vol. 3, no. 1, Jan., 1921. Mimeogram, Aug., 1920, U. S. Interdepartmental Social Hygiene Board. Monthly Bulletin of the Boston Health Department, Boston, October, 1919. Nonne, M., Die heutige Standpunkt der Lues-paralyse Frage. Deutsche Zeit- schrift fur Nervenheilhunde, vol. xlix, 1913. Pusey, W. A., Syphilis as a Modern Problem, Chicago, American Medical As- sociation, 1915, p. 99. Keport of the Commission for the Study of the Question of Marriage of Syphi- litics, Bulletin Societe franchise de dermatologie et de syphilologie, 1920, translated in Venereal Diseases by Ormsby and Mitchell, Chicago, Practical Medicine Series, vol. vii, 1920. Eesolutions of All- America Conference on Venereal Diseases, Public Health Reports, vol. 36, no. 28, July 15, 1921. Boloff, B. C, The ' 'Eugenic" Marriage Laws of Wisconsin, Michigan, and Indiana, Social Hygiene, vol. vi, no. 2, April, 1920. Salmon, T. W., General Paralysis as a Public Health Problem, Proceedings of the American Medico-psychological Association, 70th annual meeting, Balti- more, Maryland, May 26-29, 1914. Social Hygiene Legislation Manual, 1921, Publication 312, American Social Hygiene Association. Solomon, H. C. and M. H., The Effects of Syphilis on the Families of Syphi- litics Seen in the Late Stages, Social Hygiene, vol. vi, no. 4, Oct., 1920. , A Study of the Economic Status of Forty-one Paretic Patients and Their Families, Mental Hygiene, vol. v, no. 3, July, 1921. Stokes, J. H., Today's World Problem in Disease Prevention, Washington, D. C, U. S. Public Health Service, Treasury Department. and H. E. Brehmer, Syphilis in Railroad Employees, Journal of Industrial Hygiene, vol. i, no. 9, Jan., 1920. Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea and Febiger, 1918. Veeder, B. S., Hereditary Syphilis in the Light of Recent Clinical Studies, American Journal of Medical Sciences, clii, 1916. Venereal Disease Legislation, Public Health Reports? No. 450, January 18, 1918. Weiss, R. S. and A. H. Conrad, Medical and Social Care of Syphilis at the Washington University Dispensary, American Journal of Syphilis, vol. 4, no. 2, April, 1920. Wigmore, J. H, Treatise on the Law of Evidence, by Simon Greenleaf, revised by J. H. Wigmore, Boston, Wile and Brown, 1899. Worthington, G. E., Developments in Social Hygiene Legislation from 1917 to September 1, 1920, American Social Hygiene Association, Publication No. 313. CHAPTER V. THE COMMUNITY. Extragenital Infection. — The social effects of syphilis dis- cussed in the chapter on the family also have a bearing on the life of the larger unit, the community. The community is only a network or mass of families, all interrelated by mutual work or play, by necessity, or by desire. One of the out- standing aspects of syphilis from a community point of view is its contagiousness by extragenital methods. An extra- genital chancre is one which is acquired outside of sexual intercourse either by chance contact or by a sexual relation other than coitus. When First Discovered. — When was it first found out that syphilis could be transmitted extragenitally and by chance contact ? Vedder 1 claims that transmission between nurse and suckling was established in 1504. In 1509 Seitz showed that surgical instruments and cupping glasses were mediums of infection. Cases of professional exposure were recognized very early. William Clowes 2 in the first treatise on "Lues Venerea,' ' published in the English language, 1596, says "I have known, not many years past, three good and honest mid- wives infected with this disease ... by bringing abed three infected women of three infected children, which infec- tion was chiefly fixed upon the midwives' fingers and hands." The first known outbreak of innocent syphilis in America occurred in New England in 1646 and is described in the diary of John Winthrop. 3 A woman is delivered of a child. She has a sore breast. Women and children "drew" from it i Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea and Febiger, 1918, p. 147. 2 Bulkley, L. D., Syphilis in the Innocent, New York, Bailey and Fairchild, p. 175, quotes' H. Lee, Lectures on Syphilis, Philadelphia, 1875, p. 35, who quotes Clowes. 3 Lane, J. E., A Few Early Notes on Syphilis in the English Colonies of North America, Archives of Dermatology and Syphilis, vol. 2, no. 2, Aug., 1920. 187 188 SYPHILIS OF THE INNOCENT and 16 persons were infected with "lues venerea." The hus- band was thought to have infected his wife. "Though many did eat and drink and lodge in bed with those who were in- fected . . . none took it of them but by copulation or sucking. ' ' Incidence of Extragenital Infection. — The seriousness of ex- tragenital infection from a community aspect lies in its in- cidence in comparison with genital infections. Bulkley 1 made a complete study of such cases and submitted the following table: Table 32. Proportion of Extragenital to Genital Chancres 02 O g 13 O j a « a 2 a > Bassereau, Robert, Four- nier and Lefort, Hopital du Midi, Paris °© » S3 — 55 3 ^ 5 | o i 1 3 ^ -S+j 4> i—i aj CO o L 3 31 oi 5 o bfl o 11 a 3 tn o 3 o 3 s s i c 3 GO 4) o> — 3 w 1 I l 3 3 O O 4) 3 o bfl 3 a o to S o 02 o 3 o 5 o Ej -•5 cj OB'S g a 5J -ia OB 3 O u 3« 3 "-3 x i * B ^ 1 XI 03 oo % 3 "3, 2 S 3 -J2 o 3 JU -T"3 . SI'S > xT -g 8 g B»2 3 ?"2 3 3 OX! X 3 GO "I *1 o hay 4) 41 "o :i ^ 3 3 4i >> 3 O 3 .a G O .-3 -, 41 rt a Z O GO 2 & 3 S 8 N i "3 3 (3 M o 0Q co ^ 0> J3 ■3 "o 3 41 .2 CO "^ O o co 3 o S 2 bfl 3 '3 K O s >> X! 4) C O 1 S - | go m '3 T3 C (3 X2 oo 3 i i 3 2 Q 13 X? 3 4- 3 O* Li o ,2 o .'" < M 72 3 _o 'oi i 1 1 1 1 4) 41 >> o & ■3 0) 1 1 i .3 or. C -3 3 3 — c3 b -^ 8j GO .3 "S 1 § o 1 bfl 3 Q < z si £3 o oi 00 - 1 u "3 1 o XJ o .5 a; > O < . m .a 3"^ -3 3 % r 41 41 > CI "o -3 o -3 3 GO "S 3 X! a o < o cO g a u a -o c > "I c3 3 O "So co — A 3 O 15 "3 1 Xt o3 01 ^3 -3 ci > 4) as 3 S3 -2 oo * Uo S ** * w - 3 fj .2 3 GO 1 O a w \ ■Q .2 a 41 > < CO o < il « o 3 *• 41 a < 3) 3 41 < 30 ^ B Ol > 41 < 204 SYPHILIS OF THE INNOCENT Often, of course, cases of syphilis are apparently contagions while there is really no danger. This is especially true in various industrial pursuits. Case 137. Mr. Frank was a syphilitic baker. There was, however, no danger of infection to others. In the first place, the infection was in a chronic stage. Furthermore, he had no open lesions and accord- ing to the history had never had any. Thirdly, the time that elapses between the baking of breads and cakes and the eating is so long that there is no reasonable fear of the treponema living long enough to infect the consumer. Case 138. Etta Prince was a syphilitic of 22 who had been infected five years previously. Her employer was aware of her infection and when an eruption appeared on her hands at once feared that she might be a menace to her fellow employees. Examination showed that although the girl was a syphilitic she was not contagious in any way and the rash was of an eczematous character. Case 139. Boston Dispensary Case. 1 A young syphilitic girl secured a position in a restaurant folding linens. She feared that her occupation might endanger others. She had recently acquired syphilis but was no longer contagious as she had received adequate treatment, as far as the present stage of the disease was concerned. Permission was given her to retain her position. If people who might be the source of innocent infections were 100 per cent contagious very many more individuals would be infected by contact with the many syphilitics in occupations bringing them into close association with others. It is impossible to decide what factors determine the spread of innocent syphilis in industry. We cannot put the danger on a percentage basis. However, it is apparent that the danger is not quite as great as many people would think or undoubt- edly more extragenital cases would appear at hospital clinics with a history of infection acquired through occupation. The Lakeside Hospital, Cleveland, investigated 285 syphilitic cases, including many contagious ones and listed the occupa- tions as nearly as possible in order of their danger to the pub- lic from the standpoint of infections innocently acquired. Practically one fourth were employed at work involving close contact with people, food, clothes, etc. i Reported at a meeting. THE COMMUNITY 205 111 this connection we made a study of 755 paretics to find out how many of them were in occupations usually supposed to be dangerous to the community. The following groups were selected, and it was found that 154, or 20.3 per cent of the paretics were working in these occupations. The number and per cent in each group were as follows: No. P. C. People handling food 67 43 . 50 Domestics 47 30.51 Laundry Workers 3 1.94 Clothing Workers 15 9 . 74 Barbers 9 5.84 Physicians and Dentists 5 3 . 24 Musicians 6 3 . 89 Druggists 2 1.29 If the idea that all syphilitics are contagious were true the fact that 20 per cent of a random group of late syphilitics were working in occupations which brought them into close touch with others would be indicative of many other infected cases. As a matter of fact, paretics and most other syphilitics in the late stages are not contagious to others and therefore the general public need not be aroused at the idea of so many syphilitics in the above occupations. On the other hand, many of these patients were in all likelihood employed in the same occupations at the time they acquired syphilis and were in the most contagious period of the disease. Thus, the im- portant point is not whether the person is syphilitic but whether he is in a contagious state. Incidence of Syphilis and its Financial Results. — One of the most outstanding effects of syphilis on the community is the direct financial cost in dollars and cents. In every com- munity there is a certain definite yearly outlay of money for the care of syphilitics. Very few estimates of the exact cost have been computed. In order to know what the actual cost is, one should know something about the prevalence of the disease. Frequent estimates based largely on Wassermann surveys have been made indicating that somewhere between 10 and 15 per cent of the community at large are infected with 206 SYPHILIS OF THE INNOCENT syphilis. A consideration of these figures does not clearly show the amount of syphilis in the community because of the great variation to be found in different groups. The accom- panying table illustrates the difference in the percentages, which vary from a fraction of 1 per cent in a group of healthy young American men who were applicants for commissions in the Aviation Corps to 97 per cent in a group of prostitutes, with intermediate figures of approximately 4 per cent for some groups of pregnant women to 35 per cent in criminal groups. Table 37. Variation in Estimates of Prevalence of Syphilis in the Community Clinic Group Indi- viduals Positive Wassermann Reaction No. P.C Mass. State Department of Health 1 Aviation Corps 3701 21 0.56 New England Hospital for Women and Children, Boston 2 Special Hospitals or Clinics for Women 2090 52 2.48 Women's Diseases, Private Cases, Wash- ington 3 Special Hospitals or Clinics for Women 417 17 4.07 Women's Clinic, Washington* Special Hospitals or Clinics for Women 150 13 8.66 Columbia Hospital for Women, Wash- ington* Special Hospitals or Clinics for Women 188 21 11.17 Gynecological Clinic, Philadelphia 6 Special Hospitals or Clinics for Women 300 36 12. Dr. Huron W. Lawson, Washington 7 Candidates for Police Force 856 54 6.3 Lying-in Hospital, New York 8 Pregnant Women 2000 61 3.05 Maternity Department, University of Michigan Hospital, Michigan 9 Pregnant Women 381 18 4.7 1 Hinton, W. A., Specific Inhibitory Eeaction of Cholestrinized Antigens in The Wassermann Test, American Journal of Syphilis, St. Louis, vol. 5, no. 1, Jan., 1921, p. 7. 2 New England Hospital for Women and Children. Tests by Massachusetts State Department of Health, compilation by H. C. Solomon, Boston, Mass. 3 Vedder, op. cit., p. 67. Private Cases. 4 Vedder, op. cit., p. 67 gives statistics from Women's Clinic, Washington. 5 Vedder, op. cit., p. 67 gives statistics from the Columbia Hospital, Wash- ington. 6 Williams and Kolmer, The Wassermann Eeaction in Gynaecology, American Journal of Obstetrics, lxxiv, 1916, p. 639, quoted by Vedder, p. 66. 1 Vedder, op. cit., p. 81, quotes Dr. Huron W. Lawson, Washington, D. C. 8 Dr. Losee, Syphilis in Mother and Infant, Bulletin of the Lying-in Hospital of New York, June, 1916, quoted by Vedder, p. 84. 9 Dr. Peterson, Observations on the Occurrence of Syphilis in the University of Michigan Obstetric and Gynaecologic Clinic, Surgery, Gynaecology, and Obstet- rics, 1916, p. 280, quoted by Vedder, p. 59. THE COMMUNITY Table 37 — Continued 207 Clinic Group Indi- viduals Positive Wassermann Reaction No. P.C. Mass. State Dept. of Health tests on pregnant women 3 " Pregnant Women 172 8 4.7 Florence Crittenton Home, Boston 11 Pregnant Women 192 11 5.72 Lying-in Hospital, Boston 1 * Pregnant Women 4935 290 5.87 Pregnancy Clinic, Brooklyn 13 Pregnant Women 892 70 7.9 Obstetric Cases at Clinic, Brooklyn 14 Pregnant Women 1822 145 8. Pregnancy Clinic, Chicago 16 Pregnant Women 146 14 9.5 Obstetric Cases at Sloane Hospital for Women, New York 1 * Pregnant Women 2488 227 9.1 Maternity Hospital, Belfast 17 Pregnant Women 171 22 12.8 Maternity Clinic, Seclin 18 Pregnant Women 103 16 15.5 Obstetric Cases, Washington, D. C. 19 Pregnant Women 201 36 17.06 East Louisiana Hospital for Insane, Louisiana 20 Insane W'omen 516 20 4. Pennsylvania Hospital for Insane, Phila- delphia 21 Insane Women 6.5 State Hospitals, Michigan 23 Insane Women 6.65 io Vedder, op. cit.. p. 61, quotes Massachusetts State Department of Health for 1915. 11 Florence Crittenton Home, Boston. Tests by Massachusetts State Depart- ment of Health, compiled by H. C. Solomon, Boston. 12 Lying-in Hospital, Boston, Tests by Massachusetts State Department of Health, compilation by H. C. Solomon, Boston. 13 Jeans, P. C, Syphilis and Its Relation to Infant Mortality, American Journal of Syphilis, vol. iii, no. 1, Jan., 1919, p. 115, quotes Judd, American Journal of Medical Sciences, cli, 1916, p. 836. 14 Commisky, L. J. J., A Preliminary Report of the Routine Wassermann Re- action in Hospital Obstetrics, American Journal of Medical Sciences, 1916, p. 676, quoted by Vedder, p. 83. 15 Falles and Moore, The Value of the Wassermann Test in Pregnancy, Journal of the American Medical Association, vol. lxvii, 1916, p. 574, quoted by Vedder, p. 83. 16 Vedder, op. cit., p. 84, quotes Dr. Reuben Ottenberg, Sloane Hospital for Women, New York. 17 Darling, Dublin Journal of Medical Sciences, third series, no. 549, Sept., 1917, p. 147, quoted by Vedder, p. 45. is Calmette, Breton et Couveur, Application pratique de la Reaction de Wassermann •diagnosis de la Syphilis chez les Nouveau-nes. Comptes rendus des seances et memoires de la Societe de Biologie, 1, 1911, 238, quoted by Vedder, p. 39. 19 Vedder, op. cit., p. 85, quotes Dr. Lawson and Columbia Hospital for Women, Washington, D. C. 20 Holbrook, Syphilis in the East Louisiana Hospital for the Insane, Ameri- can Journal of Insanity, lxxiii, 1916, p. 261, quoted by Vedder, p. 52. 21 Newcomer, H. S. et al., One Aspect of Syphilis as a Community Problem, American Journal Medical Sciences, vol. 158, Aug., 1919, p. 141, quotes Orton, Pennsylvania Hospital for Insane, Philadelphia. 22 Commission to Investigate the Extent of Feeble-mindedness, Epilepsy, and Insanity and Other Conditions of Mental Defect in Michigan (1915). 208 SYPHILIS OF THE INNOCENT Table 37 — Continued Clinic Group Indi- viduals Positive] Wassermann Reaction No. P.C. Michigan State Hospital, Michigan 23 Insane Women 606 77 12.7 Warren State Hospital, Pennsylvania 24 Insane Women 18.5 Dr. Collie, London 2 * Apparently healthy workmen 491 46 9.36 St. Luke's Hospital, San Francisco 28 Female Adult Admissions to Hospitals and Dispensaries for Medical and Surgical Condi- tions 223 10 4.4 London Hospital, London 27 Female Adult Admissions to Hospitals and Dispensaries for Medical and Surgical Condi- tions 389 20 5.1 Infirmary, England 28 Female Adult Admissions to Hospitals and Dispensaries for Medical and Surgical Condi- ditions 288 40 17.5 Bellevue Hospital, New York 2 * Female Adult Admissions to Hospitals and Dispensaries for Medical and Surgical Con- ditions 1752 475 27.1 Post Graduate Hospital, New York" Female Adult Admissions to Hospitals and Dispensaries for Medical and Surgical Con- ditions 746 205 27.4 Health Department of New York ^ l Criminals 3809 1353 35.5 Reformatory for Women 32 Criminals 864 349 40.1 Prostitutes, Germany 33 Prostitutes 260 102 39.2 23 Influence of Syphilis Upon Insanity and Marriage. Note and Comment in Social Hygiene, 1915, i, 485. From the Report of the Commission to Investigate the Extent of Feeble-mindedness, Epilepsy and Insanity and Other Conditions of Mental Defectiveness in Michigan, quoted by Vedder, p. 52. 24 Mitchell, General Paralysis of the Insane, New Yor~k Medical Journal, vol. 100, 1914, p. 605, quoted by Vedder, p. 51. 25 Final Report of the Commissioners, Royal Commission on Venereal Diseases quotes Sir John Collie, p. 16. 26 Knapp, The Wassermann Reaction in Four Hundred Cases Investigated by Group Studv Methods, American Journal of Syphilis, vol. 1, 1917, p. 772, quoted by Vedder, p/62. 27 Final Report of the Commissioners, Royal Commission on Venereal Diseases, London, 1916, p. 16. 28 Assinder, Syphilis in the Poorer Classes : Its Diagnosis by the Wassermann Test and Its Incidence as Demonstrated Thereby, Birmingham Medical Revieiu, vol. lxxvi, 1914, p. 137, quoted by Vedder, p. 44. 29 Vedder, op. cit., p. 55, gives statistics from Bellevue Hospital, New York, compiled by Miss Sarah Greenspan. 30 Vedder, op. cit., p. 57, quotes F. C. Costen, Post Graduate Hospital of New- York, 1916. 31 Pollitzer, Syphilis in Relation to Some Social Problems, American Journal of Obstetrics, vol. lxxiii, 1916, p. 857, quoted by Vedder, p. 71. 32 Hinton, loc. cit. 33 Hecht, Die Serodiagnose in Rahmen der Prostituierten-Kontrolle, Deutscher medizinische Wochensclirift, vol. xxxvi, 1916, p. 317, quoted by Vedder, p. 48. THE COMMUNITY Table 37 — Continued 209 Clinic Group Indi- viduals Positive Wassermann Reaction / No. PC. Bedford Reformatory for Girls, New York" Prostitutes 467 224 48.0 Prostitutes, Baltimore 35 Prostitutes 327 219 67.0 Prostitutes, Berlin 38 Prostitutes 230 180 78.2 Prostitutes, San Francisco 37 Prostitutes 320 310 97.0 34 Kneeland, Commercialized Prostitution m New York, New York, The Cen- tury Company, 1913 p. 188, quoted by Vedder, p. 47. 35 Walker. Symposium on Syphilis, Congress of American Physicians and Surgeons, 1916, Journal of the American Medical Association, vol. lxvi, 1916, p. 1740, quoted by Vedder, p. 48. 36 Pinkus, Beitrage zur Kenntnis der Berliner Prostitution ; die Syphilis der Prostituierten, Archiv fur Dermatologie und Syphilis, vol. cxiii, 1912, p. 805, quoted by Vedder, p. 49. 37 Ball, Jau Don, and Haywood G. Thomas, A Sociological, Neurological, Serological, and Psychiatrical Study of a Group of Prostitutes, American Journal of Insanity, April, 1918. Expense of Late Syphilis. — It is clear that we can say very little about prevalence except as regards certain groups. Any estimates of the real cost of syphilis must necessarily be somewhat fragmentary. There are, however, some interest- ing studies which give some indication of the cost. In 1917 Dr. Williams 1 made a study of late syphilis as a cause of economic disturbance. He took 100 random cases of men who died with syphilitic mental disease at the Boston State Hospital. The cost to the Commonwealth of Massachusetts in hospital care alone, was $39,312 for 100 men who actually spent an aggregate of 126 years or over one year apiece in the state institutions at a per capita cost of $6 per week. Dr. Williams, basing his estimate on the average admission rate to Massachusetts hospitals, concluded by showing that there were 1500 men and women in Massachusetts who in the course of the next five years, would be committed to state hospitals because of syphilitic mental disease. l Williams, F. E., Relation of Alcohol and Syphilis to Mental Hygiene, American Journal of Public Health, vol. 6, 1916, p. 1277. 210 SYPHILIS OF THE INNOCENT Dr. Pollock 1 estimated the economic loss to the state of New York on account of syphilitic mental disease for one year. He found the total patient population with syphilitic mental disease under treatment in institutions during the fiscal year of 1917 to be 1554, the per capita cost of support of patients in these hospitals being $303.68 a year. The total cost of maintenance for this group of patients during one year was estimated at $471,918.72. A report of the California State Board of Health for 1919 may be quoted in this connection: "For the past two years the state of California has tested all admissions to insane hospi- tals. Fourteen and five tenths per cent showed positive evi- dence of syphilis, 8 per cent were paretics. On the basis of 8 per cent it was found to cost the state of California $160,000 yearly to support the syphilitic insane.' ' Similarly the Eoyal Commission on Venereal Diseases in England 2 estimated that England and Wales spent 90,000 pounds per year on the committed insane suffering from gen- eral paresis plus 60,000 pounds for other forms of mental dis- ease due to syphilis. Estimate of Cast of Syphilis in Massachusetts. — We have endeavored to arrive at an estimate of the cost of syphilis to the public in the Commonwealth of Massachusetts, that is, the expense incurred by the citizens of the Commonwealth as a result of syphilis. Any such attempt must, of course, be very inadequate at the present time as it is quite impossible to get complete figures. However, it seemed worth while to make a beginning in this direction, such as might indicate not only something of the cost but also the lack of information in various institutions. It was found, for instance, that many hos- pitals treating syphilis have no idea as to the expense incurred because of this disease. Many charitable agencies are spend- ing considerable unknown sums of money because of the dam- age done to various individuals by syphilis. Our experience i Pollock, Horatio, The Economic Loss to the State of New York on Account of Syphilitic Mental Diseases during the Fiscal Year Ending June 30, 1917, Mental Hygiene, vol. ii, no. 2, April, 1918, p. 278. 2 Royal Commission on Venereal Diseases, op. eit., p. 34. THE COMMUNITY 211 in the not distant past has been that many of these societies were unwilling to give money for the treatment of syphilis or the prevention of syphilis, whereas they stood the expense of supporting the families which had been damaged or left destitute because of syphilis. It seems likely that with a pre- sentation of some actual cost figures, a different attitude might be engendered. The following data explain the result of our attempt to get information on this subject. Consider- ing the actual cost of the problem to the State Department of Health, and the Boston City Department of Health, the cost of committing syphilitic insane patients, that of the care and treatment of syphilitic patients at the State Infirmary, at the City Hospital for Chronic Diseases, and at three Boston Hos- pitals, a figure of practically a quarter of a million dollars per year was reached. This quarter of a million represents only a very small fraction of the total cost. It does not take into con- sideration the care of patients in private institutions or public hospitals outside of the metropolitan district of the state, only a small number of which hospitals are included. The greater part of this money is expended for the care of the patients after they are beyond the condition where assistance might be offered them through treatment. In other words, less than 10 per cent of the total amount ($225,000) is expended for prevention and treatment, while 90 per cent is used for the maintenance of patients who have passed the stage in which help is available. The following table is a resume of our estimate of the yearly cost as borne by the above mentioned institutions and de- partments. These estimates were based upon information ob- tained as to the number of patients cared for, the per capita cost in each case, and the amount of work done by the differ- ent departments. The details of this study will be published elsewhere. 212 SYPHILIS OF THE INNOCEXT Table 38 Massachusetts State Department of Health $12067.97 Massachusetts State Infirmary 41857.28 Massachusetts State Commission on Mental Diseases 4184.40 Commitment to Massachusetts State Insane Hospitals 10220.00 Massachusetts State Insane Hospitals 96732 . 81 Boston Psychopathic Hospital 14065 . 89 Boston City Board of Health 6374.56 City Hospital for Chronic Diseases and Paupers 20721.48 Massachusetts Homeopathic Hospital 8013.48 Massachusetts Charitable Eye and Ear Infirmary 1063.96 Boston Dispensary , 9382 . 02 $224683.85 Cost of Syphilis to Private Charities Not Estimated. — In addition to the expense defrayed by the taxpayers as actual taxes there must be considered all the private endowments to take care of various invalids, defectives, and minor indigent individuals whose difficulties are directly related to syphilis. The work done by various charitable organizations, children's societies, and the like, has never been analyzed from the point of view of the cost placed upon them as the result of syphilis. A solicitation of a number of these societies in Boston has shown that they have no idea how much of their expense is to be laid to this source. Our experience, however, has indicated to us that it is fairly large. These and other expenses of a similar type must be considered as direct taxes upon the community levied by syphilis and paid by the innocent. Cost in Maintenance of Institutions. — One must always consider among the items of community expense the part played by syphilis in filling our deaf, dumb, blind, and feeble- minded institutions. To estimate this in dollars and cents we should know the exact percentage of deafness, dumbness, blindness, and feeble-mindedness caused by syphilis. These figures are not to be secured in America at the present time. The examinations of children in schools for the deaf, dumb, and blind are not thorough enough to include an exact enumeration of the percentage of syphilitics or the relation- ship between the existing syphilis and the physical handicap. Much has been done to establish percentages for gonorrhea THE COMMUNITY 213 as a cause of blindness. Something should he initiated to discover the relationship between syphilis and deafness, dumbness, and blindness. In 1913 a reliable investigation was made in England by Mr. Bishop Harmon 1 who found of 1100 children in London Blind Schools 31.2 per cent were certainly and 2.8 per cent were probably syphilitic. It is to be noted that in 1904, 18.8 was the percentage of all blindness which could be attributed to syphilis. The increase in percentage in 1913 is partly due to the efforts made to prevent ophthalmia neonatorum (gon- orrheal infection) as a cause of blindness so that there are actually fewer cases of gonorrheal blindness in the schools; and partly to the better methods of diagnosing syphilitic eye infections. Thus, though one cannot say that syphilitic eye infections are actually increasing as these figures might in- dicate, yet they are increasing relatively to gonorrhea and the interest of the public must be broadened to include syph- ilis as a cause of blindness. A similar investigation of 845 children suffering from acquired deafness in the London County Council Deaf Schools, showed that 7.21 per cent were congenital syphilitics. The percentage of deafness associated with syphilis was about twice as great in girls as in boys. This study indicates what might be done in other schools in an attempt to estimate the relation between syphilis and deafness, dumbness, and blind- ness. Cost of Syphilis in Aid to Destitute Families. — Another direct loss in addition to the cost of institutions for the diag- nosis, treatment, and custodial care of the syphilitic is the cost to the community of families made destitute by syphilis in some wage-earning member. As indicated in the chapter on the family, in the early stages of syphilis temporary aid is sometimes necessary in families who can just get along with a certain income. If this is cut down by hospitalization of the wage-earner, by a considerable loss of time from work by out-patient treatment, or by loss of a job through fear of l Harmon, op. cit., pp. 30, 152. 214 SYPHILIS OF THE INNOCENT infection of others, or what not, aid must be given either by public or private charity. There are no figures on this as far as known. In the later more incapacitating stages of syphilis perma- nent aid must often be given to the patient and to the family. Indication of what this means has been given (see page 167, Chapter IV). As an example of the cost to the public we may again consider the Eossini family already cited on page 136, Chapter IV. As a result of syphilitic mental disease the father was committed to a state hospital. The mother who also had syphilitic disease of the central nervous system received treatment, the expense of which was defrayed by the state. Her condition required a certain amount of hos- pitalization from time to time. The oldest son was sent to an industrial school. The two youngest children were con- genital syphilitics and had to be cared for in a school for the feeble-minded. Four other children were left at home and a large part of the expense of their care fell upon the state. The oldest of these children at home was syphilitic and required treatment. It is probable that the mother will be permanently incapacitated in which contingency the entire care of the children will fall upon the state or private charities. Indirect Financial Loss — Diminished Earning Capacity and Productivity. — In addition there is what might be termed an indirect financial loss represented by a diminution of existing productive power due to a gradual or sudden decline in earn- ing capacity. Temporary or permanent absence from work is only too often seen in late syphilis, and even in the beginning of the disease this loss of productivity is at times quite strik- ing. For the best protection of the individual and the com- munity, a patient acquiring syphilis should be hospitalized for a period at the beginning of his disorder. This means time off and lessened productivity. Patterson, 1 in a study of three Chicago hospitals for 1912 to 1913, found that the average time out of work because of syphilis was three weeks for each patient. The following figures present this point: l Patterson, J., An Economic View of Venereal Infections, Journal of the American Medical Association, vol. lxii, no. 9, Feb. 28, 1914, p. 670. THE COMMUNITY Number op Cases Michael Reese Hospital 107 Wesley Hospital 52 Cook County Hospital 917 Total 1076 215 Days Lost 1562 593 19389 21544 Loss of time through hospitalization in the early or late stages of syphilis was shown in a grim manner during the late war. While syphilitic s were hospitalized and kept out of action their places at the front were filled by other men. It was reported that this became such a serious matter in the Austrian army where men consciously attempted to acquire venereal disease that they might be hospitalized and removed from the front that a rule was made that any man acquiring venereal disease would be sent to the front line trenches. What the actual loss may mean to military forces is showm in the accompanying figures from the British navy. 1 For the year 1912, with an average strength of 119,540 men, there was a loss of 107,145 days because of syphilis. This was without very adequate hospitalization such as would be prescribed today. Year 1912 — Average Strength, 119,540 Number OF Cases Total Number of Days Lost Average Number Sick Daily Ratio per 1,000 Cases Sick daily Syphilis I 715 15,439 42.18 5.98 .35 Syphilis II 2744 91,706 250.56 22.95 2.09 107,145 American figures on the average number of soldiers of each one thousand incapacitated each day follow: Noneffective Rates per 1000 for Syphilis 2 Year White Colored 1917 -. 0.86 2.63 1918 0.96 2.52 1919 1.18 3.80 1 Royal Commission on Venereal Diseases, Report of the Commission, London, 1916, p. 90. 2 From the War Department, Office of the Surgeon General. 216 SYPHILIS OF THE INNOCENT In spite of the loss of time, the hospitalization of syphilitics is urged in the early stages of the disease when the person is most contagious and a community menace. It is more eco- nomical in the long run as it offers means for intensive treatment and proper training of individuals as to prophy- laxis. The more beds a community can provide for early cases the better the treatment and the smaller chance of later incapacitating syphilitic diseases which in their turn require intramural hospital care. Tarnowsky 1 tells of an unrestricted syphilitic woman who contaminated 300 men in ten months. One cannot even compute the effects of this on the innocent members of their families and the community. An obvious difficulty in hospitalization is the unwillingness of the patient to give up work. Experience at the Massachu- setts General Hospital 2 indicates that most jobs do not have to be given up. Employers are more willing to make adjust- ments for a patient sick enough to be in bed than for one who must take time off to report to an out-patient department. After hospital care they take more kindly to the idea of out- patient treatment. In the period of out-patient care the amount of time taken out of working hours may be diminished by night clinics. These are to be urged particularly for non- hospitalized contagious cases, neglect of whose treatment for one reason or another directly affects the community. Pollock 3 in his computation of the economic loss on account of syphilitic mental diseases for the state of New York during 1917 showed that the loss in earnings alone was almost $5,000,000. Williams 4 in his study of 100 cases of syphilitic mental disease shows the financial loss based on what the patients would have earned if they had lived out their normal span of life. The earning power of ten was known and this multiplied by the average expectation of life as estimated by the life insurance companies showed a financial loss of $212,248 for the group of ten. i Bulkley, op. cit., p. 204 quotes Tarnowsky, N. Y. Medical Record, March 9, 1889, p. 279. 2 Report of the Massachusetts General Hospital, 1918-19, p. 27. 3 Pollock, op. cit., p. 279. 4 Williams, loe. cit. THE COMMUNITY 217 It is evident that the indirect loss of productive power materially increases the cost of syphilis to society. Of the 100 men investigated by Williams, 78 were married and left dependent wives and children. One cannot definitely assume that the financial problem of these families will be as typical of the families of all committed late syphilitics who die in a hospital. It is indicated, however, in our study of 41 com- mitted paretics (see page 167, Chapter IV), 65 per cent of whose families received permanent financial aid. Community Effects of Actions of Paretics. — In studying the effect of the late stages of syphilis on the community one must take cognizance of the disordered judgment of the paretic patient and his acts. Paretics are occasionally responsible for minor financial losses to the community, such as the failure of public institutions through their bad business ventures. One can only wonder how many financial fiascos, how many inflated concerns floated on the market, are the creations of the general paretic in one of his grandiose moods. Dr. Mercier 1 has pointed out some of the medico-legal as- pects of general paresis. Instability of mind may result in sudden violent outbreaks such as a fight on the street or un- warranted anger at the disobedience of a child. The exalted type has no idea of property or values, and will purchase be- yond his means, make contracts he cannot fulfill, and enter into speculations. The increased sexuality of the patient may lead to immorality and the divorce court. The validity of a will may be questioned. By early recognition of the disease and care for the patient, expense to the family and the community may be prevented in reducing the cases brought before : (1) the Criminal Court (stealing) (2) the Property Court (litigation about validity of will) (3) the Divorce. Court (immorality due to increased sexu- ality) (4) the Equity Court (speculations, breaking contracts). i Mercier, C, Clinical Aspect of General Paresis. (System of Syphilis, 1914, vol. iii), sec. ed., London, Frowde, Hodder and Stoughton, p. 81. 218 SYPHILIS OF THE INNOCENT Social Losses — Decreased Marriage Rate. Another of the more important community losses is the lessened marriage rate. Many syphilitics, aware of their disease and its probable consequences, do not care to contract marriage. In others the unfortunate results of syphilis occur early in life before marriage is feasible. Reduced Number of Children. — An even greater loss is the reduced number of children in the families of married syphi- litics. We have shown in the family statistics the enormous human wastage in accidents to pregnancies. Syphilis is a destroyer of potential man power. In these post-war days anything which increases infant mortality is of extreme moment, especially abroad where the birth-rate for the last years has been dangerously low and the death-rate due to the loss of male adults in the prime of life has been extraordinarily high. Superimpose on this the additional toll of abortions, miscarriages, stillbirths, polymortality of infants, and sterile marriages, due to the increased amount of syphilis as a result of war, and one has a large problem. In Germany 1 the spread of venereal diseases has been so great that contagious cases abound everywhere. There are not enough hospitals in which to keep them. The effect on the families and the next genera- tion can be conjectured. It is estimated that in France^ army 2 so many men of the procreative age are syphilitic that for each syphilitic infection France is deprived of one soldier and one mother of a family during the period of 1936-1945. That the ex-soldiers all over the world are not going to take the necessary precautions or receive enough treatment to en- able them to have healthy children is to be feared. Dr. Ehys 3 declares that in two English brigades in which every facility for treatment was provided, no one availed himself of the privilege. If men took no trouble while away from home 1 Nederlandsch Tijdschrift quotes the Medisinische KliniJc of Berlin (Ameri- can Medical Association, December, 1919). 2 Thibierge, G., Syphilis and the Army, London, University of London Press, Ltd., 1918, p. 32. 3 Rhys, O., Analysis of 1500 Cases of Venereal Diseases, All Male, at the King Edward VII Hospital-Clinic at Cardiff, Wales, Social Hygiene Bulletin, vol. vii, no. 1, Jan., 1921. THE COMMUNITY 219 they are not likely to visit disinfecting stations near home. Hence their wives and children will suffer. Collins 1 rightly advises that a list of syphilitic ex-service men he obtained from Washington and an attempt made to get these former soldiers to report to the Public Health Service for examination and further treatment if indicated. Syphilis and Divorce. — Syphilis is rarely the sole cause of divorce. AVhen acquired early or late after marriage it may be a cause of separation or divorce but it is usually associated with other social difficulties such as alcoholism, cruelty, non- support, and it is, of course, prima facie evidence of adultery. The disclosure after marriage that syphilis has been acquired before marriage rarely disrupts the home. A possible reason is that the discovery is often made after a considerable period of satisfactory marital relations. An indication of the com- parative infrequency of divorce among syphilitics is shown by statistics of 515 married paretics admitted to the Psycho- pathic Hospital. Only 2.3 per cent were divorced. Standards of Living Lowered. — General standards of liv- ing are lowered by syphilis through its power to affect the finances of a family. The families who drop below the line of self-support because of late syphilis in any member, increase the group who cannot keep to an adequate standard of life and happiness. Loss of Life Through Inefficiency of Neurosyphilitics. — There is a certain definite yearly loss of life through the inefficiency of neurosyphilitics who, although mentally or physically incapacitated, still hold responsible positions. Many paretics are locomotive engineers or chauffeurs and if no trouble results from sudden attacks of confusion it is largely due to pure luck. At a conference 2 in January, 1920, of officials of the United States Public Health Service, United States Railroad Administration, and the American Social 1 Collins. H. G., Syphilis hi the Innocent, Journal of the Kansas Medical Society, vol. 21, no. 7, Jan., 1921. 2 Social Hygiene Bulletin, vol. 7, no. 2, Feb., 1920, p. 4. 220 SYPHILIS OF THE INNOCENT Hygiene Association, it was demonstrated that there was a definite relationship between venereal disease and impaired efficiency, accidents, and casualty costs. Several examples were cited showing that men in both the early and advanced stages of paresis were frequently found in charge of trains or in other positions endangering the lives of the public. Stokes 1 has made a rather intensive analysis of the situa- tion as regards railroad employees. In collaboration with Brehmer he writes that the investigation was undertaken because of the "impression that syphilis is an exceptionally common disease among railroad employees and that it con- stitutes a grave and unrecognized menace to their personal welfare and industrial efficiency, and to the safety of the traveling public. It impairs efficiency and brings discredit on railroad administration." In a survey of 50 syphilitic rail- road employees they found that three fourths were engaged in the operation of trains, one third being on the engines. Nearly one half of the cases were not diagnosed prior to coming to the clinic although a high percentage showed gross neurological findings and mental symptoms. Of the men examined, practically 80 per cent had syphilis of the nervous system. Definite mental symptoms were determined in nearly 40 per cent. They conclude that the routine railroad medical examination is insufficient to protect the public and make three suggestions to correct this : 1. Routine Wassermann on all employees 17-25 repeated when age of 32. (By 32nd year 91 per cent were infected.) (By 25th year 60 per cent were infected.) 2. Effective annual examination of men 25 to 40 rather than men over 50. More attention to neurological examination. (71 per cent of late symptoms occur 6 to 20 years after infection, hence should examine neurologically men 23 to 45.) 3. Educational propaganda by railroad medical departments for employees and medical staff to show importance of syphilis in industrial efficiency and hygiene. Case 140. Stokes 1 reports a case of a locomotive engineer 36 years of age who was suffering from tabo-paresis. He had been treated at l Stokes, J. H. and H. E. Brehmer, Syphilis in Eailroad Employees, Journal of Industrial Hygiene, yol. 1, no. 9, Jan., 1920, p. 420. THE COMMUNITY 221 the clinic for a year and a half and had a remission of six months ' duration, during which time he carried his usual run. He suddenly appeared at the clinic having been sentenced for 90 days because of his share in a freight-passenger wreck. He had had a lapse of memory and passed a siding where he was to meet another train. The railroad had not tried to find out if there was a medical factor responsible for his share in the wreck. Case 141. Joseph Griffin, a man of 50 years, was a railroad con- ductor. He had been in the employ of the company for 33 years. His position was a responsible one, as it is the conductor who gives the train orders. While on duty he had an attack and became uncon- scious in the baggage car. When the train reached its destination he was found in a state of coma which lasted for several days. His diagnosis was general paresis. It was mere good luck that on this particular trip he was not needed at the time the attack occurred. A study of occupations of 755 paretics who have been patients at the Psychopathic Hospital showed that 61, or 8.07 per cent held positions involving the lives of others. The number in each type of occupation was as follows: Engineers 11 Boat Captain 1 Brakemen 4 Sailors 6 Trainman 1 Life-guard 1 Switchman 1 "Lighthouse Co. 77 1 Conductors 4 Policemen 3 Motormen 4 Firemen 5 Yardmaster 1 Chauffeurs 12 Stationary Engineers 2 Coachmen 2 Naval Officers 2 Engineers and chauffeurs seem to be the most frequent occupations, although conductors, motormen, and brakemen are not far behind. We must, then, look to our transporta- tion systems, — railroads, electric cars, ships, automobiles — for our ' ' dangerous paretics. ? ' More careful medical examina- tions and licensing are indicated as preventive measures. Syphilis and Industry. — Oliver 1 brings out the importance of syphilis in industry. He takes up industrial inefficiency l Oliver, E. A., Syphilis, An Inestimable Factor in Industrial Inefficiency, Journal of Industrial Hygiene, vol. 1, no. 5, Sept., 1919, p. 247. 222 SYPHILIS OF THE INNOCENT from the point of view of the employer rather than of the employee or family. He points out the danger of employing syphilitic people in the following cases : Case 142. (Oliver's case 1) had sustained an injury while working at his job. A box fell on his back. Earlier in his life he had had a fractured spine. He recovered and returned to work, where he was a satisfactory employee for several years. Then he began to have pains in his back and legs and was sure that these pains were caused by his previous injury. He was found to be a tabetic and improved markedly under treatment at the industrial clinic. Case 143. (Oliver's case 2) was a foreman who became markedly inefficient. He had had several attacks of Unconsciousness and from an energetic foreman became a careless and absent-minded workman. He was found to have nervous system syphilis, and under treatment the standard of his work has been raised. Case 144. (Oliver's case 3) scratched the back of her hand with a piece of wire while working in a millinery department. After local treatment for a few weeks the trouble disappeared. The girl was found to be a congenital syphilitic and improved under treatment. However, she was away from work off and on for two years before she was well enough to be an efficient employee. This was a rather expensive case for the industry. Oliver advises that all employees and all applicants "be given a Wassermann test. He does not believe that those with a positive Wassermann should be discharged or not employed hut rather that they should be treated. He advises pay clinics for all industrial centers so that the men who cannot afford to pay private fees can have efficient treat- ment. He also recommends the discovery of the source of infection and all contacts as a public-health attitude for industry. A less advanced point of view is that of the shipping firm which refused to employ William Carter, who had a luetic hemiplegia, on the ground that they never employed persons with a known positive Wassermann reac- tion. The fact that the patient had a nervous system involve- ment might well be a reason for refusing to risk future in- capacitation, but employment was refused entirely because of the serum reaction. THE COMMUNITY 223 Syphilis and Industrial Compensation. — Syphilis often acts as a factor in the prolongation of convalescence of various diseases and thus puts upon industry a burden of expense in the form of compensation. Frequently insurance companies suffer considerable financial loss through the increased incre- ment of expense due to this prolongation of convalescence. Everett 1 has called attention to this matter and gives the following illustrations: Case 145. (Everett's case 1) sprained his ankle. Ordinary recov- ery would have taken place in 4 to 6 weeks, at a compensation of $72.15. Owing to a latent syphilis which was stirred up, complica- tions arose and the compensation was $336 for seven months. Case 146. (Everett's case 2) sustained a fracture of the thigh bone. After a year's compensation or $260 plus two weeks' medical service, the company would ordinarily have been able to stop payments as the injury would have healed. But owing to syphilitic complica- tions, the thigh had not healed, the chances were against the man's ever returning to work, and the insurance company would probably have to continue payments indefinitely. Mistakes in Attitude Towards Syphilis — Moralistic Point of View. — The entire question of the contagiousness of syph- ilis and public welfare as well as the financial and social losses caused by syphilis is, in the last analysis, bound up with the general attitude of the public towards the disease. A glance at the negative side brings to light the most frequent mistakes in the usual approach to syphilis. The moral attitude, the feeling that all syphilitics are renegades, does a tremendous amount of harm. It pays no heed to the large number of innocent syphilitics whom we have been studying, it brands the man who has transgressed once in early youth together with the habitual roue. It makes no distinctions, it sweeps all syphilitics into the group of outcasts. True, many God- fearing persons have been rigid moralists and have felt that they w^ere aiding in stamping out venereal diseases. But no real progress will ever be made until syphilis is freed of the idea of moral taint and just punishment for sin, and is put l Everett, E. H., The Cost of Venereal Disease to Industry, Journal of In- dustrial Hygiene, vol. ii, no. 5, Sept., 1920, pp. 178-181. 224 SYPHILIS OF THE INNOCENT on a plane with other diseases. The church can probably aid in this as mnch as any other organization. Doctors, lawyers, teachers, social workers, all must do their share. False Idea of Fear as Deterrent to Sex Appetite. — Unfor- tunately, the old idea that fear of consequences will curb the sex appetite and so avoid syphilitic infection has not proved true. Year after year medical students and others who know all that may happen to them, appear at the clinics for treatment. The value of propaganda for knowledge is not so much that individuals may remain continent outside of marriage but that men may do what they do with their eyes open, so that the innocent may be protected by proper pre- ventive and post-infection measures. Case 147. James Foster, who had had adequate treatment for his syphilis, proved his cure by acquiring a new syphilitic infection. While under treatment he said, "Doctor, I have sure learned my lesson this time. ' ' On being asked what he meant, he replied : ■ ' When I am cured again I am going to use precautions!' 7 It seems well to emphasize here the difference between prop- aganda for the dissemination of knowledge and the duty one owes to the patient as an individual. While all are definitely agreed upon the value of education to the end that the public will come to recognize venereal diseases as infectious diseases that should be cared for as are other contagious and infectious conditions, yet the individual must never be lost from sight. He has certain rights that are just as inviolate as those of any other patient who seeks medical advice. For propaganda purposes one should not hold up any given individual as an example or do anything that would lead to his definite dis- comfort. As long as the individual is not in a contagious state, it is not logical nor reasonable to expose him to the difficulties that would arise if various members of the com- munity knew of his condition. While one must work for the time when it will be possible to speak of syphilis as an afflic- tion unconnected with the thought of shame, until such a time arrives, one must do all one can to protect the individual if he is in no sense a community menace. THE COMMUNITY 225 Over or Under Emphasis on Syphilis. — There is always the danger of taking syphilis too seriously or not seriously enough. There are persons who smile at the possibility of acquiring syphilis, who shrug their shoulders when they have acquired it, scoff at the idea of prolonged treatment, and are incredulous years later when told that syphilis is causing all their recent difficulties. Others live in terror of acquiring syphilis, shudder for the future when they are syphilitic, and are skeptical of a promised cure with faithful treatment. These extremes of mental carelessness and caution apply equally to a consideration of syphilis acquired by intercourse or chance contact. Sanity and balance must be maintained and a rational public attitude established. Syphilis is prob- ably not an incurable disease if treated early and adequately. Treatment somewhat later will hold the disease in check. Treatment many years after infection when some damage has been done may give a remission and prevent future illness. Syphilis is a serious disease but not a hopeless one. All Syphilitics Not Contagious. — Allied with the above is the idea that all cases of syphilis are always contagious. If this were true few would escape, as all meet syphilitics in daily life at one time or another. Stokes 1 gives a rather amusing picture of fearful persons : 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 stair* 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 had identified for them repeatedly the dangerously contagious 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. l Stokes, J. H., To-day's World Problem in Disease Prevention, Washington, U. S. Public Health Service, Treasury Department, p. 106. 226 SYPHILIS OF THE INNOCENT Early untreated syphilis is contagious under the conditions already mentioned. Late syphilitics are practically never contagious. Although syphilitic babies are most contagious, late congenital syphilitics are not. Thus, great care must be taken in the placing out of syphilitic babies so that other chil- dren shall not be infected. All children offered for adoption should be pronounced syphilis-free by a competent doctor. As a symptom-free congenital syphilitic child of school age is quite safe from the point of view of contagiousness he can go to school, be placed out in a family, and play with children. However, it is wisest for a family not to adopt legally such a latent syphilitic child even though noncon- tagious, as he is likely to have later incapacitating diseases. The burden of care of such children should rest with the state. Case 148. The case of the Guardino 1 baby typifies the dangers oftentimes run in the poorer families. Since its birth the mother had boarded her 6 months old illegitimate baby with a woman who had no permit for keeping children. Then desiring to get rid of it perma- nently, the mother left it with a neighbor , telling her to bring it to the hospital, as she was leaving town. The neighbor, a pregnant woman with three children, brought the baby to the clinic, realizing that it was sick and undernourished. The child was obviously a con- genital syphilitic and was covered with an actively contagious syphil- itic rash. As luck would have it, no one of the two families with whom the baby had lived was infected. The baby was given syphil- itic treatment in a hospital and the mother was prevented from abandoning it. Case 149. Mr. and Mrs. McCarthy 1 brought a 6 weeks old baby to the hospital because of a rash. This was not their own child but had been taken for adoption two weeks previously. They had received the child from an infant asylum and it had been perfectly well. The "home" had received the baby two days before. No questions had been asked of the woman who brought it, and it had been placed out without examination merely because it appeared well. A few days later a skin rash and a cold developed. As the baby did not improve in two weeks the foster parents thought it wise to bring it to the hospital. The child had a syphilitic rash, snuffles, desquama- tion, and exudate in the corners of the mouth. It was in a highly l Children's Hospital, Boston. THE COMMUNITY 227 contagious state. Inquiries showed that there were two children liv- ing in the McCarthy family at this time, one of whom was only four years old. Luckily the foster mother and her sister had cared for the child, not allowing the child to touch it, as they thought its "cold" might be catching. Neither one of them had kissed the child on the mouth and had no abrasion so far as known. The baby was returned to the asylum and was placed in a hospital where it was not expected to live. This case is an indictment against placing out agencies which do not thoroughly examine all children in their care. Case 150} Massachusetts General Hospital case. A young delin- quent girl with a contagious case of syphilis was treated until all danger of contagion was over. A plan was then made whereby the child was to change her home environment and to live with a relative in another part of the city. In this home there was a child of 10. Before the hospital worker could make arrangements with the rela- tive, the probation officer had gone to the woman and told her that the girl had syphilis and that she should not be allowed to live in the family lest the little girl should become infected. All efforts of the medical social worker to show the relative that her own child was not in any danger were of no avail and the girl remained under the same bad home influence as before. As a result she ran away again, and when next arrested was sent to prison, If it had not been for the misinterpretation of the medical situation this girl might have been saved. Case 151. Samuel Cohen became a state ward at the age of 9. Although he was not contagious, he was a congenital syphilitic. Hence he was placed out but never adopted. Case 152. The 5 and 6 year old boys of Agnes Mazzarello were under treatment at the clinic, one having a positive Wassermann reaction and the other specific condylomata. They were found to need a vacation, but the agency made no attempt to place them on account of the contagiousness of the second child. The proper tech- nic was used, the children were treated, examined again when there were no longer any specific lesions, and were then sent away for their vacation. A short time after this the mother died of influenza and an examination was made again with the idea of placing them out permanently. l Lewis, O. M., Medical Social Service as a Factor in Protective Work, National Conference of Social Work, New Orleans, April, 1920, p. 313. 228 SYPHILIS OF THE INNOCENT Mistakes in Interpretation of Stigmata or Symptoms. — The layman who knows a few of the common stigmata of syphilis is only too apt to confnse them with similar non-syphilitic difficulties. All skin lesions are not syphilitic. Most youths with rashes on their faces are not suffering from syphilis but from acne. Syphilitic skin lesions are almost always on the trunk and not on the exposed part of the body. Many people think rachitic children or those with decayed teeth are syphilitic. It is an injustice for a layman to make a diagnosis on such evidence. Late congenital symptoms are often con- sidered as acquired and a juvenile general paretic branded as having acquired syphilis. Ignorance of Syphilis as Family Disease. — Another com- mon error is forgetting that the families of syphilitics are potential syphilitics. Even after realization, many people hesitate to take active steps towards examining the family for fear of causing marital discord. This subject has been covered under examination of the family. Over-Emphasis of Possible Causal Relation With Social Difficulties. — Workers with syphilitics must not take the dis- ease so seriously as to find a causal relation between all the social problems of syphilitics and the disease itself. Syphilis may cause certain social abnormalities and merely be coinci- dent with others. Remedial Measures Against Infection. — The popular mis- takes in regard to syphilis, above noted, should gradually dis- appear as the remedial measures against infection become more stabilized. In a study of innocent syphilis one must first consider the direct measures, both those which will minimize the possibility of acquiring innocent genital syphilis and those which diminish the likelihood of acquiring innocent extragen- ital syphilis. Legal Approach to Eradication of Innocent Genital and Extragenital Syphilis. — The direct measures towards the eradication of innocent genital syphilis are mostly legal and THE COMMUNITY 229 have already been discussed in the chapter on the family. The physician may be released from the bonds of professional confidence, so that he may prevent the marriage of a con- tagious syphilitic; health certificates may be insisted on for all applicants for a marriage license; marriages may be annulled when syphilis is discovered. Outside the power of the law in most cases is the insistence on the early examina- tion of the members of the families of all syphilitics. Mar- riages before the period when most men acquire syphilis would cut off a large percentage of marital infections. Unfor- tunately such marriages depend so largely on finances that one can only hope that the economic situation in the years to come may permit young men to marry earlier. Again the remedial measures against the spread of innocent extragenital infections are mostly legal. Small operations such as circumcision and tatooing, must be performed only by licensed persons ; midwives must be licensed ; public places such as barber shops and soda fountains must be inspected by the boards of health, and regulations as to the boiling of articles, use of paper cups, etc., must be enforced. Judicious publicity about the contagiousness of objects and persons is advisable. By this means contagious syphilitics can be urged to observe hygienic rules in the home and special attention can be called to the care of syphilitic infants. Value of General Preventive Measures. — In the long run any measures directed towards the eradication of syphilis, whether innocently or venereaUy acquired, will tend to diminish the amount of innocent syphilis. We will not go into detail regarding the many efforts of general prevention but will merely refer to a summary of some of the more frequent prophylactic measures, including the more direct as well as the indirect measures bearing on innocent syphilis. 1 l See Programme of Medical Education and Law Enforcement Measures issued by Treasury Department, United States Public Health Service, chapter xvi, Puolic Effort vs. Syphilis, also Dr. J. H. Stokes, The Third Great Plague, Washington, D. C, and Social Hygiene Bulletin, Nov., 1919, for further dis- cussion and suggestions. 230 SYPHILIS OF THE INNOCENT Table 39 I. Public Grants for Study and Prevention. 1. Federal appropriations to state to aid in combating venereal diseases. 2. Establishment of bureaus of venereal disease by many state boards of health and United States Public Health Service. 3. Appropriations by Interdepartmental Social Hygiene Board to uni- versities, schools, for study of venereal disease, and teaching of sex hygiene. LT. Education Efforts and Publicity. 1. Lectures ] 2. Pamphlets, journals, books I For doctors, social workers, teachers, 3. Posters and placards j> ■ heads of families. By social and mental 4. Exhibits hygiene associations, boards of health. 5. Movies III. Legal Attack: Laws and Their Enforcement. A. General. 1. Adequate examination before marriage. 2. Doing away with professional confidence. 3. Annulment of marriage because of venereal disease. 4. Enforcement of treatment of all contagious cases in institutions, prisons, etc. 5. Legal follow-up of all untreated contagious cases by boards of health through notification laws. 6. Suppression of quack advertising, practice, etc. 7. Legalizing personal prophylaxis. B. Suppression of Prostitution. 1. Workable law prohibiting prostitution with provision for probation. indeterminate sentence, industrial rehabilitation, etc. 2. Abolition of segregated districts. 3. Injunction and abatement laws. 4. Licensing of amusement places, taxicabs. 5. Enforcement of penalties against white slavery. 6. Isolation and treatment of infected prostitutes. IV. Efforts for Diagnosis. 1. Hospitals and dispensaries, sufficient in number and equipment. 2. Free laboratories for serum tests. 3. Follow-up family and contacts of syphilitics. 4. Examination (including routine Wassermann reaction) of all people in public institutions of all kinds such as child-caring, deaf, dumb, and blind, feeble-minded institutions, hospitals, and prisons. 5. Examination of employees in industrial establishments, railroads, etc. V. Efforts for Treatment. 1. Treatment of all infected persons in institutions whether contagious or not. 2. Rigid follow-up of all early and late hospital cases for continuous treat- ment. 3. More public out-patient clinics (evening and day) and hospital beds for syphilitics. 4. Standardizing of hospitals. THE COMMUNITY 231 5. Detention hospitals for contagious uncooperative cases. 6. Free expert treatment and free drugs (state or privately paid) for the poor. „ 7. Pay clinics for persons of moderate means. 8. Locating source of infection and establishing treatment. Infectious, contagious diseases are always matters of im- portance to the whole community. The effects of syphilis are even more far-reaching than of acute diseases such as typhoid fever or smallpox and do not end with the spread of the disease. However, the matter of contagiousness is very per- tinent. Accidental extragenital infections are by no means infrequent and if one numbers among the innocent victims the mates and children of the syphilitic, the extent of this phase of the problem is quite stupendous, and comes within the purview of the public-health departments, municipal, state and national. But syphilis is of greater interest to society than in its aspect of accidental contagiousness. It causes much loss of economic efficiency, it disables men and women in their prime, it leads to various defects in children, who either die early or go through life handicapped. It is a considerable factor in race suicide through its part in lessening the marriage rate and producing sterility, unsuccessful pregnancies, and infant deaths. The apparent cost to the community, great as it is, does not give more than a small fraction of the total cost. Whether viewed from the standpoint of its effect on the individual, his mate, and children, the family group, or of the dangers of contagion, the cost to society for medical and social care, the loss of economic productivity in industry, the difficulties of the mentally deranged, syphilis is always a community problem. In all its manifestations the social structure is involved. Any problem implicating the community at large to such a degree deserves the intelligent attention of the members of the community, and per contra the members of the community are entitled to a knowledge of a subject of such major importance to them individually and collectively. 232 SYPHILIS OF THE INNOCENT REFERENCES Blaisdell, J. H., The Menace of Syphilis to the Clean Living Public, Boston Medical and Surgical Journal, vol. clxxii, no. 4, April 1, 1915. Browning, C. H. and D. Watson, Venereal Diseases; A Practical Handbook for Students, with an introduction by Sir John Bland-Sutton, New York, Ox- ford University Press, 1919. Bulkley, L. D., Syphilis in the Innocent, New York, Bailey and Fairchild, 1898. Collins, H. G., Syphilis in the Innocent, Journal of the Kansas Medical Society, vol. 21, no. 7, Jan., 1921. Department of Medical Social Work, Boston City Hospital Report, Feb. 1, 1919. Diday, P., Treatise on Syphilis in Neiv-bom Children and Infants at the Breast, translated by D. W T hitley with notes by F. R. Sturgis, New York, Wm. Wood and Co., 1883. Everett, R. H., The Cost of Venereal Disease to Industry, Journal of Industrial Hygiene, vol. ii, no. 5, Sept., 1920. Hinton, W. A., Specific Inhibitory Reaction of Cholestrinized Antigens in the Wassermann Test, American Journal of Syphilis, vol. v, no. 1, Jan., 1921. Jeans, P. C, Syphilis and Its Relation to Infant Mortality, American Journal of Syphilis, vol. iii, no. 1, Jan., 1919. Lewis, O. M., Medical Social Service as a Factor in Protective Work, National Conference of Social Work, New Orleans, April, 1920. Lane, J. E., A Few Early Notes on Syphilis in the English Colonies of North America, Archives of Dermatology and Syphilis, vol. 2, no. 2, Aug., 1920. Mercier, C, Clinical Aspects of General Paresis, System of Syphilis, second edition, London, 1914, FVowde, Hodder, and Stoughton, vol. iii. Monthly Bulletin of the City of Boston Health Department, Sept., 1919. Nederlandsch Tijdschrift, reviewed in the Journal of the American Medical As- sociation, Dec., 1919. Newcomer, H. S. et al., One Aspect of Syphilis as a Community Problem, American Journal of Medical Sciences, vol. 158, no. 141, Aug., 1919. Oliver, E. A., Syphilis, an Inestimable Factor in Industrial Inefficiency, Journal of Industrial Hygiene, vol. 1, no. 5, Sept., 1919. Patterson, J., An Economic View of Venereal Infections, Journal of the American Medical Association, vol. 62, no. 9, Feb. 28, 1914. Pierce, C. C. and H. F. White, Lesson Taught by Measures for the Control of Venereal Diseases, Journal of the American Medical Association, vol. 75, no. 17, Oct., 1920. Pollock, Horatio, The Economic Loss to the State of New York on Account of Syphilitic Mental Diseases during the Fiscal Year Ending June 30, 1917, Mental Hygiene, vol. ii, no. 2, April, 1918. Porter, H. W., A Statistical Study of Extragenital Chancres, Archives of Dermatology and Syphilology, vol. 38, no. 1. Programme of Medical Education and Law Enforcement Measures, Issued by the Treasury Department, U. S. Public Health Service, chapter xvi, " Public Effort vs. Syphilis.' > Pusey, W. A., Syphilis as a Modern Problem, Chicago, American Medical As- sociation, 1915. Report of the Massachusetts General Hospital, 1918-19. Report of the Royal Commission on Venereal Diseases, Final Report of the Commissioners, London, 1916. THE COMMUNITY 233 Rhys, O., Analysis of 1500 Cases of Venereal Diseases, All Male, at the King Edward VII Hospital Clinic at Cardiff, Wales, Sooial Hygiene Bulletin, vol. vii, no. 1, Jan., 1921. Shillitoe, A., The Primary Lesions and Early Secondary Symptoms, as Seen in the Female, A System of Syphilis, London, Frowde, Hodder, and Stoughton, 1914, second edition, vol. 1. Sooial Hygiene Bulletin, vol. vii, no. 2, Feb., 1920. Stokes, J. H, To-day's World Problem in Disease Prevention. Issued by the U. S. Public Health Service, Treasury Department, Washington, D. C, 1919. , The Third Great Plague, Philadelphia and London, W. A. Saunders Co., 1917. and H. E. Brehmer, Syphilis in Railroad Employees, Journal of Industrial Hygiene, vol. 1, no. 9, Jan., 1920. Thibierge, A., Syphilis and the Army, London, University of London Press, Ltd., 1918. Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea and Febiger, 1918. Williams, F. E., Relation of Alcohol and Syphilis to Mental Hygiene, AmericaAX Journal of Public Health, vol. 6, 1916. INDEX Abortions as result of syphilis. 48 Accidents caused bv inefficiency of syphilitica, 219 to pregnancies in families of svphilitics, 121, 127 in nonsyphilitic families, 121, 134 Adoption of congenital syphilitica, 92, 226 Arsphenamin for free distribution, 154 use of in congenital syphilis, 106 value of in early syphilis for sterilization, 5 Attenuation of virus, 45 Attitude toward syphilis, 223 mistaken, 223 of different individuals, 225 Birth-rate in families of syphilitica, 120, 127 Births, ratio of still to live in families of syphilitics, 123 Blindness and syphilis, 64, 212 Bones, involvement of, in congenital syphilis, 66 Broken home as result of syphilis, 165 Cerebrospinal syphilis and syphilis in the family, 123 in congenital syphilitics, 73 Chancre extragenital, 188 location of, 197 Character defects and congenital syphilis, 76, 78 Childbearing, effect of svphilis on, 37, 47 Childlessness in families of syphi- litics, 117, 125, 133 Colles' law, 41 Compensation in relation to svphilis, 223 Congenital syphilis and adoption, 92, 226 and central nervous system involve- ment, 70 cerebrospinal syphilis, 73 juvenile paresis, 72 juvenile tabes, 74 and constitutional inferiority, 81 and delinquencies, 78 and epilepsy, 74 [234] Congenital syphilis — Continued and feeble-mindedness, 66 and marriage, 81 and placing of infants, 226 and precocity, 70 and various psychopathies^ 75 care of, 160 conditions accounting for, 43 confusion with acquired, 86 date of recognition, 36 diagnosis of, 51, 59, 82, 88 importance of early, 103 hospital schools for, 107 incidence of in general child popu- lation, 50 incidence of in syphilitic families, 55 late, 62 latent periods in, 42, 61, 104 prognosis, 102, 104, 106 severity of, not related to severity of parental syphilis, 45 social difficulties, 91 stigmata of, 62, 83 symptoms of, 57, 83 treatment importance of early, 94 of parents of congenital syphi- litics, 94, 96 prevention of symptoms by, 104 to minimize social handicaps, 108 type of treatment in, 105 value of, 104 usage of term, 36 Wassermann reaction as symptom of, 104 Conjugal syphilis, 19, 23 causes of, 25, 29 contagiousness in, 24, 25, 26 education to prevent, 29 effect of war on, 24 importance of problem, 34 incidence of in male and female, 19, 32 infection not suspected in, 33 latent, 31 methods of prevention of, 33 symptoms in husband and wife, 30 time of marriage in relation to in- fection, 27 when original patient infected, 24 Contagious cases, reporting of, 102 Contagiousness all syphilitics not contagious, 225 and homeless individuals, 199 and marriage, 168 IXDEX 235 Contagiousness — Con tinu ed and occupation, 204 and travel, 199 by extragenital methods, 187, 199 cleanliness as protection against, 197 during primary period, 4 during secondary period, 8 effect of time on, 24, 26 legal methods to prevent, 228 of body fluids, 197 of congenital syphilitics, 81, 91, 22(5 of late stages, 205 of paretics, 205 treatment as protection against, 5, 25, 198 type of lesion in relation to, 25 Constitutional inferiority and congeni- tal svphilis, 81 "Cure" compared with sterilization, 9 confusion with latency, 11 possible with adequate, early treat- ment, 6 Deafness and syphilis, 212, 213 as a handicap, 93 in congenital syphilis, 65 Delinquencies and congenital svphilis, 78 Diagnosis importance of, 13 of congenital svphilis, 51, 59. 82, 88, 103 and acquired syphilis, 86 by Wassermann reaction, 84 often late, 88 of interstitial keratitis, 63 of primary period by demonstration of organism, 3 by history, 2 by inspection, 2 by Wassermann reaction, 3 of secondary period by clinical picture, 8 by laboratory findings, 8 of tertiary period by clinical signs, 12 by spinal fluid examinations, 13 by Wassermann test, 13 Divorce as a result of syphilis, 219 from a syphilitic, 178 Doctor and examination of families of pri- vate patients, 149 and follow-up of private patient, 156 and marriage of a svphilitic, 174, 181 and social worker, 146 Education to prevent conjugal svphi- lis. 29 Effects of syphilis on different mem- bers of family, 136 Emotional disorders and congenital syphilis, 76 Epidemics of extragenital syphilis, 190 from kissing, 197 Epilepsy and congenital syphilis, 74 Examination of mates of syphilitics, 30, 34 of spinal fluid, 85 phvsical, of child and familv, 83, 88, 90 Extragenital chancre, 187 chancre from kissing, 189, 197 chancre from perversions, 189 infection, 187, 199 and occupation, 204 eradication by legal means, 228 escape from, 201 incidence of, 188 methods of transmission of, 191 Extramarital infection before and after marriage, 23 Familial examination methods of, 141 objections to, 145 technique of securing, 145 Familial involvement after entrance of syphilis, 134 as shown bv cases, 129 mild, 132 none, 134 severe, 129 of central nervous system, 136 Families of syphilitics accidents to pregnancies in, 121, 127 as affected by syphilis, 112, 128, 157 average number of living children in, 120, 127 before and after entrance of svphi- lis, 134 birth-rate in, 120, 127 cases showing svphilis in, 129 childless, 113, 120 financial difficulties in, 161 free from syphilitic defect, 113, 117 incidence of syphilis in, 112, 124 in which positive Wassermann ap- peared, 112, 127 necessity of examination of, 137 ratio of stillbirths to live births in, 123 technique of securing examination of, 145 Family discord and familial examination, 145 and syphilitic mental disease, 167 Fear as deterrent to promiscuity, 224 of transmission of syphilis, 158 236 SYPHILIS OF THE INNOCENT Feeble-mindedness and congenital syphilis, 66 as a social handicap, 93 incidence of in syphilitic families, 68 Fetal deaths and syphilis, 96 Financial difficulties and broken home, 165 caused by syphilis, 161 Financial results of syphilis, 205 indirect, 214 late, 209 loss of earning power, 216 maintenance of institutions, 212 through actions of paretics, 217 through destitution of syphilities, 213 to Massachusetts, 210 to New York, 210 to private charity organizations, 212 Follow-up difficulties and solutions, 152 of contagious cases, 199 of families of syphilities, 146 of treatment cases, 150 General paresis • age of patients when hospitalized, 166 and syphilis in the family, 124 as cause of financial difficulties, 163 as cause of social difficulties, 167 comparative frequency in males and females, 15 juvenile, 72 General weakness and congenital syph- ilis, 76 Healthy offspring of syphilitic parents, 102 of syphilitic women, 43, 56, 81 History diagnostic value in primary period, 4 family, as aid to diagnosis of con- genital syphilis, 82 importance in discovery of familial syphilis, 141 medical, of child as aid to diagnosis of congenital syphilis, 83 Home life as affected by syphilis, 157, 165 effect of financial difficulties on, 161 nursing care as a disturbance in, 161 Hospitalization due to syphilis, 214 financial results of, 214 of contagious patients, 101 of general paretics, 166 value of, 5, 216 Hospital schools for congenital syphi- lities, 107 Hysteria and congenital syphilis, 77 Ignorance of infection, 138 Immorality in women as cause of in- fection, 22 Immunity apparent, of healthy offspring, 42 apparent, of mothers of syphilitic children, 41 Incapacitation of wage earner permanent, 162 temporary, 161 Incidence of accidents to pregnancies in fami- lies of syphilities, 119, 126 of accidents to pregnancies in non- syphilitic families, 121 of blindness due to syphilis, 212 of congenital syphilis among feeble-minded, 67 in general child population, 50 in hospitals and clinics, 50 in syphilitic families, 55 of conjugal syphilis, 11, 32 of deafness due to syphilis, 212 of extragenital syphilis, 188 of feeble-mindedness in syphilitic families', 68 of living non-syphilitic children in syphilitic families, 56 of social difficulties in patients with syphilitic mental disease, 167 of sterility in families of syphilities, 117, 125, 132 of stillbirths in families of syphi- lities, 121 of syphilis, 205 among men and women, 14 effect of war, 218 in families of svphilitics, 112, 123, 126 in married and unmarried women, 20 in pregnant women, 97 in women, 96 reason for greater frequency in men, 19 shown by frequency of paresis, 14 shown by Wassermann surveys, 15 variation in figures according to groups studied, 206 of undiscovered svphilis in infants, 88 of unsuspected syphilis, 140 Incubation period, description of, 2 Industrial compensation and syphilis, 221 decline caused by syphilis, 162 Industry and syphilis,' 221 Infant mortalitv as a result of svphi- lis, 48, 60 Infection, syphilitic cleanliness as protection against, 197 escape of, 201 INDEX 237 Infection, syphilitic — Contimied extragenital, 187, 199 control of, 195 epidemics, 190 homeless individuals and, 199 ignorance of, 138 innocent, 14 innocent of married women, 22 in relation to occupation, 204 legal methods to prevent, 228 not suspected in conjugal syphilis, 33 travel and, 199 treatment as protection against, 198 Innocent infection of married women, 14, 22 Interstitial keratitis, cause of inca- pacity, 63, 92 Involvement of bones, 66 central nervous system, 7, 11, 70, 90 mental processes, 66 sensory organs, 63 ear, 65 eye, 63 Juvenile tabes, 74 Kassowitz's law, 45 Kissing and extragenital chancres, 189, 197 as method of spread of syphilis, 9 epidemic from, 198 Latent syphilis, 11, 39 as disclosed by familial examina- tion, 138 in children, 42, 61, 104 Laws concerning physician and marriage i of syphilitics, 182 concerning reporting of contagious cases, 152 concerning syphilis and marriage, 174 to prevent contagion, 228 Legal status of syphilitic women, 21 Life insurance of syphilitics, 165 Lues hereditaria tarda, 62 and deafness, 65 and f eeble-mindedness, 66 and interstitial keratitis, 63 and involvement of bones, 66 and other eye involvements, 64 Marriage and treatment, 25. 26 - laws relating to, of syphilitics, 174 rate reduced by syphilis, 218 role of physician in allowing, 181 safe for congenital syphilitic, 81 when justifiable for syphilitics, 24, 168 American opinion, 171 French opinion, 170 German opinion, 169 Mate of syphilitic importance of examination, 30 value of examining, 34 Mates of syphilitic men, 22 syphilitic women, 22 Medical certificate and marriage, 175 Mercury in congenital syphilis, 106 Methods of examination to discover familial syphilis, 141 clinical examination and Wasser- mann test, 142 history, 141 provocative treatment, 145 Methods of selection of cases for study, 55, 126 Military service, loss to through syphi- lis, 215 Miscarriages as result of syphilis, 48 Mistakes in interpretation of stigmata and symptoms, 228 Moralistic view toward syphilis, 223 Morality, double standard of, 19 Morbidity and syphilis, 157 Mortality of syphilitic infants, 48 of syphilitics, 165 Mother, effect of syphilis on mental life of, 160 Mothers of syphilitic children, 38 apparent immunity of, 41 Xervous system familial type of involvement of, 136 involvement as bar to marriage, 171 involvement in congenital syphilis, 70, 85, 90 involvement in secondary stage of disease, 7 involvement in tertiary stage of disease, 11 Xeurosyphilitics difficulties of following for treat- ment, 155 inefficiency due to, causing loss of life, 219 Oath of Hippocrates, 149, 181 Occupation of paretics, 221 relation to infection, 204 Parental syphilis relation to juvenile psychopathies, 75 results of infant or early deaths, 48 sterility and accidents to preg- nancies, 47 severity of, no relation to severity in children, 45 treatment of, 94 238 INDEX Paresis actions of paretics effect on community, 217 leading to accidents, 219 cost to California, 210 cost to community, 209 cost to England, 210 cost to Massachusetts, 209 cost to New York, 210 juvenile, 71 Perversions and extragenital chancres, 189 Placing out of congenital svphilitics, 226 Prevention of syphilis legal measures, 228 methods, 229 Primary period of syphilis apparent innocuousness of, 4 characteristics of, 2 contagiousness of, 4 diagnosis of, 2 local treatment in, 4 Productivity reduced by syphilis, 214 Professional confidence, 229 Prof eta's law, 42 Prognosis good with early treatment, 6, 9, 60, 103 of cerebrospinal syphilis in con- genital svphilitics, 73 of congenital syphilis, 102, 104 of interstitial keratitis, 63 of juvenile paresis, 71 of optic atrophy, 65 of syphilitic deafness, 66 of syphilitic infants, 60 Propaganda in relation to individual, 224 Psychoneuroses and congenital syphi- lis, 76, 77 Psychopathies, relation of juvenile to parental syphilis, 75 Psychoses and congenital syphilis, 76, 78 Eailroad employees, effect of syphilis on, 220 Secondary period and marriage, 171 characteristics of, 6 contagiousness of, 8 diagnosis of, 8 Sexual intercourse as method of spread of disease, 2 Social difficulties due to congenital syphilis, 91 of patients with syphilitic mental disease, 167 Social worker and doctor, 145 and follow-up of families, 146 Social worker — Continued and follow-up of treatment cases, 150 and free treatment, 154 Sources of infection contact between persons, 1, 14 contact through mediation of ob- ject, 1, 9 extramarital, 23 kissing, 9 mother to child, 43 of married women, 21, 23 question of paternal, 38 sexual intercourse, 2 Spinal fluid and marriage, 171 examination of for central nervous system disease, 13 examination of in congenital syphi- lis, 85 Sterility as a result of syphilis, 47 in families of syphilitics, 117, 125, 132 Stillbirths as a result of syphilis, 48 ratio to live births, 121 Stigmata of congenital syphilis, 62 Symptoms absence of in some syphilitic mothers, 40 different in parents and children, 45 of cerebrospinal syphilis in congeni- tal syphilitics, 73 of congenital syphilis, 57, 62 of interstitial keratitis, 63 of juvenile paresis, 71 of primary period, 2 of secondary period, 7 of tertiary period, 11 Syphilis acquired, 86 acquired by women in marriage, 23 and accidents to pregnancies, 119, 126 and blindness, 213 and deafness, 213 and destitute families, 213 and divorce, 219 and fetal deaths, 96 and financial difficulties, 161 and home life, 157, 165 and industrial decline, 162 and industry, 221 and marriage, 168 and mental life of mother, 160 and war, 215, 218 as cause of certain types of feeble- mindedness, 69 as cause of lessened earning power, 214 as cause of reduced marriage rate, 218 as cause of reduced productivity, 214 IXDEX 239 Syphilis — Continued as family disease, 112, 124, 129 congenital, 36 conjugal, 19 date of entry in family, 134 effect on birth-rate, li4, 118 effect on different members of family, 136 effect on next generation, 218 extragenital, 114, 118, 199 cleanliness as protection against, 197, 198 control of, 195 epidemics of, 190 escape from, 201 incidence of, 188 methods of transmission of, 193 financial results of, 205 general description of, 1 incidence of, 205, 206 incidence of. in families of syphi- litica 112, 124 incidence of, in married and unmar- ried women, 20 incidence of, in pregnant women, 97 incidence of, in women, 20, 96 incubation period, 1 mistaken attitude about, 223 primary period of, 2 secondary period of, 6 source of, in married women, 21 tertiary period of, 10, 12 transmission of, to third generation, 80 Standard of living lowered by syphi- lis, 219 Tabes, 74 Tertiary period characteristics of, 10 clinical diagnosis of, 12 Transmission paternal, 38 to children, 43, 94 to third generation, 80 Treatment amount necessary to sterilize in pri- mary period, 5 amount necessary to sterilize in sec- ondary period, 9 and marriage, 25, 26, 169 and Wassermann reaction, 106 as protection against contagion, 198 as result of examination of rela- tives, 90 difficulties of follow-up for, 152 during pregnancy, 95, 97 expense of, 154 in congenital syphilis importance of early, 94 indications for, 102 of parents of, 94 Treatment — Continued of syphilitic infants, 60, 103, 106 to minimize social handicaps, 108 to prevent symptoms, 104 type of treatment, 106 value of treatment, 104 insufficient to protect mate, 19, 25 of apparently non- syphilitic mothers of syphilitic children, 39 of symptom free children of syphi- litic parents, 42, 101 of syphilitic deafness, 65 prior to pregnancy, 95 provocative, 145 to minimize contagiousness in pri- mary period, 5 to sterilize for ordinary contact in secondary period, 9 value of early in relation to cure, 6 value of local in primary period, 4 Treponema effect of antiseptics on, 196 effect of moisture on, 196 effect of temperature on, 196 methods of spread, 195 viability of, 194, 196 Twins, one may be healthy, 47 Wassermann reaction after labor, 97 and marriage, 169, 174 and treatment of congenital syphi- lis, 106 as aid in discovery of syphilis, 142 as criterion of syphilis, 32 as routine in institutions, 33 diagnostic value in primary period, 3 diagnostic value in tertiary period, 13 interpretation in congenital syphilis, 84, 103 limitations of, 142 negative in infants, 60, 84 negative in tabes, 142 positive as indication for treatment, 101 positive in secondary period, 8 syphilitic families in which positive, 112, 127 value in survey, 50 value of treatment before reaction positive, 6 Wassermann survey of mates of syphi- litics, 32 Wet nurses directories, 195, 198 protection of, 198 Wife, effect of syphilis on mental life of, 160 Work, efficiency reduced by syphilis, 214 "HENCE MOM. CjOCKT casf