Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/syphilispublicheOOvedd \ SYPHILIS AND PUBLIC HEALTH BY EDWARD B. VEDDER, A.M., M.D. LIEUTENANT-COLONEL, MEDICAL COEPS, UNITED STATES ARMY PUBLISHED BY PERMISSION OF THE SURGEON-GENERAL UNITED STATES ARMY LEA & FEBIGER PHILADELPHIA AND NEW YORK 1918 Copyright LEA & FEBIGER 1918 CONTENTS. INTRODUCTION. 1. Importance of Syphilis in Relation to Public Health ... 17 1. Statistics Indicating the Extent of the MortaUty Due to Syphihs 18 2. Syphihs a Sanitary Problem of First Importance because it is Very Prevalent, Very Fatal and UncontroUed . 23 2. General Plan of the Work 24 References 25 CHAPTER I. The Prevalence of Syphilis. 1. The Incidence Varies in Different Groups of the Population . 27 2. Statistics from Other Coimtries 29 1. Russia 29 2. Serbia 31 3. Asia Minor 31 4. The Tropics 32 5. Africa 34 6. Germany 35 7. Budapest 38 8. Belgium 38 9. France 38 10. Austraha 40 11. England 41 12. Canada 46 3. Statistics from Different Groups in the United States ... 46 1. Prostitutes 47 2. Insane 49 3. Percentages of Syphihs among Patients in Hospitals and Dispensaries 53 4. Tuberculous Patients 68 5. Criminals 70 IV CONTENTS Statistics from Different Groups in the United States — 6. Sick Children 72 7. Individuals that are Presumably Healthy 76 8. Candidates for a Commission in the Army .... 82 9. Presumably Healthy Female Adults 83 10. Relative Prevalence of SyphiUs among Negroes ... 85 4. Summary of Results of the Investigation 96 References 102 CHAPTER II. The Sources of Infection and Methods of Transmission. I. The Sources of Infection 110 A. Immediate Bodily Contact Ill 1. The Primary Lesion or Chancre Ill 2. The Secondary Lesions 112 3. The Tertiary Lesions 114 B. Mediate Infection 116 1. Infectiousness of Various Bodily Fluids . . . . 116 Blood 116 Milk 117 Sputum, Sweat and Urine 118 SaUva 119 Spinal Fluid 119 Spermatic Fluid 120 2. ViabiUty of the Treponema Pallidum Outside the Body 120 C. Methods by which the Treponema PalUdum Gains Access to the Body 124 1. Penetrative Power of the Treponema Pallidum . 124 2. Genitotropic Tendency of the Treponema Palhdum 127 3. Syphihs "d'Emblee" 128 II. Methods of Transmission 135 A. Syphilis Insontium 135 1. Marital Syphilis 135 1. Transmission from Wife to Husband . . . 136 2. Transmission from Husband to Wife . . . 136 3. Methods of Transmission 137 The Delayed Chancre 137 Secondary Lesions that Escape Notice . 138 By Conception 140 Accidental Extragenital Infection of the Wife 142 CONTENTS V Methods of Transmission — SyphUis Insontium — • 2. Hereditary Syphilis 142 1. Methods of Transmission 142 2. Results of Hereditary Syphilis . . . . 142 3. Comparative Frequency of the Results of Hereditary SyphiUs 144 4. CoUe's and Profeta's So-called Laws . . . 146 3. SyphiUs Sine Coitu (Extragenital Chancres) . . 147 1. Frequency 148 2. Methods of Transmission 150 B. SyphiUs Pravorum 157 1. The Percentage of SyphiUtic Infections Due to Prostitution 157 References 159 CHAPTER III. Personal Prophylaxis. I. Methods that May Be Taken by the Individual to Prevent Genital Infection 162 1. The Surgical Method: Circumcision 163 2. Mechanical Method 166 3. Chemical Methods of Prevention 167 1. The Status of Such Methods Prior to the Experi- ments of Metchnikoff 169 2. Practical Results Obtained from the AppUcation of Prophylaxis ISO 4. The Ethics of Venereal Prophylaxis 192 II. Methods that May Be Taken by the Individual to Prevent Extragenital Infection 197 1. Kissing 198 2. Instruments Used in Various Trades 198 3. Smokers' Articles 198 4. Drinking Glasses 198 5. Minor Operations 199 6. Circumcision 200 7. Tattooing 200 8. Physicians, Nurses and Those in Attendance on the Sick 200 9. Wet-nurses 201 VI CONTENTS III. Syphilis and Marriage 202 1. Impracticability of Regulating Marriage of Syphilitics by Law 202 2. The Physician's Responsibihty 203 1. Rules Advocated by Various Authorities for the Marriage of SyphiUtics 205 3. The Standard of Cure 209 4. Wassermann-fast Cases 209 References 209 CHAPTER IV. Public Health Measures, A. Prostitution as a Sociological Problem . ~ 212 1. The Cause of Prostitution 213 2. Sociological Reform 214 3. Education 217 B. The Control of Venereal Diseases 219 I. Those Due to Prostitution 219 1. Laissez-faire 220 2. Suppression of Prostitution 221 3. Segregation and Reglementation 224 4. Systematic Treatment of Those Infected . . . 235 1. Notification 236 2. Quacks and Quack Remedies 242 3. PubHcity 247 4. Provision of Adequate Facilities for Treatment 249 For the General Public 255 For Prostitutes 256 A Supply of Salvarsan at a Reasonable Cost 259 II. PubUc Health Measures for the Prevention of Syphilis Insontium 261 1. Barbershops 261 2. Soda Fountains 262 3. Minor Operations 262 References 264 CONTENTS vii APPENDIX. Technic of Wassermann 265 1. Cell Suspension 265 2. Complement 265 3. Amboceptor 265 4. Antigen 265 5. Titration of Complement 266 6. Titration of Amboceptor 266 7. Titration of Antigen 267 8. Tests of Antigenic Power 267 9. Anticomplementary Test 268 10. Performance of the Test 268 Law of the State of Missouri for the Regulation of the Practice of Medicine and Surgery 270 The Control of SyphiHs in the Army 280 Methods Employed by Some Cities 292 Index of Authors 303 Subject Index 307 SYPHILIS AND PUBLIC HEALTH. INTRODUCTION. The importance of this subject cannot be too highly emphasized. SyphiHs is one of the most prevalent of all infectious diseases, causes an incalculable amount of suffering and economic loss, and because it has so far eluded sanitary control is a constant menace not only to the licentious but to the clean-living public as well. Because of the secrecy which has always shrouded the disease we do not know and perhaps never shall know the exact incidence of syphilis, but sufficient is known with regard to its prevalence to justify the above statement. For several years past syphilis has been made a reportable disease by the city of New York. During the fourteen weeks from July 4 to October 3, 1914, 25,633 infectious and contagious dis- eases were reported. Of these, syphilis stood first on the list, with 6432 cases, or 28 per cent.; tuberculosis second, with 5525 cases, or 21 per cent.; diphtheria third, with 3370 cases, or 13 per cent.; measles fourth, with 2750 cases, or 11 per cent.; scarlet fever fifth, with 1064 cases, or 4 per cent. From this and many other statistics which will be quoted later it would appear that with the exception of gonorrhea syphilis is the most prevalent of all serious infectious diseases. If statistics as to the incidence of syphilis are somewhat vague, figures as to the amount of morbidity and mortality caused by syphilis are still more vague. Syphilis appears seldom in death certificates, for the family physician always seeks a more euphonious title to cover the demise. How- ever, if it be remembered that syphilis is the real cause of 2 18 SYPHILIS AND PUBLIC HEALTH death in all cases of paresis, locomotor ataxia and aortic aneurysm, in many cases of cerebral hemorrhage and apoplexy, organic diseases of the heart, liver and kidneys, and that it is a contributory cause of death in a host of other condi- tions, including, perhaps, one-fifth of all cases of pulmonary tuberculosis, the real influence of syphilis on the mortality rate begins to be suspected. Osier some time ago made the statement that "of the killing diseases, syphilis comes third or fourth." In a more recent article^ Osier analyzes the statistics of the Registrar- General for 1915 as follows : Number of Total. syphilitics. Diseases of the nervous system .... 58,000 General paralysis . 2,263 2,263 Locomotor ataxia 735 735 Other diseases of the cord 2,846 1,500 Cerebral hemorrhage (apoplexy) . . . 25,423 3,000 Softening of the brain 1,472 500 Paralyses without specified cause . . 2,983 500 Other diseases of nervous system . . 15,000 2,000 Diseases of the vascular system: Aneurysm and aortitis 1,141 1,000 Organic disease of heart 56,000 5,000 Diseases of arteries 10,000 3,000 Total 19,498 Including stillbirths, deaths of infants under one month and other syphilitic conditions. Osier estimated that the actual deaths from syphilis were above 60,000, a number which moves syphilis from the tenth place in the Registrar- General's report to the place at which it belongs, at the top, an easy first among the infections. Downing' illustrates this fact with the vital statistics for Massachusetts for 1912. According to the records the Treponema pallidum is only responsible for 113 deaths; but of the 3188 stillbirths, half may be accredited to syphilis; 231 died of general paralj^sis and 87 of tabes. One-half of the 372 cases called paralysis without cause may be accredited to syphilis and nearly all of the 56 recorded as softening of the brain. One-tenth of the 3496 who died of cerebral hemor- rhage were probably syphilitic, for nearly 500 of these cases INTRODUCTION 19 were between the ages of twenty and fifty. It may also be estimated that one-tenth of the 1979 cases under the heading of diseases of the arteries, not to mention some of the 4610 organic diseases of the heart, a few of the 388 cirrhoses and other diseases of the hver and a few of the 478 suicides may be accredited to syphiHs. In round numbers and counting the stillbirths, Downing estimates the mortality from syphilis at 3000, or about 1 in every 18 deaths, making its record of fatality fall behind only tuberculosis, pneumonia and cancer. This estimate is none too high. Salmon finds that general paralysis in New York State stands eighth in the mortality tables and that 1 out of every 9 male deaths between forty and sixty is from general paralysis. According to Lenz,^ in the large cities 25 per cent, of syphilitics die as the result of aortitis (angina pectoris, aortic insufficiency, aneurysm), while 3 or 4 per cent, die from general paralysis, 1 or 2 per cent, from tabes and at least 10 per cent, more as the result of syphilitic diseases of the brain, liver and kidneys. Almost half of all syphilitics eventually succumb as the result of their infection. Syphilis is therefore the greatest cause of death of men in the large cities. Brooks* states that 66 per cent, of his luetic diseases die from or with serious circulatory diseases apparently of syphilitic origin. Stengel and Austin^ discuss syphilis as the etiological factor in certain cases of nephritis. Out of 84 cases of nephritis there were 66 in which possible etiolog- ical factors such as lead, alcohol, excessive work, exposure, senility, etc., could be recognized. But in 18 cases no such factors could be determined. Of these 18 cases there existed in 8 either an unquestionable history of syphilis or a positive Wassermann, or both. In 6 of the remainder no Wassermann was secured while in only 4 was syphilis definitely excluded. The nephritis occurring in early secondary syphilis is well known. It seems probable that syphilis, together with mercurial treatment, may be responsible for a considerable number of the cases of nephritis of unknown causation, and that here again the influence of syphilis on the death-rate must be taken into consideration. An estimate of the annual mortality caused by syphilis in Paris is given in the following 20 SYPHILIS AND PUBLIC HEALTH table compiled, by Leredde/ for the year 1910. from the mortality statistics Men. Syphilis 70 Cancer and malignant tumors of the buccal cavity .... 93 Affections of the nervous system: General paralysis .... 133 Ataxia 40 Encephalitis 28 Meningitis (except tuberculous) 439 Paralysis without a determined cause 240 Diseases of the spinal cord (ataxia excepted) .... 49 Epilepsy 31 Cerebral hemorrhage (apoplexy) 1142 Softening of the brain . . . 109 Different diseases of the nervous system 39 Diseases of the circulatory appa- ratus: Organic maladies of the heart . 1526 Angina pectoris 87 Arterial disease, aneurysm, ath- eroma, etc 173 Diseases of the digestive apparatus: Cirrhoses of the liver . . . 374 Diseases of the urinary apparatus: Nephritis, acute 26 Bright's disease 858 Diseases of the bones (tuberculosis excepted) 26 Sudden death 139 iVomen. Total. Syphilis. 41 Ill Ill 13 106 80 55 188 188 26 66 66 15 43 4 350 789 78 323 563 138 52 101 33 30 61 6 1161 2303 768 134 243 81 37 76 25 1807 3333 1111 39 126 96 72 245 122 225 629 125 22 48 4 642 1500 300 18 44 4 107 246 24 3364 Further, Leredde estimates that syphilis probably kills 25,000 persons each year in France. An idea as to the amount of morbidity and mortality caused by syphilis may also be obtained by observing known syphilitics for a number of years. This has been done by Mattauschek ard Pilcz,' who found that of 4134 officers of the Austrian army who contracted syphilis between the years 1800-1900, on January 1, 1912:' 198 have general paralysis. 113 have locomotor ataxia. 132 have cerebrospinal syphilis. INTRODUCTION 21 80 suffer from different psychoses. 17 died of aneurysm. 147 died of tuberculosis. 20 died with syphiHs designated as the cause. 101 developed myocarditis and arteriosclerosis and all but 15 died from this condition. Thus if we count general paralysis, tabes, cerebrospinal syphilis, malignant and inveterate syphilis, aortic aneurysm and arteriosclerotic conditions which are undoubtedly dependent on syphilis we find that 12 per cent, of these luetics died as the direct result of their infection. In addi- tion there are 2.64 per cent, who apparently die as the result of syphilis if we count the cases in which the relation between syphilis and the arteriosclerosis was probable. Finally, if we consider the large number of cases of tuberculosis that are secondary to syphilis we are then able to consider the impor- tance of syphihs to society. The actuaries of a German life insurance company estimate that the mortality of luetics is 130 to 100 for normal individuals, and in the 36- to 50-year period the average mortality in syphilitics is doubled. Finally, we have the life insurance statistics compiled in the United States. Schroeder^ states- that the Medico- Actuarial Mortality Invei tigation has recently completed a study of the experience of the companies represented, the ex- pected deaths being calculated by the medico-actuarial table based on standard lives during the years 1885-1908 inclusive. These cases are divided into three groups and only include those in which the attack occurred at least three years prior to the date of the application except group three. SYPHILIS, SURELY, THOROUGHLY TREATED, TWO YEARS' CONTINUOUS TREATMENT AND ONE YEAR FREEDOM FROM SYMPTOMS. Actual deaths. Expected deaths. Ratio of actual to expected deaths, per cent. 13 9.32 139 34 19.56 174 Between 2 and 5 years of application Between 5 and 10 years of application More than 10 years prior to applica- tion 53 24.42 217 100 53.30 188 22 SYPHILIS AND PUBLIC HEALTH SYPHILIS, SURELY, NOT THOROUGHLY TREATED OR NO DETAILS OF TREATMENT GIVEN. Actual deaths. Expected deaths. Ratio of actual to expected deaths, per cent. 44 15.52 284 54 25.52 212 Between 2 and 5 years of application Between 5 and 10 years of application More than 10 years prior to applica- tion 76 59.09 129 174 100.13 174 SYPHILIS, DOUBTFUL, Actual deaths. More than 2 years prior to application 67 Expected deaths. 48.81 Ratio of actual to expected deaths, per cent. 137 HamilP also says that syphilitics as a class are a poor risk. Thirty-four American companies have issued policies on cases that were believed to be cured. That is, they were only insured after great care had been exercised to eliminate all doubtful cures in so far as such elimination was possible and after the lapse of sufficient time to warrant the belief that cures had been effectual. This class has been under observation for thirty years. The result is unsatisfactory, for the mortality was 133 per cent. That is, where 100 deaths were expected 133 occurred. It must be remembered in considering insurance figures that the possibility of an antecedent syphilitic infection cannot be excluded, and indeed undoubtedly occurs often among the presumably normal class on whom the expectancy is based. This fact emphasizes the increased mortality observed among known syphilitics and the potentialities of syphilis as a killing disease. More and more syphilis has come to be recognized as a very fatal disease, and this fact adds greatly to its importance from a public health stand- point. A disease would not become a sanitary menace, even if it were very prevalent, if only it were innocuous, but when it is both very prevalent and very fatal, its influence on the mortality becomes of the greatest importance to the sani- tarian. Fisk^^ has pointed out that while the death-rate INTRODUCTION 23 from the usual infectious diseases has steadily declined during the past three decades the death-rates for apoplexy, kidney diseases and heart and circulatory disturbances have steadily increased. This increase has been so marked that in 1912 the death-rate for organic heart disease exceeded the rate for all forms of tuberculosis. The death-rate during the early years of life is being decreased, but it is increasing during the period beyond forty years of age. Is not the influ- ence of the syphilitic infection that pervades society observ- able here? The danger of syphilis to the general public has been inves- tigated by Blaisdell" who selected 60 cases in the early stages of the disease as they presented themselves in the skin department of the Boston dispensary. Blaisdell found that between the time of their infection to the time of their first appearance in the clinic for treatment these 60 cases exposed 34 people to the disease by coitus, 442 through family or boarding-house life and 651 by occupational association, or 1227 people in all. Of the 476 people so exposed by coitus or family life, 5 were definitely ascertained to have become infected, 4 through intercourse and 1 by being kissed by the mother, while of the remaining exposed persons no definite information was obtainable. It may be assumed that these 60 cases of fresh, untreated syphilis are the direct result of 60 other definitely active foci of infection in the community. Of these 60 foci only 2 were brought under medical control as the result of investigation of the source of infection. The danger of syphilis to the community or individual is increased in proportion to the inadequacy of the treatment received by those suffering with the disease. A careful investigation of this portion of the clinic was made in order to find out how effectively patients follow their doctor's advice. Seventy per cent, of the patients made less than five visits, a number insufficient in most cases to relieve even the symptoms for which they entered the clinic. Only 9 per cent, came more than eight times. The menace to the public in this situation is sufficiently clear. Facts such as these indicate that a careful consideration of syphilis in its relation to public health should be of value. 24 SYPHILIS AND PUBLIC HEALTH In considering the sanitary measures to be taken against a disease such as syphihs, whose immediate cause is known, the important factors to be discussed are (1) the incidence of the disease; (2) accurate information as to the various methods of transmission; (3) the practicabihty of the various methods that may be suggested for preventing this transmission. An endeavor has therefore been made in this work to collect as much information as possible with regard to the prevalence of syphilis, more particularly in the United States, both by searching the literature and by original investigation. The methods by which syphilis is transmitted are pretty thoroughly understood, and it has therefore been possible to collect a considerable amount of information on this point, including the proportion of genital and extragenital syphilis and the method of transmission in syphilis insontium. The methods that may be taken to reduce the prevalence of syphilis have been considered under the heads of personal prophylaxis, or those measures that any individual may take on his own initiative, and public health measures or sanitary regulations that can only be enforced by the community by statute or through the activity of the public health officer. The latter has necessitated a partial discussion of the old subject of prostitution. It would at first hardly seem as if anything new could be said on a theme that has been worn almost threadbare, but the Wassermann reaction and the use of salvarsan throw a new light on all phases of the subject of syphilis. The possibility of controlhng the amount of syphilis acquired, whether by prostitution or general immor- ality, by means of enforced systematic treatment, has not yet been given the serious consideration that the subject merits. The importance of the subject justifies its discussion. The writer has never had experience in public health work in civil communities, but has had opportunities for studying the subject in the army, which may fairly be called excep- tional, in that they include a long period of actual service with troops both in the field and in garrison, followed by four years of continuous experience with the laboratory side of the problem, during which time the facilities afforded by the library of the Surgeon-General have been readily accessible. INTRODUCTION 25 Hence, while the results of this investigation are presented with, it is hoped, due modesty the writer has the temerity to believe that they may have some value. REFERENCES. 1. Osier: The Campaign Against Syphilis, Lancet, 1917, i, 789. 2. Downing: Syphilis and Lung Disease, Boston Med. and Surg. Jour., 1915, clxxii, 898. 3. Lenz: Ueber die Haufigkeit der Syphilitischen Sklerose der Aorta relativ zur gewohnlichen Athero-sklerose und zur Syphilis uberhaupt, Med. Klinik, 1913, ix, 955. 4. Brooks: The Heart in Syphilis, Am. Jour. Med. Sc, 1913, cxlvi, 513. 5. Stengel and Austin: Syphilitic Nephritis, Am. Jour. Med. Sc, 1915, cxlix, 12. 6. Leredde: Etude sur la Mortalite due h, la Syphilis, Revue generale de clin. et de therapeutique, 1913, xxvii, 611. 7. Mattauschek and PUcz: Ueber die Weiteren Schicksale 4134 Katam- nesish verfolgter Falls luetischer Infection, Med. Klinik, 1913, ix, 1544. See also Waldvogel and Stissenguth: Die Folgen der Lues, Berl. klin. Wchnschr., 1908, xlv, 1213. 8. Sehroeder: Syphilis in Relation to Life Insurance, Med. Record, 1914, Ixxxv, 691. See also Solomonson: Syphilis Mortality, Med. Exam, and Practitioner, 1905, xv, 605. 9. Hamill: Syphilis from a Life Insurance Stand-point, Am. Jour. Dermat. and Gen.-urin. Dis., 1909, xiii, 144. 10. Fisk: Increasing Mortality in the United States, New York Med. Jour., 1916, ciii, 97. 11. Blaisdell: The Menace of SyphUis to the Clean-living Public, Boston Med. and Surg. Jour., 1915, clxxii, 476. CHAPTER I. THE PREVALENCE OF SYPHILIS. It is specially important to obtain accurate knowledge with regard to the prevalence and distribution of s;^q3hilis if any attempt is to be made to control the disease. Such information is necessary not only to enable public health officials to adopt appropriate measures, but especially to enlist the support of public opinion, without which no measures can be effective. Mcllroy^ in referring to the recent investigation of the British Royal Commission into the prevalence of venereal diseases in Great Britain, said: "One could almost have wished that the Royal Commission had not been appointed until some time later, when, as the result of fiu-ther investigation, the evidence of the preval- ence of venereal diseases more especially among the poorer classes, would have been so overwhelming that the public itself would have awakened to a sense of the dangers and the necessity for some measm-es of reform." It will be the object of this chapter to make some attempt toward supply- ing this need. A great many estimates or guesses have been made as to the prevalence of syphilis in different countries. Most of these are of little present value for several reasons. Many estimates have been based entirely upon the number of known cases appearing for treatment, and are therefore undoubtedly underestimates. There is no certainty that the figures obtained in another country will apply to our own, and, finally, in most cases an attempt has been made to estimate the prevalence of syphilis in the community as a whole. Now, society is not homogeneous, but consists of numerous strata or classes, and each class is composed of males and females of all different ages. The incidence of disease is INCIDENCE IN DIFFERENT GROUPS OF POPULATION 27 known to vary considerably in different classes, and because of its peculiar manner of spread, syphilis varies more in the different classes, races, sexes and ages than most other dis- eases. If 20 per cent, of the males and 1 per cent, of the females of a certain class are infected with syphilis we obviously create an erroneous impression when we state that 11 per cent, of the community are syphilitic, for this rate is ten times too high for the women and only about half the incidence among the men, and, moreover, the figures for another class of the population would be totally different. Incidence in Different Groups of the Population. — Dr. Stevenson (synopsis of the final report of the Royal Com- mission on Venereal Diseases) has tabulated all deaths from syphilis and sequential diseases in eight groups as follows : Class. Social status. 1 Upper and middle 2 Between 1 and 3 3 Sldlled labor 4 Between 3 and 5 5 Unskilled labor 6 Textile workers 7 Miners' 8 .... . Agricultural laborers 108 VIII In this classification the chief points shown are : (a) the high incidence in classes 5, 4, 1 and the lower incidence in 8, 7, 6; {h) unskilled labor was highest on all counts except locomotor ataxia, in which it was the second highest. The upper classes were second in general paralysis of the insane and aneiu-ysm, the highest in locomotor ataxia and the third in total deaths from syphilis. If these figures are correct it follows that syphilis is the most frequent in the highest and lowest social classes while agricultural laborers are relatively free. Such statistics, which are based on deaths alone, however suggestive, cannot be accepted without reservation. The poor naturally tend to die in institutions where the diagnosis is more apt to be correct, and in any case the deaths are only one index of the prevalence of syphilis, though other things being equal it should be a correct index. Death-rate. Orde 302 III 280 IV 264 v 304 II 429 I 186 VI 177 VII 28 THE PREVALENCE OF SYPHILIS Such figures, however, bear out the statement that a detailed study of the various social groups must be made before we will have accurate information as to the distribution of syphilis in the community. While it is obviously impossible at present to obtain satisfactory evidence with regard to the incidence of syphilis in all these various component parts of the population of the United States, an attempt has been made to present such data as are obtainable in the literature, and in addition the writer has been engaged for the past four years in making a series of Wassermann surveys of certain groups of the popu- lation. There may be a question in the minds of some as to the value of such surveys. A single positive Wassermann reaction in the absence of clinical evidence does not prove that the patient is syphilitic, and if the same examination is applied to thousands instead of to individuals, will not the error be multiplied? I do not think so. The error in this reaction as I have used it is apparently less than 1 per cent. : that is, of all double plus reactions that could be investigated less than 1 per cent, were presumably non-syphilitic. While it is most important to consider this error from the stand- point of the individual patient, it is not a matter of impor- tance in estimating the percentage of syphilis in a certain group by means of this test. However, throughout the dis- cussion, a distinction is maintained between estimates made by various authorities and the actual facts as obtained by statistical or scientific investigation. It is important to note that in forming conclusions as to the prevalence of syphilis both the reliability of the investigator and the thoroughness of the examination must be taken into account.* The percentage is always higher the more thorough the exami- nation is made. A clinical examination combined with a Wassermann test always shows a greater number of syphilitics than is detected by either test alone. This fact indicates that the estimates based on the Wassermann reaction alone are probably conservative. The highest and probably the * The Wassermann reaction used by the writer in his investigations is described in the appendix, p. 265. STATISTICS FROM OTHER COUNTRIES 29 most accurate figures have been obtained as the result of certain postmortem observations, of which, unfortunately, there are only too few. STATISTICS FROM OTHER COUNTRIES. While the main purpose is to deal with the prevalence of syphilis in the United States a few observations from other countries may be of value as a basis of comparison. Russia. — According to Scheuer,^ syphilis is widespread in Russia, where from 50 to 60 per cent, of the cases are due to extragenital infection, and the disease has practically lost its characteristics as a sexual disease and has become a con- tagious family disease. Sandberg^ has described remote villages in the District of Koslow where almost the whole population, old and young, were infected with syphilis, and where hardly a house could be found in which there was not some person infected. The peasants live herded together in great poverty and filth, of which some conception may be obtained by the statement that from twenty to thirty men may live in a house hardly 18 feet square. Sandberg concludes that 20.6 per cent, of all ambulatory patients were treated for syphilis, but that the actual percentage of syphilis must be much higher than this which represents only those in the active stages of the disease. In some villages the syphilization of the entire population has been accomplished, and the disease is equally distributed among men, women and children, most of the infections being extragenital. Scheuer also states that Generopitorozeff* described the epidemic of syphilis in the Parafiew District of the Government of Tschernigow. This consisted of six villages, with a population of 9500, in which, according to accurate lists, only about 5 per cent, of the people are not syphilitic; 66.1 per cent, of the cases were hereditary, 17.3 per cent, were infected by close contact, 11.9 per cent, in unknown ways and only 4.7 per cent, were infected by sexual contact. In such places syphilis ruins the people physically * Wratch, 1901, No. 38. 30 THE PREVALENCE OF SYPHILIS and mentally, and is the greatest hygienic problem of the Russian peasant life. Natm-ally, these are "horrible examples," and the incidence of syphilis in Russia as a whole can be nothing like so high. Accurate figures as to the prevalence cannot be obtained, but that it is a great sanitary problem throughout Russia may be gathered from the following statistics published by Rabinowitsch.^ These figures are claimed to give the number of syphilitic patients treated in hospitals and dispensaries, and can therefore represent only a small proportion of the actual number of infections. Thus in the United States army we have found that an admission rate of 3 per cent, usually indicates a percentage of infection ranging between 15 and 20. Number of cases Percentage Percentage Year. of syphilis. from cities. from country. 1900 936,985 ? ? 1901 961,628 ? ? 1902 1,007,429 ? ? 1903 1,054,387 29.1 70.9 1904 999,869 31.8 68.2 1905 998,965 31.0 69.0 1906 1,098,366 32.0 68.0 1907 1,100,944 33.0 67.0 1908 1,181,647 34.0 66.0 1909 ....... 1,199,148 33.0 67.0 1910 1,214,915 33.0 67.0 Feldhusen^ has translated the paper of Tschlenoff, who conducted a questionnaire with regard to the sexual life of the students in Moskow. According to the answers received, 67 per cent, had bad sexual relations before their entrance in the university; 7 per cent, were married. Of the total number of answers received from 2150 students, 69 per cent, acknowledged sexual intercourse outside the marriage relation. Half of these commenced between the ages of fourteen and seventeen years, the majority or 22 per cent, having had their first intercourse in the sixteenth year; 41 per cent, of the first exposures were with prostitutes, 39 per cent, with servant girls and 10 per cent, with married women. In regard to venereal diseases, 523, or 25.3 per cent., acknowledged infection. 19.6 per cent, of the students had STATISTICS FROM OTHER COUNTRIES 31 had gonorrhea; 3 per cent, had had chancroid, and 2.7 per cent, acknowledged syphihs. Favre® also sent a questionnaire to the students of the University and higher technical schools at Charkow. The replies were anonymous and 1298 answers were received. These indicated that 67 per cent, of these students had had sexual intercourse before entering the University. In the majority of cases the first step was taken at seventeen years and more or less regular sexual indulgence began about two years later. The incidence of venereal diseases was high, 47.2 per cent, suffering from gonorrhea; 10.8 per cent, from chancroid, and 6.9 per cent, from syphilis. Such figures can make little pretence toward scientific accuracy, but at least give some indication of the extent of venereal infections, including syphilis, and throw some light on the early age at which many such infections are acquired. The evidence indicates that the majority of infections in the United States are acquired somewhat later in life, namely, from twenty to twenty-five years of age. Serbia. — Syphilis has been demonstrated thi'oughout the whole of Serbia. Statistics completed in the years 1898 and 1899 show a proportion of 2.6 cases per thousand during the first year and 2.43 during the second year. The incidence is higher among the women, namely, 2.93 per thousand. These actual cases of the disease probably indicate an inci- dence of the disease of from 5 to 10 per cent, of the popula- tion, since only clinical cases were recorded. It is stated that infection by the genital route is comparatively infrequent and that extragenital infection is common. ■' Asia Minor. — An article by von Diiring-Pascha^ indicates that conditions in Turkey and Asia Minor are very similar to those already described in Russia. Hereditary syphilis is much more widespread than the sexually acquired type, and in all places except the cities, prostitution is of minor impor- tance. The disease is spread largely through close association and uncleanliness combined with ignorance of the danger of extragenital infection. The natives drink from vessels with a sharp spout and pass the water pipe and cigarettes from mouth to mouth with sublime carelessness. In one village 32 THE PREVALENCE OF SYPHILIS that was investigated, out of 2500 inhabitants, 495, or 19.8 per cent., were found to suffer with obvious lesions of syphilis. A Wassermann reaction would probably have shown the entire population to be syphilitic. The general distribution of the actual cases is shown in the following table: OVER TWELVE YEARS OF AGE. Men. Women. Total. Early symptoms 47 52 99 Late symptoms 109 135 244 Total 156 187 343 UNDER TWELVE YEARS OF AGE. Boys. Girls. Total. Early symptoms ...... 66 61 127 Late symptoms 16 9 25 Total 82 70 152 Grand total 495 The same conditions may very possibly occur throughout a large part of Asia.^ Jefferys and MaxwelP° state that "syphilis is met with from one end of China to the other, though mild in type." This mildness may be an illusion owing to the fact that many of the more serious conditions may never be seen by a foreign practitioner. The authors state, however, that late lesions are most commonly seen. No attempt to determine the prevalence of the disease by Wassermann surveys or intensive observation appears to have been made. The Tropics. — According to Scheube^^ syphilis is widespread over almost all tropical regions, and there are only a very few places in the heart of Africa, New Guinea and the interior of a few islands where the disease has not penetrated. He states that it is undeniable that the bearers of civilization have also always introduced syphilis. After its introduction the disease often spreads through extragenital methods of transmission, owing to the lack of clothes and close and insanitary contact; and as the disease is almost never treated, it is probable that whole races become thoroughly syphilized much faster than they become civilized. STATISTICS FROM OTHER COUNTRIES 33 It is unfortunate that no systematic investigation into the prevalence of syphiHs among the natives of the PhiHppines has been made. It is known, however, that the disease is exceedingly common, and the rates for syphilis among soldiers have always been much higher in the Philippines than in the United States. This is undoubtedly partly due to the relaxa- tion of morals that follows when men are shipped "east of the Suez where there aint no ten commandments;" but this is not the entire explanation. Outside of some of the larger cities there are no regular prostitutes, but all the native women are free and easy with the whites. It follows, there- fore, that syphilis is very common. Baermann^^ used the Wassermann reaction in order to determine the prevalence of syphilis among the laborers in Sumatra. The laboring colony consists of about 8000 (1000 Chinese, 4000 Javanese men and 3000 Javanese women). The laborers are given an examination twice yearly to detect syphilis, and the average hospital admissions for this disease, following three different examinations, was 4.5 per cent., 3.7 per cent., and 2.5 per cent. The falling rate is explained as the result of consistent treatment. The Wasser- mann reaction was performed on 900 sera from contract laborers who appeared healthy and had no manifest syphilis or yaws, with the following result : Positives in percentage. Men. Women. Javanese laborers who had been in Sumatra several years 17 22 Laborers recently arrived from Java .... 16 20 Chinese 25 Since the Wassermann reaction is only positive in about 50 per cent, of latent syphilis, Baermann suggests that to ascertain the prevalence of syphilis in this group the figures should be multiplied by two. According to this estimate, 34 per cent, of the older Javanese laborers suffer from syphilis, while 44 per cent, of the women are infected; and among recently arrived Javanese laborers the males suffer from syphilis in 32 per cent, and the females in 40 per cent. The Chinese males were estimated at from 50 to 60 per cent. These estimates may be taken for what they are worth, but 3 34 THE PREVALENCE OF SYPHILIS the results of the Wassermann reaction on this group of 900 apparently healthy natives are certainly below the actual prevalence of the disease. At least the 4.5 per cent, of those known to be infected must be added to obtain a correct idea of the incidence of the disease. Conditions are probably not much better in the tropical regions of America. Rothschuh^^ stated, in 1901, that he was well within the limits of safety when he estimated that 70 per cent, of the male population of Nicaragua were syphilitic, while about 50 per cent, of the women were infected. Africa. — Schroedter^^ observed syphilis among the natives of Southwest Africa. He states that Livingstone found a tribe in the interior of Africa that was entirely free from syphilis. Along the coast where contact with whites has occurred, syphilis is universal. No exact statistics as to prevalence are given, but the statement is made that the relative prevalence between the men and the women is 1 to 10. The reason is that the women, whether married or single, practically all have intercourse with the whites. It is a noteworthy fact that whenever Women are promiscuous, they suffer from syphilis to a greater extent than the males who may not be much more virtuous. This is undoubtedly because a promiscuous woman will have intercourse with a number of males much greater than the number of women with whom a promiscuous man has relations, so that the female is much more liable to infection. This fact explains the higher incidence of sjq^hilis among the negro women in the United States. Broc^^ made some observations concerning syphilis among the inhabitants of Tunis, and says that it is excessively prevalent, certain physicians believing that it attacks more than two-thirds of the population. Of 8000 new cases pre- senting themselves in his clinic for all conditions, he saw only 9 chancres but more than 500 cases of clear secondary or tertiary lesions. Thus, 6.3 per cent, of all his cases had clinical manifestations of the disease. He comments on the mild course of the disease among the natives. Brock^^ made a clinical examination of 7660 consecutive natives in Basutoland and comes to the conclusion that STATISTICS FROM OTHER COUNTRIES 35 nearly 80 per cent, of these natives have detectable mani- festations of syphilis; 68 per cent, of the natives have an indurated enlargement of the epitrochlear glands. Sicard and Levy-Valesi^'^ say that it is a matter of general knowledge that syphilis is exceedingly common among the Arabs and that it is usually benign in its manifestations. They performed a Wassermann reaction on 30 wounded Arabs in a military hospital. These men were between twenty and thirty-five years of age and none of them suffered from manifest lesions of the disease. Of these 30 cases, 6, or 20 per cent., were positive; 2 gave a partial reaction and 22 were negative. Ringenbach and Guyomarch^^ examined some 4000 people in the French Congo, and found 4 per cent, of obvious ter- tiary lesions. As this is necessarily only a small amount of the actual syphilitic infection that must be present, they come to the conclusion that the disease is widespread and common. Turning now to countries where conditions are more nearly like those in the United States a few references may be presented from each of the following countries: Germany. — Blaschko,^^ in 1892, estimated that for the pre- vious fifteen years there was a yearly incidence of 5000 fresh cases of syphilis to an average population of 1,270,000, or about 4 per cent., and concluded that at least 10 to 12 per cent, of the adult population either have or have had syphilis. If there were 4 per cent, of fresh cases annually this is evi- dently a very conservative estimate. Blaschko also gives the following figures for the troops of the Berlin garrison: All venereal diseases, Syphilis, Year. per cent. per cent. 73 to 78 56.3 11.3 78to83 . . 51.8 9.8 83 to 88 36.8 7.8 Lenz^" stated in 1910 that of all the men who died in Berlin in the year 1900 hardly 10 per cent, were free from syphilis, and that in the whole of Prussia at least 22 per cent, of the adult males contract syphilis at some time during their life. 36 THE PREVALENCE OF SYPHILIS Pinkus^^ wrote in 1912 that, "Roughly speaking, one may say that most German men have had gonorrhea and about 1 in 5 syphilis." Erb found that out of 10,000 cases of all varieties of disease in his practice, 21 per cent, had syphilis, and he believed that 12 per cent, of the adult population of Berlin were infected. These are all estimates of more or less signifi- cance. The following studies may also be quoted : Heller,^" in 1909, presented collected statistics as to the prevalence of hereditary syphilis in Berlin. Thus he quotes Neumann and Oberwarth, who investigated 62,221 children treated during fifteen years and found 1.4 per cent, of heredi- tary syphilis among the legitimate and 2.53 per cent, among the illegitimate. Taking only nursing children during 1904, 2.81 per cent, of legitimate and 3.43 per cent, of illegitimate babies were syphilitic. The figures from the Children's Polyklinik were lower. From 1872 to 1882, of 28,000 children, 254, or 0.9 per cent., were syphilitic. Von Cassel in another series of 17,448 nursing children found 207, or 1.18 per cent., to be syphilitic. When one considers that the Wassermann reaction was not yet in use and that this represents merely the obvious syphilis, some idea may be formed not only as to the amount of hereditary syphilis in Berlin, but also as to the amount of syphilis among the adult population which must have been many times higher. Epstein,^^ in 1913, examined 236 nursing children in an institution during the first weeks of their life. The Wassermann reaction was used in all cases, and 8, or 3.3 per cent., were shown to be luetic. Kurner^^ applied the Wassermann reaction to the weak- minded, with the intention of obtaining some information as to the prevalence of syphilis in the community at large. The investigation was limited to inmates under forty years of age in the Institution for the Weak-minded in Wiirtemberg; 1244 patients were investigated, of whom 119, or 9.6 per cent., gave a positive reaction; 88 of the positives gave a history, and it was found that 63 of them came from cities while 25 came from the country. This indicates the greater incidence of the disease in the cities. In this series about 15 per cent, of idiots and 5 to 6 per cent, of epileptics had a positive Wassermann. STATISTICS FROM OTHER COUNTRIES 37 Lippmann^^ investigated the relation between idiocy and syphilis and gave references to the previous literature on this subject, among which may be mentioned the work of Piper, who performed the Wassermann on 316 idiots, of whom 16, or 5 per cent., were positive. Lippmann examined 136 epileptics, of whom 5, or 3.6 per cent., were positive. He then examined 121 idiots, of whom 78 were less than fourteen years of age, and all were under twenty years of age; 16, or 13.2 per cent., gave a positive Wassermann. Lippmann quotes the results of Plant, who investigated a series of 52 children of luetic descent and found only 44 per cent, positive by the Wassermann reaction. Lippmann therefore estimates that of his 121 idiots the percentage actually infected with syphilis is 13.2 by -jj, or 30 per cent. The cases were also studied for evidence of hereditary syphilis, and as the result of these findings combined with the Wassermann reaction, Lippmann estimated that over 40 per cent, of these idiots were syphilitic. Dean^" examined and performed the Wassermann reaction on 330 cases of idiocy at the Potsdam asylum. Of these, 51, or 15.4 per cent., gave a positive reaction. Hubert" studied the prevalence of syphilis among the patients at the medical clinic of Dr. Romberg at Munich. The investigation lasted from October, 1912, to July, 1915, and included a complete clinical study. The Wassermann reaction was used, but not on all patients. Out of 8562 patients so studied, 759, or 8.8 per cent., were luetic. Among the 4739 males, 405, or 8.5 per cent., were luetic, while among the 3903 females, 354, or 9 per cent., were luetic. Undoubtedly the percentages would have been higher had the Wassermann reaction been used on all patients. At various times^^ efforts have been made to take a census of the venereal patients in various cities, but these attempts give little information as to the amount of syphilis actually present, as there is no proof that the physicians all reported their cases ; and, moreover, such figures include only cases which appeared of their own volition for treatment, and the much greater number of latent cases is not shown by such figures. 38 THE PREVALENCE OF SYPHILIS Budapest. — Torok^^ made an estimate of the prevalence of syphilis in Budapest, based upon the proportion of fresh cases of syphilis acquired by the members of certain work- men's associations for whom special hospital facilities were provided. Thus, in 1892 these associations contained 30,000 members (23,500 men and 6500 women). Of these, 124 men and 5 women were treated for fresh infections with syphilis. In 1893, of 44,700 members (36,000 men and 8700 women) 138 men and 10 women acquired syphilis. As these cases, coming to the hospital, represent only a small number of the total number of infections, Torok estimates that from 2.5 to 2.9 per cent, of the total adult population and from 4.5 to 5.3 per cent, "of the adult males acquire syphilis annually. Belgium. — Bayet^° estimated in 1908, as the result of his four years of observation of syphilis in Brussels, that 26 per cent, of the men of the working classes of Brussels acquired syphilis and that most of them transmitted it to their wives and sometimes to their children. France. — Fournier estimated that 15 per cent, of the adult population of Paris were infected with syphilis. While this estimate is subject to the same criticism applying to other estimates it is but fair to add that it is based on what is probably the largest clinical experience of any one man in France, and, for that matter, probably in any part of the world. An estimate of the annual mortality caused by syphilis in Paris has already been presented in the introduc- tion. Raviart, Breton and Petit,^^ in 1908, published the results of the Wassermann reaction applied to the spinal fluids of 400 inmates of the insane asylum at Armentieres; 76 were cases of general paralysis, of whom 71 gave a positive reac- tion. The remainder of the cases comprised the various forms of dementia, idiocy and imbecility. Of these 400 cases, 165, or 41.25 per cent., gave a positive reaction. Only 21 of these cases had clinical evidences of syphilis. Excluding the cases of general paralysis and 5 cases associated with tabes, 26.7 per cent, of the remainder were syphilitic. The intake of an insane asylum cannot have a very much higher percentage of syphilis than the general population if the STATISTICS FROM OTHER COUNTRIES 39 insanity specifically caused by syphilis is deducted. The sex and age of these insane was not stated. Calmette, Breton and Couvreur^^ examined blood from the cord in the case of 103 consecutive women confined at the Maternity Hospital of Seclin. There were 16 positive reac- tions, or 15.5 per cent. Most of these were respectable married women, but in a few cases the father was unknown. D 'Astros and Teissonniere^^ performed the Wassermann reaction on 500 foundling infants; 321 of these infants were from four to fifteen days old, 109 were from fifteen days to one month, 42 were between two and three months, 4 were from six months to one year of age, and 3 were from one year to fifteen months of age. An alcoholic extract of syphilitic liver was used as antigen; 477 of these infants gave a negative reaction and 18, or 3.6 per cent, gave a positive reaction. The authors conclude that approximately 4 per cent, of these foundlings have a positive Wassermann reaction and are presumably syphilitic. Leduc^^ stated that of 1213 women admitted for pregnancy to the maternity hospital at Tenon, 94, or 7.7 per cent., presented certain clinical signs of syphilis. The Wassermann reaction was not performed. Bubendorf^'^ investigated the prevalence of syphilis among the laborers in the mines of Briey and Longwy. The Wasser- mann reaction was apparently not used and the estimate was based on clinical cases and was evidently a very sketchy affair. The prevalence of the disease varied considerably in different districts, but was considered to be increasing. The following table gives the population in some of the dis- tricts, with the estimated incidence of syphilis: Estimated Industrial Population, syphilis, center. 1912. per cent. Homecourt 10,192 4.5 Joeuf 10,100 4.8 Landres 2,800 25.0 Pienne 3,700 25.0 Auboue 4,600 6.7 Moutiers 1,820 2.4 Tucquegnieux 2,265 6 to 8 Valleroy 1,500 16.0 Sancy 860 6 to 8 40 THE PREVALENCE OF SYPHILIS Letulle and Bergeron^^ performed the Wassermann reac- tion on a large number of cases at the hospital Boucicaut. They found that : Of 253 chronic nervous diseases, 136, or 53.7 per cent., gave a positive Wassermann. Of 168 vascula'r lesions, 90, or 59.5 per cent., gave a positive Wassermann. Of 116 kidney cases, 34, or 29.3 per cent., gave a positive Wassermann. Of 75 cases of cirrhosis, 34, or 45.3 per cent., gave a posi- tive Wassermann. Thus of a total of 608 chronic diseases 296, or 48.6 per cent., gave a positive Wassermann. While such figures give very little basis for deductions as to prevalence of syphilis, we may conclude that as the percentage in these cases is rather higher than that expected in the same type of cases in this country, it is a fair deduction that syphilis must be rather more common in that part of France than in most sections of the United States. Australia. — According to Barrett" for twelve months syphilis was made a notifiable disease in an area of ten miles radius from the general Post Office of Melbourne. No names were given, but the age, sex and clinical condition were certified and the information accompanied by a specimen of blood for the Wassermann reaction. At the end of the year about 5500 cases had been reported and tested, and 3157 were proved to be syphilitic. This was about 5 per cent, of the population. It does not follow that this is the correct percentage of syphilis in that part of Australia, but it does follow that at least 5 per cent, is definitely known to be infected. There was no information as to the relative prev- alence among the sexes. The percentage is naturally higher among patients in hospital, and there are several observations bearing on this point. Barrett^^ states that of 550 patients at various clinics, 44, or 8 per cent., gave a positive Wassermann, and 31, or 5.6 per cent., gave a partial Wassermann. This makes a total of 13.6 per cent, that may be estimated to be syphilitic among this class of patients. Barrett assumes that for STATISTICS FROM OTHER COUNTRIES 41 public health purposes six positive Wassermanns indicate the existence of 10 cases of syphilis. Piper^^ made a Wasser- mann survey on 100 women taken in the order of admission to the women's hospital at Melbourne. There were 10 positive, 6 partial and 84 negatives. "Thus there is a result of 16 per cent, of syphilis definitely present in a sample of 100 cases taken at random from the class of female patients admitted to a public hospital. Furthermore, as a negative Wassermann does not disprove syphilis, no estimate can be formed of the number of probable specifics among the 84 whose reaction was negative." Of these, 11 gave a history which could be regarded as indicating the possibility of syphilis. Bennie^" believed that in hospital practice in Melbourne 30 per cent, of the children show signs of syphilitic infection, and that 20 per cent, of the children in private practice are infected; so that he estimates that 25 per cent, of the sick children in Melbourne are tainted with syphilis. From his knowledge of the families whom he has often treated for many years he believed that fully 14 per cent, of these families are infected. Allen*^ published 100 consecutive postmortems from hos- pital practice in which 34 showed clear signs of syphilis, 19 others doubtful signs of syphilis and 1 was open to suspicion. A second 100 consecutive postmortems showed 3,2 clear cases and 30 others more or less doubtful. While warning against applying this percentage to the entire popula- tion, Allen writes: "After all cautions and reservations I am compelled to hold that in the hospital population syphilis is widespread, a frequent cause of death and a potent factor of physical deterioration, adding largely to the mortality from many other diseases." England. — The prevalence of venereal diseases in Great Britain has been a very live issue in recent years. Such a mass of evidence has been presented to the Royal Commis- sion on Venereal Diseases that it would be hopeless to attempt to analyze it, and much of it is hardly worth analyzing. In testifying before this Commission, Dr. French stated that in the British army the average number of cases con- 42 THE PREVALENCE OF SYPHILIS stantly on the syphilis register for two or three years and undergoing treatment was probably 3 or 4 per cent. This is about the same percentage that obtains in oiu- own army, and we know that the number thus undergoing treatment is only a fraction of the number actually infected. A very fair estimate was presented to the Royal Commission by Dr. Douglas White.^^ From a consideration of available statistics in regard to venereal disease and making an attempt to allow for differences in conditions, Dr. White arrived at the conclusion that there were every year 122,500 fresh cases of venereal disease in London and 800,000 fresh cases in the United Kingdom. He estimated that of the 800,000 fresh cases, 114,000 would be syphilis. From these figures he deduced that there must be in the United Kingdom some 3,000,000 syphilitics, which would be something under 7 per cent, for the total population. Dr. White compared the results obtained by this statistical inquiry with the estimate obtained by assuming that a certain percentage of cases of syphilis terminate in general paralysis or locomotor ataxia. The figures obtained from notification in Denmark led to the conclusion that in that country rather less than 2.5 per cent, of syphilitics died of general paralysis. In the United Kingdom there were about 2600 deaths annually from general paralysis and about 700 deaths from locomotor ataxia. If it might be assumed that 3 per cent, of cases of syphilis resulted in death from these diseases the conclusion was reached that there were about 111,000 syphilitic infec- tions annually. Without going further into the testimony offered it should be noted that the conclusion of the Royal Commissions^ in regard to the prevalence of venereal diseases in England was expressed in the following sentence: "While we have been unable to arrive at any positive figures, the evidence we have received leads us to the conclusion that the number of persons that have been infected with syphilis, acquired or congenital, cannot fall below 10 per cent, of the whole population in the large cities and the percentage infected with •gonorrhea must greatly exceed this proportion." Some results of systematic examination by means of the STATISTICS FROM OTHER COUNTRIES 43 Wassermann reaction, either alone or in conjunction with the clinical examination, are available and are of interest. Mcllroy, Watson and Mcllroy^^ performed the Wassermann reaction on 100 women in a Scotch clinic in order to deter- mine the prevalence of syphilis among gynecological patients. All suffered from a definite gynecological complaint, but only six patients gave a history pointing to syphilitic infection in the past. All of these six had a positive Wassermann. The patients attending the clinic are drawn from the respect- able working classes, all cases of ob\dous syphilis being excluded and sent elsewhere for treatment. The results obtained were very remarkable, for out of the 100 cases examined, 43 (34 married and 9 unmarried) gave a positive Wassermann; 48, all married, were negative; and 9 also married gave a partial reaction. The method used was that described by Browning, Cruikshank and Mackenzie. This investigation is only a small series, but so far as it goes it indicates an amazing prevalence of latent s;^^hilis among the gynecological patients of the working classes. Dr. Ivy Mackenzie^^ examined the blood of 786 insane patients in Scotland. Of that number 234 were supposed from the clinical examination to be general paralytics, and of these 221 gave a positive Wassermann reaction. Altogether, of the 786 cases 347, or 44.1 per cent., gave a positive reaction. A systematic examination of the patients admitted to his wards at the Victoria Infirmary showed that 15 per cent, gave evidence of syphilis. Manson and Smith^^ investigated the prevalence of syphilis in ocular diseases. Using the Wassermann reaction they studied 250 cases, including a great variety of clinical condi- tions of the eye: 125, or- 50 per cent., were positive, 3 w^ere doubtful and 122 were negative. Excluding such conditions as ocular injuries, conjunctivitis, cataract and the ordinary errors of refraction, much more than 50 per cent, were associated with a positive reaction. Elliott^^ performed a Wassermann reaction on 130 children of the city of Glasgow, selected because of their unhealthiness or because they belonged to the poorer classes; 14, or 10.8 per cent., had a definitely positive Wassermann; 4 of these 44 THE PREVALENCE OF SYPHILIS cases had definite signs of congenital s\"philis. If these cases were excluded the percentage of positive reactions becomes approximately 8.5. Elliott concludes that about 8 per cent, of all children of the poorer classes in Glasgow are syphilitic. Browning*^ investigated over 3000 cases from different groups in the community by clinical and serological methods. Some of his findings are as follows: Children. — Among 331 cases representative of the general conditions which lead to the appearance of children at the outdoor department of a hospital, 10 per cent, are syphilitic both on clinical evidence and as a result of the Wassermann test; 22 per cent, have a syphilitic association on clinical grounds, with confirmatory evidence from a doubtful result of the Wassermann test in 4 per cent. This gives practically conclusive evidence of syphilis in 14 per cent, of the children studied. Of 204 cases of mental deficiency and epilepsy in young subjects, 95, or 46 per cent., had a positive Wasser- mann. Of 25 cases of heart disease in children, 17, or 64 per cent., were positive. Of 52 cases of ozena that showed no clinical signs of syphilis, and in which no syphilitic history was obtainable, 16, or 30 per cent., gave a positive Wasser- mann. Of 46 cases of aortic disease examined, 64 per cent, had a positive Wassermann. Of 122 cases of nervous disease from a general hospital, 41 per cent, were positive. Of 104 prostitutes examined ranging in age from fourteen to eighteen years, all, or 100 per cent., were positive. Browning made no attempt to gauge the prevalence of syphilis in the general population, but states that it is impossible to avoid the conclusion that syphilis is very largely associated with the hospitalized portion of the community, and also with certain classes peculiarly liable to spread the disease. Assinder^^ performed the Wassermann reaction on 500 patients admitted to the Infirmary, Dudley Road, Birming- ham. Of the 500 patients tested, 120, or 24 per cent., gave a positive reaction: 67 of these cases were obviously luetic, and if this number be subtracted from the total number of patients, it will be seen that of 433 cases, 63, or 14.5 per cent., gave a positive reaction. In regard to sex, 272 were males and 80, or 29.4 per cent., gave a positive reaction; 288 were STATISTICS FROM OTHER COUNTRIES 45 females, of whom 40, or 17.5 per cent., gave a positive reaction. These were all cases belonging to the poorer classes. Dr. Fildes reported the results of 1002 Wassermann reac- tions made at the London Hospital. The patients tested were nineteen years of age and upward and had come to the hospital for reasons wholly unconnected with syphilis. Cases of obvious or probable syphilis were excluded. Of 616 males thus tested, 64, or 10.3 per cent., were positive, while of 386 females, 20, or 5.1 per cent., proved syphilitic. "This implies that in a typical working-class population of London at least 8 to 12 per cent, of adult males and at least 3 to 7 per cent, of adult females have acquired syphilis. If congenital syphilis were included, or if the total number of patients attending had been tested, the proportion would certainly have been higher." Sir John Collie carried out an investigation among employees referred for a medical examination. The persons examined fell into three classes: 1. 1119 disabled by accident or illness. 2. 557 apparently in perfect health but requiring examina- tion before appointment. 3. 500 of the same who submitted to the Wassermann test. The first two classes only underwent a clinical examina- tion; they showed 56 cases of syphilis, or 3.3 per cent. Among the last group who had a Wassermann, 46, or 9.36 per cent., proved to be syphilitic* Darling^'' examined the blood of 171 women admitted to the Belfast Maternity Hospital for pregnancy at term. The women were almost all married, of the artisan class, and were examined in the order of admission, making no selection in cases; 12.8 per cent, gave a positive Wassermann. She also quotes the series of Dr. Mott on 1483 patients admitted to the infirmaries of Shoreditch, Westminster and Paddington, which gave practically 20 per cent, of positive reactions. Mott also examined 71 mothers in the Shoreditch Infirmary and obtained 14.3 per cent, of positives among * Synopsis Final Report of Royal Commission on Venereal Diseases. 46 THE PREVALENCE OF SYPHILIS the married and 27.6 per cent, of positive reactions among the unmarried. Canada. — Dr. Charles K. Clarke/^ superintendent of the Toronto General Hospital, has stated that since October 6, 1916, routine Wassermann tests have been done in the wards of the Toronto General Hospital, and out of 971 tests, 125 were positive, a percentage of 12.8. Dr. Clarke con- cludes that more than 12 per cent, of the patients admitted to the public wards of that hospital for various conditions, both medical and surgical, have syphilis, and that this dis- ease must be considered a greater menace than tuberculosis. Graham,^2 [^ ^ discussion before the Toronto Academy of Medicine stated that of 412 medical cases admitted to the Toronto General Hospital the Wassermann reaction was positive in 180, or 43.6 per cent. These were consecutive cases admitted between August 11 and December 13, 1913. Among the professional class, however, the percentage of positive reactions was only 7, and among the business class it was 23 per cent. STATISTICS FROM DIFFERENT GROUPS IN THE UNITED STATES. A few random quotations indicating various opinions in regard to the prevalence of syphilis may be of some interest as a prelude to more serious investigations. Gerrish^^ is of the opinion that syphilis is one of the com- monest diseases. While its prevalence cannot be precisely determined, those best able to judge declare their belief that 10 per cent, of the community are affected by it. Fischer^^ estimates that 18 per cent, of the population suffers from syphilis and that 250,000 deaths occur each year as the result of venereal diseases. Cunningham^^ wrote, in point of prevalence, that syphilis and gonorrhea vastly overshadow all other infectious diseases, both acute and chronic. It is a conservative estimate that fully one-eighth of all human diseases and suffering comes from this source. It is a fact worthy of consideration that every year in this country 770,000 males reach the a;ge of early maturity. It STATISTICS FROM DIFFERENT GROUPS 47 may be affirmed that under existing conditions at least 60 per cent., or over 450,000, of these young men will some time during life become infected with venereal disease: 20 per cent, will occur before the twenty-second year, 50 per cent, before the twenty-fifth year and 80 per cent, before the thirtieth year. This is the venereal morbidity of the male product of a single year. It has already been pointed out that accurate figures in regard to the prevalence of syphilis in the general population are not only unobtainable, but that much more definite information is obtained by studying the prevalence of the disease in certain groups. In presenting the evidence with regard to the prevalence of syphilis in the United States, the plan will therefore be to select certain definite groups with regard to which more or less accurate information is available. Prostitutes. — The percentage of syphilis among prostitutes might be expected to be very high. Obviously the exact percentage found would depend upon the length of time those examined have followed their calling, and upon other factors. It may be supposed that after several years of this life every woman would become infected, and that such is not far from the case is indicated by the findings of Browning, already quoted. Among the older women, however, the disease often becomes latent, especially if a certain amount of treat- ment has been received. As a matter of fact, therefore, per- centages are apt to be higher among the younger women, since the old latent cases may escape both clinical and sero- logical methods of examination. Average figures are prob- ably given by Kneeland/'^ who says that the records of the Bedford Reformatory for girls show that 20.56 per cent, of the 647 inmates have clinical manifestations of venereal disease. With the Wassermann test, 224, or 48 per cent., have positive reactions, and 30, or 6.4 per cent., gave doubt- ful reactions. The same sera were tested by the complement- fixation test for gonorrhea, with the result that 306, or 65 per cent., gave positive reactions, 101, or 21.7 per cent., gave doubtful reactions, and 59, or 12 per cent., gave nega- tive reactions. The value of the complement-fixation test for gonorrhea is not yet thoroughly established. But, 48 THE PREVALENCE OF SYPHILIS accepting the results as indicating gonorrhea and syphiHs, the full significance of these results is apparent. Of the 466 girls tested only 50, or 10.7 per cent., were found to be free from venereal infection: 54.4 per cent, had a positive or doubtful Wassermann and were probably syphilitic, 86.7 per cent, probably suffered from gonorrhea and 170, or 36.4 per cent., gave positive reactions for both syphilis and gonorrhea. The complement-fixation tests in these cases were made by Dr. McNeil, of the Research Laboratory, Department of Health, New York. In a later statement, Davis^^ says that 51 per cent, of the inmates of this reformatory are syphilitic. Walker, ^^ in an examination of 327 prostitutes in Baltimore, found that 67 per cent, gave a positive Wassermann reaction. Sullivan and Spaulding^^ find that among 63 women arrested for alcoholism only, syphilis was found in 42.8 per cent., while 9.6 per cent, more show a doubtful Wassermann. Among 94 women arrested for alcoholism and other offences, syphilis was found in 46.8 per cent., with 14.9 per cent, more showing a doubtful Wassermann. Among 243 prostitutes s;\q3hilis was found in 65.5 per cent., with 9.5 per cent, more showing a doubtful Wassermann. Among the entire 500 consecutive cases who were all regular or irregular prostitutes, 75.7 per cent, had gonorrhea, and 44.7 per cent, were un- doubtedly syphilitic, while 9.5 per cent, more had a doubtful Wassermann. For the purpose of comparison the following figures obtained in foreign cities may be quoted. Meirowsky^^ examined 100 prostitutes in Cologne, using the Wassermann reaction in conjunction with the clinical findings : 74 per cent, were found to be syphilitic, although 43 cases were clinically negative; 26 of these gave a positive Wassermann. Hecht^° examined 260 prostitutes, also using the Wassermann reaction. Of these cases 191, or 73 per cent., had clinical signs of syphilis, and 49 of these had received treatment for the disease. Of the total 260, 102, or 39.2 per cent., gave a positive Wassermann, while 195, or 75 per cent., were posi- tive either clinically or by the Wassermann, or both. Hecht observes that these findings strongly indicate that almost STATISTICS FROM DIFFERENT GROUPS 49 all prostitutes that have followed their occupation for several years must be infected. While many of these cases were hospital cases, yet they were examined in rotation without regard to the cause of admission, and 69 of the 260 had no clinical evidences of syphilis. Somewhat lower figures have been obtained by Swedish investigators. According to Johansson 69 per cent, of the inscribed women examined were syphilitic, but only 31 per cent, showed clinical signs of the disease. Other observers are quoted who found from 32 to 36 per cent., and Almkvist''^ out of 32 prostitutes obtained a positive Wassermann in 8, or 25 per cent. Pinkus^2 stated in 1912 that non-syphilitic prostitutes must be extraordinarily rare in Berlin and that the majority acquire syphilis during their first year. Pinkus examined by the Wassermann reaction 230 of the older girls that had no history of syphilis and no physical signs of the disease, and 180, or 78.2 per cent., were positive, while among the 50 that were negative some of them later had symptoms of syphilis. Of 177 women who had remained for ten years without history or symptoms of infection the Wassermann reaction showed 101, or 81.2 per cent., to be positive. Excluding the occupation of prostitution which necessarily renders those engaged in it especially liable to infection with syphilis, some classification of the population must be used to divide it into groups that can be studied. Whites and negroes should, of course, be considered separately. It then becomes more or less natural to classify both races into those who are well and those who are sick and defective. Not only do patients who suffer from manifestations of syphilis naturally gravitate to hospitals and dispensaries, but these institutions have also many other patients suffering from conditions that are aggravated even if not caused by a pre- existing syphilitic infection. Under these circumstances it is natural to expect that the percentage of infections among the hospitalized portion of the community will be higher than among those individuals that are presumably well. One of the first classes of the sick to invite attention is the insane . The Insane.— Matson,«3 ^j^q applied the Wassermann reaction in the study of the insane in 1910, says: "The 4 50 THE PREVALENCE OF SYPHILIS importance of syphilis in the psychic inJBrmities is indicated by our examination of 470 inmates of the Oregon State Insane Asylum. Nearly 20 per cent, gave positive reactions while only 5 per cent, gave specific histories, and none presented visible or clinical manifestations. . . . Nearly 15 per cent, of 51 cases of dementia precox were positive, while none gave a syphilitic history: 16 per cent, of 151 cases of paranoia were positive. Twenty-five per cent, of 40 cases of chronic mania were positive, 20 per cent, of 26 cases of chronic melancholia were positive and 20 per cent, of 62 cases of dementia were positive." Paine,^* in 1912, examined 200 consecutive admissions to the Danvers State Hospital in Massachusetts. The Wasser- mann was done in every case, and when a positive or doubtful report was received a spinal puncture was also performed: 49 of these cases, or 24.5 per cent, of the admissions, showed a positive Wassermann in the blood; 146 of these cases were from cities, of whom 36, or 24.7 per cent., were positive and 54 cases were from small towns, of whom 13, or 24.07 per .cent., were positive; 82 cases were females, of whom 19, or 23.1 per cent., were positive. The seacoast cities gave a percentage of 32, the inland towns a percentage of 17, the mill cities a percentage of 28 and other cities a percentage of 19. While these figures are very suggestive as to the dis- tribution of syphilis in the different portions of the State, the number of cases studied is too small to form the basis of serious conclusions. Darling and Newcomb^^ obtained a Wassermann reaction on 849 cases at the Warren State Hospital, of which 43 cases were positive, a percentage of 5.06. They also state: "In the seventeen months elapsing since September, 1912, there were made as a routine procedure upon admissions 452 Wassermann reactions, of which 92 were positive, giving a percentage of 20.4." The low rate of 5.06 was for long resident chronic insane cases and contained very few cases of paresis, which are usually well advanced when committed to this institution, and their hospital residence is brief. Among the new admissions the high rate (20.4 per cent.) was due to cases of paresis and cerebral lues. STATISTICS FROM DIFFERENT GROUPS 51 Mitchell^^ states in regard to this same survey that 18.5 per cent, of the female admissions showed a positive serum, while 22.3 per cent, of the males gave the same result. Southard"^ gives figures for Massachusetts. In the Psychopathic Hospital 1671 random tests were made on different cases, of which 264 gave a positive Wassermann. This is a percentage of 15.8 for the psychopathic intake, and Southard says: "I consider that there is no better set of data available for Massachusetts." Vedder and Hough"^^ made a study of 1283 inmates of the Government Hospital for the Insane, Washington, D. C. The results of this examination are shown in the following tables : RESULTS OF WASSERMANNS IN SIX HUNDRED AND SIXTEEN CONSECUTIVE CASES. o 1 X B "ft 1 o Q 1 Negative Wassermann. Total syphilitic, co\mting all but =•= Wassermanns. .2 Xi g 6 o o a O m No. Per cent. White males White females . Colored males . Colored females 374 83 93 65 42 11 6 4 2 1 3 4 1 11 1 4 1 1 5* 7 7 73 22 8 19.51 23.65 12.30 Total .... 616t 59 7 8 12 6 5 14 103 16.72 RESULTS OF WASSERMANNS IN SIX HUNDRED AND SIXTY-SEVEN RANDOM CASES. Double plus. Plus. Plus-minus. Minus. No. Per cent. No. Per cent. No. Per cent. No. Per cent. Hough Vedder 235 432 17 30 7.23 6.94 5 58 2.12 13.42 5 96 2.12 22.22 208 248 88.51 57.40 Total . 667 47 7.04 63 9.44 101 15.14 456 68.36 * All of these cases had a positive Noguchi test for protein; the cell counts were respectively 9, 20, 120, 88, 160. t One Indian is included in this total. 52 THE PREVALENCE OF SYPHILIS The authors concluded that among the white males the presence of syphilis was demonstrated in 20 per cent, of the cases, that at least 30 per cent, are probably syphilitic and that at least 10 per cent, of the insanity in this institution is directly attributable to syphilis. No syphilis was detected among the 83 white females studied, but this number is so small that no deductions can be safely drawn from it except that the prevalence of syphilis among this group of insane females is less than among insane males. The statistics obtained for the colored race should be compared with those given later by Ivey under the figures given for the negro race. More than one-eighth of the cases of insanity annually admitted to Michigan State hospitals for the insane are directly caused by syphilis. In the year 1913-1914, insanity resulting from syphilis constituted 12.9 per cent, of all cases admitted to these hospitals. Syphilis was the direct cause of insanity in 17.5 per cent, of all males and in 6.65 per cent, of all females admitted. In order to ascertain the general prevalence of syphilis among the insane in the Michigan State hospitals for the insane the Wassermann test was made on 1546 patients admitted during the year 1913-1914. In 21.6 per cent, of the 940 males tested positive reactions were obtained, and 3.6 per cent, more were strongly suggestive of syphilis. Among the 606 females who were tested, positive reactions were obtained in 12.7 per cent. Of all admissions 18.1 per cent, gave positive reactions, 4.17 per cent, were questionable and 77.2 per cent, were negative. '^^ Holbrook^'' reported 2000 Wassermann reactions on the 1600 inmates of the East Louisiana Hospital for the Insane. Of 637 white males, 50, or 8 per cent., gave positive reac- tions; 516 white females, 20, or 4 per cent., gave positive reactions; 212 colored males, 15, or 7 per cent., gave posi- tive reactions; 235 colored females, 25, or 11 per cent., gave positive reactions. Thus of 1153 white patients 6 per cent, gave a positive reaction, while of 447 negroes 9 per cent, gave a positive reaction. These figures appear very low, but the majority were chronic cases, and the acetone-insoluble antigen was used. A study of the 515 cases received during the biennium STATISTICS FROM DIFFERENT GROUPS 53 ending March, 1916, showed that 11.07 per cent, were paretic and 17.4 per cent, were syphilitic. These figures are prob- ably much closer to the facts regarding the psychopathic intake of the State of Louisiana, but even here it must be remembered that higher figures would undoubtedly have been obtained had the cholesterinized antigen been used. FelP^ examined 1700 consecutive admissions to the Elgin State Hospital of Illinois and found that 16 per cent, of the admissions were syphilitic, or about 22 per cent, of the males and 9.5 per cent, of the females. Paresis formed about 12 per cent, of the admission rate, being 19 per cent, for males and 5.5 per cent, for the females. The Wassermann reaction was used in this work in conjunction with the clinical findings. Percentages of Syphilis among Patients in Hospitals and Dispensaries. — Most of the hospitals and dispensaries from which information of this character can be obtained are located in the cities. Evidence from cities in various parts of the United States will be presented. New York. — Kneeland*^ states that during the year 1911, 522,722 cases of all kinds were treated in 17 dispensaries in New York, of whom 15,781 were venereally affected. Of 5380 cases treated in 13 hospitals, 6.33 per cent, were venereally affected. These figures are far from showing the actual extent of syphilitic infection. As soon as the Wasser- mann reaction is applied the percentages increase. Thus of 308 adults admitted to the medical wards of a New York hospital during three months in 1913 the Wassermann was applied in 166 cases, of which 38, or 23 per cent., gave positive results. This is equivalent to 12.3 per cent, of the entire 308, but had the test been applied to all admissions the figures would undoubtedly have been higher. Greeley'^" reports that fully 20 per cent, of the general patrons of hospitals during the past few years and over 8 per cent, of the peddlers recently examined in New York City by the Department of Health gave positive Wassermann tests, and for other reasons, fully 10 per cent, of the general population can be conservatively regarded as having at some time or other suffered from syphilis. Dr. Haven Emerson very kindly sent me the following 54 THE PREVALENCE OF SYPHILIS additional data from the New York Department of Health : In 1915 routine tests were made on 110 masseurs and 12 were found to give a positive Wassermann reaction. During 1915 and 1916 the physicians attached to the occupational clinic examined a total of 70,714 persons, and the Wassermann test was used in 2982 of these cases. In about 20 per cent, of the cases the Wassermann was used because of some sus- picious circumstance in the history or clinical examination, but in the remainder of the cases the Wassermann was taken as a routine measure, for the most part in persons who denied all history of syphilis. Of the 2982 cases in which the reaction was performed there were 657, or 22 per cent., of positive reactions. The persons so examined were bakers, peddlers, food-handlers and certain other special trade groups. It is difficult to form any conclusions as to the prev- alence of syphilis among these workers from these figures. One-fifth of these examinations were made in selected cases suspected of syphilis. If we assume that because of this selection these figures are a fifth too high, then the actual prevalence of syphilis among this group would be four-fifths of the above figures, or 525 cases, 17.6 per cent, of the 2982 cases examined. This figure is not very different from the estimate made by Vedder in regard to the prevalence of syphilis among the class from which the army is recruited (20 per cent.). Bulkley^^ in 20,000 of his personal dermatological cases found syphilis in over 12 per cent., while in 300,000 cases compiled by members of the American Dermatological Asso- ciation, syphilis was found as a causative factor in about 11 per cent, of the cases. Symmers^^ wrote that the Wassermann reaction in Bellevue Hospital has yielded strongly positive results in over 25 per cent, of the enormous number of serums examined. Many, though not all of these, were consecutive random examinations. On the other hand, among 4880 necropsies performed at Bellevue Hospital in the past ten years, anatomical confirma- tion of the existence of syphilis was found in only 314 cases, or 6.5 per cent. Through the kindness of Dr. William F. Snow I have been STATISTICS FROM DIFFERENT GROUPS 55 able to secure a tabulation of the Wassermann reactions performed at Bellevue. The results for the year 1915 were selected because it was the year when routine tests were very largely made. The Wassermann reactions here recorded were performed by Dr. Cyrus W. Field. Fixation of the complement was on an 18-unit basis, and in the following tabulation fixation of to 3 units was considered negative, 3 to 8 units a partial reaction and 8 to 18 units a positive reaction. The work of tabulating these results was performed by Miss Sarah Greenspan at the request of Dr. Snow. I wish to express my indebtedness to both Dr. Snow and Miss Greenspan both for obtaining these results and for permitting me to use them. Cases. Positive. Partial. Negative. Service. No. Per cent. No. Per cent. No. Per cent. Men's medical Men's surgical 3012 1073 861 245 28.5 22.8 170 56 6.57 5.2 1981 772 65.7 71.9 Total males 4085 1106 27.0 226 5.5 2753 67.4 Women's medical Women's surgical Women, pregnancy . 1178 574 699 341 134 97 28.9 23.3 13.8 91 35 46 7.7 6.1 6.5 746 405 556 63.3 70.5 79.5 Total women . 2451 572 23.3 172 7.0 1707 69.3 Children, male Children, female . 116 75 22 20 18.9 26.6 13 5 11.2 6.6 81 50 69.8 66.6 Total children . 191 42 21.9 18 9.4 131 68.5 Syphilis, male Syphilis, female . Syphilis, children, male . Syphilis, children, female 2156 888 73 47 885 378 23 17 41.0 42.5 31.5 36.2 145 61 7 4 6.7 6.9 9.6 8.5 1126 449 43 26 52.2 50.5 58.8 55.3 Total syphilis . 3164 1303 41.1 217 6.8 1644 51.9 Total all cases 9891 3023 30.5 633 6.4 6235 62.8 56 THE PREVALENCE OF SYPHILIS In interpreting these results it should be noted that the cases listed in the men's and women's medical and surgical wards were taken as a routine. In the case of women admitted for pregnancy, specimens were not taken as a routine in all cases, but were partly routine and partly on women who were suspected of being syphilitic or whose infants had suspicious symptoms. It must also be noted that all the cases listed under the heading "Syphilis" are not necessarily actual cases of syphilis but are those cases in whom a preliminary diagnosis of syphilis was made, some- times on very slight grounds. These cases are tabulated under the heading "Syphilis" because it would be obviously unfair to include these cases among the routine cases from the medical and surgical wards, and yet the percentage of positive Wassermann reactions in these cases is so low (41.1) that it is obvious that many of them were not syphilitic. If all these cases be included, then out of 9891 cases, 3023, or 30.5 per cent., were positive. If we exclude the cases suspected of being syphilitic, then out of a total of 6535 routine tests on both men and women there were 1678, or 25.6 per cent., of positive reactions. Of 4085 males in the medical and surgical wards, 1106, or 27 per cent., were posi- tive, while among 1752 females in the medical and surgical wards, 475, or 27.1 per cent., were positive. It is therefore apparent that among the sick women admitted to this hos- pital the percentage of syphilis is no lower than among the sick men. It is believed that these percentages are very conservative, because they do not include the results of the physical examination or the partial Wassermann reactions, but are based solely on the positive Wassermann reaction; and also because so many cases of syphilis have been excluded among the cases in whom a diagnosis of probable or possible syphilis was made. It seems quite probable that the actual percentage of syphilis among the admissions to this hospital is at least 30 and may very well be higher. On the other hand, among women admitted for preg- nancy, and who are presumably healthy women, the per- centage is much lower, namely, 13.8 per cent. This figure is higher than that obtained for pregnant women else- STATISTICS FROM DIFFERENT GROUPS 57 where, which is to be explained because the examinations here were not routine, but partly on suspected cases, and also because the women admitted here probably belong to a poorer and more ignorant class than the admissions to some of the other maternity hospitals from which figures are presented. The higher percentage of positive reactions obtained among the children in this hospital is also worthy of note, but inasmuch as these groups are so small, no conclusions will be drawn from them. Dr. F. C. Costen has very kindly sent me the results of the Wassermann reaction as used in the Post-Graduate Hospital of New York for the calendar year 1916. Only white patients are included and no selection of cases was made. The Wassermann reactions were performed in the laboratory of Dr. Ward J. MacNeal and the reactions are on a four-plus basis. I have interpreted the four-plus and three-plus reactions as positive and the two-plus and one- plus reactions as partial reactions: Male. Female. Total. Nega- tive. + and + + + + + and + + + + Per cent, posi- tive. Total. Nega- tive. -1- and + + + + + and + + + + Per cent, posi- tive. 0-10.. 11-20 . . 21-30.. 31-40.. 41-50.. Over 50 Ill 140 262 269 221 165 76 97 158 145 133 119 15 13 29 24 11 16 20 30 75 100 77 30 18.0 21.4 28.6 37.1 34.8 18.1 74 99 202 182 105 84 46 54 120 104 67 65 12 8 23 26 8 8 16 37 59 52 30 11 21.6 37.3 29.2 28.6 28.5 13.1 Total . . 1168 728 108 332 28.4 746 456 85 205 27.4 Of a total of 1168 white male patients, 332, or 28.4 per cent., gave a positive Wassermann, while of 746 female white patients, 205, or 27.4 per cent., gave a positive Wasser- mann. From these figures we may conclude that approxi- mately 30 per cent, of the patients of this hospital are syphilitic, and, further, that the percentage is not materially 58 THE PREVALENCE OF SYPHILIS lower among the females than among the males. The figures also indicate that the percentage of those infected steadily increases with advancing years at least up to the age of forty. The sudden decline after forty is equally interesting. It is known that the death-rate among syphilitics over forty is approximately twice as high as among normal individuals, so that this affords the most probable explanation for the diminishing morbidity rate after forty. Many of the syphi- litics have already died. Chicago. — Gatewood^^ reported the results of 1400 Wasser- mann reactions performed in the Michael Reese Hospital on all classes of patients. A test may be ordered for any patient in the hospital, and some of the physicians order the Wassermann almost as a routine. Many of the patients showed no symptoms or gave no history of syphilitic infec- tion. Of this series of 1400 tests, 400, or 28.5 per cent., were positive. Since tests were not performed on all admissions this percentage does not represent the percentage of syphilis in all admissions. But if the cases diagnosed as syphilis are deducted the remainder of the tests constitute practically a random series. Among the 400 positive reactions there were 11 cases of primary syphilis, 90 of secondary syphilis, 43 of tertiary syphilis, 22 parasyphilitics and 10 cases of hereditary syphilis, or a total of 176 cases in which the clinical diagnosis of syphilis was made. Deducting these cases we find that in a series of 1224 random tests, .224, or 18.3 per cent., were positive. As the Wassermann reaction does not detect all cases of syphilis, and as the clinical cases of syphilis are deducted from these figures, the percentage of syphilis among patients admitted to the Michael Reese Hospital must be more than 18 per cent., and may be conservatively estimated at 20 per cent. Moreover a considerable majority of the patients are Jews, among whom the incidence of syphilis is generally believed to be lower than is the case in the gentile population. Moore^^ wrote in 1915: "The general medical dispensary affords a medium by which we come in contact with a certain class of persons in whom through poverty, deficient education and mental instability we might expect a higher percentage STATISTICS FROM DIFFERENT GROUPS 59 of syphilis than in the average of the community." Dm-ing several months Wassermann reactions were made as a routine test on nearly all persons attending clinics of the University of Illinois College of Medicine. Of 418 patients, 56, or 13.4 per cent., reacted positively. Omitting those who gave a weak reaction and had no history or symptoms of syphilis, and adding those who reacted negatively but who were known to have had the disease, there were 78, or 18.6 per cent., of the group who were syphilitic. Of the 89 women tested, 16, or 18 per cent., had a positive Wassermann; while of the 329 males tested, 40, or 12.2 per cent., had a positive Wasser- mann. The number of women tested was too small to afford a basis for drawing a comparison between the males and females, but at least it can be said that the percentage of syphilitic infections is probably quite as high among this class of female patients as among the male patients. Felpi examined 1700 consecutive admissions to the Elgin State Hospital, using the Wassermann reaction in conjunc- tion with a physical examination. This is a hospital for the insane, but it draws its inmates from the State as a whole, so that both urban and rural districts are about equally represented. Sixteen per cent, of admissions were sj-philitic: 22 per cent, of males and 9.5 per cent, of females. Paresis formed about 12 per cent, of the admission rate: 19 per cent, of males and 5.5 per cent, of females. Fell states that after deducting the strictly syphilitic psychoses there is no reason why the percentage of syphilitics among the admissions to the State hospital should differ materially from that of the adult population at large, and estimates on this basis that about 5 per cent, of the population of Illinois is syphilitic, with men affected somewhat more frequently than women. Michigan. — Peterson" reported the results of a study of 2000 cases admitted to the hospital of the University of Michigan, and excluding patients admitted to the depart- ment of dermatology and syphilology in accordance with the purpose of the investigation which was to determine the prevalence of syphilis among the average hospital patients. In 2000 patients there were 110 positive Wassermann reactions in which the diagnosis was confirmed by the 60 THE PREVALENCE OF SYPHILIS department of syphilology. Among patients giving a doubt- ful reaction there were eight who were subsequently proved to be syphilitic. This indicates that at least 6 per cent, of the general run of hospital patients in this institution are syphilitic. When considering this low figure it must be remem- bered that the obviously syphilitic are excluded from these figiu-es by the exclusion of the department of syphilis. But even making this allowance, these figiu'es seem very low in view of the findings of Warthin''^ in the same institution. Warthin found the Treponema pallidum together with the pathological lesions of syphilis in one-third of the adult necropsies from the University Hospital. It should be stated that this is a State hospital whose patients represent the average middle- class population of the State of Michigan. The greater part of the cases gave no history of syphilis and were ignorant of the fact that they had contracted the disease. While the Wassermann reaction may be open to some criticism as an indication of syphilitic infection, no such objection can be brought against Warthin's findings. The actual finding of the causal organism by a master of technic cannot be criticised, and Warthin's 33 per cent, must be regarded as much nearer the real truth with regard to the prevalence of this disease than the evidence obtained by Wassermann surve^^s. It is interesting, however, to note that Peterson found the percentage of syphilis in 381 cases in the maternity department to be 4.7 per cent, as shown by the Wassermann reactions and physical examinations. Boston. — Walker and Haller,^^ in 1916, investigated the prevalence of unsuspected syphilis among patients in a general hospital by performing the Wassermann reaction on 4000 cases from the Peter Bent Brigham Hospital: 1800 of these patients were in the medical wards, 350 in the neuro- logical division of the surgical service and 1850 were in the outdoor department or in the general surgical service. The original Wassermann technic, with the substitution of a 0.4 per cent, cholesterinized alcoholic human heart extract for antigen, was used. Among the 4000 cases, 600, or 15 per cent., gave complete fixation. Only 48 of these 600 patients were in any early stage of the disease, i. e., 13 had a chancre STATISTICS FROM DIFFERENT GROUPS 61 and 35 had an early rash. The remainder were the class of patients that may be found in any general hospital. It may be assumed that had the partial reactions been carefully studied in connection with the history and clinical condition the percentage of syphilitics would have been even higher. Hornon*" applied the Wassermann reaction to unselected medical cases of the Boston City Hospital. Of 500 cases so tested, 87, or 17.4 per cent., had a positive test, and In only 18 of these cases was a probable diagnosis of syphilis made before the Wassermann reaction was received. Of 312 Wassermann reactions from consecutive admissions at the Boston Marine Hospital from February to October, 1916, excluding readmissions and faulty specimens, and considering doubtful reactions as negative, 77, or 24.7 per cent., were positive. Including 11 cases giving a negative reaction on account of recent treatment the total incidence was 28.2 per cent.^^ The following table presents a resume of the 4218 Wasser- mann tests made by the laboratory of the Massachusetts State Department of Health dm'ing 1915 upon various institutional groups: Classification of patients Number, Percentage examined. Number. positive. positive. Psychopathic patients . 1997 298 14.8 Feeble-minded and delinquent 679 61 9.0 Criminal subjects .... 185 74 40.0 Tuberculous subjects . 4.32 39 9.0 Cancer 21 1 4.8 Pregnant women .... 172 8 4.7 Infants and children 136 24 18.5 Acute general hospital group . 419 68 16.2 Chronic diseases .... 177 48 26.1 Total 4218 621 15.0 San Francisco. — Whitney^^ classified 7885 case histories from the out-patient department of the University of California Hospital from July 1, 1912, to WLsiy 1, 1914. The Wassermann reaction was used in part of these cases, some departments requiring a routine Wassermann reaction and some only calling for it in selected cases. It will be seen from the follovving table that 6.9 per cent, of the entire 7885 62 THE PREVALENCE OF SYPHILIS cases were syphilitic, while of the 363 cases from the nerve chnic 82, or 22.6 per cent., were syphilitic, and in the medical clinic of 1695 cases, 370, or 21.8 per cent., were syphilitic. It may fairly be assumed that had the Wassermann reaction been universally employed the percentages would have been higher, and it is not improbable that a survey of the patients in the hospital would have furnished figures higher still. CASES OF SYPHILIS IN VARIOUS DEPARTMENTS OF THE OUT- PATIENT DEPARTMENT. Cases of Total new Percentage of Department. syphilis. cases. syphilis. Whole O. P. D 544 7885 6.9 Nerve 82 363 22.6 Medical 370 1695 21.8 Skin 134 892 15.0, Orthopedic 90 652 13.8 Genito-urinary 57 434 12.9 Eye 121 1421 8.5 Throat, nose, ear 53 1597 3.3 Children 26 890 2.9 Women's clinic 21 915 2 . 3 Surgical 28 1262 2.2 As the children's department is stated to have required a routine Wassermann in every case for several years the percentage found (2.9) may be assumed to be very close to the actual prevalence of the disease. The nerve department also demanded the reaction in almost every case and the medical department for over half the cases. Nothing was said as to the surgical department, and it is a fair assumption that the Wassermann reaction was not used to any great extent by this department. Had it been used as a routine test there is every reason to believe that the figures would have been more like those obtained by the medical depart- ment. The general average of 6.9 per cent, for the entire number of cases must therefore be taken to represent the amount of syphilis actually found, but cannot be taken as an estimate of the amount of syphilis present in this class of cases. Knappi^2 reported the results of an examination of 400 cases studied in St. Luke's Hospital, San Francisco. No STATISTICS FROM DIFFERENT GROUPS 63 selection was made of the cases and the Wassermann reaction was used as an aid in diagnosis. Of 177 male patients, 41, or 23 per cent., were syphilitic, while of 223 female patients, 10, or 4.4 per cent., were syphilitic. The work appeared to be carefully done, and while this is a small series, it is believed that such a series gives a more accurate idea of the prevalence of syphilis in the hospitalized portion of the community than many larger series in which the examination has not been so thorough. New Jersey. — Hammond^^ examined all the inmates of the New Jersey State Hospital at Trenton, which is an institution whose intake is representative of the rural type of the general population of the State. In all 1583 individuals were tested by the Wassermann reaction : 70 of these were cases of general paralysis and 1513 cases were otherwise diagnosed. Of the cases not general paralysis, 1472 gave negative reactions, and 41, or 2.7 per cent., gave positive reactions. Including cases of general paralysis about 7 per cent, of all individuals of both sexes examined and about 10 per cent, of all males were found to be syphilitic. Hammond believed that this percentage is representative of the entire general adult population of the rural parts of the State, because a careful analysis of the data obtained led to the conclusion that syphilis among the insane is no more frequent in occur- rence than in the general community. He concluded that the prevalence of lues in the entire general adult population of the State of New Jersey is 7 per cent. It is not believed that this estimate can be accepted unreservedly. In the first place the incidence of syphilis in an asylum is higher than that in the general community because of the tendency of paretics and cases of cerebral lues to gravitate to the asylum. On the other hand, if these cases be excluded the incidence of 2.7 per cent, is believed to be too low even for rural sections of the country. Hammond believed that his data indicated that the prevalence of syphilis in city and country is in general exactly two to one. Excluding paretics this would mean that the incidence of sj^hihs in cities of New Jersey would be 5.4 per cent. We have already indicated the danger of making estimates of this 64 THE PREVALENCE OF SYPHILIS character, and although the work was evidently done with care the percentage of positive cases is very low as compared with the results obtained by workers in other similar asylums. Richmond, Va. — Van der Hoof^^ reports that of 2449 patients including white and colored from the out-patient and in-patient clinics of the Medical College of Virginia, 44 per cent, showed complete fixation, with an additional 12 per cent., giving partial or incomplete reactions. In the psychopathic clinic of that college 42 per cent, of incorrigible or backward children have a positive Wassermann. The high persentages here given may be assumed to be due to the inclusion of negroes in these statistics. Birmingham. — McLester^^ reports 300 consecutive private patients seen in his practice and in consultation with other physicians. The original Wassermann reaction was per- formed by a competent technician using the original technic and a beef-heart antigen. Of the 300 cases, 56, or 18.8 per cent., gave a positive reaction. Of the positive cases, 22, or 39 per cent., gave a history of syphilis, while 34, or 61 per cent., gave no such history. Baltimore. — Major^^ reported the reactions performed at the Johns Hopkins Hospital from September 1, 1911, to August 1, 1912. The reaction was performed on the sera of 1200 patients, the great majority of whom were medical cases, and included a great variety of diseases from out- spoken syphilis to neurasthenia and similar cases in whom the reaction was performed to exclude syphilis. The series includes functional and organic nervous diseases, (iardiac diseases, nephritis, diabetes, pneumonia, t;>'phoid fever, gastro-intestinal diseases — practically every medical condi- tion seen in an active clinic. Therefore, although no attempt was made to take every admission, the results cannot be greatly above the average of the intake of this medical clinic. Of the 1200 cases, 239, or 20 per cent., gave positive reactions, while 961, or 80 per cent., were negative. The series included 185 negroes, the majority being cardiorenal cases, and of this number 61, or about 34 per cent., gave positive reactions. According to Janeway,^^ of 1272 consecutive white patients of this same medical clinic from September 21, 1914, to STATISTICS FROM DIFFERENT GROUPS 65 April 2, 1916, 106, or 13 per cent., had a positive Wassermann reaction, while of 288 colored individuals examined during the same period, 124, or 43 per cent., had a positive Wassermann. As this series consists of consecutive cases it gives an excellent picture of the prevalence of syphilis among medical patients attending hospitals and dispensaries in Baltimore. Walker^^ reported in 1916 that in a recent examination of 1080 patients, regardless of the disease for which they sought treatment, 10.8 per cent, gave a positive Wassermann. Philadelphia. — ^According to Krumbhaar and Mont- gomery,^^ of 1000 consecutive new cases at the Pennsylvania Hospital Dispensary, 34 were diagnosed as luetic and 30 of these gave positive Wassermann reactions. They state that this 3 per cent, of all dispensary cases is probably below half of the actual proportion of syphilitic patients attending the clinic and indicate only those patients having conditions obviously syphilitic. A routine Wassermann reaction on the entire number would have given much higher figures. . The following figures are given by Rosenberger,^" com- prising the Wassermann reactions performed during 1916 at the Philadelphia General Hospital. It is not claimed that all patients are included, so that it must be assumed that the Wassermann reaction is only performed on selected cases. Ward. Positive. Negative. Total. Men's medical 259 838 1097 Psychopathic .198 708 906 Insane 154 407 561 Men's and women's nervous . . 103 329 432 Men's and women's surgical . . 92 181 273 Women's medical 103 170 273 Men's and women's tuberculosis . 98 193 291 Maternity 10 126 136 Women's venereal 127 151 278 Gynecological ...... 20 49 69 Children's 8 48 56 Men's venereal 45 13 58 Total 1217 or 27.4 per cent, of 4430 Dr. John H. Musser, Jr., reports that in an examination of cases at the University Hospital, Philadelphia, 14 per cent, gave a positive Wassermann. ^^ 5 66 THE PREVALENCE OF SYPHILIS Williams and Kolmer^^ performed the Wassermann reaction on 300 gynecological cases such as might be met with in the average gynecological dispensary and ward service in Philadelphia, no selection being made as to the type of lesion present. Three antigens were used, including a cholesterinized alcoholic extract of human heart. Of 208 white cases, 35, or 20.2 per cent., gave positive reactions, while of 92 negroes, 33, or 35.8 per cent., gave positive reactions. This, however, included partial reactions. Of the total series of 300, 36, or 12 per cent., gave strongly positive reactions. The percentage of syphilis among these cases may therefore be placed at not less than 12 per cent, and as probably 22 per cent. Washington. — ^Ladd^^ reported statistics compiled on the basis of 1000 Wassermann reactions performed at the Casualty, Washington Asylum and George Washington Hospitals. Of 425 dispensary patients at the Casualty and Washington Asylum, 25.5 per cent, gave double-plus reac- tions, 21.7 per cent, were partial reactions and 52.8 per cent, were negative. Of these patients, 68.8 per cent, were white and 31.2 per cent, were colored, and of the double-plus reactions, 10.9 per cent, were in the white race and 14.6 per cent, in the colored race. Of 449 white patients in the wards of the George Washington Hospital, 10.4 per cent, were double plus, 18.4 gave partial reactions and 71.2 per cent, were negative. Of these patients 43 per cent, were females furnishing 3.6 per cent, of the positive results, while 57 per cent, were males, furnishing 6.8 per cent, of the positive reactions. Of 126 private cases, 14.1 per cent, were double plus, 23.4 per cent, had partial reactions and 62.5 per cent, were negative. There were more partial reactions among the white than the colored population, and Ladd thought this was due to the fact that the white race has pursued treatment more faithfully. He concluded from these figures that the percentage of positive reactions in the general population might be estimated at 17 per cent. We have already pointed out the danger of applying one set of statistics to the entire population. I have also made an endeavor to study the prevalence of STATISTICS FROM DIFFERENT GROUPS 67 syphilis by applying the Wassermann reaction to several institutions in Washington, and also to private patients. A special effort was made to obtain female patients because there is very little evidence obtainable covering the prev- alence of syphilis among women. The Women's Clinic and the Columbia Hospital for Women very kindly sent me specimens. While I have not obtained all admissions from these institutions the specimens have been random, and at various periods certain physicians have sent all admissions to their wards. All varieties of diseases are included, but especially gynecological conditions. The private patients were obtained from several physicians in Washington who have made a practice of sending me all their new cases for a Wassermann reaction. The results of this work are shown in the following table: WHITE WOMEN. Place. Total. Positive. Plus. Plus minus. Negative. No. Per cent. No. Per cent. No. Per cent. No. Per cent. Women's Clinic Columbia Hospital Private cases 150 188 417 13 21 17 8.66 11.17 4.07 16 27 24 10.66 14.36 5.75 14 16 36 9.33 8.51 8.63 107 124 340 71.33 65.95 81.53 Total . . . 755 51 6.75 67 8.87 66 8.74 571 75.62 WHITE MEN. Soldiers' Home* -. Private cases 621 430 97 23 15.6 5.34 85 15 13.6 3.49 93 29 14.9 6.74 346 363 55.7 84.41 Total . . . 1051 120 11.41 100 9.51 122 11.60 709 67.46 As the hospital cases all come from the poorer classes, while the private cases come from the better classes, these figures are believed to represent a fair average of the per- centage to be expected among the sick of these classes in Washington, so far as the facts may be determined by the * Published in Bulletin No. 8, W. D., Office of the Surgeon-General. 68 THE PREVALENCE OF SYPHILIS use of the Wassermann reaction. It is to be expected that these figures would be considerably higher if the serological evidence could have been combined with the clinical findings. Unfortunately this was impossible. Tuberculous Patients. — Syphilis has long been suspected as a predisposing cause of tuberculosis, a fact that has been exemplified in the expression "Syphilis makes the bed for tuberculosis." Brock/^ as a result of an investigation of 7660 consecutive South African natives, among whom tuber- culosis in any form was practically unknown at that time, comes to the following interesting conclusions : 1. Thirty-five per cent, of natives have a fibroid condi- tion of the lungs. 2. Sixty-eight per cent, have indurated enlargement of the epitrochlear gland. 3. Both conditions result from syphilis, and nearly 80 per cent, of the natives have one or both conditions present. 4. Syphilis prepares the way for tuberculosis and is in all probability the chief cause for the great prevalence of, and the high mortality from, the latter disease in the natives engaged in mine work on the Rand. 5. Syphilis plays a role in the production of lung diseases in the youth and adult, the great importance of which has not been recognized. In accordance with such considerations it would be expected that syphilis would be found to be more prevalent among the tuberculous than among those ill from other causes. That such is the fact is indicated by some of the following investigations : Letulle, Bergeron and Lepine^* investigated the prevalence of syphilis among this class of patients in Paris, and for more than a year performed the Wassermann reaction on all patients male or female admitted for tuberculosis. Thus of 346 tuberculous patients 64 gave positive reactions and 8 were doubtful. At least 19 per cent, are therefore shown to be infected with syphilis on the basis of the Wassermann reaction alone. The authors state that "In Paris among the patients in hospital for pulmonary tuberculosis, one- fifth at least suffer from syphilis more or less latent but which STATISTICS FROM DIFFERENT GROUPS G9 is still in full activity. This is shown by the Wassermann and confirmed at all points by our pathological investiga- tions." Vedder^^ investigated the prevalence of syphilis among soldiers discharged from the army for tuberculosis. All patients at Fort Bayard at the time were included except those having a history of syphilis, and a Wassermann reaction was performed on all of them. Of the 211 patients so examined, 36, or 17 per cent., gave a double-plus reaction, while 17 per cent, more gave a plus reaction. There were 17 patients known to be syphilitic, and if those known to be infected are added to those giving a double-plus Wassermann reaction, of a total of 229 patients, 53, or 23.2 per cent., were syphilitic. Snow and Cooper^*^ repeated this work at Fort Bayard, also using the Wassermann reaction on all cases, but with a somewhat different technic than that used by Vedder. Of 290 patients examined, these authors found 44, or 14.8 per cent., to be surely syphilitic, and 58, or 20 per cent., who were surely or probably syphilitic. Lyons" reports 29, or 6.2 per cent., positive out of 471 tuberculous patients, while 12, or 3 per cent, more, gave partial reactions. Jones^^ reported 73, or 29 per cent., positive out of 251 patients coming to the public clinics, but many of these were partial reactions. Out of 189 patients from a sanatorium who were undoubtedly tuberculous there were 11 per cent, of three-plus reactions, 17 per cent, of two-plus reactions and 25 per cent, of plus reactions. The original Wassermann technic was used with a three-plus reading. Of the patients 70 per cent, were males and 30 per cent, females, and the percentage of positive reactions was about the same for both sexes. Petroff,^^ using a cholesterinized heart extract for antigen, found that of 376 cases, 82, or 21.8 per cent., gave a positive Wassermann reaction. Ford^"** examined 328 patients at the Loomis Sanitarium, of whom 302, or 92 per cent., were negative, and only 2 per cent, showed a per- sistently positive reaction, and the remainder gave partial reactions. A cholesterinized antigen was used, but nothing is said as to the social status of the patients, which it is •thought may explain the remarkably low percentage found in this series. The statement is madei°i ^j^^t Wassermann 70 THE PREVALENCE OF SYPHILIS tests were made on 175 tuberculous patients at the Corlears Tuberculosis Clinic. Of these, 154, or 88 per cent., were negative, 14, or 8 per cent., were positive and 9, or 5.1 per cent., gave partial reactions. Subsequent findings con- firmed the diagnosis of syphilis in all cases that gave a strongly positive reaction, and in some that were reported weakly positive. Through the kindness of Dr. H. J, Corper I am able to quote the results which he has obtained from routine examinations of patients at the Chicago Tuberculosis Sanitarium for the last three years (1915-1917). The Wassermann reaction was performed on all admissions, using the Noguchi hemolytic system and a non-cholesterinized beef-heart antigen. Only those cases giving complete fixa- tion of complement were considered positive. The results may be tabulated as follows : Male. Female. Age in years. Total. Positive. Positive, per cent. Total. Positive. Positive, per cent. to 5 6 to 15 16 to 25 26 to 40 41 to 60 Over 61 Unknown 43 207 341 551 212 14 27 1 16 14 50 19 1 2.3 7.7 4.1 9.0 8.9 7.1 0.0 31 265 443 531 111 5 13 1 14 17 37 11 3.2 5.2 3.8 6.9 9.9 0.0 0.0 Total 1395 101 7.2 1399 80 5.7 From the above table it will be seen that of a total of 2794 cases of both sexes and all ages a positive Wassermann was obtained in 181, or 6.5 per cent. This is believed to be an absolute minimum, for it must be remembered that partial reactions are not given, that a cholesterinized antigen was not used, and that many cases known to be syphilitic were probably excluded and treated elsewhere. Many are thus treated at the County Hospital. Among males of twenty- six to forty years of age the percentage is at least 9, and may be estimated at a considerably higher figure. Criminals. — Criminals can hardly be included with the sick, nor can they be classed with the normal population. STATISTICS FROM DIFFERENT GROUPS 71 According to Boudreau^''^ the Wassermann reaction has been performed on all admissions to the prison at Auburn, N. Y., except those sent from Sing Sing. This rule has been in force since December, 1915. During the following five months there were 279 admissions, of which 47, or 16.8 per cent., had positive reactions. In addition the test was made on all inmates of the women's prison, and out of 127 specimens, 43, or 33.8 per cent., were positive. Kramer^o^ examined 1583 out of the 1800 inmates in the Ohio penitentiary on July 1, 1915: 288, or 18.1 per cent., gave either positive or partial reactions as follows: 18 were four plus, 35 were tliree plus, 149 were two plus and 86 were plus. Of these 288, 43, or 14.9 per cent., gave a clinical history of some sort. Of the colored population, 58, or 13.4 per cent., were positive; while 108, or 20.9 per cent., of the American-born population were positive. This low finding among the colored prisoners is remarkable and unexplained. Vedder^^ investigated the prevalence of syphilis among the military prisoners confined at Fort Leavenworth and Fort Jay. While these men are not criminals they include a cer- tain number of defective and abnormal individuals. Of 1 145 prisoners examined, 82 were under treatment for syphilis, 101 more had a double-plus Wassermann; so that 183, or 15.98 per cent., may be regarded as undoubtedly syphilitic. In addition to this there were 65, or 5.67 per cent., who had a plus Wassermann. Thomas^"^ reported that for a year a Wassermann reaction was made on every prisoner admitted to the Naval Prison at Portsmouth. Of the 280 tested, 59 gave a history of a chancre, and of these 49 had a positive Wassermann. None of the 221 cases denying a history of infection had a positive Wassermann, While these figm-es are almost too good to be true, and it can hardly be believed that not a single case out of 221 denying infection should have a positive Wassermann if accepted at their face value; this indicates that 21 per cent, of the prisoners at Portsmouth are syphilitic. The statistics of the New York Health Department quoted by Pollitzer^°5 are of great interest. He states that 35 per cent, of the 3809 cases from the criminal, degenerate and Number Positive, of tests. Positive. per cent. 391 45 11.5 544 37 6.8 253 62 24.5 2621 1209 45.7 72 THE PREVALENCE OF SYPHILIS derelict class have syphilis, the distribution being shown by the following table : SYPHILIS IN THE DEEELICT CLASS. Tombs prison men awaiting trial Hart's Island Reformatory — boys Penitentiary, Blaekwell's — both sexes . 253 Workhouse — both sexes 2621 Sick Children. — The prevalence of syphilis among children depends almost entirely upon the prevalence of inherited or congenital syphiHs. Such children naturally tend to be found in hospitals and institutions. While the percentage found in general hospitals for children is not large the per- centage of syphilitic children in institutions for the feeble- minded may be quite high. Much work has been done along this line, and it cannot all be quoted. ChurchilP''^ tested a series of 101 hospital children by the Wassermann reaction. None of these children were admitted for syphilis, yet 38 per cent, of the cases gave a positive reaction. Some of these were undoubtedly partial reactions, yet in investigating the clinical condition and history, Churchill came to the conclusion that there were 29 cases, or 28 per cent, of syphilitic children in this series. Blackfan, Nicholson and White^"^^ also examined 101 infants, 68 of whom were from a foundling hospital and 33 from the wards and out-patient department of the St. Louis Children's Hospital. In the first 68. children the Wassermann was negative in 66, doubtful in 1 and positive in 1. In the second group the Wassermann was negative in 32 and posi- tive in 1. Holt^''^ reported 178 tests made on hospitalized children showing no definite signs of syphilis. Positive reactions were obtained in 11 cases, and of these 5 were proved to be syphilitic by the subsequent findings and 2 were probably syphilitic. If the whole 11 are counted as syphilitic this gives a percentage of 6.1. Churchill and Austin^"^ made an analysis of the literature and an intensive study of 695 patients in the Children's Memorial Hospital, Chicago. They conclude that, according STATISTICS FROM DIFFERENT GROUPS 73 to the literature, the incidence of hereditary syphilis must vary considerably, it being variously estimated at from 2 to 14 per cent, in both Europe and America. Intensive study of their own series of 695 patients during the winter of 1915-1916, including both clinical and laboratory methods, indicated an incidence of 3.3 per cent, of hereditary syphilis. The amount among hospital infants and children in four large cities of the United States, New York, St. Louis, Chicago and San Francisco, appears to range from 2 to 6 per cent. Whitney's figures^^ indicated that of 890 children in the out-patient department of the University of California, 26, or 2.9 per cent., were syphilitic. Walker^^ examined 480 inmates of an institution for the feeble-minded in Baltimore, boys and girls, representing State charges, and found that less than 3 per cent, had a positive Wassermann. As showing the higher incidence of syphilis in certain institutions, we may quote several investigators. Johnson"" performed a Wassermann reaction on 224 children from the open-air schools of St. Louis. These schools are maintained for children suffering from anemia and malnutrition of apparently unknown origin. Of these children, 37, or 16.5 per cent., gave a four-plus reaction, 39, or 17.4 per cent., gave a three-plus reaction, 22, or 9.8 per cent., gave a two-plus reaction, 28, or 12.5 per cent., gave a plus reaction and only 98, or 48.8 per cent., gave a clean negative. If the four- and three-plus reactions are counted as indicating syphilis, 76, or 33.9 per cent., of these children were luetic. Lucas^i found that out of 111 children from two to nineteen years of age the Wassermann reaction was positive in 35, or 31.5 per cent. These were all abnormal children, mentally backward, epileptic and suffering from various nervous conditions. Anderson"^ performed the Wassermann reaction on a series of 225 cases intensively studied by exact mental tests: 41 were adults and 184 were children and adolescents; 41 per cent, of the adults and 42.5 per cent, of the children were mental defectives. Of the 41 adults, 24.6 per cent, had a positive Wassermann, and of the 184 children and ado- 74 THE PREVALENCE OF SYPHILIS lescents, 17 per cent, had a positive Wassermann. Anderson states that in every instance the Wassermann reaction was negative in those individuals classified as normal by exact mental tests, so that the percentage of positives for the mentally deficient must have been much higher than indicated by the above percentages and higher than the figures obtained by other investigators. Haines^^^ found that of 68 feeble-minded children at the psychopathic hospital about 30 per cent, were syphilitic, while the incidence of syphilis among all patients tested at this hospital was 14.7 per cent. These results agree closely with those of Dean^*^ and Lippmann^^ who studied the inci- dence of syphilis among idiots in Germany by means of the Wassermann reaction and the clinical findings. On the other hand, quite different results are recorded as the result of an investigation of weak-minded in Denmark,^^* in which out of 2061 weak-minded patients of all ages only 31, or 1.5 per cent., gave a positive reaction. However, such figures are altogether too good to be true. It will probably be admitted that the percentage of syphilis in the general population in Denmark must be higher than this, and there is no reason to suppose that the percentage among weak-minded is lower than that among the surrounding population, but rather the reverse. It would seem therefore that this particular Wassermann technic must have been inefficient in spite of the fact that Boas was one of the collaborators. Haines^^^ also studied the incidence of syphilis among juvenile delinquents and found undoubted evidence of syphilitic infection among delinquent boys andigirls in from 15 to 20 per cent, of the cases. His figures are as follows: Boys. Total tested 147 Positive Wassermann .... 34 Per cent, positive 23 . 1 In such studies of congenital syphilis by means of the Wassermann reaction, higher percentages are obtained the younger the children studied, because the Wassermann reac^ Giris. Total. 218 365 42 76 19.2 20.8 STATISTICS FROM DIFFERENT GROUPS 75 tion is always more strongly positive in early syphilis than in tertiary and so-called latent syphilis. This fact is brought out by Dean's figures on idiots, which were as follows: Number examined. Positive. Positive, per cent. . 94 20 21.27 . 142 24 16.9 . 66 4 6.06 Patients ten years and less . Patients eleven to fifteen years Patients sixteen to twenty years However, it should be noted that under one year of age this rule appears to be reversed. Rabinowitsch^ examined infants at a creche in Charkow, Russia. He made a total of 1108 Wassermann examinations, of which 153 were posi- tive. But 732 of these made on the first examination gave only 83, or 11.33 per cent,, positive; 308 who were examined the second time at a later age resulted in 16.2 per cent, of positives, while on the third examination there were 29.4 per cent, of positives. Dr. Sessions, superintendent of the Indiana Girls' School, an institution for delinquent girls, reported an examination of 243 girls in that school in May, 1915: 55, or 22.6 per cent., gave positive reactions, and Dr. Sessions thought that in 45 of these girls the disease was congenital, and that not one of these 45 had a well-balanced, dependable mind.^^^ McKay^^^ performed the Wassermann reaction on 1550 inmates in the institution for the feeble-minded at Columbus, Ohio. The patients tested ranged in age from six to sixty- one years of age: 134, or 8.6 per cent., gave positive reactions. In only 2 of these cases was there a history of syphilitic infection, sc^that in 132, or 8.5 per cent., the infection was presumably congenital. The youngest patient having a positive reaction was seven years old and the oldest was sixty-one. Moulton"8 tested 600 boys at the Minnesota School for the Feeble-minded. Noguchi's modification with the acetone- insoluble fraction for antigen was used: 523, or 87.1 per cent., were negative, while the remainder gave complete or partial reactions; 16, or 2.6 per cent., gave complete inhibition, and 61, or 10.1 per cent., gave partial reactions. Had a stronger 76 THE PREVALENCE OF SYPHILIS antigen been used, undoubtedly some of these partial reac- tions would have been completely positive. Dawson^'3 reports the results of an examination of 1113 inmates of the Sonoma State Home at Eldridge, California, using the Noguchi technic. Positive tests were obtained in 30 males and 23 females, a total of 53, or about 5 per cent. Ages were from nine to sixty-five years. Individuals Who are Presumably Healthy. — While it is com- paratively easy to obtain information in regard to the exist- ence of syphilitic infection among those individuals who are sick and have presented themselves for treatment, it is a matter of great difficulty to obtain any evidence in regard to the prevalence of syphilis among individuals who are healthy and therefore do not come under observation, and it is due to this fact chiefly that our information in regard to the prevalence of syphilis in the community as a whole is so meager. It occurred to the writer that such information could be readily obtained with regard to the young adult males of the community by making surveys of the men in the army and also of the recruits accepted for the army. This work was accordingly carried out and the results have been published. ^^ So far as healthy white males are con- cerned, these results may be summarized as follows:* Survey. Total exam- ined. Known syphilitics. + + Was- sermann. Undoubted syphilitics. + Wasser- mann. Estimate of total probable syphilitics. Recruits . Cadets White enlisted men 1019 621 1577 3.44 7.75 2.57 4.77 7.75 2.57 8.21 9.02 2.89 7.87 16.77 5.46 16.08 The cadets were from seventeen to twenty-seven years old and may be taken as representative of the better class of- young men that are found in our colleges. The enlisted men ranged from eighteen to forty years of age, but the majority * Foucar made a Wassermann survey of 500 white soldiers at Honolulu , of whom 8.25 per cent, gave a double-plus reaction. Report of Surgeon- General, 1916, p. 193. . STATISTICS FROM DIFFERENT GROUPS 77 were between twenty to twenty-five years of age and may be taken as representing the great middle class of mechanics, artisans and untrained laborers. The evidence indicated that the percentage of syphilitic infections increased with age. Of 25 men of eighteen years of age, 1, or 4 per cent., was positive. Of 64 men of nineteen years of age, 2, or 3.12 per cent., were positive. Of 86 men of twenty years of age, 7, or 8.14 per cent., were positive. The average percentage for five-year periods was as follows: 18 to 22 10.35 23 to 27 16.58 28 to 32 20.85 33 to 37 24.22 37 to 41 28.82 The recruits constituted an especially interesting class because they were not yet a part of the army and therefore represented conditions as found in civil life, except for the fact that as these men had already passed two physical exami- nations, and evident syphilitics had been rejected, it may be assumed that there was a higher percentage of syphilitic infections among the men of this class in civil life than among the picked recruits. From this study the writer drew the conclusions : 1. We may estimate that about 20 per cent, of the young adult male population of the class from which the army is recruited are infected with syphilis. 2. We may estimate that about 5 per cent, of the young men in our colleges are syphilitic. These results were sufficiently interesting to warrant further study, and accordingly, arrangements were made by the Surgeon-General and the Adjutant-General to have a Wassermann reaction performed on each recruit accepted for the army. Each recruit depot was equipped to perform this reaction, and a medical officer was detailed at each depot to perform this work. 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