Early Syphilis as a Public Health Problem.

WALTER JAMES HEIMANN, M.D.

(Assistant Professor of Dermatology and Syphilis, New York Post Graduate Hospital; Adjunct Dermatologist, Mt. Sinai and German Hospitals; Chief of Clinic New York Skin and Cancer Hospital; Pathologist Department of Dermatology, Vanderbilt Clinic.)

This paper is not to be a statistical homily. Neither shall the significance of syphilis to the public be exaggerated nor minimized. The disease, however, is a social threat, the import of which should never be permitted to sink into the background. The human race must constantly be aroused to self-defense against a foe which can be curbed, although at present not exterminated. If there were such a thing possible as premarital asceticism, if monogamy were a fact instead of a delusion, there would be no syphilis. Man, however, is as he is, and neither the sermon of the sex moralist, the raving of prudes, nor the sober warnings of those competent to warn, will suddenly alter a custom which tradition has covertly condoned, however greatly indulgence is fraught with danger. Young men will continue to desert the lecture hall of the hygienist for the brothel, and Metschnikoff's makeshift salve will remain a substitute for rational prophylaxis, so long as human nature remains essentially polygamous and polyandrous. Sexual derelictions have. been accepted as among the lesser vices and they become a source of repentance only in retrospect when their unfortunate victims labor upon the long, nay even endless road to recovery. Society, though, suffers under a burden directly proportionate to the number so afflicted. Since it is impossible for society to eliminate syphilis, it must face the practical problem of lessening its

terrors.

Syphilis, tuberculosis and cancer are humanity's greatest hygienic problems. Of these, syphilis is by no means the least. Tuberculosis is largely a matter of environment, and when society sets a value upon human health at least equal to that of

a stock dividend, so that poverty is not necessarily squalor and filth, tuberculosis will take its place with bubonic plague and variola as a historic disease. Cancer is still nowhere near solution, but unlike tuberculosis and syphilis, it is a condition that at least respects youth and does not strike at humanity during the years of maximum physical and mental effort, or during the years of reproduction, nor is it transmissible. Syphilis, on the other hand, preys upon man during the second and third of his three score and ten and is the result of impulses accepted as uncontrollable.

There are somewhere between ten and twenty million syphilitics in the United States. If only one per cent of these develop central nervous involvement, there will be one hundred and fifty thousand so afflicted, and this estimate is probably two or three times too low. Nearly all aortic insufficiency and aortic aneurisms originate in syphilis. The number of these cases cannot be estimated, nor can it be calculated how many patients suffering with arteriosclerosis, angina pectoris, chronic nephritis, or cirrhosis of the liver owe their diseases to specific origin. Possibly there are two million such cases, or one fiftieth of our total population. Who can state how many miscarriages are due to syphilis, or how many congenital syphilitics are born annually? If there are only two hundred thousand, this means twenty million in a century. Oriental populations double in this period, while Occidental ones increase by about half this figure, and yet we are not awake to the danger of squandering two-fifths of our procreative ability. The aggregate time lost to society by syphilitics in their pursuit of treatment privately or in public institutions is enormous. Assuming that there are only ten million in the United States, that three years are required for the cure, that a half hour is spent in each consultation, and that each patient makes about forty visits annually to his physician, six hundred million hours are lost in this period, or twenty-five million working days, or about eighty-four thousand working years. This represents a loss in wealth that cannot even be surmised. With the utmost desire for optimism, is not syphilis an adversary worthy of our keenest steel?

In a decade of intensive study one lesson stands out that is of practical value to the community. The earlier that the disease is recognized and treated, the greater the probability of prompt and permanent cure. Thus, the likelihood of transmission during the period of maximum infectiveness is decreased, and that of the social sequelae tends to be diminished. Society can face its problem either by destroying the disease, or by drawing its fangs. To destroy the disease, that is to eliminate it, individuals must be instructed as to its dangers. To curb the disease, society must take means to safeguard itself by an enlightened, conscientious, concerted and vigorous series of measures.

The great vehicle of transmission of syphilis is indiscriminate sex congress. In young men the belief is nurtured that continence is injurious. This is absurd, of course, as Haven Emerson recently emphasized in an address before the New York Social Hygiene Society ("How Publicity Can Help to Control Venereal Diseases"). The Germanic tribes of the first centuries of the Christian era held virginity in men as high as in women. If we compare the sexual life of the Northern races to that of the Romans whom they conquered, we can find little to justify belief in the doctrine that continence is harmful either to health or virility.

It is important, then, to combat the superstition that sowing wild oats is a necessary or beneficial activity. Adolescents should be warned by their parents against the physical risks inherent in incontinence. To regard the question as an ethical or moral transgression is another matter and one which can be settled only by the preceptor. Ethical and moral standards are purely subjective, and sermons and other similar forms of appeal are among the least efficacious means of carrying conviction to anyone but their authors.

In the last analysis, one may well despair of the likelihood of accomplishing much by addressing individuals. Although every point made may be accepted by a rational human being, everything in society militates against masculine virginity, and the hope of eliminating syphilis by an appeal to reason is slight, although actually this is the only way to attain the end. Society, then,

is confronted by a complex problem. Syphilis is an infectious disease of great economic importance, in that it materially lowers the physical and mental quality of the race and, as already indicated, alarmingly lowers the birth rate and the mean average standard of the new born. A simple expedient exists to meet the condition-sexual continence. The expedient, however, is impracticable since it is at variance with that which in amiable self-delusion we call human nature. The next best thing to preventing a disease is controlling it. Such control is within the easy reach of society, provided society will assert itself. Properly trained physicians, properly equipped institutions, and suitable legislation are all that is needed.

The training of capable syphilographers should begin in medical schools. Need for brevity forbids me to trace out in detail my reasons for the views about to be expressed concerning this phase of the question. In another paper I have elaborately analyzed the situation and here shall simply record my conclusions. A special chair of syphilography and dermatology with faculty representation is required. To divorce the two subjects, since an expert syphilographer must also be an expert dermatologist, would effect a wasteful reduplication in our colleges. The department in question should teach syphilis in its broader aspects, intimately coöperating with all other clinical departments, and with those of pathology and sero-bacteriology. Suitable clinics should be open to students, and after a two years' course, during which undergraduates in medicine have familiarized themselves with the disease in its general and special aspects, they will be ready to take up their post-graduate training. No candidate should get his degree without being able to make a dark field examination, without having been taught to administer salvarsan and mercury, without understanding the significance of the Wassermann test, or without being able to recognize early syphilis. It is in the early recognition of the disease and in its prompt cure that the hope of the race lies. Shilly-shallying or ignorance where syphilis is concerned are social transgressions on a par with criminal abortion.

The head of the department of syphilography must be a widely