one stage of tuberculosis, is an important therapeutic measure; in another stage, exercise is perhaps equally important. A patient without fever, whose lung condition is quiescent and whose physical strength is good, may be made worse by excessive "rest," for, as the poet Cowper said:

"Absence of occupation is not rest,

A mind quite vacant is a mind distressed." During this period of enforced idleness the mind of the patient, for want of occupation, turns upon himself and his disease, with the result that unhappy conditions are exaggerated, hopefulness, the prime essential for recovery, deserts him, and he loses his "backbone." For this reason, whenever strength will allow, the patient should be occupied to some extent both mentally and physically.

I have left to the last one of the most common sources of worry the financial condition of the patient. When we consider the great number who suffer with tuberculosis and the early age, usually, at which they are obliged to seek the cure, we are not astounded that it is only exceptionally that they are able to meet the demands made upon the purse. The giving up of business, the long duration of the illness, the board and the doctor's bills, all combine to make the lot of the tuberculous a difficult one, financially.

Thus we see that there are several causes operative-not all of them the direct result of the disease, but due indirectly to the worries which are in a large measure inseparable from an illness of long duration-which must tax the patience and the pocket-book of the tuberculous to no small degree. The extent to which these worries will graft mental depression onto the tuberculous condition will depend upon the original temperament of the individual. Those of a naturally pessimistic turn of mind will make but little effort to seek a bright side, but will glory in their gloominess, while those of a more sunny nature will not only accept with resignation their condition, but will ever strive to see a light-ray out of the darkness. This is the true "spes phthisica."

SOME GENERAL CONSIDERATIONS ON SYPHILIS OF THE NERVOUS SYSTEM, WITH REMARKS ON PROPHYLAXIS.

BY F. M. BARNES, JR., M.D. THE question of the importance of syphilis in the production of disease has received a great deal of attention from all sources. There is no branch of medicine which does not meet with it in some one of its protean forms. Every practitioner has had to meet and deal with the problems of health and hygiene which are variously associated with luetic infection. The social danger resident in this ability of syphilis to produce diseased states, which tend to a greater or lesser degree to lessen the value of the individual as an efficient member of the community is enormous, one may well say limitless. Not the individual alone is to be considered; the ravages do not stop with the original source of infection. Even though legal measures might be able to restrict the individual to a degree, this is no certification that the disease may not be carried into the family with the possible and not uncommon subsequent manifestation of its activity in the offspring. Thus we see plainly that we have to deal with a disease which strikes at the very unit of racial existence.

So far the question has been considered in its broadest aspect-its effects both direct and indirect as produced by pathological conditions of the organism in general. It is the purpose here to deal with only one phase of the subject-the extent, importance, and results of luetic infections of the central nervous system. Aside from all personal inclinations to thus limit the consideration, there seems to be a long series of succinct reasons why syphilis of the cerebrospinal system should merit especial attention. The very banality of its occurrence has been sufficient to excite widespread comment. The tertiary lesions of syphilis are preeminently the ones fraught with the greatest degree of danger, and of these over 30 per cent, find their localization within the tissues of the nervous sys

tem. Added to these there are yet the metasyphilitic disorders-tabes and paresis -particularly important because of their resistance to all known therapeutic measures. The additions to our knowledge concerning syphilis made within the past decade have only tended to increase our appreciation of the widespread extent of its field of action, and from the psychiatric viewpoint, to impress upon us the truly multitudinous variations in the mental symptomatology which may be produced by it. Within still more recent years the application of biologic tests in the detection of syphilitic antibodies in the fluids and tissues of the body has further served to open up before us a still clearer view of its great importance as an etiologic factor in mental medicine. Various abnormal mental states formerly associated etiologically with other factors we now see reproduced by syphilis. "Es gebe keine Form geistiger Störung die nicht gelegentlick bei Syphilitischen und infolge der Syphilis zur Enstehung kömmen könnte." This brief but rather allinclusive statement by Jolly (cited from Birnbaum, Ueber Geistesstörungen bei Gehirnsyphilis, Allg. Ztschr. f. Psychiatrie, 1908, lxv, 340) summarizes well the opinion of most observers as to the extent to which luetic infection may act as a causal agent in the production of mental disorders and incidentally emphasizes strongly the importance which must be attributed to this factor in the diagnostic consideration. of almost every psychotic state. The question of the diagnosis is here of particular moment because we know that the majority of diseases dependent upon an active syphilitic process are to a fair degree amenable to therapeutic measures, and the less so in proportion to the state of advancement which has taken place. Hence an early recognition of the causal nature of the disorder is of great value. Further, as has been claimed, treatment is not only useless but possibly even harmful in the metaluetic affections. It is not surprising, when we stop for the moment to take into account the anatomical nature of syphilitic diseases of the brain, that there should

present itself such a varying and multiform symptomatology. The diffuse meningoencephalitis, the more or less focal lesions resultant upon gummatous growths and the irregularly distributed affection of the cerebral vascular system, only need be kept in mind in order to understand the presentation of many symptom-complexes.

In view of the fact that the occurrence of syphilis and its relation to mental and nervous disorders has become widely recognized, and further that nearly every phase of the subject has been thoroughly treated by able authorities, it would seem to be hardly worth while, in a general consideration such as is given here, to attempt to discuss in a few pages the extent of its pathologic manifestations in the realm of mental activities. The widespread action which it may exert has already been mentioned. Reference to the papers of Mott "On Some Recent Developments in Our Knowledge of Syphilis in Relation to Diseases of the Nervous System" (British Medical Journal, 1908, i. 10), and “The Pathology of Syphilis of the Nervous System in the Light of Modern Researches" (British Medical Journal, 1909, i. 454, 524); of Krause ("Die Erkrankungen des Nervensystems infolge von Syphilis," Deutsche Militärarztl, Ztschr., 1907, xxxvi. 820) and many others well indicates the extreme latitude of its activities upon nervous tissues.

After the foregoing remarks concerning the great extent of the occurrence of syphilitic lesions in the nervous system, its importance no longer can remain a matter of conjecture, but rather becomes a self-evident fact which merits and will permit of further emphasis. Mental diseases, as a class, which from the very nature of their manifestations generally require the withdrawal of the affected individual from society, both as a protection to himself and the community, occupy a very important position in the problem of social existence. The very organ through the function of which the individual is normally rendered competent to adapt himself to his environment is attacked. The mental disorder thus

not only affects the individual and those dependent upon him, but reacts upon the community, which must afford proper institutions and hospitals into which he may be admitted and receive treatment. One may gain some insight into the enormity of the burden upon the community by glancing at conditions as they exist in New York State. The report of the Lunacy Commission of that State for the fiscal year ending September 30, 1910 (Twentysecond Annual Report, State Commission in Lunacy, State of New York, Albany, 1911), reveals that there remained under treatment in the State hospitals on that date 27,849 27,849 insane individuals. In another part of the same report it is stated that 7642 patients were admitted to the various institutions for the insane in that State during this year, and further that the causation of the mental disorder of those admitted in 15 per cent. of the cases was due either directly or indirectly to syphilitic infection. When one considers the sublime importance, not only from the point of view of the maintenance of a useful existence, but also from that of the mere continuance of life, of the functions mediated through the activity of the brain, the gravity of the significance of these figures cannot fail to be impressive. In addition to the damaging effects upon the social system which are. directly due to syphilis per se, there is this additional extremely important group of diseases which, though directly dependent upon the luetic infection, react upon the community in an indirect manner.

This brief general consideration of the extent and prevalence of mental and nervous disorders directly dependent upon syphilis, of their importance from an economic standpoint and of their resultant effect upon social organization, will serve as a sufficiently solid foundation upon which to base the question, How is this situation to be improved? The answer of the idealist is, by the eradication of syphilis. Let us pass on to more imminent, rational, and plausible possibilities and for

the present engage ourselves with the consideration of means by which the condition may at least be alleviated-in other words, prophylaxis.

Prophylaxis here may be considered under three main headings: legal, moral, and educational. Regarding the first: There is no doubt but that adequate medico-legal supervision of prostitution, as existent in large cities to-day, would aid in decreasing the frequency of contagion by restricting the activities of those individuals who constituted the source of infection. However, legislation can do little more than affect the mere external appearance of the situation. The pus pockets of this sloughing gangrenous area cannot be drained by such superficial methods. From past experiences great hope cannot be placed in the beneficial results to be obtained from moral or religious attacks. Although society at large may to-day show a greater veneer of virtuous modesty, it is somewhat doubtful whether the moral status of mankind has actually undergone any improvement in our times. There is no doubt but that it would afford an ideal prospect to look forward to the extinction of syphilis by the purification of present moral (!) tendencies, but it is far more practical to admit that sexual intercourse without due. legalization by civic or church ceremony will continue to exist. Rhapsodical dreaming of the Utopian age when humanity will retrace its steps into the garden of primordial innocence has no place in the consideration of the frigid facts with which the solution of this problem has to deal. So long as the individual who has unfortunately become the host of the treponema pallida is looked upon as a social outcast and moral derelict, so long as his affliction is considered as the just retribution and visitation of punishment for the sin which he has voluntarily committed, by just so long a time will all advance in prophylactic measures directed against this great plague be retarded. How often, as we see an unfortunate drag himself past with hemiplegia gait, do we hear some narrow

minded, pseudo-moralistic blot upon the page of progress remark: "No more than he deserves." The outlook upon life's problems of such a critic is surely due to a restricted visual field. Such helping sympathy could be ignored were it not for the principle which underlies it—a principle which necessarily retards advancement. Continued moralizing upon the basis of religious misconceptions will accomplish no more good in this campaign than it has in past unsuccessful ones resting upon a similarly constructed platform. It is a popular belief that one who has been so unlucky as to contract syphilis must have led a life of debauchery. It is needless to point out the fallacy of such a conception. Suppose such were the case he is not to be censured. Grant for the moment that we have to do with one who has shown an absolute and total disregard for all conventions, who in the wild endeavor to satiate his own sensual passions has exhausted the gamut of all orgies. Possibly this one, too, is in part at least excusable. It may be that he is ignorant—and herein our system of education is at fault-the individual is not to blame. Or again, very frequently, if not always, such excesses are but the outward expression of mental disorder; the mind in the execution of its function as adapter is not sufficiently well organized to adjust the individual into those environmental relations which experience has demonstrated to be within the limits of the normal. Even though such extenuating circumstances cannot be produced for the defense, our present social system seems to require one. Is it in line with existent humanitarian efforts to refuse the aid which will alleviate the suffering simply because of the manner by which the cause was made operative? Such refusal too often is the case. It is a formidable arraignment of modern conditions of civilization to say that with its current conceptions of morality it becomes incumbent upon the individual who has acquired syphilis (in whatever way) to conceal his disease to the best of his ability, in order that he may not

share in the opprobrium and disgrace associated with discovery. Thus, treatment is often interfered with, even neglected, the acute symptoms pass away and are possibly forgotten and there exists another source of propagation of infection. Grant for the moment that it is possibly irremediably unfortunate that with our present civilization circumstances that venereal infection is all too frequently sustained in carrying out one of the two most fundamental tendencies of human nature, it still is not necessary to consider it a crime for which the unfortunate one is to be punished by being looked upon as a social outcast and renegade.

are such

And finally what aid is to be expected from educational efforts directed toward the betterment of the present condition? Are there sufficient reasons to justify the hope that any radical change is to be promoted by such measures? Most assuredly there are. Past experience in dealing with problems of national importance from the hygienic standpoint have conclusively proven that the success attained has been derived largely from the practice of the principle of the education of the public in

more fundamental facts regarding health and disease. To a higher standard of hygienic education preventive medicine owes a great element of its brilliant accomplishments. On the other hand, the retardation of all advancement due to the suppression of learning as reflected in the history of the Dark Ages offers a sufficient criticism of the danger inherent in the further continuance of the policy of ignorance. When we come to the consideration of the value of education in the matter of sexual activities, and especially concerning diseases resulting from such activities, difficulties of peculiar and unique character are encountered. As has been mentioned previously, our social system has shunned heretofore the mention of such subjects, the individual has been forced into an attitude of concealment owing to the public censure to which discovery would lead. Why, it is asked, should we

attempt to educate those who knowingly subject themselves to the recognized dangers of venereal infection? But in the majority of instances, is the disease acquired by those who have a full knowledge of the consequences? Statistics would go to show that the opposite state of affairs obtains. Syphilographers have demonstrated that, in men, the most frequent age of infection is at twenty-three; for women, some five years younger. It cannot be claimed that at these ages the individual has attained the full quota of experience allotted.

Following the plan that the less youth is instructed in matters of sexual relationship the better will he be protected from its malignant results, few at this age have any adequate conception of its myriad dangers. Scrupulous care has been practiced to keep them in deepest ignorance of all matters of sex. Childish inquiry is set aside by lies; the new arrival was left on the housetop by the mythical stork, or perhaps, in our more practical days, on the doorstep by the milkman. By such subterfuge the growing youth is compelled to obtain his information of these subjects and obtain it he most certainly and inevitably willfrom whatever source he may. It is obvious that knowledge thus obtained must necessarily be not only inadequate, but even pernicious and dangerous. To attempt to satisfy the continual inquiry of the developing mind concerning the mysteries of sex, in the manner practiced in the past, is futile as well as inexcusable and culpable. The sexual instinct is the most fundamental factor furthering the continuance of existence. Therefore, it is not surprising that coincident with the occurrence of almost any episode leaving a mental impression, it should be found to have exerted some direct or mediate influence upon the reaction of the individual. Although one may be unwilling to accept in toto the ideas regarding the preeminent importance of the sexual life, in the development of psychic anomalies as elaborated in hypothesis, yet

it must be admitted that by these rediscovered studies we have learned that the sexual element becomes active at a much earlier age than was formerly believed.

In this untutored state, covered by the pall of ignorance and armed with his wealth of inexperience, the young man in some affaire d'amour contracts syphilis. What happens? Very often, fearing parental displeasure and punishment, he conceals his misfortune from those who, though to a degree culpable for not having instructed him, are yet not only willing, but also probably in a position to give him. valuable advice. Again, in his ignorance some quack or charlatan is called upon, and for a brief period he may receive treatment (?), under which the initial signs of disease vanish, and he goes away with the quieting assurance that he is cured. Still further, ignorant of the far-reaching possibilities of this apparently simple disease to provoke subsequent serious dangers, het dismisses the affair from his mind. Often later manifestations make the recall painful because of the widespread effects of its unmerited acquirement by members of his family.

Having thus indicated that we may hope to eradicate some of the baneful results of this disease by decreasing the prevalent ignorance concerning it by educational measures, the question naturally arises as to the manner of conducting the campaign and to whom the work is to be intrusted. That there has heretofore been displayed a marked tendency by those upon whom the task should devolve to shirk the responsibility is evident from the ignorance which yet prevails. It is not intended here to enter upon the field which more properly belongs to the scientific educator, the one best fitted by observation and experience with educational problems, to formulate a curriculum by which the best results may be expected. In this connection no more than mention will be made to show that the initial steps have been taken and some advance made, as may be seen by reference