and Miss Ora M. Lewis, chief social worker of the Department; the Children's Hospital, Boston, for the privilege of using cases from their clinics; Dr. W. A. Hinton of the Wassermann Laboratory of the Massachusetts Department of Public Health who, through his coöperation over a period of years, has enabled us to examine and follow our cases serologically in a manner that is rarely possible, and who gave us access to original statistics concerning the Wassermann reaction on various groups of patients; our present chief, Dr. C. Macfie Campbell, who has been most helpful in reading the manuscript and offering valuable suggestions, in addition to having done everything possible to facilitate our work from the material side; Dr. H. A. Bunker, who has been kind enough to give a very careful reading of the proof.

The work has been greatly lightened by the conscientious and intelligent secretarial assistance of Miss Louise C. Francis and Miss Theresa Vesce. Finally, we acknowledge our indebtedness for editorial assistance and care of publication details to the American Social Hygiene Association and especially to Mr. Kenneth M. Gould.

Boston Psychopathic Hospital.

H. C. S.

M. H. S.

CHAPTER I

THE INDIVIDUAL

Syphilis as a Disease.-Syphilis is a chronic, infectious, contagious disease, caused by a specific organism known as the Treponema pallidum, or the Spirochaeta pallida. It is a disease, which, unless cured, runs a course as long as the life of the person infected. It is characterized by exacerbations of symptoms and by long periods in which there is no evidence of disease so far as the subjective feelings of the patient are concerned. It has a tendency, nevertheless, to cause various types of physical and mental deterioration, and may lead to incapacity or death.

Syphilis has a very much broader significance than attaches to mere consideration of the individual who originally acquired the disease. Every syphilitic person must be considered as a focus of infection, as a potential danger to the community, in the same category with the "typhoid carrier." He is thus liable to certain rules and regulations for the benefit of the public health. In addition, as the disease may lead to disintegration of the person's mental and physical abilities, the infected individual must be viewed as a possible social liability. He is likely to become incapable of caring for his family, to be the progenitor of defective children, or to become an inmate of a public institution.

Methods of Infection; Incubation and Primary Periods.— It will probably be most satisfactory to sketch the life history of syphilis by considering it in relation to an individual. Infection with syphilis means that the Treponema pallidum, the organism of the disease, has in some manner made its way through the skin or mucous membrane of the body, and thus gained access to the underlying tissues. As a rule this occurs through contact between person and person. It is possible, although less usual, for this contact to occur through the mediation of an object which has been contaminated by treponemata from the body of an infected individual. These

treponemata may then be carried over to the body of a second person. Sexual intercourse is the most frequent method by which the disease is spread, but there are many instances of extragenital infection. For some little time there is no indication that anything has happened. Then at the end of from three to six weeks there occurs what is known as a chancre, or primary sore. The period from the moment that the treponemata enter the body until the appearance of this sore is known as the incubation period. During the incubation period the treponemata which have entered the body begin to multiply. They make their way through the lymphatic vessels which drain the locus at which they entered and reach the blood stream by which they are carried throughout the body. Thus, during this incubation period, although the patient knows of nothing untoward, his body is being invaded by numerous organisms. Finally, after several weeks, the local reaction appears, and with its development the so-called primary period of the disease begins. This local reaction characteristically takes the form of a painless papule, which slowly increases in size, reaching, ordinarily, the dimensions of a small pea. It is prone to assume a crater-like shape, and with the surrounding tissue to become indurated. Unless it is then secondarily infected by some pus-producing organism, there is no purulent exudate, but only a thin serous excretion. The glands which drain this region shortly become enlarged and fairly hard. It is rare, indeed, that they become secondarily infected. Thus, if the sore is on the genitals, the glands in the groin will become easily palpable and have a shot-like hardness. If the chancre is on the lip, the glands under the chin will become swollen.

Diagnosis of Primary Stage by Inspection.-The primary sore is rarely painful or in itself a serious symptom. Occasionally it becomes infected and leads to grave and unpleasant consequences. Such infected chancres are spoken of as phagedenic, and a considerable amount of local damage may be done. Ordinarily the chancre will begin to disappear, with or without treatment, after the third or fourth week. It slowly recedes in size, and soon becomes only a scar. If