between the selective inhibition of syphilitic serums by raw human serum, as described by Rein, and the inhibition of false positive serums by albumin, as observed here, have not fully materialized, we have shared the alternating moments of elation and disappointment which always accompany research on an elusive problem such as the present one.

The Chairman: Dr. Neurath's paper will be discussed by Dr. R. C. Arnold, of the Public Health Service Venereal Disease Research Laboratory, Staten Island, N. Y.

DISCUSSION

R. C. ARNOLD, Surgeon,

United States Public Health Service

Associate Director, Venereal Disease Research Laboratory
Staten Island, N. Y.

Undue emphasis has not been placed on the occurrence of false positive reactions in the serology of syphilis. The diagnostic and quantitative serologic procedures give positive reactions in syphilis but also may produce positive reactions in certain nonsyphilitic conditions. The clinician and health officer may expect to encounter an increase in this type of serodiagnostic problem when the members of the armed services, who have had various vaccination procedures as well as tropical and acute infectious diseases, return to civil life. Until such time as the work of Dr. Neurath and other investigators gives a laboratory solution to the question of nonspecific reactivity, the diagnosis of syphilis remains a clinical problem.

A patient with nonspecific serologic reactions may require several weeks or even months of continued clinical observations and laboratory studies before the final diagnosis can be established. A review of the anamnestic record may reveal the details of a previously denied venereal infection. The detailed physical examination should include special studies of the cardiovascular, cutaneous, skeletal, and nervous systems. Members of the immediate family or nonrelated sexual contacts should be consulted with casefinding methods. The serologic base line established with the approved qualitative and quantitative tests may be used to gage future serologic trends. Spinal fluid examinations should be rechecked if discrepancies are evident in the clinical and laboratory reports. X-ray photographs may reveal abnormal conditions of the cardiovascular stripe, in the osseous structure, or heavy metal deposits in the gluteal muscles.

The clinical and laboratory data may not be adequate for making a definite diagnosis at first. The majority of nonspecific positive reactions usually revert to the seronegative phase within a few months. However the host mechanism for the production of reactive substances in the blood may need only a minimal stimulant to prolong the abnormal serologic reactivity. With a few nonsyphilitic patients the nonspecific positive reactions may persist for years. Unfortunately the diagnostic problem is complicated by a group of patients, especially females, who have developed a symptomless invasion of syphilis with the positive serologic results as the sole indicator of the disease. Provocative tests with arsenical

drugs do not yield fruitful results. Active antisyphilitic therapy should be deferred until the definite diagnosis of syphilis is confirmed. Except in pregnancy and early infectious syphilis, treatment may be deferred safely for several months during which time the majority of nonsyphilitic positive reactions will become negative. However, in a residual number of patients it may not be possible to establish a definite diagnosis with the available diagnostic methods.

The behavior characteristics of the globulin fractions, obtained from syphilitic and other serums, are most interesting phenomena. The results of the experimental study at this time indicate certain definitive patterns in various types of specimens. The development of a procedure for separating the components of blood serum and the testing of individual and composite fractions presents a new approach for differentiating syphilitic and nonsyphilitic specimens. The evaluation of clinical data and laboratory reports in certain patients are expected to present perplexing diagnostic problems for the clinician until a specific test is available which will prevent the unwarranted diagnosis of syphilis and which will shorten the prediagnostic periods of extensive investigation.

Dr. Neurath and his coworkers have had the courage to tackle one of the most baffling problems in the diagnosis of syphilis. Whether or not their method will afford the greatly needed answer, as it now gives promise of doing, the ultimate end of all such research must be one of benefit to the science of serology and to the clinician who calls it to his aid.

The Chairman: The next paper will be given by Dr. Richard A. Koch, in collaboration with Dr. Ray Lyman Wilbur of California.

Dr. Richard A. Koch: It is indeed a pleasure to have had the opportunity to assist Dr. Ray Lyman Wilbur, President of the American Social Hygiene Association, in the preparation of this paper. Dr. Wilbur sincerely regrets that he has been unable to be present at this meeting.

PROMISCUITY AS A FACTOR IN THE SPREAD OF
VENEREAL DISEASE

RICHARD A. KOCH, M.D., Chief, Division of Venereal Diseases,
City and County of San Francisco, Department of
Public Health

and

RAY LYMAN WILBUR, M.D., President,
American Social Hygiene Association

INTRODUCTION

Venereal diseases are one of the greatest preventable human tragedies. The reason we fail to conquer them is our prudery and our failure to face the over-all problems, their causes, and background. The sex urge is as fundamental as that of hunger and thirst, and in our sensate society that urge has led to promiscuity. Sexual promiscuity is the most vital factor in the spread of venereal diseases. If sexual promiscuity were eliminated from our national life, venereal disease would as a natural course disappear from our State without the necessity of medical intervention. Venereal disease control is concerned inseparably with the physical

and social aspects of our national life. It is thus concerned with the moral fiber of the community, the church, the home, and with those factors and agencies, official and nonofficial, which strengthen that moral fiber, as well as with those factors that tend to weaken it. We must remember that we cannot control the morals of people by legislation, but we certainly can control the environment of youth. Venereal disease control is, therefore, related to church activity, school activity, parent-education programs, youth agencies, recreational activities, law enforcement, protective care of girls and boys, training in leadership, and a long range public health educational program.

This diversity of factors related to the control of venereal diseases is not characteristic of the venereal diseases alone. The control of typhoid fever is not exclusively a medical problem. Its control is related to the control of the sanitary environment and to the vast ramification of engineering feats that are necessary to effectuate this control. The control of tuberculosis is not alone a medical problem. Its control is related to the provision of improved housing conditions through slum clearance; to the provision of adequate parks and playgrounds; to the development of a general concept of a healthy social life providing sufficient recreation, freedom from overcrowding, balanced nutrition, and an understanding of family hygiene. There are many nonmedical factors also used in the control of malaria, yellow fever, cholera, dysentery, plague, and other communicable diseases.

Unquestionably, venereal disease control is of a more personalized nature than the control of the other communicable diseases. Perhaps for this reason the venereal diseases have, to a large degree, defied control. It is for us to recognize the diversity of the problems involved and to effectuate programs directed towards their solution.

The nonmedical problems related to venereal disease control are those that relate to sexual promiscuity. Promiscuity in the male has always been more or less condoned as long as such promiscuity was not blatantly forced upon the public. Just as the satisfaction of hunger and thirst is commercialized by the food establishments with the preparation of attractive articles of food, so also is the satisfaction of the sex urge likely to be commercialized. Such commercialization, if the community permits, involves the establishment of houses of prostitution with the result that where such houses exist a high percentage of venereal disease is certain to be found. It has been shown that if commercialized prostitution is actively repressed, a decline in the incidence of venereal disease follows. Prostitution is, of course, a system intended to serve male promiscuity. It is intolerable in a democratic society.

In our past history, promiscuity of the female has not been accepted. We are only a few decades away from the days when a promiscuous woman would find her door painted with tar as the sign of disapproval of her moral looseness. If we attempt to trace the acute development of female promiscuity in contemporary times, we need search no further than World War I, when women gained more freedom outside the home, and the passage of the Nineteenth Amendment in 1920, when women gained the same political privileges and freedom held by men.

As a woman has become more prominent in the business world and has accepted greater freedom outside of the home, she has also to some degree accepted the same masculine freedom in relationship to sex. A few years ago the largest percentage of venereal disease came from prostitutes, but since the repression of commercialized prostitution the promiscuous girl has been left as the major source of venereal infection. Therefore, today the problem of venereal disease control is with the promiscuous girl and not the prostitute. Not only is this a wartime problem, but with the lowering of moral conduct and the loosening of old controls and safeguards, more and more, the promiscuous girl as the spreader of venereal disease will be a definite postwar problem.

Those who have worked in the field know that if ever venereal diseases are to be eradicated, the control must be related not only to medicine and public health but also to welfare, church, law enforcement, education, and public understanding, and must be supported by all agencies, private and governmental.

The solution of the problem of promiscuity does not lie in the hands of the medical profession. It will be corrected only by cultural changes in society. Surgeon General Thomas Parran has written (1) "It is my opinion that too often in the past health officers have neglected their direct medical responsibilities in controlling syphilis and have diluted their efforts by attempting to function in the whole field of social hygiene. The repression of prostitution is primarily the responsibility of the law enforcement agency. The teaching of sex hygiene is primarily the function of the parent and educator, secular, and religious. As a good citizen, the health officer should work wholeheartedly with both. As a public servant, he should do his own job and endeavor to coordinate it intelligently with both."

The official health agency, being directly concerned with the control of all communicable diseases, must act as a community catalyst in bringing about a public awareness of the over-all community problems pertaining to the dissemination of venereal dis

eases.

STATISTICAL ANALYSIS

We have found among 8,027 persons examined in a prewar serologic survey among labor unions in northern California (2) that the incidence of positive serologic findings among the employed was 3.7 percent, whereas among the unemployed it was 5 percent. In a summary of studies made from 1935 to 1940, Dr. Walter Clarke (3) reported syphilis was more prevalent in the relief (unemployed) groups than in the employed groups. We further found (2) in the northern California area group the incidence of positive serology to be 3.8 percent in the resident and 6.3 percent in the nonresident or transient, a difference of incidence indicating that those who live transient, migratory lives are more prone to promiscuity and have a higher incidence of syphilis than those who live a resident, nontransient life.

In the serologic examination of 14,354 new employees of a San Francisco war industry (table 1) which represent, in the large, a transient population, or a population which did not have its roots

deeply established in a communal environment, we have found 1,590 (11.1 percent) to have a positive serology; 685 (6.0 percent) whites and 905 (30.6 percent) Negroes. These statistics again illustrate the high incidence of syphilis among the relatively promiscuous transient. On the other hand, examination of 3,610 workers from the same industry before the introduction of large masses of migratory workers (table 1) showed 214 (5.9 percent) to have positive serologic reactions; 108 (3.7 percent) white and 106 (15.5 percent) Negro; thus again is illustrated the lower incidence of syphilis in the resident, less promiscuous class of our population. Further analysis of this table shows the low incidence of positive serology in our stable population.

TABLE 1.-Serologic findings in employees of San Francisco industries

Serologic survey of the migratory workers White... 11,400 employed by the above war industry..._ | / Negro---| 2,954

Occupational status is related to social stability and the establishment of a permanent home. In various industrial surveys in the San Francisco area (4), out of a total of 7,147 workers whose occupation was known the incidence of positive serologic reaction in percentages was as follows:

The incidence of syphilis decreased with increase of employment stability.

The Psychiatric Service of the San Francisco City Clinic offers figures related to promiscuity. Patients referred to this service in 1943 were those who had been interviewed by public health nurses and doctors and found to be sexually promiscuous, not prostitutes, and generally under 22 years of age. Promiscuity was