The reader who has read this far is already aware of the practical impossibility of ever being sure that a given case is or is not "syphilis." He knows that "syphilis" cannot be definitely determined by the clinical symptoms; that the dark-field test is not always reliable; that the various blood tests are not fully dependable and, finally, that the spinal test cannot be depended on to give an unequivocal answer. In the midst of so much uncertainty, how is it proposed to diagnose the disease? By adding all of the uncertainty together and getting a diagnosis as a final summation.

   Parran says, "In the typical textbook form primary and secondary syphilis are easy to recognize. The trouble is that so few are typical cases. Moore, of Johns Hopkins, says that in one man out of nine, one woman out of three all early symptoms are so evanescent as to be unrecognized unless by accident. Yet the Wassermann is positive, and if this test were used routinely by all physicians in all physical examinations, it would uncover many unsuspected cases."

   The fact is that there has long been a tendency for more and more of the maladies with which people suffer to be attributed to syphilis. This is especially true of nervous maladies. Because of the consequent ever increasing multiplicity and variability of its manifestations it is very difficult to diagnose. Like man, it is "fearfully and wonderfully made," in fact, so "fearfully and wonderfully made," that even its creators cannot recognize it.

   Dr. Tilden says, Venereal Diseases, p. 93, "The profession saddles on syphilis everything that cannot be cured by an irrational treatment. If a symptom presents that by exclusion cannot be attributed to any known disease, then it must come from syphilis, whether or not a scintilla of evidence can be discovered by all the Sherlock Holmes of the profession that the patient has ever had the disease." He says elsewhere that "syphilis" "truly represents a professional monomania. The profession has given so much study to the subject that it has become a real insanity. Why? Because of the fixedness of cause. The premise is that the cause is specific, and it is a mind-upsetting task to undertake to fit a fixed cause to a set of symptoms that are paradoxical as well as heterogeneous."

   Illustrative of the truth of Dr. Tilden's assertions let us look at a few cases cited by Dr. Becker. He tells of a woman whom he examined for "syphilis".She gave a history of "severe tuberculosis" which she had many years previously. She recovered in six months. He declares that severe tuberculosis does not heal so quickly and "her symptoms were interpreted as those of a tuberculoid type of syphilis." Another woman said she had had diptheria of the throat for many weeks before it finally healed. Since diptheria does not last that long "the conclusion arrived at was that the woman may have had the sore throat often typical of early syphilis." A third woman gave a history of a generalized skin eruption involving the whole surface of the body, including palms and soles, "since other skin ailments are not likely to involve the palms and soles," he says, "she probably had experienced an early eruption of syphilis."

   He tells us that "revelations such as these are valuable aids in diagnosing syphilis in cases where there may be some doubt." All the physician needs to do is to pick out something the patient had ten to twenty years previously, the details of which have escaped his or her memory, and arbitrarily decide that it was "syphilis." It is a very convenient method and saves the profession much embarrassment in endeavoring to explain the "late stages" in those who have long been "infected with syphilis" but have never had any knowledge of it.

   This is the reason that it is so very "important to ask (the patient) careful questions relative to all possible types of signs and symptoms, many of which may have been misinterpreted by the patient and at times by the physician." The above mentioned cases "well illustrate the value of the examining physician's ability to interpret the patient's replies to questions."

   Who does not know that the doctor's interpretations will be determined or biased by his premise. If he starts with a suspicion of "syphilis," this will determine how he interprets the patient's replies.

   This method has its drawbacks however; for, "In spite of all the questions a physician may ask, *** it often is impossible to obtain any suggestive history relative to the infection."

   Discussing the diagnosis of "syphilis" in Gonorrhea and Syphilis, by Tilden and Alsaker, Dr. Alsaker says: "some diagnose by exclusion; that is, they try out the case in hand with every other known disease, and if the symptoms fail to agree with all other diseases they can think of, it must be syphilis." It should be obvious to the reader who has followed us this far that a diagnosis by "exclusion" is all but impossible. He will remember that "syphilis" is "the clown of diseases, that it is a dissembler, it is more versatile than any protean actor; it is more varied and variegated than Joseph's coat; its skin manifestations simulate, in different subjects, nearly all cutaneous disorders known."

   Physicians no longer diagnose syphilis "by mere inspections and general impressions," although this was the only method known and employed before the discovery of the "elusive spirochete of syphilis" and the "perfecting" of "the blood test or both. We are told that the "germs of syphilis can be found by the dark field microscope as soon as the chancre appears, which may be several weeks before the blood test becomes positive."

   However the spirochetes are hard to find and there are other organisms that so closely resemble the spirochetes as to be easily mistaken for them, while "failure to find the germs on a dark field examination does not necessarily mean that the lesion is not syphilitic." In addition to this, it is not definitely known that the spirochete is the cause of the chancre. Finally, there is often no chancre or other lesion in which to find the germs. "It already has been pointed out," says Becker, "that at least fifty percent of patients do not have any signs or symptoms of early syphilis which they are able to recognize."

   It is next necessary to examine the rest of the family, perhaps all of ones friends and associates. "Family examinations," though it often "requires considerable ingenuity and effort to convince the family of the need of examination, since there is no legal method, (and they want means of compulsion) of requiring its members to submit to such scrutiny," "assists in the solution of doubtful cases by finding definite infection in other members of the family, and results in placing other infected individuals under treatment."

   If the physician is not sure that his patient has "syphilis" he must examine the rest of the family. With remarkable ease he can positively discover "syphilis" in some other member of the family, even if he does not find it easy to determine whether or not the patient before him has "syphilis." Just as it is easier to find "syphilis" in Indians who have been dead a thousand years than in living Indians; just as it is easier to diagnose a "syphilitic" condition the patient had ten years ago that it is to diagnose the "syphilitic" condition he now has; so it is easier to find "syphilis" in some other member of the family than to find it in the patient.

   The next step is to make one or more of the various serologic tests and follow these with "check tests," for durring the first stage ten percent give a negative test; during the second stage five percent give a negative test; during the third stage thirty percent give a negative test. Even then, we are not sure that the patient has syphilis. Becker says, the blood test "varies from day to day, week to week, month to month, and year to year. This is the case after the early stages of the disease have been passed. If blood tests were taken on a patient with late syphilis every day for a month, there would be some that would be strongly positive, some weakly positive, and some negative. The author, in one or two instances, has seen the results alternately very positive and negative every other day for a week." Because of such experiences Dr. Stokes recommends that the blood test report "should be used as a clew rather than as a clutch." It merely suggests further investigation and is not to be accepted as an infallible diagnostic procedure.

   Let me at this point, repeat a question asked by Dr. Tilden: "If tests are made every few days and they come Wassermann positive every third time, what is the state of the body when the test comes negative, after being positive just a short time before? If the test is worth anything, the patient should be cured — well — when the test shows negative."

   Next the spine must be punctured, a dangerous and barbaric procedure, and fluid drawn and tested. Four tests are made upon the spinal fluid. The white blood cells are counted in the fluid. These are said to be "present in abnormally large numbers in many nervous diseases, including syphilis." A chemical test is performed for globulin, "which is present in greater amount in syphilis and some other nervous conditions." A Wassermann or a precipitation test is made. This is "practically always" but not always, positive in "syphilitic involvement." The fourth is "a very delicate colloidal test," which "tells whether the syphilitic nervous disease may at some future date develop softening of the brain." Taken together the results of the four tests are claimed to show "whether the nervous system is diseased, and to some extent in what way and how severely."

   Not one of these tests is specific. Even the delicate colloidal test often shows that the patient is going to develop softening of the brain (paresis), and he subsequently does nothing of the kind, as de Kruif tacitly admits in The Fight For Life. As unreliable as are these tests of the spinal fluid and as rarely as they are made, Dr. Becker says they supply "information that can be obtained in no other way, and it is so indispensible to the management of a patient that intelligent treatment cannot be undertaken without it in the average case."

   . Becker tells us that in addition to all these "rather simple examinations" described above, "numerous special examinations often are necessary. Assistance of specialists in diseases of the eye, ear, nose, throat, nervous system, genito-urinary system, and heart, in X-ray and electrocardiograph records, and in many other branches of medicine and surgery is necessary. There is no disease known at present in connection with which so much cooperation is necessary as with syphilis."

   Now that we fully understand how difficult it is to accurately and positively diagnose "syphilis," what a lot of tests and check tests and microscopic inspections are necessary and what an army of specialists are required, we naturally wonder how the ignorant physicians of the sixteenth century, who had neither tests nor specialists, ever discovered the existence of "syphilis."

   The modern doctor has a final test to fall back upon when all the above fail him. After all examinations fail he can resort to treatment as a diagnostic method. This is the "therapeutic test," and consists, as Becker says, "in a mere trying out of treatment, whether or not syphilitic infection is present." The drugs are given and "careful observation" of the patient's "signs and symptoms" is made. If the patient improves under treatment he has "syphilis" or something else; if he fails to improve he has something else, or "syphilis." The "therapeutic test" is, in the very nature of things, as utterly unreliable as all the other tests. Why? Because all troubles commonly improve with or without treatment and all troubles often grow worse with or without treatment.

   Although Dr. Becker insists that the "importance of correct diagnosis cannot be over emphasized" and that "absolute diagnosis must be made before treatment is begun, since treatment, to be efficient, is severe on the patient as well as being expensive," he recommends telling the patient, in which there is doubt ("doubtful cases, such as those with weakly positive blood tests"), that "while the evidence is not absolute, you should be treated to insure health, just as patients are sent for a sanitarium rest when tuberculosis is only suspected and not proved." He might have added, just as thousands have their appendices removed when appendicitis is only suspected, or as thousands are operated on for cancer when it is only suspected. He thinks this plan of causing fear, doubt, apprehension in his victim "places the decision with the patient."

   If the patient dies or is killed and the doctor is still uncertain, he can, as the final resort, perform an autopsy. It is true that relatively few autopsies are performed and these are made chiefly on the abused classes, but this does not deter men like Parran from telling us that "any series of autopsies in any hospital in the country will demonstrate *** quite clearly" that thousands of "syphilitics fail to complete the full course of treatment." He is sure that he can tell syphilis in the dead, even if he cannot always detect it in the living.

   It can be of no value to a patient to have his disease diagnosed at necropsy, and, yet, it is quite evident that if he undertakes to spend the money and time necessary to have all the tests and examinations made to arrive at a guess that he does or does not have syphilis he will not get the diagnosis until after fear or starvation have killed him. He can die happy, however, with the thought that he has contributed to the wealth of numerous physicians, specialists, and pathologists. The diagnostic program outlined by Becker certainly gives jobs to the whole profession.

   Much that is supposed to be known about the diagnosis and treatment of "syphilis" is pure hallucination and scientific fabrication. The profession saddles on "syphilis" everything that cannot be, accounted for in a rational way, so that "the disease" has grown more protean with the passage of time. Today there are physicians who hold that all disease is syphilis and that everybody is infected.

   A woman gives birth to a dead child. Now there are many causes for still-births, chief of which are ergot and anesthetics used in labor, but the attending physician "suspects" syphilis. He carefully questions the mother and he learns that a few years before, she had a rash on her body which she thought was due to eating strawberries. Probably it was a strawberry rash, but it becomes another link in the chain of "syphils." Next, he makes a blood test. It is negative, but he is unconvinced.

   He examines the husband. The husband recalls once having had a "cold sore" on his lip, which developed a short time after he attended a party where he took part in a kissing game. Some weeks later he had a headache and a slight fever which were accompanied with an eruption on his chest, which his physician diagnosed as shingles. A blood-test is now made of the husband. It is positive. The doctor is satisfied up to this point. He has discovered the "source of infection" and he now has the husband under treatment. He returns to the wife. He has several kinds of blood tests made and, while part of them are negative one of them is positive. Now he is getting somewhere. Spinal tests are made. Two are positive, two are negative. The woman has "syphilis." There is no doubt about it.

   He calls in an army of specialists. They examine her heart, they X-ray it and make an electrocardiogram. They examine her eyes, ears, nose, throat; her genito-urinary organs; her nervous system, etc. It's too bad, but she certainly has syphilis. He places her under treatment. It is a tragi-comedy in four acts, in which the doctor-hero traces down the corkscrew villian and saves the charming heroine from his evil designs. Since she is already married, the hero and heroine do not marry and live happily ever afterward. In this last particular the play is like a western movie in which the hero, after saving the girl and the ranch, rides away on his pinto to new adventures.