The World-wide Movement Against Venereal Disease.—This chapter is intended to give some account of the great movements now begun to control syphilis and its fellow-diseases throughout the world. A campaign of publicity was the starting-point of the organized attempt to control tuberculosis, and in the same way a similar campaign has been at the bottom of movements which now, under the pressure of the tremendous necessities of war, are making headway at a pace that generations of talking and thinking in peaceful times could not have brought about. Although this country at the present writing is probably farther in the rear than any other great nation of the world in its efforts to control the venereal diseases as a national problem, it is fortunate in having had the way paved for it by epoch-making movements such as those of the Scandinavian countries, and by the studies of the Sydenham Royal Commission on whose findings the British Government is now undertaking the greatest single movement against syphilis and gonorrhea that has ever been launched. For many years Germany has had a society whose roll includes some of the greatest names in modern science, directing all its energy toward the solution of the problem of sexual[Pg 165] disease, and German sentiment on these matters is developing so fast that it is difficult, even for those in touch with such matters, to keep pace with it. In this country progress has been much slower, hampered by peculiarities of mental outlook and tradition very different from those which have controlled the thought of Europe. The association of syphilis with prostitution has been largely instrumental in putting much valuable statistical and general knowledge of the disease into semi-private reports and sources not available to the large mass of the thinking public. The effect of finding the problem of syphilis invariably bound up with discussions of the social evil has been to perpetuate in popular thought an association which simply blocks the way to any solution of the public health problem. While the control of prostitution will influence syphilis, ignoring syphilis, or treating it as incidental, will never contribute anything to the conquest of either. It is one of the most significant features of the great movements now on foot all over the world that they have finally adopted the direct route, and are attacking syphilis and gonorrhea as diseases and not by way of their association with prostitution.

The agencies in this country which are making notable efforts to push the campaign against syphilis and gonorrhea deserve every possible support from the thinking public. The American Social Hygiene Association is a clearing-house for trustworthy information in regard to the problems of sexual disease, and publishes a quarterly journal.[16] The National[Pg 166] Committee for Mental Hygiene and its branch societies are also engaged in spreading knowledge of the relation of syphilis to mental disease and degeneration. State and City Boards of Health are active in their efforts to further the campaign, and notable work is being done by New York City, Buffalo, Cleveland, and Rochester, New York, both on publicity and in the provision of facilities for recognizing and treating the diseases in question. Certain states, such as Ohio, Michigan, and Vermont, have made steps toward an intelligent legislative attack on different aspects of the problem. Influential newspapers and magazines have made the idea of a campaign against these diseases familiar enough to the public, for example, to bring a young girl to me to ask outright without affectation that she be told about syphilis, because she had seen the word in the paper and did not fully understand it. The aggregate of these forces is large, and an awakening is inevitable.

[16] Social Hygiene, New York.

To prepare ourselves for an active and intelligent share in the movement, we should review briefly the essential elements of a public campaign against syphilis as they have been developed by recent investigations and legislative experiments.

Undesirable and Freak Legislation.—Syphilis has had a limited amount of recognition in law, unfortunately not always wise or timely. Freak legislation and half-baked schemes are the familiar preliminaries which precede the grim onset of a real attack supported by public sentiment. Typical examples of such premature legislation may be found in the setting[Pg 167] up of the Wassermann test as evidence of fitness for marriage by certain states, and in the efforts of certain official agencies to enforce the reporting of syphilis and gonorrhea by name. Proposals to quarantine and placard all syphilis are in the same category, though seriously entertained by some. The plan to establish by state enactment or municipal appropriation special venereal hospitals falls in the same class, since it is obvious that in the present state of opinion none but down-and-outs would resort to them. The stigma attached to them would effectually make them useless to the very group of worth-while people which it is to the public interest to conserve and re?ducate.

Value of Conservative Action.—It cannot be said too often that a reasonable conservatism should temper the ardor of reformers, or more harm than good will be done by the collapse and failure of ill-considered special legislation. Unified action against syphilis and gonorrhea as public health problems is as important as unified action on the problems of railroad control, child labor, or corporate monopoly. For that reason it is a matter of some uncertainty how much can be accomplished by individual states in this country in the way of restrictive legislation, such as that controlling the marriage of infected persons, or punishing persons who fail to carry treatment to the point of cure. Under the direction of a national bureau or department of health administration there is no doubt that the movement against syphilis would advance at a much more rapid pace[Pg 168] than with the sporadic and scattered activities of mixed state and private agencies.

The Essential Features of a Modern Campaign.—The repeated sifting of the facts which has been done in recent years by important investigations, such as that of the Sydenham Commission in Great Britain and the Society for Combatting Sexual Disease in Germany, and the legislative programs already mentioned, have gradually crystallized into fairly definite form, the undoubted essentials of a program for controlling venereal diseases, syphilis among them. These may be summarized as follows:

    The provision of universally available good treatment, at the expense of the state, if necessary, for the diseases in question.
    The provision by the state of efficient means of recognizing the diseases at the earliest possible time and with the greatest possible certainty in any given case.
    The suppression of quack practice, drug-store prescribing, and advertising of cures for these diseases.
    Moral and educational prophylaxis and the vigorous suppression of prostitution.

In addition to these measures, which are common to all proposals and working systems for the control of sexual disease, certain other recommendations may be classed as debatable, inasmuch as they are still under discussion and have been incorporated into some and omitted from others. These are as follows:[Pg 169]

    General instruction in personal prophylaxis for the population at large.
    Compulsory measures and penalties obliging patients to receive treatment and continue it until cured, regardless of their own desires in the matter.
    Notification or reporting of cases of sexual disease to the health authorities.
    Indirect legislation, as it might be called, which aims to detect infected persons before they enter on marriage rather than at the outset of the disease, either by releasing the physician in charge of the case from the bond of professional confidence, or by requiring health certificates before marriage, and which annuls marriages after infection is discovered.

Easily Available Treatment.—It will be noticed that toleration of prostitution with supervision has finally disappeared from the modern program for the control of sexual diseases. The provision for universally available treatment, regardless of the patient\'s means or circumstances, should be thought of as the one fundamental requirement without which no program has made even a beginning. For over a century Denmark has provided for the free treatment of all patients with venereal disease. The Norwegian law, essentially similar, dates from 1860. Italy a few years ago adopted a similar program, placing squarely upon the state the responsibility of providing for the care of all patients with venereal diseases. England has just adopted a mixed provision which will in practice place most of the responsibility upon the state and very little on the individual, as far as the expense of treatment is concerned.[Pg 170] Germany has compelled her insurance companies to shoulder the burden, and under pressure of war is hastening matters by invoking more and more governmental aid. The recent West Australian Act provides that every medical officer in the pay of the state shall treat venereal disease free of charge. In comparison with the tremendous advances over previous indifference which such programs represent, this country makes a poor showing. Among us, no public agency is formally charged with any duty in the matter of preventing, recognizing, or treating the vast amount of venereal infection that mars our national health. Certain state boards of health are attempting to perform Wassermann tests, and certain municipalities have well-organized laboratories for the detection of syphilis and gonorrhea, but there are few purely public agencies that even pretend to have a specialist in their employ to assist in the recognition of cases and conduct the treatment of patients who cannot afford private care. Hospital and dispensary treatment of venereal diseases is almost entirely in semi-private hands, and a recent investigation of clinics and dispensaries for the treatment of syphilis and gonorrhea in New York city, for example, showed that many of them were so poorly equipped and run at such unreasonable hours that they were frequented only by vagabonds, were of no value in the early recognition of syphilis, could not administer salvarsan under conditions to which a discriminating patient would dare to trust himself, and made no pretense at following their cases beyond the door or[Pg 171] discharging them from medical care as cured. One of the largest cities in this country until a year ago had not even a night clinic to which day workers could come, and is scarcely awake now to the necessity for such a thing.

Dispensary Service.—The provision of adequate treatment and diagnostic facilities, on a par with those which will presently cover Europe, will mean the following things: First of all, dispensaries, and many of them, for the identification of early cases, fully equipped with dark-field microscopes, with record systems, and with the means for following patients from the time they enter until they are cured. This means nurses, it means social service workers, it means doctors with special and not general knowledge of syphilis and gonorrhea. The Brooklyn Hospital Dispensary is an admirable example of what such an institution should be, but it is one where such institutions should be numbered by dozens and by hundreds. Copenhagen, with a population less than that of several cities in this country which have none, has seven municipal clinics whose hours and names are prominently advertised.

Hospitals.—In the second place there must be hospital facilities. They must not be venereal hospitals, but services or parts of general hospitals, so that patients who are received into them will be protected from stigma and comment. Pontopidan, a Danish expert, estimated that for the care of venereal disease one hospital bed to every 2000 of population was insufficient, and yet there are cities[Pg 172] in this country which do not have one bed available for the purpose to 100,000 people. The hospital performs a peculiarly valuable function in the care of syphilis in particular. It provides for temporary quarantine, and for the education of the patient in his responsibility to the community when he is discharged. Three weeks or more under hospital direction is the best possible start for an active syphilis that is to be cured. The privacy of a syphilitic can be protected in a hospital as successfully as in a specialist\'s office, and the quality of treatment which can be given him is distinctly better than he can obtain while out and around. Hospitals in general have kept their doors closed to syphilis until recently, and it is only under the pressure of a growing understanding of what this means to the public health that they are awakening to their duty.

Cheap Salvarsan.—Before a general campaign for the successful treatment of syphilis can be made a fact, salvarsan must become, as has already been pointed out, a public and not a private asset. It must be available to all who need it at the lowest possible cost[17]—practically that of manufacture—and must be supplied by the state when necessary. The granting of patent rights which make possible the present exploitation for gain of such vital agents in the protection of the public health is a mistake which we should lose no time in remedying. While salvarsan does not mean the cure of syphilis, it does[Pg 173] mean a large part of its control as an infectious disease. When it can be given only to the person who can muster from five to twenty-five dollars for each dose which he receives, it is evident that its usefulness is likely to be seriously restricted.

[17] The price of salvarsan before the war was $3.50 per full dose for the drug alone. It can be profitably marketed at less than $1.00 per dose. The patent rights have been temporarily suspended during the war, and their renewal by Congress should not be permitted.

Reduction of the Expense of Efficient Treatment.—Free treatment for those who cannot afford to pay is a necessary part of the successful operation of any scheme for the control of sexual disease. But for those who can and are willing to pay a moderate amount for what they receive, there should be pay clinics which will bridge the gap between the rough and ready quality and the unpleasant associations of a free dispensary, and the expensive luxuries of a specialist\'s office. This is a field which is almost virgin in this country, and which deserves public support. There is no reason why, for a reasonable fee, the patient with syphilis should not secure all the benefits of hospital care, the personal attention of specially trained men, an intelligent supervision of his case, and the benefit of co?peration between a hospital service in charge of experts and the home doctor who must care for him during a considerable part of the course of his disease. Provision of this sort makes treatment both more attractive and more available to large numbers of people whose pride keeps them away from the public provision for charity cases, and whose limited means leave them at the mercy either of quackery or of well-meaning but entirely inexperienced physicians.

Value of Expert Services.—The factor of expert judgment in the care and recognition of syphilis is[Pg 174] an important one, and a progressive public policy will not neglect to provide for it. The state, municipal or hospital laboratory which professes to do Wassermann tests should not be in charge of some poorly paid amateur or of a technician largely concerned with other matters, or its findings will be worthless. Every clinic and hospital should also attach to its staff an expert consultant on syphilis on whom it can draw for advice in doubtful cases and for the direction of its methods of work. Every city health board which undertakes a serious campaign against syphilis should not be satisfied merely with doing Wassermanns, but should enlist in behalf of the public consultation of the same grade which it expects to employ in the solution of its traction and lighting problems, and in the management of its legal affairs. No one would think nowadays of placing a physician in charge of a great tuberculosis sanitarium whose knowledge of the chest was confined to what he had learned in medical school twenty or more years before—yet in a parallel situation one often finds the subject of syphilis handled with as little attention to the value of expert knowledge. Expert service is expensive, and if the state wishes to command the whole energy of progressive men, it must be prepared to pay reasonably well for what it gets.

Suppression of Quacks and Drug-store Prescribing.—The suppression of quackery is nowhere more urgent than in the control of syphilis. Every important legislative scheme that has come into existence in recent years has recognized this fact. The[Pg 175] devil may well be fought by fire, and reputable agencies should enter the field of publicity with some of the vigor of their disreputable opponents. The brilliant success of this scheme was admirably illustrated by the results of the recent efforts of the Brooklyn Hospital Dispensary, which, by replacing the placards of advertising quacks in public comfort and toilet rooms, and running a health exhibit on Coney Island, attracted to a clinic where modern diagnosis and treatment were to be had an astonishing number of young people who would have fallen victims to quacks. The evil influence of the drug store in perpetuating the hold of syphilis and gonorrhea upon us is just being understood. The patient with a beginning chancre, at the advice............