The Third Great Plague A Discussion of Syphilis for Everyday People online

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 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 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 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 reëducate.

+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 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:

1. The provision of universally available good treatment, at the expense
of the state, if necessary, for the diseases in question.

2. 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.

3. The suppression of quack practice, drug-store prescribing, and
advertising of cures for these diseases.

4. 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:

1. General instruction in personal prophylaxis for the population at
large.

2. Compulsory measures and penalties obliging patients to receive
treatment and continue it until cured, regardless of their own desires
in the matter.

3. Notification or reporting of cases of sexual disease to the health
authorities.

4. 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. 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 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 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 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 coöperation 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 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 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 of a drug clerk, tries a little calomel powder on the sore,
and it either "dries up" and secondary symptoms of syphilis appear in
due course, or it gets worse or remains unchanged and the patient
finally goes to a doctor or a dispensary to find that his meddling has
lost him the golden opportunity of aborting the disease. If secondaries
appear, a bottle or two of XYZ Specific, again at the suggestion of the
all-knowing drug clerk, containing a little mercury and potassium iodid,
disposes of a mild eruption, and a year or so later a marriage with
subsequent mucous recurrences and the infection of the wife signalizes
the triumph of ignorance and public shortsightedness. The health
commissioner of one of the largest and most progressive cities in this
country stated before a recent meeting of the American Public Health
Association that he had sent a special investigator to twelve
representative drug stores in his city, and that simply on describing
some symptoms, without even the ceremony of an examination, he had
received from ten of them something to use on a sore or to take for
gonorrhea. It is only justice to say that occasionally one finds drug
stores which will refer a patient to a doctor or a dispensary. Drastic
legislation to suppress this sort of malpractice is part of the program
of Great Britain, Germany, and West Australia, and we in this country
cannot too quickly follow in their steps.

+Publicity Campaign.+ - The educational campaign against sexual disease
has already been discussed in theory. In close relation to it is the
question of the use of publicity methods for legitimate ends, mentioned
above. It has had a number of interesting applications in practice. The
West Australian law has taken the stand of prohibiting all advertising,
replacing the method of attracting the patient into coming for treatment
of his own free will by the method of making treatment compulsory under
heavy penalty. In this country, where compulsory legislation will be
slow of adoption, publicity methods will have a certain vogue and a
proper place. It has been of great service in the campaign against
tuberculosis and in the movements for "Better Babies" and the like. It
should never be forgotten that it is a two-edged weapon, however, and
that where a stigma exists, as in the case of sexual disease, too much
advertising of the place of treatment as distinguished from the need for
it will drive away the very people whose sensitiveness or need for
secrecy must be considered. On the other hand, the publication of
material relating to sexual diseases in the public press has not yet
reached the height of its possibilities, and should be pushed.

+Utilization of Personal Prophylaxis.+ - Passing now to the debatable
elements in a public campaign, opinion about the value of personal
prophylaxis (Metchnikoff) against syphilis shows interesting variations
in different countries at the present time. English-speaking countries
hesitate over this. On the other hand, eminent German authorities, such
as Neisser and Blaschko, urged it at the outset of the present war, and
their views have apparently overcome a vigorous opposition. As a result,
the knowledge of methods of preventing venereal infection are being
spread broadcast over Germany in the hope of diminishing the inevitable
risk that will arise with the disbanding of armies after peace is
concluded, no matter how stringent the precautions taken to insure the
health of soldiers before their return to civil life. The results of
this experiment will be watched with the most intense interest by all
those familiar with the situation, and the results will be of value as a
guide for our own policy when we have had time to develop one. It is
interesting that the most radical departure in the way of legislative
provision for sexual disease, that of West Australia, takes up the
patient at the point where his infection begins and promptly places him
under penalty in the hands of a physician, but assumes no responsibility
for other than indirect prevention. The most radical of all present-day
legal measures against the disease has therefore not yet reached the
radicalism of compulsory prophylaxis as it exists in armies, or even the
radicalism of compulsory vaccination for smallpox.

+Reporting of Syphilis to Health Officers.+ - The question of reporting
syphilis to health officers as a contagious disease is a good one to
raise in a meeting when a stormy session is desired. Upon this question
wide differences of opinion exist all over the world. The right of a
sick person to privacy, always deserving of consideration, becomes acute
when it touches not only his physical but his social, economic, and
moral welfare. It becomes a matter of importance to the state also when
the prospect that his secret will not be kept leads him to conceal his
disease and to avoid good public aid in favor of bad private care. It is
a question whether the amount gained by collecting a few statistics as
to the actual presence of the disease will be offset by the harm done in
driving to cover persons who will not be reported. Modified forms of
reporting sexual diseases, without name or address, for example, can be
employed without betraying a patient's identity, thus doing away with
some of the objections, and they have been in force in such cities as
New York for some time. Vermont has recently adopted a compulsory
reporting system, with the almost ludicrous result that by the figures
her population shows 0.5 per cent syphilis, when the truth probably
stands nearer 10 per cent. Much of the difficulty with reporting systems
goes back to the lack of an educated public or professional sentiment
behind them. For this reason they may be fairly placed in the category
of premature legislative experiments, and should be postponed until a
more favorable time. That this view has the sanction of students of such
problems is borne out by the recent comment of Hugh Cabot on this issue,
and by the decision of the British Royal Commission which, after careful
deliberation, decided not to recommend to the Government at the present
time any form of reporting for sexual disease. The West Australian law
recognizes the wisdom of providing the patient having sexual disease
with every safeguard for his secret provided he conforms to the
requirement of the law in the continuance of his treatment. German
sentiment is strongly against reporting, and no provision is made for it
in the civil population. On the other hand, the very complete programs
of the Scandinavian countries provide for reporting cases without names.
It is, therefore, apparent, in view of this conflict of opinion, that we
can afford to watch the experience of our neighbors a little longer
before committing ourselves to the risk of arousing antagonism over a
detail whose importance in the scheme of attack on syphilis is at best
secondary to the fundamental principles of efficient treatment and
diagnosis. There is no apparent reason why we should not be satisfied,
for the present, at least, with drawing to our aid everything which can
give us the confidence and the willing coöperation of those we want to