jpjV® 1' I 'S '' ' NATIONAL HEALTH SERIES 
Announcement 
In .order to provide the general public with authoritative 
books on health at low cost, the National Health Council has 
arranged with the Funk & Wagnails Company for the publi- 
cation of The National Health Series. This series will 
contain twenty books on all phases of human health, written 
by the leading authorities in the United States. 
Man and the Microbe: How 
Communicable Diseases are Con- 
trolled. By C.-E. A. Winslow, 
Dr. P. H.; Professor of Public 
Health, Yale School of Medicine. 
A description of germs and 
germ diseases and how they are 
spread, together with practical 
methods of disease prevention by 
means of sanitation. 
The Baby's Health. By Richard 
A. Bolt, M.D., Gr. P. H.; Di- 
rector, Medical Service, Ameri- 
can Child Health Association. 
How to care for the baby so 
that it will be healthy, will de- 
velop properly, and be strong and 
free from disease. 
Personal Hygiene; The Rules 
for Right Living. By Allan J. 
McLaughlin, M.D.; Surgeon 
United States Public Health 
Service. 
Practical suggestions as to how 
to apply personal hygiene to pro- 
mote health and get the most out 
of life. 
Community Health; How to 
Obtain and Preserve IL By D. 
B. Armstrong, M.D.; Sc.D.; Ex- 
ecutive Officer of the National 
Health Council 
An outline of what the com- 
munity should do for the health 
of its citizens and what each 
person should do to make his 
community a healthy place. 
Cancer: Nature, Diagnosis, and 
Cure. By Francis Carter Wood, 
M.D.; Director, Institute for 
Cancer Research, Columbia Uni- 
versity. 
The best statement about can- 
cer ever written for the laity. 
It tells what it is and how to 
know it and have it cured. 
The Human Machine; How the 
Body Functions. By W. H. 
Howell, Ph.D., M.D., LL.D., 
Sc.D.; Associate Director, School 
of Hygiene and Public Health, 
Johns Hopkins University. 
A non-technical, literary de- 
scription of the anatomy and 
physiology of the human body, 
the most wonderful machine of 
all. 
The Young Child's Health. By 
Henry L. K. Shaw, M.D.; Clin- 
ical Professor, Diseases of Chil- 
dren, Albany Medical College. 
How to care for the health of 
Uie runabout child from two to 
six years of age. 
The Child in School; Care of 
Its Health. By Thomas D. Wood, 
M.D.; Professor of Physical Edu- 
cation, Teachers College, Colum- 
bia University. 
Promotion of health habits in 
children of school age and ex- 
actly how to go about it. 
Tuberculosis; Nature, Treat- 
ment, and Prevention, by Linsly 
R. Williams, M.D.; Managing 
Director, National Tuberculosis 
Association. 
Covers the whole field of tuber- 
culosis, the cause, spread, treat- 
ment, prevention and duties of 
citizens, patients, and the com- 
munity. 
The Quest for Health; Where 
It is and Who can Help Secure 
It. By James A. Tobey, M.S.; 
Administrative Secretary, Nation- 
al Health Council 
A statement of what health is, 
how it may be obtained, and a 
description of the actual help 
which the government. States, 
municipalities, physicians, and 
voluntary health agencies can 
give to individuals. NATIONAL HEALTH SERIES 
Love and Marriage; Normal 
Sex Relations; By T. W. Gallo- 
way, Ph.D., Litt.D.; Associate 
Director of Educational Measures. 
American Social Hygiene Asso- 
ciation. 
The various elements, biologi- 
cal, social, and sexual, which 
make up a successful and happy 
married life. 
Food for Health's Sake; What 
to Eat. By Lucy H. Gillett, 
M.A., Superintendent of Nutri- 
tion, Association for Improving 
the Condition of the Poor, New 
York. 
An outline of what and how to 
eat for maximum efficiency and 
health building. 
Health of the Worker; How to 
Safeguard It By Lee K. Frankel 
Ph.D.; Chairman, National Health 
Council. 
Hygieme and sanitation in 
factory and shop and how in- 
dustrial workers can protect and 
promote their health. 
Exercises for Health. By Lenna 
L. Meanes, M.D., Medical Direc- 
tor, Women's Foundation for 
Health. 
Illustrative material giving to 
individuals the type of exercise 
best suited to each one's per- 
sonal needs. 
Venereal Diseases; Their Med- 
ical, Nursing, and Community 
Aspects. By W. F. Snow, M.D., 
General Director, American So- 
cial Hygiene Association. 
A non-technical discussion of 
cause, spread, treatment, cure, 
and prevention of each of these 
diseases and related social hy- 
giene questions. 
(Continued) 
Your Mind and You; Mental 
Health. By Frankwood E. Wil- 
liams, M.D., Medical Director, 
National Committee for Mental 
Hygiene, and George K. Pratt, M.D. 
Describes how your mind can 
be a friend or enemy and how 
it can be enlisted as your ally. 
Taking Care of Your Heart. 
By T. Stuart Hart, M.D., Presi- 
dent, Association for the Preven- 
tion and Relief of Heart Disease, 
New York. 
How to avoid and prevent heart 
troubles, which form the lead- 
ing cause of death in this 
country. 
The Expectant Mother; Care of 
Her Health. By R. L. DeNor- 
mandie, M.D.; Specialist, Bos- 
ton, Mass. 
The health care needed during 
pregnancy in order that both 
mother and baby may be healthy 
and well. 
Home Care of the Sick; By 
Clara D. Noyes, R. N.; Director 
of Nursing, American Red Cross. 
What to do in the home when 
illness is present. Practical sug- 
gestions for the care of the sick. 
Adolescence; Educational and 
Hygienic Problems. By Maurice 
A. Bigelow, Ph.D.; Professor of 
Biology and Director School of 
Practical Arts, Teachers College, 
Columbia University. 
The scientific and sociological 
aspects of adolescence to explain 
the proper transition from child- 
hood to adult life. 
THE NATIONAL HEALTH SERIES 
20 Volumes. 18mo. Flexible Fahrikoid. Average number of pages, 70. 
Price per set, $6.00 net; per volume, 30c. net 
FUNK & WAGNALLS COMPANY, Publishers 
NEW YORK and LONDON NATIONAL HEALTH COUNCIL 
American Child Health .Association, 
370 Seventh Avenue, New York City. 
American Public Health Association, 
370 Seventh Avenue, New York City. 
American Red Cross, 
17th Street between D and E, Washington, D. C. 
American Social Hygiene Association, 
370 Seventh Avenue, New York City. 
American Society for the Control of Cancer, 
370 Seventh Avenue, New York City. 
Conference of State and Provincial Health Authorities of 
North America, 
Care of State Department of Health, Lansing, Mich. 
National Committee for Mental Hygiene, 
370 Seventh Avenue, New York City. 
National Committee for the Prevention of Blindness, 
130 East 22d S.treet, New York City. 
National Organization for Public Health Nursing, 
370 Seventh Avenue, New York City. 
National Tuberculosis Association, 
370 Seventh Avenue, New York City. 
Direct Members 
United States Public Health Service, 
Washington, D. C. 
United States Children's Bureau, 
Washington, D. C. 
Conference Members 
American Association of Industrial Physicians and Surgeons, 
Care of Dr. W. A. Sawyer, Eastman Kodak Co., 
Rochester, N. Y. 
Women's Foundation for Health, 
370 Seventh Avenue, New York City. 
Associate Members 
OFFICERS 
Lee K. Frankel, Chairman. 
William F. Snow, M.D., Vice-Chairman. 
James L. Fieser, Recording Secretary. 
Linsly R. Williams, M.D., Treasurer. 
STAFF 
A. J. Lanza, M.D., Executive Officer. 
James A. Tobey, Administrative Secretary. 
Thomas C. Edwards, Business Manager. 
Elizabeth G. Fox, Washington Representative. 
Offices of the National Health Council 
Administrative:-370 Seventh Avenue, New York City. 
Washington:-17th and D Streets, N. W., Washington, D. C, THE 
VENEREAL DISEASES 
THEIR MEDICAL; NURSING, AND 
COMMUNITY ASPECTS 
BY 
WILLIAM FREEMAN SNOW, M.D. 
General Director, American Social Hygiene Association 
THE NATIONAL HEALTH SERIES 
THE NATIONAL HEALTH COUNCIL 
EDITED BY 
FUNK & WAGNALLS COMPANY 
NEW YORK AND LONDON 
1924 FUNK & WAGNALLS COMPANY 
Printed in the United States of America 
Published, May, 1924 
Copyright Under the Articles of the Copyright Convention 
of the Pan-American Republics and the 
United States, August II, 1910 INTRODUCTION 
The proudest boast of civilization is universal 
education; its greatest triumph the suppression of 
disease and vice. And in no field is there more 
honest prejudice to be overcome, more insidious and 
powerful organized vicious antagonists to be com- 
bated in order that these ends may be achieved, 
than in that which we call Social Hygiene. 
Here is a record from the pen of the man who 
more than any other has commanded the forces 
waging the war for Social Hygiene. To him we owe 
the direction of its education, the sobriety of its 
regulations, resulting in the American ideal of con- 
tinence with which our armies startled the world 
during its great war; to him the triumph of its 
exalted and unbelievable success. 
This little volume exhibits in simple prose the 
epic of standardization uniting medicine and law 
with morals to establish a foundation upon which 
the future will found for all time the health and 
idealism of youth, the strength of its maturity, the 
protection of its family life, the soundness of its 
legislation. 
Edward L. Keyes, M.D., 
Professor of Urology, 
Cornell University Medical School. 
New York, March, 1924. CONTENTS 
I-Nature of the Venereal Diseases i 
II-Diagnosis and Treatment of Syphilis io 
III- Diagnosis and Treatment of Gonor- 
rhea 19 
IV- Public Health and the Venereal 
Diseases 26 
V-The Nurse and the Social Worker 
as Aids to the Health Officer and 
the Physician in the Control of 
Venereal Diseases 36 
VI-The Community Safeguards Against 
the Spreadofthe Venereal Diseases 40 
VII-The United States Public Health 
Service and the American Social 
Hygiene Association 51 THE VENEREAL DISEASES 
CHAPTER I 
THE NATURE OF THE VENEREAL DIS- 
EASES AND THEIR PREVALENCE 
THE history of the venereal diseases, like that 
of most of the dangerous communicable dis- 
eases, is one of gradual discovery of the identity, 
the cause, and the treatment for each of the diseases 
included in the venereal-disease group. Science 
gives to the two which will be discussed here the 
names Syphilis and Gonorrhea. Each of these is 
distinct from the other; the micro-organism (or 
germ) which causes one can not cause the other. 
They are grouped together and called venereal dis- 
eases because they find their chief opportunity for 
dissemination at the time of sexual relations between 
persons already infected and those who are sus- 
ceptible to infection. There are, however, other 
ways in which they occasionally enter the bodies of 
their victims: for example, the organism causing 
gonorrhea may succeed in escaping from the tissues 
of the mother and, entering the eyes of her child 
during birth, cause a condition called ophthalmia 
neonatorum frequently resulting in permanent blind- 
ness or impairment of vision; or the syphilis organ- 
ism may escape from mucous patches in the mouth 
of a father who kisses his child, thus giving the 
organism a chance to enter the body of the child 
through a fever blister or other abrasion of the lips. 
Fortunately all transmission of these diseases is 
comparatively rare except through sexual intercourse. 
1 2 
THE VENEREAL DISEASES 
This fact offers the great opportunity for control 
and prevention of these diseases and at the same 
time furnishes the great difficulty in getting the 
public to do anything effective about them. 
Scientific and medical achievement relating to 
syphilis and gonorrhea may be summed up by saying 
that they are communicable diseases, each caused by 
an identified organism; their methods of transmission 
are known; practical laboratory and clinical technique 
has been worked out for diagnosing each of them; 
effective treatment can greatly lessen the period of 
danger to others and will improve the chances of 
complete recovery for infected individuals, but the 
treatment must be thorough and the patient must 
be continuously under the supervision of the doctor 
until discharged as cured. Syphilis in its early 
stages is especially a danger to the public, altho at 
that time it often seems to the infected individual 
to be of little consequence. In its late manifesta- 
tions the disease is not as a rule communicable, but 
frequently causes the breakdown of its victims phys- 
ically and mentally. Gonorrhea, on the other hand, 
is a particularly painful disease at the beginning 
and then may become so mild that the individual 
thinks he is completely cured, while he actually 
remains for years a source of danger to others, 
particularly through sexual intercourse. 
From a public-health point of view we know the 
cause of these diseases; we know that they outrank 
practically every other group of the more dangerous 
preventable diseases in the amount of serious illness 
and tragedy they cause; we know how to control 
them; but we also know that the application of neces- 
sary measures of prevention and control can not 
proceed more rapidly than the formation of public 
opinion in support of these measures. Therefore the 
public-health officer must at present depend largely NATURE AND PREVALENCE 
3 
upon two methods of control which are outside his 
own jurisdiction: first, the reduction in the number 
of human carriers of the disease in the community- 
through the diagnosis and treatment of infected indi- 
viduals by private physicians, and, second, the reduc- 
tion of the number of exposures to infection through 
legal and educational agencies promoting such stand- 
ards of personal conduct and environmental condi- 
tions that a minimum of persons will be sexually 
promiscuous. The history of the public-health pro- 
gram has accordingly been one of uneven develop- 
ment, often attended with controversy over the value 
and soundness of the measures adopted. Difference 
of opinion regarding how far compulsory reporting 
of venereal disease and quarantine constitute an 
interference with personal liberty, has been one of 
the main causes of conflict regarding public-health 
measures. Another equally vital point of difference 
has been whether certain measures for compulsory 
examination of women prostitutes promote rather 
than decrease sexual immorality and whether such 
measures constitute an unwarranted and unfair dis- 
crimination between the sexes. At the present time 
there is general agreement among all who have 
studied the problem carefully that the venereal dis- 
eases must be conquered by a simultaneous use of 
educational, moral, recreational, legal, and protective, 
as well as medical measures. Some account of these 
activities will be given in the following sections. 
The concurrent history of these related moral, 
social, and educational activities has had an impor- 
tant bearing upon the story of the venereal diseases. 
If sexual intercourse could be limited to marriage 
as sanctioned by law and religion, or if all persons 
infected could be diagnosed promptly and thereafter 
would refrain from all sexual intercourse until treat- 
ment has rendered them non-infectious, these diseases 4 
THE VENEREAL DISEASES 
would soon disappear. Theoretically they are more 
readily'subject to attack and eradication than any of 
the diseases public-health departments have brought 
largely under control, yet actually they remain among 
the most prevalent of diseases throughout the world, 
taking their toll of health and life from individuals 
of every race, age, sex, and condition of people. 
They are so insidious in their attack, so indirect in 
their methods of maiming and killing their victims, 
and so favored by the complicated relations between 
the moral and the medical aspects of their eradica- 
tion, that the public has remained without an organ- 
ized defense against them until recent years. 
Recognition of the necessity for encouraging and, 
where necessary, requiring the infected individual 
to place himself under adequate treatment and to 
carry out instructions for the protection of others, 
and for urging those not infected to avoid exposure, 
has led to the beginning of essential team-work 
among three major groups: (i) Those dealing with 
the medical and public-health phases of the problem 
-doctors, health officials, laboratory technicians, 
nurses, social workers; (2) those dealing with edu- 
cational and character-training phases-educators, 
the clergy, the many other educational and ethical 
training workers; (3) those dealing with the environ- 
mental phases-members of the legal profession, 
police officials, delinquency and protective workers, 
playground and recreation workers, representatives 
of all the varied forces favorably influencing the 
wholesome use of leisure time and combating vice 
conditions which constantly promote sex appeals to 
the youth of the country. As this team-work has 
developed, increasing progress has been noted in 
bringing the venereal diseases under control. The 
public has begun to understand that these diseases 
are in themselves neither moral nor immoral; they NATURE AND PREVALENCE 
5 
are the pathological results of infection by dangerous 
parasitic enemies of mankind, which can be seen 
under the microscope and whose life histories have 
been worked out. The fact that they most frequently 
find opportunity to enter the body through the genito- 
urinary system is analogous to the fact that the 
diphtheria organism gets into the body through the 
throat, and the hookworm through the skin. Real- 
izing this, people have now generally agreed that 
diagnosis, treatment, and after-care should be pro- 
vided for the victim of a venereal disease just as 
they are provided for the victims of any other dis- 
ease, and that every measure consistent with sound 
public policy should be instituted to this end. 
It is impossible to present adequate statistical 
statements of the prevalence of the venereal diseases 
in the general population, because of the incom- 
pleteness of the reporting of cases. Information 
regarding their prevalence in special groups of the 
population is, however, available. The following 
statements are included to give some idea of the 
evidence which has been obtained upon the signifi- 
cance of the venereal diseases as a public-health 
problem. 
The most important information available was 
obtained during the World War through the physical 
examinations of the drafted men, when a large 
number of men proportionately distributed through- 
out the entire country were examined. Among the 
second million men, 5.67 per cent, had a venereal 
disease at the time of examination. Syphilis showed 
a rate of 1 per cent., gonococcus infection a rate 
of 4.5 per cent., and chancroid less than two-tenths 
of 1 per cent. These figures show the result of 
clinical inspections only, without general laboratory 
tests of all troops. There are other reasons for 
pointing to these figures as a minimum statement. 6 
THE VENEREAL DISEASES 
The prevalence of infections detected through 
clinical examinations as compared with the preva- 
lence as determined by laboratory tests of the whole 
group is shown in the following record. In a Was- 
sermann test survey of 1,577 enlisted men of whom 
over 3.4 per cent, were known through clinical 
observation to have syphilis, 12.64 Per cent, of posi- 
tive reactions were obtained. The percentage of 
infections was lower among the younger men and 
increased regularly with advancing age in this group 
studied. Lower infection-rates were found among 
men in certain officer candidate groups: among 3,203 
candidates for commissions in the Regular Army, 
188, or 5.86 per cent., yielded evidence of syphilis 
by laboratory tests. Among the cadets enrolled at 
West Point during one year, 5.46 per cent, gave 
such evidence. Both of these statements furnish 
only evidence of venereal disease present at the time 
of examination. 
Other interesting figures are available in Army 
reports to show the number of infections discovered 
during extended periods of observations. For exam- 
ple, among the enlisted men stationed in the United 
States, a group with an average strength of 96,612 
men, 6,093 venereal-disease cases were reported 
during the calendar year 1922. This makes an annual 
rate of 63.07 per 1,000. There were 3,984 admissions 
for gonococcus infection, 1,288 for syphilis, and 821 
for chancroid. About 12 per cent, of all admissions 
to sick report for diseases were occasioned by 
venereal diseases. More admissions were due to 
gonococcus infection than were due to any other 
diseases except tonsilitis, bronchitis, and pneumonia. 
Sickness from the combined group of venereal dis- 
eases resulted in absence from duty amounting to 
169,497 days, or 24 per cent, of all absences on NATURE AND PREVALENCE 
7 
account of sickness. Gonococcus infection alone 
caused a greater loss of time than any other disease. 
The average loss of time per case of this infection 
was 26 days. 
In thus making use of Army figures, it can not 
be emphasized too strongly that the Army deserves 
the greatest credit for frankly and openly recog- 
nizing this problem, and for earnestly attacking it. 
Figures from the Army and Navy and from certain 
other government services are often quoted exten- 
sively because they are available and give some basis 
for estimating what probably is the extent of these 
diseases among civilians. Valuable evidence concern- 
ing the prevalence of syphilis in another class of sup- 
posedly healthy persons has been obtained through 
Wassermann tests of pregnant women by many hos- 
pitals and dispensaries. These tests are given as a 
part of the routine procedure of admission, because 
it has already been established that treatment of the 
mother during pregnancy is a means of guarding 
the child against the serious consequences of a 
syphilitic infection acquired before birth. In an 
important study of 4,000 patients in the obstetrical 
department of the Johns Hopkins Hospital, Balti- 
more, 449, or 11.2 per cent., presented a "positive" 
reaction. The percentage of infection was much 
higher among colored than among white women; 
16.29 Per cent, of the colored and only 2.48 per cent, 
of the white women gave positive reactions. 
There have been no similar surveys to determine 
the prevalence of gonorrhea in the general popula- 
tion. It is almost a hopeless task to gather adequate 
data for this widely spread disease. Because there 
are so many mild cases and so many which are not 
diagnosed for various reasons which will be apparent 
to the reader, it has been impossible thus far to get 
anything like complete reporting of gonorrhea. All 8 
THE VENEREAL DISEASES 
the evidence, however, points to a prevalence three 
or four times as great as that of syphilis. 
Further evidence as to the prevalence of the 
venereal diseases, particularly of syphilis, is ob- 
tained through the examination of mortality records. 
As a cause of death, gonorrhea is apparently of 
less importance than syphilis. At least it is not 
often reported as a direct cause of death. Syphilis, 
on the other hand, is reported as one of the leading 
causes of death. The reporting of syphilis deaths is 
far from complete for two main reasons: First, 
syphilis appears in so many different forms, physi- 
cians are frequently unable to identify it; and syphilis 
as the cause of death is often unknown until a post- 
mortem examination reveals the fact. Second, some 
physicians in order to spare the feelings of the 
families of patients, report deaths really caused by 
syphilis as technically due to other causes. In spite 
of this recognized underreporting, enough deaths 
from syphilis were reported in the registration area 
of the United States in 1922 to rank this cause 
twelfth among the leading causes of death. Many 
attempts have been made to estimate the actual pro- 
portion of deaths due to syphilis. Sir William Osler, 
in 1917, presented an estimate, important because 
of his wide experience as a pathologist and his 
international reputation, showing that instead of 
ranking in the tenth place in the Registrar-General's 
Report for England, syphilis should be "at the top, 
an easy first among the infections." The estimates 
of statisticians and specialists vary, but all agree 
that syphilis is one of the most important causes 
of death-one of the very first, ranking with tuber- 
culosis, pneumonia, and heart-disease. 
Weighing opinion has its dangers, but it is inter- 
esting that the prevailing opinion of the health 
authorities in the United States is that syphilis and NATURE AND PREVALENCE 
9 
possibly gonorrhea have reached their maximum of 
prevalence, and that during the past two years there 
has begun a definite decline in many parts of the 
country. There is as yet no adequate way of veri- 
fying this opinion, but those who hold it have many 
apparently sound arguments in support of their 
views. If they are right, the situation is full of hope 
for marked progress in reducing both the morbidity 
and the mortality from these diseases in the next 
ten years. CHAPTER II 
THE DIAGNOSIS AND TREATMENT OF 
SYPHILIS 
THE important thing in dealing with syphilis 
is to get the cases under treatment at the begin- 
ning of the infection. For the individual this gives 
the greatest promise of cure, and for the public the 
greatest assurance that the disease will be brought 
under early control and the patient made non-infec- 
tious for others. Three weeks or more after infec- 
tion the disease usually first manifests itself as a 
sore (called a chancre) at the site of an abrasion 
or wound of the skin or mucuous linings of the 
genitals or other parts of the body, through which 
the organism causing syphilis (named the Spiro- 
chaeta pallida) has entered. It is desirable to do 
everything possible to induce any one who has such 
a sore, the cause and nature of which is not definitely 
known, to seek the advice of a physician promptly. 
The physician will either find that the sore has 
none of the characteristics of a chancre, or he will 
keep it under observation and will make or have 
made a miscroscopic examination. He will do this 
in the case of practically all sores on the genitals 
as a precaution, because it is often very difficult to 
diagnose syphilis in this or subsequent stages with- 
out the aid of the microscope and the laboratory. 
The microscope may show the syphilis organisms, 
and treatment can be begun at once with great hope 
of checking the disease before it has seriously dam- 
aged the patient. Prompt treatment is so important 
that where a person happens to know exposure may 
10 THE DIAGNOSIS OF SYPHILIS 
11 
have occurred, many physicians advise beginning 
treatment immediately in an attempt to prevent any 
active development. Only an experienced physician 
can determine the existence of syphilis in this vitally 
important early stage, and only the trained physician 
can treat the disease adequately. Therefore, the 
soundest advice that can be given any one is "consult 
your doctor and tell him frankly why you came." 
While the microscope is the first resource of the 
physician in supplementing his clinical examination 
of a patient at the beginning of syphilis, he gains 
additional information by having a blood examina- 
tion made. One of these has become widely known 
and talked about-the Wassermann test. This test 
requires the careful taking from a vein of a small 
quantity of blood which is sent to the laboratory 
for examination. Great skill is demanded of the 
laboratory worker to interpret the results correctly, 
and the conditions under which the blood was taken 
from the patient must be known. For example, 
if alcohol has been drunk within twenty-four hours 
or a heavy meal has just been eaten, the blood-test 
is not so reliable. For the present purpose it may 
be said that if the Wassermann test is "negative" 
and the physician has already found the syphilis 
organisms in the sore, he has reason to hope that 
he can limit the disease and effect an early cure; if 
this blood-test is "positive," under these conditions, 
the disease has already extended through the body 
and the treatment will have to cover a long period. 
Of course, if he did not find the syphilis organisms 
and the blood-test is also negative, it is possible 
that the patient has a sore which looks to the physi- 
cian like a syphilis lesion but is not; under these 
circumstances he has to make a further clinical study 
and use other laboratory tests of the case before 12 
THE VENEREAL DISEASES 
deciding what to do in addition to preliminary treat- 
ment of the sore itself. 
The reason for discussing this at length is that 
syphilis requires the joint efforts of the physician 
and the laboratory expert to make certain of the 
diagnosis in this early stage, when everything is to 
be gained and sometimes everything lost, according 
to the result. Every person who has been, or thinks 
he may have been, exposed to syphilis ought to go 
immediately to a competent physician and then 
patiently await the verdict. Any physician who does 
not now use the laboratory as an aid in diagnosis 
and direction of treatment is incompetent or is 
taking unwarranted chances unless such facilities 
are inaccessible and the situation is fully explained 
to the patient. Patients should insist on thorough- 
ness or seek another physician. 
Unfortunately the first symptoms and sore are 
often so slight or so concealed that the patient either 
does not know of their existence or can not believe 
that they have any relation to so dreaded a disease 
as syphilis. For such reasons many cases are not 
seen by the physician until later in the course of the 
disease. Generally in from one to six weeks after 
the chancre appeared symptoms and evidence of the 
second stage begin to show. Syphilis has been 
called the great imitator, and this name characterizes 
the difficulties of the physician in making a diagnosis 
and promptly getting the patient under treatment 
at this time. The symptoms-headaches, pains in 
the joints and long bones especially at night, some- 
times slight fever and loss of weight, and a sense 
of being unwell, followed by slight sore throat and 
disturbance of other mucous membranes causing 
discomfort-are frequently so mild and so like those 
of many other diseases that nothing is done about 
them. There follow usually the clinical signs which THE DIAGNOSIS OF SYPHILIS 
13 
the physician looks for: a general skin eruption 
which sometimes is very mild, and mucous patches 
in the mouth and throat. If these are pronounced, 
the patient and his friends are alarmed and he goes 
to a doctor; if very mild, this stage of the disease 
is also frequently ignored and the opportunity to 
treat the individual and to protect the public is lost. 
The eruption takes so many forms that no one except 
an experienced physician ought to attempt to say 
it is caused by syphilis; but all eruptions ought to 
be examined because they always mean some ab- 
normal condition. There is practically no danger 
to the family or friends of a syphilis patient from 
the skin eruption. Unless the skin becomes broken 
and secretions containing the Spirochates get a 
chance to come in contact with a wound in another 
person's skin, infection can not occur, and this chance 
is very remote. This statement concerning the 
unlikelihood of infection does not apply, however, 
to the secretions of the mouth or the mucous mem- 
branes of the genito-urinary passages. In these 
the destruction of the surface of the mucous mem- 
branes is easily accomplished and the syphilis organ- 
isms await the opportunity to transfer themselves 
directly to the mucous membranes of other victims. 
It is for this reason that, for example, an infected 
man at this stage is so dangerous to his children 
through kissing them, to his wife, and to his fellow 
workmen through loaning his pipe, and through 
similar intimate relations. After a time these signs 
and symptoms disappear, leaving no visible trace; 
and a further period of quiescence ensues. 
Physicians and health officials have long been in 
a quandary about how to tell the public the story 
of syphilis and its course. Obviously it is theoreti- 
cally desirable for every citizen to know the dangers 
which may beset him and to be prepared for action 14 
THE VENEREAL DISEASES 
in the face of these dangers. But to tell him vaguely 
about an unseen enemy which may insidiously creep 
upon him or his family and attack so cleverly that 
he has only the slightest warning, if any at all, is 
likely to fill him either with undue alarm or a feeling 
that the situation is so hopeless he can do nothing 
about it. Again, to tell him specifically what science 
knows of the terrible effects of this disease and the 
ways in which it finds opportunity to spread, may 
fill him with unspeakable horror and start him out 
on a hysterical campaign of needless precaution and 
suspicion of his fellow citizens. The middle course 
has been attempted many times and should be per- 
sisted in-to tell him as many of the facts as will 
make him intelligent, give him a clear picture of 
why early diagnosis and effective treatment are 
necessary for all cases, and assure him that personal 
hygiene and strict adherence to the highest code 
of morality will practically guarantee his individual 
protection. This chapter is an attempt at this middle 
course. 
If the syphilis organism had found it easy to 
transfer from one person to others, our ancestors 
would probably all have been killed off many genera- 
tions ago. Theoretically, dishes, spoons and forks, 
cups, dental instruments, handkerchiefs, clothing, 
and a host of other things may be a source of danger, 
but practically they are not so, under conditions of 
ordinary usage. Powerful as is the Spirochaeta once 
it has entered the body of a victim, its life is very 
frail when exposed to water and soap, to sunlight 
and drying, to the disinfecting measures of the 
careful dentist. Such value as so-called prophylactic 
measures have is based on this fact. This is dis- 
cussed in connection with public health aspects of 
the disease. 
History has proved that very small boats can THE DIAGNOSIS OF SYPHILIS 
15 
cross the Atlantic ocean, but we are not much afraid, 
as a practical matter, of an enemy limited to such 
transportation. If we were warned, however, that 
such an enemy existed, and that he was equipped 
with a deadly poison which, if he succeeded in land- 
ing in our country, would spread in the course of 
a few months to every part of the nation and in the 
course of years completely ruin us and our children, 
there is not the slightest doubt that we would main- 
tain an efficient coast-patrol and even send expedi- 
tions to the foreign shore to control or exterminate 
this enemy. This is an analogy which is not over- 
drawn. Science has seen the enemy and knows its 
life history, but can not protect the people by any 
methods of immunization, control of food or water- 
supply, extermination of insect-carriers, nor by any 
method except early detection of infected persons, 
the treatment of them until cured, and the carrying 
out continuously of the precautions indicated. 
This digression has seemed advisable at this point 
because failure to seize the precious opportunity 
of finding the syphilis case and starting treatment 
in the so-called secondary stage results in the great- 
est damage to the public through possible spreading 
of the disease and starts the patient on his progress 
toward the tissue-destroying final stages. This is 
not to say that recurrences of these secondary-stage 
conditions with temporary danger to the public and 
especially to the patient's family may not develop 
at irregular intervals throughout the final stage of 
the disease; but frequently the enemy disappears 
within the body into the heart and great blood- 
vessels, the abdominal organs, the central nervous 
system, and the tissues of other vital organs, there 
to remain apparently latent for months, and even 
for many years, without any evidence whatever of 
the impending fate of the individual. If physicians 16 
THE VENEREAL DISEASES 
could only know of these persons and have them 
under periodic examination for such treatment as 
is necessary, these patients, their families, the public, 
and the unborn generations would reap an enormous 
harvest in health, wealth, efficiency, and averted 
tragedy. 
Little need be said about treatment, because this 
is always a matter for decision of skilled physicians. 
No two cases are just alike; accurate knowledge of 
the progress of the disease determines everything. 
Only one drug will be mentioned-arsphenamine- 
because of its great value and its interesting history. 
At one time this drug was widely advertised as 
"606" and as "salvarsan"; but during the war the 
Government gave it the official name of arsphena- 
mine and provided for safeguarding its manufacture 
by requiring all laboratories to be inspected and 
registered by the Hygienic Laboratory of the United 
States Public Health Service before receiving a 
permit to operate. This action was necessary be- 
cause of the difficulties of production and of the 
grave dangers of its use except when prepared and 
used exactly according to methods worked out in 
a long series of experiments and tests before the 
drug was originally announced. This is, of course, 
only one of many valuable drugs used in treating 
syphilis, but it is important that it should be avail- 
able for every patient requiring it. Many States 
and cities now provide this drug at public expense 
to free clinics and to patients of private physicians 
when the latter also contribute their services. This 
is justified both for the sake of the infected citizen 
and for the protection of the public, because it has 
the effect, when rightly used, of very quickly ren- 
dering the patient non-infectious for others. 
All through the years of observation and treat- 
ment that follow the second stage of syphilis, the THE DIAGNOSIS OF SYPHILIS 
17 
physician needs the aid of periodic laboratory exam- 
inations of the blood, of secretions, of tissues, and 
particularly of the spinal fluid in many cases. After 
a year or more of persistent treatment and repeated 
tests showing "negative" findings the patient may 
hope that a cure, rather than an arrestment of the 
disease, is being accomplished, and after several 
years the physician may discharge him as cured. 
On the other hand this may not be the outcome; 
the disease may be kept under control but give 
evidence that the third stage will develop if the 
treatment is permitted to lapse. 
Again the term-The Great Imitator-is appro- 
priate. The tertiary lesions, so-called, appear in the 
most varied forms, and only a specialist in the diag- 
nosis and treatment of syphilis, or the physician 
who constantly keeps in mind the possibility of 
syphilis as a cause of the ill health of patients whose 
conditions are obscure, is likely to detect many of 
these late manifestations until they have so exten- 
sively destroyed vital organs as to render medical 
aid of very little value. The walls of the arteries 
frequently become hardened and inelastic, bringing 
with this condition the long train of ills due to 
imperfect circulation. In many parts of the body 
diseased tissues develop and break down, causing 
large ulcers which may not heal or may heal leaving 
great scars; when these occur on the face and result, 
for example, in the loss of the nose, they are cruelly 
disfiguring. The most tragic of all these effects 
of syphilis are the attacks upon the brain and spinal 
cord which often result in loss of mind due to 
softening of the brain, in locomotor ataxia which 
is a form of slowly developing loss of control of 
the legs and arms and other parts of the body, in 
paralysis due to the bursting of a blood-vessel. 
Little can be done in these late phases of syphilis 18 
THE VENEREAL DISEASES 
except to relieve pain, heal ulcers, and perhaps delay 
or arrest progress of the infection. 
Perhaps the greatest tragedy in the story of 
syphilis relates to its attack upon children. Great 
numbers of infants die before birth or in their first 
year of life, because of the disease being transmitted 
to them through their parents; others live on with 
defective bodies or minds, blind, or deaf. If the 
condition could be known, something-sometimes 
much-could be done by the treatment of the mother 
both for her sake and for that of the child; and 
where the child lives on for several years, complete 
control of the disease can often be secured. So 
important has become this method of dealing with 
the disease that too much emphasis can not be placed 
on the importance of physicians, nurses, social 
workers, maternity associations, and similar agencies 
doing everything possible to secure prenatal exam- 
ination, advice, and treatment of pregnant women. 
This whole group of cases adds evidence of the 
importance of regarding every case when discovered 
by the doctor or the clinic as a starting point for 
learning if any relatives or intimate associates of 
the patient may have been exposed. THE DIAGNOSIS AND TREATMENT OF 
GONORRHEA 
CHAPTER III 
GONORRHEA is a very different disease from 
syphilis in almost every way, but the micro- 
organism which causes it-the gonococcus-does 
have the same ability as the spirochseta to keep 
alive somewhere in the tissues of the body for 
several years after its first attack and await its 
chance to become active again at intervals. Gonon- 
rhea after its first development in the body is a 
more difficult disease to control than syphilis and 
is more dangerous in many ways to women and 
children. This is so because of the ability of the 
gonococcus to lie dormant in the genital organs 
of the male long after the disease has apparently 
been cured, and to escape into the genital tissues 
of the wife, resulting in acute infection. Such an 
infection may cause death, or sterility, or a local 
inflammation may occur and subside only to recur 
in the mother when a child is born. This frequently 
occurs and causes subsequent sterility in the woman, 
incidentally infecting the child's eyes during birth 
and often causing blindness. It is for such tragic 
reasons that all the forces of society must be brought 
to bear upon the treatment and prevention of this 
disease. 
Gonorrhea usually begins in from nine to four- 
teen days after infection as a local inflammation 
which develops rapidly into an acute condition with 
pain, discharge of pus, and involvement of increas- 
ing areas of the membranes lining the external 
19 20 
THE VENEREAL DISEASES 
genito-urinary organs. If the body successfully 
resists or is promptly aided by treatment to resist, 
the extent of the inflammatory process may be lim- 
ited and there is some chance of killing the invading 
organisms and restoring the tissues to normal. If 
attempts to combat the disease are not markedly 
successful or the body's resistance is generally weak, 
the disease extends with serious consequences to 
the deeper genito-urinary structures including the 
prostate, bladder, and sometimes kidneys, and the 
testes in the male and particularly through the 
uterus to the Fallopian tubes in the female. From 
the latter the disease may extend like wild-fire to 
the ovaries and prepare the way for acute inflam- 
mation of the lining of the abdominal cavity, which 
accounts for many deaths in gonorrhea cases among 
women as contrasted with lack of such a termina- 
tion in the male. In both men and women steriliza- 
tion may result, which causes a considerable pro- 
portion of the childless marriages. The disease 
may also extend to other parts of the body, espe- 
cially to the joints where it produces a most painful 
form of the disease, frequently described as a 
"rheumatism." 
Early diagnosis, immediate and persistent treat- 
ment are the great measures in dealing with this 
malady, both for the sake of the individual and 
the protection of the public. As in the case of 
syphilis, so, in this disease, we have an illustration 
of a dangerous insidious enemy masquerading under 
many forms and manifestations. It required many 
long years of patient research for medicine to track 
down the gonococcus and link all the evidence 
together. The microscope is the great aid to the 
physician in making a prompt and certain diagnosis, 
but there are many laboratory tests of one character 
or another which guide him in treating the case and TREATMENT OF GONORRHEA 
21 
in advising the patient regarding himself and the 
protection of his family and others. Public health 
demands the provision of ample facilities, main- 
tained either at private or public expense, for these 
laboratory aids to the physicians treating gonorrhea. 
The treatment of cases presents no outstanding 
method or drug which can be described. Success 
inevitably depends on real team-work between the 
doctor and the patient. The physician must give 
time to study his case thoroughly, check up his 
findings through laboratory aids, and vary his treat- 
ment from day to day in the acute stage, and at 
longer intervals for an indefinite period of months 
or years thereafter until repeated search fails to 
show any evidence of dormant gonococci hidden 
away in the body of the patient. All this is costly 
and often interferes seriously with work and pleas- 
ure, and appetites, such as those for alcohol, certain 
foods, and for sexual intercourse; but if the patient 
values his life, an uncrippled body, and the protec- 
tion and health of those who may become dearer 
to him than his own life in the future, he will 
frankly and honestly accept the situation and go 
through with the course of treatment. For this 
type of intelligent patient everything should be done 
to aid in selection of a competent physician or 
adequate clinic, and also to aid in providing neces- 
sary drugs, dressings, and facilities for carrying 
out the treatment at the times and places necessary 
to secure maximum effects of the various steps in 
the treatment. All this means adequate office, dis- 
pensary, hospital, and home equipment; and also 
adequate personal instruction and medical social- 
service follow-up. It means, too, that gonorrhea 
is a very different disease in some of these demands 
from syphilis, and the fact that the two are grouped 
together as venereal diseases must not be permitted 22 
THE VENEREAL DISEASES 
to confuse the public or limit its support of the 
practical campaign for protection and treatment of 
gonorrhea cases and of the campaign against the 
gonococcus. 
This fact needs emphasis, for gonorrhea has 
always been overshadowed by the dangers of syphilis. 
Because the physician sees much more hope of 
effective and definite control of the latter and be- 
cause it is a disease of more general interest to 
physicians as a whole, it is much more likely to 
be diagnosed, effectively treated, and followed up. 
Yet gonorrhea is more prevalent and more dan- 
gerous in many ways-at least to women and chil- 
dren. The public has until recent years considered 
gonorrhea as a mild catarrhal disease to be joked 
about and considered as a concomitant of "wild 
oats." . The concealment of the real cause of many 
abdominal operations on wives, of the life-long 
invalidism of many more women after marriage, 
of the loneliness of old men and women who have 
had no children, has added to this unfortunate state 
of public opinion. 
If the conditions under which gonorrhea is con- 
tracted were not such as to cause moral condemna- 
tion of the individual or of intimate friends or 
members of a family-if in other words it were 
possible to record the infection as "in the line of 
duty"-enormous advances could now be made in 
bringing every one infected under treatment and 
in protecting all the rest of the people. Conceal- 
ment is often practised both on the part of the 
patient and of the physician, because an impersonal 
and only half-understanding public will brand the 
patient with immorality if the nature of the disease 
becomes known. This concealment extends itself 
even to the immediate family circle, and the doctor 
thus often becomes party to the most tragic and TREATMENT OF GONORRHEA 
23 
needless sacrifice of human lives and happiness in 
an attempt to safeguard the secret of extra-marital 
sexual experiences of a husband, or, infrequently, 
of a wife. In either of these cases a child often 
becomes an added victim. This is a heavy price 
to pay for that demand of professional ethics which 
exacts silence from the physician if the patient is 
selfish enough to wish to protect his reputation and 
character at the cost of others. 
As the people are awakening to this situation 
two hopeful things are happening: (i) Physicians 
are being urged and required by law to interpret 
their duties to patients as not extending to the pro- 
tection of patients in acts of conduct prejudicial 
to the "life, liberty, and the pursuit of happiness" 
of other individuals and to the public welfare; 
(2) the people themselves are realizing that the 
difficulties of the patients and the doctors are due 
to failure of the public to apply in good faith the 
principle that a citizen should be considered innocent 
until proved guilty, and are insisting that this prin- 
ciple be applied to the moral-law as well as to the 
civil-law aspects of gonorrhea. This step is being 
followed by the holding of all records of the venereal 
diseases as closed records except for those who 
have proper administrative and official right to see 
them. In time this greatest obstacle to advance in 
dealing with these diseases scientifically, humanely, 
and effectively will be removed. 
Little more can be said about a disease which 
always requires a physician for diagnosis and treat- 
ment at all stages and for all of the many complica- 
tions and forms in which it appears. The possi- 
bilities and limitations of medical prophylaxis re- 
ferred to in the discussion of syphilis apply with 
even less degree of assurance in the case of exposure 
to gonorrhea; but to the drowning man even a 24 
THE VENEREAL DISEASES 
straw is worth while-and many believe in promul- 
gating such measures. The chief difficulty of doing 
this rests in the differences between theory and 
practise. In the Army and Navy some good results 
come from prophylactic measures, because they are 
applied after exhaustive efforts have been made to 
educate the men to understand the purpose, meth- 
ods, and limitations of the measures; and they are 
followed up by periodic compulsory medical inspec- 
tion of all troops for evidences of infection. None 
of these administrative measures are practicable in 
civil life-and it might be added would fail in mili- 
tary life also if our Army and Navy were made up 
of women, because such measures can not be applied 
to the female with the same thoroughness possible 
with the male. 
In civil life the health official is protecting the 
public, and this means men, women, and children. 
Whenever the application of a measure, having some 
merit in itself for a portion of the people, comes 
into conflict with other measures having value in 
protecting all the people, the whole situation has 
to be reviewed and the measures so adapted as to 
be mutually supportive, or the ones of lesser impor- 
tance discarded. This is the present status of 
medical prophylaxis or self-disinfection; it is scien- 
tifically sound and should be used, if and when ways 
can be demonstrated for its use without misunder- 
standing or interference with the great measures 
which have already attained a permanent place in 
the campaign against gonorrhea. This question is 
discussed further in connection with the public- 
health aspects of the disease. 
Perhaps a reference at this point to one of the 
causes of ophthalmia neonatorum, which is a form 
of blindness, may be made with advantage. It has 
become the standard practise to treat the eyes of a new-born baby with certain solutions which will 
kill gonococci which may have lodged there during 
birth from an infected mother, and may cause per- 
manent impairment of vision or blindness if not 
destroyed. 
This constitutes an important factor in the treat- 
ment and the prevention of gonorrhea. Since this 
procedure meets with general approval, it empha- 
sizes the fact that the public is not opposed to 
prophylactic measures when they are clearly demon- 
strated to be generally applicable, effective, and not 
in conflict with other measures. 
When all is said and done, gonorrhea remains 
at present an intrenched enemy, not because we do 
not possess knowledge or scientific methods of 
attack, but because this enemy is too clever to kill 
and maim outright and in its own name. Since it 
works under cover the unsuspecting public is not 
aroused to fight it vigorously. 
TREATMENT OF GONORRHEA 
25 CHAPTER IV 
THE PUBLIC HEALTH AND THE VENEREAL 
DISEASES 
WHILE the health officer of a community has 
many duties, he is primarily the representa- 
tive of the people in protecting them from com- 
municable diseases and in seeing that those of their 
number who do become infected are properly treated 
and cared for under conditions which do not endan- 
ger others. The venereal diseases are not affected 
by any measures for obtaining pure food or water- 
supplies, nor by any attack upon insect-carriers of 
disease, nor directly by any nutrition-work or hous- 
ing supervision, nor by industrial hygiene and simi- 
lar work of health departments, except as such 
measures may promote better living conditions 
which lessen sexual promiscuity. The health officer 
is, therefore, limited in what may be done officially, 
but he can always endorse and encourage other 
agencies to carry on many activities bearing on 
the reduction in number of exposures to infection. 
He can also more directly promote accurate diag- 
nosis and successful treatment of infected persons, 
and he can do much to induce such persons to seek 
treatment and remain under medical care until 
reported cured. 
The need of laboratory examination for evidence 
of syphilis or gonococcus infections is one of the 
first measures the health departments have recog- 
nized and have gained public support in estab- 
lishing. The aid thus extended to private physicians 
and clinic staffs has been of great value in securing 
26 THE PUBLIC HEALTH 
27 
the early diagnosis of cases and in checking up 
the progress of treatment and the termination of 
communicability. Practically all the States and the 
large cities now have laboratory facilities for exam- 
ining specimens of blood, spinal fluid, secretions 
from suspicious sores, and pus discharges, which 
physicians can with advantage send to public-health 
laboratories. Other methods for encouraging the 
discovery of infected persons have been developed, 
especially through lectures, the distribution of pam- 
phlets, the appropriate posting of placards, and the 
insertion in newspapers of announcement of free 
advice offered by the health department regarding 
venereal diseases. Labor union officials, employers, 
fraternal organizations, and many other groups have 
cooperated actively in circulating health-department 
pamphlets regarding the diagnosis and treatment of 
venereal diseases. Following the example of the 
Army and Navy examinations for admission, many 
industrial firms require medical examinations before 
employing applicants; hospitals and dispensaries 
very generally include examination for syphilis, 
particularly in obscure cases; increasing numbers 
of persons who seek periodic health examinations 
and also those who apply for life insurance are being 
examined for evidence of syphilis or gonococcus 
infections. All such measures encouraged by the 
health departments are adding to the numbers of 
infected persons found and brought under treatment. 
It does not help the individual to be told that he 
has a dangerous communicable disease if he does 
nothing about it, and the community, also, is no 
better off. The health officer, therefore, is con- 
cerned with securing prompt treatment for all per- 
sons infected. He first appeals to the medical 
profession to do everything its members can do 
to provide for all who can pay any reasonable sum 28 
for treatment. To reduce this cost to a minimum 
for patients in limited circumstances, the health 
departments not only provide free laboratory aid, 
but also in many States and cities furnish drugs 
and sometimes other facilities for carrying out treat- 
ment. To provide still further for the treatment 
of persons who can pay something but who earn 
very little money, pay-clinic services available at 
various hours of the day or evening are encouraged 
and receive similar public aid. Finally, free 
venereal-disease clinics are necessary as a part of 
the general hospital and dispensary services for 
the poor. As an emergency measure, State and 
local health departments, frequently in cooperation 
with the federal government and voluntary organi- 
zations, have set up and financed such free clinics. 
In cities these have sometimes been special clinics 
but are usually sections of a general clinic service. 
In rural districts they take the form of services 
provided through the offices of physicians selected 
as representatives of the State health department. 
Whether or not such treatment services are to be- 
come a permanent feature of health department 
activities is a question which remains to be worked 
out. In some countries this plan is adopted, but 
in the United States it is the present opinion that 
public authorities should provide only for those 
patients who can not avail themselves of the services 
of private practitioners. There is general recogni- 
tion, however, that all infected persons should be 
treated, and in 1922 there were 831 recorded clinics1 
in operation which are estimated to have treated 
200,000 persons in addition to the cases treated by 
the private practitioners. 
One of the difficult tasks is to convince patients 
THE VENEREAL DISEASES 
1 "Dispensary Service in the United States," Journal of the 
American Medical Association, August 5, 1922, pp. 5, 23. THE PUBLIC HEALTH 
29 
of the necessity for treatment continued until their 
infection is brought under control, and for frequent 
subsequent examination to prevent relapse and fur- 
ther danger of spreading infection. The health 
departments attempt to meet this by furnishing the 
doctors and dispensary staffs with instruction pam- 
phlets to be handed patients, by informational 
placards to be posted on clinic walls, and by arrang- 
ing for social-service follow-up work of public- 
health nurses or trained social-service hospital work- 
ers, who induce patients to return promptly for 
treatment and encourage members of their families 
and others probably exposed to be examined and 
treated if necessary. In addition, the health officer 
requests all physicians to report to him patients 
who fail to remain under treatment or to carry out 
necessary precautions for the protection of their 
immediate families and associates. This is done 
in order that the public health may be protected by 
whatever additional measures the health officer may 
be able to take through the facilities of his own 
department and through cooperation with other 
departments and welfare organizations. 
In order to relieve the medical profession from 
responsibility for selecting cases to be reported and 
to enable the health officer to estimate as fully as 
possible the extent of the venereal-disease problem, 
most of the States have now passed laws requiring 
in some manner the reporting of all cases. In the 
majority of these States, however, either by per- 
missive regulation or by interpretation in practise, 
the doctor is not required to report the names and 
addresses of his venereal-disease patients as long 
as he can say that the public is not being endan- 
gered and that his patients continue under treatment. 
In 1923, 338,681 cases were reported, of which 
number 192,255 were syphilis, 156,826 gonorrhea, 30 
THE VENEREAL DISEASES 
and 7,777 other venereal diseases.2 These figures 
are far from complete, but they illustrate the growth 
of reporting. In New York State, for example, 
during the month of August, 1923, syphilis ranked 
first with 2,736 reported cases and gonorrhea third 
with 1,206 cases among all the communicable dis- 
eases reported. Reporting in this State is not direct 
but through confirmation of diagnosis by labora- 
tories. This partly accounts for more syphilis than 
gonorrhea cases reported because the physician more 
frequently calls on the laboratory for aid in diag- 
nosing syphilis, than in diagnosing gonorrhea. This 
reason also still largely influences the relative report- 
ing of these two diseases in all States. 
In the large majority of cases of venereal diseases, 
just as in other communicable diseases, the health 
department counts upon the infected persons volun- 
tarily carrying out instructions to avoid spreading 
their disease; but also as in other diseases, cases 
occasionally arise in which the general quarantine 
power of the health officer must be invoked. In 
these cases the quarantine measures adopted vary 
according to the circumstances in each instance. 
The object of quarantine is, of course, to protect 
others from infection with the least possible inter- 
ference in the daily pursuits and freedom of the 
infected person. The venereal diseases have such 
limited opportunities for transmission that quaran- 
tine is seldom necessary unless other measures fail 
which are more effective and represent sounder 
public policy when applied. That is to say, children 
suffering from these infections do not need to be 
quarantined; they may require hospital care or 
nursing in the home, but this is not a quarantine 
measure. Similarly, except in rare instances, in- 
fected men and women do not need to be quarantined 
a Annual report U. S. Public Health Service, 1923, p. 257. THE PUBLIC HEALTH 
31 
unless they belong to one of several groups, each 
of which can and should be dealt with by other 
agencies than the health department; and when so 
dealt with the necessity for quarantine disappears. 
Four of these outstanding groups are: women who 
engage in prostitution while infected and in a con- 
dition to infect their patrons; men in a similar 
condition who seek prostitutes; feeble-minded per- 
sons, particularly girls, who because of their men- 
tality are easy victims of sexual promiscuity, become 
infected, and in turn infect others; other socially 
inadequate men and women whose lives, either in 
an environment of wealth or of poverty, lead to 
sexual relations between those susceptible and those 
infected. Measures relating to these groups are 
discussed later. 
Having discovered and induced a large number 
of persons to undergo treatment, the health depart- 
ment is interested in setting up regulations for 
determining, first, when the patient is no longer 
infectious, second, the conditions under which the 
patient may be discharged as cured. Progress has 
been made on both these points, but no practical 
administrative program has yet received general 
approval. Because marriage is such an important 
contract (the only one in which sexual relations 
are sanctioned by both civil and religious regula- 
tions), and is so vital to the health and welfare 
of children, persistent attempts have been made to 
ensure freedom from venereal diseases of those who 
marry. These efforts have usually taken the form 
of legislation requiring a medical examination of 
the man or of both parties seeking a license. None 
of these measures have thus far proved wholly 
practicable, but some of them have served a useful 
purpose in calling the attention of the contracting 
parties to their responsibilities in the matter and 32 
THE VENEREAL DISEASES 
in providing the basis for application of legal or 
public-health penalties later if infection occurs as 
a result of the marriage. The ultimate working 
out of practical measures for the general safe- 
guarding of marriage may be expected. 
Having made every effort to find, treat, and keep 
under supervision until cured all persons infected 
with venereal diseases, the health officer turns his 
attention to those who are not infected. This means 
the general public. There are no effective methods 
of immunizing any one, and there are no methods 
of readily pointing out those who are infected. The 
health officer, therefore, is forced to undertake a 
campaign of informing every one as to what these 
diseases are and how they are spread. In this 
work he needs the aid of every citizen who under- 
stands clearly and can helpfully promote such public- 
health educational propaganda. This propaganda 
must necessarily center around two outstanding 
objectives: first, getting every one who is infected 
under early treatment and sympathetic follow-up 
supervision; second, marshaling every available 
force and influence to prevent exposures to infection. 
The first of these objectives is the task of the health 
authorities, aided by the medical and nursing pro- 
fessions and medically trained social-service workers. 
The second objective is largely the task of other 
public authorities and social agencies aided by 
educators, clergy, and all the moral forces. 
Between these two fields of endeavor lies the 
possibility of applying a scientifically sound measure 
variously known as medical prophylaxis, early treat- 
ment, or self-disinfection. These measures are all 
based on efforts to instruct the individual seeking 
sexual intercourse to use cleansing and disinfecting 
measures calculated to prevent the development of 
infection following exposure. Under the precise THE PUBLIC HEALTH 
33 
conditions of laboratory experiment or the rigidly 
controlled conditions of Army and Navy service, it 
has been shown that such final efforts to prevent 
infection are of great value to those individuals 
who apply the measures thoroughly. It was to be 
expected that the health officials would eagerly 
endeavor to use this measure, but experience has 
shown that in civil life its promotion is attended 
with difficulties. Unless this treatment is applied 
thoroughly and within an hour or two after exposure 
it has little effect. It has been found that such meth- 
ods have very limited value in the protection of 
women and that men are indifferent or careless in 
their application. Added to this is the danger of 
creating a false sense of security because of official 
assurance that these methods are effective. Public- 
health advertising of such methods weakens the 
slogan which has been so serviceable in all other 
communicable diseases. "If you think you have 
been exposed, immediately consult your doctor or 
go to the health department for advice." After 
careful consideration of the scientific and the prac- 
tical sides of this question nearly all health depart- 
ments and most physicians have concluded that in 
the United States, at least, medical prophylaxis has 
no value as a public-health measure in civil life, 
except as it may be prescribed in the private prac- 
tise of physicians or as a part of the treatment of 
individual cases in clinics. 
Indirectly a further reason of importance in crys- 
tallizing the opposition of health departments to 
medical prophylaxis has been the strong objec- 
tions of moral and religious forces to advocacy 
of any measures which presuppose recognition 
of sexual promiscuity or the intention of indi- 
viduals to seek such gratification. This is but 
a part of the opposition which has been directed 34 
THE VENEREAL DISEASES 
toward the early efforts of health departments to 
bring the most active of venereal-disease carriers- 
the prostitutes-under treatment by recognition of 
commercialized prostitution and compulsory exam- 
ination of the women involved. There has been, 
of course, another important reason for this oppo- 
sition which is based on the manifest injustice of 
compulsory examination measures applied only to 
the woman and not to her male partners in prosti- 
tution. Health departments have found, as in the 
case of medical prophylaxis, that while in theory 
measures based on scientific possibilities of exam- 
ination and treatment applied to inmates of houses 
of prostitution ought to succeed, in practise they 
are not administratively sound and are against public 
policy in the larger field of conserving moral stand- 
ards. Practically all important health officials and 
other public authorities are now agreed that meas- 
ures for repression of prostitution in all its forms 
must be applied, for their influence in health con- 
servation as well as in promoting moral and social 
welfare. The carrying out of these measures, 
however, is not a function of health departments. 
An important chapter in the work of health 
authorities in combating the venereal diseases has 
been the struggle against the medical charlatan and 
the advertising quack. It was to be expected that 
diseases which were considered shameful would be 
concealed from relatives and family physicians, and 
that opportunities for free consultation with reputed 
experts would be eagerly sought under conditions 
which permitted imagined concealment of identity. 
All sorts of unprincipled and harmful practises 
grew up which have required courage and persistent 
effort to overcome. The increasing team-work 
between the medical profession and the health offi- THE PUBLIC HEALTH 
cials in providing adequate treatment facilities and 
educating the public to look upon the sufferers from 
these diseases with sympathetic desire to see them 
properly treated and cared for, will complete the 
eradication of the quack from this field. 
35 CHAPTER V 
THE NURSE AND THE SOCIAL WORKER AS 
AIDS TO THE HEALTH OFFICER AND 
DOCTOR IN THE CONTROL OF 
THE VENEREAL DISEASES 
THE HISTORY of syphilis and gonorrhea shows 
that after patients have been diagnosed and 
treatment has begun, a large percentage of them 
drift away from both the doctor and the clinic before 
they are cured and often while they are still a source 
of danger to others. Many efforts have been made 
to overcome this situation. Patients have been 
warned of the danger of discontinuing treatment; 
printed instructions and pamphlets have been handed 
them when they were examined; notices of appoint- 
ments and letters advising them to return have been 
sent. Of still greater value have been the efforts 
of nurses and hospital social workers who have gone 
out to find these patients and learn their reasons 
for not continuing treatment. Work of this type 
has greatly increased the attendance at clinics and 
is helping solve the question of keeping private 
patients continuously under treatment. 
The general principle of medical social service 
has become recognized as of value to the patient 
in removing obstacles to attendance at clinics or 
at the office of a private physician, and in sustaining 
his morale and interest in continued treatment. 
Such service stimulates and aids the clinic in effi- 
ciency of administration and in increasing its 
influence as an educational center. It particularly 
helps in creating a friendly spirit of service and 
36 CONTROL 
37 
personal understanding of the patient as a human 
being who needs not only cold scientific examination 
and treatment but also sympathetic practical advice 
as to how to reorganize his life and activities to 
take advantage of medical care and how to avoid 
future difficulties. To the extent that private physi- 
cians are employing social-service workers, they 
and their patients are being similarly benefited. 
The community, as well, is benefited through in- 
creased control of patients and by the tracing of 
sources of infection and of exposure of other mem- 
bers of the patient's family or intimate associates. 
The encouraging of the latter to seek treatment or 
to be examined is of very great importance. It 
would require the space of this entire booklet to 
describe in convincing detail how the trained social 
worker manages tactfully to get the patient to fur- 
nish the needed information and then proceeds 
without embarrassing the patient or violating the 
professional ethics of the doctor to apply this infor- 
mation so as to aid the health officer in his general 
task. It may be said, however, that this is being 
done and the soundness of methods employed is no 
longer in question. 
One of the weakest points in the campaign against 
the venereal diseases has been the failure to keep 
adequate records of patients, not only with regard 
to the technical data regarding diagnosis and treat- 
ment, but also regarding other facts necessary in 
preventive work, including housing, industrial, and 
recreational conditions which are factors in devel- 
oping focuses of infection. The growth of confiden- 
tial social-case record-sheets of this character is prov- 
ing an important factor in perfecting the facilities for 
bringing about coordinated action by the three great 
agencies-the medical profession, the health depart- 
ment, and the social and legal forces concerned. 38 
Just as the medical profession must play so large 
a part in diagnosis and treatment of venereal 
diseases, so the nursing profession and the trained 
social workers must play a similar part in this 
medical follow-up work and social service. Among 
the organized nursing groups the Visiting Nurse 
Associations are particularly well situated to supple- 
ment the official public-health nursing activities and 
the work of private nurses. These associations, as 
well as the public-health nursing department of the 
American Red Cross, and the nursing and medical 
social-work staffs of organized charities, and homes 
such as those maintained by the Florence Crittenton 
Mission and the Salvation Army, are steadily broad- 
ening the public concept of the venereal-disease 
problem and crystallizing support of sound policies. 
Perhaps there is no better way to emphasize the 
need for the trained social worker in this field of 
preventive medicine than to refer to a recent study 
of the effect of syphilis on the families of syphi- 
litics seen in the late stages.1 The families of 555 
patients were seen and it was found that at least 
one-fifth of the families had one or more syphilitic 
members in addition to the original syphilitic parent. 
Between one-third and one-fourth of the families 
have never given birth to a living child-this in 
contrast to the fact that one-tenth of normal families 
remain childless. More than one-third of the fami- 
lies have accidents to pregnancies, through abortions, 
miscarriages, or stillbirths-which is about twice 
the normal number of such occurrences. The birth- 
rate in syphilitic families is 2.05 per family as 
compared with 3.80 per normal family. Two-thirds 
of the families show defects in relation to children, 
THE VENEREAL DISEASES 
1 "Syphilis of the Innocent-'A Study of the Social Effects of 
Syphilis on the Family and the Community," by Harry C. and 
Maida H. Solomon, Washington, United States Interdepartmental 
Social Hygiene Board, 1922. CONTROL 
39 
including syphilitic children, accidents to pregnancy, 
and sterility. Between one in twelve and one in 
six of the children examined showed definite evi- 
dence of syphilis. These statements are not included 
as a basis on which to generalize, or as giving any 
summary of the findings of many studies on the 
subject, but rather to show the tragic cost of neg- 
lecting the opportunity of following up every case 
of syphilis as a dangerous communicable disease. 
Somewhat similar statements could be made regard- 
ing gonorrhea. The application of the recognized 
methods of patient, resourceful, medical, social 
service will enable us to make great gains in this 
direction. CHAPTER VI 
COMMUNITY SAFEGUARDS AGAINST THE 
SPREAD OF VENEREAL DISEASES 
MANY community activities which are not 
public-health measures can be instituted as 
safeguards against the contraction and spread of 
syphilis and gonorrhea. 
The first method deals with the reduction of com- 
mercialized prostitution to a minimum. The unani- 
mous conclusion of all the vice investigations has 
been summarized in the words of the Chicago Com- 
mission : "Constant and persistent repression of 
prostitution, the immediate method; absolute anni- 
hilation, the ultimate ideal." Experience has shown 
that the commercialized aspects of prostitution, so 
far as they relate to its advertisement, its exploita- 
tion, and its protection by third parties, including 
public officials, can be suppressed, and all its aspects 
can be minimized in any community by law enforce- 
ment. Efforts to deal directly with the men who 
purchase sexual gratification and the women who 
sell themselves for this purpose are less successful 
because less securely founded on established prin- 
ciples of law and justice and for other reasons 
referred to later. It has been found that when a 
city or a county refuses to permit recognized houses 
of prostitution to operate, the profits of prostitution 
are cut off from unscrupulous landlords, vice pro- 
moters, women who keep such houses, and others 
who make a business of inducing men to come to 
them. If the laws are adequate and the police 
authorities are thorough in enforcing them, the 
40 commercialized aspect of prostitution can be elimi- 
nated, and the problem is reduced to the clandestine 
dealings of men and women who seek each other 
directly. This makes the difficulties and cost much 
greater to the man and reduces the number of men 
received by the woman during her life of prosti- 
tution. The evidence from every part of the United 
States is convincing in regard to the venereal- 
disease rates being lowered as a result of court 
and police action against commercialized prostitu- 
tion when such action is vigorous and sustained 
over a period of years. 
Supplementing the organized law-enforcing pro- 
gram against commercialized prostitution, which 
includes preventing the use of hotels, lodging houses, 
taxicabs, and public parks for prostitution purposes, 
the community can institute protective measures 
for adequate supervision of commercialized dance 
halls, other public amusement places, and many 
other similar institutions which these illustrations 
will suggest. Many ideas have been put into opera- 
tion toward these ends. Women police have been 
found a valuable addition to the police force, and 
special moral squads have been established whose 
duties often relate to all these phases of safeguarding 
environment. The licensing of hotel and rooming- 
house proprietors under conditions making them 
share responsibility for immoral practises on their 
premises, and making owners of buildings also 
responsible under proper legal conditions, have 
helped. The better lighting and general policing 
of public parks and cooperation between city, county, 
and State police in applying measures beyond city 
limits have greatly reduced opportunities for clan- 
destine prostitution. Successful enforcement of 
prohibition laws against the use of alcohol is a 
factor in all these community safeguards. 
COMMUNITY SAFEGUARDS 
41 42 
THE VENEREAL DISEASES 
In applying law-enforcement measures against 
commercialized prostitution, it is sometimes for- 
gotten both by the authorities and by the public 
that the object is to eliminate an illegal business, 
damaging alike to the community and to the men 
and women weak enough to be drawn into it. It 
is so much easier, for example, to secure evidence 
that a certain woman is a prostitute than to discover 
and proceed against those who rent her a room for 
this purpose, provide liquor and suggestive music, 
and employees to go out on the streets to bring in 
men customers to her, that police and court officials 
are often content with periodic raids and arrests 
of such women. Their male patrons are generally 
not arrested, and the promoters of the business are 
infrequently called to account. Such half-hearted 
measures are unjust to the woman prostitute, who 
is often the victim of environment, evil influence, 
and poor heredity. They are, of course, inadequate 
as measures for restriction of the venereal diseases 
because they make no attempt to bring under control 
the large number of males equally exposed to infec- 
tion and known by their habits of sexual promiscuity 
to be carriers of infection. They are also inadequate 
as moral measures because they make no attempt 
to remove from the community places which invite 
men and women to come together for purposes of 
prostitution. Only when all of these objects of 
law enforcement are included are the measures 
adopted of great value to the campaign against the 
venereal diseases. 
Recognition of this has led largely to the aban- 
donment of fines for women convicted of prostitu- 
tion and the substitution of probation, commitment 
to appropriate institutions, or other action designed 
to remove the woman from her life of prostitution 
and sympathetically encourage her to return to a legitimate occupation and good habits-if infected 
with venereal diseases or any other disease, oppor- 
tunity is afforded, incidentally, to treat her. Some 
progress is being made and efforts of many organi- 
zations are being concentrated on securing the 
arrest, conviction, and similar treatment of the men 
who purchase sexual satisfaction from women. The 
old, officially recognized, segregated, "red light" 
districts which used to exist have almost entirely 
disappeared in the United States, and even tolerated 
houses have ceased to operate in most cities. Pros- 
titution is thus gradually being stripped of its enor- 
mous middleman profits and reduced to the narrow- 
ing limits of women clandestinely making direct 
appointments with men who must learn how to find 
such women. 
It was believed for many years that segregation 
of houses of prostitution and periodic medical exam- 
ination of the women inmates was necessary to 
control the spread of venereal diseases and prevent 
the scattering of vice all over the city; hence a 
comment on these points is advisable. Experiment 
has shown that there is no practical way to examine 
women with sufficient frequency and thoroughness 
to reduce greatly the numbers of men infected. 
Experience has shown on the contrary that because 
of the increased numbers of men who visit those 
women as a result of the inevitable advertising of 
inspected women and the segregated districts which 
are set up with all their associated evils, the actual 
total of persons exposed is much larger. It may 
also be remarked in passing that the fear of scat- 
tering prostitution over the city by closing red-light 
districts has not been borne out by experience. 
Another belief, closely related to these ideas of 
regulation of prostitution for the sake of cutting 
down the prevalence of venereal diseases, has to 
COMMUNITY SAFEGUARDS 
43 44 
THE VENEREAL DISEASES 
do with attempts to promote cleansing or medical 
prophylactic measures immediately before or after 
sexual relations. These have been urged particu- 
larly upon the men, and scientifically have been 
proved sound under controlled conditions. However, 
such measures are of little practical value, because 
neither the men nor the women exposed will carry 
them out with the requisite thoroughness and 
promptness. Failing to do this, the false sense of 
security leads to ignoring subsequent mild evidences 
of disease. Only in an Army, where medical prophy- 
laxis so-called has been carried out in organized 
treatment stations to which the men are required 
to report within a few hours after exposure, has 
this method had any large measure of success. 
In all such measures as those referred to in the 
preceding paragraph there is the added objection 
that, even if they could be made effective, they would 
require wide publicity and toleration of moral evils 
which every community desires to eliminate. The 
public is unalterably opposed to endorsing practises 
which depend for success upon degrading women 
and telling men that we expect them to be sexually 
immoral. Both law and medicine have to make 
their proposals support prevailing standards of 
moral conduct, or ultimate defeat is certain. It 
happens in the case of both law and medicine, how- 
ever, in dealing with prostitution and the venereal 
diseases that the highest standards of sexual morality 
are conducive to the greatest gains. It is not the 
duty of the health officer to enforce a standard of 
continence outside of marriage, but the more effec- 
tive that education, public opinion, and law enforce- 
ment are in securing the application of this standard, 
the smaller does the venereal-disease problem become. 
Accordingly, in a country like the United States, 
the health officer encourages forces outside his COMMUNITY SAFEGUARDS 
45 
department which may be more effective than any 
at his command in the field of medicine. In the 
past, health officers and physicians have sometimes 
not only encouraged higher moral standards but at 
the same time have also tried to advance plans for 
inspection of prostitutes and medical prophylaxis 
for their patrons. Inevitably this position becomes 
complicated. Whenever measures are instituted 
which are not fully endorsed by the public, secrecy 
develops and the way is opened for abuse of au- 
thority or for endless controversy. In practise such 
small value as medical examination of prostitutes 
possesses, has no basis for application in the United 
States, and medical prophylaxis (or self-disinfection 
as it is sometimes called) has no general application 
except in the Army and Navy and in the private 
practise of physicians. The numbers of individuals 
who can conceivably be reached under such 1 limita- 
tions without unsound and objectionable advertising, 
are so small that the measure becomes unimportant in 
the general campaign against the venereal diseases. 
In addition to the law and order programs for 
the protection of weak individuals and the control 
and punishment of exploiters of sexual vice, there 
are a great many ways in which the community 
may encourage people to utilize their leisure time 
in such manner as will minimize temptations and 
sex adventure. Investigation has proved that there 
is a mental as well as a physical side to body- 
building and character-training which is adequately 
stimulated only by genuine and wholesome play. 
Recreation may be made to serve the development 
of sound ideas and practises of fair play and pro- 
tection of individual rights regarding sex, if care- 
fully studied and adapted to community conditions. 
The saloon became an intolerable institution through 
its catering to the underworld promoters of drunk- 46 
THE VENEREAL DISEASES 
enness, prostitution, and other vices, but its abolition 
has brought the problem of providing adequate sub- 
stitute gathering places for large numbers of men 
who used the saloon as a club where they could 
meet friends and enjoy an evening after the day's 
work. The motion-picture theater does much to 
provide entertainment, but the men and women who 
go there must be purely passive and silent on- 
lookers; it does nothing to draw them into active 
participation, and the sex appeal in some form or 
other is an outstanding feature of most of the 
entertainments on either the screen or the stage. 
Churches are struggling with this problem but have 
not yet found the method of successfully meeting 
the needs of young people. Community centers, 
playground associations, organizations such as the 
Boy and Girl Scouts, innumerable other agencies 
deserving of the highest praise, are steadily learning 
how to weave into their programs sex information, 
standards of conduct, and ideals calculated to guide 
young people from early adolescence to adult life 
and marriage without encountering the moral and 
physical hazards of misuse of sex. This is one 
of the most hopeful as well as most complicated 
phases of the social hygiene movement. 
Another factor of very great value to the cam- 
paign against venereal diseases in the United States, 
is the systematic development of sex education and 
character-training now going forward. Parents are 
being reached in increasing numbers; also students 
in normal schools, in schools for nurses, for social 
workers, for physicians and the clergy, and in many 
other institutions whose graduates have to consult 
and visit parents in the home. These are gradually 
finding ways of interpreting to parents the meaning 
of sex as a great factor in human life and they in 
turn are imparting this knowledge to their children COMMUNITY SAFEGUARDS 
47 
under conditions which make it a permanent in- 
fluence in molding character and conduct. Science 
indicates that ideas received and attitudes developed 
early by the child have a great part in determining 
lifelong habits.1 One of the most frequent reasons 
advanced by our American soldiers during the 
World War to account for their not going with 
prostitutes was loyalty to a wife or sweetheart at 
home, or a resolution that the decent and square 
thing to do was to keep oneself clean. Colonel 
Ashburn, who had unusual opportunity to observe 
the men in France, said, "My opinion, based on 
conversations with men, gratuitous information 
inserted in replies to questionaries, and my obser- 
vations of the men, is that by far the most important 
factors (speaking of chastity among men in the 
U. S. Army) were those inherent in the men rather 
than in the anti-venereal campaign, factors such as 
character, religion, love, loyalty, and self-respect." 
It was inevitable that sex education like other phases 
of education should go through stages of being 
popularly discussed, then exploited by irresponsible 
or unprincipled persons, and finally taken up seri- 
ously by the leaders of education. Now that the 
novelty of freedom to talk about sex and sex-social 
problems has worn away there are indications that 
the next ten years will see sound instruction in 
this matter effectively and quietly incorporated in 
our program of education and training, so far as 
this may be necessary to supplement the instruction 
and influence of the parents in the home. Progress 
in this direction is being further accelerated by the 
serious interest of the clergy and schools of religion 
in character-training as it relates to sex conduct. 
Still another problem of social welfare which is 
1 See also "Adolescence," by M. A. Bigelow, Ph.D., in the 
National Health Series. 48 
THE VEIsJEREAL DISEASES 
not within the jurisdiction of the health officer, 
but which is of importance, is the control of the 
feeble-minded. Especially is the feeble-minded girl, 
who becomes an easy victim of designing boys or 
men, a menace in spreading venereal diseases. Much 
is being done to protect this group of the population 
and to protect society from its irresponsible acts. 
A fallacy sometimes popularly voiced is that laws 
requiring the sterilization of mental defectives would 
benefit the venereal-disease campaign. When prac- 
tical and just laws of this character are finally 
worked out they will be of great value to the nation 
through decreasing the numbers of descendants from 
these unfortunate individuals, but such laws will 
have no immediate effect on reducing the venereal 
diseases; in fact if their application should result 
in greater liberty for mentally incompetent girls 
and women the prevalence of prostitution and the 
venereal diseases would both be increased. 
An encouraging development of the last few years 
has been the active participation of universities, 
colleges, and normal schools in the teaching of 
hygiene, the content of which includes sound and 
tactful instruction regarding sex, prostitution, the 
venereal diseases, and related subjects. In a still 
more effective way, so far as the future is con- 
cerned, educational institutions have begun to study 
ways and means of teaching, and sex education in 
its larger meaning. Great benefit may be expected 
from these efforts. Real efforts are being put forth 
also by communities to devise successful chap- 
eronage acceptable and helpful to our youth. Every- 
where underneath the surface facts which give cause 
for anxiety about the nation's moral standards, there 
is evidence of determination to find and correct the 
difficulties which may lie in the path of steady 
progress. COMMUNITY SAFEGUARDS 
49 
The great obstacle in writing a brief outline 
such as this regarding the venereal diseases lies 
in the fact that their control and ultimate eradica- 
tion depends so largely upon team-work of all the 
educational, moral, and social, as well as medical, 
forces of the community, that discussion seems 
irrelevant or unconvincing. The foregoing com- 
munity safeguards are, however, vitally important 
to the success of the venereal-disease campaign, 
and are representative of many others which exert 
their influence. Only one other factor will be men- 
tioned by the way of illustration. Labor turnover 
and efficiency of men and women in industry are 
common terms in commerce and labor. Gradually 
labor leaders and managers of great business enter- 
prises are learning that the venereal diseases are 
insidious and very great causes of loss. They are, 
therefore, studying ways and means of introducing, 
through appointment of industrial physicians and 
welfare directors, all the direct and indirect measures 
for reducing exposure to infection and for prompt 
treatment of those who become diseased. Because 
of the great numbers of men and women employed 
and because of the possibilities of thoroughly carry- 
ing out plans agreed upon, this is one of the most 
promising aids to the health officer. It has been 
estimated that, since the Army draft figures showed 
5.6 per cent, of the men infected, the 10,000,000 
men employed in manufacturing plants alone proba- 
bly have among them over 500,000 venereal-disease 
cases. Of these 50 per cent, are between 20 and 
30 years of age and an additional 38 per cent, are 
over 15 years and under 40 years of age. All these 
are beyond the immediate influence of the school 
or the home. Except for variations of prevalence 
in various occupations and a much lower infection- 
rate among women, this illustration may be applied 50 
THE VENEREAL DISEASES 
to all industry and commerce and shows how impor- 
tant if is that labor organizations and industrial 
managements should be increasingly brought into 
this campaign. 
Science can only say thus far that syphilis still 
remains one of the greatest killers of men and 
women, and gonorrhea is still the greatest sterilizer 
of the race. Altho knowledge of the facts exists, 
its application could make these diseases as rare 
as yellow fever and bubonic plague which in past 
centuries devastated whole nations of the world. CHAPTER VII 
THE UNITED STATES PUBLIC HEALTH 
SERVICE AND THE AMERICAN SOCIAL 
HYGIENE ASSOCIATION 
TO SUMMARIZE the practical campaign against 
the venereal diseases it may be said that three 
main lines of attack conducted simultaneously are 
essential. The first line of attack consists of the 
discovery, treatment, and control of infected indi- 
viduals. It should be led by the health departments 
cooperating with clinics, hospitals, and the private 
practitioners. The efforts of these forces must be 
supplemented by the activities of industrial surgeons, 
school physicians, life insurance examiners, private 
nurses, social-service workers, dentists and dental 
hygienists, and the many other professional and 
organized forces of which these are examples. 
The second line of attack comprises efforts to 
eliminate commercialized prostitution and other 
environmental influences which promote sexual 
promiscuity and thereby increase exposures to the 
venereal diseases. This attack should be led by 
the police and court authorities cooperating with 
law-enforcement forces and the legal profession. 
These efforts must be supplemented by the work 
of protective and probation agencies, organizations 
for the prevention of delinquency, recreational agen- 
cies, and a large number of special committees 
created to deal with phases of this work. 
The third line of attack includes a wide range 
of activities which in varying degrees influence 
particularly the education and character-training of 
51 52 
the children and youth of the nation. These efforts 
should- be led by the departments of education and 
teaching profession, aided by the educational so- 
cieties, parent-teacher organizations, religious and 
ethical teaching agencies, and a long list of other 
institutions which in some specific way can aid in 
developing sound views and habits of sex conduct 
among the members of each generation before they 
come to full maturity and assume the responsibility 
of government and of being parents of later genera- 
tions. The community as a whole must participate 
in bringing this about. 
Of these three great divisions of the campaign 
against the venereal diseases the last is by far the 
most important when results to be achieved in a 
hundred years are considered; therefore, it is vitally 
essential that this division of the program be sound 
and that all the time necessary be taken to plan 
and test out ways and means before a general 
advance along the line is begun. Everything that 
has been or is being done now should be patiently 
studied as experiment and demonstration in this 
field. It may be some years yet before a perfected 
program can be put forward, but when it is an- 
nounced the health officer will see the beginning 
of the end of his long fight to gain a large measure 
of control over the venereal diseases. 
The second of the three great divisions outlined 
is likewise second in importance in the long run. 
The constant efforts of vice promoters to place 
opportunity for sexual promiscuity before men and 
women and surround them by uses of alcohol, music, 
art, and emotional appeals conducive to yielding 
thereto, show that it is necessary constantly to 
stimulate men if large numbers are to be persuaded 
><j become patrons of commercialized prostitution, 
oy women are to be drawn into prostitution in any 
THE VENEREAL DISEASES form. The counteracting of these influences by 
legal interference and by attracting interest of the 
men and women to wholesome pursuits and enter- 
tainment is of vast importance to preventive medi- 
cine. In the past ten years significant gains have 
been made and the evidence is convincing that the 
next twenty-five years will at least see the elimina- 
tion of commercialized prostitution and great ad- 
vance in other directions. This influence on the 
reduction of venereal diseases will be marked and 
justifies the health officer in encouraging to the 
utmost this line of attack, altho like the educational 
attack it is not in his province administratively. 
The first of these group divisions of the campaign 
is first only in urgency and logical outline; it comes 
last in importance when the winning of the war 
against venereal diseases is planned. Nevertheless 
urgency is always a real factor; we have to do first 
that which is immediately necessary, and the salvage 
work of finding and treating the victims of diseases 
and protecting them from reinfection is an imme- 
diate necessity. It is the first-line trench which is 
being held while the other divisions are being 
brought into action. A hundred years is not an 
unduly long or discouraging period for a nation to 
contemplate fighting a war of control over so pow- 
erful a disease enemy. Less than fifty years have 
elapsed since science discovered these enemies; the 
first advocates of a war against them began organ- 
ized efforts to arouse the nation less than twenty 
years ago; and the last ten years covers all united 
national efforts to attack this problem on a broad 
scientific and social basis. The future is most 
promising in the light of this past. 
As in the conduct of all great wars, success 
depends partly upon a central planning division 
which has the opportunity and the freedom from 
PUBLIC HEALTH SERVICE 
53 54 
details of action necessary to study the whole situa- 
tion and point out ways and means of strengthening 
both the defensive and the offensive movements. 
The Division of Venereal Diseases of the United 
States Public Health Service is an outgrowth of 
recognition by the Federal Government of this need. 
This Service, through its cooperation with the State 
Health Departments, provides advice and guidance 
for all official efforts of federal, State, and city 
official departments and of related laboratories, 
clinics, and hospitals. In addition, the Public Health 
Service and the State Departments have found 
opportunity to aid the United States Bureau of 
Education and other federal and State agencies to 
do a great deal of educational work, and some sound 
law-enforcement work. 
Recently the opportunities of the United States 
Children's Bureau to cooperate in this work have 
been greatly increased through the maternity and 
infancy welfare work made possible by the Shep- 
pard-Towner Act. The nature and complexity of 
the problem, however, has necessarily placed limita- 
tions on what can be done by the federal bureaus 
and the State health departments, particularly in 
the law-enforcement and educational divisions of 
the campaign. All efforts to establish any coordi- 
nating official body have met serious administrative 
difficulties, and altho most important advances were 
made through such efforts during and immediately 
following the World War,1 it is evident that all 
the component parts of the complex program for 
combating the venereal diseases will have to be 
fitted bit by bit info the several permanent depart- 
ments of government; the coordination of the whole 
THE VENEREAL DISEASES 
1 The history of the U. S. Interdepartmental Social Hygiene 
Board should be studied by every one especially interested in the 
full story of social hygiene in the United States. Government 
reports of this Board from 1918-1923 are available. PUBLIC HEALTH SERVICE 
55 
being left to suggestion and persuasion of voluntary 
agencies which are free to investigate, study, and 
propose new measures, in a way that no official 
department is free. 
Realization of this situation led to the establish- 
ment in 1914 of the American Social Hygiene Asso- 
ciation as a national, voluntary agency equipped 
with the necessary personnel and funds from popular 
subscription to do two things. First, it serves as 
a skirmish line for the public-health authorities and 
other official bodies in discovering new ways of 
advancing all three divisions of the campaign, testing 
out by demonstration the practicability of new 
measures, and developing public opinion in support 
of official departments, making these measures a 
permanent part of the activities of government. 
Second, it acts as a voluntary coordinating influence 
in bringing about simultaneous effort on the part 
of all agencies concerned, both official and voluntary. 
This national association with its affiliations with 
State and local societies and committees and its 
cooperative relations with other national organiza- 
tions and their local units, is in a strategic position 
to be the complement of official agencies in this field. 
The first task of propaganda assumed by the 
Association was to build up in the minds of the 
people a clear understanding of the medical aspects 
of the venereal-disease problem and to gain their 
support in carrying out necessary measures. This 
came to fruition and received nation-wide recogni- 
tion during the first year of the World War. The 
next task was that of convincing the public of the 
relationship of commercialized prostitution to the 
spread of these diseases and the feasibility of a 
successful program against this form of vice. The 
necessary foundation for this propaganda was fur- 
nished through studies and reports of the Bureau 56 
THE VENEREAL DISEASES 
of Social Hygiene, which since 1911 has done 
invaluable work in research in the various fields 
of social hygiene. But communities are induced 
largely to take action only when an evil is shown 
to exist in their own midst, and the Association 
found it necessary to demonstrate in a selected 
series of cities in the United States both the exist- 
ence of organized prostitution and the practicability 
of proposed measures for combating it and related 
evils. The World War, likewise, gave this line of 
attack an added opportunity to secure nation-wide 
interest and action. Public attention having been 
gained for two of the major divisions of the pro- 
gram, the Association has put its emphasis since 
the War upon the third and most far-reaching line of 
attack-the educational and moral training division. 
It has been difficult to hold public support for 
all the diversified measures necessarv to secure 
steady progress. In the confusion of urgent appeals 
for every conceivable effort in behalf of health 
conservation and public welfare, the wonder is that 
the public should have continued even the support 
it has given since war days for the venereal-disease 
campaign. Those who know the frightful toll the 
venereal diseases take of health, business, and social 
efficiency, and of lives and mentality of unborn 
generations must carry on and seize every oppor- 
tunity to make new gains. Every citizen has it 
in his power to aid this great warfare against 
disease and moral disaster by direct participation 
in its battles and by supporting his government, 
and voluntary agencies such as the American Social 
Hygiene Association for whose constitution Presi- 
dent Charles W. Eliot wrote the following statement 
of purpose: "To acquire and diffuse knowledge 
of the established principles and practises and of 
any new methods which promote or give assurance PUBLIC HEALTH SERVICE 
57 
of promoting social health; to advocate the highest 
standards of private and public morality; to suppress 
commercialized vice; to organize the defense of 
the community by every available means, educational, 
sanitary, or legislative, against the diseases of vice; 
to conduct on request inquiries into the present 
condition of prostitution in American towns and 
cities; and to secure mutual acquaintance and sym- 
pathy and cooperation among local societies for 
these or similar purposes." 58 
THE VENEREAL DISEASES PUBLIC HEALTH SERVICE 
59 
The Susceptible Individual 
IB. Sex education as a factor in influencing 
character and conduct. 
2B. Religious and moral training. 
3B. Wholesome recreation and entertain- 
ment. 
4B. Protective measures designed to prevent 
sexual promiscuity and delinquency. 
5B. Legal measures applicable to the re- 
pression of prostitution, measures for 
the control of sex delinquency. 
6B. Custodial care when necessary to protect 
individuals and the public. 
1C. General promotion of public information concerning the venereal diseases and prostitution. 
2C. General promotion of public information concerning the importance of adequate sex educa- 
tion, recreation, and protective measures. 
SC. General promotion of measures for eliminating the use of intoxicating beverages and of 
habit-forming drugs. 
4C. Requirement of health affidavits or certificates before marriage. 
5C. Promotion of early marriage and the establishment of legal and voluntary aid for adjust- 
ment of marital difficulties. 
6C. General efforts to safeguard the family and provide better economic and social conditions 
for all the members of tbe family. 
The Infectious Individual 
1A. Medical advice and diagnosis for the 
individual. Disinfection measures when 
practicable. 
2A. Treatment for the benefit of the indi- 
vidual and the protection of the public. 
8A. Personal instruction regarding protec- 
tion of others. 
4A. Social service follow-up measures for the 
benefit of the individual and protection 
of the public. 
5A. Requirement of notification of cases to 
the health authorities under specified 
conditions. 
6A. Isolation or quarantine measures when 
necessary because of inability, refusal, or 
failure of the individual to carry out 
instructions of the Health Department.