Value of Expert Services.—The factor of expert judgment in the care and recognition of syphilis is an important one, and a progressive public policy will not neglect to provide for it. The state, municipal or hospital laboratory which professes to do Wassermann tests should not be in charge of some poorly paid amateur or of a technician largely concerned with other matters, or its findings will be worthless. Every clinic and hospital should also attach to its staff an expert consultant on syphilis on whom it can draw for advice in doubtful cases and for the direction of its methods of work. Every city health board which undertakes a serious campaign against syphilis should not be satisfied merely with doing Wassermanns, but should enlist in behalf of the public consultation of the same grade which it expects to employ in the solution of its traction and lighting problems, and in the management of its legal affairs. No one would think nowadays of placing a physician in charge of a great tuberculosis sanitarium whose knowledge of the chest was confined to what he had learned in medical school twenty or more years before—yet in a parallel situation one often finds the subject of syphilis handled with as little attention to the value of expert knowledge. Expert service is expensive, and if the state wishes to command the whole energy of progressive men, it must be prepared to pay reasonably well for what it gets.
Suppression of Quacks and Drug-store Prescribing.—The suppression of quackery is nowhere more urgent than in the control of syphilis. Every important legislative scheme that has come into existence in recent years has recognized this fact. The devil may well be fought by fire, and reputable agencies should enter the field of publicity with some of the vigor of their disreputable opponents. The brilliant success of this scheme was admirably illustrated by the results of the recent efforts of the Brooklyn Hospital Dispensary, which, by replacing the placards of advertising quacks in public comfort and toilet rooms, and running a health exhibit on Coney Island, attracted to a clinic where modern diagnosis and treatment were to be had an astonishing number of young people who would have fallen victims to quacks. The evil influence of the drug store in perpetuating the hold of syphilis and gonorrhea upon us is just being understood. The patient with a beginning chancre, at the advice of a drug clerk, tries a little calomel powder on the sore, and it either "dries up" and secondary symptoms of syphilis appear in due course, or it gets worse or remains unchanged and the patient finally goes to a doctor or a dispensary to find that his meddling has lost him the golden opportunity of aborting the disease. If secondaries appear, a bottle or two of XYZ Specific, again at the suggestion of the all-knowing drug clerk, containing a little mercury and potassium iodid, disposes of a mild eruption, and a year or so later a marriage with subsequent mucous recurrences and the infection of the wife signalizes the triumph of ignorance and public shortsightedness. The health commissioner of one of the largest and most progressive cities in this country stated before a recent meeting of the American Public Health Association that he had sent a special investigator to twelve representative drug stores in his city, and that simply on describing some symptoms, without even the ceremony of an examination, he had received from ten of them something to use on a sore or to take for gonorrhea. It is only justice to say that occasionally one finds drug stores which will refer a patient to a doctor or a dispensary. Drastic legislation to suppress this sort of malpractice is part of the program of Great Britain, Germany, and West Australia, and we in this country cannot too quickly follow in their steps.
Publicity Campaign.—The educational campaign against sexual disease has already been discussed in theory. In close relation to it is the question of the use of publicity methods for legitimate ends, mentioned above. It has had a number of interesting applications in practice. The West Australian law has taken the stand of prohibiting all advertising, replacing the method of attracting the patient into coming for treatment of his own free will by the method of making treatment compulsory under heavy penalty. In this country, where compulsory legislation will be slow of adoption, publicity methods will have a certain vogue and a proper place. It has been of great service in the campaign against tuberculosis and in the movements for "Better Babies" and the like. It should never be forgotten that it is a two-edged weapon, however, and that where a stigma exists, as in the case of sexual disease, too much advertising of the place of treatment as distinguished from the need for it will drive away the very people whose sensitiveness or need for secrecy must be considered. On the other hand, the publication of material relating to sexual diseases in the public press has not yet reached the height of its possibilities, and should be pushed.
Utilization of Personal Prophylaxis.—Passing now to the debatable elements in a public campaign, opinion about the value of personal prophylaxis (Metchnikoff) against syphilis shows interesting variations in different countries at the present time. English-speaking countries hesitate over this. On the other hand, eminent German authorities, such as Neisser and Blaschko, urged it at the outset of the present war, and their views have apparently overcome a vigorous opposition. As a result, the knowledge of methods of preventing venereal infection are being spread broadcast over Germany in the hope of diminishing the inevitable risk that will arise with the disbanding of armies after peace is concluded, no matter how stringent the precautions taken to insure the health of soldiers before their return to civil life. The results of this experiment will be watched with the most intense interest by all those familiar with the situation, and the results will be of value as a guide for our own policy when we have had time to develop one. It is interesting that the most radical departure in the way of legislative provision for sexual disease, that of West Australia, takes up the patient at the point where his infection begins and promptly places him under penalty in the hands of a physician, but assumes no responsibility for other than indirect prevention. The most radical of all present-day legal measures against the disease has therefore not yet reached the radicalism of compulsory prophylaxis as it exists in armies, or even the radicalism of compulsory vaccination for smallpox.
Reporting of Syphilis to Health Officers.—The question of reporting syphilis to health officers as a contagious disease is a good one to raise in a meeting when a stormy session is desired. Upon this question wide differences of opinion exist all over the world. The right of a sick person to privacy, always deserving of consideration, becomes acute when it touches not only his physical but his social, economic, and moral welfare. It becomes a matter of importance to the state also when the prospect that his secret will not be kept leads him to conceal his disease and to avoid good public aid in favor of bad private care. It is a question whether the amount gained by collecting a few statistics as to the actual presence of the disease will be offset by the harm done in driving to cover persons who will not be reported. Modified forms of reporting sexual diseases, without name or address, for example, can be employed without betraying a patient's identity, thus doing away with some of the objections, and they have been in force in such cities as New York for some time. Vermont has recently adopted a compulsory reporting system, with the almost ludicrous result that by the figures her population shows 0.5 per cent syphilis, when the truth probably stands nearer 10 per cent. Much of the difficulty with reporting systems goes back to the lack of an educated public or professional sentiment behind them. For this reason they may be fairly placed in the category of premature legislative experiments, and should be postponed until a more favorable time. That this view has the sanction of students of such problems is borne out by the recent comment of Hugh Cabot on this issue, and by the decision of the British Royal Commission which, after careful deliberation, decided not to recommend to the Government at the present time any form of reporting for sexual disease. The West Australian law recognizes the wisdom of providing the patient having sexual disease with every safeguard for his secret provided he conforms to the requirement of the law in the continuance of his treatment. German sentiment is strongly against reporting, and no provision is made for it in the civil population. On the other hand, the very complete programs of the Scandinavian countries provide for reporting cases without names. It is, therefore, apparent, in view of this conflict of opinion, that we can afford to watch the experience of our neighbors a little longer before committing ourselves to the risk of arousing antagonism over a detail whose importance in the scheme of attack on syphilis is at best secondary to the fundamental principles of efficient treatment and diagnosis. There is no apparent reason why we should not be satisfied, for the present, at least, with drawing to our aid everything which can give us the confidence and the willing coöperation of those we want to reach. Physicians who work with large numbers of these patients realize that privacy is one of the details which has an attraction that cannot be ignored.
Compulsory Treatment.—Compulsory provisions in the law form the third debatable feature of a modern program against syphilis. The Scandinavian countries have adopted it, and in them a patient who does not take treatment can be made to do so. If he is in a contagious condition, he can be committed to a hospital for treatment. If he infects another, knowing himself to have a venereal disease, he is subject, not to fine, but to a long term of imprisonment. The West Australian law is even more efficient than the Scandinavian in the vigor with which it supplies teeth for the bite. The penalties for violations of its provisions are so heavy as to most effectually discourage would-be irresponsibles. At the other end of the scale we find Great Britain relying thus far solely upon the provision of adequate treatment, and trusting to the enlightenment of patients and the education of public sentiment to induce them to continue treatment until cured. Italy has, in the same way, left the matter to the judgment of the patient. The Medical Association of Munich, Germany, in a recent study has subscribed to compulsory treatment along the same lines as the West Australia act, although thus far enforcement has been confined to military districts. The program for disbanding of the German army after the war, however, includes, under Blaschko's proposals, compulsion and surveillance carried to the finest details. A conservative summary of the situation seems to justify the belief that measures of compulsion will ultimately form an essential part of a fully developed legal code for the control of syphilis. The reasons for this belief have been extensively reviewed in the discussion of the nature of the disease itself (pages 104-105). On the whole, however, the method of Great Britain in looking first to the provision for adequate diagnosis and treatment, and then to the question as to who will not avail himself of it, is a logical mode of attacking the question, and as it develops public sentiment in its favor, will also pave the way for a sentiment which will stand back of compulsion if need be, and save it from being a dead letter.
Backwardness of the United States in the Movement.—It will be apparent, from the foregoing review of the world movement against syphilis, and the essentials of a public policy toward the disease, that the majority of our efforts in this direction have been decidedly indirect. We have no national program of which we as a people are conscious. It is all we can do to arouse a sentiment to the effect that something ought to be done. In these critical times we must mobilize for action in this direction with as much speed at least as we show in developing an army and navy, slow though we are in that. To limit our efforts to the passing of freak state legislation regulating the price of a Wassermann to determine the fitness of a person for marriage, when both Wassermann test itself, and Wassermann test as evidence of fitness for marriage, are likely, under the conditions, to be absolutely worthless, is to play penny eugenics. The move to take the gag from the mouth of the physician when an irresponsible with a venereal disease aims to spread his infection by marriage is at least intelligent, preventive, even if indirect, legislation, because it acts before and not after the event. Although at the present time we cannot boast a single example of a complete program of direct legislation, the example of Michigan, which is providing free hospital treatment for adults and children with syphilis, should be watched as the first radical step in the right direction. If war and our mobilization for defense leave us with every hospital and dispensary and public health resource and all the expert judgment we have available within our borders enlisted finally in a great campaign against gonorrhea and syphilis, it will have accomplished a miracle, though it will have done no more than war has done for Europe. If it leaves us even with our more progressive states committed to an expanding program of universal efficient and accessible diagnosis and treatment, it will have conferred a blessing.
Relation of War to the Spread of Venereal Disease.—The frequent reference to the relation of war to the problems of sexual disease seems to justify a concluding paragraph on this aspect of the matter. Much of the impetus which has carried European nations so far along the road toward an organized attack on syphilis and gonorrhea, as has been said, is undoubtedly due to the realization that war in the past has been the ally of these diseases, and that a campaign against them is as essential to national self-defense as the organization of a vast army. Conflicting reports are coming from various sources as to the prevalence of syphilis and gonorrhea among European troops, although hopeful indications seem to be that troops in the field may have even a lower rate of disability than in peace times (British figures). The most serious risks are encountered in troops withdrawn from the front or sent home on leave, often demoralized by the strain of the trenches. The steady rise in the amount of syphilis in a civil population during war is evidenced, for example, by the figures of Gaucher's clinic in Paris, in which, just before the war, 10 per cent of patients were syphilitic; after the first sixteen months of the war 16.6 per cent were syphilitic, and in the last eight months, up to December, 1916, 25 per cent had the disease. There can be no doubt that a campaign of publicity can do much to control the wholesale spread of infection under war conditions, and we should bend our efforts to it, and to the more substantial work of providing for treatment and the prevention of infectiousness, with as much energy as we devote to the other tasks which preparedness has forced upon us. The rigorous provisions proposed for continental armies should be carefully studied, and in no cases in which either syphilis or gonorrhea is active should leave or discharge be granted until the infectious period is over. Compelling infected men to remain in the army under military discipline until cured might have a deterrent effect upon promiscuous exposure. In addition we should create as rapidly as possible a mechanism for keeping inactive cases under surveillance after discharge until there can no longer be the slightest doubt as to their fitness to reënter civil life. Observers of European conditions in the population at large are emphatic in saying that home conditions must have as much attention as the army, and that suppression of open prostitution, a watchful eye on the conditions under which women are employed or left unemployed, and the control of contributory factors, such as the liquor traffic, must be rigorously carried out. Nation-wide prohibition will do much to control venereal disease.[18] It is interesting and significant that little reliance is being placed on the obsolete idea that prostitution can be made a legitimate and safe part of army life solely by personal prophylactic methods, or by any system of inspection of the women concerned. It is a hopeful sign that this conception is at last meeting with the discredit which has long been due it.
[18] Through the effect on prostitution. A well-known and very intelligent prostitute, with whom this question was recently discussed, rated the liquor traffic first among the influences tending to promote prostitution.
The question has occurred to those interested in compulsory military service as a measure of national defense as to whether the mobilization of troops for training will favor the spread of sexual disease. Unfortunately, there are no satisfactory figures for the civil population showing how many persons per thousand per year acquire syphilis or gonorrhea, to be compared with the known figures for the onset of such infections in the army. Arguing from general considerations, however, there seems to be no reason to suppose that the army will show a higher proportion of infections than civilians. In fact, there is every ground for believing that the percentage will be lower, since the army is protected by a fairly efficient and enforceable system of prophylaxis which is taught to the men, and they live, moreover, under a general medical discipline which reduces the risk of infection from other than genital sources to the lowest possible terms. In opposition to the conception that the sexual ideals of the army are low, it may be urged that they are no lower than those of corresponding grades in civil life, and that hard work and rigid discipline have a much better effect in stiffening moral backbone than the laxities of present-day social life. In the last analysis, the making of the moral tone of the army is in our own hands, and by putting into it good blood and high ideals, we can do as much to raise from it a clean manhood as by submitting that same manhood to the temptations and inducements to sexual laxity that it meets on every street corner.