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CONQUERING
AN OLD ENEMY
BY
WILL IRWIN
THE AMERICAN SOCIAL HYGIENE ASSOCIATION
Incorporated 370 SEVENTH AVENUE, NEW YORK
Copyright, 1 910, by
The American Social Hygiene Association, Inc.
Publication No. 2.50
CONQUERING AN OLD ENEMY
Bv Will Irwin
T^WO young men, escorting two very nice young girls, once went boating on a Western river. Suddenly they heard muffled shouts from the rapids below them. They looked and saw that a man, swimming, had been caught in the swift current, was going under. The young men rowed toward him. And then, one of the girls began to scream.
"Heavens!" she cried, "we can't take him aboard. He isn't dressed! He's — he's naked!" The other girl joined in the protest. Their escorts, ignoring all this, continued to row. The girls went hysterical. They clutched at the arms of the rowers. Before that struggle finished, it was too late. The swimmer had gone under for the last time. All this happened, exactly as I tell it, in the Far West when I was a boy.
These were foolish girls, lacking in all sense of proportion. And still, neither you nor I can afford to cast against them the first stone; for this little story is an allegory of the human race. In these United States and in this year of peace 1920, more lives than the whole em- pire of Great Britain lost during any year of the Great War will be flicked out by two diseases which are curable and preventable dis- eases. Nor will the year 1920 stand alone. In the four and a half years of intensive warfare between 1914 and 1918, the fifteen civilized nations which fought at Armageddon gave to these twin scourges a heavier toll than they did to bullets, shells, gas, air-bombs, all the ghastly, wholesale killers of modern battle. Yet these two diseases present no mystery to the modern physician. They may be cured; and their infection can be checked at its source. Why, then, have we not acted, we who thought we were civilized? Because we as a world have assumed the attitude of the silly girls in the boat. We have been too nice, too rotten, nasty nice, to organize and come out in open fight against syphilis and gonorrhea.
Even medical science has seemed until lately to struggle against this same handicap of modesty. We have long understood the dangers
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and horrors of tuberculosis and cancer; but not until the last decade or so has any one known exactly how terrible are the "secret diseases," the "social diseases," the "hidden scourges." At last, we have seen the face of the enemy. The facts which I am about to quote are not the conjectures, guesses, and exaggerations of partisans and alarm- ists. They are a brief synopsis of cold statistics gathered by calm men of science, proved and approved by our government.
Of the two diseases, syphilis is by far the greater killer — at least directly. In its fatal tertiary stage, it runs into several well-recognized complaints which must be reckoned in the indictment. Every case of locomotor ataxia, for example, is in origin syphilitic, — there is no other cause for this grotesque and terrible affliction. The same thing is true of paresis. Again, a definite proportion of other fatal diseases, such as certain varieties of organic brain, heart, and kidney diseases, have for origin syphilis. It is estimated by authorities that, together, they kill annually in these United States more than 300,000 people. France, we used to say, was "bled white" in the war. She lost about 1,350,000 lives by the fatalities of battle. During the four years and four months of Armageddon, our tribute to syphilis was about the same as hers to the Kaiser. It causes, year in and year out, two American deaths out of thirteen, leading by a wide margin tubercu- losis, which is next on the list. That dreaded "white plague"; heart disease, the terror of declining years; pneumonia, the savage slayer of maturity, the gentle reliever of age; cancer, the dark mystery of science — all give place to syphilis. When we consider that America is on the whole less generally infected than Europe, we must realize that it is the chief enemy of the white race. Again I say: I am reporting not the fancies of alarmists, but the approved facts of cold science.
None of this generation is likely to forget the influenza of 1918. This was a swift, raging epidemic, as syphilis is a slow, persistent one. In that year, when the new plague divided interest with the war, syphilis was quietly taking nearly if not quite as many lives as influenza. The influenza epidemic ran its course in a year and dis- appeared; not, probably, to return in such a form for many years. Syphilis goes on the same, year after year. Its percentage of deaths for 1918 was virtually the same as for 1917, 1916, 1915 — for every period since medical statistics enabled us to see what it is doing. And unless we act, its death-roll will never diminish.
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To finish the indictment against syphilis, no disease worth con<= sidering is inherited. The theory of hereditary cancer was exploded long ago. Neither tuberculosis nor, strictly speaking, the tuberculous tendency passes on from generation to generation. But syphilis— stating the matter practically, though not quite scientifically — may be in- herited. At certain stages of this long, chronic disease, syphilitic parents transmit the germ to their children before birth. The child so infected may have all the complications of the disease, together with other special complaints peculiar to the second generation.
So much for the dreadful elder sister of this pair. Gonorrhea, al- though much more common, is far less fatal. It seldom if ever kills directly; it may, however, lead its victim into certain fatal diseases, and increase the mortality in others. But the statistics on gonorrhea are still so uncertain that we would better leave its fatal effects out of consideration. In modern war, artillery fire kills two men where it wounds three; in actions of a certain kind, rifle and machine-gun fire kills one man where it wounds six or seven. Syphilis is the artillery of our hidden foe; gonorrhea is his small-arms. And the wounds and mutilations inflicted by this lesser but more prevalent disease rival the wounds and mutilations of war. Until recently, most of the chil- dren blind from birth owed their pathetic affliction to a parent in- fected with gonorrhea. Modern research into the causes of so-called "female complaints" has brought out appalling facts. Far the greater and more dangerous part of these diseases arises from gonorrhea, and from nothing else. When this kind of "female complaint" has gone far enough, nothing will prevent premature invalidism but a drastic surgical operation. The woman so treated can never again bear chil- dren. This is a pathetic feature of the case against gonorrhea. Most of these victims cannot be dismissed with the glib, shallow phrase, "They brought it on themselves." A large part of the pelvic and ab- dominal operations on women are made necessary by gonorrhea. Many if not most of the women who submit to this operation, which leaves them barren for life, have never transgressed the accepted law of sexual morality — they are paying the penalty for the promiscuity of their husbands before marriage.
However, in striking at the foundations of the race, gonorrhea does not strike through the woman alone. In another manner, equally cer- tain, it produces sterility in males. Syphilis cuts down the trunk of
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our race; gonorrhea attacks it at its origin. Syphilis destroys life in its full bloom; gonorrhea prevents life.
We Americans, as a people, think a great deal of efficiency. Prob- ably national efficiency has no enemy so powerful and persistent as this lesser of the two antisocial diseases. Except in its more acute early stages or its long, late complications, it seldom puts its victim to bed. If, like smallpox or typhoid fever, it ran a violent course, killed or passed over in a few weeks, it would trouble us less. The victim goes about week after week, month after month — in the cases where he is not properly treated, year after year — in a state of reduced vitality. The bill is large, owing to the astonishing prevalence of this disease. Though they thought they knew the worst, our army medical authorities were appalled, when they examined our recruits for the late war, by the number of men infected with gonorrhea. Many authorities say flatly that it is second if not the most common of all diseases. One authority estimates that in reduced efficiency it costs us $300,000,000 a year. This figure, unlike those which I have quoted above, is only shrewd guesswork. Still, few who understand the sub- ject would call it exaggerated.
So much for what they are, these two costly plagues. There would be no use in advertising them, as I am doing here, were the case hope- less. It is far from that. They may be cured. They can, with sufficient effort, be generally eliminated from the race, reduced to the status of the rare diseases. That is the tragedy of the situation. With the weapons long forged and ready, we have meekly submitted year after year to our greatest racial enemy.
How many pock-marked acquaintances have you? Myself, I can call to mind one. How often do you notice on the streets a pock- marked face? Looking back over the past four months, I recall but two. If you had lived a century ago, you would have seen pock- marking as commonly as you now see baldness. Again and again in the biographies of the time — as of Samuel Johnson or Fanny Kemble — you encounter the simple phrase, "he was pock-marked." In those days, smallpox was never entirely quiescent. It killed every year its thousands in small epidemics. Occasionally it burst out into a great epidemic which sent the rich scurrying away from the centres of infection, and slew by the tens of thousands those who must remain. Now, smallpox is so rare that we scarcely take the trouble to tabulate
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it among the causes of death. What quelled this scourge ? An act of Providence? Not at all. The race took the matter into its own hands. First, medical men discovered, if not yet the germ of smallpox, at least the conditions under which it spread. They learned first that contact with an infected person, and, second, contact with the articles he had worn or used during his illness, might cause the disease. Next, that great pioneer Jenner found in vaccination a sure method of prevention. Then the race went to work. The clothing, the bed- clothing, the dwelling of an infected person were disinfected. We set up hospitals, to which smallpox patients were removed, in which they were kept isolated. Slowly at first, and then with increasing speed, civilized humanity, especially in those places most subject to the disease, took to vaccination. In a generation after Jenner we had controlled smallpox; in a century we have put it behind us. But mark this: the movement went no faster and no slower than public education in the causes and prevention of the disease. Not until every physician knew exactly what to do in the face of an epidemic; not until local mayors, aldermen, supervisors, and boards of health knew that to maintain hospitals, to isolate acute cases, and to disinfect all polluted objects was their solemn duty; not until the dullest person knew that he must instantly report every case, and that he could escape the disease entirely if he got himself vaccinated — not until education and open discussion had established all this did we con- quer smallpox.
A generation ago, the warm regions of the American continent trembled under the fear of yellow fever. Science went to work, guided now by a light which Jenner lacked — the germ theory of disease. Our medical investigators found that the germ of yellow fever was transmitted from victim to victim by the bite of a certain mosquito. They studied the habits of this insect; found how it could be de- stroyed. At first in the semi-tropic parts of the United States, then in Cuba, and later in the more thickly settled parts of South America, sanitary engineers went to work. Now, unless we grow shockingly careless, yellow fever will never again trouble a well-organized com- munity. Yet here, too, the work went no faster than public educa- tion. The governing bodies of states and municipalities, and the public which kept them in power, had to learn that the Stegomyia mosquito was deadlier than a rattlesnake, and that they might better poison
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their wells than leave water-barrels and sewers uncovered and cis- terns unscreened.
The same thing is happening to typhoid fever, which used to cause more deaths in armies than the casualties of battle, and which, during the late war, was thrust back into the category of rare diseases. The same thing is happening to bubonic plague and cholera. And always, the plot of the story is the same. Medical investigation finds the germ or the exciting cause. With that clue, medicine goes on to ascertain what conditions favor its spread. It works out remedies, both curative and preventive. It starts a campaign of education and organization. The medical profession and we, the public, move against it as a body — and that war is won. The first battle, the discovery of cause and cure, is usually the hardest. We should be moving now as an organized army of health against cancer, did we know its cause. That, alas, remains a baffling mystery of science.
The first battle against venereal diseases was won long ago. We know that both syphilis and gonorrhea are germ diseases. Their deadly agents have been seen and studied in the field cf the microscope. It was Schaudinn who first beheld and described those pale, minute spirals which cause the syphilis plague; it was Wassermann who devised a blood test to find the disease even when it lies dormant in the body. Long before that, we knew all we needed to know about the germs of gonorrhea. And the cure followed. Even when we were still uncertain whether or no syphilis was a germ disease, the doctors understood that a long treatment with mercury, scientifically applied, would arrest — possibly cure. Then came Ehrlich, some eight or ten years ago, with his famous discovery of " 606," or salvarsan. "This," said an enthusiast, "will clean syphilis out of the human system as a reagent will clean the poison out of a reservoir." Salvarsan did not quite live up to this early reputation. But it did prove one of the most valuable healing agents known to medicine. Further, physicians discovered that a combined salvarsan and mercury treatment, ex- pertly and persistently applied, worked wonders. In plain, everyday language, salvarsan held down the troublesome and dangerous symp- toms while killing a part of the germs, and mercury cleaned up the rest. Any intelligent physician will tell you that no other chronic disease may be so easily, certainly cured as syphilis — only provided that the patient will stick to a long treatment and start it early.
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The story of the gonorrhea cure is not quite so complete and dramatic as that of the syphilis cure. Syphilis is a blood disease, running through the hidden courses of the human system. Gonor- rhea attacks the mucous membranes — lies, in a manner of speaking, on the surfaces of the body-channels. Several chemical compounds were known to be deadly enemies of the gonorrhea germ. Long ex- perience showed which of these were most efficient. Medicine dis- covered mechanical means of getting at those deposits of germs which lie quiescent in the hidden folds of the body, and which make this disease so treacherous. It is not, really, so easy of treatment as syphilis, especially when it occurs in women. But still it belongs in the category of curable diseases — provided the skilled physician catches it in the early stages. With both of these plagues, an ounce of prompt treatment is worth a pound of late treatment. Syphilis practically never, and gonorrhea seldom, runs its course and cures itself as do typhoid fever, smallpox, and most epidemic diseases. If neglected, both not only entrench themselves in the system, but they often lead to complications which are virtually incurable.
So the cause and cure were known; the first battle was won. Knowl- edge of the conditions under which these diseases spread was almost as old as the diseases themselves; and science bolstered that knowledge with hard facts. The open sewer which spreads venereal disease is prostitution. Most epidemic diseases have some "carrier." In typhoid fever it is infected water or milk, or the household fly. In yellow fever, it is the Stegomyia mosquito. In bubonic plague, it is the rat — or rather his parasite, the rat-flea. The fly, the mosquito, the rat of venereal disease is the commercialized prostitute. Whenever we dipped into the underworld in pursuit of knowledge on this subject, we found astonishing figures. Three hundred and twenty Barbary Coast prostitutes in San Francisco were examined during their working hours for syphilis alone. Ninety-seven per cent had the disease! The Baltimore Vice Commission found that of 320 prostitutes in the red- light district, 96 per cent had either syphilis or gonorrhea or both. A similar investigation by the Detroit Board of Health showed 94 per cent. Let us be honest and admit that not every man who goes with these women will catch disease. In certain stages, neither syphilis nor gonorrhea can be communicated, as in certain other stages they most certainly can. Further, not every one directly exposed to venereal
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disease catches it; but the same is true of other contagious diseases. During the typhoid-fever epidemic at Stanford University some fifteen years ago, four students stopped at a dairy farm; and all had a drink of milk from the same can. This milk was infected with typhoid. None of the four was technically immune, for none had ever gone through typhoid fever; and this was before the discovery of the typhoid inoculation. Two of the four came down with typhoid fever; two escaped absolutely. Smallpox has its stages when it can be communicated and when it cannot; and certain people in certain conditions of the system do not "catch" it, even when exposed. The man who goes with one of these women stands about the same chance to escape undamaged that he would stand if he had spent an hour in the embraces of a smallpox patient, had been bitten by a Stegomyia mosquito, or had drunk from a well polluted with typhoid germs.
Step one: find the cause and cure of the disease. Step two: find the conditions under which it develops. Step three: organize and put it out of business. With the medical profession as officers, with state and national boards of health as a general staff, raise and train your battalions, divisions, and armies from us, the people. This last step, though by far the most laborious, is in the typical fight against a disease the easiest of all. To track down a disease to its ultimate cause and to discover the remedy takes genius; and genius is very rare and precious. To organize, when the facts and the remedy are known, takes only the big, wide-thinking, common mind which we use every day in big business and big politics.
But this fight is different. The difficulty is to raise the forces. Just now, the army against venereal disease looks like a general staff and a fine corps of trained officers without sergeants, corporals, and pri- vates. So far, and in the face of the appalling facts which I have quoted above, the eminent and devoted leaders in our struggle against venereal disease have not succeeded in getting the country "heated up" on the subject, as New Orleans got heated up on yellow fever, as we all got heated up on influenza. Why? Because as a gen- eral rule the moral, decent, and devoted part of our communities, the very people whom we most need in this endeavor, take the attitude of the silly little girls in the boat. It is a shameful thing; therefore it is not to be discussed. The average newspaper which, until a few years ago, printed for money the obscene advertisements of quacks,
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shrank from admitting to its columns the words "syphilis" and "gonorrhea," or even the idea of venereal diseases. And this was not so much the fault of the editors as of subscribers, who would stop a newspaper containing "such thoughts."
Public ignorance on this topic is dense, black. Among intelligent, educated, able men of my acquaintance, I find common the belief that syphilis and gonorrhea are one and the same disease, whereas they bear no more relation to each other than scarlet fever to small- pox. In America, we cannot create enthusiasm without discussion; and we need enthusiasm to arouse that gigantic national will by which America works her marvels.
Yet the general staff has ordered battle with what forces it has, and the organized fight has even now begun. In the late war, the medical officers of every army made a systematic struggle against venereal disease. They had to; left alone, it might have beaten them unassisted by the enemy. Do the best they could, the British Royal Army Medical Corps reported that the venereal diseases kept con- stantly out of action enough British soldiers to diminish seriously the fighting strength of the army. The war, further, dragged into action and put on a common field the great directing medical men of all the allied nations. On its medical side, it was one long world- convention of great physicians. Before they separated and sailed from France, they had consulted, thrashed out plans to put world- wide team-work into the fight against diseases, especially tubercu- losis, gonorrhea, and syphilis. The great Red Cross Conference at Cannes, France, convened in April, 19 19. Every day a considerable portion of the time was given to a discussion of the venereal disease problem. Here a general plan of strategy was laid out and agreed on; our delegates returned home to do their part.
I have no room here to describe the plan of strategy laid out by the Red Cross Conference at Cannes; but I will touch upon some of the phases which most concern us. First is the curative campaign.
Until a few years ago, the average man stricken with either syphilis or gonorrhea was a prey first to his own ignorance and second to the quacks. If these diseases stretched a man at once on his back, impotent with fever and pain, they would doubtless be less trouble- some to society. But usually he keeps on his feet; he can still go about his business. So a certain proportion of the afflicted applied
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some patent remedy, always worse than useless, or neglected the early stages altogether. A greater proportion ran to the quacks. These men, usually physicians without standing in their profession, used to fill the newspapers with display advertisements of "sure-shot" cures. As a class, the venereal quacks were after but one thing — the victim's money. Sometimes they applied, though carelessly and inexpertly, the approved remedies. Sometimes they gave no treatment worth the name, but only hocus-pocus. And usually, when they saw no more money in sight, they applied some temporary alleviant, per- suaded the victim that he was cured, and turned him loose. So general and dense was the ignorance about the "secret diseases" and their treatment that the farm-hands and cowboys of the West, for example, believed that a regular physician would not handle a case of venereal disease — that the victim must take to quacks or to patent medicines.
There was a shade of truth in this idea. So disreputable had the quacks made the treatment of these diseases, so nasty nice was the attitude of the public, that general practitioners disliked to take a case of venereal disease. Even yet, they tend to pass it on when they can. And the quack, though long ago shut out from most of the news- papers, is still with us, slaying his thousands. So here is the first movement of the campaign. The United States Public Health Service, which is officially leading the campaign, wants to make it possible and even compulsory for every person afflicted with venereal disease to get good, expert treatment regardless of his ability to pay. Already, many of the larger cities have free venereal disease dispensaries, where, usually, the patient fares better than he would at the hands of a general practitioner, since the staffs of these dispensaries are specialists. The medical profession wants to extend the system until every city of more than 8,000 inhabitants has such an institution. In these days of rapid transportation, they believe this will cover the rural as well as the city population.
Of course, the $4,100,000 appropriated by Congress, and the funds added from other federal sources, will not begin to cover the cost of dispensaries. The funds of the American Social Hygiene Association will serve but to aid the campaign of organization and education — the expenses of the general staff. States, counties, and municipalities must do the rest. Already, the authorities of almost every state have re- sponded— some weakly, some whole-heartedly. The weak ones will
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never put heart into the work until forced by the public. There is the first job for you, John Smith, and for you, the lately enfranchised Mary Smith. The general procedure will be in all states the same. An expert on the treatment of venereal diseases and on the social methods of fighting them will be detailed to the state board of health by the surgeon-general of the United States Public Health Service. He will father the work of the dispensaries. Part of his job will be holding the dispensaries up to the most approved modern methods. From laboratories under governmental supervision, he will get in their purity the drugs necessary to the cure. This is important. Arsphenamine ("606"), for example, requires expert manufacture. It was devised in Germany, and until the war Germany had a monopoly of its manufacture. With the German supply cut off, our chemists had to learn the method. Now the laboratories of America make the best of all remedies; and the product of these laboratories is available for the state and municipal dispensaries.
A closely knit organization encompassing the efforts of all agencies fighting for venereal disease control has been effected through the Division of Venereal Diseases of the United States Public Health Service, for the purpose of meeting the problems in medical service, education, law enforcement, and social service.
Even at this moment, the work has gone far enough so that a victim of syphilis or gonorrhea who is unable to pay a private physi- cian may get in touch with the best modern treatment by writing to his state board of health. How much this spread of scientific treat- ment will do to reduce deaths from syphilis, devastating operations on women, blindness, physical defects, and idiocy in children, we cannot even guess. Yet here is a glimpse. Babies of gonorrheal mothers are likely to go blind. At birth, they get the infection in their eyes. Now the surfaces of the eye are easily reached by drugs, and nitrate of silver is almost invariably fatal to the germ of gonorrhea. One by one, our states passed laws requiring physicians and midwives to treat the eyes of all babies, at birth, with nitrate of silver. In the past generation, 80 per cent of blind children were said to owe their affliction to this cause; in this generation, only 20 per cent.
The universal free dispensary will do much toward quelling the old enemy. And still, it is only the lesser feature of the campaign. In a yellow fever epidemic we establish hospitals, staff them with
experts, send for the best drugs and apparatus, screen our houses against the fatal mosquito. But that is not enough. If we want to be free from the disease, then and forever, we must get at the mos- quito and at the environment where he breeds. So, if we are to succeed in the most important piece of sanitary work ever undertaken by- man, we must drain the stagnant swamps of the underworld where flourishes that deadly mosquito, the commercialized prostitute.
That job is not easy; not nearly so easy as draining the swamps, flushing the sewers, and screening the cisterns of a yellow fever dis- trict. In New Orleans during the trying days of epidemic, no sensible person who understood the problem was ever in two minds about what must be done. Especially, no one was driven by any natural or unnatural desire to have contact with a Stegomyia mosquito. But when we come to attack commercial prostitution we meet a human problem. On the respectable side of society we must deal with diverse views of morals and law enforcement, with whims, notions, fancies, and especially with false modesty. And the prostitute cannot be wiped out with one swat, like a mosquito. She is a human being — sometimes purely wicked, sometimes only unfortunate, sometimes intelligently evil, sometimes merely underbrained — but a human being with a soul and with certain inherent rights. The job is hard, but when did Americans ever hesitate to tackle a hard job? Our gigantic will is our main hold, and "It can be done" our motto. I shall not stop here to dwell on methods. The American Social Hygiene Asso- ciation is waiting eagerly to explain that. If you will write them, addressing 105 West Fortieth Street, New York, they will give you the benefit of accumulated human experience and governmental co- operation in putting down commercial prostitution and in curbing the diseases which it breeds.
Only, in spite of our national will, our courage in attacking the desperately hard job, we shall never succeed with this one if we maintain the attitude of the silly little girls in the boat. Chambers of commerce, central labor organizations, boards of education, churches, and not least of all, women's clubs, must get sincerely, enthusiastically into the fight. They must educate the public until the dullest yokel knows that a case of venereal disease is as dangerous to himself as a case of smallpox and more dangerous to society in general, that it demands immediate report to the proper authorities,
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and early, expert treatment, and that the best treatment is to be had for the asking. They must force city governments, sometimes half- compromise with the powers of evil, to drain the swamps and flush the sewers of the underworld. Going further, they must work to replace the low dance-hall, the red-light resort, with innocent and healthful recreation. But they will not do this, they cannot, while venereal disease is a subject only for shameful mention, in blushing whispers, among intimates. The great ally to this most dangerous enemy of the human race is false modesty.
We tingle with pride over our mighty achievement in crowning the Great War with victory. Because all America was working with a common good will, we created out of raw material an army of 4,000,000 men, equipped them, sent them overseas at the rate of 300,000 a month; we raised sums of money beyond imagination; we saved voluntarily from our own tables the food which kept France, Great Britain, Italy, and Belgium from starvation. Could we have done that if we had barred all references to Germany from polite society, if we had mentioned the atrocities in Belgium and northern France only in shamefaced whispers, if our newspapers had refused to print the name of the Kaiser? The leaders in our fight against venereal disease want to take over for this campaign some of the organized, self-sacrificing enthusiasm which won for us the late war. That enthusiasm cannot live in a democracy like ours without open, high-minded discussion.
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