TREASURY DEPARTMENT UNITED STATES PUBLIC HEALTH SERVICE LECTURES ON SOCIAL HYGIENE FOR NURSES 1919 Prepared by direction of the Snrgeon General V. D. Bulletin No. 40 WASHINGTON, D. C. The first four of these lectures were written by Dr. Paul B. Jolmson, XJ. S. Public Health Seryice (now with the Army). The presentation of the Government Plan to Combat Venereal Disease was contributed by Dr. Katherine B. Davis. TREASURY DEPARTMENT UNITED STATES PUBLIC HEALTH SERVICE LECTURES ON SOCIAL HYGIENE FOR NURSES 1919 Prepared by direction of the Surgeon General V. D. Bulletin No. 40 WASHINGTON, D. C. The War Programme of the United States Government To Combat Venereal Disease. LECTUKB I. Introductoet. The profession of nursing, like the profession of medicine, exists for the relief of human suffering. It has, therefore, the great dou- ble purpose of restoring the sick to health and of preventing disease altogether when that is possible. The past fifty years have seen v^onderful advances in the art of preventive medicine. Certain diseases, like yellow fever, formerly common in this country, are now rarely seen, and others, like typhoid fever, occur much less often than formerly. Up to the beginning of the present great war, however, no broadly organized attempt had been made by health authorities, to control the group of infections known as the venereal diseases, syphilis, gonorrhea, and chancroid, which are spread chiefly by sex immor- ality. Their great prevalence and seriousness, however, were well known to medical men, and had made a strong impression upon many thoughtful individuals. The problem of preventing these dis- eases had been carefully studied, much valuable information on all its phases had been collected, and in a few places plans of control had been developed, which seemed to promise success if they could be put into operation with public support. Thanks to the efforts of our Government all of this work has now been developed into a great national movement for controlling the spread of these diseases. Not only the health authorities, but the leaders among our people in all walks of life, both men and women, are actively interested and determined that a better state of morals and health shall prevail. During your course of training you have come in contact with some phases of life of which you previously knew little or nothing. You have seen the needless suffering, the diseased bodies, the young mothers and babes with no husbands for their protection — all the results of ignorance, folly and bad environments. You have been shocked, distressed, and indignant. You have wanted to give help ; you have wanted to punish ; above all, because you have seen these poor souls months and years too late, you have wanted to prevent any more of such misery and to allow happiness to keep its rightful place. And yet you did not know how. That is why this course of lectures is being given, so that you may understand this problem better and may be of. greater helpful- ness. And these lectures are being given also to the nurses all over our land. You will form a part of this great body of influential educated women, and you can do much to shape public opinion and hasten the changes upon which improvement depends. 3 4 In the first place, we must understand something of what under- lies this problem. When we begin to study the laws of human ex- istence we find that there are two great struggles in our life which are at the bottom of practically everything that we do. One is the struggle for existence, or self preservation ; the other is the struggle for reproduction, or race preservation. Humanity would cease to exist if either of these struggles came to an end.~ Therefore, there are implanted in us two appetites which urge us to keep up these struggles. One is the hunger for food, and one is the hunger for the other sex. We eat to satisfy our appetite for food and thus keep our bodies alive. But the act of eating is only a small part of all the activities that result from hunger. Whatever our- occupation, we work, first of all, to buy food, and then, at our three meals each day, we trans- form the satisfying of a physical appetite into the most delightful occasions for cementing friendships and enjoying family affection. In the same way, we find that the satisfying of sex hunger is wonderfully transformed, in love and family life and occupation. Men admire strength and love beauty; women admire beauty and love strength. But it is not only the beauty and strength of the body that attract us. Strength and beauty of character, personal- ity, and intellect, draw men and women together in the noblest and truest friendships. And if friendship deepen into love and two such persons marry, they do so, not as mere sex partners, but as life partners. Marriage for them is not the result of a blind, mo- mentary passion, but of a pure affection and strong devotion, and they look far into the future and intelligently accept the responsi- bilities of married life. This normal satisfaction of sex hunger, thus means a happy life companionship, with mutual affection and unselfish consideration. It means parenthood, the care and training of children, and the de- velopment of family pride. It means the making of a home, and all the labor and delight of sustaining and beautifying it. It means improvement of the home's environment, and thus nobler ideas of citizenship and patriotism. It includes also all our recreations, our dances and gatherings, where young and old, men and women, enjoy each other's society. And it includes the manifold progress of the world, which is a preparation for the life of coming gen- erations. The ideals of love and marriage are all opposed by sex-immor- ality, for immorality wishes merely to satisfy the vagrant and transitory passion, without regard to true love and the responsibil- ity to the race which marriage accepts. While the sex impulse it- self is normal, it becomes abnormal when not controlled, for its acts then retard the progress of the race. The teachings of religion and the highest thought of men, alike, urge a clean life leading up to an inviolate marriage. The difference in the character and temperament of men and women is inherent in their sex. Men's restless energy, courage and impatience, combined with his greater bodily strength, lead him to defend his home, to fight when necessary, to seek food in face of danger, to discover new lands, to invent new devices. Woman, with 5 her physical handicaps of menstruation and maternity, and her weaker body, is unfitted for violent struggles with nature. But by her qualities of loyalty, sympathy, patience and thoughtfulness, she makes heaven of home, cares for and inspires her husband and chil- dren, and particularly excels in work that demands devotion, ac- curacy and patience. These characteristic qualities of men and women correspond with the differing manifestations of their sex natures. Sex hunger, in the form of a longing for affection, home, and children, is stronger in women than in men. But in the form of a definite, active im- pulse, a desire that demands satisfaction, it is stronger and more aggressive in men than in women. However firmly -it may be con- trolled in virtuous single men, it is never extinguished, but may be suddenly and frequently aroused ; wliile virtuous single women, are, for the most part, less often conscious of such an impulse. The presence of the normal sex impulse has nothing to do with sin. It is as altogether natural and right as the appetite for food. The sex glands — the ovaries in women, the testicles in men — are normal and necessary parts of our bodies. They are essential to the proper development of the child's body into that of the mature adult ; they govern the development of certain manly and womanly qualities of character that we call the great virtues; and they give rise to the sex impulse, and produce the germ cells that keep the race alive. All through nature, we find this general law of the sexes; the female attracts and the male pursues ; the male is active, the female passive. It is true even among the plants although they have no feelings, as we understand them. The male cells of the yellow pollen are carried by the wind, or by insects, from flower to flower, to the female cells which remain in the bodies of the flowers and await them. The male fish, in the spawning season, follows every movement of his female mate until he has fertilized the eggs which she finally deposits. Mating birds flash through the sweet, spring air, the male in close pursuit of the female of his choice. And the higher animals, to which our domestic creatures belong, follow this same law, the female attracts the male and the male pursues the female. When we study ourselves, we find that the law still holds good. Woman attracts man and man seeks after woman. She slips away and eludes him, but with a look in her eye and a laugh in her voice that bring him following after her. We think it proper that a woman should make herself attractive; we even say that it is a woman's duty to look as well as she can. But if she goes further, and is evidently straining hard to attract a man's attention, we criticise her or joke about her. In the same way, we enjoy seeing a fine young fellow pressing his attentions on a sweet, modest girl. We make fun of the slowpoke, and the boy who runs away from the girls, and we get angry at the soft dandy and at the girls who hang around him. In all this, though we little think it, we are trying to enforce the ancient law of nature and of the race, which says that the male must seek the female. 6 Since sex hunger has different manifestations in men and women, it is not surprising to find that their temptations show a similar difference. The man who would pursue woman as the noblest ideal of his holiest moments, is still powerfully tempted to pursue her as a mere creature of flesh; and a woman who would appeal to man's highest nature, to aspire after the divine qualities of her soul, may nevertheless also be tempted to attract men to her form. It is most difficult for good women to understand how good men can be tempted to immorality; they often think that such temptation shows, even in the best of men, a debased and sinful nature. Just so, it is almost impossible for good men to understand how good women can dress and act as they sometimes do. They acquit such women of evil intentions, but think that they ought surely to know that such dress and actions arouse men's sex impulses against their will. Dress is the universal language with which men talk about them- selves to women, and women talk about themselves to men. When a woman is a long way off, a man can only hear her clothing say, "I am a woman." But near at hand, each costume speaks its own words plainly. Dress speaks of the refinement or coarseness of the wearer, of good taste and bad taste, and otherwise reveals character. Some dresses talk loudly, some very softly ; some are demure, others laugh boisterously and joke familiarly. The greater number smile bashfully, with dimples in their cheeks, and say prettily, "Please look at me. I-I'm a very nice, sweet girl." A few speak in a hard voice, "I have no time to bother with men. Good day." And still others toss their heads ^ith a bold and reckless look and say, well, they say things that men who are considerate of women do not like to hear. The women who wear dresses of this last sort — extremely thin, conspicuous or suggestive garments, often have not the slightest idea of what their clothes are saying to men. But the men are often embarrassed or tempted by such means, and some of them finally lose faith in woman's honest eyes and modest dignity, and believe the foolish chatter of such dress instead. Clothes, like parrots, speak what they are taught, and the fashion designers are their teachers. Fashions do not grow, they are created, and their object is to make men and women more attractive to each other. Each year's fashion becomes the expression of our ideal of looking well, and our self-respect demands that we follow it. But much more than that, fashionable clothes are the symbol of human fellowship and brotherhood, because they are what "everybody" is wearing. For a person not to adopt this symbol, and not to dress in style so far as able, is to be^careless of this great bond of human fellowship, and even to flout 'and despise it. "As well be out of the world as out of the fashion," for it makes one appear odd, out of sympathy with one's fellows, and in a way a man or woman without a country. But here comes a difficulty. The fashion makers well know that women crave the admiration of men, and they understand how strongly men are attracted by the feminine figure, and they play upon these two points. A woniap who is dressed so that her body is strikingly apparent, finds numerous masculine eyes turned in her direction. She often estimates this attention as true admiration, whereas more frequently it means simply physical sex attraction, and sometimes sensuality, derision, astonishment or disgust. The fashion makers have been very bold, but they have not failed so far to secure the acceptance of every fashion that they have brought for- ward. The large manufacturers of clothing make the new styles at once available for all incomes. No matter how extreme the fashion may be, simpler and more sensible garments become more expensive be- cause they are not in demanji and are made in smaller quantities. Therefore, even as a matter of economy, clothes of the prevailing style must be purchased. But even so, women who understand the effects of dress, have been able to modify their clothes so as to make them unobjectionable and still in the best of style and taste. Heretofore the fashion makers have been autocratic, largely be- cause the subject of dress and its psychological and social effects, has not been widely understood, and because women have not been suificiently well organized to compel their wishes to be followed in the designing of new fashions. We must certainly have styles — charming, graceful, beautiful styles ; we would lose much of the joy of life if we did not. And men and women should exert themselves to dress in style. But, with the formation of a well organized and better informed public opinion among women, we may look forward to the day when their representatives, in all civilized countries, will dictate the character of their fashions, in accordance with the sound principles of art, ethics and psychology. This is not the first time in the world's history that women's dress and actions have struck men with open-mouthed amazement. The prophet in the old Hebrew scriptures found cause for complaint, and the long-suffering man of today must chuckle in sympathetic de- light at dear Isaiah's bad temper toward the Israelitish maidens of his time. "The daughters of Zion are haughty, and walk with stretched- forth necks and wanton eyes, walking and mincing as they go, and making a tinkling with their feet." And he goes on to catalogue their finery on parade — the anklets and bracelets, earrings and nose jewels, head bands and crisping pins, mantles and mufflers, and hoods, nets and veils. It is probable that in those days, as in these, some fashions originated as the devices of im'moral women to lure men after them, and the great prophet was angry to see such fashions adopted by the daughters of good families. Women commonly believe that the evil ones among their sex may arouse men's lower natures. But many excellent women regard themselves as not capable of tempting high-minded men. Quite the contrary is true. To self-respecting men, bad women offer compara- tively little temptation; such men refuse to associate with strange women, and easily resist the advances of prostitutes. Good women, however, whom they admire and reverence, and with whom they freely associate, have them, so to speak, oft their guard. These women, therefore, especially if they are not careful, may present 8 the most serious diflficulties to the very men whose nobility they admire, and whose morals they would wish to protect. A humble Englishman, who oberved human nature several hun- dred years ago, William Shakespeare, portrayed this very clearly in "Measure for Measure." Angelo, a man of the sternest virtue, was at length swept off his feet, and not by a woman of the street, but by a lovely, innocent lady. In his amazement, he said to him- self: Can it be That modesty may more betray our sense Than woman's lightness? . . . O cunning enemy, that, to catch a saint, With saints dost bait thy hook ! Most dangerous Is that temptation that doth goad us on To sin in loving virtue: never could the strumpet. With all her double vigour, art and nature. Once stir my temper ; but this virtuous maid Subdues me quite." But in trying to solve our problem today it does no good for men to rant at woman's dress and behavior, nor for women to nod their heads and pronounce against man's brutish nature. The war of temperament will last interminably, because neither sex has the bodily organs necessary to permit it to understand the other. When a young father begs his wife to tell him how she feels towards the babe at her bosom, she looks pityingly at him and calls him "poor stupid!" She kno^vs that he cannot understand, because he has neither the organs of motherhood nor inborn mother love. In the same way, men and women cannot hope to understand each other's impulses and feelings toward the other sex. They must, then, take each other's word regarding their differences, and be sympathetic toward each other's temptations. Each sex must control its own tendencies and correct its own faults; and where each is weak, the other must protect it. In addition to those men and women who have high moral ideals and are trying to follow them, we find three other main groups of people in modern life, first, those who say that these high ideals are right, but who make little effort to follow them ; second, those who lack all appreciation of such ideals; and, third, the feebleminded. The last group has to be restrained by law, or kept under super- vision, because the feebleminded are actually incapable of keeping out of trouble. A large proportion of delinquent girls, prostitutes and criminals are of this class, people who cannot distinguish be- tween right and wrong, or, if they can, have no power to keep from doing wrong. While many of them, indeed, appear childish, others are exceedingly clever, though often cruel and beastly. And for all that they are feebleminded, their lack of morals often has a very bad effect on their associates. There is still another very different group in our population— the immigrants. During the last fifty years the nations of all the earth have sent their people to our shores, bringing with them their ancient beliefs and customs. Some of these customs are survivals from a heathen and barbaric age, and were held by our own half- savage ancestors, centuries ago; but we have long since cast them 9 aside as unworthy of the ideals of our modern life. The people of these different nationalities keep largely by themselves in their family life, religion, and pleasures, and so each group tends to preserve its own customs and practices, and to pass them on to its children. But in their occupations, businesses, and schools, as well as through their servants, the native Americans and those of foreign birth, are mingled to a large extent, and the ideals, beliefs, and prac- tices of one group influence all the others, and especially their chil- dren. Under these circumstances, care is necessary lest undesii* able customs and standards of right and wrong be adopted by one people from another. All human beings tend to think, talk and act like those around them. Weak characters imitate their associates more than strong ones do. The race has improved because the virtues of strong minded people have been imitated by others. But at the same time, the vices of other strong minded people have penetrated into every class, of society. There is a widespread belief that the sex impulses should be freely satisfied because it is natural, and that this is necessary to health and to the proper development of the body. As a matter of fact, none of these things are true. The sex impulse can be controlled ^ without the slightest harm to body or mind, and men who have lived clean lives maintain physical and mental vigor to a ripe old age. The strong old man, Adam, in "As You Like It" says: "For in my youth I . . . . . . did not with unbashful forehead woo The means oi weakness and debility ; Therefore my age is as a lusty winter, Frosty but kindly." The sex impulse is controlled by great numbers of people in all walks of life, through their unswerving devotion to lofty ideals, and by using their will power and healthy exercise of mind and body to govern emotion. Persons who keep their minds free from sexual thoughts and engage whole heartedly in the activities of life, find self-control comparatively easy, especially when, by constant en- deavor, it has become a matter of habit and is seldom thought of. You will, however, undoubtedly be called upon occasionally to nurse individuals who have become morbid about sex matters. They are often high-minded, sensitive, introspective persons, who, because they have these normal impulses, worry pitifully and imagine that they are more wicked than other people. Their mental distress may even result in neurasthenia or more severe nervous troubles. These cases experience the greatest relief imaginable, when they have been delicately, but forcefully, made to understand that such tempta- tions are normal, and, as St. Paul says, "common to mankind." These cases must also be taught how to fill the mind with healthy activities, and thus master their impulses, not by dwelling upon them, but by displacing them by more worthy interests. You will also sometimes find women, looking forward to mar- riage with a little dread, and sometimes with actual fear, of sex relations. This is usually because of their complete ignorance of the normal relationships of marriage. You must explain to them 10 that sexual intercourse between a husband and wife who love each other truly, is a perfectly pure expression of affection on the part of both. While the union of the genital organs is physically the same act as in immoral sex relations, it is wonderfully transformed in ideal marriage, and made profoundly spiritual by its motive, meaning, and purpose. Its motive is love, its meaning is the supreme expression of that love, and its purpose the strengthening of love and the glorious service of bringing a new life into the world. You must make it plain that in this way, it is absolutely without brutality and lust, and awakens no fear. And you can lead women to see, as Canon Lyttleton of Westminster, England, believed, that "viewed rightly, the subject of sex, the ever-recurring miracle of generation and birth, is full of goodness, purity and health." Women, as a rule, are very ignorant of all sex matters. Many have even married without knowing the simplest facts about child- birth. They learn little from their husbands, even if they ask questions, because most men have hitherto been poorly and inaccu- rately informed. Their sensitive natures, too, shrink from inquiring of their women friends, and they rarely ask their physicians for such information. Many married women, however, realize their need for accurate information, both for their own sakes, and to enable them to train their children intelligently. Some of them will ask questions of you when they would not of any one else, because your uniform is the badge of intelligence and training, of helpfulness, and human sympathy and womanliness. , Others wiU not ask questions, but will give you an opening, and, if you show your willingness, you may talk with them fully and helpfully about this most sacred part of their life. You should be prepared and ready to take such op- portunities for service. A number of satisfactory books and articles on this subject have now been published, and are being increasingly read. A list of some of them will be given at the close of this lecture, to those of you who wish it. Mothers will ask your advice about teaching their children, for most parents have inherited the old belief that the sex life, although necessary, is something to be ashamed of. So they have thought it wrong to speak of it to their children, or to allow them to ask ques- tions concerning it. They have believed that by keeping silent they would better preserve their children's morals. This belief has been very generally held by our people. It has kept them from teaching their children the meaning of the miracle of life, and from guiding them through the perilous years of puberty or adolescence. It has even prevented them from teaching proper cleanliness and care of the genital organs and functions. This has exposed the children to greater temptations, and to physical dis- orders, and has caused great mental distress to young and old, who have worried because of the normal impulses and experiences of Ufe, As a result of learning nothing from their parents about what seems, to their naturally curious minds, an important and mysteri- ous matter, children have eagerly listened to what their playmates and others could tell them. This information has been inaccurate 11 and full of vulgarity, and has given children a horrible, distorted conception of what should be beautiful and inspiring. Their par- ents' attitude, and unwillingness to talk, have made the children be- lieve this evil picture to be true, and so the wicked and false notion that sex is shameful has been passed on from one generation to an- other, and the children have been given no help for resisting temp- tation when it comes. It is of the utmost importance that children should grow up with- out any distressing memories of early sexual experiences. But at present we find unmarried mothers, even as young as twelve or fourteen years of age, chiefly, but by no means wholly, among the unprotected girls of the lower classes of society. Where children are given little or no supervision, it is sometimes discovered that sexual relations are taking place even between very much younger children. There are also shocking cases in which the little ones have learned evil from depraved grown persons. While you must watch for all of these things in your work with children, you must especially be on the alert for cases that have formed the habit of masturbation, or "self abuse," in which the child excites sexual feeling in its own organs, by movements of its hands, legs, or body, or by rubbing against projecting objects. This habit is very common among improperly trained boys of twelve to fifteen years of age; but it is also found among girls, and some abnormal adults practice it. Most children who form this habit are taught it by their playmates ; but it is also often learned by chance, in the same way that the habit of thumb sucking is acquired, some- times as early as the first or second year of life, or not until much older. All of these experiences are harmful in themselves, especially to the child's nervous system. The younger the child, the less these acts partake of immorality, but they may pave the way to vice in later years. The great majority of older children who acquire the habit of masturbation, fortunately become disgusted vrith the prac- tice because of their own self-respect, and stop it before they do themselves much harm. In younger children and infants, eternal watchfulness is necessary to discover the cases, and to aid the phy- sician in curing them. But above all, we should try to prevent these harmful habits. The attempt to protect children's morals by keeping silent about sex has utterly failed. On the other hand, it is the growing opinion of modern physicians and educators that children should be taught in these matters, truthfully, but delicately, wisely and simply, and no more fully than the child's age and understanding will permit. Dr. E. L. Keyes, of New York City, says, regarding the preven- tion of the venereal diseases, that the most important measure for preventing syphilis "is the protection of childhood by intelligent instruction." This is because instruction prevents sex immorality, and immorality is what spreads syphilis. Prof. M. A. Bigelow, of Columbia University, New York City, states that the most important thing is to teach children to have a . respectful and reverent attitude towards the processes of birth and reproduction; next, that they should be taught enough about the 12 hygiene of the sexual organs to enable them to take proper care of the body ; third, that this training should develop in children a sense of responsibility to themselves and their future families and society, and, lastly, that, for older children, there should be a short, clear statement regarding the venereal diseases. In other words, the Avhole broad meaning of the sex life and the means of avoiding danger, should be impressed upon the growing child. And this teaching should be given, not simply upon one or two formal oc- casions, but gradually and by stages, as a part Of the child's general training. The processes of reproduction and birth, about which children have a natural curiosity, should be explained little by little to the growing child as he or she is able to understand them. And par- ents cannot do this unless they themselves are well informed. Every suitable question should be answered by the parents promptly and ■without embarrassment, telling the truth, however sim[)ly. The growth of plants from seeds, the hatching of chickens, and the birth of kittens or other pets, can all be used as object lessons for helping the child to understand how the new life grows within the mother's body. And with regard to the questions whose answers cannot be made sufticiently simple, such as the manner in which the baby is born, the child should be told that these will all be fully explained when he is older. If this is done, and the father and mother neither scold nor laugh at the child's questions, they will win his confidence and keep it always. He will come to them with the most intimate questions, and will tell them what he hears and sees outside the home; so that bad associates can be guarded against, and evil talk at once made harmless, by explaining the facts involved. And it is to be especially emphasized that this training and instruction is every bit as much needed for girls as for boys. At the same time, the child should be made to understand that these things are not what we speak of before others ; in other words, we are to keep our natural reserve about sex matters, just as we show our natural modesty and reserve in other matters. Sex instruction should never be an excuse for sex conversation. The approach of puberty, or adolescence, should be explained to girls of eleven or twelve, and to boys of twelve or thirteen. They should be taught the meaning of the changes that they will soon notice in their bodies, and should be made to feel the dignity and worth of their developing manhood and womanhood. Th^ should be prepared, too, for the new experiences that will come to them. For many girls have been injured by nervous shock and worry at the first appearance of menstruation, because their mothers had not prepared them for it in a reassuring and sympa- thetic manner. Others have suffered harm by following ignorant advice with regard to -their monthly illnesses. Boys have a corresponding experience, beginning at this time. Two or three times a month, the seminal fluid or semen is dis- charged from the urethra during sleep, often during a dream that is sexual in character. This is known as a seminal emission, though it is often spoken of as a night loss or a wet dream. These experi- ences are just as natural and normal for boys, and virtuous un- 18 married men, as menstruation is for girls and women. You will find, however, that mothers are sometimes anxious because their boys have these emissions, not knowing of their true character, and perhaps because they have been frightened by the untruthful ad- vertisement of fraudulent quack doctors. You should reassure them by telling them that they are normal, although they may be in- creased in number if the boy is constipated, not exercising enough, or harboring unclean thoughts. If the parent have the boy's confi- dence, they can help him, but if not, a good physician or one of his fine men friends may be of greatest service. It is important for parents to realize how necessary outdoor games and other forms of recreation are for children, how lively play, under wholesome conditions, promotes normal relations be- tween boys and girls, and develops not merely strength of body, but alertness of mind and fine. moral qualities. Parents should make it their business to provide such recreation just as they should realize that the whole training of their children is their most im- ■ portant work in life. It is important, too, that they should realize that the things which are called improper or unconventional may actually be full of danger for their children. For the conventions and proprieties which society has developed are not artificial things ; they have been devised to prevent actions and avoid situations which naturally tend to arouse the sexual impulse. They are, therefore, safeguards which we have learned to throw around the boys and girls, before they have developed to the point of always being masters of themselves. Young people have no conception of the power of the emotions and feelings that lie dormant within them. In certain situations these forces flare up utterly unexpectedly to the boy or girl, and -before they realize it, they have been overwhelmed, and impelled to actions which their conscience and reason immediately condemn, but too late. Never having experienced such feelings, young people cannot be expected to know of the danger, unless they are warned beforehand. Proper chaperonage is a reasonable measure and should be so generally used that it would be accepted by young people as a perfectly natural and delightful association with their elders. It is important, too, that children should early be led to take a keen interest in things outside themselves, in books, pictures, music, \ sports, and household duties, and especially in the outdoor world. Flowers, pets, and the wild life of field, forest and water, as well as the stars, all offer opportunities for enjoyment and education; they keep the child's mind occupied with wholesome and inspiring objects, and they may lead the child on to take up some delightful occupation later. It must also be insisted upon, that children should be trained in habit of cleanliness, order, and system, in their daily life. A boy or girl who, from long force of habit, is neat in appearance and cleanly in person, will naturally shrink from coming in contact with uncleanness of any sort. Systematic habits, fair play in sports, 14 and orderly behavior in school and society, develop self-co'ntrol and self-respect, and these, too, are safeguards to a boy or girl in any situation. Tennyson says, in "Oenone," "Self revereuee, self knowledge, self control, These three alone lead life to sovereign power." Early impressions sink deepest and last longest. The child ab- sorbs the atmosphere of its home, and the character of its parents, from the time when its sober eyes begin to watch what happens around it. Many things which it does not understand, are written into its memory, to influence it years afterwards. As the child grows older, it is more strongly impressed by repeated instruction and daily example. Later still, public opinion or custom directs us all. Strong characters, however, are not bound by public' opinion in matters that concern their conscience; their beliefs, their convic- tions, determine conduct. Parents can awaken in their children a glowing enthusiasm for the great moral ideals, and a heroic deter- mination to live and die for those ideals. This is the great privi- lege of parents, and their golden opportunity comes and passes, dur- ing the first few years of each child's life. The children who are now growing up, and who are receiving such help and instruction from their parents, will not be spared all sex temptations by any means, for such temptations belong to _ our bodies. But they will be prepared to meet them; they will know how to avoid many of them, they will know how to master the others, and they will be inspired to master them. For it is the fight that makes the man — or the woman. In Eobert Browning's poem, "The Eing and the Book," the old Pope, who is thinking of a splendid young priest, who had been severely tempted and had won his fight, says : "Was the trial sore? Temptation sharp? Thank God a second time! Why comes temptation but for man to tneet And master and make crouch beneath his foot, And so be pedestaled in triumph." LECTURE IL THE SOdAIi IMPORTANCE OP THE VENEBEAIi DISEASES. Gonorrhea is probably five times as prevalent as syphilis, and chancroid probably twice as prevalent. Chancroid is not of great importahce to the race except economically. The illness of any worker is a cost to society, and when it comes from a preventable disease, it is like throwing money away. Syphilis and gonorrhea, however, are of the very greatest im- portance to society and to the race. Keyes says of gonorrhea : "A disease that attacks more than half our young men, a disease that affects thousands of children and hundreds of thou- sands of women, is important to society by its prevalence alone. "A disease that enters the family almost exclusively through illicit sexual contact, a disease that may be transmitted long after the patient thinks himself or herself well, a disease that may be transmitted to the wife from the prostitute via the offending 15 husband, a disease that may be passed from the Wife thus inno cently infected to the eyes of her infant at birth or to its genitals thereafter, is eminently important to society. "A disease that incommodes the man and may invalid the woman, a disease that is the cause for most of the major gyne- cology of today, a disease that unsexes thousands of women, that makes chronic invaUds of many, that kills not a few, a disease ■ that in this country causes from one-quarter to one-half of the congenital blindness, that is accountable for about one-third of the blind in our asylums, is a real peril to society. "A disease that causes fully 50 per cent of the involuntary sterile, or one-child sterile marriages, that destroys the power of procreation in man as well as in women, is indeed a peril to the race." Similarly it might be said of syphilis that it alfects at least five, and i^rhaps ten, per cent of all our people— that is, live or even ten millions of men, women, and children in this country alone. Syphilis pauperizes wage-earners, lengthens our bread lines, and brings about the rapid degeneration of good family stock. Syphilis burdens our general hospitals with its multitude of com- plications and results, and causes one-quarter of the mental disease in our hospitals for the insane. Syphilis kills thousands in our country annually. Syphilis wipes out years of life. Syphilis devours children and thins the ranks of coming generations. The venereal diseases are thus extremely com- mon. All of them are most prevalent, and most severe, among the poorer classes of society, whose living conditions predispose to im- morality and to accidental infections, and whose ignorance prevents them from seeking treatment unless painfully or openly diseased. But they are very prevalent also among our wealthier classes. The venereal diseases probably affect more people altogether than any one other disease, excepting possibly tuberculosis. Many people have both syphilis and gonorrhea, and occasionally some one has these and chancroid also. A long life of gross immorality is not necessary to contract a venereal disease. A decent young man may be swept off his feet by severe temptation, and become infected in his first offense — and so may a woman. On the other hand, a man or woman may lead a dissipated life for some weeks or months and escape infection. In certain isolated sections of our country, immorality has been com- mon for many generations, but there was almost no venereal disease there until within the last twenty years. Travellers have now car- ried these diseases in, and they are rapidly being spread. These diseases are not punishments for sin. Let us rid ourselves of that old, cruel notion, that unrighteous and irreligious idea. A lovely woman may, in divine pity, stoop and kiss a forlorn syphilitic child, and in consequence develop syphilis. An immoral man who is diseased, has done no more wrong than an immoral man who is not diseased. Immorality is a sin that is punished and that is forgiven ; it may or may not be accompanied by a venereal disease, just as a horse may carry a rider or go bare. The majority of persons infected with venereal diseases do not look ill, unless suffering from some severe complication. Until within a few years, most hospitals refused to admit any person Ifi known to have a- venereal disease, either to the wards or to the dispensary. But they were able to exclude only a part of them in that way. For, in the hospitals that now make a Wassermann ex- amination of every patient admitted, whatever the apparent disease may be, it has been found that from ten to twenty-five per cent of all patients have uncured syphilis; and similar examinations would probably show that a large percentage have uncured gonorrhea. It is, therefore useless, as well as inhuman, to refuse to care for venereal patients. We cannot avoid it, unless doctors and nurses change their occupations, and hospitals go out of business. We must, therefore, know how to care for these patients without be- coming infected. The rules are very simple. Give all treatment necessary for the patient's welfare, but no unnecessary handling or caressing, and do not kiss the patient. Do not let a syphilitic patient cough or sneeze in your face. Do not touch with bare hands, any open lesions or eruptions, or parts soiled by saliva, pus or other dis- charges, but use sponges, instruments, or rubber gloves instead. If you should happen to soil your hands with such discharges, dis- infect them carefully, and if there are cuts or abrasions on your hands, touch them immediately with tincture of iodine. If pus or other fluids from these cases should spatter into your eyes, instill immediately a drop of twenty-five per cent argyrol solution. Scrub the hands thoroughly, immediately after giving treatments. Get out of the habit of rubbing your eyes and stop putting your fingers in your mouth. In other words, you are to observe with venereal cases, precautions similar to those which you observe in cases of typhoid fever or septicemia. Strict cleanliness is itself a consider- able protection in all your work. SYPHILIS. Syphilis, also known as "the pox," "the bad disease," "a dose of syph," etc., is a chronic infectious disease, caused by the spiro- chaeta pallida, or the pale spirochete. This is a spiral shaped or- ganism, looking much like a curly bit of thread when seen through the microscope. Although it had long been searched for by many scientists, it was not discovered until 1905, by Schaudinn and Hofif- man. For all of its great power of destroying human life, this germ is a very delicate creature, dying within a few hours after leaving the -iuman body, and easily killed by antiseptics. If it were as hardy as the tubercle bacillus, we would all of us be in danger of having syphilis. As it is, however, there is very little danger of contract- ing the disease, except by intimate contact with one who has it. The spirochete cannot penetrate the healthy skin, but may easily enter through even the smallest scratches, cuts, hang nails, cracked lips, etc. Rooms that have been occupied by syphilitics are not dangerous for later occupants. The living spirochetes are seldom carried in the air, except when expelled from the mouth by cough- ing and sneezing, as when a patient has syphilitic sores in the mouth, nose, or throat. They then die quickly, and are not con- tained in dust. Toilet seats may be a source of infection, but, as 17 a matter of fact, seldom are. Drinking cups, pipes, musical instru- ments, or anything that is passed from one mouth to another, may convey the living spirochetes and easily spread the disease. Every little while, some one becomes infected through being kissed by a syphilitic. In one instance, seven young women were infected with syphilis, at a party at which they played kissing games, one of the young men present having syphilis of the mouth. Healthy wet nurses have contracted this disease from the babies they were nursing, and, on the other hand, syphilitic wet nurses have given their disease to healthy babies. A great many innocent wives have been infected by their husbands, and some innocent husbands by their wives. Syphilis can be inherited, and, consequently, large numbers of children are born already infected by their parents. Syphilis is acquired by far the most frequently, however, by sexual intercourse outside of married life. After the spirochetes have entered the body, it is three or four weeks before the first sign of the disease appears. This is a small, insignificant, painless sore, looking something like a cold sore, and is known as the chancre or initial lesion. It is so insignificant that it seems absurd to treat it seriously; and as we look at the patient, it is most difficult to realize that he or she is actually infected with one of the most serious diseases. The patient may be in the full strength of youth ; the chancre is but a small spot, a mere blemish, apparently, on the otherwise perfect body. Yet we know that it is the small, faint signal of a great disaster -approaching ; it is the beginning, of which the ending, in very many cases, is death. The chancre is found usually on the genitals, but it may be almost anywhere on the body, wherever the spirochetes are deposited and are able to enter the tissues. It often occurs on the lips or cheeks, sometimes on the female breast, and rarely on the tongue or tonsil. Little children have had a chancre on the lip or cheek, as the result of being kissed by syphilitics. Physicians have developed chancre of the finger because they had hang nails, or other abrasions of the skin, and did not protect their hands or carefully disinfect them after examining or treating syphilitic patients. The spirochetes are so easily killed, by careful cleansing of the hands and ordinary anti- septics, that it is practically unnecessary for any one to become infected through attending a case that is known to be one of syphilis. More risk is run with those cases which are not known to be syphilitic, for with them less care is used. Soon after the chancre appears, the nearest lymphatic glands be- come enlarged and hard, and remain so for several weeks. They never suppurate nor become matted together in a mass, as in the case of the bubo of chancroid. If the chancre is on the genitals, it is the inguinal glands that are enlarged; when on the face, it is the submaxillary or other cervical glands; and if on the hand, the axillary glands. The first appearance of the chancre, is the time when a cure is easiest and speediest, and when the patient can usually be saved from serioiis disability or death. It is, furtiiermore, the time when he can be most easily prevented from spreading his disease to others, and so be relieved of that great moral responsibility ; for the chancre 18 is dangerous to others, because of the spirochetes present on its surface, sometimes in large numbers. We cannot, therefore, im- press our patients too strongly with the absolute need for the most prompt and thorough treatment, immediately upon their disease being diagnosed as syphilis. About six weeks after the appearance of the chancre, the so- called secondary symptoms of the disease appear. These are sore throat, aching bones and general ill feeling, with perhaps some fever, and in some cases mental depression. An eruption usually appears, and the hair falls out more or less in some cases. The disease is now no longer a mere local lesion, but has become a general sys- temic infection. The spirochetes have been distributed by the blood stream throughout the entire body, and the patient is suffering from the rather mild toxemia. In some cases all of these symptoms are aggravated and the patient is acutely ill. The eruption may cover practically the entire body, or a small part only, and may vary from faint, rosy patches to the most severe pxistules. In some cases, the eruption and general symptoms are so slight, that the patient entirely fails to notice them, just as in some cases the chancre may escape notice. These are the cases which later give an honest but misleading history of not having had syphilis. The eruption occurs also on the mucous membranes of the mouth, thrdat, and genitals, where, because of the moisture, it takes the form of superficial ulcerations, or "mucous patches." These various eruptions last from a few weeks to several months, depending upon the severity of the disease and the thoroughness of treatment. The patient, in this stage of the disease, is dangerously infectious to others, much more so than with the chancre, although he himself is usually suffering no serious results as yet. The mucous patches swarm with the spirochetes, and the germs may be in the discharge from any open lesion on the skin. It is, therefore, of the utmost importance to the public health, as well as to the patient, that treatment should be immediately and thoroughly applied, for the lesions usually heal rapidly when this is done. The spirochetes are then locked up within the patient's own body, and the case becomes non-infectious, or much less infectious, for others. Complete cure may follow in this stage, if the patient is faithful in continuing the treatment until repeated Wassermann examinations are nega- tive. But if the treatment is not persisted in, until a complete cure is obtained, the patient ultimately may show the symptoms and lesions of what is called the third stage of the disease, or the tertiary period ; and these lesions sometimes develop even in spite of the most thorough treatment. Just what wiU happen to any individual patient, is entirely uncertain. The spirochetes have penetrated to the deepest parts of the bones, the brain, liver, heart and all other organs. In some of these places, they produce comparatively mild changes; in others, they are veritable Huns, and carry on a cam- paign of frightfulness, destroying the tissues completely, and la;\'ing waste the most vital or the most indispensable structures. Such an area of complete destruction is known as a gumma, and may be 19 « of any size from that of a pm head to that of an orange. The skin is very frequently affected ag;ain in this stage, both in the form of extensive eruptions, and as local areas of deep ulcera- tion, often on the face and lower parts of the legs, but in other localities also. Syphilis often attacks the bones, causing enlargement of the part with destruction later. In many cases, chronic ulcers or discharg- ing sinuses lead from the surface of the body to the diseased bone. The hard palate and the bones in the nose are sometimes destroyed, causing the deformity known as "saddle nose," which is accom- panied by a hollow, sepulchral voice and difficulty in speaking and swallowing. Syphilis brings about fatal disease of the heart or blood vessels in a great many cases, causing valvular heart disease, hardening of the arteries, aneurysm, or apoplexy. It must be distinctly under- stood, however, in thinking of syphilis as a cause of these various conditions, that there are other causes for them also. We have no right to think that every case of heart disease, for instance, is due to syphilis ; many are, but very many are not. Syphilis frequently attacks the liver and spleen. It may cause serious disease of the stomach, and occasionally brings on intestinal obstruction. In the lungs, it is sometimes mistaken for tuberculosis. Syphilis of the spinal cord causes tabes or locomotor ataxia, with its severe pains and paralysis, and the ultimate death of the patient. A most distressing form' of insanity, known as paresis, or general paralysis, is the result of syphilis attacking the meninges and the gray matter of -the surface of the brain. It is always fatal. Both tabes and paresis usually develop rather late, often eight or ten years after the infection was acquired ; and it is remarkable that in many of these cases, neither the chancre nor the secondary symp- toms were noticed, or were so mild as not to attract serious atten- tion. Some of the other late manifestations of syphilis also develop so slowly that the patient is not aware that he ought to consult a phy- sician until permanent damage has already been done. This is par- ticularly true of syphilis of the heart, blood vessels, and liver, in addition to the lesions of the brain and spinal cord. The most that can be done in such cases, is to prevent the syphilitic changes from progressing further. In other late forms of the disease, however, very wonderful improvement often follows active treatment. SYPHILIS IN WOMEN. Syphilis affects women much as it does men, although often in a milder form. Furthermore, ' the chancre is less apt to be noticed by the patient, if it is in the folds of the vulva, and is not seen at all when on the cervix, unless the case is examined by a physician. Also syphilis is less often suspected in women, and in consequence is not examined for, and so escapes diagnosis and treatment. Hence, very many syphilitic women honestly deny ever having had the disease. 20 HBREDITABY SYPHHilS. In hereditary or congenital syphilis it seems probable that the fetus always contracts the disease directly from the mother, even though she herself shows no outward evidence of disease. In most instances the father first has syphilis and is alone responsible for the disease being in his family. It is he who infects his wife. The spirochetes in her body then infect the ovum or the growing fetus, or, at a later date, infect the placenta and pass thence, by the blood vessels of the umbilical cord, into the body of the fetus. If the parents have recently acquired syphilis, or if the disease is very active, the children are very liable to become infected. If, however, the parents have been thoroughly treated, or if it has been at least four or five years since they contracted the disease, their offspring are in much less danger and may escape altogether. Fig- ures quoted by Dr. J. Whitridge Williams, of Johns Hopkins Uni- versity, show that about three-quarters of the children of syphilitic mothers are born dead as a result of that disease, usually by a mis- carriage in the latter half of pregnancy. Eepeated miscarriages, or still births, should always arouse a suspicion of syphilis, even though the parents seem to be perfectly healthy. Of the small proportion of syphilitic children that are born alive, many are plainly diseased at birth and usually live but a few hours, or, at the most, a few weeks. These children are emaciated, wrinkled, and feeble, with a severe eruption on the skin and a hoarse, weak voice. Others of these children show no sign of the disease when bom. Some of them are below normal weight, but they may be plump and firm and have a clean skin. Within a few weeks, however, symptoms may develop which a nurse should promptly bring to the attention of the physician. Just as with the chancre of acquired syphilis, we must regard, with the greatest seriousness, the apparently in- significant symptoms of the inherited form of this grave disease. Often the earliest symptom of hereditary syphilis is restlessness, as though the child were disturbed by noise and excitement about it. Soon there is running at the nose, and a hoarse voice when crying, and the mother thinks the child has a cold in the head. The condition persists, however, the discharge from the nose becomes profuse, and an eruption appears. In other cases, the first thing that disturbs the mother, is the appearance of one or more swollen joints in the child's hands, feet or limbs, the child crying whenever the diseased part is moved. If no physician is in attendance, the nurse should ask the parents to consult one immediately, for the earlier the treatment is begun, the more hope there is of saving the life of the child and of curing the disease. Hitherto, the outlook has not been good. Most of these cases have died and the others have been chiefly frail, sickly, and backward. Not many of them have reached adult life, thougli a few have seemed to recover completely. This number will prob- ably be increased by the modern methods of treatment. 21 LABORATORY DIAGNOSIS. The Wassermann reaction, or test, which was developed in 1906, is for syphilis what the Widal test is for typhoid fever, it confirms the diagnosis where the symptoms point to syphilis, and it helps us to make a positive diagnosis in most of the doubtful cases. The Wassermann reaction depends on the fact that the blood of men and animals acquires the power of destroying certain substances, germs, etc., when these are present in the body for some time, or are intro- duced into it repeatedly in small quantities. The method of per- forming the test is as follows, though different laboratories have slightly different variations. Mix together in a test tube: 1. The patient's blood serum, which has been heated and later cooled. 2. Blood serum from a normal guinea pig. 3. A watery extract of syphilitic tissue which contains the spirochetes in large numbers. This mixture is placed In an incubator for one hour. Next there are added : 1. A definite quantity of red blood corpuscles from a normal sheep. 2. Blood serum from a rabbit, which has had sheep's red blood corpuscles injected into Its body at repeated Inter- vals ; this blood serum has been heated and later cooled. The whole mixture is then placed in the incubator again for two hours. If the blood of the patient, as in a case of syphilis, contains sub- stances that tend to destroy the spirochetes, there will be no change in the appearance of the opaque red mixture of blood corpuscles, serum, etc; or, as it is said, there will be no hemolysis. This is called a strongly positive Wassermann reaction, or the reaction is said to be "four plus." If, however, the patient's blood contains no such substances, as is the case when the patient has never had syphilis, the red opaque mixture will become clear like water; that is to say, complete hemolysis will have taken place. This is a nega- tive Wassermann reaction. Between these two extremes, the blood mixture in different cases may show varying degrees of hemolysis. It may show but a very slight change, it may be about half way clear, or it may be almost completely clear, with but a slight cloudiness re- maining. These different degrees of cloudiness are called three plus, two plus, and one plus. The strongly positive or four plus Wassermann indicates uncured syphilis in practically all cases. The three plus Wassermann means almost the same thing, and yet there might be a little doubt. There is more doubt when the Wassermann is only two plus, and a one plus Wassermann does not count for very much, unless there are definite symptoms of syphilis present. It is desirable always to have a second Wassermann test made, even where the first is strongly positive, in order to be as sure as possible of the diagnosis, before beginning treatment. When the Wassermann is only one plus or two plus, it is desirable to have several additional examinations. A single negative Wassermann does not necessarily mean that the patient is free from syphilis, but repeated negative reactions 22 TiBually do. There is this exception, that the Wassermann is nearly always negative for the first ten days or two weeks after the chancre has appeared. The Wassermann may be negative at one time and positive at another, even in a patient known to have syphilis. In about 95 per cent of the active cases of syphilis, the Wassermann is positive. In the very late tertiary cases, about 75 per cent are positive, and in latent syphilis, when the patient ap- pears healthy and may not know that he was ever infected, about 50 per cent of the cases give a positive Wassermann. The Wassermann reaction is affected by treatment, and may be temporarily negative in a case of syphilis that is being given mercury or arsphenamine. But under all circumtances, if it is carefully made and properly in- terpreted by an experienced worker, the Wassermann reaction is the best test for the presence of syphilis that we have. The same sort of reaction is also performed with the spinal fluid as obtained by lumbar puncture. In cases of syphilis of the nerv- ous system, such as locomotor ataxia, the reaction with the spinal fluid is often positive when the reaction with the blood is negative. Hence,, the spinal fluid Wassermann is often of the greatest value in forming a correct diagnosis. The Wassermann reaction has shown that syphilis is present in a number of people who do not know that they have ever had syphilis, and who show no evidence of the' disease at the time of examination. It has shown, too, that thousands of persons who have had more or less treatment, are still suffering from uncured syphilis, many of them years after the last symptoms were noticed. The Wassermann test, therefore, is more and more being used by physicians, not only for diagnosis, but also to guide them in treating these cases, after the outward evidences of the disease have disappeared. For it shows as nothing else does, when the treatment can be stopped with apparent safety, and when it must be increased or begun again. Because of these facts, too, it is now believed by some authorities, that every person who has had syphilis should have a Wassermann test at least once a year, for the rest of his or her life, in order to guard against the treacherous relapses that are so prone to occur. It should be urged, also, that all persons who have ever had any venereal disease, should have at least one T^assermann test made on their blood. This would undoubtedly show a large number of otherwise unsuspected cases of syphilis ; and this number would be greatly increased if the test were done, also, on all persons who have ever exposed themselves to syphilitic infection, through sex relations or in other ways. For, as we have seen, many persons have con- tracted syphilis without knowing it. Physicians and clinics that make a Wassermann test as a part of their routine examination of all patients, find syphilis in a surpris- ingly large number of patients in whom the disease would not other- wise be suspected. In this way many latent cases are discovered and cured. A large number of state and city boards of health are now making Wassermann tests free of charge, and it will probably not be long before this is done in eveiy State, This will enable phy- 23 sicians and hospitals generally, to make much more comjnon use of this most valuable means of diagnosis. It is extremely important to make a positive diagnosis of syphilis as soon as the chancre appears, so that the patient may have the benefit of treatment, even before the Wassermann reaction has be- come positive. This very early diagnosis can be made by finding the spirochetes of syphilis in the chancre. They are most easily found by what is known as a dark field examination, with the microscope, of the puid squeezed from the chancre. This examination is usually made immediately, since the spirochetes die and are less easily dis- tinguished in a short time. TREATMENT. The older treatment of syphilis, by mercury and the iodides, was very efficient when skillfully and persistent carried out, but it took a long time, and the patient remained infectious for many months, at least. In 1909, after a long and patient search, Paul Ehrlich discovered the drug "606," or "salvarsan," which we now call "arsphenamine." This wonderful medicine heals syphilitic sores and eruptions very quickly — the mucous patches and other open lesions, that are so dan- gerous to the associates of a careless patient. The period of in- fectiousness can usually thus be reduced to only a few weeks. This is of the greatest importance from the standpoint of the public health, because it prevents the possibility of the further spread of the disease, by a patient so treated, no matter how careless he or she may be. Arsphenamine, however, is generally regarded as not being suflficient by itself to cure syphilis; most leading clinicians de- pend on mercury also, to effect a permanent cure. Arsphenamine is given by injection into a vein through a hollow needle. One injection is given every five to seven days, for six or eight doses, and during this period the patient is also receiving mercurial treatment. Mercury is given in a variety of ways, but- to be most effective it should be injected into the muscles, usually in the buttock, or rubbed into the skin in the form of mercurial oint ment. These inunctions of mercurial ointment can be given daily, but the injections are given less often — soluble salts, like the bi- chloride, every second day, and insoluble salts, like the salicylate, once or twice a week, two or three days after an injection of arsphenamine. This combined treatment with mercury and arsphenamine is to be continued for six or eight weeks. Then the patient must be given a rest of six or eight weeks, and after that another six or eight weeks of treatment. If the case is seen early, and put under active treatment soon after the chancre appears, these two series of treat- ments may be suflScient to cause the Wassermann reaction to become negative. Cases not seen until later will need still more treatment, and all cases must receive enough to render the Wassermann reac- tion permanently negative. The Wassermann must be done once a month or once in two months, for a year after the treatment is stopped. If it should be positive at any time, or if further symptoms of syphilis should de- velop, treatment must be begun again at once. 24 Patients receiving arsphenamine or mercury should be given a simple, nourishing diet, with or without a touic, and should take good care of themselves generally during the treatment. The teeth and gums should receive especial care on account of the danger of salivation from the mercury. The urine should be examined weekly, because both arsphenamine and mercury irritate the kidneys. If the urine shows actual damage to the kidneys, the treatment must be stopped for a while and later begun again with reduced dosage. In other words, while treating syphilis, we must not forget to treat the patient. The modern treatment of syphilis is altogether very encouraging, when it is possible to make early and abundant use of both arsphe- namine and mercury, and to guide the treatment intelligently by the Wassermann reaction. Even so, however, a number of cases do not respond well to treatment, and may still give a strongly positive Wassermann after the most vigorous use of both drugs. Such cases should invariably continue under medical supervision, for repeated courses of treatment may at least hold the disease in check. CHANCROID. Chancroid is an infectious ulcer, often accompanied by a mass of inflamed lymphatic glands, called "the bubo." It is caused by the bacillus of Ducrey, discovered by him in 1889, A chancroid, or chancroidal ulcer, is known also as a soft chancre, or soft sore. It has nothing to do with the chancre of sy])hilis, al- though the names are so similar. Chancroid is a local disease only, and does not atfect the body generally, as syphilis always does and gonorrhea sometimes. The chancroid appears in from three to five days after exposure, and lasts for four or five weeks as an open ulcer. It sometimes •spreads considerably, destroying the tissues as it goes. The germs often become transplanted from the original sore, and form other chancroids, on the genitals, thighs, or elsewhere. This is called auto- inoculation. When the ulcer occurs on the genitals, the lymphatic glands in the groin often become infected, usually on both sides. They are swollen, tender, and matted together by the infiltration of tlie sur- rounding tissues. Walking is so painful that the patient frequently has to remain in bed. AVhen the sores are elsewhere on the body, other groups of glands are affected. The buboes frequently suppur- ate and discharge for two or three weeks; and the pus sometimes causes new ulcers, if it enters abrasions in the skin. Although the disease sometimes destroys a considerable part of the external genitals, and may be very painful, it would not be a matter of very great importance, were it not for the difficulty of positively distinguishing between a single chancroid and a true syphilitic chancre. Sometimes one closely resembles the other. The patient, too, may have been infected with both diseases at the same time. The chancroid then develops within a few days, but before it has healed, several weeks later, the chancre of syphilis develops 26 in it. The discharge from a chancroid should be examined micro- -scopically many times, to determine whether or not the spirochetes of syphilis are present, and the Wassermann test should be made several times during the next few months for great certainty re- garding the diagnosis. LECTURE III. Gonorrhea, often spoken of as "the clap" or "a dose," is an acute infectious disease, that later frequently becomes chronic, and is caused by the gonococcus. This germ was discovered by Neisser in 1879. In shape, when seen through the microscope, it somewhat resembles two coffee beans placed with their flat sides together. Here, as in the case of syphilis, the public health is safeguarded against frequent accidental infections, because the gonococcus dies within a few hours after drying. Moist discharges, however, left upon towels, douche nozzles, toilet seats, etc., may infect those who use them later. Gonorrhea is usually contracted by sexual intercourse with an infected person, but it may be acquired in other ways. One attack does not protect a person against future attacks, although these are usually milder than the first. Urethral gonorrhea is only one of a large number of conditions caused by the gonococcus, which are spoken of collectively as the gonococcus infections. The course and symptoms of the disease are very different in men, women, and children, and will, therefore, be considered separately. GONORRHEA IN MEN. Gonorrhea in men begins in from three to seven days after ex- posure, as an acute urethritis, or inflammation of the anterior por- tion of the urethra; and the patient first notices a little burning pain on urination and a slight discharge from the urethra. The pain increases for about a week, and the discharge becomes thick and yellowish. The symptoms remain severe for from three to five weeks, and then slowly subside. During a large part of this time there is considerable suffering, especially at night, and the symp- toms are usually made worse if the patient is up and about. Phy- sically, he is unfit for work, and if he exerts himself, he runs a greater risk of complications. Furthermore, he is a constant danger to his associates unless he is careful and clean in his habits. Proper treatment of the disease, from its very beginning, gives hope of a rapid cure, which requires, however, at least four or five weeks. It further decreases the danger of complications, but they occur in a large proportion of cases, in spite of the best treatment. They are of two sorts: first, those caused by an extension of the disease to other parts of the geni to-urinary system, such as the posterior part of the urethra, the prostate gland, and the epididy- mis ; and, second, those resulting from the germs being washed into the blood stream and carried to distant parts of the body. Gonorrheal infection of the epididymis, which is commonly known as swollen testicle, is exceedingly painful and disabling to the pa- tient ; but its chief importance lies in the fact that It often causes 26 sterility, when it occurs on both sides. It makes no difference whether this happens during a single attack, or whether one side is affected at one time and the other in a subsequent attack. This complication is often the real cause of childless marriages, where sterility in the wife is supposed to be to blame. Infections of the posterior urethra, the prostate gland, and semi- nal vesicles, are very common and resist treatment stubbornly; without treatment they may persist for a number of years. When these infections become chronic, they may cause so little inconveni- ence that the patient may not seek medical treatment. He has only a trifling mucoid discharge, perhaps nothing but a small drop of clear fluid that he notices on rising, the so-called morning drop. Only a careful clinical and microscopical examination can show that the disease, in many cases, is still uncured. A man with this slumbering infection, may think himself completely well of his old gonorrhea, and in his ignorance he may marry, honestly believing that there is no danger for his wife. In a short time, however, he finds to his horror that he has infected her with the disease. There are, unfortunately, also, a great many irresponsible men, who simply do not care to go to the trouble of being thoroughly cured. They suffer little themselves, and will heed no warning as to the infectiousness of their slight chronic discharge. While these men often do not wish to marry, they recklessly continue to expose to their disease, the unfortunate women with whom they consort. And if they finally marry they do so in the same spirit of criminal carelessness, and when they infect their wives, they appear to bear their reponsibility very lightly. Cases of general infection of the blood stream with the gonococ- cus are more frequent than is generally supposed. The most com- mon result of this is the so-called gonorrheal rheumatism. This is a true infectious arthritis, usually attacking the knee or other large joints ; it is exceedingly painful, and of long duration, though not often permanently disabling. A much more serious result of the germs entering the blood, is infection of the heart, gonorrheal endocarditis, which is usually fatal. Fortunately, this is not very common. Still more rarely, the germs multiply in the Wood stream to such an extent that a fatal, general septicemia results. This condition can hardly be distinguished from typhoid fever, without a bacteriological exami- nation of the blood. Every case of gonorrheal rheumatism should be treated with these fatal complications in mind, and kept in bed as long as there seems to be any danger of their developing. In any case of gonorrhea there is always the danger that the pa- tient's fingers may carry some of the germs into his own eyes. If this happens, a virulent gonorrheal conjunctivitis may follow, which usually results in the loss of one or both eyes. Fortunately, this eye infection is rare in grown persons, considering the large num- ber of cases of gonorrhea that there are. But while adults are not nearly so susceptible to this complication as infants and young children, it is more difficult to save tte infected eyes of adults by treatment, and every gonorrheal patient, whether man or woman, should be frequently and emphatically warned of the danger. 27 A late result of gonorrhea, quite common in men, is stricture of the urethra. This causes difficuly in urination, and sometimes complete obstruction to the flow. Unless it is cured by operation, it tends to produce serious damage to the bladder and kidneys, and sometimes fatal results follow. GONORRHEA IN WOMEN. In women, gonorrhea is much less violent and painful at the be- ginning than in men, but in its later complications it is far more serious. A few days after a woman is exposed to this infection she may notice that urination is a little more frequent than usual, with some smarting and a very slight discharge which becomes a green- ish yellow and stains the clothing. Because of the mildness of these symptoms, she may fail to notice either of them, particularly if she already has a leucorrhea. The parts first affected are the vulva, the urethra, and the interior of the cervix. Any of these may be affected alone, but the disease tends to spread rapidly and involve all three. The vagina seldom suffers much. Abscess of the vulva is not uncommon, as a result of the infection extending into the vulvo-vaginal glands. The internal os may, for a long time, shut off the disease from the interior of the body of the uterus. When it does infect the uterus, it usually causes slight heaviness in the lower part of the abdomen, and some menstrual irregularity, or, perhaps, no symp- toms at all will be noticed. In about half of these cases the disease extends ultimately into the Fallopian tubes. Menstruation is then more disturbed; the periods last longer, the intervals between are shorter, and there is more or less pain low down in the abdomen on both sides, especially when the woman is on her feet. Gonorrhea tends to be somewhat worse at the menstrual periods, for the gonococci acquire greater poisonous power or virulence at those times. If a man with a mild, chronic gonorrhea has infected his wife with his own slightly poisonous germs, he may later, dur- ing one of her menstrual periods, receive from her a fresh infection of severe, acute gonorrhea, because the germs have grown more powerful in her body. And this has often happened. A woman who has a gonorrheal inflammation of the lining of the uterus, an endometritis, may never become pregnant, because the fertilized ovum cannot become attached to the diseased mucous membrane. If it should become attached, the fetus may die later, on account of the imperfect blood supply, and a miscarriage results. On the other hand, a woman with a mild gonorrhea, that has not extended above the cervix, may readily become pregnant. But dur- ing pregnancy the disease is much more liable to extend up into the uterus and, as before, the life of the fetus is terminated. Gon- orrhea thus causes abortion or miscarriage usually in the early months; syphilis, more commonly, in the latter half of pregnancy. Again, gonorrhea may not invade the uterus until after delivery, but then the gonococci multiply rapidly in the congested tissues, and the disease is apt to extend swiftly. It frequently is the cause of mild 28 cases of puerperal septicemia, and some of these even develop fatal- ly. In a larger number of the cases of gonorrhea that grow worse after delivery, there is an extension of the disease to the I^allopian tubes, causing gonorrheal salpingitis, or tubal inflammation. This may be mild, or very severe with pus formation. Further, since the Fallopian tubes open into the peritoneal cavity, in the pelvis, a little of the gonorrheal pus may often leak out and cause various degrees of pelvic peritonitis. Each time that this occurs, the wo- man has an acute illness of greater or less severity, with griping pains or cramps that have often been mistaken for indigestion or appendicitis. The peritonitis may be so severe that a pelvic abscess is formed, or it may extend upward into the general peritoneal cavity. As a result of the inflammation, the ends of the tube are apt to become closed. Whatever pus is then formed in the tube, accumu- lates and distends it. This extremely painful condition is known as a pyo-salpinx or pus-tube, and may occur on either or both sides. It is really an abscess, which, in its early stages, swarms with gon- ococci, though these lose their virulence later and die out. While still infectious, the abscess may break and "discharge into tlie peri- toneal cavity. This has caused the death of many women, from generalized peritonitis. If the case is properly diagnosed, and operation can be deferred for some weeks until the germs have become less virulent, these pus tubes may be safely removed by a laparotomy and the woman's life saved. But whether they are removed by operation, or rendered useless by the gonorrheal inflammation, the function of the tubes is lost and the woman is made sterile in a large proportion of cases. Whether pus tubes occur or not, the pelvic peritonitis may be so extensive as to cover the tubes and ovaries with adhesions, so that no ovum can escape. The uterus, too, is often bound down in a bad position, forwards or backwards, or dragged to one side. These deformities of the uterus, tubes, and ovaries, as well as the recurring attacks of salpingitis and pelvic peritonitis, are the causes of much of the chronic invalidism of our women. The long continued pelvic and abdominal pain, the dragging sensations, the backaches, make them, at the best, unable to engage comfortably in their former ac- tivities. These symptoms also wear on their nervous systems, and may produce neurasthenia or even serious mental disturbances. In this connection, it must be emphasized that much of the in- validism that has popularly been regarded as due to "female weak- ness," or "to the married state," is in reality simply the manifesta- tion of chronic gonorrhea. We must, however, beware of thinking that every such case is due to gonorrhea. For the lacerations of childbirth, infections with the streptococcus and the colon bacillus, and tuipons, account for a very large number of the disabilities of women. Gonorrhea, like syphilis, may be best cured if placed under proper medical treatment early. Women should, therefore, know the ear- liest symptoms of gonorrhea as described above, and, if suspicious of such trouble, should at once seek skillful medical treatmen*^ Even when the symptoms are very mild, the most thorough and per- 29 sistent treatment is essential to a cure. Douches alone, and other self-applied medications, are by no means sufficient. No woman should attempt to treat herself, nor should any nurse assume the responsibility. It must be carefully explained to women that the iniection very early penetrates into parts which are inaccessible to them ; and further, that in a disease which has such dangerous possibilities as gonorrhea, they can do justice to themselves and their families, only by at once obtaining the very best medical care possible. Gonorrhea in women is often extremely stubborn, and the patients naturally tend to, be discouraged. The nurse will, therefore, never forget the patient, while treating the disease. She must remember the woman's disheartenment over the sudden failure of her youthful vigor, and her bitter disappointment, if she learns that her husband is to blame for her condition. The nurse will sympathetically re- member, too, that long suffering sets many a splendid woman's nerves on edge, and her disposition may suffer accordingly. A fine nurse will exercise self-control and tact in such cases, and while working for the patient's physical comfort, she will bring all bright- ness, cheer and determination to her daily encouragement. GONORRHEA IN CHILDREN. Young children are far more susceptible to gonorrheal infection than adults. It readily attacks the eyes of both sexes, and the genitals of female children, and, in rare cases, even the nose and mouth. It only spares the male genitals as a rule, because of the better protection of their mucous membranes. Most institutions that care for babies and young children have occasional distressing epidemics of gonorrheal vulvo vaginitis. The disease, when introduced into a ward of healthy infants, runs through it like wild fire, attacking practically every female child. It never spreads to the nurses and other adult attendants, unless, by some extreme carelessness. The germs are undoubtedly carried from one child to another by napkins, towels, thermometers, etc., and by the hands of the nurses. Because of its contagiousness, every case of gonorrheal vulvo- vaginitis must be isolated from other children as soon as recog- nized. Some hospitals will not admit a female child into their wards until microscopic examination of a vaginal smear has shown the child to be free from this disease. In the average case of gonorrheal vulvo vaginitis, there is com- paratively little discharge; the vulva may be simply red or more moist than normal. Older children have severe itching and painful urination, but infants appear to have no discomfort whatever. Un- less a nurse is on her guard, therefore, such a child may have the disease for some time, and infect other children, and its own eyes, before the condition is recognized. The appearance of the vulva should always be noticed at the daily bath, and any redness or ex- cessive moisture immediately reported to the physician. Micro- scopic examination is often necessary for a positive diagnosis. This disease is extremely difficult to cure, requiring five or six months at least, and it is known to persist sometimes for several 30 years. In private liomes, girl children are often accidentally in- fected by sleeping in the same bed with an infected parent or other person. Such a case may continually be reinfected, and so will not be cured until separated from the source of its infection. It is even possible for one of these girls to remain infectious until ma- turity. Gonorrheal conjunctivitis, or ophthalmia neonatorum, or "sore eyes," is a severe inflammation of the eyes of new-born babies, that often causes blindness within a few days or weeks after birth. In these cases, the mother is already infected with gonorrhea, and the germs are forced between the child's eyelids during birth, or while it is being handled shortly after. The eyes, like the genitals, how- ever, may also become infected at any later time, and from any case of gonorrhea with which the child comes in contact. Once infected, the disease progresses swiftly. The eyelids and conjunctiva are red and greatly swollen, and there is a purulent discharge, which contain^ the gonococci and is therefore infectious. The transparent cornea is deeply buried in a well of pus and, without treatment, becomes swollen and ulcerated very quickly. After the disease comes to an end, the cornea, if not destroyed, remains more or less distorted, opaque, or clouded, and vision is greatly diminished or lost altogether. By the most prompt and thorough treatment, and unremitting care on the part of the nurse, the eyes can be saved unharmed, in a large proportion of cases, in infants. In adults, on the other hand, while the eyes are not so readily attacked, the sight is oftener destroyed in spite of all treatment. We are filled with supreme pity and indignation as we look at the white, clouded eyes of a blind baby, or into the vacant upturned faces of the children in our schools for the blind. For we know that these children must walk a dark road through the world, as long as they live, deprived of the sight of beauty and handicapped for self- support, and through no fault of their own. Immorality on the part of one of the parents is, in the first place, usually to blame for their condition. But when the motlier is once infected, the re- sponsibility for the child's eyes rests u])on those who help to bring it into the world. ^ Because of the great prevalence of gonorrhea, as well as from the fact that other germs, such as the pneumococcus, also sometimes destroy the sight of new-born infants, it has come to be regarded as criminal negligence, on the part of any person who manages a de- livery, who does not immediately instill into the child's eyes one of the solutions known to prevent the most of such infections. TREATMENT OF GONORRHEA. In a disease so serious as gonorrhea, there is no such thing as successful self-treatment, any more than there is in the case of syphilis, and advertised.remodies are frauds. Every patient should be under the care of a skilled physician. Gonorrhea is chiefly a local disease, not a systemic or blood disease as syphilis is. Tlierefore, it is treated very largely by local measures. In men the acute stage is best treated by rest in bed, .31 abundant drinking of water, bland diet, and remedies to relieve the severe urethral pain, such as sitz baths. Sandalwood oil is given internally for its curative effect, and also to lessen the irritation of the urine. After the severest inflammation has subsided, and in many cases from the beginning, urethral injections or irrigations of silver preparations, such as argyrol or protargol, are begun. These are for the purpose of killing the gonococci. When the discharge and other symptoms have largely disappeared, after three or four weeks, these silver preparations are discontinued, and irrigations with astringent solutions, such as zinc sulphate, take their place. If complications occur, such as extension of the infection into the prostate gland, seminal vesicles, or deeper structures, the disease runs a much longer course, and the treatment varies according to the parts aff'ected and the degree of the inflammation. After the acute stage of these complication^ has passed, the measures most frequently employed are massage of the prostate gland and seminal vesicles through the rectum, the passage of sounds, etc. Urethral irrigations are continued. Various operations of greater or less severity are often needed, such as for the relief of epididymitis, urethral stricture, prostatic abscess, etc. Though the acute stage is not so severe in women as in men, every woman with a beginning gonorrhea should be put to bed and given the most careful treatment. This should include abundant douches, and the thorough application of argyrol or other silver preparations, or iodine solutions, to the infected surfaces and tubes, such as the vulva, the urethra, the ducts of Skene's and Bartholin's glands, ^nd the cervical canal. While the urethra is frequently in- fected in women, it is a smaller structure than in the male, and inflammation there does not produce such severe symptoms. As the disease tends to paSs upwards into the cervical canal and beyond, the treatment should, if possible, kill the gonococci in the vulva, urethra, and vagina, before the inflammation extends beyond the external os. And if the interior of the cervix is already in- fected, there shoiild be the utm.ost endeavor to keep the disease from passing through the internal os into the body of tlfe uterus. Great care must be taken in treating a female patient, just as in the case of male patients, not to carry the infecting germs deeper or higher than they already are. For, it is possible, by carelessness, to infect the cervical canal or uterine cavity from below, and thus make matters worse. If the inflammation extends into the body of the uterus and the Fallopian tubes, local treatment of the disease in the vulva and vagina must cease in many cases, because of the severity of the other symptoms. Hot douches, however, may even then be continued, be- cause they tend to relieve the pelvic symptoms. If the inflammation in the tubes goes on to pus formation, or if a pelvic abscess develops, the patient must usually be relieved by operation. The infection of the pelvic organs is sometimes so ex- tensive and destructive that the uterus and tubes have to be re- moved altogether. If possible, operations are not to be done during the height of the gonorrheal inflammation, becaiise of the danger of setting up acute peritonitis, followed by the patient's death. The 32 woman should rather be carefully nursed until the acute inflamma- tion subsides, the gonococci becomes less virulent, and the pus is localized and walled olf by adhesions. Gonorrheal opthalmia demands immediate skilled treatment, much of which is to be given by the nurse. She must show constant watchful care to keep the conjunctival sac washed free from pus, by boric acid or other mildly antiseptic irrigations, followed at in- tervals by the use of argyrol or other suitable antiseptics. Cold compresses are often used constantly with great benefit. The child must be prevented from carrying the infection to its genitals, or to the other eye if only one is involved. Gonorrheal arthritis is treated much as any other acute joint inflammation, by rest of the parts and applications of heat or cold. The patient must be most carefully watched for the appearance of heart symptoms ; the arthritis develops in consequence of the gon- ococci entering the blood, and the heart valves are also sometimes affected. The primary disease in the urethra, seminal vesicles, etc., must always be carefully and thoroughly treated during the course of the joint inflammation, because it is the source of that infection. Endocarditis, or inflammation of one or more of the valves of the heart, is one of the most dreaded complications of gonorrhea, for it is usually fatal. It must be treated as a case of malignant endo- carditis, by absolute rest, ice bag to the heart, and the most ca.reful nursing. Gonococcus vaccine has been used to some extent in chronic gon- orrheal conditions. TESTS FOR THE CURE OF GONORRHEA. ' It has been stated that gonorrhea is often very difficult to cure. It is probable, however, that most cases can finally be cured, if the patient will persist in taking treatment. The following method is used to determine whether a patient is cured. On the day previous to the examination, the patient must have taken vigorous physical exercise, to stir up the activity of any re- maining inflammation. On the day of the examination : 1. All siKns of the disease must Uave disappeared, both In the external genitals and in the pelvic organs. Rectal or vaginal examination is necessary for this. 2. Microscopical examination of smears must show no gonococci. In males, these smears are made from the secretions expressed from the prostate and seminal vesicles, and should show but few leucocytes, as well as no gonococci. In females, the smears are made from the secretions of the urethra, the ducts of the vulvo- vaginal (Bartholin's) glands, and the cervical canal. 3. In males, the urine must be free from pus in what is Irnown as the two-glass test. The patient passes the first part of his urine into one glass and the last part into another. Both glasses should be clear. In females, this test of the urine has no value. This entire examination is repeated on at least three different occasions, at least two days apart. On account of the danger of relapses, every patient should be ordered to report for another such •examination in two months, and again in six months, haAdng taken no treatment during this time. If the patient passes all of these examinations successfully, he or she is regarded as <:ured, and mar- 3S riage is permitted. In the majority of such cases, the marriage partner and the children are never infected. THE PREVENTION OF THE VENEREAL DISEASES. The three venereal diseases, which are so prevalent and two of which are so serious to individuals and to the race, are among the most easily preventable of all communicable, infectious diseases. They are peculiar to the human species. They are not carried or spread by any animal or insect, nor are their germs carried by water, milk, fQod, air, or dust. The living germs may, it is true, be carried by various articles that have been soiled by the mouth, genitals, or open sores on the skin of infected persons. The chief means of spread, however, is by intimate contact with persons already infected, who are called car- riers, human carriers. This intimate contact may be of many com- mon sorts, but in the vast majority of cases it is sexual contact, either within the marriage bond or through illicit sexual intercourse. This is well stated by Lieutenant Colonel William F. Snow and Major Wilbur A. Sawyer, both of the Army Medical Corps, as follows : "The commonest manner of transfer is through sexual inter- course, and all the other ways of spread may well be regarded as Incidental or secondary to transfer through promiscuous sex relations. As long as venereal diseases are prevalent there will be many infections through other methods than sex contact; for example, the transmission of syphilis from the mother to the unborn child, the spread of syphilis through kissing or by the use of common drinking or eating utensils, the gonorrheal infection of the eyes of the child In the birth canal, the infection of eyes by fingers soiled with gonorrheal discharges, and the infection of chil- dren with gonorrhea through contact with soiled objects in the household." Our knowledge of the methods by which these diseases are spread, plainly indicates what we must do by law and in a" purely medical way, for their prevention. First, and most important, we must know where every case is. And so the venereal diseases must be reported to the health authorities, as are other communicable in- fections. This is provided for by law in forty-two States. Then, every infected person must be required to take medical treatment until cured, and meanwhile must be taught how to avoid infecting others. Cases that refuse to take treatment, and persist in carelessly or criminally infecting other people, must be quaran- tined and compelled to receive treatment, as is now provided for by law in over twenty-five States. It is not necessary, however, to quarantine careful, intelligent, and willing patients, for they can take such care of themselves that they will not endanger others. The Wassermann test, or other suitable laboratory examinations, should be used in all cases to make certain of the diagnosis, and at intervals later, to guide the treatment, and to give all possiI)le as- surance that the patient is cured and can be safely discharged. The treatment of these cases takes so much time, and there are so many who need treatment who cannot afford it, that only a part of tbem can be handled by private physicians. It is absolutely neces- 34 sary, then, that every city and large town shall have one or more dispensaries or clinics, attached to a general hospital if possible, where these cases may be treated. More patients can be carefully treated in a short time, in such a well equipped dispensary, than in any other way. At the clinic, too, the patients can be most successfuly educated, and it is on education that the success of the tight against venereal diseases largely depends. The patients must be taught the nature and seriousness of their disease, and the need of persistent, long con- tinued, thorough treatment in order to become completely cured. They should be made to understand that they are a danger to others if they are careless, and shown what they must do to prevent in- fecting others. Educational pamphlets on tlie venereal diseases are being distributed for this purpose at many clinics. The patients must be urged to follow all directions exactly, and should be made to feel their responsibility. They should wear suit- able dressings, that will protect both clothing and bedding from contamination. Soiled dressings should be wrapped in newspapers or paper bags, and burned as soon as possible, and soiled napkins and supporters should be boiled. Patients should wash their hands carefully after changing their dressings, and after touching the diseased parts, and they should keep their fingers out of their eyes. Each patient should sleep alone if it can possibly be arranged, and there should be no sex relations under any circumstances. Pa- tients with syphilis should kiss no one; and, in general, all intimate contact with others is to be avoided, by all persons who have ven- ereal infections. If there are children in the house, the greatest . care should be used to keep them from close contact with the patient, and when the patient is a child, it is to be remembered that the home may contain some other infected person, 'who should, if possible, be brought under treatment. The clothing and handkerchiefs of these cases, should be scalded separately before being washed; and toilet seats, wash bowls, and bath tubs, should be thoroughly washed after being used by them. No one should ever use their syringes, douche bags, or nozzles, or enema tips, unless these have been thoroughly boiled, nor should any one use their shaving articles, pipes, or anything that goes into their mouths. At present, a very large proportion of these cases are not under any physician at all ; they are biiying various medicines at the drug stores, or are going to the advertising doctors, the quacks, who care little about their patients, except to get their money. This evil will be lessened by every patient who has learned from his physician, or at the clinc, the facts about the venereal diseases, and what their thorough, scientific treatment really means ; for he will talk about it, and send his infected friends to get the same sort of care that he received. The nurse's work in such a dispensary is most valuable, and with the women patients she is indispensable. She assists in the treat- ment, and after she is trained, gives part of it herself. She keeps the records, takes histories, looks after the supplies, and helps the physician to maintain an encouraging atmosphere in the place. 35 A nurse who has a knowledge of human nature, and above all a sympathetic love for human kind, will perform a service in a ven- ereal disease clinic that no one else can, and that few other services can equal. As the patients see her with the doctor, day after day, they accept her as a part of the clinic, and both men and women talk with her freely. She tells the women the nature of their disease. In rare cases this may be avoided. But how else can most women be persuaded to come regularly and often, for three months or a year, to take troublesome treatment, long after they feel perfectly well? And how else can one be induced to take such precautions at home as will protect her children from infection? Many patients, men and women both, are shocked and frightened when they learn that they have one of these diseases, especially if it is syphilis. In the case of married women, infected by their hus- bands, the shock and sorrow are often excessive, or, on the other hand, anger may impel them to do violence. In some cases the home has to be broken up, but this is usually a greater evil than to endeavor to reconcile the wife for the sake of the children. The nurse talks with the men about their families, and tactfully leads them to ask permission to bring their wives and children in for examination. She saves the doctor's time by teaching the wo- men patients, and the wives of the men patients, how they must manage themselves and their homes, with this new care. They in- vite her to visit them, or if they do not, she calls on them anyway. At their homes she shows them how to prevent the accidental in- fection of other members of the family, and how to carry out all of the physician's instructions in the best way. On these visits, also, new cases come to her knowledge, through the women of the neighborhood who know her, and she can often bring them to the physicians at the clinic, weeks or months before they would otherwise have come. This means stopping the spread of infection just so much earlier. These frequent home visits encourage the patients to continue coming regularly. Most cases of syphilis and gonorrhea tend to stop treatment, when the discharges and pains have disappeared and when the sores have healed. But the disease itself is not by any means cured. The nurse holds such patients to treatment by per- suasion or arguments, and in extreme cases by the law. But her greatest power is the influence of her personality and friendship, that will make many patients trust her word, even more than that of the doctor whom they do not come to know so well. EARLY TREATMENT, OR MEDICAL PROPHYLAXIS, OF VENEREAL DISEASES. At the present time, the attempt is being made to promote normal living, by all social, educational, and legal measures, and thus to lessen the amount of sex immorality. But after everything possible has been done in this direction, humanity requires that a further at- tempt must be made to protect the persons, who have exposed them- selves to venereal disease, so that if possible, th^ will not develop 36 infection. For the venereal diseases, and their spread to innocent persons, must be prevented if possible, even where it has proved im- possible to prevent immorality. For many years we have been protecting the eyes of new-born infants against gonorrheal infection, by instilling silver nitrate solution, or a similar preparation, into their eyes immediately after birth. Methods were devised, a few years ago, for preventing also the development of syphilis, gonorrhea or chancroid, after exposure through sexual contact. The medical measures used for this pur- pose make up what is known as early or prophylactic treatment. It consists of a thorough cleansing of the external genital organs, and the application to the urethral mucous membrane of an anti- septic silver preparation, such as argyrol, to kill the germs of gonorrhea, followed by an application of calomel ointment to the skin and mucous membrane, to kill the germs of syphilis. The germs of chancroid are also killed by these processes. This treatment is very successful in preventing the development of venereal infections, if it is given within the first hour after the exposure, before the germs have penetrated beneath the surface. Its value rapidly diminishes from then on, and when four hours have elapsed since the exposure, it is of very little usefulness. The early treatment has been largely used in the Army and Navy, and to a small extent among civilian men. Similar treatment could be applied to women, though it would be more difficult and the re- sults would be more uncertain, because of the larger surface and greater number of structures that might be infected. All persons who have been exposed to a venereal disease, whether they have had the early treatment or not, should be examined by a physician every second day for ten days, and after that once a week for two months, in order that any infection may be detected at the earliest moment. CONCLUSION. It is necessary that people generally shall become informed of the main facts about the venereal diseases, much as you have learned them in these lectures. When these facts are commonly known, the people will surely demand increased opportunities for medical treatment for these sufferers, and better laws, for the control of these devastating diseases. Laws cannot help men and women to control their sex impulses, but laws can do a great deal to lessen the temptations to immorality. Especially, laws can, and should, greatly reduce the amount of commercialized vice, or prostitution. This alone will make it more difficult for men and women to go astray. And when such laws are once on the statute books, they should be vigorously enforced, and this again requires a well in- formed, vigorous public opinion. - The best people of our communities are learning that they must share the burden of the fight against vice, however much they may feel disinclined to consider the subject. For the evil is always among us and will grow great if not opposed. Our life is a long struggle of right against wrong, that will never stop while humanity holds to its great ideals, and battles for them. 37 LECTURE IV, mSTORIOAIi, In the preceding lectures it has been shown that the venereal diseases are exceedingly prevalent, that they have the most serious effects on individuals and on the race, and that they are spread al- most wholly by immorality in the relations of the sexes. Sex immorality, besides speeding on the racial degeneration caused by syphilis and gonorrhea, is itself the most malignant dis- ease of our society. Syphilis and gonorrhea eat at the heart of a nation and breed decay in its brain and brawn. But immorality clouds the soul of a people, and rob it of the ideals of progress and service that make a strong nation. Immorality absorbs energy, lessens ambition, brutalizes; it destroys the sense of justice, is cruelly selrtsh, and brings with it, carelessly, the tragic wrongs of illegitimate births and venereal diseases. Immorality has, there- fore, always been a destroyer of nations ; it has helped to topple over great civilizations, and to bury them beneath the forest and the jungle and the waste of centuries. The late Prof. W. G. Sumner, of Yale University, wrote that the experience of nations and peoples proves that vice "can corrupt the finest brain and the most cultivated character; also that, if it be- comes current in a society it will eat out all manly virtues, all cooperative devotion, the love of children, the energy of inven- tion and production, of an entire population." This monstrous twin iniquity, of immorality and the venereal diseases, never couM have been sustained so long among us but for some great force or forces back of it. The natural sex impulse, as we saw in the first lecture, is, of itself, such a powerful force. But it would be a great mistake to suppose that that alone accounts for the conditions which we now face. For, large numbers of people have proved that the sex impulse can be brought under the domina- tion of the will. The other great force back of these evils is the force of custom. Custom rules us from our birth to our grave. It commands us, every hour of the day, what to do apd what not to do; what to think and what not to think; what to call right and what to call wrong. We are controlled by public opinion, the opinion of "our people ;" we share their beliefs, we do things as they do them. The great mass of people act blindly according to custom; it is a strong man or woman who goes against it, and thinks and acts according to conscience and reason. Even the strongest persons, however, cannot wholly escape its influence ; for the training which we received in childhood, which clings to us always, was a training in the customs of our people. Customs'are handed down from one generation to another. The older they are, the more reverence is attached to them. They change, however, as conditions of living change, and as new knowledge is gained. Farm life had changed very little in a thousand years, but in the last fifty years its customs have been greatly modified by having farm machinery, the telephone, the mail delivery and the automobile; Newspapers have changed customs greatly, because they tell the people what other people, all over the world, are doing 38 and thinking. Ideas and notions are thus changed, and this changes customs. For customs rest upon ideas — ideas as to the best way of doing things; they result from the attempt of people to live more securely and more comfortably in their environment. The idea back of a custom was usually very sensible in the begin- ning, but it was often forgotten later. Then the custom might be kept up, simply because it had become fixed as a custom, even though it was no longer necessary and even harmful. A certain town had unhealthful water. Therefore, the college boys there used to buy spring water to drink. And it became the custom, for every boy who cared for the good opinion of his mates, to have a box of water bottles in his room, or set on the outside of his window. Finally, the town water was made healthful, and it was no longer necessary to buy drinking water. But the college boys continued to do so, because it was their custom ; and boxes of water bottles sat on the window ledges for many years, until the idea slowly spread through the college, that the town water was safe to drink. Then the old custom was gradually abandoned. The old idea that the earth was flat kept people from exploring beyond the countries which they knew, for fear they would fall off. Then Columbus sailed a thousand miles into the unknown, and dis- covered a new world; and by this one voyage, this one man, of in- tense convictions, courage, and determination, broke down the solid wall of ancient custom and scattered explorers all over the world. In regard to the sex relations of men and women, there is an ancient and very powerful custom, which until recently, has per- mitted men to follow their sex impulses freely, while it forbade women to do so. It has called the same act right in man and un- pardonable in woman. And this custom, although it has been some- what modified, is still very powerful in human society. This cus- tom is called "the double standard of morals." However inevitably this double standard developed in bygone ages, we pass judgment on it today in the light of twentieth cen- tury ideals. It invites and promotes immorality among men. It is a most cruel injustice to women, not because it makes sex immorality difficult for them, but because it makes it so easy for their future husbands, the fathers of their children, and for their own sons when they grow up. And the double standard of morals has become more than doubly hateful, because people are learning that it results in the spread of the venereal diseases to innocent women and children, thus piling one tragedy on another. Nothing can be said in defense of the double standard, even taking into account the fact that man's sexual nature is more compelling than woman's. Its plea, that nature makes sex relations necessary for men, is the threadbare excuse of weak natures. Or it is the honest belief of misguided men, who have never been shown what ideal manhood means, nor fought to attain it. The double stand- ard of morals is unnecessary, wholly barbarous, unworthy of our modern civilization, and an insult to our pure religion. It is most difficult to understand how it ever could have come into being, until we see how it has developed as a custom, in connection with the de- velopment of the human family. ■ 39 Among most of the lower forms of animal life, the sexes come to- gether only for the fertilization of the female's eggs, and the young, when hatched, have to care wholly for themselves. Among some birds, however, we find an almost human family. Both male and female share in building the nest. The female sits on the eggs for most of the time, but is relieved by the male. They join in caring for the young, and in teaching them to fly, and both will risk their lives to protect them. It is also said that some varieties of birds mate for life. With most warm blooded animals, the sexes are together only for a short time at the mating season. The female nurses her young and brings them up, and alone acts as their protector. In some, however, such as the squirrels, the male stays with the female until after the birth of the young, and assists her in protecting their off- spring. Among the highest animals, there are curious and close resemb- lances to the human family. For example, the gorillas often live in pairs, though sometimes one male has several families. The male is the protector of the family in time of danger, the female and her young flee to safety in the forest, while he advances alone to meet the enemy. The female and her young one sleep in a nest high up in a tree, while the male spends the night on a lower branch, or at the foot of the tree, to protect them from night attacks of leopards and other animals. The male gorilla even builds nest for his preg- nant mate, where she is delivered. Among very many of the higher animals, the males show a large degree of jealousy, battling fiercely among themselves for the possession of the females, and afterwards to prevent other males from approaching their mates. The human family began in the same rough world. Men and wo- men had to struggle with nature for a living. Women were strong enough for the most part to get along without the assistance of men; but their sexual natures drew men and women frequently to- gether, and pregnancies resulted. When a woman became far ad- vanced in pregnancy, she was less able to hunt food, and this was a handicap in primitive times. On the day of her delivery, she was for at least a short time utterly helpless and in deadly peril from the attacks of wild beasts. Then for years she was encumbered with her nursing babes and playing children, which the beasts were always seeking as their prey. These things made it impossible for her alone to get suflicient food, or to protect herself and her chil- dren. She needed the help either of a man or of another woman. Though man frequently wanted woman as a sex partner, this was not enough to make him wish to take care of her. But he also wanted her as a working partner or slave. He liked to hunt and fight, which she could not do as well as he; and he did not want to cultivate the soil or carry burdens, which she could do because she had more patience than he, though less strength. And so they became partners and divided between themselves the necessary labor of a primitive household. Man gave her and her children the pro- tection that they needed. She was his wife, she cared for their children, and did many things for him which otherwise he must have done for himself. It is probable, too, that even in those early 40 days, she made their cave, or shelter, a homelike place to which he was glad to come back. But because woman needed this arrangement more than man, he regarded her distinctly as his inferior, and treated her so. He was trained in fighting and had the weapons of w.ar. She was in his power; he could compel her to do whatever he wanted her to do. If she pleased him and was submissive to him, all went well. If he became angry with her, he could beat her or kill her or drive her out. Primitive man did not object to taking as his wife a woman who already had a child ; for though it meant another mouth to feed, it also meant another worker growing up. But after he took the woman, he regarded her as his property and was jealous regarding her. He demanded loyalty of her. He fought mortal combats with other men who approached her. If he won, he might kill his wife, too, unless she had shown that she was loyal to him. If he was killed, she might become the other man's wife, or be taken from him in turn by some one still stronger. The woman was sometimes jealous also of her husband, but she could not show it, for fear of angering him. He followed his de- sires and she had no power to prevent him, except by scolding. When he brought in another wife, she had to accept the situation, although she could still scold. But, on the other hand, she often asked him to get another wife, since it made her labor easier; it was like getting in a new probationer. If she wanted still further to better her condition, however, the most that she could do was to gain the favor of another man, and elope or let him take her from her husband by force. In these savage ways, many of the fundamental characteristics of men and women were developed. Man gained greater courage and a strong, impetuous temper, and the custom became fixed that he should defend his home. Woman developed something of modesty and reserve, of patience, tact, and quickness of mind, to avoid offend- ing the man on whom she depended. And even among the early human families, it is possible that in some cases the man and wo- man developed a sort of attachment, manifested by rough kindness and crude expressions of affection . Where food was plentiful, a powerful man might take several wives. On the contrary, where food was always scarce, several men might support one wife, among them. In these cases, the re- lation between husbands and wives was often as jealously guarded as where there was but one of each.. All of the wives were the property of the one man, and, in the second case, all of the hus- bands shared in the ownership of the one wife. No other man could touch either the many or the one, without the consent of the hus- bands. Wife stealing, or marriage by capture, was a common method of obtaining a wife, after family life had become well organized ; for early man, as a rule, had a horror of the marriage of ne^r relatives, and custom often commanded men to obtain their wives outside the tribe. A man, with a party of his friends to help him, would raid a distant village and carry oflf a young woman. In the fight some 41 Blight be killed or wounded on both sides. The girl's ijeoi)le, too, might get Tip a war party, and raid the man's village in turn, rescue the girl if possible, and perhaps carry off other women in addition. So the practice of wife stealing led to constant fighting and enmity between the little scattered communities, but it had to be done until a better way could be found. Finally men came upon the peaceful plan of buying their wives, just as they bartered with each other for food and other property. Women had proved their value as laborers. If they Avere no longer to be captured they must certainly be paid for, for their parents, who had raised them and trained them, would not let a valuable worker go for nothing. The price paid for the bride was sometimes very high, but it varied according to her abilities and attractiveness, dnd so she was proud to bring a good price. It also depended upon the circum- stances of both parties, and upon the scarcity of marriageable wo- men, compared with the number of men who wanted wives. Usually money or [iroperty was given to the father of the girl, sometimes on the installment plan, but in other cases the man paid for his bride by months or years of labor. The woman's consent was not considered necessary, though the man often attempted to gain it, and sometimes would not marry a girl who was unwilling. But she was -the property of her father, and absolutely under his control, and he could sell her, if he chose, to any man who wanted to buy her, unless she found a way of escape. She simply exchanged her father's authority for that of her husband, for woman was always under the control of some man. That was the custom ; neither man nor woman questioned it. A wife who had been captured, had no rights which her husband was bound to respect. While he was not likely to destroy valuable property by killing her, he could sell her if he chose, or he could lend Ler to his friends as a mark of hospitality. But if another man took her without his consent, that was a very different thing because it invaded his property rights. A wife who had been purchased, however, would iave such rights as her father was able and willing to secure for her. She became her husband's property only under these conditions, which were agreed upon by her father and her husband at the time of sale. In this way, woman's position was slowly improved as civilization advanced and a higher type of man developed. Consideration for woman began to be evident. Villages, tribes,, custom, and religion little by little set limits to man's power over her. The wealthier and more cultured men began to give presents to the husbands of their daughters, or to accept only small, nominal gifts from them. Their vanity, and desire to display their wealth, prompted them to do this, but it also gave them the opportunity to help their daughters. A woman was thus practically given in marriage, her self-respect was preserved, and her husband was put under some obligation to treat her more nearly as an equal. Later still, the husband, or the bride's father, made presents di- rectly to her, and so the custom arose of giving a dowry or wedding portion to the bride. In many nations, this remained under her 42 control, and became wholly hers if her husband died or divorced her. It thus protected her and her children against want, and it certainly increased her husband's respect for her. Marriage among people of rank, finally became a union more of two families, than of two individuals. It was commonly arranged by the parents of the young people, often without asking their con- sent. The great objects were to keep up the rank, and increase the wealth and power of both families. The material welfare of the couple was thus secui*ed, and legitimate children and their inherit- ance of the property were provided for. But love marriages be- came discredited by this custom, many marriages were very un- happy, and sex relations outside of marriage were more likely to result. As the human race developed, man's vanity and jealousy de- manded, not only that woman must be loyal to him after marriage, but that she must have been loyal to him from her birth — that she must have been chaste always. And this custom, once established, was as strictly enforced by parents, as the custom of woman's fidelity after marriage was by husbands. Death was the usual pen- alty for violating either of them. On the other hand, both before and after marriage, man was left to range as freely as he chose. This arrangement was unfair and unjust, but, as a step in develop- ment, if was a great advance. It was better to have purity in half of the family, than no purity at all. In some civilizations, a man could take as many wives as he had the means to support. Therefore, it became the custom for men of wealth to take more wives than they wanted, simply out of vanity and a desire to surpass their fellows. Where custom thus permitted polygamy it was olten the case that few of the common people were able to follow it, because of the trouble and expense of keeping several wives. But, on the other hand, several wives were often regarded as a good investment, for the sake of their labor. Again, as the sexes are about equal in numbers, in most parts of the world, some men had to go without wives when others took more than one. One wife was, therefore, the rule, and we find, in ancient literature, many beautiful stories of devoted couples, who nevertheless lived where polygamy was allowed. Even among wealthy men, polygamy fell much into disrepute, because of the jealousy and plotting among the several wives. Each desired to be first in the favor of their lord and master, and each was determined that her favorite son should become his heir. Among these half-brothers, too, hatred took the place of brotherly love, and many eastern empires fell to pieces because of fratricidal warfare in the royal families. King David had to put down a re- bellion led by his son Absalom, and years later another led by his son Adonijah, wha sought to seize the kingdom which David had promised to his youngest son, Solomon. These three sons were half- Ijrothers. The Old Testament is full of reference to the ancient forms of marriage. When six hundred young men of the tribe of Benjamin needed wives, the other tribes of Israel provided four hundred young women for tliem by capturing a city. The other two hundred 43 men were told to lie in wait outside another city, at a time when its young women were to hold one of their ceremonial dances, outside the walls. Each man then seized and carried off a girl. In the Book of Ruth, Boaz announced to the elders of Bethlehem that he had purchased Euth to be his wife. Jacob became a servant for seven years in order to purchase Rachel. But her father cheated him, and deceived him into marrying her older sister. Her father then gave him Rachel also, on his agreeing to serve seven years more for her. Abraham drove his slave woman, and the son she had borne him, into the desert, because of his wife's jealousy for her own son. In much later and more civilized times, King Solomon had seven hundred wives and three hundred concubines, to match the lavish splendor of his court and to impress his royal visitors. Survivals of these old customs are still approved by custom in many countries at the present day. Savage people continue to cap- ture or purchase their wives, and some tribes still lend their wives to strangers who are their guests. The dowry is used in many coun- tries of different grades of civilization. The harems of the Orient are the best modern examples of polygamy, approved by custom, while in Tibet one woman is still allowed to be the wife of several men. In many of the modern nations, marriages are still arranged by the parents for reasons of rank or property, especially among the royal families, though freedom of choice is increasing. Our present marriage ceremony contains traces of the former methods by which a wife was secured. The wedding gifts repre- sent the dowry, and the earlier purchase of the bride from her father, who now gives her away. The best man represents the friends who helped a man capture his wife by force, and the wed- ding journey is the flight of the man with his stolen bride. Custom finally gave its approval to the marriage of one man to one woman, as being the type that would best provide for the hap- piness of both, for the welfare and training of their children, and for the progress of the race. And it was this type of marriage which was recognized by the Christian religion. The early Christians formed perhaps the purest communities that the world has ever seen, though set in the melting pot of the degenerating Roman Empire. During the first centuries after Christ, while Rome rode drunkenly to her fall, the early Church Fathers perfected the doctrine that marriage was a sacrament, a lifelong holy union of two lives, to be entered into by the man as by the woman, thoughtfully and under the blessing of the Church. And this ideal of marriage was very carefully guarded by Church laws. When the Roman Empire fell, civilized society broke in pieces. Learning, culture, virtue, law — all seemed lost. The worst vices of Roman life spread everywhere. Our barbarian ancestors, the tribes of Northern and Central Europe, who had overthrown the Empire, were contaminated. But the institution of marriage was not wholly lost. Since those dark days, fourteen hundred ytears ago and later, modern society and the modern nations have grown up. The an- cient customs have been slowly modified by such great events and 44 social movements as the Crusades, the discovery of printing, the translation of the Bible into the languages of the common people, the Reformation, the rise of democratic government, the modern industrial development, and the growth of a more liberal attitude toward women. Today, in this country, we believe that men and women should be drawn together in marriage by mutual affection; that, they should choose each other without compulsion or influence, and that fidelity and affection ought to continue until death. This ideal of marriage is publicly approved by custom, the law, and the Church. This is a great achievement over the ancient standards. It repre- sents an enormous advance in the elevation and greater security of woman's position, and a corresponding softening of man's treat- ment of her. And this change in the rock-bound customs of the race, it has taken thousands of years to bring to pass. But while marriage has constantly been developing in woman's favor through all the ages, its deadly enemy, prostitution, has also been growing. As far back as when custom first demanded chas- tity of women, we learn that there were those who, for one reason or another, were willing to eat the bread of shame and dishonor, and be despised by their own kind. And, always, custom let men purchase honorably what women dishonorably bartered. One great civilization after another developed the most excessive and degrading immorality, after rising to great power and wealth. It was so in Egypt and Babylon, Greece and Rome. Many pagan religions also stimulated sex immorality, because the religious rites at some temples included prostitution. Prostitution has always sought the cities and larger towns. It found a better market there, it could advertise itelf more boldly, and it could better give secrecy to its patrons, when that was neces- sary to preserve their reputations in society. It has also been present, however, in the small country towns and villages. Of recent years it developed commercial aspects on a large scale, both in Europe and America. Our people were amazed and indig- nant to find out that such a nefarious business had grown up in this country, and had acquired such cold-blooded brutality. It was learned that large numbers of innocent girls had been lured into houses of prostitution by deceit and false pretenses, and forced into an evil life against their will, in addition to those who had entered such a life of their own accord. It was learned, too, that girls were transported from one city to another, according as the demand for their services varied. This business was carried on by the most unscrupulous men and women, to whom money was more than ruined lives. It was con- ducted like any other business, to increase its profits. For the money paid by men has not commonly enriched the prostitutes, but the men and women who controlled them. In a great many places, the police were corrupted bv bribery to allow unlawful conduct, and even men in high authority, and wealthy real estate owners were parties to the shameful business. The development of modern industry has increased the business of prostitution. Since the invention of the steam engine and fac- 45 tory machinery, a much larger part of the population has been drawn into the cities from the farms. The results have been over- crowded living and working conditions ; people are forced into each other's society, children are brought up among bad moral condi- tions, and temptations are multiplied for both men and women. In these crowded districts, opportunities for healthful recreation have been wanting. Low wages have produced overwork, and the bodily and mental fatigue which weaken moral resistance ; and actual want has made any means of income seem, to some people, justified. Fatigue and monotony of life have made alcoholic in- dulgence common, and alcohol increases immorality, because it diminishes the finer sensibilities and lessens self-control. In such environments, especially, commercialized vice has procured its young girl victims ; for it has always been true, that the daughters of the poor have been sacrificed to the sons of the rich. The National Government, and many State and city governments have, by law, checked many of the criminal activities connected with prostitution, but the business still exists under cover, and has constantly to be watched. When the training camps for our new army were established, preparations were made for increasing the number of prostitutes in nearby towns. Some of these attempts were temporarily successful, but, thanks to the splendid efforts of the Government, conditions in these towns have now been made even better than they were before we went to war. This work of the Government will be considered in the next lecture. Prostitution, with all its enormous mass of attendant evils, con- tinues to exist only by favor of the old familiar custom — man may, but women must not. It is, therefore, most encouraging to recognize that this custom itself is being slowly changed for the better. It has, like marriage, been modified in woman's favor, and this is due largely to the influence of the Hebrew and Christian religions. In the midst of magnificent but corrupting neighbors, the ancient Hebrew religion stood as the one great world influence for virtue. From the days of the Ten Commandments and the teachings of the Prophets, it has held up the ideal of man's fidelity to his wife after marriage. And this ideal has slowly won acceptance among large groups of people. It is strongly approved in this country today by most intelligent persons, and there is a distinct sentiment in its favor among even the more ignorant men. But the idea that men ought to be chaste before marriage, was a later development, and has been built into custom very slowly. In city life particularly, this idea has been accepted very slowly, except where sturdy, upright fathers taught their sons to hate baseness. The proverbs, "boys will be boys," and "young men must sow their wild oats," are even yet commonly current, but are rapidly becoming discredited among intelligent, self-respecting men. This new idea of chastity before marriage has been powerfully opposed by the ancient custom, which men had inherited, and which they chose to believe was right, because it was the custom and always had been thought right, and because it agreed with their desires. But when its rightness began to be seriously questioned, and men were called upon to defend it, they asserted what many of 46 them believed to be true, that sex relations were absolutely neces- sary for men, tor the sake of their health, because of their strong passions. This doctrine of sex necessity became a strong defense for the old custom, for many years; but it, too, is falling now. The ideas on which it rested have changed ; for the wide experience, of fine types of men, has sliown that sexual intercourse is not neces- sary for health, and that unmarried men can and do live virtuously, in the full vigor of manhood, when they determine to do so. While sex immorality among men had long been fought by moral leaders, it was easily condoned by many people, because of the old custom. It was held to be a commonplace moral offense — a sin that would be easily blotted out later by the man's repentance. But so- ciety has learned increasingly of the ravages of the venereal diseases, and of their monstrous results among innocent women and children, which no repentance can avert, and n« word of forgiveness cure. And society is developing a nobler conception of human life, and is more aware of its spiritual possibilities. Parents, too, have begun to see that they have not helped matters, by refusing to show their children where the right path lay; they see that they have allowed them to be trained according to the ancient custom. They are more willing to teach their children, also, because the scientific study of the life of plants and animals, in the schools, has helped to remove the old belief that sex is un- clean and shameful. This unfortunate belief was fostered by the ancient Hebrew religion, and was taught by the early Christian Church, which did not yet fully apprehend the larger meaning of sex in the spiritual life of mankind. WomaDi's position has been very greatly elevated since our Revo- lutionary War, by the progress of ideals of self-government among us, and among other nations. Where man had ceased to bow to "the divine right of kings," it was the next logical step that woman, too, should strive to win greater freedom. She was admitted to educational advantages; these proved her powers of intellect, and the needs of modern life have given her the opportunity to use her trained abilities. Her great services, and her fineness of character have developed a higher regard and respect for her on the part of men, which her work in this war is greatly increasing. Men are prejudiced — that is, under the control of custom. And yet, when they understand a situation, they want to see a square deal given. They have believed in the old ideas, and followed the ancient custom, but they are becoming better educated. They are being convinced that women have not had a square deal in mar- riage. They see that women should have every chance to marry clean men and bear healthy children. And when the power of the old custom is broken, and they believe that they can keep pure, then they will keep pure. There will grow up among them, as Dr. Edith H. Hooker says, 'the new tradition of continence as opposed to the old tradition of sex necessity." In all of these ways, the, ancient custom is slowly but surely de- veloping in accordance with our finest conception — that men and women alike should bring unsullied lives and pure hearts to the marriage altar, and live in devoted 'affection ever after. 47 For the future, we have the greatest ground for encouragement The public conscience has been awakened by such great leaders as President Charles W. Eliot, of Harvard University; Miss Jane Adams, of Hull House, Chicago, and many other brave and far-see- ing men and women. All of the great organizations, that are work- ing for humanity and a better social order, are back of the work for better morals. And as the old custom is being more and more broken down^ and the problems of immorality and venereal disease are becoming better understood, the leading men and women all over the country are coming to give the full weight of their influ- ence to advancing the standards of clean living. There are also organizations, actively at work in this country, wliose sole business it is to promote the solution of these great moral problems. As long ago as 1902, an International Congress, attended by representatives from practically every civilized country, was held in Brussels, Belgium, for the purpose of studying the methods of preventing the venereal diseases. In the words of the late Dr. Prince A. Morrow, who represented this country at the congress : 'Especial recognition was given to the fact that moral as well as medical issues were involved in the problem of prevention, and the congress recommended that societies should be organized in all countries for the study of the best means of every order, moral, social, legislative, as well as medical, to be employed In the prophylaxis of these diseases." There had been some such organizations in this country since J 886. Dr. Morrow organized more effective work, and, by his prominence as a leading genito-urinary surgeon of New York City, as well as by his tact and wisdom, was able greatly to advance the social hygiene movement in this country. In 1914, the society which he organized, joined with another in forming the American Social Hygiene Association. Its president this year (1919), is Dr, William H.> Welch, of the Medical Department of .Tohns Hopkins University, formerly president of the American Medical Associa- tion, and now colonel on the staff of the Surgeon General of the Army. Its field of work is thus stated by its secretary, Dr. William F. Snow, now lieutenant colonel on the staff of the Surgeon General of the Army: "The American Social Hygiene Association is engaged in pro- moting a nation-wide' movement for the conservation of human life, efficiency, and morality. Sex education, the suppression of • prostitution, and the reduction of venereal diseases are among its distinctive objects. The promotion of these objects brings the Association into constructive relations with other agencies in a campaign for wider knowledge, better homes, and better conditions for work and recreation." Dr. E. L. Keyes, of New York City, an authority on the venereal diseases, and now lieutenant colonel in the Medical Department of the Army, has well stated the great objects to be attained by the work of such national, state, and city organizations: "The elimination of disease and prostitution cannot he attained solely by the enforced registration of venereal diseases, the raiding of disorderly houses, and the enactment of laws against procura- tion and solicitation. Such police and legislative activity achieves 48 temporary or local ends. But reform of this sort rapidly bums Itself out and the police remain singularly human in their weak- ness. The real strength of the social hygiene movement of today lies In the cooperative activities of the great religious, social, and educational organizations. They are striking the evil at its source ; not by driving the prostitute into the street and then out of it again, but by preventing our young girls from becoming prosti- tutes, and our young men from preying upon them. This they hope to achieve by informing the mind so as to banish prurient curi- osity, by diverting the imagination to emotions joyous apd clean, by exercising the body in playgrounds and dance halls that are safe, and above all by inspiring the soul with the highest religious and famUy and civic ideals." The Oregon Social Hygiene Society has developed state-.wide edji- cational work in sex hygiene and the prevention of the venereal disease in a particularly effective way. The number of such state societies and the effectiveness of their work is slowly increasing. Their educational work is justified by such a statement as that made by Professor W. T. Sedgwick, in his presidential address before the American Public Health Association a few years ago: "We shall doubtless learn regarding alcohol and venereal disease that it is easier to prevent habits than to conquer appetites." This whole work has been very greatly advanced by the passage of a law in Congress, July, 1918, appropriating funds for combating venereal diseases, and creating a Division of Venereal Diseases in the United States Public Health Service. This new Division of Venereal Diseases has two main sections — medical and educational, and is working to standardize methods of venereal disease control all over the country. As trained nurses, you will form a most valuable part of public opinion, in this great movement. You have learned something of the serious aspects of the sex problem. You have seen the evil effects of the double standard of morals. You realize that devotion to the highest moral ideals and standards of conduct can change that old, old custom. You will have rare opportunities to meet many women, some of them of great influence. Your work will bring you into the most intimate relations with them, and will often lead to strong and lasting friendship. There will be times when you can proi»erly tell them what you know about this problem, and you should endeavor to interest them in it. They, in turn, will arouse their husbands and their women friends to active interest. And so you will help to build up the strong public opinion, which is rapidly growiAg in our country, and which will finally wipe out of existence the double standard of morals. For, the power of that ancient custom, that savage, brutish custom, must be completely overthrown and broken. Just as the earth has shaken with the supreme struggle of the peoples to over- throw the ancient, outgrown, evil power of kings, and have done with it forever. This is a day of incomparable service. You are to have a part in it. 49 LECTUEE V. I. Introduction. Up to April 6, 1917, there were no accurate data available from any source as to the prevalence of syphilis and gonorrhoea in the civilian communities of the United States. Inasmuch as the men in the army and navy were under direct supervision, we had defi- nite information as to the prevalence of disease in this group. For example, in the regular army for the three years previous to the breaking out of the war, the figures, as reported by the Surgeon General of the Army, were, respectively, 84, 90, and 88 per 1000. Inasmuch as soldiers and sailors are a specialized group, not leading a normal family life, it was supposed that venereal disease was more common among them than in the community at large. In certain penal institutions accurate statistics for limited groups have been compiled. For syphilis, among 500 cases at the Ee- formatory for Women at Framingham, Massachusetts, 44 per cent had positive Wassermann reactions, while 10 per cent were doubtful. At the New York State Eeformatory for Women, in 440 cases, 48 per cent gave positive reactions. At Auburn prison, the percentage among women was 33. In the Department of Correction of New York City for the year 1916, the percentage was 55.83. In each of these cases a very high per cent of these women were prostitutes. In the report of the Baltimore Vice Commission, where 289 prosti- tutes were examined, the percentage rose to 63.7. Among men in penal institutions, fewer examinations have been made. In Auburn prison, 16 per cent of the men, and in Sing Sing prison, according to Dr. Glueck, of 940 cases admitted, 18.9 per cent gave a one, two, three or four plus Wassermann reaction, while but 10.3 per cent gave a four plus Wassermann reaction. As to gonorrhoea, at the Massachusetts Eeformatory, 75 per cent of the total population had gonorrhoeal infection. This was based on bacteriological evidence as well as on clinical symptoms. At the New York State Eeformatory, based on the complement fixation test, 73 per cent had gonorrhoea. According to the statistics of the Baltimore Vice Commission, 92.1 per cent of the 266 prostitutes examined had gonorrhoea. At Framingham, alcoholic women who had not been arrested for any offense against chastity showed 52 per cent. These percentages of venereal disease in the prison population have only recently been available, and the ordinary person to whose notice they came would naturally say that here, too, we could look for an abnormally high percentage. It therefore came with a great shock to the community at large when the results of the selective draft showed for certain weeks a percentage of venereal disease larger than in the army and navy, and, for some specific weeks, larger than the percentage found among Inen in penal institutions. II. The Situation in the Aemt. The figures given out early in 1918 in the reports published by the Committee for Combating Venereal Disease of the General Medical Board of the Council of National Defense give the annual rate for venereal disease per 1000 men in the National Army, com- 50 puted upon the returns of weekly reports^that is to say, if the rate given for any one week were maintained for one year — the results would be as indicated. The figures are as follows: 1917 For week ending September 21 194 " 28 388 " . " " October 5 277 12 205 " " " 19 146 ** ** " ** 26 * . 139 ' November 2....... 136 " " " " 9 115 " " " " 16 95 " " " " 23 69 " SO 104 December 7 80 The week ending September 28 marks the entry of the first large increment of drafted men into the army, and the highest ratio of venereal disease incidence ever reported in U. S. troops is recorded in the National Army figures for this week. The annual rate of 388 cases per 1000 men reported for the week ending September 28 means that one man infected with venereal disease was found in every 134 men examined during this week. This high ratio may be explained by the large number of cases brought into the army dur- ing this week under the new policy of accepting infected men for military service, and also by the fact that many cases, coming in during the preceding weeks, when the cantonments were first opened, and which had not been discovered or reported theretofore, were undoubtedly included in the report for this week. As the drafted men ^reached camp and came under military control, the ratios of those newly infected naturally , fell. In examining the records of the individual camps, we find that the effect on the percentages of the entrance to the camp of new batches of draft men is remarkable, the figures in every instance immediately rising. The medical authorities of the United States Army and Navy have had the great advantage of watching the treatment of the problem of venereal disease in the armies of the Allies. Great bodies of trooi^s have been disqualified for service by venereal disease. Vari- ous estimates have been given as to the number in hospitals 'at one time. It was said that more men were incapacitated by venereal disease than by bullets, and that the number sometimes amounted to from three to six army divisions. With the English troops, prophylactic measures were not used, public sentiment being strongly opposed on the ground that this was a first step toward the licensing or regulation of vice. The fact that the percentage of diseases was highest in the Canadian and Australian forces was thought possibly to be due to their great dis- tance from home and the fact that on their furloughs it was impos- sible for them to spend their time with friends and relatives as could the French or English troops. Therefore, they were more likely to resort to the society of diseased women for recreation. The Surgeon General of our Army, immediately on the assembling of the National Army, the National Guard and the Kegular Army divisions, adopted stringent measures for dealing with venereal dis- 51 eases in the various camps and cantonments.' Every man was sub- jected to careful examination. Isolation hospitals were provided for those who were in an infectious stage. Orders were given that no man who was in danger of imparting disease could go with his company overseas. Moreover, he was deprived of pay while in the isolation hospital. Prophylactic clinics were established inside the camps, and every man who exposed himself to infection was re- quired to report immediately upon his return to camp. If he com- plied with this regulation and received treatment, no further action was taken. This was to encourage as many as possible to report, not to encourage them, however, to indulge. If they failed to re- port and a venereal disease developed, they were subject to court- martial. This course has given rise to some criticism, on the ground that the punishment comes only to the man who develops the disease and not to the man who exposes himself to infection. The course taken by the medical authorities is the only one apparently which can be used with any assurance of successful control. It is obvious that men would not go to the prophylactic clinics if they were to be punished for indulging. The measure is one of practical necessity, but, as will be shown later, the early treatment is by no means the whole story. III. The Situation in the Navy. In the Navy, measures similar to those taken in the camps were put into efiEect. It was for awhile the practice in the Navy to give to every sailor going on leave what was called a "preventive packet,'^ which was to be used by him provided he ran the risk of venereal infection. This never was a satisfactory method. Sailors lost their packets, used them carelessly or traded them oflf. Secretary Daniels, in a letter to all commanding officers in 1915, said: "The spectacle of an officer or hospital steward calling up boys in, their teens as they are going on leave and handing over these •preventive packets' is abhorrent to me. It is equivalent to the government advising these boys that it is right and proper for them to Indulge in an evil which perverts their morals. I would not permit a youth in whom I was interested to enlist in a service that would thus give virtual approval to disobeying the teachings ot his parents and the dictates of the highest mora! code. You, may say that the ideal raised is too high and we need not expect young men, to live up to the ideal of continence. If so, I cannot agree. It is a duty we cannot shirk to point to the true ideal, to chastity, to a single standard of morals for men and women." At the time there was considerable misunderstanding of Secretary Daniels' attitude. It was interpreted to mean that he was not will- ing to have prophylactic treatment applied to men in the Navy. This was not true. He recognized, first, the unwisdom of assum- ing that all sailors on shore leave would with certainty visit loose women. He recognized the ineffectiveness of self-treatment. He believed that there would be a large response to an attitude on his part which demanded and expected self-control of the men, but he wns quire willing to and did make adequate provision for the treat- ment of those who were weak enough to fall when tempted. The measures taken for the treatment of the disease in the Navy are accordingly well organized and efficient. 52 IV. The Public Health Sbevicb. The medical authorities of the Army take care of the soldiers while they are in the camp. To deal with them outside the limits of the cantonment or divisional camps, the U. S. Public Health Service is the proper agency. The Selective Draft Law passed by Congress on April 28, 1917, under Section 12, gave the President the power to prohibit the sale of alcohol in or near military camps. Section 13 authorized the Secretary of War to do everything deemed by him necessary to prohibit "the keeping or setting up of houses of ill-fame, brothels or bawdy houses within five miles of any mili- tary camp, station, fort, post, cantonment, training or mobilization place being used for military purposes by the United States." A broad interpretation of the powers given to the President and the Secretary of War by these Sections has made it possible to take radical steps in the extra-cantonment zones (that is, the zones outside the military camps), and even to extend them where com- munities adjacent to the zones were not complying with the law. The Secretary of War and the Secretary of the Navy have power to make a regulation, if it seems necessary, prohibiting soldiers and sailors from visiting any community where conditions are found to be bad. This power is l^eing used effectively as a club. It is plain that no community would like to be publicly stigmatized as an unsafe place for a soldier or sailor. Aside from any moral sig- nificance, it is bad for business. Secretary Baker, immediately upon the grant of these regulative powers, wrote the governors of all the States requesting their active cooperation, through all appropriate means. The Surgeon General of the U, S. Public Health Service took steps also to secure the co- operation of all State boards of health for the same purpose. In response to the request of the Federal authorities, State legis- lators and municipal law-makers are rapidly passing measures in support of the Government's programme. In securing the passage of these measures, representatives of the Army, Navy, and Public Health Service have cooperated with State boards of health and approved organizations. In the Public Health Reports of May 24, 1918, issued by the U. S. Public Health Service, an account is given of the progress in venereal disease control. The work was stimulated by an offer of the Surgeon General of the Public Health Service to appoint in each State an oificer to assume charge of ven- ereal disease control, in cooperation with the State board of health. When this offer was accepted the salary was to be paid by the State and Federal Governments jointly, but the officer wore the uniform of the Public Health Service. In view of the demonstrated fact that civilian communities contained a higher percentage of persons infected by venereal disease than either the Army or the Navy, it is evident that it was of the utmost importance that the civilian communities should be cleaned up. It was important that this should happen not only in the extra-cantonment zones where there was danger of their infection while on leave, but also in the country at large from which the drafted men continued to be drawn. The situation among the industrial population was also recog- nized as second only in importance, inasmuch as upon the indus- 58 trial community must depend the production of munitions of war and supplies of all sorts. Incapacity from venereal disease can be as little tolerated among them as among the soldiers and sailors themselves. The Surgeons General of the Army and Navy and of the Public Health Service urged that in each State a bureau of venereal dis- ease should be created in the State Health Department and that work should be undertaken along lines definitely laid down. These were as follows: "1. Notification of cases of venereal disease to the health authorities. 2. Repressive measures, looking toward isolation and treat- ment in detention hospitals of infected persons who are unable or unwilling to take measures to prevent their becoming a menace to others ; also measures for the suppression of prostitution. 3. Educational measures, including measures for informing the general public as well as infected individuals in regard to the nature and manner of spread of venereal diseases and the steps that should be taken to combat them. 4. Extension of facilities for early diagnosis and treatment. State to be systematically divided and organized for this purpose with representatives of the division of venereal disease in charge of the work in each area. The time is opportune for immediate active cooperation between the Public Health Service and state departments of health in carrying out all measures mentiooed under the four preceding heads. It is believed, however, that the whole programme can be most advantageously carried out if special stress is laid upon . the last feature, because, with the organization of each state into districts and the establishment of venereal clinics in strategic area*!, the machinery necessary for the entire plan will auto- matically be set in motion. Although the operation of this machinery will at first undoubtedly be imperfect, the following twofold results should be immediately accomplished : First. Establishment of centers for carrying out workable regu- lations on reporting and the institution of repressive and educa- tional measures appropriate to particular communities. Second. Immediate reduction in venereal-disease foci, with a marked decrea.se in the prevalence of such diseases in both the civilian and military population. The first aim, therefore, of the State Bureau and Division of Venereal Diseases should be to establish a chain of venereal- disease clinics. The operation of these clinics should be stand- ardized according to methods to be presented and agreed upon at the State health officers' conference in June, but in the mean- time it is not advisable to await the perfection of all the details before starting the work. An emergency exists and the clinics should be (^ened without delay. One small clinic in a populous community is worth more than a ton of literature distributed broadcast over the entire country." Acting independently or in response to the request of the Sur- geons General, six States : Colorado, Indiana, Maryland, New Jer- sey, Ohio and Vermont, soon passed notification laws making it incumbent upon physicians to report venereal diseases by name in precisely the same fashion as other contagious diseases are reported. In thirty-six other States and one Territory (Hawaii) physicians are required to report cases of venereal disease by serial number. Out of these thirty-six States, twenty-five will report the case by name if the patient fails to comply with the regulations in regard 54 to treatment. In thirty-two States and one Territory it is further provided that if a patient is in a dangerous state and likely to be a menace to the general public health, he may be isolated until the infectious stage is passed. Thirteen States have established bureaus within their public health departments for the control of venereal disease. Forty-two States have accepted the offer of the U. S. Public Health Service to place a medical officer at their service. Twenty- five States have established venereal disease clinics. The number of States adopting such measures has increased so rapidly that by now there may be additions to the list. In many large cities near cantonments prophylactic stations have been established, usually near the railroad stations through which most of the soldiers or sailors enter the city. These stations are for the exclusive use of soldiers and sailors. To assist, how- ever, in the cleaning up of the extra-cantonment zones as a measure of protection to the soldiers, twenty-six venereal disease clinics, operated by the United States Public Health Service in coopera- tion with the American Bed Cross, have been established. To these civilian clinics women social workers have been assigned for the special purpose of following up women who report once and then fail to return for the prescribed treatment. These social workers not only trace the women who fail to report, but lend their help in re-establishing those prostitutes who desire to obtain work and lead a decent life. In many of the laws adopted by the various States a provision has been inserted for the compulsory examination of suspected per- sons. The wording of the law makes this examination applicable to both men and women. In the case of the New York law, for in- stance, it becomes obligatory for any man or woman arrested for any offense connected with sexual immorality to submit to such examination, and, if found to be diseased, to be quarantined for treatment. Inasmuch as a far greater number of women than men are arrested and convicted in our cities for such offenses, fears have already been expressed that this was the beginning of a virtual licensing or state regulation of prostitution. If it were true that the health authorities had in view simply holding diseased prostitutes for the short period of time necessary in most cases to cure open lesions and then discharging them to go back to their old life, with the attendant dangers of a speedy re- newal of the contagious conditions, there might be ground for criti- cism. Such, however, is not the case. These laws are explicit in stating that no certificate of freedom from disease is to be given to any individual. The position of the Surgeon General of the Public Health Section is shovm by the following extract from a letter dated May 27, 1918, signed by Surgeon General Rupert Blue. Speaking of the fear entertained in some quarters that our women would believe "that the Federal plan for the control of venereal disease embodied steps 55 looking toward the regulation of prostitution rather than its elimi- nation," the Surgeon General goes on to say: "I take pleasure in sending you herewith three circular letters , which should certainly convince the most skeptical that the Gov- ernment is (1) taking every precaution that prostitutes shall under no circumstances be given a 'clean bill of health,' (2) main- taining that the institution oi prostitiition, either clandestine or open, shall be fought to a finish, (3) treating men who on account of venerea] disease are a menace to the public health in exactly the same way as women. You are at liberty to use these enclo- sures and this letter in any way you see fit, and you can rest assured that the only reason the Public Health Service does not shut up in hospital or reformatory every one of the diseased prostitutes (either male or female) who are brought to Govern- ment Clinics for treatment is solely because facilities for such isolation are not always available. The Government now operates 24 such clinics in extra-cantoument zones. In two of these arrangements have either been made or are in the process of ■completion whereby these persons can be kept under definite con- trol in institutions wherever such control is necessary to protect the health and morals of the community. Lack of funds for subsistence constitutes the chief obstacle in the rapid extension of this phase of the work. Besides the institutional control in these extra-cantonment areas it is a part of the plan to organize the states so tliat prostitutes shall not be driven from one area to another, but shall be confined in reformatory institutions or hos- pitals according to the special indication." The three letters referred to are, first, a circular letter to medi- cal officers in charge of extra cantonment zones. This letter reads in part as follows: "The attention of the Bureau has been called to the practice in some extra-cantonment zones of issuing certificates to employees of food establishments, barber shops, etc., upon which appears a statement that the person named has been examined and found free from communicable diseases. In some instances this physical examination has included the microscopic examination of vaginal smears for the detection of gonorrhoea in female employees. It has been intimated that these certificates have been exploited to show freedom from venereal disease." "In view of the above, ofl3cers in charge of Service operations in extra-cantonment zones are hereby directed to discontinue the use of any form of certificate stating or indicating a person is free from communicable diseases. It is suggested that a statement be made that upon physical examination the person named is permitted to continue service in food establishments." The two other letters were sent out on his own responsibility by an officer of the service in one of the extra-cantonment zones. The first letter, addressed to men of draft age whose registration papers show they have venereal disease, but who have not yet been called to the colors and are therefore not under the supervision of the Army and Navy, follows : "Tour registration papers show that you admit, claim, or were found to be infected with gonorrhoea, syphilis, chancroid. Under existing law, yoxi must either — (1) Prove to the Board of Health that you are under regular treatment by a registered physician, or at a clinic; or (2) Agree to be so treated; or (3) Be isolated under direction of the Board of Health in order that you may be treated. 56 You are hereby notified to appear at the clinic at the Medical College, at o'clock, a. m., p. m., on , 1918, and to bring with you the necessary proof in case you claim to come under paragraph (1), or to make arrangements to be classified under paragraph (2) or (3). As satisfactory evidence that you are being treated we must have a written statement from your physician that you are carry- ing out regularly and consistently his instructions as to medical treatment. All of our records are kept as confidential, unless we are obliged to make them public in order to enforce the law. A failure to comply with this notice will submit you to the pos- sibility of being brought before the Recorder's Court." The second letter, addressed to known prostitutes in the city, is self-e:5:planatory : "1. On April 17th I requested the City Government to furnish me with a list of the known prostitutes in , with their addresses. 2. In a letter dated April 19th, the Police furnished a list of names of women who had 'formerly resided within the restricted district' which was abolished in August, 1017, and stated that these women have been seen on our streets recently. 3. In view of the fact that your name is on this list, you are subject to examination under paragraph 3 of the Venereal Ordi- nance passed by the local Board of Health, April 18, 1918, and you are hereby notified to appear at the U. S. Government Clinic at at a. m., p. m., 1918, for examination. 4. If you fail to report as instructed, it will be necessary for me to send an inspector to take you to Board of Health Hospital No for isolation during the examination. 5. For your information I will state that the Federal Govern- ment and the local Board of Health consider that the repressidn of prostitution is an urgent public health measure and that I am ordered by the Federal Government to cooperate with the State and the local authorities in repressing it. 6. Accordingly, I will leave nothing undone that is legally within my power to stamp out prostitution, not only from this City and County, but also from the entire State of 7. No system of certification will be recognized. Prostitutes who are found infected will be isolated and will be kept isolated. Prostitutes who are not found on first examination to be Infected will be watched closely and will be re-examined as frequently as feasible. 8. You can state positively to all prostitutes whom you know that there will be no let-up in this matter, but that PROSTITU- TION MUST AND SHALL BE REPRESSED." The danger that officials will deal solely with the women and pass by the men who are infected can only be overcome through public opinion brought to bear upon officials responsible for execut- ing the law. To shape this public opinion and in many instances to aid in enforcing- the law, is part of the duty of the women of the country. The impression which , is slowly but surely being made upon the people of the United States as to the urgency of permanent con- structive work along social hygiene lines has been shown most sig- nificantly in the passage on July 9, 1918, of what is known as the Chamberlain-Kahn Bill, which went through both houses of Con- gress with almost no discussion or dissent. 57 This bill provides for an Interdepartmental Social Hygiene Board, "to consist of the Secretary of War, the Secretary of the Navy, and the Secretary of the Treasury, as ex-olBcio member^; and of the Surgeon General of the Army, the Surgeon General of the Navy, and the Surgeon General of the Public Health Service, or of per- sons whom the Secretaries of the Army, Navy, and Treasury may, respectively, designate." It provides furthermore for the establish- ment of a Division of Venereal Disease in the Bureau of the Public Health Service, to be under the charge of an Assistant Surgeon General of the Public Health Service. The Interdepartmental Board's chief duties will be the expendi- ture of the funds appropriated by this Act. These funds include the sum of |l,000,000 to be paid to the States annually for two fiscal years for the use of their respective boards or departments of health for the prevention, control and treatment of venereal disease. This will be apportioned the first year according to population. The second year the allotment is to be so conditioned that for each dollar paid to any State, the State shall appropriate an equal amount. Another million dollars is to be used under the joint direction of the Secretary of War and the Secretary of the Navy for such gen- eral measures as will promote efficiency in carrying out the pur- poses of this Act. Three hundred thousand dollars is to go to universities and col- leges selected by the Interdepartmental Board to promote scientific research, "for the purpose of discovering and developing more effec- tive educational measures in the prevention of venereal diseases, and for the purpose of sociological and psychological research re- lated thereto." Another one hundred thousand dollars goes to educational in- stitutions for discovering more effective medical measures in the prevention and treatment of venereal diseases, while two hundred thousand dollars is to be used for defraying the expenses of the Division of Venereal Diseases. ^ It will thus be seen that a large sum of money will be available for Federal and State use in combating disease — ^both on the edu- cational side and on the side of treatment. Assistant Surgeon General C. C. Pierce, U. S. Public Health Ser- vice ; Colonel William F. Snow, M. C, TJ. S. Army, and Lieutenant Commander J. R. Phelps, U. S. Navy, have been appointed by the Secretary of the Treasury, the Secretary of War, and the Secretary of the Navy, respectively, to represent the surgeons general on the Interdepartmental Board, and Assistant Surgeon General Pierce has been placed in charge of the Division of Venereal Diseases. Under an order issued by the President, all health activities for civilians are placed under the general direction of the Public Health Service. These new agencies have only begun their task of organization. When fully developed, they wiU undoubtedly constitute the coordi- nating medium for all social hygiene work in the United States. 58 V. Moral Issues. While the primary dutj of the Army and Navy ofiScials is to deal with the disease as a danger to the efficiency of the fighting forces, and that of the Public Health Service is primarily to treat the ques- tion as one of public health, yet all of these officials not only feel but have expressed themselves as concerned with the moral issues involved. Lieutenant Colonel William F. Snow, of the Surgeon General's office, in charge of the Venereal Disease Section, who was before the war general secretary of the American Social Hygiene Association, and before that Professor of Hygiene and Public Health at Leland Stanford University, has well said that just as the public health official who is attempting to eradicate yellow fever or malaria gives his attention not only to the cure of the disease, but to getting rid of the swamps which breed the mosquitoes which are the disease carriers, so, in dealing with venereal disease, we must consider the sources of the infection which lie very largely in irregular sexual relations. General Gorgas, Surgeon General of the Army, in an address be- fore the American Public Health Association, comparing the meth- ods employed in the elimination of yellow fever with those which should be employed looking toward the elimination of venereal dis- ease, says : "For military purposes and the purposes of this war, it would be obviously unwise to wait for any slow process of education. We have to do as we did in yellow fever, — load our gun as we would a shotgun and fire at everything in sight; and such are the plans that we are evolving in the army and around our military camps, appealing for every possible assistance that the civil population in contact with the army can give us in this direc- tion, and at the same time doing everything that we can do in the army towards individual prophylaxis of the men. Such a possi- bility as educating the population is not a vague dream. Customs and manners can be controlled almost absolutely by education." The quotation from Secretary Daniels' letter of 1915 shows his stand-in the matter. Secretary Baker, in a letter written August 10, 1917, to mayors of cities, says in regard to restricted districts : "The only practical policy which presents itself in relation to this problem is a pojicy of absolute repression." He says in a letter to the governors of the States : "Our responsibility in this matter is not open to question. We cannot allow these young men, most of whom will have been drafted to service, to be surrounded by a vicious and demoralizing environment, nor can we leave anything undone which will protect them from unhealthy Influences and crude forms of temptation." It is a most encouraging fact that Government authorities are recognizing that the only absolutely certain method for the preven- tion of venereal disease is to avoid the source of contamination. Just so long as the institution of prostitution remains will it be impossible to completely stamp out syphilis and gonorrhea. The experience of European countries has shown conchisively that no 59 method of segregation, licensing, registration or examination has succeeded in even partially effecting this. The English Eoyal Com- mission on Venereal Diseases, in its recent report, says : "If venereal diseases are to be stamped out, it will be necessary not only to provide the medical means of combating them, but to raise the moral standards and practice of the community as a whole. The instruction given should be based upon moral princi- ples and spiritual considerations, and should by no means be con- centrated on the physical consequences of immoral conduct." Prostitution has flourished largely as the result of a more or less general belief in the physical necessity for men of sex intercourse outside of the marriage tie. The falsity of this idea is being grad- ually recognized and is now publicly advanced by physicians of the Iiighest standing. A statement to the effect that continence and chastity are not incompatible with the highest physical and intel- lectual development has been approved by the American Medical Association and signed by hundreds of leading physicians from all over the United States. Following out the belief on the part of the authorities that the only safety for the Army and Navy lies in self-control and the ab- solute avoidance of all chances of infection, a Social Hygiene Di- vision has been created in the War and Navy Departments' Com- mission on Training Camp Activities. This Division consists of three sections. The section on Army and Navy work has as its task the teaching of the soldiers and sailors as to why liquor and prostitution are denied our fighting men. As the working plan of the Social Hygiene Division shows, the Government has a double responsibility: First, to make its soldiers and pallors a necessary part of a perfect fight- ing machine ; second, it has the not less important duty of returning them to civil life and to their families in as good condition, if not better, than when they entered the service. A group of selected lecturers visit the various camps to give talks on venereal diseases and their consequences. The way is prepared for them by intro- ductory talks given by company commanders, following a prepared outline. Most of the men have been entirely ignorant of the extent and the dangers of venereal disease, because these are matters that they never hear discussed in the homes, in the schools, or in the communities at large. Special literature has been prepared in simple language, setting forth the facts in regard to disease and its dangers and the necessity for self-control and chastity. In the Y. M. C. A. huts, in the Knights of Columbus halls and in other meeting places of men, placards and exhibits are displayed, stereo- motorgraphs are used and the moving picture, "Fit to Fight," is shown to large audiences in the liberty theaters. This film makes a great appeal to the men. It shows in a dramatic way the careers of five young men drafted from widely differing stations in life. It follows their career in camp and shows how some of them exer- cise self-control while others yield to temptation. Of these latter, some follow the directions to report for prophylactic treatment, while others fail to comply. As a result, when the men who have kept themselves clean sail away for France, their comrades who have «0 yielded to temptation are shown remaining behind in the hospitals — the victims of disease which has incapacitated them for service to their country. Kecognizing that disease is more prevalept in the civilian commu- nities than in the camps themselves, because less under control, and that we must depend absolutely upon public opinion, not only for the making and enforcing of adequate laws against vice, but in the education of the men and women of the country who may in their turn educate the youth of the country, sections on work among civilians were created. The aim of the Section on Men's Work is to reach influential men in communities contiguous to camps, to stir them to immediate ac- tion, where it is necessary, for local betterment. Public opinion is aroused through correspondence, and in many instances important results have followed. The Men's Section" realizes that it is impos- sible to reach the workingmen by correspondence. Accordingly, they have worked out a programme which is very complete and which has been launched through patriotic employers^ Booklets have been prepared for use in factories; there are posters for dis- play purposes and a series of pay-envelope enclosures. Medical care and instruction are provided for those infected. An advisory news reference board has been formed as well as a board of adver- tising men who are going over material to be submitted to make sure it is in language that will "put it over," while the advertising men assist in getting before the public through the press such pub- licity as may be helpful to the cause. The latest section to be formed is that on Women's Work. This section is needed because women, being one-half of the community, form half of the public opinion. In many States they do more than this; through their vote they can determine who shall make the laws and who shall enforce them. Their influence in this direc- tion is already felt in many communities. In some ways they are in a position to assist to a far greater degree than are the "men. They control the home education necessary to assist the Govern- ment's plan. They are in a position to advise and watch over not only those women whose interest in the fighting men is purely mer- cenary, but also those who tlirqugh a spirit of misdirected patriotism and hysteria are thoughtless in their aqtions and forget the serious results that may befall them. To the men in command of troops this latter class represents even the greater menace, because they are a new problem with which it is extremely delicate and difficult to deal. , This applies particularly to the young girl, who through lack of home instruction is not made to realize that she, too, by her be- havior, has it in her hands to help or obstruct one of the most serious problems we have in dealing with the fighting men. The purpose of the Women's Section is, therefore, in the first place, to tell the women of the country about the remarkable steps taken by the Government to safeguard the boys of our Army and Navy both morally and physically. Then it is proposed to show just how women of all ages can help to secure clean conditions in their own 9 61 communities — to see that their surroundings are as clean as they expect those others to be in the community near which their own boys are encamped. The section is supplying magazines and papers with articles o'n the Government's plan. It already has a staff of over forty-five lecturers, chiefly women physicians, who are carrying on a cam- paign of education from one coast to the other. Recently a hun- dred physicians from^ all over the United States met in conference in New York City for the purpose of furthering this_ educational campaign. Exhibits have been prepared, and a moving picture, called "The End of the Road," designed to do for girls what "Fit to Fight" does for the boys, has been completed and given preliminary showings. We are asking the cooperation of all groups of women through national women's organizations. Through programmes for club Meetings, the furnishing of topics for discussion and reports on what other communities are doing, we suggest ways whereby women can help in their own communities to meet special local needs. It is particularly desirable that the following topics among others, be considered frankly and fearlessly. XA) Repression of prostitution, with provision for the feeble- minded prostitutes, the medical treatment of the diseased ones and the training and guidance of those who can be persuaded to earn an honest living. (B) Local legislation that will enable the health authorities to deal effectively with this vital but heretofore neglected health prob- lem. _ (C) Emphasis on the social standards, the scientific basis for a single standard of morality, and the many economic questions in- volved. (D) The dissemination of necessary facts about venereal diseases, to show their seriousness and dispel the enormous amount of igno- rance and indifference which has existed about them. The changed attitude indicated by these frank discussions of sub- jects long held to be unmentionable rests upon medical and social investigation. The war has revealed with appalling plainness the extent of venereal disease infection in civil life. The remedy for these conditions lies to no small extent in the hands of the women of this country, and it is hoped that their response will be both spontaneous and whole-hearted. The way is open to conquer the greatest of all scourges and to lay the foundations upon which to build a constructive and perma- nent work. This is nothing less than slowly and surely, through education, to create a belief in, and a practice of, a single standard of social morality. 62 LIST OP AUTHORITATIVE BOOKS AND PAMPHLETS SOCIAl, HYGIENE. SEX EDUCATION, By Maurice A, Bige'-ow: Macmillan, New York. $1.25. A comprehensive study of sex education, including its meaning, need, and scope, its problems and tbe mode of attack; the teachers and how they shall be selected; the value and the dangers of sex books; special instruction for pre-adolescents, and the like, with a bibliog- raphy, THE WAT tIFE BEGINS. By B. C. Cady and V. M. Cadn With foreword by William F. Snow, M. D., American Social Hygiene Association, New York. $1.25. A simple scientiflcally accurate book for parents and teachers on the subject of the way plant, animal, and human life begins. Illustrated , with colored plates. HOW SHAXl I TEIL, MY CHItD? By Mrs. Woodallen Chapman. Kevell, New York. $ .30. Shows the mother how to answer in the simplest manner the early ques- tions of her children concerning the origin of life. Especially h;eli)ful ■ in its rational treatment of the problem of masturbation In young children. THE SOCIAL EMERGENCY. By William T. Foster. Houghton, Mifflin, Boston. $1.35. Twelve papers by President Foster, of Reed College, and others, on various social hygiene suojects. An excellent book for the general reader. FOB GIEIS AND THE MOTHERS OF GIRIS. By Mary G. Hood. Bobbs-Merrill, New York. $1.25. A straightforward book presenting the facts of life for girls and their mothers in simple language. HERSELF. By Edith B. Xowry. Forbes, Chicago. $1.10. A simple statement of the physiology and hygiene of reproduction; medical . in style, and generally accurate. Especially helpful to young women because it emphasizes the normal. TOWARDS RACIAL HEALTH. . By Norah March. Button, New York. $1.25. Covers the field of practical sex education, laying equal emphasis on the biological approach and on ethical considerations. It studies the child physically, mentally, and emotionally, from the earliest years through adolescence, and indicates how he may be prepared for understanding parenthood and adult social responsibilities. SYPHILIS AND PUBLIC HEALTH. By Edward B. Vedder, M. D., Lieut.-Col. Medical Corps, United States Army. Lea & Feblger, New York. SEX EDUCATION. By Ira S. Wile. Duffleld, New York. $1.00. A very useful book for parents. JOHN'S VACATION. By W. S. Hall, M. D., American Medical Association, Chicago. $ .10. On nature-study basis, for pre-adolescent boys. IDEAL MARRIED LIFE. By Mary Wood-Allen. Eevell, New York. $1.25. Best book by this well-known physician and author. SEX IN LIFE. By D. B. & E. B. Armstrong. Parents' Association, New York. A discussion of physical development and the significance of sex. For adolescent boys and girls. PAMPHLETS. Pamphlets on many phases of social hygiene, for men, women, young peo- ple, parents, school teachers, etc., may be obtained free of charge on request from many State Boards of Health. An increasing number of such pamphlets is published by the Division of Venereal Diseases, United States Public Health Service, Washington, " D. C, and will be sent on request free of charge. Bequests should always state whether the pamphlets are desired for men, women, boys or girls, etc. HISTORICAL BOOKS. FOLKWAYS. ■• » By w. O. Sumner. Oinn & Co. HISTORY OF HUMAN MARRIAGE. By B. VTestermarck. Macmillan Co., New York City.