A Public Health Problem.—The two diseases that are usually classed as venereal are gonorrhea and syphilis. A third one of less importance is chancroid. Their specific micro-organisms are given off from open lesions upon the skin or the mucous membranes. Each disease is produced by the entrance of discharges from an infected person directly into an open wound upon the skin or mucous membrane, or through the mucous membrane at an orifice of the body.

There has been a popular belief that a venereal disease is of merely temporary importance, and concerns only the person who is infected. There is often little discomfort or gross evidence of sickness. The severer symptoms often subside promptly, and the patient may be able to mingle with society without exciting suspicion. But the specific germs often remain in unhealed and unnoticed lesions, and are transmitted to innocent persons, especially to a wife by an uncured husband. The germs that remain in the body may produce severe forms of diseases months or years after apparent recovery. Many cases of rheumatism and bone disease, a quarter of all cases of insanity, many severe gynecologic conditions, and all cases of locomotor ataxia and paresis are late manifestations of uncured venereal disease. Grave effects are left in probably 10 per cent. of all cases. Venereal diseases are plagues which rank with tuberculosis in their prevalence and in their evil effects on individuals and society. They are both curable and preventable, and their control is a public health problem which concerns every health officer and physician.

Chancroid is an ulceration caused by bacterial infection. It is usually located upon an external sexual organ, hut it may occur upon any other part of the body. It may cause enlargements and abscesses of the neighboring lymph-nodes. Its affects are usually local, and resemble those of a streptococcus infection. It is important to a health officer chiefly because it may resemble a syphilitic sore. A diagnosis may be made by examining the scraping from the ulcer with a microscope. If the sore is syphilitic, the characteristic spirilli of syphilis may be found.

Gonorrhea is caused by a diplococcus called the gonococcus or the Micrococcus gonorrhoeae. The germs nearly always enter the body through the genitourinary tract or the eye. The incubation period is usually about four days, but it varies from one up to eight days. The bacteria grow among the epithelial cells of the mucous membrane at the point of entrance, and produce an acute inflammation with a discharge of pus. They may destroy the epithelium and produce ulcerations which lead to strictures or blindness on healing. The germs may remain alive and dormant in the unhealed ulcers, and may regain their original virulency when they are transferred to another person. Those in whom evidences of the disease remain are usually carriers of virulent germs.

Gonococci may enter the blood-stream and produce septicemia, or endocarditis, or an inflammation of the joints which may persist for weeks. They may enter the peritoneum and produce peritonitis or abscesses. Many cases of peritonitis in married women are caused by gonococci which are derived from the uncured disease of their husbands. The disease is the cause of most cases of sterility by closing either the spermatic tubes in the male or the fallopian tubes in the female. Gonorrheal ophthalmia is the principal cause of blindness in children. The crippling effects of the chronic forms of the disease and the damaging results of the acute forms are more common than are popularly supposed, for physicians often conceal the true nature of the disease by calling it rheumatism, or heart disease, or peritonitis, or by giving it some other general term which describes the symptoms regardless of their cause.

A diagnosis of gonorrhea is made, first, by finding gonococci in the pus or discharges from the surface of the body, and second, by complement-fixation tests upon the blood.

A search for gonococci is a standard procedure both for diagnosis and also for ascertaining when a cure is complete. Gonorrhea is similar to diphtheria in that it is often mild, and that its virulent germs frequently persist without causing discomfort or inconvenience. An up-to-date physician will make use of laboratory tests in all cases in which gonorrhea may be suspected. The departments of health of some of the states and cities supply the slides, mailing cases, and blank forms for information, and make the examinations free.

A specimen for making a laboratory diagnosis of gonorrhea is prepared by collecting some of the discharge with a small swab or a wire loop, smearing it in a thin film on a microscope slide, and letting it dry. If there is little or no discharge in a male, some may be obtained by massaging the deep urethra or prostate gland or by injecting a weak solution of nitrate of silver which will irritate the mucous membrane and set up a discharge. Two samples are usually taken from a female, one from the vaginal wall and one from the cervical canal. A specimen taken within twelve hours after an antiseptic douche is likely to be free from gonococci, but if no antiseptics have been used within twenty-four hours, gonococci may nearly always be found if any are present in the tissues.

A specimen is stained with the Gram stain, and examined with a 1/12 oil-immersion objective. Typical gonococci appear as Gram-negative diplococci within pus-cells. The location of the germs within a pus-cell is determined by raising and lowering the objective while observing the cell. The measure of the thickness of a pus-cell is two or three times that of the depth of focus of a 1/12 oil-immersion lens. If the objective is focussed on the upper surface of a cell, and is slowly lowered, the diplococci within the cell first come into clear view and then the lower surface of the cell may be seen.

A complement-fixation test is valuable in determining the nature of the disease in gonorrhea of the joints or internal organs. A specimen of blood is taken in the same manner as one for the Wassermann reaction. The test is usually positive in gonorrheal rheumatism and other conditions in which the micro-organisms exist in the blood; but it is negative in the acute forms of disease in which the germs do not enter the blood. The test is especially valuable in determining the nature of obscure forms of inflammation of the joints.

Ophthalmia neonatorum, or gonorrheal inflammation of the eyes, may occur in newborn children as a result of infection from mothers who either have gonorrhea or are carriers of the gonococci. It also occasionally occurs in adults by the transference of infected pus to the eyes by means of soiled fingers, and by towels and other toilet articles. The disease is an intense inflammation of the conjunctiva, with much pus and swelling of the eyelids. A similar condition may be caused by virulent streptococci derived from mothers who do not observe cleanliness. A diagnosis is made by a microscopic examination of the pus. The condition is dangerous to sight, and requires skilful treatment. It may be prevented in babies by putting 1 drop of a 1 per cent. solution of nitrate of silver into each eye of a baby immediately after its birth.

Gonorrheal infection of the eves is so likely to occur that the New York state Department of health supplies outfits of nitrate of silver solution for giving the preventive treatment to every newborn child. The department requires that every birth certificate shall contain a statement of the means used for preventing the development of the disease; and if none are used, the reason for omitting them must be stated. It also requires that every case of ophthalmia neonatorum shall be reported to the health officer.

Syphilis is apparently either a new disease which appeared about the close of the fifteenth century, or an old One which suddenly acquired an intense virulency similar to that of poliomyelitis in 1916. Its severe nature is indicated by its name, pox, or great pox, by which it was distinguished from the less virulent disease, smallpox. Its virulency is probably as great as ever, but severe acute cases are now comparatively rare owing to the common use of the specific drugs—mercury, arsenic, and the iodids—in the treatment of the disease. Chronic forms of the disease, such as arterial degeneration, locomotor ataxia, and paresis, which were not formerly ascribed to syphilis, are now recognized as late manifestations of the disease, especially in persons in whom its early stages were mild and unrecognized.

Syphilis is caused by a micro-organism, the Spirochwta pallida, which may be classed as an intermediate form between the bacteria and the protozoa. It appears like the worm of a corkscrew having from three to twenty well-marked turns. The spirochetes multiply at their point of entrance into the body, which is usually upon a genitourinary organ, although it may be upon any other part. The period of incubation is about three weeks. The first evidence of the disease is an open sore, called the primary lesion or chancre, which appears at the point of infection, and heals spontaneously after a few weeks.

The spirochetes begin to enter the blood-stream as soon as the primary sore is developed, and in about six weeks they produce an eruption, called the secondary lesion, upon the skin and mucous membranes. This period of the disease corresponds to that of the eruption in smallpox, and is accompanied by fever, pain, and evident sickness. This is the stage in which infection is usually spread, for the spirochetes are contained in the eruptive spots, and are given off when the spots become abraded or ulcerated. Patches on the mucous membranes and moist surfaces of the skin are particularly infective.

The spirochetes may remain alive in a localized part of the body after the acute symptoms have subsided, and after years of dormancy they may produce chronic symptoms in almost any organ, especially in the arteries, bones, and nervous system. The late manifestations of the disease are called tertiary lesions. It was formerly supposed that the disease was not infective during this stage, but the living spirochetes can often be found in the lesions of tertiary syphilis, and may be given off if there are open lesions upon the surface.

An exact diagnosis of syphilis may be made by either of two laboratory methods, first, by finding the characteristic spirochetes, and second, by a complement-fixation or Wassermann test. The spirochetes are usually present in the serum that exudes from the primary sore, and if they are found, the diagnosis is made with certainty. A satisfactory method of obtaining a specimen from a primary sore for diagnosis is as follows:

1. Wash the sore with clean, sterile water, and dry it with sterile gauze.

2. Curet the edge until blood begins to appear.

3. Wipe the sore with sterile gauze until clear serum oozes from it.

4. Take a drop of this serum upon a microscope slide for examination.

A specimen of serum must he examined fresh with a dark-field illumination. The organisms are as large as the larger bacteria, and fresh specimens show a twisting motion.

The spirochetes may also he found among the tissues beneath the primary sore. A small amount of tissue may be taken from the edge of the sore, preserved in a 2 per cent. solution of formalin, and sent to a laboratory to be sectioned, stained, and examined.

Transmission of Venereal Diseases.—The venereal diseases are similar in the methods of their transmission and control. A considerable number of cases of venereal diseases are spread by ordinary contact with infected persons. This is true in both gonorrhea and syphilis. Epidemics of gonorrhea occur in children's hospitals and orphanages, and are difficult to prevent or to suppress. Persons affected with active syphilis frequently spread the disease by kissing, towels, and other direct means of transferring the germs. But transmission of venereal diseases usually occur by sexual contact between persons of opposite sexes. An epidemic of the diseases usually comes from a very few local sources, that is, from one or a few infected females. Males are not the cause of an outbreak, for each infected male seldom puts himself in a situation to spread the disease extensively. An epidemic is caused by an infected female, for she often comes in infectious contact with many males. There is a close analogy to the development of an epidemic of typhoid or diphtheria. A number of cases of venereal disease, or of typhoid fever, or of diphtheria, points to a limited virulent source of infection, and its suppression will control a very large proportion of all cases—say at least three-fourths. The main part of the problem of preventing venereal diseases is practically to discover and eliminate infected prostitutes. The prevention of the infection of prostitutes by discovering and treating infected males is also necessary.

Control.—The control of venereal diseases has been considered to be impossible, owing largely to the fact that a large number of men and women voluntarily and deliberately expose themselves to infection. The former attitude of the public toward the diseases was that of secrecy. Each case was regarded as a private matter, and the continual existence of a grave epidemic of preventable disease was ignored. But from the time when venereal diseases have been recognized as public health problems, great progress in their control has been made. A similar development from secrecy to open discussion and control has taken place in the attitude of the public toward tuberculosis. Experience shows that venereal diseases may be discussed in the same open manner as tuberculosis or any other public health matter. Effective measures for preventing venereal diseases have been introduced into the American Army, with the result that they are rare among the troops in many large camps. These experiences clearly indicate the lines of work which promise success among the civilian population.

The measures for the control of venereal diseases may be divided into four groups: 1, medical; 2, legal; 3, educational; 4, social. A health officer is directly interested in the medical means of control, and to a great extent also in the legal and educational means. He is indirectly interested in the social and moral measures for the control of venereal diseases.

Medical Measures.—There are two essential medical measures for controlling any infectious disease: 1, the discovery of cases, and 2, their treatment to remove the sources of infection. A responsibility rests upon health officers and physicians to make an accurate diagnosis of cases of venereal diseases, to give efficient treatment to every case, and to educate the patients in the means of preventing the spread of the diseases to others. A laboratory diagnosis is as important in venereal diseases as in diphtheria. An examination of specimens from every case is necessary for diagnosis and in order to determine whether or not the disease is cured. Physicians must be educated to use the laboratory, and the public must be educated to demand its use.

The departments of health of the larger cities are establishing clinics and hospitals for the treatment of venereal diseases. They have a great value in educating physicians to use the modern methods of treatment, and in causing patients to shun quack doctors and to seek scientific treatment.

Medical measures for preventing the development of a venereal disease after an exposure to possible infection are used in the American Army and Navy, but they have not come into general use among civilians. The wisdom and propriety of their use have been questioned on moral grounds, but from a public health point of view any medical means of preventing the diseases are proper. If a person exposed to a venereal disease seeks prophylactic treatment, there is no valid reason for denying him its benefits. The method used in the Army and Navy is as follows:

1. Wash the parts with soap and an antiseptic solution.

2. Inject a 2 per cent. solution of protargol into the urethra.

3. Apply calomel ointment to the organs.

The procedure is usually successful when used soon after exposure, and its value is lessened in proportion to the time during which the germs have grown in the body.

Legal Measures.—The laws of customs of American people require patients who are afflicted with communicable diseases to submit to inconveniences and restrictions in order to prevent the spread of the diseases to others. The ideal requirements in venereal diseases are that every patient shall submit to efficient treatment, and shall not expose another person to the danger of infection. These measures are observed in the Army and Navy, and a beginning has been made looking toward their ultimate adoption among civilians. In 1917 and 1918 New York State adopted four measures for controlling patients suffering with venereal diseases. First, the Council of the State Department of Health put chancroid, gonorrhea, and syphillis on the list of diseases which are subject to supervision and control. The effect is that a careless venereal patient like a careless consumptive, may be subjected to the control of the health officer under Section 25 of the Public Health Law, which reads as follows: "Every local board of health and every health officer shall guard against the introduction of such infectious and contagious or communicable diseases as are designated in the sanitary code, by the exercise of proper and vigilant medical inspection and control of all persons and things infected with or exposed to such diseases, and provide suitable means for the treatment and care of sick persons who cannot otherwise be provided for." Under this section of the law a health officer may exclude a venereal case from occupations involving close contact with children and other persons.

Second, the State Department of Health amended the State Sanitary Code so that Regulation 29a of Chapter II reads as follows: "It will be the duty of every physician when first attending a person affected with chancroid, gonorrhea, or syphilis to furnish said person with a circular of information issued or approved by the State Commissioner of Health, and to instruct such person as to the precautions to be taken in order to prevent the communication of the disease to others." This regulation will stimulate physicians to give efficient treatment and advice to their venereal cases, and to see that they are cured. It will doubtless soon lead to the adoption of regulations requiring that venereal diseases shall be reported to the health officer.

Third, the Legislature of New York State amended the domestic relations law so as to require every applicant for a marriage license to subscribe to the following statement: "I have not to my knowledge been infected with any venereal disease, or if I have been so infected within five years, I have had a laboratory test within that period which shows that I am now free from infection from any such disease." This brings the question of venereal disease home to every young man and woman who expects to be married. The observance of the law does not seem to cause embarrassment or objection to those applying for marriage licenses.

Fourth, the Legislature added subdivisions to Section 343 of the Public Health Law, authorizing boards of health and health officers to examine and control any person whom they have good reason to suspect to be likely to spread a venereal disease. This law subjects a careless person suffering with a venereal disease to the same kind of control that would be applied to a person who has diphtheria or smallpox.

Education.—The conditions regarding the control of venereal diseases are now about the same that they were regarding tuberculosis during the early days of the antituberculosis movement. Further progress will depend largely on the education of physicians, patients, and the public, as in the control of tuberculosis.

Every health officer is expected to become familiar with modern methods of diagnosis and treatment of venereal diseases, and to recommend them to the physicians in his jurisdiction. He is expected to have supplies of diagnostic outfits and educational literature if they are furnished by his state department of health or other agency.

When patients afflicted with venereal diseases receive the benefits of scientific treatment and the advice required by the sanitary code of the New York State Department of Health, they become centers for spreading the knowledge to others and of influencing others to seek adequate treatment. The education of patients is a valuable means of reaching the public.

The education of the public regarding venereal diseases is conducted along two lines, first, concerning the diseases themselves, and second, regarding sex matters in general. It is the work primarily of social workers and teachers, but a health officer can be of great assistance to them.

The very great value of moral teaching must also be recognized. An appeal to the moral nature is one of the most compelling forces for controlling the passions and animal inclinations of men and women.

Social Measures.—Social and community measures are also necessary for controlling venereal diseases. One measure is provision for proper amusement and recreation for young people. If thoughts of animal passions and feelings are to be controlled, they must be displaced by higher thoughts and feelings.

The prevention of venereal diseases is closely connected with the problem of alcoholic liquors. Temperance measures are among the most necessary and efficient means of suppressing venereal diseases, and of dealing with many problems concerning sexual relations.

Measures for the control and suppression of prostitution are also necessary. Experience has shown that the regulation of prostitution is a failure in preventing venereal diseases. Prostitution is the greatest factor in spreading venereal diseases, and the moral sense of the American people will not allow its legalization and supervision. Its suppression is a necessary public health measure.

Summary.—The various protective measures against attacks of venereal diseases may be represented by circles of outposts surrounding each individual. These circles from without inward are:

1. Social and moral forces, and the standards of civilized society.

2. Education regarding sex matters and sex diseases.

3. Wholesome recreation and mental occupations.

4. Legal control of prostitutes.

5. The treatment and cure of cases.

6. Prophylactic treatment for those who, in spite of other measures, persist in exposing themselves to infection.

Frank Overton

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