William F. Snow, M.D.
General Secretary, The American Social Hygiene Association
The phrase social hygiene has had an interesting and varied history and will, I venture to predict, develop other and larger meanings before it finds its permanent usage in the public's vocabulary. In America we experiment with words as we do with the forces of nature and we are constantly replacing old vehicles of expression with new inventions or applications. The word social we understand, hygiene we understand, but these words combined are to the uninitiated like the words glass and eye which standing alone refer to transparent bodies while as a phrase they designate something we do not see through at all. Social hygiene owes its present usage largely to our newspaper editors who felt the necessity for some descriptive term covering the diverse activities directed toward the reduction of venereal diseases and the repression of prostitution. Apparently the phrase originated in Chicago through its adoption in 1907 by the Chicago Society for Social Hygiene, although this organization was at the time devoting its energies primarily to sex education.
During the period 1905-1910 a number of state and local societies, special committees of women's clubs, church, and medical associations, and other organizations were developing the pioneer work of focusing public attention on the need for organized effort in the social hygiene field. One group of these societies was mainly concerned with the medical and sex education aspects of the problem. In 1910 a meeting, held in St. Louis for the purpose of organizing a national society, endeavored to select a name from such titles of local societies as "Sanitary and Moral Prophylaxis," "The Study and Prevention of Syphilis and Gonorrhoea," "Social and Moral Prophylaxis," "Social
( 38) and Moral Hygiene." The name agreed upon for the time being was The American Federation for Sex Hygiene. A second group of societies and committees devoted their attention during this period to the problems of prostitution and other forms of sexual vice. These organizations likewise utilized many titles and effected many combinations and affiliations, which finally centered in the American Purity Alliance whose activities were broadened in 1912 and the naine changed to the American Vigilance Association. There has always existed a third group interested primarily in measures for the protection of the family and the development of moral character. The National League for the Protection of the Family in its history of development during the past twenty-five years illustrates the efforts to establish a special society devoted to this field of endeavor. Through the consolidation of The American Federation for Sex Hygiene and the American Vigilance Association the present American Social Hygiene Association came into existence in 1914.
The progress of the social hygiene movement began in the closing years of the nineteenth century; but as this is only another way of saying fifteen years, the story does not take long to summarize. Prior to 1900 scientific and sociologic data were being recorded. With increasing frequency papers or addresses appeared on the programs of various organizations calling attention to medical, economic, and moral phases of the problem. The Brussels Conferences of 1902 and 1904 greatly influenced the final decisions to inaugurate educational propaganda in many countries. In part, we owe Dr. Prince A. Morrow's invaluable pioneer work to these conferences which he attended as delegate from the United States. From 1900 to 1910 the available data were being formulated for the educational campaigns already mentioned as having begun in local experiments and discussions by small groups of interested citizens. During this period new facts of the highest importance were discovered. In the medical field there were added new observations of gonorrhea and its ravages, the discovery of the organism of syphilis in 1905, the development of the Wassermann reaction in 1907, the preparation of salvarsan for the treatment of syphilis in 1910, and
( 39) in 1911 the successful innoculation of syphilis and cultivation of its organism, crowning the faithful and brilliant research of many investigators over almost a decade. These advances made possible by 1912 a practical campaign against venereal diseases as soon as public opinion could be developed in support of it. In the law and law-enforcement field the records show many persistent and self-sacrificing efforts to utilize existing statutes and to devise new legislative and administrative measures. Typical of these have been the federal "white slave" enactments, the state injunction and abatement laws, the "tin plate" ordinance, and municipal regulations directed toward the elimination of commercialized prostitution. Good environment and observance of moral standards have become recognized as vitally important forces in any campaign for ultimate eradication of venereal diseases and prostitution as great social ills. Something has been done by social hygiene societies toward applying these forces, and a great deal has been done in this direction by other organizations. One has only to think back five years to realize how much has been accomplished in the creation of public opinion in support of medical, legal, social, and moral lines of attack upon the social hygiene problem.
Social hygiene has become recognized as an inclusive phrase covering activities of which the campaigns against venereal diseases and prostitution are only a part, but up to the present time these activities have necessarily been brought most prominently before the public. Recently the idea is gaining ground that social hygiene is essentially a constructive movement for the promotion of all those conditions of living, environment, and personal conduct which will best protect the family as an institution and secure a rational sex life for the individuals of each generation. This changing viewpoint is well illustrated by the forceful statement of Dr. Edward L. Keyes, Jr., descriptive of the aims and methods of social hygiene societies today. The elimination of disease and prostitution can not be attained solely by the enforced registration of venereal diseases, the
( 40) raiding of disorderly houses, and the enactment of laws against procuration and solicitation. Such police and legislative activity achieves temporary or local ends. But reform of this sort rapidly burns itself out and the police remain singularly human in their weaknesses. 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 prostitutes, and our young men from preying upon them. This they hope to achieve by informing the mind so as to banish prurient curiosity, by diverting the imagination to emotions joyous and 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 family and civic ideals. To turn lust into love, `into the enthralling love of mate for equal mate, into civic love for freedom, home, and state, into the eternal love of God and of all things create' —such is our aspiration." Eventually it is possible that social hygiene may find its place as an inclusive designation for a group of organized and affiliated movements which deal with community problems in which social and moral factors as distinct from sanitary factors are of primary importance. In this sense it is logically a companion term to public hygiene, or public health which is its popular equivalent. The constitution of this association  already relates its purposes to the promotion of social health. At our annual meeting in Boston, October 8th, President Eliot expressed his opinion in favor of the increased efficiency which would follow the bringing together of a number of organizations at present working independently, provided a satisfactory form of centralized control, with unhampered bureau administration for each division of work, could be developed.
Returning to the consideration of the major activities of social hygiene as it is at present defined, an encouraging prospect is presented. As the period from 1905 to 1910 was one of industri-
( 41) -ous tabulation of scientific and social data and pioneer experiments in organization, and the period from 1910 to 1915 has been one of persistent education and formation of public opinion, so the period from 1915 to 1920 promises to be one of active administrative effort to achieve results which have been demonstrated to be attainable. In the medical field a fairly definite program has been launched.
In attacking any disease from which he is attempting to protect the public, the health officer first secures through investigations, physicians' reports, and personal interviews all the information obtainable upon existing cases and arranges for their treatment and supervision under conditions which will preclude transmission of the disease to others. He then proceeds to carry out such additional measures as are calculated to protect the non-infected portion of the population from any cases he has not discovered. Looking toward the future, he finally endeavors to secure those community conditions and standards of personal hygiene and conduct which will prevent the recurrence of the disease after it has once been eradicated. Analyzing on this basis the evidences of progress in reducing the prevalence of venereal diseases, we find now in many parts of the United States diagnostic facilities, advisory stations, dispensary services, and, to a limited extent, hospital care, provided in an endeavor to benefit the infected and to teach them how to protect the public during the continuance of their disease. The extension of hospital social service to this class of cases is' steadily being demonstrated to be wise and practicable, and progress is being made in getting venereal diseases reported.
The instruction of the public in measures for protection of non-infected individuals has also progressed. Obviously, continence outside of marriage for both men and women is the greatest factor in the prophylaxis of these diseases, and the acceptance of this standard has been steadily urged by the social hygiene societies, a few health officers, and those moral agencies which have been induced actively to participate in the campaign. The other factor in personal prophylaxis—i.e., medical prophylactic measures—is still on the firing line and illustrates the great
( 42) difficulties which have attended all progress in the past five years. That society is not opposed to the popularization of methods of preventing the spread of diseases by means of medical applications, or even to the furnishing at public expense and compelling the use of medical prophylactics is amply demonstrated by numerous instances, as witness the requirement of vaccination against smallpox, the distribution at public expense of diphtheria antitoxin, and, in earlier days before the nature of communicable diseases was understood, the wearing of a piece of asafetida about one's neck or the placing of saucers of carbolic acid about the house. The opposition to medical prophylactic measures in venereal diseases is based primarily upon the public's determination to safeguard something it holds far more precious than health, namely, the morals of the community. The approval accorded the use of silver nitrate solutions in preventing gonococcus infections of new-born babies' eyes is still better evidence of this. Before medical prophylactics can be wisely utilized their bearing upon the moral problems must be worked out and well-considered plans adopted.
The attack upon community conditions indirectly influencing the prevalence of venereal diseases or favoring their return to a community, could they be once eradicated, is viewed by the health official largely as an academic question. These diseases, like tuberculosis, are endemic and his executive responsibility leads him naturally to interest himself primarily in the existing eases and those individuals in immediate contact with them. It is significant, however, that the section of public health officials of the American Public Health Association adopted in September of this year a program for combating venereal diseases which included the following :
"Group 3. Measures contributing to the reduction and ultimate eradication of syphilis and gonococcus infections.
"1. Repression of prostitution through law enforcement.
"2. Provision of ample facilities for wholesome play and recreation; and elimination of environmental and social conditions, which encourage extra-marital sex relations.
"3. Elimination of alcoholic drinks.
"4. Promotion of sex education and standards of personal conduct which are in keeping with high moral principles.
"5. Encouragement of early marriage and promotion of economic and social conditions conducive thereto."
This evidence of the health officers' appreciation of the complex factors involved is paralleled by the conclusions reached by the Committee on Venereal Diseases of the Maine Medical Society: "Your Committee feels that of the different plans for the prevention of venereal disease in Maine, the following offer the most at the present time:
"1. Assisting in awakening the people of Maine to the dangers of venereal disease.
"2. Assisting to some degree in establishing higher ideals of sexual morality.
"3. Arousing parents to a sense of responsibility in regard to the sexual morals of their children.
"4. Calling the attention of parents to the need of arousing in developing boys and girls a feeling of responsibility in regard to the health and welfare of their future families.
"5. Assisting in awakening public opinion to support officers of sanitation in applying modern hygiene methods to the control of venereal disease.
"Your committee hopes that its work is contributing toward the carrying out of these plans, and asks that the committee be continued."
A similar note is struck in the popular pamphlets now beginning to follow the work of the British Royal Commission on Venereal Diseases. One such pamphlet concludes with the following: —
"If we drop figures and return once more to the level of bare fact, it is certain that the Royal Commission in its final report will lay great stress on the necessity of making it as easy as possible for those who are suffering from venereal disease to secure first-rate advice and treatment. It will no doubt advise the use of public money in order to place modern means of diagnosis and treatment within the reach of the poorest, and the most extensive possible programme of education and warning for the young, and for those diseased. But it will certainly, as far as one can judge, not recommend much in the way of legislation, nor the use of compulsion for the civilian population in any shape.
''It will suggest that the `stigma' or reproach attached to these diseases is one great obstacle to people who might otherwise be willing to apply at once for treatment. Now if there is to be no compulsion there must be a helpful atmosphere; a feeling of helpfulness in the air, sprung from the sense of a common responsibility, and a common burden to be borne. It would be a pity to make too much of the fear of reproach. Our men are not wanting in common sense, and certainly they are not cruel, nor reckless about the sufferings of women and children. Still, it is useless to pretend that the responsibility lies with equal weight upon all, or to adopt the policy of whitewashing corruption. Unclean living, whether occasional or habitual, is not a
( 45) misfortune, but a vice. It would be nothing short of a public calamity if the idea gained acceptance that syphilis is not to be more abhorred than smallpox, and that he who carelessly, or after warning, transmits its poison to his wife and children, ought not to be held guilty of a crime.
"Any man who reads this pamphlet fairly must admit that it is common sense to do the best he can to avoid the risks to himself and others that it describes; while, as for the women and children, well—we take it for granted that they go first into the boats, because this has become a national habit. When it has become a national habit to put them first in what is much more than a matter of mere life or death, syphilis and prostitution itself will be in a fair way to disappear. "
Such evidence seems clearly to indicate that the public will soon assume the same attitude toward venereal infections that it does toward other dangerous communicable diseases. This attitude as expressed in tuberculosis or typhoid fever, for example, is one of sympathy and assistance for the infected individual, while a frank and searching inquiry is made into the source of the infection and the conditions of the community which may have contributed to the opportunity for his infection. It is true of American communities today that public opinion demands the reporting of typhoid fever cases with ample explanations of high or low rates. Perhaps the time will come when the concealment of syphilis and gonorrhea cases will be followed by a suspicion that the opportunities for spread of these diseases are unusually large, and that the community thus failing to record frankly its morbidity rate for these diseases is not a safe place in which to establish a home. Every health officer knows the power of such an argument in securing funds and support for the battle against such diseases as typhoid fever, malaria, and even tuberculosis. Social hygiene societies are endeavoring to turn this power to account in the battle against the venereal diseases.
So much for progress in the medical field; in the law and law-enforcement field the endeavor to repress prostitution and to es-
( 46) -tablish activities which may ultimately be expected to eliminate at least its commercialized aspects has made notable advances. The battle for the abandonment of segregation or other forms of regulation of prostitution as a public policy has been won. New Orleans and San Francisco are the only two large cities in the United States where publicly acknowledged red light districts are maintained. The agitation aroused in the Louisiana legislature last winter over an abatement and injunction bill and the persistent fight for better conditions in California that has been maintained against the greatest conceivable opposition of the vice interests are indications that these remaining strongholds of the segregation policy will ultimately give way.
Certain important cities secretly tolerate centers of prostitution and occasionally efforts are made to bring about a return to a policy of recognized segregation, but the results of the vice investigations in this country and the Flexner report upon conditions in Europe have crystalized public opinion in favor of the abolition of commercialized prostitution. The creation of such effective organizations as the Committee of Fourteen in New York and the Committee of Fifteen in Chicago is evidence of determination to go steadily forward toward its ultimate eradication. The activity of other agencies including the several departments and bureaus of the Federal Government empowered to deal with special phases of the problem is further evidence of progress in this direction.
Looking toward the prevention of its return, once open prostitution has been driven out of a community or measurably reduced, various laws and administrative measures have been developed. In the main these provide: (1) ready means for an individual or small group of citizens to set in motion existing law enforcement machinery, as illustrated by the various abatement and injunction laws; (2) public facilities for proper investigation of individual cases leading to official action in the best interests of both the public and individuals, as illustrated by the creation of morals commissions or morals courts; (3) provision of adequate institutions for the treatment, discipline, and segregation of delinquents,
( 47) as illustrated by the increasing cooperation between officers and agents of the law, directors of psychiatric and medical clinics, probation and protective associations, and homes for the feebleminded. The personal factor in moral prophylaxis, like that in medical prophylaxis, is in a state of uncertain development. Progress is being made by social hygiene societies and by other agencies in building up better environmental conditions, and slowly the public is coming to realize the important bearing of such factors as alcoholism, feeble-mindedness, lack of self-control, toleration of extra-marital alliances, illegitimacy, desertion, and divorce upon social hygiene problems. Efforts are also being made to correlate the existing laws and ordinances and to standardize procedure in the several states.
The study of all the notable advances in social hygiene show certain common principles of procedure. First there have been comprehensive and thorough investigations of each phase of the problem. On the basis of evidence thus secured plans for dealing with the situation have been worked out, the public has been informed of the facts, and one or more practical demonstrations of the proposed measures have been arranged. These steps have been followed by the launching of a careful campaign to develop public opinion in support of general application of the demonstrated measures. Attempted short-cuts in this procedure have usually proved disastrous or delayed permanent gains. The movement can not afford to be unduly forced by impatient enthusiasts or retarded by the over-cautious. It must lead public opinion in its field but the administrative measures advocated can not hope for success in advance of a general belief in their efficacy and the public's determination to have them enforced. The old adage "Well begun is half done'' has often proved true. Whether it is given to this generation to accomplish so much for the social hygiene movement time will show. The future seems full of promise.