Studies in the Psychology of Sex Volume Vi Part 19

Yet, even from the standpoint which we here occupy, it is scarcely possible to ignore the question of venereal disease, for the psychological and moral aspects of prost.i.tution, and even the whole question of the s.e.xual relationships, are, to some extent, affected by the existence of the serious diseases which are specially liable to be propagated by s.e.xual intercourse.

Fournier, one of the leading authorities on this subject, has well said that syphilis, alcoholism, and tuberculosis are the three modern plagues. At a much earlier period (1851) Schopenhauer in Parerga und Paralipomena had expressed the opinion that the two things which mark modern social life, in distinction from that of antiquity, and to the advantage of the latter, are the knightly principle of honor and venereal disease; together, he added, they have poisoned life, and introduced a hostile and even diabolical element into the relations of the s.e.xes, which has indirectly affected all other social relationships.[220] It is like a merchandise, says Havelburg, of syphilis, which civilization has everywhere carried, so that only a very few remote districts of the globe (as in Central Africa and Central Brazil) are to-day free from it.[221]

It is undoubtedly true that in the older civilized countries the manifestations of syphilis, though still severe and a cause of physical deterioration in the individual and the race, are less severe than they were even a generation ago.[222] This is partly the result of earlier and better treatment, partly, it is possible, the result also of the syphilization of the race, some degree of immunity having now become an inherited possession, although it must be remembered that an attack of syphilis does not necessarily confer immunity from the actual attack of the disease even in the same individual. But it must be added that, even though it has become less severe, syphilis, in the opinion of many, is nevertheless still spreading, even in the chief centres of civilization; this has been noted alike in Paris and in London.[223]

According to the belief which is now tending to prevail, syphilis was brought to Europe at the end of the fifteenth century by the first discoverers of America. In Seville, the chief European port for America, it was known as the Indian disease, but when Charles VIII and his army first brought it to Italy in 1495, although this connection with the French was only accidental, it was called the Gallic disease, "a monstrous disease," said Cataneus, "never seen in previous centuries and altogether unknown in the world."

The synonyms of syphilis were at first almost innumerable. It was in his Latin poem Syphilis sive Morbus Gallicus, written before 1521 and published at Verona in 1530, that Fracastorus finally gave the disease its now universally accepted name, inventing a romantic myth to account for its origin.

Although the weight of authoritative opinion now seems to incline towards the belief that syphilis was brought to Europe from America, on the discovery of the New World, it is only within quite recent years that that belief has gained ground, and it scarcely even yet seems certain that what the Spaniards brought back from America was really a disease absolutely new to the Old World, and not a more virulent form of an old disease of which the manifestations had become benign. Buret, for instance (Le Syphilis Aujourd'hui et chez les Anciens, 1890), who some years ago reached "the deep conviction that syphilis dates from the creation of man," and believed, from a minute study of cla.s.sic authors, that syphilis existed in Rome under the Caesars, was of opinion that it has broken out at different places and at different times, in epidemic bursts exhibiting different combinations of its manifold symptoms, so that it pa.s.sed unnoticed at ordinary times, and at the times of its more intense manifestation was looked upon as a hitherto unknown disease. It was thus regarded in cla.s.sic times, he considers, as coming from Egypt, though he looked upon its real home as Asia. Leopold Gluck has likewise quoted (Archiv fur Dermatologie und Syphilis, January, 1899) pa.s.sages from the medical epigrams of a sixteenth century physician, Gabriel Ayala, declaring that syphilis is not really a new disease, though popularly supposed to be so, but an old disease which has broken out with hitherto unknown violence. There is, however, no conclusive reason for believing that syphilis was known at all in cla.s.sic antiquity. A. V. Notthaft ("Die Legende von der Althertums-syphilis," in the Rindfleisch Festschrift, 1907, pp. 377-592) has critically investigated the pa.s.sages in cla.s.sic authors which were supposed by Rosenbaum, Buret, Proksch and others to refer to syphilis. It is quite true, Notthaft admits, that many of these pa.s.sages might possibly refer to syphilis, and one or two would even better fit syphilis than any other disease. But, on the whole, they furnish no proof at all, and no syphilologist, he concludes, has ever succeeded in demonstrating that syphilis was known in antiquity. That belief is a legend. The most d.a.m.ning argument against it, Notthaft points out, is the fact that, although in antiquity there were great physicians who were keen observers, not one of them gives any description of the primary, secondary, tertiary, and congenital forms of this disease. China is frequently mentioned as the original home of syphilis, but this belief is also quite without basis, and the j.a.panese physician, Okamura, has shown (Monatsschrift fur praktische Dermatologie, vol. xxviii, pp. 296 et seq.) that Chinese records reveal nothing relating to syphilis earlier than the sixteenth century. At the Paris Academy of Medicine in 1900 photographs from Egypt were exhibited by Fouquet of human remains which date from B.C. 2400, showing bone lesions which seemed to be clearly syphilitic; Fournier, however, one of the greatest of authorities, considered that the diagnosis of syphilis could not be maintained until other conditions liable to produce somewhat similar bone lesions had been eliminated (British Medical Journal, September 29, 1900, p. 946). In Florida and various regions of Central America, in undoubtedly pre-Columbian burial places, diseased bones have been found which good authorities have declared could not be anything else than syphilitic (e.g., British Medical Journal, November 20, 1897, p. 1487), though it may be noted that so recently as 1899 the cautious Virchow stated that pre-Columbian syphilis in America was still for him an open question (Zeitschrift fur Ethnologie, Heft 2 and 3, 1899, p. 216). From another side, Seler, the distinguished authority on Mexican antiquity, shows (Zeitschrift fur Ethnologie, 1895, Heft 5, p. 449) that the ancient Mexicans were acquainted with a disease which, as they described it, might well have been syphilis. It is obvious, however, that while the difficulty of demonstrating syphilitic diseased bones in America is as great as in Europe, the demonstration, however complete, would not suffice to show that the disease had not already an existence also in the Old World. The plausible theory of Ayala that fifteenth century syphilis was a virulent recrudescence of an ancient disease has frequently been revived in more modern times. Thus J. Knott ("The Origin of Syphilis," New York Medical Journal, October 31, 1908) suggests that though not new in fifteenth century Europe, it was then imported afresh in a form rendered more aggravated by coming from an exotic race, as is believed often to be the case.

It was in the eighteenth century that Jean Astruc began the rehabilitation of the belief that syphilis is really a comparatively modern disease of American origin, and since then various authorities of weight have given their adherence to this view. It is to the energy and learning of Dr. Iwan Bloch, of Berlin (the first volume of whose important work, Der Ursprung der Syphilis, was published in 1901) that we owe the fullest statement of the evidence in favor of the American origin of syphilis. Bloch regards Ruy Diaz de Isla, a distinguished Spanish physician, as the weightiest witness for the Indian origin of the disease, and concludes that it was brought to Europe by Columbus's men from Central America, more precisely from the Island of Haiti, to Spain in 1493 and 1494, and immediately afterwards was spread by the armies of Charles VIII in an epidemic fashion over Italy and the other countries of Europe.

It may be added that even if we have to accept the theory that the central regions of America const.i.tute the place of origin of European syphilis, we still have to recognize that syphilis has spread in the North American continent very much more slowly and partially than it has in Europe, and even at the present day there are American Indian tribes among whom it is unknown. Holder, on the basis of his own experiences among Indian tribes, as well as of wide inquiries among agency physicians, prepared a table showing that among some thirty tribes and groups of tribes, eighteen were almost or entirely free from venereal disease, while among thirteen it was very prevalent. Almost without exception, the tribes where syphilis is rare or unknown refuse s.e.xual intercourse with strangers, while those among whom such disease is prevalent are morally lax. It is the whites who are the source of infection among these tribes (A. B. Holder, "Gynecic Notes Among the American Indians," American Journal of Obstetrics, 1892, No. 1).

Syphilis is only one, certainly the most important, of a group of three entirely distinct "venereal diseases" which have only been distinguished in recent times, and so far as their precise nature and causation are concerned, are indeed only to-day beginning to be understood, although two of them were certainly known in antiquity. It is but seventy years ago since Ricord, the great French syphilologist, following Ba.s.sereau, first taught the complete independence of syphilis both from gonorrha and soft chancre, at the same time expounding clearly the three stages, primary, secondary and tertiary, through which syphilitic manifestations tend to pa.s.s, while the full extent of tertiary syphilitic symptoms is scarcely yet grasped, and it is only to-day beginning to be generally realized that two of the most prevalent and serious diseases of the brain and nervous system-general paralysis and tabes dorsalis or locomotor ataxia-have their predominant though not sole and exclusive cause in the invasion of the syphilitic poison many years before. In 1879 a new stage of more precise knowledge of the venereal diseases began with Neisser's discovery of the gonococcus which is the specific cause of gonorrha. This was followed a few years later by the discovery by Ducrey and Unna of the bacillus of soft chancre, the least important of the venereal diseases because exclusively local in its effects. Finally, in 1905-after Metchnikoff had prepared the way by succeeding in carrying syphilis from man to monkey, and La.s.sar, by inoculation, from monkey to monkey-Fritz Schaudinn made his great discovery of the protozoal Spirochta pallida (since sometimes called Treponema pallidum), which is now generally regarded as the cause of syphilis, and thus revealed the final hiding place of one of the most dangerous and insidious foes of humanity.[224]

There is no more subtle poison than that of syphilis. It is not, like smallpox or typhoid, a disease which produces a brief and sudden storm, a violent struggle with the forces of life, in which it tends, even without treatment, provided the organism is healthy, to succ.u.mb, leaving little or no traces of its ravages behind. It penetrates ever deeper and deeper into the organism, with the pa.s.sage of time leading to ever new manifestations, and no tissue is safe from its attack. And so subtle is this all-pervading poison that though its outward manifestations are amenable to prolonged treatment, it is often difficult to say that the poison has been finally killed out.[225]

The immense importance of syphilis, and the chief reason why it is necessary to consider it here, lies in the fact that its results are not confined to the individual himself, nor even to the persons to whom he may impart it by the contagion due to contact in or out of s.e.xual relationships: it affects the offspring, and it affects the power to produce offspring. It attacks men and women at the centre of life, as the progenitors of the coming race, inflicting either sterility or the tendency to aborted and diseased products of conception. The father alone can perhaps transmit syphilis to his child, even though the mother escapes infection, and the child born of syphilitic parents may come into the world apparently healthy only to reveal its syphilitic origin after a period of months or even years. Thus syphilis is probably a main cause of the enfeeblement of the race.[226]

Alike in the individual and in his offspring syphilis shows its deteriorating effects on all the structures of the body, but especially on the brain and nervous system. There are, as has been pointed out by Mott, a leading authority in this matter,[227] five ways in which syphilis affects the brain and nervous system: (1) by moral shock; (2) by the effects of the poison in producing anaemia and impaired general nutrition; (3) by causing inflammation of the membranes and tissues of the brain; (4) by producing arterial degeneration, leading on to brain-softening, paralysis, and dementia; (5) as a main cause of the para-syphilitic affections of general paralysis and tabes dorsalis.

It is only within recent years that medical men have recognized the preponderant part played by acquired or inherited syphilis in producing general paralysis, which so largely helps to fill lunatic asylums, and tabes dorsalis which is the most important disease of the spinal cord. Even to-day it can scarcely be said that there is complete agreement as to the supreme importance of the factor of syphilis in these diseases. There can, however, be little doubt that in about ninety-five per cent. at least of cases of general paralysis syphilis is present.[228]

Syphilis is not indeed by itself an adequate cause of general paralysis for among many savage peoples syphilis is very common while general paralysis is very rare. It is, as Krafft-Ebing was accustomed to say, syphilization and civilization working together which produce general paralysis, perhaps in many cases, there is reason for thinking, on a nervous soil that is hereditarily degenerated to some extent; this is shown by the abnormal prevalence of congenital stigmata of degeneration found in general paralytics by Nacke and others. "Paralyticus nascitur atque fit," according to the dictum of Obersteiner. Once undermined by syphilis, the deteriorated brain is unable to resist the jars and strains of civilized life, and the result is general paralysis, truly described as "one of the most terrible scourges of modern times." In 1902 the Psychological Section of the British Medical a.s.sociation, embodying the most competent English authority on this question, unanimously pa.s.sed a resolution recommending that the attention of the Legislature and other public bodies should be called to the necessity for immediate action in view of the fact that "general paralysis, a very grave and frequent form of brain disease, together with other varieties of insanity, is largely due to syphilis, and is therefore preventable." Yet not a single step has yet been taken in this direction.

The dangers of syphilis lie not alone in its potency and its persistence but also in its prevalence. It is difficult to state the exact incidence of syphilis, but a great many partial investigations have been made in various countries, and it would appear that from five to twenty per cent. of the population in European countries is syphilitic, while about fifteen per cent. of the syphilitic cases die from causes directly or indirectly due to the disease.[229] In France generally, Fournier estimates that seventeen per cent. of the whole population have had syphilis, and at Toulouse, Audry considers that eighteen per cent. of all his patients are syphilitic. In Copenhagen, where notification is obligatory, over four per cent. of the population are said to be syphilitic. In America a committee of the Medical Society of New York, appointed to investigate the question, reported as the result of exhaustive inquiry that in the city of New York not less than a quarter of a million of cases of venereal disease occurred every year, and a leading New York dermatologist has stated that among the better cla.s.s families he knows intimately at least one-third of the sons have had syphilis. In Germany eight hundred thousand cases of venereal disease are by one authority estimated to occur yearly, and in the larger universities twenty-five per cent. of the students are infected every term, venereal disease being, however, specially common among students. The yearly number of men invalided in the German army by venereal diseases equals a third of the total number wounded in the Franco-Prussian war. Yet the German army stands fairly high as regards freedom from venereal disease when compared with the British army which is more syphilized than any other European army.[230] The British army, however, being professional and not national, is less representative of the people than is the case in countries where some form of conscription prevails. At one London hospital it could be ascertained that ten per cent. of the patients had had syphilis; this probably means a real proportion of about fifteen per cent., a high though not extremely high ratio. Yet it is obvious that even if the ratio is really lower than this the national loss in life and health, in defective procreation and racial deterioration, must be enormous and practically incalculable. Even in cash the venereal budget is comparable in amount to the general budget of a great nation. Stritch estimates that the cost to the British nation of venereal diseases in the army, navy and Government departments alone, amounts annually to 3,000,000, and when allowance is made for superannuations and sick-leave indirectly occasioned through these diseases, though not appearing in the returns as such, the more accurate estimate of the cost to the nation is stated to be 7,000,000. The adoption of simple hygienic measures for the prevention and the speedy cure of venereal diseases will be not only indirectly but even directly a source of immense wealth to the nation.

Syphilis is the most obviously and conspicuously appalling of the venereal diseases. Yet it is less frequent and in some respects less dangerously insidious than the other chief venereal disease, gonorrha.[231] At one time the serious nature of gonorrha, especially in women, was little realized. Men accepted it with a light heart as a trivial accident; women ignored it. This failure to realize the gravity of gonorrha, even sometimes on the part of the medical profession-so that it has been popularly looked upon, in Grandin's words, as of little more significance than a cold in the nose-has led to a reaction on the part of some towards an opposite extreme, and the risks and dangers of gonorrha have been even unduly magnified. This is notably the case as regards sterility. The inflammatory results of gonorrha are indubitably a potent cause of sterility in both s.e.xes; some authorities have stated that not only eighty per cent. of the deaths from inflammatory diseases of the pelvic organs and the majority of the cases of chronic invalidism in women, but ninety per cent. of involuntary sterile marriages, are due to gonorrha. Neisser, a great authority, ascribes to this disease without doubt fifty per cent, of such marriages. Even this estimate is in the experience of some observers excessive. It is fully proved that the great majority of men who have had gonorrha, even if they marry within two years of being infected, fail to convey the disease to their wives, and even of the women infected by their husbands more than half have children. This is, for instance, the result of Erb's experience, and Kisch speaks still more strongly in the same sense. b.u.mm, again, although regarding gonorrha as one of the two chief causes of sterility in women, finds that it is not the most frequent cause, being only responsible for about one-third of the cases; the other two-thirds are due to developmental faults in the genital organs. Dunning in America has reached results which are fairly concordant with b.u.mm's.

With regard to another of the terrible results of gonorrha, the part it plays in producing life-long blindness from infection of the eyes at birth, there has long been no sort of doubt. The Committee of the Ophthalmological Society in 1884, reported that thirty to forty-one per cent. of the inmates of four asylums for the blind in England owed their blindness to this cause.[232] In German asylums Reinhard found that thirty per cent. lost their sight from the same cause. The total number of persons blind from gonorrhal infection from their mothers at birth is enormous. The British Royal Commission on the Condition of the Blind estimated there were about seven thousand persons in the United Kingdom alone (or twenty-two per cent. of the blind persons in the country) who became blind as the result of this disease, and Mookerji stated in his address on Ophthalmalogy at the Indian Medical Congress of 1894 that in Bengal alone there were six hundred thousand totally blind beggars, forty per cent. of whom lost their sight at birth through maternal gonorrha; and this refers to the beggar cla.s.s alone.

Although gonorrha is liable to produce many and various calamities,[233] there can be no doubt that the majority of gonorrhal persons escape either suffering or inflicting any very serious injury. The special reason why gonorrha has become so peculiarly serious a scourge is its extreme prevalence. It is difficult to estimate the proportion of men and women in the general population who have had gonorrha, and the estimates vary within wide limits. They are often set too high. Erb, of Heidelberg, anxious to disprove exaggerated estimates of the prevalence of gonorrha, went over the records of two thousand two hundred patients in his private practice (excluding all hospital patients) and found the proportion of those who had suffered from gonorrha was 48.5 per cent.

Among the working cla.s.ses the disease is much less prevalent than among higher-cla.s.s people. In a Berlin Industrial Sick Club, 412 per 10,000 men and 69 per 10,000 women had gonorrha in a year; taking a series of years the Club showed a steady increase in the number of men, and decrease in the number of women, with venereal infection; this seems to indicate that the laboring cla.s.ses are beginning to have intercourse more with prost.i.tutes and less with respectable girls.[234] In America Wood Ruggles has given (as had Noggerath previously, for New York), the prevalence of gonorrha among adult males as from 75 to 80 per cent.; Tenney places it much lower, 20 per cent. for males and 5 per cent. for females. In England, a writer in the Lancet, some years ago,[235] found as the result of experience and inquiries that 75 per cent. adult males have had gonorrha once, 40 per cent. twice, 15 per cent. three or more times. According to Dulberg about twenty per cent. of new cases occur in married men of good social cla.s.s, the disease being comparatively rare among married men of the working cla.s.s in England.

Gonorrha in its prevalence is thus only second to measles and in the gravity of its results scarcely second to tuberculosis. "And yet," as Grandin remarks in comparing gonorrha to tuberculosis, "witness the activity of the crusade against the latter and the criminal apathy displayed when the former is concerned."[236] The public must learn to understand, another writer remarks, that "gonorrha is a pest that concerns its highest interests and most sacred relations as much as do smallpox, cholera, diphtheria, or tuberculosis."[237]

It cannot fairly be said that no attempts have been made to beat back the flood of venereal disease. On the contrary, such attempts have been made from the first. But they have never been effectual;[238] they have never been modified to changed condition; at the present day they are hopelessly unscientific and entirely opposed alike to the social and the individual demands of modern peoples. At the various conferences on this question which have been held during recent years the only generally accepted conclusion which has emerged is that all the existing systems of interference or non-interference with prost.i.tution are unsatisfactory.[239]

The character of prost.i.tution has changed and the methods of dealing with it must change. Brothels, and the systems of official regulation which grew up with special reference to brothels, are alike out of date; they have about them a mediaeval atmosphere, an antiquated spirit, which now render them unattractive and suspected. The conspicuously distinctive brothel is falling into disrepute; the liveried prost.i.tute absolutely under munic.i.p.al control can scarcely be said to exist. Prost.i.tution tends to become more diffused, more intimately mingled with social life generally, less easily distinguished as a definitely separable part of life. We can nowadays only influence it by methods of permeation which bear upon the whole of our social life.

The objection to the regulation of prost.i.tution is still of slow growth, but it is steadily developing everywhere, and may be traced equally in scientific opinion and in popular feeling. In France the munic.i.p.alities of some of the largest cities have either suppressed the system of regulation entirely or shown their disapproval of it, while an inquiry among several hundred medical men showed that less than one-third were in favor of maintaining regulation (Die Neue Generation, June, 1909, p. 244). In Germany, where there is in some respects more patient endurance of interference with the liberty of the individual than in France, England, or America, various elaborate systems for organizing prost.i.tution and dealing with venereal disease continue to be maintained, but they cannot be completely carried out, and it is generally admitted that in any case they could not accomplish the objects sought. Thus in Saxony no brothels are officially tolerated, though as a matter of fact they nevertheless exist. Here, as in many other parts of Germany, most minute and extensive regulations are framed for the use of prost.i.tutes. Thus at Leipzig they must not sit on the benches in public promenades, nor go to picture galleries, or theatres, or concerts, or restaurants, nor look out of their windows, nor stare about them in the street, nor smile, nor wink, etc., etc. In fact, a German prost.i.tute who possesses the heroic self-control to carry out conscientiously all the self-denying ordinances officially decreed for her guidance would seem to be ent.i.tled to a Government pension for life.

Two methods of dealing with prost.i.tution prevail in Germany. In some cities public houses of prost.i.tution are tolerated (though not licensed); in other cities prost.i.tution is "free," though "secret." Hamburg is the most important city where houses of prost.i.tution are tolerated and segregated. But, it is stated, "everywhere, by far the larger proportion of the prost.i.tutes belong to the so-called 'secret' cla.s.s." In Hamburg, alone, are suspected men, when accused of infecting women, officially examined; men of every social cla.s.s must obey a summons of this kind, which is issued secretly, and if diseased, they are bound to go under treatment, if necessary under compulsory treatment in the city hospital, until no longer dangerous to the community.

In Germany it is only when a woman has been repeatedly observed to act suspiciously in the streets that she is quietly warned; if the warning is disregarded she is invited to give her name and address to the police, and interviewed. It is not until these methods fail that she is officially inscribed as a prost.i.tute. The inscribed women, in some cities at all events, contribute to a sick benefit fund which pays their expenses when in hospital. The hesitation of the police to inscribe a woman on the official list is legitimate and inevitable, for no other course would be tolerated; yet the majority of prost.i.tutes begin their careers very young, and as they tend to become infected very early after their careers begin, it is obvious that this delay contributes to render the system of regulation ineffective. In Berlin, where there are no officially recognized brothels, there are some six thousand inscribed prost.i.tutes, but it is estimated that there are over sixty thousand prost.i.tutes who are not inscribed. (The foregoing facts are taken from a series of papers describing personal investigations in Germany made by Dr. F. Bierhoff, of New York, "Police Methods for the Sanitary Control of Prost.i.tution," New York Medical Journal, August, 1907.) The estimation of the amount of clandestine prost.i.tution can indeed never be much more than guesswork; exactly the same figure of sixty thousand is commonly brought forward as the probable number of prost.i.tutes not only in Berlin, but also in London and in New York. It is absolutely impossible to say whether it is under or over the real number, for secret prost.i.tution is quite intangible. Even if the facts were miraculously revealed there would still remain the difficulty of deciding what is and what is not prost.i.tution. The avowed and public prost.i.tute is linked by various gradations on the one side to the respectable girl living at home who seeks some little relief from the oppression of her respectability, and on the other hand to the married woman who has married for the sake of a home. In any case, however, it is very certain that public prost.i.tutes living entirely on the earnings of prost.i.tution form but a small proportion of the vast army of women who may be said, in a wide sense of the word, to be prost.i.tutes, i.e., who use their attractiveness to obtain from men not love alone, but money or goods.

"The struggle against syphilis is only possible if we agree to regard its victims as unfortunate and not as guilty.... We must give up the prejudice which has led to the creation of the term 'shameful diseases,' and which commands silence concerning this scourge of the family and of humanity." In these words of Duclaux, the distinguished successor of Pasteur at the Pasteur Inst.i.tute, in his n.o.ble and admirable work L'Hygiene Sociale, we have indicated to us, I am convinced, the only road by which we can approach the rational and successful treatment of the great social problem of venereal disease.

The supreme importance of this key to the solution of a problem which has often seemed insoluble is to-day beginning to become recognized in all quarters, and in every country. Thus a distinguished German authority, Professor Finger (Geschlecht und Gesellschaft, Bd. i, Heft 5) declares that venereal disease must not be regarded as the well-merited punishment for a debauched life, but as an unhappy accident. It seems to be in France, however, that this truth has been proclaimed with most courage and humanity, and not alone by the followers of science and medicine, but by many who might well be excused from interfering with so difficult and ungrateful a task. Thus the brothers, Paul and Victor Margueritte, who occupy a brilliant and honorable place in contemporary French letters, have distinguished themselves by advocating a more humane att.i.tude towards prost.i.tutes, and a more modern method of dealing with the question of venereal disease. "The true method of prevention is that which makes it clear to all that syphilis is not a mysterious and terrible thing, the penalty of the sin of the flesh, a sort of shameful evil branded by Catholic malediction, but an ordinary disease which may be treated and cured." It may be remarked that the aversion to acknowledge venereal disease is at least as marked in France as in any other country; "maladies honteuses" is a consecrated French term, just as "loathsome disease" is in English; "in the hospital," says Landret, "it requires much trouble to obtain an avowal of gonorrha, and we may esteem ourselves happy if the patient acknowledges the fact of having had syphilis."

No evils can be combated until they are recognized, simply and frankly, and honestly discussed. It is a significant and even symbolic fact that the bacteria of disease rarely flourish when they are open to the free currents of pure air. Obscurity, disguise, concealment furnish the best conditions for their vigor and diffusion, and these favoring conditions we have for centuries past accorded to venereal diseases. It was not always so, as indeed the survival of the word 'venereal' itself in this connection, with its reference to a G.o.ddess, alone suffices to show. Even the name "syphilis" itself, taken from a romantic poem in which Fracastorus sought a mythological origin for the disease, bears witness to the same fact. The romantic att.i.tude is indeed as much out of date as that of hypocritical and shamefaced obscurantism. We need to face these diseases in the same simple, direct, and courageous way which has already been adopted successfully in the ease of smallpox, a disease which, of old, men thought a.n.a.logous to syphilis and which was indeed once almost as terrible in its ravages.

At this point, however, we encounter those who say that it is unnecessary to show any sort of recognition of venereal diseases, and immoral to do anything that might seem to involve indulgence to those who suffer from such diseases; they have got what they deserve and may well be left to perish. Those who take this att.i.tude place themselves so far outside the pale of civilization-to say nothing of morality or religion-that they might well be disregarded. The progress of the race, the development of humanity, in fact and in feeling, has consisted in the elimination of an att.i.tude which it is an insult to primitive peoples to term savage. Yet it is an att.i.tude which should not be ignored for it still carries weight with many who are too weak to withstand those who juggle with fine moral phrases. I have even seen in a medical quarter the statement that venereal disease cannot be put on the same level with other infectious diseases because it is "the result of voluntary action." But all the diseases, indeed all the accidents and misfortunes of suffering human beings, are equally the involuntary results of voluntary actions. The man who is run over in crossing the street, the family poisoned by unwholesome food, the mother who catches the disease of the child she is nursing, all these suffer as the involuntary result of the voluntary act of gratifying some fundamental human instinct-the instinct of activity, the instinct of nutrition, the instinct of affection. The instinct of s.e.x is as fundamental as any of these, and the involuntary evils which may follow the voluntary act of gratifying it stand on exactly the same level. This is the essential fact: a human being in following the human instincts implanted within him has stumbled and fallen. Any person who sees, not this essential fact but merely some subsidiary aspect of it, reveals a mind that is twisted and perverted; he has no claim to arrest our attention.

But even if we were to adopt the standpoint of the would-be moralist, and to agree that everyone must be left to suffer his deserts, it is far indeed from being the fact that all those who contract venereal diseases are in any sense receiving their deserts. In a large number of cases the disease has been inflicted on them in the most absolutely involuntary manner. This is, of course, true in the case of the vast number of infants who are infected at conception or at birth. But it is also true in a scarcely less absolute manner of a large proportion of persons infected in later life.

Syphilis insontium, or syphilis of the innocent, as it is commonly called, may be said to fall into five groups: (1) the vast army of congenitally syphilitic infants who inherit the disease from father or mother; (2) the constantly occurring cases of syphilis contracted, in the course of their professional duties, by doctors, midwives and wet-nurses; (3) infection as a result of affection, as in simple kissing; (4) accidental infection from casual contacts and from using in common the objects and utensils of daily life, such as cups, towels, razors, knives (as in ritual circ.u.mcision), etc; (5) the infection of wives by their husbands.[240]

Hereditary congenital syphilis belongs to the ordinary pathology of the disease and is a chief element in its social danger since it is responsible for an enormous infantile mortality.[241] The risks of extragenital infection in the professional activity of doctors, midwives and wet-nurses is also universally recognized. In the case of wet-nurses infected by their employers' syphilitic infants at their breast, the penalty inflicted on the innocent is peculiarly harsh and unnecessary. The influence of infected low-cla.s.s midwives is notably dangerous, for they may inflict widespread injury in ignorance; thus the case has been recorded of a midwife, whose finger became infected in the course of her duties, and directly or indirectly contaminated one hundred persons. Kissing is an extremely common source of syphilitic infection, and of all extragenital regions the mouth is by far the most frequent seat of primary syphilitic sores. In some cases, it is true, especially in prost.i.tutes, this is the result of abnormal s.e.xual contacts. But in the majority of cases it is the result of ordinary and slight kisses as between young children, between parents and children, between lovers and friends and acquaintances. Fairly typical examples, which have been reported, are those of a child, kissed by a prost.i.tute, who became infected and subsequently infected its mother and grandmother; of a young French bride contaminated on her wedding-day by one of the guests who, according to French custom, kissed her on the cheek after the ceremony; of an American girl who, returning from a ball, kissed, at parting, the young man who had accompanied her home, thus acquiring the disease which she not long afterwards imparted in the same way to her mother and three sisters. The ignorant and unthinking are apt to ridicule those who point out the serious risks of miscellaneous kissing. But it remains nevertheless true that people who are not intimate enough to know the state of each other's health are not intimate enough to kiss each other. Infection by the use of domestic utensils, linen, etc., while comparatively rare among the better social cla.s.ses, is extremely common among the lower cla.s.ses and among the less civilized nations; in Russia, according to Tarnowsky, the chief authority, seventy per cent. of all cases of syphilis in the rural districts are due to this cause and to ordinary kissing, and a special conference in St. Petersburg in 1897, for the consideration of the methods of dealing with venereal disease, recorded its opinion to the same effect; much the same seems to be true regarding Bosnia and various parts of the Balkan peninsula where syphilis is extremely prevalent among the peasantry. As regards the last group, according to Bulkley in America, fifty per cent. of women generally contract syphilis innocently, chiefly from their husbands, while Fournier states that in France seventy-five per cent. of married women with syphilis have been infected by their husbands, most frequently (seventy per cent.) by husbands who were themselves infected before marriage and supposed that they were cured. Among men the proportion of syphilitics who have been accidentally infected, though less than among women, is still very considerable; it is stated to be at least ten per cent., and possibly it is a much larger proportion of cases. The scrupulous moralist who is anxious that all should have their deserts cannot fail to be still more anxious to prevent the innocent from suffering in place of the guilty. But it is absolutely impossible for him to combine these two aims; syphilis cannot be at the same time perpetuated for the guilty and abolished for the innocent.

I have been taking only syphilis into account, but nearly all that is said of the accidental infection of syphilis applies with equal or greater force to gonorrha, for though gonorrha does not enter into the system by so many channels as syphilis, it is a more common as well as a more subtle and elusive disease.

The literature of Syphilis Insontium is extremely extensive. There is a bibliography at the end of Duncan Bulkley's Syphilis in the Innocent, and a comprehensive summary of the question in a Leipzig Inaugural Dissertation by F. Moses, Zur Kasuistik der Extragenitalen Syphilis-infektion, 1904.

Even, however, when we have put aside the vast number of venereally infected people who may be said to be, in the narrowest and most conventionally moral sense, "innocent" victims of the diseases they have contracted, there is still much to be said on this question. It must be remembered that the majority of those who contract venereal diseases by illegitimate s.e.xual intercourse are young. They are youths, ignorant of life, scarcely yet escaped from home, still undeveloped, incompletely educated, and easily duped by women; in many cases they have met, as they thought, a "nice" girl, not indeed strictly virtuous but, it seemed to them, above all suspicion of disease, though in reality she was a clandestine prost.i.tute. Or they are young girls who have indeed ceased to be absolutely chaste, but have not yet lost all their innocence, and who do not consider themselves, and are not by others considered, prost.i.tutes; that indeed, is one of the rocks on which the system of police regulation of prost.i.tution comes to grief, for the police cannot catch the prost.i.tute at a sufficiently early stage. Of women who become syphilitic, according to Fournier, twenty per cent. are infected before they are nineteen; in hospitals the proportion is as high as forty per cent.; and of men fifteen per cent. cases occur between eleven and twenty-one years of age. The age of maximum frequency of infection is for women twenty years (in the rural population eighteen), and for men twenty-three years. In Germany Erb finds that as many as eighty-five per cent men with gonorrha contracted the disease between the ages of sixteen and twenty-five, a very small percentage being infected after thirty. These young things for the most part fell into a trap which Nature had baited with her most fascinating lure; they were usually ignorant; not seldom they were deceived by an attractive personality; often they were overcome by pa.s.sion; frequently all prudence and reserve had been lost in the fumes of wine. From a truly moral point of view they were scarcely less innocent than children.

"I ask," says Duclaux, "whether when a young man, or a young girl, abandon themselves to a dangerous caress society has done what it can to warn them. Perhaps its intentions were good, but when the need came for precise knowledge a silly prudery has held it back, and it has left its children without viatic.u.m.... I will go further, and proclaim that in a large number of cases the husbands who contaminate their wives are innocent. No one is responsible for the evil which he commits without knowing it and without willing it." I may recall the suggestive fact, already referred to, that the majority of husbands who infect their wives contracted the disease before marriage. They entered on marriage believing that their disease was cured, and that they had broken with their past. Doctors have sometimes (and quacks frequently) contributed to this result by too sanguine an estimate of the period necessary to destroy the poison. So great an authority as Fournier formerly believed that the syphilitic could safely be allowed to marry three or four years after the date of infection, but now, with increased experience, he extends the period to four or five years. It is undoubtedly true that, especially when treatment has been thorough and prompt, the diseased const.i.tution, in a majority of cases, can be brought under complete control in a shorter period than this, but there is always a certain proportion of cases in which the powers of infection persist for many years, and even when the syphilitic husband is no longer capable of infecting his wife he may still perhaps be in a condition to effect a disastrous influence on the offspring.

In nearly all these cases there was more or less ignorance-which is but another word for innocence as we commonly understand innocence-and when at last, after the event, the facts are more or less bluntly explained to the victim he frequently exclaims: "n.o.body told me!" It is this fact which condemns the pseudo-moralist. If he had seen to it that mothers began to explain the facts of s.e.x to their little boys and girls from childhood, if he had (as Dr. Joseph Price urges) taught the risks of venereal disease in the Sunday-school, if he had plainly preached on the relations of the s.e.xes from the pulpit, if he had seen to it that every youth at the beginning of adolescence received some simple technical instruction from his family doctor concerning s.e.xual health and s.e.xual disease-then, though there would still remain the need of pity for those who strayed from a path that must always be difficult to walk in, the would-be moralist at all events would in some measure be exculpated. But he has seldom indeed lifted a finger to do any of these things.

Even those who may be unwilling to abandon an att.i.tude of private moral intolerance towards the victims of venereal diseases may still do well to remember that since the public manifestation of their intolerance is mischievous, and at the best useless, it is necessary for them to restrain it in the interests of society. They would not be the less free to order their own personal conduct in the strictest accordance with their superior moral rigidity; and that after all is for them the main thing. But for the sake of society it is necessary for them to adopt what they may consider the convention of a purely hygienic att.i.tude towards these diseases. The erring are inevitably frightened by an att.i.tude of moral reprobation into methods of concealment, and these produce an endless chain of social evils which can only be dissipated by openness. As Duclaux has so earnestly insisted, it is impossible to grapple successfully with venereal disease unless we consent not to introduce our prejudices, or even our morals and religion, into the question, but treat it purely and simply as a sanitary question. And if the pseudo-moralist still has difficulty in cooperating towards the healing of this social sore he may be reminded that he himself-like every one of us little though we may know it-has certainly had a great army of syphilitic and gonorrhal persons among his own ancestors during the past four centuries. We are all bound together, and it is absurd, even when it is not inhuman, to cast contempt on our own flesh and blood.

I have discussed rather fully the att.i.tude of those who plead morality as a reason for ignoring the social necessity of combating venereal disease, because although there may not be many who seriously and understandingly adopt so anti-social and inhuman an att.i.tude there are certainly many who are glad at need of the existence of so fine an excuse for their moral indifference or their mental indolence.[242] When they are confronted by this great and difficult problem they find it easy to offer the remedy of conventional morality, although they are well aware that on a large scale that remedy has long been proved to be ineffectual. They ostentatiously affect to proffer the useless thick end of the wedge at a point where it is only possible with much skill and prudence to insinuate the thin working end.

The general acceptance of the fact that syphilis and gonorrha are diseases, and not necessarily crimes or sins, is the condition for any practical attempt to deal with this question from the sanitary point of view which is now taking the place of the antiquated and ineffective police point of view. The Scandinavian countries of Europe have been the pioneers in practical modern hygienic methods of dealing with venereal disease. There are several reasons why this has come about. All the problems of s.e.x-of s.e.xual love as well as of s.e.xual disease-have long been prominent in these countries, and an impatience with prudish hypocrisy seems here to have been more p.r.o.nounced than elsewhere; we see this spirit, for instance, emphatically embodied in the plays of Ibsen, and to some extent in Bjornson's works. The fearless and energetic temper of the people impels them to deal practically with s.e.xual difficulties, while their strong instincts of independence render them averse to the bureaucratic police methods which have flourished in Germany and France. The Scandinavians have thus been the natural pioneers of the methods of combating venereal diseases which are now becoming generally recognized to be the methods of the future, and they have fully organized the system of putting venereal diseases under the ordinary law and dealing with them as with other contagious diseases.

The first step in dealing with a contagious disease is to apply to it the recognized principles of notification. Every new application of the principle, it is true, meets with opposition. It is without practical result, it is an unwarranted inquisition into the affairs of the individual, it is a new tax on the busy medical pract.i.tioner, etc. Certainly notification by itself will not arrest the progress of any infectious disease. But it is an essential element in every attempt to deal with the prevention of disease. Unless we know precisely the exact incidence, local variations, and temporary fluctuations of a disease we are entirely in the dark and can only beat about at random. All progress in public hygiene has been accompanied by the increased notification of disease, and most authorities are agreed that such notification must be still further extended, any slight inconvenience thus caused to individuals being of trifling importance compared to the great public interests at stake. It is true that so great an authority as Neisser has expressed doubt concerning the extension of notification to gonorrha; the diagnosis cannot be infallible, and the patients often give false names. These objections, however, seem trivial; diagnosis can very seldom be infallible (though in this field no one has done so much for exact diagnosis as Neisser himself), and names are not necessary for notification, and are not indeed required in the form of compulsory notification of venereal disease which existed a few years ago in Norway.

The principle of the compulsory notification of venereal diseases seems to have been first established in Prussia, where it dates from 1835. The system here, however, is only partial, not being obligatory in all cases but only when in the doctor's opinion secrecy might be harmful to the patient himself or to the community; it is only obligatory when the patient is a soldier. This method of notification is indeed on a wrong basis, it is not part of a comprehensive sanitary system but merely an auxiliary to police methods of dealing with prost.i.tution. According to the Scandinavian system, notification, though not an essential part of this system, rests on an entirely different basis.

The Scandinavian plan in a modified form has lately been established in Denmark. This little country, so closely adjoining Germany, for some time followed in this matter the example of its great neighbor and adopted the police regulation of prost.i.tution and venereal disease. The more fundamental Scandinavian affinities of Denmark were, however, eventually a.s.serted, and in 1906, the system of regulation was entirely abandoned and Denmark resolved to rely on thorough and systematic application of the sanitary principle already accepted in the country, although something of German influence still persists in the strict regulation of the streets and the penalties imposed upon brothel-keepers, leaving prost.i.tution itself free. The decisive feature of the present system is, however, that the sanitary authorities are now exclusively medical. Everyone, whatever his social or financial position, is ent.i.tled to the free treatment of venereal disease. Whether he avails himself of it or not, he is in any case bound to undergo treatment. Every diseased person is thus, so far as it can be achieved, in a doctor's hands. All doctors have their instructions in regard to such cases, they have not only to inform their patients that they cannot marry so long as risks of infection are estimated to be present, but that they are liable for the expenses of treatment, as well as the dangers suffered, by any persons whom they may infect. Although it has not been possible to make the system at every point thoroughly operative, its general success is indicated by the entire reliance now placed on it, and the abandonment of the police regulation of prost.i.tution. A system very similar to that of Denmark was established some years previously in Norway. The principle of the treatment of venereal disease at the public expense exists also in Sweden as well as in Finland, where treatment is compulsory.[243]

It can scarcely be said that the principle of notification has yet been properly applied on a large scale to venereal diseases. But it is constantly becoming more widely advocated, more especially in England and the United States,[244] where national temperament and political traditions render the system of the police regulation of prost.i.tution impossible-even if it were more effective than it practically is-and where the system of dealing with venereal disease on the basis of public health has to be recognized as not only the best but the only possible system.[245]

In a.s.sociation with this, it is necessary, as is also becoming ever more widely recognized, that there should be the most ample facilities for the gratuitous treatment of venereal diseases; the general establishment of free dispensaries, open in the evenings, is especially necessary, for many can only seek advice and help at this time. It is largely to the systematic introduction of facilities for gratuitous treatment that the enormous reduction in venereal disease in Sweden, Norway, and Bosnia is attributed. It is the absence of the facilities for treatment, the implied feeling that the victims of venereal disease are not sufferers but merely offenders not ent.i.tled to care, that has in the past operated so disastrously in artificially promoting the dissemination of preventable diseases which might be brought under control.

If we dispense with the paternal methods of police regulation, if we rely on the general principles of medical hygiene, and for the rest allow the responsibility for his own good or bad actions to rest on the individual himself, there is a further step, already fully recognized in principle, which we cannot neglect to take: We must look on every person as accountable for the venereal diseases he transmits. So long as we refuse to recognize venereal diseases as on the same level as other infectious diseases, and so long as we offer no full and fair facilities for their treatment, it is unjust to bring the individual to account for spreading them. But if we publicly recognize the danger of infectious venereal diseases, and if we leave freedom to the individual, we must inevitably declare, with Duclaux, that every man or woman must be held responsible for the diseases he or she communicates.

According to the Oldenburg Code of 1814 it was a punishable offence for a venereally diseased person to have s.e.xual intercourse with a healthy person, whether or not infection resulted. In Germany to-day, however, there is no law of this kind, although eminent German legal authorities, notably Von Liszt, are of opinion that a paragraph should be added to the Code declaring that s.e.xual intercourse on the part of a person who knows that he is diseased should be punishable by imprisonment for a period not exceeding two years, the law not to be applied as between married couples except on the application of one of the parties. At the present time in Germany the transmission of venereal disease is only punishable as a special case of the infliction of bodily injury.[246] In this matter Germany is behind most of the Scandinavian countries where individual responsibility for venereal infection is well recognized and actively enforced.

In France, though the law is not definite and satisfactory, actions for the transmission of syphilis are successfully brought before the courts. Opinion seems to be more decisively in favor of punishment for this offense than it is in Germany. In 1883 Despres discussed the matter and considered the objections. Few may avail themselves of the law, he remarks, but all would be rendered more cautious by the fear of infringing it; while the difficulties of tracing and proving infection are not greater, he points out, than those of tracing and proving paternity in the case of illegitimate children. Despres would punish with imprisonment for not more than two years any person, knowing himself to be diseased, who transmitted a venereal disease, and would merely fine those who communicated the contagion by imprudence, not realizing that they were diseased.[247] The question has more recently been discussed by Aurientis in a Paris thesis. He states that the present French law as regards the transmission of s.e.xual diseases is not clearly established and is difficult to act upon, but it is certainly just that those who have been contaminated and injured in this way should easily be able to obtain reparation. Although it is admitted in principle that the communication of syphilis is an offence even under common law he is in agreement with those who would treat it as a special offence, making a new and more practical law.[248] Heavy damages are even at the present time obtained in the French courts from men who have infected young women in s.e.xual intercourse, and also from the doctors as well as the mothers of syphilitic infants who have infected the foster-mothers they were entrusted to. Although the French Penal Code forbids in general the disclosure of professional secrets, it is the duty of the medical pract.i.tioner to warn the foster-mother in such a case of the danger she is incurring, but without naming the disease; if he neglects to give this warning he may be held liable.

In England, as well as in the United States, the law is more unsatisfactory and more helpless, in relation to this cla.s.s of offences, than it is in France. The mischievous and barbarous notion, already dealt with, according to which venereal disease is the result of illicit intercourse and should be tolerated as a just visitation of G.o.d, seems still to flourish in these countries with fatal persistency. In England the communication of venereal disease by illicit intercourse is not an actionable wrong if the act of intercourse has been voluntary, even although there has been wilful and intentional concealment of the disease. Ex turpi causa non oritur actio, it is sententiously said; for there is much dormitative virtue in a Latin maxim. No legal offence has still been committed if a husband contaminates his wife, or a wife her husband.[249] The "freedom" enjoyed in this matter by England and the United States is well ill.u.s.trated by an American case quoted by Dr. Isidore Dyer, of New Orleans, in his report to the Brussels Conference on the Prevention of Venereal Diseases, in 1899: "A patient with primary syphilis refused even charitable treatment and carried a book wherein she kept the number of men she had inoculated. When I first saw her she declared the number had reached two hundred and nineteen and that she would not be treated until she had had revenge on five hundred men." In a community where the most elementary rules of justice prevailed facilities would exist to enable this woman to obtain damages from the man who had injured her or even to secure his conviction to a term of imprisonment. In obtaining some indemnity for the wrong done her, and securing the "revenge" she craved, she would at the same time have conferred a benefit on society. She is shut out from any action against the one person who injured her; but as a sort of compensation she is allowed to become a radiating focus of disease, to shorten many lives, to cause many deaths, to pile up incalculable damages; and in so doing she is to-day perfectly within her legal rights. A community which encourages this state of things is not only immoral but stupid.

There seems, however, to be a growing body of influential opinion, both in England and in the United States, in favor of making the transmission of venereal disease an offence punishable by heavy fine or by imprisonment.[250] In any enactment no stress should be put on the infection being conveyed "knowingly." Any formal limitation of this kind is unnecessary, as in such a case the Court always takes into account the offender's ignorance or mere negligence, and it is mischievous because it tends to render an enactment ineffective and to put a premium on ignorance; the husbands who infect their wives with gonorrha immediately after marriage have usually done so from ignorance, and it should be at least necessary for them to prove that they have been fortified in their ignorance by medical advice. It is sometimes said that the existing law could be utilized for bringing actions of this kind, and that no greater facilities should be offered for fear of increasing attempts at blackmail. The inutility of the law at present for this purpose is shown by the fact that it seldom or never happens that any attempt is made to utilize it, while not only are there a number of existing punishable offences which form the subject of attempts at blackmail, but blackmail can still be demanded even in regard to disreputable actions that are not legally punishable at all. Moreover, the attempt to levy blackmail is itself an offence always sternly dealt with in the courts.