THE CONQUEST OF THE VENEREAL DISEASES

Studies in the Psychology of Sex, Volume 6 by Havelock Ellis is part of the HackerNoon Books Series. You can jump to any chapter in this book here. THE CONQUEST OF THE VENEREAL DISEASES

VIII. THE CONQUEST OF THE VENEREAL DISEASES

The Significance of the Venereal Diseases—The History of Syphilis—The Problem of Its Origin—The Social Gravity of Syphilis—The Social Dangers of Gonorrhœa—The Modern Change in the Methods of Combating Venereal Diseases—Causes of the Decay of the System of Police Regulation—Necessity of Facing the Facts—The Innocent Victims of Venereal Diseases—Diseases Not Crimes—The Principle of Notification—The Scandinavian System—Gratuitous Treatment—Punishment for Transmitting Venereal Diseases—Sexual Education in Relation to Venereal Diseases—Lectures, Etc.—Discussion in Novels and on the Stage—The "Disgusting" Not the "Immoral."

It may, perhaps, excite surprise that in the preceding discussion of prostitution scarcely a word has been said of venereal diseases. In the eyes of many people, the question of prostitution is simply the question of syphilis. But from the psychological point of view with which we are directly concerned, as from the moral point of view with which we cannot fail to be indirectly concerned, the question of the diseases which may be, and so frequently are, associated with prostitution cannot be placed in the first line of significance. The two questions, however intimately they may be mingled, are fundamentally distinct. Not only would venereal diseases still persist even though prostitution had absolutely ceased, but, on the other hand, when we have brought syphilis under the same control as we have brought the somewhat analogous disease of leprosy, the problem of prostitution would still remain.

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 prostitution, and even the whole question of the sexual relationships, are, to some extent, affected by the existence of the serious diseases which are specially liable to be propagated by sexual 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 sexes, 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 classic authors, that syphilis existed in Rome under the Cæsars, 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 passed 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 classic times, he considers, as coming from Egypt, though he looked upon its real home as Asia. Leopold Glück has likewise quoted (Archiv für Dermatologie und Syphilis, January, 1899) passages 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 classic antiquity. A. V. Notthaft ("Die Legende von der Althertums-syphilis," in the Rindfleisch Festschrift, 1907, pp. 377-592) has critically investigated the passages in classic authors which were supposed by Rosenbaum, Buret, Proksch and others to refer to syphilis. It is quite true, Notthaft admits, that many of these passages 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 damning 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 Japanese physician, Okamura, has shown (Monatsschrift für 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 für Ethnologie, Heft 2 and 3, 1899, p. 216). From another side, Seler, the distinguished authority on Mexican antiquity, shows (Zeitschrift für 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 constitute 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 sexual 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 Bassereau, first taught the complete independence of syphilis both from gonorrhœa and soft chancre, at the same time expounding clearly the three stages, primary, secondary and tertiary, through which syphilitic manifestations tend to pass, 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 gonorrhœa. 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 Lassar, by inoculation, from monkey to monkey—Fritz Schaudinn made his great discovery of the protozoal Spirochœta 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 succumb, leaving little or no traces of its ravages behind. It penetrates ever deeper and deeper into the organism, with the passage 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 sexual 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 anæmia 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 Näcke 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 Association, embodying the most competent English authority on this question, unanimously passed 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 class 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, gonorrhœa.[231] At one time the serious nature of gonorrhœa, 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 gonorrhœa, 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 gonorrhœa have been even unduly magnified. This is notably the case as regards sterility. The inflammatory results of gonorrhœa are indubitably a potent cause of sterility in both sexes; 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 gonorrhœa. 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 gonorrhœa, 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. Bumm, again, although regarding gonorrhœa 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 Bumm's.

With regard to another of the terrible results of gonorrhœa, 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 gonorrhœal 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 gonorrhœa; and this refers to the beggar class alone.

Although gonorrhœa is liable to produce many and various calamities,[233] there can be no doubt that the majority of gonorrhœal persons escape either suffering or inflicting any very serious injury. The special reason why gonorrhœa 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 gonorrhœa, 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 gonorrhœa, 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 gonorrhœa was 48.5 per cent.

Among the working classes the disease is much less prevalent than among higher-class people. In a Berlin Industrial Sick Club, 412 per 10,000 men and 69 per 10,000 women had gonorrhœa 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 classes are beginning to have intercourse more with prostitutes and less with respectable girls.[234] In America Wood Ruggles has given (as had Noggerath previously, for New York), the prevalence of gonorrhœa 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 gonorrhœa 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 class, the disease being comparatively rare among married men of the working class in England.

Gonorrhœa 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 gonorrhœa 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 "gonorrhœa 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 prostitution are unsatisfactory.[239]

The character of prostitution 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 mediæval atmosphere, an antiquated spirit, which now render them unattractive and suspected. The conspicuously distinctive brothel is falling into disrepute; the liveried prostitute absolutely under municipal control can scarcely be said to exist. Prostitution 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 prostitution 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 municipalities 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 prostitution 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 prostitutes. 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 prostitute who possesses the heroic self-control to carry out conscientiously all the self-denying ordinances officially decreed for her guidance would seem to be entitled to a Government pension for life.

Two methods of dealing with prostitution prevail in Germany. In some cities public houses of prostitution are tolerated (though not licensed); in other cities prostitution is "free," though "secret." Hamburg is the most important city where houses of prostitution are tolerated and segregated. But, it is stated, "everywhere, by far the larger proportion of the prostitutes belong to the so-called 'secret' class." In Hamburg, alone, are suspected men, when accused of infecting women, officially examined; men of every social class 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 prostitute. 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 prostitutes 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 prostitutes, but it is estimated that there are over sixty thousand prostitutes 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 Prostitution," New York Medical Journal, August, 1907.) The estimation of the amount of clandestine prostitution can indeed never be much more than guesswork; exactly the same figure of sixty thousand is commonly brought forward as the probable number of prostitutes 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 prostitution is quite intangible. Even if the facts were miraculously revealed there would still remain the difficulty of deciding what is and what is not prostitution. The avowed and public prostitute 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 prostitutes living entirely on the earnings of prostitution form but a small proportion of the vast army of women who may be said, in a wide sense of the word, to be prostitutes, 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 Institute, in his noble and admirable work L'Hygiène 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 attitude towards prostitutes, 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 gonorrhœa, 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 goddess, 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 attitude 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 analogous 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 attitude 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 attitude which it is an insult to primitive peoples to term savage. Yet it is an attitude 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 sex 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 circumcision), 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-class 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 prostitutes, this is the result of abnormal sexual 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 prostitute, 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 classes, is extremely common among the lower classes 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 gonorrhœa, for though gonorrhœa 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 sexual 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 prostitute. 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, prostitutes; that indeed, is one of the rocks on which the system of police regulation of prostitution comes to grief, for the police cannot catch the prostitute 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 gonorrhœa 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 passion; 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 viaticum.... 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 constitution, 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: "Nobody 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 sex 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 sexes 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 sexual health and sexual 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 attitude 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 attitude towards these diseases. The erring are inevitably frightened by an attitude 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 coöperating 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 gonorrhœal 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 attitude 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 attitude 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 gonorrhœa 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 sex—of sexual love as well as of sexual disease—have long been prominent in these countries, and an impatience with prudish hypocrisy seems here to have been more pronounced than elsewhere; we see this spirit, for instance, emphatically embodied in the plays of Ibsen, and to some extent in Björnson's works. The fearless and energetic temper of the people impels them to deal practically with sexual 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 practitioner, 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 gonorrhœa; 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 prostitution. 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 prostitution and venereal disease. The more fundamental Scandinavian affinities of Denmark were, however, eventually asserted, 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 prostitution 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 entitled 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 prostitution. 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 prostitution 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 association 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 entitled 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 sexual 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 sexual 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 Després 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. Després 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 sexual 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 sexual 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 practitioner 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 class 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 God, 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 causâ 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 illustrated 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 gonorrhœa 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.

It is possible to trace the beginning of a recognition that the transmission of a venereal disease is a matter of which legal cognizance may be taken in the English law courts. It is now well settled that the infection of a wife by her husband may be held to constitute the legal cruelty which, according to the present law, must be proved, in addition to adultery, before a wife can obtain divorce from her husband. In 1777 Restif de la Bretonne proposed in his Gynographes that the communication of a venereal disease should itself be an adequate ground for divorce; this, however, is not at present generally accepted.[251]

It is sometimes said that it is very well to make the individual legally responsible for the venereal disease he communicates, but that the difficulties of bringing that responsibility home would still remain. And those who admit these difficulties frequently reply that at the worst we should have in our hands a means of educating responsibility; the man who deliberately ran the risk of transmitting such infection would be made to feel that he was no longer fairly within his legal rights but had done a bad action. We are thus led on finally to what is now becoming generally recognized as the chief and central method of combating venereal disease, if we are to accept the principle of individual responsibility as ruling in this sphere of life. Organized sanitary and medical precautions, and proper legal protection for those who have been injured, are inoperative without the educative influence of elementary hygienic instruction placed in the possession of every young man and woman. In a sphere that is necessarily so intimate medical organization and legal resort can never be all-sufficing; knowledge is needed at every step in every individual to guide and even to awaken that sense of personal moral responsibility which must here always rule. Wherever the importance of these questions is becoming acutely realized—and notably at the Congresses of the German Society for Combating Venereal Disease—the problem is resolving itself mainly into one of education.[252] And although opinion and practice in this matter are to-day more advanced in Germany than elsewhere the conviction of this necessity is becoming scarcely less pronounced in all other civilized countries, in England and America as much as in France and the Scandinavian lands.

A knowledge of the risks of disease by sexual intercourse, both in and out of marriage,—and indeed, apart from sexual intercourse altogether,—is a further stage of that sexual education which, as we have already seen, must begin, so far as the elements are concerned, at a very early age. Youths and girls should be taught, as the distinguished Austrian economist, Anton von Menger wrote, shortly before his death, in his excellent little book, Neue Sittenlehre, that the production of children is a crime when the parents are syphilitic or otherwise incompetent through transmissible chronic diseases. Information about venereal disease should not indeed be given until after puberty is well established. It is unnecessary and undesirable to impart medical knowledge to young boys and girls and to warn them against risks they are yet little liable to be exposed to. It is when the age of strong sexual instinct, actual or potential, begins that the risks, under some circumstances, of yielding to it, need to be clearly present to the mind. No one who reflects on the actual facts of life ought to doubt that it is in the highest degree desirable that every adolescent youth and girl ought to receive some elementary instruction in the general facts of venereal disease, tuberculosis, and alcoholism. These three "plagues of civilization" are so widespread, so subtle and manifold in their operation, that everyone comes in contact with them during life, and that everyone is liable to suffer, even before he is aware, perhaps hopelessly and forever, from the results of that contact. Vague declamation about immorality and vaguer warnings against it have no effect and possess no meaning, while rhetorical exaggeration is unnecessary. A very simple and concise statement of the actual facts concerning the evils that beset life is quite sufficient and adequate, and quite essential. To ignore this need is only possible to those who take a dangerously frivolous view of life.

It is the young woman as much as the youth who needs this enlightenment. There are still some persons so ill-informed as to believe that though it may be necessary to instruct the youth it is best to leave his sister unsullied, as they consider it, by a knowledge of the facts of life. This is the very reverse of the truth. It is desirable indeed that all should be acquainted with facts so vital to humanity, even although not themselves personally concerned. But the girl is even more concerned than the youth. A man has the matter more within his own grasp, and if he so chooses he may avoid all the grosser risks of contact with venereal disease. But it is not so with the woman. Whatever her own purity, she cannot be sure that she may not have to guard against the possibility of disease in her future husband as well as in those to whom she may entrust her child. It is a possibility which the educated woman, so far from being dispensed from, is more liable to encounter than is the working-class woman, for venereal disease is less prevalent among the poor than the rich.[253] The careful physician, even when his patient is a minister of religion, considers it his duty to inquire if he has had syphilis, and the clergyman of most severely correct life recognizes the need of such inquiry and may perhaps smile, but seldom feels himself insulted. The relationship between husband and wife is even much more intimate and important than that between doctor and patient, and a woman is not dispensed from the necessity of such inquiry concerning her future husband by the conviction that the reply must surely be satisfactory. Moreover, it may well be in some cases that, if she is adequately enlightened, she may be the means of saving him, before it is too late, from the guilt of premature marriage and its fateful consequences, so deserving to earn his everlasting gratitude. Even if she fails in winning that, she still has her duty to herself and to the future race which her children will help to form.

In most countries there is a growing feeling in favor of the enlightenment of young women equally with young men as regards venereal diseases. Thus in Germany Max Flesch, in his Prostitution und Frauenkrankheiten, considers that at the end of their school days all girls should receive instruction concerning the grave physical and social dangers to which women are exposed in life. In France Duclaux (in his L'Hygiène Sociale) is emphatic that women must be taught. "Already," he states, "doctors who by custom have been made, in spite of themselves, the husband's accomplices, will tell you of the ironical gaze they sometimes encounter when they seek to lead a wife astray concerning the causes of her ills. The day is approaching of a revolt against the social lie which has made so many victims, and you will be obliged to teach women what they need to know in order to guard themselves against you." It is the same in America. Reform in this field, Isidore Dyer declares, must emblazon on its flag the motto, "Knowledge is Health," as well of mind as of body, for women as well as for men. In a discussion introduced by Denslow Lewis at the annual meeting of the American Medical Association in 1901 on the limitation of venereal diseases (Medico-Legal Journal, June and September, 1903), there was a fairly general agreement among all the speakers that almost or quite the chief method of prevention lay in education, the education of women as much as of men. "Education lies at the bottom of the whole thing," declared one speaker (Seneca Egbert, of Philadelphia), "and we will never gain much headway until every young man, and every young woman, even before she falls in love and becomes engaged, knows what these diseases are, and what it will mean if she marries a man who has contracted them." "Educate father and mother, and they will educate their sons and daughters," exclaims Egbert Grandin, more especially in regard to gonorrhœa (Medical Record, May 26, 1906); "I lay stress on the daughter because she becomes the chief sufferer from inoculation, and it is her right to know that she should protect herself against the gonorrhœic as well as against the alcoholic."

We must fully face the fact that it is the woman herself who must be accounted responsible, as much as a man, for securing the right conditions of a marriage she proposes to enter into. In practice, at the outset, that responsibility may no doubt be in part delegated to parents or guardians. It is unreasonable that any false delicacy should be felt about this matter on either side. Questions of money and of income are discussed before marriage, and as public opinion grows sounder none will question the necessity of discussing the still more serious question of health, alike that of the prospective bridegroom and of the bride. An incalculable amount of disease and marital unhappiness would be prevented if before an engagement was finally concluded each party placed himself or herself in the hands of a physician and authorized him to report to the other party. Such a report would extend far beyond venereal disease. If its necessity became generally recognized it would put an end to much fraud which now takes place when entering the marriage bond. It constantly happens at present that one party or the other conceals the existence of some serious disease or disability which is speedily discovered after marriage, sometimes with a painful and alarming shock—as when a man discovers his wife in an epileptic fit on the wedding night—and always with the bitter and abiding sense of having been duped. There can be no reasonable doubt that such concealment is an adequate cause of divorce. Sir Thomas More doubtless sought to guard against such frauds when he ordained in his Utopia that each party should before marriage be shown naked to the other. The quaint ceremony he describes was based on a reasonable idea, for it is ludicrous, if it were not often tragic in its results, that any person should be asked to undertake to embrace for life a person whom he or she has not so much as seen.

It may be necessary to point out that every movement in this direction must be the spontaneous action of individuals directing their own lives according to the rules of an enlightened conscience, and cannot be initiated by the dictation of the community as a whole enforcing its commands by law. In these matters law can only come in at the end, not at the beginning. In the essential matters of marriage and procreation laws are primarily made in the brains and consciences of individuals for their own guidance. Unless such laws are already embodied in the actual practice of the great majority of the community it is useless for parliaments to enact them by statute. They will be ineffective or else they will be worse than ineffective by producing undesigned mischiefs. We can only go to the root of the matter by insisting on education in moral responsibility and instruction, in matters of fact.

The question arises as to the best person to impart this instruction. As we have seen there can be little doubt that before puberty the parents, and especially the mother, are the proper instructors of their children in esoteric knowledge. But after puberty the case is altered. The boy and the girl are becoming less amenable to parental influence, there is greater shyness on both sides, and the parents rarely possess the more technical knowledge that is now required. At this stage it seems that the assistance of the physician, of the family doctor if he has the proper qualities for the task, should be called in. The plan usually adopted, and now widely carried out, is that of lectures setting forth the main facts concerning venereal diseases, their dangers, and allied topics.[254] This method is quite excellent. Such lectures should be delivered at intervals by medical lecturers at all urban, educational, manufacturing, military, and naval centres, wherever indeed a large number of young persons are gathered together. It should be the business of the central educational authority either to carry them out or to enforce on those controlling or employing young persons the duty of providing such lectures. The lectures should be free to all who have attained the age of sixteen.

In Germany the principle of instruction by lectures concerning venereal diseases seems to have become established, at all events so far as young men are concerned, and such lectures are constantly becoming more usual. In 1907 the Minister of Education established courses of lectures by doctors on sexual hygiene and venereal diseases for higher schools and educational institutions, though attendance was not made compulsory. The courses now frequently given by medical men to the higher classes in German secondary schools on the general principles of sexual anatomy and physiology nearly always include sexual hygiene with special reference to venereal diseases (see, e.g., Sexualpädagogik, pp. 131-153). In Austria, also, lectures on personal hygiene and the dangers of venereal disease are delivered to students about to leave the gymnasium for the university; and the working men's clubs have instituted regular courses of lectures on the same subjects delivered by physicians. In France many distinguished men, both inside and outside the medical profession, are working for the cause of the instruction of the young in sexual hygiene, though they have to contend against a more obstinate degree of prejudice and prudery on the part of the middle class than is to be found in the Germanic lands. The Commission Extraparlementaire du Régime des Mœurs, with the conjunction of Augagneur, Alfred Fournier, Yves Guyot, Gide, and other distinguished professors, teachers, etc., has lately pronounced in favor of the official establishment of instruction in sexual hygiene, to be given in the highest classes at the lycées, or in the earliest class at higher educational colleges; such instruction, it is argued, would not only furnish needed enlightenment, but also educate the sense of moral responsibility. There is in France, also, an active and distinguished though unofficial Société Française de Prophylaxie Sanitaire et Morale, which delivers public lectures on sexual hygiene. Fournier, Pinard, Burlureaux and other eminent physicians have written pamphlets on this subject for popular distribution (see, e.g., Le Progrès Médical of September, 1907). In England and the United States very little has yet been done in this direction, but in the United States, at all events, opinion in favor of action is rapidly growing (see, e.g., W. A. Funk, "The Venereal Peril," Medical Record, April 13, 1907). The American Society of Sanitary and Moral Prophylaxis (based on the parent society founded in Paris in 1900 by Fournier) was established in New York in 1905. There are similar societies in Chicago and Philadelphia. The main object is to study venereal diseases and to work toward their social control. Doctors, laymen, and women are members. Lectures and short talks are now given under the auspices of these societies to small groups of young women in social settlements, and in other ways, with encouraging success; it is found to be an excellent method of reaching the young women of the working classes. Both men and women physicians take part in the lectures (Clement Cleveland, Presidential Address on "Prophylaxis of Venereal Diseases," Transactions American Gynecological Society, Philadelphia, vol. xxxii, 1907).

An important auxiliary method of carrying out the task of sexual hygiene, and at the same time of spreading useful enlightenment, is furnished by the method of giving to every syphilitic patient in clinics where such cases are treated a card of instruction for his guidance in hygienic matters, together with a warning of the risks of marriage within four or five years after infection, and in no case without medical advice. Such printed instruction, in clear, simple, and incisive language, should be put into the hands of every syphilitic patient as a matter of routine, and it might be as well to have a corresponding card for gonorrhœal patients. This plan has already been introduced at some hospitals, and it is so simple and unobjectionable a precaution that it will, no doubt, be generally adopted. In some countries this measure is carried out on a wider scale. Thus in Austria, as the result of a movement in which several university professors have taken an active part, leaflets and circulars, explaining briefly the chief symptoms of venereal diseases and warning against quacks and secret remedies, are circulated among young laborers and factory hands, matriculating students, and scholars who are leaving trade schools.

In France, where great social questions are sometimes faced with a more chivalrous daring than elsewhere, the dangers of syphilis, and the social position of the prostitute, have alike been dealt with by distinguished novelists and dramatists. Huysmans inaugurated this movement with his first novel, Marthe, which was immediately suppressed by the police. Shortly afterwards Edmond de Goncourt published La Fille Elisa, the first notable novel of the kind by a distinguished author. It was written with much reticence, and was not indeed a work of high artistic value, but it boldly faced a great social problem and clearly set forth the evils of the common attitude towards prostitution. It was dramatized and played by Antoine at the Théâtre Libre, but when, in 1891, Antoine wished to produce it at the Porte-Saint-Martin Theatre, the censor interfered and prohibited the play on account of its "contexture générale." The Minister of Education defended this decision on the ground that there was much in the play that might arouse repugnance and disgust. "Repugnance here is more moral than attraction," exclaimed M. Paul Déroulède, and the newspapers criticized a censure which permitted on the stage all the trivial indecencies which favor prostitution, but cannot tolerate any attack on prostitution. In more recent years the brothers Margueritte, both in novels and in journalism, have largely devoted their distinguished abilities and high literary skill to the courageous and enlightened advocacy of many social reforms. Victor Margueritte, in his Prostituée (1907)—a novel which has attracted wide attention and been translated into various languages—has sought to represent the condition of women in our actual society, and more especially the condition of the prostitute under what he regards as the odious and iniquitous system still prevailing. The book is a faithful picture of the real facts, thanks to the assistance the author received from the Paris Préfecture of Police, and largely for that reason is not altogether a satisfactory work of art, but it vividly and poignantly represents the cruelty, indifference, and hypocrisy so often shown by men towards women, and is a book which, on that account, cannot be too widely read. One of the most notable of modern plays is Brieux's Les Avariés (1902). This distinguished dramatist, himself a medical man, dedicates his play to Fournier, the greatest of syphilographers. "I think with you," he writes here, "that syphilis will lose much of its danger when it is possible to speak openly of an evil which is neither a shame nor a punishment, and when those who suffer from it, knowing what evils they may propagate, will better understand their duties towards others and towards themselves." The story developed in the drama is the old and typical story of the young man who has spent his bachelor days in what he considers a discrete and regular manner, having only had two mistresses, neither of them prostitutes, but at the end of this period, at a gay supper at which he bids farewell to his bachelor life, he commits a fatal indiscretion and becomes infected by syphilis; his marriage is approaching and he goes to a distinguished specialist who warns him that treatment takes time, and that marriage is impossible for several years; he finds a quack, however, who undertakes to cure him in six months; at the end of the time he marries; a syphilitic child is born; the wife discovers the state of things and forsakes her home to return to her parents; her indignant father, a deputy in Parliament, arrives in Paris; the last word is with the great specialist who brings finally some degree of peace and hope into the family. The chief morals Brieux points out are that it is the duty of the bride's parents before marriage to ascertain the bridegroom's health; that the bridegroom should have a doctor's certificate; that at every marriage the part of the doctors is at least as important as that of the lawyers. Even if it were a less accomplished work of art than it is, Les Avariés is a play which, from the social and educative point of view alone, all who have reached the age of adolescence should be compelled to see.

Another aspect of the same problem has been presented in Plus Fort que le Mal, a book written in dramatic form (though not as a properly constituted play intended for the stage) by a distinguished French medical author who here adopts the name of Espy de Metz. The author (who is not, however, pleading pro domo) calls for a more sympathetic attitude towards those who suffer from syphilis, and though he writes with much less dramatic skill than Brieux, and scarcely presents his moral in so unequivocal a form, his work is a notable contribution to the dramatic literature of syphilis.

It will probably be some time before these questions, poignant as they are from the dramatic point of view, and vitally important from the social point of view, are introduced on the English or the American stage. It is a remarkable fact that, notwithstanding the Puritanic elements which still exist in Anglo-Saxon thought and feeling generally, the Puritanic aspect of life has never received embodiment in the English or American drama. On the English stage it is never permitted to hint at the tragic side of wantonness; vice must always be made seductive, even though a deus ex machina causes it to collapse at the end of the performance. As Mr. Bernard Shaw has said, the English theatrical method by no means banishes vice; it merely consents that it shall be made attractive; its charms are advertised and its penalties suppressed. "Now, it is futile to plead that the stage is not the proper place for the representation and discussion of illegal operations, incest, and venereal disease. If the stage is the proper place for the exhibition and discussion of seduction, adultery, promiscuity, and prostitution, it must be thrown open to all the consequences of these things, or it will demoralize the nation."

The impulse to insist that vice shall always be made attractive is not really, notwithstanding appearances, a vicious impulse. It arises from a mental confusion, a common psychic tendency, which is by no means confined to Anglo-Saxon lands, and is even more well marked among the better educated in the merely literary sense, than among the worse educated people. The æsthetic is confused with the moral, and what arouses disgust is thus regarded as immoral. In France the novels of Zola, the most pedestrianally moralistic of writers, were for a long time supposed to be immoral because they were often disgusting. The same feeling is still more widespread in England. If a prostitute is brought on the stage, and she is pretty, well-dressed, seductive, she may gaily sail through the play and every one is satisfied. But if she were not particularly pretty, well-dressed, or seductive, if it were made plain that she was diseased and was reckless in infecting others with that disease, if it were hinted that she could on occasion be foul-mouthed, if, in short, a picture were shown from life—then we should hear that the unfortunate dramatist had committed something that was "disgusting" and "immoral." Disgusting it might be, but, on that very account, it would be moral. There is a distinction here that the psychologist cannot too often point out or the moralist too often emphasize.

It is not for the physician to complicate and confuse his own task as teacher by mixing it up with considerations which belong to the spiritual sphere. But in carrying out impartially his own special work of enlightenment he will always do well to remember that there is in the adolescent mind, as it has been necessary to point out in a previous chapter, a spontaneous force working on the side of sexual hygiene. Those who believe that the adolescent mind is merely bent on sensual indulgence are not less false and mischievous in their influence than are those who think it possible and desirable for adolescents to be preserved in sheer sexual ignorance. However concealed, suppressed, or deformed—usually by the misplaced and premature zeal of foolish parents and teachers—there arise at puberty ideal impulses which, even though they may be rooted in sex, yet in their scope transcend sex. These are capable of becoming far more potent guides of the physical sex impulse than are merely material or even hygienic considerations.

It is time to summarize and conclude this discussion of the prevention of venereal disease, which, though it may seem to the superficial observer to be merely a medical and sanitary question outside the psychologist's sphere, is yet seen on closer view to be intimately related even to the most spiritual conception of the sexual relationships. Not only are venereal diseases the foes to the finer development of the race, but we cannot attain to any wholesome and beautiful vision of the relationships of sex so long as such relationships are liable at every moment to be corrupted and undermined at their source. We cannot yet precisely measure the interval which must elapse before, so far as Europe at least is concerned, syphilis and gonorrhœa are sent to that limbo of monstrous old dead diseases to which plague and leprosy have gone and smallpox is already drawing near. But society is beginning to realize that into this field also must be brought the weapons of light and air, the sword and the breastplate with which all diseases can alone be attacked. As we have seen, there are four methods by which in the more enlightened countries venereal disease is now beginning to be combated.[255] (1) By proclaiming openly that the venereal diseases are diseases like any other disease, although more subtle and terrible than most, which may attack anyone from the unborn baby to its grandmother, and that they are not, more than other diseases, the shameful penalties of sin, from which relief is only to be sought, if at all, by stealth, but human calamities; (2) by adopting methods of securing official information concerning the extent, distribution, and variation of venereal disease, through the already recognized plan of notification and otherwise, and by providing such facilities for treatment, especially for free treatment, as may be found necessary; (3) by training the individual sense of moral responsibility, so that every member of the community may realize that to inflict a serious disease on another person, even only as a result of reckless negligence, is a more serious offence than if he or she had used the knife or the gun or poison as the method of attack, and that it is necessary to introduce special legal provision in every country to assist the recovery of damages for such injuries and to inflict penalties by loss of liberty or otherwise; (4) by the spread of hygienic knowledge, so that all adolescents, youths and girls alike, may be furnished at the outset of adult life with an equipment of information which will assist them to avoid the grosser risks of contamination and enable them to recognize and avoid danger at the earliest stages.

A few years ago, when no method of combating venereal disease was known except that system of police regulation which is now in its decadence, it would have been impossible to bring forward such considerations as these; they would have seemed Utopian. To-day they are not only recognizable as practical, but they are being actually put into practice, although, it is true, with very varying energy and insight in different countries. Yet it is certain that in the competition of nationalities, as Max von Niessen has well said, "that country will best take a leading place in the march of civilization which has the foresight and courage to introduce and carry through those practical movements of sexual hygiene which have so wide and significant a bearing on its own future, and that of the human race generally."

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