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 _Spirochoeta 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, gonorrhoea.[231] At one time the serious nature of gonorrhoea, 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 gonorrhoea, 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 gonorrhoea have been even unduly magnified. This is notably the case as regards sterility. The inflammatory results of gonorrhoea 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 gonorrhoea. 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 gonorrhoea, 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 gonorrhoea 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 gonorrhoea, 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 gonorrhoeal 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 gonorrhoea; and this refers to the beggar class alone.
Although gonorrhoea is liable to produce many and various calamities,[233] there can be no doubt that the majority of gonorrhoeal persons escape either suffering or inflicting any very serious injury. The special reason why gonorrhoea 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 gonorrhoea, 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 gonorrhoea, 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 gonorrhoea 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 gonorrhoea 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 gonorrhoea 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 gonorrhoea 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.
Gonorrhoea 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 gonorrhoea 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 "gonorrhoea 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 gonorrhoea, 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.