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 gonorrhoea
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 gonorrhoea.
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 _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.

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 gonorrhoea, for though gonorrhoea 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 gonorrhoea
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 gonorrhoeal 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 gonorrhoea
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 gonorrhoea;
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