Studies in the Psychology of Sex, Volume 6 Sex in...

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.