RECA P lem oitli A. CORBETT-SMITH ^AtUvmtt BItbrarg THE PROBLEM OF THE NATIONS Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/problemofnationsOOcorb The Problem of the Nations A Study in the Causes, Symptoms and Effects of Sexual Disease, and the Education of the Individual therein BY A. CORBETT- SMITH M.A.Oxon. ; Barrhter-at-Law ; Captain {for7nerly R.F.A.) ; F.R.G.S. ; " Officier de I'lnsirticiion Ptcbliqtie"; Editor of ^' The Journal of State Medicine" ; Lecturer in Public Health Law at the Royal histitute of Public Health " The heart of England is not callous to the sufferings of her children. Men upon these subjects are for the most part either indolent or ignorant. They do not think about them ; they do not know about them, and they turn away from them as they turn away from other unpleasant subjects, not with a cynical, callous, determined dislike, but simply with unawakened sympathy. But once let the heart of England be really aroused, let the conscience of this country be really excited, then I do not believe for a moment that there will be any lack of workers in the cause, or any lack of enthusiasm for the great objects which that cause undertakes."— ZOi?/) COLERIDGE (a Lord Chief Justice of England). NEW YORK PAUL B. HOEBER 67-69, East 59TH Street 1914 LONDON ; JOHN BALE, SONS AND DANIELSSON. LTD. OXFORD HOUSE 83-91, GREAT TITCHFIELD STREET, W. DEDICATION. This little book has been written, or rather compiled, FOR ALL YOUNG MEN UPON THE THRESHOLD OF LIFE. THEIR MOTHERS AND FATHERS, FOR ALL MEN AND WOMEN WHO HOPE SOME DAY TO BE IN THE SAME PROUD POSITION. A/ /9/f Vll FOREWORD. This is not a Scientific Treatise. It is, or at least I hope it will be found to be, a plain, straightforward account of the greatest curse known to civilization ; a plague which is indeed the Problem of the Nations. I have tried to write the account in such a fashion that all may understand. Some technical terms there must be, but in writing about intimate details of sex there is only one language which can, with proper decency, be employed, and that is the language of medical science. In any case there will be found a short glossary at the end of the'^book which may prove useful. I am not a medical man. If I were I probably could not have tackled the subject from this independent point of view. My out- look would, I feel, have been prejudiced. I have the deepest respect and admiration for the medical profession. I am told that the first man my eyes ever looked upon was a doctor, and I have been most intimately associated with the profession ever since. But, with all due respect to its members, I cannot help thinking that those who specialize in a subject such as Sexual Disease are too prone to work with their eyes glued to the microscope. They discover and record details with the utmost nicety of precision ; they cannot always grasp the subject in its entirety, the big human side of it. Those who do not specialize must needs possess a good working knowledge of the subject, but they must also give an equal share of attention to half a hundred other departments of their work. They have not the time nor opportunity to go into details. My own methods of investigation have been perfectly simple. In fact it has been so easy that I never cease to wonder why in this country it has not been done years ago. There is no doubt whatever that it should have been done ; nor should it have been left for a layman to take it up, almost by pure accident. Certainly, I have had exceptional facilities for acquiring information, and for these I must record my indebtedness to my connection with The Koyal Institute of PubHc Health. Vm THE PROBLEM OF THE NATIONS That kej' has unlocked the doors of official statistical bureaux and Ministries of Health all over the world. It has enabled me to approach some of the greatest of living specialists ; men like Professor Ehrlich, to whom all bow in homage ; Professor Dr. S. Hata, of Tokyo, his former collaborator ; Dr. Simon Flesner, of New York ; the Director of the Health Department in St. Peters- burg ; Dr. Georges Miron, of Bucarest ; Dr. L. J. Landouzy, of Paris ; Professor Gosio, of Eome ; and many others whose names are too numerous to mention. In London I have received the courteous and willing assistance of men like Dr. F. Mott, F.E.S., Mr. J. Ernest Lane, Dr. J. J. Perkins, Dr. B. Burnett Ham, late Director of the Health Depart- ment, Victoria ; Lt. -Colonel C. H. Melville, E. A.M. C, and several others. And, lastly, but really first, I have turned the pages of a hundred or more publications of varying importance, from the invaluable works of Professor Alfred Fournier, Professor Blaschko, Sir Jonathan Hutchinson, and Dr. C. F. Marshall, down through medical journals of every country, reports of proceedings, blue- books of all sorts and sizes, to newspaper cuttings from a press- cutting agency. These acknowledgments, which I now tender most gratefully to all these gentlemen, will at least serve to show that, although I do not possess a medical degree, my statements are based upon the highest authorities. In a word, I have dehberately set to work, in the guise of a journalist, to pick the brains of the specialists, to put this and that fact together and to build a composite whole. I trust that the end will be held to justify the means, and that I am pardoned. The reader will find that my account of the subject is placed before him in two different ways. If he desire merely to become acquainted with the broad facts, then I suggest that he confine himself to " the Letter " which I have written to my godson. If full details and figures are desired, then he may turn to the remainder of the book. My investigation has been concerned not only with the causes, symptoms and effects of Sexual Disease, but with many side issues ; the preventive measures adopted in various countries, the regulation of prostitution, clandestine prostitution, education of young people in the elements of sex hygiene, and so on. But the general public is not immediately concerned with all FOEEWOED IX these matters, and so it was decided to publish immediately only the articles which are now presented, and at a price which will place the book within the reach of all. There can be little or no margin of profit. Such as there is will serve to help forward still more this work of education. " Education is the transmission of life " — so it has once most strikingly been defined. I can give no finer explanation of the word as I employ it in these pages. We would appeal most of all to the great captains of industry and employers of labour, to the Governing Bodies of the great educational establishments and the Headmasters of the Public Schools, to the Universities and Heads of Colleges, to the Directors of the Polytechnic establishments, in fact to all bodies having under their control the Young Man of Eighteen and upwards. This plague has got to be wiped out of existence and the surest way to achieve this end is by warning men of its perils ; especially at that age, from 18 to 25, when it is most frequently encountered. We are confident that once the grave dangers of the diseases are appreciated by any of these responsible individuals no further appeal will be necessary to secure their whole-hearted devotion to the cause. My very grateful thanks are due to Professor Sir Thomas Oliver for giving up some of his valuable time to read through the final proofs of the book. His encouragement, too, from the pub- lication of the first article in the Journal of State Medicme, has been of the greatest value in so delicate an undertaking. I have also to thank Dr. A. W. Stewart for his kindness in helping me with the Index ; and Mr. Ernest Braddock for checking my statistical calculations in Chapter YII. Finally, and as a personal note, if it is demanded why I, a mere layman, should have dared such a publication (no little jealousy has already been encountered), my reply will be found in the following pages, plain writ that all may read. A. C.-S. The Middle Tem2yle, London. May, 1914. CONTENTS. PAGES I. THE PEOBLEM AND ITS SOLUTION 1—9 II. THE SEXUAL DISEASES— SIMPLE CHANCRE AND GONOERHOEA 10—22 Chancre — Antiquity of Gonorrhoea — ^Vitality of the Microbe — Gonorrhosa v. Syphilis— Prevalence of Gonorrhoea — Symptoms and Eesultant Effects — Ophthalmia and Blindness — Summary. in. SYPHILIS 23—36 Historical Note — Symptoms — The Tertiary Period— Resultant Effects — Syphilis and the Nervous System — Syphilis and Other Diseases — " A Lost Leader." IV. SYPHILIS [continued) 37—44 Innocent Contagion — in Women — Syphilis and Marriage. V. SYPHILIS [continued) 45—54 Children and the Hereditary Factor — Infant Mortality — in Great Britain — Hereditary Symptoms in Children. VL SYPHILIS [continued) 55—61 Innocent Contagion of Nurses and Infants — Doctors and Midwives — Some Miscellaneous Cases of Innocent Contagion— Indus- trial Employment. VII. THE PREVALENCE OF SYPHILIS 62—82 Prevalence in Various Localities throughout the World — An Estimate for England and Wales. VIII. SUMMARY AND CONCLUSION 83—89 Salvarsan Treatment — The Education of the Individual. IX. A LETTEE TO A GODSON, when he is 18 years old ... 90—104 A GLOSSARY OF TECHNICAL TEEMS 105 INDEX 106,107 THE PROBLEM OF THE NATIONS. I. THE PEOBLEM AND ITS SOLUTION. Ap%a TToXtTeias a,Tra(T7]S vecov rpocpa. " The foundation of every State is the education of its youth." — Diogenes. " That which is a common concern to all is very generally neglected. The energies of man are stimulated by that which depends on himself alone, and of which he only is to reap the whole profit or glory. In concerns common to him with others he employs with reluctance as much attention and activity as his own interest requires. He neglects that of which he thinks other men will take care, and as other men prove equally negligent, the common interest is universally abandoned." — Aristotle, Politics, Book II, chap. ii. " Reforms directed towards the advancement of the Pablic Health must ever take precedence of all others." — Disraeli. " Till cant cease nothing else can begin." — Carlyle, The French Revolution. One of the most salient characteristics of Thought, or, rather, of its expression in speech and Hterature, of the present decade will be found, I think, in its attitude towards problems of Sex and their relative issues. During the past two or three years we have gradually accustomed ourselves to the frank discussion of subjects which, in this country at least, have been hitherto considered suitable for treatment only between the covers of a medical journal, or other similar publication with a strictly limited circulation. To-day, almost to our consternation, we find ourselves not only speaking and writing of topics of the most intimate nature, but discussing them in a manner and a language unknown since the period of the Restoration. The merits of this trend of thought in our modern social life may, in many respects, be open to question, if not actually deprecated. But in one issue, at least, of the many problems of sex it has come to be recognized by all clear-thinking men and women that fearless and open discussion is not only desirable but absolutely necessary. The ravages of what is known as "Venereal Disease," or " Sexual Disease " as I prefer to term it, are at last being brought home to the community in so menacing an aspect that the British 1 2 THE PKOBLEM OF THE NATIONS Press, as the mouthpiece of the " man in the street," has been induced to demand, with no uncertain voice, of those in authority that " something be done " to check the evil. At last, after years of patient and earnest endeavour on the part of a handful of men and women, a few definite details and statistics of this most dread scourge have been published for general information. At last has the Press under the authoritative influence of The Times and Morniyig Post (to their honour be it said) agreed to forgo the " conspiracy of silence," to speak of the facts as they exist, and, in so doing, to employ terms which shall admit of no secondary interpretation. Nor is it in the daily press alone that such articles have appeared, for, most remarkable of all perhaps, the English Beview has recently published an authoritative paper upon "The Doctors and Venereal Disease," and followed it up by other articles bearing closely upon kindred topics. However greatly we may deplore the abnormal introduction of sex problems into our present-day literature, we cannot but regard it as a praiseworthy policy when the motive is concerned solely with the exposure of certain facts which constitute the gravest danger to the health and well-being of thousands of our fellow-countrymen and women, and with the sincere desire to stamp out the evil. And it is only by the widest propagation of these facts, the nature of the diseases and the remedy therefor, that the evil can be checked and ultimately obliterated. It is not a matter in which the State, at least in this country, can take action, save in a secondary degree only. " Speaking generally, and of present-day conditions, the ^irevention and cure of venereal disease among the civil population of this cou7itry is a matter which depends primarily, often wholly, on the action of the itidividual." ^ It is a well-worn axiom that in this country the State can be induced to help only those who first help themselves. Practically every movement of genuine importance must rely primarily upon individual effort. Such effort has been evidenced by the agitation on the subject during the past eighteen months, and the State has, upon its side, now given evidence of its serious, if belated, con- sideration of the problem. To take one issue only of the problem, as it has been ignored ' " Eeport to the Local Government Board on Venereal Diseases." By Dr. E, W. Johnstone. 1913. Cd. 7029. Price 2^- THE PEOBLEM AND ITS SOLUTION 3 by the State. The number of inmates of lunatic asylums and of other similar institutions, public and private, shows a steady increase each year that passes.^ . A very large proportion of these cases is due directly, or indirectly, to sexual disease, and they are more or less incurable. The V7astage of sight, due to ophthalmia neonatorum (a result of gonorrhoeal infection) involves a loss of over £350,000 per annum to the State.^ Thus we are spending hundreds of thousands, probably millions of pounds annually upon the erection and upkeep of institutions for the admission and treatment of cases for which there is little or no hope of recovery. Our institutional treatment shows itself more and more inadequate in proportion as the number of cases increases. We continue recklessly to spend these large sums in the vain endeavour to cure the results of disease. We spend — do we spend anything at all, apart from the Navy and Army, in attempting to check and exterminate the disease itself? If such a procedure is regarded as reasonable, it would appear equally reasonable to ignore vaccination, allow small-pox to ravage the land, and involve ourselves in a huge expenditure attempting to cure the vast number of cases which would result. Naturally so broad a comparison invites criticism, but the basis is sound. We do not begin at the wrong end in dealing with small-pox, why should we do so with sexual disease, which to-day is as terrible a scourge as ever small-pox was? You will not make a community a good one by Act of Parlia- ment, nor will the average man or woman trouble to read through Official Eeports and Blue Books, nor the evidence given before the Royal Commission now sitting. But the facts must be made known, and secure the widest possible circulation, before any real or lasting good effect can be produced. They concern not only the present generation, not only those men who through pure selfishness or thoughtlessness acquire and spread the disease, but thousands of innocent women and children, and the generation yet unborn. It is not merely a National but an International question. Nor have we any guarantee that the outcome of the delibera- tions of this Royal Commission will differ from others which will have preceded it. With the knowledge of what has happened upon ^ I may direct attention to the article by Dr. Ettie Sayer upon " Mentally Defective Children," in the Journal of State Medicine, March, 1914. 4 THE PECBLEM OF THE NATIONS previous occasions he would be a bold man who asserts that" the Government proposes seriously to adopt the resolutions which will be passed. But after all there is only one genuine measure of lasting practical value which the Commission can urge for adoption. Let them by all means recommend increased hospital accommodation ; let the evidence for and against " compulsory notification" be care- fully weighed ; the extension of facilities for treatment be strongly urged ; anything and everything which will tend to alleviate suffering be advocated. But before everything else they must strike at the very root of the evil. The solution of the problem lies in the Education of the Individual. Nothing else will serve. Until adequate measures to this end are universally adopted sexual disease will retain its grip upon the human race. Professional prostitution, which is quite erroneously presumed to form the basis of the evil, is, as I have shown elsewhere, but a comparatively insignificant factor of propagation. The dissemina- tion of the disease is due in large measure to what may be termed clandestine or amateur prostitution, to young girls and women who accept lovers either, it may be, for the sake of additional pocket-money or from mere sensuality— sexual impulse, if you will. This factor will, from the nature of things, never be eliminated so long as civilization exists. The preaching of abstract morality is a sheer waste of time and energy! Inculcate principles oi practical morality, the advantages of continence and such like, by all means ; but, first of all, make a^n honest and unbiassed attempt to understand something of human nature, something of the strongest impulse which Nature has bestowed equally upon men and women. Then, having done so, weigh the facts in the balance. In this complex modern civilization of ours the possibilities of clear thinking upon the part of the individual seem to become ever more and more remote. He is overwhelmed with such a mass of detail, intricate data upon every conceivable subject in the world's affairs, that in attempting a broad conception of the whole he fails to grasp even the significant facts of a single part. In nothing is this more noticeable than in the subject of sexual disease, save that there is little or no real attempt to visualize either the whole or a definite part. Here we have a mighty inter- national problem which is so vast that it practically escapes notice. THE PKOBLEM AND ITS SOLUTION 5 It is for all the world like that game which one played at school, the game of trying to find the name of a place on the map. The boy with a little more imagination than the rest would set the name of a country or province which would be printed in capitals right across the page. The ruse seldom failed. This system of haphazard thought has caused the oddest con- fusion in methods of approaching the problem. Of course the vast majority of people never think about it at all, unless they chance to be directly affected. Then it is regarded as a by no means unexpected result of a deliberate act which must be concealed from everyone, the medical adviser included. But if ever it is given a thought you will find it muddled up with doctors and medicine and scientific research. Now most men and women of education who take any count of ' things which matter ' have heard of the Ehrlich-Hata Remedy, " 606." At least I have been greatly surprised at the number of people having no interest at all in things medical who have heard of it. But if it is to them anything more than a mere catch-figure (to coin the term) it will probably be vaguely dismissed as some striking scientific discovery which only concerns the medical pro- fession. That it has any immediate connection with the biggest problem of civilization never enters their minds. For another instance of this indiscriminate kind of thought take the attitude adopted by the more advanced section of the Women's Movement, and as it is indicated by one of their leaders. In a book recently published this lady reiterates again and again her proposals for exterminating sexual disease. These are : (a) Votes for Women ; and (b) the absolute chastity of men. I have been unable to gather what line of action is proposed in the event of the extension of the suffrage; but as regards the second proposal one can only reply that the authoress has not studied her own sex sufficiently, nor the real meaning of sexual impulse. It is once again the old futile attempt to make a community good by Act of Parliament. Women can and must give invaluable help in exterminating the disease ; but they do not need the suffrage to assist them, nor will they achieve their object by holding a pistol at the man's head. Let them set their own house in order first, check the rapid spread of amateur prostitution, so far as it is the fault o£ the women, by educating their sex in an intelligent and rational manner. This will not be effected by hysteria and fanaticism. b THE PROBLEM OF THE NATIONS People will persist in thinking of sexual disease and possible remedies just as they think of the measles or scarlet fever ; probably as more trivial than these. If necessary, which would seem to be seldom, it is a matter for medical advice. They will not realize that sexual disease as a factor of suffering stands absolutely alone. It is a thing quite apart from the well-known ailments and disorders of life because it has its origin, in the majority of cases, in a deliberate act of the individual : and that act is an integral part of the biggest factor in human affairs, Sex. " The merest platitude ! " it will be exclaimed. Possibly it is, but it is one which has been persistently ignored in the considera- tion of preventive measures. Or if it has not been wholly ignored no more than the vaguest proposals on the subject have been forth- coming. By the State regulation of prostitution certain Governments evinced their recognition of the driving impulse of sex. It was a genuine attempt to localize and so to check the disease. But the measure has failed. I do not know of a single country where it can be said with truth to have succeeded. Take Japan, for instance, where prostitution is controlled like a Government department, and where the strictest measures are in force. In Professor Hata's own words to me, " In spite of all the attempts which the Government has made to prevent the disease, there is little influence upon the number of cases of young men and prostitutes, or upon the statistics." That method has failed, or rather it has not wholly succeeded, because it did not strike deep enough. From whatever point of view the problem is regarded, you must ultimately come down to the individual factor. ^-' It has been urged that the elimination of sexual disease will place a premium upon immorality ; that the knowledge of safety, or of preventive measures, will tend to an increase of extra- marital intercourse and vice. My reply will be found in the fol- lowing pages. But I may remark here that those who make the assertion have very little knowledge of human nature. Fear of contagion has never yet banished sexual impulse. It would not destroy the impulse even if infection were practically a certain result. Medical students at the hospitals may be presumed to know something of the evil effects of sexual disease, but I have yet to learn that such knowledge has acted in any degree as a deterrent. THE PROBLEM AND ITS SOLUTION 7 And we must also take into account the effects of indulgence in alcoholic liquor. This is the invariable companion of sexual indul- gence, when knowledge and the restraining influence of dread are thrown to the winds. One cannot give direct evidence in support of such a reply, but I would state my honest conviction — and I make it with the most genuine sincerity — that knowledge of the dire results of, and of an adequate treatment for sexual disease, can only affect the question in an infinitesimal degree. Get at the individual himself by recognizing the intensely human aspect of the subject. Educate him not merely in the exact nature of the disease, in the grave risks he may run, in the seeking of medical advice, and in the unspeakable suffering which he may bring upon innocent people — those who are probably his nearest and dearest : but educate him also to realize that continence itself is worth cultivating. There must be no question of preaching morality and chastity, for every sane person recognizes the futility of attempting to eliminate sexual passion. But show him that he will ba the finer man for his continence ; that his brain will be in better working order, that his body and general physique will be the hardier and more strongly developed. In short, educate him to realize that, by "self knowledge, self reverence, self control," to his own self he will be the more true, and to his Country of the more noble service. And such a measure is quite practicable, it is not the dream of . a visionary. It has been adopted in our own Army with the most striking results. The marked decrease during the past two or three years in the prevalence of sexual disease has been due entirely to improved methods of treatment, and to the education of the individual. And, as a direct corollary of the latter, there is a healthier and keener interest in outdoor games, there is greater temperance, and there is a finer sense of esprit de corps. As Englishmen we have always been proud of our Army, even though it is " such a little one " ; but it is no insular pride which impels me to assert that of all the nations' armies our own men now yield pride of place to none in those qualities I have named. Is there any reason why the measure should not be extended to other of our national organizations, to the great centres of industry and of education, to the Government departments, to the various departments of local authorities and municipalities, to the banks ? In particular the Boy Scout Movement and the Church Lada' 8 THE PROBLEM OF THE NATIONS Brigades would provide unique opportunities for getting at the future manhood of the country. All these are thoroughly organized bodies with trades unions, councils or executive committees. Turn over the pages of WhitaJcer's Ahnanack and realize how many employees there are in the Civil Service alone, or even in the Educational offices of the London County Council. All these are especiallj^ easy of approach. With a carefully devised organization the scheme is not only thoroughly practicable but comparatively easy of achievement. And we go muddling along, in the traditional British manner, with our lunacy statistics ever rising ; our women-folk compelled to undergo serious operations, the need for which should never arise ; our children incapacitated from birth ; ophthalmia and blindness on the increase ; our whole national morale seriously impaired. And our remedy is to give grudging support to institutions which are hopelessly inadequate to deal with the big influx of cases. * Grudging ' because sexual disease is presumed to be the result of sin. Oh, let us have done with this cant and hypocrisy and face the problem like men ! " It can be done, and England should do it," has inspired many a fine thing in the past. Let that motto of Millais's picture inspire to this, one of the greatest and most needed reforms of civilization. Of all the great things which England has given to the world, the measures for the health of the community have been amongst the greatest and noblest. Let us face this problem too as English- men ever face an enemy, no matter what the odds. Strike deep at the heart of it, and show the world that we are still a nation to be reckoned with, that this pessimistic talk about race degeneration is a myth bred of diseased minds. Stamp out this evil and in less than a decade of years we shall be a new nation, a nation more worthy of the " place in the sun " which she has won ; more worthy of the children whom she has sent overseas to uphold her honour and keep the flag flying. It shall be done, and England will do it. But if this campaign of education is to be embarked upon there mnst be clean and frank discussion. " Till cant cease," said Carlyle, " nothing else can begin." This is the difficult part of the problem; but at least the first barriers have already been broken down. Sexual disease is a horrible subject, and the fact cannot be disguised. It seems to me that the time is past for vague, general hints as to THE PKOBLEM AND ITS SOLUTION 9 its nature and symptoms. We have come to such a pass that the pubhc must receive a clean knock-out blow straight from the shoulder. They must be told exactly what sexual disease means to the individual, to the family, to the next generation, and to the nation. They must be made to realize how ma,ny and how serious are the diseases which are the direct or indirect sequelae of syphilis and gonorrhoea. They must be made to realize the immense importance of immediate and sound medical treatment. In conclusion I would expressly state two facts to which I shall constantly recur, and which it is impossible to over-emphasize, in that they constitute the moral (if one may so term it) of the whole subject : — (a) That sexual disease is less dangerous than, say, typhoid fever if adequate remedies be applied in the initial stages and duly persisted in ; and conseque?itly (b) That the present ignorance and false modesty which prevail on the subject generally constitute the most powerful aids in the widespread propagation of the disease. And it is with these considerations in mind that the following articles are written. "Prefaces," Francis Bacon once said, "are great wastes of time, and though they seem to proceed of modesty, they are bravery." The " bravery " in the present instance would seem to lie in attempting a task which there are so many better qualified to perform. For the writer's qualifications, such as they are, consist almost wholly in the fact that he has for many years made a close study of this and kindred problems in many European countries and in the Far East ; that he possesses no medical degree; and that he attempts, of set purpose, to deal with it from the broadly human aspect rather than from the scientific. " But Hercules himself must yield to odds ; And many strokes, though with a little axe, Hew down, and fell the hardest timbered oak." 10 II. THE SEXUAL DISEASES. Their Characteristics, Incidence, and Significance. The sexual diseases are three in number : Syphilis, Gonorrhoea and Simple Chancre — these in order of severity. Simple Chancre. A consideration of this, the least malignant of the diseases, need occupy no more than a few lines. Simple chancre is merely a local affection which neither infects the blood nor poisons the system. It takes the form of a contagious ulcer or series of suppurative sores which are produced upon the contaminated organ. Certainly there may result complications, such as swelling in the glands of the groin, or, in very rare cases, a disease known as phagedena. But chancre is readily accessible and comparatively easily treated ; nor are there any of the serious after-effects which must claim our attention when discussing the two other forms of sexual disease. Gonorrhoea. Gonorrhoea (popularly known as the " clap ") is a specific disease which may invade the urethral mucous membrane during sexual intercourse, and is caused by infection from a pathogenic microbe — the gonococcus — discovered by Neisser in 1879. The disease was well-known to, and prevalent amongst ancient civilizations, and constant references to its attendant disorders are to be found in the works of classical writers, from Hippocrates, Aristotle and Plato down to the present day.^ The first description ' For the historical aspect of Gonorrhcsa reference should be made to " Considerations Historiques sur la Blennorragie," Dr. Eoucayrol, Paris, 1907. For a brief historical summary, together with some Notes upon the Legal Aspect, " A Text Booh on Gooiorrhcea," by Dr. Georges Luys, translated into English by Dr. Arthur Foerster, London, 1913, is recommended. This work is one of the most authoritative and up-to-date of any upon the subject, and it goes far to fill that gap in scientific literature which is referred to later. GONOEEHCEA 11 of gonorrhoea (so far as I can ascertain) is to be found in the Book of Leviticus xv. 2 and 3 {circa 1490 B.C.) : — " Speak unto the children of Israel, and say unto them, when any man hath a running issue out of his flesh, because of his issue he is unclean. "And this shall be the uncleanness in his issue: whether his flesh run with his issue, or his flesh be stopped from his issue, it is his uncleanness." Incidentally, it may be noted that Moses fully appreciated the contagious nature of the disease, for he gives specific directions as to articles of furniture and clothing in ordinary, everyday use. In an article of this character it will be unnecessary to devote any detailed attention to the historical side. The serious nature of gonorrhoea lies more particularly in the fact that unless adequate treatment is applied in the early stages, and so soon as possible after infection, it is liable to become chronic and so extremely difficult to cure. It may, for instance, remain quiescent in the system for years, to break out again, long after the patient has imagined himself to be fully cured, in a variety of complications of which ophthalmia and blindness are particularly frequent and serious examples.^ On the other hand, if remedies are promptly forthcoming upon the immediate appearance of the primary symptoms, or, better still, upon the mere suspicion that infection has been acquired, and if the treatment be continued in strict accordance with medical advice, there is comparatively little danger. One definite example may here be given of the retention by the gonococcus or microbe of its vitality over a period of years.^ A man has contracted gonorrhoea. Under medical advice he applies the necessary remedies, and after a time, with the disappearance of all symptoms, he discontinues them under the belief that he is cured. At the end of, say, two years, he marries, and the gonococci, which all this time have remained dormant in the urethra, are transferred to the virgin vagina and are there rejuvenated. The wife becomes infected and the husband becomes reinfected with his own gonococci. Under these circumstances he is practically ^ Eicord treated in 1840 a patient whose illness dated from 1800. Desormeaux attended, in I860, an officer who had not been free from gonorrhoea, or its sequelse, since 181C. * " SypMloloffy," by Dr. C. F. Marshall, 1906, p. 415. 12 THE PEOBLEM OF THE NATIONS certain to attribute the blame to his wife, and it needs no effort of the imagination to visualize the serious complications which may thereby ensue. I have quoted this particular example because it must supply some explanation of the extraordinary number of cases of infection amongst married women. Despite the hysterical assertions of the more irresponsible section of the Women's Movement, I refuse to believe that any man, save a callous criminal, will knowingly infect his wife with such a disease. For herein lies its insidious nature. A man may adopt all reasonable precautions, and yet he may not persist in them for a sufficient length of time. Careless he may be, but not necessarily criminal, for criminality implies the knowledge and the will. And yet his carelessness may be the cause of infinite suffering. GONORRHGEA V. SYPHILIS. While the fact noted above, as to the liability of gonorrhoea becoming a chronic malady, is equally true of syphilis, the second of the sexual diseases, yet it is of the first importance that the fact be particularly emphasized because gonorrhoea is far more prevalent than syphilis. In Japan, for instance, taking the youths of 20 years of age upon their medical inspection for army service, the average for the years 1909-1912 is officially given as 4"75 per 1,000 suffering from syphilis, and 15'68 from gonorrhoea : — Japanese War Depabtment. Per 1,000 Youths. Year Syphilis Gonorrhoea Chancroid Total 1909 5-73 13-30 4-45 23-48 1910 4-92 16-83 5-35 27-10 1911 4-08 16-63 4-54 25-25 1912 4-27 4-75 15-93 15-68 - 4-97 4-83 -25-19 Average 25-26 Per 100 Sexual Disease Patients. Tear Syphilis Gonorrhcea Chancroid 1909 24-42 . . 56-62 .. 18-96 1910 18-13 62-11 19-75 1911 16-17 . . 65-83 17-99 1912 16-93 .. 63-37 .. 19-70 Average 18-93 61-98 19-10 GONORRHCEA 13 The statistics (such as exist) of several European countries indicate a similar prevalence. I append, as an instance, some figures taken from the 20th supplementary volume of the Zeit- schrift des Koniglich Freussischen statistischen Bureaus. These form a part of the result of an inquiry instituted in 1900 by the Prussian Board of Education : — Berlin Industrial Sick Club. Per 10,000 Male and Female Members. Year 1892 1S93 1894 1395 1S96 1897 1898 The Three Sexual Disbasbs Men 490-9 550-1 554-8 549-0 655-2 619-0 687-5 Cases of Gonorrhcea Women 302-1 305-2 92-2 63-0 136-6 171-6 134-9 Men Women 309-1 135-0 352-5 ■ . 175-5 353-2 47-4 367-9 85-1 443-1 93-9 403-5 99-8 412-0 69-0 It is also of importance because public attention is being directed more particularly to the ravages of syphilis, to the exclusion of an adequate consideration of the suffering caused by gonorrhoea. And yet, if it were possible to obtain direct evidence upon the subject, it would, I think, be found that in a centre such as London of every ten individuals suffering from sexual disease perhaps seven would be infected with gonorrhoea. But this is no more than an estimate, based upon personal general observation, for statistics are not available save in the Navy and Army, and these certainly support ray contention. Cases op Sexual Disease in the Navy and Akmy. Navy — 1911 1912 Army — Admissions into Hospital 1911 1912 Chancroid 2,349 2,321 2,839 2,684 Syphilis 3,617 3,459 3,601 3,421 Gonorrhoea and its sequelae 7,593 6,887 7,708 7,S74 Army. 1911 1912 Average Number " Constantly Sick." Syphilis Gonorrhtsa 415-63 .. .. 875-98 350-65 846-18 Dr. J. Douglas C. White, speaking at a Congress in Dublin in 1911, gave it as his opinion that no fewer than 500,000 cases of 14 THE PEOBLEM OF THE NATIONS sexual disease occurred annually in the United Kingdom, say 1 per cent, of the total population, and that of this number gonorrhoea accounted for at least three times as many as syphilis. Dr. Johnstone states^ that a large proportion of the operations performed at women's hospitals are rendered necessary by gono- coccal infection, that the proportion is, in fact, as high as 25 to 60 per cent, of the major operations performed. More serious still, from the point of view of our racial develop- ment, is the estimate that about one-third of the childless marriages are due to gonococcal infection in the female ; for gonorrhoea is one of the most potent causes of sterility. Another fact which is not properly appreciated is that a subject may become infected with the disease merely through contact with infected articles.^ A child may, for instance, contract gonorrhoeal ophthalmia from the infected touch of a parent's fingers, or from the mother during parturition. Comment upon such a point is wholly superfluous, for it will readily be seen how extensive is the suffering which may be inflicted. And the disease might so easily be avoided. It depends upon the individual. It is outside my immediate purpose to detail specific remedies either for this or other forms of sexual disease. I would only indicate how simple the course of treatment may be if only the patient will disabuse his or her mind of all cant and false modesty, go direct to the best available medical man or institution immediately he may suspect infection, and follow implicitly and to the last letter the directions given. This is only from the "curative" point of view; of the far more important aspect of "prevention" I shall speak later on. But in a simple case of gonorrhoea, with an immediate applica- tion of remedies, and the exercise of proper care in general treat- ment of diet, &c., there is no reason why a patient should not feel perfectly himself again within a fortnight, although this certainly does not mean that the remedies are to be discontinued. Actual discomfort may not indeed extend over a longer period than a week. But it must emphatically be understood that each day which ' L. G. B. " Eeport upon Venereal Disease." ^ Dr. Palmer Findley quotes cases of a woman infected from towels used by an inmate of the house, and who, in turn, infected her husband ; and of several members of a family acquiring infection from the bathroom. (" Gonorrhoea in Women" p. 21.) GONOKRHGEA 15 passes without treatment will almost certainly involve the addition of a vv^eek to such course of treatment either inside or outside a hospital. Prevalence of Gonorrhcea. For the reasons stated above I have referred to the prevalence of gonorrhoea over syphilis ; there remains to give some indication of the extraordinary prevalence of gonorrhoea itself as a disease. In doing so it is obviously most difficult to quote actual figures, and one must therefore depend largely upon authoritative statements by medical men and others who are in a position so to speak. I have little doubt that the assertions made will be received with frank incredulity by the average individual, but they must be faced. I append some quotations direct, and without comment. " The statement that, of the adult male population inhabiting large towns, only an insignificant proportion escapes gonorrhoeal infection is not at all exaggerated." — Neisser. " The majority of all young men acquire gonorrhoea before the age of 30." — Dr. J. Douglas White and Colonel C. H. Melville, B.A.M.C. "It is estimated that from 40,000 to 50,000 prostitutes die annually ; at least 80 per cent, of this mortality is due to the direct effects of gonorrhoea." — J. Taber Johnson. " In New York, of 1,000 married men, 800 have had gonorrhoea ; 90 per cent, of all these have not been healed and can infect their wives." — NOEGGERATH. " The elimination of syphilis and gonorrhoea would reduce by half the number of diseases now treated by physicians, and a large proportion of the operations performed by surgeons." — Dr. B. Burnett Ham. " It has been established beyond doubt nowadays that about 70 per cent, of (various specific diseases) met with in married women are due to the infection (the ' gleet ') of their careless, ignorant or unscrupulous husbands." — Dr. Georges Luys. It is indeed difficult to write of this widespread prevalence of gonorrhoea without appearing to exaggerate. I have never been able to understand why the subject of this disease has been so neglected in favour of syphilis, and whenever any discussion has taken place the impression has always been conveyed that, of the two diseases, gonorrhoea is far the less serious. For example, in 16 THE PROBLEM OF THE NATIONS Dr. Johnstone's report the subject is dismissed in a single page, a fact which seems inexpHcable when the two concluding lines are read: "Probably there is considerably more gonorrhoea in this country than syphilis. Erb estimated that in Berlin six times as many persons suffered from the former as from the latter." The literature bearing upon syphilis and its treatment is most extensive, while gonorrhoea is, comparatively speaking, ignored. And yet Dr. A. Prince Morrow has stated that " in the case of gonorrhceal infection the individual risks the wife is made to incur are much more serious than those following syphilis. The infection may invade the cavity of the uterus and ascend to the annexial organs, causing salpingitis, ovaritis, peritonitis, &c., destroying her conceptional capacity and rendering her irrevocably sterile, to say nothing of the resulting dangers to life and the frequent necessity of surgical operations to remove her tubes and ovaries." Indeed when no more than a cursory consideration is given to the question the figures and facts which present themselves are simply appallmg, incredible. It is as though we were asked to believe that the Great Plague of London, when one in every four fell dead, were actually now raging, but in secret and behind closed doors. To read an authoritative statement such as " Gonorrhoea is the most widespread and universal of all diseases in the adult male population, embracing 75 per cent, or more," ^ or that of Noeggerath quoted above, and then to sit still for a few minutes with closed eyes, is to conjure up a mental picture of misery and suffering worthy to find a place in "II Inferno " of Dante. One could fill pages with such quotations, with heart-breaking instances of innocent sufferers; of women deprived, perhaps from their very wedding night, of their dearest privilege in life ; of ruined homes ; of babes doomed to a lingering death in life ; of — but the brain refuses to frame the sentences, it is all too hideous. At the outset one may dispose oneself to write calmly and dispas- sionately of these things, to discuss them in the cold light of science and reason ; but human feelings must assert themselves when all else is swept aside and forgotten save only the figure of a little child who kneels with imploring, upraised hands to the gaunt spectre of this loathsome disease. One is indeed almost tempted to agree with Miss Pankhurst's ' Dr. A. Prince Morrow. GONORRHCEA 17 assertion^ that gonorrhoea has not been brought prominently to pubhc attention because the medical profession hesitate to publish the appalling facts. And yet this would not account for the scarcity of purely medical literature (apart from short papers) upon the subject. Statistics in any country are practically non- existent ; but of this fact the explanation is a simple one. When a man contracts gonorrhoea it is fairly certain that he will consult, not a properly qualified medical man, but a neighbour- ing chemist. The chemist, or quack, will probably sell him (at an exorbitant price) a box of capsules, or some drug possessing some curative properties, and the man will be temporarily cured. Then there may ensue one or other of the sequela noted above. In the case of syphilis a man is simply compelled sooner or later to seek medical advice, or go into hospital. Hence, in our Navy and Army at any rate, and in our hospitals, the case is duly recorded. Have I said sufficient to show the meaning of gonorrhoea to the individual and to the community? And then I recall a remark once made to me by a driver of the Field Battery in which I served. "Why, sir," he said, "a man isn't a man until he has had the • clap.' " And, to our shame, that is the attitude of thousands of men. Who can wonder that women are uniting to insist that such things shall cease? And so I force myself to continue, to set down facts still more direct, that men shall realize (so far as this may serve) the misery and suffering of which they may be the agents so long as they adopt such an attitude, so long as they consider gonorrhoea a mark of virility, a trivial thing, a lesser evil than a severe cold.^ "It is quite true," as Fournier' remarks, "that when properly treated and free from complications, gonorrhoea is only a small affair ; that it may be got rid of with comparative ease. It is also true that, even when negligently treated (which is the usual case) gonorrhoea is most often cured without actual complications, and without future consequences, except the long duration, which is ^ " The Great Scourge,'" by Christabel Pankhurst. 1913. ' I would, however, here disclaim any intention of pointing to sexual disease as the inevitable retribution of sin. Such an attitude is whoUj^ wrong and has already worked incalculable harm ; I shall deal with this point in due course. ■■' The works of Professor Alfred Fournier, late Physician to the St. Louis Hospital, Paris, are regarded as amongst the most masterly and authoritative of all literature bearing upon sexual disease. 2 18 THE PEOBLEM OF THE NATIONS reckoned, not by weeks, but by months or even years. But things are not always so simple." Speaking in a broad general sense it is found that there is a distinct difference in the pathology of the disease as it affects the sexes. The difference is one in which the philosopher may suitably discover material for thought. It lies in the fact that in the male the incidence of gonorrhoea is more visible, easily diagnosed, but it is also attended by a far greater degree of pain and dis- comfort than in the case of the female. On the other hand, in the female, it is very frequently non-apparent^ ; there is often con- siderable difficulty in distinguishing possible symptoms from those of other disorders ; there is comparatively little, if any, discomfort ; but, finally, the resultant effects are often of the most serious character, involving, as remarked above, sterility and acute abdominal diseases. Having regard, then, to this tolerant attitude adopted by so many men towards gonorrhoea it only remains that the facts must be driven home into the public mind still more emphatically. And in attempting the task, I cannot do better than follow the scheme adopted by Fournier.^ In the first place, in the case of the male, the initial treatment, from the fault of either patient or doctor, may not prove efficacious, and the gonorrhoeal discharge from the urethra may persist for some considerable time. This obviously tends to a possible spread of infection ; for instance through the media indicated in the note to p. 14 {suijra). Secondly, the discharge may fail to dry up completely and so may generate a chronic disorder and discharge called gleet. This is certainly one of the most obstinate of all disorders and one of the most difficult to cure. It involves a prolonged and painful treatment ; it is liable to frequent recurrences, and may indeed after all prove refractory to every kind of treatment. Under a third heading may be classed two of the most common complications attending gonorrhoea : (a) Epididymitis, consisting of an acute, painful inflammation of the epididymis, a small organ ' Incidentally it should be noted that this frequent ignorance on the part of the female that she has actually contracted gonorrhoea forms another significant factor in its propagation. - " TJie Prophylaxis of Syphilis,'" by Alfred Fournier; English translation by Dr. C. F. Marshall, 1906, pp. 197 et seq. GONORRHCEA 19 attached to the testicle ; and (b) GonorrhcBal Bheumatism, which is constituted by symptoms resembling ordinary rheumatism. In addition to these gonorrhoea may, in more exceptional cases, react upon a number of other organs. To quote verbatim from Fournier : " It may, for instance, react on the bladder, on the prostate, in the form of congestion, inflammation and abscess which requires to be opened immediately to avoid worse dangers ; on the kidneys ; on the eye, by inoculation carried there by the fingers soiled with pus, or in some other manner, an inoculation which causes an acute ophthalmia which may destroy the eye in a few days ; on the heart ; even on the spinal cord, causing paralysis of the lower limbs and the bladder; even on the brain." "What! Are you answered?" one may exclaim with Shylock. Is gonorrhoea still that trivial disease, to be treated of no account ? Here, then, we have a definite statement, from one of the greatest authorities, which it is impossible to contravert, for the actual cases are duly recorded ; functional disorders of the gravest character from which death itself must often come as a merciful release — for death has been known in many cases to supervene. "To cite one order of cases only," says Fournier, "out of eleven cases of acute inflammation of the spinal cord caused by gonorrhoea eight have been known to terminate fatally." I have referred to the liability of gonorrhoea developing into a chronic complaint, and have given instances of ophthalmia and blindness, and of the sterility and serious disorders which may be inflicted upon innocent women through the, often, reckless careless- ness of an infected husband. Perhaps most sad and cruel of all, I have spoken of the helpless babe contracting at birth some form of the disease. Surely no more potent argument than this last is needed to secure a full consideration of all the facts, and the determination on the part of the individual and the community to stamp out gonorrhoea from civilization. Is it realized what sterility (especially when it is apparently inexplicable) means, to the individual, apart from the community '? To the husband or wife who reads these lines it may mean nothing save an order of things definitely pre-arranged, a deliberate intention to refrain from procreation. With such a one I am not immediately concerned. But what of the young wife to whom the gift of a child would prove the dearest pledge of her love for her husband ? Ignorant of the cause, she undergoes the humiliation "20 THE PROBLEM OF THE NATIONS of childlessness. In vain she sets afloat over the Serpentine her little prayer to old Solomon Caw. In vain she listens for the tiny voice of her dream-child crying to come to her ; the patter of " little feet along the floor." And so may come gradual estrangement between husband and wife ; the break between two hearts which, a few short years before, had seemed to join in a lifelong union; and at last the dissolution of a home which had never been a home. And all because, perhaps, of one single, seemingly trivial incident in the husband's life of years ago — a birthday dinner, a visit to a music-hall, a little half-hour in a woman's company. And the blame attaches to the wife, not to the husband ! " What ! Are you answered yet ? " Ophthalmia and Blindness. Here, then, are a few facts and figures concerning the prevalence oi a form of 'pi-eventible blindness — Ophthalmia Neonatorum^ — which, as already remarked, is a result of gonorrhoeal infection. These details are taken from a report issued in 1909 by the British Medical Association. I will set them down, again without comment : — (1) Ophthalmia neonatorum is by far the most common cause of blindness in children. (2) It was estimated that, in 1899, about 7,000 persons in the United Kingdom had lost their sight from ophthalmia neonatorum. (3) In the United States it was estimated that, of the total cases of blindness under one year, over 25 per cent, were due to ophthalmia neonatorum. (4) In London it was calculated that of all children born 1 per cent, suffer from ophthalmia during the first few days of life, and, of these, one in twenty is blinded or partially blinded as a result of the disease. (5) In Lancashire the figure stands at 2 per cent. ; cf. (4), supra. (6) In the various blind asylums and schools the percentage of cases due to ophthalmia neonatorum varies from 27 to 75 per cent., the average being about 35 per cent. From these and other data the conclusion that ophthalmia neonatorum accounts for upwards of 10 per cent, of all cases of blindness can hardly be termed an exaggeration. ' By Local Government Board Order of February 5, 1914, Ophthalmia Neonatorum has been rendered compulsorily notifiable in England and Wales. GONOERHCEA 21 And yet it is seriously asserted that sexual disease, and its sequelae, is the "retribution of sin." May I invite the attention of those who labour under that delusion to the above details? If gonorrhoea is stamped out of existence ophthalmia neonatorum will also cease to exist. As a corollary I may add another fact, which will appeal, I have no doubt, to the London taxpayer. It is estimated that 36 per cent, of the blind children in the London County Council schools have lost their sight from this form of ophthalmia. It is also estimated that the cost of the educa- tion of a blind child varies from £350 to ^6500, compared with about £60 in the case of a child with normal vision. If we take the figure of cost as £400, and if we imagine for the moment that ophthalmia neonatorum had not existed, the London taxpayer would have saved £12,600 over that one deal. I mentioned, in the in- troductory chapter, that the State is involved in a loss of over £350,000 per annum owing to this preventible wastage of sight. ^ Two more specific divisions in possible resultant effects from gonorrhoea and I conclude this chapter. The most common and also the most serious of all such results is found in stricture of the urethra. " Sometimes," says Fournier, " it is amenable to mild forms of treatment, but it is often only cured by surgical intervention. Further, a neglected stricture may become the point of origin of grave complications^ affecting the prostate, bladder and kidney. Then everything is possible, even death, which is not rare in such cases." And, lastly, there are frequently to be found definite and permanent affectio7is of the joints resulting from gonorrhoeal rheumatism. Here again there may be no more than a per- manent stiffness, say of the fingers ; but many cases are upon record of a total disablement of various limbs. ^ Summary. For reasons already indicated I have dwelt in considerable detail upon this subdivision of sexual diseases ; and yet I cannot but feel that " the half is not yet told." But at least we have ^ If further evidence upon this subject is desired, those interested may obtain it from " Report to the Local Government Board for Scotland upon the Incidence ' of Ophthalmia Neonatorum in Scotland," by Dr. T. F. Dewar. 1912. Price 4d. - In the woi-k above referred to Fournier quotes several specific cases. 22 THE PEOBLEM OF THE NATIONS sufficient data from which to draw some definite conclusions and a summary : — (1) That gonorrhoea, though comparatively ignored as a disease by the medical profession and by the public generally, is in reality one of the most prevalent of all diseases, if not actually the dominant disease of the human race. (2) That in comparison with the incidence of syphilis, gonor- rhoea is probably three times as prevalent. (3) That it forms one of the most potent causes of sterility in women, and is accountable for a large proportion of the major surgical operations performed on women. (4) That gonorrhoea forms the direct cause of ophthalmia neonatorum, and so of more than 10 per cent, of all cases of blind- ness ; of more than one-third of the blindness affecting inmates of schools and asylums below the ages of 16 or 18 years. (5) That if submitted to adequate treatment in its initial stages gonorrhoea constitutes only a mild affection, at least in the majority ■of cases. (6) That through inadequacy of treatment, or similar causa- tions, it has a strong tendency to become chronic, involving various more or less serious complications. (7) That in some cases, happily comparatively rare, the disease itself, or its remains, becomes the most serious affection and one capable of the gravest terminations, even of death. The solution of the problem lies in the Education of the Individual. 23 III. SYPHILIS. [there is] " sheer moral cowardice in shirking from a large and serious inquir into the extent, the causes, the palliating of this hideous scourge." — Loed Morlei at the Banquet to the International Medical Congress, 1913. Historical Note. " The origin of syphilis in Europe," it has been said, *' is one c the classical battle-fields of medical history." The point at issue i whether the disease has been known to our civilization sine remotest antiquity, or whether it was introduced into Europe b the sailors of Christopher Columbus, who are said to have contracte it in Haiti and Central America. The matter has, however, little bearing upon our present purpos and it may be remarked in summary of the discussion that th evidence of all contemporary writers tends to show that syphili was unknown in Europe before the year 1493, and that it wa actually introduced from America. Our English literature of th Tudor and Stuart periods abounds in references to the disease, c 'pox' and anyone interested may find at least twenty or thirt such references in the plays of Shakespeare.-^ In short, syphilis was most prevalent in Europe at that perio of history, and the most direct cause of its propagation was to t found in the wars continuously waged between European State and the formation of large bands of mercenaries which wei invariably accompanied by considerable numbers of camp-followin women. In Scotland it is first heard of in 1497, when James I published a decree that all syphilis-infected cases should lea\ Edinburgh for treatment near Leith. • I am indebted to Dr. David Newman, of Glasgow, for drawing my attentic to the fact that syphilis formed the subject of Cardinal Wolsey's indictme] before the House of Lords in 1529 : " Whereas your Grace is our Soverei^ Lord and Head, in tvhom standeth all surety and tuealth of this realm, t) same Lord Cardinal, knowing himself to have the foul and contagious disea of the great pox, broken otit upon him in divers places of his body, came dai to your Grace, roivning in your ear, and bloioing upon your most noble Gra with his perilous and infected breath, in marvellous danger of your Highness: 24 THE PEOBLEM OP THE NATIONS What is Syphilis? To give a purely technical definition, " Syphilis is a contagious- disease, chronic in evolution, intermittent in manifestations, and indefinite in duration, caused by a specific microbe discovered by Schaudinn in 1905."^ Or to describe it in more simple language, syphilis is a disease caused by a certain definite poison w^hich is introduced into the system only by actual contact with the poisoned or infected part of another's body, or an article. When once infected, and unless adequate remedies and treatment are forthcoming, the poison may in time permeate to any part of the body, from the glands nearest to the infected spot to the nervous system itself.^ Speaking generally a person may become infected in one of two- ways : by (a) sexual contact, i.e., through sexual intercourse with an infected person, and (6) non-sexual contact, i.e., from some infected person, or from an article, such as a barber's razor, a vaccination lancet, &c., or from kissing, from drinking out of an infected cup,, &c. Under this heading I include all cases of ' innocent ' conta- gion. These two methods of contagion will be more carefully con- sidered and differentiated later. While sexual infection is by far the more common, yet it is a grave mistake not to take serious account of the large number of cases due to non-sexual contact. A mistake because of the attitude of stern morality which people are wont to adopt towards the unfortunate sufferer ; the conviction that the disease must neces- sarily be due to — a " moral lapse," shall we say? I shall give some specific instances of such causes of infection. The poison of syphilis may first attack practically any part of the body. It is by no means confined, as is popularly supposed, to the genital organs, although that is naturally the region where the disease, when due to sexual contact, more commonly first manifests itself. Syphilis is a clironic disease. That is to say, when once the poison has invaded the system, the body remains in a state of infection, either latent or open, for an absolutely indefinite period. The disease may show signs of its presence five or ten years after 1 " SypJiilology," by Dr. C. F. Marshall, London, 1906. ' " The whole body is its domain," says Fournier, "from head to foot. It is hence par excellence a general disease." SYPHILIS 25 the original infection. Cases are recorded of symptoms appearing from twenty-live to fifty-five years after. But these symptoms are intermittent in their appearances. Though the body may remain infected there may quite possibly be no open and visible sign of the disease, save at intervals. The patient may, in fact, imagine himself to be fully cured. Then another outbreak, more serious than the last, may appear in a totally different part of the body. Fournier compares a body in such a condition to a volcano in a state of intermittent eruption ; a series of distinct outbreaks separated from each other by periods of quiescence. Following, then, the technical definition, such is the general character of syphilis, one of the most terrible diseases known to civihzation ; the " modern plague," as it has been termed. And yet this disease is less dangerous than typhoid fever, pro- vided that treatment is promptly applied and rigidly adhered to. It depends upon the individual. Symptoms. The symptoms of syphilis are classified under three distinct heads, as they appear in chronological order.^ Thus the first appearance of the disease after contagion, usually in about thirty days, and evidenced by no more than a comparatively insignificant sore called the chancre, is spoken of as the primary sij7nptom. This primary period usually lasts about six weeks, and the chancre, which appears at the spot where contagion was effected, will probably heal up quite rapidly. And herein lies the danger. The chancre is in many cases so insignificant in size or appearance that it may readily be mistaken for a pimple, a small abrasion ; or, indeed, it may not even be noticed.^ Attention is generally directed to the chancre by a certain itching, or feeling of irritation. This is an ordinary, normal case, but it must be remembered that in all stages of the disease, even from the primary period, the severity of the attack and exact nature of the symptoms vary with the individual. Imagine then that the primary period has run its course ; that the symptoms have been made light of, or that the application of > Strictly speaking the clinical course of syphilis is divided into six stages. Eor a clear and detailed account of these reference may be made to " Syphilis;' by Colonel F. J. Lambkin, R.A.M.C. London, 1910. - " The Treatment of Syphilis;' Alfred Fournier. 26 THE PROBLEM OF THE NATIONS remedies has ceased with their speedy disappearance. The secondary period is then entered. The poison has by now more or less thoroughly permeated the entire body, and it begins to indicate its presence by eruptions on the skin and mucous membranes. Generally the secondarij symptoms begin with a rash upon the trunk, or perhaps with head- aches and insomnia, and, in women particularly, with ansemia. There may follow such disorders as ophthalmia, pains in various joints and muscles, affections of the nerves. In all this there is nothing really serious ; nothing, that is, which may not be cured comparatively easily. The particular danger of the secondary period lies in the fact that it is the period when the disease is most contagious, when it becomes most dangerous to others. There is, naturally, acute discomfort, even pain, and certainly disfigurement. These symptoms should subside under proper treatment. " By itself it is a trifle ; but by its contagious- ness it is a plague." The Tertiaey Period. If then the subject has, at this stage, consented to undergo pro- longed and careful treatment, and if such treatment has proved successful, then one may reasonably expect to find the disease at an end. But if the subject has been insufficiently treated then the tertiary symptoms are inevitable. In fact the chief cause of the development of tertiary symptoms is almost invariably inadequate treatment.^ At the same time, however, it should be observed that there is no sharp dividing line between seco7idary and tertiary symptoms. Cases of secondary or contagious lesions have been observed so long as fifteen years after the original infection ; and instances of tertiary lesions have been recorded during the second year of the disease. But assuming, once again, inadequate treatment we now come to the real disease in all its gravity. It is the tertiary period which makes syphilis the hideous plague it is. In a work of this nature, destined for wide general circulation, one naturally hesitates ^ Fournier gives statistics showing that, out of 100 cases of tertiary syphilis, 78 were due to inadequate treatment, 19 had received average treatment, and 3 only had been properly treated. Major W. S. Harrison, R.A.M.C., states that since treatment in the British Army has been properly' systematized cases of malignant syphilis are almost unknown. SYPHILIS 27 to write of these facts in detail, to state definitely what these symptoms are. And yet if this is not done how else may one bring home to the public the meaning of syphilis ? Perhaps it will be best to give here, with but little comment, a table prepared by Fournier to show, in relative proportion, the various organs of the body attacked by the disease in its tertiary period. Observations had been carried out upon an aggregate number of 4,700 patients : — Cases Affections of the skin . . . • . . • • • • • • 1,518 Subcutaneous tumours . . . . . . • . • • • • 220 Tertiary lesions of the genital organs 540 ,, tongue .. .. .- •• •• 277 ,, palate .. .. •• •• •• 218 ,, throat .. .. 118 ,, lips 45 ,, tonsils .. .. •• •• •• 12 , , nasal mucous membrane . . . • 10 ,, bones . . . . • • • • • • 556 ,, joints . . . . • • ■ ■ • • 22 , , muscles . . . . ■ • • • • • ".S ,, digestive tube .. .- .. ■• 22 ,, larynx .. .. .. •• •• ^^ ,, lung .. .. •• •• •• 23 , , heart . . . . • • • • • • ^2 , , aorta . . . • • • • • • • ^^ , , liver - . • . • • • • ■ • ^1 , , kidney . . . . • . • • • ■ ^9 ,, eye . . . • • • • • • • 111 99. , , ear . . . . • • • • • • ■^^ , , . , , , arteries and veins . . . . • • 17 Syphilis of the brain, spinal cord and nervous system generally 2,009 Other lesions . . . . . . . . . • • • • • • • "^ Two points, arising out of the above table, suitably call for comment. The first thing which must at once strike the reader is the astonishing uhiquitij of the disease ; that no single organ of the body is immune from attack. I have referred to the fact that the severity and exact nature of that attack vary with the individual subject. Thus, taking three cases of tertiary symptoms, the first subject may develop epilepsy, the second some form of lung disease, and the third may become totally blind. Syphilis and the Nervous System. The second point which will be noticed is the enormous number of cases in which the nervous system is affected: 2,009 in 4,700 patients! Does this fact throw any additional light upon my introductory remarks on the subject of insanity? The very centre and directing agent of the human body forms the CHIEF POINT OF ATTACK BY TERTIARY SYPHILIS. And the converse 28 THE PROBLEM OF THE NATIONS of this is equally true : that syphilis is by far the most important cause of disease of the nervous system. The close inter-relationship between syphilis and the degenera- tion of the nervous system would provide material for a bulky volume. Especially is this so at the present time when, owing to the conditions under which most of us live, the nervous system offers less and less resistance to the strain placed upon it. Statistics for Great Britain are not available,^ but the evidence given by specialists all tends to confirm the experience of Founiier.^ Erb, for instance, speaking of locomotor ataxia, or tabes, records that out of 300 cases in private practice, 89 per cent, had had syphilis. Moebius has said, " The longer I reflect upon it the more firmly I believe that tabes never originates without syphilis.'' And, according to Sir William Osier, writing in 1912, recent results of cases tested with the Wassermann reaction bear out this statement. As regards general paralysis, I venture to quote verbatim an entire paragraph from a work^ of Sir "William Osier's : — "As in tabes, the important factor is syphilis, which is ante- cedent in both conditions in practically all cases. Males are affected much more frequently than females. It occurs chiefly between the ages of thirty and fifty-five, although it may begin in childhood as the result of congenital syphilis.* An overwhelming majority of the cases are in married people, and not infrequently both husband and wife are affected. Statistics show that it is more common in the lower classes of society, but in America, in general medical practice, the disease is certainly more common in the well-to-do classes. Heredity is a more important factor here than in tabes, although its influence is not great. . . . The habits of life so frequently seen in active business men in our large cities, and well expressed by the phrase ' burning the candle at both ends,' strongly predispose to the disease." ^ Of Continental statistics Hjelmann gives 15-25 cases of nervous disease per 1,000 syphilitics, excluding general paralysis and tabes ; Reumont 85 per cent., and Engelstedt 5 per cent. - For specific cases and other valuable data reference should be made to Dr. F. W. Mott's Address published in Proceedings of the Royal Sociehj of Medicine, vol. V, No. 9 (Supplement). 3 " The Principles and Practice of Medicine," 1912 Edition, p. 922. ■♦ Vide the article on " The Heredity Factor," post page 45. SYPHILIS 29 The Eeport upon the Census of 1911 in England and Wales has recently been published. There has been a steady increase in the rate of insanity since 1871, which has assumed alarming proportions in the case of children under fifteen years of age. With these the figure stands at 823 per million, showing an increase since 1871 of 30"8 per cent. Taking all ages together, 4,491 per million were insane, an increase of lO'l per cent, since 1901. Further, about 60 per cent, of cases known to be syphilitic admitted into asylums between the years 1908-12 were general paralytics. A serious state of things indeed. And yet we continue to attempt impossible cures and pay no heed to preventive measures. The guiding principle which has always dictated our foreign policy w^hen Great Britain has become involved in a war is that our country's frontiers are high-water mark upon the enemy's coasts. In other words, the policy of sitting quietly at home and awaiting attack is an impossible one for us. Perhaps we are apt to forget the lessons of the past in the imagined security of the present ; but may not the analogy be applied when the war is one against so insidious an enemy as sexual disease ? Syphilis and other Diseases. We have seen from Fournier's statistics that no single organ of the body is immune from syphihtic attack. But it is possible to go further and to assert that there are few disorders or diseases known to mankind which may not be developed, either directly or indirectly, from syphilis. Take tuberculosis, for instance, which is so much in the public mind at the present time. Tuberculosis, per se, is not a direct out- come of syphilis, because the subject must first become infected with the tubercle bacillus. But syphilis, by weakening the powers of resistance of the lungs, renders the subject more open to attack and, in fact, forms a very yoioerful predisposing cause to tuberculosis. ^ Especially is this the case when the factor of heredity is intro- duced. The child of a syphilitic father is extremely liable to tuberculosis. And so when we speak of there being " hereditary consumption in the family," it would probably be discovered that it was not consumption but rather a disposition to consumption inherited from, say, a grandfather who had contracted syphilis. ' For more specific details on tuberculosis and syphilis vide " Syphilology," Dr. C. F. Marshall, London, 1906. 30 THE PROBLEM OF THE NATIONS Certain diseases, which are known to have directly originated in syphilis, are showing a strong tendency to increase in prevalence in proportion to the population. Of these one of the most important is aneurysm. Now the direct connection between aneurysm and syphilis lias been recognized for at least 200 years. Even before the dis- covery in 1907 of the Wassermann test for syphilis, medical practitioners could definitely assert that 90 per cent, of the cases of aneurysm had originated in syphilis.^ At the present time the presence of syphilitic poison is always presumed unless direct evidence to the contrary is forthcoming. A very large proportion of the cases are drawn from the class of "working poor," especially men who are engaged in work demanding big muscular effort — draymen, for instance, bargees, iron and steel workers. And many of these men have served in the Army, and the prevalence of aneurysm seems to be in direct proportion to that of syphilis. Dr. J. J. Perkins, to whom I am indebted for much valuable information, has pointed out to me that many of the disorders which seem, at first sight, to fall under the heading of Nervous Disease, are really some form of aneurysm. I append the returns, recorded by the Eegistrar-General, of deaths from aneurysm and other diseases of the blood-vessels, from 1901-1911. The steady increase will be noticed : — Year Deaths Year Deaths 1901 2,191 1906 3,339 1902 2,396 1907 3,652 1903 2,348 1908 3,606 1904 2,764 1909 4,285 1905 2,945 1910 4,408 1911 5,177 A similar line of reasoning may be adopted in other diseases, blindness, cancer, and so on. In fact, it would seem that it is upon this point in particular that the fullest enlightenment should be given to the community. Since the discovery of the Wasser- mann test, we have come directly to connect an ever increasing number of diseases with syphilis. So remarkable have been the 1 " The infection with which aneurysm is especially connected is syphilis, and nowadaj's it is rare not to find a ' positive ' Wassermann reaction in an anem-ysmal patient under 50." — " Tlie Princijiles and Practice of Medicine," Sir William Osier. SYPHILIS 31 results of the test that we may assert that at least one-half of all disease, if not a still larger proportion, is due more or less directly to syphilis. If gonorrhoea be also taken into account, I should be strongly disposed to say, from a careful study of the question, that perhaps tioo-thirds of the diseases known to civilization either have their origin in sexual disease, or that sexual disease is an important predisposing cause of them. Now that is a serious statement to make, but I will give some further evidence in support of it. Dr. Carl H. Browning, the Director of the Pathological Laboratories, Glasgow University, has recently carried out observations upon 3,000 cases.^ In this work he used the most scrupulous care and precision of detail not only in aiming at a complete investigation in each case of {a) the condi- tion of the patient, {b) the condition of members of the patient's family, and (c) the history of the health of the patient and his family ; but also in the actual working of the Wassermann test. This latter point will be apprecia,ted by medical men. I may, how- ever, add in explanation that Dr. Browning first of all thoroughly satisfied himself that the test gave what is called a " positive reaction" only when the poison of syphilis was actually present. Here is a summary of the results: — (1) Amongst 331 unselected cases of children attending hospital as outdoor patients, syphilis was present in a proportion of 14 per cent. (2) Mental Deficiency and Epilepsy. — Out of 204 cases of young people examined, syphilis was present in 95 cases ; 46 per cent. Of these, 105 children were either under school age (13 being less than 5 years old) or were not fit to attend through mental defect. Taking into account as well other members of the patients' families, the proportion of syphilitic infection was found to be 59 per cent. (3) Heart Disease in Children. — 25 cases were examined. Infection was present in 17 and 1 doubtful, the ages of these ranging from 1 month to 3 years. Of the 18 cases, 9 died when less than 6 months old. (4) Deafness in Children. — 82 deaf children were examined ; 17 gave a " positive " reaction. There was, further, every indication that syphilis plays a much greater part in this condition than could be detected by the test. ' For full details of the investigations see British Medical Journaly January 10, 1914. 32 THE PROBLEM OF THE NATIONS (5) OzcBna (bone diseases). — Out of 52 cases, 16 gave a " positive " reaction (30 per cent.). (6) Aortic Disease. — Out of 46 cases a "positive" reaction was present in 64 per cent. (7) Nervous Diseases. — 122 cases were examined. A " positive " reaction was given in 41 per cent. (8) E7je Diseases. — Out of 84 cases the presence of syphilis was indicated in no fewer than 57. In one form of eye disease {inter- .stitial keratitis) the percentage was 95 per cent, of "positive" reactions. (9) Severe Gynecological Ailments of Women. — 37 cases were examined : 20 gave " positive " reactions, and 2 others had children who gave similar indications of syphilis. Of another subdivision 39 cases were examined and 18 reacted "positively," 59 and 46 per cent. These results of Dr. Browning's observations, taken in con- junction with Fournier's statistics, certainly furnish us with very weighty evidence. The value of this lies not only in the actual facts and details but also in its suggestion. It will be observed that a large proportion of Dr. Browning's cases were children, and there- fore that the taint of syphilis was hereditary or congenital. This fact bears upon the question of " innocent " contagion, which we have yet to consider ; also upon the hereditary effects of syphilis, which will also be dealt with in due course. In attempting to submit evidence upon this relationship between syphilis and other diseases, it should be remembered that there are no of&cial statistics in existence to guide us. At least, I have made diligent search for some in many countries, but without success. We have to depend almost entirely upon the records kept by individuals and specialists, such as Fournier and N6isser, or upon some exceptional series of observations like those of Dr. Browning and of the specialists at the Eoyal Army Medical College. Unfor- tunately individual specialists rarely tabulate records of cases with such care as Fournier. I have consulted several eminent authorities upon this point, but the information which I have been able to obtain has been almost negligible. I will take at random one or two more human disorders. Of all the internal organs the liver is the one most prone to be affected,^ * '■'■ Syphilis.'" Sir Jonathan Hutchinson, p. 319. SYPHILIS 33 and jaundice is frequently observed to be present in the early stages of syphilis. Again I must emphasize the fact that such syphilitic disease of the liver is not confined to adults, but has been observed in children} Acute Bright's Disease is often of syphilitic origin. Syphilis, either in its inherited form or in its secondary or tertiary periods, very frequently attacks the larynx, and causes disorders of the vocal cords. Dr. J. Kerr Love, of Glasgow, has estimated that, from his own experience, 25 per cent, of cases of congenital deafness are due to syphilis. That this condition of affairs was due, amongst the poorer classes, to untreated syphilis. Diseases and malformations of the teeth have in many cases been traced back to syphilis. Once more this is so not only with adults but with children. Abnormahties in the growth of limbs ; dislocations of limbs from birth^ ; deformations in the eye, ear and mouth ; rickets, epilepsy, paralysis — in fact it would seem that it is only when one turns to diseases like measles, scarlet fever or mumps that one cannot trace any connection with syphilis. And yet in face of all these appalling facts we still go on drifting. One is simply dumb with astonishment that no practical measures have ever been taken to enlighten the public. What is the use of publishing articles in medical journals and leaving them there to be bound up at the end of the year ? What is the use of reading papers at minor Congresses, and passing resolutions which are forgotten in a month ? The public will not listen ? The subject is too dreadful ? The public must be made to listen ; and to insist that these Augean Stables of civilization shall be cleansed. Sexual disease is less dangerous than tuberculosis or even gout if only it is attacked in its primary stages. If the nations can enter upon a great campaign against tuber- culosis, which is far less serious — I say nothing of the sequelae of syphilis and gonorrhoea — who will assert that sexual disease cannot similarly be attacked ? If twenty millions sterling can be found to fight tropical ^ Transactions of the Pathological Society, vol. xvi. ' Many of the " freaks " exhibited by Barnum were certainly cases of hereditary syphilis. 3 34 THE PROBLEM OF THE NATIONS diseases on the frontiers of the Empire will there be no response to the demand when it is realized that the enemy is already within oiir very gates ? I wonder how much money is spent annually in trying to convert the so-called heathen to Christianity. I wonder how much time, money, and energy is being wasted over half-a-dozen political and party questions of the day. How many people are affected in any real degree by them ? How many by this curse of civilization ? What is the Church doing towards stemming the tide of disease ? Is it concentrating its energies upon making its adherents a cleaner, healthier, finer body of men and women, of genuine service to themselves, their families, and their country ; or is it bent rather upon nurturing their souls for the Hereafter ? The solution of the problem lies in the Education of the Individual. What is being done to that end ? Before proceeding with the next section, I would propose to summarize my account of the three periods of syphilis in the form of a short story taken from life and actual facts, names and localities only being altered. "So by example may our purpose stand revealed." I will call it A Lost Leader. Seldom, if ever, does a man make a big name for himself during his first year at Oxford. And yet Brentwood proved a notable exception. At Charchester, he had done everything which a boy could do in the field and classroom. He went up to Oxford with the biggest reputation of any of his year, and won a double blue by the end of his third term. Brentwood was one of the finest, cleanest and straightest young fellows you could wish to meet ; the type, at its very best, which is directing and fulfilling the destinies of the Empire all over the world. A man built for a great career. He was adored by children and dumb animals — and there is no finer praise. The landlord of his ' digs ' — in those days they were off the Corn- market — had a daughter of twenty-two. This young woman had already set the gossips talking— and not without cause. Naturally enough Brentwood attracted her very strongly ; but there it had ended, for Brentwood was a healthy young fellow with too many other things to think about ; and Nellie was not a particularly pretty girl. At the end of the second year at Oxford came his 21st birthday ; and it was duly celebrated in the fashion dear to Oxford. I should not say that Brentwood was actually drunk when the party finally broke up, but SYPHILIS 35 at any rate he was merry and muddled— and it was Nellie who helped him to find his bedroom. In a little less than a month, he noticed the appearance of what he took to be a small boil. It caused some little discomfort, but thinking it merely an indication that he was run down, a little out of sorts, or that his blood was in poor condition, he paid no attention to the sore save by consulting a local chemist, and applying a boracic acid lotion. It disappeared in due course. Those were the darkest days of the South x\frican War, the winter when disaster after disaster struck chill to the hearts of the people, but only nerved the country's manhood to finer effort. Brentwood volun- teered, and sailed with the first troop of Imperial Yeomanry to leave England. Towards the end of the voyage he began to feel decidedly ill, with sick headaches and intermittent feverish attacks, but he struggled some- how through the week of landing, parades and movement up country. The night before A Troop went into their first action, Brentwood felt fit only for hospital. A week of drenching rain and no rest. The next day his troop was engaged in a prolonged skirmish in which Brentwood was badly wounded in the shoulder. They got him back to the hospital tent, and then it was discovered that he had developed an extensive red rash all over back and chest. The surgeon was a young man of little experience, and he completely failed to diagnose the real nature of the symptoms. Also hospital accom- modation and staff were inadequate, and Brentwood had to get along with little attention. He got steadily worse, his skin was now in a very bad condition, and so he was invalided to Cape Town. There they found that he was well advanced in the secondary period of a bad attack of syphilis. But the mischief was done, never to be repaired. That fortnight of unceasing hard work in bad weather with the grip of fever upon him, the wounded shoulder, the subsequent neglect, had all served fully to under- mine a constitution already weakened by the insidious poison within his- system. He stayed on in South Africa for a year under treatment and was then pronounced sufficiently recovered to return to England. But it was the ghost of the Brentwood we had known who landed at Southampton, a Brentwood whom none of us recognized. Stanmore, Tipley and I met him ; and when he insisted that he really was the dear fellow whom we had seen off from Oxford in the dark of a December morning eighteen months before, none of us could face him for the tears in our eyes. And all because of one little incident of which he had been at the time almost ignorant, almost the victim. 36 THE PROBLEM OF THE NATIONS But the saddest was yet to come. Inevitably prevented from entering the Diplomatic Service, upon which he had set his heart, too weakened in health for continuous concentration in any serious work, Brentwood at last decided to join a friend who con- trolled a large tea-planting estate in Ceylon. He sailed, leaving his heart behind in the keeping of a charming girl whom he worshipped. But he never told his love, like the man of grit he was. And she — she too loved him, and wondered. She knows now ; and the shrine of his memory is very sacred to her. For a few months I heard good accounts of him. But, almost un- wittingly, the poison was still at work and the end was near, though none of us realized how near. I had been preparing to leave for the Far East upon business, when a cablegram arrived from Brentwood begging me to start by the first steamer. I got to Ceylon just in time to hold him in my arms as he died. A paralysis of certain internal organs had gradually developed, and the agony during that last fortnight had been intense. Almost his last words were, " They say the woman always pays ; but, by God, I think I've worked off some of the debt ! " So died one of the finest men and one of the noblest characters I have known. His country was immeasurably the poorer for his loss. He died one more victim to ignorance. His father, who might have warned him of the new element, woman, which would enter his life on leaving school, had failed to do so. No one had warned him of possible results, and these things are not learned by instinct. The actual incident with the girl (an amateur prostitute, be it noted) might possibly have happened in any case, if not with Nellie then with another ; but at least Brentwood would have been fore-armed, and the disease would have been arrested in its development. And that is how these Articles come to be written. 37 IV. SYPHILIS {continued). Non-sexual, or Innocent Contagion. I HAVE indicated that a person may acquire syphilis either by sexual intercourse or by contact with some infected person or article. In considering this latter form of contagion it will be more convenient if we further qualify those two divisions and speak of syphilis either as ' merited ' or ' innocent.' Under the former will naturally be classed the majority of cases of the disease, where con- tagion has been effected through what may be termed extra-marital intercourse. Under the latter we may include those cases in which an individual has acquired the disease innocently. As cases of * innocent ' contagion I would include {a) wives who have contracted the disease from their husbands ; (6) children from their parents or nurses ; (c) medical men and nurses from their patients; and {d) generally, those from infected articles.^ These several subdivisions will be considered in due course. In these days, when hardly a week passes which does not see some new bogey dangled before the public by the medical or daily press, those who insist upon the dangers in impure milk, unclean restaurant dishes, the house-fly and half a hundred similar germ carriers, have come to be regarded with an amused tolerance. 'Similarly if I set forth here a few cases of syphilis acquired by such -contagion, I shall at once be met with the criticism that they are but isolated cases and have no real bearing upon the prevalence of the disease. But if we would be honest in our endeavour to discover the rea meaning and significance of syphilis, we mustiQk.e into consideration such cases of ' unmerited ' contagion. Admit, by all means, thai those cases are in the minority, but, in doing s'o, remember that the suffering caused by them is proportionately greater, because the ' I had almost included in this division victims by a single act of sexual intercourse, such as Brentwood in my story. Why should a minute of forget- fulness be permiitted to poison a whole existence ? 38 THE PROBLEM OP THE NATIONS subjects are innocent ; and remember that the factor of heredity is now at work. Apart from the fact that sexual disease is not a topic of pohte conversation, one of the principal reasons why methods of prevention have not been seriously taken in hand by national Governments is that the disease- is always presumed to be due to immorality. Whenever dej&nite measures have been advocated — and this has happened so many times within the last fifty years — they have invariably been met by certain intensely moral individuals who have argued that a premium would thus be put upon vice, " Sexual disease," they assert, "is an admirable corrective ; it is a just retribution. Give us tuberculosis or small-pox to deal with and we shall be most happy to pass any Bill. These involve no question of immorality ; the sufferers are all innocent people. But sexual disease ! If a man likes to go out of his way to expose himself to infection, and to seek for it in a questionable manner, then he must abide by the consequences." Such an attitude as this, which certainly prevails amongst a very large section of the public, evinces itself in many ways, and not only in the obstruction of State measures. " It prevents the charitable from subscribing towards the proper cure and treatment of venereal diseases ; it influences our general hospitals through their lay committees against the provision of accommodation for these diseases ; and it emphasizes the stigma and disgrace attached to the inmates of lock hospitals and the lock wards in our Poor Law institutions. While it operates as a deterrent to the provisions of proper treatment, it operates still more seriously by leading to concealment of the disease, and by preventing sufferers from seeking the aid and advice which are essential for their cure and for the prevention of the spread of the disease." ^ Let us now consider the argument which these very moral individuals put forward, and, for the present, only from the point of view of non-sexual contagion. Let us see how far, in such cases, sexual disease is a 'just retribution of sin'; and whether, even admitting the number of cases to be proportionately small, the facts,, solely upon their own merits, do not warrant some remedial action being taken against the disease as a whole. And again I must beg for a little patience and indulgence upon ' Eeport on Venereal Diseases to the Local Government Board, 1913. SYPHILIS 39 the part of the reader, for specific data are most difficult to procure and statistics do not exist, save in the case-books of specialists and institutions. In the exhaustive observations carried out by Fournier, and others there is, however, much suggestive material to be found ; nor does there appear any need, in the light of present-day condi- tions, to suggest any modification in his deductions, especially those in connection with this particular point we have to consider. It is a curious fact that these figures have received so little attention. Innocent Contagion in Women. To take this subdivision first. In the course of twenty-seven years of private practice Fournier states that 887 women affected with syphilis passed through his consulting room. These he distinctly classified into 842 cases where the disease was of sexual origin, and 45 where it was certainly non-sexual. This was his first classi- fication, and it gave a figure of a little over 5 per cent, of cases of unmerited contagion. He then carefully considered the 842 cases. Bringing his observations down to percentage form Fournier states that " out of 100 women affected with syphilis 81. belong to the demi-monde, or loose women of all classes, and 19 are married women." Thus, adding these two percentages together, the figure was obtained of nearly 25 per cent, as the average of cases of unmerited syphilis in women. "That is my reply," says Fournier, '' to those who regard syphilis as being necessarily due to immorality." He adds, further, that he had observed the most scrupulous care and impartiality in making these deductions ; and that Kicord, his predecessor and teacher, remarked in comment, "You have not exaggerated the point at all ; I have seen the same as you, and in the same proportions." Such is the result of observations in Paris upon patients drawn from all classes of society. Have we any reason to suppose that the facts will differ materially in this country ? I put this point to Mr. J. Ernest Lane, the senior surgeon of St. Mary's Hospital and of the London Lock Hospital, and asked him what he had to say upon the subject. He tells me that the most significant fact of the present time ia that the majority of the female patients whom he has to treat are 40 THE PROBLEM OF THE NATIONS very young girls, mostly under the age of 20. That 15 per cent, of the patients are married women, and therefore presumably mostly innocent. " All the cases," he said, " in the children's wards and the greater part of the married women are cases of ' innocent ' syphilis." It must be remembered that these are cases passing through a public hospital ; that the observations do not take any account of the well-to-do classes, the upper and middle strata of society, who would naturally seek treatment from private practitioners. The fact is of particular importance, because Dr. T. H. C. Stevenson, Superintendent of Statistics to the Eegistrar-General, expressly states that the mortality recorded against these classes from the more serious syphilitic diseases is high, and highest of any class of the community in that of locomotor ataxy. Incidentally, Dr. Stevenson remarks that syphilis appears to be most prevalent amongst the upper and upper middle, and the lowest (unskilled labour) classes of the community. At this point I am almost tempted to exclaim, " What need have we of further witnesses ? " These two statements by specialists of the highest authority are not to be read casually through and then left. Their importance, again, lies not only in the actual facts recorded but in their suggestion of the possible results arising out of the cases themselves. Bear carefully in mind what I have already said about the nature and characteristics of syphilis, and then apply some of those details to any one of the cases mentioned by Fournier and Lane. Those innocent women, and children, now in our hospitals are not being treated for a trivial complaint from which they will shortly recover and face the world again completely healed. It is fairly safe to presume that the majority of them are already in an advanced stage of the disease and that previous treatment, before they thought of entering hospital, was wholly inadequate. Hence their present condition, and hence the increased difficulty in effecting a total cure. And you must realize what that means. It means that, in all probability, for each case in the wards there may be three more outside not being treated. Apart from the husband who has infected his wife you must take into account other possible members of the household. The chances are that the woman has had no idea how contagious her disease is. Her children may have SYPHILIS 41 become infected by the mother's kiss. A friend may have been similarly infected. The servant, or the daily help, may have drunk out of an infected cup, and, in her turn, taken the disease to her own home. You v^ill see that the possibilities are simply endless. And M^hen that point has been grasped, then think what syphilis actually means, what it looks like. This is not an exaggeration. I could tell the most heart- rending stories of this ' innocent ' contagion. I could take you to Russia, to the mountain-districts of Roumania, to South America, to China, and show you whole villages literally decimated by syphilis. Places where there is no such thing as prostitution. But this does not affect Great Britain, does it ? A volcanic eruption in Japan accounting for 5,000 deaths is of far less interest to Londoners than the announcement of the latest theatrical star's marriage. No, sexual disease doesn't really matter ! In any case it is all due to immorality. We are not going to interfere. What is every- body's business is nobody's business. I wonder what the good people of Philadelphia thought about it when eight cases of syphilis occurred through playing " kiss in the ring," one evening, three years ago.^ But perhaps " kiss in the ring" is an immoral game, and so it was a 'just retribution.' Here is another case of ' innocent ' contagion, recorded by Dr. R. Ledermann, of Berlin. I give it in his own words. " A married man, living happily with his wife, and occupying a good social position, was so unfortunate as to acquire syphilis quite innocently. In the third year after the infection he suffered from an apoplectic seizure, and as he had not told his family doctor anything about his former illness no specific treatment was adopted. A permanent paralysis was the result. The consequence was that the family, who had no other resources but a small pension, was thrown from comparative affluence into the most abject poverty." One could hardly find a more striking instance of the results not only of * innocent ' contagion, but of the neglect of adequate treat- ment in the earlier stages of the disease. There is our problem, again : To educate the individual to go to the best available doctor in the shortest possible time. But I have not yet finished with * innocent ' contagion in married women. Apart from the observations of Fournier and ^ Lancet, 1911, vol. ii, p. 901. 42 THE PBOBLEM OF THE NATIONS Lane, and many other specialists whom I could quote, I would refer back to the facts given in the previous chapter on gonorrhoea. The remarks there made about possibilities of infection from husbands apply equally in the case of syphilis ; only, thank heaven, syphilis is not nearly so prevalent. I sincerely hope that I have said sufficient to indicate the prevalence of such contagion and the possible results. But I would still make some brief comment upon two points in connection with syphilis and marriage. Syphilis and Marriage. There almost invariably arises considerable difficulty in affording adequate treatment to the husband or wife who has become infected, or in whom the symptoms develop after marriage. And the reason is the very natural one that neither cares to confess to the other, even if the gravity of the disease is appreciated. Consequently a local chemist or an advertising ' quack ' is often consulted, secret remedies are applied, and the poison of the disease continues at its insidious work until some virulent outbreak or collapse ensues. This will perhaps throw a little more light upon the nature of the cases in the hospitals to which I have referred. In married women the early symptoms of syphilis are very frequently mistaken for those of some other ailment.' Thus even secret remedies may not be applied until the disease has got a firm hold. And I need hardly add that in such secret remedy cases the danger of infection for other members of the family is very great. These several facts probably account in great measure for the higher statistic percentage of women, as compared with men, who develop the more serious disorders of tertiary syphilis. For the percentage is higher. The second factor in syphilis and marriage which calls for mention is the more advanced age of the individuals concerned. I mean that syphilis is more dangerous in the old than the young. A married woman of 28, for instance, may possibly develop graver symptoms than would a girl of 19. It is obviously impossible in a work of this nature to speak in detail upon all these points. The question of syphilis in relation to marriage is naturally of the very first importance, but I can only attempt to indicate here that it is important and so leave it to the ' Cf. the chapter on Gonorrhoea, p. 18 supra, also vide " Health and Disease in Belation to Marriage," Senator-Kaminer, vol. ii, English translation, pp. 574 et seq,. SYPHILIS 43:^ individual to follow up the suggestion. The most important aspect of the question is that of hereditary transmission, and of this I have still to speak. I have already given several instances, for it is difficult to avoid an overlapping of subjects. There are several other points upon which I might well dilate under this sub-heading. There is the question of syphiHs and Life Assurance, for instance; a subject which is receiving very close attention at the present time owing to the relationship which is now known to exist between syphilis and the more serious diseases, paralysis, arterial and cardiac diseases, and so on. The statistics, too, to be obtained through life assurance societies afford valuable evidence of such relationship and of the prevalence of sexual disease itself. Then there is the vexed question of the duration of the treatment which a syphihtic should undergo before he thinks of marriage. That is a question which I shall not attempt to discuss, because it seems to me that each individual, in consultation with his medical adviser, must be a law unto himself. It will be observed that I have made no reference to the morality of the matter. Is it really necessary to do so ? In writing of this subject of sexual disease I believe that the best way to carry conviction of its gravity is to confine myself so far as possible to simple statements of fact. If these will not convince then " a little bench of heedless bishops here," with all their preaching, would fail. " It is the true office of history," said Bacon, " to represent the events themselves, together with the counsels, and to leave the observations and conclusions thereupon to the liberty and faculty of every man's judgment." And if at times I fall away from so excellent a counsel I may perhaps be pardoned for a natural and just indignation at the hideous and unnecessary suffering — the appalling cruelty of it all ! I could, were I so minded, draw lurid pictures of families into which the plague of syphilis has been introduced by the husband. To a pure-minded, virtuous woman syphilis is a loathsome thing, a thing belonging to debauch and loose women. It needs little imagination to conjure up the results when It has crept into the home. I recall a case where the wife, after two miscarriages, gave birth to a child infected with syphilis which died almost im- mediately. Then the revelation of the disease came upon her in a lightning flash, she realized that her husband was the murderer of 44 THE PKOBLEM OF THE NATIONS her three children. Mad with grief and hate she stabbed him to the heart, and then killed herself. Certainly this was an exceptional tragedy, but the case-books of private practitioners will furnish hundreds of narratives of lesser tragedies — of divorce, social ruin and all the attendant miseries to husband, wife and children. Syphilis, during the active period of life, does not as a rule lead to sterility in the wife, but it is estimated that 42 per cent, of miscarriages and abortions are due to the disease. With both parents infected the proportion is so high as 70 per cent. Proper treatment will hold syphilis in abeyance even if it does not actually cure it. From careful comparison of results the broad rule has been established that : — without adequate treatment abor- tion will result ; with proper treatment there will be healthy children ; but when the treatment ceases there will be syphilitic children.^ It is asserted that the elimination of sexual disease will put a premium upon immorality. Even supposing, for the sake of argument, that it will, what have we to say for the 20 to 25 women out of a hundred, to say nothing of the children, who are innocently condemned to such suffering ? Have they no claims upon our sense of justice ? And yet, with all that I have said about these tragedies of ' innocent ' contagion, I would again emphasize the fact that, with the sterling remedies which are now at command, sexual disease is less serious thafi tuberculosis if only treatment is secured and persisted in from the very beginning. It depends upon the individual. ' Address by Dr. C. W. MacGillivray to the Edinburgh Medico-Chirurgical Society, January 5, 1910. 45 V. SYPHILIS (conti7iued). Non-sexual, oe Innocent Contagion (continued).. Children and the Heredity Factor. "The world has no such flower in any land, And no such pearl in any gulf the sea. As any babe on any mother's knee." — Swinburne. " "Where children are not, heaven is not." — Swinburne. I HAVE now to speak of the most cruel aspect of all this harrowing subject. Not only the most cruel, but the most signi- ficant in our consideration of the causes and effects of sexual disease. The question of the innocent infection of children, and its hideous results, is so inextricably woven into the subject of ' hereditary transmission ' that it seems best to take both aspects under one sub-heading. Again I must attempt to set forth the facts with as little comment as possible, for I dare not trust myself further. I will begin with two authoritative quotations : — " If I were asked, as an old practitioner, what is the worst result of syphilis, I should have no hesitation in replying that it is the hereditary effect, which manifests itself by causing hecatombs of infants, without any exaggeration." — Foueniee. " Syphilis is the hereditary disease par excellence. Its hereditary effects are more inevitable, more multiple, more diverse, and more disastrous in their results on the progeny and the race than in the case of any other disease. Syphilis has, in fact, a more harmful influence on the species than on the individual." — Dr. C. F. Maeshall. Speaking in a general sense, the unborn babe, or the child after birth, may become infected with the poison of syphilis in one of three ways, which may be further subdivided : — (1) By hereditary transmission. This means either {a) that tha -46 THE PROBLEM OF THE NATIONS (potential) mother is already infected with the poison before the child is actually conceived, or (6) that the father transfers the poison to the mother in the spermatozoa. (2) By conge?iital transmission. This means that the unborn child has been conceived in a healthy condition, but has become infected either before or at birth from the infection of the mother subsequent to conception. (3) By contagion after birth. That is when a healthy child is born, but the disease is subsequently acquired from an infected parent, a nurse, or, generally, from an infected article. Taking (1) and (2) we come to speak of * transmission ' as being either (a) Mixed, from both parents ; or (b) Maternal, which includes infection from the mother either at conception or during pregnancy ; or (c) Paternal, where the mother is healthy, but the poison is conveyed as noted in (1), 6. ^ It may be urged that these exact details appear unnecessary in a work of this character. But a moment's thought will reveal the importance of making such a differentiation. Let me instance a case of congenital transmission which recently came under my own notice. A married couple were perfectly healthy. The wife became pregnant. In the course of this period the husband, who was devoted to his wife, was led, under the influence of boon com- panions, a cheery supper and over-much champagne, to indulge in extra-marital intercourse. He became infected with syphilis, which he did not recognize as such, and subsequently infected his wife. Five months later a child was born. It died before it was a year old. Here is another instance of what may occur through paternal transmission. The mother was quite healthy, but the father had a latent syphihs. He infected, not his wife, but the child to be in the manner indicated above. The wife remained uninfected until the moment of giving birth and then became infected from her babe. I have mentioned these two cases, which will naturally suggest ' It should be remarked that there is considerable controversy on the subject of paternal transmission, but the weight of evidence and expert opinion is decidedly in favour of its frequent possibility. Eeference may be directed to a Paper on the subject by Dr. C. F. Marshall, Journal of Children's Diseases, vol. ix, p. 204. SYPHILIS 47 a further endless variety, because I think that the pubhc should realize something of the manner in which the child may become infected. It will readily be understood that hereditary transmission is by far the most harmful in its effects, because the child is actu- ally conceived in a state of infection. Fournier estimated that the morbidity, or prevalence of disease, due to mixed transmission was 92 per cent., and the death-rate amongst such infants 68"5 per cent. The morbidity from maternal transmission he estimated at 84 per cent., and the death-rate at 60 per cent. From 'paternal transmission the morbidity was 37 per cent, and the mortality 28 per cent. It will also be realized that the results must differ according to the state of development of the foetus at the time of infection.^ For instance, as a result of hereditary transmission, there may be a definite cessation of development of the foetus, or of particular limbs or organs. Conge^iital transmission may, on the other hand, produce only some of the specific symptoms of syphilis. I do not wish to dwell upon this part of the subject longer than is necessary, but it seems well to clear the ground. What I desire to emphasize at this point is the appalling child mortality which results from infected parents. The above percentage figures give some indication of this, and I would invite a very thoughtful attention to them. Let me set them down in tabular form : — Mode of transmission Syphilis present in Death-rate Mixed Maternal Paternal 92 per cent. 84 „ 37 „ 68 "5 per cent. 60 28 Take only the least dangerous of those subdivisions, that of paternal transmission. There we find that children born from an infected father and a healthy mother die in the proportion of 1 in 4. But look at the figures of mixed and maternal trans- mission. They are almost too terrible to reahze. It has, in fact, been laid down as an axiom that a child born of a mother in a state of recent infection is almost fatally condemned to death. Syphilology," Dr. C. F. Marshall, p. 318. 48 THE PROBLEM OF THE NATIONS The case-books of an eminent specialist in private practice' record the history of 44 women who became pregnant in a state of infec- tion. Of the 44 births there were 43 deaths and one living child ! The same specialist also records 208 births from 100 infected women. Of these 60 only survived. The remainder were mis- carriages or stillbirths. A mortality of 71 per cent. ! And all of these cases were drawn from the upper and middle classes, to whom the best medical care was open, and who may have been presumed to possess a reasonable amount of intelligence and knowledge. Imagine the figure in the case of the lower classes. In fact, at the Lourcine Hospital, Paris, the mortality reached the figure of 86 per cent., and at the St. Louis Hospital, where the patients are of a somewhat better class, the figure is 84 per cent. Another set of cases was that of 90 women, infected by their husbands, who became pregnant during the first year of the disease. The births resulted as follows : Fifty miscarriages or stillbirths, 38 deaths shortly after birth, and two infants who survived. A death-roll of 88 out of 90. Again all these cases were drawn from the higher classes of society, and observed in the course of private practice. It is of the first importance to note that these three series of observations were taken in the ordinary course of practice ; that there was no idea of selecting a number of malignant cases with a view to making a pessimistic return. The figures were compared with the results obtained by some fifteen other specialists, and the outcome was practically identical, the mortality averaging 77 per cent. Still further confirmation, if any were desired, is to be found in the statistics published in 1911 by Dr. Leroux, as the results of his observations made at the Furtado-Heine Dispensary, Paris.^ These percentage returns and figures work out as almost identical with those quoted. Dr. Hochringer, of Vienna, published in 1910 the results of his observations at the Children's Hospital in that city.^ He records that out of 516 births from syphilis-infected parents 253 were born dead or died soon after birth. Of the 263 survivors 55 died before the age of 4, despite careful treatment ; and of the ^ " The Prevention of Syphilis,'" Alfred Fournier. ' " Annuaire cle Medecine et Chirurgie Inf.,'' Paris, 1911, xv, p. 337. ^ Munch.'med. Woch., 1910, p. Ivii, 1156. SYPHILIS 49 remaining 208 only 51 were normally healthy. Once again then we find a similar percentage, only about 25 per cent, of syphilis infected children growing into healthy adults. In fact, in every country from which I have gathered informa- tion, the story is the same. I have already referred to the preva- lence of the disease in certain villages in Russia ; I will quote from two more authorities in that country. A careful record was kept in Moscow for a period of ten years. During that time there were recorded 2,002 births from syphilis- infected parents. Of this number only 577 children survived. A mortality of 71 per cent. ! Dr. Tarnowsky records a case of three famihes with 22 children. Of all these individuals only one healthy adult survived. Major H. C. French, E.A.M.C, records his personal experience of a similar condition of affairs in India between the vears 1896 and 1901. Dr. Bennie ^ gives evidence in support of his theory that every child possesses a syphilitic taint if either parent has ever had syphihs. He adds that of Australian children 10 per cent, are so infected, and that for these the chances of death before puberty are seven times as great as in the case of normally healthy children. Infant Mortality in Great Britain. This last statement naturally suggests a consideration of the state of affairs in Great Britain ; a comparison with other countries. Here I must honestly confess that I am at a loss. Data upon the general prevalence of syphilis in this country are both meagre and unreliable, and still more so upon the question of infantile mortality from the disease. For instance, in the Eeports to the Local Government Board, 1900-1910, 1912-1913, upon Infant Mortality in England and Wales, sexual disease is not even mentioned. "We English," said Mr. H. A. Jones in one of his plays, ''are no better than our neighbours, but, thank heaven, we do pretend to be." The remark seems rather a propos. In view of the facts which I have quoted have we any just grounds for presuming that we are any better than our neighbours in respect to infant mortality from syphilis ? Why should we presume that we are ? For the moment I am trying to consider ' Writing in the Intercollegiate Medical Journal of Australia, March 20, 1909. 4 50 THE PROBLEM OF THE NATIONS "infant mortality" apart from/' general prevalence," althougli it is difficult to do so. Taking the Registrar-General's Annual Eeports for the years 1906-1911 we find that the average number of deaths frovi syphilis alone of the whole population is 1,709. Now three-fourths of this figure represents infant mortality (i.e., under one year of age), or an average number each year of 1,282 deaths of infants from syphilis. As the population of England and Wales in 1911 was returned at 36,000,000, this death-rate is not very startling, although it should be noted that the birth-rate has been steadily declining since 1895 in proportion to the increase of the population : i.e., from 29*4 per 1,000 in 1895 to 24-0 in 1912. In Ireland the records show that syphilis, per se, plays a relatively small part as a cause of mortality, the figure being 0"78 per 10,000 of the total population. In Dublin the figures are abnormally high, being double those of London. The official returns of infant mortality from syphilis alone for the United Kingdom are : — 1-29 per 1,000 for England and Wales ; 1-4 for Scotland ; and 0'59 for Ireland. Dr. J. Kerr Love recently recorded his observations upon twenty-one families infected with syphihs. Two-thirds of the children were born dead, or, if alive, were blind or deaf or both. But, as we have seen, syphilis is an elastic term. When we find recorded that so many infants died of syphilis, it means that obvious syphilitic symptoms were present. It does not include any of those many other diseases from which children suffer as a more or less direct result of hereditary or congenital syphilis. And if you will refer back for a moment to Dr. Browning's investigations on p. 31, you will see what some of those diseases are. For instance, of the eighteen cases of heart disease nine died under the age of six months. However, in order to give some general indication of the rate of infant mortality due to some of these diseases I will set down some figures taken from the last Annual Eeport of the Registrar-General for England and Wales, that for 1911. I may add that, exclusive of diarrhoea mortality, the rate for 1911 was only 2 per 1,000 in excess of that for 1910, the lowest until then recorded. It will be noted that I have included the death rate of illegitimate infants, for some of these figures are, by comparison, particularly instructive : — SYPHILIS Peoportion of Deaths under 1 year to 1,000 Births. 51 Cause of death All infants Legitimate infants Illegitimate infants Tuberculous diseases 3-81 3-66 7-20 Developmental and toasting diseases . . 41-37 39-60 81-07 Laryngitis 0-20 0-20 0-24 Syphilis .. 1-29 0-99 8-10 Rickets 0-39 0-36 1-09 Congenital malformations 3-68 3-67 3-85 Premature birth . . 20-10 19-47 34-23 Atrophy, debility and marasmus 15-90 14-80 40-68 Further than this I feel I cannot go. Where the Koyal Com- mission has failed in obtaining evidence it is hardly likely that I should succeed. Syphilis is not a notifiable disease, and it is a surprising fact, not that the number of recorded deaths should be so few but that they should be so numerous. For it can be only in exceptional cases that syphilis is actually recorded as the cause of death. And I shall be confronted with the same difficulty in speaking of general prevalence. In writing of this subject of sexual disease I prefer, as far as possible, to set forth definite facts rather than hypothetical suggestions. But before leaving this brief consideration of infant mortality I would once again emphasize the beneficial effects which come from early and adequate treatment. We have seen that the gravest danger arises during the first year of the parents' infection ; the " year of terror," as Fournier terms it. But from this period the danger gradually decreases, although it depends to a large extent upon the action of the individual. Thus, at the outset, we find abortions ; then still- births ; then living children in whom symptoms of syphilis may develop at any time ; and, lastly, healthy children. And even this progression is modified. For with thorough treatment there seems no reason why there should not be healthy children from, say, the second or third year.^ It depends upon the individual. Finally, medical science is concentrating every effort to combat the effects of the disease upon the unborn child, and already the salvarsan treatment has secured good results in this direction.' ^ Vide p. 44 supra, for the axiom upon this point. ^ This upon the authority of Dr. Jeanselme, of the Broca Hospital, Paris, one of the first medical men in France to use Ehrlich's remedy. 52 ♦ THE PROBLEM OF THE NATIONS Hereditary Symptoms in Children. Ill speaking of innocent contagion of children I have dealt so far solely with effects upon mortality. We have now to consider very briefly the effects of syphilis upon living children. And then I hope to have finished with this most painful part of the subject. I may add that for my authorities upon this question I rely chiefly upon the records and observations of Professor Fournier, Sir Jonathan Hutchinson, Dr. C. F. Marshall, and others who will be indicated. For the sake of convenience I will adopt Fournier's summary, in three groups : — (1) The symptoms which affect the individual in a partial manner only, i.e., the part of a system, or a single organ. (2) Those affecting the body as a whole. (3) Those which are still more serious, and constitute monstrosities. As regards the third subdivision, which is comparatively uncommon, I think it unnecessary, for obvious reasons, to speak. And surely we have " supped full with horrors." The ordinary symptoms of syphilis are, for the most part, absent in infected children. The effect of the poison manifests itself in such ways as malformations of the teeth (which are particularly common) and palate ; of the head and skull ; of the spine, nose, eyes and ears ; of the limbs, such as dislocations of the hip, club-foot, &c. ; and in disorders of the heart, &c. All these are included under the first subdivision. I do not propose to go into further details, for they would be too horrible. The finest object-lesson for anyone who doubts the hideous effects of syphilis upon children would be a visit to the London Hospital and an inspection of half a dozen cases of children ranging from 8 to 1.5 years old.-^ I can assure such a visitor that the nightmare would haunt him to his dying day. But the public does not see such things, they are guarded by hospital walls. And so we go on in our smug complacency, drifting, drifting. " God's in His heaven — All's right with the world ! " " But the young, young children, my brothers, They are weeping bitterly ! They are weeping in the playtime of the others, In the country of the free." 1 For anyone who dares to brave some details and photographs he wiU find them in the Lancet of January 3, 1914 ; five cases recorded by Dr. J. H. Sequeira. SYPHILIS 53 Under the second subdivision are included cases where the general constitution, temperament or vital resistance is affected ; where the child is born " a weakly, puny, wizened creature," too weak to suck or cry. Or it may be brought to life seemingly healthy and may, in a few years, be carried off because it does not appear to have the will to live ; dying of no definite complaint, just passing away. Another tj^pe, under this subdivision, is the child whose physical development is permanently arrested ; a stunted growth like that of a Japanese dwarf tree, and yet growing older, ever older. Then there is this question of Mental Deficiency in children. Some observations of the first importance on the subject have recently been carried out by Dr. Kate Fraser and Dr. H. Ferguson AVatson, upon 204 cases of mentally deficient children, ranging from 1 month to 8 years old. In the great majority of cases there were no palpable traces whatever of syphilis, even when an examination of the parents and relatives gave practically conclusive evidence that it must be present. Of these 204 cases the presence of syphilis was detected, by the Wassermann test, in no fewer than 60 per cent. Summing up, these specialists concluded that syphilis was the causative factor in more than 50 per cent, of cases of tnental deficiency ; and that syphilis was associated with a far higher percentage of cases than could be ascertained by an examination of the patients alone. Rickets, in children, is also closely allied to hereditary syphilis. Dr. Pinard, of Paris, states that he had never observed a case of rickets apart from heredo-syphilis. Infected children are also especially liable to Convulsions, and so to serious brain diseases. Now it will be seen how valueless are our statistics of infant mortality due to syphilis. Apart from deaths due to all the hundred and one distinct manifestations of the poison of which statistics take no account as such, we have no record of these thousands of cases (there must be) of death in life. Who shall tell the tale of the children who linger on in physical and mental agony, looking out with wide-wondering eyes upon the life which their brothers and sisters find so full of sunshine. Shall they not at the last call their parents before the Bar of 54 THE PROBLEM OF THE NATIONS Judgment and demand the reason of their summons into the world ! And the parents ■will answer, " We didn't know ; we didn't realize " ! The excuse may have served ; let us see to it that it shall serve no longer. If there is anything in all this ghastly subject which can awaken the conscience of the nation — no, the conscience of civilization — surely it must be the cry of the children. I read in the press of a public meeting held to protest against the action of the head-mistress of a school in daring to instruct her pupils in the elements of sex hygiene. I read the comment of a worthy town councillor at that meeting, " We don't want our children to be educated as midwives." Have, then, those parents who thronged the hall been at pains themselves to instruct their children in the things which a child should learn, and in the most beautiful manner ? Have they fulfilled their obligations in such a way that they may properly resent interference from a third person ? Oh ! this miserable hypocrisy and cant ; are we never going to break it down? But it has to be broken down, and this generation is going to do it. I refuse to believe that the public will not respond so soon as it has learned the facts. There must be initiated such a cam- paign of education as will break up once and for all this conspiracy of silence. That campaign has indeed already been begun and recruits are enrolling themselves by hundreds in the ranks of the invading army. Let the watchword, " For the Children," be emblazoned upon its standard, to be carried like a fiery cross to the confines of the world. " Do you hear the children weeping, O my brothers, Ere the sorrow conies with years ? " 55 VI. SYPHILIS {continued). Innocent Contagion {continued). Nurses arid Infants. Leading directly out of the contagion of children we may suitably consider a few facts concerning the infection of nurses by infants ; also the converse, the suckling of healthy children by an infected nurse. Particular attention has recently been directed to this question by the production of Brieux's play, "Les Avaries " ("Damaged Goods"). In this there is an episode where the medical attendant forbids the suckling, by a healthy nurse, of a child in whom syphi- litic symptoms have developed. It will at once be apparent how very real this danger must be. The danger is immediate when the symptoms have already developed ; but it also exists in the numerous cases in which the child remains apparently healthy for some time after birth. Pinard gives statistics showing that symptoms appear in infants : in 70 per cent., during the first month ; in 20 per cent, during the second month ; and in 10 per cent, up to the end of the fourth month. Thus a child born of syphilitic parents cannot be held non-contagious during this period. The subject is one which presents considerable difficulties to the medical attendant, and Brieux has well indicated these in his plaj^ Without going into the point at length the alternatives may be briefly stated. The main point to be decided is the one considered by Brieux — whether the first duty is due to the infected infant or to the healthy nurse. If the infant is deprived of its natural food given by the natural method then it will undoubtedly suffer. On the other hand the nurse will become infected and will, in all pro- bability, spread the contagion. Here are two cases in point quoted by Fournier : — 56 THE PROBLEM OF THE NATIONS (1) A child born of a syphilitic father was given to a healthy nurse. The child soon developed symptoms of syphilis and infected the nurse. The latter, in turn, infected her husband, who lost an eye by syphilitic iritis. The nurse died soon afterwards of syphilitic paralysis. (2) A husband infected his wife, and the child subsequently born was given to a nurse. The child developed symptoms of syphilis and infected the nurse. The nurse, in turn infected her own child, which died in a few months, and also her husband. The nurse also lost an eye through syphilitic iritis, and a year later gave birth to a syphilitic child, which died in two months. From these and other similar considerations the rule must be established that ' we have not the right to give syphilis to a nurse in order to save an infant.' There are many other issues involved in this question andi Fournier has dealt with them in detail.^ I will quote one case to show the converse side, viz., the infection spread by a syphilitic nurse. It will be noted that nearly all the cases which are given throughout this work bear upon several other points in addition to the one immediately at issue. AVhile the details are invariably unpleasant I think that definite examples of the effect of syphilis will have more practical value than mere descriptive writing. A healthy child, of some 8 months, born of young and healthy parents, was given to a strong and apparently healthy nurse. In about six weeks the nurse developed certain symptoms which were subsequently diagnosed as syphilitic. (It was afterwards discovered that she had been undergoing treatment for syphiHs, and that her child had died of the disease.) The child began to waste and developed sores in the mouth, followed by other and more serious secondary symptoms. The mother contracted a chancre on the lip through kissing the child ; and this was followed by secondary symptoms, and a subsequent abortion. The grandmother also contracted the disease about the same time as the mother ; as did also two sisters of the child, ail developing secondary symptoms. Finally, the father of the child, who had been warned of the ' " The Prevention of Syphilis," Alfred Fournier, English translation, pp. 43 et se SYPHILIS 57 danger of cohabiting with his wife, also became infected, and subsequently developed secondary symptoms. Here then, in resume, were six serious contaminations and one death, all in a single family, through the infection introduced by a nurse. I have been accused of selecting the most serious cases to illustrate the various points of the subject ; that in laying too much stress upon the dire effects I may come to frighten the public too much. One cannot, heaven knows, exaggerate the effects of this disease, but I would not have it thought that my object consists merely in making out the case as serious as possible. My whole object is directed towards setting forth actual facts as clearly as possible and, at the same time, towards emphasizing how fully adequate is the treatment which medical science has at its command if only people will learn to avail themselves of it. That despite all that I have said about the ravages of syphilis the disease is less dangerous than, say, typhoid fever, if only remedies are applied and persisted in from the very outset. It depends entirely upon the individual concerned. Thus, now that I have given some three, or four instances under this sub-heading of grave results from syphilitic infection, I would also allow some little ray of light to penetrate through the gloom. I find it in some recent results of salvarsan treatment recorded by Colonel T. W. Gibbard, of the Koyal Army Medical College. Speaking in February, 1914, Colonel Gibbard states that of sixty-two consecutive cases of primary syphilis occurring in the past eighteen months, and kept under observation for six to nine months, not a single one has developed secondary symptoms. In other words the disease had been absolutely arrested in its development by efficient treatment from its early stages. He further states that salvarsan treatment renders the patient non-infective in twenty-four to forty-eight hours. I can conceive no more potent argument than this to induce a patient to present himself for treatment at the earliest possible moment. Doctors and Midwives. Owing to the scrupulous care which is observed by medical men and nurses in the matter of disinfection, both of themselves and their instruments, cases of contamination are now comparatively 58 THE PROBLEM OF THE NATIONS rare. But they do occur and contagion may be, all unwittingly, passed on to others. Three recorded instances will suffice in illustration :^ A dentist contracted a chancre of the finger after operating upon a patient with syphilitic patches in the mouth. A surgeon, in the course of an operation upon a syphilitic patient, chanced to wound one of his fingers very slightly with an instrument. Primary symptoms developed. Another similar case^ was that of a surgeon with a large midwifery practice, who pricked his finger with a needle while putting in some stitches. He knew his patient to be infected, but as no primary symptoms developed the surgeon concluded that he had escaped the danger. Some time afterwards pronounced secondary symptoms appeared. Cases of infection by mid wives are more common. Dr. Duncan Bulkley records an epidemic of syphilis in a district in England, where a midwife continued her work although actively infected. Her victims numbered forty-one. Of these thirty were women, nine were husbands, and two children. A similar epidemic, from similar causes, occurred in Brive, France, some forty years ago. There the victims were more than one hundred. Some Miscellaneous Cases of Innocent Contagion. Apart from the cases of innocent contagion in women and children it has been estimated that extragenital chancres^ 'form nearly 10 per cent, of all chancres.' They are most commonly found on the lips and mouth. ^ The poison may be conveyed to the mouth in a variety of ways. Kissing is obviously a very common medium. I have already referred to the small epidemic which occurred in Philadelphia through playing 'kiss-in-the-ring' {ante, p. 41). And there must be many hundreds of cases in which children and women have thus been infected. It should be remarked that a single kiss, ' Recorded by Sir Jonathan Hutchinson. - I.e., primary symptoms appearing in various parts of the body, and such as are not due to sexual intercourse. ^ Fournier observed 1,124 cases of ' extragenital ' syphilis and, of these, the lips were affected in 567 cases. SYPHILIS 59 even one of respect, is quite sufficient to transfer the infection. Also that the infection may be transferred in this manner not only to the lips, but to the inside of the mouth, the cavity of the throat and tonsils. Then there is what is known as " mediate " contagion, where infection is carried by drinking vessels, feeding utensils, paper- knives, penholders, toys, speaking tubes, &c. This may seem an exaggeration, but indeed there are very many cases on record of such contagion. I will take four at random by way of illustration. A little boy was given a new toy trumpet. But none of his brothers and sisters, nor his father and mother, could blow it so delightfully as an uncle. Unfortunately the uncle was suffering from syphilitic patches upon the inside of the mouth, and so the infection w^as spread, with fatal results for mother and boy. A man of 60 developed similar mucous patches on the mouth. After prolonged investigation it was discovered that his valet had been smoking one of his master's pipes. The valet already suffered from syphilis and had previously infected his fiancee by kissing. A medical student was not careful enough to disinfect his hands after his work. He had the habit of holding his pen between his lips while making notes. As a result the poison was carried to his mouth. A well-known physician was in the habit of sucking an ivory paper-knife while reading. One day he used the knife as a tongue- depressor while examining a girl with a sore throat (sic). He forgot to clean the knife, and, as the girl was really suffering from syphilis, he also developed the disease, and with fatal results, for he subsequently died of paralysis of the brain. These four cases, out of hundreds which might be quoted, will probably suffice to indicate not only how terribly contagious syphilis is, but also in how many cases the disease may be acquired innocently. Under this same heading I should also mention a class of cases where syphilis has been contracted through industrial employment. The most common, or at least the best known, is that of glass- blowing, and the infection is spread by the custom of handing the glass-blower's tube from mouth to mouth. Several epidemics of such infection are recorded, ^ and I noticed * " J)e la Syphilis des Verriers" Guinaud, Paris, 1881. 60 THE PROBLEM OF THE NATIONS a case reported in The Times about two months ago. Similarly infection has been transferred by orchestral instrumentalists, by electricians testing a current with the tongue; by upholsterers holding tacks in the mouth and returning those not used to a bag. In fact it may be spread through the most unlikely media ; in any way where there is a possibility of mouth to mouth infection, or through towels, sponges, a barber's razor and so on. Under this heading of innocent contagion we have now, I think, fairly considered the argument of those intensely moral individuals who assert that sexual disease is adjust retribution" of immorality. We have investigated the causes and effects of the innocent contagion of women, and have noted the average percentage of such cases — 20 to 25 per cent. We have also seen some of the dire effects of syphilis upon the married state. It will possibly be noticed that I have made no reference to the converse side of my argument regarding infection through marriage, viz., the infection of an innocent husband by a guilty wife. For one reason and another such cases are seldom heard of. But they must occur and, probably, far more frequently than is imagined. Personally, I have come across two instances ; one in which the wife had been a professional prostitute, and the man married her, naturally at his own risk; the other was the case of an amateur prostitute. Here the girl had served in a shop in Oxford, and being an attractive young lady, secured for the proprietor no small amount of undergraduate custom. She had probably two or three lovers, and eventually married a man in her own rank of life, who believed her an innocent girl. As a matter of fact she was at the time of her marriage in a condition of active syphilis. I can record no details save that she naturally infected her husband, and that her first child was born dead. But when one considers the amount of amateur prostitution in existence, and that it is one of the objects of such a prostitute to make herself out to be an innocent woman, especially to the man whom she proposes to marry, one cannot but think that a great deal of tragedy lies hidden from the world. Always the wife is presumed to be the innocent sufferer. To resume. I have tried to indicate the appalling amount of infant mortality which is due to syphilis, and also something of the SYPHILIS 61 hideous effects upon children, the living death to which they are so often condemned. And lastly I have suggested how many are the ways in which infection may be spread amongst the innocent. Is sexual disease still to be accounted the " just retribution of sin"? I leave the answer to " the liberty and faculty of every man's judgment." 62 VII. THE PEEVALENCE OF SYPHILIS. I HAVE been trying to make up my mind upon a somewhat difficult point involved in the general scheme of this work — whether it is advisable or not to give statistics. It is not unlike the position of Launcelot Gobbo, pulled this way and that by "the fiend" and his conscience. Does the average individual care a rap about statistics ? And if he does, will he place any reliance upon them ? They are, at best, suspicious things, admirable witnesses if they support one's arguments, to be carefully omitted if they do not. Carlyle's "crabbed satirist" used to remark that a judicious man looks at statistics, not to get knowledge but to save himself from having ignorance foisted on him. And I cannot help feeling that this remark may be vigorously applied in the present case. But then there are the critics. And I generally find that the critics are apt to be far more tolerant towards statistics, even though inadequately compiled, than they are towards expressions of opinion, however eloquent and persuasive. In the present case I must say that I agree with them. On the whole, however, it appears best in this consideration of sexual disease to abide by the vote of the majority. The "Noes," therefore, have it, and there shall be as few statistical tables as possible ; although I must quote figures if I am to indicate the prevalence of the disease. At the same time, however, I have found in the course of my inquiry that the statements or estimates made by specialists are most misleading unless the basis upon which such an estimate is founded is also carefully set forth. This is very rarely the case. Several eminent personages in Church and State who have perused those statistics which have already been given, and others which I proposed should follow in this chapter, have remarked quite frankly that they did not believe them, and have advised me to be as sparing with them as possible. And if I THE PREVALENCE OF SYPHILIS 63 have — only for tlie moment I hope — been unable to convince such masters of learning of the widespread prevalence, I fear that my chances of convincing the general public are very slender indeed. But I would remark that these figures, far from exaggerating the gravity of the matter, must indeed fall considerably short of the actual truth. I refer more particularly to those of the civil population in the various countries. As regards those of the Navies and Armies of the world, I see no reason to doubt their exactness. Nor indeed do I doubt the figures which I have obtained from Japan. I particularly mention Japan because every one who knows the Far East is most suspicious (and rightly so, I must confess) of any official Government returns. But I can conceive no line of reasoning which would induce a Government to assert that the prevalence of sexual disease in its country was greater than it actually was. And the state of affairs in Japan appears to be particularly serious. As I have already several times remarked, the official statistics of sexual disease are only concerned with the three specific forms, and take no account of the many other diseases which, we have seen, are so frequently the outcome. And even here we find further confusion in trying to arrive at an estimate. For it by no means necessarily follows that because the mortality from, say, aneurysm is on the increase,^ therefore syphilis is also on the increase. Nor must we deduce a corresponding increase in syphilis from the steady rise (in Great Britain) since 1876 of admissions into lunatic asylums.^ In both cases we might trace back the causes to the more improved methods in investigating the results of syphilis. Suppose we consider the numbers of would-be recruits annually refused admission into the British Army on account of their being infected. On the face of it, this would seem to offer a reasonable basis for a broad calculation as to the prevalence of sexual disease amongst the civil population. We should know, moreover, what part of the country each of these men came from, and this would be an additional help. Upon this basis we should deduce that syphilis was decidedly upon the decrease, for the number of refusals has been steadily decreasing since 1873. For instance, 106 men out of a total of ^ Vide supra, p. 30. ^ Vide supra, p. 29. 64 THE PEOBLEM OF THE NATIONS 61,278 were refused on account of syphilis in 1908, and 56, out of 47,008, in 1911-12. But before accepting such a deduction there are several facts which must be remembered.^ Of these the most significant is, I think, that candidates for enlistment are now generally well aware that if they go up for medical examination with symptoms of syphilis they will be rejected. And equally as important to our inquiry is the fact that candidates for enlistment are by no means representative of the civil population. Continental armies are recruited, under the compulsory service system, from all classes of the community, whereas the British Army has to rely upon volunteers, and those who volunteer do so from definite motives — love of adventure, possibly ; destitution or failure in obtaining other employment, more frequently. Would-be recruits are thus drawn from two or three classes only and we are therefore entitled to draw our inferences as to prevalence of sexual disease only amongst those particular classes. Some systematic and international basis for the collection of statistics in sexual disease is sadly needed. Now and again a state or city will adopt some temporary means for collecting evidence, but it is seldom any more than the glimmer from a shepherd's lantern across a dark moor. New York City, for instance, has just concluded a year's period of compulsory notification. Then we have definite figures from Christiania. Ten years ago the Prussian Board of Education instituted a careful inquiry throughout Germany. Most important of all, perhaps, we have the results of the careful investigation initiated by Dr. B. Burnett Ham in the State of Victoria, Australia ; an investigation which has, I honestly believe, done more than anything else to arouse the public to an appreciation of the gravity of the situation, and to the appointment of a Royal Commission. Incidentally, this was the first occasion in any country when any sound scientific basis (the Wassermann reaction) was utihzed to determine the prevalence of syphilis on a large scale. Apart from these and the careful records of the Russian Health Department, our material is very meagre. I may assert that in certain States of South America syphilis is simply rampant, that probably 20 per cent, of the foreigners (men) are infected. I might ' Some are detailed in Dr. Johnstone's Report to the Local Government Board, 1913. THE PEEVALENCE OF SYPHILIS 65 quote evidence to show that the Esquimaux suffer from the disease in a particularly virulent form ; that it is very prevalent along the littoral of Northern Africa ; that it runs like a plague through the native races of South Africa ;^ that its grisly fingers have stretched spectre-like through the teeming millions of China ; that Islam knows its horrors no less than Protestantism ; that wherever our so-called civilization has penetrated there will syphilis already be found sapping the manhood and womanhood of the country. Are all these but travellers' tales ? But, after all, this consideration of the prevalence of syphilis is no more than a digression. The ' man-in-the-street ' is not particularly concerned with it. It may possibly form matter of additional interest in the same way as the succeeding articles on international aspects, prostitution, and other side issues, but that is all. I will, however, for the sake of completeness, attempt some kind of estimate from such selected data as we have available. Let us take first the results of the investigation in Melbourne.^ For twelve months syphilis was made compulsorily notifiable, but it is known that a certain number of private practitioners did not report any cases. Of 5,700 cases reported, 3,160 were found to be syphilitic, or 0'5 per cent, of the population. Five hundred and fifty cases at the Victoria Eye and Ear Hospital w^ere also examined. Of these 13*3 per cent., or 1 in 8, were syphilitic. As a result of these and other investigations upon similar lines it was concluded that approximately 5 per 1,000 of the Melbourne population were infected with syphilis ; that the damage caused by this and gonorrhoea must be enormous. These results are particularly instructive because Australia is, practically speaking, a new country, and one in which syphilis would scarcely be expected to have obtained so firm a foothold. The important fact should also be noted that while prostitution does flourish in the cities of Australia there is no economic necessity for women there to earn their living in such a manner. ' The Lancet of March 28, 1914, records particulars of the rapid spread of syphilis in South Africa, especially amongst the Zulus, one of the finest of native races. In the same Journal (May 11, 1912) will be found a suggestive paper by Mr. B. G. Brock upon " The Prevalence of Syphilis amongst the Natives of South Africa." ' A detailed account of this investigation will be found in Proceedings of the Boyal Society of Medicine, vol. v, No. 9 (Supplement), p. 174 et seq. ; also in Bedrock, April, 1913. 5 66 THE PEOBLEM OF THE NATIONS With centuries of crowded life behind us have we any reason- able grounds for presuming that Great Britain is in a better position than South Australia ? Think for a moment of the conditions which obtain in our great cities, industrial centres, and seaports — the overcrowded homes of the poorer classes,^ the impossibility of decent privacy in their daily lives, the constant intermingling of the sexes, the absence of sanitation, the use and abuse of alcoholic liquor — all powerful factors in the spread of sexual disease. Think of the vast amount of uncontrolled professional prostitu- tion, and the increase in amateur prostitution. Think of the hope- less inadequacy of our existing facilities for treatment of patients. Paris, with a population of 2| millions, has 2,000 beds available for such cases ; Berlin, with over 2 million inhabitants, has a still larger number ; London, with a population of 4^ millions, can muster no more than 200. Prevalence iti Japan. The figures given on page 12 to indicate the prevalence of gonorrhoea over syphilis in Japan afford also valuable evidence of the incidence of syphilis amongst the civil population in that country ; 4*75 per 1,000 of the young men of 20 years old are infected. And if chancroid and gonorrhoea are also taken into account we get the extraordinary figure of 25*26 per 1,000 males at this age suffering from sexual disease. As regards the mortality from syphilis in Japan the returns of the Imperial Statistical Bureau of the Cabinet show that, since 1907, the figure stands at 0'2 per 1,000 of the population, and 9 per 1,000 deaths. The general mortality has been 20 per 1,000 of the population. Here are the figures in tabular form : — Japan. Mortality from Syphilis. Sex Per 1,000 population Per 1,000 deaths 1907 190S 1909 1907 1908 1909 Male Female . . 0-20 0-17 0-21 0-18 0-22 0-19 9-8 8-1 10-0 8-5 10-1 8-5 Total 0-19 0-19 0-20 8-9 9-3 9-3 Especially in Dublin, where syphilis is particularly prevalent. THE PREVALENCE OF SYPHILIS 67 The Japanese Army. As already indicated, professional prostitution in Japan is regu- lated like a definite State Department. In the Ai'my aud Navy any intercourse with an unlicensed prostitute is strictly prohibited, and in certain of the Army divisions imprisonment is inflicted upon 23Cr 220 2IQ ;oo 190 180 170 £0 26 24 22 20 18 16 14 1897 i 1896 1899 1900 1901 1902 1903 1904 1905 1906 1907 IS08 1SC9 1910 1911 1 A . ■ 1 1 ^ y / \ 1 1 / \ A 1 1 1 \ / \ \ 1 M j A ! \ \ / \ Y f / ^ / / \ \l f \ V 1 \ ,\ \ A^ t \ \ S "^ / V' »'** t ^-^ I \ f 1 \^ ^' '■ 1 1 \/ ^^. V' I ■ 14Q 130 120 110 100. 90 80 70 The upper black line denotes the number of new cases of sexual disease per 1,000 average daily number of sailors. The lower dotted line, with the figures to the left, denotes the number of new sexual disease cases against the total number of new cases of sickness of all kinds, including sexual disease. a soldier who is proved to have so acted. Apart from the various preventive measures in force a soldier who has contracted any form of sexual disease is penalized by confinement to barracks and stoppage of part of his pay. 68 THE PROBLEM OF THE NATIONS Prevalence of Disease. — As in our own Army, the incidence of sexual disease is found to be diminishing, though by no means to the same extent. The average of cases during the period 1896-1905 was 64'2 per 1,000 soldiers, but in 1902 the figure was only 36"1. In 1905 the average again rose to 43'0 per 1,000. The present average is approximately 47"5 per 1,000, or of syphilis alone 9"5 per 1,000. The Japanese Navy. Preventive measures in the Japanese Navy include a monthly medical examination of all men below the rank of warrant officer, when any case of infectious sexual disease is confined to his ship for treatment and for the week following the establishment of cure. Lectures upon the subject are given at regular intervals, and all possible methods are adopted to check the disease. Apparently, however, the results have not proved so satisfactory as in the Army. Professor Dr. S. Hata has very kindly prepared for me a diagram to illustrate the prevalence of sexual disease in the Navy, per 1,000 sailors, and this I append (see page 67). Elsewhere I propose to speak of the regulation of prostitu- tion in Japan, and of the laws in force for the prevention of sexual disease. I am giving a more detailed consideration to causes and effects in this country, partly because the facts are compara- tively unknown, even amongst eminent specialists in Europe ; and also because I cannot but think that Japan, in this respect, affords the most valuable object-lesson of all the countries in the world. New YorJi City. — On January 1, 1913, the Board of Health of this city initiated a system of compulsory notification of all cases of sexual disease, both those receiving treatment in institutions and also at the hands of private physicians. Naturally a considerable number of these latter cases have not been reported, but at least we now have some kind of a record for one year. 10,625 cases of syphilis alone have been reported. As the population of New York is, in round figures, 4| millions, we get a figure of 2-2 per 1,000. But, as Dr. Goldwin tells me, this figure represents a small fraction only of the total incidence during that year. For instance, in a New York State Eeformatory for women the Wassermann test was applied to 466 inmates, with the result that 48 per cent. THE PREVALENCE OP SYPHILIS 69 gave " positive " reactions. And the results of other similar investigations suggest a heavy incidence. Again, we have the estimate given by Dr. A. Prince Morrow to the effect that there are over 200,000 infected persons at large in New York ; but this figure includes gonorrhoea as well as syphilis. The percentage of sexual disease cases in the United States Navy is also very high. Siberia. — The number of cases of syphilis officially reported from Siberia for the year 1911 was 57,360. The population is given as 9|- millions. An average of 6 per 1,000. The percentage for Russian Central Asia is rather less than this. Russia in Europe. — The official returns published by the Health Department of St. Petersburg are extraordinarily complete. They give not merely the number of cases reported of sexual disease in its three varieties, but they record the number of cases of primary, secondary, and tertiary syphilis respectively in every province throughout the whole Empire, and also the number of these cases attended by fully qualified medical men and by irregularly qualified students ^ respectively. I will take some four or five localities and give the figures of cases of syphilis per 1,000 of the population as I have calculated them from the official records : — Moscow Industrial Begion Central Agricultural Region Lithuania . . Little Russia City of St. Petersburg City of Moscow 10 per 1,000 16 1-3 5-1 27 22 These figures are of particular interest for purposes of com- parison. Thus we find in an agricultural region a higher per- centage than in an industrial one, and the exact converse of this is generally the rule. Little Russia is perhaps the richest and most populous province of the Empire; Lithuania is probably the poorest, and the condition of the peasantry is deplorable. And yet in this province there were, in 1911, over 7,300 cases of syphihs in a population of 5-| millions. The reason for these high percentages in the country districts lies in the fact, to which I have already referred, that in many of ^ We have no exact equivalent in this country. Perhaps th3 old " barber surgeon'' is the nearest. 70 THE PROBLEM OF THE NATIONS the villages syphilis is endemic. It is there a plague which spares none, men, women nor children. According to Tarnowsky 70 per cent, of the cases are due to " innocent " contagion. In Tambov and Saratov, two towns in South-east Bussia, the percentage of cases is second only to St. Petersburg. A further point of interest is that in Little Russia there were far more cases of tertiary syphilis than secondary; while in Lithuania there were three times as many secondary cases as tertiary. Having the official records before me it may possibly be ot interest if I give the figures for the whole of the Russian Empire. In 19ll there were recorded rather fewer than 1,265,000 cases of syphilis, in all its forms. The population of the Empire is given as 167,520,000. Thus there were infected 75 per 10,000 of the population of a territory representing one-sixth of the land surface of the globe. Boumania. — Statistics upon the incidence of syphilis in Roumania are somewhat incomplete and are not recorded with care. All infectious disease is subject to compulsory notification with the exception of sexual disease and measles. Amongst the civil population throughout the country in 1909 the average number of syphilitics was found to be 2 "35 per 1,000. Taking Bucharest alone the figure of sexual disease is given as 5*2 per 1,000. As in Russia, we find a distinct difference in the prevalence of syphilis according to the locality. In the mountainous district of Roman, for instance, the average is as high as 15 per 1,000, while in Romanatzi it is only O'l per 1,000. In the Roumanian Army the official returns give an average of 50 men per 1,000 suffering from sexual disease. Norway. — Perhaps the most reliable figures upon the prevalence of sexual disease are those recorded in Christiania, where the diseases have been notifiable in one form or another since 1876. I append the figures for the years 1906 — 1911 : — Population I Gonorrhcea ^Hf^^^l^^:,^ syptu^per ?000 of the population 1906 1907 1908 1909 1910 1911 229,324: 231,687 235,674 239,511 244,038 247,488 1,240 1,015 1,162 1,250 1,359 1,467 2-1 1-8 20 2-2 2-1 2-2 THE PREVALENCE OF SYPHILIS 71 It may be added that since 1887 all cases of sexual disease have been notifiable daily instead of monthly and thus still greater accuracy has been ensured. Copenhagen. — I take this city immediately after Christiania for a comparison between the figures of the two capitals is of interest, because the system of notification in Copenhagen is very inadequate compared with that of Christiania, and yet the figures are very much higher. Probably this is owing in great measure to the fact that a case may be notified more than once. About 2,000 neiv cases of syphilis are annually notified in Copenhagen, 3'5 per 1,000 of the total population. From this figure, and taking the average age of incidence as 25 j'-ears. Professor Erik Pontoppidan calculates that " 50,000 individuals out of a population of 400,000, at any fixed period, have or have had syphilis." This means 12"5 per ceiit. of the population. I will merely quote the official average of syphilis : — 1906 3-3 per 1,000 1909 4*9 per 1,000 1907 4-5 „ 1910 5-3 1908 5-6 ,, 1911 5-8 ,, Germany. — There is such a mass of literature by German authors upon this subject that it is very difficult to sift the evidence. Perhaps the most trustworthy figures are those published in the report to which I have referred on page 13. But even these are not particularlj^ satisfying, and it is possible only to make an approximate calculation. On April 30, 1900, according to the official returns, there were 14'2 per 1,000 adult men in Berlin under treatment for sexual disease. The prevalence amongst the female population was rather less than half that of the male. The population of Berlin ten years ago may be given as 2 millions. Of the figure 14" 2 per 1,000 it is estimated that four-fifths are recent cases, or 11*4 recent cases of sexual disease per 1,000 men. Now let us add in the women, taking the incidence as j^ths that of the men. Also let us add in the odd fifth to give us the total number of cases, recent and standing. This calculation gives us about 106,000 cases of sexual disease as a whole, recent and standing, amongst the Berlin population — 53 per 1,000 ! From the official figures I calculate that cases of syphilis represent approximately one-third of the total number of cases of 72 THE PROBLEM OF THE NATIONS sexual disease.^ We therefore get the figure 3"8 recent cases of syphilis per 1,000 men. Add the female incidence to this and the figure is 5*4 per 1,000 men and women recently infected with syphilis alone. Following this system of calculation we find the incidence of syphilis, recent and standing cases, is 35,416 men and women. And thus the average of syphilis in Berlin is 17'5 (say 18) per 1,000 of the total population. As a side-light upon this issue I may quote a passage from Professor Blaschko's work, " Hygie^ie der Prostitution." There he estimates that 45 per cent, of the clerk and merchant class in Berlin, between the ages of 18 and 28, have had syphilis, and 120 per cent, have contracted gonorrhoea. In Breslau the figures are 77 per cent, for syphilis, and 200 per cent, gonorrhoea. He adds, further, that every university student, during his four years' course, contracts one form or other of sexual disease at least once.^ Another eminent authority estimates that one German in five has had syphilis, and that the average for gonorrhoea is more than one attack per man.^ Of course the condition of affairs amongst the male population which these statements imply is simply appalling. It is partly because the number of women in the total population is so much in excess over the men that the percentage of disease is brought down to a credible limit. There are many other estimates and figures which I migTit quote, particularly in respect to prevalence in the army and navy. But this work is written for the general public and it has no pretensions to be regarded as a scientific treatise, for relegation to the shelves of a medical library. There is, however, one more point in the German statistics to which I may invite attention. It is found that the incidence of sexual disease is almost always proportionate to the size of the town. Thus, taking the adult males alone, we find the following proportions : — ' Cf. the table, Incidence in Berlin Sick Clubs, on page 13 ante. ' And yet the official inquiry returns give the figure for sexual disease as a whole as only 14"2 per 1,000 males in Berlin. How is it possible to reconcile this figure with an authoritative estimate that 120 men per 1,000 are infected with syphilis alone ? What is one to believe ? How hopeless all this investigation is ! ^ " Verhutv/ng der Geschlechtshrankheiten." — Pinkus. THE PREVALENCE OF SYPHILIS 73 Berlin, with 2,000,000 inhabitants . . Cities with more than 100,000 inhabitants „ 30,000 14-2 per 1,000 males 10-0 ,, 5-8 „ 4-5 ,, „ „ In other words it is found that the number of prostitutes, professional and amateur, and so the incidence of disease, increases with the size of the town. Presumably it is a question of demand and supply. This fact naturally suggests another factor, that of the regula- tion of prostitution, upon which I shall have something to say in another article. But I may remark here that between the years 1903-5 the percentage of sexual disease infection amongst recruits for the German Army was highest in those cities where regulation of prostitution is most effective. Also that the incidence of disease amongst the recruits decreased proportionately with the size of the town. I have now, I think, given a suihcient general indication of the prevalence of syphilis through the world. I have purposely avoided a detailed account, and I have refrained also, so far as possible, from accepting the estimates of specialists save only where they expressly state the basis of their calculations. The figures given are without exception extracted from official com- munications, and it was not until I had concluded, quite in- dependently, my own calculations that I turned to estimates already published for the sake of comparison. I then discovered the series of inaccuracies to which I refer later. For the sake of convenience we may now consider our seventeen results in tabular form : — INCIDENCE OP SYPHILIS IN VARIOUS LOCALITIES. Bemarks Period Locality Per 1,000 of the population 1911 . . City of St. Petersburg . . *27 1911 . , , Moscow . . .. *22 .. 1900 . ,, Berlin .. "18 .. 1911 . . Central Agricultural Reg ion, Russia .. *16 .. 1909 . . Roman (Roumania) . . 15 . . 1911 . . Moscow Industrial Region .. *10 .. 1911 . . Siberia .. * 6 .. 1911 . . City of Copenhagen .. 5-8 .. Notification not very exact. Fairly represents, I think, the number of recent and standing cases. 74 THE PEOBLBM OF THE NATIONS _ . , T i-t Per 1,000 of Penod Locality ^j^^ population 1909 .. Bucarest 5-2 .. 1911 .. Little Russia *5-l .. 1910-11 Melbourne *5 .. 1909-12 Japan 5 1909 1913 Eoumania New York City 1906-11 City of Christiania 1911 . . Lithuania (Russia) 1909 . . Romanatzi (Roumania) 2-3 2-2 ►2-0 '■1-3 0-1 Remarks One of the richest provinces in the Empire. Underestimated, and vide p. 65 ante. Very approximate only. The incidence of syphilis is about i the total amount of sexual disease. One year's compulsory noti- fication : much under- estimated. Average for five years. Noti- fication reliable. One of the poorest provinces in the Empire, * Fairly represents, I think, the number of recent and standing cases. I must once again emphasize the fact that these returns are approximate only and can only be accepted as affording a general indication of the incidence of syphilis. No account whatever, save to some degree in the Melbourne figure, is taken of the results of syphilis, and we have already seen the nature and extent of some of those results. I hope that my methods of calculating these figures are quite clear. The chief difi&culty lies in distinguishing between an annual incidence {i.e., number of fresh cases notified in a year) and those which I have termed " standing " cases. For instance, under Copenhagen I have given a specialist's calculation of the amount of the syphilised population to be 125 per 1,000. While it is naturally invidious upon my part to criticize such an authority he seems to me to have presumed that none of his cases have been cured. But, unless otherwise indicated, I have taken figures supplied to me by the various statistical bureaux and then worked in simple proportion. As regards Bussia, I felt justified in adding together the number of cases of primary, secondary, and tertiary syphilis, and stating the result to represent " recent" and " standing" cases. For the rest, I think I have, in every case, stated how I arrived at my results, and these results, in the tabular form, are certainly fairly uniform. I am sorry to be compelled to inflict these explanations upon THE PREVALENCE OF SYPHILIS 75 the reader, but he will probably have no idea of the great difficulties involved and how open to criticism any sexual disease figures are. England and Wales. Now it will be asked, " What of England and Wales ? How do we stand?" I must needs reply that I can find no evidence of any real value upon which to base '^ven a very broad estimate. The attempt has been made upon several occasions, but it has resolved itself for the most part into mere guess-work. For reasons already given I regard the Army recruiting figures as valueless for our purpose. Returns from the hospitals are, with one exception, non-existent, or at least untrustworthy.^ The Eegistrar-General's mortality statistics are equally useless when it comes to the question of prevalence. There is no system of notification of sexual disease ; nor has any definite official inquiry ever been made upon the lines adopted in Germany in 1900, in Melbourne three years ago, or in New York last year.^ The only fact of any real value which can be adduced is that the incidence of sexual disease in the British Navy and Army has been steadily decreasing during the past twelve years or so. Even this knowledge is of little or no use to our inquiry. It is good to be able to record it because it shows how effectively the disease may be combated by measures of education and improved treatment. And, as a result, we know that our sailors and soldiers are proportionately a finer body of men. But I fail to see that we can trace the least connection between this and the incidence of disease in the civil population. There appears to be a general consensus of opinion amongst British speciahsts that syphilis, in its ordinary symptoms, is far less in evidence than it was forty years ago, but, on the other hand, that the cases of grave disorders and diseases derived from syphilis are on the increase. Of this fact I have already quoted evidence. Now before I go any further into this question of prevalence of syphilis in Great Britain, I would make brief criticism of one or two estimates on the subject which have already been published. I do so, not for the sake of criticizing, but rather to indicate how ' Dr. Johnstone's Report to the Local Government Board, 1913, p. 9. '^ A Committee was appointed by the British Admiralty in 1864 to determine ways and means of checking sexual disease in the Navy and Army. 76 THE PROBLEM OF THE NATIONS very easily mistakes may be made in this most difficult subject, and how misleading an impression may thereby result.^ I have already suggested that my object in writing these articles is primarily to give to the public only an account of the causes, symptoms and effects of sexual disease ; that the question of prevalence is but incidental. The prevalence of syphilis throughout the world is certainly very wide, but I would strongly deprecate any attempt at exaggeration. Now in a report recently issued, and one which is being very extensively quoted, I find that the author has mis-read a certain estimate of a distinguished Continental specialist. Upon this mis-reading he has made a calculation for London which produces an enormous figure. In other words the specialist has given an estimate of so many per cent, of the male population, and the author has read it as referring to the total population. A vastly different thing. Again, another medical man, in the course of an address at a recent Health Congress, stated that 7 per cent. (70 per 1,000) of the Melbourne population was syphilitic, and upon this basis calculated that in Greater London {sic) there were over 500,000 cases. But the percentage of infection in Melbourne is not 7, but 0*7, or, to be more exact, 0'5 (5 per 1,000). The other figure is preposterous, and exists nowhere in the world. Upon this real percentage basis the cases in the county of London would number 50,750. Unfortunately this author did not sto|) there but went on with further misquotations. He stated that the percentage of syphilis for the great capitals was " commonly estimated at about 20." But if 50 per 1,000 is impossible, what shall v/e say of 200 per 1,000 ? He then added in gonorrhoea and chancre and brought the incidence to five times as large a figure. From that point the author became involved in such a maze that I gave up all idea of further checking. I have recently been dipping into a book dealing incidentally ' In a letter to the Lancet (A.pril 4, 1914), I invited the attention of the medical profession to some of these inaccuracies. The Editor, supporting this letter in a leading article, wrote seriously of the dangers arising from inaccurate and carelessly estimated figures. " If an evil, admittedly very large, is mag- nified, " he concluded, " many people will consider that nothing can be done in the face of such appalling mischief." It is significant that none of the medical men, whose statements I had criticized, replied to the letter or article. Pre- sumably, there was no answer to be made. THE PREVALENCE OF SYPHILIS 77 with this subject and issued from an authoritative source. The author gives certain statistical tables of prevalence of sexual disease, but it is impossible to tell whether his figures mean so many per cent., per 1,000 or per 10,000. The percentage basis seems correct in one figure but impossible in the next. In fact it is just over this percentage basis that these various authors have come to grief. And the mistakes are so obvious that I cannot imagine how they were ever made. In nearly everv case the author has omitted to follow the excellent piece of advice quoted by Lord Kosebery, "Always wind up your watch and verify your quotations," and the results are deplorable. And the unfortunate thing is that these statements are coming to be quoted more and more. Other authors will calculate upon them, lecturers will glibly reel them off, the Press will repeat them, the ' man-in-the-street ' will discuss them, until at last some insignificant individual will prick the bubble and discredit will fall upon the medical profession. Not that I pretend to any mathematical accuracy, for with these sexual disease figures it is like trying to thread needles in the dark. Bat at least it is independent working and the whole subject has been approached with an open mind. But to resume. How can we arrive at any estimate of pre- valence in Great Britain ? Speaking quite frankly I know of no means. I shall doubtless be accused of shirking, but it cannot be helped. We have literally no data of any value. I have tried half a dozen methods, only to discard the results as useless. So far as I can see the only two facts which are capable of any use are (a) the figures for Melbourne and Christiania, and (b) that the incidence of disease tends to increase with the size of the town. But even this system of arithmetical progression will not serve. It may give an approximately reliable figure for a series of towns of one nation, but when we apply it to a number of nations, various other factors, such as racial characteristics and temperaments, must be taken into account. I do not trace any connection between climatic conditions and sexual disease. Perhaps the incidence in certain parts of South America is more heavy than anywhere else in the world, but, on the other hand, St. Petersburg and Moscow are in almost as serious a plight. I can best show the results of the " progression" basis, starting with Melbourne, by setting down side by side the incidence figures 78 THE PEOBLEM OF THE NATIONS per 1,000 per 1,( 5 — 2 2 5 2 5 4 18 17 22 12 27 13 2 39 — 35 of seven cities which I have already given, and the figures which one would expect : — „ , Incidence as calculated Progression basis City- Melbourne Christiania Bucarest Copenhagen Berlin Moscow St. Petersburg New York County of London Not very satisfactory, is it ? Although three of the cities, including, curiously enough, Berlin, give almost even results. Thirty-five per thousand for London is, I think, quite impossible. As regards the Kussian cities we know that the prevalence there is abnormal. Most authorities upon the Continent seem to think that there is less syphilis in London than in Berlin or Paris. I am a little uncertain why they should think so, because in very many respects the factors which tend to the spread of the infection are more numerous and more serious in London than in those other capitals. Some of these I have already indicated {ante, p. 66) ; and it should also be remembered that London is a great port whither come folk from every country in the world, as they have done since London was a wattled village : — ' And Norseman and Negro and Gaul and Greek Drank with the Britons in Barking Creek,' The serious problem of unchecked alien immigration^ has long since been recognized, but it needs a visit to the harbour and dock regions of our ports to reahze how serious a factor it is in the propagation of disease. Also London is cursed with the most unbridled and widespread prostitution of any city in the world; and our laissez-faire policy in this and in any attempts at checking sexual disease is notorious. But — and it is a big ' but ' — we may set against these factors certain of our racial characteristics. I do not mean to suggest that we are more moral than our neighbours, because I do not think that we are. Human nature is much the same all over the world. But we have a different way of looking at sexual questions. In some respects it is a good way, in others it is a bad way. It is ' The number of immigrants into the United Kingdom during the years 1908-12 is given as nearly 1,600,000. THE PREVALENCE OF SYPHILIS 79 a bad way when it degenerates into prudishness, hypocrisy and cant, into a refusal to recognize the elementary facts of sex life and the need of teaching them to our children. It is a good way when we find our young men regarding women as but incidents in their lives, until the moment when they may give their whole- hearted devotion, their clean passionate love to " the one in the world." And that is the big fact which in great measure out- balances all the rest. Your French, German or Eussian student sees things differently. He is improving, according to our standards, because he wants to be, and is becoming a good sportsman ; and you cannot ride straight to hounds, or row in the Eights, or make a century at cricket, if you spend your evenings in a cafe or a girl's bedroom. A Britisher does not talk about women in the same way because he does not think of them like that. It isn't ' the thing.' There is literally no comparison between Oxford and Cambridge and a Continental university town. In the former opportunities for promiscuous intercourse hardly exist, in the latter prostitution is rampant. So long as our young men maintain the fine ideal of being ' sportsmen ' and of playing the game for their side, not looking on while others do the work, so long will they be the envy of their contemporaries across the water in their freedom from sexual disease. For it is precisely between the ages of 18 and 25 that most men contract syphilis. And there is another aspect in this difference of outlook between the Anglo-Saxon and the German or Frenchman which I do not think has ever been fully recognized. It already counts for much in this question of prevalence of disease, but it might count for so much more. The young French or German of the great towns is apt to regard every woman in the light of a possible mistress.^ The young Anglo-Saxon — and I include the American — 1 It must not be presumed that this is evidence of an inferior standard of morality. It is simply a question of the difference in emotional outlook upon life between the Anglo-Saxon and the Teuton, Latin or Slav. This same difference is, of course, to be observed in Literature and the Fine Arts. One may also compare the fundamental bases of the Woman's Movement in Ger- many and England. In the former nation the movement is based upon emotion, the desire for a sexual relationship of the highest character, the adequate training of the children, in a word, the " home." In England it would appear to be mainly in the direction of the suffrage. Morality is, after all, a matter of geography. Every cominunity adopts the form which it considers to be the most suitable to its needs. 80 THE PROBLEM OF THE NATIONS generally only asks for a girl ' pal.' In other words, with the former it has come by force of habit and mode of thought to be an instinc- tive desire for sexual intercourse, to him the obvious and natural out- come of friendly relationship with a woman ; with the latter it is more frequently a simple sex-hunger. I could give so many instances of this simple and most natural desire ; I will merely give one illustration which must appeal very forcibly to any man or woman. In Shanghai, a great international settlement, there are some six or eight "houses of ill-fame" of the better class which purport to serve the desires of the young Britisher or German or American of the community. Shanghai knows no distinction of social rank. If a young fellow is a sportsman and a good sort, he is received everywhere quite irrespective of his position in business or his monthly salary. The prostitutes in these houses, some five or six in each, are almost invariably English or American, and girls of some educa- tion. In each house there is a fairly large room which is used for dancing. Wine and spirits are sold, of course at a big profit. Now here there is every possible temptation to a young man to indulge his sexual appetite ; and, further, every facility, in that he need not pay cash down for his pleasure, but has only to sign a "chit" which is presented for payment at the beginning of the following month. And yet over and over again I have known instances of our young fellow-countrymen resorting to these houses solely for the sake of the girls' society, a couple of dances, a drink, perhaps not so much as a kiss, and so back to their own homes none the worse for the evening's amusement. I can imagine no more striking illustration of the young Britisher's attitude towards women. It would be striking enough in London ; but east of Suez, where the sexual impulse is enormously strengthened, it seems almost incredible. I would not appear to generalize, but would merely suggest this aspect of the case for consideration. Where there is real freedom and comradeship between the sexes as in America, and opportunities for friendly intercourse, I am convinced that there is much less desire for the more intimate relationship. Where the female element is non-existent the man turns to the women of the streets, and generally with disastrous results. If we accept this view of the Anglo-Saxon's regard for women it is equally applicable to our soldiers and sailors. With compara- THE PREVALENCE OF SYPHILIS 81 tively rare exceptions the only women the average Tommy meets are those of the lower prostitute class. These women are out for business only and the man does not escape. But in my experience there is not more than one man in ten whose primary object in seeking some female society is a desire for intercourse. During the last year or so, since our Fleets have been concen- trated in Home waters, the marriage-rate of the lower deck has increased to an extraordinary extent. If only from the point of view of the checking of disease this is all to the good. But it is also very significant in this question of sex-hunger. A man very rarely marries a girl to satisfy a purely physical desire of her. This may seem to be an unnecessarily lengthy digression, but it all bears upon our study of the prevalence of sexual disease in the United Kingdom. We have come to see, in short, that if certain conditions tending to the spread of infection are far more grave in this country than on the Continent, yet we find a definite counterbalance in our attitude towards sexual matters and our women-folk. To this we may add the fact already noted that syphilis is far less in evidence than it was forty years ago ; and also that in our •country districts it is comparatively unknown, that the gradual ingress into the great towns has tended to eliminate it — to the detriment of the town populations. We have also noted that many of the very serious disorders and diseases of which syphilis is a direct or indirect cause are steadily increasing. This latter is, I think, almost the most serious fact with which we have to deal, for it indicates an increasing number of cases in which either there has been no treatment or the treatment has been inadequate. In a word the syphilis has been driven inwards — if we may use the expression — driven inwards until it has secured a firm and immov- able grip upon the constitution. Now I am going to suggest a reference back to the table on p. 73, and ask whoever may be sufficiently interested in the problem to compare the figures, to bear in mind all these various facts and to draw his own conclusions as to the prevalence of syphilis in London and England and Wales. It is necessarily guess-work, and I am going to make a guess based simply and solely upon these general observations and deductions, I estimate the prevalence of syphilis, recent and standing cases, to be in London about 12 per 1,000. This is 6 Aggregate Rate per IS'mnber of population 1,000 cases 4,500,000 12 54,000 1,986,900 5 9,935 3,563,800 2 7,127 4,300,000 1 4,300 3,500,000 0-SO 1,750 10,861,000 0-25 2,715 82 THE PROBLEM Of THE NATIONS exclusive of allied diseases, but it includes primary, secondary and tertiary cases in the same way as indicated in the Russian statistics. If anything, I have underestimated ; I am certain that I have not exaggerated. Let us then see how many cases, approximately, this figure gives. Eor the great towns I am going to calculate downwards upon the basis which we have seen holds good in Germany, starting with the Melbourne and Copenhagen figure (5 per 1,000) as reasonable for the towns with 5 to 700,000 inhabitants. As a matter of fact we should really start with a considerably higher basis than 5 per 1,000, but I am taking the lowest possible estimate : — (a) 1 city of more than 1 million inhabitants (b) 3 cities of more than 500,000 ,, (c) 12 towns „ ,, 200,000 {d) 28 „ ,. „ 100,000 „ (e) 54 „ „ „ 50,000 (/) Remainder of urban districts Total ... 79,827 79,827 recent and standing cases out of an urban population in England and Wales of 28 millions, or, say, 3 per 1,000. We will allow that the incidence in the country districts is negligible. This is syphilis alone. Now take careful count of all those allied diseases which I have mentioned, the increase in the nmnber of mentally deficient and paralytic cases, aneurysm and diseases of the blood-vessels (5,177 deaths in 1911) ; congenital diseases in children and the infantile mortality rate from syphilis, deafness and blindness, and all the rest. Who will hazard any guess at the figures ? Then, after all this, we have still gonorrhoea to reckon with, and gonorrhoea is perhaps three times as prevalent as syphilis, and probably every man is infected at least once in his life. We shall thus he arriving at a figure of a third of a million cases of sexual disease in England and Wales, at the lowest of estimates. Dr. Douglas White, giving evidence before the Royal Commis- sion, in March, 1914, estimated that there were every year 122,500 fresh cases of sexual disease in London alone, and 800,000 in the United Kingdom ; of these 114,000 would be syphilis. From these figures he deduced that there must be in the United Kingdom some 3 million syphilitics. It will be noted that so far as London is concerned my own estimate is approximately the same. 83 VIII. SUMMAEY AND CONCLUSION. There I think we may leave it. Whatever the approximate figures may be, it must be obvious to anyone v^^hc has follovv^ed the estimates vs^hich I have attempted to make that civihzation has got to face, vt^ithout further delay, a plague of the first magnitude I have tried to indicate the exact nature of the symptoms of gonor- rhoea and syphilis, and from thence its effect upon the individual. I have tried to show, with a little success, I hope, that science is able to deal successfully with these diseases, and effectively to arrest their development, if only the patient loill consent to careful treatment immediately he discovers or suspects that he is infected. Salvarsan Treatment. — I am well aware that, so far as syphilis is concerned, there is no little discussion about the real effects and the possible dangers of the salvarsan treatment. Whenever a case occurs of " injurious effects from salvarsan " it is magnified out of all proportion and eagerly seized upon and quoted by the opposi- tion. Personally, I am content to pin my faith to the results of the treatment obtained in our Army Medical Service, a Service which is fully recognized all the world over as second to none in its splendid fight against sexual disease. I submit that the public is justified in placing the fullest confidence in a treatment which, as Major W. S. Harrison, E.A.M.C, has definitely asserted, has been applied in 3,000 cases at Eochester Eow, London, without a single death resulting nor indeed any ill-effects. And similar over- whelming evidence is forthcoming from other countries. Professor Wechselmann, of Berlin, who was the first to administer Ehrlich's remedy in hospital work, records that he has given 45,000 injections and stoutly denies that it is a poison.^ One death only had resulted, and that was in a case where mercurial treatment had also been applied. ' British Medical Journal, March 14, 1914. 84 THE PROBLEM OF THE NATIONS Dr. Jeanselme, of Paris, the first medical man in France to administer the treatment, has said that the surest proof of the efficacy of salvarsan was that during his three years' experience of its application he had known four unquestionable cases of re-infection. In his twenty-five years of previous medical experience he had never seen a single one/ How can I emphasize sufficiently the immediate and admirable results which a patient will find in this treatment ? Sometimes I am in despair that the public will ever realize how easy it is to deal with syphilis in its early stages. Only this year a young fellow of 21 spoke to me of a syphilis which he had contracted. He was cramming for the Army, and was engaged to be married. It was by the merest chance that he mentioned it, and he had actually made up his mind to take an overdose of chloral, in the firm conviction that his life was ruined. He was soon persuaded of his madness ; and the treatment is proving all that could be desired if only he will persist in it. There must be hundreds of such cases in a year ; young men who are terrorized by vague stories of the results of syphilis, and know literally nothing of the possibility of cure. Is not this alone a sufficient plea for the education of the individual ? Still keeping to the individual aspect, I have then tried to show something of the results of syphilis, the great variety of diseases which may attack the individual as the outcome of his neglect and indifference to treatment. Then I have spoken of syphilis in relation to marriage and the family ; the insensate, criminal folly which permits a man to inflict so hideous a gift upon an innocent woman, and so upon his children. I have written of the effect of syphilis upon innocent children. The writing of that chapter was one long nightmare. The facts had to be faced, but I pray that I may never be set another such a task. I have touched briefly upon the question of " innocent con- tagion," and it is sincerely to be hoped that the illusion of sexual disease being "a just retribution of sin" is dispelled once and for all. Finally, I have attempted to indicate, by the previous chapter, the effects of syphilis upon the race and upon civilization. ' The Times, February 3, 1914. SUMMARY AND CONCLUSION 85 Here, then, are the facts. What is going to be done ? What is the solution of the problem, the " Problem of the Nations " ? I set out to write these articles with the one fact clearly in my mind, that the solution is to be found only in bringing home to each individual member of the community the exact meaning of sexual disease. If there is another and better one let it be proposed. How that education may be effected is a matter for individual and collective effort, we cannot rely upon the State. That it is possible, indeed comparatively easy, I have already suggested. The first thing to be done is undoubtedly to educate men and women how to carry on the work of education. The details need not be discussed here. The provision of facihties for treatment is then the concern of the State, of Local Authorities, and of the Medical Profession. The technique of treatment is by no means easy; the Profession must see to it that their members receive careful instruction. The campaign against cant and any " conspiracy of silence " must be continued with ever-increasing vigour. This plague has got to be wiped out of existence, and to do so we must have clean and frank discussion. It concerns, directly or indirectly, every man and woman in the country, in the world, for it is based upon the most elemental facts of human existence, sexual impulse and motherhood. There is no question of appeal to sentiment, and I make none, save on one score only, that of the children. If that appeal fails, and a father or mother is content to create a life condemned to lingering agony, then such a person is fit only to be hounded out of the community, for he is no human being. Nor is there any appeal to patriotism and pride of race. If a man or woman will not do a thing for the sake of himself and his own flesh and blood he is not likely to bother about his country. But let us look at the question simply from the point of view of practical common-sense. Take a young fellow who is just leaving school for the University, or to enter some business firm. From the more or less sheltered cloister of the school he will be plunged direct into the great world. He will be brought face to face with a new element, "woman," and he is practically certain to seek opportunity to follow the sexual impulse. The chances are that, through ignorance, his first experience may prove disastrous. 86 THE PROBLEM OF THE NATIONS Now, putting the question to his father as a business man, which is the better alternative to follow : — (a) Avoid the subject, let your boy * gang his ain gait ' and run his own risks. Let him be faced with a possible attack of syphilis which he is certain to conceal, and which will perhaps drive him to contem- plate suicide (as my friend did). Let him get married, perhaps, in an infected state, with all the horrible results — and you know that to have a grandchild is your dearest wish — or, (b) Have half-an-hour's chat with him as his best 'pal.' Let him see that you were once young yourself and know all about his feelings. Tell him that there is not the least physical reason why he should have anything to do with women, that he will be ever so much better without them, that no one whose opinion is worth counting will think any the better of him for trafficking with prostitutes. Give him some idea of the risks he would be running, to himself, to his future wife, to his children. And, finally, if after all it should be necessary, tell him that his only chance is to go straight off to the best medical man he knows. Which is it to be ? At least the latter is worth a trial, and it will do no harm. More, it will probably be the means of making you and your boy friends for life, and that alone is worth an effort. Again I would urge that the attempted teaching of abstract morality is a sheer waste of time. Indeed it is more than this, it is wrong. Before we do so Society must be regenerated, else we impose upon youth a burden too heavy for him to bear. But practical morality is a different thing. We can and should urge the value of abstinence. It is, I think, agreed that in this country, and in these latitudes generally, a young woman does not attain to her full maturity of sex until she is 20, and a young man until he is about 25. Up to this age a man seldom experi- ences the full driving force of sexual impulse ; it is a power of moods and moments only. Unfortunately we have also to recognize that it is before these ages of sex maturity that a man or woman generally contracts disease. This fact is borne out in every country by statistics and expert opinion. Opportunity and alcohol are the two panders to irregular intercourse in the case of a young man. If we would have our sons to run straight in this matter of sex we must first see to it that their general training is sound and wise. And the two factors upon which I would lay stress are these. First, the SUMMARY AND CONCLUSION 87 imparting from an early age of a graduated knowledge of sex fmictions and hygiene. There must be no secrecy nor reservation about this most vital of all subjects. Why should there be ? Once again, a father is presented with a choice between two alternatives. Either his boy will learn the facts in a clean healthy way, and so will come to regard the subject as the natural and wonderful thing it is. Or he will acquire a most harmful and distorted view of it from the loose, ignorant talk of his companions. Surely no father would hesitate to choose the first for his son. The ennobling influence which such wise knowledge would bestow remains and directs a man throughout his life. The second factor is the cultivation in every way possible of a love of the open air, and I mean this in its broadest sense. Great Britain owes her supremacy in the world to the love of the Open Life engendered in her men and women. If that love ever becomes stifled by the smoke and dust of encroaching city life we shall begin to go downhill. The man who hearkens to the call of the sea, who understands the language of the murmuring forest, who responds to the touch of the myriad invisible things by moorland, mountain and field, that man sees deep into the heart of life. Of such stuff our Empire builders are made. Strathcona, Kitchener, Scott, and a thousand others who work or have worked for England on the confines of her Empire owe their knowledge of human nature and unerring grasp of detail to their love of the Open. The language of the Open is the surest passport to the heart of the great public. Lord Salisbury knew this when he told his fellow-countrymen that they were " putting their money on the wrong horse." We read of the latest despicable outrage by a militant suffragette and we say, "It's not cricket." Wellington's remark, if he ever made it, about the " playing-fields of Eton " has created a deal of discussion, but it struck right home. Educate our sons to love the Open Life and to be sportsmen and we shall send them out into the world well armed and equipped for any work, professional, commercial or political. And especially so in this matter of sex. A young fellow who is a sportsman will " play the game " all the harder in his work. And if he does this he will have very little time or inclination to go petticoat-hunting or drinking in saloon-bars. In the German Army a man is kept hard at it from morning to night. He has little opportunity to bother about 88 THE PROBLEM OF THE NATIONS women, and he turns in early and sleeps as soundly as he works. But our two factors will not meet every contingency. So we will add a third by adopting the motto of the Boy Scouts, " Be prepared." If these three formed the basis of a system of universal education what a nation ours would be. This to the fathers ; what suggestion can be made for the mothers and daughters ? In the first place a mother must instruct her daughter in the elemental facts of sex and sexual life. Surely there are no longer two opinions as to the wisdom of such a course where girls are con- cerned. This is not the place to enlarge upon a question with which we are not for the moment concerned. But if such instruction is given at a reasonable age, in the proper manner, and with a deep sense of noble purpose, I can conceive no valid argument which can be brought forward against it. I could give fifty in support. But sexual disease is rather different. My own feeling in the matter (I give it for what it is worth) is that there appears no actual necessity for a girl to know the details. I speak now of the average girl of the middle and upper classes. But there is no particular objection to a girl knowing the broad facts without a mass of detail, and the knowledge would certainly prove a great safeguard and a deterrent in certain eventualities. It will seem that I draw too wide a distinction between the sexual lives of men and women. I do not forget for a moment the tendency of the present age to a genuine sex equality in the physical relationship, with or without a recognized form of contract, but a woman is of a more sensitive and delicate fibre and the know- ledge might have a harmful effect. It is, after all, the man's business to see that he gives himself to the woman of his choice in precisely as sound a physical condition as he expects to find in her. I have sought the opinion of several women of education and knowledge of the world, and I must confess that, without exception, they have advocated imparting this knowledge — of course at a proper age. And their main reason may be summed up in the words, " It will frighten her." It is a little difficult to decide, and the solution may be left to the good judgment of the many women who with single-minded purpose are devoting their lives to the increasing welfare of their SUMMARY AND CONCLUSION 89 sex and so of the community. This is the real end in view for women, not the attainment of the suffrage. The latter is but a very problematical means to a part of the end. Years ago Disraeli remarked that measures for the furtherance of the Public Health must ever take precedence of all other social reforms. The sentiment was received with ridicule, but time has justified its wisdom. The suppression of sexual disease will be the greatest blessing to civihzation which preventive medicine can ever bestow. Not only will it be the greatest of all achievements in the cause of Public Health, but it will create such a revolution in the social life that no man can foretell how far-reaching may be the effects. Science, the magician, has it in his power to create a new world — a world which is no longer " such stuff as dreams are made of," but the certain achievement of practical effort. But the miracle will not be wrought unasked, and in despite of the peoples who shall benefit. Like the Genie of the Lamp, the magician must first be invoked. It is for the nations to decide whether he shall be summoned. And the name of the Magic Lamp is Knowledge. How may it be placed within the grasp of every man and woman ? There is the problem. Will you help to solve it? 90 IX. TO A GODSON. WHEN HE IS 18 YEARS OLD. My DEAR Hugh, It is just eighteen years since that morning when I stood beside your Mother, as she held you in her arms, and took for you the vows which our Faith enjoins. That afternoon I wrote to you my first letter. A little of it I can remember. "Tell your Father," I said, "to teach you how to play with a straight bat and to stand up to the fastest bowling; how to ride clean across country and not to funk the fences; how to bring down a pheasant coming fast over the tree-tops in a high wind. And tell your Mother to teach you, for her sake, to be gentle and courteous in reverence to all women." These seemed to me a summing up of the qualities which go to the making of the best of all products, an English Gentleman. It was not for the sake of the sport, but for what the Open Life made you. And given these qualities you are ready to face anything, in Church, State or Business. Now you are shortly leaving the best of schools for the great world outside and your tussle with life. And you are going to encounter — not, perhaps, just yet, but in a year or two — one of the biggest factors in life, the other sex. How are you going to tackle it? Of course, just for the moment, you won't understand. You cannot imagine what you will have to do with women or they with you, at least, to make a serious business of it. I know when I was at school we used to think girls a rare nuisance and we never used to talk about them, I don't suppose things have very much changed, have they? But there was Miss Dorothy, whom you met last holidays down in Surrey, an " awfully decent sort," as you told me. I know she is, and if they were all jolly, healthy, out-of-door girls like that I should have nothing more to say, and I certainly shouldn't be writing this letter. But I am afraid that Mistress Dorothy is rather an exception. Now I am not going to preach to you about what you ought to do and what you ought not; I have never done that, have I ? I just want to tell you LETTER TO A GODSON 91 a few facts about a rather unpleasant subject and leave the rest to your good sense. Don't imagine, either, that I am going to write you an essay upon that most delightful and elusive of topics, " Woman." For one thing you would only be terribly bored, and for another every man has to find these best things out for himself. " It's mean " — as a young lady once remarked to me — " to profit by other people's experiences; I want to profit by my own." But there are some things which j^ou will not find out for yourself, or if you do it will probably be in the wrong way and with possibly disastrous results. It is just those things that I want to tell you about if you will let me. And if you can't quite get the hang of it all right away just put this letter down and read it again in a year or so. * * * How shall I begin? It is a little difficult, and yet not so difficult as it might be because we're starting fair, you and I. We talked over certain things when you first went away to school. Since then you have gradually come to understand what sex means and there is nothing more to tell you about the simple facts. Every young fellow, when he arrives at a certain age, experi- ences some more or less certain impulses for which he cannot properly account. There is nothing whatever to be ashamed of in them; they are perfectly natural, and girls experience them in much the same way. But up to now there has been no opportunity, and probably no inclination on your part for directing those impulses tov/ards the other sex. You liked Miss Dorothy because she was a good pal, played a most creditable game of golf, and made a jolly good innings for you when we played against Deepcut. But I'll swear that you never wanted to kiss her; and it would have spoiled everything if you had. Well, now you are going to face life in reality. You'll find yourself with men who are beginning to look upon girls from a new point of view. You'll take a little time to adjust yourself. But I shall not be at all surprised to find, if you ask me to lunch in your new quarters, that you have become quite an ardent admirer (from a platonic standpoint, of course) of one or other of those extremely pretty young ladies who dress so daintily and sing so charmingly in " The Staircase Girl." No, you need not trouble to hide their photographs, because if you do I shall only ask to see them; and I am fairly certain to admire your taste. After all, a pretty English girl is one of the loveliest things God ever made, and if they are not to be admired and made a fuss of (within reason) I don't quite see why they were ever created. 92 THE PKOBLEM OF THE NATIONS But coming back to this question of impulse, it seems to me that there arc two ways in which a young fellow feels it. The one is a simple desire for the companionship of a being of the other sex, a feeling, an attraction which no one has ever properly defined and no one ever will. This we may call ** sex-hunger," for want of a better term. The other is an impulse to gratify the sexual appetite by actual physical intercourse with a woman; either with some particular woman or with women as a sex. Do you quite see what I mean, or shall I try and put it a little more clearly? Mind you, both these impulses are perfectly natural. If anyone tells you that the former is natural and proper, and that the latter is unnatural and wrong, then he has not grasped the rudiments of human nature. The sexual impulse is the greatest of all natural laws. It is wrong only when it is used unworthily and to base ends. I am going to say very little about "sex-hunger" because, in one sense, there is very little to say. You are quite capable of looking after yourself. Some men feel the need of female companionship more than others. It rather depends on your general line of work and how fully you are occupied. In any case you are certain to find a big difference when your hard physical exercise is cut off, a big gap to be filled. You must keep up your cricket and football as long as you can after you leave school. If you are working hard and manage to get in a fair amount of exercise you will be happy enough. Go and visit, too, at a few good houses and meet nice people. Cultivate the acquaintance of a few charming women, pay little attentions, and so on, and you will probably find as much female companionship as you want. I must confess that I am a great believer in freedom and comradeship between men and women. Each sex reacts upon the other, each learns from the other, and this is all to the good. If a young fellow has been brought up with a love of the open air — and it is this love which makes the Britisher what he is — I can see no danger in his comradeship with a nice girl. Such a man, too, is generally rather fastidious in his choice. He will never be really content in carrying on a flirtation with a golden-haired maiden in a photographer's shop, or v/ith a waitress in his favourite tea-shop. It really isn't worth it. Of course you will have your little love affairs, passing moments of delicious, stolen joys. You need not fear for my sympathy. When I was about your age I remember that my affections were fairly equally divided between a lady, who was perhaps ten or twelve years older than I, and a girl {very beautiful LETTER TO A GODSON 93 I then thought her) whom I met at Earl's Court Exhibition. The former relationship did me a world of good, and I am proud to think that even after all these years we are still dear friends. The latter affair came to an untimely end when the young lady prevailed upon me to visit her people; I think they kept a stationer's shop in Chelsea. But if you are working and living alone in London and you don't get much exercise and you are rather cut off from pleasant female society, then I see danger ahead. And this brings me to the other kind of impulse. Sex-hunger and sexual impulse are each parts of the great law of Sex Attraction, but there is a certain difference between them although it is difficult to define. As I honestly believe, and I say this in all reverence, the Creator bestowed this sexual impulse upon man that it might serve two ends. The first is the reproduction of life, and the second is that it might form the supreme manifestation of love between man and woman. The world must recognize the first, it does not always recognize the second. Different peoples have different standards of morality upon the relation- ship of the sexes. What is regarded as quite ordinary in a certain country on the Continent is looked upon as most immoral in this country. And certain habits and customs which we British never think about because they are prac- tically a part of our everyday life — these would be regarded as grossly immoral by, say, the Chinese. It comes to this, that in this question of morality you must abide by the customs of the society in which you live or take the conse- quences. In the same; way you may saunter across one of the pleasant tracts of grass in Hyde Park, but if you go to Berlin and indulge in a similar recreation in one of the parks there you will be fined a few marks for the privilege. But a man is not apt to bother very much about the morality oi the act when his sexual impulse drives. I may be accounted somewhat of a revolu- tionary, but I hold that to sin against Love and one's own conscience is graver far than to sin against the morals of the society. And so I put the matter to you from this point of view first of all. You are given a very wonderful and beautiful thing. Are you going to abuse the gift and drag it through the mire, or carefully cherish it until you may place it to the noble uses for which it was given ? If the former, you will experience some brief moments of mad, sensual passion, with immediate and unfailing 94 THE PROBLEM OF THE NATIONS self-reproach and self-disgust; if the latter, you will realize all the ecstasy of the most perfect thing in life, the clean and passionate intimacy of union in all its freshness with the woman whom you come to love and make your wife. Does this seem too ideal a programme? Well, youth is the age of ideals. It may be difficult to carry out but it is by no means impossible, and at least it is worth setting before yourself. You will come to understand better as the years pass. Now we will turn to hard facts. After you have knocked about the world for a little you will very naturally ask me why I would attempt to deny you an experience which most other young men indulge in. You will say that you probably will not be in a position to marry for at least another ten years. Am I going to condemn you to a celibate life all those years and stifle what I admit to be a natural impulse ? That the experience will do you no harm; that you must learn what life means; these and other like arguments. Yes, that question has been put by thousands of young fellows to men who are far better qualified than I am to reply to it, and I do not believe that a satisfactory answer can ever be given. I am young enough to remember vividly my own youth with all its desires and impulses, and yet old enough to have seen more of the world and of men and women than most can crowd into a life-time. And so I am not going to say hardly and definitely ' ' Thou shalt not," nor tell you that it is morally wrong or anything like that. But I am going to answer your argument in the approved Irish fashion by setting another one before you for you to solve. In a word I am going to try to show you the other side of the picture and then leave the whole matter to your own practical common-sense. *• -* * Someone will perhaps tell you, or you may come to think it for yourself, that continence (or abstention from sexual intercourse) is apt to be physically hcirmful to a man. Such an idea is absolutely and entirely wrong. I believe that Nature has made one or two mistakes, but she certainly has not made one in this. The harm is supposed to arise from the overmuch accumulation of semen, the discharge of which at such times does indeed give relief. But, as you know. Nature has provided what we may call a safety-valve, and if this does not act normally at proper intervals, then I think that it is a matter for medical advice. The temporary discomfort is a very trifling affair beside that which LETTEK TO A GODSON 95 every woman experiences each month. And I do beg you, old man, not to imagine that you ought to seek relief in, shall we say, an irregular way. I assure you, and I know that I am well backed by medical opinion, that there is absolutely no necessity. I admit that the sexual impulse is strongest at those times, but the remedy lies in your own hands. If you fight it down once or twice, throw yourself into some extra hard work, get a long day on the golf-links, or a good tramp across Surrey commons, you will find that things come to adjust themselves quite easily. Above all, keep away from "The Staircase Girl " and such like performances, and don't read erotic books. Now we will imagine that one evening things are too strong to resist even with a fight. I can see you throw your books across the room unable to con- centrate on anything. You feel that you simply must go and face the unknown. Or perhaps you have had a particularly good dinner at the Trocadero and three or four of you are going to have a really jolly evening of it. You'll probably look in at the Empire, there will be more drinks, and before you know where you are you will find yourself talking trivial nonsense to a beauti- fully gowned young woman who naively suggests that you see her home. Why not? What does anything matter? You are feeling like the mouse who got tipsy over a puddle of whisky and then sat up and said, " Where's that damned cat that chased me yesterday ? ' ' I am imagining your first serious attempt to realize this big thing of life. And as it is the first it is ten chances to one that you fall into the hands of an ordinary professional prostitute, and not one of the better class, either. Well, you are making a mistake to start with. What you really desire — and I see you as a clean-limbed, healthy young Englishman — is the gratification of your appetite under the glamour of love. You want to feel that the woman, whoever it is, gives herself to you because she is attracted by you, by your pleasant talk, by your good looks. You will be disappointed. A prostitute is out solely to make money. It is with her as regular a trade as the selling of potatoes is to the greengrocer at the corner. She has got to live, pay an exorbitant rent for her rooms, buy good clothes, and so she must needs make as much money as she can. She cannot afford to be generous. It is to her interest to counterfeit love, to act a comedy for your particular edification. But you will not be deceived. In any case you will quickly be disillusioned when it comes to the sordid business of paying in hard cash for your few hours' amusement. And probably, seeing that you are a novice at the game, she will attempt to extort every penny she can. Do not blame her. 96 THE PKOBLEM OF THE NATIONS it is her trade. Men made her what she is; she is absolutely right to repay her debt, with interest. I am not going to paint for you all the mean and shabby details of your business deal. You will have experienced in a very tentative way the thing which you set out to experience and the net result will be, for the woman, two or three pounds in pocket; for you, the loss of so much good money which you can ill afford, no real physical satisfaction, but merely a feeling of deep disgust at yourself and a longing to kick yourself downstairs. You do not believe me? Very well, try it; and if you prove me wrong I promise to pay for your evening's amusement, and any expenses which you may be put to as the consequences of it. Yes, " consequences " — for I have only suggested what your feelings will be as the immediate result of your experience. Now you shall hear what some of those consequences may be. * * * There are certain diseases which a man is liable to acquire from sexual intercourse with a prostitute; we call them " venereal," or " sexual " diseases. And if I were disposed to back your chances against infection in such a first experience as I have described I would not take odds at 1 00 to 1 . The two special diseases are " Gonorrhoea " and " S3T5hilis," and you may have contracted either. I will take each separately and tell you a little about them. You will know within a week whether it is gonorrhoea, in its more usual form. There will be a dull aching in the groins, and a yellowish, matter-like discharge from the inflamed urethra. You will naturally be a little alarmed, and, in a few days more, as you go about your ordinary business and eat and drink as usual, you will find things beginning to look serious. Then you will probably mention it to an acquaintance, for you won't care to tell your father or me. " Oh, that's all right," he will say — " it's quite simple. Everybody gets it and we'll cure it in no time." He will tell you to go to a chemist and ask for a certain drug and then follow the directions. If he has told you the right thing and you follow the instructions with scrupulous care, you may find that the symptoms disappear in a fortnight or so. Then you will stop the treatment and go on with your usual life. If the attack was a mild one you may) have got safely through; but again I am not backing your chances. It is the most curious and the most dangerous fact about sexual diseases that the symptoms — ■even serious ones — disappear under treatment in an incredibly short time. * * * LETTEE TO A GODSON 97 Now we will suppose that the attack was not a mild one, or that you have not applied proper remedies, or that you have consulted a " quack" doctor advertising in one of the lower-class papers, or that you have not persisted long enough in your treatment. All very reasonable suppositions. The disease may then turn into something really serious and become chronic; that is, it will get a grip of your system and break out again long after you have imagined yourself fully cured — even years after. Perhaps you may not be able to get the discharge to dry up and disappear. From this infection will possibly be spread from soiled linen, towels and such like, and a perfectly innocent person may contract the disease. And if the gonorrhoea becomes chronic you will not necessarily find the original symptoms again attacking you, but a variety of complications may ensue. For instance, there may result a very painful inflammation of a certain small organ connected with the testicles, or perhaps an attack of a form of rheumatism, or, very frequent and particularly serious, you may develop ophthalmia and so blindness. Gonorrhoea is very contagious — you see how easily you may have con- tracted it. A man who imagines himself fully cured may marry, and then he will infect his wife. The results with her are infinitely more serious. To begin with, gonorrhoea is known to be one of the most frequent and powerful causes which prevent a woman having children. The disease may also get a firm hold of certain internal organs and she will have to undergo serious operations, risking disablement and even life. You must not think that I am selecting rare cases and telling you all the worst facts with the object of frightening you. I only want you to understand that gonorrhoea is indeed a serious thing which, supposing you ever contract it, you must tackle the very moment you think you are infected, and persist in treatment under skilled medical advice until you are pronounced absolutely cured. I am not exaggerating things one little bit; in fact I am not telling you the worst. If you still need convincing you should turn up my little book, " The Problem of the Nations." I am not going to give you any bothering figures, but I can assure you that there is no disease in the world more prevalent than gononhoea. I will just quote for you one statement by an eminent man who has made a special study of this disease, and from that you will see that you are up against a really tough proposition : — " It has been established beyond doubt nowadays that about seventy out 7 98 THE PROBLEM OF THE NATIONS of a hundred of various serious diseases ' * (which he names) ' ' met with in married women are due to the infection of their careless, ignorant or unscrupulous husbands." * * * Two words more and then I have done with gonorrhoea. Supposing that you ever do contract it you must not necessarily blame the woman, A woman is not attacked by the disease in the same way as a man, and, indeed, it is very rare for her to know that there is ans^thing the matter with her. Even medical men often fail to diagnose the symptoms. And the other word is this, although I hardly think it necessary to say it to you. Whatever any friend of yours may remark, to have contracted gonorrhoea is not a sign of manhood and so something to be proud of. You are an English gentleman, old fellow, and no gentleman thinks cf women like that. Now I am going to tell you something about " Syphilis," the other disease which you may have contracted from that one trivial adventure with a woman. And as syphilis is really serious, unless you begin treatment right away and carefully persist in it for a long time, I shall have to say a good deal about it. The first danger with syphilis is that you may pass over as unimportant the primary symptoms, or first indication that you are infected. You may have become pwisoned by the microbe either in the sexual act or, if the woman happens to be infected on the lips or mouth, by kissing her. In any case the first symptom appears in about three weeks, a small, hard ulcer, which is called a " chancre." This forms either upon the genital organs or upon the mouth, or indeed upon any part of the body which came in contact with the infected place upon the woman. The chancre is often quite insignificant; you will take it to be a trivial boil, perhaps, and it will gradually disappear with or without any kind of treatment. Very probably you will hear it said, " Gonorrhoea is a very ordinary complaint, easily cured, but if you get syphilis you might just as well go and shoot yourself right away." Those very words were said to me by a young fellow only last month; he had got syphilis and was seriously proposing to poison himself. Even educated men often think very much the same, and, what is far worse, say it. Hugh, such an idea is not only absolutely wrong, it is criminal, and does immense harm. Of the two it is syphilis which is more easily treated. I will not say cured outright, because it is rather a lengthy business. But I give LETTER TO A GODSON 99 you my word that a case of syphilis can be made non-infective in forty-eight hours. If only a man will go straight to the very best medical man he can find directly he suspects that he is infected, and if only he will rigidly follow the advice and treatment given, then he need not be afraid. It will take time, it may take a couple of years before he is absolutely cured, but he will be non-infectious and the disease will have been stopped from attacking other parts of the body. * * * But if you neglect this advice and discontinue treatment then look out. The next thing that happens is the breaking out of a particularly disfiguring rash. You see the poison has by now begun to spread through your body. The rash generally indicates what are called " secondary " symptoms, but very few cases are exactly alike. This is the time when the disease is most con- tagious. You remember how careful they were when you had scarlet fever; how they separated you from everyone and disinfected everything. Well, this period of syphilis is much the same. You may give it to anyone in all kinds of unlikely ways, by a towel, a cup, a pipe. A workman, for instance, may become infected through drinking out of the same mug of beer which an infected comrade has used. Then he, too, will go through the same course of the disease, beginning with the " chancre." I don't want to horrify you too much, old fellow, but I do want you to realize what is likely to happen if you don't go straight off to that doctor and stick to the treatment. If you stop the treatment the thing will break out worse than ever somewhere else. In some parts of the world, particularly in some country districts in Russia, syphilis has become an absolute plague, attacking every single family, men, women and children. They never get treated properly because doctors are few, and so the disease steadily spreads and develops into other diseases which are almost too dreadful to talk about. And it is these other diseases, produced by syphilis, which give to syphilis the evil reputation it has acquired. It is, I think, quite safe for me to say that the " tertiary " symptoms, or evil results, only follow when there has been inadequate treatment in the earlier stages. Well, then, if the treatment has not been of the proper kind, or if it has been stopped too soon, there is not a single organ in the body which may not be attacked. And the part which is most liable to attack is also, unfortunately, the most important of all — the brain, and the nervous system generally. A 100 THE PROBLEM OF THE NATIONS great French specialist made careful notes upon 4,700 cases of these " tertiary " symptoms and, out of all the various parts of the body affected, no fewer than 2,009 developed syphilis of the brain and spinal cord. I could fill pages with details of these symptoms, but I will only most earnestly beg you to weigh very carefully every word that I have written, for I have not exaggerated one iota. There is not a single organ in the human bod}) which ma]) not be attacked and destro'^ed b's untreated or neglected syphilis. And to destroy some oj these organs means certain death. Last of all I must tell you of the gravest of all results of syphilis — its effect upon children, either by death before or soon after birth, or by the suffering to which they are condemned in life. I don't want to say much about this side of it. You will understand why. It is the last but the strongest appeal of all to every man. Some day, Hugh, you will meet a girl whom you will love very dearly, who will become all the world to you. She, too, will have learned to love you and, because she is a woman, it will be her dearest pride to give into your keeping in full, over- flowing measure all her pure soul and body. This is, perhaps, too big a thing for you to understand yet av/hile, so just for the sake of argument we will imagine that you have begun to realize that Miss Dorothy means a great deal more to you than " an awfully decent sort "; that in fact you have come to see that she is a very dear girl v/hom, the gods willing, you would really like to marry. Now supposing that as a result of that little adventure of yours you were so unfortunate as to contract syphilis. You must not forget that this would have been a very ordinary result. You might, had I not now warned you, have neglected to get fully cured and so have married Miss Dorothy while in a state of infection, although believing yourself to be quite fit. In the first place you would convey the poison into her system, with all the possible results to her which I have told you of. Ah, Hugh, that is not pleasant to contemplate, is it? The one being in the world whom you would love and cherish above all others. Then there might be a child. You love children, Hugh, and they, too, love you. You should be very proud of that. A child bom of syphilitic parents is almost fatally condemned to death, either before birth or during the first few days or weeks after birth. If it lives it LETTER TO A GODSON 101 grows up a being apart from other children. Perhaps, with the stamp of years of life and suffering upon its little face from the hour of birth, it may grow into a poor, wizened creature, developing all sorts of ailments, never free from suffering — need I go on, old man? Oh, you will think of this, won't you! For your wife's sake, for your children's sake, think. Is all this worth an hour's unsatisfied indulgence? If you must do it, and the evil thing befals you, then I implore you, by all you hold or may hold sacred, to face the consequences like the man you are and not to rest until you have driven out the last trace of the poison from your body, and you are clean once more. Promise me, Hugh ! * * -* There are two more points which you may possibly think to put to me. You may say that gonorrhoea may be very common, but that surely syphilis is rare. Again I do not want to give you a lot of figures, but I will just take two cities on either side of the world and tell you how many cases of syphilis were actually under medical treatment at a certain time. In Melbourne, out of a population of 600,000, and during 1910-1911, there were about 3,000 cases. In St. Petersburg, out of a population of 1,620,500 in 1911, there were recorded 45,023 cases of syphilis and 61,355 cases of other forms of sexual disease, including gonorrhoea. That will show you how prevalent it is. If I were to tell you how many young men in Berlin or Paris contract these diseases you probably would not believe me. And the other point might be this. You may argue with yourself some- what in this fashion : " Yes, I see that there certainly is a big risk if I have anything to do with one of those women of the streets. But all those arguments do not apply in the case of a girl who is practically straight and earning her living in ordinary business. She will not have anything the matter with her." I am afraid that I must dispel that illusion too. "Practically straight," I think you said. It is just the girls who are *' practically straight " who are the most dangerous, from the point of view of disease. I will tell you why. The average professional prostitute knows well that her prospects of trade depend very largely upon keeping herself free from infection. She may not know that she is in an infective state, but she is certain to take reasonable precautions. She is a woman of experience, she knows what to do, and she realizes the value of cleanliness. If she neglects this she. is doomed. The " practically straight " girl (shall we call her an " amateur " prosti- 102 THE PROBLEM OF THE NATIONS tute?) is not a woman of experience. Under the conditions in which the average girl of to-day is brought up in this country she is fairly certain to be almost entirely ignorant of the most elementary facts of sex and the functions of her body. She may not even have heard of the existence of sexual disease; and she certainly will have very little idea of putting into practice those regular habits of strict cleanliness which her professional sister rightly regards as a necessity. From every country in the world comes the same report : " It is not the professional prostitute whom we fear, but the amateur. We can exercise some control and supervision over the former, we can have none whatever over the latter." You seek for the glamour of love over your sexual impulse and act. Ycu think that you have found it in a girl who does not expect payment in cash for her favours. You are wrong. Once again you are putting your money on the wrong horse. If it is to the interest of a professional to counterfeit love, it is still more so with an amateur. A girl takes her first false step through ignorance of the consequences, through curiosity to realize the big thing of life, and, most frequently of all, for love of the man. Once the act is accomplished the barrier, physical and mental, is broken down and she is an entirely different woman. You cannot realize what that barrier is to a girl — very few men can. Once it is down she is at the mercy of the world. Her maidenly reserve, innocence if you will, is torn from her. She has lost for ever a great possession. The man who has taken it is responsible in the sight of God and men for her future life. Well, she has parted from her first lover. She may run straight afterwards, but it is improbable. The restraining influence has vanished. From her experience of the sexual impulse she becomes reckless and other lovers follow in succession. But a woman knows only one real passionate love in her life, all the others are merely shadows. She may seek to regain that love in another man, she may have her passing dreams that she has found it once more — they are only dreams. And so the comedy is played. She would have each new lover believe that she is chaste, or, if the mask falls for a moment, then " practically straight." She, too, would throw the glamour of love over the act. It is a mockery; she knows it, and you in your heart know it. Believe me, old man, it isn't worth it. » * * LETTBB TO A GODSON 103 You will find your amateur prostitute everywhere. In the chorus at the Pantheon Theatre; behind the counter at Messrs. Snip and Farthingale's; hastening to fetch you your toasted bun and pot of China tea at that select little tea-room in Threadneedle Street, When you go abroad you will find her — but there, I could write for you pages of romantic disguises which dis- creetly veil the amateur. In fact, the professional has long since recognized the value of these disguises in her quest of trade, and it is now exceedingly difficult to trace the dividing line. So you see that if you must be on your guard with the professional, you must none the less beware of the amateur. The former is absolutely certain to become infected sooner or later despite all her precautions; the latter generally contracts the disease at an early age, before she is 18 or 19. Indeed, it is most sad to think that the majority of female patients now being treated in the hospitals for sexual disease are young girls below the age of 20. * * * There, that is all that I am going to say about it. I have tried hard not to let you imagine that I wanted to give you a " pi-jaw "; you won't think that, will you, Hugh? We, your Mother and Father and I, desire your happiness and good fortune more than anything else. We want you to turn out what we have tried to make you, an English gentleman in the best sense of the word. We can only lay the foundation, the rest is in your hands. I have told you these things only for your own health's sake and that you may at least be forearmed. I once had a dear friend who was killed by syphilis simply because he knew nothing about it. If you would read the story you will find it in that little book of mine which I have already mentioned. But I swore then that I would not rest until I had done what I could to warn others, to leave the world a little better than I found it. * * * There are now many hundreds of men and women working hard to stamp out these diseases from civilization. Syphilis and gonorrhoea are, in them- selves, no more immoral than small-pox or scarlet fever. It is not a disgraceful thing to have contracted them, but a deep misfortune. And so we would, if we may, make the world a more beautiful place to live in. We would win to a finer and purer relationship between men and women, each living for and with the other. We would see our children grow into strong and sturdy citizens " of no mean city," the Empire of which, at heart, we are so proud. 104 THE PROBLEM OF THE NATIONS Perhaps you are going up to Oxford in a year or so, and of course you want to get your cricket blue. We should be proud of you. You won't get it if you go fooling around with women. Later, perhaps, you are going to read for the medical or legal professions. If you spend evenings in a girl's bedroom your brain will refuse to answer when you call upon it. You will find it impossible to perform a delicate operation, or to plead a case in Court. You will not be able to concentrate. If you steadily fight that sexual impulse you will be incomparably the finer man for it, in brain and body. If ever you must give way, then for God's sake remember what I have told you : opav reXo^, ," look to the end," as old Aristotle said. Here is a little cheque to help you through the Summer Half. Yours always affectionately, A. Corbett-SmiTxH, 105 A GLOSSAEY. The definitions are, in nearly every case, taken from " The Oxford Dictionary," 1911. Ancemia — Lack of blood. Aneurysm — The abnormal enlargement of an artery ; and so the gradual weakening of the wall of the vessel through the blood pressure. Aorta — The great artery, or trunk of the arterial system issuing from the left ventricle of the heart. Congenital — Belonging to an individual from birth. Contagious — Communicating disease by contact, cf. infectious. Embryo — The child in the womb before birth. Endemic — Eegularly found in a community, cf. epidemic. Epidemic — Prevalent in a community at a special time, cf. endemic. Fcetus — The fully developed embryo in the womb. Qleet — Thin morbid discharge from the urethra. Gynecology — The science of the diseases of women. Infectious — Communicating disease by air or water, cf. contagious. Locomotor Ataxy — Constitutional unsteadiness in the use of the arms, legs, &c. Mucous Membrane — The internal skin covered with the slimy secretion of the body. Ovaries — The reproductive organs in the female in which the ova are produced. Parturition — Childbirth. Pathogenic — Productive of disease. Pathology — The science of diseases. Prostate — A glandular body situated around the neck of the bladder in the male. Rickets — Children's disease, with softening of the bones, especially the spine. Suppurative — Tending to fester. Tabes — Wasting disease of the spinal cord. Urethra — The canal by which urine is discharged from the bladder. Uterus — The womb. Vagina — The sexual passage in the female from the uterus to the external orifice. 106 INDEX. Aboetion, 44 Alcohol (a factor in disease), 7, 66, 80, 86, 95 Alien immigration, 78 Anaemia, 26 Aneurysm, 30 Aortic disease, 32 Army (British), 7, 13, 63, 64, 75, 81 — , German, 72, 73, 87 — , Japanese, 12, 67 Australia, 49, 65 Bennie, Dr. (quoted), 49 Berlin, 13, 16, 66, 71-73, 78 Blaschko, Professor (quoted), 72 Blindness, 3, 20, 21, 22, 30, 50 Boy scouts, 7, 88 Brieux (quoted), 55 Bright 's disease, 33 Brock, B. G., 65 Browning, Dr. Carl H., 31, 32 Bucharest, 70, 74, 78 Bulkley, Dr. Duncan (quoted), 58 Canceb, 30 Central Asia (Russian), 69 Chancre, simple, 10 — , syphilitic, 25, 58, 98 Children, infection of, 45-54, 84, 100 China, 41, 65 Christiania, 64, 70, 74, 77, 78 Contagion, innocent, 14, 15, 19, 24, 28, 32, 37-61, 70, 84 — , "mediate," 59, 99 — , mixed, maternal and paternal, 46-48 — through industrial employment, 59, 60 Convulsions, 53 Copenhagen, 71, 74, 78, 82 Deafness, 31, 33, 50 Dublin, 50 Education of the individual, 4, 7, 8, 14, 22, 25, 33, 34, 36, 41, 44, 51, 57, 85-89 Ehrlich, Professor P., viii, 5, 57, 83 England and Wales, 49-51, 75, 81, 82 English Review, The, 2 Epididymitis, 18 Epilepsy, 31, 33 Eye diseases, 32 POURNIBR, Professor Alfred (quoted), 17, 18, 19, 21, 24, 25, 26, 27, 39 Eraser, Dr. Kate (quoted), 53 French, Major H. C. (quoted), 49 Germany, 64, 71-73 Gibbard, Colonel T. W. (quoted), 57 Glass blowing, 59 Gleet, 15, 18 Goldwin, Dr. (quoted), 68 Gonorrhoea, chronic, 11, 19, 22 — , definition of, 10 — , history of, 10 — , ignorance of symptoms, 18, 93 — , pathology of, 18 — , prevalence (general) of, 15, 16, 22 — , prevalence oi, versus syphilis, 12, 15, 22, 82, 98 {see also under names of countries and cities) — , quack treatment of, 17, 97 — , statistics (inadequate) of, 17 — , symptoms of, 10, 11, 96 — , treatment of, 18, 22 Gout, 33 Guinaud, Dr. (quoted), 59 Ham, Dr. B. Burnett, viii, 15, 64 Harrison, Major W. S. (quoted), 83 Hata, Professor S., viii, 5, 6, 57, 68, 83 Heart diseases, 31, 52 Heredity, 28, 29, 32, 43, 45-54 Hochringer, Dr. (quoted), 48 Hutchinson, Sir Jonathan (quoted), 32, 58 Hygiene, sexual, 54, 79, 87, 88 Industrial employment, 59, 60 Infantile mortality, 46-51, 60, 100 Inflammation of bladder, 19 — kidneys, 19 — prostate, 21 — spine, 19, 27 Illegitimate infants, 51 Insanity, 3, 8, 29, 31, 53, 63 Ireland, 50 Japan, 12, 63, 66-68, 74 INDEX 107 Jeanselme, Dr. (quoted), 51, 84 Johnson, J, Taber (quoted), 15 " Kiss in the ring," 41, 58 Lane, J. Ernest (quoted), 39 Laryngitis, 33, 51 Ledermann, Dr. R. (quoted), 41 Leroux, Dr. (quoted), 48 Life Assurance, 43 Liver, 32 Local Government Board, Report on Venereal Diseases, 2, 14, 38, 64, 75 London, 66, 76, 78, 81, 82 Love, Dr. J. Kerr (quoted), 33, 50 Luys, Dr. Georges (quoted), 10, 15, 97 MacGillivray, Dr. C. W. (quoted), 44 Marriage and syphilis, 42-44, 60, 84, 100 Marshall, Dr. 0. P. (quoted), 24, 29, 45, 46, 47, 52 Melbourne, 64, 65, 74, 76, 77, 78, 82, 101 Melville, Colonel C. H., viii, 15 Midwives, 58 Morrow, Dr. A. Prince (quoted), 69 Moscow, 49, 69, 73, 77, 78 Navy (British), 13, 75, 81 — , Japanese, 68 — of U.S.A. ,69 Neisser, Professor, 10, 15 Nervous system, 27, 32, 99 New York City, 64, 68, 74, 78 Noeggerath, Dr. (quoted), 15 Northern Africa, 65 Nurses, 55-57 Ophthalmia, 3, 8, 11, 14, 19, 20, 21, 22, 26 Osier, Sir William (quoted), 28, 30 Ozoena, 32 Paralysis, 19, 29, 33 Paris, 48, 51, 66 Philadelphia, 41, 58 Pinard, Dr. (quoted), 55 Pinkus, Prof, (quoted), 72 Pontopiddan, Prof. Erik (quoted), 71 Prostitution, professional, 4, 6, 15, 66, 73, 78, 80, 95 — , amateur, 4, 36, 60, 66, 101-3 " Retribution, Just," 38, 61, 84 Rheumatism, 19, 21 Rickets, 33, 51, 53 Roumania, 41, 70, 73, 74 Royal Commission on Venereal Diseases, 3, 4, 51, 64 Russia, 49, 64, 69, 70, 73, 99 St. Petersburg, 69, 73, 77, 78, 101 Salvarsan, (" 606)," 5, 57, 83 Sayer, Dr. Ettie, 3 Sequeira, Dr. J. H. (quoted), 52 Shanghai, 80 Siberia, 69, 73 South Africa, 65 South America, 41, 64, 77 Sterility, 14, 19, 22, 44 Stevenson, Dr. T. H. C, 40 Syphilis, chronic nature of, 24, 25 — , congenital, 46, 47 — , definition of, 24 — , general prevalence of, 40, 49 (see also under names of countries and cities) — , history of, 23 — , ignorance of symptoms, 25, 40, 42, 98 — , prevalence of, versus gonorrhoea, 12, 15, 42,98 — , quack treatment of, 42 — , statistics, 28, 32, 62 (see also under countries and cities) — , symptoms of, 25, 26 , primary, 25, 35, 57, 98 , secondary, 26, 35, 57, 99 , tertiary, 26, 27, 36, 99 — , treatment of, 17, 26, 43, 44, 51, 83, 84, 99 — , ubiquity of, 24, 27 Tabes, 28 Tarnowski, Dr. (quoted), 49, 70 Teeth diseases, 33, 52 Tuberculosis, 29, 33, 44, 51 Urethra, 10, 21 Victoria, 64 Vienna, 48 Was^ermann Test, 30, 31, 32, 53, 64, 68 Watson, Dr. H. Ferguson (quoted), 53 Wechselbaum, Prof, (quoted), 83 White, Dr. J. Douglas C. (quoted), 15, 82 Women's movement, 5, 12, 16, 17, 79 ZULULAND, 65 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE ! C2e(i 1 40) M too COLUMBIA UNIVERSITY LIBRARIES 0047946377 i ■M^.