I have been taking only syphilis into account, but nearly all that is said of the accidental infection of syphilis applies with equal or greater force to gonorrhoea, for though gonorrhoea does not enter into the system by so many channels as syphilis, it is a more common as well as a more subtle and elusive disease.
The literature of Syphilis Insontium is extremely extensive. There is a bibliography at the end of Duncan Bulkley's _Syphilis in the Innocent_, and a comprehensive summary of the question in a Leipzig Inaugural Dissertation by F. Moses, _Zur Kasuistik der Extragenitalen Syphilis-infektion_, 1904.
Even, however, when we have put aside the vast number of venereally infected people who may be said to be, in the narrowest and most conventionally moral sense, "innocent" victims of the diseases they have contracted, there is still much to be said on this question. It must be remembered that the majority of those who contract venereal diseases by illegitimate sexual intercourse are young. They are youths, ignorant of life, scarcely yet escaped from home, still undeveloped, incompletely educated, and easily duped by women; in many cases they have met, as they thought, a "nice" girl, not indeed strictly virtuous but, it seemed to them, above all suspicion of disease, though in reality she was a clandestine prostitute. Or they are young girls who have indeed ceased to be absolutely chaste, but have not yet lost all their innocence, and who do not consider themselves, and are not by others considered, prostitutes; that indeed, is one of the rocks on which the system of police regulation of prostitution comes to grief, for the police cannot catch the prostitute at a sufficiently early stage. Of women who become syphilitic, according to Fournier, twenty per cent. are infected before they are nineteen; in hospitals the proportion is as high as forty per cent.; and of men fifteen per cent. cases occur between eleven and twenty-one years of age. The age of maximum frequency of infection is for women twenty years (in the rural population eighteen), and for men twenty-three years. In Germany Erb finds that as many as eighty-five per cent men with gonorrhoea contracted the disease between the ages of sixteen and twenty-five, a very small percentage being infected after thirty. These young things for the most part fell into a trap which Nature had baited with her most fascinating lure; they were usually ignorant; not seldom they were deceived by an attractive personality; often they were overcome by passion; frequently all prudence and reserve had been lost in the fumes of wine. From a truly moral point of view they were scarcely less innocent than children.
"I ask," says Duclaux, "whether when a young man, or a young girl, abandon themselves to a dangerous caress society has done what it can to warn them. Perhaps its intentions were good, but when the need came for precise knowledge a silly prudery has held it back, and it has left its children without _viaticum_...I will go further, and proclaim that in a large number of cases the husbands who contaminate their wives are innocent. No one is responsible for the evil which he commits without knowing it and without willing it." I may recall the suggestive fact, already referred to, that the majority of husbands who infect their wives contracted the disease before marriage. They entered on marriage believing that their disease was cured, and that they had broken with their past. Doctors have sometimes (and quacks frequently) contributed to this result by too sanguine an estimate of the period necessary to destroy the poison. So great an authority as Fournier formerly believed that the syphilitic could safely be allowed to marry three or four years after the date of infection, but now, with increased experience, he extends the period to four or five years. It is undoubtedly true that, especially when treatment has been thorough and prompt, the diseased constitution, in a majority of cases, can be brought under complete control in a shorter period than this, but there is always a certain proportion of cases in which the powers of infection persist for many years, and even when the syphilitic husband is no longer capable of infecting his wife he may still perhaps be in a condition to effect a disastrous influence on the offspring.
In nearly all these cases there was more or less ignorance--which is but another word for innocence as we commonly understand innocence--and when at last, after the event, the facts are more or less bluntly explained to the victim he frequently exclaims: "Nobody told me!" It is this fact which condemns the pseudo-moralist. If he had seen to it that mothers began to explain the facts of sex to their little boys and girls from childhood, if he had (as Dr. Joseph Price urges) taught the risks of venereal disease in the Sunday-school, if he had plainly preached on the relations of the sexes from the pulpit, if he had seen to it that every youth at the beginning of adolescence received some simple technical instruction from his family doctor concerning sexual health and sexual disease--then, though there would still remain the need of pity for those who strayed from a path that must always be difficult to walk in, the would-be moralist at all events would in some measure be exculpated. But he has seldom indeed lifted a finger to do any of these things.
Even those who may be unwilling to abandon an attitude of private moral intolerance towards the victims of venereal diseases may still do well to remember that since the public manifestation of their intolerance is mischievous, and at the best useless, it is necessary for them to restrain it in the interests of society. They would not be the less free to order their own personal conduct in the strictest accordance with their superior moral rigidity; and that after all is for them the main thing. But for the sake of society it is necessary for them to adopt what they may consider the convention of a purely hygienic attitude towards these diseases. The erring are inevitably frightened by an attitude of moral reprobation into methods of concealment, and these produce an endless chain of social evils which can only be dissipated by openness. As Duclaux has so earnestly insisted, it is impossible to grapple successfully with venereal disease unless we consent not to introduce our prejudices, or even our morals and religion, into the question, but treat it purely and simply as a sanitary question. And if the pseudo-moralist still has difficulty in coöperating towards the healing of this social sore he may be reminded that he himself--like every one of us little though we may know it--has certainly had a great army of syphilitic and gonorrhoeal persons among his own ancestors during the past four centuries. We are all bound together, and it is absurd, even when it is not inhuman, to cast contempt on our own flesh and blood.
I have discussed rather fully the attitude of those who plead morality as a reason for ignoring the social necessity of combating venereal disease, because although there may not be many who seriously and understandingly adopt so anti-social and inhuman an attitude there are certainly many who are glad at need of the existence of so fine an excuse for their moral indifference or their mental indolence.[242] When they are confronted by this great and difficult problem they find it easy to offer the remedy of conventional morality, although they are well aware that on a large scale that remedy has long been proved to be ineffectual. They ostentatiously affect to proffer the useless thick end of the wedge at a point where it is only possible with much skill and prudence to insinuate the thin working end.
The general acceptance of the fact that syphilis and gonorrhoea are diseases, and not necessarily crimes or sins, is the condition for any practical attempt to deal with this question from the sanitary point of view which is now taking the place of the antiquated and ineffective police point of view. The Scandinavian countries of Europe have been the pioneers in practical modern hygienic methods of dealing with venereal disease. There are several reasons why this has come about. All the problems of sex--of sexual love as well as of sexual disease--have long been prominent in these countries, and an impatience with prudish hypocrisy seems here to have been more pronounced than elsewhere; we see this spirit, for instance, emphatically embodied in the plays of Ibsen, and to some extent in Björnson's works. The fearless and energetic temper of the people impels them to deal practically with sexual difficulties, while their strong instincts of independence render them averse to the bureaucratic police methods which have flourished in Germany and France. The Scandinavians have thus been the natural pioneers of the methods of combating venereal diseases which are now becoming generally recognized to be the methods of the future, and they have fully organized the system of putting venereal diseases under the ordinary law and dealing with them as with other contagious diseases.
The first step in dealing with a contagious disease is to apply to it the recognized principles of notification. Every new application of the principle, it is true, meets with opposition. It is without practical result, it is an unwarranted inquisition into the affairs of the individual, it is a new tax on the busy medical practitioner, etc. Certainly notification by itself will not arrest the progress of any infectious disease. But it is an essential element in every attempt to deal with the prevention of disease. Unless we know precisely the exact incidence, local variations, and temporary fluctuations of a disease we are entirely in the dark and can only beat about at random. All progress in public hygiene has been accompanied by the increased notification of disease, and most authorities are agreed that such notification must be still further extended, any slight inconvenience thus caused to individuals being of trifling importance compared to the great public interests at stake. It is true that so great an authority as Neisser has expressed doubt concerning the extension of notification to gonorrhoea; the diagnosis cannot be infallible, and the patients often give false names. These objections, however, seem trivial; diagnosis can very seldom be infallible (though in this field no one has done so much for exact diagnosis as Neisser himself), and names are not necessary for notification, and are not indeed required in the form of compulsory notification of venereal disease which existed a few years ago in Norway.
The principle of the compulsory notification of venereal diseases seems to have been first established in Prussia, where it dates from 1835. The system here, however, is only partial, not being obligatory in all cases but only when in the doctor's opinion secrecy might be harmful to the patient himself or to the community; it is only obligatory when the patient is a soldier. This method of notification is indeed on a wrong basis, it is not part of a comprehensive sanitary system but merely an auxiliary to police methods of dealing with prostitution. According to the Scandinavian system, notification, though not an essential part of this system, rests on an entirely different basis.
The Scandinavian plan in a modified form has lately been established in Denmark. This little country, so closely adjoining Germany, for some time followed in this matter the example of its great neighbor and adopted the police regulation of prostitution and venereal disease. The more fundamental Scandinavian affinities of Denmark were, however, eventually asserted, and in 1906, the system of regulation was entirely abandoned and Denmark resolved to rely on thorough and systematic application of the sanitary principle already accepted in the country, although something of German influence still persists in the strict regulation of the streets and the penalties imposed upon brothel-keepers, leaving prostitution itself free. The decisive feature of the present system is, however, that the sanitary authorities are now exclusively medical. Everyone, whatever his social or financial position, is entitled to the free treatment of venereal disease. Whether he avails himself of it or not, he is in any case bound to undergo treatment. Every diseased person is thus, so far as it can be achieved, in a doctor's hands. All doctors have their instructions in regard to such cases, they have not only to inform their patients that they cannot marry so long as risks of infection are estimated to be present, but that they are liable for the expenses of treatment, as well as the dangers suffered, by any persons whom they may infect. Although it has not been possible to make the system at every point thoroughly operative, its general success is indicated by the entire reliance now placed on it, and the abandonment of the police regulation of prostitution. A system very similar to that of Denmark was established some years previously in Norway. The principle of the treatment of venereal disease at the public expense exists also in Sweden as well as in Finland, where treatment is compulsory.[243] It can scarcely be said that the principle of notification has yet been properly applied on a large scale to venereal diseases. But it is constantly becoming more widely advocated, more especially in England and the United States,[244] where national temperament and political traditions render the system of the police regulation of prostitution impossible--even if it were more effective than it practically is--and where the system of dealing with venereal disease on the basis of public health has to be recognized as not only the best but the only possible system.[245] In association with this, it is necessary, as is also becoming ever more widely recognized, that there should be the most ample facilities for the gratuitous treatment of venereal diseases; the general establishment of free dispensaries, open in the evenings, is especially necessary, for many can only seek advice and help at this time. It is largely to the systematic introduction of facilities for gratuitous treatment that the enormous reduction in venereal disease in Sweden, Norway, and Bosnia is attributed. It is the absence of the facilities for treatment, the implied feeling that the victims of venereal disease are not sufferers but merely offenders not entitled to care, that has in the past operated so disastrously in artificially promoting the dissemination of preventable diseases which might be brought under control.
If we dispense with the paternal methods of police regulation, if we rely on the general principles of medical hygiene, and for the rest allow the responsibility for his own good or bad actions to rest on the individual himself, there is a further step, already fully recognized in principle, which we cannot neglect to take: We must look on every person as accountable for the venereal diseases he transmits. So long as we refuse to recognize venereal diseases as on the same level as other infectious diseases, and so long as we offer no full and fair facilities for their treatment, it is unjust to bring the individual to account for spreading them. But if we publicly recognize the danger of infectious venereal diseases, and if we leave freedom to the individual, we must inevitably declare, with Duclaux, that every man or woman must be held responsible for the diseases he or she communicates.
According to the Oldenburg Code of 1814 it was a punishable offence for a venereally diseased person to have sexual intercourse with a healthy person, whether or not infection resulted. In Germany to-day, however, there is no law of this kind, although eminent German legal authorities, notably Von Liszt, are of opinion that a paragraph should be added to the Code declaring that sexual intercourse on the part of a person who knows that he is diseased should be punishable by imprisonment for a period not exceeding two years, the law not to be applied as between married couples except on the application of one of the parties. At the present time in Germany the transmission of venereal disease is only punishable as a special case of the infliction of bodily injury.[246] In this matter Germany is behind most of the Scandinavian countries where individual responsibility for venereal infection is well recognized and actively enforced.
In France, though the law is not definite and satisfactory, actions for the transmission of syphilis are successfully brought before the courts. Opinion seems to be more decisively in favor of punishment for this offense than it is in Germany. In 1883 Després discussed the matter and considered the objections. Few may avail themselves of the law, he remarks, but all would be rendered more cautious by the fear of infringing it; while the difficulties of tracing and proving infection are not greater, he points out, than those of tracing and proving paternity in the case of illegitimate children. Després would punish with imprisonment for not more than two years any person, knowing himself to be diseased, who transmitted a venereal disease, and would merely fine those who communicated the contagion by imprudence, not realizing that they were diseased.[247] The question has more recently been discussed by Aurientis in a Paris thesis. He states that the present French law as regards the transmission of sexual diseases is not clearly established and is difficult to act upon, but it is certainly just that those who have been contaminated and injured in this way should easily be able to obtain reparation. Although it is admitted in principle that the communication of syphilis is an offence even under common law he is in agreement with those who would treat it as a special offence, making a new and more practical law.[248] Heavy damages are even at the present time obtained in the French courts from men who have infected young women in sexual intercourse, and also from the doctors as well as the mothers of syphilitic infants who have infected the foster-mothers they were entrusted to. Although the French Penal Code forbids in general the disclosure of professional secrets, it is the duty of the medical practitioner to warn the foster-mother in such a case of the danger she is incurring, but without naming the disease; if he neglects to give this warning he may be held liable.
In England, as well as in the United States, the law is more unsatisfactory and more helpless, in relation to this class of offences, than it is in France. The mischievous and barbarous notion, already dealt with, according to which venereal disease is the result of illicit intercourse and should be tolerated as a just visitation of God, seems still to flourish in these countries with fatal persistency. In England the communication of venereal disease by illicit intercourse is not an actionable wrong if the act of intercourse has been voluntary, even although there has been wilful and intentional concealment of the disease. _Ex turpi causâ non oritur actio_, it is sententiously said; for there is much dormitative virtue in a Latin maxim. No legal offence has still been committed if a husband contaminates his wife, or a wife her husband.[249] The "freedom" enjoyed in this matter by England and the United States is well illustrated by an American case quoted by Dr. Isidore Dyer, of New Orleans, in his report to the Brussels Conference on the Prevention of Venereal Diseases, in 1899: "A patient with primary syphilis refused even charitable treatment and carried a book wherein she kept the number of men she had inoculated. When I first saw her she declared the number had reached two hundred and nineteen and that she would not be treated until she had had revenge on five hundred men." In a community where the most elementary rules of justice prevailed facilities would exist to enable this woman to obtain damages from the man who had injured her or even to secure his conviction to a term of imprisonment. In obtaining some indemnity for the wrong done her, and securing the "revenge" she craved, she would at the same time have conferred a benefit on society. She is shut out from any action against the one person who injured her; but as a sort of compensation she is allowed to become a radiating focus of disease, to shorten many lives, to cause many deaths, to pile up incalculable damages; and in so doing she is to-day perfectly within her legal rights. A community which encourages this state of things is not only immoral but stupid.
There seems, however, to be a growing body of influential opinion, both in England and in the United States, in favor of making the transmission of venereal disease an offence punishable by heavy fine or by imprisonment.[250] In any enactment no stress should be put on the infection being conveyed "knowingly." Any formal limitation of this kind is unnecessary, as in such a case the Court always takes into account the offender's ignorance or mere negligence, and it is mischievous because it tends to render an enactment ineffective and to put a premium on ignorance; the husbands who infect their wives with gonorrhoea immediately after marriage have usually done so from ignorance, and it should be at least necessary for them to prove that they have been fortified in their ignorance by medical advice. It is sometimes said that the existing law could be utilized for bringing actions of this kind, and that no greater facilities should be offered for fear of increasing attempts at blackmail. The inutility of the law at present for this purpose is shown by the fact that it seldom or never happens that any attempt is made to utilize it, while not only are there a number of existing punishable offences which form the subject of attempts at blackmail, but blackmail can still be demanded even in regard to disreputable actions that are not legally punishable at all. Moreover, the attempt to levy blackmail is itself an offence always sternly dealt with in the courts.
It is possible to trace the beginning of a recognition that the transmission of a venereal disease is a matter of which legal cognizance may be taken in the English law courts. It is now well settled that the infection of a wife by her husband may be held to constitute the legal cruelty which, according to the present law, must be proved, in addition to adultery, before a wife can obtain divorce from her husband. In 1777 Restif de la Bretonne proposed in his _Gynographes_ that the communication of a venereal disease should itself be an adequate ground for divorce; this, however, is not at present generally accepted.[251] It is sometimes said that it is very well to make the individual legally responsible for the venereal disease he communicates, but that the difficulties of bringing that responsibility home would still remain. And those who admit these difficulties frequently reply that at the worst we should have in our hands a means of educating responsibility; the man who deliberately ran the risk of transmitting such infection would be made to feel that he was no longer fairly within his legal rights but had done a bad action. We are thus led on finally to what is now becoming generally recognized as the chief and central method of combating venereal disease, if we are to accept the principle of individual responsibility as ruling in this sphere of life. Organized sanitary and medical precautions, and proper legal protection for those who have been injured, are inoperative without the educative influence of elementary hygienic instruction placed in the possession of every young man and woman. In a sphere that is necessarily so intimate medical organization and legal resort can never be all-sufficing; knowledge is needed at every step in every individual to guide and even to awaken that sense of personal moral responsibility which must here always rule. Wherever the importance of these questions is becoming acutely realized--and notably at the Congresses of the German Society for Combating Venereal Disease--the problem is resolving itself mainly into one of education.[252] And although opinion and practice in this matter are to-day more advanced in Germany than elsewhere the conviction of this necessity is becoming scarcely less pronounced in all other civilized countries, in England and America as much as in France and the Scandinavian lands.
A knowledge of the risks of disease by sexual intercourse, both in and out of marriage,--and indeed, apart from sexual intercourse altogether,--is a further stage of that sexual education which, as we have already seen, must begin, so far as the elements are concerned, at a very early age. Youths and girls should be taught, as the distinguished Austrian economist, Anton von Menger wrote, shortly before his death, in his excellent little book, _Neue Sittenlehre_, that the production of children is a crime when the parents are syphilitic or otherwise incompetent through transmissible chronic diseases. Information about venereal disease should not indeed be given until after puberty is well established. It is unnecessary and undesirable to impart medical knowledge to young boys and girls and to warn them against risks they are yet little liable to be exposed to. It is when the age of strong sexual instinct, actual or potential, begins that the risks, under some circumstances, of yielding to it, need to be clearly present to the mind. No one who reflects on the actual facts of life ought to doubt that it is in the highest degree desirable that every adolescent youth and girl ought to receive some elementary instruction in the general facts of venereal disease, tuberculosis, and alcoholism. These three "plagues of civilization" are so widespread, so subtle and manifold in their operation, that everyone comes in contact with them during life, and that everyone is liable to suffer, even before he is aware, perhaps hopelessly and forever, from the results of that contact. Vague declamation about immorality and vaguer warnings against it have no effect and possess no meaning, while rhetorical exaggeration is unnecessary. A very simple and concise statement of the actual facts concerning the evils that beset life is quite sufficient and adequate, and quite essential. To ignore this need is only possible to those who take a dangerously frivolous view of life.
It is the young woman as much as the youth who needs this enlightenment. There are still some persons so ill-informed as to believe that though it may be necessary to instruct the youth it is best to leave his sister unsullied, as they consider it, by a knowledge of the facts of life. This is the very reverse of the truth. It is desirable indeed that all should be acquainted with facts so vital to humanity, even although not themselves personally concerned. But the girl is even more concerned than the youth. A man has the matter more within his own grasp, and if he so chooses he may avoid all the grosser risks of contact with venereal disease. But it is not so with the woman. Whatever her own purity, she cannot be sure that she may not have to guard against the possibility of disease in her future husband as well as in those to whom she may entrust her child. It is a possibility which the educated woman, so far from being dispensed from, is more liable to encounter than is the working-class woman, for venereal disease is less prevalent among the poor than the rich.[253] The careful physician, even when his patient is a minister of religion, considers it his duty to inquire if he has had syphilis, and the clergyman of most severely correct life recognizes the need of such inquiry and may perhaps smile, but seldom feels himself insulted. The relationship between husband and wife is even much more intimate and important than that between doctor and patient, and a woman is not dispensed from the necessity of such inquiry concerning her future husband by the conviction that the reply must surely be satisfactory. Moreover, it may well be in some cases that, if she is adequately enlightened, she may be the means of saving him, before it is too late, from the guilt of premature marriage and its fateful consequences, so deserving to earn his everlasting gratitude. Even if she fails in winning that, she still has her duty to herself and to the future race which her children will help to form.