CHAPTER XIV
The central problem of the sexual question is, as I pointed out at the commencement of the previous chapter, the suppression of prostitution and of venereal diseases, the former evil being the principal focus of the latter. I say the principal “focus,” not the “cause.” For, if all prostitutes were healthy, we could leave prostitution quietly alone—leaving out of consideration the moral depravity to which it gives rise—and venereal diseases would spontaneously disappear.
This opinion I advance at the beginning of the chapter on venereal diseases because, even at the present day, there is a remarkable species of philosophy, or rather theology, of venereal diseases, which propounds the most extraordinary hypothesis regarding their origin.
For example, the Alsatian writer Alexander Weill, in his confused work “The Laws and Mysteries of Love,” writes:
“Why should we bother our heads about the cure of syphilis? If anyone wishes to get rid of any evil, he must first of all ascertain its causes in order to remove these. If the cause of it is removed, the evil disappears spontaneously. If the snake has been killed, its poison no longer does any harm. But how can we put an end to the causes of syphilis, when this disease is spontaneously renewed and increased day by day by means of neglected prostitution, and by our social laws which combine to oppose the monogamy of youth and the increase of population? If to-day we could cure all patients suffering from syphilis, to-morrow the same disease would return in a new form, for it would be recreated by the same irregularities that first led to its production (!) It is absolutely useless to employ iodide of potassium and mercury, for every new infringement of natural laws would again bring into being new incurable diseases, which can only be avoided by those who have firmly resolved to observe these laws strictly.”
Weill, indeed, goes so far as to maintain that every man who simultaneously, or rather in brief succession, has intercourse with two healthy women, acquires syphilis, even although both these women remain faithful to him, because “any kind of libertinism in sexual intercourse suffices by itself to give rise to this disease!”
According to this view, which is shared by many members of the laity, venereal diseases, and, above all, the worst of them, syphilis, would be as old as sexual licentiousness itself—that is, as old as the human race, and an inalienable associate of that race.
In my book on “The Origin of Syphilis” I have disproved this view. I have answered the question, so important alike on general philosophical and on social-hygienic grounds, regarding the true nature of syphilis, and have proved that syphilis (and also the other venereal diseases) had a definite local and temporal origin; that syphilis has not existed since the beginning of time; and that some day, when certain definite conditions are fulfilled, the disease will disappear.
The history of syphilis is a matter of profound practical importance. From that history we learn with certainty that the most dangerous and most dreaded of the venereal diseases has, for the European world, and for the “old world” in general, the character of a pure chance comer; and we learn that retrospectively—regarded from the point of view of our present experience—at the time when the disease first began to flourish, it might perhaps have been nipped in the bud.
It is hardly possible to overestimate the practical importance of the recognition of this fact—that for the old civilized world syphilis represents a historical phenomenon, that it has a history, a beginning, or, as Voltaire half-ironically remarks, a genealogy.
Is there not a deliverance, a redemption, in the idea that for the old world there was a time in which syphilis did not exist; that this time, in comparison with the time which has elapsed since syphilis first appeared, was almost infinitely long; and that for this reason, when we look out into the future, the history of the lues venerea assumes the character of a simple episode in the history of European civilized humanity?
At the same time, the definite acceptance of this view would be an urgent warning to all those obscurantists of both sexes who imagine that the problem of the diffusion of venereal diseases can be solved exclusively by religious and moral considerations, and who thus confuse the simplest and clearest relationships, place everything upon an insecure foundation, and exclude every possibility of a successful campaign against syphilis.
Even to-day it unfortunately happens that many continue, as of old, to believe that sexual intercourse is a sin for which a punishment has been provided, and that this punishment is a venereal disease—for example, syphilis. Tylor, the celebrated English anthropologist, has proved that this idea has developed out of the animism extending back into prehistoric times, which regarded all illnesses as the work of demons. We are still influenced by this doctrine, this gloomy, demoniacal conception in respect of everything sexual. I need hardly remind the reader of the ideas of Tolstoi, and of his disciple, the unhappy Dr. Weininger, a disciple exceeding even his master in respect of fanatical condemnation of sexual intercourse. Until recently the laws regulating our German system of workmen’s insurance against illness continued to exhibit definite traces of our legislators’ adhesion to this view. The majority of physicians and historians who said that syphilis was as old as sexual intercourse itself, who employed the phrase ubi Venus ibi syphilis, were unconsciously influenced by this idea, that venereal diseases are to be regarded as a mark of the Divine wrath.
This theological theory, as we may call it, of the origin of syphilis is opposed by certain incontrovertible facts, which suffice to show its utter nullity and untenability.
The mere fact that there exists a blameless infection with syphilis (syphilis innocentium), that, for example, in certain districts of Russia as many as 90 % of the cases of this disease are acquired quite independently of sexual intercourse, by simple contact, shows the absurdity of this superstitious idea.
In the second place, it is a widely known fact that quite frequently persons who are still entirely uncontaminated, blameless initiates, become infected with syphilis on the very first occasion in which they have sexual intercourse, whilst greater experience and more exact knowledge of the threatening dangers induce notorious debauchees to adopt effective measures of protection (which, however, would be useless if syphilis were really a divinely decreed punishment for licentiousness of this kind!).
In the third place, the occurrence of syphilis in little children—partly owing to inheritance, partly, however, acquired in the way already mentioned by casual contact—affords a striking refutation of the above idea, which, unfortunately, still dominates and fascinates a large circle of people.
We could adduce further arguments against this view, but what we have said should suffice to show clearly the untenability of such a superstition. The syphilis of one individual is not the consequence of sexual intercourse, but the consequence of another case of syphilis in another individual—that is to say, syphilis is a specific infective disease, transmissible only by means of its peculiar specific virus, and this transmission can be effected without any sexual intercourse, by means of contacts of other kinds. Syphilis arises only from syphilis.
We have, therefore, to attack this disease precisely in the same manner as the other venereal diseases. As a Portuguese physician has most aptly remarked, to the tyranny of syphilis we must oppose the tyranny of human reason. The principal aim of a campaign against venereal diseases will be the organization of the means offered to us by reason and experience to cope with the disease. The knowledge of these means must be diffused in ever-wider circles of humanity, and care must be taken that every individual is fully and clearly informed regarding the importance and the dangers of syphilis and the other venereal diseases.
Here also history is our teacher, our lamp of truth, and promises us complete success as the result of our campaign against venereal diseases.
The results of my investigations regarding the origin of syphilis all point to a single extremely important fact—namely, that in the case of syphilis, and as regards the “old world,” we have to do with a specific disease of modern times, which made its first appearance at the end of the fifteenth century, and of the previous existence of which, even in the most distant prehistoric times, not the minutest trace remains. This view was held by very eminent physicians, even before the publication of my own critical work, based upon entirely new sources of study. Among these authorities I may mention Jean Astruc and Christoph Girtanner, in the eighteenth century; in the nineteenth century, the Spanish army surgeon Montejo, and of German physicians, above all, Rudolf Virchow, A. Geigel, von Liebermeister, C. Binz, and P. G. Unna. The great philosopher Arthur Schopenhauer held the same view.[312]
Ricord, the celebrated French syphilologist, spoke once of a romance of syphilis which still remained to be written. I should rather compare it with a drama, the separate acts of which are centuries. Of this drama, four acts have already been played. At the present moment we find ourselves at the beginning of the fifth act. Thus, we have an entire century before us, in which, with all the powers placed at our disposal by scientific medical research, by practical therapeutics, and by hygiene in association with social measures, we must work to this end, that this fifth act shall also be the last, as it is in the case of a proper drama.
The history of syphilis has remained so long obscure, because, until the time of Philipp Ricord—that is to say, until the beginning of the second half of the nineteenth century—the three venereal diseases, syphilis, or lues, the so-called soft chancre (venereal ulcer or chancroid), and gonorrhœa, were regarded as essentially one disease; whereas we know to-day that syphilis is a specific infective disease of a constitutional character, which permeates the whole body, and must be absolutely distinguished from the other venereal diseases, these latter being purely local in character. This earlier belief in the identity of all venereal infections, an error held even by so great an authority as John Hunter, who was misled by falsely interpreted experiments, renders it necessary that the historical side of the question should be considered also from this point of view.
If gonorrhœa and chancroid were of a syphilitic nature, then certainly syphilis must have existed from very early times. It would not be difficult to refer to syphilis some descriptions and accounts of diseases of the genital organs given by the ancient and medieval writers. It was the progressive enlightenment regarding the essential differences between the three venereal diseases which first proved the untenability of such opinions; we were further assisted by the knowledge of pseudo-venereal and pseudo-syphilitic diseases which we have obtained from modern dermatology. Moreover, in the old world syphilitic bones belonging to ancient or medieval times have never been discovered.[313] The first syphilitic bones date from after the time of the discovery of America. They appear, above all, after the outbreak of the great epidemic of syphilis which followed the Italian campaign of King Charles VIII. of France, in the years 1494 and 1495; it was then that syphilis first became diffused in the old world.
In my work on “The Origin of Syphilis” (Jena, 1901),[314] I have adduced proof, basing my views upon the criticism of older opinions, and assisted by the utilization of very abundant new sources of material, that syphilis was first introduced into Spain in the years 1493 and 1494 by the crew of Columbus, who brought it from Central America, and more especially from the island of Hayti; from Spain it was carried by the army of Charles VIII. to Italy, where it assumed an epidemic form; and after the army was disbanded the disease was transported by the soldiers to the other countries of Europe, and also was soon taken by the Portuguese to the Far East, to India, China, and Japan. At the time of its first appearance in the old world, syphilis was extraordinarily virulent. All the morbid phenomena produced by the disease had a more rapid and violent course than at the present day; the mortality was much higher; the consequences, even when a cure was effected, were much more severe. This virulence of syphilis at the time of its first introduction can only be explained, in accordance with our modern views of the nature and mode of appearances of the disease, by the fact that the nations of the old world (who, nota bene, were all attacked with equal intensity) had, until that time, been completely free from syphilis. All classes of the people and all nations were visited by syphilis to an equal extent and with the same violence.
Even to-day we observe everywhere, when syphilis is introduced into regions which have hitherto been free from the disease, that it has the same acute course, the same violence of morbid manifestations, that characterized its first appearance in Europe. In the four centuries that have elapsed since its introduction into Europe there has occurred a gradual mitigation of the syphilitic virus, or rather a certain degree of immunization of European humanity against the disease. Speaking generally, syphilis has to-day—in comparison with that earlier time—a relatively mild course. To this point we shall return later.[315]
The two other venereal diseases, gonorrhœa and chancroid, unquestionably existed in Europe in the days of antiquity. But they also are specific infective diseases, and are only produced by the virus peculiar to each, just as syphilis has its own peculiar virus.
Ricord (1800-1889), in the years 1830 to 1850, proved the complete diversity of syphilis and gonorrhœa, established the doctrine of the three stages of syphilis—primary, secondary, and tertiary—and, finally, taught us to distinguish the soft, non-syphilitic chancre (chancroid) from the hard, syphilitic chancre. Virchow, in his celebrated essay on “The Nature of Constitutional Syphilitic Affections” (Virchow’s Archiv, 1858, vol. xv., p. 217 et seq.), then threw a clear light on the peculiar course of constitutional syphilis and on the causes of the occasional disappearance and sudden reappearance of the morbid phenomena. Hitherto, however, our knowledge of venereal diseases had rested on an extremely insecure foundation; and the truly scientific study of the subject may be said to have begun in the year 1879, with Albert Neisser’s epoch-making discovery of the gonococcus as the specific exciting cause of gonorrhœa. In the years 1889 to 1892 there followed the discovery of the bacillus of chancroid by Ducrey and Unna, by means of which discovery the complete distinction between the soft and the hard chancre was definitely proved; and, finally, the three years 1903 to 1906 were characterized by remarkable discoveries, the full importance of which is not as yet fully realized, regarding the nature of the syphilitic virus. In the year 1903 Eli Metchnikoff succeeded in transmitting syphilis from human beings to apes, and thus laid the foundation for progressive research regarding syphilis by means of experiments on animals; this was carried further by Lassar, by the inoculation of the syphilitic virus from one ape to another, and also by A. Neisser in his experimental researches in Java;[316] and in March, 1905, the Berlin protozoologist Fritz Schaudinn, since prematurely lost to the world of science, published his first studies on the probable exciting cause of syphilis, the so-called “spirochæte pallida.” Numerous subsequent investigations have established the connexion between this spirilla-form, belonging to the order of protozoa, and syphilitic disease. In this way we have been brought notably nearer to the discovery of the certain cure of syphilis and to the discovery of means of immunization against the disease. In this direction quite new views are opening before our eyes.[317] Numerous ideas suggested by recent discoveries in the province of syphilitic research are described in the admirable essay by J. Jadassohn, “Contributions to Syphilology,” published in the German “Archives for Dermatology and Syphilis,” 1907. Cf. also the account of the recent doctrines regarding syphilis by P. G. Unna and Iwan Bloch, “Die Praxis der Hautkrankheiten,” pp. 548-592 (Vienna and Berlin, 1908).
When some day humanity has been freed from the “sexual plague,” from the hydra of venereal diseases, and when a monument is erected to the liberators, four names will there be commemorated: Ricord, Neisser, Metchnikoff, and Schaudinn!
After these preliminary remarks on the nature of venereal diseases, I proceed to a short description of them, and I begin with the most dangerous of all the venereal diseases, syphilis.[318]
The first manifestations of syphilis make their appearance about three or four weeks after infection, at the place at which infection has occurred, and this is not in every case the genital organs. It is true that syphilis is most commonly transmitted by means of sexual intercourse, but frequently also by contacts of other kinds—for example, by kissing; by gynecological or surgical examinations and operations; by drinking from a glass which has previously been used by some one suffering from syphilis; by the use of uncleansed pocket-handkerchiefs, towels, and bedding, which have been used by a syphilitic patient; by the use of tobacco-pipes, wind-instruments, tooth-brushes, tooth-picks, a glass-blower’s mouthpiece, etc., belonging to strangers; by an uncleansed razor; by the nasty habit of licking the point of a pencil; by moistening postage-stamps with the tongue; by sucking the wound in circumcision; by the suckling of the infant at the breast of a syphilitic wet-nurse, etc.[319] In England the custom, when taking a judicial oath, of kissing the Bible has repeatedly sufficed to transmit syphilitic infection.
In certain districts in which the level of civilization is a low one—as, for example, in some parts of Russia and of Turkey—as many as 50 to 60 % of all infections occur independently of sexual intercourse.
All the discharges from syphilitic lesions in all three stages of the disease are infective. The infective character of the tertiary stage of syphilis was formerly doubted, but has recently been proved beyond dispute. Blood also, although more rarely, can prove infective. On the other hand, the pure secretions—that is, the physiological secretions, not contaminated by morbid products—such as the saliva, tears, and milk, are not infective. Syphilis is, however, very frequently transmitted by means of the semen.
Infection occurs in places in which there is a solution of continuity of the skin or mucous membrane, such as a scratch or a superficial wound, through which the virus can enter. In this way an apparently healthy syphilitic patient—when, for example, he gets a small abrasion on the penis (or, in the case of a woman, in the vagina)—can transmit syphilis if the other individual also has a similar abrasion through which infection can occur.
As we have said, it is not till the lapse of two to four weeks after infection has occurred that the first manifestations of syphilis appear, in the form of a small vesicle or nodule in the infected area; less often merely an abraded area of a peculiar red colour. Gradually this nodule or area enlarges, and becomes continually harder at the base, whilst the surface often undergoes ulceration, and secretes extremely infective pus (the so-called “hard chancre” or “primary lesion”[320]).
This induration is in most cases a certain sign that the syphilitic virus has already entered the body; at least, it has only been possible in a few very rare cases, by excision or cauterization of the hard chancre, to prevent syphilis from entering the blood. Almost always, notwithstanding such endeavours, the manifestations of general infection of the body soon appear.
From the place of infection—that is, from the place at which the hard chancre forms—the syphilitic virus next passes by way of the lymph-stream into the inguinal glands, so that these, in the third or fourth week after the appearance of the hard chancre, begin to swell and to become hard. This swelling of the inguinal glands is painless (the so-called “indolent bubo”), in contrast to the painful swelling which accompanies the soft chancre. From this region the poison now proceeds by way of the bloodvessels and lymph paths on its wanderings all over the body, the individual stages of which can be detected by swellings of the lymph-glands of the axilla, the elbow, the neck, etc. Sometimes other symptoms of general infection are noticeable; above all, the appearance of fever (never earlier than forty days after infection), pains in the muscles, joints, nerves, also severe headaches, a general feeling of lassitude, pallor, and a falling-off in the nutritive condition.
These are the forerunners of the so-called secondary stage of syphilis, which now manifests itself by the appearance of a multiform skin eruption, rendering the diagnosis of syphilis absolutely certain. For this reason, in doubtful cases of ulceration of the genital organs the patient should inspect his skin very carefully every day for several weeks or months, and keep watch for the appearance of red spots or nodules. This syphilitic eruption on the skin is also in the later periods one of the most certain and most characteristic insignia of the disease.
The eruption commonly appears first on the trunk, in the form of rose-coloured spots (the so-called “roseola syphilitica”), spreads thence over the whole body, and in many cases, simultaneously with or shortly after the spotted eruption, nodules appear on the skin, and marked thickenings form on the mucous membranes, especially at the anus, in the mouth, and on the tongue (the so-called “plaques muqueuses,” or “condylomata”). The patient’s attention is spontaneously directed to these lesions by painful sensations in the mouth or by itching of the anus. Often it is these painful sensations, associated with a violent inflammation of the tonsils and pharynx (the so-called “angina syphilitica”), which first lead the patient to consult a doctor, after all the earlier symptoms have passed by unnoticed! As characteristic forms of the secondary syphilitic changes in the skin must, therefore, be mentioned the so-called “corona Veneris,” by which distinguished name is denoted an eruption on the forehead, especially along the margin of the hair, which by members of the laity is easily confused with other affections of the skin common in this locality; the so-called “collier de Venus,” or leukoderma syphiliticum, a peculiar pigmentation of the skin on the throat and the back of the neck in the form of brown patches with white intervening areas. This symptom, which occurs almost exclusively in women, is an absolutely certain sign of syphilis. Equally characteristic is the so-called “syphilitic psoriasis,” the appearance of peculiar patches and thickenings on the palms of the hands and the soles of the feet; characteristic also is the syphilitic loss of hair, by its sudden onset and by the patchy way in which it occurs. Not rarely do we see purulent eruptions on the skin in this secondary stage of syphilis.
The syphilitic eruption of the skin is only an external manifestation of a disease affecting the entire body, for the internal organs also suffer. The affection of the liver manifests itself by jaundice; that of the brain and the meninges by headaches and by weakness of memory, which is often well marked at this stage; that of the spleen by swelling; that of the kidneys by the appearance of albumin in the urine; that of the bones by very painful inflammatory swellings; that of the eyes specially by the well-known syphilitic iritis (60 % of all inflammations of the iris are syphilitic in nature!).
If the disease remains untreated, the appearances just described become more general and continually more severe; and after some time, quite new morbid symptoms are superadded (often as early as the third year, on the average five to ten years after infection, but also later), resulting from the transformation of the syphilitic morbid process into the tertiary stage. To these new manifestations belong the appearance of large nodules in the skin and other organs, which sooner or later undergo ulceration, the so-called “syphilitic gummata”; their ulcerative destruction may entail the greatest disfigurement or danger to life—for example, perforation of the hard palate; sinking of the bridge of the nose (the syphilitic “saddle-nose”); ulcerative destruction of large portions of the bones of the skull, of the intestine, of the liver, the lungs, the testicles, the bloodvessels (especially dangerous are gummous diseases of the bloodvessels of the brain), the brain, and the spinal cord. Apoplectic strokes occurring in comparatively young persons and nervous paralysis of the most various kinds, as well as sudden deafness and blindness, are in most cases referable to syphilitic disease. Many chronic diseases of the liver, kidneys, and nervous system, are consequences of previous syphilis; also calcification of the arteries, the very dangerous dilatation of the great bloodvessels, especially of the aorta (aneurism of the aorta), are very often of syphilitic origin.
By the researches of Alfred Fournier and Wilhelm Erb, we know to-day that two severe diseases of the central nervous system—tabes dorsalis or locomotor ataxy, and general paralysis of the insane (paralytic dementia)—are almost always (in about 95 % of the cases) referable to earlier syphilis. Among 5,749 cases of syphilis encountered in his own private practice, Fournier observed no less than 758 cases of brain syphilis, 631 cases of tabes, and 83 cases of softening of the brain. Tabes and general paralysis of the insane are all the more dangerous because they are no longer, properly speaking, “syphilitic” diseases, and therefore they cannot be cured by antisyphilitic treatment; they are severe degenerative changes of the central nervous system, which has been, as it were, prepared for their occurrence by the previous syphilis. These belong to the class of the so-called “parasyphilitic” diseases in which antisyphilitic treatment has little or no good effect.
Even more tragic are the consequences of syphilis to the family, the offspring, and the race. Syphilis in married life, congenital syphilis, and the degeneration of the race by syphilis—these are the tragic manifestations which come under consideration in this connexion.
In his admirable work on “Syphilis and Marriage,” Alfred Fournier, the greatest living authority on syphilis in all its manifestations and relationships, has described the momentous influence exercised by syphilis in conjugal life; and in his recently published work, “Syphilis a Social Danger,” he has dealt also with congenital syphilis and racial degeneration. He found that, on the average, among 100 women suffering from syphilis, 20 had been infected by their husbands, either at the very commencement of married life, or in its later course, or finally through the offspring after conception. Divorce on the ground of syphilitic infection by the husband is at the present day of frequent occurrence.
The transmission of syphilis to the child by inheritance may be effected either by the father or the mother; when both the father and the mother are syphilitic, it occurs with absolute certainty. The various possibilities of transmission, and the contingent immunity of mother or child, as they are expressed in Colles’s law (Baumès’s law), and in Profeta’s law, cannot here be further dealt with. If the mother has herself been infected with syphilis, or if she was previously syphilitic, either the child is not carried until term, abortion or miscarriage ensuing, or, finally, it is born with symptoms of congenital syphilis.[321]
The frequent occurrence of premature births and still-births in any family suggests strong suspicions that they are due to syphilis. The general mortality of the children in a family is regarded by Fournier as an important sign to the physician of congenital syphilis. Syphilitic infection of the father gives rise to a mortality in the children of 28 %; syphilis in the mother causes a mortality in the children of 60 %; when the disease affects both parents, the mortality among the children amounts to 68 %. Absolutely astounding is the mortality of the children of syphilitic prostitutes; it amounts to from 84 to 86 %.
Children born alive, suffering from congenital syphilis, are generally weakly,[322] of deficient body-weight; have often a flaccid, wrinkled skin, covered with typical syphilitic eruptions, and frequently with great purulent vesicles, especially on the palms of the hands and the soles of the feet (“pemphigus syphiliticus”); the internal organs also, the spleen, the liver, and the bones, exhibit morbid changes. Characteristic is the syphilitic affection of the upper air-passages, especially the syphilitic “cold in the head” (syphilitic rhinitis—“snuffles”), of new-born congenitally syphilitic children. Congenital syphilis further gives rise to severe disturbances of development and to phenomena to which Fournier has given the name of “late syphilis” (“syphilis hereditaria tarda”), because they first make their appearance in the later years of life.[323] Permanent debility, arrest of development, stigmata of degeneration, in the form of various malformations—as, for example, notching of the edge of the upper central incisor permanent teeth (a symptom first described by Jonathan Hutchinson), malformations of the nose, the ears, and the palate, dwarfing, deaf-mutism, malformations of the external and internal reproductive organs, rickets,[324] epilepsy, and mental weakness—are the consequences of congenital syphilis. Tarnowsky, Fournier, and Barthélémy have traced the consequences of congenital syphilis into the second and third generation, and so have discovered an important cause of racial degeneration. Syphilis in the grandfather can still exercise its disastrous influence in the grandson, and give rise to the above-mentioned stigmata of degeneration.[325] Indeed, congenital syphilis of the second generation often appears with the same severity as that of the first generation; and, like acquired syphilis, congenital syphilis in women can cause a predisposition to miscarriages and still-births.
According to statistics obtained by Edmond Fournier, relating to 11,000 cases of syphilis (10,000 men, 1,000 women) from the private practice of his father, Alfred Fournier, regarding the age at which infection occurs, it appears that in men it most commonly occurs between the ages of twenty and twenty-six years (the maximum number of infections during the twenty-third year); in women, between the ages of eighteen and twenty-one; 8 % of syphilitic males and 20 % of syphilitic females were infected before the age of twenty years. Syphilis is to a considerable extent at the present day a disease of inexperienced youth. This fact is important in relation to the problem of prevention and the problem of enlightenment.[326]
Of much less importance than syphilis is the purely local soft chancre, or chancroid, which never results in general infection. Chancroid is produced by a specific exciting cause, a chain-forming bacillus (streptobacillus), Bacillus ulceris cancrosi, which is found in the pus secreted by the ulcer. One or two days after infection, a small pustule forms at the site of inoculation, generally on the external genital organs. This pustule soon bursts, and a deeply hollowed ulcer makes its appearance, which usually undergoes rapid increase, and frequently, owing to the infective character of the pus, gives rise to new chancres in the neighbourhood of the original one, so that the soft chancre is commonly multiple. When suitably treated with antiseptic powders and cauterization, chancroid usually heals quickly; there are, however, very dangerous varieties of chancroid—for instance, the serpiginous chancre, which continues to creep irresistibly forward; and the phagedænic or gangrenous chancre, which puts the skill of the physician to the utmost test. A less dangerous but extremely disagreeable complication of chancroid is inflammation of the inguinal glands, most commonly only on one side; this painful “bubo” (painful in contrast with the painless syphilitic bubo) has a well-marked tendency to suppuration. If this occurs, and the pus finds its way to the surface, fistulas and new chancrous ulcers are liable to occur at the place where it opens. By rest in bed, the inunction of iodide ointment, the application of cold compresses, the injection into the bubo of a solution of nitrate of silver, and the internal use of iodide of potassium, this unfortunate course may be prevented.
A remarkable change of views has, in the course of the last thirty years, taken place in respect of the nature and importance of gonorrhœa.[327] Whereas formerly this was regarded as a comparatively harmless disease, we know to-day that gonorrhœa in the male, and still more in the female, gives rise to tedious dangers and painful morbid phenomena, and is the source of unspeakable sorrows, and of the miserable ill-health of numerous women, and that it is the chief cause of sterility in both sexes.
Gonorrhœa is principally a disease of the mucous membrane, and is, in this way, distinguished from syphilis, which is a general disorder, diffusing itself by way of the bloodvessels. In rare cases, indeed, gonorrhœa can exhibit general morbid manifestations, the so-called gonorrhœal rheumatism, gonorrhœal affections of the spinal cord and of the heart, and gonorrhœal nervous troubles, all of which are so rare, that for practical purposes they can be left out of consideration.
The typical seat of gonorrhœa is the mucous membrane of the urinary and the genital organs of the male and the female; in the male affecting chiefly the urinary organs, and in the female affecting chiefly the genital organs. The cause of genuine gonorrhœa is always infection, the transmission from one human being to another of the purulent inflammation produced by the gonococcus discovered by Neisser in 1879. Simple urethral inflammations with a purulent discharge also occur in which no gonococci are found. These arise also from infection, but their actual exciting cause has not yet been discovered. Not less obscure is the relationship of many of the irritants giving rise to simple urethral catarrh—for example, that which is active during menstruation—to the supposed exciting cause. In any case, these simple catarrhs have a very mild course, and undergo a cure after a few days or weeks, spontaneously or as a result of treatment with mild injections.
Quite otherwise is it with genuine gonorrhœa. In the male it begins from two to six days after the infective intercourse, with a burning sensation on passing water, itching at the urethral orifice, which very easily becomes reddened, and this is soon followed by the discharge, either spontaneously or as a result of pressure on the urethra, of a thick fluid, at first mucous, later purulent, and then of a yellow or a greenish colour. Inflammation, discharge, and pain, the latter especially in association with urination, increase during the subsequent weeks; in addition, in a good many cases there are slight fever, lassitude, and mental depression, and the patient is tormented, especially during the night, by violent, painful erections. In exceptional cases there are hæmorrhages from the urethra (the so-called “Russian clap”). In some cases the disease terminates favourably; this is especially observed after the first attack of gonorrhœa. As early as the third week the above symptoms become less severe, and in the fourth or sixth week after infection the whole morbid process may come to an end, the discharge ceases, the urine becomes clear once more, and, in fact, definite cure of the gonorrhœa ensues.
But the number of those who are so fortunate is comparatively small. In the majority of cases, there are other morbid phenomena and complications; the gonorrhœa becomes “subacute,” and later “chronic.” Ricord wrote many years ago: “When anyone has once acquired gonorrhœa, God only knows when he will get well again!” Happily, this pessimism is no longer fully justified at the present day; but it is a fact that in the majority of cases even to-day gonorrhœa is a very obstinate, wearisome illness, a long-continued burden, not only for the patient, but also for the doctor. The gonococci proliferate in the deeper layers of the mucous membrane, and pass upwards into the posterior part of the urethra, this latter migration being manifested especially by frequent and painful strangury; further, the bladder, the prostate gland, and the epididymis may be attacked. Bilateral epididymitis has often serious consequences as regards the procreative capacity. In about 50 % of the cases incapacity for fertilization (impotentia generandi) has resulted.
If the gonorrhœa becomes chronic, thickenings occur in isolated portions of the urethral mucous membrane; the urine remains turbid for a long time; the discharge, it is true, becomes scantier, but shows itself with the most annoying persistency every morning as soon as the patient leaves his bed, in the form of the so-called “bon jour” drops in the meatus; there are also troubles connected with the prostate (painful sensations, especially during defæcation), and symptoms of stricture of the urethra may occur. Very often, also, relative impotence and severe sexual neurasthenia are observed, as consequences of chronic gonorrhœa. Worst of all is the long duration of the infectivity. There is always the danger that somewhere or other some gonococci may remain hidden, and, given an opportunity, may start the process all over again, or may transmit the infection to another person. Zweifel reports a case in which a man actually infected a woman thirteen years after he had first acquired gonorrhœa!
The infection of a woman with gonorrhœa, as we know to-day, is a disaster. It is the immortal service of the German-American physician Noeggerath that, in the year 1872, he proved that the majority of the stubborn “diseases of women” were nothing more than the consequences of gonorrhœal infection. Gonorrhœa selects by preference the internal reproductive organs of woman; upon the extensive mucous membranes of these organs the gonococci find the most favourable conditions for their persistent life; they find a thousand out-of-the-way comers and hiding-places, where they can elude the therapeutic activity of the physician.
“They grow luxuriantly, like a weed which it has not been possible to uproot, over the entire surface of the genital mucous membrane, attacking with the same vigour the mucous membrane of the uterus and that of the Fallopian tubes. In women, as in men, they induce ulceration, they cause adhesions, and they give rise to sterility. But in the case of women, something further must be added—that, namely, this disease has upon them a miserably depressing effect, and that, in contradistinction from men, they are likely to suffer for many years from intense pains. Whenever they execute certain bodily movements, it may be during ten years in succession, they experience pains, often horribly severe, and in most cases they are condemned to a life of deprivation and misery—not usually for any fault of their own, since most women are infected by their husbands” (Zweifel).
Gonorrhœa in women, attacking successively the vagina, the uterus, the Fallopian tubes, the ovaries, and the peritoneum, is a true martyrdom, a hell upon earth. Sick in body and in mind, these unhappy women drag out a miserable existence; and to them so often the last consolation, that of motherhood, is denied, for gonorrhœa is the most frequent cause of sterility in woman.
Patients infected with gonorrhœa further run the danger of blindness, by transference of the gonorrhœal virus to the eye. This is one of the most distressing of the possible results of the disease. New-born children whose mothers are infected with gonorrhœa are during birth exposed to the same danger of eye infection, as they pass down the genital passage. In earlier days a very large proportion of the blind were persons who had lost their sight in this way very shortly after birth. Since Crédé advocated the admirable method of introducing nitrate of silver solution into the conjunctival sacs of new-born children, gonorrhœal inflammation of the eye has become one of the greatest rarities.
APPENDIX
VENEREAL DISEASES IN THE HOMOSEXUAL
It is an old belief, shared by the homosexual themselves, that venereal infections are extremely rare among them. If male homosexual persons had sexual intercourse only with one another, this assumption would be in some degree plausible. For the principal focus of venereal infection is feminine prostitution, by which venereal diseases are transmitted to heterosexual men. But since these homosexual men often undertake sexual acts with heterosexual men—apart from occasional sexual intercourse with women—a priori there is a possibility of infection in their case, and such infection is, in fact, observed. Above all, many male prostitutes also indulge in intercourse with women, and thus diffuse venereal troubles among homosexual men.
It is obvious that syphilis can be diffused among the homosexual as easily as among the heterosexual, for syphilis is transmitted by many varieties of contact—by kisses, other caresses, etc. But how is it as regards gonorrhœa?
In the case of heterosexual men and women gonorrhœa is almost exclusively transmitted by the sexual act, by the introduction of the male penis into the female vagina. The analogous act between men—that is to say, pæderasty, immissio penis in anum—is unquestionably far rarer than the ordinary sexual act between men and women; it is commonly replaced by mutual onanism, by kisses and other caresses, and quite frequently by coitus in os. This last is much commoner than genuine pædication. Of gonorrhœa of the rectum produced by pædication when the active man is suffering from gonorrhœa, we very rarely hear. But is there, in the case of homosexual men, any possibility of gonorrhœal infection due to coitus in os?
There can be no doubt that typical gonorrhœa of the mouth occurs. The observations of Kuttler, Atkinson, Rosinski, Dohrn, and Kast, have proved it.[328] Horand and Cazenave have even observed gonorrhœal infection of the urethra as a result of oral coitus![329] A homosexual patient told me that some years before, after coitus in os with a man, he had for several weeks had a discharge from the urethra, which spontaneously ceased, and therefore cannot have been genuine gonorrhœa, but only urethritis resulting from infection by contagious angina. In the case in question, the urethral catarrh was certainly due to the coitus in os, since any other sources of infection could be excluded.
On the other hand, in a second case an apparently gonorrhœal infection of the oral cavity was transmitted from the urethra.
A homosexual man, forty-five years of age, one day allowed a heterosexual man to perform coitus in os on him. Some days afterwards he experienced difficulty in swallowing, was feverish, and saw in the looking-glass that the uvula was swollen. A specialist for throat troubles diagnosed merely a catarrhal infection. The illness became worse, and a second throat specialist detected the presence of a purulent angina of both tonsils, ordered painting with argentamin, also vapour baths, and an astringent gargle, whereupon the affection gradually subsided. Six weeks later the patient had swelling and pain in the joints of the right knee and foot; under cold compresses these swellings subsided after a fortnight. Of the whole trouble nothing now remains.
This description, on the part of a patient who is thoroughly trustworthy, aroused strong suspicion of a gonorrhœal angina, with a consecutive gonorrhœal arthritis. Unfortunately, the purulent discharge from the tonsils was not examined for gonococci by either of the physicians in attendance. The case remains, anyhow, very remarkable.
In the case of homosexual women, it is obvious that syphilis, and also gonorrhœa, can be transmitted, the latter by mutual friction of the genital organs. I do not know what actually occurs in practice.
[312] Cf. Iwan Bloch, “Schopenhauer’s Illness in the Year 1823. A Contribution to Pathography based upon an Unpublished Document.” Published in Medizinische Klinik, 1906, Nos. 25 and 26. (This gives an account of all Schopenhauer’s utterances regarding syphilis.)
[313] At a meeting of the Société d’Anthropologie de Paris, held on April 19, 1906, I read a paper on “La Syphilis Prétendue Préhistorique,” in which I discussed this question. The important question of ancient bones is further considered in the second volume of my work on “The Origin of Syphilis,” pp. 317-364 (now in the press).
[314] The results of this study I have briefly epitomized in an address given before the Social Science Congress in Berlin, entitled “The First Appearance of Syphilis in Europe” (Jena, 1904).
[315] Regarding the gradual acquirement (by means of natural selection) of immunity to epidemic diseases, the works of Archdall Reid may be most profitably consulted (“The Present Evolution of Man,” London, 1896; “The Principles of Heredity,” London, 1905). Dr. Reid’s views on the part played in human history by the transference of diseases from immunized to non-immunized races are of especial interest. Unfortunately, as regards syphilis, he accepts Hirsch’s erroneous statements relative to the antiquity of that disease, and its origin in the eastern hemisphere (see also [p. 384], note [346]).—Translator.
[316] Cf. A. Neisser, “The Experimental Investigation of Syphilis as it Stands at the Present Day” (Berlin, 1906).
[317] Cf. Erich Hoffmann, “The Etiology of Syphilis” (Berlin, 1906); Hans Hübner, “Recent Researches into the Nature of Syphilis,” published in the Journal for the Suppression of Venereal Diseases, 1906, vol. v., pp. 468-481.
[318] I must not omit allusion to some recent admirable works on venereal diseases: A. Blaschko, “Venereal Diseases”—a popular exposition—(Berlin, 1904); Paul Zweifel, “Venereal Diseases and their Importance to Health” (Leipzig, 1902); Alfred Fournier, “Syphilis a Social Danger”; Karl Ries, “Blameless Sexual Infection” (Stuttgart, 1904); O. Burwinkel, “Venereal Diseases” (Leipzig, 1905); Waldvogel, “The Dangers of Venereal Diseases and their Prevention” (Stuttgart, 1905). In view of the large number of popular works on venereal diseases, those without professional knowledge should confine themselves to the best names, because in this province trashy literature is extraordinarily abundant, and by the false and erroneous views it diffuses, it does much more harm than good. The writings mentioned in this note I am able to recommend as thoroughly scientific and trustworthy.
[319] Galewsky, “The Transmission of Venereal Diseases in the Suckling of Children,” published in the Journal for the Suppression of Venereal Diseases, 1906, vol. v., pp. 365-371.
[320] It is true that such a hardening may also occur in other non-syphilitic affections of the genital organs—for example, when they are peculiarly situated or as a result of cauterization. Only the physician can determine whether in such a case syphilitic infection has actually occurred.
[321, 322] According to English experience, the congenitally syphilitic child rarely exhibits any sign of syphilis when born. Thus, Hutchinson writes (“Syphilis,” p. 73): “At the time of birth, the congenitally syphilitic infant almost invariably has a clear skin, and appears to be in perfect health.” According to Osler also (“Medicine,” sixth edition, p. 269): “The child may be born healthy-looking or with well-marked evidence of the disease. In the majority of instances the former is the case, and within the first month or two the signs of the disease appear.”—Translator.
[323] Cf. the recently published admirable work of Edmond Fournier, “Recherches et Diagnostic de l’Hérédo-Syphilis Tardive” (Paris, 1907).
[324] Parrot regarded rickets as a manifestation of congenital syphilis, but this view has never found acceptance in England. Hutchinson remarks (“Syphilis,” p. 408): “The typical forms of rickets are constantly met with in conditions which do not lend the slightest support to the suggestion of syphilis.” As Cheadle remarks: “Syphilis modifies rickets; it does not create it.”—Translator.
[325] This view must be accepted with reserve. See, for instance, Osler’s “Medicine,” sixth edition, p. 271: “Is syphilis transmitted to the third generation? The general opinion is opposed to this view. Occasionally, however, cases of pronounced congenital syphilis are met with in the children of parents who are perfectly healthy, and who have not, so far as is known, had syphilis, and yet, as remarked by Coutts, who reported such a group of cases, they do not bear careful scrutiny. The existing difference of opinion is well illustrated in the account by G. Boeck (Berl. Klin. Wochenschrift, September 12, 1904) of four instances of hereditary lues in the second generation, while in the same journal Jonathan Hutchinson expresses his belief that syphilis is not transmitted to the third generation.”—Translator.
[326] As more important scientific works on syphilis I must mention that of Isidor Neumann (Vienna, 1899, second edition), containing the entire bibliography of the subject; that of Joseph Lang (Wiesbaden, 1896, second edition); but, above all, the epoch-making work of Alfred Fournier, “Traité de Syphilis” (Paris, 1898)—English translation, Fournier, “The Treatment and Prophylaxis of Syphilis” (Rebman Ltd., London, 1906).
[327] The most important scientific work on gonorrhœa is that of Ernest Finger, “Blennorrhœa of the Sexual Organs,” fifth edition (Leipzig and Vienna, 1901).
[328] Cf. M. von Zeissl, “Diagnosis and Treatment of Venereal Diseases,” third edition, pp. 171, 172 (Berlin and Vienna, 1905).
[329] Op cit., p. 172.
CHAPTER XV
PROPHYLAXIS, TREATMENT, AND SUPPRESSION (BEKÄMPFUNG) OF VENEREAL DISEASES
“The friend of humanity may with some confidence anticipate a gradual diminution in the prevalence of venereal diseases, and may hope for their complete extinction in a not too distant future. All that is requisite for the attainment of this end is that those engaged in the study and practice of general hygiene, and those concerned in the safeguarding of public morality, should not weary in their efforts; and that scientific research should pursue its aims firmly and clearly, uninfluenced by the tyranny of custom, and independent of prejudice.”—K. F. Marx.