During recent years we have witnessed a remarkable attempt—more popular and more international in character than any before—to deal with that ancient sexual evil which has for some time been picturesquely described as the White Slave Traffic. Less than forty years ago Professor Sheldon Amos wrote that this subject can scarcely be touched upon by journalists, and "can never form a topic of common conversation." Nowadays Churches, societies, journalists, legislators have all joined the ranks of the agitators. Not only has there been no voice on the opposite side, which was scarcely to be expected—for there has never been any anxiety to cry aloud the defence of "White Slavery" from the house-tops—but there has been a new and noteworthy conquest over indifference and over that sacred silence which was supposed to encompass all sexual topics with suitable darkness. The banishment of that silence in the cause of social hygiene is, indeed, not the least significant feature of this agitation.
It is inevitable, however, that these periodical fits of virtuous indignation by which Society is overtaken should speedily be spent. The victim of the moral fever finds himself exhausted by the struggle, scarcely able to cope with the complications of the disease, and, at the best, only too anxious to forget what he has passed through. He has an uneasy feeling that in the course of his delirium he has said and done many foolish things which it would now be unpleasant to recall too precisely.
There is no use in attempting to disguise the fact that this is what happened in the White Slave Traffic agitation. It became clear that we had been largely misled in regard to the evils to be combated, and that we were seduced into sanctioning various remedies for these evils which in cold blood it is impossible to approve of, even if we could believe them to be effective.
It is not even clear that all those who have talked about the "White Slave Traffic" have been quite sure what they meant by the term. Some people, indeed, have seemed to think that it meant prostitution in general. That is, of course, an absurd misapprehension. We are concerned with a trade which flourishes on prostitution, but that trade is not itself the trade or (as some prefer to call it) the profession of prostitutes. Indeed, the prostitute, under ordinary conditions and unharassed by persecution, is in many respects anything but a slave. She is much less a slave than the ordinary married woman. She is not fettered in humble dependence on the will of a husband from whom it is the most difficult thing in the world to escape; she is bound to no man and free to make her own terms in life; while if she should have a child, that child is absolutely her own, and she is not liable to have it torn from her arms by the hands of the law. Apart from arbitrary and accidental circumstances, due to the condition of social feeling, the prostitute enjoys a position of independence which the married woman is still struggling to obtain.
The White Slave Traffic, therefore, is not prostitution; it is thecommercialised exploitation of prostitutes. The independent prostitute, living alone, scarcely lends herself to the White Slave trader. It is on houses of prostitution, where the less independent and usually weaker-minded prostitutes are segregated, that the traffic is based. Such houses cannot even exist without such traffic. There is little inducement for a girl to enter such a house, in full knowledge of what it involves, on her own initiative. The proprietors of such houses must therefore give orders for the "goods" they desire, and it is the business of procurers, by persuasion, misrepresentation, deceit, intoxication, to supply them. "The White Slave Traffic," as Kneeland states, "is thus not only a hideous reality, but a reality almost wholly dependent on the existence of houses of prostitution," and as the authors ofThe Social Evilstate, it is "the most shameful species of business enterprise in modern times."[1]
In this intimate dependence of the White Slave Traffic on houses of prostitution, there lies, it may be pointed out, a hope for the future. We are concerned, for the most part, with the more coarse-grained part of the masculine population and with the more ignorant, degraded, and weak-minded part of the army of prostitutes. Although much has been said of the enormous extension of the White Slave Traffic during recent years, it is important to remember that that extension is chiefly marked in connection with the great new centres of population in the younger countries. It is fostered by the conditions prevailing in crude, youthful, prosperous, but incompletely blended, communities, which have too swiftly attained luxury, but have not yet attained the more humane and refined developments of civilisation, and among whom women are often scarce.[2] Although there are not yet any very clear signs of the decay of prostitution in civilisation, there can hardly be a doubt that civilisation is unfavourable to houses of prostitution. They offer no inducements to the more intelligent and independent prostitutes, and their inmates usually present little attraction to any men save those whose demands are of the humblest character. There is, therefore, a tendency to the natural and spontaneous decay of organised houses of prostitution under modern civilised conditions; the prostitute and her clients alike shun such houses. Along this line we may foresee the disappearance of the White Slave Traffic, apart altogether from any social or legal attempts at its direct suppression.[3]
It is sometimes said that the relation of the isolated prostitute to hersouteneurconstitutes a form of "white slavery." Undoubtedly that may sometimes be the case. We are here in a confused field where the facts are complicated by a number of considerations, and where circumstances may very widely differ, for the "fancy boy"—selected from affection by the prostitute herself—may easily become thesouteneur, or "cadet" as he is termed in New York, who seduces and trains to prostitution a large number of girls. The prostitute is so often a little weak in character and a little defective in intelligence; she is so often regarded as a legitimate prey by the world in which she moves, and a legitimate object of contempt and oppression by the social world above her and its legal officers, that she easily becomes abjectly dependent on the man who in some degree protects her from this extortion, contempt, and oppression, even though he sometimes trains her to his own ends and exploits her professional activities for his own advantage. These circumstances so often occur that some investigators consider that they represent the general rule. No doubt they are the most conspicuous cases. But they can scarcely be regarded as representing the normal relations of the prostitute to the man she is attracted to. She is earning her own living, and if she possesses a little modicum of character and intelligence, she knows that she can choose her own lover and dismiss him when she so pleases. He may beat her occasionally, but all over the world this is not always displeasing to the primitively feminine woman. "It is indeed true," as Kneeland remarks, "that many prostitutes do not believe their lovers care for them unless they 'beat them up' occasionally." The woman in this position is not more of a "white slave" than many wives, and some husbands, who submit to the whims and tyrannies of their conjugal partners, with, indeed, the additional hardship and misfortune that they are legally bound to them. And thesouteneur, although from the respectable point of view he has put himself into a low-down moral position, is, after all, not so very unlike those parasitic wives who, on a higher social level, live lazily on their husbands' professional earnings, and sometimes give much less than thesouteneurin return.
When, however, we put aside the complicated question of the prostitute's relationship to the man who is her lover, protector, and "bully," we have to recognise that there really is a "White Slave Traffic," carried on in a ruthlessly business-like manner and on an international scale, with watchful agents, men and women, ever ready to detect and lure the victims. But even this too amply demonstrated fact was not found sufficiently highly spiced by the White Slave Traffic agitators. It was necessary to excite the public mind by sensational incidents. Everyone was told stories, as of incidents that had lately occurred in the next street, of innocent, refined, and well-bred girls who were snatched away by infamous brigands beneath the eyes of their friends, to be immured in dungeons of vice and never more heard of. Such incidents, if they ever occurred, would be too bizarre to be justifiably taken into account in great social movements. But it is even doubtful whether they ever occur. The White Slave traders are not heroes of romance, even of infamous romance; less so, indeed, than many more ordinary criminals; they are engaged in a very definite and very profitable business. They have no need to run serious risks. The world is full of girls who are over-worked, ill-paid, ignorant, weak, vain, greedy, lazy, or even only afflicted with a little innocent love of adventure, and it is among these that White Slave traders may easily find what their business demands, while experience enables them to detect the most likely subjects.
Careful inquiry, even among those who have made it their special business to collect all the evidence that can be brought together to prove the infamous character of the White Slave Traffic, has apparently failed to furnish any reliable evidence of these sensational stories. It is easy to find prostitutes who are often dissatisfied with the life (in what occupation is it not easy?), but it is not easy to find prostitutes who cannot escape from that life when they sufficiently wish to do so, and are willing to face the difficulty of finding some other occupation. The very fact that the whole object of their exploitation is to bring them in contact with men belonging to the outside world is itself a guarantee that they are kept in touch with that world. Mrs. Billington-Grieg, a well-known pioneer in social movements, has carefully investigated the alleged cases of forcible abduction which were so freely talked about when the White Slave Bill was passed into law in England, but even the Vigilance Societies actively engaged in advocating the bill could not enable her to discover a single case in which a girl had been entrapped against her will.[4] No other result could reasonably have been expected. When so many girls are willing, and even eager, to be persuaded, there is little need for the risky adventure of capturing the unwilling. The uneasy realisation of these facts cannot fail to leave many honest Vice-Crusaders with unpleasant memories of their past.
It is not only in regard to alleged facts, but also in regard to proposed remedies, that the White Slave Agitation may properly be criticised. In England it distinguished itself by the ferocity with which the lash was advocated, and finally legalised. Benevolent bishops joined with genteel old maids in calling loudly for whips, and even in desiring to lay them personally on the backs of the offenders, notwithstanding that these Crusaders were nominally Christians, the followers of a Master who conspicuously reserved His indignation, not for sinners and law-breakers, but for self-satisfied saints and scrupulous law-keepers—just the same kind of excellent people, in fact, who are most prone to become Vice-Crusaders. Here again, it is probable, many unpleasant memories have been stored up.
It is well recognised by criminologists that the lash is both a barbarous and an ineffective method of punishment. "The history of flagellation," as Collas states in his great work on this subject, "is the history of a moral bankruptcy."[5] The survival of barbarous punishments from barbarous days, when ferocious punishments were a matter of course and the death penalty was inflicted for horse-stealing without in the least diminishing that offence, may be intelligible. But the re-enactment of such measures in so-called civilised days is an everlasting discredit to those who advocate it, and a disgrace to the community which permits it. This was pointed out at the time by a large body of social reformers, and will no doubt be realised at leisure by the persons concerned in the agitation.
Apart altogether from its barbarity, the lash is peculiarly unsuited for use in the White Slave trade, because it will never descend on the back of the real trader. The whip has no terrors for those engaged in illegitimate financial transactions, for in such transactions the principal can always afford to arrange that it shall fall on a subordinate who finds it worth while to run the risks. This method has long been practised by those who exploit prostitution for profit. To increase the risks merely means that the subordinate must be more heavily paid. That means that the whole business must be carried on more actively to cover the increased risks and expenses. It is a very ancient fact that moral legislation increases the evil it is designed to combat.[6]
It is necessary to point out some of the unhappy features of this agitation, not in order to minimise the evils it was directed against, nor to insinuate that they cannot be lessened, but as a warning against the reaction which follows such ill-considered efforts. The fiery zealot in a fury of blind rage strikes wildly at the evil he has just discovered, and then flings down his weapon, glad to forget all about his momentary rage and the errors it led him into. It is not so that ancient evils are destroyed, evils, it must be remembered, that derive their vitality in part from human nature and in part from the structure of our society. By ensuring that our workers, and especially our women workers, are decently paid, so that they can live comfortably on their wages, we shall not indeed have abolished prostitution, which is more than an economic phenomenon,[7] but we shall more effectually check the White Slave trader than by the most draconic legislation the most imaginative Vice-Crusader ever devised. And when we ensure that these same workers have ample time and opportunity for free and joyous recreation, we shall have done more to kill the fascination of the White Slave Traffic than by endless police regulations for the moral supervision of the young.
No doubt the element of human nature in the manifestations we are concerned with will still be at work, an obscure instinct often acting differently in each sex, but tending to drive both into the same risks. Here we need even more fundamental social changes. It is sheer foolishness to suppose that when we raise our little dams in the path of a great stream of human impulse that stream will forthwith flow calmly back to its source. We must make our new channels concurrently with our dams. If we wish to influence prostitution we must re-make our marriage laws and modify our whole conception of the sexual relationships. In the meanwhile, we can at least begin to-day a task of education which must slowly though surely undermine the White Slave trader's stronghold. Such an education needs to be not merely instruction in the facts of sex and wise guidance concerning all the dangers and risks of the sexual life; it must also involve a training of the will, a development of the sense of responsibility, such as can never be secured by shutting our young people up in a hot-house, sheltered from every fortifying breath of the outside world. Certainly there are many among us—and precisely the most hopeless persons from our present point of view—who can never grow into really responsible persons.[8] Neither should they ever have been born. It is our business to see that they are not born; and that, if they are, they are at least placed under due social guardianship, so that we may not be tempted to make laws for society in general which are only needed by this feeble and infirm folk. Thus it is that when we seek to deal with the White Slave Trader and his victims and his patrons we have to realise that they are all very much, as we have made them, moulded by their parents before birth, nourished on their mothers' knees. The task of making them over again next time, and making them better, is a revolutionary task, but it begins at home, and there is no home in which some part of the task cannot be carried out.
It is possible that at some period in the world's history, not only will the White Slave Traffic disappear, but even prostitution itself, and it is for us to work towards that day. But we may be quite sure that the social state which sees the last of the "social evil" will be a social state very unlike ours.
[1] The nature of prostitution and of the White Slave Traffic and their relation to each other may clearly be studied in such valuable first-hand investigations of the subject asThe Social Evil: With Special Reference to Conditions Existing in the City of New York, 2nd edition, edited by E.R.A. Seligman, Putnam's, 1912;Commercialised Prostitution in New York City, by G.J. Kneeland, New York Century Co., 1913;Prostitution in Europe, by Abraham Flexner, New York Century Co., 1914;The Social Evil in Chicago, by the Vice-Commission of Chicago, 1911. As regards prostitution in England and its causes I should like to call attention to an admirable little book,Downward Paths, published by Bell & Sons, 1916. The literature of the subject is, however, extensive, and a useful bibliography will be found in the first-named volume.
[2] This is especially true of many regions in America, both North and South, where a hideous mixture of disparate nationalities furnishes conditions peculiarly favourable to the "White Slave Traffic," when prosperity increases. See, for instance, the well-informed and temperately written book by Miss Jane Addams,A New Conscience and an Ancient Evil, 1912.
[3] See Havelock Ellis:Sex in Relation to Society (Studies in the Psychology of Sex), Vol. VI., Ch. VII.
[4] "The White Slave Traffic,"English Review, June, 1913. It is just just the same in America. Mr. Brand-Whitlock, when Mayor of Toledo, thoroughly investigated a sensational story of this kind brought to him in great detail by a social worker and found that it possessed not the slightest basis of truth. "It was," he remarks in an able paper on "The White Slave" (Forum, Feb., 1914), "simply another variant of the story that had gone the rounds of the continents, a story which had been somehow psychologically timed to meet the hysteria which the pulpit, the Press, and the legislature had displayed."
[5] G.F. Collas,Geschichte des Flagellantismus, 1913, Vol. I., p. 16.
[6] I have brought together some of the evidence on this point in the chapter on "Immorality and the Law" in my book,The Task of Social Hygiene.
[7] The idea is cherished by many, especially among socialists, that prostitution is mainly an economic question, and that to raise wages is to dry up the stream of prostitution. That is certainly a fallacy, unsupported by careful investigators, though all are agreed that the economic condition of the wage-earner is one factor in the problem. Thus Commissioner Adelaide Cox, at the head of the Women's Social Wing of the Salvation Army, speaking from a very long and extensive acquaintance with prostitutes, while not denying that women are often "wickedly underpaid," finds that the cause of prostitution is "essentially a moral one, and cannot be successfully fought by other than moral weapons."—(Westminster Gazette, Dec. 2nd, 1912). In a yet wider sense, it may be said that the question of the causes of prostitution is essentially social.
[8] This is a very important clue indeed in dealing with the problem of prostitution. "It is the weak-minded, unintelligent girl," Goddard states in his valuable work onFeeblemindedness, "who makes the White Slave Traffic possible." Dr. Hickson found that over 85 per cent. of the women brought before the Morals Court in Chicago were distinctly feeble-minded, and Dr. Olga Bridgeman states that among the girls committed for sexual delinquency to the Training School of Geneva, Illinois, 97 per cent. were feeble-minded by the Binet tests, and to be regarded as "helpless victims." (Walter Clarke,Social Hygiene, June, 1915, andJournal of Mental Science, Jan., 1916, p. 222.) There are fallacies in these figures, but it would appear that about half of the prostitutes in institutions are to be regarded as mentally defective.
The final Report of the Royal Commission on Venereal Diseases has brought to an end an important and laborious investigation at what many may regard as an unfavourable moment. Perhaps, however, the moment is not so unfavourable as it seems. There is no period when venereal diseases flourish so exuberantly as in war time, and we shall have a sad harvest to gather here when the War is over.[1] Moreover, the War is teaching us to face the real facts of life more frankly and more courageously than ever before, and there is no field, scarcely even a battlefield, where a training in frankness and courage is so necessary as in this of Venereal Disease. It is difficult even to say that there is any larger field, for it has been found possible to doubt whether the great War of to-day, when all is summed up, will have produced more death, disease, and misery than is produced in the ordinary course of events, during a single generation, by venereal disease.
There are, as every man and woman ought to know, two main and quite distinct diseases (any other being unimportant) poetically termed "Venereal" because chiefly, though not by any means only, propagated in the intercourse over which the Roman goddess Venus once presided. These two diseases are syphilis and gonorrhoea. Both these diseases are very serious, often terrible, in their effects on the individual attacked, and both liable to be poisonous to the race. There has long been a popular notion that, while syphilis is indeed an awful disease, gonorrhoea may be accepted with a light heart. That, we now know, is a grave mistake. Gonorrhoea may seem trivial at the outset, but its results, especially for a woman and her children (when it allows her to have any), are anything but trivial; while its greater frequency, and the indifference with which it is regarded, still further increase its dangers.
About the serious nature of syphilis there is no doubt. It is a comparatively modern disease, not clearly known in Europe before the discovery of America at the end of the fifteenth century, and by some authorities[2] to-day supposed to have been imported from America. But it soon ravaged the whole of our world, and has continued to do so ever since. During recent years it has perhaps shown a slight tendency to decrease, though nothing to what could be achieved by systematic methods; but its evils are still sufficiently alarming. Exactly how common it is cannot be ascertained with certainty. At least 10 per cent., probably more, of the population in our large cities have been infected by syphilis, some before birth. In 1912 for an average strength of 120,000 men in the English Navy, nearly 300,000 days were lost as a result of venereal disease, while among 100,000 soldiers in the Home Army for the same year, an average of nearly 600 men were constantly sick from the same cause. We may estimate from this small example how vast must be the total loss of working power due to venereal disease. Moreover, in Sir William Osler's words, "of the killing diseases syphilis comes third or fourth." Its prevalence varies in different regions and different social classes. The mortality rate from syphilis for males above fifteen is highest for unskilled labour, then for the group intermediate between unskilled and skilled labour, then for the upper and middle class, followed by the group intermediate between this class and skilled labour, while skilled labour, textile workers, and miners follow, and agricultural labourers come out most favourably of all. These differences do not represent any ascending grade in virtue or sexual abstinence, but are dependent upon differences in social condition; thus syphilis is comparatively rare among agricultural labourers because they associate only with women they know and are not exposed to the temptation of strange women, while it is high among the upper class because they are shut out from sexual intimacy with women of their own class and so resort to prostitutes. On the whole, however, it will be seen, the poison of syphilis is fairly diffused among all classes. This poison may work through many years or even the whole of life, and its early manifestations are the least important. It may begin before birth: thus, one recent investigation shows that in 150 syphilitic families there were only 390 seemingly healthy children to 401 infant deaths, stillbirths, and miscarriages (as against 172 in 180 healthy families), the great majority of these failures being infant deaths and thus representing a large amount of wasted energy and expense.[3] Syphilis is, again, the most serious single cause of the most severe forms of brain disease and insanity, this often coming on many years after the infection, and when the early symptoms were but slight. Blindness and deafness from the beginning of life are in a large proportion of cases due to syphilis. There is, indeed, no organ of the body which is not liable to break down, often with fatal results, through syphilis, so that it has been well said that a doctor who knows syphilis thoroughly is familiar with every branch of his profession.
Gonorrhoea is a still commoner disease than syphilis; how common it is very difficult to say. It is also an older disease, for the ancient Egyptians knew it, and the Biblical King Esarhaddon of Assyria, as the records of his court show, once caught it. It seems to some people no more serious than a common cold, yet it is able to inflict much prolonged misery on its victims, while on the race its influence in the long run is even more deadly than that of syphilis, for gonorrhoea is the chief cause of sterility in women, that is to say, in from 30 to 50 per cent. of such cases, while of cases of sterility in men (which form a quarter to a third of the whole) gonorrhoea is the cause in from 70 to 90 per cent. The inflammation of the eyes of the new-born leading to blindness is also in 70 per cent. cases due to gonorrhoea in the mother, and this occurs in over six per 1,000 births.
Three years ago a Royal Commission was appointed to investigate the best methods of controlling venereal disease, as small-pox, typhus, and to a large extent typhoid, have already been controlled. The Commission was well composed, not merely of officials and doctors, but of experienced men and women in various fields, and the final Report is signed by all the members, any difference of opinion being confined to minor points (which it is unnecessary to touch on here) and to two members only. The recommendations are conceived in the most practical and broad-minded spirit. They are neither faddy nor goody-goody. Some indeed may wish that they had gone further. The Commission leave over for later consideration the question of notifying venereal disease as other infectious diseases are notified, and there is no recommendation for the provision of preventive methods against infection for use before intercourse, such as are officially favoured in Germany. But at both these points the Commissioners have been wise, for they are points to which sections of public opinion are still strongly hostile.[4] As they stand, the recommendations should carry conviction to all serious and reasonable persons. Already, indeed, the Government, without opposition, has expressed its willingness to undertake the financial burden which the Commission would impose on it.
The main Recommendations made by the Commission, if we put aside the suggestions for obtaining a more exact statistical knowledge, may be placed under the heads of Treatment and Prevention. As regards the first, it is insisted that measures should be taken to render the best modern treatment, which should be free to all, readily available for the whole community, in such a way that those affected will have no hesitation in taking advantage of the facilities thus offered. The means of treatment should be organised by County Councils and Boroughs, under the Local Government Board, which should have power to make independent arrangements when the local authorities fail in their duties. Institutional treatment should be provided at all general hospitals, special arrangements made for the treatment of out-patients in the evenings, and no objection offered to patients seeking treatment outside their own neighbourhoods. The expenditure should be assisted by grants from Imperial Funds to the extent of 75 per cent. It may be added that, however heavy such expenditure may be, an economy can scarcely fail to be effected. The financial cost of venereal disease to-day is so vast as to be beyond calculation. It enters into every field of life. It is enough merely to consider the significant little fact that the cost of educating a deaf child is ten times as great as that of educating an ordinary child.
Under the head of Prevention we may place such a suggestion as that the existence of infective venereal disease should constitute legal incapacity for marriage, even when unknown, and be a sufficient cause for annulling the marriage at the discretion of the court. But by far the chief importance under this head is assigned by the Commission to education and instruction. We see here the vindication of those who for years have been teaching that the first essential in dealing with venereal disease is popular enlightenment. There must be more careful instruction—"through all types and grades of education"—on the sexual relations in regard to conduct, while further instruction should be provided in evening continuation schools, as well as factories and works, with the aid of properly constituted voluntary associations.
These are sound and practical recommendations which, as the Government has realised, can be put in action at once. A few years ago any attempt to control venereal disease was considered by many to be almost impious. Such disease was held to be the just visitation of God upon sin and to interfere would be wicked. We know better now. A large proportion of those who are most severely struck by venereal disease are new-born children and trustful wives, while a simple kiss or the use of towels and cups in common has constantly served to spread venereal disease in a family. Even when we turn to the commonest method of infection, we have still to remember that we are dealing largely with inexperienced youths, with loving and trustful girls, who have yielded to the deepest and most volcanic impulse of their natures, and have not yet learnt that that impulse is a thing to be held sacred for their own sakes and the sake of the race. In so far as there is sin, it is sin which must be shared by those who have failed to train and enlighten the young. A Pharisaic attitude is not only highly mischievous in its results, but is here altogether out of place. Much harm has been done in the past by the action of Benefit Societies in withholding recognition and treatment from venereal disease.
It is evident that this thought was at the back of the minds of those who framed these wise recommendations. We cannot expect to do away all at once with the feeling that venereal disease is "shameful." It may not even be desirable. But we can at least make clear that, in so far as there is any shame, it must be a question between the individual and his own conscience. From the point of view of science, syphilis and gonorrhoea are just diseases, like cancer and consumption, the only diseases with which they can be compared in the magnitude and extent of their results, and therefore it is best to speak of them by their scientific names, instead of trying to invent vague and awkward circumlocutions. From the point of view of society, any attitude of shame is unfortunate, because it is absolutely essential that these diseases should be met in the open and grappled with methodically and thoroughly. Otherwise, as the Commission recognises, the sufferer is apt to become the prey of ignorant quacks whose inefficient treatment is largely responsible for the development of the latest and worst afflictions these diseases produce when not effectually nipped in the bud. That they can be thus cut short—far more easily than consumption, to say nothing of cancer—is the fact which makes it possible to hope for a conquest over venereal disease. It is a conquest that would make the whole world more beautiful and deliver love from its ugliest shadow. But the victory cannot be won by science alone, not even in alliance with officialdom. It can only be won through the enlightened co-operation of the whole nation.
[1] The increase of venereal disease during the Great War has been noted alike in Germany, France, and England. Thus, as regards France, Gaucher has stated at the Paris Academy of Medicine (Journal de Medicine, May 10th, 1916) that since mobilisation syphilis had increased by nearly one half, alike among soldiers and civilians; it had much increased in quite young people and in elderly men. In Germany, Neisser, a leading authority, states (Deutsche Medizinische Wochenschrift, 14th Jan., 1915) that the prevalence of venereal disease is much greater than in the war of 1870, and that "every day many thousands, not to say tens of thousands, of otherwise able-bodied men are withdrawn from the service on this account."
[2] The chief is Iwan Bloch who, in his elaborate work,Der Ursprung der Syphilis(2 vols., 1901, 1911), has fully investigated the evidence.
[3] N. Bishop Harman, "The Influence of Syphilis on the Chances of Progeny,"British Medical Journal, Feb. 5th, 1916.
[4] It is true that in my book,Sex in Relation to Society(Ch. VIII.) I have stated my belief that notification, as in the case of other serious infectious diseases, is the first step in the conquest of venereal disease. I still think it ought to be so. But a yet more preliminary step is popular enlightenment as to the need for such notification. The recommendations seem to me to go as far as it is possible to go at the moment in English-speaking countries without producing friction and opposition. In so far as they are carried out the recommendations will ensure the necessary popular enlightenment.
It was inevitable that we should some day have to face the problem of medical reorganisation on a social basis. Along many lines social progress has led to the initiation of movements for the improvement of public health. But they are still incomplete and imperfectly co-ordinated. We have never realised that the great questions of health cannot safely be left to municipal tinkering and the patronage of Bumbledom. The result is chaos and a terrible waste, not only of what we call "hard cash," but also of sensitive flesh and blood. Health, there cannot be the slightest doubt, is a vastly more fundamental and important matter than education, to say nothing of such minor matters as the post office or the telephone system. Yet we have nationalised these before even giving a thought to the Nationalisation of Health.
At the present day medicine is mainly in the hands, as it was two thousand years ago, of the "private practitioner." His mental status has, indeed, changed. To-day he is submitted to a long and arduous training in magnificently equipped institutions; all the laboriously acquired processes and results of modern medicine and hygiene are brought within the student's reach. And when he leaves the hospital, often with the largest and noblest conception of the physician's place in life, what do we do with him? He becomes a "private practitioner," which means, as Duclaux, the late distinguished Director of the Pasteur Institute, put it, that we place him on the level of a retail grocer who must patiently stand behind his counter (without the privilege of advertising himself) until the public are pleased to come and buy advice or drugs which are usually applied for too late to be of much use, and may be thrown away at the buyer's good pleasure, without the possibility of any protest by the seller. It is little wonder that in many cases the doctor's work and aims suffer under such conditions; his nature is subdued to what it works in; he clings convulsively to his counter and its retail methods.
The fact is—and it is a fact that is slowly becoming apparent to all—that the private practice of medicine is out of date. It fails to answer the needs of our time. There are various reasons why this should be the case, but two are fundamental. In the first place, medicine has outgrown the capacity of any individual doctor; the only adequate private practitioner must have a sound general knowledge of medicine with an expert knowledge of a dozen specialties; that is to say, he must give place to a staff of doctors acting co-ordinately, for the present system, or lack of system, by which a patient wanders at random from private practitioner to specialist, from specialist to specialistad infinitum, is altogether mischievous. Moreover, not only is it impossible for the private practitioner to possess the knowledge required to treat his patients adequately: he cannot possess the scientific mechanical equipment nowadays required alike for diagnosis and treatment, and every day becoming more elaborate, more expensive, more difficult to manipulate. It is installed in our great hospitals for the benefit of the poorest patient; it could, perhaps, be set up in a millionaire's palace, but it is hopelessly beyond the private practitioner, though without it his work must remain unsatisfactory and inadequate.[1] In the second place, the whole direction of modern medicine is being changed and to an end away from private practice; our thoughts are not now mainly bent on the cure of disease but on its prevention. Medicine is becoming more and more transformed into hygiene, and in this transformation, though the tasks presented are larger and more systematic, they are also easier and more economical. These two fundamental tendencies of modern medicine—greater complexity of its methods and the predominantly preventive character of its aims—alone suffice to render the position of the private practitioner untenable. He cannot cope with the complexity of modern medicine; he has no authority to enforce its hygiene.
The medical system of the future must be a national system co-ordinating all the conditions of health. At the centre we should expect to find a Minister of Health, and every doctor of the State would give his whole time to his work and be paid by salary which in the case of the higher posts would be equal to that now fixed for the higher legal offices, for the chief doctor in the State ought to be at least as important an official as the Lord Chancellor. Hospitals and infirmaries would be alike nationalised, and, in place of the present antagonism between hospitals and the bulk of the medical profession, every doctor would be in touch with a hospital, thus having behind him a fully equipped and staffed institution for all purposes of diagnosis, consultation, treatment, and research, also serving for a centre of notification, registration, preventive and hygienic measures. In every district the citizen would have a certain amount of choice as regards the medical man to whom he may go for advice, but no one would be allowed to escape the medical supervision and registration of his district, for it is essential that the central Health Authority of every district should know the health conditions of all the inhabitants of the district. Only by some such organised and co-ordinated system as this can the primary conditions of Health, and preventive measures against disease, be genuinely socialised.
These views were put forward by the present writer twenty years ago in a little book onThe Nationalisation of Health, which, though it met with wide approval, was probably regarded by most people as Utopian. Since then the times have moved, a new generation has sprung up, and ideas which, twenty years ago, were brooded over by isolated thinkers are now seen to be in the direct line of progress; they have become the property of parties and matters of active propaganda. Even before the introduction of State Insurance Professor Benjamin Moore, in his able book,The Dawn of the Health Age, anticipating the actual march of events, formulated a State Insurance Scheme which would lead on, as he pointed out, to a genuinely National Medical Service, and later, Dr. Macilwaine, in a little book entitledMedical Revolution, again advocated the same changes: the establishment of a Ministry of Health, a medical service on a preventive basis, and the reform of the hospitals which must constitute the nucleus of such a service. It may be said that for medical men no longer engaged in private practice it is easy to view the disappearance of private practice with serenity; but it must be added that it is precisely that disinterested serenity which makes possible also a clear insight into the problems and a wider view of the new horizons of medicine. Thus it is that to-day the dreamers of yesterday are justified.
The great scheme of State Insurance was certainly an important step towards the socialisation of medicine. It came short, indeed, of the complete Nationalisation of Health as an affair of State. But that could not possibly be introduced at one move. Apart even from the difficulty of complete reorganisation, the two great vested interests of private medical practice on the one hand and Friendly Societies on the other would stand in the way. A complicated transitional period is necessary, during which those two interests are conciliated and gradually absorbed. It is this transitional period which State Insurance has inaugurated. To compare small things to great—as we may, for the same laws run all through Nature and Society—this scheme corresponds to the ancient Ptolomaean system of astronomy, with its painfully elaborate epicycles, which preceded and led on to the sublime simplicity of the Copernican system. We need not anticipate that the transitional stage of national insurance will endure as long as the ancient astronomy. Professor Moore estimated that it would lead to a completely national medical service in twenty-five years, and since the introduction of that method he has, too optimistically, reduced the period to ten years. We cannot reach simplicity at a bound; we must first attempt to systematise the recognised and established activities and adjust them harmoniously.
The organised refusal of the medical profession at the outset to carry on, under the conditions offered, the part assigned to it in the great National Insurance scheme opened out prospects not clearly realised by the organisers. No doubt its immediate aspects were unfortunate. It not only threatened to impede the working of a very complex machine, but it dismayed many who were not prepared to see doctors apparently taking up the position of the syndicalists, and arguing that a profession which is essential to the national welfare need not be carried out on national lines, but can be run exclusively by itself in its own interests. Such an attitude, however, usefully served to make clear how necessary it is becoming that the extension of medicine and hygiene in the national life should be accompanied by a corresponding extension in the national government. If we had had a Council of National Health, as well as of National Defence, or a Board of Health as well as a Board of Trade, a Minister of Health with a seat in the Cabinet, any scheme of Insurance would have been framed from the outset in close consultation with the profession which would have the duty of carrying it out. No subsequent friction would have been possible.
Had the Insurance scheme been so framed, it is perhaps doubtful whether it would have been so largely based on the old contract system. Club medical practice has long been in discredit, alike from the point of view of patient and doctor. It furnishes the least satisfactory form of medical relief for the patient, less adequate than that he could obtain either as a private patient or as a hospital patient. The doctor, on his side, though he may find it a very welcome addition to his income, regards Club practice as semi-charitable, and, moreover, a form of charity in which he is often imposed on; he seldom views his club patients with much satisfaction, and unless he is a self-sacrificing enthusiast, it is not to them that his best attention, his best time, his most expensive drugs, are devoted. To perpetuate and enlarge the club system of practice and to glorify it by affixing to it a national seal of approval, was, therefore, a somewhat risky experiment, not wisely to be attempted without careful consultation with those most concerned.
Another point might then also have become clear: the whole tendency of medicine is towards a recognition of the predominance of Hygiene. The modern aim is to prevent disease. The whole national system of medicine is being slowly though steadily built up in recognition of the great fact that the interests of Health come before the interests of Disease. It has been an unfortunate flaw in the magnificent scheme of Insurance that this vital fact was not allowed for, that the old-fashioned notion that treatment rather than prevention is the object of medicine was still perpetuated, and that nothing was done to co-ordinate the Insurance scheme with the existing Health Services.
It seems probable that in a Service of State medical officers the solution may ultimately be found. Such a solution would, indeed, immensely increase the value of the Insurance scheme, and, in the end, confer far greater benefits than at present on the millions of people who would come under its operation. For there can be no doubt the Club system is not only unscientific; it is also undemocratic. It perpetuates what was originally a semi-charitable and second-rate method of treatment of the poorer classes. A State medical officer, devoting his whole time and attention to his State patients, has no occasion to make invidious distinctions between public and private patients.
A further advantage of a State Medical Service is that it will facilitate the inevitable task of nationalising the hospitals, whether charitable or Poor-law. The Insurance Act, as it stands, opens no definite path in this direction. But nowadays, so vast and complicated has medicine become, even the most skilful doctor cannot adequately treat his patient unless he has a great hospital at his back, with a vast army of specialists and research-workers, and a manifold instrumental instalment.
A third, and even more fundamental, advantage of a State Medical Service is that it would help to bring Treatment into touch with Prevention. The private practitioner, as such, inside or outside the Insurance scheme, cannot conveniently go behind his patient's illness. But the State doctor would be entitled to ask:Whyhas this man broken down? The State's guardianship of the health of its citizens now begins at birth (is tending to be carried back before birth) and covers the school life. If a man falls ill, it is, nowadays, legitimate to inquire where the responsibility lies. It is all very well to patch up the diseased man with drugs or what not. But at best that is a makeshift method. The Consumptive Sanatoriums have aroused enthusiasm, and they also are all very well. But the Charity Organisation Society has shown that only about 50 per cent. of those who pass through such institutions become fit for work. It is not more treatment of disease that we want, it is less need for treatment. And a State Medical Service is the only method by which Medicine can be brought into close touch with Hygiene.
The present attitude of the medical profession sometimes strikes people as narrow, unpatriotic, and merely self-interested. But the Insurance Act has brought a powerful ferment of intellectual activity into the medical profession which in the end will work to finer issues. A significant sign of the times is the establishment of the State Medical Service Association, having for its aim the organisation of the medical profession as a State Service, the nationalisation of hospitals, and the unification of preventive and curative medicine. To many in the medical profession such schemes still seem "Utopian"; they are blind to a process which has been in ever increasing action for more than half a century and which they are themselves taking part in every day.
[1] The result sometimes is that the ambitious doctor seeks to become a specialist in at least one subject, and instals a single expensive method of treatment to which he enthusiastically subjects all his patients. This would be comic if it were not sometimes rather tragic.