472

them at the time. The suffering, the dead, and the fear ofdeath were forgotten too soon. Now perhaps an epidemic isupon us again, and it is too late to lament over the little usemade of the 18 years of respite.

Of course, much has, as a matter of fact, been done, butnot nearly so much as should have been done. To use afamiliar simile, it is as if war had begun again. The earlycases notified may be compared with the enemy’s scoutsand skirmishers who may be said to have crossed thefrontier and invaded our part of Europe. Will they reportthat they have seen food for plunder and thus entice themain body to invade our lands ; or will they return crest-fallen because they found everything so clean and in suchgood order that it did not seem worth while attempting ageneral attack’? ’) The cholera invasion of 1892 was notso successful as the previous outbreak of the same character,so perhaps this time the enemy may not venture on morethan threats such as those recorded above. Should this,fortunately, prove to be the case, it is to be hoped that thealarm raised will suffice to draw attention to the fact that

many of the obvious lessons taught by the previous epidemichave not yet been fully applied.

I am, Sir, yours faithfully,Fulbam, August 8th. 1911. ADOLPHE SMITH.

A QUESTION IN EUGENICS.To the Editor of THE LANCET.

SiR,—As an alienist physician and a teacher with a notinconsiderable experience of mental diseases, and beingacquainted with the care of epileptics suffering from mentalsymptoms, I consider it to be my duty to offer advice to yourcorrespondent (of July 29th) who desires to have his epilepticson of 12 sterilised to prevent his having children if he shouldlive to a marriageable age.

Let me be certain about the actual state of this boy.Presumably there are no (or only slight) mental symptoms,for otherwise detention in a special institution under specialtreatment would meet the circumstances, whilst the epilepsyitself, although it would seem not to prohibit matrimonyshould the son reach his majority and then care to exercisehis privileges, is yet of such a nature as to disqualify for theordinary avocations of life and is non-traumatic. Altogetherthis opportunity to discuss a very vexed question in eugenicsacknowledges that you are conscious of the "signs of thetimes," and it will certainly afford the medical professionand others the means of ascertaining views presented on bothhorns of a very difficult dilemma and upon a matter of greatpublic importance.

In spite of the tendency on the part of Nature towards thenormal, and in spite of the apparent disposition of thegerminal molecules to sustain and reproduce under favour-able conditions of selection what is healthy and normal,epilepsy in my opinion, and in that of. others who havestudied and written upon the subject, has been proved byirrefragable statistical evidence to be the most heritable ofall the neuroses and of all mental diseases ; that is to say,.. pure " epilepsy, or even epilepsy associated with insanity,

is more often the antecedent of epilepsy than is insanity ofinsanity ; and this is probably known to your correspodent,who by his suggestion in regard to this disease a fortiorisuggests the treatment for many other less prominentneuroses-thus proposing to extinguish or at any rate to

endeavour to prevent the extension of epilepsy in his owndescendants.The first question is whether we, as doctors, are to con-

sider ourselves bound mainly to do the best we can for theindividual or whether our care is to be for the race, and

possibly the view taken depends on the ethical standardaccepted by each person who ventures upon advice. Per-

sonally I am strongly in favour of the individualist view, forI conceive the ethical end to be the " perfection of ourpatient, and this in the most active, most moral, and mostintelligent direction consistent with time, circumstances, andenvironment.

As to the legal and moral aspect, a father is morallybound-i.e., by custom, by family ties, and by bloodrelationship-to do the best in his power for his son (ordaughter), because the solidarity of the family is the essentialprinciple to be kept in view in any community, and parentalresponsibility must be uppermost for the head of the family.He is bound to sustain, to preserve, and to shield his sonfrom harm, so that his son’s mental and physical powers,

whether limited or of the ordinary range, may develop to thegreatest perfection, and so that he may derive from them thegreatest use and happiness.The question of operation (or according to some " mutila-

tion ") for mental deficiencies or bodily ailments, is, in myopinion, not one to be entertained by the father, for he isconcerned only with fostering the directly self-preservativeinstincts of his offspring-speaking generally, those relatingto his own livelihood-and not those remotely relating toposterity. Legally, therefore, he,has no option, but I amnot a lawyer, and to him posterity is an unrealisable respon-sibility ; still, if the community should enforce such anordinance as sterilisation for its own future welfare, whichit is entitled to do, then the parent is bound to accede tosuch indirectly self-preservative rules as may be agreed. Ihave no doubt in my own mind that the race would greatlybenefit in physique by such enactments, but possibly notequally so in moral and mental qualities, for I look upon thepresence of human weakness as a moral appeal to the strongand as serving a useful purpose in the moral development ofany people.

I should like to be informed at what limit-i.e., for whatdefects-are such mutilations to cease ? 1 Are such operationsto apply only to epileptics or those who are insane, some ofwhom we know occasionally recover completely ? 1 If forthese, then why not for inebriates and criminals, or thosewith cancerous or tubercular tendencies, or those who arepredisposed to paralysis, and if for these, again, why not forother persons who may be deficient in other forms of self-control, those, for instance, who inordinately gratify appetiteand passion, those who are wanting in thrift and other

prudential considerations, or for that matter those whoexhibit the unpardonable crime of political defection or forany other apostasy ? 1 Furthermore, who is to be the finalarbiter ? 1 And is the father himself averse from beingsubjected to the operation to prevent the possibility of moreepileptic descendants ? 1The treatment least trying to parents and most acceptable

to the main body of opinion in this country would be theprovision by the State (or the local authority), with thesanction of Parliament, of a home " wherein such cases couldbe made busy and happy, in which their lives would be fullyoccupied with employment congenial and graded to theirabilities, and where their health and pastime could be

adequately supervised. In this direction alone, in myopinion, lies the best and only justifiable solution. Weare as yet unprepared for the (?) moral effect of a largenumber of sterilised " men (and, of course, women) in thecommunity; and even the State of Indiana, U.S.A., where700 such persons are already said to exist, is blenching atthe prospect community;

Let me, in conclusion, relate an experience. I once hadthe care of a young medical man who had been thefavourite pupil and " interne of one of the physiciansto the late Queen Victoria. He developed delusions, underthe influence of which he so mutilated himself that heremoved the whole of the external genitalia. Later, hesank into a state of unambitious passivity, without thedesire or the capacity to originate conversation or to heedhis surroundings. His mental state was that of carelessand listless indifference to outward stimuli. He couldoccasionally be roused by questions referring to his past life,but he took no interest in the present or the future, whichwas beyond the power of any appeal to effort or action. He

lounged or sat about, a slovenly inert wreck, dishevelled,self-neglectful, untidy, and personally disordered-a state ofliving death worse than could happen to the average epilepticwho not infrequently enjoys a useful interparoxysmal life.That such a state was partly the result of sex " mutilation"

"

admits of no doubt in my mind, and such reducing mental con-sequences of

I I restrictive eugenics must not be overlooked.I am strongly of opinion, after consultation with the titularheads of the medical profession, that suggestions in regardto sterilisation are at the present moment premature andwould not be tolerated. They have no moral support andcertainly, at present, they have no legal justification.

I am, Sir, vours faithfully,Claybury, August 3rd, 1911. ROBERT JONES, M.D. Lond.

To the Editor of THE LANCET.

SiR,-The sterilisation of the unfit is legalised in the Stateof Indiana and also in Switzerland. In the former severalhundreds of cases have been performed with very successful

473

results, but so far as I know eugenic sterilisation has neverbeen done in Great Britain. Assuming, however, that thelaw permits it, in my opinion a surgeon would be morallyright in acceding to the request of the parent who desiredthat an epileptic child should be sterilised. Nay, I wouldgo further, and after careful delving into the family history,should it be apparent that there is some morbid flaw in themosaic of the germ plasm of the parents, I would stronglyadvise that they also should be sterilised if still capable ofproducing offspring. The method which should be adoptedis most important. Castration is crude and brutal; X raysuncertain and inefficient ; the simplest, the best, and themost permanent would be vasectomy, which makes no differ-ence to the bodily functions, has no ill-effects, secondarysexual characters would be developed, and nothing would beprevented but the power of procreation.The answer to the question depends upon whether you

regard the rights of the individual as absolute and the claimsof the race as non-existent. If you do, sterilisation will bean accursed thing ; if not, it will be gladly welcomed. As

marriage is the supreme eugenic institution, why should anepileptic child be permitted to grow up, marry, and produceoffspring suffering from physical and mental defects ? Is

marriage the intimate personal affection, the spiritual tie, theindissoluble union, which purifies the passions of the sexesand raises us above the level of the beasts ? Is marriage forthe sake of parentage and parentage a trust for the race ?Must we be ever satisfied that the ghastly burden of diseaseof body and mind should be freely transmitted from age toage and no steps be taken to dam the overflow of this reekingcesspool ? Should we leave open the flood-gates throughwhich has poured a devastating torrent of degradedhumanity ? Mr. Roosevelt has said" A nation’s chief

blessing was that it should leave its seed to inherit the land.No refinement of life, no delicacy of taste, no material

progress, no sordid keeping up of riches, no sensuous develop-ments of art and literature, can in any way compensatefor the loss of the great fundamental virtues, and of thesegreat fundamental virtues the greatest is the race’s power toperpetuate the race." " Ruskin stated that the veins ofwealth are purple and that the Divine intent of all wealth isthe production of a healthy race.The unfit should have the right to live, and live well-no

one will question that-but the right to propagate should bedenied them. The average quality of a race is but the

average quality of the individuals composing it. If the

physically and mentally weak be allowed to propagate, andif, as it seems to be the case at present, they reproduce them-selves faster than the better strains, the relative numbers ofsuch persons in the country must increase and the averagequality of the race deteriorate. The best stocks are post-poning marriage and restricting the number of their offspring.The latter are producing motor-cars, the former children.

" Better, oh better, cancel from the scrollOf universe one luckless human soul,Than drop by drop enlarge the flood that rollsHoarser with anguish as the ages roll."-FITZGERALD.

I am, Sir, yours faithfully,Claybury, August 1st, 1911. C. T. EWART, M.D. Aberd.

SALVARSAN (" 606") AND MERCURY INTHE TREATMENT OF SYPHILIS.

To the Editor of THE LANCET.

Sm,-In to-day’s LANCET (July 29th) Major H. C. French,R.A.M.C., replies to the criticisms of myself and others on Ihis paper on this subject that appeared in THE LANCET ofJune 24th. The party system in politics, by insuringsearching criticism, gives the country the opportunity ofarriving at an unbiassed opinion on the questions at issue ;and likewise with any new therapeutic agent it is essentialthat adverse critics should be found to lay before the medicalpublic all the possible evidence against the new treatment.The medical profession must always be equally indebted tothe opponents and advocates of any new " specific."

Major French observes the rules of debate and withcourtesy replies to criticism, and it is a matter of regretthat Mr. Ernest Lane makes no attempt to reply to

my criticism of his published opinion. Mr. Lane has

apparently changed his mind in regard to the dangerand value of salvarsan treatment, and makes it a

grievance that I should have thought that he meant whathe said in December last, which I quoted as the onlyrecord of his opinion that I can find. Major French quotesme as writing in support of the great value of inunctionsand injections of mercury as shown by the Wassermannreaction. I am sorry that he thought my advocacy ofsalvarsan meant detraction of mercury. That this is not myview is shown by the paper that I wrote with Dr. A. Manuel inthe Practitioner for June, where we concluded that I I salvarsanwhen it does produce an alteration of the serum reactiondoes so more rapidly than mercury. On the other hand,in the present state of our knowledge it would appear thatthe percentage of negative results after one or two injectionsis lower than that observed after a year’s course of efficientmercurial treatment." The Wassermann reaction frequentlybecomes negative after one or two courses of inunction orinjection, but these negative reactions are rarely permanent,whereas after salvarsan apparently about 75 per cent. ofcases that become negative as the result of such treatmentremain so.

I am entirely in accord with Major French’s quotation ofMr. Boas’s opinion as to the superiority of Wassermann’soriginal technique and the importance of q1UJ/ntitative estima-tions. My modifications are solely trifling matters of

technique, with the exception that I use alcoholic extractof rabbit’s heart in place of alcoholic extract of syphiliticorgans. I have made parallel experiments, using rabbit’sheart extract and syphilitic organ extract suppliedfrom Professor Wassermann’s own laboratory, and haveobtained practically identical results with both, the veryslight difference being in favour of the heart extract.At the British Medical Association discussion on the

Diagnostic Use of the Complement Fixation Method thattook place in July, 1910, and was opened by a paper fromProfessor Wassermann, I had the honour of reading thesecond paper. I then said 1: " Many observers have triedto simplify the test and obviate the necessity for usingrabbits and guinea-pigs by making use of the complementand hsemolysin for sheep’s corpuscles present in humanblood serum. It seems to me, however, that the mostessential of all factors in a comparative test such as this isthat all factors except the one to be tested should beconstant. With Hecht’s, Bauer’s, Stern’s, or Fleming’stechnique, however, variants are substituted for constants,for the complement content of human serum varies greatly,and some human serums contain no basmolytic antibody tosheep’s corpuscles, while others contain some but in varyingquantities." Later on I said: .. I have for the last sixmonths used two strengths of complement and so obtained aroughly quantitative measurement of the complement deviat-ing power of the serum." In a footnote I wrote: I I This

quantitative measurement can obviously not be determinedby the so-called simplified methods."

In the Quarterly Journal of Medioine for January, 1911, Iwrote : "It is remarkable that though innumerable modifica-tions and simplifications have been introduced during thelast two years, the consensus of expert opinion is still

strongly in favour of the original technique, or of such slightmodifications of the original method as do not necessitate thesubstitution of variant factors for constant factors." MajorW. S. Harrison, R.A.M.C., agrees with me that the originaltechnique is the most reliable, and probably Major Harrisonand myself have greater opportunities for extended investi-gations on this subject than other workers in this country.I have personally examined well over 2000 sera, and as amatter of routine determine the reaction in about 30 cases

every week. I am cordially in sympathy with Major French’sopinion as to the necessity for standardising the test, and onDec. 2nd, 1910, said: " I am entirely in accord with Mr.Arthur Shillitoe in desiring the universal adoption of thesame technique for the Wassermann reaction." 2The points I wished to emphasise were : (1) the extremely

small casualty proportion, which, being less than 0. 2 percent. even in the early days, is almost negligible ; and

(2) that salvarsan should be given as a routine in all casesexcept the very exceptional ones when it is contra-indicated.These points I do not think have been satisfactorily metby Major French and have been ignored by Mr. Lane.I do not suggest, and never have suggested, that the timehas yet arrived when mercury can be dispensed with in

1 Brit. Med. Jour., Nov. 5th, 1910, p. 1430.2 West London Medical Journal, January, 1911, p. 48.