ABOLITION AND DISEASE
Abolition not necessarily _laissez-faire_.—Norwegian handling of
disease problem.—Danish plan.—Italian plan.—Voluntary and compulsory
provisions compared.—Denunciation of alleged sources of
infection.—Attendance at free dispensaries.—Attitude of
prostitutes,—of medical practitioners.—Notification of venereal
disease.—Hospital provisions for treatment in Great Britain,—on the
Continent.—Statistics unreliable and imperfect.—Census of venereal
disease in Prussia,—in Sweden,—Venereal disease in European
armies.—Regulation without effect in England.—Decline in amount of
disease after its abolition.—Prussian army statistics.—Statistics from
Christiania,—from Copenhagen,—from Zurich.—Fluctuations in venereal
infection.—Reduction in amount of disease.—Abolition more favorable to
such effort than regulation.
In the preceding chapter I remarked that though abolition may be
accompanied by a _laissez-faire_ policy, this is not necessarily the
case. The situation in respect to venereal disease best illustrates this
statement. We shall see that the public in England is well-nigh entirely
indifferent on the subject; almost total _laissez-faire_ prevails there.
Abolition Scandinavia has, on the other hand, displayed great vigor and
originality in grappling with the problem of disease. Abolition
includes, therefore, the countries least active and most active in this
respect,—both extremes.
The Norwegians were in this matter first in the field with a scheme, the
essential points of which can be most clearly stated by means of a
contrast with regulation. Regulation endeavors to protect the public
health by safeguarding through police agencies the health of registered
prostitutes,—these prostitutes being periodically examined by police
surgeons and forcibly treated when found diseased; the distinctive
features of sanitary regulation are, therefore, its limitation to
professional inscribed prostitutes, its management by the police, and
the prison-like nature of the cure. In contradistinction to this
procedure, the unsatisfactory nature and outcome of which we have
discussed, the Scandinavian experiment, generally speaking, aims to
reach all those suffering with venereal disease, men and women alike;
and it seeks to accomplish this end by transferring the function from
the police to the health department, by the provision of free treatment,
and by endeavoring to enlist the patient’s aid in ascertaining the
source of infection, and in the isolation and cure of disease.
Separation from the police is intended to allay the patient’s dread of
becoming involved with the criminal authority, and, as nearly as may be,
to establish the feeling that venereal disease is after all a disease
and not a crime,—an evil that, aside from all else, requires
consideration on its own account The voluntary nature of submission to
treatment is intended still further to deepen the impression that the
entire matter is left to the patient’s intelligence and
self-interest—precisely as though he were otherwise afflicted; free
treatment is designed to strengthen the inducement and to dispose of the
competition of quacks.
The Norwegian law under which this system has been organized dates from
1860; by its terms local health boards with very extensive powers in
reference to epidemic and contagious diseases were organized; and these
boards were left free to determine what precautions should be taken and
to require reports.
In order to assist the health—not the police—authorities in controlling
the diseases in question, all physicians are required to report
daily—usually without names[613]—their venereal patients, to furnish the
patient with a copy of the laws relating to the communication of
venereal disease[614] and to require the patient to sign a statement
acknowledging the fact that he (or she) has been thus explicitly
warned.[615] The physician also endeavors to ascertain the source of the
infection and the person inculpated is reported to the Health Office.
This latter individual on calling by invitation[616] is informed of the
nature of the charge—the name of the accuser being withheld—and is
invited to submit to examination at a hospital or by a municipal
physician. No compulsion is applied; the advantages of knowing the truth
and the offer of free and skilful treatment in complete privacy form the
entire inducement. If disease is thus proved to exist, treatment can be
compelled, to the extent of forcibly confining the infected person in a
hospital. But reliable persons receive ambulatory treatment at the hands
of municipal physicians,—men, at the office of the physician, women at
the Board of Health office where a woman physician is on duty. The
police are invoked only if an individual having been “denounced”
neglects or refuses to comply with the summons of the Health Department.
Persons who, having knowledge of their infectious condition, communicate
disease, are punished with imprisonment for not exceeding three years.
The Danish law dealing with the subject represents a gradual evolution
greatly hastened in its final stages by the Norwegian example.[617] The
proffer of free treatment dates back to 1788; a law of 1874 sought to
impose an obligation to take advantage of this opportunity; in the law
of March 30, 1906, fifteen of the eighteen paragraphs which compose the
statute deal with the problem of venereal infection.[618] The main
provisions are the following:[619] It is made a punishable offence to
communicate venereal infection even as between husband and wife; any
person who in ignorance of his or her condition infects another is
liable for the medical charges and damages; venereally infected persons
may, regardless of their ability to pay, receive free treatment from the
municipality; they are in duty bound to submit to such free treatment if
they are themselves unable to employ a physician; if the manner of
living of the patient is such as to endanger others, or if the patient
does not observe directions, or is a pauper in receipt of aid, he or she
may be forcibly interned,—_the decision to rest with the police
officials_[620]; patients can be required to continue under medical
observation even after the conclusion of their regular treatment; every
physician is obligated to hand venereal patients a printed warning
against marriage and against sexual intercourse, and to explain the
legal liabilities incurred through violation of this injunction; every
physician must report the instances in which such action has been taken
by him[621]; patients are free to indicate the supposed source of their
infection, though not obliged to do so, and the physician may in his
discretion report such alleged source to the police, who may or may not
take action thereon; a child, suffering with syphilis may not be nursed
by any one other than its own mother; nor may a syphilitic wet nurse
continue the practice of her vocation. A woman arrested for any offence
connected with prostitution or on the charge of infecting another may
with her consent be medically examined through the police; in case of
refusal to submit, the courts shall have the power to order the same;
compulsory examination must be carried out by paid municipal physicians
of the same sex as the accused; these same physicians are obligated to
examine all applicants and to treat all venereal patients without either
demanding or accepting a fee; in Copenhagen municipal clinics must be
maintained by the department of health in different parts of the city;
the patient can be required to return for treatment at appointed times
and if sent to the hospital may be compelled to remain until discharged
by the physician. Should the patient fail to obey instructions, the case
must be reported by the attending physician to the City physician, who
is authorized to take action.[622]
The municipal clinics, maintained for the purposes above stated, seven
in number, are prominently announced on every advertising obelisk. As
indicating the direct way in which the subject is handled, I reproduce
on page 350 the bulletin.[623]
At Rome, side by side with the ineffective municipal regulatory system
previously described, the royal government of Italy has, by a law
approved August 1, 1907, instituted a dispensary system, in many
respects closely following the Danish type. The measure provides for
“gratuitous public prophylaxis of gonorrhœa, soft chancre, and
syphilis.”[624] The dispensaries are to be organized by the communes
acting in coöperation with the ministry of the Interior, or in default
of such arrangement, by the Interior department itself; the expense is
to be borne by the commune assisted by governmental aid; physicians
shall be appointed by the government; “they shall treat without any
distinction all sufferers from venereal diseases who apply to the
dispensaries. The cure is gratuitous for all alike.”[625] Provision is
further made for hospital facilities. Supplementary sections endeavor to
bring professional prostitutes within the scope of the act.
AT THE FOLLOWING PLACES AND FROM THE FOLLOWING PHYSICIANS, ALL PERSONS SUFFERING
FROM VENEREAL DISEASE, REGARDLESS OF ABILITY TO PAY, HAVE THE RIGHT TO DEMAND FREE
TREATMENT WITHIN THE HOURS INDICATED:
────────┬────────┬────────────────────────────────────────────────────────────────
PLACE │NAME OF │ CONSULTATIONS FOR MEN
│ PHYSI- │
│ CIAN │
────────┼────────┼──────────┬─────────┬──────────┬──────────┬───────────┬─────────
│ │ MON. │ TUES. │ WED. │ THUR. │ FRI. │ SAT.
────────┼────────┼────┬─────┼───┬─────┼────┬─────┼────┬─────┼─────┬─────┼───┬─────
│ │Day │Even.│Day│Even.│Day │Even.│Day │Even.│ Day │Even.│Day│Even.
────────┼────────┼────┼─────┼───┼─────┼────┼─────┼────┼─────┼─────┼─────┼───┼─────
Rudolph │ Ravn │12½–│ │ │ │12½–│ │12½–│ 6–7 │ │ │ │
Berghs │ │ 1½ │ │ │ │ 1½ │ │ 1½ │ │ │ │ │
Hospital│ │ │ │ │ │ │ │ │ │ │ │ │
„ │Jersild │9½– │ │ │ 6–7 │9½– │ │9½– │ │ │ │ │
│ │10½ │ │ │ │10½ │ │ 1½ │ │ │ │ │
Isted │Meincke │3–4 │ 6–7 │3–4│ │ │ │3–4 │ │ │ 6–7 │3–4│
Street │ │ │ │ │ │ │ │ │ │ │ │ │
30 │ │ │ │ │ │ │ │ │ │ │ │ │
Griffen-│ Einar │2–3 │ │ │ │2–3 │ │2–3 │ │ │ 6–7 │ │
feldt │Petersen│ │ │ │ │ │ │ │ │ │ │ │
Street 8│ │ │ │ │ │ │ │ │ │ │ │ │
„ │H. Levy │ │ 6–7 │10–│ │10– │ │ │ │10–11│ │ │
│ │ │ │11 │ │ 11 │ │ │ │ │ │ │
Osterbro│ H. │ │ │9½–│ │ │ 6–7 │9½– │ │ │ │9½–│
Street │Sorensen│ │ │10½│ │ │ │10½ │ │ │ │10¼│
56 D │ │ │ │ │ │ │ │ │ │ │ │ │
„ │ C. E. │3–4 │ │ │ │3–4 │ │ │ 6–7 │ 3–4 │ │ │ 7–8
│ Jensen │ │ │ │ │ │ │ │ │ │ │ │
Torve │ H. │ │ │8½–│ │ │ │ │ 6–7 │8½–9½│ │ │
Street │Bonnesen│ │ │9½ │ │ │ │ │ │ │ │ │
12 │ │ │ │ │ │ │ │ │ │ │ │ │
„ │ P. │ │ 6–7 │3–4│ │ │ │3–4 │ │ │ │3–4│
│Haslund │ │ │ │ │ │ │ │ │ │ │ │
St. │ Gold- │ │ │11–│ │ │ │11– │ │ │ │11–│
Kongens │schmidt │ │ │12 │ │ │ │ 12 │ │ │ │12 │
Street │ │ │ │ │ │ │ │ │ │ │ │ │
46 │ │ │ │ │ │ │ │ │ │ │ │ │
════════╪════════╪════╧═════╧═══╧═════╧════╧═════╧════╧═════╧═════╧═════╧═══╧═════
PLACE │NAME OF │ CONSULTATIONS FOR WOMEN
│ PHYSI- │
│ CIAN │
────────┼────────┼──────────┬─────────┬──────────┬──────────┬───────────┬─────────
│ │ MON. │ TUES. │ WED. │ THUR. │ FRI. │ SAT.
────────┼────────┼────┬─────┼───┬─────┼────┬─────┼────┬─────┼─────┬─────┼───┬─────
│ │Day │Even.│Day│Even.│Day │Even.│Day │Even.│ Day │Even.│Day│Even.
────────┼────────┼────┼─────┼───┼─────┼────┼─────┼────┼─────┼─────┼─────┼───┼─────
Rudolph │ Ravn │ │ │9½–│ │ │ 6–7 │10– │ │ │ 6–7 │ │
Berghs │ │ │ │10½│ │ │ │ 11 │ │ │ │ │
Hospital│ │ │ │ │ │ │ │ │ │ │ │ │
„ │Jersild │ │ 6–7 │ │ │ │ │ │ │ │ │ │ 6–7
Isted │ Miss │10– │ │10–│ │ │ │ │ │ 2–3 │ │ │
Street │ Ham- │ 11 │ │11 │ │ │ │ │ │ │ │ │
30 │ burger │ │ │ │ │ │ │ │ │ │ │ │
Griffen-│ Einar │ │ │ │ 6–7 │ │ │ │ │12½– │ │ │
feldt │Petersen│ │ │ │ │ │ │ │ │ 1½ │ │ │
Street 8│ │ │ │ │ │ │ │ │ │ │ │ │
„ │H. Levy │ │ │ │ │ │ 6–7 │ │ │ │ │10–│
│ │ │ │ │ │ │ │ │ │ │ │11 │
Osterbro│ H. │ │ │ │ │9½– │ │ │ │ │ 6–7 │ │
Street │Sorensen│ │ │ │ │10½ │ │ │ │ │ │ │
56 D │ │ │ │ │ │ │ │ │ │ │ │ │
„ │ C. E. │ │ │ │ 6–7 │ │ │ │ │ │ │3–4│
│ Jensen │ │ │ │ │ │ │ │ │ │ │ │
Torve │ H. │ │ │ │ 6–7 │8½– │ │ │ │ │ │8½–│
Street │Bonnesen│ │ │ │ │ 9½ │ │ │ │ │ │9½ │
12 │ │ │ │ │ │ │ │ │ │ │ │ │
„ │ P. │3–4 │ │ │ │ │ │ │ │ │ 6–7 │ │
│Haslund │ │ │ │ │ │ │ │ │ │ │ │
St. │ Gold- │ │ │ │ 6–7 │ │ │ │ │11–12│ │ │
Kongens │schmidt │ │ │ │ │ │ │ │ │ │ │ │
Street │ │ │ │ │ │ │ │ │ │ │ │ │
46 │ │ │ │ │ │ │ │ │ │ │ │ │
Venders │Miss N. │ │ 6–7 │10–│ │10– │ │10– │ 6–7 │10–11│ │ │
Street 8│Nielsen │ │ │11 │ │ 11 │ │ 11 │ │ │ │ │
────────┴────────┴────┴─────┴───┴─────┴────┴─────┴────┴─────┴─────┴─────┴───┴─────
Health Board of Copenhagen, April 1, 1912.
Between the Italian and the Scandinavian legislation above summarized
there is, however, an important distinction. The Italian scheme is
wholly and unconditionally voluntary and hygienic; it lacks altogether
compulsory features, addressing itself unreservedly to health, without
regard to either order or morals. A ministerial circular, interpreting
its scope and purpose declares: “Any construction of the law aiming to
ascertain the presence of disease is unlawful and in opposition to its
purport, because the police spirit leads to the concealment of disease
and avoidance of cure. Compulsory action is offensive to the liberty and
dignity of human personality. The prophylaxis of venereal disease is to
be kept entirely distinct from the protection of morals and the measures
of the police. The two services differ in object,—the one having a
hygienic end, the other aiming to protect public order. Confusion is
dangerous and constitutes an abuse.”[626]
As contrasted with this thoroughgoing acceptance of the voluntary point
of view, the Danish policy retains certain vestiges of police
complicity. It includes, for example, the right of compulsory
examination in case of women arrested for offences indicative of
professional prostitution[627]; it continues to relate the police to
venereal disease, through the compulsory proviso above cited and through
the provisions encouraging the disclosure of the supposed source of the
infection.[628]
As to the wisdom of the above mentioned provisions grave doubt exists.
They are unquestionably in conflict with the spirit animating the
statute as a whole. Dr. Santoliquido, the author and administrator of
the unqualified Italian scheme, is strongly of the opinion that the
slightest taint of police complicity or the slightest suggestion of
publicity seriously impedes the utilization of the facilities
offered.[629] The Danish lawmakers were evidently afraid to be
thoroughgoing. On the one hand they were entirely clear that regulation
failed, not only because it reached no men and relatively few women, but
because the association of disease with crime tended to drive disease
into hiding. They saw that, to entice it out, to ensure more general,
more skillful, more thorough treatment, the interest and the
intelligence of the patients had to be appealed to; they must be taught
to be cured for their own sakes and that of others; and in order that
every obstacle thereto might be removed, treatment offered in a
scientific spirit must be made free and accessible. They feared,
however, to leave the matter at this point; they felt that some
provision had to be made for backsliders; and to keep these under
treatment, even against their own inclination, the intervention of the
police was made possible. Undoubtedly the individuals immediately
concerned may thus gain,—for they may be helped. But the danger is that
unfortunate indirect effects may more than outweigh the direct favorable
effects. The vestige of the police spirit may hinder the very
transformation in the attitude of those afflicted that the legislation
hoped to bring about. Thus incidental compulsion may tend to tear down
what the law as a whole endeavors to build up.[630]
As opposed then to the Italian policy of leaving the matter wholly to
individuals and endeavoring to educate them to take advantage of
abundant facilities, the Danish plan leaves the matter to individuals,
if the individual is willing to act intelligently; but it endeavors to
coerce the rest. There is, however, some doubt as to whether the second
part of the Danish arrangement does not tend to defeat the first. Even
under police regulation we observed that most was achieved where force
was most completely dissembled; and, wherever, as at Paris, police
regulation and voluntary hospital facilities are both provided, the
latter are far more effective than the former. Moreover, the remnant of
police compulsion is always in danger of relapsing into regulation,
applicable mainly, perhaps altogether, to women,—a policy to which we
have discovered insurmountable objections.
From the standpoint of the theory of the law, then,—that abundant
facilities for treatment coupled with an unqualified appeal to the
intelligence and self-interest of the patient is likely to reach, on the
whole, the largest number of the afflicted—grave question may also be
raised regarding denunciation of the source of a particular venereal
infection. On its face, the transaction appears reasonable enough: a
sufferer, after interrogation by his physician or of his own motion, may
report his belief that he was contaminated by this woman or that.[631]
The information communicated by the doctor to the police is held in
strict confidence, and the person involved may be requested to call at
police headquarters; where, being informed of the nature of the
accusation, it is suggested that he (or she) consult a physician,—a
municipal physician or a physician of the individual’s own choosing;
should he (or she) be reported as ill, treatment may be compelled, if
the individual declines otherwise to submit.[632]
On its face, I say, this looks like a not unreasonable method of
attacking infection at its source in the case of persons who lack the
conscience or the intelligence to act of their own accord; for clearly
the foci thus reached might, if left alone, have continued, ignorantly
or malevolently, to breed further contamination. Denunciation aims to
bring these concealed sources to light; offers them treatment, if they
are intelligent enough to take advantage of such opportunity; and adds
the state’s right and power to compel a proper course of action, if, for
any reason whatsoever, they are differently minded.
As a matter of fact, the thing is by no means so simple. In the first
place, with the best intention, the patient may be mistaken as to the
source of his or her infection. Prostitution is promiscuous on both
sides. The women notoriously consort in quick succession with many men;
men often consort with different women. The periods of incubation are
more or less indefinite and variable, so that a mere reckoning back to a
particular act of intercourse is not conclusive. In one set of cases,
carefully studied from this standpoint,[633] over half of those
questioned were unable to throw any light on the subject.
The very difficulty in question opens the way to error and abuse.
Despite the confidential fashion in which the subject is handled, the
humiliation involved in a mistaken or false accusation is no trifle. The
same principle holds here as in respect to arrest for alleged
solicitations—a single error is worse than a hundred omissions. It is a
totally different thing from a mistaken allegation that some other
infectious disease exists in a given house or person,—diphtheria, for
example, or scarlet fever. The manner in which venereal disease is
usually contracted, the implications attending its presence, set it off
in a class by itself, and open the door to abuses for which other
contagious diseases give no opportunity. A procedure that might,
therefore, be safely employed in reference to scarlet fever, if feasible
or necessary, may be totally inapplicable to syphilis.
The experience of Copenhagen has quite fully justified these doubts.
Denunciation is an invitation to blackmail; it can be and has been
employed by men simply to rid themselves of women of whom they have
tired; for, while in theory equally applicable to both sexes, under
existing conditions women have most to fear from it. For this reason,
physicians do not regularly report to the police the alleged sources of
infection; nor do the police always act even on such denunciations as
reach them. But despite the caution with which the police act, it
happens not infrequently that denounced women prove on examination to be
free of infection. Women wishing to be revenged upon former “friends” or
lovers do not hesitate to employ the same device; and not infrequently
with a similar result. The following table shows the results of the
examinations made at the instance of the Copenhagen police during a
series of years:[634]
──────────────────────────────────────────────────────────────────────
No. No. No. persons reported No. of
No. Men Women for not continuing these
Year Examined Men Women ill ill treatment reached
„ „ „ „ „ „ Men Women „
1907 410 22 388 21 172 154 37 68
1908 609 61 548 54 195 218 60 89
1909 739 36 703 28 226 238 95 112
1910 822 25 797 14 155 336 130 141
1911 780 40 740 24 160 364 117 133
──────────────────────────────────────────────────────────────────────
The figures above given by no means represent all the accusations filed
with the police. They are those only that the department felt justified
in following up. As the police cannot permit themselves to be made an
indiscriminate instrument of private oppression or vengeance, they use
their own discretion as to whether they will act on a given
“denunciation.” Necessarily therefore their action is so uncertain as to
be quite ineffective; with anything less than the most complete
integrity it might readily be something worse than uncertain. The
officials are therefore in serious doubt as to whether denunciation is
workable even under the comparatively simple conditions of the Norwegian
and Danish capitals; of a commission of nine persons recently appointed
to consider the question in Copenhagen, five members favored repeal;
four favored retention, not on the ground of its general value, but as a
means of reaching utterly reckless or insane individuals who go so far
as to boast of their success in disseminating disease.[635]
But perhaps a more serious objection to denunciation from the purely
sanitary standpoint lies here;—that it continues the hurtful association
of venereal disease with the police. It works in this respect like the
reporting of patients who break off treatment without authorization. A
certain number can, of course, be laid hold of. Of 1,749 cases recorded
in the table given, 543 were compelled or induced to resume treatment.
This is, of course, so much to the good; but suppose it impedes the
wider acceptance and operation of the voluntary principle, on which, in
the long run, the success of the dispensary system depends? The large
number of disappearances above noted suggests the repellent outcome of
this traditional association, which must be completely uprooted, if
persons ill of venereal disease are to seek treatment as readily as
those ill of measles or mumps.[636]
The final columns of the table given on page 356 deserve comment on
another score. During five years, 1,749 persons discontinued treatment
for venereal disease before they were dismissed by their physicians: of
them, 1,310 were men, 439 were women. It would appear, therefore, that
men may be less intelligent and conscientious than women in the pursuit
of regular and voluntary treatment. Either sex may, of course, be the
means of indefinitely spreading infection,—women by infecting a series
of men, men by infecting a series of women. If compulsory medical
examination and treatment (i. e. regulation) are therefore to be applied
to only one sex, they ought, in the light of the Copenhagen figures, to
be applied to men rather than to women,—for of the two sexes,
compulsion, if desirable, would be best applied to the sex that makes
the less use of voluntary opportunity.
The problematical points above discussed do not, however, touch the
heart of the subject. At bottom, the issue between regulation and
abolition turns upon this question: are the ravages of venereal disease
more likely to be mitigated by the medical examination and compulsory
treatment of registered prostitutes, assuming such examination and
treatment to be as intelligent as they can be made, or by the provision
of free, abundant and confidential opportunities for all sufferers,
assuming that the dispensaries are as well conducted as they can
possibly be? In behalf of patient and thorough experimentation along the
latter line, the failure of regulation is of course the first and
perhaps most powerful argument. The Italian sanitarians lean largely on
another,—that compulsion can in no event be defended, since it involves
an infraction of personal liberty. In my judgment, it is a pity to raise
a metaphysical issue of this kind. Could it be once proved that
compulsion succeeds, society would probably not permit itself to be
balked by abstract principles of personal liberty; a not dissimilar
argument by anti-vaccinationists has been peremptorily overruled by most
civilized states. No individual’s liberty can be made to include the
privilege of spreading contagion, if a demonstrated method of checking
the process is known. In this volume, I have throughout endeavored to
meet regulation on its own ground. A verdict unfavorable to regulation
has been found in the first instance, not because it violates personal
liberty, but because it fails; because it is at least useless in respect
to order, and worse than useless in respect to venereal disease. In the
same way, the voluntary system is recommended, not because it is
consonant with modern theories of individuality, but because it may
prove the most effective way of throwing light upon the dark corners in
which disease huddles and multiplies.
Experience affords as yet no conclusive proof of the superiority of the
voluntary system. Its introduction is too recent and too limited to have
as yet affected the general situation. Moreover, the system can not be
judged until communities have been educated to take advantage of it,
or—what comes to the same thing—until it becomes evident that it is
impossible to educate the afflicted to take advantage of it. Time is a
most important factor in this matter. The ancient police association
must altogether die out; even the feeling of personal humiliation about
contamination must be taught to subordinate itself to a realization of
the duty of submitting to competent treatment. It is not surprising to
find that the women formerly registered in Copenhagen used their freedom
in the first instance to stay away; the more intelligent consulted
private physicians, but the others simply ignored their condition. This
experience does not prove either the wisdom or necessity of regulation;
it proves only the baneful effect of associating hygiene with the police
and the necessity of patience until the former association is dissolved
and an entirely new association created.
How far results may be claimed for the voluntary system, I shall
consider in a moment. But certainly the way the system operates creates
a presumption thus far in its favor. Notwithstanding the partial
retention of the police connection, the dispensaries of Copenhagen are
already treating more women than formerly were reached by regulation; in
the year 1910, of all cases reported to the Health Office, 40% had taken
advantage of the dispensaries. The following tables exhibit the
attendance of new patients at the free dispensaries during the years
1910 and 1911:[637]
Reported
for failure
Sent into to keep up
Year Men Women Children Hospital Treatment
1910 3,991 1,090 78 750 238
1911 3,748 1,165 72 644 277
Moreover, the attitude of the prostitutes themselves is perceptibly
changing. I mentioned above that at the outset they refused to attend
the dispensaries. I was, however, reliably informed that this is no
longer the case to anything like the same extent. Women who formerly
endeavored to “evade the whole thing” describe themselves now as only
“too glad to come.” M. Augagneur submitted to the French
Extra-Parliamentary Commission a comparative table strongly confirmatory
of the Danish experience. The record in question runs from 1876 to 1903;
it shows the number of women—registered and non-registered prostitutes
respectively—who were treated for venereal disease at the Hospice de
l’Antiquaille: in 1876, 835 registered prostitutes, 281 non-registered.
Thereafter, the former steadily declined with the inevitable
disintegration of the regulatory system; the latter tended to rise. In
the final year (1903) the registered prostitutes compulsorily treated
numbered only 180; the clandestines voluntarily treated had increased to
327,—i. e., the number receiving voluntary treatment was almost twice as
large as the number receiving compulsory treatment, despite the
continuance of the police association.[638]
The attitude of the medical profession is an interesting indication of
the way in which the new law has worked. At the outset, nine-tenths of
the Copenhagen doctors were regulationists; even those favorable to
abolition were fearful of sudden abolition. Nowadays the medical
professions of both Christiania and Copenhagen are described as
practically unanimous against regulation. Dr. Hoff in his vigorous
pamphlet above quoted declares that the Danish law may indeed be
modified as to details; but its main outlines are secure. And this,
despite the fact that the free dispensary has practically effaced the
specialists in venereal diseases,—an incidental result philosophically
accepted by those whom it has affected.[639]
A word as to one other peculiarity of the Scandinavian laws,—viz. the
notification of venereal disease. In Christiania, physicians are
required to report daily to the Health Department, without names, new
patients suffering with any venereal disease.[640] The Danish law is
similar; while other contagious diseases are notifiable with names,
venereal diseases are notified without names as a rule. The policeman on
the beat collects the notices as he makes his rounds. A circular, dated
July 1, 1912, institutes a similar form of notification in Sweden. It is
stated that all cases of contagious sexual disease must be reported by
the attending physician in franked envelops to the “official physician
of the province or the board of health, with the name of the disease,
the age and sex of the patient, but without name and address.”
Notification answers in general a statistical purpose; but in Denmark, a
patient who interrupts treatment may be reported by name and find
himself forced to continue treatment or to fly. It is impossible to
discover that notification itself has had any bad effects whatsoever. It
appears rather to have assisted in making the sufferer realize his
danger to others,—precisely as the notification of other diseases has
resulted in increased conscientiousness. The fear one observes among
English abolitionists, that notification may prove an indirect method of
reinstating regulation of one sex is baseless, in so far as Denmark and
Norway are concerned.
Of the other abolition countries,—Great Britain, Switzerland and
Holland, none has as yet taken the disease problem seriously.
_Laissez-faire_—an unreasoning, prejudiced _laissez-faire_, at
that—still prevails.
In England, the public authorities concerned with the prevention and
treatment of disease have thus far made “no organized effort to diminish
the prevalence of venereal disease,” nor would the desirability of their
interesting themselves in the matter “be accepted as indisputable.”[641]
The hospital provisions for venereal diseases are utterly inadequate.
Indoor accommodation in the large voluntary hospitals of London there is
practically none,—and this even in teaching hospitals. It is held that
“it is unreasonable to expect subscribers to spend their money on
rescuing persons from the consequences of their sins.”[642] The
Inspector for the Local Government Board reports that “no beds or wards
were reserved for infective venereal cases in any of 30 general
hospitals visited in London and the provinces. In one of the London
hospitals, a rule precluded the treatment of unmarried women suffering
from venereal disease, though no such rule existed with regard to
unmarried men.”[643] A more liberal policy characterizes the out-patient
departments, though their organization and equipment are both defective.
The poor law infirmaries and workhouses are apt to be better equipped;
and it is interesting to note in passing that the administrators of
these institutions when asked for their “opinion regarding the
advisability of endowing the guardians with the powers of compulsory
detention (of those seeking treatment for venereal complaints) were
practically unanimous in declaring that it would deter patients from
coming.” A few special hospitals called lock-hospitals (the name is
etymologically obscure, but has nothing to do with “lock-up”) are also
devoted to the care of venereal patients. Of these, recent writers
state: The lock-hospitals are pathetically meager, containing “in London
136 beds for females, 27 for males; elsewhere about 70, making perhaps
250 in the United Kingdom.”[644] Out-patient services are also found in
connection with the lock-hospital. English conditions in this respect
therefore deserve the severe language of Sidney and Beatrice Webb: “The
man or woman suffering from gonorrhœa or syphilis, even if the innocent
victim of another’s guilt, is refused admission to the voluntary
hospital; deterred, and as often as possible, hustled out of the
workhouse; and wholly unprovided for by the local health
authority.”[645] Moreover, the method of conducting the only available
resort—the lock-hospital—is more or less repellent. The patient is made
to feel that his cure ought also to be a penance. The head nurse opens
and reads all letters sent or received, a measure that marks off the
venereal from any other patient. The sanitary spirit is as yet quite
undeveloped: “I don’t believe in making it safe”—remarked the secretary
of a lock-hospital to me, just as we entered the children’s ward, where
thirty to forty innocent victims were under his care, the moral and
medical aspects of the problem as yet hindering each other in his mind!
The abolition cities on the Continent are in respect to hospital
facilities much better off, for dermatological clinics, including beds
for venereal diseases, form part of the general hospitals in large
cities.
I have now briefly described conditions as to the laws and hospital
provisions relating to venereal disease in various abolition countries.
The issue between abolition and regulation ought in theory to be
determinable by an inspection of statistical results, contrasting the
results in regulation and abolition countries respectively. Is this the
case?
There are many reasons why a summary method of settling the question by
results is inapplicable. In the first place, available data are neither
sufficiently reliable nor sufficiently complete.[646] Recent
improvements in diagnostic art show the existence of venereal disease
where mere clinical examination—up to recently the sole reliance of the
physician—is incapable of discerning it; in some cases, the same
improvements now result in a negative diagnosis where superficial
appearance might formerly have led to a positive opinion. Hence one
serious defect of even conscientiously compiled figures. But there is
another serious source of error. Such general statistics as exist are in
an extraordinary degree fractional and unscientific. Only in certain
small sections of Scandinavia has a more or less accurate system of
reporting been in vogue for even a relatively short period. Elsewhere
our inferences must be based on hospital and insurance reports or rough
personal estimates. In these conditions, so narrow a question as the
issue between regulation and abolition does not lend itself to
statistical determination.[647]
Statistics and opinion, however, both concur in an indirect contribution
to the problem. Venereal disease is shown by both to be so widely
prevalent in regulated cities that one marvels whether the situation
could really be any worse under even the most radical _laissez-faire_
abolition. It is a truism that physicians eager to equip themselves as
specialists in venereal disease resort to the crowded clinics of Paris,
Vienna, and Berlin, all regulated towns, because there disease is found
in greatest abundance and richest variety,—a strange comment on the
alleged efficacy of regulation! On the basis of all available sources of
information, Blaschko calculates that of the clerks and merchants in
Berlin between 18 and 28 years of age, 45% have had syphilis, 120% have
had gonorrhœa; 77% have had syphilis, 200% have had gonorrhœa in
Breslau.[648] Similar inquiry among students shows according to the same
investigator, that “in the course of his four years at the University,
every student is venereally infected at least once,—a statement that no
one familiar with the facts will be inclined to question.”[649] Pinkus
declares that in Germany one man in every five has had syphilis,[650]
and that gonorrhœa averages more than one attack per man.[651]
An attempt was made by the Prussian Government to take a census of the
amount of venereal disease among men in the Kingdom on April 30, 1900.
It developed—as far as the returns showed—that in general on that day 28
men out of every 10,000 were infected; in Berlin, however, the average
was 142 per 10,000; in cities of over 100,000 inhabitants, 100 per
10,000; in the cities of over 30,000 inhabitants, 58 per 10,000; in
cities under 30,000 inhabitants, 45 per 10,000. The results may be
represented thus:
[Illustration: FIGURE I.—Venereal disease among males in the population
of Prussia, April 30, 1900.]
The inference to be drawn from Figure I is obvious: the amount of
venereal disease is in direct relation to the size of the town. The
figures given cannot accurately represent the actual totals; but they
may nevertheless give a fairly reliable indication of relative
conditions. The steady decrease with the size of the city appears to
suggest the main, perhaps the sole important concrete factor, viz., the
size of the city; a factor upon which we shall stumble again in another
connection.
A similar inquiry was also made in Sweden, with a view to determining
how many persons were under treatment for infectious venereal disease
January 31, 1905. A questionnaire was sent to 1,264 physicians, of whom
1,181 replied.[652] The Swedish and Prussian figures are set side by
side in the following table:[653]
SWEDEN (JAN 31, 1905)
Syph. Soft chancre Gon.
Stockholm (pop. 317,964) 23. 1.2 31.2
Göteborg (pop. 138,030) 15.6 1.4 18.9
Malmö (pop. 70,797) 14.4 3.1 28.6
Norrköping (pop. 44,378) 11.3 0.3 16.8
Whole Kingdom 3.6 0.3 5.4
PRUSSIA (APR. 30, 1900)
Berlin 23.6 5.8 53.2
Seventeen cities of more than 100,000 inhab. 17.8 3.5 32.6
Forty-two cities 30–100,000 10.8 1.9 19.6
Whole Kingdom 5.1 1.1 9.9
A more definite impression is obtainable regarding the incidence of
venereal disease in European armies: do the curves thus arrived at throw
any light on the issue between regulation and abolition? The subjoined
graph (Fig. II) embodies the official statistics of the war offices of
Europe from 1881 to 1905.
[Illustration: FIGURE II.—Venereal disease in European armies.]
At first sight, the graph might be interpreted as a conclusive argument
in behalf of regulation. But careful consideration entirely changes its
significance. In the first place, the earlier or more unfavorable
English statistics are stated to be altogether unreliable. It is indeed
on the face of the matter impossible to credit anything like the
precipitous decline depicted. Moreover, the implied comparison is itself
unfair. A continental army includes the youth of the entire nation,—all
those between certain ages,—city and country boys alike; the good
elements dilute the showing that would be made by the bad. The English
army, on the other hand, is a volunteer force, largely recruited from
among the adventurous and the derelict,—precisely those among whom an
inordinately large proportion of venereal disease would naturally occur.
The continental curves may represent the condition of the total male
population of the ages in question; the English curve speaks for only a
single section and the two cannot be directly compared. Moreover, the
very magnitude of the discrepancy is fatal to its explanation by
regulation. The marked variations between the armies of regulated
countries,—Italy, Austria, and Prussia, indicate clearly the existence
of other factors. Finally, there is observable a general movement
downwards coinciding with the breakup of regulation on the Continent. If
regulation exerts a perceptible effect, its narrowing scope ought to be
attended by a gradual rise in the curves, instead of the reverse.
To whatever the general differences in the curves be due, there is
nothing in them to suggest that regulation plays any rôle whatsoever.
Closer consideration of separate curves will establish this proposition
beyond dispute. The English Contagious Diseases Acts, under which
medical inspection of prostitutes was instituted, were repealed in
1886,[654] the very year in which the graph records the highest
incidence of venereal disease in the army. Repeal was followed, not by a
rise, but by a fall that, except for the interlude created by the Boer
War, has continued almost uninterruptedly from that day to this.
Regulation was at its height in England from 1870 to 1882. In the former
year, of 38,408 recruits inspected, 15.78 per thousand were rejected on
the score of syphilis; the number of recruits increased during the
period in question to 45,423, of whom in the last year of effective
regulation 10.72 per thousand were rejected for the same reason. Is this
improvement attributable to regulation? Clearly not; for the rate of
rejection has declined since abolition more rapidly than at any other
time: in 1886, 77,991 were examined and 8.18 rejected per thousand; in
1897, 59,986 were examined and 3.47 rejected per thousand.[655]
The annual admission of enlisted men to hospitals for venereal diseases
tells the same story. In 1886—the year of the repeal, this reached the
startling total of 267.1 to the thousand; by 1900, the figure had fallen
to 93.2; it rose to 125 in 1903, and fell thereafter steadily to 66 in
1909.[656]
The curve (page 374)[657] shows admissions, per thousand of strength,
for syphilis (primary and secondary) in the army at home and in India
for the years 1880–1908.
[Illustration: FIGURE III.—Admissions per 1,000 for syphilis, British
army, 1880–1908.]
Finally, a comparison made between regulated and non-regulated military
stations before and during regulation and after abolition exhibits
capricious variations indicating clearly the negative outcome of
regulation: (See Fig. IV, p. 376.)
Col. Melville’s analysis is as follows: “The most obvious fact is the
parallelism of the curves. Though the curve for unprotected stations is
on the whole higher, they follow the same general trend. They both fall
at first, and from 1875, they both rise steadily. Regulation did not
keep disease down between 1876 and 1882; its increase in unprotected
stations was proportionately somewhat less than in the protected. The
marked increase in the protected stations after relaxation of the rules
in 1882 only continues the rise originating six years previously. Total
repeal in 1886 is followed by a very marked fall in both curves, which,
however, had begun in 1883 in the unprotected, and in 1884 in the
protected, stations.”[658]
Statistics of
the British
Army.
Admission to
Hospital for
Venereal
Disease. Ratio
per 1,000 of
Strength.
Year Home Army
1882 246.0
1883 260.0
1884 270.7
1885 275.7
1886 267.1
1887 252.9
1888 224.5
1889 212.1
1890 212.4
1891 197.4
1892 201.2
1893 194.6
1894 182.4
1895 173.5
1896 158.3
1897 139.7
1898 132.7
1899 122.4
1900 93.2
1901 105.4
1902 122.7
1903 125.0
1904 107.6
1905 90.5
1906 82.0
1907 71.9
1908 68.4
1909 66.0
[Illustration: FIGURE IV.—Comparison of 14 protected with 14 unprotected
stations in respect to admissions with primary venereal sores.]
German army statistics, intensively studied, yield a similarly negative
result as to benefits of regulation in respect to the incidence of
venereal disease. Recurring to Figure II (p. 370) we observe that the
extent of infection decreased continuously from 1881 (as in all other
armies except the Italian, where irregularities are considerable) up to
1900, despite the fact that, as has been shown, methods of medical
examination were so crude that they probably caused more disease than
they isolated. The Dutch curve has also consistently dropped,—most of
all so, since abolition.[659] In Stockholm, the statistics exhibit the
same decline, coincidentally with the gradual weakening of
regulation.[660]
Closer inspection of the Prussian statistics brings to light the one
significant factor that we have already remarked in a previous
correction, viz., the size of the community involved. It appears that
during a series of years the percentage of venereally infected recruits
is practically constant at 7.7%, despite the ups and downs of regulation
meanwhile; but infection in different army corps shows wide
discrepancies, varying from four per cent. in the XI, XIII, and XIV army
corps to 20.7 per cent. in the III, which is stationed in and about
Berlin. The same relation holds as to recruits. In the years 1903–5,
41.3 of the Berlin recruits were venereally infected; 30 per cent. of
the recruits from Hamburg and Altona,—yet these are the most effectively
regulated towns in the German Empire. I do not mean to imply that the
amount of infection is to be accounted for by the existence of
regulation, but rather that it is clear that regulation does not lessen
it. The really important factor is the size of the town. For throughout
the period just mentioned (1903–5) the extent of infection among
recruits dwindled with the size of the places from which they were
drawn; regulation had nothing whatever to do with it. Berlin, as I have
said, showed an infection of 41.3 per cent.; towns of more than 100,000
inhabitants 15.8 per cent.; towns between 50,000 and 100,000, 10.2 per
cent.; those between 25,000 and 50,000, 8 per cent.; smaller towns and
the country districts, 4.4 per cent. The size of the garrison has a
similar effect. A small garrison (less than 400) shows venereal
infection of 11.9 per cent. in 1905–6; a garrison between 1,000 and
3,000, 16.9 per cent.; a garrison between 5,000 and 10,000, 19.8 per
cent.; garrisons of over 10,000, 26.6 per cent. Regulation can have had
no influence whatever on these figures; and this is all the more certain
in view of the fact, that though regulation has tended to disintegrate
in the last two decades, the percentage of infection, everywhere a
matter of the size of the place or the garrison, has in this period,
everywhere in absolute amount markedly decreased: in the smallest
garrisons, from 33.2 per cent. in 1885 to 11.9 per cent. in 1905; in the
largest, from 36.8 per cent. in the former year to 26.6 in the
latter.[661]
Evidence more direct, though of limited range in point of time, is
contributed by various towns that have adopted the abolition policy. Of
these, Christiania is by far the most satisfactory. It has the longest
record and the most satisfactory statistics; for venereal diseases have
been notifiable since 1876, though the form of notification has
undergone some modification. If diagnostic means have not been too
defective in the past, a stretch of something like 20 years is
represented by the abolition experience of the Norwegian capital, which
has increased in population during the period in question from something
below 80,000 to almost a quarter of a million.
The official table (see p. 380) gives the local situation from 1876 to
1911, inclusive.[662]
════╤═══════════════╤═══════════════╤═══════════════╤═══════════════
│ │ │ │
│ │ │ │
│ │ │ │
│ │ │ │
│ │ │ │
│ │ │ Acquired │ Congenital
Year│ Gonorrhea │ Soft Chancre │ Syphilis │ Syphilis
────┼────┬─────┬────┼────┬─────┬────┼────┬─────┬────┼────┬─────┬────
„ │ Men│Women│Both│ Men│Women│Both│ Men│Women│Both│ Men│Women│Both
────┼────┼─────┼────┼────┴─────┴────┴────┴─────┴────┼────┼─────┼────
1876│ │ │ 593│ 419 │ │ │
1877│ │ │ 909│ │ │ 134│ │ │ 297│ │ │ 33
1878│ │ │1040│ │ │ 166│ │ │ 311│ │ │ 31
1879│ 951│ 176│1127│ 200│ 114│ 314│ 211│ 154│ 365│ 21│ 15│ 36
1880│1208│ 219│1427│ 265│ 99│ 364│ 268│ 156│ 424│ 21│ 22│ 43
────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────
1881│1277│ 199│1468│ 353│ 78│ 431│ 302│ 151│ 453│ 33│ 39│ 72
1882│1140│ 146│1286│ 580│ 127│ 707│ 308│ 188│ 496│ 21│ 23│ 44
1883│1100│ 186│1286│ 257│ 49│ 306│ 175│ 111│ 286│ 21│ 15│ 36
1884│1118│ 142│1260│ 208│ 57│ 265│ 172│ 126│ 298│ 17│ 22│ 39
1885│ 997│ 186│1183│ 175│ 32│ 207│ 148│ 123│ 271│ 33│ 29│ 62
────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────
1886│1095│ 99│1194│ 292│ 65│ 357│ 163│ 101│ 264│ 25│ 14│ 39
1887│ 829│ 106│ 935│ 306│ 37│ 343│ 175│ 97│ 272│ 21│ 23│ 44
1888│ 509│ 66│ 575│ 71│ 16│ 87│ 103│ 109│ 212│ 18│ 14│ 32
1889│ 585│ 85│ 670│ 73│ 8│ 81│ 187│ 107│ 294│ 10│ 22│ 32
1890│ 679│ 60│ 739│ 213│ 25│ 238│ 330│ 178│ 508│ 16│ 13│ 29
────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────
1891│ 759│ 42│ 801│ 180│ 15│ 195│ 303│ 170│ 473│ 10│ 10│ 20
1892│ 935│ 90│1025│ 192│ 13│ 205│ 355│ 208│ 563│ 9│ 18│ 27
1893│1069│ 97│1166│ 260│ 23│ 283│ 278│ 229│ 507│ 12│ 15│ 27
1894│1283│ 121│1404│ 281│ 29│ 310│ 353│ 193│ 546│ 25│ 17│ 42
1895│1482│ 126│1608│ 387│ 34│ 421│ 518│ 206│ 724│ 26│ 14│ 40
────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────
1896│1471│ 149│1620│ 393│ 49│ 442│ 498│ 235│ 733│ 32│ 28│ 60
1897│2031│ 173│2204│ 447│ 46│ 493│ 450│ 233│ 683│ 25│ 25│ 50
1898│2125│ 207│2332│ 433│ 51│ 484│ 565│ 259│ 824│ 25│ 27│ 52
1899│1966│ 191│2156│ 491│ 44│ 535│ 543│ 221│ 764│ 35│ 34│ 69
1900│1871│ 170│2041│ 507│ 43│ 550│ 457│ 195│ 652│ 28│ 26│ 54
────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────
1901│1684│ 174│1858│ 292│ 32│ 324│ 432│ 208│ 640│ 23│ 17│ 40
1902│1576│ 159│1735│ 418│ 37│ 455│ 368│ 196│ 546│ 20│ 28│ 48
1903│1570│ 183│1753│ 401│ 39│ 440│ 431│ 183│ 614│ 24│ 20│ 44
1904│1392│ 139│1531│ 347│ 20│ 367│ 355│ 154│ 509│ 26│ 34│ 60
1905│1384│ 139│1523│ 278│ 16│ 294│ 340│ 128│ 468│ 24│ 26│ 50
────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────
1906│1108│ 132│1240│ 169│ 14│ 183│ 802│ 129│ 431│ 19│ 16│ 35
1907│ 903│ 112│1015│ 133│ 10│ 143│ 251│ 123│ 374│ 10│ 25│ 35
1908│1055│ 107│1162│ 198│ 21│ 219│ 278│ 134│ 412│ 24│ 26│ 50
1909│1149│ 101│1250│ 172│ 19│ 191│ 315│ 142│ 457│ 31│ 27│ 58
1910│1261│ 98│1359│ 206│ 14│ 220│ 332│ 141│ 473│ 27│ 13│ 40
────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────┼────┼─────┼────
1911│1373│ 94│1467│ 327│ 27│ 354│ 356│ 163│ 519│ 19│ 17│ 36
────┴────┴─────┴────┴────┴─────┴────┴────┴─────┴────┴────┴─────┴────
════╤═════╤══════════╤══════════╤══════════
│ │ │ │ Reported
│ │ │ │ cases of
│ │ │ Reported │ syphilis
│ │ │ total as │ as
│ │ │percentage│percentage
│ │ │ of │ of
Year│Total│Population│population│population
────┼─────┼──────────┼──────────┼──────────
„ │ „ │ „ │ „ │ „
────┼─────┼──────────┼──────────┼──────────
1876│ 1012│ 79 022│ 1.28│ 0.53
1877│ 1373│ 106 781│ 1.28│ 0.31
1878│ 1548│ 112 977│ 1.37│ 0.30
1879│ 1842│ 116 801│ 1.58│ 0.34
1880│ 2258│ 119 407│ 1.39│ 0.39
────┼─────┼──────────┼──────────┼──────────
1881│ 2424│ 122 036│ 1.99│ 0.43
1882│ 2533│ 122 424│ 2.07│ 0.44
1883│ 1924│ 124 155│ 1.55│ 0.26
1884│ 1862│ 128 300│ 1.45│ 0.27
1885│ 1723│ 130 790│ 1.32│ 0.25
────┼─────┼──────────┼──────────┼──────────
1886│ 1854│ 134 036│ 1.39│ 0.23
1887│ 1594│ 135 615│ 1.18│ 0.23
1888│ 906│ 138 319│ 0.66│ 0.18
1889│ 1077│ 143 347│ 0.75│ 0.23
1890│ 1514│ 151 130│ 1.00│ 0.26
────┼─────┼──────────┼──────────┼──────────
1891│ 1489│ 156 535│ 0.95│ 0.31
1892│ 1820│ 161 151│ 1.13│ 0.37
1893│ 1983│ 167 588│ 1.18│ 0.32
1894│ 2302│ 174 717│ 1.32│ 0.34
1895│ 2793│ 182 856│ 1.52│ 0.42
────┼─────┼──────────┼──────────┼──────────
1896│ 2855│ 192 554│ 1.48│ 0.41
1897│ 3430│ 203 337│ 1.69│ 0.36
1898│ 3692│ 221 255│ 1.67│ 0.40
1899│ 3525│ 226 423│ 1.56│ 0.37
1900│ 3297│ 228 929│ 1.44│ 0.31
────┼─────┼──────────┼──────────┼──────────
1901│ 2862│ 224 909│ 1.27│ 0.30
1902│ 2802│ 225 709│ 1.24│ 0.27
1903│ 2851│ 223 649│ 1.27│ 0.29
1904│ 2467│ 222 373│ 1.11│ 0.26
1905│ 2335│ 226 774│ 1.03│ 0.23
────┼─────┼──────────┼──────────┼──────────
1906│ 1889│ 229 324│ 0.82│ 0.21
1907│ 1567│ 231 687│ 0.68│ 0.18
1908│ 1843│ 235 674│ 0.78│ 0.20
1909│ 1956│ 239 511│ 0.82│ 0.22
1910│ 2092│ 244 038│ 0.86│ 0.21
────┼─────┼──────────┼──────────┼──────────
1911│ 2376│ 247 488│ 0.96│ 0.22
────┴─────┴──────────┴──────────┴──────────
In the period covered by these statistics, the population of Christiania
has trebled; we might, therefore, expect a marked rise in the presence
of venereal disease. As a matter of fact, the incidence of syphilis was
never again so high as in the first year; with certain fluctuations, it
fell, despite the marked increase in population, from .53 per cent. in
1876 to .22 per cent. in 1911. The decline in all three diseases taken
together, though not quite so striking, is sufficiently noteworthy in
the face of general conditions that might account for a rise: 1.28 per
cent. in 1876, .96 per cent. in 1911. Abolition took place in 1887.
During some of the following years a rise is observable, explicable in
several ways: (1) It was the purpose of the law to induce disease,
hitherto hidden, to come out into the open. The breaking of the police
association, the prominence given to the free dispensary, ought to have
brought out cases that under the old order were handled secretly and
thus escaped reporting; a rise in the number recorded might mean not
more fresh cases, but merely more cases under proper treatment. (2)
Coincidently with the introduction of the new law, these diseases had to
be reported daily, instead of monthly, and greater accuracy in this
respect might account for a rise indicating not more disease, but more
complete statistics.
The experience of Copenhagen is unfortunately too brief to be of
commanding importance; a proper system of notification was introduced
for the first time in July 1912. Available statistics, obviously very
incomplete, make the following showing:[663]
Soft Acquired Congenital
Years Gonorrhœa Chancre Syphilis Syphilis Syphilis Total
1907 5,684 728 1,869 39 63 8,383
1908 6,320 1,164 2,349 63 61 9,957
1909 6,029 1,034 2,108 57 52 9,280
1910 6,076 848 2,330 39 85 9,378
1911 6,500 692 2,543 66 87 9,888
During five years there has been on the face of the figures a rise of 18
per cent. in the total number of cases reported. Does this indicate
wider contamination as a result of abolition? Let us consider. During
the same period the population increased from 426,540 to 462,161, (i. e.
8 per cent.), so that to some extent at least the apparent increase is
relative, not absolute. Moreover, the entire tendency, here as in
Christiania, has been to lay hold of as many infected persons as
possible; in other words, unless more cases were brought to light for
some years to come, the dispensary policy would be a failure. Indeed, in
the early years, the dispensary physicians were paid per patient, in
order to enlist their active coöperation in ferreting out foci of
infection.
Graphic representation shows that abolition has done no harm, even
though the most unfavorable interpretation be placed upon the figures.
The rapid decline immediately prior to repeal would appear to indicate
that abolition took place when Copenhagen was, in respect to venereal
disease, in the trough of the wave. Free dispensaries brought some
hidden cases to light; hence, a brief rise,—a reaction from which is
already in progress, partly explicable, perhaps, by the extinction of
some active foci through treatment.
The curves (pp. 383, 384, 385) show the course of venereal diseases in
Copenhagen on the basis of the Reports of the Health Department.[664]
[Illustration: FIGURE V.—Course of syphilis at Copenhagen.]
[Illustration: FIGURE VI.—Course of gonorrhœa at Copenhagen.]
[Illustration: FIGURE VII.—Course of soft chancre at Copenhagen.]
In relation to population, the following table shows the incidence of
venereal disease per 10,000 inhabitants since 1867. Needless to repeat,
only the statistics of more recent years are of any genuine
consequence:[665]
────────────────────────────────────
Year Gonorrhœa Soft chancre Syphilis
1867 128 50 49
1868 144 73 56
1869 152 92 58
1870 158 59 47
1871 148 49 42
1872 160 72 45
1873 147 71 39
1874 159 69 40
1875 162 42 33
1876 178 53 32
1877 186 46 32
1878 196 37 32
1879 194 38 41
1880 190 40 40
1881 200 54 40
1882 222 60 42
1883 226 51 45
1884 207 61 49
1885 212 51 66
1886 202 55 73
1887 183 32 59
1888 174 24 41
1889 148 31 31
1890 140 28 30
1891 129 25 31
1892 129 24 28
1893 135 20 32
1894 122 20 36
1895 118 13 40
1896 124 16 39
1897 128 22 42
1898 133 22 48
1899 125 19 48
1900 129 17 50
1901 137 24 57
1902 127 14 46
1903 125 11 43
1904 115 11 39
1905 114 11 32
1906 112 18 33
1907 129 17 45
1908 142 26 56
1909 134 23 49
1910 132 18 53
1911 140 15 58
────────────────────────────────────
Dr. Rudolf Krefting, of Christiania, has plotted out two highly
interesting curves by way of depicting and comparing the course of
events in Copenhagen and Christiania in respect to syphilis.[666] (See
Fig. VIII, p. 387.)
[Illustration: FIGURE VIII.—Copenhagen and Christiania compared in
respect to syphilis.]
Despite considerable variations, the dotted line shows, as we have
already observed, that there was relatively to population less syphilis
in Christiania in 1910 than in 1890; that, though the amount of disease
treated in abolition Christiania was in the years immediately succeeding
repeal greater than the amount reported in Copenhagen, conditions
rapidly improved, so that the situation is now well in hand. The maximum
was reached almost twenty years ago (1895). The Copenhagen curve
continues to rise until 1901, when it falls unaccountably, rises on
repeal of regulation and shows a declining tendency as the new system
gets to working more smoothly. In any event, Copenhagen with control and
with an imperfect system of notification actually shows almost
uninterruptedly more syphilis than Christiania without control and with
a much more thorough system of notification.[667] That abolition alone
is to be credited with the decline or with the difference between the
two cities cannot be maintained; for similar declines—less credible,
perhaps, inasmuch as the data are less reliable—are observable under
regulation also. A very marked instance I have just noted, viz., the
decline in reported cases of syphilis at Copenhagen between 1901 and
1905,—while regulation was still in vogue. That abolition with the
dispensary system treats more disease than regulation is beyond all
question; that it treats enough more to affect sensibly the disease
curves one may believe, but may not yet hold to be scientifically
demonstrated. But this is not essential, for unless the evidence is
clearly in its favor, regulation falls to the ground. As to this, there
is no question whatsoever. The medical profession, the health
authorities, the police of both Christiania and Copenhagen are well-nigh
unanimous in their conviction on the basis of experience and statistics
that abolition has done no harm; and if abolition has done no harm,
assuredly regulation can have done no good.[668]
A single bit of evidence may also be gleaned from the experience of
Zurich. The records of the Policlinic (out-patient department or
dispensary) and the cantonal hospital are available since 1894. Bordells
were forbidden in 1897. The population of the city was at that time
140,000; by 1911, it had risen to 195,600. Yet the total number of cases
treated at the dispensary fell from 483 in the former year to 392 in the
latter. The number of venereal patients admitted to the cantonal
hospital, 114 in 1897, has now risen to 251, but the ratio to population
has decreased. These facts are indicated on Figures IX and X.
[Illustration: FIGURE IX.—Venereal diseases, Zurich Policlinic.]
Let us now bring together the results of the two chapters in which we
have discussed this problem. In the first place, let me remind the
reader of the absurdity of supposing that regulation means that the
authorities are alive to the problem of venereal disease and that
abolition means that they close their eyes to it. Regulation means
simply that the police deal with a very small portion of venereal
disease; on the Continent, at least, abolition means that the health
authorities are energetically attempting to reach more and more of it.
[Illustration: FIGURE X.—Venereal diseases, Canton hospital, Zurich.]
In the second place, we must emphasize the fact that venereal disease is
inevitably attendant upon sexual promiscuity. Venereal disease is an
evil in itself and deserves to be combated with all the resources and
facilities known to science and to sanitation; but so long as
prostitution exists, venereal disease will remain serious and
widespread; we have discovered absolutely no reason—statistical or
other—to believe that regulation at all reduces its ravages; there is,
however, good reason to believe that the bordell and the medical
examination contribute to its aggravation by increasing miscellaneous
commerce and by decreasing resistance. On the other hand, there is no
ground—statistical or other—for believing that abolition increases
disease; there is excellent reason for believing that abolition, plus a
deliberately planned and organized dispensary system, has already proved
a mitigating factor and is capable of much greater usefulness than has
yet been anywhere realized.
This summary still leaves on our hands the problem of understanding the
fluctuations of venereal infection. But in this respect, venereal
disease is one with other infections and contagions. All alike are
subject to unaccountable ups and downs. We know as yet practically
nothing of the factors which determine the rise and fall of infectious
disease curves, or the outbreak and the subsidence of epidemics. Apart
from any prophylactic measures yet known to science, such scourges as
syphilis and gonorrhœa wax and wane. Throughout the world, there is some
evidence to suggest that aside from temporary disturbances due to
war,[669] they have been for a decade or two in the declining stage;
whether this is temporary or permanent we have absolutely no means of
telling; experience suggests the former, but time alone will tell.
I would not, however, convey the notion that all fluctuations are
mysterious and spontaneous and that therefore nothing can be
accomplished by intelligent action. The army curves are an argument
against any such fatalistic view. With increased keenness of military
competition, every factor conducive to efficiency has to be reckoned
with; the outcome of war would, it is felt, depend not only on
battleship tonnage and the paper strength of the army, but on the health
of the crew and of the enlisted men; their physical vigor is at least as
important as smokeless powder and a powerful rifle. Almost
simultaneously, therefore, the war authorities of Europe have undertaken
to compete with the tavern and the wanton. Games are cultivated, places
of recreation provided, the spirit of emulation has been aroused; and
instruction is given,—the enlisted man is taught that continence is
possible and wholesome; he is urged, if he has indulged himself, to
employ prophylactic measures;[670] in the highly probable event of their
failure, he is to have prompt recourse to the surgeon. A successful
effort to bring about more sparing use of alcohol has perhaps done more
than anything else to make these devices and suggestions fruitful.
The indisputable improvement that intelligent endeavor has thus effected
in all European armies is a strong argument in behalf of applying a
similar policy to the general population. I have said that venereal
disease is an evil in itself,—a serious drain on the efficiency of the
body politic. That nation which first succeeds in reducing it will have
scored heavily on its competitors. The German Society for combating
venereal disease[671] is the most vigorous organ in Europe engaged in
the cultivation and dissemination of this point of view. Waiving
consideration of other aspects of the problem of prostitution, for the
time being, it urges that the same methods be employed in the contest
with venereal disease that are invoked against other scourges: medical
research for the means of prevention, isolation and cure; enlightenment
of all those afflicted or liable to affliction in order that the willing
intelligence of the patient may cooperate with the rational intent of
the community. Thus tuberculosis, measles, small-pox, cholera and other
pests have been attacked with some measure of success. Venereal disease
offers indeed peculiar difficulties, but they are difficulties that only
strengthen the argument for intelligence and resource broadly utilized.
If this be true, the situation described does not call for regulation,
tending, as it does, to concentrate its fire upon a few foci, and to
cover up other sources of infection so that they fester in darkness, but
rather for the more liberal and enlightened policy, which, if not
identical with abolition, follows naturally in its wake.