“One who, being aware that he is suffering from a contagious venereal disorder, performs coitus, or in any other way exposes another human being to the danger of infection, shall be punished with imprisonment for a term of two to three years, and in addition shall be deprived of civil rights.”
“One who, being aware that he is suffering from a contagious venereal disorder, performs coitus, or in any other way exposes another human being to the danger of infection, shall be punished with imprisonment for a term of two to three years, and in addition shall be deprived of civil rights.”
Schmölder enlarged this clause by an amendment relating to the punishment of prostitutes disseminating venereal diseases.
On the other hand, von Bar drew attention to the inconveniences and dangers which a punishment of this nature would involve, especially to the dangers ofblackmail, and to theduty it would impose on physiciansof breaking their obligations of professional secrecy. Moreover, a proof of theknowledgeof venereal infection is difficult to obtain; the proof that infection is derived from a definite person is also far from easy. Von Bar opposed the addition of such a clause on this and other grounds. In the discussion upon the motion, this view was shared by C. Fränkel, Ries, Oppenheimer, and others; Neisser was in favour of a punishment of this kind, because then, at any rate, there would be a public recognition of the fact that such an action was open to severepunishment, and was adisgracefulone; thus, by the mere existence of the paragraph aneducative influencewould be exerted.
In any case, such a punishment would be a two-edged weapon, and as far as present necessity goes, we have sufficient powers in the application to such offences of the paragraphs of the Criminal Code relating to bodily injury.
The second great means for the limitation and entire suppression of venereal diseases isto deal with them by medical treatment, to cure as speedily as possible persons suffering from syphilis of gonorrhœa, and thus to prevent these persons from becoming sources of fresh infection. Systematic, methodical treatment on a large scale—that is thegoalat which we have to aim. To the poor man or woman suffering from venereal infection the same advantages should be opened as to the wealthy voluptuary. The provision of means of treatment of venereal diseasescannot be too free. In public hospitals, private clinics, ambulatoria, and sanatoria, in convalescent homes, and polyclinics for prostitutes, everywhere must be provided means for an intelligent treatment of venereal diseases. Just as tuberculosis is now attacked systematically and vigorously, so must it be with venereal diseases.
Sincesyphilisconstitutes only about 25 %—only one-fourth part, that is to say—of venereal diseases in general, since also during the last four centuries the disease has shown a natural tendency to decline in virulence, since a mitigation in the intensity of the virus is clearly recognizable, it is in the case of this disease that thehope of radical successis especially great.
Our forefathers carried out for us a great part of the campaign against syphilis. Thecomparatively mildcourse of syphilis in the majority of uncomplicated cases leads us to infer that there has been a relative immunization against syphilitic poison.
Albert Reibmayr remarks that “during the last 400 years, every human being now living in Europe has had about 4,000 ancestors; of these, however disagreeable the fact may seem, a considerable number must have had to contend withsyphilis.”[345]
But this undoubted fact, thatall of ushave been to a certain extent“syphilized,”[346]plays its part to our advantage in the campaign against syphilis—that campaign which our own time has taken up with joyful hope of success.
Above all, let honour be paid to the ever youthful and fresh master and Nestor of European research into the subject of syphilis, Alfred Fournier, the evening of whose life is devoted to the campaign against syphilis as a “social danger.” To the great scientific works of his life he has now added the small, but not less valuable,explanatory writings, which are being sold at a low price all over France, and in part also have already been translated into German andEnglish.[347]Their aim is to get thepeopleon our side in the campaign against syphilis.
When, in April, 1906, I paid the master a visit, he gave me thelast of these popular campaign writings. Its title was in the form of a question:
“En Guérit-on?” (“Is it Curable?”).
And the answer given on p. 4 runs: “Yes, it is curable, for of all diseases syphilis is the one which can best, most easily, and most certainly be cured.” And why? Because we have a wonderful specific against this disease, which, when givenat the proper timeandin the proper manner, works a miracle. This remedy is
Mercury.
I put this name clearly and visibly before the eyes of the reader, a name which for every physician to whose lot it falls to treat cases of syphilis has a truly miraculous sound, a name against whichthe unconscientious ignoramuses, the evil-disposed enemiesof the human race have spoken their anathema, one which a great thinker and honourable man like Schopenhauer regarded as a “triumph of medicine,” a fact which he experienced personally in his own body. All honourable, critical, and scientific physicians agree in this opinion. In my work on “The Origin of Syphilis,” vol. i., p. 127, I have expressed the matter in the following words:
“Mercury is and remains—notwithstanding the ignorant and ill-considered hostility of quacks and their kindred—thedivine meansfor the treatment of syphilis; mercury is to syphilis whatwater is to fire, in the handsof that physician who knows how to use the drug rightly, how to apply itat the right timeandin the right form, who watches closely thecourseof the disease in his patient, and who supports the mercury cure (always ofprimary importance) by other therapeutic measures as indicated.”
“Mercury is and remains—notwithstanding the ignorant and ill-considered hostility of quacks and their kindred—thedivine meansfor the treatment of syphilis; mercury is to syphilis whatwater is to fire, in the handsof that physician who knows how to use the drug rightly, how to apply itat the right timeandin the right form, who watches closely thecourseof the disease in his patient, and who supports the mercury cure (always ofprimary importance) by other therapeutic measures as indicated.”
Only thephysician, the scientifically trained medical man, can cure syphilis; the quack certainly cannot; in his hands mercury is truly enough a dangerous “poison.” But he has no right to say, and he speaks deliberate untruths when he says, that we physicians “poison” the “unfortunate” syphilitics with mercury. To such preposterous accusations we can give a brief and incisive answer.
Therefore, during my lecturing journey, undertakenrecently[348]under the auspices of the German Society for the Suppression ofVenereal Diseases, I prepared the following brief account of the therapeutic employment of mercury in syphilis, which in my opinion suffices to throw the proper light upon the value and importance of the mercurial treatment of the disease; it is a sufficient answer to the “Nature-Healers,” who are opposed to the use of this “poison”:
1.In innumerable instances it has been observed by the most experienced and scientific physicians, that cases of syphilis treated without mercury run a very severe course, accompanied by the most dangerous symptoms, such as extensive destructive lesions of the skin, lesions of the internal organs, brain syphilis, eating away of the bones, loss of the nose, etc.
2.In cases which previously have been treated without mercury, the administration of the latter drug immediately arrests the destructive processes, and saves the patient from death, or from very severe illness, and from physical disfigurement.
3.No less an authority than Virchow, in his celebrated treatise “On the Nature of Constitutional Syphilitic Affections,” pp. 7-14 (Berlin, 1859), has shown that the hypothesis ofHermann[349]is entirely devoid of foundation in fact.
4.I should feel conscientiously compelled to denounce myself for the commission of grievous bodily harm if I ventured to-day, after the accumulated experience of four centuries, to treat a case of syphilis without mercury.
What use is it to continue to fight against the disbelief and superstition which clings to mercury? Why should we for ever be occupied in contradicting the false accusations brought against this drug? For four centuries the divine mercury has withstood all attacks, and will continue to withstand them, until a greatly desired and even better measure is discovered—prophylactic immunization against syphiliticinfection.[350]
How mercury is to be given, whether in the form of the long-prized “schmierkur” (cure by inunction), or byhypodermic injection, or byordinary internal use, must be left in individual cases to the decision of the medical man, for numerous considerations, which can only be properly weighed by the physician, have to be taken into account. A mercury cure is aseriousmatter, but always also one which repays all the trouble that we take. In “En Guérit-on?” Fournier has most admirably described thewonderful results of acritically considered and carefully conductedmercury cure. I do not, indeed, belong to the “doctors who build for themselves a house of pure quicksilver,” when they enter the field against the “French” (= syphilis), as the phrase runs in Schiller’s work “The Robbers.” I hold by areasonable, measureduse of mercury in the course of the treatment of syphilis, and I advise a good “after-treatment” in addition to the treatment withmercury.[351]Mercury, when given in moderate but sufficient doses, not only destroys the syphilitic virus, but also has a very favourable influence on the general condition, and sometimes even gives rise to an increase in the number of the red blood-corpuscles. Thus, mercury is not only not a poison: it is a most valuablerestorative and vitalizing means. This is well illustrated by the following case, which came under my own observation, and which I recommend to the Nature-Healers, in the hope that it may lead them to revise their views regarding the action of mercury:
The case was that of an official, thirty years of age, who had been under my care several times before since the year 1898 for other troubles (gonorrhœa, etc.), and who was always pale and with hollow cheeks, in no way giving the impression of possessing a constitution with strong powers of resistance. Late in the summer he was infected with syphilis; the attack proved a severe one, running a serious course, complicated by an extremely painful suppurative inflammation of the lymphatic vessels of the penis, and accompanied by fever, lassitude, and a sense of exhaustion. An energetic inunction cure was immediately begun. Under this not only did the morbid symptoms rapidly disappear, but there occurred a remarkable change in the general condition, in the sense of an increase of strength, such as had not existed before the illness. Notwithstanding slight stomatitis, the patient during and after the curefelt stronger and more fit for work than he ever had before, and even now this favourable state continues unaltered, as is manifested above all by the increase in the body-weight, by the good appearance, etc.The patient, who now, one and a half years after the cure, has had no relapse,informed me repeatedly and spontaneously that this delightful improvement in his health could only be attributed to his syphilis (!) or to the mercury!
The case was that of an official, thirty years of age, who had been under my care several times before since the year 1898 for other troubles (gonorrhœa, etc.), and who was always pale and with hollow cheeks, in no way giving the impression of possessing a constitution with strong powers of resistance. Late in the summer he was infected with syphilis; the attack proved a severe one, running a serious course, complicated by an extremely painful suppurative inflammation of the lymphatic vessels of the penis, and accompanied by fever, lassitude, and a sense of exhaustion. An energetic inunction cure was immediately begun. Under this not only did the morbid symptoms rapidly disappear, but there occurred a remarkable change in the general condition, in the sense of an increase of strength, such as had not existed before the illness. Notwithstanding slight stomatitis, the patient during and after the curefelt stronger and more fit for work than he ever had before, and even now this favourable state continues unaltered, as is manifested above all by the increase in the body-weight, by the good appearance, etc.The patient, who now, one and a half years after the cure, has had no relapse,informed me repeatedly and spontaneously that this delightful improvement in his health could only be attributed to his syphilis (!) or to the mercury!
Asinglemercury cure will suffice, in some cases, to cure syphilis for ever! Regarding this, we have numerous trustworthy observations. In most cases, indeed, during the early years relapses occur, and then we need to use the indispensable mercury cure once morewith care, and to employ all the other measures which make up the above-mentioned “after-treatment,” the supplementary means being, above all,iodide of potassium, sulphur(in the long-celebratedsulphur-baths of Aix, Nenndorf, etc.) andarsenic(first recommended by me); also the water cure, brine-baths, and iodide-baths, and a visit to the seaside or to the mountains, and massage, are good accessory means to the cure. Above all, however,the State of nutritionof thepatient[352]must always be kept under consideration, and assisted where necessary, for which purpose preparations of iron, nutritive preparations like sanatogen, and milk cures, are of value.Strict abstinencefrom alcohol is always necessary in the treatment of syphilis. Alcohol has avery unfavourableinfluence on the syphilitic process, and is often the only cause of continually recurring relapses of this disease.
Thethoroughtreatment of syphilis is a matter of several years, during which the patient must repeatedly present himself to the physician for examination, and should any relapse occur, he must be subjected to renewed treatment. Such thoroughness will invariably be rewarded.Attention to detailwill always bear fruit. Syphilis iscurable. It is purely fanciful to say that syphilis is never cured, that it pursues its victims up to the end of life, that it knows no pardon. That is not true.Treatyour syphilitic patients, treat them properly and thoroughly, if necessary for years in succession, and they will be freed from the disease. “Syphilis,” says Fournier, “is a misfortune, but it is a misfortune from which complete recovery is possible.” From the day when the patient becomes aware that he is suffering from syphilis, he must face the situation “in a calm and manly fashion,” and must say to himself:
“Now there is to be a fight between syphilis and me. To work, therefore, and courage! Courage, because science assures me that with the aid ofmercury, ofhygiene, and oftime, an end will come to the syphilis, and because science gives me an absolute assurance that some day I shall be as healthy as I was before, and that I shall again have the right to a family, that I shall attain the freedom and the happiness of being afather!”[353]
“Now there is to be a fight between syphilis and me. To work, therefore, and courage! Courage, because science assures me that with the aid ofmercury, ofhygiene, and oftime, an end will come to the syphilis, and because science gives me an absolute assurance that some day I shall be as healthy as I was before, and that I shall again have the right to a family, that I shall attain the freedom and the happiness of being afather!”[353]
With these admirable words of the greatest living authority on syphilis, I close my account of the suppression of syphilis by medical treatment, and turn to the not less important question of themanagement of gonorrhœa.
Recent scientific researches, especially those of A. Neisser and E. Finger, have shown that the infective urethritis of the maleproduced by gonococci is by no means the “trifling and childish complaint” which it was formerly supposed to be, but, on the contrary, is a very serious and obstinate trouble, often resisting the very best means of treatment, so that it maypersist for years, andremain for years infective. Still worse is it as regards gonorrhœa of the female genital organs, the cure of which is even more difficult, and the consequences of which are even more disastrous than in the case of the male. If thephysicianis needed for the cure of syphilis, still more is this the case as regards gonorrhœa. He only can command the scientific methods, and the very complicated technique of the treatment of gonorrhœa. He only can undertake theindispensablecontrol of the treatment by means ofmicroscopicand other methods of investigation. Every cobbler thinks he can cure gonorrhœa, and yet it is this disease which, even more than syphilis, demands the most precise knowledge of the local anatomical and pathological conditions. Blaschko rightly says:
“While no one gives a damaged watch to a baker to mend, or a torn coat to a tinsmith, every one seems to believe that in order to restore the most valuable gift of humanity, health, it is unnecessary to possess the profoundest knowledge of the human body, and to understand the nature and the causes of the disease. Anyone who has come to grief in his ordinary profession, but who understands how with a brazen voice to denounce the so-called ‘medicine of the schools,’ and to praise with sufficient confidence his own successes, is supposed to possess the wonderful power, without any exact knowledge at all, of charming all the illnesses of mankind out of the world.”
“While no one gives a damaged watch to a baker to mend, or a torn coat to a tinsmith, every one seems to believe that in order to restore the most valuable gift of humanity, health, it is unnecessary to possess the profoundest knowledge of the human body, and to understand the nature and the causes of the disease. Anyone who has come to grief in his ordinary profession, but who understands how with a brazen voice to denounce the so-called ‘medicine of the schools,’ and to praise with sufficient confidence his own successes, is supposed to possess the wonderful power, without any exact knowledge at all, of charming all the illnesses of mankind out of the world.”
Gonorrhœa is also acurabledisease, though curable often with great difficulty. We see this from the fact that, notwithstanding the extraordinarily wide diffusion of gonorrhœa (for a far greater number of infections with gonorrhœa occur than of infections with syphilis), still ultimately themajorityof the men, and a large proportion of the women, infected with gonorrhœa arecompletely curedof their trouble.
The treatment of gonorrhœa is a complicated affair.Within the first two days, by the injection ofpowerful caustic agents, we are sometimes able to cut the matter short and to put an end completely to the gonococci. In every case the patient, as soon as he perceives a discharge, though not yet purulent, from the urethra, shouldimmediatelyconsult a physician, in order to determine the nature of his disease, which, in the majority of cases, will be found to be true gonorrhœa. If it is not possible to abort the gonorrhœa, then the disease will have to run its course. Thebest measure, whenever possible, isrest in bedfor a week or two, in association with amild, unstimulating diet, and theabsolute prohibition of all alcoholic beverages—the last is indispensable throughout the duration of the gonorrhœa—the drinking of uva ursi tea, and, if the inflammatory symptoms are severe, the application of cold compresses to the penis. Only when the first more severe symptoms have passed away, by which time, owing to the reaction of the urethral mucous membrane, a large proportion of the exciters of the disease will already have been expelled, is it time to begininjectionsorirrigationsof theurethra, containing medicaments the nature of which must be left to the decision of the experiencedphysician, who will regard each individual case on its own merits. If rest in bed is not possible, the patient must wear a so-called “suspensory” bandage, in order to give as much rest as possible to the testicles and the epididymis, which are gravely endangered in every attack of gonorrhœa. If, as often happens, gonorrhœa ascends to the posterior part of the urethra, or to the bladder, or to the prostate, or if, finally, it becomes chronic, then special methods of treatment, withinternal medicines, with local cauterization, massage, distension, medicated bougies, baths, etc., are needful. The cure will ensue very gradually; relapses are frequent; even cessation of the discharge is no certain sign of cure, as the presence in the still turbid urine of “threads” containing gonococci sufficiently proves. Only when the urine has become perfectly clear, and any threads which it may contain are shown by repeated search to contain no more gonococci; when also the prostate, a favourite seat of the last remnants of gonorrhœa, is free from inflammation, can the cure be regarded as complete. Even more difficult is the determination of a cure in women. But persistency in the treatment, and frequently repeated examinations, will lead also in women to the desired goal, or, at any rate, will overcome the capacity for spreading the infection.
In the campaign against venereal diseases by the methods of medical treatment, thefacilitationof treatment for thegreat masses of impecuniouspersons, for the proletariat, is of great value. For them, above all, the provision ofKrankenkassen[354]is needed, and it is very satisfactory to note that during recent years the Krankenkassenhave especially directed their attention to venereal diseases, since A.Blaschko,[355]A.Neisser,[356]R.Ledermann,[357]and AlbertKohn[358]drew attention to the duties of Krankenkassen in this relationship in a number of admirable works. Krankenkassen are in a position to obtain exact statistics regarding venereal diseases; to diffuse information, verbally and in writing, to the widest extent among their members; to facilitate hospital treatment, and treatment by specialists; to give medical aid as required to infected relatives of the insured; to carry out regularly every year, once or twice, a medical examination of all members, and to distribute among all these writings on the prophylaxis of venereal diseases. The question also of payment on the part of the patient requires new regulations as regards venerealdiseases.[359]
Finally, it has been recommended that, in association with the Krankenkassen there should be founded “daily sanatoria” (Neisser), “work sanatoria” (Saalfeld), “ambulatory places for treatment” (Ledermann), and “convalescent homes” (Stern), for members of Krankenkassen suffering from venereal disease, and for insured persons similarly affected. All these institutions would, moreover, be valuable to the community at large.
What admirable results are obtainable by such asystematictreatment of as far as possibleallthe venereal patients throughout an entire country has been shown by the astonishing decline in the number of cases of venereal diseases in Sweden and Norway, and in Bosnia, where a gratuitous treatment of all such patients at the cost of the state has been introduced. Thus theorganizedcampaignagainst venereal diseases, which during recent years has been initiated in all the civilized countries of Europe, has led more particularly to efforts in the direction of the sufficient treatment and speedy cure ofrecentsyphilis andrecentgonorrhœa.
We pass now to the consideration of thethirdfactor in the campaign against venereal disease, which comprises the duty of thestate, the task ofsocial hygiene, and the task ofpublic pedagogy.
Thefoundationfor the suppression of venereal diseases by state effort consists in a knowledge of theextent of the diffusionof these diseases; we need, that is to say,accurate statistics regarding venereal diseases.
It is once more the great service of Blaschko to have been the first in Germany to work on theselines.[360]
Dismissing from consideration the distribution of venereal diseases in countries outside of Europe, regarding which he gives interesting reports, we find that the European conditions are of such a nature that the large towns, the centres of industry and manufacture, garrison towns, and university towns, are most severely affected; that the smaller provincial towns suffer less; that the agricultural population is comparatively free from this disease, with the exception of the uncultivated country districts of Russia and of the Balkan States, where the country people suffer from syphilis to a terrible extent. No exact statistical data are at present available regarding the diffusion of venereal diseases in the individual countries of Europe. The best measure of the prevalence of these diseases is afforded by the figures for the different armies. From these we learn that Denmark, Germany, German Austria, and Switzerland, show the most favourable conditions; next come Belgium, France, Spain, Portugal, North and Middle Italy. Worst of all are the conditions in Southern Italy, Greece, Turkey, Russia, and—England. These army statistics are, however, insufficient, for, as a matter of fact,Englandis most favourably placed in respect of the diffusion of venereal diseases. The most exact reports come from the Scandinavian countries, from Norway and Denmark, in which for several yearsall physicianshave kept a list of all the infective diseases treated by them, as they are compelledevery weekto make a return to the Board of Public Health. According to these reports, it appears that venereal diseases in Copenhagen constitute the greater part of such diseases in the entire country; but in theperiod between 1876 and 1895 these diseases have notablydeclinedin frequency in Copenhagen, and all venereal diseases have shared in this decline; gonorrhœa constitutes 70 %of allcases of venereal disease. With regard to the diffusion of infection, it appears from the Copenhagen statistics thatonewoman with venereal disease serves to transmit it tofourmen; on the other hand, offourmen with venereal disease,oneonly will transmit that disease to a woman. On the average, there are infected with venereal disease every year 16 to 20 % of all young men between the ages of twenty and thirty years; with gonorrhœa 1 in 8 are infected; with syphilis 1 in 55 are infected. In these last ten years, for every 100 young men living, there have been 119 infections during ten years; that is to say,on the average every one has been infected once, and a great many have been infected more than once; in the same period of ten years, for every 100 young men, there have been 18 infected with syphilis—that is to say, 1 for every 5·5.
Especially valuable also are the figures which Blaschko obtained in 1898 from the carefully kept books of a large mercantile Krankenkasse whose operations were diffused throughout Germany; these figures also give the result of an inquiry regarding venereal diseases amongst workmen, waiting-maids, secret prostitutes, and students. The result of these statistics, as regards Berlin, are given briefly in the following table:
ChartSecret Prostitutes, 30 %.Students, 25 %.Shop Employees, 16 %.Workmen, 9 %.Soldiers, 4 %.Venereal Diseases Affecting Various Classes of the Population of Berlin (after Blaschko).
Secret Prostitutes, 30 %.Students, 25 %.Shop Employees, 16 %.Workmen, 9 %.Soldiers, 4 %.
Secret Prostitutes, 30 %.Students, 25 %.Shop Employees, 16 %.Workmen, 9 %.Soldiers, 4 %.
Venereal Diseases Affecting Various Classes of the Population of Berlin (after Blaschko).
According to these statistics, the diffusion of venereal diseases amongshop employees,students, andsecret prostitutes(chieflybarmaidsandwaitresses), is the greatest; it is muchlessamongworkmenandsoldiers. It further appears, from Blaschko’s inquiry, thatof the men who entered on marriage for the first time when above the age of thirty years, each one had, on the average, had gonorrhœa twice, andabout one in four or five had been infected with syphilis. Wilhelm Erb, in Heidelberg, obtained similar results.
Still more remarkable were the results of the statistical investigation which was carried out for theentire Kingdom of Prussiaby the Prussian Ministry of Ecclesiastical Affairs and Public Instruction on April 30,1900.[361]
According to this investigation, it appeared that on this day, in Prussia, there were 41,000 persons suffering from venereal disease, among whom 11,000 were infected with recent syphilis; in Berlin, on the same day, there were 11,600 cases of venereal disease, among whom 3,000 were infected with recent syphilis. The general relations are shown in the following table:
ChartThe whole of Prussia, 0·28 %.Berlin, 1·42 %.Towns over 100,000 inhabitants, 1 %.Towns over 30,000 inhabitants, 0·58 %.Towns below 30,000 inhabitants, 0·45 %.The Army, 0·15 %.Venereal Diseases Affecting the Male Population of Prussia, April 30, 1900 (after Blaschko).
The whole of Prussia, 0·28 %.Berlin, 1·42 %.Towns over 100,000 inhabitants, 1 %.Towns over 30,000 inhabitants, 0·58 %.Towns below 30,000 inhabitants, 0·45 %.The Army, 0·15 %.
The whole of Prussia, 0·28 %.Berlin, 1·42 %.Towns over 100,000 inhabitants, 1 %.Towns over 30,000 inhabitants, 0·58 %.Towns below 30,000 inhabitants, 0·45 %.The Army, 0·15 %.
Venereal Diseases Affecting the Male Population of Prussia, April 30, 1900 (after Blaschko).
Thus, for every 10,000 adult men there were on this day persons suffering from venereal diseases to the following numbers: in Berlin, 142; in the remaining large towns, 100; in the smaller towns, 50; and in the whole of Prussia, on the average, 28. Naturally the figures should in reality be larger, for of the physicians to whom inquiries were sent, only 63 % returned ananswer. Moreover, theannualfigure of cases is a very much larger one.Kirchner[362]assumes thatevery dayin Prussia more than100,000 individuals—that is to say, about 3 per mille—are suffering from a transmissible venereal disease, and he estimates the damage to the national property by typhoid fever as about 8 million marks annually, but that from venereal diseases as not less thanninety million marks annually. In these reports of April 30, 1900, the ratio of men to women suffering from recent syphilis was as 3 : 1.
In order to obtain more exact information regarding the diffusion of venereal diseases, and the actual number of those affected by them, it is of very great importance that there should be arevisionof the duty of medical men in respect of thenotification of diseases, and also in respect of the duty ofprofessionalsecrecy.[363]
This latter question is also of importance in respect of the prevention of venereal infection in married life. (The question of syphilitic infection of married women by their husbands has recently been considered by Alfred Fournier: “Syphilis in Honourable Women.”)
In addition to the question of the diffusion and frequency of venereal diseases, the greatest interest attaches to thesources of dangerous infections—that is to say, the question where men and women most frequently contract venereal disease.
Here also Blaschko has obtained interesting information; he states:
Of 487 syphilitic men, the disease was acquired by 395 (81·1 %) from professional prostitutes (officially inscribed or secret); 23 (4·7 %) from waitresses and barmaids; 23 (4·9 %) from their “intimate”; 45 (9·2 %) from casual acquaintances, shop-girls, or workwomen.
According to this report, it appears thatprostitution, publicand secret (under which heading the waitresses and “casual acquaintances” must be numbered), forms theprincipal focusof venereal infection.
And that wild sexual intercourse is here almost exclusively to blame is shown by the following statistics, given by Blaschko:
Of 67 syphilitic wives, almost all the wives of workmen, 64 were infected by theirhusbands; whereas,on the contrary, of 106 husbands, 7 only acquired the disease from their wives; the remaining 99 acquired it byextra-conjugal sexual intercourse, either before or after marriage.
Another very valuable set of statistics dealing with the sources of infection has been published by HeinrichLoeb.[364]
These relate to the conditions in Mannheim. It appears that the sources of infection were as follows:
Here, as we see, the chief types ofsecretprostitution, thewaitressesandbarmaids, play the principal part; next, but a long way after, come maidservants and shop-girls. This, however, does not amount to saying that public prostitution is less dangerous. We know that a prostitute who has never been infected with venereal disease is something very rarely seen; that prostitutes under regulation are almost all, especially when still quite young, in an infective state, and that they serve just as much as secret prostitutes for the diffusion of venereal disease. It is a well-known fact that youthful prostitutes aremore dangerousthan women who have long practised prostitution, because the former are all suffering from more or less recent infection, and bothgonorrhœa and syphilis are present in them in the stages in which they are still strongly infective. H. Berger bases upon statisticalinvestigations[365]his belief that red-haired girls have the most delicate epithelium, fall sick most rapidly and in the greatest numbers; dark haired women at first suffer less. After they have been prostitutes for some time, there is no important difference between blonde, brown, and black-haired women; but black-haired prostitutes are, in fact, more inclined to infectionlaterin their career, because they are more in request.
Now that we have learned that at the present dayprostitutionremains the principal source of venereal infection, the following question immediately demands an answer:What can the state do in order to remove these sources of infection? and have the measures which the state has hitherto put into operation been of any use in this direction?To put it shortly, what part has been played by the stateregulationof prostitution, as hitherto practised, in the campaign against venereal diseases?
WithSchmölder,[366]we understand by “regulation” the following practice, which is what obtains in the majority of civilized countries: The police keep a list in which the girls and women regarded by them as prostitutes have their names entered. The “inscribed” (inscrites) receive a “licentia stupri”—that is to say,the permission to practise professional fornication under continual observation on the part of the police(the renowned “moralcontrol”[367]), which is associated with a number of commands, prohibitions, and regulations—above all, with thenecessity of submitting to medical examination at definitely stated intervals, and, where necessary, tocompulsory medical treatment. At the same time, public prostitution on the part of those who are not inscribed is suppressed as much as possible. Berger has admirably described (“Prostitution in Hanover,” pp. 1-19) the methods of regulation and their consequences. Above all, however, have Blaschko, Schmölder, and Neisser considered the modes of regulation customary at the present day from the moral, legal, and medical points of view, and have in part entirely condemned them (Blaschko and Schmölder), in part declared them to be gravely in need of reform(Neisser).[368]
Among those who have recently discussed the question of the regulation of prostitution, we may mention AnnaPappritz,[369]who condemns the practice; Clausmann, who is in favour ofit;[370]Friedrich Hammer, also in favour ofit;[371]and, finally, S. Bettmann, who leaves the questionopen.[372]
In our consideration of the coercive system of regulation, we take asingle standpoint—namely, that of its possible value for the suppression of venereal diseases. Some demand theabolitionof regulation on ethical and humanitarian grounds, and we do not wish in any way to make light of these grounds. But they could not be decisive, if, as an actual fact, regulation had an effect either in diminishing the prevalence of venereal diseases or in checking prostitution; but, in truth, thereverseis the case!
Schmölder[373]has shown beyond dispute that the compulsory inscription of prostitutes, introduced from France, is in our country an utterlyillegalmeasure, arbitrarily enforced by the police. It has been amply proved that this illegal compulsory inscription has actually made prostitutes of many girls who had no inclination to permanent professional prostitution; that this methodproduces artificial prostitutes. What errors of judgment, what abuses of power, occur on the part of the police, in connexion with this compulsory inscription! How often does the inscription result from a denunciation made on grounds of private spite! The “Committee of Fifteen,” constituted for the study of prostitution in New York, declares in its report:
“Men with political insight are of opinion that every limitation of the freedom of the individual is in itself an evil, and that such a limitation can only be justified in cases in which the good derived from the infringement can really be estimated at a very high valuation. A system which permits the police, simply on grounds of suspicion, to arrest a citizen, to submit him to an injurious examination, only with the aim of discovering a disease he is suspected to have, and then toput him into prison, on the suspicion that he might have indulged in immoral intercourse if he had been left at liberty, cannot possibly be regarded as harmonizing with the principles of personalfreedom.”[374]
“Men with political insight are of opinion that every limitation of the freedom of the individual is in itself an evil, and that such a limitation can only be justified in cases in which the good derived from the infringement can really be estimated at a very high valuation. A system which permits the police, simply on grounds of suspicion, to arrest a citizen, to submit him to an injurious examination, only with the aim of discovering a disease he is suspected to have, and then toput him into prison, on the suspicion that he might have indulged in immoral intercourse if he had been left at liberty, cannot possibly be regarded as harmonizing with the principles of personalfreedom.”[374]
Blaschko and Fiaux have proved that regulation concerns only asmall fractionof prostitutes, usually the older ones; whereas thebeginners, who are precisely those most dangerous in respect of venereal infection, and, further, the army ofsecret prostitutes,half prostitutes,occasional prostitutes, and thehalf-world, remain free from regulation—are probably left free deliberately—and anyhow could not possibly be supervised, on account of the enormous cost of supervision. In Berlin, speaking generally, onlyone-fifthpart of the girls arrested are subjected to regulation, four-fifths are simply “warned and discharged”; and even of this fifth part, in reality a large percentage does not come under control because “escape from the lists” renders permanent observation impossible. Fiaux proves thatmore than 50 %of the medical examinations which ought to have been made on the 4,000 women under regulation in Berlin during the years 1888 to 1901,were in factneglected.[375]
It iscertainthat regulated prostitution ismore dangerousfrom the point of view of public health than free prostitution. The prostitute remaining under surveillance is in constant fear of compulsory treatment in the lock hospital, and therefore endeavours to conceal her illnessas long as possible, or temporarily to avoid medical examination altogether. The free prostitute has a personal interest in becoming well again as soon as possible, and generally goes voluntarily and at once to seek treatment from a physician. Thus it happens that, among the regulated prostitutes, the number of those infectedappearssurprisingly small. In addition, we have to consider theinadequacy of the medical examination, because the number of the physicians and the time assigned to them are too small. And whilst it appears to be a fact that every third prostitute is infected with gonorrhœa, in Berlin, during the year 1889, as the result of official examination under regulation, only one prostitute in 200 was declared infected, and in 1884 only 1 in 1,873. Moreover,very manyinfected prostitutes under compulsorymedical treatment are, as Blaschko proves, allowed to resume their professional occupation in an uncured state, and to diffuse their illness freely once more. The figures given by Blaschko speak very clearly on this point:
From this it is clear that theabolitionof the regulation of prostitutes will not have an unfavourable, but, on the contrary, will have a thoroughlyfavourable, influence in respect of the frequency of venereal diseases. The conditions in England and Norway show this very clearly. In Christiania, after the abolition of regulation in the year 1888, syphilis declined in frequency—in the first place, because the number of girls who applied for treatment increased, whilst prior to the abolition of regulation they had concealed their illness in order to avoid falling into the hands of the police; and in the second place, because now the fear of venereal infection kept many young men from having intercourse with prostitutes, whereas previously they had erroneously believed that the “control” would free them from the danger of venereal infection. The same was the case in London, where there is no regulation; the frequency of venereal disease has decreased because young men now avoid intercourse with prostitutes as much as possible. In France, the country in which regulation was first introduced, the commission formed for the study of prostitution came to the conclusion that “regulation of prostitutes should be abolished.” The principal reason for which the police continue to advocate the preservation of the system of regulation—namely, that they have an interest in the matter on account of theintimate connexion between many prostitutes and criminality—will not bear examination. It is true enough thatsoutenage[376]is inseparable from prostitution. Moreover,the world of criminalsis very near to prostitution, in the first place, because the prostitute also has need of a man on whom she can lean, who can be something to her from thepersonalpoint of view, to whom she is not simply achattel;[377]and, in the second place, because the prostitute is, like the criminal,despised and defamed—she shares with the criminal the pariah nature. Lombroso’s doctrine that prostitution is throughout equivalent to criminality is certainly not justified.It is only by the outward circumstances of their life that the bulk of prostitutes are driven into intimate relations with criminality.And among these outward circumstances,regulation, and theexpulsionof prostitutes from honourable society (which is a necessary part of regulation) play the principal rôle! For this reason, if for this reason alone, regulation must be abolished, because then a strong supplement to criminality from the circles of prostitution would be cut off.
Even before investigators had become convinced of the uselessness and danger of regulation the cry arose: “Away with the brothels!” We have already alluded to the continuousdeclinein the number of brothels in all large towns. In 1841 there were in Paris still 235 brothels (to 1,200,000 inhabitants); in 1900 there were only 48 brothels (to 3,600,000 inhabitants); and for St. Petersburg and other large towns a similar decline in the number of brothels can be established, notwithstanding the fact that everywhere the population has markedly increased. This proves that the brothels no longer correspond to any realneed.[378]At the present day, owing to the great development of intercourse in modern times, brothels are a public calamity; they bring the quarter of the town in which they exist into disrepute, and deprive the neighbourhood of its proper monetary value. Moreover, the time is past for slave-holding on the part of the brothel-owner. The existence of brothels favours the traffic in girls (the “White Slave Trade”), encourages sexual perversities, and increases the diffusion of venereal diseases. The prostitute living in a brothel is sometimes compelled to have intercourse with ten or twelve men in a single day, and is thus pre-eminently exposed to venereal infection, all the more because she must admit the embraces ofeveryman who pays the brothel-keeper money; whilst the prostitute living freely can at least refuse to have anything to do with a man who appears to her to be ill. According toLecour, Mireur, Diday, and Sperk, prostitutes in brothels suffer from syphilis aboutthree times as oftenas freeprostitutes.[379]
Other modifications of brothel life, such as the so-called “controlledstreets,”[380]the best known of which are inBremen[381]—that is to say, streets closed to ordinary traffic, the houses of which are inhabited only by prostitutes under control, but the girls being in other respects free and not living under the domination of a brothel-keeper; also the“Kasernierung”[382]of prostitutes, their confinement to particular streets, or special “quarters” of the town(“Dirnenquartiere”)[383]—are all to be rejected on the same grounds.
The whole nature of brothel life, and the very serious dangers it involves, have been discussed in excellent works by E. vonDüring,[384]HenrietteFürth,[385]KarlNötzel,[386]and MartinBruck.[387]They illumine the whole question, and provide sufficient grounds for the condemnation of brothels.
A few authors, however, continue to advocate the preservation of brothels, and some of these wish to enforce medical examination, not only of prostitutes, but also of their masculine clients. This proposition is made, for example, by Ernst Kromayer in his work, which, notwithstanding many Utopian ideas, is nevertheless very stimulating, “The Eradication of Syphilis,” pp. 67, 68 (Berlin, 1898). Von Düring, in his criticism of these ideas, rightly points out that this recommendation would be quite useless in practice, because, in the first place, only a small proportion of men visit brothels at all. In the second place, in the hurry in these resorts no proper examination could be undertaken. In the third place, the doctors who were to be appointed as a kind of medical porters to brothels, would not easily be foundto accept such situations. Lassar, who answers this last criticism, is of opinion that the brothel-master, or anybody with a little experience, could easily undertake this examination in the case ofmen.[388]
But these men would probably also decline the office; and even if they were willing, it is very doubtful if they would be in a position to make the suggested examinations, which, after all, requirereal medical skill; and, finally, the only result would be—to increase the number of quacks. Therefore, this idea of the examination of the male visitors to brothels is Utopian.
No, the true hope lies inabsolute freedom; inrelieving prostitution from the oppression of the police; in its gradualseparation from criminality; in—I am not afraid of the word—in an “ennoblement” ofprostitution.[389]The “prostitute” (GermanDirne= drab) must disappear, and the “human being” must reawaken. The prostituted woman must be readmitted into the social community. No more coercion!Free and voluntary treatment, inpolyclinics[390]and hospitals; the “rescue” of youthfulprostitutes,[391]not in the prison-like “Magdalen Homes,” but by means of ethically instructive influencefrom human being to human being, of the value of which the “Letters to Prostitutes” of the noble philanthropist FrauEggers-Smidt,[392]and also the experiences of the SalvationArmy,[393]give such admirable evidence.
Very aptly, also, Kromayer has shown to what an extent a change in our present attitude towards sexual intercourse outside the conditions of coercive marriage, the removal of the stamp of infamy from such intercourse, would limit prostitution, and therewith also limit venerealdiseases.[394]This is as clear as daylight. But, unfortunately, those very persons who declare the existing conditions in respect of prostitution to be absolutely intolerable will not admit its truth.
The misery of the life of these unhappy creatures must be relieved,butwemust do itourselves, and soon; for they are not in a position to do so. The last, the highest goal of the campaign against venereal disease is the humanization of theprostitute.[395]