CHAPTER VII
REGULATION AND DISEASE
Regulation nowadays concerned chiefly with sanitation.—Variety of methods employed.—Berlin system.—Equipment and procedure.—Equipment in Paris, Vienna, Brussels, etc.—Quality of medical inspection in Berlin,—in Budapest,—in other cities,—in Paris.—Effect of medical inspection on male indulgence.—Peculiar characteristics of syphilis,—of gonorrhœa.—Amount of disease detected among inscribed women.—Clinical methods inaccurate.—Deceptions practised.—Flux in inspected body.—Failures to report.—Periods of hospital detention brief.—Minors, usually non-inscribed, most infectious.—Inspection and disease among clandestines.—System conceded to have accomplished nothing hitherto.—Its possibilities remain to be proved.—No basis for favorable expectation.—Insuperable difficulties in the way of successful medical regulation.—Does isolation of even a small number of infected women achieve some good?—Amount of disease depends on amount of irregular intercourse.—The bordell and disease.—Absurdity of linking disease and crime.—System illogical and inequitable.
The preceding chapters have presumably shown that regulation is not necessary to the maintenance of public order; indeed, even the pretense that it is needed for that purpose is now in a fair way to be generally discarded. As I have pointed out, the traveler is rarely aware of differences in external conditions that suggest different police methods of restraining or controlling prostitution. Prostitution may be described as perhaps equally prominent in Berlin and London,—one a regulated, the other a non-regulated city. Regulation is therefore not a factor that, from this point of view, needs to be taken into account. Moreover, as we shall see later, the few cities in which the underworld is distinctly inconspicuous are without regulation. For the rest, cities long without regulation and cities that have recently dispensed with it are at least as quiet as those that still adhere to it; nay more, to find a really disorderly section one must resort to the bordell quarters of regulated towns. As far as order goes, therefore, it is impossible to make out a case favorable to regulation.
As the argument in behalf of regulation on the score of public decency loses force, the maintenance of the system depends more and more on the assertion of its sanitary efficacy; and on this aspect increasing emphasis is laid. A prominent official of the Berlin morals police, tracing the history of the institution for me, remarked: “The historical function of the _Sittenpolizei_ was to deal with decency; but under present conditions the sanitary object has come to the fore. The morals police could be dispensed with, if only their original business were in question. They should certainly now be called the health police.” The recent reconstruction of the Vienna system was undertaken in execution of just such a program: “Conversion of the morals police control into a sanitary control, and its extension as far as possible over clandestine prostitution.”[378] The main effort to save regulation through readjustment to modern knowledge has thus been made on the sanitary side. In the present chapter I shall endeavor to describe regulation as a sanitary policy and to determine what it achieves in that direction.
The diversity previously commented on in connection with regulation prevails also in respect to its sanitary details. Between the worst and the best organized systems on the medical side, there is perhaps an even greater discrepancy than between the worst and the best systems on the side of police methods. Thus far experience has worked out no accepted sanitary model. Important variations will be noted in reference to the method of inspection, its quality, its frequency, the disposition made of disease when discovered, the payment of physicians, and the extent to which free choice of physicians is still allowed.[379]
Berlin, where the bureau has been completely reorganized in recent years, may serve as a point of departure. Women under control are required to report to police headquarters for examination twice weekly, if under 24 years of age; once a week, if between 24 and 34 years of age; and fortnightly, if over 34. In addition, the inscribed or controlled prostitute is re-examined whenever arrested for any offence, regardless of the date of her last or her next regular examination.[380] Clandestine prostitutes may be subjected to compulsory examination at the discretion of the bureau chief,—the examination being conducted by a woman physician attached to the division for this purpose.[381] By special request, an examination by an approved private physician may be substituted. In either event, the woman is herself at no expense for the examination.
A staff of eight police physicians and four microscopists are occupied with medical inspection, of whom four are on duty at one time; the work goes on daily, except Sunday,[382] from nine to twelve o’clock and from twelve to three. The examination consists of a clinical inspection and the use of the speculum. For the detection of gonorrhœa, microscopic examinations of the secretions are made fortnightly in case of women under 34; monthly, in case of older women. At any time, however, when appearances are suspicious, the physician is instructed to ask for a microscopic examination without waiting for the regular day. Female assistants are provided for this work; the word of the assistant is sufficient in case the microscopic preparation is found to be negative; the physician must by his own observation confirm a positive result. The medical policy of the police department is directed by a physician who holds the rank of commissary,—the sole instance in all Europe of expert medical control of what is admittedly a sanitary matter.[383]
Inscribed women discovered to be infected are confined under duress in a municipal hospital, on the theory that, being professional prostitutes, who can maintain themselves only by plying their business, they must be interned in order that the carrying on of their business may be temporarily suspended. In very rare cases, however, even when found to be diseased, they are permitted to retain their freedom provided an approved physician makes himself responsible for their systematic treatment, and provided, further, that there is reliable evidence to show the possession of resources which will enable the women in question to keep their engagement to refrain from plying their vocation for the time being. Women are also at times released from the hospital on condition that they report at intervals for further treatment; should this understanding be violated, they are once more interned.
Clandestine and occasional prostitutes if found diseased on being arrested are somewhat differently managed. If without resources, they are sent to the hospital; but the bureau chief may, in his discretion, permit them to remain at large on condition that they place themselves in charge of a competent physician. It is, however, admitted that pledges, whether given by clandestine or registered women, are not to be relied on.
At both hospital and police headquarters in Berlin conscientious and intelligent efforts have been made to provide satisfactory arrangements. Registered and non-registered women are scrupulously separated at every stage, on the ground that the latter group may contain young, innocent or, at least, not yet hardened persons, who should not be further contaminated by the carelessness of the state. Premises not adapted to this end have, therefore, been extensively remodeled. The rooms utilized for the medical examinations at the police headquarters are light and equipped with a modern examining chair, hot and cold water, and electric light; the microscopic-room has the necessary equipment for clean and accurate work.[384] The hospital, though old and small, has been latterly renovated and its staff reorganized. The present medical chief of the police division in charge of venereal disease is a specialist of distinction, who has made important contributions to the literature of the subject on both medical and sociological sides. The division possesses an excellent laboratory manned with trained assistants; and it is properly equipped with microscopes, culture-ovens, animals for experimental purposes, etc. Patients are examined separately in a clean, well-lighted room, containing all necessary paraphernalia. Women at different stages of demoralization,—registered, non-registered, first offenders,—are scrupulously kept apart; clean and orderly as the women are in appearance, there is nothing in their demeanor or surroundings to suggest prison confinement.[385]
In many other towns, two examinations per week for the youngest class of inscribed prostitutes are also required; but by no means everywhere. In Paris, for example, women in bordells are examined weekly, those at large at least fortnightly; in Dresden examinations take place once a week. In Hamburg, women under “light control” are examined only once a month, and even for this examination a certificate from a private physician may be substituted; the same is true in Cologne, where enrolled women discovered to be diseased are permitted to obtain treatment privately, provided they keep the police informed of their progress.[386] At Stockholm most women report twice a week; some thirty older women, once a week.
Examination and treatment are not always free. Dresden requires every inscribed woman to contribute to a sick insurance fund, paying four marks as initiation fee, and two and a half marks weekly dues; she is thereby entitled to 13 weeks’ hospital care if ill.[387] A sick fund, out of which the cost of the weekly examination is also paid, is similarly supported in Hamburg; in Bremen, the women bear the expense of the medical inspection; Brussels permits examination to take place in the rooms of the women on payment of five francs monthly; Stockholm allows a woman to appear for examination privately on payment of a crown; at Stuttgart, the examination is free at police headquarters, paid for, if at home; in Geneva, the girls pay two francs for each examination; in Rome the bordell stands the expense, and also, subject to the approval of the health authorities, selects the physician. In Vienna, girls were formerly required to pay one crown if examined at headquarters, two crowns if examined in their rooms; but since January 1912, a system of free examination has been gradually introduced. It is universally conceded that abuses creep in wherever the physician derives his income in whole or in part from the women or the bordells.
Much greater and more significant diversity exists in respect to the equipment of the examining-rooms at police headquarters and the method of conducting the examinations. Facilities as good as those of Berlin exist only in Dresden, Bremen and Budapest. In the last named city, twenty-two physicians, eight of whom come daily, are employed. Unlike Vienna, where a physician usually examines the same woman from week to week, the women are purposely sent to different physicians for successive examinations,—a policy adopted in order the better to prevent deceit, bargaining, etc. A bacteriologist is on hand to make microscopic tests in suspicious cases.
In all other cities the appointments are meager and antiquated, conducing to mistaken diagnosis, on the part of even honest physicians, and to fraud, on the part of the women. In Paris, for example, bordell women are examined in their own quarters, where no facilities for good work can possibly exist, where imposition is easily practised by the women, and where the environment is apt to interfere with the seriousness of the occasion. Examinations so conducted need not be seriously discussed. Inscribed Parisian prostitutes living at large and non-inscribed women who are arrested, are examined at police headquarters, where the equipment consists of two rude chairs, an ancient sterilizer in which a few specula are boiling, and a glass of sterilized water in which the spatulæ used in holding down the tongue are hastily dipped from time to time. Arrested women—whether registered, clandestines, or mere suspects—are huddled indiscriminately with all other varieties of female offenders, into a dark and ill-ventilated “dépôt,” not inaptly called the “human pound.”
In Vienna, as in Paris, the medical examination is still conducted either at headquarters or at the dwellings of the women, though the tendency is in the direction of concentrating work at the former. The Viennese accommodations and facilities are distinctly better than those of Paris, even though the establishment does not yet boast a microscope. At Hamburg, girls arrested are clinically examined at headquarters; inscribed women are examined in the bordells,—a convenient bordell being selected in each neighborhood,—but beyond a deal table, and the spoon and speculum which each girl brings, no equipment whatever is provided.
Elsewhere facilities answer the same general description. In Brussels a plain table is carried into the reception room of the bordell. Rome is no better; in one establishment, on asking to see the facilities for medical examination, I was shown a filthy old metal table and a few dirty basins; in another, a tattered leather chair; in a third, a small table.
Of hospitals provided for the reception of diseased women, Budapest possesses perhaps the best that I visited anywhere; the service contains three hundred beds, excellent laboratories, operating and treatment rooms of the most modern pattern. Cologne provides a satisfactory, renovated building, with one hundred and twenty beds, equally divided between controlled and uncontrolled women. The appointments are modern in character, attractive in appearance. Hamburg possesses similar facilities with one hundred and thirteen beds; Frankfort sets apart eighty beds in an excellent institution; Bremen, forty-four; Stockholm, sixty in an attractive building situated in a pleasant garden. In most of these establishments a deliberate effort is nowadays made to efface the impression of enforced detention. The Stockholm clinic, among others, has no locked doors or barred windows, in consequence of which the girls are rarely refractory.[388] Though the subject lies outside our present inquiry, it should be added in passing that all continental cities make, in addition to the above mentioned facilities, more or less liberal provision for other venereal patients.[389]
Conditions are less favorable in Vienna, where there is no special hospital for diseased prostitutes; they must be distributed between the three skin clinics of the city. Even so, there is such a scarcity of beds that they are often kept waiting in prison several days before they can be placed and then are dismissed too soon. But for really disgraceful accommodations one must cite Paris. The infected Parisian prostitute is interned in a medieval prison—St. Lazare—a name, at the mere sound of which, the most hardened offender blanches with terror. In this bleak dungeon, young and old, the new offender and the hopeless hag, mingle freely; they sleep in the same huge dormitory, meet in the same dark corridors, and get their brief airing in the same narrow courtyard.[390]
The quality of the examination varies widely. At Berlin, typical of the four best, clinical inspection is made of the mouth, hands, feet, and other external surfaces; the genitalia are invariably explored with the speculum; microscopic examination for gonococci are made fortnightly, or oftener in suspicious cases. The magnitude of the work may be roughly indicated as follows: On the basis of 3,500 inscribed women, each examined twice weekly, 28,000 clinical examinations would be made monthly,—3,500 by each of the eight physicians. As a matter of fact, the figures are smaller, since bi-weekly examinations are required only of women under 24. It would be nearer the truth to estimate that each physician makes from 1,500 to 2,000 clinical examinations monthly. In August 1911, each of the four assistants made 2,646 microscopic examinations for gonococci,—an average of 98 for each working-day.[391] It is estimated that on the average three minutes are available for the examination: but as this takes no account of time lost, the actual duration of the operation is much less.[392] Women sent to the hospital are discharged only after three successive negative microscopic findings, followed by an examination at police headquarters confirming this result.[393]
The Budapest system is modeled on that in use in Berlin. Inscribed prostitutes are card-indexed at police headquarters, according to the days of the week on which they are scheduled for examination. Their cards are removed as they appear; the cards remaining over at the close of the day form thus a list of those who have failed to keep their appointment. Every girl carries her own spatula. The examination does not materially differ from the Berlin pattern, above described, except that the microscope is utilized only whenever suspicion is aroused,—not at regular intervals regardless of suspicion.[394] Between 600 and 700 girls are examined daily between the hours of 9 and 2. In the month of August 1912, 341 specimens were subjected to microscopic examination; had the 2,200 enrolled girls been subjected on each inspection to microscopic examination, 17,600 specimens would have been required.[395]
Vienna is the most favorable example of the large group by no member of which the microscope is employed at all. The women appear stripped for the examination, which consists of a cursory clinical inspection, always including the vagina. A wooden spatula—discarded after a single use—is the only distinctive feature. The examination is very brief,—a matter of seconds, not minutes.
In the remaining cities, the examination is still less thorough. At Hamburg, for example, the women convene in a bordell, as many as can be accommodated crowding into the room in which batches are examined. The physician takes a hasty look into their mouths in succession, and then glances at the genitalia, with only occasional use of the speculum. His hands are not cleansed before he proceeds from one girl to the next. Only a few seconds are devoted to each case. In Cologne it is frankly admitted that the medical examination is not “intensive.” In Geneva the clinical inspection is confined to the mouth and the genitalia. In Rome the examining physician assured me that “if the woman is sound, he (I) could tell it at the first glance; he is more circumspect, if the case is suspicious.”
The Paris examination deserves a paragraph to itself. All day long a dismal succession of groups of abandoned women file into the rudely-equipped rooms in which two physicians ply their repellent task perfunctorily. A line is formed; with open jaws and protruding tongue they march rapidly past; the doctor uses one spatula for all, wiping it hastily on a soiled towel from time to time. This finished, the same group in quick succession ascends two surgical chairs to permit a cursory vaginal inspection; the physician, stationing himself between them, loses no time, for one woman is assuming the recumbent position while he is engaged in the examination of another; he switches back and forth as rapidly as the women can get up and down,—indulging in good-humored and sometimes unseemly jocularity as the work proceeds. Of the two physicians employed on the occasion of one of my visits, one used a rubber glove, the other a rubber finger,—in both cases the same for all; though wiped on a towel from time to time, neither was changed or cleansed. On one occasion I observed one of the physicians examine 25 or 30 girls without changing, washing, or wiping the rubber fingers he wore; and a number of those examined were adjudged “diseased.” The speculum was rarely used. In one instance, pressure by the finger on the urethra discharged an abundant suspicious secretion; the same finger, unwashed, was used in examining the next case; in another instance, the same rubber finger was used on the genitalia and about the mouth. The inspections consumed from 15 to 30 seconds each; “for vaginal examinations,” so read my notes made on the spot, “it takes less time to examine one woman than it takes another to mount the examining chair and offer herself for examination, despite the fact that her clothing has been adjusted before entering the room.”
The printed accounts give the impression that the medical inspections are more deliberately carried on. Bettmann, for example, publishes a table in which it is stated that each examination averages 1½ minutes in Paris, 5 minutes in Vienna;[396] to the same effect is Blaschko’s calculation, though he himself says that even so, “the length of time devoted to the examination is too brief.”[397] I feel sure, however, that these and other similar estimates were arrived at by dividing the entire time at the disposal of the physicians by the number of women to be inspected,—a fallacious method of getting at the facts. The truth can be learned only by observation registered on the spot. At Paris, and elsewhere as well, much time is lost in making ready for a task which is subsequently rushed, so that the nominal period is by no means entirely devoted to the business in hand.
What is the value of each of the types of medical inspection above described? The question must be subdivided for answer; we must inquire as to the general effect of sanitary inspection of women on participation in irregular sexual indulgence on the part of men; as to the utility of each of the methods in reference to the women subjected to them, respectively; as to the effect of police control of inscribed women on the sanitary habits of the non-inscribed; finally, as to the incidence of venereal disease, its fluctuations and their relation to sanitary control of prostitutes.
Continental Europe, as I have pointed out in a previous chapter, traditionally condones incontinence on the part of the male sex. No single cause accounts for this phenomenon; but certainly among the most important factors is not only the existence of a powerful instinct in man, but also the extent to which its indulgence is facilitated by the low social status of woman. This attitude was incorporated in, not originally due to, regulatory systems of dealing with prostitution. The continental attitude towards prostitution and all the machinery developed in connection with handling it, both from the police and the sanitary sides, were undoubtedly not originally the cause, but the result, of an indulgent attitude towards the male sex, on the one hand, and a disregard of woman’s dignity, on the other.
Once instituted, however, the system itself became a factor in perpetuating the conditions out of which it sprang. The existence of regulation amounts to a concession by the state that a vast volume of promiscuous intercourse is to be accepted as a fact;[398] that for this purpose professional prostitution is recognized and, despite verbal quibbles, authorized. For the prosecution of what is thus treated as an essential and in a sense legitimate traffic, these women obtain a privileged position on the streets or in quarters notorious for the use to which they are put. The prominence thus given to immorality operates psychologically as an incitement to it. The complacent attitude towards indulgence implied in the mild effort made by the state to remove or reduce its dangers indubitably diminishes internal inhibition on the part of the male. Nothing is more certain in the domain of effort and ethics than that good conduct is largely the response of the individual to the expectation of society: men “can because they think they can.”[399] Social stigma is a most powerful deterrent; social assent a powerful stimulus. Regulation implies the absence of any expectation of male self-restraint; it is society’s tacit assent to laxity.[400] Nay more, it is an invitation to laxity in so far as it deprives dissipation of one of its terrors, for the existence of medical regulation must be interpreted as implying a certain degree of efficacy in the attainment of its object. There can, therefore, be no question that state regulation of vice increases the volume of irregular intercourse and the number of those who participate in it. Certain it is that the notion that male self-control is both possible and wholesome has spread “pari passu” with the attack on regulation and with the elevation of the status of woman that invariably accompanies this movement.
The utility of regulation is thus opened to serious question not only on ethical but on hygienic grounds. For the present, I take no position as to the hygienic condition of the woman examined; I am looking at the problem more broadly. Regulation tends to increase miscellaneous sexual congress. Such congress takes place in the long run with both inscribed and non-inscribed women. Irregularity craves variety; and infection is the well-nigh inevitable penalty of sexual promiscuity. To whatever extent regulation tends to increase irregular commerce by diminishing individual and social resistance, to that extent it tends to increase the amount of venereal disease. Therefore, even if regulation should be found to be more or less effective, its sanitary achievement has to be offset against the increased amount of congress to which it indubitably conduces; one has to ask whether more congress with regulation is not likely to result in more disease than would result from less congress without any regulation at all.
It is occasionally denied that the mere existence of regulation tends to develop recklessness on the basis of assumed security. Blaschko, for example, a distinguished authority, while conceding that here and there an individual is misled, does not believe that the problem as a whole is appreciably affected.[401] But Blaschko starts with the assumption that things have always been as they are and will never be much different. My own impressions are, however, distinctly opposed to Blaschko’s view: I have, I think, observed unmistakable evidence that regulation is itself one of the factors in demoralization, by reason of the prominence it gives to prostitution, the undermining of the forces that make for good conduct, and the illusions of safety that it creates. My notes contain many random conversations which cannot be wholly without representative significance as to the last named point. I happened, for example, to call on one of the most eminent of French dermatologists at the time when he was consulted by a wealthy Mexican gentleman who was passing the winter in the gay capital. A prompt diagnosis of syphilis was made. “Impossible!” rejoined the perturbed patient. “I have had nothing to do with any woman except an inmate of a well known resort of high character (he named the house and street), who possesses a certificate of good health. For this security I pay 100 francs.” “You could purchase equal security much cheaper on the streets,” replied the French savant. Communications of precisely the same tenor have been made to me by intelligent men—foreigners as well as Americans—in Paris, Berlin, Rome, and Stockholm. Schneider, an exceptionally candid witness as to the well-to-do German youth, declares: “A very large proportion of men who hunt out official prostitutes live in the belief that sexual intercourse with inscribed women is, in consequence of medical control, practically without danger. In my earlier years I myself held to this view, and only after I had taken pains to study the subject thoroughly, did I perceive that there was no safety at all. Alas, too late! And the same thing happens to thousands of others, who are lulled into a false sense of security and whose moral scruples are also weakened.”[402] If such is the state of mind among the intelligent, is it not probable that the uneducated make the same assumption? Experienced physicians can be quoted in support of this view. “The public is fooled. The laity is led to believe that it is possible to distinguish diseased from healthy prostitutes. As all the diseased ones are sent to the hospital, relations with controlled prostitutes are free from danger. This is the popular conclusion.”[403] The official rules themselves practically concede the point. For the police are now at pains to disavow the natural consequence of their own policy. The Paris regulations state in bold type that “the card delivered to inscribed women must not be regarded as an incentive to debauch;” and the public is commonly warned that the medical examination is not to be interpreted as a guarantee of safety.
Regulation may therefore be regarded as calculated to increase the volume of irregular intercourse: what does it accomplish by way of rendering such intercourse harmless?
Medical control is concerned chiefly with two diseases, syphilis and gonorrhœa,[404] in reference to both of which its object is not primarily to heal the woman, but rather to protect her patrons from infection. It is therefore not essential, from the standpoint of regulation, that prostitutes who have contracted syphilis should be interned during the several years during which the disease runs its regular course; it is only essential that the woman be kept under lock and key during the infectious stages of that tedious process. And the same is true, theoretically at least, of gonorrhœa.
The salient points in connection with these diseases are, for our purposes, these. Both are contracted early in the prostitute’s career. Syphilis is a protracted affair, but the girl who has run the entire gamut of a single infection is subsequently immune; she does not herself freshly contract the disease. She may, of course, at any time, act as a carrier, receiving the germ from one patron and conveying it to another, even while herself not becoming actively infected. Having herself, however, contracted the disease, she is highly infectious during the primary stage, calculable in weeks, and during the secondary stage, usually occupying from two to three years, but sometimes lasting from five to ten. During this time, fresh manifestations, indicative of danger, appear from time to time; but infection may also be communicated when no signs of disease are visible. It is very important at the very outset to get clear notions as to these points. Syphilis is highly infectious during the entire duration of the primary local lesion. In the secondary stage, it is highly infectious when florid; probably not infectious, when really latent;—that is, when the disease is active only in liver, brain, and other internal organs or tissues. But the difficulty is that syphilis is often regarded as latent when it is actually florid,—the signs escaping observation. At any time, infection may take place not only in sexual intercourse, but also through the mouth, saliva, and other secretions and contacts.[405] Relapses are also very common. Of 722 prostitutes with secondary syphilis, 529 relapsed 1,601 times in the first year, 204 relapsed 303 times in the second year, 90 relapsed 120 times in the third year, 53 relapsed 73 times in the fourth year.[406] Often the symptoms are almost unnoticeable, at times escaping the vigilance of a careful observer. The clinical history of a syphilitic woman is by no means a sufficient assurance that she is no longer a source of peril to her patrons.
Gonorrhœa is wholly incalculable. No matter how frequent its attacks, no immunity results. Prostitutes, it is true, appear to contract acute infections less often as they grow older; but this is probably due, not to an acquired immunity, but to toughening of the tissues and decreased exposure to infection through falling off in business. Clinical appearances as to the presence or cure of the disease are entirely unreliable. Of the elements on which such judgments rest—the color, odor, and consistency of the secretions—Güth declares: “No criterion could be more arbitrary or deceptive, for, on the one hand, the clinical character of the gonorrhœal excretion varies so often and so suddenly, that a person who appears suspicious to-day may be free of secretion to-morrow, and subsequently again show suspicious symptoms. An apparently innocent manifestation may be infectious; a transparent vaginal secretion may be infectious; a purulent discharge may be non-communicable.”[407] Whether even a microscopical examination is competent to decide the question involved is open to grave doubt. Unquestionably the microscope can note the decrease in the number of gonococci; but it is not yet proved that their virulence diminishes in the same ratio. Moreover, a secretion relatively poor in gonococci may still transmit infection, even though the secretion is so poor in them that successive slides fail to indicate their presence.[408] Finally, gonococci of diminished virulence quickly recover their full virulence when transferred to a favorable membrane.
What does regulation, as we have described it, accomplish, first, with those examined, next, with respect to the general situation? It needs little argument to show that the crude clinical procedures of which Paris is typical achieve little in the way of isolating infected foci. In the first place, the examination is so rapidly and carelessly conducted that, if the truth were known, it might well be found to communicate more infection than it detects, (as, for example, when a finger, used to separate actively diseased parts, is applied uncleansed to the same parts of others). In ascertaining clinical conditions the commonest precautions are by no means invariably employed. One physician examined in my presence 30 girls, using the speculum only three or four times; all were pronounced well; his neighbor, who used the speculum regularly found a few infected cases, such as the former must have missed. The examining physicians realize the slipshod nature of their work. A suspicious secretion having been noted by a bystander in the case of a woman pronounced “well,” the physician was asked how he knew. He shrugged his shoulders: “I don’t know; but there’s no way to tell. If we kept cases like that, we’d keep over half.” Another of the examining physicians disposed of a similar case in the same way: “We can’t keep them, we haven’t space, though we aren’t sure that they are well.” Still another: “Accurate diagnosis is impossible; under these conditions, gonorrhœa, unless virulent, is ignored; our real effort is to detect syphilis.” In another case, a woman pronounced “well” was leaving the chair when, on a bystander’s skeptical remark, the physician reversed his opinion and sent the unfortunate to St. Lazare. The total number of women incarcerated at any one time on the score of venereal infection is negligibly small. On the occasion of my visit to St. Lazare, 170 venereal women were confined there, and I was informed by the chief clerk that this was a fair average; these are the scapegoats for the venereal disease in circulation among the prostitutes of the French capital! Assuredly the temporary withdrawal of 170 infected women from the thousands with whom Paris teems is utterly without influence in the long run; more especially as these women are themselves turned adrift before their infectiousness has passed. Regulation of this type has less effect in reducing disease than a rainy night or a spurt of police activity,—both temporarily diminishing the accessibility of supply to demand and its provocative character.
The medical examination at Geneva, Brussels, and Rome is of the same general type and works in the same way. The City Physician of Geneva explained to me that it required only “about an hour or so” to examine the 86 inscribed women of that city. To my comment “this is pretty quick work,” he replied, “Yes, but I know them!” I asked how often disease is found. “Very, very rarely,” he candidly replied. Elsewhere I learned that as a rule the hospital of Geneva is free of women in so far as this source of supply is concerned. The conditions under which the examinations are made in Brussels and Rome preclude anything beyond primitive work. The provincial health officer at Rome declared that the official examinations by the police physicians disclosed “very little disease”; subsequently one of the latter conceded that “the examination is good enough to detect primary syphilis; it is of little value otherwise. Of course virulent gonorrhœa would be observed. But it is absurd to suppose the others safe,—in so far as gonorrhœa is concerned, no public woman is ever safe.” At Brussels, during the two years preceding my visit, a total of 26 prostitutes had received hospital treatment,—inscribed and non-inscribed. The year before—1910—nine inscribed prostitutes and 27 clandestine were pronounced “diseased.”[409] “The real harmlessness of the registered prostitute,” says Dr. Baget, head of the hospital division at Brussels, “consists in this,—that she is practically non-existent. My clinic at Hospital St.-Pierre contains four beds for prostitutes, and even these are almost always empty.”[410]
The above description has dealt with regulation at its worst. In reply, it may be fairly urged that, though showing how regulation has worked in the past, it does not prove that better results are either unattainable or unattained. Let us see, therefore, what happens in Vienna and most German cities in which a more conscientious type of clinical examination obtains. In these, at least, the examination is not in itself a direct factor in spreading infection; for individual spatulæ and individual specula are commonly used. If not, the instruments employed are as a rule properly cleansed. The overburdened physicians have, however, neither time nor facilities to make proper observations. I was present at Hamburg at the examination of 42 women in a bordell; the whole process occupied less than 20 minutes. These women are supposed to be “under strict control”;[411] on another occasion, I witnessed the examination of 50 women, some under “light control,”[412] others, clandestine; the speculum was not generally used and the entire transaction, including the writing of the protocol, occupied less than a quarter of an hour. All were pronounced well.[413] The medical service in Cologne suffers—as it suffers in all great cities—on account of the inadequacy of the staff. “A thorough hygienic examination is impossible. Syphilis especially in its most infectious forms can be quickly recognized by an experienced observer; but chronic gonorrhœa can be made out only after accurate scrutiny: the preparation and study of a microscopic specimen demands more time than a police surgeon can give.”[414] In consequence, the number of women who are isolated is everywhere inconsiderable; at Cologne, on the day of my visit to the police hospital, 30 registered women were confined for treatment; in the course of January, 1912, 75 women were found to be suffering with disease in Hamburg; in February, 67; in April, 53. In Vienna, the total found diseased during five successive years was as follows:
1906 1907 1908 1909 1910 Soft Chancre 129 97 82 80 70 Gonorrhœa 127 87 107 70 94 Syphilis 224 162 185 206 168 ——— ——— ——— ——— ——— Total 480 346 374 356 332
In Berlin, during the vogue of the clinical examination, the average number of women interned ranged from 260 in 1895–6, to 157 in 1903– 4.[415] In Stockholm, for all causes, 522 enrolled prostitutes were sent into the hospital 955 times in the year 1904.[416]
It is obvious that among the registered prostitutes of a city there are at every moment many more diseased women than any of the above figures indicate. Why are they not detected? The doctors are overburdened with work, which is of such a nature as to make severe and uniform scrutiny impossible. Enormous fluctuations therefore occur, fluctuations which cannot possibly be due to sudden improvement or sudden deterioration in the condition of the women. For instance, in Vienna, with an enrolment of 2,569 in 1901, 1,185 women were found to be diseased; of 2,380 enrolled in 1905, 543 were diseased; with 2,329 in 1910, 332 were diseased. At Stockholm, between 1890 and 1904, the annual number committed to the hospital ranged from 523 to 1,026.[417] Sixty-seven girls were sent to the police hospital of Berlin in December, 1907; under the same system, 349 were sent in May 1911; 230 in December of the same year. The average daily hospital roll numbered 262 in 1897–8, 184 in 1900–1, and 122 in 1908–9. A change of doctors is invariably followed by an increase in the amount of disease detected,—surely not in an increase in the amount of disease existing. Thus in 1903–4, 1,258 cases of venereal disease were discovered in women, both inscribed and uninscribed; a new medical staff found 1,845 cases the next year.[418]
The utter baselessness of any confidence placed by the patron on the fact of medical inspection is thus obvious: inspected women may not only be diseased at the moment they are sent to the streets and bordells to do business as sound,—but, as we shall also see, if found diseased, they are, as a rule, even after treatment, allowed to return to their avocation while still highly dangerous.
But aside from such variations, the clinical method is utterly incompetent to detect any considerable portion of infectious disease.[419] I have already quoted Güth on the difficulty attending a clinical diagnosis in gonorrhœa; his position can be fully sustained by both figures and opinions. Güth himself tells of a series of cases, 35% of which showed clinical symptoms of gonorrhœa; the microscope showed 90%.[420] The figures for three years at Budapest are highly instructive,—those for 1907 the result of clinical examination, those of 1909 and 1911 the result of clinical assisted by some microscopic work:
Number of enrolled Total cases venereal Year prostitutes disease Gonorrhœa Syphilis Bubo 1907 1,717 884 328 105 451 1909 1,914 2,775 1,112 897 766 1911 2,097 2,100 839 697 564
Between 1907 and 1909 the number of prostitutes increased 22%; the amount of ascertained disease increased 137%—gonorrhœa, 156%, syphilis, 25%. So at Berlin, the number of cases detected leaped from 1,258 in 1903–4 to 3,721 in 1911–12, with change of personnel of the medical staff and the introduction of partial use of the microscope; consider the amount of misplaced confidence and resultant disease that medical inspection had previously made itself responsible for! Dr. Möller of Stockholm gives confirmatory statistics; in 1874, 19 cases of gonorrhœa were found among 298 prostitutes by clinical methods (6 per cent.); in 1884, 64 among 431 women (15 per cent.); in 1894, 141 among 464 (30 per cent.); partial use of the microscope in 1904 with 408 registered women revealed 749 cases, i. e., 174 per cent. in the course of the year.[421] Baermann at Breslau concludes after long experience that “without the use of the microscope the question as to whether an exudate from the urethra or cervix is infectious or harmful cannot be decided.” This being the result of incomplete use of the microscope, to how much infection did the privileges conferred by regulation lead in Cologne in the year 1905, when among 2,048 prostitutes examined in the course of the year, 148 (i. e., 7.2 per cent.) were pronounced venereally diseased?[422] Or at Vienna, when, out of 2,116 enrolled women, 87 were found to be suffering with gonorrhœa and 162 with syphilis in the course of the year 1907?[423] The following table[424] shows the absurdly inadequate amount of disease detected by clinical methods in the prostitutes of those German cities that I visited.[425]
No. inscribed women No. found diseased City 1903 1905 1907 1903 1905 1907 Berlin[426] 2,231 2,663 2,272 620 576 733 Hamburg 1,266 1,291 920 759 719 791 Munich 248 215 175 165 46 36 Dresden[426] 277 394 281 248 333 426 Cologne 500 500 500 312 212 336 Frankfort a/M [A]449 [A]412 [A]512 341 529 493 Stuttgart 23 16 22 22 18 28
Footnote A:
About.
The women themselves have learnt the trick of defeating the examination. So crude an examination for gonorrhœa as that with which we are now dealing can be eluded by thorough irrigation before examination. Güth specifies various devices by which clinical inspection may be deceived and declares that there are “in the large cities persons who make a business of undertaking these manipulations for controlled women.”[427] The more careful type of clinical examination can also be eluded: “If one remembers that especially women who are regularly examined are highly expert in concealing the traces of disease, one realizes that the medical examination has after all only a relative value,”[428] writes Professor Zinnser, who calls himself a regulationist. The bacteriologist of the Budapest police regards these practices as serious obstacles even to the more refined methods practised in that city. “The visible symptoms of disease are rendered either invisible or misleading. These disreputable physicians perform antiluetic cures and treat the urethra with injections, thus enabling the prostitute to ply her trade.”[429]
The actual scope of regulation is, however, less than its apparent scope; for an inscription list of 6,000 at Paris or 3,000 at Berlin or 25 at Stuttgart does not mean that the number of prostitutes in question is in each city under continuous, even if periodic, inspection, so that there is a more or less stable body of approved women. No system of inspection can be effective if it is discontinuous; hence a large subtraction from even the possible efficacy of a limited and imperfect system must be made on the score of irregularity. Though 6,000 women are registered at Paris, the number who continue for a considerable period and who come regularly to inspection is relatively small. In a few instances, a withered hag reports for examination and one is told that she has been under observation for 25 years or longer; but far the greater number are constantly shifting. For example, in 1884, 1,006 women were newly inscribed, 1,089 disappeared from the rolls; in 1886, 1,145 were inscribed, 2,283 dropped out; in 1902, 1,574 and 1,717, respectively.[430] Some of these are, of course, restored to the list, but as a rule only to slip away again. Of 629 women newly inscribed in Breslau during the year 1886, 147 dropped out in the first year, 94 in the second, 80 in the third.[431] In Vienna, as already shown, the number of disappearances and the number of enrolments keep close together. A small body of older women are more or less stationary; the remainder are in perpetual transit,—and this remainder includes the younger and more aggressive, whom effective regulation would have to keep under continuous observation. The same is true at Berlin; additions and disappearances from the list are as follows:[432]
Year 1902 1903 1904 1905 1906 Newly inscribed 538 590 683 917 1,207 Dropped out 699 696 1,105 1,069 824
Whether even the humane spirit of the new regulations will greatly affect disappearances remains yet to be proved; in a single month, as many as 60 have dropped out; in 1911, 218 disappeared.[433]
In Stockholm, Möller found that of 857 controlled women, 286 were missing after one month; 109 more after two months; 100 more after three; 76 more after four: at the close of the 15th month, i. e., 5% were left.[434] A cursory inspection of police records at Bremen showed me that with few exceptions a woman was rarely on the rolls longer than a few months. Of Stuttgart’s small roll of 24, 22 had been inscribed less than a year,—of these, 10 less than a half-year.[435]
In addition, visits are frequently missed, so that those who remain on the rolls are examined less frequently than the regulations require. Under the old Berlin system, more than 50% of the visits from 1888 to 1901 were thus omitted; there should have been 208,000 examinations; 94,000 were actually performed.[436] At Stockholm, out of 6,667 examinations ordered from July to December, 1905, 2,242 were missed on the appointed day.[437] Taking the entire period 1870 to 1912, Johansson finds that fully 40% of the women who ought to appear at least fortnightly for medical inspection fail to remain under regular control. The office records seem to make a more favorable showing only because they note merely the beginning of an interruption in the woman’s attendance which may, however, last several weeks.[438]
The tendency to disappear is of course strongest in the case of women who, knowing themselves diseased, face the prospect of detention. Between 1885 and 1899, for example, Johansson finds 156 inscribed women who stayed away from the medical inspection; of these, 92, i. e., just under 60%, had primary syphilitic sores.[439] In 1904, 31% of the Stockholm women sent to the hospital missed inspection just before their commitment. During that year 9% of the women had to be apprehended on the charge of missing the medical visit; hence, staying away from medical examination was more than three times as frequent among the sick as among the general list.[440] It appears, further, that of 845 women who between 1885 and 1906 contracted syphilis after enrolment the primary symptoms escaped detection, through interruption of inspection in 656 cases (77.6%).[441] Inspection is therefore apt to be terminated by the act of the woman just at the moment when it becomes important. The women whom the police find to be ill are therefore largely those who, arrested for infraction of the rules, are subjected to an unexpected examination; women who are deceived as to their condition; and those who have bungled in the attempt to hide it or have not yet learned how to do so. Thus the system is even less effective than the size of the enrolment and the method of conducting the examination themselves indicate.
But the system undermines itself at another point: the women, if found to be diseased, are not detained long enough. Dr. Commenge, head of the Paris bureau, reported to the Brussels conference that in the two decades between 1877 and 1897, 15,095 syphilitic prostitutes were confined in St. Lazare an average of 30 days each.[442] In Vienna, between 1893 and 1896, cases of gonorrhœa were detained from 18 to 21 days, cases of syphilis from 21 to 27 days.[443] The police bacteriologist of Budapest states: “One and the same prostitute might come into the hospital repeatedly for the same infection. We know that syphilis lasts for years; it is undeniable that, since the hospitals are crowded and the beds therefore insufficient in number, prostitutes are obliged to leave before they are cured;” syphilis is there kept “at least three weeks,” gonorrhœa “at least two.”[444] At Stockholm, 174 women with primary symptoms were detained an average of 48 days each; 140 with secondary symptoms an average of 35 days each.[445] Partially in consequence of premature dismissal, partially in consequence of re-infection or recrudescence, women often alternate for years between freedom and hospital detention. Of 498 Stockholm inscribed prostitutes, 81 escaped the hospital altogether while on the lists. The following table shows the experience of the others:[446]
No. in hospital Once 71 Twice 42 Three times 42 Four times 41 Five times 37 6–10 times 98 11–15 times 42 16–20 times 29 21–25 times 7 26–30 times 6 31–50 times 2
In Bremen it is now the practice to detain gonorrhœal patients from three to six weeks; syphilitics were receiving at the time of my visit[447] two injections of Salvarsan and were discharged at the end of a fortnight. Finally, at Berlin the average length of the hospital stay of venereally diseased prostitutes has tended steadily to decline as the following figures indicate:[448]
Average stay of each Year prostitute 1895–6 36.4 days 1896–7 32.2 days 1897–8 36.8 days 1898–9 36.4 days 1900–1 39.5 days 1901–2 48.8 days 1902–3 36.7 days 1903–4 41.0 days 1908–9 23.0 days 1909–10 19.91 days 1910–11 19.6 days 1911–12 22.0 days
The sudden drop since 1907 follows the introduction on a considerable scale of ambulatory treatment, allowed theoretically on condition that the women refrain from the prosecution of their business,—an obviously unsafe calculation. It is clear therefore that at all times the period of detention is too brief; hospital care goes far enough to remove the obvious evidence of disease,—the evidence that might, if left untouched, itself deter a more or less cautious patron. Disease being once rendered latent, or apparently latent,[449] the customer presumes, at his own sure cost, on the supposed safety of the woman whom medical regulation has just discharged from the hospital as fit to prosecute her calling.
Even if we take regulation at its word and assume that it is fairly successful in isolating disease, it still remains true that it arrests more healthy than diseased prostitutes and thus increases the commerce of the undetected sick,—professional or clandestine. For the number of supposedly well prostitutes arrested for trifling violations of the rules is always larger, indeed much larger, than the number of ill ones. In Paris, 35,625 such arrests were made in 1897, 32,122 in 1898. The culprits, most of them well according to police standards, were sent to prison to serve short sentences, for “racolage” (soliciting). I observed the handling of a group of such cases: a girl found in the Avenue Wagram at 1.30 A. M. pronounced “well,” got 4 days in prison; the next had just four hours previously finished a four-day sentence; re-arrested last night for loitering and sent back for four days more. The others were of the same type: all were “well” and all were sent to prison. Blaschko found the same conditions prevailing in Berlin under the old régime: 13,591 healthy prostitutes were imprisoned for “ridiculous trifles” in the years 1897–98, while 1,998 diseased prostitutes were under compulsory treatment:[450] that is, regulation removed seven times as many healthy prostitutes as diseased. In 1909, 1,122 different registered women were arrested for violation of rules, 327 different registered women were detained on the score of illness; in 1910 and 1911 the figures were 1,984 and 434 respectively.[451] In Stockholm, at the close of 1911, 28 women were in the hospital, 127—supposedly well—in prison. In Cologne, 438 registered prostitutes were detained on the score of disease, 1,334 for violation of rules, in 1906; in 1911, 272 for disease, 2,066 for infraction of regulations.[452]
I have thus far dealt with registered prostitution alone: in reference to it, I believe we are justified in asserting that the numbers treated have nowhere been relatively large and that the methods of conducting the examinations and their actual working greatly reduce even the apparent efficacy of the system. In Stockholm it has been calculated that three-fourths of the disease current escapes detection.[453] It is therefore an incontrovertible fact that only a small part of the disease in existence among inscribed women has been isolated and that these diseased women have been discharged before they are very much safer: in consequence of which, men consorting with medically inspected prostitutes are the victims of misplaced confidence. If, then, regulation, on account of the general attitude it encourages and on account of the feeling of security it must logically create, has at all enlarged the volume of irregular intercourse, it has operated to increase, not to decrease, the volume of venereal disease.
So much for regulation taken fairly and strictly on its own ground. But the case against it is greatly strengthened when the remaining factors of the situation are taken into account. Regulation has always had to be cautious in the inscription of minors and nowadays tends more and more to omit them altogether. It is held—and of course rightly—that no civilized society can permit a minor to brand herself as a professional prostitute, authorized by the community to earn her livelihood as such. Now, immoral girls still in their minority are at once the most attractive and the most dangerous prostitutes; ignorant and reckless, they are quickly infected and their infection is distributed to a larger clientele. How many infecting foci escape sanitary control by the exclusion of minors a few figures will make clear. Out of 4,341 cases of obviously infectious syphilis in Viennese prostitutes, 44.9 per cent. were between 15 and 20 years of age, 38.1 per cent. between 21 and 25.[454] The chief physician of the Vienna police in 1908 gave a most striking proof of the collapse brought about by excepting minors from regulation,—as he admitted must be the case: in 1900, 329 prostitutes were newly enrolled, 303 of whom (92.2%) were between 15 and 25 years of age: in that year, 2,686 cases of venereal disease were detected among inscribed women. In 1907, 83 prostitutes were newly enrolled, of whom 63 were between 15 and 25 years old: 426 venereal cases were discovered in that year. “In the same measure as the enrolment of minors declines, the total amount of disease discovered declines correspondingly.”[455] In the relatively few instances in which minors are still inscribed at Berlin, the percentage of active gonorrhœa detected by the microscope is very high: of 38 controlled girls between 18 and 20 years of age, 29, i. e., 75% were discovered to have gonorrhœa.[456] Penzig declares that of prostitutes under 18, fully 50% are venereally infected. Pinkus, studying 1,357 inscribed prostitutes at Berlin found that at least 624, i. e., 45.9% had been syphilitically infected before enrolment.[457] Paris statistics teach the same lesson: of 12,615 unregistered minors arrested between 1878 and 1887, 56.26% were syphilitic.[458] More recent statistics sustain this result showing, as is claimed, that active disease is “ten times as common” among the unregistered minors as among the older women who are inscribed.[459] In Zurich, 39.7% of the syphilitics described by Müller and Zürcher were between 12 and 17 years of age, 42% between 16 and 21 years old; of those over 26 years old, very few indeed showed active signs of the disease, proving “the well-known saying, that the prostitute becomes syphilitically infected at the very outset of her career.”[460] Roget at Brussels verifies this conclusion; he states that most infections occur between 16 and 22.[461] At Munich, of 2,686 clandestines arrested and medically examined, 711 were found diseased, and of these, 326, i. e., over 50% were minors. That is to say, even assuming forcible inscription of adults, over 50% of the diseased would have been missed as the sufferers were ineligible to enrolment on account of age. Of 88 such cases, 55 per cent. of those 15 years old were infected, 61 per cent. of those 16 years old, and 67 per cent. of those 17 years old.[462] A Viennese estimate showed that out of every 1,000 prostitutes arrested for offences, over 57 per cent. were minors,—practically ineligible to inscription and medical control. Infection takes place so early that it is believed that in general “every prostitute who has followed the business a year is infected.”[463] Regulation is therefore in the position of creating a certain presumption in favor of the hygienic security of irregular intercourse; even if it could create a monopoly in favor of inscribed women, there would be no reason to believe in its efficacy; but as the appetite that it fosters satisfies itself indiscriminately, the result is that bad is simply rendered worse.
One arrives at the same conclusion from another angle. I have repeatedly pointed out that on any rational definition of prostitution the total army of prostitutes is many times as large as the registered portion. Most of these women ply their business unhindered. Having had precisely the same history as the registered women and conducting their affairs with similar promiscuity, disease is of course equally rife among them. Yet, as long as they conduct themselves with discretion they are free from police interference: in towns where compulsory enrolment takes place (e. g. Berlin and Hamburg, etc.) they must be thrice warned before they are arrested and compelled to submit to medical examination, with a chance of compulsory registration; elsewhere, as at Bremen, Munich, Stuttgart, etc., they are, if arrested for disorder, medically inspected, but are in no event compelled by forced inscription to submit to regular examination afterwards. Thus only the disorderly clandestine or non-inscribed woman is ever anywhere inspected at all. The cautious street-walker and fashionable and showy women who in Berlin frequent the Palais de Danse[464] are never inscribed, despite their notorious character. Women of the latter type are, in fact, nowhere enrolled; yet they do a large business, dangerous not so much on account of syphilis, which is with them long since a matter of the past, as on account of gonorrhœa, from which they are chronic sufferers. How much disease regulation in one way or another thus permits to go untouched among the non-inscribed is made clear by the amount of disease detected among the small part of clandestine or non-registered prostitution that the police lay hold of. A single clinical examination of each of 12,825 non-inscribed women arrested in Berlin in five successive years (1903– 1907 inclusive) showed 17% venereally diseased;[465] of 1,514 arrested in 1909 and 1910, 421 were diseased.[466] At Cologne, the percentage is much higher: 660 non-inscribed women were arrested in 1906, 178 were infected; 1,626 were arrested in 1911, 304 were infected.[467] At Vienna, 1,319 such arrests were made in 1910: 222 cases of infection were discovered among them.[468] It must be emphasized that the police surgeons get hold of these women, not because they are diseased, but because they are disorderly. Had they remained sober and quiet, regulation would have permitted them to continue undisturbed in the work of spreading infection, precisely as it does not touch the thousands of others, who, however diseased, are careful to keep the peace. The amount of disease thus surprised is interesting as a symptom of the vastly larger amount that wholly eludes observation; and, finally, the disease thus detected is—like the disease occurring among inscribed women—but a part of that actually existing among those examined; and, like all the rest, is readmitted to circulation while still infectious after an inadequate period of detention. An incident related by Welander may well close this line of argument. “It is superfluous to mention,” he writes in his account of venereal disease and prostitution in Sweden, “that the clandestines are the main sources of infection. Recently there has been a small epidemic of soft chancre in Stockholm. Daily, male patients thus afflicted are admitted to the St.-Göran Hospital; but the hospital for prostitutes, during this entire period, has received only five women thus infected. This epidemic cannot be attributed to inscribed women,”[469] and, further, he might have added, inscription did not locate or isolate the infecting foci.
I have, at the risk of being tedious, discussed the foregoing points in considerable detail in order that we might be in position to decide whether—whatever may be held theoretically as to the possibilities of regulation—it has in the past operated to reduce the amount of venereal disease. Let it be remembered that, except in three or four cities shortly to be taken up, regulation throughout Europe has been and is of the type above described or worse, and that in the three or four cities in question, improvements are so recent that no effect is as yet noticeable. Whatever, then, one may hold as a matter of theory, it is clear that, as a matter of practice, regulation as it has been carried on during the past century has increased, not decreased, the volume of venereal disease. No successful experience in the past can anywhere be quoted in its behalf. Those who believe in its possibilities are loudest in condemning its actual results. Professor Finger of Vienna, a regulationist, so-called, and one of the authors of the recent improvements there, says of the usual system: “As far as the good of regulation goes, I can speak from experience: the good can’t possibly amount to much.”[470] Professor Neisser of Breslau, the discoverer of the gonococcus,—a regulationist, too—declares: “If a radical reconstruction cannot be brought about, it is better to drop the entire system. The present system not only does not effect a real sanitary control of the inscribed women,—it rather operates to increase the volume of venereal disease.”[471] Professor Zinnser, of Cologne, likewise a regulationist, opens a discussion with these words. “The knowledge that the regulation of prostitution as generally conducted heretofore is obsolete, defective and urgently in need of reform, is not new.”[472] The Hamburg system, in the form in which I have above discussed it, is the creation of Dr. Julius Engel-Reimers, whose authority in Hamburg was, during his lifetime, so great as practically to render criticism futile. Nevertheless in a volume of lectures on venereal disease, published in 1908, Dr. Engel-Reimers, at the close of a career identified with regulation, declares: “Medical control of prostitutes has very slight influence on the incidence of syphilis and gonorrhœa among the male population. It is absolutely clear that these diseases are no less common where regulation exists than in places where prostitutes enjoy unrestrained freedom to ply their trade.”[473] This is assuredly candid, as well as startling testimony. As to the point here touched on, viz., the incidence of venereal disease in the general population, as far as it can be made out, I shall have something to say when I discuss conditions in non-regulated countries.[474] For the present it is enough to note that the authorities above quoted—and the number can be extended—all call themselves regulationists; but it is some new form of regulation, not regulation as it exists historically, that they believe in. Those who defend the system and its results against the regulationist medical authorities above quoted are in the main police officials, whose favorable judgment will be accounted for in the next chapter.[475]
If regulation has, even in the opinion of authorities theoretically inclined to believe in it, failed in the past, is there any evidence to support an opinion favorable to it in some revised form in the future? In certain cities, the medical examination has been reconstructed on modern lines,—Berlin, Budapest, Bremen and Dresden; the same modifications and improvements could be generally introduced if money and intelligence—both procurable—were provided. Would regulation then be efficacious as a sanitary measure?
Let me call attention at the outset to the peculiar position in which the system is placed the moment one asks this question. It implies that regulation is not a policy more or less approved by experience, but an experiment, the value of which as a possibility has nowhere as yet been demonstrated. So far as history goes, the verdict is against its efficacy; so far as the revised system is concerned, not even those trying it as yet pretend to be able to assert for it any perceptible measure of success. “I must note at the very outset,” says the candid police bacteriologist of Budapest as recently as May 29, 1912, “that the time which has elapsed since the new ordinance has been in force is as yet entirely too short for us to render a final opinion concerning its advantages.”[476] “There is no telling whether the new regulations have accomplished anything,” said one of their authors, Dr. Dumitreanu Agoston, to me. Regulation in its historic form is thus something worse than a failure; in its modern form, an experiment, of whose success not even its authors can give any evidence or venture any prediction!
Is there any substantial reason to believe that the improved system will successfully cope with the difficulties fatal to the old? The number that it reaches is less rather than more. Under the clumsy old system, Berlin enrolled 5,098 women in 1896; under the improved new system, 3,559 in 1912,—a decrease of over 30%, despite the city’s growth; under the old system, Dresden enrolled 394 in 1905; under the new, 293 in 1912; at Budapest, the numbers are practically unchanged. The increased leniency and humanity of the new system thus decrease enrolment and tend to offset any advantage gained by improved medical methods.
Nor does the new system enjoy any advantage over the old in other important respects. Women continue to miss visits and to disappear: at Budapest, for example, with an enrolment of 2,000, the monthly non-attendance in 1912 ran as follows:[477]
March 293 April 353 May 398 June 315 July 414 August 319
Finally, the sick are not detained for longer periods of time: indeed, ambulatory treatment is more apt to be allowed as the administration of the system becomes more lenient, and thus additional loopholes are created.
These are, however, matters of detail on which it is not worth while to pause longer. The issue turns mainly on the effect of the partial use of the microscope,—at least once in two weeks at Berlin, on suspicion in other places. How far-reaching is the improvement thus wrought among the small number of women affected by it?
In respect to syphilis, the situation is hardly modified at all, except in so far as the general quality of the personnel has unquestionably been improved by the introduction of more modern methods and a more dignified environment. But these factors are not far-reaching. The inscribed women have either had syphilis before inscription, in which event no check was placed on them at the time; or they contract it subsequently, in which case they are interned only until the active ulceration has been converted to more or less latency, without certain termination of the infectious character of the disease. The scope of improved regulation in dealing with inscribed syphilitics is thus practically as limited as that of the older form; it has no definite or reliable effect during the dangerous primary and secondary stages and is, of course, unnecessary in the tertiary stage.
For the reasons just urged, neo-regulation concerns itself mainly with gonorrhœa. Figures already given[478] show that the moment the use of the microscope begins, the amount of gonorrhœa detected increases; indeed, the more slides one prepares in dealing with a group of women at a single inspection, the higher the percentage of infectious subjects. Whether gonorrhœa is discovered in a prostitute or not is largely a question of the microscopist’s patience: “the oftener microscopical examinations are made, the more girls are found diseased.” Lochte examined 172 girls once each, when 19.1 per cent. gave positive evidence of gonococci; on a second trial, twice as many (38.6 per cent.). Different investigators have discovered that from 50 to 65 per cent. of inscribed women carry the gonococcus hidden in glands or folds.[479] Ten successive daily examinations of a former servant gave negative results for 5 days, positive on the fifth and seventh, negative, sixth, eighth, ninth, and tenth. Instances are known in which the disease has been contracted by a patron from a woman in whom the microscope was unable to demonstrate the gonococcus. The explanation is obvious. When the germs are less numerous, it is a matter of chance whether the infinitesimal amount of the secretion examined happens to contain a sample or not; but infectiousness exists none the less. The microscopist may not encounter it; the customer may. In order to reduce chances of error, negative findings on three successive days are required before release; but Professor Pinkus told me of women released from the hospital on these terms in the morning who—without intercourse in the meanwhile—gave positive specimens at the police examination in the afternoon. Besides, under sexual excitement, the gonococcus that has burrowed more deeply is all the more apt to be exuded. The explanation is simple: “Gonorrhœa in the male is almost invariably curable, if the patient submits to treatment; gonorrhœa in the female is almost never cured at all.”[480] And again: “Every prostitute, even though not acutely and violently diseased, is always more or less infectious and not the least confidence in her freedom from gonorrhœa can be justified.”[481] A chronic condition supervenes that is always infectious,—and most of all so during intercourse. Professor Havas of Budapest, long the head of the hospital service to which diseased prostitutes were sent, a regulationist at first, and now a strenuous opponent thereof on the basis of experience, refused to certify released women as “well”; he struck the word from the woman’s protocol and inserted “improved”; but in the “improved” condition, the danger of communicating infection is always present.
All that I have just urged would be true even if the microscope were constantly used. But, as a matter of fact, even where neo-regulation is most systematically installed, the labor and the time involved are so enormous that it has proved impracticable to institute anything beyond occasional microscopical control.[482] What does the fortnightly microscopic slide in Berlin prove? That at two moments in the course of a month, a random shot failed to elicit positive proof of infectiousness! During two weeks, the utterly incompetent clinical examination alone threatens the woman’s withdrawal from business; should she be even palpably infected, she may easily be allowed to continue the distribution of gonococci during this period. At the close of two weeks, her chances of detention momentarily increase. Yet, even so, the numbers at any time interned show the inadequacy of the method to reach and to isolate any considerable volume of infection. During four months—December 1910; January February and March 1911—809 cases of gonorrhœal infection were discovered among the registered prostitutes at Berlin:[483] that is, on the average, the number of women in circulation was reduced about 200 per month. On the last day of four successive years (1908–9–10–11) the total number of interned prostitutes was as follows: 98, 105, 140, 242.[484] In the other towns where the improved system is in use, its inadequacy is equally striking. At the time of my visit to Dresden (June 19, 1912), 9 inscribed and 27 non-inscribed women were in the venereal hospital ward; at Bremen there is an average of 18 to 20 patients of all kinds. All this is well-nigh negligible even when compared only with the total inscription; when viewed in connection with the total amount of prostitution and disease, it is not worth mention.
It is, of course, urged that, be the number removed and temporarily confined ever so small, infection is at least reduced by that amount. The argument holds only in case the number removed is large enough to affect the accessibility of temptation. Ten women in a bordell will, for example, satisfy all the customers who come; if one is withdrawn—and the percentage withdrawn by medical inspection is by no means so large—the remaining nine will dispose of the same volume of trade. The amount of congress is therefore hardly affected: is the amount of disease reduced? That depends on the condition of the nine with whom the business is transacted. Similarly, on the streets: two hundred women are withdrawn from the streets of Berlin, on which every evening thousands of others roam. The provocation is not perceptibly influenced. Let us follow what happens to a prospective customer. A woman—Marie, let us say—to whose solicitations some man would have succumbed, is in the hospital. Is her clientele so attached to her that they will abstain until she is released? If so, undoubtedly, there being less congress, there is less disease in that interval. But the traffic is not organized in that way. Marie’s customers are picked up by Gretchen or by some one else. Does the withdrawal of 250 women reduce disease, if it involves only redistributing business so that what would have been intercourse with the interned Marie is transferred to others?
That depends on the condition of the other women. Are they safe? The vast clandestine army not hygienically supervised is no safer than it would be if there were no medical regulation; and this army is so large a proportion of the whole that we may declare at once that the effect of removing a controlled prostitute is to force her business largely upon prostitutes who are uncontrolled; and the latter are so numerous and prominent that the business is kept to the maximum permitted by general conditions, regardless of the forced isolation of an inconsiderable number. Those of Marie’s customers who fall to controlled prostitutes are hardly likely to fare better,—for the controlled prostitute is suffering with a chronic cervical gonorrhœa which any customer may contract. When 150 inscribed women are withdrawn from the roll of 3,000, all having gonorrhœa in some form, when 70 women are withdrawn from the uninscribed thousands, mostly infected, the good luck of a patron may save him once or twice with or without regulation, but sooner or later he will fall a victim.
The amount of disease communicated and contracted is, therefore, in the long run, dependent not on the existence or the non-existence of medical inspection, but on the frequency and amount of irregular intercourse. Professor Havas, in discussing with me the Budapest situation, urged vehemently that there is but one factor to be reckoned with, viz., the amount of promiscuous coitus. Whatsoever reduces such coitus, reduces disease: a rainy night, driving women and men from the streets, an outburst of police repression, do more to check disease than any system of regulation; on the other hand, regulation, by making controlled—and in consequence uncontrolled—prostitution prominent, by weakening the inhibitions, social, individual and hygienic, increases the amount of coitus and thereby increases the amount of disease. It is surely not without significance that Professor Pinkus, head of the hospital for venereally infected prostitutes, has published a book, called the “Prevention of Venereal Disease,” in which he emphasizes the infectiousness of all prostitutes, controlled as well as uncontrolled, and bids his readers refrain or utilize mechanical preventives for their protection!
It is therefore not surprising to find how frequently afflicted men in regulated cities refer their infection to professional prostitutes. Pinkus, inquiring of 2,512 male patients, traced 1,571 cases (62.54 per cent.) to prostitutes, of whom 1,350 (52.74 per cent.) were professionals.[485] Of 661 infections in Stockholm, 297 could be traced to their sources: 151, or over 50 per cent., were known to come from inscribed women.[486] Dealing with 102 infected gymnasial students, Meirowski traced little less than half to registered women.[487]
Does the foregoing condemnation of sanitary control apply to the bordell inmates as well as to scattered prostitutes? Or does the medically regulated bordell offer an increasing measure of hygienic protection? Assuredly not on the score of more thorough medical examination. In so far as the inspection takes place in the bordell, as is the case in Paris, Hamburg, Rome, Geneva, and Brussels, the situation is aggravated rather than improved; for nowhere are there proper facilities, and the women may all the more readily practise imposition.[488] Disease is therefore not more likely to be discovered.
On the other hand, it is more likely by far to be widely distributed: for the bordell prostitute entertains, as we have learned, a stream of patrons. Schrank estimated that the Vienna women averaged three to ten visitors daily; but the number is known on occasions to have risen to thirty or higher.[489] An authentic instance of 57 visitors in one day is recorded;[490] the city physician of Rome vouched for a case of 60 visitors; the mayor of Bordeaux told the French commission of a woman who had received 82 clients in a single day.[491] The sale of alcohol in the bordell markedly increases the range of infection, for it provokes recklessness and banishes caution. It has been estimated that one-third of the gonorrhœal infections are incurred while the victim is in liquor.[492] If then, the woman is herself infected, she has enlarged facilities for distributing disease; even if not herself infected, she may be the carrier of disease from one of her patrons to others of the series. The chief physician of the Vienna police remarked in a public discussion of this point: “The prostitute is often only the carrier of an infection. It is nothing new to find a man who has contracted disease from a woman whom the most careful examination pronounces ‘healthy.’ These things happen with all infectious diseases.”[493]
Statistics favorable to this contention can be submitted; but in view of the liability of the patient to error[494] in locating the source of his infection, the argument is perhaps more conclusive than the figures. A single set of statistics from Bremen that appears to prove the reverse will be presently accounted for. More significant, however, is the contrast between the amount of disease discovered in the bordell inmates of Hamburg and the scattered prostitutes of Berlin:[495]
Number inscribed women Year 1903 1904 1905 1906 1907 Berlin 3,709 3,287 3,135 3,518 3,692 Hamburg 1,266 1,258 1,291 1,039 920
Number found diseased Year 1903 1904 1905 1906 1907 Berlin 620 505 576 660 732 Hamburg 759 843 719 721 791
Percentage diseased Year 1903 1904 1905 1906 1907 Berlin 16.7 15.3 18.3 18.7 19.8 Hamburg 59.9 67.0 55.7 69.3 85.9
When the comparison is made in terms of examinations rather than individuals, the result is similarly to the disadvantage of the bordell. Of 1,000 examinations made of bordell inmates in Brussels between 1881 and 1885, 2.71 per cent. showed disease; of the same number of examinations of scattered women 2.51 per cent.[496] But perhaps the best statistical proof is derived from Vienna, where substantially the same methods—if poor, at any rate consistently poor—were applied to both sets of registered women, the bordell women making regularly the worse record:[497]
Percentage diseased Year 1888 1889 1890 1891 1892 1893 Bordell inmates 13 12 15 13.5 13.5 12 Scattered prostitutes 2 3.6 5.3 4.7 6.5 5.8
The bordell is particularly dangerous to youth, whose curiosity it excites; and recklessness and ignorance characteristic of that period results in an exceptionally high ratio of infection. Pinkus gives some statistics collected at Kiel, showing that of 100 boys under 20, 33.75 per cent. had been infected in the bordells of that city; of 100 men over 20, the bordells were held responsible in only 19.75 per cent.[498] Hecht, discussing the experience of Prague, points out the “relatively greater frequency of infection in bordells” and attributes it confidently to the “greater volume of their business in consequence of their readier accessibility.”[499]
Against the position above taken, the experience of Bremen has recently been cited. There the percentage of infection discovered among bordell women has been steadily reduced by the system of regulation in vogue. In 1900, the 50 inhabitants of Helenenstrasse averaged 1.4 infections each; in 1905, the seventy-odd women there averaged .73 infections each; in 1910, .38 apiece.[500]
Can it be fairly inferred that a strictly supervised bordell system will thus greatly diminish danger? As a matter of fact, there is no pretense that the total amount of venereal disease in Bremen has been perceptibly influenced by the bordell control. The business of the bordells is steadily shrinking; the clandestine prostitute—uncontrolled and unregulated—thrives. Hence, even if effective, the Bremen remedy is impossible. Seventy women can be drilled to exercise all kinds of precaution,—but the moment the number is largely increased, supervision collapses. The smaller number of women here interned can be forced to provide their guests with mechanical devices—and themselves to utilize strong antiseptic douches.[501] But it by no means follows that the same policy could be operated wholesale. The figures are themselves, however, without the significance attributed to them. In the first place because, as the oft-infected prostitute suffers from chronic gonorrhœa, she is always a menace, most of all so during coition (let the examination say what it will); strong douches simply wash away accessible evidence. In the second place, because the membership of the little colony is so constantly changing that the figures do not speak for the condition of a definite set of women. The following table brings this point out clearly:
Year Enrolment Jan. 1st Added during year Withdrawn 1902 47 33 28 1903 52 59 41 1904 68 78 72
There was thus a constant entrance and exit, the entire membership being transformed in a short space of time.[502] Looking through the police records, I ascertained that one woman had been resident six years, one or two others one and a half years; all the rest were recent additions.
There is therefore no basis in experience for a verdict favorable to bordells on the ground that they conduce to a form of medical inspection that tends to diminish disease. The fact is that, though infection can be lessened by the use of mechanical devices, the recklessness developed in bordells consequent on alcoholic indulgence operates to prevent rather than to encourage precautionary measures. The women never cease to be dangerous; and as they transact an amount of business impossible outside, the actual amount of infection is enormously increased.
On the medical side, therefore, regulation is even weaker than on the side of order. There is a connection between prostitution and disorder, in such wise that some sort of police control of disorderly or criminal prostitution might conceivably be a useful way of keeping them in easy reach. Experience proves that the same object can indeed be otherwise attained, and without granting enrolled prostitutes privileges which are themselves damaging to the public and straightway involve the extension of similar privileges to the uncontrolled. But there is still a grain of truth at the bottom, namely, that the low grade prostitute tends to align herself with crime and for that reason may be properly made a constant object of police surveillance.
It is absurd, however, to infer that machinery devised in the interest of order is equally applicable to sanitation. On the score of order, the police are interested in criminal and semi-criminal prostitutes. The discreet women who ply their vocation inconspicuously and in a businesslike spirit give no trouble and are therefore never inscribed. Disease however, is an altogether different matter. From that there is for the prostitute no exemption whatsoever. She contracts it irrespective of her outward demeanor; and she communicates it, regardless of the general decorousness of her behavior. The criminal law runs against a part of the prostitute army; the bacteriological law against all. A form of control adequate to the former is therefore entirely inadequate to the latter.
There is then on the sanitary side no support whatever for the theory of police regulation. It assumes that those dangerous to order are the ones most dangerous to health; that crime and disease go together; that if the police inscribe women inclined to join prostitution and crime, they will thus get hold of the main sources of infection. But the truth is far otherwise. The non-criminal prostitute is at least as dangerous to health as the criminal prostitute. The young, who cannot be inscribed; the older, more cautious and more showy who take care not to annoy the police; the occasionals and incidentals, who oscillate between or mingle prostitution and work;—these are perhaps even more active agents in spreading disease than the utterly repulsive women whose thieving or drinking propensities make them the peculiar objects of police care on the score of order.
There is another objection to identifying disease and crime, as the association of medical inspection with the police inevitably does. The infected prostitute has been taught that the consequences of disease resemble the consequences of crime; they lead to arrest and condemnation,—even though condemnation means only a hospital ward. This ward is in some places still a prison; in others, prison associations cling to it. In consequence, the woman’s first impulse on realizing her condition is to flee or to hide. She resorts to a quack, she employs superficial remedies to conceal the ravages and signs of infection; and she plies her business. Hence a few wretched or foolish girls and women who are in ignorance of their condition or who have been suddenly apprehended find themselves pronounced “diseased.” One sees them at St. Lazare and other less hideous places,—all alike poor and friendless. The more clever of the inscribed women, if diseased, disappear into remote lodgings or to other towns; the fear of the prison hospital leads them to conceal and to scatter infection. Nor is there any hope of breaking off the association in the woman’s mind so long as a pretended sanitary function is lodged in police hands.
The women have thus completely penetrated the sanitary insincerity of regulation. They know that they are not regulated simply because they are prostitutes,—not even because they are diseased prostitutes. Too many mere prostitutes are never touched; the diseased prostitute is too rarely apprehended just on that account. A woman is inscribed because, being a prostitute, with or without disease, she has incurred,—justly enough, doubtless, as a rule—the suspicion and displeasure of the police. The hygienic motive did not and does not start the machinery to move, and its connection with ordinary police functions, methods and spirit results in its own discredit and defeat.
A final absurdity remains to be pointed out. What can it avail to incarcerate for brief periods a few unhappy women, if meanwhile the manufacture of fresh foci of infection proceeds unhampered? As long as regulation completely omits men,[503] new sources of infection are produced far more rapidly than by any known method they can be eradicated. A vicious circle exists. Men infect the beginners—themselves at the time out of reach—who in their turn infect other men. I pointed out in the opening chapter that prostitution is a concept involving two persons. Logic and justice alike require that both parties be considered as equal partners in the act; and in no respect is it more completely impossible to omit either of the two essential factors from the reckoning than in the matter of disease. Society has chosen to overlook the man; but nature has righted the balance by impartially distributing disease and suffering; nor will she permit herself to be outwitted by any one-sided scheme, even though it be far more extensive and efficient than regulation has thus far anywhere been.
Regulation, needless on the score of order, is thus seen to be positively harmful in its bearing on disease. As a system, therefore, it runs counter to the modern spirit in ethics, in politics, and in hygiene. Why then should it still exist in places, why should it fight so stubbornly for survival? To the answering of this question, the last chapter dealing with the subject will be devoted.