An Important Social Question

Kai Tiaki : the journal of the nurses of New Zealand, Volume VIII, Issue 3, 1 July 1915, Page 117

An Important Social Question

An Address to the N.Z.T.N.A. (Wellington Branch), May 26th, 1915, by Dr. Wm. Young.

Dr. Collins, who is unfortunately unable io be present to-night, having answered his country's call, considered it his duty to bring before you the question of the treatment of venereal diseases, from a public health point of view. Dr. Collins has been for some time past studying the matter with a view to legislation, especially as regards notification and treatment. He was Chairman of the Special Committee set up by the Australasian Medical Congress to report on Syphilis, and which presented its report at Auckland, in February last year. As I have undertaken the lecture at short notice, I beg your forbearance for any shortcomings. The Australasian Congress, of 1908 had, in appointing the Special Committee, resolved : : ' That Syphilis is responsible for an enormous amount of damage to mankind, and that preventive or remedial measures directed against it are worthy of the utmost consideration." The same also may be said of gonorrhoea. It seems to me that nurses do not get enough instruction in venereal diseases, a subject often kept too much in the background, although it is one of the most terrible scourges we have to deal with. There is no doubt that gonorrhoea is much more common than syphilis. Amongst recruits for the Army it has bee n found that syphilis has diminished ; but gonor rhoea increased. Gonorrhoea often sets up severe inflammatory infections of the generative organs, and is apt to sterilise both male and female. Most of you must have seen the tubal abscesses and other severe inflammatory pelvic conditions which follow on gonorrhoea in the female. Unfortunately one attack does not confer immunity. Some physicians consider this even a more serious complaint, in the case of women, than syphilis. There is good reason to think that, bad as it is, syphilis is not such a malignant disease as it used to be, It is, however,

generally recognised to be by far the most important cause of disease of the nervous system. Mott says : "If the virus attacks the nervous system it is rarely that a complete and permanent cure results even with efficient treatment. Some degree of paralysis, feeblemindedness, or functional defect will be left in consequence of syphilitic disease of the nervous system, in the great majority of cases, even if they are treated ; in many instances in spite of treatment, the patient is left with an invalid brain rendering him more or less helpless." Locomotor ataxia and genera] paralysis, both incurable diseases, are now known to be due to syphilis either congenital or acquired, more often the latter. Probably, however, only 3 or 4 per cent, of cases develop these diseases (Mott). Marriage of syphilitics is apt to result in miscarriages, stillbirths, children dying in infancy of convulsions, meningitis, and hydrocephalus, followed later by children who lived, but suffered in various ways physically and mentally. Many children who are born apparently healthy develop later interstitial keratitis, nerve-deafness, bone, skin and visceral lesions. Many of you know well the appearance of congenital syphilides with their "peg" teeth, saddleshaped nose and linear scarring around the angles of the mouth. At puberty the genital organs may remain infantile, and the individual show signs of idiocy or imbecility. Children of syphilitic parents, whether born apparently healthy or showing obvious signs of syphilis may subsequently develop various nervous affections :■ — tabes, general paralysis, primary optic atrophy, epilepsy, chorea, hysteria, or meningitis. The following is one example of many of the results of one parent being syphilitic : Twelve children — Ist Died, 5 months foetus. 2nd Died, 5 or 6 months foetus 3rd Died, 6 or 7 months foetus 4th Died, 7 months foetus, lived 8 hours,

sth Born alive, frail and delicate. 6th Developed signs of general paralysis and dementia at 14, and died 3 years later. 7th Living and well, aged 16. Bth Living and well, aged 14. 9th Living and well, aged 12. 10th Died of convulsions, aged 11 months 11th Died at 8 months, brain disease and club foot. 12th Living and well. (Mott). After quoting this case as illustrating what a terrible curse syphilis is to some families, it is unnecessary to enumerate other cases equally distressing. My whole object is to impress upon you the necessity of taking some action to lessen the scourge, and with this end in view to ask your support for the legislation which Dr. Collins proposes to put before Parliament. Whilst on the subject of syphilis it is interesting to recall that it was not until 1905 that the spirochaete which causes it, was discovered, that two years later, Wasserman published his ' blood test," which can detect a large proportion of cases, and that two years later Ehrlich issued his remedy, "606," Salvarsan. There is no doubt whatever but that i( 606 J: effectively and rapidly causes a disappearance of symptoms ; but it is only lime that can show whether or not it gives a complete cure in all cases. The disease is one which often remains latent. All symptoms may disappear for years and the patient imagine himself cured, when symptoms of nervous disease appear. Only recently I saw a case of locomotor ataxy in which the patient had seemed to be cured and was free from symptoms for about 20 years, was married and had children apparently healthy. These are very sad cases. It is in these latent cases that the Wasserman test is especially useful. The test is not absolutely certain, but often reveals the disease in doubtful cases. With regard to the Salvarsan and Neosalvarsan treatment of syphilis, many doctors supplement it with the oldfashioned mercury. Some doctors even rely more on mercury than on the newer remedies ; the favourite method of administration being by intra-muscular injections ; but oral administration has still many adherents,

The Frequency of Syphilis jin New Zealand. It is impossible to estimate accurately the number of cases which occur each year, but the Special Committee, referred to above, made enquiries from all medical men in New Zealand, as to the number of primary and secondary cases seen in the last two years. The total reported was 1,941, but only about half the doctors replied ; of this number, 412 occurred in Wellington. Little is to be learnt from death certificates, for private practitioners, out of consideration for relatives, often omit using the term " Syphilis." However we know that 451 persons died in New Zealand during the past ten years, from general paralysis of the insane, and we know that Fournier, a great authority on the subject, alleges that 3 per cent, of all syphilitics develop that form of the disease. This would give an average for this Dominion of 1,500 cases annually. Mental experts state that this disease (acquired or inherited) is the cause of at least 25 per cent, of all mental diseases. We all know that our mental hospitals are all over-crowded. If mental experts are right, the disease must be much more prevalent than is usually supposed. There is no doubt that many cases never come under the notice of medical men. but are treated by chemists and quack?. Source of Infection and Prevention. The Special Committee reported that the replies were practically unanimous that the infection is sea-borne, Australia, especially Sydney, being most commonly mentioned ; then the South Sea Islands, with a proportion of cases from other oversea routes. To Sydney, the disease is supposed to be brought largely by the Indian Coolie population of the Islands, and from the East Indies, China, and Japan. There is a prevailing impression amongst the laity that, as syphilis is a loathsome disease, it is found only amongst abandoned persons and that prostitutes are the commonest source of infection. However clandestine immorality, immorality clothed with a semblance of respectability, is a far greater source of infection. It is partly on this account that legislation in the past has. failed to check the disease,

Prostitution dates, unhappily, from the earliest stages of human culture, and was a recognised institution in the times of the Jewish patriarchs. It was recognised in ancient Babylonia, Athens, and Rome, Christian Kings issued at various times, strenuous laws aiming at the suppression of the vice ; Charlemagne was one of the earliest of these. In modern times various laws have been made to regulate and to suppress the vice, but all to no purpose, and often worse than useless. For example, 'The Contagious Diseases Act" (an Act by which a system of inspection was established, and by which Magistrates were v empowered to order the examination and detention in hospital of women suffering from contagious diseases), which was repealed in England, in 1866, operated unequally, and therefore unfairly, as between the sexes, it was degrading to women, and failed to limit or mitigate the evils which it was intended to mitigate, and did not lessen the consequences of those evils in the shape of venereal diseases. No legislation is likely to improve the morals of the people, and so education is our main hope. Immorality results from bad heredity, bad environment, and bad or defective education. At the Portsmouth Conference held last year, Dr. Helen Wilson pointed out what an important part home conditions play as a cause of immorality ; out of 165 consecutive cases in an institution for fallen girls, she found that in 60 the mother was dead, in 40 the mother was bad, and in 81 the father was dead or worthless. Again, in another series of 356 cases, investigated by her, she found that only 88, a quarter of the whole, had good homes. At the same meeting, Dr. Skinner, of Sheffield, stated that our best line of attack on syphilis was to compel early treatment of those infected, and to improve the general state of morals by such educational methods as are best fitted to that end. We must not forget that many people, including nurses and doctors, contract the disease innocently. The fact that the saliva of patients, in the secondary stage of the disease , conveys infection makes it important that all cases should be notified and segregated, for even cups and glasses Vised by them become sources of danger,

Hence you must all agree that in the interests of the community these cases should be not only isolated, but also thoroughly treated. The Special Committee pointed out that the medical profession is concerned as a profession with the prevention of venereal disease, and cannot associate itself with the penalising of certain members of a sex which contains the minority of infected individuals, and who certainly are not the greatest cause of the syphilis prevalent in New Zealand. The only legislation now relating to the social evil is directed, not for the purpose of checking it or preventing the spread of the disease, but for the purpose of preventing disorder in public places and annoyance to neighbours. Thus the "Police Offences Act, 1908/' imposes a punishment on any " Common prostitute," who, for the purpose of prostitution loiters or importunes passengers in a public place, or who behaves in a riotous or indecent manner in any such place.^lt also^ provides for the punishment of persons who have no lawful and visible means of support, or who habitually consortj^with reputed thieves or prostitutes. There are other provisions in the " Justices of the Peace Act," imposing punishment onjpersons who keep or assist in the Management of brothels, or who knowingly permit their premises to be used as brothels.^ It has been decided that a place in which only one woman receives her patrons is not a " brothel." There is no legislation providing for the compulsory treatment of persons suffering from venereal disease, except in the case of persons voluntarily submitting themselves for treatment. Then they may be detained until they cease to be a menace to the public health. (Clause 19, Hospital and Charitable Institutions Amendment 1913, No. 56). CONTROL. This Committee recommends : — (1). The provision of free treatment at all General Hospitals and Public Dispensaries ; advice to be available at hours suitable for all classes of patients. Beds should be provided in all General Hospitals for treatment of such disease, no reference being made to any wards as being Lock Wards. (2). Th£ control of the disease amongst

merchant sailors. Our information shows that the disease is brought to New Zealand mainly from Australia and Oceania. It is asserted by those acquainted with the men that they are apparently ignorant on the subject, yet probably willing to learn. We advise that merchant seamen be treated in the same way as sailors are in the Royal Navy. To do this it would be necessary that every steamer trading on the routes to the places mentioned, should be compelled to carry the necessary preventive treatment adopted in the Navies. There should be by regulation, pamphlets available referring to the nature of the disease and its prevention, and information should be given as to places for free treatment. There can be no question that the simple measures adopted in the Navy have had a very marked effect in reducing the amount of syphilitic infection. The Journals of the Royal Army Medical Corps contain several references to the influence of these precautions. It is recognised in the Navy according to the evidence of the Medical Director-General given to the Royal Commission on Venereal Diseases, November, 1913, that the education of the men by means of lectures is beginning to show good results and the sharp fall in invaliding from venereal disease was to a certain extent attributed to this. It may be mentioned with regard to the Navy that no person suffering from active venereal disease is allowed to land whilst the ship is in any port. DIAGNOSIS AND TREATMENT. It is essential for the purpose of effective treatment that microscopical and bacteriological methods of diagnosis of this disease should be available in the four principal cities of the Dominion. The laboratories must be under the official control and management of a skilled bacteriologist. These establishments would be of immense benefit to the Hospitals, Mental Hospitals, Gaols, and other Public institutions of the Dominion, as well as to the public generally . They are already established in Dunedin, Christchurch, and in Wellington. The value of having such laboratories in the four principal cities would be that practitioners would be able to establish a diagnosis with as little delay as possible. Their practical efficiency do-

pends to a great extent upon the rapidity with which they can supply the necessary information. The diagnosis of syphilis can in the earlier stages be very readily made long before the organisms have reached the general circulation. At this stage, that is before the signs in the shape of rashes, etc., are visible to the naked eye, the disease is curable without a prolonged course of treatment. The percentage of cures after proper treatment at this time may be reckoned at nearly 100 per cent., though each succeeding day the chances of cure progressively diminish, until finally after the second year, when, though the outward manifestations may be abolished, the infection is very difficult to eradicate. The Committee believes that syphilis is beneficially and quickly affected by appropriate treatment. Its disappearance in the community seems to be accelerated by natural and social causes in this Dominion — hence means should be taken as far as possible to prevent the entrance of infected individuals, and to offer them free and efficient treatment by the medical profession. An absolute necessity is Legislation preventing the treatment of syphilitics by unqualified persons. The Wasserman blood test, and the treatment by Salvarsan can only be made use of by medical men. They now permit the medical profession to speak with certainty, where they previously had to rely on impressions. They have shown that the disease is more widespread than was thought previously. It is definitely proved that if adequately used they could nearly always cure the disease in its earliest stages. (Vide British Medical Journal, Nov. 22nd, 1913). Hence the necessity from the public standpoint of placing the public and private treatment of syphilis in the hands only of qualified medical men, for the only treatment available to unqualified persons has never, in the opinion of the most eminent pathologists cured a single case of syphilis. Dr. Wasserman has stated that the fate of every syphilitic is decided within the first two years following the infection. Neglect of treatment during this period cannot, so far as medical knowledge now goes, be made good afterwards. Another important point is, that under

the older methods of treatment a large number of cases (minimum of 8 per cent, of those affected by syphilis) which had been apparently cured, developed conditions known as parasyphilis. This includes general paralysis and locomotor ataxia, which may be roughly described as degeneration of the brain and spinal cord respectively. Under more recent methods of treatment by salvarsan or salvarsan and mercury combined, the symptoms are so much more quickly and effectively removed, that it may be inferred that the number of cases of subsequent parasyphilis will be correspondingly diminished. As regards the safety of treatment offered by the profession, in a series of 3,800 injections, given under proper supervision and technique and in properly selected cases, the mortality was nil. In another series of 6,000 cases one death has occurred, but with precautions now taken, that death might not have happened. Consequently, we think the administration of the modern treatment so safe, as to justify its recommendation as a public measure in all ordinary cases. NOTIFICATION. The consideration of this is under two heads : — (1) Compulsory. (2) Encouraged but not compulsory. This Co mmittee c onsider s that notification of contagious disease of cny kind is sound in principle and in the interests of public health. All serious contagious diseases except syphilis are notifiable by law. Syphilis, a very contagious disease, has not hitherto been placed amongst notifiable contagious diseases, because of its peculiar association with the morals of people and the ethics of private life. In reference to notification, Major French, (R.A.M.C.) stated before the Royal Society of Medicine, London, in 1912, that he had practised the system at Malta, with marked success for the past three years. In Denmark and Norway, notification has been in force for a number of years, and is accompanied by free treatment. In reference to encouraged but not compulsory notification it goes without saying that every medical practitioner would inform a syphilitic patient of the necessity of undergoing a thorough course of treatment until he was cured ; also of the danger

of spreading the disease until such course has been carried out. If the medical practitioner had reason to believe that the patient was not carrying out the prescribed treatment in a satisfactory manner the practitioner ought to be encouraged to warn the patient that it might be necessary for him to notify the authorities confidentially about his disease. After having assured himself that the warnings have been neglected he should thereupon notify the authorities if he considered that the person would be a menace to the public health. In no case ought a medical man to endeavour to implicate another person through any information given to him by the patient, but he should advise the latter to inform any second party of his (the patient's) condition, and request that the second party should seek medical advice. But no system of confidential notification by medical men will be of any use unless unqualified persons are by law prevented from treating this disease. The Committee therefore recommend that Syphilis be declared a notifiable disease, that the notification be encouraged, but not compulsory, and that the Chief Medical Officer of Health should be the only person to whom the notification be made. In order to guide the ignorant to efficient advice and so prevent concealment, the Committee recommends that legislation be enacted against the treatment of this disease by any unqualified person. This is recommended by the Medical Inspector of the Local Government Board in his evidence tendered to the Sydenham Royal Commission on Venereal Diseases. To recapitulate the arguments given in the earlier parts of our report, it is incontrovertible — That effective methods of treatment can be carried out only by duly qualified medical practitioners — That the treatment carried out by unqualified persons may temporarily conceal the disease during the period of the first two years, when modern treatment is effective — That during the first three years medical supervision and advice are of vital importance, as the syphilitic then is most likely in the unmarried state to disseminate the disease in its active form, and when married to his progeny as well- — That the older methods of treatment, consisting of drugs by the mouth, etc., are unable to cure positively any case — That if

free public treatment be provided the ethics of the profession will ensure that the confidences of infected persons will be more effectively guarded by a qualified official than they would be by a person so unscrupulous as to treat a disease of which he is of necessity greatly ignorant. The Committee recommended : — ■ (1) That syphilis be declared a notifiable disease. That notification be encouraged, and discretionary but not compulsory ; and that the Chief Medical Officer of Health be the only person to whom the notification be made. (2) That provision be made through, the Hospital Boards to establish Laboratories in the four centres where not already existent for the diagnosis of syphilis. (3) That free treatment in the public hospitals and dispensaries be provided for syphilitics. (4) That steps be taken to educate the Mercantile Marine as to the dangers of syphilis, and that provision be made for preventive

treatment on the Intercolonial Service. (5) That Legislation be enacted against the treatment of syphilis by unqualified persons. It was further resolved at the Australasian Congress last year that steps be taken for the provision (after consultation with educational experts as to the lines to be followed) of education for adults and adolescents in the nature, causes, consequences, and mode of prevention of venereal disease. Whilst the medical profession here arc not agreed that compulsory notification of all venereal disease is desirable, few take exception to the notification of syphilis. Nurses sometimes have an opportunity of expressing their views on this subject to their women patients, and I hope that all of you are now in possession of such facts as will induce you to feel strongly that some further attempt must be made to check the disease and that you will when possible, impress on your patients and friends the desirability of fresh legislation to deal with the disease in both sexes.