- Email: [email protected]
CONTROL OF VENEREAL DISEASES
33
blankets, loss of blood, and postoperative vomiting may all take part ; and finally shock causes
in
internal dislocations of fluid balance. Elsewhere in our present issue Dr. WALTHER reports some observations that illustrate both the gravity of surgical dehydration and the readiness with which it responds to treatment. His data suggest that where the oral route is impassable saline is better given by rectum than intravenously, and he surmises that fluid entering the circulation by way of the intestine may pick up protein in the liver and so become less liable to leak out of the vascular
channel. The present popularity of intravenous saline infusions gives these observations practical importance. Not many years ago the surgeon would marshal an array of scalpels, ligatures, coils of rubber tubing, and bottles of cocaine, and would proceed to dissect out a vein, tie in a cannula, and squirt in saline with an inadequate rubberpistoned syringe. Small wonder that the operation was reserved as a last desperate attempt to revive the moribund. Nowadays the technique is so simple that there may be a real danger of causing harmful waterlogging of the lungs by overenthusiastic use of saline. There are, of course, many surgical occasions when fluid cannot be given by mouth and a few when rectal administration is also impossible. It is in these circumstances that Dr. WALTHER regards plasma transfusion as the ideal. But when fluid can be given by the alimentary tract it is clearly desirable to introduce it in this way, which (unlike intravenous injection) at least allows the body to regulate the rate of absorption and to reject excess if necessary. If further experience confirms Dr. WALTHER’S conclusions they should prevent us from forgetting that the patient has a mouth and an alimentary tract designed for the absorption of fluid.
CONTROL OF VENEREAL DISEASES WHETHER through ignorance or lack of interest, the general public is usually apathetic to the control of venereal disease, and this attitude is reflected in the tardiness with which public policy adapts itself to meet the changing needs of the problem. In the United States, where the incidence of venereal disease is high, the vigorous propaganda instituted by a zealous public health service has in recent years caused some stirring of the public conscience. In 1935 the mayor of New York City appointed a commission representative of New York (City and State) to study the methods of control adopted in the Scandinavian countries and in Great Britain, where it was thought that some measure of success had been achieved. The 1 of this which is now commission, available, report includes a review and appraisal of the administrative measures adopted in this country for the prevention, diagnosis, and treatment of venereal disease, and a critical comparison of these methods with those adopted in the Scandinavian countries in the light of brief observation and available statistics. 1
Amer. J. Syph.
July, 1936,
Part 2.
It seems that in Denmark, Norway, and Sweden, in some of the British Dominions, venereal diseases are notifiable by law and treatment is compulsory. If persuasive methods fail, the health authorities have power to enforce submission to medical care, including admission to hospital if this is considered necessary-a precaution which is commonly employed in the early infectious stages. Penalties may be inflicted on those who knowingly transmit infections and power is given to trace contacts and known sources of infection. Coercive measures may be adopted for the non-cooperative or defaulting patient. The Scandinavian peoples are well accustomed to the discipline of social control so that it is possible to enforce these regulations without serious difficulty. Frequent use of in-patient facilities is necessary because the populations are scattered and the facilities of treatment are often inaccessible. In highly industrialised Britain, where the population is largely grouped in relatively small areas and traditionally resentful of interference with personal liberty, centralfacilities for treatment are readily accessible and regulation for compulsory treatment would be difficult to enforce. In other respects the measures adopted in these countries are similar to our own and include free diagnosis and treatment for all regardless of economic status. In comparing the results attributable to these schemes the commission finds that there has been no decline in the incidence of gonorrhoea in any of the countries and that in Great Britain it has possibly increased in prevalence. On the other hand the figures indicate a general diminution in early syphilis, the reported cases in 1933 showing an incidence of 7 per 100,000 in Sweden, 20 in Denmark, and 30 in Oslo, the chief city of Norway. The commission formed the opinion that in Sweden and Denmark, at all events, the reporting of cases was faithfully carried out by medical practitioners and that these figures fairly represent actual prevalence. For this country the figures are less impressive ; in 1933 the number of new cases of syphilis applying to treatment centres amounted to 21,525, an incidence of 56 per 100,000 in a population of 38,000,000. Clearly this figure is not the total incidence, because no account is taken of patients treated elsewhere than at treatment centres. In its report the commission makes the guarded suggestion that lack of legal power for the enforcement of treatment in this country may be partly responsible for the disparity ; while recognising that this absence of legislation is due to the peculiar nature of the local circumstances, it points out that a strong minority opinion in this country favours the introduction of laws to make venereal diseases notifiable and treatment compulsory. From the evidence collected by this commission and that available from other sources it seems to be established that the incidence of syphilis has declined in this country, but it will be agreed that the rapidity of the decrease is hardly commensurate with the ease with which patients may be rendered non-infectious by modern methods of treatment. The success achieved compares unfavourably with as
,
’
34
that in countries where social control is more vigorous and the question may be asked how far the arguments against compulsory notification and penalisation of the delinquent are still valid. There are nowadays so many incursions into the personal liberty of the subject that it is by no means certain that the provision of limited powers to coerce the infectious defaulter or the neglectful parent would cause resentment. A clue to the popular feeling on this point was provided a short time ago. In 1934 a questionnaire2 was submitted to patients attending the Salford municipal clinic for the treatment of venereal diseases, inviting expressions of opinion on two points: (1) Should a person suffering from a venereal disease be compelled to receive treatment, provided it is given confidentially and free ?1 (2) Should the parents or guardians of children suffering from venereal disease be compelled to have such children treated under the same conditions ?1 In reply to both questions there were 429 ayes and 5 noes. The opinion among this group of infected people was thus overwhelmingly in favour of some form of
compulsion. Nevertheless, in considering the coercion of
cooperative
or
defaulting patients
we
non-
must not
risk losing all that has been gained by the persuasive approach. The risk is that minatory drive the disease underground, and will regulations 2
City of Salford V.D. Scheme.
Annual Report, 1934, p. 14.
this risk is far greater in England than, for example, in the Soviet Union where venereal diseases are regarded as diseases like other diseases and nobody thinks the worse of a man because he contracts them. The conditions are really not comparable. But in England and Russia alike the object must be to make the patient realise how much he stands to gain by cure, and a useful illustration of this comes from the social service department of the University of Pennsylvania,3 where there has been complete freedom to experiment in what Louise Ingraham calls " technics of persuasion." Here as in many other places the aim has been to obtain from the syphilis patient his voluntary disclosure of recent sexual intimates and his services in personally recruiting them for medical examination. On this basis persuasion was 92 per cent. effective when the individual contact could be personally reached, and this success was independent of the type of community, whether black or white, well-to-do or indigent. - Of 201 patients with syphilis it appears that 114 of them identified 174 exposures, being an identification-rate of 1’5 contacts per productive case. Possibly, the author admits, a more aggressive technique would give greater immediate reward, but at the same time it would almost certainly sacrifice future gains. Father O’Flynn, who had a way with him, did however sometimes coax the lazy ones on with a stick. 3 J. Amer. med. Ass. Dec. 12th, 1936, p. 1990.
ANNOTATIONS GREAT ALTITUDE AT a time when the sport of mountain-climbing is attracting every summer a larger crowd of devotees, especially in England and Germany, any sound research into the medical aspects of great altitude must have a practical interest. A more serious importance comes from the growing conviction that aeroplanes are likely to fly at increasingly greater heights, and the recognition of anoxoemia as a factor in pulmonary and circulatory disturbances. On the firm foundations built at Oxford by Haldane, Douglas, Priestley, ’and their co-workers, there is arising a superstructure, much of the work on which has been done in America. It is possible that there is lacking in the United States the coordinating influence of Barcroft over the Cambridge school. But the Americans are fortunate in having high mountains near at hand, a circumstance which has given to much of their work a very practical bent. Somervell, Raymond Greene, and others in this country have written of the digestive disturbances and failure of appetite accompanying the many efforts which have been made to climb Everest. Recently, working in a steel chamber, Van Liere1 has shown that at only 14,000 feet there is an average prolongation of the emptying-time of the stomach of 35 per cent., the least susceptible subject showing a prolongation of 13-2 per cent. The delay is caused by a loss of motility, which may be due to the increased output of adrenaline during anoxaemia. It will be recalled that medical officers of various Everest expeditions have laid stress upon loss of 1 Van Liere, E. J. (1936) Arch. intern. Med. 58, 130.
appetite as a possible factor in the degeneration noted after prolonged residence above 20,000 feet, but it has generally been held that its influence was not the paramount cause. From this point of view, the new work of Talbott and Dill,2 of Harvard, is of importance. They describe a disease, first reported by Monge, and named after him, which develops after residence over many years at such altitudes as 15,000 feet. It seems probable that though Monge did not observe it in anybody who had lived in the highlands for less than two years, it might appear much sooner at a greater altitude. Talbott and Dill give as its symptoms headache, hoarseness, loss of appetite, weakness, paraesthesise, and transient spells of stupor; and, as its signs, cyanosis, pigmentation, generalised vasodilatation, and hypotension. Some, though not all, of these signs and symptoms have been observed in climbers suffering from altitude deterioration. The exact aetiology of the disease is unknown, and in discussing it Talbott and Dill pay, perhaps, too little attention to the work of Argyll Campbell. The time seems ripe for trying to elucidate this and many kindred problems of growing importance. Everest was almost climbed in 1933. In 1936, through no fault of the climbers, the expedition was a fiasco. A repetition of this fiasco, due to weather conditions, can never be excluded. Yet if the last expedition had included a scientific programme it would have produced some solid return for the many thousands of pounds expended. It is not enough that the medical officer should pursue a line of 2 Talbott, J. H., and Dill, D. 192, 626.
B.
(1936) Amer. J. med. Sci.
blankets, loss of blood, and postoperative vomiting may all take part ; and finally shock causes
in
internal dislocations of fluid balance. Elsewhere in our present issue Dr. WALTHER reports some observations that illustrate both the gravity of surgical dehydration and the readiness with which it responds to treatment. His data suggest that where the oral route is impassable saline is better given by rectum than intravenously, and he surmises that fluid entering the circulation by way of the intestine may pick up protein in the liver and so become less liable to leak out of the vascular
channel. The present popularity of intravenous saline infusions gives these observations practical importance. Not many years ago the surgeon would marshal an array of scalpels, ligatures, coils of rubber tubing, and bottles of cocaine, and would proceed to dissect out a vein, tie in a cannula, and squirt in saline with an inadequate rubberpistoned syringe. Small wonder that the operation was reserved as a last desperate attempt to revive the moribund. Nowadays the technique is so simple that there may be a real danger of causing harmful waterlogging of the lungs by overenthusiastic use of saline. There are, of course, many surgical occasions when fluid cannot be given by mouth and a few when rectal administration is also impossible. It is in these circumstances that Dr. WALTHER regards plasma transfusion as the ideal. But when fluid can be given by the alimentary tract it is clearly desirable to introduce it in this way, which (unlike intravenous injection) at least allows the body to regulate the rate of absorption and to reject excess if necessary. If further experience confirms Dr. WALTHER’S conclusions they should prevent us from forgetting that the patient has a mouth and an alimentary tract designed for the absorption of fluid.
CONTROL OF VENEREAL DISEASES WHETHER through ignorance or lack of interest, the general public is usually apathetic to the control of venereal disease, and this attitude is reflected in the tardiness with which public policy adapts itself to meet the changing needs of the problem. In the United States, where the incidence of venereal disease is high, the vigorous propaganda instituted by a zealous public health service has in recent years caused some stirring of the public conscience. In 1935 the mayor of New York City appointed a commission representative of New York (City and State) to study the methods of control adopted in the Scandinavian countries and in Great Britain, where it was thought that some measure of success had been achieved. The 1 of this which is now commission, available, report includes a review and appraisal of the administrative measures adopted in this country for the prevention, diagnosis, and treatment of venereal disease, and a critical comparison of these methods with those adopted in the Scandinavian countries in the light of brief observation and available statistics. 1
Amer. J. Syph.
July, 1936,
Part 2.
It seems that in Denmark, Norway, and Sweden, in some of the British Dominions, venereal diseases are notifiable by law and treatment is compulsory. If persuasive methods fail, the health authorities have power to enforce submission to medical care, including admission to hospital if this is considered necessary-a precaution which is commonly employed in the early infectious stages. Penalties may be inflicted on those who knowingly transmit infections and power is given to trace contacts and known sources of infection. Coercive measures may be adopted for the non-cooperative or defaulting patient. The Scandinavian peoples are well accustomed to the discipline of social control so that it is possible to enforce these regulations without serious difficulty. Frequent use of in-patient facilities is necessary because the populations are scattered and the facilities of treatment are often inaccessible. In highly industrialised Britain, where the population is largely grouped in relatively small areas and traditionally resentful of interference with personal liberty, centralfacilities for treatment are readily accessible and regulation for compulsory treatment would be difficult to enforce. In other respects the measures adopted in these countries are similar to our own and include free diagnosis and treatment for all regardless of economic status. In comparing the results attributable to these schemes the commission finds that there has been no decline in the incidence of gonorrhoea in any of the countries and that in Great Britain it has possibly increased in prevalence. On the other hand the figures indicate a general diminution in early syphilis, the reported cases in 1933 showing an incidence of 7 per 100,000 in Sweden, 20 in Denmark, and 30 in Oslo, the chief city of Norway. The commission formed the opinion that in Sweden and Denmark, at all events, the reporting of cases was faithfully carried out by medical practitioners and that these figures fairly represent actual prevalence. For this country the figures are less impressive ; in 1933 the number of new cases of syphilis applying to treatment centres amounted to 21,525, an incidence of 56 per 100,000 in a population of 38,000,000. Clearly this figure is not the total incidence, because no account is taken of patients treated elsewhere than at treatment centres. In its report the commission makes the guarded suggestion that lack of legal power for the enforcement of treatment in this country may be partly responsible for the disparity ; while recognising that this absence of legislation is due to the peculiar nature of the local circumstances, it points out that a strong minority opinion in this country favours the introduction of laws to make venereal diseases notifiable and treatment compulsory. From the evidence collected by this commission and that available from other sources it seems to be established that the incidence of syphilis has declined in this country, but it will be agreed that the rapidity of the decrease is hardly commensurate with the ease with which patients may be rendered non-infectious by modern methods of treatment. The success achieved compares unfavourably with as
,
’
34
that in countries where social control is more vigorous and the question may be asked how far the arguments against compulsory notification and penalisation of the delinquent are still valid. There are nowadays so many incursions into the personal liberty of the subject that it is by no means certain that the provision of limited powers to coerce the infectious defaulter or the neglectful parent would cause resentment. A clue to the popular feeling on this point was provided a short time ago. In 1934 a questionnaire2 was submitted to patients attending the Salford municipal clinic for the treatment of venereal diseases, inviting expressions of opinion on two points: (1) Should a person suffering from a venereal disease be compelled to receive treatment, provided it is given confidentially and free ?1 (2) Should the parents or guardians of children suffering from venereal disease be compelled to have such children treated under the same conditions ?1 In reply to both questions there were 429 ayes and 5 noes. The opinion among this group of infected people was thus overwhelmingly in favour of some form of
compulsion. Nevertheless, in considering the coercion of
cooperative
or
defaulting patients
we
non-
must not
risk losing all that has been gained by the persuasive approach. The risk is that minatory drive the disease underground, and will regulations 2
City of Salford V.D. Scheme.
Annual Report, 1934, p. 14.
this risk is far greater in England than, for example, in the Soviet Union where venereal diseases are regarded as diseases like other diseases and nobody thinks the worse of a man because he contracts them. The conditions are really not comparable. But in England and Russia alike the object must be to make the patient realise how much he stands to gain by cure, and a useful illustration of this comes from the social service department of the University of Pennsylvania,3 where there has been complete freedom to experiment in what Louise Ingraham calls " technics of persuasion." Here as in many other places the aim has been to obtain from the syphilis patient his voluntary disclosure of recent sexual intimates and his services in personally recruiting them for medical examination. On this basis persuasion was 92 per cent. effective when the individual contact could be personally reached, and this success was independent of the type of community, whether black or white, well-to-do or indigent. - Of 201 patients with syphilis it appears that 114 of them identified 174 exposures, being an identification-rate of 1’5 contacts per productive case. Possibly, the author admits, a more aggressive technique would give greater immediate reward, but at the same time it would almost certainly sacrifice future gains. Father O’Flynn, who had a way with him, did however sometimes coax the lazy ones on with a stick. 3 J. Amer. med. Ass. Dec. 12th, 1936, p. 1990.
ANNOTATIONS GREAT ALTITUDE AT a time when the sport of mountain-climbing is attracting every summer a larger crowd of devotees, especially in England and Germany, any sound research into the medical aspects of great altitude must have a practical interest. A more serious importance comes from the growing conviction that aeroplanes are likely to fly at increasingly greater heights, and the recognition of anoxoemia as a factor in pulmonary and circulatory disturbances. On the firm foundations built at Oxford by Haldane, Douglas, Priestley, ’and their co-workers, there is arising a superstructure, much of the work on which has been done in America. It is possible that there is lacking in the United States the coordinating influence of Barcroft over the Cambridge school. But the Americans are fortunate in having high mountains near at hand, a circumstance which has given to much of their work a very practical bent. Somervell, Raymond Greene, and others in this country have written of the digestive disturbances and failure of appetite accompanying the many efforts which have been made to climb Everest. Recently, working in a steel chamber, Van Liere1 has shown that at only 14,000 feet there is an average prolongation of the emptying-time of the stomach of 35 per cent., the least susceptible subject showing a prolongation of 13-2 per cent. The delay is caused by a loss of motility, which may be due to the increased output of adrenaline during anoxaemia. It will be recalled that medical officers of various Everest expeditions have laid stress upon loss of 1 Van Liere, E. J. (1936) Arch. intern. Med. 58, 130.
appetite as a possible factor in the degeneration noted after prolonged residence above 20,000 feet, but it has generally been held that its influence was not the paramount cause. From this point of view, the new work of Talbott and Dill,2 of Harvard, is of importance. They describe a disease, first reported by Monge, and named after him, which develops after residence over many years at such altitudes as 15,000 feet. It seems probable that though Monge did not observe it in anybody who had lived in the highlands for less than two years, it might appear much sooner at a greater altitude. Talbott and Dill give as its symptoms headache, hoarseness, loss of appetite, weakness, paraesthesise, and transient spells of stupor; and, as its signs, cyanosis, pigmentation, generalised vasodilatation, and hypotension. Some, though not all, of these signs and symptoms have been observed in climbers suffering from altitude deterioration. The exact aetiology of the disease is unknown, and in discussing it Talbott and Dill pay, perhaps, too little attention to the work of Argyll Campbell. The time seems ripe for trying to elucidate this and many kindred problems of growing importance. Everest was almost climbed in 1933. In 1936, through no fault of the climbers, the expedition was a fiasco. A repetition of this fiasco, due to weather conditions, can never be excluded. Yet if the last expedition had included a scientific programme it would have produced some solid return for the many thousands of pounds expended. It is not enough that the medical officer should pursue a line of 2 Talbott, J. H., and Dill, D. 192, 626.
B.
(1936) Amer. J. med. Sci.