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“Syphilis in relation to infant mortality” and public health
1916.
PUBLIC
,, S Y P H I L I S IN R E L A T I O N TO I N F A N T M O R T A L I T Y " AND P U B L I C H E A L T H . ~ BY F. VV. MOTT, M.D., F.R..S., F.R.C.P., pathologist to the L.C.C. Asylums ; Consulting Physician to Charing Cross Hospital and the Queen Atexandra Military Hospital. of my paper, "Syphilis in Relation T H Eto title Infant Mortality," I have found would limit too much the scope of the larger question which medical officers of health have to consider in relation to the effects of venereal affections in the production of death and disease. I will therefore deal with the subject of venereal infection in its wider application to public health. Every medical man is fully aware of the fact that the Registrar-General's returns afford a very inadequate conception of the influence of venereal disease on the death-rate ; and the statistics upon which the public rely for information are altogether misleading regarding the terrible effects wrought by these diseases. For obvious reasons the Registrar-General's returns must be erroneous, all the while the certificate of the cause of death is seen by the relatives or friends of the deceased. Consequently, syphilis as the cause of death seldom appears on the death certificate; for this reason a large proportion of those cases of death in which syphilis is certified as the cause, come from institutions, and largely relate to children dying in early infancy of congenital syphilis in which case the two sexes are equally affected. This may serve as an explanation of the anomalous fact that males certified as dying of syphilis only exceed females by a fraction (the proportion being 1"23--1"o) ; from which it might be inferred that the number of females infected are nearly as numerous as males. The Registrar-General's returns, however, show that in paralytic dementia and aneurism the proportion is four males to one female. 'I hese two diseases until quite recently have not been known to the public as being syphilitic, therefore when they occur the doctor has no hesitation in stating the cause of death. Consequently the returns of these two diseases in the Registrar-General's reports afford some indication of the incidence of syphilis in a population, also the relative incidence in the two sexes. I shall have occasion to return to this later. But I now pass on to show how inadequate a conception of the effects of venereal disease would be gained by statistics taken from the RegistrarGeneral's returns. * Read at a meeting of the ~tetropolitan Branch of tile SoQiety of Medical Officers of Health on 27th March, 1914.
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253
Syphilis is now the recognized essential cause of all cases of tabes and general paralysis, and latterly they have been regarded as syphilitic diseases by the Registrar-General. But in the Registrar-General's returns we find hemiplegia, paraplegia, brain softening, cerebral tumour, meningitis and paralysis given as the causes of death in a large number of instances, without any indication that a large proportion of these were due to syphilis. Yet experience teaches us that of all the causes of these diseases, syphilis is by far the most important ; especially does this apply to adults that die under the age of 50. " A man is as old as his arteries " is a trite saying, but of all the causes of disease of the arteries, especially the aorta, the cerebral and spinal arteries and the coronary arteries, syphilis is by far t h e most important. It operates in two ways: firstly by a specific inflammation, leading to thrombosis and occlusion of the cerebro-spinal vessels and causing brain softening, paraplegia and hemiplegia; secondly by causing inflammatory thickening and roughening of the aortic valves and incompetence ; by inflammatory aortitis it is the essential cause of aneurism; by nodular thickening and blocking of the coronary arteries it produces fatty degeneration and fibroid heart and it is a frequent cause of Stokes Adams disease. Heart disease and sudden fatal syncope registered as cardiac failure, not infrequently therefore owe their origin to syphilis, but none of tt~ese fatal conditions enumerated appear in the RegistrarGeneral's returns as being due to syphilis. Besides, syphilis by its devitalizing influence, especially in conjunction with alcohol, leads to a wearing-out of any, or all the tissues of the body, especially the arteries; it is therefore an important cause of atheroma and arterio-sclerosis. Again, by its devitalizing influence it favours the development of tuberculosis and other infections. Lastly may be mentioned the fact that syphilitic leuko-placia of the tongue frequently ends in epithelioma. Now with regard to the Registrar-General's returns concerning infant mortality. Marasmus is a frequent certified cause, pemphigus is given as a cause, and convulsions; also meningitis and hydrocephalus; all these conditions may be really syphilitic in origin, and in the case of pemphigus all the cases so certified are congenital syphilis, and are now recognised as such. I shall presently show you a number of pedigrees indicating that syphilis of the parents shows itself in the history of pregnancies by
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miscarriages, abortions, still-births, and children dying in early infancy of marasmus, convulsions, hydrocephalus, and meningitis. And although I have no statistical data beyond family histories of sixty cases of juvenile general paralysis to base my conclusions on, yet it is well recognised by physicians and practitioners that syphilis is responsible for abortions, still-births; and infants dying in early infancy, and that when a woman gives such a history of the results of pregnancies syphilis is the first cause which comes to mind. Examination of the blood by the Wassermann test shows a latent or active syphilis in a large number of such cases. Dr. Rcuth has calculated that the ante-natal mortality in England and Wales is about Ioo,ooo annually--z'2 stillbirths, 8"8 abortions, for Ioo live births. An inquiry at Glasgow suggests that syphilis is a potent factor in the production of still-births and abortions. The g~eater incidence of the same among the poor does not, however, necessarily indicate that syphilis is more prevalent, for the greater number of still-births and the greater infant mortality may be due to ignorance of the cause, and no treatment or later inefficient treatment. The remedial measures which would serve to combat this waste of pregnancies and infant life, and protect the unborn millions from the dangers of venereal infection have naturally occurred to you as medical officers of health. Your first object, undoubtedly, would be to obtain scientific proof of the extent of the waste of pregnancies and infant mortality from syphilis ; and this could be done by : - (I.) Universal notification of still-births, for which a fee should be paid, provided certain information was afforded to a central authority, by the medical man or midwife; the parents or friends should not see this certificate. The information should include facts relating to the health of the mother and presumed cause of death of the foetus, whether the foetus has been dead some time, and its appearance. This could be advantageously supplemented by a free Wassermann reaction of the blood of the mother and of blood obtained from the umbilical cord if obtainable. (2.) Free examination of the foetus for the presence of spirochmtes. I have found spiro: ch;etes in Ii out of 22 stilt-born children or toetuses from Shoreditch Infirmary. A research of this kind would, to be of scientific value, have to be undertaken at a central institution or hospital, and a series of
MAy,
still-births, dead premature births, and foetuses of all ages would have to be examined without any selection being made. In this way syphilis as a cause could be fairly estimated. Such an investigation could be conducted under the direction of the medical officer of health of the district or town. The result of this inquiry would enable the medical officer of health to advise the organisation of treatment of syphilitic mothers by approved methods; the treatment to be conducted .by experienced medical men under favourable hospital conditions. Periodic examination of the blood of an infected mother could be made with a view to treatment at intervals; in this way offspring born of infected parents, instead of being born dead or with the seeds of disease implanted in them, would be born healthy. The infected infant's blood could be tested periodically, and treatment resorted to if necessary. Now, it might be said that this would entail great financial difficulties, and before you could hope to get the State or municipal authorities to carry it out you would have to prove, first, that it was necessary and right on moral and eugenic grounds; and, secondly, that it was a saving to the rates. Now, to convince the authorities you would doubtless be required to show what proportion of still-births and deaths in early infancy which occur in (a) a city, (b) an urban and (c) a rural district are due to congenital syphilis. W e should find that the larger and denser the population, the greater the number of cases of congenital syphilis. Consequently, we should expect large cities like Birmingham, Liverpool, Glasgow, Manchester, and Leeds ready to undertake measures for the public health; whereas in small towns it would not be easy to get this done. (3.) Having proved the extent of the venereal disease in the population in an active or a latent form, you would endeavour to convince the authorities that not only is it their duty to prevent the immense amount of misery and suffering caused by venereal disease, but it would, in the long run, be an economy. I am of opinion that gonorrhoea is a much more serious affection than is generally supposed, and in any prospective measures for diagnosis and treatment should not be neglected. It is a fruitful cause of sterility in innocent women, leading to an immense amount of illhealth and to mental distress from the nongratification of the maternal instinct; it is also a cause of serious bodily disease--
1914.
PUBLIC
salpingitis and pyosa]pinx--which not infrequently ends in fatal peritonitis; it is also a cause of severe arthritis. Moreover,it is the most extensive cause of blindness from ophthalmia neonatorum. In the male, gonorrhccal epididymitis, stricture and subsequent cystitis with secondary nephritis are common sequelae, so that some authorities assert that gonorrhea is a more serious affection than syphilis. If it were not for the fact that syphilis destroys the fruits of conceptions of syphilitic parents by abortions, still-births or deaths in early infancy, it is appalling to think what a number of miserable creatures, blind, deaf, paralysed, imbeciles, and idiots of all grades there would be. There are, however, enough congenital syphilitics in our midst, and the blood test seems conclusively to prove that there are far more than we had any conception of. In my own hospital experience the value of the Wassermann test in proving this proposition has been brought home to me with striking force. Let me cite a few instances. A lad of 18 was admitted with all the signs of basic meningitis; he had no signs of syphilis on the body, nor was there any history pointing to the fact that he could have acquired the disease. The cerebro-spinal fluid gave a marked lymphocytosis, the Wassermann reaction was negative of the fluid, positive of the blood. The mother's blood was tested, and found to be positive, although she said she had never ailed, and was quite unconscious of t h e fact that she had been infected. Salvarsan and mercury led to a great improvement in the boy's condition. I will cite yet another case. A boy was seen by me aged 18 (he looked I O ) ; there was marked infantilism; no history of syphilis could be obtained from the mother; she had been married 30 years. The boy's blood and fluid gave a positive reaction, and the clinical signs and symptoms showed that he was a juvenile general paralytic. Examination of the mother's blood showed she was a latent syphilitic. The same occurred in a case of optic atrophy and tabo-paralysis in a girl aged I5 years. There are other facts which I will relate later to show the prevalence of syphilitic infection in the population. But I will now revert to the proposition of convincing the authorities that in the end they will save the ratepayer by adopting apparently costly measures to prevent innocent women and children suffering from the effects of venereal disease.
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The first duty of the State is to prevent disease, failing that to cure disease, and failing that to prolong life and relieve suffering. There may be conscientious objections on the part of the " pillars of society " to provide free treatment for men and women who have contracted the disease as a result of immorality. Personally, I think this is a false and unchristian sentiment, and such people should be reminded of the rebuke of Christ to~ the crowd who would stone the woman taken in adultery. Venereal disease should be regarded as a great misfortune rather than an odious sin. However, any objection which might be made to the expenditure of public money on this account fails in respect to the protection of married women and children, doctors, nurses and others who innocently acquire the disease. But if an appeal to the duty of the authorities on moral and eugenic grounds fails, let us see whether we cannot appeal to their commonsense on economic and financial grounds. The civic worth of an individual can be measured by length of useful life as a social unit. As an asset to the nation, the value of each individual depends upon the amount of mental and physical work he or she can produce and the capacity of breeding and rearing children healthy in mind and body. Now venereal disease, especially syphilis, although in the majority of instances by its direct effects does not prevent a man or woman working by making them bedridden, nevertheless by direct or indirect effects on the vital organs and tissue5 of the body diminishes considerably the efficiency and length of productive usefulness of the individual; and in at least 12 per cent. of the persons infected with syphilis causes fatal incapacitating diseases which render the individual prior to death a monetary burden to the State for a number of years. From an economic point of view, therefore, the State and municipal authorities would save enormous sums of money in the end by a wise expenditure in preventing the spread of this disease and by promoting its cure in the earlier stages. INCIDENCE OF SYPHILIS IN THE POPULATION.
I have estimated that I2 per cent. of persons infected with syphilis suffer with incapacitating and later fatal diseases. It is a rough estimate based upon some valuable statistics from Vienna. Mattauschek and Pdcz analysed the cases of 4,x34 officers who between the years I88o and I9oo were infected by syphilis and they found that 198 died of general paralysis, 1 I6 of tabes, and 134 of cerebro-spinal syphilis,
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P U B L I C H E A L TH.
making in all over io per cent. from diseases of the nervous system. If we add aneurism, arterio sclerosis, heart disease, etc., it would amount to 12 per cent. in which syphilis had been the cause. According to these statistics 4'78 per cent. of males infected died subsequently of general paralysis, and of this disease I have had a large experience and I therefore will now limit myself to a consideration of it. I have always maintained that the essential factor in the production of general paralysis is syphilis. I was led to this conclusion by collecting 6o cases of the juvenile form due to hereditary syphilis. Clinically there is little difference in the disease as seen in the juvenile form and the adult who has acquired syphilis, and there is no difference in the pathological changes. With the discovery of the spirochaete in the brains of general paralytics, the last link in the chain of circumstantial evidence has been forged in showing that syphilis is the essential factor in the production of this disease. I show preparations of spiroch~etes from the brains of general paralytics, and I may mention that I have found them in 66 per cent. of a series of 9o cases. They are found much more readily in the acute maniacal stage tlaan subsequently in the arrested demential stage for reasons which I have not time in this paper to dwell upon. Admittirig the premiss that syphilis is the essential cause of general paralysis, we can easily understand why general paralysis, due to hereditary syphilis causing the juvenile form of the disease, affects the two sexes equally. Obviously it is because the chances of male and female being infected are equal. T w o per cent. of the admissions to the asylums are the juvenile form; there would undoubtedly be a great many more were it not for the fact that, when the syphilitic organism invades::the nerv0as system in the ~nfant, it is almost invariably fatal. The history of families in which a case of juvenile general paralysis occurs rather suggests that the specific organism has become modified by the action Of the antibodies of the mother. Now the equal affection of the sexes when the disease is due to congenital syphilis is in striking contrast to that occurring when the disease is acquired; for here we find four males to one female, and whereas all social grades in the male sex contribute in about equal proportions, the lower we sink in the social scale the more numerous are the cases of general paralysis and tabes in the female sex. W e can thus
M AV,
explain the higher incidence of males admitted to asylums suffering from general paralysis from the \Vest-end than the East-end and the somewhat higher incidence of females from East-end t h a n West-end parishes. All these facts tend to show that the incidence of general paralysis in a population corresponds with the relative incidence of syphilis in the two sexes. I will throw on the screen some statistics relating to the incidence of general paralysis in the different parishes in London in relation to the total admissions to the asylums. TABLE
I.
Table showing the percentage incidence of male general paralytics among the male admissions from the various London parishes to the London County Asylums during the years i91i-i2:-I. 2. 3. 4. 56. 7. 8. 9. lO. 11. i2. 13. 14. 15. 16. i7. 18. 19. 2o. 21. 22. 23. 24. 25. 26. 27. 28. 29. 3 o.
St. George's, W Whltechapel . Shoreditch . Fulham . . . . Paddington . Hotborn . . . . St. Marylebone . Islington . . . . Kensington . Wandsworth . Lambeth . . . . Woolwich . Hammersmith . Westminster . St. Pancras . Hampstead . Lewisham . Camberwell . Greenwich . Bermondsey . Southwark St, George's,E~" Mile End . Bloomsbury . Chelsea . . . . Hackney . . . . Poplar . . . . Strand . . . . Stepney . . . . 13ethnal Green
.
.
. . . . . . . . . . . . . . . . . . .
. . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29"0 per 24"2 23'2 22"5 2o 7 19' 5 19" 3 18'6 18" 4 18'3 i8"1 17"o 17"o 13" 4 15'o 14'6 14" i i3"8 13'2 13"o 12" 4 i2"t i2"olO'3 lO"2 9"3 9"o 8"9 8"8 4'8
cent. ,, ,, ,, ,, ,, ,, ,,
,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,,
The number o f cases admitted trom single parishes suffering' from general ~paralysis are not sufficient to draw any conclusions from, yet I cannot refrain from calling attention to the low incidence of Bethnal Green with a population of 128,282, viz., x"9 per cent. of the total admissions compared with St. George'sin-the-West with a population of 117,968, where there is 5"2 per cent. of the total admissions due to general paralysis. On account of the numbers I have grouped parishes into east and west; (a): ~north, and (b) south.-of t h e Thames. Table II. refers to group (a), Table III. to group (b). Table II. shows on the one hand a relatively high percentage of male genejcal paralytics in the West-end parishes north of the Thames, viz., I7"3 per cent. against I3"2 per cent. for
1914.
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257
HEALTH.
TABLE II. Showing a comparison of the incidence of insanity and of dementia paralytics in the admissions to the London County Asylums during the years i 9 i i - I 2 , from the parishes north of the Thames, west and east respectively. Parish.
Total Adnfissions, 19~I-12.
Population.
Admissions per Male Adi,ooo In- missions. habitants.
Male G,P,I.
Percentare G.P,I.
3° 6 18 17 17 18 25 23 6 24 6 6 9
15 '°'~ I4'6 I9"3 19"5
Female Female AdmisG.P.I, sioas. ~
Percentage G.P.I,
W~ts'r, St, P a n c r a s
,.
Hampstead St, Marylebone Holborn . . . Paddington Hammersmith Fulham . . . Kensington Chelsea . . . St. G e o r g e ' s Westminster Bloomsbury Strand . . .
. . . .
ai8,453 85,5m 118,221 112,247 142,576 121,6o 3 I53,325 172,4o2 66,404 II7,968 25,451 25,°65
..
.. . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . .
. . . . . .
393 89 220 174 168 228 276 271 I2I I78 57 113 I3I
I6~858 .
Total Total percentage'G.P.I[
1,376,o83
]
.
1'8o I'o4 t'86 1"42 1"18 1"87 1'80 I'57 1-82 1"5t 2"24 4'51 7'77
.
I
.
.
I"75
2.419
2Ol 41 93 87 82 IO6 III I25 59 83 39 58 98
I
.
.
1183
.
2o5
,
192 48 127 87 86 122 165 146 62 95 18 55 33
I
t 1,2~6
~
20'7:
]
I7'0 ~ 22"5~ 18'4 IO'2 29-0 ] 15" 4 lO'3 { 8'9 ]
.
[.
173
EAST.
Istington . . . Shoreditch Hackney . . . St. G e o r g e ' s Bethnal Green Stepney . . . Poplar Mile EndJJ Whltechapel
. . . . . . . . .
. . . . . . . . .
3 I 3 2 4 4 I 4 2 5 .. I i .
.
I'5 2 o 2"3 2' 3 4 6 3'2 o'6 2" 7 3'2
;% yo .
.
31
2' 5 =9"7
6 2 IO 2 i i 5 4 3
2' 4 2" 7 4'i 5"9 i' 9 2' 9 4"6 47 - - 3-' 9-
34
Y4 =8'2
1
. . . . . . . . . . . . . . . . .
.. .. .. .. .. .. .. ..
Total Total percentage ' G.P,i"
435 141 457 67 115 83 305 169 139
327,423 111,463 273,270 47,1Ol 128,282 53,798 162,449 111,375 67,750
0"89
1"54 1"88 I 1'52 2".___..05 ~
1,9II
I~282,9II
36 I6 20 4
I93 69 215 33 63 45 166 84 6_____2- -
1'33 I'26 1'67 1'42
1"49
93O
t'"
15 io I5.~ I23
I'"
I'"
18'6 242 ~3"2 72 9'3 242 I2'I 34 4'8" 52 8'8 38 9"o 139 12"o 85 24'__._~27 7 . ~ 13"2
I i I
__.
981
/'"
i"l
"'l
TABLE III. Showing a comparison of the incidence of insanity and of dementia paralytics in the admissions to the London County Asylums during the years I911-12, from the parishes south of the Thames, west and east respectively. Parish.
Population. _ _ _ _
Total Ad- i Admis- i sions per I Male Admlsmons, [ I,ooo In- [ missions. ] 1911
Male G,P,I.
Percentage G.P.I,
Female Aomlssions.
55 43
18' 3 18"1
214
18'3
641
Female ~ I ~J,r..
a
ii
]
""
Percentge G,P.I,
W E S T ,
Wandsworth . . . . . . Lambeth . . . . . . . .
479,I95 298,126 -
Total Total percentage G.P.i."
-
727
t
i
451
I'52 I'51
i i i !
T
300 237
1.51 i537 ! 98
777,32I
4271
1.
.
.
3"1
•.
..
'5 4"2
=
I0"O
.
EAST. Camberwell Bermondsey Lewisham Greenwich Woolwich Southwark Total
Total
. . . . . .
. . . . . .
. . . . . .
. . . . . .
. . . . . .
. . . . . .
p~riJntagi'~.v.i."
261,357 125,96o
174,296 185,688 127,737 191,951 1,o66,989 ,o
l
159 197 260
I i
1"52 1"26 1"13
I9~ !
1"4°
i
27
1"52 I '86
94
I
161
!
II 17 35 20
I '46
741
i
Io2
°-
[
"°
• o
78 128
i i
13"8 13"o I4 I Iy2 17"o 12" 4
203 74 119 132 IOI 196
i
-
i
5 2 9
! i
0'9 5"4 o 8 3 .8 i. 9 4 .6 =7'9
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PUBLIC HEALTH.
the East-end parishes. On the other hand, the percentage of females is higher in the East-end parishes, 3'4 per cent. compared with 2"5 per cent. in the We~t-end parishes. The percentage incidence of general paralysis of the total admissions in the West-end parishes is 9"7 against 8"2 East-end parishes. The average incidence of insanity in these two groups of parishes north of the Thames shows I"75 West-end group and 1"49 East-end group per I,OOO resident population; consequently there is a larger incidence of insanity and general paralysis in the richer West-end parishes north of the Thames than the poorer East-end. "Fable i l i . gives a comparison of east and west parishes south Of the T h a m e s ; here we find that the western parishes, \¥andsworth and Lambeth have a higher percentage of admissions with general paralysis, both male and fem~.le, than the eastern parishes. The average incidence of insanity in these two groups of east and west parishes is west 1"51, east I"46 per i,ooo resident. These two groups south of the Thames, however, do not show quite the same results as the two groups north of the Thames, for the western parishes of Lambeth and Wandsworth show both a higher rate of incidence in males (18"3 per cent.) and females (3"1 per cent.) than the eastern parishes (males 13"9, females 2'7 per cent.); this is not surprising when we consider the class of population living in the twowestern parishes south o f t h e T h a m e s . We might ask the question: W h y should general paralysis occur more frequently'in admissions from West-end parishes than Eastend? To answer this question let us first consider the fact that the lower we sink in the social scale the greater is the incidence in women of general paralysis; undoubtedly, the reason for this is the greater number of women who are exposed to infection, for poverty is the most fruitful cause of prostitution. The incidence of general paralysis in t,he total female admissions as compared with the total male admissions is on~ female to seven males. We have seen that the West-end parishes north of the Thames have a higher percentage of males than the East-end parishes, and a lower percentage of females. TABLE IV. West-end parishes north of the Thames.. ~7'3 per cent. G.P. males, 2"5 per cent. G.P. females, equals 7 males to I female. East-end parishes north of the Thames.. t3.2 per cent. G.P. males, 34 per cent. G.P. females, equals 4males to : female. West-end parishes south of the Thames..18.3 per cent, G.P. males, 3"I per cent. G.P. females, equals
MAT,
6 males to I femaIe. East-end parishes south of the Thames..i3"7 per cent. G.P. males, 2"7 per cent. G.P. females, equals 5 males to I female. As there are a considerable number of betterclass males who develop every year general paralysis and do not come into the London County Asylums, the incidence of seven males to one female in West-end parishes is probably considerably under the mark. The average percentage of male general paralytic admissions annually to the London County Asylums is 15"6 per cent. At Coiney Hatch Asylum all the Jews are received, and 15 per cent. of the total admission o f Jews are suffering with general paralysis, so that this about corresponds with the average admission rate. Some years ago I made a personal investiga. tion of the family history of a number of cases of juvenile general paralysis with a view of showing that this disease is invariably caused by syphilis." Unlike the disease affecting adults due to acquired syphilis, where males exceed females by a proportion of four or five to one, the juvenile form affects the two sexes in equal proportions, the obvious reason being that the chances of infection are equal. The family histories show a number of interesting facts, which I will consider under different groups. First, let me call attention to some generalisations. The usual history is that the mother, after one or more miscarriages followed by abortions and still-births, had one or more children who generally died in early infancy of convulsions or meningitis; later a child survived, and at puberty or early adolescence developed general paralysis. The histories of 34 syphilitic mothers gave 175 conceptions; these were made up as follows:--Io 4 premature births or deaths in early infancy, 4 t diseased in some serious form or a n o t h e r ; 30 were abparently healthy, but many of these may have suffered later, and certainly a considerable percentage of these apparently healthy children would have given a positive Wassermann reaction. In four instances the mothers were infected after marriage, and after each had given birth to healthy children. It is of interest to note what followed in respect to conceptions before and after the mothers had been infected. Taken together there were 15 conceptions before infection, resulting in the birth and rearing of 15 healthy children. After infection there were 22 conceptions; of these 13 were abortions, still-births, 0 r . children dying in early infancy; of the remaining nine there were five seriously diseased, and there was no
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these cases of congenital syphilis, with a brief descriptive account, are given. Each one is selected to illustrate some interesting point.
absolute proof that the remaining four were healthy. The family history charts of a number of
Died ~ I yr. 9 m ~ ,
~ Hg,
;;,gd0 Otitis G~.P,I, Kerat*tis.
Optic Atrophy. Cyclo.plegia,
I_M_L_L_J
Died 9 years,
Healthy.
GRouP G R O U P 1. ~. q'o show the effect of treatment and Iater neglect of treahnent of the mother in the blrth of healthy and disea~-'d children. 2. A mild form of syphilis of the father later causing tabes--inad.equate lreatmcnt. Marriage two years after infection; the mother was probably not infected, therefore heallhy family.
G.P.
I.
3. The father was Inertial.| five years afiur ]nfectioa, and in spilt of prolonged trealnll'nt ihe moiher was infectr'd, and gave birlh 1o syphilitic offal)ring. 4. Large healthy fanfilv; wife infech.d, followed ];y two miscarriages, two born dead, and one living child, who at pul)erty dew:loped tabo-paralyqls and optlc ah-nphy,
I C o n t r a c t e d ~
I9
12
lllt ob t 6b Ob b g d I9 6 i Twln~ died at
Died in infancy. ,
Healthy Children
? WassermannReaction.
Juvenile CleneralPalaly~is.
early age.
Drunk Soldier,
Twins
Juvenile
General Paralysis.
,.~Heahhy Children
? Wassermann Reaction.
Juvenile l~ri'nary Convulsiot~s G.P.I Optic Death at 15 rnor~ths,
At rophy,
GROUP I I , G R O U P II. i. Man contracted syph'ilis during wif,e's second pregnancy and infected her The offspring of the marriage is as follows : Daughter alive, ageLt 27; son alive, aged 24; then follmved four miscarriages in succession; an infant which lived only three m o n t h s ; an infant which lived six m o n t h s ; then the patient, who at the age el ~4 was able 1o earn 8s. a week, but who in early adolescence developed gencrfil
paralysis; then a daughter, who is r2 years of age; then a miscarriage; and, lastly, a frail little gM, aged eight. 2. The falher was a drunken imbecile soldier, wt~o had an insane brother. Th,e hlslory of the conceptions obtained from tile mother was as follows: A miscarriage shortly after marriage, nil intervaI of six years, twins born dund, a still-birth, then a child with si~ns of eongenltal syphilis, also developed general l)aralysis ,at puborly. This wa~ folB
MAY,
PUBLIC HEALTH.
2(;0
lowed hy five apparently healthy children. Several, if not all, of these might have given a positive \Vaqsernmnn rein'lion indicative of latent syphilis. 3- f h i s pedigree shows that the bh'til .of apparently healthy children following abortions and deaths in early infancy is no fl'ee pass: for we find the last-born male developed general paralysis. Doubtless, all the apparenlly
healthy children would have given a positive Wassermann reaction. 4 - E a r l y age of marriage and virulence of infection. The father was ~a; the mother 2o. All {he conceptio~s resulted in premature births, death in early infancy of convulsionq or late congenital syphilis of the nervous
SVStPHI.
Never had a day's
#
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.... ....
Newer had a day's ....... illness
Brain dlsea~e. Club f o o t . had snuffles.
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.
d ; ; sesd(5 13ied at Darentl~.
GRoup I I I . GROUP IlI. L Transmission to third generation. Two sisters with very definite signs of congenital syphilis. The mother gave a history of three prematuT-e births, two children born dead; she herself had never had an), illness. Both of the daughters had marked s f i g m a | a of congenital syphilis; one of them married and had a syphilitic child, The lmsband had not had syphilis, and not been in the way of getting it.
1 J
i l I J
2. I t u s b a n d went for a voyage, came home and infected wife, followed by miscarriages and abortions. 3. Latent syphilis no free pass to succeeding offspring. In this chart we find four apparently healthy children tprobably latent syphilitic) following on diseased children; Hlen two children dying in early" infancy. 4-FaIl~er, general paralytic; infected wife; one ntiscarriaNe and two still-births ; then typical congenital syphilitic, who developed tabo-paralysis.
Juvenile G,P,I,
O ~ r ~ 1 9
I)ied of ageS.e& Case acquired before marriage Husband no Syphilis; [ Gmnmalosis ~ S o r e s , Psoriasis. R
Juvenile General Paralysis. GROUP I V .
1914.
PUBLIC HEALTH. G R O U P IV.
~, Father, gcw:ral paralysis ; mother, ~ab,,s; 'du-ce preg~lan~ies, two miscarriages, one premature birth. 2. Father, general paralysis ; mother, syphilitic ; one juvenile general paralysis, one miscarriage, one healthy. 3. Father, healthy; mother, tabeCic; four pregnanch.s, two miscarriages, one child born dead, one miscarriage. 4. Father, healthy; mother lahellc; three pregnanch.s, all miscarriages or abortions. 5- Fathers healthy; mother married twice; four pregnanele% one born dead, .three miscmriages. 6. Father, not syphilitic; ~nother (lied of tabo-paratysis. Ihlsband knew nothing of the lfislory of the woman. She had one syphilitic sear on leg, which she hid from lfim. Six p~,egnnncies, one chiM born dead, followed by llve miscarriages. 7. Latent syphilis in mother; I'ather, alcohollc, shown by eh'cle in quadrants, collateral insanity nnd alcoholism both sides. Eight pregnancies--0) still-birth, (2) juvenile paral3,fic, (3) apparently healthy, (4) congenital syphilis, (S) apparently healthy, (6) death in early infancy, (7) and (8) apparently healthy. G E N E R A L PARALYSIS IN R E L A T I O N S Y P H I L I S tN A P O P U L A T I O N .
TO
Seeing that the death-rate from general paralysis about equals the admission rate, and that the two have not varied to any great degree in the London County Asylums during the last 15 years, we can estimate roughly (perhaps it is safer to say very roughly) the number of infectioas every year. W e may take the Vienna statistics as the most reliable to give us a factor indicative of the percentage of persons affected with syphilis who subsequently develop general paralysis. It is 4"75. Now if we allow that in the stationary population of London 400 fresh cases of general paralysis developed every year, then :-400 x IOO Numberoffreshinfectionswhich 4"75 occurred lO-15 years ago. From this it might be deduced that approximately about 8,non-in,non fresh cases of infection occur in adults per annmn in London between the ages of 18 and 48 . There are, it must be admitted, many fallacies in such a mode of calculation. It is rare that general paralysis occurs after 55; the great majority of cases occur in the 3rd and 4th decades, ten to fifteen years after prima~ry infection. All that can be asserted, on sure grounds, at present is that syphilitic infection is much more extensive than is generalIy believed. A positive Wassermann reaction shows from 2o-25 per cent. of admissions to infirmaries have either active or latent syphilis. W e have done more than I,OOO tests on sera from two infirmaries. Now I need only refer to general paralysis to prove that a serious attempt to grapple with the problem of the prevention of venereal disease would be of the greatest economic advantage to the State;
261
Of the total admissions to the asylums of the County of London every year, about Io per cent. are general paralytics. More than 15 per cent. of the males admitted are general paralytics, and these are recruited from men of all social grades and, prior to the onset of the disease, efficient and productive units of civic worth and capacity. True, the females are largely recruited from the unfortunate class of women, many of whom have been driven by destitution to prostitution, but a good number are the innocent wives of men by whom they have been infected and who are unaware of the real cause of their disease. Moreover, the history of the families of many of these women suffering with general paralysis shows that they have transmitted the infection to their offspring. If it were not for the fact that there is no accumulation of general paralytics in the asylums, as the death-rate equals the admissionrate, the cost of maintenance from this disease alone would be enormous. The London County Council expended last year £6oo,ooo in the maintenance of lunatics. Although general paralysis is rapidly fatal, and therefore the cost of maintenance ia not nearly as much as it otherwise would be, it must be remembered that many cases of organic dementia, imbecility, idiocy and arterio-sclerosis, due to syphilis, remain in the asylums a great number of years; consequently syphilis is responsible for a considerable portion of the expenditure. Investigation shows that syphilis is the most potent cause of nervous disease, paralysis, blindness, deafness and arterial disease of patients who have to be maintained for a great number of years in asylums, infirmaries and institutions for incurables. A fraction of this money wisely spent in preventing the disease and curing it, before it has wrought irretrievable damage, consequently would be an enormous saving to the ratepayer, who has not only to consider the money spent upon maintaining the human derelicts caused by venereal disease, but also he has to consider the enormous and wasteful expenditure of the public money upon costly buildings to house them. Asylums have been built costing £5oo per bed, but has this expenditure led to any improvement in the treatment of insanity? Lord Rosebery wisely remarked at the opening of the new Edinburgh Asylum some time ago: " A working man to be properly housed must become insane." The experience of early and modern scientific diagnosis and treatment of B2
262
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venereal diseases in the services is a sure indication of what might be done for the civil population, and such results doubtless have already attracted your attention.. RESULTS OF EARLY DIAGNOSIS AND TREATMENT IN THE SERVICES.
The results of early diagnosis and efficient treatment of venereal disease in the services, both Army and Navy, are remarkable in two respects. Firstly, the efficiency of the regiments as regards numbers of sick in hospital and dura. tion of stay in hospital has been improved to an extraordinary degree, corresponding to the services annually of nearly a whole battalion of a regiment. If the period of productive usefidhess of the soldier can be increased to such an extent by efficient diagnosis and treatment, why should not the same happen to the industrial army of labourers, artisans, clerks, shoPmen, and others, who toil, and are unable at present to obtain the same advantages as the soldier and sailor ? Secondly, early diagnosis and efficient treatment has in a large number of instances aborted the disease or arrested its progress, so that there is every indication that the soldiers so treated will not in the future suffer with those incapacitating and fatal diseases which I have mentioned. The efficiency of the intensive treatment adopted in the Army and Navy of intravenous injection of salvarsan in the primary stage, followed by mercury injections, before generalisation of spiroch~etes in the body has occurred, and, therefore, before the vascular and nervous systems have become infected, is strikingly shown by the number of reinfeetions which have occurred, a sure proof--and perhaps the 0nly proof--that the disease has been cured by the eradication of the specific organism. FREE DIAGNOSIS AND FREE TREATMENT.
I think the facts I have given have shown the economic advantages which would arise to the State by the adoption of effective measures to prevent the spread of venereal diseases. I do not intend here to discuss any plan, but whatever is done must be on efficient lines and be universal throughout the country. Whether existing hospitals and institutions are sufficient and efficient, or under what authority the scheme is worked, it seems to me that you, as public health officers, must have a large voice in its control and direction. Already some municipalities--Glasgow, for example--has take~ the matter of free diagnosis up. The
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crux of the problem is how to induce infected people of both sexes to avoid quacks, herbalists, and chemists, who are incapable of diagnosis of the primary sore, and following it by emcient treatment, and in place thereof induce them to apply as early as possible to the qualified medical man, who will be able to utilise, free of charge, the advantages of the central institution. As there are fifteen millions of people medically treated by panel doctors, it may be assumed that these medical men will not be loth to make use of these institutions, as it would in no way increase or diminish the payment received. The success of a scheme will largely depend upon the education of the public conscience to the removal of the moral stigma, and the suppression of quack advertisement, of quick cure without operation, use of mercury or other poisons, in newspapers and periodicals by which unqualified persons attract their victims. If a system of clinics (preferably at night) is established by the Municipality or the State in hospitals and institutions for free diagnosis and treatment, it is obvious that there must be an efficient staff of experienced and qualified men acting under a central controlling authority. It would be necessary for each applicant for treatment to have a card indicating such points as diagnosis, progress, treatment on one side and on the other directions as to the conduct of the patient ; this latter I regard as of great importance, yet I think such necessary directions as to conduct is too often neglected at hospitals and dispensaries, and even b y medical men when attending patients suffering with venereal disease. Lastly, it must be recognised that the position of woman is undergoing an entire change. She rebels against a system which leaves the man the freedom to infect without social degradation. As public health officers, whose duty it is to prevent disease in the community of which each. respectively is the guardian, you have naturally considered the following problems and the difficulties of their solution : - I. What is to be done with those of either sex who do not allow themselves to be treated at all, or only insufficiently ? 2. With those who, after being warned, continue to spread infection by sexual intercourse ? 3- Should a certificate of reasonable ~afety from a properly qualified
1914.
4.
PUBLIC HEALTH. medical m a n before m a r r i a g e be demanded ? I n the interest of the individual and the State, should m e a s u r e s be t a k e n to p r e v e n t unqualified p e r s o n s from t r e a t i n g venereal disease ?
I n s t i t u t i o n or H o s p i t a l . . . . . . . . . . . . . . . . . Card of A.B. Date ........................ Diagnosis. Clinical Signs. Microscopic Serological Examination. E x a m i n a t i o n . Sp. Wassermann. NATURE
Dates.. Dates.
OF T R E A T M E N T .
S a l v a r s a n or Neo-salvarsan.
I n t r a v e n o u s or Intramuscular. M e r c u r y injections or inunctions. R E S U L T S OF T R E A T M E N T .
Dates.
Clinical.
Serological.
DIRECTIONS.
z. You are suffering from a venereal disease, syphilis, your disease is in fective and remains so for some years. 2, You mu~t therefore take care t h a t you do not co nve y your disease to others, w h i c h m a y h a p p e n by sexual intercourse, by kissing, or by sleeping in t h e same bed with others, or by using the s a m e eating a n d d r i n k i n g utensils. 3, Your disease is not curable by a single course of treatment. 4. At s o m e future time it is p r o b a b l e you will suffer from tra~es of t h e disease, e,g., u l c e r s in the m o u t h , p a i n s in t h e neck, or eruptions on t h e body, squint, headache. 5, As soon as you notice any s y m p t o m s you must at once r e t u r n to be ag ain treated. 6, T ak e no notice of " q u a c k s " and only be treated by a pro perly qualified medical m a n . 7. E v e n if you notice no new p h e n o m e n a of y o u r disease you o u g h t to consult a medical m a n e v e r y four m o n t h s in order p e r h a p s to receive a n o t h e r course of treatment. 8. T h i s cours~ need not n e c e s s a r i l y be m a d e in a h o s p i t a l ; you will in all p r o b a b i l i t y be able to c o n t i n u e at y o u r work. 9- On ly w h e n a b o u t three years h a v e passed wil l it be safe for you not to u n d e r g o r e g u l a r l y several t i m e s in t h e year a course of t r e a t m e n t , and you will p r o b a b l y t h e r e b y be saved from later s~rious disease of bones, nerves, spinal cord and brain. Io. F o u r to five years after infection, and only after obtaining p e r m i s s i o n of the doctor, will it be safe for you to marry. I f you m a r r y you m a y c o m m u n i c a t e the disease to your wife an d to the children. i i, A co mp lete cure may be expected if you a t t e n d to all the directions given. i2. Keep th is c ard and show it to t h e doctor w h o m you m a y later consult, also a l w a y s ask h i s advice. S h o w the card to no one else, (Addition.) Take care to keep y o u r teeth clean by brushing them twice a day, rinse the m o u t h after each meal. Li ve a simple, regular, a b s t e m i o u s life, a v o i d i n g a l c o h o l and excessive smoking.
THE GRADING OF MILK. H E R E seems every prospect that if the Local Government Board Milk Bill is introduced into the H o u s e of Commons an a m e n d m e n t will bs proposed, and will be accepted by Mr. Samuel, to provide for milk which complies with a high standard Of purity, to be sold under a name which will be restricted in its use to milk possessing this quality. Such milk would have to stand a test which would ensure its freedom from tubercle bacilli and from contamination such as frequently takes p h c e in the farms and in transit.
T
963
T H E L A T E DR. H E R B E R T M A N L E Y . H E following is a complete list of the subscribers to the fund initiated by the Society of Medical Officers of Health for the benefit of the widow of the late Dr. Herbert Manley. The amount has been forwarded to Mrs. Manley snd the fund is now closed by order of the Council.
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Dr. F . J . AtIan ,. i Dr.H.E.Armstrong i Dr. A. A s h k e n n y o Dr, T. R i d l e y B a i l e y i D r . S . B a r w i s e .. i Dr. J. G. B e a s l e y i Dr, B. S. B r o w n e r Dr.A.K. Chalmers i D r . J . A . C odd .. ] Dr. J. M. C o w i e . . I Dr, Sidney D a v i e s o Dr. F. E. F r e m a n t l e 5 Dr. J. H. G a r r e t t I Dr. M. Gepp" .. f Dr. R e g i n a l d G r e e n o Dr..HenryHandford2 D ' r/ A l fre d H i l l .. i Dr. A. Bostock H i l l 5 Prof. E. W . H o p e 5 Dr. H o w a r t h .. 2 Ma j or R. W . H . Jackson, R A.M.C. I Dr. W . F. M a r s h J a c ks on . . . . I Dr. G. P e t g r a v e Johnson .. 2 Dr. J. Mount ford J ohns on .. i Dr. H e r b e r t J one s -i D r . J . R . K a y e .. i Dr. J. Doig Mc C ri ndt e I Dr. A. B. McMast'er i Dr. H. Ma l e t .. 2
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u R . . . . . o o" JDr.-- E . S . I-~obinson o D r . F r a n k Robinson D r . F . E . R oc k .. o D r. J. E. Saudio l a nds .. Dr. E d w a r d SerO O geant . . . . Dr. E. H. Snell I o Dr. R. W o o l s e y Stocks . . . . 2 o Dr. J o h n T a y l o r . . Dr, J. C. T h r e s h , i o Dr. T . M . T i b b e t t s i o Dr.A.S. Underhill r o Dr. J. W i l l i a m s o n Dr. A. H a m i l t o n I o Wood . . . . i o Yorkshire Branch 2 o
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APPOINTMENTS. DE. F. C. BRODIE ha s been appointed medical officer to t h e N e w S h o r e h a m P,S.A, DR. F. A. COATES h a s been a ppoi nt e d m e d i c a l officer of h e a l t h of W h i t c h u r c h (Hunts) R ,D . D m EFFIE M. D. CRAIG has been appointed to the past of l a dy assistant medical officer of h e a l t h of B i r m i n g h a m . DR. E, T. H. DAVIES ha s been appointed m e d i c a l officer of h e a l t h of T r e d e g a r . DE, A, E. EVANS h a s been appointed a me di c a l inspector u n d e r the B o a r d of C o n t r o l (Mental Deficiency Act). DR. R. A. GLEGG, the county medical officer of h e a l t h and school m e d i c a l officer, ha s been a p p o i n t e d chief tuberculosis officer of t he Lindsey (Lines). C o u n t y Council, DR. J. THERESA HILL h a s been a p p o i n t e d a s s i s t a n t school m e d i c a l officer to t he S m e t h w i c k E d u c a t i o n Committee. DR. OSCAR M. HOLDEN has been a p p o i n t e d a s s i s t a n t me di c a l officer of h e a l t h of S o u t h a m p t o n . DR. G. S. LEWIS ha s been a p p o i n t e d one of the a s s i s t a n t tuberculosis officers of t he Li nds e y (Lines,) C ount y Council. DR, HENRY LLOYD h a s b ~ n appointed t e m p o r a r y medical officer of h e a l t h to t h e St. A s a ph (Flint) a n d St. A s a p h (Denbigh) R . D , C ' s . DR. WILLIAM MACEWEN ha s received a joint a p p o i n t m e n t u n d e r the L.C .C . and Me t ropol i t a n A s yl ums B oa rd as medical inspector of schools to the former and e p i d e m i o l o g i s t to the l a t t e r. D E . DUNCAN F . MACRAE, Of Newcastle, ha s been a p p o i n t e d cIinical tuberculosis officer for B u r y a nd district. M i s s OL1VE ROBERTS0N, M,B., b a s b e e n appointed assist a n t medical officer in the P u b l i c H e a l t h D e p a r t m e n t of the L,C.C. DR. %¥. H . R o s s , of C h a t b u r n , h a s b s e n a p p o i n t e d medical officer of B o w l a n d R .D . (York@ D m A. J. -WILLIAMSON has been a p p o i n t e d one of the t u b e r c u l o s i s officers under the Es s e x C.C. DR. J. E. WILSON has been appointed one of the assistant t u b e r c u l o s i s officers of the Lindsey (Lincs,) C o u n t y Council. DR. W . A. B, Y O U N G ha s been a ppoi nt e d a s s i s t a nt school me di c a l officer to t h e B l a c k b u r n Educ a t i on C ommi t t e e ,
PUBLIC
,, S Y P H I L I S IN R E L A T I O N TO I N F A N T M O R T A L I T Y " AND P U B L I C H E A L T H . ~ BY F. VV. MOTT, M.D., F.R..S., F.R.C.P., pathologist to the L.C.C. Asylums ; Consulting Physician to Charing Cross Hospital and the Queen Atexandra Military Hospital. of my paper, "Syphilis in Relation T H Eto title Infant Mortality," I have found would limit too much the scope of the larger question which medical officers of health have to consider in relation to the effects of venereal affections in the production of death and disease. I will therefore deal with the subject of venereal infection in its wider application to public health. Every medical man is fully aware of the fact that the Registrar-General's returns afford a very inadequate conception of the influence of venereal disease on the death-rate ; and the statistics upon which the public rely for information are altogether misleading regarding the terrible effects wrought by these diseases. For obvious reasons the Registrar-General's returns must be erroneous, all the while the certificate of the cause of death is seen by the relatives or friends of the deceased. Consequently, syphilis as the cause of death seldom appears on the death certificate; for this reason a large proportion of those cases of death in which syphilis is certified as the cause, come from institutions, and largely relate to children dying in early infancy of congenital syphilis in which case the two sexes are equally affected. This may serve as an explanation of the anomalous fact that males certified as dying of syphilis only exceed females by a fraction (the proportion being 1"23--1"o) ; from which it might be inferred that the number of females infected are nearly as numerous as males. The Registrar-General's returns, however, show that in paralytic dementia and aneurism the proportion is four males to one female. 'I hese two diseases until quite recently have not been known to the public as being syphilitic, therefore when they occur the doctor has no hesitation in stating the cause of death. Consequently the returns of these two diseases in the Registrar-General's reports afford some indication of the incidence of syphilis in a population, also the relative incidence in the two sexes. I shall have occasion to return to this later. But I now pass on to show how inadequate a conception of the effects of venereal disease would be gained by statistics taken from the RegistrarGeneral's returns. * Read at a meeting of the ~tetropolitan Branch of tile SoQiety of Medical Officers of Health on 27th March, 1914.
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253
Syphilis is now the recognized essential cause of all cases of tabes and general paralysis, and latterly they have been regarded as syphilitic diseases by the Registrar-General. But in the Registrar-General's returns we find hemiplegia, paraplegia, brain softening, cerebral tumour, meningitis and paralysis given as the causes of death in a large number of instances, without any indication that a large proportion of these were due to syphilis. Yet experience teaches us that of all the causes of these diseases, syphilis is by far the most important ; especially does this apply to adults that die under the age of 50. " A man is as old as his arteries " is a trite saying, but of all the causes of disease of the arteries, especially the aorta, the cerebral and spinal arteries and the coronary arteries, syphilis is by far t h e most important. It operates in two ways: firstly by a specific inflammation, leading to thrombosis and occlusion of the cerebro-spinal vessels and causing brain softening, paraplegia and hemiplegia; secondly by causing inflammatory thickening and roughening of the aortic valves and incompetence ; by inflammatory aortitis it is the essential cause of aneurism; by nodular thickening and blocking of the coronary arteries it produces fatty degeneration and fibroid heart and it is a frequent cause of Stokes Adams disease. Heart disease and sudden fatal syncope registered as cardiac failure, not infrequently therefore owe their origin to syphilis, but none of tt~ese fatal conditions enumerated appear in the RegistrarGeneral's returns as being due to syphilis. Besides, syphilis by its devitalizing influence, especially in conjunction with alcohol, leads to a wearing-out of any, or all the tissues of the body, especially the arteries; it is therefore an important cause of atheroma and arterio-sclerosis. Again, by its devitalizing influence it favours the development of tuberculosis and other infections. Lastly may be mentioned the fact that syphilitic leuko-placia of the tongue frequently ends in epithelioma. Now with regard to the Registrar-General's returns concerning infant mortality. Marasmus is a frequent certified cause, pemphigus is given as a cause, and convulsions; also meningitis and hydrocephalus; all these conditions may be really syphilitic in origin, and in the case of pemphigus all the cases so certified are congenital syphilis, and are now recognised as such. I shall presently show you a number of pedigrees indicating that syphilis of the parents shows itself in the history of pregnancies by
254
PUBLIC HEALTH.
miscarriages, abortions, still-births, and children dying in early infancy of marasmus, convulsions, hydrocephalus, and meningitis. And although I have no statistical data beyond family histories of sixty cases of juvenile general paralysis to base my conclusions on, yet it is well recognised by physicians and practitioners that syphilis is responsible for abortions, still-births; and infants dying in early infancy, and that when a woman gives such a history of the results of pregnancies syphilis is the first cause which comes to mind. Examination of the blood by the Wassermann test shows a latent or active syphilis in a large number of such cases. Dr. Rcuth has calculated that the ante-natal mortality in England and Wales is about Ioo,ooo annually--z'2 stillbirths, 8"8 abortions, for Ioo live births. An inquiry at Glasgow suggests that syphilis is a potent factor in the production of still-births and abortions. The g~eater incidence of the same among the poor does not, however, necessarily indicate that syphilis is more prevalent, for the greater number of still-births and the greater infant mortality may be due to ignorance of the cause, and no treatment or later inefficient treatment. The remedial measures which would serve to combat this waste of pregnancies and infant life, and protect the unborn millions from the dangers of venereal infection have naturally occurred to you as medical officers of health. Your first object, undoubtedly, would be to obtain scientific proof of the extent of the waste of pregnancies and infant mortality from syphilis ; and this could be done by : - (I.) Universal notification of still-births, for which a fee should be paid, provided certain information was afforded to a central authority, by the medical man or midwife; the parents or friends should not see this certificate. The information should include facts relating to the health of the mother and presumed cause of death of the foetus, whether the foetus has been dead some time, and its appearance. This could be advantageously supplemented by a free Wassermann reaction of the blood of the mother and of blood obtained from the umbilical cord if obtainable. (2.) Free examination of the foetus for the presence of spirochmtes. I have found spiro: ch;etes in Ii out of 22 stilt-born children or toetuses from Shoreditch Infirmary. A research of this kind would, to be of scientific value, have to be undertaken at a central institution or hospital, and a series of
MAy,
still-births, dead premature births, and foetuses of all ages would have to be examined without any selection being made. In this way syphilis as a cause could be fairly estimated. Such an investigation could be conducted under the direction of the medical officer of health of the district or town. The result of this inquiry would enable the medical officer of health to advise the organisation of treatment of syphilitic mothers by approved methods; the treatment to be conducted .by experienced medical men under favourable hospital conditions. Periodic examination of the blood of an infected mother could be made with a view to treatment at intervals; in this way offspring born of infected parents, instead of being born dead or with the seeds of disease implanted in them, would be born healthy. The infected infant's blood could be tested periodically, and treatment resorted to if necessary. Now, it might be said that this would entail great financial difficulties, and before you could hope to get the State or municipal authorities to carry it out you would have to prove, first, that it was necessary and right on moral and eugenic grounds; and, secondly, that it was a saving to the rates. Now, to convince the authorities you would doubtless be required to show what proportion of still-births and deaths in early infancy which occur in (a) a city, (b) an urban and (c) a rural district are due to congenital syphilis. W e should find that the larger and denser the population, the greater the number of cases of congenital syphilis. Consequently, we should expect large cities like Birmingham, Liverpool, Glasgow, Manchester, and Leeds ready to undertake measures for the public health; whereas in small towns it would not be easy to get this done. (3.) Having proved the extent of the venereal disease in the population in an active or a latent form, you would endeavour to convince the authorities that not only is it their duty to prevent the immense amount of misery and suffering caused by venereal disease, but it would, in the long run, be an economy. I am of opinion that gonorrhoea is a much more serious affection than is generally supposed, and in any prospective measures for diagnosis and treatment should not be neglected. It is a fruitful cause of sterility in innocent women, leading to an immense amount of illhealth and to mental distress from the nongratification of the maternal instinct; it is also a cause of serious bodily disease--
1914.
PUBLIC
salpingitis and pyosa]pinx--which not infrequently ends in fatal peritonitis; it is also a cause of severe arthritis. Moreover,it is the most extensive cause of blindness from ophthalmia neonatorum. In the male, gonorrhccal epididymitis, stricture and subsequent cystitis with secondary nephritis are common sequelae, so that some authorities assert that gonorrhea is a more serious affection than syphilis. If it were not for the fact that syphilis destroys the fruits of conceptions of syphilitic parents by abortions, still-births or deaths in early infancy, it is appalling to think what a number of miserable creatures, blind, deaf, paralysed, imbeciles, and idiots of all grades there would be. There are, however, enough congenital syphilitics in our midst, and the blood test seems conclusively to prove that there are far more than we had any conception of. In my own hospital experience the value of the Wassermann test in proving this proposition has been brought home to me with striking force. Let me cite a few instances. A lad of 18 was admitted with all the signs of basic meningitis; he had no signs of syphilis on the body, nor was there any history pointing to the fact that he could have acquired the disease. The cerebro-spinal fluid gave a marked lymphocytosis, the Wassermann reaction was negative of the fluid, positive of the blood. The mother's blood was tested, and found to be positive, although she said she had never ailed, and was quite unconscious of t h e fact that she had been infected. Salvarsan and mercury led to a great improvement in the boy's condition. I will cite yet another case. A boy was seen by me aged 18 (he looked I O ) ; there was marked infantilism; no history of syphilis could be obtained from the mother; she had been married 30 years. The boy's blood and fluid gave a positive reaction, and the clinical signs and symptoms showed that he was a juvenile general paralytic. Examination of the mother's blood showed she was a latent syphilitic. The same occurred in a case of optic atrophy and tabo-paralysis in a girl aged I5 years. There are other facts which I will relate later to show the prevalence of syphilitic infection in the population. But I will now revert to the proposition of convincing the authorities that in the end they will save the ratepayer by adopting apparently costly measures to prevent innocent women and children suffering from the effects of venereal disease.
HEALTH.
~66
The first duty of the State is to prevent disease, failing that to cure disease, and failing that to prolong life and relieve suffering. There may be conscientious objections on the part of the " pillars of society " to provide free treatment for men and women who have contracted the disease as a result of immorality. Personally, I think this is a false and unchristian sentiment, and such people should be reminded of the rebuke of Christ to~ the crowd who would stone the woman taken in adultery. Venereal disease should be regarded as a great misfortune rather than an odious sin. However, any objection which might be made to the expenditure of public money on this account fails in respect to the protection of married women and children, doctors, nurses and others who innocently acquire the disease. But if an appeal to the duty of the authorities on moral and eugenic grounds fails, let us see whether we cannot appeal to their commonsense on economic and financial grounds. The civic worth of an individual can be measured by length of useful life as a social unit. As an asset to the nation, the value of each individual depends upon the amount of mental and physical work he or she can produce and the capacity of breeding and rearing children healthy in mind and body. Now venereal disease, especially syphilis, although in the majority of instances by its direct effects does not prevent a man or woman working by making them bedridden, nevertheless by direct or indirect effects on the vital organs and tissue5 of the body diminishes considerably the efficiency and length of productive usefulness of the individual; and in at least 12 per cent. of the persons infected with syphilis causes fatal incapacitating diseases which render the individual prior to death a monetary burden to the State for a number of years. From an economic point of view, therefore, the State and municipal authorities would save enormous sums of money in the end by a wise expenditure in preventing the spread of this disease and by promoting its cure in the earlier stages. INCIDENCE OF SYPHILIS IN THE POPULATION.
I have estimated that I2 per cent. of persons infected with syphilis suffer with incapacitating and later fatal diseases. It is a rough estimate based upon some valuable statistics from Vienna. Mattauschek and Pdcz analysed the cases of 4,x34 officers who between the years I88o and I9oo were infected by syphilis and they found that 198 died of general paralysis, 1 I6 of tabes, and 134 of cerebro-spinal syphilis,
256
P U B L I C H E A L TH.
making in all over io per cent. from diseases of the nervous system. If we add aneurism, arterio sclerosis, heart disease, etc., it would amount to 12 per cent. in which syphilis had been the cause. According to these statistics 4'78 per cent. of males infected died subsequently of general paralysis, and of this disease I have had a large experience and I therefore will now limit myself to a consideration of it. I have always maintained that the essential factor in the production of general paralysis is syphilis. I was led to this conclusion by collecting 6o cases of the juvenile form due to hereditary syphilis. Clinically there is little difference in the disease as seen in the juvenile form and the adult who has acquired syphilis, and there is no difference in the pathological changes. With the discovery of the spirochaete in the brains of general paralytics, the last link in the chain of circumstantial evidence has been forged in showing that syphilis is the essential factor in the production of this disease. I show preparations of spiroch~etes from the brains of general paralytics, and I may mention that I have found them in 66 per cent. of a series of 9o cases. They are found much more readily in the acute maniacal stage tlaan subsequently in the arrested demential stage for reasons which I have not time in this paper to dwell upon. Admittirig the premiss that syphilis is the essential cause of general paralysis, we can easily understand why general paralysis, due to hereditary syphilis causing the juvenile form of the disease, affects the two sexes equally. Obviously it is because the chances of male and female being infected are equal. T w o per cent. of the admissions to the asylums are the juvenile form; there would undoubtedly be a great many more were it not for the fact that, when the syphilitic organism invades::the nerv0as system in the ~nfant, it is almost invariably fatal. The history of families in which a case of juvenile general paralysis occurs rather suggests that the specific organism has become modified by the action Of the antibodies of the mother. Now the equal affection of the sexes when the disease is due to congenital syphilis is in striking contrast to that occurring when the disease is acquired; for here we find four males to one female, and whereas all social grades in the male sex contribute in about equal proportions, the lower we sink in the social scale the more numerous are the cases of general paralysis and tabes in the female sex. W e can thus
M AV,
explain the higher incidence of males admitted to asylums suffering from general paralysis from the \Vest-end than the East-end and the somewhat higher incidence of females from East-end t h a n West-end parishes. All these facts tend to show that the incidence of general paralysis in a population corresponds with the relative incidence of syphilis in the two sexes. I will throw on the screen some statistics relating to the incidence of general paralysis in the different parishes in London in relation to the total admissions to the asylums. TABLE
I.
Table showing the percentage incidence of male general paralytics among the male admissions from the various London parishes to the London County Asylums during the years i91i-i2:-I. 2. 3. 4. 56. 7. 8. 9. lO. 11. i2. 13. 14. 15. 16. i7. 18. 19. 2o. 21. 22. 23. 24. 25. 26. 27. 28. 29. 3 o.
St. George's, W Whltechapel . Shoreditch . Fulham . . . . Paddington . Hotborn . . . . St. Marylebone . Islington . . . . Kensington . Wandsworth . Lambeth . . . . Woolwich . Hammersmith . Westminster . St. Pancras . Hampstead . Lewisham . Camberwell . Greenwich . Bermondsey . Southwark St, George's,E~" Mile End . Bloomsbury . Chelsea . . . . Hackney . . . . Poplar . . . . Strand . . . . Stepney . . . . 13ethnal Green
.
.
. . . . . . . . . . . . . . . . . . .
. . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29"0 per 24"2 23'2 22"5 2o 7 19' 5 19" 3 18'6 18" 4 18'3 i8"1 17"o 17"o 13" 4 15'o 14'6 14" i i3"8 13'2 13"o 12" 4 i2"t i2"olO'3 lO"2 9"3 9"o 8"9 8"8 4'8
cent. ,, ,, ,, ,, ,, ,, ,,
,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,,
The number o f cases admitted trom single parishes suffering' from general ~paralysis are not sufficient to draw any conclusions from, yet I cannot refrain from calling attention to the low incidence of Bethnal Green with a population of 128,282, viz., x"9 per cent. of the total admissions compared with St. George'sin-the-West with a population of 117,968, where there is 5"2 per cent. of the total admissions due to general paralysis. On account of the numbers I have grouped parishes into east and west; (a): ~north, and (b) south.-of t h e Thames. Table II. refers to group (a), Table III. to group (b). Table II. shows on the one hand a relatively high percentage of male genejcal paralytics in the West-end parishes north of the Thames, viz., I7"3 per cent. against I3"2 per cent. for
1914.
PUBLIC
257
HEALTH.
TABLE II. Showing a comparison of the incidence of insanity and of dementia paralytics in the admissions to the London County Asylums during the years i 9 i i - I 2 , from the parishes north of the Thames, west and east respectively. Parish.
Total Adnfissions, 19~I-12.
Population.
Admissions per Male Adi,ooo In- missions. habitants.
Male G,P,I.
Percentare G.P,I.
3° 6 18 17 17 18 25 23 6 24 6 6 9
15 '°'~ I4'6 I9"3 19"5
Female Female AdmisG.P.I, sioas. ~
Percentage G.P.I,
W~ts'r, St, P a n c r a s
,.
Hampstead St, Marylebone Holborn . . . Paddington Hammersmith Fulham . . . Kensington Chelsea . . . St. G e o r g e ' s Westminster Bloomsbury Strand . . .
. . . .
ai8,453 85,5m 118,221 112,247 142,576 121,6o 3 I53,325 172,4o2 66,404 II7,968 25,451 25,°65
..
.. . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . .
. . . . . .
393 89 220 174 168 228 276 271 I2I I78 57 113 I3I
I6~858 .
Total Total percentage'G.P.I[
1,376,o83
]
.
1'8o I'o4 t'86 1"42 1"18 1"87 1'80 I'57 1-82 1"5t 2"24 4'51 7'77
.
I
.
.
I"75
2.419
2Ol 41 93 87 82 IO6 III I25 59 83 39 58 98
I
.
.
1183
.
2o5
,
192 48 127 87 86 122 165 146 62 95 18 55 33
I
t 1,2~6
~
20'7:
]
I7'0 ~ 22"5~ 18'4 IO'2 29-0 ] 15" 4 lO'3 { 8'9 ]
.
[.
173
EAST.
Istington . . . Shoreditch Hackney . . . St. G e o r g e ' s Bethnal Green Stepney . . . Poplar Mile EndJJ Whltechapel
. . . . . . . . .
. . . . . . . . .
3 I 3 2 4 4 I 4 2 5 .. I i .
.
I'5 2 o 2"3 2' 3 4 6 3'2 o'6 2" 7 3'2
;% yo .
.
31
2' 5 =9"7
6 2 IO 2 i i 5 4 3
2' 4 2" 7 4'i 5"9 i' 9 2' 9 4"6 47 - - 3-' 9-
34
Y4 =8'2
1
. . . . . . . . . . . . . . . . .
.. .. .. .. .. .. .. ..
Total Total percentage ' G.P,i"
435 141 457 67 115 83 305 169 139
327,423 111,463 273,270 47,1Ol 128,282 53,798 162,449 111,375 67,750
0"89
1"54 1"88 I 1'52 2".___..05 ~
1,9II
I~282,9II
36 I6 20 4
I93 69 215 33 63 45 166 84 6_____2- -
1'33 I'26 1'67 1'42
1"49
93O
t'"
15 io I5.~ I23
I'"
I'"
18'6 242 ~3"2 72 9'3 242 I2'I 34 4'8" 52 8'8 38 9"o 139 12"o 85 24'__._~27 7 . ~ 13"2
I i I
__.
981
/'"
i"l
"'l
TABLE III. Showing a comparison of the incidence of insanity and of dementia paralytics in the admissions to the London County Asylums during the years I911-12, from the parishes south of the Thames, west and east respectively. Parish.
Population. _ _ _ _
Total Ad- i Admis- i sions per I Male Admlsmons, [ I,ooo In- [ missions. ] 1911
Male G,P,I.
Percentage G.P.I,
Female Aomlssions.
55 43
18' 3 18"1
214
18'3
641
Female ~ I ~J,r..
a
ii
]
""
Percentge G,P.I,
W E S T ,
Wandsworth . . . . . . Lambeth . . . . . . . .
479,I95 298,126 -
Total Total percentage G.P.i."
-
727
t
i
451
I'52 I'51
i i i !
T
300 237
1.51 i537 ! 98
777,32I
4271
1.
.
.
3"1
•.
..
'5 4"2
=
I0"O
.
EAST. Camberwell Bermondsey Lewisham Greenwich Woolwich Southwark Total
Total
. . . . . .
. . . . . .
. . . . . .
. . . . . .
. . . . . .
. . . . . .
p~riJntagi'~.v.i."
261,357 125,96o
174,296 185,688 127,737 191,951 1,o66,989 ,o
l
159 197 260
I i
1"52 1"26 1"13
I9~ !
1"4°
i
27
1"52 I '86
94
I
161
!
II 17 35 20
I '46
741
i
Io2
°-
[
"°
• o
78 128
i i
13"8 13"o I4 I Iy2 17"o 12" 4
203 74 119 132 IOI 196
i
-
i
5 2 9
! i
0'9 5"4 o 8 3 .8 i. 9 4 .6 =7'9
258
PUBLIC HEALTH.
the East-end parishes. On the other hand, the percentage of females is higher in the East-end parishes, 3'4 per cent. compared with 2"5 per cent. in the We~t-end parishes. The percentage incidence of general paralysis of the total admissions in the West-end parishes is 9"7 against 8"2 East-end parishes. The average incidence of insanity in these two groups of parishes north of the Thames shows I"75 West-end group and 1"49 East-end group per I,OOO resident population; consequently there is a larger incidence of insanity and general paralysis in the richer West-end parishes north of the Thames than the poorer East-end. "Fable i l i . gives a comparison of east and west parishes south Of the T h a m e s ; here we find that the western parishes, \¥andsworth and Lambeth have a higher percentage of admissions with general paralysis, both male and fem~.le, than the eastern parishes. The average incidence of insanity in these two groups of east and west parishes is west 1"51, east I"46 per i,ooo resident. These two groups south of the Thames, however, do not show quite the same results as the two groups north of the Thames, for the western parishes of Lambeth and Wandsworth show both a higher rate of incidence in males (18"3 per cent.) and females (3"1 per cent.) than the eastern parishes (males 13"9, females 2'7 per cent.); this is not surprising when we consider the class of population living in the twowestern parishes south o f t h e T h a m e s . We might ask the question: W h y should general paralysis occur more frequently'in admissions from West-end parishes than Eastend? To answer this question let us first consider the fact that the lower we sink in the social scale the greater is the incidence in women of general paralysis; undoubtedly, the reason for this is the greater number of women who are exposed to infection, for poverty is the most fruitful cause of prostitution. The incidence of general paralysis in t,he total female admissions as compared with the total male admissions is on~ female to seven males. We have seen that the West-end parishes north of the Thames have a higher percentage of males than the East-end parishes, and a lower percentage of females. TABLE IV. West-end parishes north of the Thames.. ~7'3 per cent. G.P. males, 2"5 per cent. G.P. females, equals 7 males to I female. East-end parishes north of the Thames.. t3.2 per cent. G.P. males, 34 per cent. G.P. females, equals 4males to : female. West-end parishes south of the Thames..18.3 per cent, G.P. males, 3"I per cent. G.P. females, equals
MAT,
6 males to I femaIe. East-end parishes south of the Thames..i3"7 per cent. G.P. males, 2"7 per cent. G.P. females, equals 5 males to I female. As there are a considerable number of betterclass males who develop every year general paralysis and do not come into the London County Asylums, the incidence of seven males to one female in West-end parishes is probably considerably under the mark. The average percentage of male general paralytic admissions annually to the London County Asylums is 15"6 per cent. At Coiney Hatch Asylum all the Jews are received, and 15 per cent. of the total admission o f Jews are suffering with general paralysis, so that this about corresponds with the average admission rate. Some years ago I made a personal investiga. tion of the family history of a number of cases of juvenile general paralysis with a view of showing that this disease is invariably caused by syphilis." Unlike the disease affecting adults due to acquired syphilis, where males exceed females by a proportion of four or five to one, the juvenile form affects the two sexes in equal proportions, the obvious reason being that the chances of infection are equal. The family histories show a number of interesting facts, which I will consider under different groups. First, let me call attention to some generalisations. The usual history is that the mother, after one or more miscarriages followed by abortions and still-births, had one or more children who generally died in early infancy of convulsions or meningitis; later a child survived, and at puberty or early adolescence developed general paralysis. The histories of 34 syphilitic mothers gave 175 conceptions; these were made up as follows:--Io 4 premature births or deaths in early infancy, 4 t diseased in some serious form or a n o t h e r ; 30 were abparently healthy, but many of these may have suffered later, and certainly a considerable percentage of these apparently healthy children would have given a positive Wassermann reaction. In four instances the mothers were infected after marriage, and after each had given birth to healthy children. It is of interest to note what followed in respect to conceptions before and after the mothers had been infected. Taken together there were 15 conceptions before infection, resulting in the birth and rearing of 15 healthy children. After infection there were 22 conceptions; of these 13 were abortions, still-births, 0 r . children dying in early infancy; of the remaining nine there were five seriously diseased, and there was no
059
PUBLIC H E A L T H .
1914.
these cases of congenital syphilis, with a brief descriptive account, are given. Each one is selected to illustrate some interesting point.
absolute proof that the remaining four were healthy. The family history charts of a number of
Died ~ I yr. 9 m ~ ,
~ Hg,
;;,gd0 Otitis G~.P,I, Kerat*tis.
Optic Atrophy. Cyclo.plegia,
I_M_L_L_J
Died 9 years,
Healthy.
GRouP G R O U P 1. ~. q'o show the effect of treatment and Iater neglect of treahnent of the mother in the blrth of healthy and disea~-'d children. 2. A mild form of syphilis of the father later causing tabes--inad.equate lreatmcnt. Marriage two years after infection; the mother was probably not infected, therefore heallhy family.
G.P.
I.
3. The father was Inertial.| five years afiur ]nfectioa, and in spilt of prolonged trealnll'nt ihe moiher was infectr'd, and gave birlh 1o syphilitic offal)ring. 4. Large healthy fanfilv; wife infech.d, followed ];y two miscarriages, two born dead, and one living child, who at pul)erty dew:loped tabo-paralyqls and optlc ah-nphy,
I C o n t r a c t e d ~
I9
12
lllt ob t 6b Ob b g d I9 6 i Twln~ died at
Died in infancy. ,
Healthy Children
? WassermannReaction.
Juvenile CleneralPalaly~is.
early age.
Drunk Soldier,
Twins
Juvenile
General Paralysis.
,.~Heahhy Children
? Wassermann Reaction.
Juvenile l~ri'nary Convulsiot~s G.P.I Optic Death at 15 rnor~ths,
At rophy,
GROUP I I , G R O U P II. i. Man contracted syph'ilis during wif,e's second pregnancy and infected her The offspring of the marriage is as follows : Daughter alive, ageLt 27; son alive, aged 24; then follmved four miscarriages in succession; an infant which lived only three m o n t h s ; an infant which lived six m o n t h s ; then the patient, who at the age el ~4 was able 1o earn 8s. a week, but who in early adolescence developed gencrfil
paralysis; then a daughter, who is r2 years of age; then a miscarriage; and, lastly, a frail little gM, aged eight. 2. The falher was a drunken imbecile soldier, wt~o had an insane brother. Th,e hlslory of the conceptions obtained from tile mother was as follows: A miscarriage shortly after marriage, nil intervaI of six years, twins born dund, a still-birth, then a child with si~ns of eongenltal syphilis, also developed general l)aralysis ,at puborly. This wa~ folB
MAY,
PUBLIC HEALTH.
2(;0
lowed hy five apparently healthy children. Several, if not all, of these might have given a positive \Vaqsernmnn rein'lion indicative of latent syphilis. 3- f h i s pedigree shows that the bh'til .of apparently healthy children following abortions and deaths in early infancy is no fl'ee pass: for we find the last-born male developed general paralysis. Doubtless, all the apparenlly
healthy children would have given a positive Wassermann reaction. 4 - E a r l y age of marriage and virulence of infection. The father was ~a; the mother 2o. All {he conceptio~s resulted in premature births, death in early infancy of convulsionq or late congenital syphilis of the nervous
SVStPHI.
Never had a day's
#
I
@
Q
.... ....
Newer had a day's ....... illness
Brain dlsea~e. Club f o o t . had snuffles.
Contracted S. wh~teo n
a
voyage,|
~ -
z
I
V
Died at • :
.
d ; ; sesd(5 13ied at Darentl~.
GRoup I I I . GROUP IlI. L Transmission to third generation. Two sisters with very definite signs of congenital syphilis. The mother gave a history of three prematuT-e births, two children born dead; she herself had never had an), illness. Both of the daughters had marked s f i g m a | a of congenital syphilis; one of them married and had a syphilitic child, The lmsband had not had syphilis, and not been in the way of getting it.
1 J
i l I J
2. I t u s b a n d went for a voyage, came home and infected wife, followed by miscarriages and abortions. 3. Latent syphilis no free pass to succeeding offspring. In this chart we find four apparently healthy children tprobably latent syphilitic) following on diseased children; Hlen two children dying in early" infancy. 4-FaIl~er, general paralytic; infected wife; one ntiscarriaNe and two still-births ; then typical congenital syphilitic, who developed tabo-paralysis.
Juvenile G,P,I,
O ~ r ~ 1 9
I)ied of ageS.e& Case acquired before marriage Husband no Syphilis; [ Gmnmalosis ~ S o r e s , Psoriasis. R
Juvenile General Paralysis. GROUP I V .
1914.
PUBLIC HEALTH. G R O U P IV.
~, Father, gcw:ral paralysis ; mother, ~ab,,s; 'du-ce preg~lan~ies, two miscarriages, one premature birth. 2. Father, general paralysis ; mother, syphilitic ; one juvenile general paralysis, one miscarriage, one healthy. 3. Father, healthy; mother, tabeCic; four pregnanch.s, two miscarriages, one child born dead, one miscarriage. 4. Father, healthy; mother lahellc; three pregnanch.s, all miscarriages or abortions. 5- Fathers healthy; mother married twice; four pregnanele% one born dead, .three miscmriages. 6. Father, not syphilitic; ~nother (lied of tabo-paratysis. Ihlsband knew nothing of the lfislory of the woman. She had one syphilitic sear on leg, which she hid from lfim. Six p~,egnnncies, one chiM born dead, followed by llve miscarriages. 7. Latent syphilis in mother; I'ather, alcohollc, shown by eh'cle in quadrants, collateral insanity nnd alcoholism both sides. Eight pregnancies--0) still-birth, (2) juvenile paral3,fic, (3) apparently healthy, (4) congenital syphilis, (S) apparently healthy, (6) death in early infancy, (7) and (8) apparently healthy. G E N E R A L PARALYSIS IN R E L A T I O N S Y P H I L I S tN A P O P U L A T I O N .
TO
Seeing that the death-rate from general paralysis about equals the admission rate, and that the two have not varied to any great degree in the London County Asylums during the last 15 years, we can estimate roughly (perhaps it is safer to say very roughly) the number of infectioas every year. W e may take the Vienna statistics as the most reliable to give us a factor indicative of the percentage of persons affected with syphilis who subsequently develop general paralysis. It is 4"75. Now if we allow that in the stationary population of London 400 fresh cases of general paralysis developed every year, then :-400 x IOO Numberoffreshinfectionswhich 4"75 occurred lO-15 years ago. From this it might be deduced that approximately about 8,non-in,non fresh cases of infection occur in adults per annmn in London between the ages of 18 and 48 . There are, it must be admitted, many fallacies in such a mode of calculation. It is rare that general paralysis occurs after 55; the great majority of cases occur in the 3rd and 4th decades, ten to fifteen years after prima~ry infection. All that can be asserted, on sure grounds, at present is that syphilitic infection is much more extensive than is generalIy believed. A positive Wassermann reaction shows from 2o-25 per cent. of admissions to infirmaries have either active or latent syphilis. W e have done more than I,OOO tests on sera from two infirmaries. Now I need only refer to general paralysis to prove that a serious attempt to grapple with the problem of the prevention of venereal disease would be of the greatest economic advantage to the State;
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Of the total admissions to the asylums of the County of London every year, about Io per cent. are general paralytics. More than 15 per cent. of the males admitted are general paralytics, and these are recruited from men of all social grades and, prior to the onset of the disease, efficient and productive units of civic worth and capacity. True, the females are largely recruited from the unfortunate class of women, many of whom have been driven by destitution to prostitution, but a good number are the innocent wives of men by whom they have been infected and who are unaware of the real cause of their disease. Moreover, the history of the families of many of these women suffering with general paralysis shows that they have transmitted the infection to their offspring. If it were not for the fact that there is no accumulation of general paralytics in the asylums, as the death-rate equals the admissionrate, the cost of maintenance from this disease alone would be enormous. The London County Council expended last year £6oo,ooo in the maintenance of lunatics. Although general paralysis is rapidly fatal, and therefore the cost of maintenance ia not nearly as much as it otherwise would be, it must be remembered that many cases of organic dementia, imbecility, idiocy and arterio-sclerosis, due to syphilis, remain in the asylums a great number of years; consequently syphilis is responsible for a considerable portion of the expenditure. Investigation shows that syphilis is the most potent cause of nervous disease, paralysis, blindness, deafness and arterial disease of patients who have to be maintained for a great number of years in asylums, infirmaries and institutions for incurables. A fraction of this money wisely spent in preventing the disease and curing it, before it has wrought irretrievable damage, consequently would be an enormous saving to the ratepayer, who has not only to consider the money spent upon maintaining the human derelicts caused by venereal disease, but also he has to consider the enormous and wasteful expenditure of the public money upon costly buildings to house them. Asylums have been built costing £5oo per bed, but has this expenditure led to any improvement in the treatment of insanity? Lord Rosebery wisely remarked at the opening of the new Edinburgh Asylum some time ago: " A working man to be properly housed must become insane." The experience of early and modern scientific diagnosis and treatment of B2
262
PUBLIC
venereal diseases in the services is a sure indication of what might be done for the civil population, and such results doubtless have already attracted your attention.. RESULTS OF EARLY DIAGNOSIS AND TREATMENT IN THE SERVICES.
The results of early diagnosis and efficient treatment of venereal disease in the services, both Army and Navy, are remarkable in two respects. Firstly, the efficiency of the regiments as regards numbers of sick in hospital and dura. tion of stay in hospital has been improved to an extraordinary degree, corresponding to the services annually of nearly a whole battalion of a regiment. If the period of productive usefidhess of the soldier can be increased to such an extent by efficient diagnosis and treatment, why should not the same happen to the industrial army of labourers, artisans, clerks, shoPmen, and others, who toil, and are unable at present to obtain the same advantages as the soldier and sailor ? Secondly, early diagnosis and efficient treatment has in a large number of instances aborted the disease or arrested its progress, so that there is every indication that the soldiers so treated will not in the future suffer with those incapacitating and fatal diseases which I have mentioned. The efficiency of the intensive treatment adopted in the Army and Navy of intravenous injection of salvarsan in the primary stage, followed by mercury injections, before generalisation of spiroch~etes in the body has occurred, and, therefore, before the vascular and nervous systems have become infected, is strikingly shown by the number of reinfeetions which have occurred, a sure proof--and perhaps the 0nly proof--that the disease has been cured by the eradication of the specific organism. FREE DIAGNOSIS AND FREE TREATMENT.
I think the facts I have given have shown the economic advantages which would arise to the State by the adoption of effective measures to prevent the spread of venereal diseases. I do not intend here to discuss any plan, but whatever is done must be on efficient lines and be universal throughout the country. Whether existing hospitals and institutions are sufficient and efficient, or under what authority the scheme is worked, it seems to me that you, as public health officers, must have a large voice in its control and direction. Already some municipalities--Glasgow, for example--has take~ the matter of free diagnosis up. The
HEALTH.
MAY,
crux of the problem is how to induce infected people of both sexes to avoid quacks, herbalists, and chemists, who are incapable of diagnosis of the primary sore, and following it by emcient treatment, and in place thereof induce them to apply as early as possible to the qualified medical man, who will be able to utilise, free of charge, the advantages of the central institution. As there are fifteen millions of people medically treated by panel doctors, it may be assumed that these medical men will not be loth to make use of these institutions, as it would in no way increase or diminish the payment received. The success of a scheme will largely depend upon the education of the public conscience to the removal of the moral stigma, and the suppression of quack advertisement, of quick cure without operation, use of mercury or other poisons, in newspapers and periodicals by which unqualified persons attract their victims. If a system of clinics (preferably at night) is established by the Municipality or the State in hospitals and institutions for free diagnosis and treatment, it is obvious that there must be an efficient staff of experienced and qualified men acting under a central controlling authority. It would be necessary for each applicant for treatment to have a card indicating such points as diagnosis, progress, treatment on one side and on the other directions as to the conduct of the patient ; this latter I regard as of great importance, yet I think such necessary directions as to conduct is too often neglected at hospitals and dispensaries, and even b y medical men when attending patients suffering with venereal disease. Lastly, it must be recognised that the position of woman is undergoing an entire change. She rebels against a system which leaves the man the freedom to infect without social degradation. As public health officers, whose duty it is to prevent disease in the community of which each. respectively is the guardian, you have naturally considered the following problems and the difficulties of their solution : - I. What is to be done with those of either sex who do not allow themselves to be treated at all, or only insufficiently ? 2. With those who, after being warned, continue to spread infection by sexual intercourse ? 3- Should a certificate of reasonable ~afety from a properly qualified
1914.
4.
PUBLIC HEALTH. medical m a n before m a r r i a g e be demanded ? I n the interest of the individual and the State, should m e a s u r e s be t a k e n to p r e v e n t unqualified p e r s o n s from t r e a t i n g venereal disease ?
I n s t i t u t i o n or H o s p i t a l . . . . . . . . . . . . . . . . . Card of A.B. Date ........................ Diagnosis. Clinical Signs. Microscopic Serological Examination. E x a m i n a t i o n . Sp. Wassermann. NATURE
Dates.. Dates.
OF T R E A T M E N T .
S a l v a r s a n or Neo-salvarsan.
I n t r a v e n o u s or Intramuscular. M e r c u r y injections or inunctions. R E S U L T S OF T R E A T M E N T .
Dates.
Clinical.
Serological.
DIRECTIONS.
z. You are suffering from a venereal disease, syphilis, your disease is in fective and remains so for some years. 2, You mu~t therefore take care t h a t you do not co nve y your disease to others, w h i c h m a y h a p p e n by sexual intercourse, by kissing, or by sleeping in t h e same bed with others, or by using the s a m e eating a n d d r i n k i n g utensils. 3, Your disease is not curable by a single course of treatment. 4. At s o m e future time it is p r o b a b l e you will suffer from tra~es of t h e disease, e,g., u l c e r s in the m o u t h , p a i n s in t h e neck, or eruptions on t h e body, squint, headache. 5, As soon as you notice any s y m p t o m s you must at once r e t u r n to be ag ain treated. 6, T ak e no notice of " q u a c k s " and only be treated by a pro perly qualified medical m a n . 7. E v e n if you notice no new p h e n o m e n a of y o u r disease you o u g h t to consult a medical m a n e v e r y four m o n t h s in order p e r h a p s to receive a n o t h e r course of treatment. 8. T h i s cours~ need not n e c e s s a r i l y be m a d e in a h o s p i t a l ; you will in all p r o b a b i l i t y be able to c o n t i n u e at y o u r work. 9- On ly w h e n a b o u t three years h a v e passed wil l it be safe for you not to u n d e r g o r e g u l a r l y several t i m e s in t h e year a course of t r e a t m e n t , and you will p r o b a b l y t h e r e b y be saved from later s~rious disease of bones, nerves, spinal cord and brain. Io. F o u r to five years after infection, and only after obtaining p e r m i s s i o n of the doctor, will it be safe for you to marry. I f you m a r r y you m a y c o m m u n i c a t e the disease to your wife an d to the children. i i, A co mp lete cure may be expected if you a t t e n d to all the directions given. i2. Keep th is c ard and show it to t h e doctor w h o m you m a y later consult, also a l w a y s ask h i s advice. S h o w the card to no one else, (Addition.) Take care to keep y o u r teeth clean by brushing them twice a day, rinse the m o u t h after each meal. Li ve a simple, regular, a b s t e m i o u s life, a v o i d i n g a l c o h o l and excessive smoking.
THE GRADING OF MILK. H E R E seems every prospect that if the Local Government Board Milk Bill is introduced into the H o u s e of Commons an a m e n d m e n t will bs proposed, and will be accepted by Mr. Samuel, to provide for milk which complies with a high standard Of purity, to be sold under a name which will be restricted in its use to milk possessing this quality. Such milk would have to stand a test which would ensure its freedom from tubercle bacilli and from contamination such as frequently takes p h c e in the farms and in transit.
T
963
T H E L A T E DR. H E R B E R T M A N L E Y . H E following is a complete list of the subscribers to the fund initiated by the Society of Medical Officers of Health for the benefit of the widow of the late Dr. Herbert Manley. The amount has been forwarded to Mrs. Manley snd the fund is now closed by order of the Council.
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£s.d.
Dr. F . J . AtIan ,. i Dr.H.E.Armstrong i Dr. A. A s h k e n n y o Dr, T. R i d l e y B a i l e y i D r . S . B a r w i s e .. i Dr. J. G. B e a s l e y i Dr, B. S. B r o w n e r Dr.A.K. Chalmers i D r . J . A . C odd .. ] Dr. J. M. C o w i e . . I Dr, Sidney D a v i e s o Dr. F. E. F r e m a n t l e 5 Dr. J. H. G a r r e t t I Dr. M. Gepp" .. f Dr. R e g i n a l d G r e e n o Dr..HenryHandford2 D ' r/ A l fre d H i l l .. i Dr. A. Bostock H i l l 5 Prof. E. W . H o p e 5 Dr. H o w a r t h .. 2 Ma j or R. W . H . Jackson, R A.M.C. I Dr. W . F. M a r s h J a c ks on . . . . I Dr. G. P e t g r a v e Johnson .. 2 Dr. J. Mount ford J ohns on .. i Dr. H e r b e r t J one s -i D r . J . R . K a y e .. i Dr. J. Doig Mc C ri ndt e I Dr. A. B. McMast'er i Dr. H. Ma l e t .. 2
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Sir Shirley Murphy Dr. J. T. C. N a s h . . Dr. A. N e w s h o l m e , CB . . . . . Northern Branch Mr. C. E. P a g e t . . D r . L . C, P a r k e s . . D r. H. C oope r Pattin ,° D r . G . H, P e r c i v a i D r . L , W , Pole .. Dr. A. E, P o r t e r Dr. J o s e p h P r i e s t l e y Dr. M a b y n R e a d Dr. G e orge R e i d
u R . . . . . o o" JDr.-- E . S . I-~obinson o D r . F r a n k Robinson D r . F . E . R oc k .. o D r. J. E. Saudio l a nds .. Dr. E d w a r d SerO O geant . . . . Dr. E. H. Snell I o Dr. R. W o o l s e y Stocks . . . . 2 o Dr. J o h n T a y l o r . . Dr, J. C. T h r e s h , i o Dr. T . M . T i b b e t t s i o Dr.A.S. Underhill r o Dr. J. W i l l i a m s o n Dr. A. H a m i l t o n I o Wood . . . . i o Yorkshire Branch 2 o
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APPOINTMENTS. DE. F. C. BRODIE ha s been appointed medical officer to t h e N e w S h o r e h a m P,S.A, DR. F. A. COATES h a s been a ppoi nt e d m e d i c a l officer of h e a l t h of W h i t c h u r c h (Hunts) R ,D . D m EFFIE M. D. CRAIG has been appointed to the past of l a dy assistant medical officer of h e a l t h of B i r m i n g h a m . DR. E, T. H. DAVIES ha s been appointed m e d i c a l officer of h e a l t h of T r e d e g a r . DE, A, E. EVANS h a s been appointed a me di c a l inspector u n d e r the B o a r d of C o n t r o l (Mental Deficiency Act). DR. R. A. GLEGG, the county medical officer of h e a l t h and school m e d i c a l officer, ha s been a p p o i n t e d chief tuberculosis officer of t he Lindsey (Lines). C o u n t y Council, DR. J. THERESA HILL h a s been a p p o i n t e d a s s i s t a n t school m e d i c a l officer to t he S m e t h w i c k E d u c a t i o n Committee. DR. OSCAR M. HOLDEN has been a p p o i n t e d a s s i s t a n t me di c a l officer of h e a l t h of S o u t h a m p t o n . DR. G. S. LEWIS ha s been a p p o i n t e d one of the a s s i s t a n t tuberculosis officers of t he Li nds e y (Lines,) C ount y Council. DR, HENRY LLOYD h a s b ~ n appointed t e m p o r a r y medical officer of h e a l t h to t h e St. A s a ph (Flint) a n d St. A s a p h (Denbigh) R . D , C ' s . DR. WILLIAM MACEWEN ha s received a joint a p p o i n t m e n t u n d e r the L.C .C . and Me t ropol i t a n A s yl ums B oa rd as medical inspector of schools to the former and e p i d e m i o l o g i s t to the l a t t e r. D E . DUNCAN F . MACRAE, Of Newcastle, ha s been a p p o i n t e d cIinical tuberculosis officer for B u r y a nd district. M i s s OL1VE ROBERTS0N, M,B., b a s b e e n appointed assist a n t medical officer in the P u b l i c H e a l t h D e p a r t m e n t of the L,C.C. DR. %¥. H . R o s s , of C h a t b u r n , h a s b s e n a p p o i n t e d medical officer of B o w l a n d R .D . (York@ D m A. J. -WILLIAMSON has been a p p o i n t e d one of the t u b e r c u l o s i s officers under the Es s e x C.C. DR. J. E. WILSON has been appointed one of the assistant t u b e r c u l o s i s officers of the Lindsey (Lincs,) C o u n t y Council. DR. W . A. B, Y O U N G ha s been a ppoi nt e d a s s i s t a nt school me di c a l officer to t h e B l a c k b u r n Educ a t i on C ommi t t e e ,