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The treatment of venereal diseases in U.S.A.
204 THE
PUBLIC HEALTH.
TREATMENT OF V E N E R E A L DISEASES IN U.S.A. M O D E OF HANDLING P A T I E N T S . BY
GEORGE W. GOLER, M.D., Heallh Older o/ lhe Rochester, U.S.A., Bureau o/ Health Consultalion.
X~THEN a patient comes to the consultation-vv and they are referred to us by physicians, dispensaries, churches, police, charitable organisations, or directed through the signs and advertisement--he is received in a room alone ; sometimes in the case of a woman a nurse is present in the room. At any rate, a nurse is always just outside the door. Patients are politely and considerately treated, asked why they came for advice. If they simply require reference to a physician or dentist, they are given the names of two or three practitioners, whom we believe will best serve them, or referred back to their own physician. If unable to pay, the statements are verified by reference to the Charities Department, and they are referred to a district physician. If suffering from gonorrhea and unable to pay, they are referred to one of the city genitourinary clinics. If suffering with syphilis and not able to pay, a brief history is taken upon a card, blood for a Wassermann test secured, a Leutin test made, or in case a sore is present, diagnosis is established through the examination of scrapings under dark field illumination. Diagnosis having once been established, the patient is given a card, and his name is entered on a tally book, and he is referred to the Municipal Hospital for a course of diarsenal. When the course of diarsenal has been finished at the Municipal Hospital, he is referred back to the consultation at the Health Bureau, where intramuscular injections of mercury are given at stated intervals. At the end of the mercurial course, the patient is given a month's rest, and then another Wassermann taken, and the course of mercury repeated. Thus, diarsenal, mercury, blood Wassermanns, spinal fluid Wassermanns when necessary, are repeated at prescribed intervals, until the patient shows a persistent negative Wassermann. Then a provocative Wassermann is made, and the patient required to report at the end of three months. If Wassermann is negative, then at the end of six months or a year. In the beginning we tried referring these patients to clinics or giving t h e m mercurial
JuN]~,
inunction, but found in order to hold them we were required to give them some material thing. In this way we keep them under o]oservatiotL and give them mercurial injections at the same time. As has been stated, the patient's attendance at the consultation is entered upon a tally book. If the patient does not return, a note is sent. If the patient does not answer the note at the next consultation, the police notify~the patient, and if t h a t does not answer, a warrant is secured for the arrest of the patient, and the patient either spends a night in jail or is required t o appear in police court, and in either case is committed to the care of the Health Officer, under the Public Health Law. This operation of the Public Health Law and the co-operation of the police, have enabled us to keep under observation more than IOO persons with syphilis.* Of course, m a n y of these people will be found to be " floaters," and even the well-directed efforts of the police fail to find them ; but thus far we feel t h a t we should h a v e been unable to carry on the work had it not been for this close co-operation with the police. In case of syphilis, those people who come to the consultation, who afterwards choose to employ a physician, are referred to their physician, and the physician is requested to notify us at the end of each month whether the patient is still under treatment. If the patient refuses to carry out the direction, of the physician, we then invoke the aid of the police, and in this way we have co-operated with the physician, so t h a t his patient with syphilis m a y continue treatment after the definite manifestations of syphilis have disappeared. When other genitourinary clinics send us patients for diarsenal, upon request we return these patients to the clinics, with the understanding t h a t they will report if patients do not continue t h e prescribed treatment. In this way we are attempting a general consultation with particular opportunity for the poor man and woman with syphilis. At the same time these people are coming to a general and not a specific clinic. We do not use the word " Venereal Disease," and we treat them kindly as if they were poor, sick, and unfortunate. In 1916 there were 125 new cases of syphilis, * W h e n one person in a family has been shown to have syphilis, Wassermanns are required from every other member of that~family who is at all suspicious.
1917.
PUBLIC HEALTH.
of which 89 showed 4 +Wassermann on admittance; II, 3 + ; 8, 2 + ; i, I + ; 4+--; 5 were negative; 7 infants with hereditary syphilis, no initial Wassermann. Of these the results of treatment are shown by the following table : Apparently Im- UnimStage of Disease recovered proved proved Died Total
Primary . . . . i Secondary .. IO Tertiary . . . . -Hereditary • - - Asymptomatica II
3 36 12 7 --
i 14 23 6 --
-i 2 --
5 60 36 15 9
58
44
3
125
-
-
SERUM D I A G N O S I S OF S Y P H I L I S AND GONOCOCCUS INFECTION BY COMP L E M E N T FIXATION. BY
AUGUSTUS B. WADSWORTH, M.D., Director, Division of Laboratories and Research, Slate Departmenl of Health, New York. U P to February, 1914 , the diagnostic work of the State Laboratory was limited to the examination of cultures from diphtheria, sputum from tuberculosis, and specimens of blood for the Widal reaction. During 1914 the diagnostic work was extended to include all examinations t h a t are of definite practical value with the exception of the Wassermann test, which could not be developed without careful s t u d y and preparation. During October, November, and December, the Wassermann work was fully organized and outfits distributed to physicians and health officers, but only 15 examinations were made before J a n u a r y Ist, 19I 5. From this time on, however, the increase in the work has continued without interruption. In 1915 nearly 6,ooo specimens were received, and over 12,ooo tests were made, and in 1916 over lO,OOO specimens were received, and more than 2o,ooo tests were made. At the present time the work continues to increase month by month, and in view of the mobilization of troops in camps and the recruiting of large numbers of men for the army and guard of the State, the number of examinations should increase enormously if the authorities take the proper precautions to safeguard against the spread of venereat disease among these men and in the
205
communities where they m a y be stationed. The Wassermann test is an essential factor in a campaign of prevention against the spread of venereal disease. Accordingly, to prepare for the emergencies which m a y arise from the demands for the examination of the specimens, the laboratory staff has been and will be even more rapidly increased to do the work. Volunteer assistants and more experienced candidates will be trained in m a n y phases of the technical procedure of the work so t h a t the staff can be augmented at short notice without materially interfering with the efficiency of the work. In the laboratory from the beginning serum has been drawn from the specimens, and the Wassermann test has been carried out with two antigens and by two methods of fixation. One of the antigens is a crude alcoholic extract of beef heart with which tests are fixed in the ice box at temperatures from 5 ° to IO° C. The other antigen is a cholesterinized extract of guinea pigs' hearts with which tests are fixed for one-half hour in the water bath at 37 ° C. A sheep-rabbit system is used, and all reagents are carefully standardized daily. Comparative tests are made with other laboratories at intervals. A record of the methods in use b y other laboratories engaged in public health work is kept on file for reference, and notice of a change in these methods b y the laboratories is sent to the Albany laboratory. In this way the laboratories of the State are in as close touch as to method and technic as it is possible to keep with the present staff and the increasing demands of the work. The gonococcus complement fixation test was introduced in 1915 , but only 54 specimens were received and on these 59 tests were made. In 1916 , however, the work rapidly increased. Over 1,2oo specimens were received, and on these 3,0oo tests were made. The problem of standardizing the gonococcus complement fixation test so t h a t the results will possess definite practical significance, has been an extremely difficult one, and there is undoubtedly much work to be done to improve the technical procedures. The results of the examinations should be interpreted only in the light of careful clinical observation.
PUBLIC HEALTH.
TREATMENT OF V E N E R E A L DISEASES IN U.S.A. M O D E OF HANDLING P A T I E N T S . BY
GEORGE W. GOLER, M.D., Heallh Older o/ lhe Rochester, U.S.A., Bureau o/ Health Consultalion.
X~THEN a patient comes to the consultation-vv and they are referred to us by physicians, dispensaries, churches, police, charitable organisations, or directed through the signs and advertisement--he is received in a room alone ; sometimes in the case of a woman a nurse is present in the room. At any rate, a nurse is always just outside the door. Patients are politely and considerately treated, asked why they came for advice. If they simply require reference to a physician or dentist, they are given the names of two or three practitioners, whom we believe will best serve them, or referred back to their own physician. If unable to pay, the statements are verified by reference to the Charities Department, and they are referred to a district physician. If suffering from gonorrhea and unable to pay, they are referred to one of the city genitourinary clinics. If suffering with syphilis and not able to pay, a brief history is taken upon a card, blood for a Wassermann test secured, a Leutin test made, or in case a sore is present, diagnosis is established through the examination of scrapings under dark field illumination. Diagnosis having once been established, the patient is given a card, and his name is entered on a tally book, and he is referred to the Municipal Hospital for a course of diarsenal. When the course of diarsenal has been finished at the Municipal Hospital, he is referred back to the consultation at the Health Bureau, where intramuscular injections of mercury are given at stated intervals. At the end of the mercurial course, the patient is given a month's rest, and then another Wassermann taken, and the course of mercury repeated. Thus, diarsenal, mercury, blood Wassermanns, spinal fluid Wassermanns when necessary, are repeated at prescribed intervals, until the patient shows a persistent negative Wassermann. Then a provocative Wassermann is made, and the patient required to report at the end of three months. If Wassermann is negative, then at the end of six months or a year. In the beginning we tried referring these patients to clinics or giving t h e m mercurial
JuN]~,
inunction, but found in order to hold them we were required to give them some material thing. In this way we keep them under o]oservatiotL and give them mercurial injections at the same time. As has been stated, the patient's attendance at the consultation is entered upon a tally book. If the patient does not return, a note is sent. If the patient does not answer the note at the next consultation, the police notify~the patient, and if t h a t does not answer, a warrant is secured for the arrest of the patient, and the patient either spends a night in jail or is required t o appear in police court, and in either case is committed to the care of the Health Officer, under the Public Health Law. This operation of the Public Health Law and the co-operation of the police, have enabled us to keep under observation more than IOO persons with syphilis.* Of course, m a n y of these people will be found to be " floaters," and even the well-directed efforts of the police fail to find them ; but thus far we feel t h a t we should h a v e been unable to carry on the work had it not been for this close co-operation with the police. In case of syphilis, those people who come to the consultation, who afterwards choose to employ a physician, are referred to their physician, and the physician is requested to notify us at the end of each month whether the patient is still under treatment. If the patient refuses to carry out the direction, of the physician, we then invoke the aid of the police, and in this way we have co-operated with the physician, so t h a t his patient with syphilis m a y continue treatment after the definite manifestations of syphilis have disappeared. When other genitourinary clinics send us patients for diarsenal, upon request we return these patients to the clinics, with the understanding t h a t they will report if patients do not continue t h e prescribed treatment. In this way we are attempting a general consultation with particular opportunity for the poor man and woman with syphilis. At the same time these people are coming to a general and not a specific clinic. We do not use the word " Venereal Disease," and we treat them kindly as if they were poor, sick, and unfortunate. In 1916 there were 125 new cases of syphilis, * W h e n one person in a family has been shown to have syphilis, Wassermanns are required from every other member of that~family who is at all suspicious.
1917.
PUBLIC HEALTH.
of which 89 showed 4 +Wassermann on admittance; II, 3 + ; 8, 2 + ; i, I + ; 4+--; 5 were negative; 7 infants with hereditary syphilis, no initial Wassermann. Of these the results of treatment are shown by the following table : Apparently Im- UnimStage of Disease recovered proved proved Died Total
Primary . . . . i Secondary .. IO Tertiary . . . . -Hereditary • - - Asymptomatica II
3 36 12 7 --
i 14 23 6 --
-i 2 --
5 60 36 15 9
58
44
3
125
-
-
SERUM D I A G N O S I S OF S Y P H I L I S AND GONOCOCCUS INFECTION BY COMP L E M E N T FIXATION. BY
AUGUSTUS B. WADSWORTH, M.D., Director, Division of Laboratories and Research, Slate Departmenl of Health, New York. U P to February, 1914 , the diagnostic work of the State Laboratory was limited to the examination of cultures from diphtheria, sputum from tuberculosis, and specimens of blood for the Widal reaction. During 1914 the diagnostic work was extended to include all examinations t h a t are of definite practical value with the exception of the Wassermann test, which could not be developed without careful s t u d y and preparation. During October, November, and December, the Wassermann work was fully organized and outfits distributed to physicians and health officers, but only 15 examinations were made before J a n u a r y Ist, 19I 5. From this time on, however, the increase in the work has continued without interruption. In 1915 nearly 6,ooo specimens were received, and over 12,ooo tests were made, and in 1916 over lO,OOO specimens were received, and more than 2o,ooo tests were made. At the present time the work continues to increase month by month, and in view of the mobilization of troops in camps and the recruiting of large numbers of men for the army and guard of the State, the number of examinations should increase enormously if the authorities take the proper precautions to safeguard against the spread of venereat disease among these men and in the
205
communities where they m a y be stationed. The Wassermann test is an essential factor in a campaign of prevention against the spread of venereal disease. Accordingly, to prepare for the emergencies which m a y arise from the demands for the examination of the specimens, the laboratory staff has been and will be even more rapidly increased to do the work. Volunteer assistants and more experienced candidates will be trained in m a n y phases of the technical procedure of the work so t h a t the staff can be augmented at short notice without materially interfering with the efficiency of the work. In the laboratory from the beginning serum has been drawn from the specimens, and the Wassermann test has been carried out with two antigens and by two methods of fixation. One of the antigens is a crude alcoholic extract of beef heart with which tests are fixed in the ice box at temperatures from 5 ° to IO° C. The other antigen is a cholesterinized extract of guinea pigs' hearts with which tests are fixed for one-half hour in the water bath at 37 ° C. A sheep-rabbit system is used, and all reagents are carefully standardized daily. Comparative tests are made with other laboratories at intervals. A record of the methods in use b y other laboratories engaged in public health work is kept on file for reference, and notice of a change in these methods b y the laboratories is sent to the Albany laboratory. In this way the laboratories of the State are in as close touch as to method and technic as it is possible to keep with the present staff and the increasing demands of the work. The gonococcus complement fixation test was introduced in 1915 , but only 54 specimens were received and on these 59 tests were made. In 1916 , however, the work rapidly increased. Over 1,2oo specimens were received, and on these 3,0oo tests were made. The problem of standardizing the gonococcus complement fixation test so t h a t the results will possess definite practical significance, has been an extremely difficult one, and there is undoubtedly much work to be done to improve the technical procedures. The results of the examinations should be interpreted only in the light of careful clinical observation.