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Venereal diseases and the general community
352
PUBLIC HEALTH.
Venereal
AUGUST,
D i s e a s e s and t h e General Community.
By A. O. R o s s , M.D., D.P.H., Venereal Diseases Officer, Seamen's Dispensary, Liverpool; Honorary Surgeon, Lock Departme~nt, Royal Infirmary, Liverpool.
This paper, read at a meeting of the North-Western Branch, by an o~cer of so much experience as Dr. Ross, dealing, as it does, with matters of prime importance in relation to the venereal disease problem, is certain to be found of i~zterest and real value by all health officers concerned in its solution. ' N this paper it is my intention to deal only the incidence of venereal disease as seen in our clinics, the way in which it seems best to bring infected members of the community under treatment, and the correlation of this treatment with other public health services. First, as to the incidence of venereal diseases in adults. I think we have every reason to be satisfied with the results of propaganda and the free treatment provided by clinics especially in the case of infection in the male. For the three years 1926, 1927 and 1928, after an apparent fall in the number o.f syphilis cases in the preceding five years, we have seen an increase, but I feel certain the main reason is that the all-day ad hoc type of clinic is proving a much more efficient and attractive treatment centre than the earlier arrangement which .usually consisted of the basement of a hospital with no facilities for treatment except at odd hours. In Liverpool there were four hospital clinics functioning in 1923, and in 1924 an ad hoc clinic, called the Seamen's Dispensary, was opened. In 1923 the fresh cases seen numbered '3,026, while in 1929 this figure rose to 4,289, of which close on one-Salf were registered at the Seamen's Dispensary. In 1923 the percentage of non-venereal cases included in the figure of 3,026 was 17, while in 1929, 23 per cent. of the cases reporting" for the first time were non-venereal. This increase in nonvenereal patients suggests that propaganda is having an educative effect upon the population and, further, that those who have exposed themselves to infection are prepared to come for treatment if infected. Another point of importance is that in Liverpool the average number of attendances per fresh venereal case has risen from 19 to 33 in these six years. From yet another aspect we can learn that things are going well, and that is the ratio of gonorrhoea cases to syphilis cases in the male. In the services, where in peace-time
I .with
we expect to find little or no concealed disease, the ratio of gonorrhoea fresh cases to syphilis fresh cases, is somewhere in the region of 6 or 7 to 1. In civil life the same proportion should hold in males, but we still fall below that figure. In 1.929 the proportion was 5 to 1--a very definite increase on the 3 to 1 ratio of 1923. From the type of case seen in the clinics to-day we gather that the average man is coming much earlier in the course of his disease. In 1915 most of the cases seen in venereal disease hospital clinics were florid syphilis showing skin and mucous membrane lesions. These conditions are not seen more often than about one in ten cases of syphilis to-day, and the bulk of our work is concerned with either sero-negative or sero-positive primary cases. Dr. Clements o.f St. T h o m a s ' s Hospital, has shown that between 1921 and 1927 the ratio of extremely earl)' syphilis cases with blood W a s s e r m a n n still negative to all other early cases had increased from 1 to 5"1 to 1 to 2"8. Early treatment means cheaper and more effective treatment, and diminishes the number of possible contact*. It is of interest to note from Sir George Newman's Annual Report on the State of the Public Health in 1929 that of all-patients marked off in the records of the clinics of E n g l a n d and Wales during 1929, 39 per cent. were classed as cured, and an additional 26 per cent. who might, be called probably cured. In 1920 the known cures amounted to only 24 per cent. of the cases marked off. There can be no doubt that this very welcome advance is decidedly cheering, and if it really betokened a general desire on the part of the infected person to be rid of the disease because he detested it, further and continuous progress would be assured. As it is, I feel that the real reason for the first attendance of our patients is fear of the consequences of the disease, and I believe that this fear is greater than the fear of notification. Quite
1931.
PUBLIC HEALTH.
20 per cent. of all the defaulting cases are patients who attend once only to see the medical officer, and after a few intermediate attendances they vanish. These are men who, because urethral discharge has decreased o.r disappeared, imagine themselves ',cured, or who, after seeing so many people similarly infected, imagine that venereal disease cannot be so bad after all. There are others who do not realise the essential difference between venereal diseases and, say, abdominal colic. T h e fact that pain has gone means in the case of colic that there is no need to revisit the .doctor; in fact, the doctor would be surprised if his patients did return to. report complete cure. How different is venereal disease. Here we have pain as a symptom present only in the very early acute stage as a rule, and the absence of pain has no relation whatsoever to the cure of the disease. Perhaps in time the method adopted in sickness benefit under the National Health Insurance, where initial, intermediate and final certificates are issued, may accustom the patient to revisiting his doctor in spite of the absence of symptoms. Defaulting and irregularity in treatment were so serious a few years ago that at St. T h o m a s ' s Hospital, one of the best-managed clinics in the country, Colonel Harrison investigated the records of 3,598 cases of syphilis with a view to assessing the value of arsenic and bismuth treatment, and intended to divide those cases into. 14 different groups, depending on the age of the infection, syphilitic manifestations, etc., but, largely because of defaulting, had to reduce his groups to four. There is no need for me to stress the importance of propaganda. All of you know that where active propaganda is continuous a larger number of cases come for t r e a t m e n t - - m a n y of them may be nonvenereal but that is a good sign--patients attend better, even to the extent of double the number of attendances as compared with non-active areas, and I have no doubt that fear of venereal disease deters many others from taking any risks. I believe that propaganda should take the form of talks to. small established audiences, for instance, a youths' social club, and cinematograph shows to large mixed audiences. T h e advent of the talking picture should make this variety even more valuable. As a preventive measure the education of adolescents of both sexes in the facts of sex should be most valuable, because the peak o.f fresh cases of venereal disease is in the
353
18-22 years age group. I am informed that only half of the population of the country is covered by efficient propaganda, while in a quarter of the country there is no propaganda whatever. It has been suggested that E1 per 1,000 of the population should be the amount spent on propaganda yearly, of which 5s. should be subscribed to a national scheme for propaganda, such as the British Social H y g i e n e Council, which is an experienced and influential body. It is a melancholy fact that the mothers, actual or potential, of the nation, many of them innocent victims of venereal disease but still the most certain means of passing on venereal disease to the succeeding generation, whether as o.phthalmia, vulvo-vaginitis, or congenital syphilis, are of all people least provided for in our present clinic system. The all-day clinic would, I am sure, be a great benefit to women patients because the usual hours for female clinics do not conduce to the regular attendance, of housewives, maidservants, barmaids, shop assistants and so. on. T h e clinic hours in m a n y areas seem to be set apart for the idle classes and for girls working in offices or factories. At present there is evidence to show that while the ratio of women to men attending for the treatment of syphilis is fairly good (1 to 1"8) the number attending for gonorrhoea makes poor showing (1 to 4). This is probably due to the difficulty of self-examination on the part of the woman, but is all the more reason for the establishment of better clinic facilities for them. Married women, it appears to me, present a field where earnest endeavour on the part of the health authorities would bear much fruit. Once the infected married women is found she is a much better attender at the clinic than her husband, and is more amenable to reason if visited by a social worker in the event of her ceasing to attend. Of course, it is not much good to have a married woman attending a clinic if her husband is not ,under treatment, and possibly that is a very good reason for treating a woman in all her' pregnancies if she has at any previous time suffered from syphilis. The possibility of paternal syphilis is thus counteracted. A great deal of good can be done if there is a working system between male and female clinics. W'hen a male patient comes to the clinic and gives a history of infection contracted from his wife or some girl friend, I make it my business to influence the woman through the man to go
:3.54
PUBIJC
for examinaiion to a female clinic. A card addressed to the medical officer o.f the clinic by name, stating the clinic hours and giving the short diagnosis of the infected male, " G " or " S , " is given to the man to hand to his wife or friend. In the same way, when a man may have infected his wife or girl friend during the incubation period of Iris disease, a similar card is issued and I make it clear to the man that if he has infected or been infected by his wife it is useless going on with Iris treatment m,.til his wife is also undegsupervision. The clinical venereal diseases officer treating any woman for syphilis should instruct her that if at any time she becomes pregnant she should return for treatment. There is, however, a much larger opportunity for doing good work open to the administrative public health officer. He has now control over the large poor law hospitals with their maternity wards and children's wards. He has also under his charge corporation maternity homes, ante-natal clinics, post-natal clinics and the medical inspection of school children, and soon I expect he will have charge of the health of the children of preschool age. In all of these wide-filing activities of public health there are responsibilities for discovering and treating diseases which concern the public weal. To my mind there is no good having health weeks and o.nslaughts of propaganda if we are not prepared to seize opportunities that already await us. In the memorandum prepared by the Maternal Mortality Committee in June, 1929, under the heading " Principles of Ante-Natal Care " we r e a d : " Measures should be taken to include within the scope of ante-natal care the diagnosis and treatment of venereal diseases," and further: "Ante-natal care should ineIude measures directed against infection and measures increasing resistance to infection." There are in E n g l a n d and Wales, fourteen maternity and child welfare centres treating venereal diseases in women, and if we are to do our best for this and succeeding generatio.ns, this number will have to be increased, and treatment with arseno-benzol preparations and bismuth given to every pregnant woman with a h!story of signs of syphilis or a positive Wassermann. Professor F. J. Browne of K i n g ' s College, London, states that 7 per cent. of the women attending the ante-~atal department of the Ro.val Maternity Hospital in Edinburgh were proved syphilitics. Dr. Picken of Cardiff
HEALTH.
AUaUST,
states that 10"3 per cent. and Dr. Cruickshank of Glasgow 9"4 per cent. of the women attending their ante-natal centres are syphilitic, while in a rural district of Lincolnshire tire percentage , according to Dr. Brunyate is 5. I)r. Kettlewell in Plymouth made a survey of school children and stated that 2-3 per cent. were congenital syphilitics. W e are aware that the child suffering from congenital syphilis has tess chance of survival than tile normal child, and here I might give some figures collected by one of Mr. Lees' assistants in :Edinburgh. One thousand and twenty-nine preg~mncies in women suffering from syphilis resulted in foetal death in 293 cases (28"4 per cent. of the total). It is interesting to note, and this is characteristic of pregnancies in the syphilitic, that close on one-half of the foetal deaths were really premature births, since delivery of a stillborn infant occurred between the sixth and the ninth months of gestation. There remained 736 children born alive; 245 or one-third had died before attaining the age of five, 21 died later, and out of the remnant (469) 213 had positive blood \Vassermanns and 16 had stigmata of syphilis though the blood was negative. It is of interest to assess the value of the preventive treatment of congenital syphilis, that is to say, the steps takdn to find what pregnant women are suffering from syphilis, and the value of efficient treatment in such women. It is universally agreed that the earlier in preoJnancy that treatment is instituted ~ttle safer for the child, and as Earl Moore of Baltimore has shown that in a series of 2,438 women sufferi,g from syphilis, 47"5 per cent. were .diagnosed on the evidence of a positive ~vVassermann alone, apart from a few who gave a suspicious histo.ry, it is absolutely essential that a blood Wassermann should be done on every pregnant woman at her first attendance at the ante-natal clinic. If this test proves positive, treatment by the arsenobenzenes and bismuth should be started and continued throughout the pregnancy. The figures o.f Boas and Gammeltoft, published in 1927 after careful scrutiny of 545 pregnancies in women suffering from syphilis, show that mercury is cornparatively inefficient in preventing congenital syphilis; in fact, 72 per cent. of the children born were found to be infected if mercury alone was exhibited during the pregnancy. It is possible that a child may be no.rma/ at birth and for a year or more, and thereafter* develop signs of con-
J931.
PUBLIC HEALTH.
genital syphilis. Boas and Gammeltoft's follow-up system has kept continuous watch on children for fifteen years, hence the high figure. In X&Yhitridge ~3/illiams' figures the results of treatment are plainly shown. 48"5 per cent. of infants born to :untreated syphiIitic women, 89 per cent. of infants born to partiatly treated women, and 7 per cent. of infants born to well treated women, were found to be suffering from syphilis. In France, where there are now 400 state-aided dispensaries working to prevent congenital syphilis, we find that the Baudilocque Maternity Hospital, which in 1919 originated the intensive treatment of infected pregnant women, has now an annual ante-natal death-rate of 14'5 per thousand as opposed to 23"7 per 1,000 for the 80 years prior to 19t9. The fact that.the patient has a negative Wassermann does not rule out syphilis, and quite often a child suffering from congenital syphilis is born to parents whose blood W*assermann is negative. It is therefore essential to examine patients physically, and to go. into. their previous history, obstetrical and general, before excluding syphilis. The history of repeated premature stillbirths strongly suggests syphilis, and some authorities proceed to treat such cases and frequently a live full-time child is born. Colonel Harrison has lately called attention to the Kline test as a substitute for the W a s s e r m a n n . The test is actually done on finger blood and takes about half-an-hour to do. Several tests can be done at the same time, and the technique appears to. be no more difficult than the \ ¥ i d a l . This test should prove of great: value in tl{e case of children because of the ease with which the blood is obtained. ~;Vith regard to. the diagnosis of gonorrhoea, Browne states that he treats all cases of purulent discharge from the vagina whether gonococci are found in cervical smears or not. The essential demanding treatment is the presence of pus, because of the twofold danger of ophthalmia and puerperal sepsis. The presence of free pus at the urinary meatus after stripping the urethra through the anterior vaginal wall, pyuria or the presence of shreds containing pus in the urine, should make one extraordinarily suspicious, as should a history of ophthalmia neonatorum in previous pregnancies. Special in-patient beds should be available in cases of pelvic damage from gonorrhoea, and for arthritis, which is said to be the most frequent complication in pregnancy.
as~
In the maternity wards, and even in the midwifery practice of doctors and midwives in the homes of the people, the search for the syphilitic mother should not be abated. W e have vaiqous methods of discovering the hidden plague. Blood from the cord may be collected and sent in a Wassermann tube to an approved laboratory. T o popularise the system, doctors and n~idwives might be paid a small fee for their services. In Glasgow, tip to t9PA, a fee of 2s. 6d. per blood specimen sent for Wassermann test to the city laboratory was paid to encourage medical practitioners to. be on the look-out for syphilis. Cooke and Jeans state that a cord blood W a s s e r m a n n will discover 63 per cent. of syphilitic infants. Again, macroscopic examination of the placenta may reveal syphilis. Professor Browne says that the " greasy syphilitic placenta " of the text-books o.nly occurs with a macerated foetus. It is the end result of syphilitic sclerosis of the chorionic villi. In the viable child it is the weight of the placenta which counts. A placenta weighing more than one-quarter of the weight of the child is syphilitic and suspicion attaches to one which exceeds one-sixth. \¥hitridge Williams states that micro-examination of the ptacenta reveals the presence o.f syphilis in 80 per cent. of all congenital syphilitic children, but Cooke and Jeans state~ that in thei, series the percentage discovered was 27, and that the Wassermann test of the cord blood was more reliable. Examination of the cord at the foetal end for tissue spirochaetes and pert-vascular infiltrations may be performed, and in the case of stillborn children all the organs are available for examination. In Liverpool and Blackburn this is systematically done, and where spirochmtes are discovered, valuable knowledge is gained as to the conduct of the next pregnancy, and, in fact, all succeeding pregnancies. Browne's observation that he had never found spirochmtes in the tissues of a child dead of syphilis where lhe mother's blood was negative, is to. be borne in mind, and his statement that where prematurity or dead-born children are the rule in a family, it is well worth while giving" arseno-benzol and bismuth in the succeeding pregnancies. Where congenital syphilis is discovered in lhe new-born babe, treatment should be immediate and continuous for from two to five years. Congenital syphilis as seen in the school years is either static or so severe as to call
356
PUBLIC
for i m m e d i a t e hospital t r e a t m e n t in m o s t cases. T h e m e r e fact that the s i g n s of s y p h i l i s are static, as e x p r e s s e d b y rhagades, Hutchinson's teeth, b a d molars, scrotal t o n g u e , etc., d o e s not m e a n t h a t n o , t r e a t m e n t is necessary, but I feel that m a n y cases are not r e p o r t e d s i m p l y because the lesions seen are the scars of battles l o n g a g o . T h e disease m a y h a v e c o m p l e t e l y s p e n t itself in' the child u n d e r review, but there are p r o b a b l y b r o t h e r s a n d sisters to, be considered, a n d if these children are f o u n d to h a v e a positive W a s s e r m a n n , t r e a t m e n t s h o u l d be instituted at once. I n all cases w h e r e families are involved, we a r e justified in s a y i n g t h a t s y p h i l i s can c o m e f r o m a g r a n d f a t h e r or g r a n d m o t h e r , a n d o n e can b e certain t h a t the g u i l t y p a r e n t will p o u n c e on this w a y out a n d m a k e t h i n g s e a s y for the t r e a t m e n t of the little patient. It is in p r o b l e m s such as c o n g e n i t a l s y p h i l i s in a f a m i l y that one sees the definite need for correlation of the v a r i o u s p u b l i c health services, a n d it is here that a health visitor p o s s e s s e d of the n e c e s s a r y tact c a n d o y e o m a n service, especially in a large t o w n where the v a r i o u s d e p a r t m e n t s tend to be too d e p a r t m e n t a l . I f she can be a d o p t e d as p a r t of the confidential venereal diseases scheme, j u s t as a n o r d e r l y w o r k i n g in a v e n e r e a l diseases centre is p a r t of the scheme, a n d is also a t t a c h e d to the tuberculosis, m a t e r n i t y a n d child welfare a n d school m e d i c a l inspection services, she w o u l d act as a v e r y powerful linl~. I n the counties a n d s m a l l e r b o r o u g h s I a m a w a r e t h a t a s s i s t a n t medical officers w o r k u n d e r all the s c h e m e s , a n d t h e r e f o r e control of the v a r i o u s cases is m a d e m u c h easier. It is, of course, entirely w r o n g to r e p o r t a case of venereal disease b y n a m e to the medical officer of health, b u t that, I u n d e r s t a n d , does not hold in c o m m u n i c a t i o n s f r o m o n e clinical d e p a r t m e n t to a n o t h e r . M r . D a v i d Lees, the V e n e r e a l D i s e a s e s Officer of the C i t y of E d i n b u r g h , has been k i n d e n o u g h to send m e p a r t i c u l a r s of the correlation of a n t e - n a t a l a n d child welfare clinics with the venereal diseases scheme, a n d the f o l l o w i n g is a r d s u m d : - " At the Royal Maternity Hospital, where an antenatal clinic is held, the venereal diseases officer of the city is on the staff, and one of his senior assistants is always on duty during clinic hours. This assistant is on duty at the Royal Infirmary evening clinic for males, where husbands of pregnant women found to be diseased are asked to report. All cases suspected of having venereal disease at the ante-natal clinic are referred to him, and if the diagnosis is confirmed he undertakes the treatment. A.11 patients attending the
HEALTH.
AucusT,
ante-natal clinic use the same waiting-room and the same nurses attend all patients. The two house physicians of the hospital have usually been residents in the female lock department of the Royal Infirmary. All patients have a Wassermann test done, and the blood is taken by the obstetrical staff. After confinement, the infected mother is followed up by the venereal diseases department and her treafment is continued either as an in-patient, if necessary, or as an out-patient at one of the subsidiary centres. Very striking success has attended the working of this scheme and not the least result has been the diminution of congenital syphilis in children of under one year by about 50 per cent. Further, as regards ophthahnia neonatorum, with the exception of one unfortunate case which was seen last month, no permanent damage has occurred to the eye of any baby born during the last eight years in Edinburgh and the Lothians. Still another indication of thoroughness is that attention has been directed to children blind through congenital syphilis, and contiriuous treatment is being given to them at the Royal Blind School." T o s u m m a r i s e - - - o u r t a s k in public health w o u l d a p p e a r to include :--(i) G r e a t e r efforts in p r o p a g a n d a w h i c h will r e a c h the m a r r i e d w o m a n a n d e x p e c t a n t mother. (2) T h e p r o v i s i o n in all large centres of alld a y clinics for b o t h sexes,. (3) A n t e - n a t a l clinics to be m o r e actively e n g a g e d in the p r e v e n t i o n of c o n g e n i t a l syphilis, o p h t h a l m i a a n d vulvo-vaginitis. T h e routine t e s t i n g of the sera of all w o m e n a t t e n d i n g s h o u l d be considered essential. (4) T h e p r o v i s i o n of b e d s for infected p r e g n a n t w o m e n with c o m p l i c a t i o n s , a n d for neonatal cases of o p h t h a l m i a , v u l v o - v a g i n i t i s a n d congenital syphilis. (5) H o m e s for u n m a r r i e d girls suffering f r o m venereal disease, especially if p r e g n a n t . (6) H e a l t h visitors to be a t t a c h e d to w o m e n ' s a n d c h i l d r e n ' s venereal disease clinics for social w o r k . (7) E n c o u r a g e m e n t of school medical officers a n d child welfare officers to a t t e n d p o s t - g r a d u a t e courses in congenital syphilis. (8) C h i l d r e n of m o t h e r s s u f f e r i n g f r o m s y p h i l i s to be k e p t u n d e r o b s e r v a t i o n in the pre-school a g e . I feel certain t h a t the a d o p t i o n of s u c h m e a s u r e s in p r e s e n t - d a y public health w o r k w o u l d s h o w a s t r i k i n g d e c r e a s e * i n the prenatal a n d infantile m o r t a l i t y rate, a n d p o s s i b l y in the m a t e r n a l m o r t a l i t y a n d m o r b i d i t y rates also., to. s a y n o t h i n g of the g r e a t e r health a n d h a p p i n e s s of a m u c h l a r g e r p r o p o r t i o n of the g e n e r a l c o m m u n i t y t h a n is u s u a l l y realised even b y the m o s t rabid of o u r venereal diseases officers.
PUBLIC HEALTH.
Venereal
AUGUST,
D i s e a s e s and t h e General Community.
By A. O. R o s s , M.D., D.P.H., Venereal Diseases Officer, Seamen's Dispensary, Liverpool; Honorary Surgeon, Lock Departme~nt, Royal Infirmary, Liverpool.
This paper, read at a meeting of the North-Western Branch, by an o~cer of so much experience as Dr. Ross, dealing, as it does, with matters of prime importance in relation to the venereal disease problem, is certain to be found of i~zterest and real value by all health officers concerned in its solution. ' N this paper it is my intention to deal only the incidence of venereal disease as seen in our clinics, the way in which it seems best to bring infected members of the community under treatment, and the correlation of this treatment with other public health services. First, as to the incidence of venereal diseases in adults. I think we have every reason to be satisfied with the results of propaganda and the free treatment provided by clinics especially in the case of infection in the male. For the three years 1926, 1927 and 1928, after an apparent fall in the number o.f syphilis cases in the preceding five years, we have seen an increase, but I feel certain the main reason is that the all-day ad hoc type of clinic is proving a much more efficient and attractive treatment centre than the earlier arrangement which .usually consisted of the basement of a hospital with no facilities for treatment except at odd hours. In Liverpool there were four hospital clinics functioning in 1923, and in 1924 an ad hoc clinic, called the Seamen's Dispensary, was opened. In 1923 the fresh cases seen numbered '3,026, while in 1929 this figure rose to 4,289, of which close on one-Salf were registered at the Seamen's Dispensary. In 1923 the percentage of non-venereal cases included in the figure of 3,026 was 17, while in 1929, 23 per cent. of the cases reporting" for the first time were non-venereal. This increase in nonvenereal patients suggests that propaganda is having an educative effect upon the population and, further, that those who have exposed themselves to infection are prepared to come for treatment if infected. Another point of importance is that in Liverpool the average number of attendances per fresh venereal case has risen from 19 to 33 in these six years. From yet another aspect we can learn that things are going well, and that is the ratio of gonorrhoea cases to syphilis cases in the male. In the services, where in peace-time
I .with
we expect to find little or no concealed disease, the ratio of gonorrhoea fresh cases to syphilis fresh cases, is somewhere in the region of 6 or 7 to 1. In civil life the same proportion should hold in males, but we still fall below that figure. In 1.929 the proportion was 5 to 1--a very definite increase on the 3 to 1 ratio of 1923. From the type of case seen in the clinics to-day we gather that the average man is coming much earlier in the course of his disease. In 1915 most of the cases seen in venereal disease hospital clinics were florid syphilis showing skin and mucous membrane lesions. These conditions are not seen more often than about one in ten cases of syphilis to-day, and the bulk of our work is concerned with either sero-negative or sero-positive primary cases. Dr. Clements o.f St. T h o m a s ' s Hospital, has shown that between 1921 and 1927 the ratio of extremely earl)' syphilis cases with blood W a s s e r m a n n still negative to all other early cases had increased from 1 to 5"1 to 1 to 2"8. Early treatment means cheaper and more effective treatment, and diminishes the number of possible contact*. It is of interest to note from Sir George Newman's Annual Report on the State of the Public Health in 1929 that of all-patients marked off in the records of the clinics of E n g l a n d and Wales during 1929, 39 per cent. were classed as cured, and an additional 26 per cent. who might, be called probably cured. In 1920 the known cures amounted to only 24 per cent. of the cases marked off. There can be no doubt that this very welcome advance is decidedly cheering, and if it really betokened a general desire on the part of the infected person to be rid of the disease because he detested it, further and continuous progress would be assured. As it is, I feel that the real reason for the first attendance of our patients is fear of the consequences of the disease, and I believe that this fear is greater than the fear of notification. Quite
1931.
PUBLIC HEALTH.
20 per cent. of all the defaulting cases are patients who attend once only to see the medical officer, and after a few intermediate attendances they vanish. These are men who, because urethral discharge has decreased o.r disappeared, imagine themselves ',cured, or who, after seeing so many people similarly infected, imagine that venereal disease cannot be so bad after all. There are others who do not realise the essential difference between venereal diseases and, say, abdominal colic. T h e fact that pain has gone means in the case of colic that there is no need to revisit the .doctor; in fact, the doctor would be surprised if his patients did return to. report complete cure. How different is venereal disease. Here we have pain as a symptom present only in the very early acute stage as a rule, and the absence of pain has no relation whatsoever to the cure of the disease. Perhaps in time the method adopted in sickness benefit under the National Health Insurance, where initial, intermediate and final certificates are issued, may accustom the patient to revisiting his doctor in spite of the absence of symptoms. Defaulting and irregularity in treatment were so serious a few years ago that at St. T h o m a s ' s Hospital, one of the best-managed clinics in the country, Colonel Harrison investigated the records of 3,598 cases of syphilis with a view to assessing the value of arsenic and bismuth treatment, and intended to divide those cases into. 14 different groups, depending on the age of the infection, syphilitic manifestations, etc., but, largely because of defaulting, had to reduce his groups to four. There is no need for me to stress the importance of propaganda. All of you know that where active propaganda is continuous a larger number of cases come for t r e a t m e n t - - m a n y of them may be nonvenereal but that is a good sign--patients attend better, even to the extent of double the number of attendances as compared with non-active areas, and I have no doubt that fear of venereal disease deters many others from taking any risks. I believe that propaganda should take the form of talks to. small established audiences, for instance, a youths' social club, and cinematograph shows to large mixed audiences. T h e advent of the talking picture should make this variety even more valuable. As a preventive measure the education of adolescents of both sexes in the facts of sex should be most valuable, because the peak o.f fresh cases of venereal disease is in the
353
18-22 years age group. I am informed that only half of the population of the country is covered by efficient propaganda, while in a quarter of the country there is no propaganda whatever. It has been suggested that E1 per 1,000 of the population should be the amount spent on propaganda yearly, of which 5s. should be subscribed to a national scheme for propaganda, such as the British Social H y g i e n e Council, which is an experienced and influential body. It is a melancholy fact that the mothers, actual or potential, of the nation, many of them innocent victims of venereal disease but still the most certain means of passing on venereal disease to the succeeding generation, whether as o.phthalmia, vulvo-vaginitis, or congenital syphilis, are of all people least provided for in our present clinic system. The all-day clinic would, I am sure, be a great benefit to women patients because the usual hours for female clinics do not conduce to the regular attendance, of housewives, maidservants, barmaids, shop assistants and so. on. T h e clinic hours in m a n y areas seem to be set apart for the idle classes and for girls working in offices or factories. At present there is evidence to show that while the ratio of women to men attending for the treatment of syphilis is fairly good (1 to 1"8) the number attending for gonorrhoea makes poor showing (1 to 4). This is probably due to the difficulty of self-examination on the part of the woman, but is all the more reason for the establishment of better clinic facilities for them. Married women, it appears to me, present a field where earnest endeavour on the part of the health authorities would bear much fruit. Once the infected married women is found she is a much better attender at the clinic than her husband, and is more amenable to reason if visited by a social worker in the event of her ceasing to attend. Of course, it is not much good to have a married woman attending a clinic if her husband is not ,under treatment, and possibly that is a very good reason for treating a woman in all her' pregnancies if she has at any previous time suffered from syphilis. The possibility of paternal syphilis is thus counteracted. A great deal of good can be done if there is a working system between male and female clinics. W'hen a male patient comes to the clinic and gives a history of infection contracted from his wife or some girl friend, I make it my business to influence the woman through the man to go
:3.54
PUBIJC
for examinaiion to a female clinic. A card addressed to the medical officer o.f the clinic by name, stating the clinic hours and giving the short diagnosis of the infected male, " G " or " S , " is given to the man to hand to his wife or friend. In the same way, when a man may have infected his wife or girl friend during the incubation period of Iris disease, a similar card is issued and I make it clear to the man that if he has infected or been infected by his wife it is useless going on with Iris treatment m,.til his wife is also undegsupervision. The clinical venereal diseases officer treating any woman for syphilis should instruct her that if at any time she becomes pregnant she should return for treatment. There is, however, a much larger opportunity for doing good work open to the administrative public health officer. He has now control over the large poor law hospitals with their maternity wards and children's wards. He has also under his charge corporation maternity homes, ante-natal clinics, post-natal clinics and the medical inspection of school children, and soon I expect he will have charge of the health of the children of preschool age. In all of these wide-filing activities of public health there are responsibilities for discovering and treating diseases which concern the public weal. To my mind there is no good having health weeks and o.nslaughts of propaganda if we are not prepared to seize opportunities that already await us. In the memorandum prepared by the Maternal Mortality Committee in June, 1929, under the heading " Principles of Ante-Natal Care " we r e a d : " Measures should be taken to include within the scope of ante-natal care the diagnosis and treatment of venereal diseases," and further: "Ante-natal care should ineIude measures directed against infection and measures increasing resistance to infection." There are in E n g l a n d and Wales, fourteen maternity and child welfare centres treating venereal diseases in women, and if we are to do our best for this and succeeding generatio.ns, this number will have to be increased, and treatment with arseno-benzol preparations and bismuth given to every pregnant woman with a h!story of signs of syphilis or a positive Wassermann. Professor F. J. Browne of K i n g ' s College, London, states that 7 per cent. of the women attending the ante-~atal department of the Ro.val Maternity Hospital in Edinburgh were proved syphilitics. Dr. Picken of Cardiff
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AUaUST,
states that 10"3 per cent. and Dr. Cruickshank of Glasgow 9"4 per cent. of the women attending their ante-natal centres are syphilitic, while in a rural district of Lincolnshire tire percentage , according to Dr. Brunyate is 5. I)r. Kettlewell in Plymouth made a survey of school children and stated that 2-3 per cent. were congenital syphilitics. W e are aware that the child suffering from congenital syphilis has tess chance of survival than tile normal child, and here I might give some figures collected by one of Mr. Lees' assistants in :Edinburgh. One thousand and twenty-nine preg~mncies in women suffering from syphilis resulted in foetal death in 293 cases (28"4 per cent. of the total). It is interesting to note, and this is characteristic of pregnancies in the syphilitic, that close on one-half of the foetal deaths were really premature births, since delivery of a stillborn infant occurred between the sixth and the ninth months of gestation. There remained 736 children born alive; 245 or one-third had died before attaining the age of five, 21 died later, and out of the remnant (469) 213 had positive blood \Vassermanns and 16 had stigmata of syphilis though the blood was negative. It is of interest to assess the value of the preventive treatment of congenital syphilis, that is to say, the steps takdn to find what pregnant women are suffering from syphilis, and the value of efficient treatment in such women. It is universally agreed that the earlier in preoJnancy that treatment is instituted ~ttle safer for the child, and as Earl Moore of Baltimore has shown that in a series of 2,438 women sufferi,g from syphilis, 47"5 per cent. were .diagnosed on the evidence of a positive ~vVassermann alone, apart from a few who gave a suspicious histo.ry, it is absolutely essential that a blood Wassermann should be done on every pregnant woman at her first attendance at the ante-natal clinic. If this test proves positive, treatment by the arsenobenzenes and bismuth should be started and continued throughout the pregnancy. The figures o.f Boas and Gammeltoft, published in 1927 after careful scrutiny of 545 pregnancies in women suffering from syphilis, show that mercury is cornparatively inefficient in preventing congenital syphilis; in fact, 72 per cent. of the children born were found to be infected if mercury alone was exhibited during the pregnancy. It is possible that a child may be no.rma/ at birth and for a year or more, and thereafter* develop signs of con-
J931.
PUBLIC HEALTH.
genital syphilis. Boas and Gammeltoft's follow-up system has kept continuous watch on children for fifteen years, hence the high figure. In X&Yhitridge ~3/illiams' figures the results of treatment are plainly shown. 48"5 per cent. of infants born to :untreated syphiIitic women, 89 per cent. of infants born to partiatly treated women, and 7 per cent. of infants born to well treated women, were found to be suffering from syphilis. In France, where there are now 400 state-aided dispensaries working to prevent congenital syphilis, we find that the Baudilocque Maternity Hospital, which in 1919 originated the intensive treatment of infected pregnant women, has now an annual ante-natal death-rate of 14'5 per thousand as opposed to 23"7 per 1,000 for the 80 years prior to 19t9. The fact that.the patient has a negative Wassermann does not rule out syphilis, and quite often a child suffering from congenital syphilis is born to parents whose blood W*assermann is negative. It is therefore essential to examine patients physically, and to go. into. their previous history, obstetrical and general, before excluding syphilis. The history of repeated premature stillbirths strongly suggests syphilis, and some authorities proceed to treat such cases and frequently a live full-time child is born. Colonel Harrison has lately called attention to the Kline test as a substitute for the W a s s e r m a n n . The test is actually done on finger blood and takes about half-an-hour to do. Several tests can be done at the same time, and the technique appears to. be no more difficult than the \ ¥ i d a l . This test should prove of great: value in tl{e case of children because of the ease with which the blood is obtained. ~;Vith regard to. the diagnosis of gonorrhoea, Browne states that he treats all cases of purulent discharge from the vagina whether gonococci are found in cervical smears or not. The essential demanding treatment is the presence of pus, because of the twofold danger of ophthalmia and puerperal sepsis. The presence of free pus at the urinary meatus after stripping the urethra through the anterior vaginal wall, pyuria or the presence of shreds containing pus in the urine, should make one extraordinarily suspicious, as should a history of ophthalmia neonatorum in previous pregnancies. Special in-patient beds should be available in cases of pelvic damage from gonorrhoea, and for arthritis, which is said to be the most frequent complication in pregnancy.
as~
In the maternity wards, and even in the midwifery practice of doctors and midwives in the homes of the people, the search for the syphilitic mother should not be abated. W e have vaiqous methods of discovering the hidden plague. Blood from the cord may be collected and sent in a Wassermann tube to an approved laboratory. T o popularise the system, doctors and n~idwives might be paid a small fee for their services. In Glasgow, tip to t9PA, a fee of 2s. 6d. per blood specimen sent for Wassermann test to the city laboratory was paid to encourage medical practitioners to. be on the look-out for syphilis. Cooke and Jeans state that a cord blood W a s s e r m a n n will discover 63 per cent. of syphilitic infants. Again, macroscopic examination of the placenta may reveal syphilis. Professor Browne says that the " greasy syphilitic placenta " of the text-books o.nly occurs with a macerated foetus. It is the end result of syphilitic sclerosis of the chorionic villi. In the viable child it is the weight of the placenta which counts. A placenta weighing more than one-quarter of the weight of the child is syphilitic and suspicion attaches to one which exceeds one-sixth. \¥hitridge Williams states that micro-examination of the ptacenta reveals the presence o.f syphilis in 80 per cent. of all congenital syphilitic children, but Cooke and Jeans state~ that in thei, series the percentage discovered was 27, and that the Wassermann test of the cord blood was more reliable. Examination of the cord at the foetal end for tissue spirochaetes and pert-vascular infiltrations may be performed, and in the case of stillborn children all the organs are available for examination. In Liverpool and Blackburn this is systematically done, and where spirochmtes are discovered, valuable knowledge is gained as to the conduct of the next pregnancy, and, in fact, all succeeding pregnancies. Browne's observation that he had never found spirochmtes in the tissues of a child dead of syphilis where lhe mother's blood was negative, is to. be borne in mind, and his statement that where prematurity or dead-born children are the rule in a family, it is well worth while giving" arseno-benzol and bismuth in the succeeding pregnancies. Where congenital syphilis is discovered in lhe new-born babe, treatment should be immediate and continuous for from two to five years. Congenital syphilis as seen in the school years is either static or so severe as to call
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for i m m e d i a t e hospital t r e a t m e n t in m o s t cases. T h e m e r e fact that the s i g n s of s y p h i l i s are static, as e x p r e s s e d b y rhagades, Hutchinson's teeth, b a d molars, scrotal t o n g u e , etc., d o e s not m e a n t h a t n o , t r e a t m e n t is necessary, but I feel that m a n y cases are not r e p o r t e d s i m p l y because the lesions seen are the scars of battles l o n g a g o . T h e disease m a y h a v e c o m p l e t e l y s p e n t itself in' the child u n d e r review, but there are p r o b a b l y b r o t h e r s a n d sisters to, be considered, a n d if these children are f o u n d to h a v e a positive W a s s e r m a n n , t r e a t m e n t s h o u l d be instituted at once. I n all cases w h e r e families are involved, we a r e justified in s a y i n g t h a t s y p h i l i s can c o m e f r o m a g r a n d f a t h e r or g r a n d m o t h e r , a n d o n e can b e certain t h a t the g u i l t y p a r e n t will p o u n c e on this w a y out a n d m a k e t h i n g s e a s y for the t r e a t m e n t of the little patient. It is in p r o b l e m s such as c o n g e n i t a l s y p h i l i s in a f a m i l y that one sees the definite need for correlation of the v a r i o u s p u b l i c health services, a n d it is here that a health visitor p o s s e s s e d of the n e c e s s a r y tact c a n d o y e o m a n service, especially in a large t o w n where the v a r i o u s d e p a r t m e n t s tend to be too d e p a r t m e n t a l . I f she can be a d o p t e d as p a r t of the confidential venereal diseases scheme, j u s t as a n o r d e r l y w o r k i n g in a v e n e r e a l diseases centre is p a r t of the scheme, a n d is also a t t a c h e d to the tuberculosis, m a t e r n i t y a n d child welfare a n d school m e d i c a l inspection services, she w o u l d act as a v e r y powerful linl~. I n the counties a n d s m a l l e r b o r o u g h s I a m a w a r e t h a t a s s i s t a n t medical officers w o r k u n d e r all the s c h e m e s , a n d t h e r e f o r e control of the v a r i o u s cases is m a d e m u c h easier. It is, of course, entirely w r o n g to r e p o r t a case of venereal disease b y n a m e to the medical officer of health, b u t that, I u n d e r s t a n d , does not hold in c o m m u n i c a t i o n s f r o m o n e clinical d e p a r t m e n t to a n o t h e r . M r . D a v i d Lees, the V e n e r e a l D i s e a s e s Officer of the C i t y of E d i n b u r g h , has been k i n d e n o u g h to send m e p a r t i c u l a r s of the correlation of a n t e - n a t a l a n d child welfare clinics with the venereal diseases scheme, a n d the f o l l o w i n g is a r d s u m d : - " At the Royal Maternity Hospital, where an antenatal clinic is held, the venereal diseases officer of the city is on the staff, and one of his senior assistants is always on duty during clinic hours. This assistant is on duty at the Royal Infirmary evening clinic for males, where husbands of pregnant women found to be diseased are asked to report. All cases suspected of having venereal disease at the ante-natal clinic are referred to him, and if the diagnosis is confirmed he undertakes the treatment. A.11 patients attending the
HEALTH.
AucusT,
ante-natal clinic use the same waiting-room and the same nurses attend all patients. The two house physicians of the hospital have usually been residents in the female lock department of the Royal Infirmary. All patients have a Wassermann test done, and the blood is taken by the obstetrical staff. After confinement, the infected mother is followed up by the venereal diseases department and her treafment is continued either as an in-patient, if necessary, or as an out-patient at one of the subsidiary centres. Very striking success has attended the working of this scheme and not the least result has been the diminution of congenital syphilis in children of under one year by about 50 per cent. Further, as regards ophthahnia neonatorum, with the exception of one unfortunate case which was seen last month, no permanent damage has occurred to the eye of any baby born during the last eight years in Edinburgh and the Lothians. Still another indication of thoroughness is that attention has been directed to children blind through congenital syphilis, and contiriuous treatment is being given to them at the Royal Blind School." T o s u m m a r i s e - - - o u r t a s k in public health w o u l d a p p e a r to include :--(i) G r e a t e r efforts in p r o p a g a n d a w h i c h will r e a c h the m a r r i e d w o m a n a n d e x p e c t a n t mother. (2) T h e p r o v i s i o n in all large centres of alld a y clinics for b o t h sexes,. (3) A n t e - n a t a l clinics to be m o r e actively e n g a g e d in the p r e v e n t i o n of c o n g e n i t a l syphilis, o p h t h a l m i a a n d vulvo-vaginitis. T h e routine t e s t i n g of the sera of all w o m e n a t t e n d i n g s h o u l d be considered essential. (4) T h e p r o v i s i o n of b e d s for infected p r e g n a n t w o m e n with c o m p l i c a t i o n s , a n d for neonatal cases of o p h t h a l m i a , v u l v o - v a g i n i t i s a n d congenital syphilis. (5) H o m e s for u n m a r r i e d girls suffering f r o m venereal disease, especially if p r e g n a n t . (6) H e a l t h visitors to be a t t a c h e d to w o m e n ' s a n d c h i l d r e n ' s venereal disease clinics for social w o r k . (7) E n c o u r a g e m e n t of school medical officers a n d child welfare officers to a t t e n d p o s t - g r a d u a t e courses in congenital syphilis. (8) C h i l d r e n of m o t h e r s s u f f e r i n g f r o m s y p h i l i s to be k e p t u n d e r o b s e r v a t i o n in the pre-school a g e . I feel certain t h a t the a d o p t i o n of s u c h m e a s u r e s in p r e s e n t - d a y public health w o r k w o u l d s h o w a s t r i k i n g d e c r e a s e * i n the prenatal a n d infantile m o r t a l i t y rate, a n d p o s s i b l y in the m a t e r n a l m o r t a l i t y a n d m o r b i d i t y rates also., to. s a y n o t h i n g of the g r e a t e r health a n d h a p p i n e s s of a m u c h l a r g e r p r o p o r t i o n of the g e n e r a l c o m m u n i t y t h a n is u s u a l l y realised even b y the m o s t rabid of o u r venereal diseases officers.