VENEREAL DISEASES IN NEW ZEALAND.
REPORT OF THE COMMITTEE OF THE BOARD OF HEALTH APPOINTED BY THE HON. MINISTER OF HEALTH.
Presented to both Houses of the General Assembly by Leave.
CONSTITUTION OF THE COMMITTEE.
Hon. W.H. TRIGGS, M.L.C., Chairman. J.S. ELLIOTT, M.D., Member of the Medical Board. Mr. MURDOCH FRASER (New Plymouth), representing the Hospital Boards of the Dominion. J.P. FRENGLEY, M.D., D.P.H., Deputy Director-General of Health. Lady LUKE, C.B.E. Sir DONALD McGAVIN, K.C.M.G., C.M.G., D.S.O., Director-General of Medical Services.
PART I.—INTRODUCTORY AND HISTORICAL. Page
Section 1.—Origin and Scope of Inquiry: Witnesses; Sittings, Date and Place of; Appreciation of Services rendered 2
Section 2.—Venereal Diseases and their Effects: Ignorance, Effect of; Sex Education for Young; Syphilis and Gonorrhoea, Origin and Description; Treatment after Exposure; Diagnosis, Methods of; Treatment, Importance of Early and Completed 4
Section 3.—Accidental Infection: Sources of Infection; Metchnikoff's Investigation; Food-conveyance; Lavatories, Towels, Drinking-cups, &c. 5
Section 4.—Previous Inquiries and Conferences: Contagious Diseases Act, England; Royal Commission, 1913, Evidence, View of Compulsory Notification, Divorce and Venereal Disease, Sex Education, Instruction, and Propaganda; Australasian Medical Congresses. Committee appointed; Auckland Congress, 1914, Report presented, Nature of Notification recommended; Melbourne Conference, 1922, Review of Legislation, Comments and Recommendations; England, Committee recently appointed to report on Venereal Diseases 5
Section 5.—Legislation in New Zealand, Past and Present: Contagious Diseases Act, 1869 (A), Reference to; Cases Cited (B) which require New Legislation to deal with; Hospital and Charitable Institutions Act, 1913 (C); Detention Provisions; The Prisoners Detention Act, 1915 (D); Provisions for dealing with Venereal Diseases in Convicted Persons; Social Hygiene Act, 1917 (E); Provisions of the Act outlined; Subsidy for Maintenance in Hospitals 7
PART II.—PREVALENCE OF VENEREAL DISEASE IN NEW ZEALAND.
Section 1.—Medical Statistics (A): Medical Practitioners, Special Returns from, Cases reported, Gonorrhoea and Syphilis: Chancroid; Prevalence. Clinic Statistics (B): Department of Health Data; Clinic Distribution; Age Distribution; Marital Condition. Mental Hospital Statistics (C): Syphilis and Dementia Paralytica; Computations as to Prevalence of Syphilis based on Fournier's Estimate. Incidence among Maoris (D): Early Days, Miscarriages; Prevalence at Present, Origin. Death-certificates (E): Two Certificates, one for Relatives, other for Registrar; British Empire Statistical Conference, Resolutions passed; Committee's Conclusion 9
Section 2.—Causes of the Prevalence of Venereal Diseases in New Zealand: Infected Individuals, neglect to undergo or continue Treatment; Chiropractors; Herbalists: Overseas Introduction; Promiscuous Sexual Intercourse; Professional Prostitution; Police Evidence; "Amateur" Prostitution; Social Distribution; Extra-marital Sexual Intercourse, Result of; Parental Control; Sex Education; Housing and Living Conditions; Hostels, Advantages of; Moral Imbeciles, Danger from; Delayed Marriages; Alcohol; Accidental Infections; Dances; Cinema; Returned Soldiers 11
PART III.—BEST MEANS OF COMBATING AND PREVENTING VENEREAL DISEASES.
Section 1.—Education and Moral Control: Chastity, Value of; Relationship between Sexes; Infected Persons, Responsibility; Church and Press influence; Parents duty to Children; Pamphlet for Parents; Sex Hygiene in Schools, Mode of Teaching; School Mothers, Value of, in Girls' School; Instruction in Sex Hygiene; Adolescents; Moral Standard, Value of 12
Section 2.—Clinics for the Treatment of Venereal Disease: Distribution; Work performed; Male and Female Attendance; Locality of Clinics; Hours of Attendance; Lady Doctors; Supply of Apparatus and Drugs for certain Cases; Advertising Clinics; Extension of Clinics; Training at Clinics for Nurses, Students, &c.; Cases attending until non-infective; Male and Female; Lady Patrols; Social Hygiene Society, Work of; Laboratories and Free Treatment: Complement Fixation Test for Gonorrhoea 14 Page Section 3.—Licensed Brothels: Observations on; Dangers of Infection from; Statistics; North European Conference's Resolution; Flexner's Views; American Opinion. 15
Section 4.—Exclusion of Venereal Cases from Overseas: Health Act, 1920, Provisions; Attendances at Clinics; Recommendations; Immigration Restriction Act and Syphilis. 16
Section 5.—Prophylaxis: Packet System; Early Treatment; Inter-departmental Committee on Infectious Diseases, Conclusions; Notices in Public Conveniences; Prophylaxis, Efficiency of 16
Section 6.—Legislation required: Conditional Notification (A)—National Council of Women, View on; Number or Symbol Notification; Infectious Diseases Notification Bill, England (1889), Opposition to, Comparisons with Control of Infectious Diseases; Present System, Disadvantages of; West Australia Act; New Zealand Legislation suggested. Compulsory Examination and Treatment (B).—Department of Health, proposed Legislation, Contagious Diseases Act compared with; West Australia Legislation, Effect on Attendances at Clinics 17
Section 7.—Marriage Certificate of Health: Royal Commission on Venereal Diseases; National Birth-rate Commission; Medical Certificate; Statement before Registrar, Communicable and Mental Disease; Recommendation; Medical Practitioners' duty 20
Section 8.—Treatment of Unqualified Persons: Chemists, Herbalists, Chiropractors; Effect of such Treatment; Clinic Statistics relating to same; West Australian 20
Section 9.—Mentally Defective Adolescents: Danger and Cost to the State; Supervision and Control proposed 20
PART IV.—SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS.
Section 1.—Conclusions 21
Section 2.—Recommendations 21
Section 3.—Concluding Remarks 22
* * * * *
The Hon. the Minister of Health, Wellington.
The Committee of the Board of Health appointed by you to inquire into and report upon the subject of venereal diseases in New Zealand have the honour to submit herewith their report.
PART I.—INTRODUCTORY AND HISTORICAL.
SECTION 1.—ORIGIN AND SCOPE OF INQUIRY.
A perusal of departmental files reveals that many persons and bodies have during recent times urged upon the Government the desirability of setting up a Committee or Commission of Inquiry to go into this subject. The appointment of the present Committee, however, arose out of a suggestion forwarded to the Chairman of the Board of Health, under date of the 20th June, 1922, from the Council of the New Zealand Branch of the British Medical Association. The Board of Health duly considered the representations of the Association and passed a resolution recommending the Minister to set up a committee to gather data and to make recommendations as to the best means of preventing and combating venereal diseases. The proposal thereafter took concrete form, following the receipt by the members of this Committee of the under-quoted letter, dated 13th July, 1922, sent out under your direction by the Secretary of the Board of Health:—
"I am directed by the Hon. the Minister of Health, Chairman of this Board, to inform you that, acting upon the recommendation of the Board, he has decided to appoint a special Committee from among the members of the Board to conduct an inquiry into the question of venereal diseases in New Zealand. The following members are being asked to become members of the Committee, and the Chairman trusts you will see your way to accept the position: Dr. Valintine, Dr. Elliott, Lady Luke, Hon. Mr. Triggs, Sir Donald McGavin, Mr. Fraser. The Hon. the Minister has asked the Hon. Mr. Triggs to accept the chairmanship of the Committee.
"I am further directed to state that the function and duty laid upon the Committee is as follows:—
"(1.) To inquire into and report upon the prevalence; of venereal disease in New Zealand.
"(2.) To inquire into and report any special reasons or causes for the existence of venereal disease in New Zealand.
"(3.) To advise as to the best means of combating and preventing venereal disease in New Zealand, and especially as to the necessity or otherwise of fresh legislation in the matter.
"The Minister of Health is anxious that the Committee should hear such evidence and representations on the above-mentioned matters as may be necessary to fully inform the Committee on the items referred to it, and with respect to which it is asked to report, and he further suggests to the Committee that the various organizations and persons likely to be interested should be notified that the Committee will, at a certain place and date, in Wellington, hear any evidence they may desire to tender."
The Committee regrets that owing to ill health Dr. Valintine, Director-General of Health, was unable to act as one of its members. His place was taken by Dr. J.P. Frengley, Deputy Director-General of Health. Unfortunately, illness also overtook Mr. Murdoch Fraser, who has been unable to attend the sittings of the Committee since the middle of August. The remaining members have been present at all sittings of the Committee, details of which are appended in the following table:—
+ Places and Dates of Sittings. Witnesses examined or Work done. + Wellington, 26th July, 1922 Preliminary meeting. (forenoon only) Wellington, 8th August, 1922 Dr. M.H. Watt, Director, Division of (forenoon only) Public Hygiene. Dr. B.F. Aldred, Officer in Charge Venereal Diseases Clinic. Wellington, 9th August, 1922 Hon. Dr. W.E. Collins, M.L.C. (forenoon only) Mr. J. Caughley, M.A., Director of Education. Auckland, 17th August, 1922 Dr. Falconer Brown, Officer in Charge Venereal Diseases Clinic. Dr. Hilda Northcroft. Dr. Frank Macky. Dr. W. Gilmour, Bacteriologist and Pathologist, Auckland Hospital. Dr. C.E. Maguire, Medical Superintendent, Auckland Hospital. Dr. W.H. Parkes. Dr. J. Hardie Neil. Dr. R. Tracy Inglis, Medical Officer, St. Helens Hospital. Dr. E.W. Sharman, Port Health Officer. Dr. W.H. Pettit. Auckland, 18th August, 1922 Mrs. De Treeby, representing Women's International and Political League. Dr. D.N.W. Murray, Medical Officer to Prisons Department. Mr. R.J. Pudney. Mr. Egerton Gill. Mrs. Harrison Lee Cowie. Mrs. E.B. Miller. Dr. Kenneth Mackenzie. Dr. E.H. Milsom. Dr. E. Carrick Robertson. Rev. Jasper Calder. Mr. F.L. Armitage, Government Bacteriologist. Dr. W.A. Fairclough. Dr. A.N. McKelvey, Medical Officer, Costley Home. Christchurch, 29th August, 1922 Dr. A.C. Thomson, Officer in Charge Venereal Diseases Clinic. Dr. P.C. Fenwick. Mrs. E. Roberts, President Women's Branch, Social Hygiene Society. Mrs. A.E. Herbert. Dr. A.B. Pearson, Bacteriologist and Pathologist, Christchurch Hospital. Nurse E.M. Stringer, Health Patrol. Dr. W. Fox, Medical Superintendent, Christchurch Hospital. Dr. C.H. Upham, Port Health Officer. Dr. C.L. Nedwill, Medical Officer to Prisons Department. Dr. D.E. Currie. Dr. J. Guthrie. Dr. W. Irving, Medical Officer, St. Helens Hospital. Dr. A.C. Sandston, President, Men's Branch Social Hygiene Society. Major R. Barnes, Salvation Army Officer. Dr. A.B. Lindsay. Dunedin, 31st August, 1922 Dr. A. Marshall, Officer in Charge Venereal Diseases Clinic. Dr. A.R. Falconer, Medical Superintendent, Dunedin Hospital. Dr. H.L. Ferguson, Dean Medical Faculty, Otago University. Dr. Emily H. Seideberg, Medical Officer, St. Helens Hospital. Dr. J.A. Jenkins. Canon E.R. Nevill, representing the Dunedin Council of Sex Education. Miss Pattrick, Director of Plunket Nursing. Mr. J.M. Galloway, representing Society for Protection of Women and Children. Dr. F.R. Riley. Wellington, 12th September Dr. W. Young. (forenoon only) Mr. T.R. Cresswell, Headmaster, Wellington College. Mr. W.W. Cook, Registrar-General. Mr. Malcolm Fraser, Government Statistician. Mr. W.D. Hunt. Rev. R.S. Gray. Wellington, 13th September Dr. Frank Hay, Inspector-General of (forenoon only) Mental Defectives. Mrs. Henderson, Representative Women Prisoners' Welfare Society and Wellington Branch National Council of Women. Rev. Van Staveren, Jewish Rabbi. Wellington, 14th September Dr. Agnes Bennett, Medical Officer, St. Helens Hospital. Mrs. F. McHugh, Health Patrol. Mr. F. Castle, President Pharmacy Board, and Chairman Wellington Hospital Board. Dr. D.M. Wilson, Medical Superintendent, Wellington Hospital. Mr. A.H. Wright, Commissioner of Police. Mr. W. Dinnie, ex-Commissioner of Police, representing Bible in Schools Propaganda Committee. Rev. J.T. Pinfold, D.D., representing Wellington Ministers' Association. Canon T. Feilden Taylor, appointed by the Bishop of Wellington. Wellington, 15th September Major Winton, Salvation Army. Mr. W. Beck, Officer in Charge Special Schools Branch, Education Department. Dr. D.E. Platts-Mills, representing Young Women's Christian Association. Mrs. Morpeth, representing Young Women's Christian Association. Miss Dunlop, representing Young Women's Christian Association. Mrs. Glover, Salvation Army. Wellington, 26th September Consideration of report. Wellington, 10th October Consideration of report. Wellington, 12th October Consideration of report. Wellington, 13th October Consideration of report. Wellington, 18th October Final meeting. +
It will thus be seen that, apart from time spent in travelling, the Committee have met on seventeen days and have heard seventy-four witnesses in person.
The Committee would like to express their thanks to the witnesses, many of whom had gone to considerable trouble to collect information and prepare their evidence. Thanks are also due to the British Medical Association for their willing co-operation and assistance; to the large number of members of the medical profession throughout the Dominion who responded to the Committee's request for information; to Dr. J.H.L. Cumpston, Federal Director-General of Health, Melbourne, for much Australian information on the subject, particularly in relation to Commonwealth quarantine provisions; to Dr. Everitt Atkinson, Commissioner of Public Health, Perth, West Australia, for a most lucid and informative report on the working of the legislation in force in that State; and to many other persons who by means of correspondence and literature have placed at the Committee's disposal a large amount of information which has been of material assistance in considering various aspects of the problems involved.
The Committee desire to acknowledge their indebtedness to their secretary, Mr. C.J. Drake, whose wide knowledge of public-health matters has been of material assistance in their investigations and who has discharged his duties with marked zeal and ability.
SECTION 2.—VENEREAL DISEASES AND THEIR EFFECTS.
One result of the Committee's investigations has been to show that the public in general are very ignorant regarding the nature of venereal diseases, and their lamentable effects not only upon the individuals infected, but upon the health and well-being of the community as a whole. This ignorance of the nature of the problem and of the grave issues involved naturally stands in the way of the evil being grappled with effectually. Furthermore, the policy of reticence which has prevailed in the past, while it has led to the omission of proper instruction of the young, either by their parents or as part of our system of education, has not prevented the dissemination of an incomplete or perverted knowledge of the facts relating to sex, which, being derived as a rule from tainted sources of information, has been productive of a great deal of evil.
In these circumstances the Committee feel it their duty, before making known their recommendations, to state in as plain terms as possible the medical aspects of the problem they have had to consider.
There are three forms of venereal diseases namely, syphilis, gonorrhoea, and chancroid—and of these the first two are the common and most serious diseases. That sporadic syphilis existed in antiquity and even in prehistoric times is probable, but there is no doubt that the disease was a malignant European pandemic in the closing years of the fifteenth century. The first reference to its origin is in a work written about the year 1510, wherein it is described as a new affection in Barcelona, unheard of until brought from Hayti by the sailors of Columbus in 1493. The army of Charles VIII carried the scourge through Italy, and soon Europe was aflame. "Its enormous prevalence in modern times," says Dr. Creighton, "dates, without doubt, from the European libertinism of the latter part of the fifteenth century." Gonorrhoea also has its origin in the shades of antiquity, but that it became common in Europe about 1520 is a fact based on the highest authority.
Syphilization follows civilization, and syphilis is an important factor in the extermination of aboriginal races. Syphilis was introduced into Uganda when that country was opened to trade with the coast, and Colonel Lambkin reported that "In some districts 90 per cent. suffer from it.... Owing to the presence of syphilis the entire population stands a good chance of being exterminated in a very few years, or left a degenerate race fit for nothing." The earliest known account of the introduction of syphilis into the Maori race is in an old Maori song composed in the far North. The Maori population in a village on the shores of Tom Bowline's Bay was employed in a whaling-station on the Three Kings Islands, and there they became infected and carried the disease to the mainland. Venereal disease is not common now among the Maoris, but it made great ravages in the early days of colonization, to which may be attributed much of the sterility and repeated miscarriages in the transitional period of Maori history.
Through the ages great confusion existed as to the origin and nature of venereal disease, but in 1905 a micro-organism, the Spironema pallidum, was demonstrated as the infective agent in syphilis, and the gonococcus as the infecting organism of gonorrhoea had been discovered in 1879. As regards modes of infection, syphilis is contracted usually by sexual congress; occasionally the mode of infection is accidental and innocent, and congenital transmission is not uncommon. Gonorrhoea is contracted by sexual congress as a rule, but occasionally from innocent contact with discharges, as in lavatories.
Syphilis, therefore, is a markedly contagious and inoculable disease. It gains entrance, and usually in three weeks (although this period may be much shorter) a slight sore appears at the site of infection. It may be so slight as to pass unnoticed. This is the primary stage of syphilis. Later, often after two months, the secondary stage begins, and if not properly treated may last for two years. The patient is not too ill usually to attend to his avocation, and has severe headache, skin rashes, loss of hair, inflammation of the eyes, or other varied symptoms. The tertiary stage may be early or delayed, and its effects are serious. Masses of cells of low vitality, known as "gummata," with a tendency to break down or ulcerate, may form in almost any part of the body, and the damage that occurs is considerable indeed. Various diseases result which the lay mind would not associate with syphilis, but it would be difficult to overestimate the resultant diseases that may occur in any organ of the body:—
This racks the joints; this fires the veins: That every labouring sinew strains; Those in the deeper vitals rage.
Many deaths ascribed to other causes are the direct consequence of syphilis. It cuts off life at its source, being a frequent cause of abortion and early death of infants. It slays those who otherwise would be strong and vigorous, sometimes striking down with palsy men in their prime, or extinguishing the light of reason. It is an important factor in the production of blindness, deafness, throat affections, heart-disease and degeneration of the arteries, stomach and bowel disease, kidney-disease, and affections of the bones. Congenital syphilis often leads to epilepsy or to idiocy, and most of the victims who survive are a charge on the State. This indictment against syphilis is by no means complete. The economic loss resulting from this disease is enormous as regards young, old, middle-aged. It respects not sex, social rank, or years.
Gonorrhoea is characterized in its commonest form by a discharge of pus from the urethra, and causes acute pain at its onset in the male, but in the female it commonly causes little or no discomfort. Unless carefully treated, and treated early, it gives rise to many complications, such as inflammation of the bladder, gleet, stricture, inflammation of joints, abscesses, and rheumatism. It is a common cause of sterility and of miscarriages, and, in the female, of many internal inflammations and disablement, and in its later effects requires often surgical operations on women. It is a very common disease, and the public know little of the evil consequences which may follow what they have persisted in regarding as a simple complaint. From its prevalence and its complications it is one of the most serious diseases that affect mankind.
As regards treatment of venereal disease of all kinds, it should be clearly understood that the causative germs are well known and can readily be destroyed immediately after exposure to infection by thorough cleansing with antiseptic lotion or ointment. The use of soap and water only would lessen the incidence of infection. On the first suspicious sign of venereal disease the patient should apply at once for medical advice. There are methods of diagnosis, such as microscopic examination and the Wassermann test, the result of recent discovery, which make diagnosis simple and certain; and if treatment is begun early according to modern methods, which are much more effective than the remedies formerly applied, the germs of infection are easily vanquished. When sufficient time, however, is lost to enable these germs to become entrenched in parts of the body not readily accessible to treatment, cure is difficult, prolonged, and perhaps in some cases uncertain.
For their own sakes, as well as for the sake of others, patients suffering from any form of venereal disease should continue treatment, which may be prolonged in the case of syphilis for two years, until their medical adviser is satisfied that further treatment is unnecessary.
Women suffer less pain than men in these diseases, and consequently are more apt to neglect securing medical advice and treatment, and more ready to discontinue treatment before a cure is effected.
SECTION 3.—ACCIDENTAL INFECTION.
Occasionally cases are met with in which syphilis is acquired innocently by direct or indirect contact with syphilitic material, and then the primary sore is often located on some other part of the body than the genitals. Thus the lip may be infected by kissing, or by drinking out of the same glass, or smoking the same pipe as a syphilitic patient. A medical witness reported a case to the Committee in which syphilis was conveyed to two girls "through a young fellow handing them a cigarette which he was smoking." Metchnikoff has proved that the spironema of syphilis is a delicate organism and quickly loses its virulence outside the human body, and it cannot enter the system through unbroken skin or mucous membrane. It is extremely doubtful if any form of venereal infection can be conveyed in food. Frequently venereal disease is deceitfully attributed by patients to innocent infection, and no doubt some genuine cases do occur, but how seldom is illustrated by the statement of the Officer in Charge of the V.D. Clinic at Christchurch, who said, "I cannot remember a case where I was absolutely certain that infection was acquired innocently or extragenitally."
Gonorrhoea may be conveyed innocently from infective discharge on a closet-seat, or from an infected towel, &c., and undoubtedly gonorrhoeal discharge if brought into contact with the eye sets up a violent suppuration.
The Committee are of opinion that the extent of accidental infection is greatly exaggerated in the public mind, but a few cases occasionally occur, and the Committee recommend that there should be better provision of public conveniences, especially for women, and the U-shaped closet-seat should be adopted. The use of common towels and drinking-cups in railway-trains, schools, factories, and elsewhere is condemned not only for the reasons stated above, but on general sanitary grounds.
SECTION 4.—PREVIOUS INQUIRIES AND CONFERENCES.
After the repeal of the Contagious Diseases Act in England in 1886, various Committees and Royal Commissions, such as the Inter-departmental Committee on Physical Deterioration in 1904, the Royal Commission on the Poor-laws in 1909, and the Royal Commission on Divorce in 1912, drew attention to the frightful havoc wrought by venereal disease, and urged that further action should be taken to deal with the evil. In 1913 the British Government appointed a Royal Commission to inquire into the prevalence of venereal diseases in the United Kingdom, their effects upon the health of the community, and the means by which these effects could be alleviated or prevented, it being understood that no return to the policy or provisions of the Contagious Diseases Acts was to be regarded as falling within the scope of the inquiry.
The Commission took a great deal of most valuable evidence, and did not present their final report until 1916. They recommended improved facilities for diagnosis and treatment, including free clinics. They came to the conclusion that at that time any system of compulsory personal notification would fail to secure the advantages claimed. The Commission added, however, "it is possible that the situation may be modified when these facilities for diagnosis and treatment [recommended by the Commission] have been in operation for some time, and the question of notification should then be further considered. It is also possible that when the general public become alive to the grave dangers arising from venereal disease, notification in some form will be demanded." The Commission supported the adoption of a recommendation by the Royal Commission on Divorce to the effect that where one of the parties at the time of marriage is suffering from venereal disease in a communicable form and the fact is not disclosed by the party, the other party shall be entitled to obtain a decree annulling the marriage, provided that the suit is instituted within a year of the celebration of the marriage, and there has been no marital intercourse after the discovery of the infection. The Commission urged that more careful instruction should be provided in regard to moral conduct as bearing upon sexual relations throughout all types and grades of education. Such instruction, they urged, should be based upon moral principles and spiritual considerations, and should not be based only on the physical consequences of immoral conduct. They also favoured general propaganda work, and urged that the National Council for Combating Venereal Diseases should be recognized by Government as an authoritative body for the purpose of spreading knowledge and giving advice.
Another important Commission, sitting almost simultaneously with that just referred to, was the National Birth-rate Commission, which began its labours on the 24th October, 1913, and presented its first Report on the 28th June, 1916. The Commission was reconstituted, with the Bishop of Birmingham as Chairman, in 1918, to further consider the question, and especially in view of the effects of the Great War upon vital problems of population. Among the terms of reference the Commission were requested to inquire into "the present spread of venereal disease, the chief causes of sterility and degeneracy, and the further menace of these diseases during demobilization." The Commission in their report, presented in 1920, stated that they realized the difficulties involved in the introduction of any efficient scheme of compulsory notification and treatment of venereal diseases, but, they added, they "feel that it has now passed the experimental stage both in our colonies and in forty of the forty-eight of the United States of America, and think it is advisable for the State to make a trial of compulsory notification and treatment in this country, provided that there should be no return to the principles or practice of the Contagious Diseases Act." Referring to the finding of the Royal Commission on Venereal Disease that it would not be possible at present to organize a satisfactory method of certification of fitness for marriage, the National Birth-rate Commission thought this question should now be reconsidered with a view to legislation. "If," says the report, "a certificate of health was to become a legal obligation for persons contemplating marriage, many of the legal, ethical, and professional difficulties surrounding this question would be removed."
In Sweden, where a Venereal Diseases Law was passed in 1918, stress was laid on the importance of general enlightenment with regard to venereal disease and germane subjects, such as sex hygiene. A committee was appointed, consisting of experts in medicine and pedagogy, to inquire into the best means of providing such education. Their report, which has just been issued, is described by the British Medical Journal as a document of considerable value, promising to become the charter of a new and complete system of sex education and hygiene in schools throughout Sweden. Further reference will be made to this document in the section of this report dealing with education.
The subject of venereal disease has also been considered by more than one important Medical Conference in Australia and New Zealand.
At a general meeting of the Australasian Medical Congress held in Melbourne in October, 1908, it was resolved that the executive be recommended to appoint a committee to investigate and report on the facts in regard to syphilis. Such a committee was appointed, and reported to the Congress in Sydney in 1911. In 1914 the Congress was held in Auckland, and a special committee which had been appointed, with the Hon. Dr. W.E. Collins, M.L.C., as chairman, presented a valuable report giving some interesting information in regard to the prevalence of venereal disease, in New Zealand. The committee recommended that syphilis be declared a notifiable disease; that notification be encouraged and discretionary, but not compulsory; and that the Chief Medical Officer of Health be the only person to whom the notification be made. They also recommended the provision of laboratories for the diagnosis of syphilis, and that free treatment for syphilis be provided in the public hospitals and dispensaries. These recommendations were embodied in the report adopted by the Congress.
In February of the present year an important Conference, convened by the Prime Minister of Australia, was held in Parliament House, Melbourne. It was attended by official representatives of the Health Departments of all the States, together with representatives from the British Medical Association, the Women's Medical Staff at the Queen Victoria Hospital Diseases Clinic in Melbourne, and other scientific and medical authorities. The Commonwealth subsidizes the work of the States in combating venereal disease, and the object of the Prime Minister in calling the Conference was in order that it might inquire into the effectiveness of the present system of legislation, of administrative measures, and of clinical methods, with a view of determining whether the best results were being obtained for the expenditure of the money.
Western Australia has an Act, which came into operation in June, 1916, providing for what is known as conditional notification of patients, together with other provisions for the control of venereal disease which are on a more comprehensive scale than has been attempted anywhere with the possible exception of Denmark. In December, 1916, Victoria passed a similar Act, and this example was followed by Queensland, Tasmania, and New South Wales.
The Conference, answering the several questions put to it, found that a greater proportion of persons infected with venereal disease were receiving more effective treatment than before the passing of the Venereal Diseases Act. In the opinion of the Conference this was due partly to the passing of legislation and partly to the opening of clinics affording greater opportunities for free treatment. They considered the operations of the Act had been more successful in bringing men under treatment than it had been in the case of women. Among the opinions expressed by the committee were the following: The Act was not equally successful in respect of private and hospital patients in regard to notification, but was equally successful in respect of securing to both more effective treatment. There has been an apparent reduction in the prevalence of venereal diseases, and the Conference were strongly of opinion that the results so far justify the continuance of these Acts in operation.
The Conference found that venereal diseases are the most potent of all causes of sterility and of infant and foetal morbidity and mortality. It recommended, among other remedial measures, that prophylactic depots, both for males and females, should be established as widely in the community as possible. Referring to the educational aspect, the Conference urged that children should be instructed in general biological facts up to the age of puberty, when more explicit information concerning facts of sexual life should be given. They urged on all parents and educational, philanthropic, and religious organizations the pressing necessity for a sustained campaign, in co-operation with the medical profession, in order to inculcate in the community higher ideals of personal hygiene and health.
Lastly, it may be mentioned that, at the instance of Lord Dawson of Penn, a highly qualified and representative committee of medical men, with Lord Trevethin as chairman, has been appointed in England to report to the Minister of Health upon "the best medical measures for preventing venereal disease in the civil community, having regard to administrative practicability, including cost." The appointment of such a committee was requested by Lord Dawson chiefly with a view to obtaining an authoritative pronouncement on the subject of medical preventive measures, and the committee's report will be awaited with much interest.
SECTION 5.—LEGISLATION IN NEW ZEALAND, PAST AND PRESENT.
(A) Contagious Diseases Act (repealed).
The Contagious Diseases Act was passed in 1869, and repealed in 1910. Briefly, its aim was to secure periodical examinations of prostitutes, and to detain for treatment those prostitutes found infected with venereal disease.
There appears to be, in some quarters, an apprehension that hidden beneath the movement to combat venereal diseases is an implied desire or intention to reinstate the antiquated and detested provisions of that Act. The Committee deem it necessary to say that they have not found grounds for this suspicion; that no legislation can be effective unless it deals equally and adequately with all men, women, and children sufferers from venereal diseases of all kinds; that it finds little evidence of a definite prostitute class in New Zealand, and, even if there were such, the Contagious Diseases Acts have been proved to be useless as measures towards the prevention of venereal infections; and it is the Committee's individual and collective opinion that anything involving a return to the administrative procedure of the Contagious Diseases Act should have no part whatever in any new legislation in this Dominion.
(B.) Examples of Difficulties—Concrete Cases.
Before proceeding to refer to present and suggested legislation, a few incidents and cases taken from the evidence may help, as concrete examples, to indicate the difficulties to be contended with:—
Case 1.—A man—young and married, a municipal employee in a city—associated sexually with a female employee in an eating-house frequented by himself and co-employees. In due time he sought the advice of the Medical Officer of Health for (what he suspected) severe syphilis. Steps were taken to obtain his speedy admission to the local hospital. The woman continued in her employment.
Case 2.—A social-hygiene worker in her evidence said: "I think the majority of cases I deal with (girls attending a hospital clinic) are caused through mental depravity, and in some instances you cannot convince them—they continue to carry on. I have tried all I know how to show them the dangers, but they just laugh at me. I think it is really in many cases just a mental condition—mental degeneration, possibly." This officer explained that even while actually attending the clinic some of these girls (affected with gonorrhoea), without any semblance of reserve or decency, would discuss arrangements for further intercourse with men, and on leaving the clinic (still in an infectious state) were even seen to go off with young men waiting for them.
Case 3.—Asked if he knew of any cases where the disease had been contracted innocently, a medical practitioner stated in evidence: "I know of a case where two girls in —— were infected (syphilis) on the lip through a young fellow handing them a cigarette which he was smoking."
Case 4.—A medical man in private practice, and Medical Superintendent of the hospital in a small country town, states: "Although, judging from an experience of over fifteen years, this district would appear to be peculiarly free from any variety of venereal disease, I think it may be of interest to your Committee to know what happened here in the early part of 1918. At that time there came to reside with her father in ——, a township about nine miles south of ——, a woman, ——, who, shortly after her arrival consulted the late Dr. ——, and was found to be the subject of secondary syphilis.... In all, three cases of gonorrhoea, four of soft chancre (three of whom suffered from phagadoemic ulceration which laid them up for weeks), and six cases of purely syphilitic infection came under my care, all traceable to this same woman. As every case of gonorrhoea and soft chancre afterwards developed syphilis, ultimately I had thirteen cases of syphilis under my treatment alone. Others, I have good reason to believe, went to other towns, and doubtless some failed to seek any kind of help.... Having prevailed upon the woman to come to my surgery ... I told her that she was suffering from three varieties of venereal disease, which she was freely disseminating. I then read to her that part of the Act which deals with those who "knowingly and wilfully disseminate venereal infection." That same afternoon she left for ——, where she continued to ply her calling unhindered. Who can estimate the sum of the damage done by one such person? Not one of those men infected was properly treated, although I did all I possibly could to convince them of their own danger and of the risk of spreading infection to others. Gradually, as the obvious signs of active disease abated, they drifted away. I may say the Wassermann reaction proved strongly positive in every case.... One of these men passed on his infection (syphilis) to a young girl in this town, and she in turn infected other men, one of whom came to me, while others went to my colleagues. Another man of the first group, about middle age, and previously a very healthy, sober, hard-working fellow, has developed thrombosis of his middle cerebral artery as the result of a syphilitic endarteritis. He is totally incapacitated, and in the Old Men's Home at ——. He remains a permanent charge on the community."
(C.) Hospital and Charitable Institutions Act, 1913, Section 19.
In 1913 the need for detention provisions, to cover any infectious or contagious disease, received the attention of Parliament, and these are embodied in section 19 of the Hospitals and Charitable Institutions Act, 1913, thus:
"19. (1.) The Governor may from time to time, by Order in Council gazetted, make regulations for the reception into any institution under the principal Act of persons suffering from any contagious or infectious disease, and for the detention of such persons in such institution until they may be discharged without danger to the public health.
"(2.) Any person in respect of whom an order under this section is made may at any time while such order remains in force appeal therefrom to a Magistrate exercising jurisdiction in the locality, and the Magistrate shall have jurisdiction to hear such appeal and to make such order in the matter as he thinks fit. An order of a Magistrate under this subsection shall be final and conclusive.
"(3.) Regulations under this section may be made to apply generally or to any specified institution or institutions."
The Committee are advised that this section was not aimed solely at venereal diseases. In that year, and prior thereto, was prominent the difficulty of detaining consumptives who refused to take precautions to prevent the spread of their disease to others; and, again, much attention was being centred on the chronic typhoid and diphtheria "carrier." It seemed rational to compel isolation of such persons in hospital until there was some assurance that they would no longer be a danger to the community if allowed their liberty. Regulations under the Act were not issued, owing to opposition manifested at the time, and consequently the section never became operative.
(D.) The Prisoners Detention Act, 1915.
This Act secures that individuals of one class of the community—viz., convicted persons—can be held until freed from venereal disease with which they were known or found to be infected. The measure is of value, but logically seems unsound, because the venereal diseases from which such persons suffer are in no way a greater danger to the public than the same diseases in the law-abiding subject of any class, and, furthermore, the Committee have no reason to conclude from the evidence that convicted persons, as a whole, show a higher percentage of venereal cases than those who never enter a prison. The Controller-General of Prisons submitted a schedule showing that the number of prisoners detained under the Prisoners Detention Act from its commencement in 1916 to 1922 was twenty-eight, consisting of nineteen males and nine females.
(E.) Social Hygiene Act, 1917.
In the words of the Commissioner for Public Health of West Australia, who prepared the first comprehensive legislation on venereal diseases in 1915, this Act "can hardly be classed with recent Australian legislation, for the reason that it provides for no notification of the disease and no compulsory examination." By this Act infected persons are required to consult a medical practitioner and go under treatment by him, or at a hospital; but no penalty is provided, and there is nothing to compel such persons to do either of these things.
Reference to case 1 in the concrete examples cited above will show the weakness of the Act. The waitress continued in employment, handling cups and spoons and cakes, &c. The Medical Officer of Health had every reason to believe she was infected with syphilis, but, not having the power to insist on her obtaining medical advice, he could do nothing to enforce the provisions of section 6 of the Act.
Section 7, making it an offence for any person not being a registered medical practitioner to undertake for payment or other reward the treatment of any venereal disease, has, in the opinion of the Commissioner of Police, proved beneficial in restricting the operation of quacks, but he suggests that it should be amended by deleting the words "for payment or reward," as it is sometimes easy to prove the treatment and difficult to prove the payment, and it is the treatment by unqualified persons that is aimed at.
Section 8, which makes it an offence knowingly to infect any person with venereal disease, is practically inoperative, as will be shown later in this report, owing to the extreme difficulty, in the absence of any system of notification and compulsory treatment, of proving that the offence was committed knowingly.
The Committee desire to draw attention to section 13. Herein is provided towards hospital maintenance a higher subsidy for venereal patients than is receivable for the maintenance of patients suffering from other infectious diseases. They think that it is inadvisable to particularize venereal sufferers, or, indeed, to draw any distinction between different classes of diseases in a hospital, and that the ordinary subsidy should be paid in all cases.
In this Act also is power to make regulations for the "classification, treatment, control, and discipline of persons detained in such hospitals," but apparently, owing to the opposition to the almost analagous provision in the Hospitals and Charitable Institutions Act, 1913, no such regulations have as yet been made.
PART II—PREVALENCE OF VENEREAL DISEASES IN NEW ZEALAND.
(A.) Medical Statistics.
The first item on the Committee's order of reference is "To inquire and report, as to prevalence of venereal diseases in New Zealand."
One of the first matters which engaged the attention of the Committee was the question how reliable information could be gathered which would indicate the present prevalence of these diseases in this country. Recognizing that it would be impossible to obtain trustworthy figures without securing the widespread co-operation of the medical profession, the Committee at an early stage sought and was readily given the help of the British Medical Association in the matter. Representatives of the Association gave their assistance in the preparation of a form to be sent to and filled in by all practising members of the profession, and in the current number of the New Zealand Medical Journal an appeal to members for their collaboration was made. Suitable circular letters were also prepared by the Committee asking medical practitioners for their co-operation, and the Committee are pleased to be able to report that out of about 750 in actual practice, no fewer than 635 medical practitioners sent in completed returns. A copy of the form used for these returns will be found as an appendix to this report, as also a tabulated return of the replies received and compilations therefrom.
It will be seen that the total number of cases of all forms of venereal diseases and of diseases attributable to venereal disease under the personal care of the doctors reporting is 3,031; and, taking the population of New Zealand as 1,296,986 (estimated population 31st March, 1922), this means that about one person in every 428 of our population is at present being treated for venereal infection or for the results thereof. Acute and chronic gonorrhoeal infections give a total of 1,598, being about one person in every 812 of the population. This is most likely a very low estimate, for the Committee have had it very definitely in evidence that many persons suffering, at least from acute gonorrhoea, seek treatment at the hands of persons other than registered medical practitioners. For syphilitic infections in all forms the total is 1,419, about one person in every 914 of the population. The return bears out other evidence showing that the chancroid or soft-sore type of infection is rare in this Dominion.
The Committee regard the result obtained as furnishing some indication of the amount of active venereal disease existing in the Dominion. The Committee consider, however, that these figures must be considerably on the low side, for these reasons: (a) that a number of medical practitioners have not replied: (b) that some diseases attributable to venereal disease may not have been conclusively diagnosed as such, and, therefore, not included in the return. The return necessarily does not include cases, probably numerous, which have not been under medical care for some time, if at all; (c) to secure a complete return would have involved the keeping by each doctor of full records of all cases and a careful and laborious collation of figures.
With respect to the expression of opinion asked of medical practitioners upon the question "If venereal disease in this Dominion has or has not increased in a greater proportion than the population during the last five years," it will be seen that of 322 who replied, 199 answered "Yes" and 203 "No." This is necessarily purely a matter of impression, and it must also be borne in mind that the evidence shows that patients are now using the clinics in large numbers, while others who formerly went to general practitioners now consult specialists who have recently started in practice. On the other hand, it is possible there is a compensating influence in the fact that the public are being educated to the importance of seeking skilled medical treatment for these diseases.
(B.) Clinic Statistics.
A second source of information as to the prevalence of venereal diseases was provided by the statistics which have been compiled by the Department of Health as the result of the establishment of the venereal-diseases clinics. Among the appendices to this report will be found a return showing the number of persons attending at each of these clinics for the years 1920, 1921, and part of 1922, and recorded under the headings "Sexes" and "Diseases." These statistics are valuable insomuch as they record facts, but with respect to the total prevalence they are but an indication, since they relate only to a small proportion of the population who have become infected and sought treatment. From this table (B) it will be found that the males attending for the first time represent 83.60 per cent. of the total, and females 16.40 per cent., or, roughly, a ratio of six males to every female.
Clinic Distribution.—In the figures for syphilis the following points are worthy of note: Auckland: A distinctly higher number of cases than the other centres. A marked drop in 1921 for males, but the return for this year indicates a rise; female cases show a rise for this year. Wellington: Returns appear fairly uniform, with a slight falling tendency, most marked in the females. Christchurch: A drop in male cases, with a fairly uniform rate of females. Dunedin: Here the rates appear uniform, with exception of a fall for males in 1922.
As to gonorrhoea, these points may be noted: Auckland: A marked rise. Wellington: Steady rise with exception of females. Christchurch: Slight rise since 1920: females uniform rate. Dunedin: Slight rise, with indication of male increase in 1922.
Age Distribution.—The age-period of persons attending the clinics is mainly eighteen to thirty.
Marital Condition.—From the evidence of the clinics it is very apparent that venereal disease is especially a problem associated with the unmarried.
(C.) Mental Hospital Statistics.
A third source of estimation of prevalence was opened to the Committee by the Inspector-General of Mental Hospitals. The method of investigation adopted by Dr. Hay is based on Fournier's estimate that 3 per cent. of the cases of syphilis existing at any one time will ultimately develop dementia paralytica.
The introduction of the Wassermann test and treatment by salvarsan or other arsenical preparations will vitiate this index in future, for the reasons that by the Wassermann test more cases will be diagnosed, and by the use of recent remedies the complete cure of many more cases will be effected, and consequently fewer will develop dementia paralytica. This disability does not develop until about ten to fifteen years after infection. The Wassermann test and the modern arsenical preparations have not yet been in use for that period, therefore these figures, as an estimate of the prevalence of syphilis in 1921, would not be materially affected by these developments. An estimate based on these data may therefore be regarded in the meantime as approximately correct.
During the past ten years 4,763 males and 3,747 females have been admitted into New Zealand mental hospitals. The percentage of syphilitic admissions of all types was 4.74, while the percentage of cases of dementia paralytica was 3.89. In other words, of the admission of syphilitics 82 out of every 100 cases were dementia paralytica. The average yearly number of deaths from dementia paralytica according to the Government Statistician's returns between 1908 and 1921 was just under 40.
If Fournier's estimate that 3 per cent. of syphilitics ultimately develop dementia paralytica be accepted, one would arrive at the annual infection by multiplying 40 by 33, which gives 1,320. Assuming the average duration of life, after infection, to be twenty-five years, this means that at any given time there are twenty-five years' infections on hand. Dr. Hay computed from this the number of persons in New Zealand now who have, or have had, syphilis to be 1,320 x 25, equalling 33,000, or 1 to every 38 of the population. If the average duration of life after infection were assumed to be thirty years, the figures would be 1 to every 32 of the population.
Taking the figure for syphilitic infections over a period of years at 1,320 per annum, this would mean for the population of New Zealand (exclusive of Maoris) 1 fresh infection annually in about every 850 persons.
(D.) Incidence among Maoris.
It is even more difficult than in the case of the European population to say what is the prevalence of venereal diseases amongst Maoris. The Director of the Division of Maori Hygiene (Dr. Te Rangi Hiroa) in a statement to the Committee says:—
"Venereal disease made great ravages amongst the Maori population in the early days of colonization. To this may be attributed much of the sterility, with histories of repeated miscarriages, that existed in the transitional period of Maori history. Most of the old men—hemiplegias, and paraplegias, and subsequent general paralysis of the insane—gave an old history of syphilis. These cases that I saw twenty years ago have now disappeared.
"In my experience of eighteen years' constant work amongst the Maoris venereal disease has been comparatively rare. It disappeared amongst the people, only to recrudesce in some localities as fresh infection was introduced by the white man, or brought back to the settlements by visits to the white towns. I see very little of it at present, but now and again hear reports from medical officers that it has cropped up in the settlements near them ... In all these cases I am convinced that the origin is from a white source, and the problem amongst the Maoris is not nearly so serious as amongst Europeans. It seems to me unjust that the idea should be circulated that the Maoris are a source of danger to the European community—the reverse is much more likely.
"It is impossible for me to supply accurate data as to the incidence of the disease amongst the Maori race at present, but I am confident that reports have a natural tendency to become exaggerated. I do not consider that returned Maori soldiers, owing to the treatment they received before being discharged from the service, have been a factor in the introduction of the disease amongst the settlements. If they have in some areas, it has been from fresh infection, which their experience of prostitution in Egypt and Europe has made them more liable to acquire from professional and amateur prostitutes in towns. At the same time, the experience of returned soldiers as to the value of treatment makes them more likely to seek such aid."
There are no trustworthy statistics in any part of the British Empire of the deaths due to venereal disease. Many persons die from illnesses which result from an initial syphilis contracted perhaps many years prior to death. It is well known that medical practitioners, from a laudable desire to spare the feelings of relatives, refrain from stating the primary cause of death in such cases, and merely enter the secondary or proximate cause. For the same reason, the statistics regarding deaths due to alcoholism, and perhaps in a less degree some other factors in the mortality returns, are incomplete and consequently useless.
Both the Royal Commission on Venereal Diseases and the Birth-rate Commission recommended that the medical attendant should issue two certificates—one, which would be a simple certificate of death, to be handed to the relatives, and the other, a confidential certificate giving the primary cause of death, which would be transmitted to the Registrar.
The Registrar-General for New Zealand, Mr. W.W. Cook, in his evidence in chief, stated that he did not favour these suggestions. A certificate of death, he said, cannot be regarded as confidential, as the information contained therein is recorded in the death entry, which may be inspected by the public, and of which a copy may be obtained by any applicant. In reply to questions, however, he stated that the law could no doubt be altered so as to make the death-certificate confidential, the information to be given up only on an order from a Court of justice. Apart from the fact that the insurance companies might object, he did not see any objection from the public point of view.
Mr. Malcolm Fraser, the Government Statistician, said that there was considerable division of opinion on this question at the British Empire Statistical Conference held in London in 1920, when statisticians from all parts of the Empire were present. It was generally agreed that the system was good theoretically, but some doubt was expressed whether in practice there would be as much improvement as was expected, since the system would depend entirely on the medical attendant strictly complying therewith and disclosing the true cause of death in every case. Any system of confidential information always had that failing. The witness thought the register must be open for persons having a right to call for copies of entries. In dealing with insurance claims at death the truth or otherwise of the statement in the proposal form was important, and might require verification by inspection of the death entry. At the Conference Dr. Stevenson, the Statistician to the Registrar-General of the United Kingdom, was very pronounced in his advocacy of the confidential form of certificate. The Conference passed the following resolutions: "(1.) That the present system of open certification tends to prevent candid statements of the causes of death, and thus introduces a systematic error into death statistics. (2.) That the error would be eliminated by a system of confidential certification."
The Committee, while agreeing that such a system of registration of deaths would undoubtedly afford better means of approximating to correct returns of mortality not only from venereal diseases but also from alcoholism and some other diseases, would point out that, if New Zealand were to adopt the reform while the rest of the Empire retained the present system, the result would be to place the Dominion in an apparently unfavourable light in comparison with other parts of the Empire in regard to the mortality from these diseases.
SECTION 2.—CAUSES OF THE PREVALENCE OF VENEREAL DISEASES IN NEW ZEALAND.
In discussing this order of reference the Committee desire it clearly understood that these causes are not peculiar to New Zealand, and do not operate more extensively in New Zealand than elsewhere. The Committee are concerned, however, in discussing this question only as it affects New Zealand.
The causes of the spread of venereal disease may be classified under two main headings: (1) The presence of infected individuals acting as foci of infection; (2) the occurrence of promiscuous sexual intercourse, by which in the great majority of cases the disease is actually transmitted from one individual to another.
(1.) The Presence of Infected Individuals.
These sources of infection arise and persist for the following reasons:—
(1.) Neglect by infected persons to undergo treatment. (2.) Neglect to continue treatment till no longer infective. (3.) The treatment of infected individuals by unqualified persons, such as chemists, herbalists, chiropractors, &c. In these cases the disease becomes chronic, and the best opportunity for its treatment and cure has passed before the case is seen by a medical man. (4.) By the introduction of venereal disease to this country from overseas.
(2.) The Occurrence of Promiscuous Sexual Intercourse.
A striking portion of the evidence placed before the Committee was that which showed the very small amount of professional prostitution in New Zealand. This was supported by the valuable evidence of Mr. W. Dinnie, ex-Commissioner of Police, and Mr. A.H. Wright, Commissioner of Police. The latter witness stated that there were only 104 professional prostitutes in the Dominion.
It would appear also that the professional prostitute, as a result of her knowledge and experience, is less likely to transmit venereal disease than the "amateur." It is therefore principally to clandestine or amateur prostitution that one must look for the dissemination of the disease, and inquiry into the conditions which tend to the production of the amateur prostitute is a direct inquiry into the causes of the prevalence of venereal disease.
The evidence before the Committee shows that this promiscuity is very prevalent, and that it is not confined to any particular social strata. The fact is also strikingly demonstrated by Table A in the appendix. From this table it will be seen that during the period 1913-21 there were 10,841 illegitimate births and 33,738 legitimate first births within one year after marriage. If to the illegitimate births we add the total number of live births occurring within the first seven months of marriage viz., 12,235—which may be safely considered to have been conceived before marriage, we get a total of 23,076 births in which conception took place extra-maritally. In other words, more than 50 per cent. of total first births occurring within twelve months of marriage result from sexual contact prior to marriage.
Some factors which contribute in a greater or less degree to the moral laxity which leads to promiscuous sexual intercourse are:—
(1.) The relaxation of parental control, which was emphasized by many witnesses. Girls stay less at home and assist less in the work of the home, preferring whenever opportunity offers, to go to the pictures or some other form of entertainment.
(2.) Lack of education of the young in the facts pertaining to sex. Especially the Committee would call attention to the unfounded belief of many that continence in young men is injurious to health.
(3.) Bad housing and general conditions of living. When members of both sexes are crowded together in restricted accommodation in which often insufficient conveniences are supplied, it is easy to conceive of a relaxation of the proprieties of life which might lead to acts of immorality.
In this connection the Committee desire to call attention to the excellent work done by the Y.W.C.A. and other bodies in the provision of hostels in which girls are provided with board and lodging at very reasonable cost. The Committee were surprised to learn that full advantage was not taken of these provisions, and that the accommodation at these hostels was not fully occupied. It would appear that many girls resent the very slight amount of supervision and restraint exercised over them, precisely as they do parental control.
(4.) The presence in the community of individuals, especially girls, who are to some degree mentally defective or morally imbecile. The Committee were given several individual instances in which such girls had acted as foci of infection; they are easily approached, and facile victims for men. In spite of a degree of mental or moral defect they may be physically attractive.
(5.) Economic conditions which delay marriage may reasonably be regarded as a factor in conducing to an increased frequency of extra-marital sexual relationship. Graph A in the appendix shows clearly that the age of marriage in both sexes has, with slight fluctuations, steadily increased from 1900 to 1921.
(6.) Alcohol tends to the dissemination and persistence of venereal disease: it increases sexual desire, lessens control, causes the individual to be less careful as regards cleanliness, &c., after exposure to infection, and militates against effective treatment. It is to be pointed out, however, that the lower control possessed by some individuals may be the actual predisposing cause, both of laxity in sexual matters and of the excessive ingestion of alcohol. There appears no doubt that alcohol is an important factor in the prevalence of venereal disease, although probably not so potent as represented by some witnesses.
(7.) Accidental infections are undoubtedly rare. They may arise from contact with W.C. seats, dirty towels, and eating and drinking utensils in public places.
(8.) Other factors of minor importance which were mentioned in evidence were the modern dress of women, which was stated to be in certain cases sexually suggestive, and certain modern forms of dancing. There appears some grounds to suppose that dances conducted under undesirable conditions contribute to sexual immorality, but the Committee see no reason to condemn dancing generally because the coincident conditions under which it has been or is conducted in some cases have contributed to impropriety. The cinema was stated by some witnesses to have an immoral tendency both in the nature of the pictures presented and in the conditions under which they are viewed by the audience. The Committee suggest that a stricter censorship might with advantage be exercised, and should include the posters advertising the films.
It has been stated that venereal disease has increased in New Zealand with the return of the Expeditionary Force from overseas. Ample evidence, however, was given to the Committee that there has been no increase of the disease due to returned soldiers. These men were treated prior to their discharge until non-infective.
PART III.—BEST MEANS OF COMBATING AND PREVENTING VENEREAL DISEASE.
SECTION 1.—EDUCATION AND MORAL CONTROL.
There is no question that the most effective way of avoiding venereal disease is to refrain from promiscuous sexual intercourse. The problem which the Committee have been asked to consider has very important medical aspects, but, while these must not be neglected, it is essential to the health and well-being of the nation that the enemy should be attacked with every moral and spiritual weapon:—
Self reverence, self-knowledge, self-control,— These three alone lead life to sovereign power.
The absence of proper training and instruction of the young is undoubtedly responsible for a great deal of the evil which has been shown to exist. Children are led into bad habits through ignorance, and young men and young women grow up with utterly false ideals of life, and in many cases fall into deplorable laxity of conduct.
There is an impression among many young men that chastity is either impossible or at least is inconsistent with physical health. There is the highest medical authority for stating that this notion is absolutely wrong, while there is no difference of opinion whatever as to the serious risks of contracting diseases of a very loathsome character incurred by those who do not restrain their passions. Apart from this aspect of the question, it must be obvious to every thinking person that looseness of conduct between the sexes such as is shown to exist in New Zealand is destructive to the high ideals of family life associated with the finest types of British manhood and womanhood, and if not checked must lead to the decadence of the nation.
A sounder state of public opinion needs to be cultivated. The moral stigma at present attached to sufferers from venereal disease should rest upon all who sacrifice to their own selfish passions the chivalrous relations which should subsist between the sexes. Those who are unfortunate enough to contract disease incur a punishment so terrible that they deserve our pity and our succour, always provided that they seek skilled treatment and refrain from any conduct likely to communicate the disease to others. The man or woman who negligently or wilfully does anything likely to lead to the infection of any other person is a criminal, and should be treated as such.
To bring about this healthier state of public opinion much might be done by the various Churches, by the Press, and by all who are in a position to influence the thoughts of others. It is a duty which should be shared by all—it cannot be left entirely to the Government, to Parliament, or to the medical profession. If a healthier atmosphere were created for the proper consideration of this subject, instead of the unwholesome fog of prudery in which it has been enveloped in the past, a great deal will have been gained.
One result of the mistaken policy of reticence which has prevailed is to be seen in the fact, already mentioned, that children are allowed to grow up either in ignorance of sex physiology or with perverted ideas due to the want of proper instruction. Nearly every witness who spoke on the subject before the Committee agreed that such instruction would come best from the parents, but there is also practical unanimity among those who gave evidence that very few parents are capable of giving such instruction in the right way, and the vast majority are unwilling to attempt it. In these circumstances our chief hope for the future seems to lie in an endeavour to educate the children in such a way that they, the parents of the future, may be enabled to deal justly with their own children in this vital matter. Nevertheless, the Committee would be failing in their duty did they not point out that all parents have a serious responsibility to their children which they cannot evade without laying themselves open to grave reproach. It is probable, as one of the witnesses remarked, that "nothing they could do for their children's happiness in life would be of equal value to the outlook which they might give to their children upon this matter. Apart from any possibility of moral ruin or disease, such an outlook would colour the whole mature life of their children in respect to what is probably the foundation of the greatest human happiness—namely, home relationship."
The Committee recommend that the Department of Health be asked to prepare a suitable pamphlet to assist those parents who desire to instruct their boys and girls on this subject. It is also suggested that where parents feel themselves unable to undertake the necessary instruction, the family doctor should be asked to talk to the boys. Instruction to the girls should certainly come from the mother, but failing this a little wise counsel and advice from a woman doctor should be secured.
In regard to the teaching of sex hygiene in schools some interesting evidence was given to the Committee by Mr. Caughley, Director of Education, Mr. T.R. Cresswell, Principal of the Wellington College (speaking on behalf of the Secondary Schools Association), and by some of the women doctors and others who were good enough to attend as witnesses.
Mr. Caughley stresses the point that it is not mere knowledge of physiology that will meet the case. He considers that the most important thing of all is to establish in the minds of the children noble ideals with regard to infanthood and motherhood. Lessons in connection with the care of all birds and animals for their young, with the love and devotion of parents for their young, with all that is beautiful and tender connected with the homes of animals and birds, would establish a kind of reverence about everything that is connected with birth. He deprecates mechanical, systematic, and consecutive instruction in the mere facts of sex hygiene, for even the fullest knowledge on this subject is known to have very little deterrent effect in the temptations of life. He would rather aim at creating the right atmosphere in a school, such as would make any coarse or unworthy mention of any of these matters in the hearing of a child appear more or less repulsive, and would in general enable him to put in its proper setting any knowledge that might come to him from various sources.
Mr. Cresswell gave the Committee an extremely interesting resume of the answers to a questionnaire which he addressed to the head of every secondary school in the Dominion. He suggested—(1) That a determined public effort should be made to rouse parents to a sense of their responsibility in regard to this matter by means of broadcasted pamphlets, and that they should be furnished with simple, specially written leaflets to assist them in giving instruction to their children; (2) that sex hygiene be made a compulsory subject in all training-colleges, the instructors being specially qualified doctors; (3) that regular courses of public lectures be delivered in suitable centres; (4) that teachers, and especially physical instructors, be encouraged to stress the value of physical fitness to pupils collectively, and, where need is indicated, to have private talks with individuals; (5) that teachers be advised to take every opportunity during lessons in hygiene, physiology, botany, &c., to give children a sane and normal outlook on sex matters.
Incidentally it was suggested that girls' schools suffer somewhat through being staffed almost exclusively by celibate teachers. "The knowledge and sympathy of a real mother would," it was urged, "be invaluable to many girls in our secondary schools. Does it seem a trivial suggestion that in every girls' school there should be one honoured official, the 'school mother,' a sympathetic motherly person whose duty it should be to get into personal touch not only with individual girls but also with individual parents?"
The views expressed by the Swedish Committee of Experts in Medicine and Pedagogy are well worthy of quotation: "It is illustrative of the broad view taken by the committee of their task," says the British Medical Journal, "that they deal with the education of the child from the time it learns to speak and address inquiries as to how it came into the world. The committee look forward to the time when parents will be so enlightened that they will not tell their children silly stories about babies being brought into the home by storks, but will give a simple account which the child in later years will not discover to be mendacious. The committee hope that the child, who is gradually taught more and more about sex hygiene as it passes from one school grade to another, will eventually become a parent wise enough to instil in the next generation a frank and healthy attitude towards sex problems. Parents, it is hoped, will learn to protect their infants from the undesirable caresses and kisses of strangers ... As for sex teaching in school, this should be associated with the teaching of biology, Christianity, sociology, and psychology. The question of venereal disease should not come into the curriculum until comparatively late, and until the physiology of fertilization and reproduction has been fully taught. Advanced sex teaching should preferably be in the hands of doctors; but they are not always available, in which case other teachers should give instruction on this subject, male teachers dealing with boys and female teachers with girls. Teaching of sex hygiene in high schools for girls should include the subject of venereal disease, and special emphasis should be laid on the protection of infants from infection. A further recommendation is that a carefully supervised library of works on sex hygiene and venereal disease should be compiled at the cost of the State for the use of teachers and classes."
The Committee of the Board of Health agree with the suggestion that teachers should be trained to deal with this question, and that school medical officers or other qualified practitioners should give occasional "talks" to the elder boys and girls. A great deal may be done by physical instructors preaching the gospel of "physical fitness" and personal cleanliness in thought, word, and deed. Bathing and outdoor sports and games of all kinds should be encouraged. The Committee would point out, however, that not all teachers and not all medical men possess the qualities fitting them to give instruction and advice in this delicate matter. The task should be entrusted to those who have shown themselves specially adapted by sympathy and tactfulness for the work, and preferably those who are parents, otherwise harm instead of good may result.
More than one witness spoke with approval of "The Cradleship" and other books by Miss Edith Howes as suitable for use with young children.
The Committee are of opinion that addresses on sex questions by lay persons, except selected teachers, to young people in mass are of doubtful value.
Sufficient instruction should be given to adolescents regarding venereal diseases and their effects to ensure that if they do contract them it shall not be through ignorance. The Committee cannot too strongly emphasize their belief, however, that knowledge of the effects of venereal diseases is in itself by no means a sufficient safeguard; that in addition to such knowledge the cultivation of a high moral standard is necessary, and if this is reinforced by religious sanctions it is likely to be more effective.
The Committee agree with the view expressed by Dr. E.T.R. Clarkson in a recent text-book, entitled "The Venereal Clinic," that in many instances an excessive stress has been placed upon the factor of fear. He says that a very small proportion of the community are restrained from indulging in promiscuous sexual intercourse through fear, and it is irrational to rely so much upon an emotion which at the best is but slightly inhibitory, and which cannot in itself exercise a direct energizing influence for good. "We do not," he continues, "wish to deter the community from living a life of sexual promiscuity by rendering them fearful of the possibilities of acquiring venereal disease, but we want rather to instil such an ideal into them, whether it be of a religious, ethical, or altruistic nature, as will tend to make them regard such a life as incongruous with those tenets and therefore as undesirable, however much it may be desired on other grounds." He adds that the emphatic reiteration of fear possesses another and dangerous disadvantage. "There is no doubt, as venereologists will testify, that many individuals are seriously suffering from the effects of fear thus engendered in their minds. In some instances the resultant damage to their mentality is more serious than the venereal disease from which they are suffering: whilst in others an obsession that they are infected, when there is no foundation for the fear, may develop in such a manner as to inflict serious and permanent damage."
SECTION 2.—CLINICS FOR THE TREATMENT OF VENEREAL DISEASE.
Early in 1919 clinics for the treatment of venereal disease were established in each of the four main centres. Arrangements were made by the Department of Health for the treatment by Hospital Boards throughout the Dominion of cases of venereal disease, and in the absence of local institutions arrangements were made with private practitioners. There is therefore opportunity for all to receive free treatment, wherever they may be, in New Zealand.
Table B sets out the work done at the four clinics during the two and a half years ended 30th June, 1922. From this table it will be seen that 3,038 males and 596 females attended these clinics during the period named. The total number of attendances was 110,792—101,995 males and 8,797 females. The disproportion between the number of males and females attending is notable. It is clear from the evidence that this does not represent a difference in the incidence of these diseases in the sexes, but that women do not attend so freely when suffering.
These clinics are attached to the public hospitals in each centre, and all evidence goes to show that this is most desirable. If the clinics were apart, the object of the patients' visits would be obvious, whereas the actual purpose for which they go to a hospital is not so. It is to be strongly emphasized that the less publicity given to the attendance of these patients, the greater the number of patients who will be likely to take advantage of the treatment offered. This applies especially to the attendance of women.
The clinics are now open only at certain hours. The Committee suggest that they might with advantage remain open continuously (except at certain fixed hours on Sunday). In the absence of the Medical Officer a sister could take charge of the women's clinic, and a trained orderly of the men's clinic. It would be necessary in this case to have separate clinics for male and female patients—the same rooms would not be available for both sexes.
The majority of witnesses asked were of opinion that if a lady doctor were made available for the treatment of women the number of women attending would increase.
It is suggested that in certain cases of gonorrhoea, where it is an advantage that the treatment should be carried out twice or more often daily, arrangements might he made for the supply of the necessary apparatus and drugs to patients at cost price, and in indigent cases free of charge. This is particularly important to women who may have to continue treatment for several months.
The clinics should be more widely advertised by notices in public conveniences and other suitable places.
The Committee are impressed with the valuable work done at these clinics, and recommend their extension to other centres as opportunity offers and necessity is shown to exist.
The existing clinics are conducted by medical men who have had special experience and training in the treatment of these diseases. The Dunedin clinic is attended by medical students for purposes of instruction. In view of recent advances in the processes of diagnosis and treatment of these diseases, the Committee consider that opportunity should be given to medical practitioners to attend these clinics in order to familiarize themselves with the most recent advances in this field. It would he an advantage also if nurses in the course of their training attended the female clinics, so that they might he taught to recognize the commoner manifestations of these diseases.
The most disappointing feature in the records of the clinics is the cessation of treatment by so many patients before they have ceased to be infective. The following evidence was given in this connection:—
Percentage of Cases attending till Non-infective. Auckland Clinic: 80 per cent. cases of syphilis, 50 per cent. cases of gonorrhoea. It was stated that no woman suffering from gonorrhoea continued treatment till non-infective.
Wellington Clinic: 40 per cent. of all cases continued treatment till non-infective, and very few of these were women.
Christchurch Clinic: Men with syphilis, 75 per cent.: men with gonorrhoea, 98 per cent.: women with syphilis, 50 per cent.: women with gonorrhoea, 14 per cent.
Dunedin Clinic: In this clinic only thirty-one males suffering from gonorrhoea were discharged cured: thirty-two absented themselves while still infective; three female cases remained under treatment till cured, and six ceased to attend while still infective. Forty male syphilitics remained till non-infective, and seventy-four ceased treatment before it was completed. For female syphilitics the figures are four and eighteen.
It will be noted that in each case the proportion of women who attend till non-infective is much smaller than of men, especially in cases of gonorrhoea. The reasons for this are probably that owing to anatomical considerations women infected with venereal disease suffer less pain and the disease is less obvious than in men. On cessation of the more urgent and obvious signs and symptoms they stop treatment. Again, it is probable that the publicity of attending the clinics is felt more by women than men. A third reason is the prolonged period of treatment (often extending over many months) necessary to eradicate gonorrhoea in women. These difficulties could to some extent be mitigated by the provision of arrangements for women to carry out treatment in their homes, which would avoid the publicity and loss of time entailed in attending clinics.
The Committee were impressed with the value of the work done by the lady patrol in Christchurch, and considers that lady patrols would help greatly in securing the attendance of women at the clinics. It is recommended that these patrols should be attached to the Hospital Boards and that they should be trained nurses. They would be available to give advice to patients as to treatment in their homes.
The Committee would also draw attention to the very valuable work done by the Social Hygiene Society in Christchurch, and recommended the establishment of similar voluntary societies in other centres.
The Committee recommend that all bacteriological and other examinations required for the diagnosis and treatment of cases of venereal diseases should be carried out in laboratories of the Department of Health and public hospitals free of cost, on the recommendation of medical practitioners.
The Committee made inquiries from competent witnesses as to the present position of the complement fixation test in gonorrhoea. It appears that this test has not reached yet such a degree of reliability as to render it of great diagnostic value, but that it is reasonable to hope that it may be perfected to such an extent to give it a value in the diagnosis of gonorrhoea comparable to that of the Wassermann test in syphilis.
SECTION 3.—LICENSED BROTHELS.
Inasmuch as one of the many letters addressed to the Committee favoured the adoption of the Continental system of licensed houses of prostitution, with medical inspection of the inmates, it seems desirable to examine the arguments for and against such a proposal. Those who support it contend that so long as human nature remains as it is prostitution will continue, therefore it is better that it should be regulated with a view to controlling the spread of disease. It is also urged that the system acts as a safeguard against sexual perversion by providing an outlet for the unrestricted appetites of men; that in its absence clandestine prostitution increases, and innocent girls are more likely to be led astray or become the victims of sexual violence. Apart from the moral aspect of the case, these arguments are entirely fallacious; and even in the countries where the licensed-house system prevails enlightened public opinion has come to that conclusion. In the first place, the idea that the system tends to lessen disease is a dangerous delusion. Owing to the fact, already referred to, that venereal disease in the early stages is difficult to detect in women, even by skilled experts working with the best methods and with practically unlimited time at their disposal, the routine inspection given, for example, in the French and German houses is no guarantee of the inmates being free from communicable disease even at the time of inspection.