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 _résumé_ 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 gonorrhœa, 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 gonorrhœa. It was stated that no woman suffering from gonorrhœa 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 gonorrhœa, 98 per cent.: women with syphilis, 50 per cent.: women with gonorrhœa, 14 per cent.

Dunedin Clinic: In this clinic only thirty-one males suffering from gonorrhœa 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 gonorrhœa. 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 gonorrhœa 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 gonorrhœa. 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 gonorrhœa 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.

Flexner, who spent two years in making inquiries and writing his classic work on "Prostitution in Europe," is most emphatic on this point. The experience of the American troops in the Great War is further strong confirmation. The following is an extract from an article published by the American Red Cross in May, 1918: "During the months of August, September, October, and the first half of November, the houses of prostitution flourished and were half-filled with soldiers. On November 15th rigid orders were issued placing these houses out of bounds, and the immediate result was a great reduction of sexual contacts. As a result there was a steady decline in venereal infections, and the monthly rate per 1,000, which in October reached 16.8, dropped in January to 2.1 among the white troops. During the same period there was an even more striking drop in the infections among the negro labourers, the percentage dropping from 108.7 per 1,000 a month to 11 per 1,000. No statistics could speak more eloquently for the doctrine of closing the houses of prostitution. Our studies showed numerous infections coming from houses 'inspected' three times a week."

In May, 1921, a conference (the North European Conference on Venereal Diseases), in which England, Finland, Germany, Holland, Norway, Sweden, and Denmark participated, passed the following resolution: "This conference, having considered the general measures for the combating of venereal diseases which have been adopted by the participating countries, is unanimously of the opinion, so far as the experience of these countries is concerned, that the legal and official toleration of professional prostitution has been found to be medically useless as a check on the spread of venereal diseases, and may even prove positively harmful, tending as it does to give official sanction to a vicious trade."

On the same point Flexner says: "It is a truism that physicians requiring to equip themselves as specialists in venereal disease resort to the crowded clinics of Paris, Vienna, and Berlin, all regulated towns, because there disease is found in greatest abundance and richest variety--a strange comment on the alleged efficacy of regulation."

Dr. Clarkson, in "The Venereal Clinic," already quoted, says, in reference to the fancied security of licensed houses, "It may strengthen the hands of practitioners to be able to tell interrogators in this subject that in the opinion of leading venereologists, &c., no foundation exists for any such feeling of confidence or security. In other words, the system of licensed houses is a failure, and the 'red light' of lust shines out as the lurid signal of disease and death."

It is surely hardly necessary to urge the moral objections to the proposal. The United States Public Health Service not long ago sent out a _questionnaire_ to representative citizens in various walks of life asking for opinion in regard to open houses of prostitution. There was an overwhelming preponderance of replies against the system on moral as well as hygienic grounds. One Illinois miner answered: "The life of a prostitute is short, and her place must be filled when she dies, and, being the father of two girls, I would not want mine to fill a vacancy, and I think all parents think the same." A Colorado carpenter replied: "The woman engaged in such business may not be my wife, mother, sister, or daughter, but she is somebody's wife, mother, sister, or daughter. It is a violation of all law." One Chief of Police wrote: "Open houses of prostitution breed disease, crime, increase the number of prostitutes, corrupt the morals of the community, and are a menace to the youth of the country." Another replied: "The only reason I have ever heard advanced in favour of houses of prostitution is that they protect innocent girls. I am opposed to sacrificing any woman to benefit others."

If statistics could be obtained it would be probably found that the system tends not only to increase disease, but the volume of sexual immorality and crime. From the most materialistic point of view the system is indefensible; while, looking at it from the moral aspect, it is inconceivable that British people, who spent millions of money to stop the traffic in black slaves, would ever officially countenance a system which enslaves the souls as well as the bodies of its victims and defiles the community in which it exists.

SECTION 4.--EXCLUSION OF VENEREAL CASES FROM OVERSEAS.

The Committee are of the opinion that by the strict exercise of the provisions of section 111 of the Health Act, 1920, much may be done to prevent introduction of venereal diseases from overseas. They suggest, however, that where any person so suffering is required or permitted to attend a clinic he should be accompanied by some responsible officer of the ship, or person authorized by the shipping company concerned, and that the question on the "Report of Master of the Ship" defined by regulations--"Are you aware of the presence on board of any person suffering from ... _(b)_ venereal disease?"--might be strengthened by adopting the Australian quarantine service equivalent viz., "Is there now or has there been on board during the voyage any person suffering from demonstrable syphilis in an active condition, or other communicable disease?"

The evidence given does not show that the number of venereal-diseases cases already in the Dominion is greatly added to by the introduction of cases from overseas. Since 1903 persons suffering from syphilis have been "prohibited immigrants" within the meaning of the Immigration Restriction Act.

SECTION 5.--PROPHYLAXIS.

Before discussing this question it is desirable clearly to distinguish between the procedures which are included under this term. These are--

(1.) The supply of drugs and appliances which are made available for use by the individual before exposure to infection. This may be described as "anticipatory prophylaxis," and has commonly been designated the "packet system."

The Committee condemn this procedure, for these reasons: (i) That the system suggests a moral sanction to vice; (ii) that the individual is lulled into a false sense of security, and may thereby be encouraged repeatedly to expose himself to infection; (iii) that the individual may be thereby deterred from seeking early advice or treatment; (iv) that the drugs supplied may be used for treating disease should it arise, and so delay may result in seeking skilled treatment in the early stages when it is likely to be most effective.

(2.) Treatment applied after exposure to infection. This is called "early treatment." This term is inapplicable, as a disease cannot be treated before it exists. It is also likely to be confused with "abortive treatment," which implies treatment immediately on the appearance of symptoms.

The evidence before the Committee shows that this form of prophylaxis, if applied by skilled persons and within a few hours of exposure, is effective in preventing disease in a great majority of the cases in which it is used.

The Inter-departmental Committee on Infectious Diseases set up by the Ministry of Health in 1919 in connection with demobilization, in a note on "Prophylaxis against venereal disease," reported among its conclusions based on service experience, "That where preventive treatment is provided by a skilled attendant after exposure to infection the results are better than when the same measures are taken by the individual affected, even after the most careful instruction." After exposure to infection there appears no reason why these diseases should not be regarded in precisely the same manner as other infectious diseases, and precautions taken to sterilize the parts which have been exposed to infection.

It is to be noted that it is recommended that the prophylactic treatment is to be carried out by some properly instructed person. This need not necessarily be a medical man. It is suggested that this form of prophylaxis might be carried out by an orderly at the venereal-disease clinics. The notices posted in the public conveniences and other suitable places indicating the existence of the clinics and the necessity for treatment might include a guarded reference to their use for this purpose.

This form of prophylaxis applies to males. In the case of females the methods adopted would be also contraceptive, and the Committee do not recommend that facilities should be provided for this.

The Committee must not be supposed to advocate prophylaxis as in any way a substitute for continence and the cultivation of that high moral tone that repels any suggestion of promiscuous sexual relationships, but they feel that they could not properly ignore reference to a method of prevention of these diseases which has proved very efficient in the services, to which there appears no reasonable ethical objection, and which brings their prophylaxis into line with that of other infectious diseases.

SECTION 6.--LEGISLATION REQUIRED.

(A.) _Conditional Notification._

The only subjects of importance upon which the witnesses examined differed materially in opinion were--(1) whether there ought to be any system of notification of cases of venereal disease, and (2) what steps, if any, should be taken to deal with persons suffering from such disease in a communicable form who refused to be treated, and in some cases were even known to be spreading the disease broadcast. Ladies who attended to give evidence on behalf of the National Council of Women and one or two other women's organizations objected to notification and compulsory treatment. They argued that there was at present a "scare" on the subject of venereal disease, and deprecated "panic legislation." They contended that the adoption of notification would deter patients from seeking treatment for fear of publicity. They were opposed to compulsory treatment of recalcitrant patients, arguing that any law of the kind would be used most oppressively against women. They contended that reliance should be placed on greater facilities for free treatment at the clinics, the work of women patrols, suppression of liquor, and above all education and propaganda on moral lines.

When confronted with typical cases of difficulty already quoted some of the witnesses admitted that it was not easy to see how such cases could be dealt with satisfactorily without compulsion of some kind. But they argued that, even so, it would be a greater evil if the fear of publicity and the fear of compulsion should have the effect of deterring sufferers from seeking treatment and so drive the disease underground.

The National Council of Women, by a substantial majority, at a recent conference in Christchurch, carried a resolution protesting against a proposal to introduce compulsory notification and treatment of venereal diseases, and urging the Government to increase the facilities for free treatment. The President of the Council, however, informed the Committee that most of the nineteen societies affiliated to the Auckland Branch of the National Council are in favour of some form of compulsion, but a number of the southern branches are opposed to it. Speaking as an individual, and not as President of the National Council of Women, she added:

"Personally, I have no first-hand knowledge as to whether the disease is so prevalent in the community as to demand urgent measures, but there is an opinion among women social workers and medical practitioners, whom I have consulted, that something should be done, and they are in favour of compulsion under the Act, provided its administration is satisfactory. There is no doubt that there is a genuine and widespread fear among a large number of women that, although in the Act itself there is no discrimination between men and women, in actual practice there will be, and they fear that the Act will be enforced against women, and particularly immoral women, while the men concerned will be allowed to go free. This fear arises partly from the remembrance, particularly among elderly women, of the old Contagious Diseases Acts, both here and in England, and partly from the reports of the working of compulsion in Western Australia and elsewhere. I am of opinion that there is no serious ground for fear in view of the changed attitude in the public mind in connection with these diseases, the fuller knowledge that people generally have, and the high status of women in our country; also the ready access that all persons have to the protection of the law and the Courts in the event of false information being given, and the safeguards embodied in the Bill as I understand it is drafted. My view is that the objection to the compulsory clauses of the Bill would be removed in the opinion of many women if women patrols or women police were appointed, so that the administration of the Act in its compulsory clauses wherever it treated women could be in the hands of those women officers."

Among the witnesses questioned on this subject there was an overwhelming preponderance of opinion that the time had now arrived for the adoption of notification of all cases of venereal disease by number or symbol, if only for the purpose of getting more accurate statistics; the notification by name of those recalcitrant patients who refused to continue treatment until cured; and compulsory examination of those whom the Director-General of Health had good grounds for believing to be suffering from the disease and likely to communicate it to others, and who refused to produce a medical certificate as to their condition. Only three medical men expressed themselves as being against these proposals. On the other hand, the lady doctors examined (two of them members of the National Council of Women, and the third representing the Young Women's Christian Association) gave evidence in favour of conditional notification, and compulsory examination, and compulsory treatment of recalcitrants. It should be added that all the witnesses who were engaged in rescue work, or other work bringing them face to face with the horrors of venereal disease, were most emphatic in their opinion that compulsory notification and treatment should be adopted.

It is noteworthy that when the notification of ordinary infectious disease was first proposed in England almost exactly the same arguments were brought against the proposal as are now advanced against the notification of venereal disease. Sir W. Foster, member for Ilkeston, and a medical man of standing, speaking in the House of Commons in the debate on the Infectious Diseases Notification Bill, on the 31st July, 1889, said,

"The Bill calls upon medical men to perform something more than the ordinary duties of citizenship by requiring them to become informers of the occurrence of diseases. The relation of a medical men to his patient ought to be one of complete confidence, and anything that comes to the knowledge of a medical man in the practice of his profession is practically an inviolable secret; and I do not like any Bill to interfere with that relationship. I know myself that one of the results of this Bill, if passed into law, will be that in scores of cases medical men will not be called in to attend people suffering from infectious diseases ... I admit the difficulty of the position, but I am anxious that no measure should pass into law which will induce the public to keep these diseases more secret than they have been in the past, with the risk of adding to the spreading of them. We must be very cautious not to do anything which will prevent the public from placing full and implicit confidence in their medical man. I can quite conceive it to be possible that, if an outbreak of infectious disease occurs in a populous part of London, the people may, in order to prevent exposure, refuse to allow a medical man to come in, and in such cases we shall have tenfold more difficulty than at present. Therefore, while I am anxious to promote the notification of disease, I do not want the Government to promote rebellion on the part of the public."

Needless to say, these gloomy anticipations have not been realized. Probably the more enlightened generations to succeed us will wonder how there could ever have been any opposition to the notification of venereal disease, just as we to-day read Sir W. Foster's words and marvel that any person of intelligence could have committed himself to such statements.

Notification of infectious diseases and isolation of patients suffering from such diseases have for many years been compulsory. Isolation, when spoken of by opponents to a similar measure for venereal diseases, is opprobriously described as "compulsory detention." For twenty years it has been the law in New Zealand that an authorized medical practitioner may examine any person suspected to be suffering from any infectious diseases (save venereal diseases), and the Medical Officer of Health may, if he deems it expedient in the interests of the public health, compel the removal to a hospital of any person so suffering. This long-established procedure as referable to venereal diseases is by antagonists termed "compulsory examination" and "compulsory removal."

It is contended by some witnesses that notification will drive these diseases underground; but syphilis and gonorrhœa for generations past have been underground.

Under the present system numbers of unfortunate persons either delay calling in medical assistance until the case has become almost desperate so far as the patient is concerned, or they resort to unqualified persons, with the result that in most cases what was in the first instance a simple attack, capable of treatment, results in serious complications most difficult to deal with. In either case the patient may be communicating diseases to others, and should this come to the knowledge of the Health Department it has no effective means of checking him--no power to warn those who are being endangered by his criminal neglect.

The Committee think there is some force in the argument that notification by name, in the first instance, as in the case of ordinary infectious diseases, would tend to discourage some from coming forward for medical treatment. They recommend, therefore, the adoption of what is known as the system of conditional notification embodied in the West Australia Act. Under this plan the cases are notified by the doctor to the Health Department by number or symbol only. The name is not sent in unless the patient discontinues treatment before he is free from infection and refuses either to go to a clinic or to another doctor. In cases of those who "play the game," the name of the patient is kept confidential, and does not pass beyond the medical man attending him. It is only in cases of those who contumaciously refuse to do what is necessary for their own safety and the safety of others that the name is sent to the Health Department, in order that appropriate steps may be taken in the interests of public health. Even then the name is given only to officers who are pledged to keep it confidential.

Following are the clauses in suggestions for a Bill, drawn up by the Health Department, which in the opinion of the Committee should in substance be adopted:---

"(1.) Every medical practitioner shall forthwith give notice to the Director-General of Health, in the prescribed form, upon becoming aware that any person attended or treated by him is suffering from any venereal disease in a communicable form. The notice shall state the age and sex and occupation of the patient and the nature of the disease, but shall omit the patient's name and address.

"(2.) Every medical practitioner, other than the medical officer in charge of a public hospital or of a clinic established by direction of the Minister of Health, shall be paid for each such notification a fee to be prescribed by regulation.

"(3.) The provisions of subsection (1) hereof shall apply in the case of a child under the age of sixteen years who is suffering from congenital syphilis.

"(4.) Whenever a patient has changed his medical adviser, in accordance with subsection (2) hereof, the medical practitioner under whose care the patient has placed himself shall notify the Director-General of Health in accordance with subsection (1) hereof, and shall include in such notice the name and address of the previous medical adviser."

Without some such system of preliminary notification no adequate statistics can be collected as to the prevalence of venereal diseases in New Zealand, and no conclusion could be arrived at in the future as to the effect of the whole or any part of the programme for combating these scourges. Again, without such notification, and the attachment thereto of some method of ensuring that the patient is made definitely acquainted with his condition, it is practically impossible to enforce the provisions of section 8 of the Social Hygiene Act for the crime of "knowingly" infecting any other person.

Here the Committee would refer to case 2 quoted above. Of what use is it to provide free clinics if those who make use of them are permitted, as soon as the urgent symptoms are relieved, to disseminate disease broadcast, widening the circle of infection? Again, where is our humanity if no step is to be taken to try to prevent a syphilitic child being born to the man in case 1?

A very valuable result of anonymous notification would be the possibility afforded of observing any unusual "flare-up" or succession of cases, especially in country districts and small towns. Study of case 4 will show the great value it would have been to have a record of an unusual increase of syphilis in that township, giving an opportunity for prompt investigation by the Medical Officer of Health for the district.

(B.) _Compulsory Examination and Treatment._

This question obviously presents more difficulty than that of notification, but it is clear that unless some means are provided of bringing under treatment and, if necessary, isolating persons who are suffering from highly contagious diseases, and who will not avail themselves of medical treatment although this is provided free of cost by the State, and who are knowingly or recklessly communicating the disease to others, it will be impossible to keep in check this terrible scourge. Without such provision any abandoned woman, as in case 4, or any male libertine, may continue to sow disease broadcast without any power to stop them. Failing some such measure, table articles and food may continue to be smeared by hands soiled with syphilitic material, as in case 1; section 6 of the Social Hygiene Act remains mere useless verbiage, and the infecting of innocents, as in case 3, may continue unchecked.

Legislation dealing with this subject needs to be carefully framed with suitable safeguards, but the Committee think that an amendment of the Social Hygiene Act on the lines proposed by the Department of Health should be adopted. These provisions are:--

(1.) That whenever the Director-General of Health has reason to believe that any person is suffering from venereal disease, and has infected or is liable to infect other persons, he may give notice in writing to such person directing him to consult a medical practitioner, and to produce within a time specified in the notice a certificate from such medical practitioner to the satisfaction of the Director-General of Health that such person is or is not suffering from venereal disease.

(2.) Should the person not comply with this request, the Director-General of Health may obtain a warrant from a Magistrate ordering such person to undergo examination to prove the existence, or non-existence, of venereal disease.

(3.) Making it possible for a Magistrate, on the application of the Director-General of Health, to order the detention in a hospital or other approved place of a person who is likely to be a danger to other persons until that person is cured of venereal disease.

These provisions are applicable equally to both sexes, and the Committee see no reason to fear that the law would not be carefully and impartially administered. If it should appear that more women than men came under the operation of the law this result would be due to the fact that, as disclosed in the evidence, a much larger proportion of women than men fail to seek treatment, and of those treated a much larger proportion of women fail to continue treatment until no longer infectious.

It is hardly conceivable that a responsible officer, such as the Director-General of Health, would take action under these provisions unless he had strong reason to believe that such action was justified. But, even if he makes a mistake or is misinformed, the worst that can happen to an innocent person wrongfully suspected is that he or she will be required to produce a medical certificate, which can be procured free of cost from any hospital or V.D. clinic. This is wholly different from the provisions of the Contagious Diseases Act, under which a woman suspected of prostitution was liable to be arrested by a constable in the street.

The Committee recommend that the serving of notices, &c., under these sections be done by officers of the Health Department and not by the police. They also recommend that all proceedings taken under any Act having reference to venereal diseases should be heard in private unless the defendant applies for a hearing in open Court.

With regard to the effects of the actual operation of notification, examination, and isolation, the Commissioner of Public Health for West Australia, under date 25th August, 1922, advises the Committee that there is an increase in the number of cases attending public clinics, and that this is regarded not as evidence of increased incidence, but of increased interest and appreciation of early treatment by those suffering from the diseases.

SECTION 7.--MARRIAGE CERTIFICATE OF HEALTH.

The Royal Commission on Venereal Disease reported that there was a vast amount of ignorance as to the dangers arising from the sexual intercourse of married persons one of whom had previously to the marriage contracted syphilis or gonorrhœa. The effect upon the birth-rate, and the misery caused during married life, and in many cases to the offspring who survive, as they pointed out, are most serious, and the fact that the actual cause of the trouble often remains unknown and unrecognized prevents the calamity from serving the purpose of example or warning.

Some of the witnesses heard before the present Committee have urged that a certificate of good health, or at least a certificate of freedom from communicable disease, should be required from each party to a proposed marriage before the Registrar issued a license to marry. The Royal Commission considered that "it would not be possible at present to organize a satisfactory method of certification of fitness for marriage." The National Birth-rate Commission, however, reported that in their opinion the question should be reconsidered with a view to legislation.

There is much to be said in favour of such a proposal from the point of view of national health. If the system were adopted the certificate should, in the opinion of the present Committee, include freedom from mental disease as well as freedom from communicable disease. But there are manifest difficulties in the way, chiefly in regard to the delicate and searching examination which would be required in the case of women before a doctor could certify positively to the absence of communicable disease.

The Committee recommend that instead of a medical certificate each party to a proposed marriage should be required to answer appropriate questions in regard to the presence or absence of communicable and mental disease, and to make a sworn statement before the Registrar as to the truth of the answers. It should be the duty of the Registrar to communicate the contents of the statements to the other party in the event of any admission of the presence of communicable disease.

In addition to the penalty for making a false statement it might be provided, as in the Queensland Act, that venereal disease shall be a ground for annulling a marriage contract when one party is suffering at the time of marriage from such disease in an infectious state, provided the other party was not informed of the fact prior to marriage.

The Committee would also recommend the adoption of a further provision that it should be the duty of a medical practitioner attending a case of venereal disease which is or is likely to become infective, if he has reason to believe that the patient intends to marry, to warn him or her against doing so, and if he or she persists it should be the duty of the doctor forthwith to notify the case by name to the Director-General of Health, whose duty it should be to inform the other party. It should also be provided that _bonâ fide_ communications made in such a case, either by the Director-General of Health or the doctor, to the other party to the marriage, or to the parents or guardian of such party, shall be privileged.

SECTION 8.--TREATMENT BY UNQUALIFIED PERSONS.

The evidence given before the Committee shows that while reputable chemists refer to a medical man patients coming to them for treatment for venereal disease, and while these constitute the great majority of the profession, there are still far too many cases of venereal disease treated by chemists, herbalists, chiropractors, and other unqualified persons. The treatment of venereal disease has become a specialized branch of medicine, and many general practitioners prefer to refer such cases to experts. The result of trusting to unqualified persons for the treatment of such serious and difficult diseases is that the patient usually drifts on uncured, and serious complications may occur. One specialist in venereal disease informed the Committee that of 200 of his cases whose cards showed particulars, 104 consulted chemists in the first place and received more or less treatment from them. He was able to give details of twenty-three cases showing the type of treatment given. In several cases there were severe complications which could have been avoided by proper treatment. There were also cases in which the patient, after taking medicine for a time, had communicated the infection to others. This witness further stated that some chemists charged consultation fees in addition to charges for drugs applied, and in certain cases charges for drugs were made which were little short of blackmail.

The Committee recommend that, in place of section 7 of the Social Hygiene Act, a more comprehensive clause from the West Australian Act be adopted. This is to the following effect: "No person [other than a registered medical practitioner] should attend or prescribe for any person for the purpose of curing, alleviating, or treating venereal disease, whether such person is in fact suffering from such disease or not."

The Committee would suggest that if the Pharmaceutical Society were to do all in its power to discourage its members from treating these diseases it would have a good effect.

SECTION 9.--MENTALLY DEFECTIVE ADOLESCENTS.

Mr. J. Caughley, Director of Education, stated in evidence: "From a general inquiry made by the Department a few years ago it was ascertained that there were at least six hundred or seven hundred mental defectives in New Zealand under the age of twenty-one. I need scarcely point out the moral danger to the community of so many of these defectives being at large. In particular, the girls are a source of danger to themselves and to the community, since they have little or no will-power or sense of restraint. I am of opinion that all such cases should be registered, and that, unless it can be shown that the mental defective is under thoroughly safe and proper care at home, he should be taken charge of by the State. I am certain that by this means the increasing number of mental defectives would be reduced to a minimum, since mental defectiveness is almost entirely hereditary."

Mr. Beck, Officer in Charge of the Special Schools under the Education Department, cited illustrative cases, one of which may be thus stated: "Two feeble-minded parents in New Zealand have had up to the present time ten degenerate children, all of whom are a lifelong burden on the State. Taking the case of these children, and assessing the cost to the State of maintaining them, the total amount for this family will not be less than £16,000."

The Committee are of opinion that supervision of mentally defective children and adolescents is an important factor in lessening venereal disease, and urge the Government as soon as possible to adopt a system of registration and classification of mental defectives, and of segregation where necessary, either in mental hospitals or in special institutions where these defectives may be suitably taught, and, where possible, usefully employed to defray the cost of their maintenance.