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:—

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.

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.

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.

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."

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.

Following are some of the conclusions drawn from the evidence by the Committee:—

There is very general ignorance among the public on the subject of venereal disease, and this has stood in the way of its being grappled with effectively.

Syphilis not only causes loss of life directly, but many deaths ascribed to other causes in the Registrar-General's returns are due to the after-effects of this disease. It is responsible for many still-births and abortions, and its evil effects are seen in such children as survive. These effects may persist until the third generation.

Gonorrhœa, popularly, but quite erroneously, supposed to be a comparatively mild complaint, is regarded by medical men as being as serious a disease as syphilis. It is difficult to cure, especially in women, unless properly treated at the outset. It is a great cause of sterility in both sexes.

Owing to the absence of accurate statistics it is impossible to make comparisons between New Zealand and other countries as regards the prevalence of venereal disease, or to say whether it is increasing or decreasing in this country.

There are in New Zealand no fewer than 3,031 persons being treated by registered medical practitioners for venereal disease in some form, or for the effects thereof—1 person in every 428 of our population. At the clinics since their establishment 3,634 patients have been treated—3,038 males, 596 females.

An interesting calculation as to the prevalence of syphilis in New Zealand has been made by Dr. Hay, Inspector-General of Mental Hospitals. Working on what is known as Fournier's Index—the relation of the number of cases of dementia paralytica existing at any one time to the number of concurrent syphilitic infectious—he computes the number of persons in New Zealand now who have or have had syphilis to be 33,000, or 1 to every 38 of the population.

The Committee desire to state, however, that in their opinion there can be no accurate estimate of the prevalence of venereal disease until some system of obtaining accurate statistics has been adopted. One point which has come out clearly in their investigations is that venereal disease is sufficiently prevalent to cause serious concern and to call for energetic action.

Evidence was given to the Committee to show that children with mental and physical defects due to venereal diseases may become a charge on the State; that a proportion of these on being released become parents of defective children, who in their turn have to be supported at the public expense. It was also shown that such defectives have little sexual control, and are usually very prolific.

According to the Commissioner of Police there are only 104 professional prostitutes in New Zealand.

There is, however, a great deal of "amateur" prostitution, and this is chiefly responsible for the spread of venereal diseases.

The evidence points to a good deal of laxity of conduct among young people of all social conditions, especially in the large towns. This is generally attributed by the witnesses to the weakening of home influence and the restlessness of the age.

Apart from the venereal disease among those who indulge in promiscuous intercourse, there are many cases in which innocent wives are infected by their husbands, and other cases (not so frequent) of innocent husbands being infected by their wives.

Children suffer innocently from venereal disease, not only by inheritance from infected parents, but by accidently coming in contact with the germs on towels, &c., which have been used by a patient. There are also cases which come before the Courts where disease has been conveyed directly in crimes of violence by sexual perverts.

The free clinics in the chief centres are conducted by experts, and are doing good work. Their influence for good is greatly impaired, however, by the fact that a proportion of the male patients and the majority of the female patients leave off treatment before they are cured. As the law stands there is no power to compel them to continue treatment, and in many cases they resume promiscuous intercourse and spread the disease.

Evidence has been given of other cases, some of them of a very shocking character, in which persons suffering from venereal disease are not seeking medical treatment and are communicating the disease to others. As the law stands at present there is no power to restrain them from such conduct or to compel them to receive medical treatment.

The Committee stress in the strongest terms the duty of moral self-control.

They urge the cultivation of a healthier state of public opinion. The stigma at present attached to sufferers from venereal disease should be transferred to those who indulge in promiscuous sexual intercourse.

Parents have a great responsibility as regards the instruction and training of their children so as to safeguard them against the dangers resulting from ignorance of sexual laws. There is too little parental control generally in New Zealand. The Committee recommend the training of teachers, and provision for giving appropriate instruction in schools.

The following medical measures for preventing and combating the disease are recommended:—

The clinics should be made more available by being open continuously. Every effort should be made to secure privacy. A specially trained nurse should be in attendance at women's clinics, and women doctors should be secured where possible.

The Committee recommend that provision be made at the clinics for prompt preventive treatment of those who have exposed themselves to infection.

Lady patrols should be appointed in other centres to perform the kind of work that is being carried on in Christchurch.

The Committee, having regard to the good work especially of an educational nature which is being done by the Social Hygiene Society, Christchurch, consider voluntary effort of the same kind in other centres would be very helpful.

The Committee are entirely opposed to the Continental system of licensed brothels, or a revival of the C.D. Acts in any shape or form.

They recommend legislation be introduced providing for what is known as conditional notification of venereal disease. It will be the duty of a doctor to notify to the Health Department, by number or symbol only, each case of venereal disease he treats. If a patient, however, refuses to continue treatment until cured, and will not consult some other doctor or attend a clinic, it will then be the duty of the doctor last in attendance to notify the case to the Department by name.

If the patient continues recalcitrant and refuses to allow himself to be examined by the medical practitioner appointed by the Director-General of Health, then the latter should be empowered to apply to a Magistrate for the arrest of such person and his detention in a public hospital or other place of treatment until he is non-infective.

The Committee also recommend further provision to deal with cases in which persons suffering from venereal disease are not under medical treatment and are likely to infect others. If the Director-General of Health has reason to believe that any person is so suffering he may call on that person to produce a medical certificate, which may be procured free of charge from any hospital or venereal-disease clinic. If the person refuses to produce such a certificate he or she may be taken before a Magistrate, who may order a medical examination. Penalties, including detention in a prison hospital, should be provided for recalcitrant cases. The proceedings in all these cases are to be heard in private unless defendant desires a public hearing.

The Committee recommend that before a license to marry is issued the intending parties must sign a paper answering certain questions as to freedom from communicable disease and from mental disease, and must make a sworn statement that the answers to such questions are true.

They recommend the adoption of a provision in the Queensland Act making venereal disease a ground for annulling a marriage contracted whilst one party is suffering from such a disease in an infectious stage, provided the other party was not informed of the fact prior to marriage. Also that it should be the duty of a medical practitioner attending a case of venereal disease, 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 to notify the case by name to the Director-General of Health, whose duty it should be to inform the other party, or the parents or guardian of such other party. Such communications made in good faith either by the doctor or the Director-General of Health should be absolutely privileged.

The Committee recommend that the law prohibiting treatment of patients for venereal disease by unqualified persons shall be strengthened, and suggest that the Pharmaceutical Society might assist in preventing such practices.

The Committee in carrying out their task have been brought into contact with some uninviting aspects of our social life. Some of the facts disclosed are of a character to give serious concern to those lovers of their country who rightly regard it as exceptionally favoured by nature, and desire to see its people healthy and vigorous, clean in body and mind, worthy of their heritage. The late war showed that the pick of our population, physically as well as mentally, were of the finest possible type, the admiration of all who saw them; but the medical examination of the recruits disclosed that of 135,282 examined after the introduction of the Military Service Act—mostly young men in the prime of life—only 57,382, or say, 42½ per cent., could be accepted as fit for training, unmistakably proving that the nation as a whole was much below the standard of physical fitness which it ought to exhibit.

The investigations of the Committee show that already there is far too large a proportion of mental and physical defectives reproducing their kind. In the absence of accurate statistics it is impossible to say what proportion of these defectives are the direct product of venereal disease, but there is clear evidence that a tendency to lead dissolute lives is especially noticeable in the females belonging to this unfortunate class. "A feeble-minded girl," says Mr. Beck, "has not sense enough to protect herself from the perils to which women are subjected. Often amiable in disposition and physically attractive, they either marry and bring forth a new generation of defectives, or they become irresponsible sources of corruption and debauchery in the communities where they live." Obviously some method of dealing with mental defectives—by segregation or otherwise—must be found as part of the problem of dealing with venereal disease.

As regards the effect of venereal disease on the general health of the community, we have the statement of the late Sir William Osler that he regards syphilis as "third on the list of killing diseases"; while Neisser, a leading authority, says that "with the exception of measles, gonorrhœa is the most widely spread of all diseases. It is the most potent factor in the production of involuntary race suicide, and by sterilization and abortion does more to depopulate the country than does any other cause."

The Committee are of opinion that, far from conditional notification and compulsory treatment on the lines proposed being prejudicial to woman in any way, it is they who will reap the greatest benefit from these measures. In fact, sufferers from venereal disease, as a whole, have everything to gain and nothing to lose so long as they will continue under treatment, and to enable them to do this the best medical skill is placed at their disposal free of cost. The only persons in the community who will be penalized by the proposed legislation are those who, having contracted venereal disease, are so reckless and unprincipled that they will take no pains to avoid communicating it to others.

The Committee, it will be seen, regard the legislative and medical measures which they propose as of great importance, but with all the earnestness at their command they desire in conclusion to emphasize the moral and social aspects of the question. With the changing social conditions, especially in the larger towns, we are losing the home influence and home training which are the best safeguards to preserve the young against the temptations and dangers which beset their path in life. The Committee would impress upon parents the paramount duty they owe to their children in this matter. There is also a duty cast upon all leaders of public opinion, and upon the community at large, to do what is possible to bring about better living-conditions, especially for girls in the towns, to encourage all forms of healthy sport and amusement, and to cultivate a higher moral standard. Whatever sanitary laws may be passed, and whatever success may be attained in dealing with bodily disease, there can be no true health if the soul of the nation remains corrupt. If this inquiry should serve to remove some of the popular ignorance regarding venereal disease, and to quicken the public conscience so that appropriate steps may be taken to deal with this dreadful scourge, the Committee feel that their labours will not have been in vain.

GRAPH A.

TABLE A.

Illegitimate Births, and Births within One Year after Marriage, in New Zealand, 1913-21.

NOTE.—The figures refer to accouchements, not to children born, multiple cases being counted once only (Only live births are included.)

MALCOLM FRASER,
Government Statistician.

TABLE B.

Table Showing Number of Cases Treated and Attendances at the Venereal-disease Clinics during the years 1920-21 and up to June, 1922.

Reply Form.—Venereal Diseases.

(Confidential.)