The Work of the Connecticut State Department of Health in the Prevention of Venereal Diseases.

DR. JOHN T. BLACK, HARTFORD.

Venereal diseases have been reportable in this state since 1915, but no special effort was made by the State Department of Health to require observance of this law. There were two reasons for this, first, the Department, until recently, was not in position to get in close touch with the health officer and physician, and, second, public opinion would not support great activity along these lines on the part of either the physician or the health officer.

Legislation has obviated the first difficulty by coördinating state and local health activities, and the war has so altered public opinion that the physician and health officer are now not only permitted, but expected to take active measures looking toward the control of these diseases.

It might be said, however, that free examinations of Wassermanns and smears have been made in the laboratory of the State Department of Health since 1913, and this service has, no doubt, aided in the control of these diseases in certain localities.

The first real step towards systematic control was brought about by the adoption of the Sanitary Code this year, referring particularly to Sections 37 and 38, which specifically designate the method of control of venereal diseases, and which are as follows:

REGULATION 37. THE CONTROL OF VENEREAL DISEASE.

When any physician or hospital superintendent reporting a case of gonorrhoea or syphilis agrees in writing to assume the responsibility for the proper instruction of the patient, the health officer shall supply such physician or hospital superintendent with printed instructions for such patient.

It shall be the duty of the physician or hospital superintendent who has thus signified his willingness to assume control of such patient, to report

to the local health officer on or before the first of each month a statement to the effect that such patient is or is not still under his care. When such patient neglects or refuses to follow the prescribed instructions, discontinues treatment, or is discharged as cured, the physician or superintendent shall immediately notify the health officer.

In investigating cases or suspected cases of the above mentioned diseases, the health officer shall treat all information as confidential, but such course shall not preclude the making of reports to the state department of health.

REGULATION 38. CONTROL OF CARELESS OR REFRACTORY PERSONS AFFECTED WITH VENEREAL DISEASES.

When it comes to the attention of a health officer that a person is suffering or presumably suffering from gonorrhea or syphilis in an actively contagious form and is liable to jeopardize the health of any person or persons in or on the premises occupied or frequented by the affected person, he shall immediately investigate and take proper measures to prevent the spread of such disease for the protection of public health, and he shall direct such person to report regularly for treatment to a licensed physician or to a public clinic, if facilities for clinical treatment are available, there to be treated until such person is free from infectious discharges. If such person refuses or fails to submit to such treatment and if, in the opinion of the health officer, such person is a menace to public health, it shall be the duty of the health officer to order the removal of such person to an isolation hospital or other proper place there to be received and kept until he shall no longer be a menace to public health.

For the convenience of the physician, report cards have been printed in duplicate, one to be forwarded to the health officer when a case is recognized, the other to be retained in the office of the physician for reference and record. These cards are of a size to fit the ordinary filing cabinet and are arranged for monthly memoranda.

Instruction leaflets for the patient, to be distributed by the physician, are being prepared and monthly report cards will be supplied to the physician by the health officer.

The whole system is arranged to inconvenience the physician as little as possible, and it is believed that with the hearty coöperation of the physicians of the state, the damage done by these destructive diseases will be greatly lessened.

Plans are about completed for the establishment of clinics in

several of the larger cities of the state where cases can be diagnosed and directed to treatment, or to provide treatment if

necessary.

Serious consideration is also being given to the engaging of a state supervisor in coöperation with the federal government. The Commission on the State Farm for Women will probably provide for the segregation of a class of cases in need of intensive treatment and those reached through the medium of the

courts.

It might be said that all of these activities are nearing consummation, and it is believed that with or without state assistance, all will be in operation before the end of the summer.

Venereal disease control in any of its phases cannot be carried on successfully without the coöperation of the medical profession, and the profession that has so well demonstrated its patriotism along other lines, we believe will not fail in this, a most patriotic duty.

In closing, I wish to impress these facts:

First. Prompt and efficient laboratory service at the Department's Laboratory is available for all.

Second. All reports sent by physicians are held strictly confidential, so long as the physician indicates by his monthly report that the case is under his supervision.

Third. Every effort will be made to avoid free treatment and pauperism,-all cases are to be first directed to regularly practicing physicians.

Fourth. Without coöperation, we will fail.

DISCUSSION.

Papers of Professor Winslow and Doctor Black.

DR. HEPBURN (Hartford): Professor Winslow has raised in my mind a very interesting question in his reference to the prophylactic treatments after exposure to venereal disease. Does he advise the application of this army procedure to civil life? We must face this question now before it has come upon us, for if we have trained several million to expect from their Government this care during their military life, will they not have a right to expect it in some form when they have returned to civil

life? Or, if this procedure is necessary for our army population now, should it not also be necessary to our civil population now? I feel very strongly that before adopting this prophylactic policy, the success of which is still sub-judice, we must face its logical development very clearly, and ask ourselves as doctors whether we relish the thought of staying in our offices late at night in order to give these treatments. I would like to have Professor Winslow state what he thinks will be the practical development of this policy.

In regard to Dr. Black's paper, I would like to ask just how the State is going to segregate those cases of venereal disease which apparently are going to be unmanageable, in case we report them? What hospital facilities has the State Board of Health in mind at present where we can put these cases? I know we have very few hospital facilities in Hartford.

It strikes me that the code is very fine, and I am proud to see Connecticut have such a code, but I would like to know when its next step is going to be applied.

Another question comes to my mind in regard to reporting venereal diseases as if they were exactly comparable to tuberculosis. I do not think the comparison is exact. The victims of tuberculosis are usually brought by some members of their family rather than of their own volition. They have nothing to conceal from their families. Their management is much simpler, while the victims of venereal disease come alone in an effort to conceal their disability. Above all, they wish to keep the secret from their families. Their management at homes, or even at clinics, is therefore much more difficult. If we attempt to enforce these regulations rigidly, will it not have a tendency to make the venereal cases use the so-called "private prescriptions" and drugstore treatment, or go to the less conscientious physicians who will not report them, rather than go where they can get efficient treatment? Thereby we would defeat our fundamental purpose, which is to see that these cases receive good treatment. I would like to hear Dr. Black discuss that possibility.

PROF. WINSLOW (New Haven): I think Dr. Hepburn asked me a harder question than the one Dr. Mead asked Dr. Kelley. I don't know. I am content to wait and see. I think if this subject continues to develop at the rate at which it has developed in the past year that no one can tell what the state of the public mind and what the state of medical opinion will be about this problem two or three years from now.

DR. BLACK (Hartford): Regarding the care of venereal disease cases, refractory cases particularly, there is no provision, as Dr. Hepburn has said, in the state at the present time for the care of these cases. But the state commission on the farm for women is now providing quarters for women. The commission is a little bit short of money. We are after that

and going to get it in some way or other. Quarters will be provided for thirty to fifty women there within six weeks. The farm was only purchased about two weeks ago and they are working on the property already, so progress is being made along this line.

So far as the men are concerned, that isn't a matter that we have solved altogether yet. A certain number of them we think can be sent to the inebriate farm at Norwich, although I am not sure of it at the present time. I feel very confident that we are going to get some place to put them. I will say that this is the only great drawback at the present time to the entire program.

In reply to the second question, the deterring effect upon people seeking treatment because of physicians reporting, reports have been required since 1915, of venereal diseases. They have been reported, as the law requires them to be reported, the name not disclosed. The new system of reporting does not require the disclosing of the name, but it does provide for a number, and where the physician or person feels inclined, as most of them do, that even this be kept confidential, it certainly will as long as they are under the care of the physician. We feel that by this system it will help them or make them stay with the physician more than they would otherwise, because if they leave or stop treatment the physician is under obligation to report to the health officer.

This gives the health office the opportunity to endeavor to ascertain the identity of the person. Of course, the physician is at no time permitted to reveal the identity of the person by name. But the health officer, if he is any good at all, can locate the individual, if he uses the information furnished by the physician when reporting.

After the passage of the law in 1915, there were 451 cases of venereal disease in 1916. That's the first year. Last year there were 265 reported. But, as I said in my paper, there has been absolutely nothing done to remind the physicians that these diseases are reportable and the large number reported started right in after the law went into effect, and the law was circulated by the health officers and the physicians' attention called to it. But aside from this preliminary notice I think there has been very little done, except little notices which have occasionally been published in the Bulletin and which I am sorry to say all physicians do not regularly read.