VENEREAL DISEASES IN ENGLAND AND WALES*

Transcription

1 Brit J. vener. Dis. (1961), 37, 74. VENEREAL DISEASES IN ENGLAND AND WALES* EXTRACT FROM THE ANNUAL REPORT OF THE CHIEF MEDICAL OFFICER FOR THE YEAR 1959 During 1959 the trends of incidence of the venereal diseases at the clinics followed the characteristic pattern of recent years, with a general tendency to increase in prevalence which was considerable for some diseases but slight or absent for others. VENEREAL DISEASES Syphilis.-The number of cases of early infectious syphilis treated at the clinics for the first time during 1959 (Appendix, Table B) showed a distinct rise for both sexes although the total remains small. Slight increases were recorded for males and females in 1955 and for females in The present increase is larger than for either of these years and whether it is due to temporary fluctuation or indicates that syphilis is about to follow gonorrhoea in increasing prevalence remains to be seen. Rises in incidence have already been reported in some other western * Part II of the Report of the Ministry of Health for the year ended December 31, Cmnd. 1207, p. 66. Appendix C, p countries. In the Report for 1957 it was noted that the falling incidence of infectious syphilis was hard to understand in relation to the continuing rise of gonorrhoea and it was suggested that the use of penicillin in increasing dosage for gonorrhoea might be adequate to abort concurrent syphilitic infection in the incubation period. The development of the present situation will be watched with interest and some anxiety. Early syphilis seems to occur almost exclusively in large centres of population and, as before, there is evidence of considerable local variation. Some of the details are shown in the following Table which gives the numbers of cases in ten urban areas. The London area, which showed a slight reduction in 1958, now shows an appreciable increase. Merseyside, where there was a notable increase last year, shows a reversal of this trend to a figure almost identical with that for Other centres show slight increases, except Birmingham and Southampton, where there was some diminution. EARLY SYPHILITIC INFECTIONS DEALT WITH FOR THE FIRST TIME IN 1958 AND 1959 IN TEN SAMPLE AREAS Urban Areas Males Females Total Males Females Total London Administrative Area (3,204,000)* Merseyside (Liverpool, Bootle, Birkenhead, Wallasey) (1,086,170) Manchester and Salford (834,300) Tyneside (Newcastle, South Shields, Tynemouth) (449,100) Hull (301,800) Southampton (200,000) Bristol (436,600) Birmingham (1,091,500) Leeds and Bradford (802,400) Sheffield (499,400) * The figures in brackets are the estimated population at June 30,

2 VENEREAL DISEASES IN ENGLAND AND WALES In the Report for 1957 it was mentioned that there was evidence to suggest that the incidence of infectious syphilis among practising homosexuals was disproportionately high. This is still true, for at one large clinic for venereal diseases in London, 24 out of sixty patients suffering from early syphilis gave a history of homosexual contact. The number of new patients suffering from late syphilis continues to decline but it is still uncertain whether this is a true indication of diminished incidence or whether it reflects the fact that general physicians and others are now much more willing to undertake the treatment of these conditions. The Table which follows shows a decline in reported cases of cardiovascular syphilis, neurosyphilis, and all other late manifestations. The figures for late latent syphilis include a considerable number of immigrants from areas where yaws is endemic. In many of these cases positive serological tests may be due to latent syphilis or to yaws contracted in early life. When the patient gives the history of yaws or has characteristic scars of that disease, the diagnosis of yaws rather than syphilis may be made, but some measure of uncertainty usually remains. In 1959 yaws was diagnosed in 301 cases as compared with 280 in LATE SYPHILIS, 1958 AND 1959 Late Syphilis Year Males Females Total Cardiovascular Syphilis Neurosyphilis All Other Late or Latent Stages ,205 1,075 1, ,299 2,046 Total Late or Latent Syphilis ,822 1,575 1,363 1,207 3,185 2,782 The Registrar General's figures for 1959 show that deaths from general paralysis of the insane and from tabes dorsalis have shown some increase, although the figures remain very low. Those from syphilitic aneurysm of the aorta show a decrease which is more marked for females than for males (Appendix, Table E). The number of new cases of congenital syphilis in infants less than one year old rose slightly in 1959 to twenty as compared with seventeen in The death rate of infants under 1 year certified as dying from congenital syphilis in returns to the Registrar General was per 1,000 live births (Appendix, Table D). Even if it be accepted that some cases are missed and some of the patients are treated elsewhere than at the venereal diseases clinics, these must be regarded as very satisfactory figures. The comparative rarity of these manifestations of syphilis has led to the suggestion in some quarters that antenatal blood tests for syphilis are no longer necessary. It is certain, however, that this simple precaution has prevented much prenatal infection and is an excellent method of helping to maintain the present satisfactory situation. Experience with gonorrhoea indicates that decline in the apparent incidence of a venereal infection is not synonymous with control of the disease and the case for retention, and indeed extension, of the practice of routine serological tests in pregnancy is overwhelming. The number of cases of later congenital syphilis (Appendix, Table C) again shows a fall, to 352 in 1959 as compared with 420 in It is satisfactory to note that the manifestations of this condition are becoming quite uncommon. Testing for Syphilis in Pregnancy.-Results of routine serological tests for syphilis of pregnant women at certain regional blood transfusion centres are shown in the following Table: CASES OF ANTENATAL SYPHILIS, 1959, AT SIX REGIONAL CENTRES No. of Antenatal Patients Tested Positive Syphilis Tests Parity Regional Blood Parity Primiparae Multiparae not Transfusion Centre Primiparae Multiparae not known known - Per. Per. No. cent. No. cent. No. Leeds.8,349 6,647 3, Sheffield 14,582 7, * *32 - Liverpool.22,332 24, Plymouth*.2,116 1, * Oxford.1,933 2, Cambridge. 7,650 3,525 1, * In addition six "doubtful" results were recorded in primiparae and six in multiparae. 75

3 76 BRITISH JOURNAL OF VENEREAL DISEASES A summary of the results of tests from primiparae and multiparae at these centres during 7 years (shown below) indicates that the fall in the incidence of positive tests was maintained in Year Primiparae Multiparae Percentage Percentage No. Positive No. Positive , , , , ,392 0*21 40,712 0* ,420 0*28 40,295 0* , , , , , , Gonorrhoea.-The number of new cases of gonorrhoea diagnosed at the clinics rose from 27,887 in 1958 to 31,344 in This number is the highest since The increase over 1958 is just over 12 pe.r cent. and is proportionately much the same for women as for men. The rise is not limited to large centres of population but is now fairly general throughout the country. It was pointed out in 1958 that the total number of cases is appreciably increased by the fact that some patients attend with two or more infections in the course of any one year. The Table below gives numbers of cases and of patients treated at seven large clinics (four in London and three in the provinces) during 1958, and indicates that during that year re-infections were again responsible for many new cases. CASES OF GONORRHOEA, 1958, IN SEVEN LARGE CLINICS Clinic Cases Patients Males Females Males Females St. Mary's Hospital.. 2, , London Hospital.. 1, , General Hospital, Birmingham 1, St. Luke's Clinic, Manchester 1, SS. Peter's and Paul's Hospital 1, St. Thomas's Hospital General Hospital, Newcastleupon-Tyne It seems likely that several factors are responsible for the continuing serious increase in gonorrhoea. The Working Party of the Medical Research Council, which is investigating the problem of the sensitivity of the gonococcus to penicillin, has already performed a large number of tests. The results, so far, confirm the reports that some strains of gonococci are exhibiting an increased resistance to penicillin. In spite of good advice at the clinics and of propaganda in newspapers and on television, a considerable proportion of patients discontinue attendance when symptoms are relieved. Many of these may be harbouring latent infection which is transmissible. In large centres of population immigrants living in difficult social circumstances still contribute greatly to the high prevalence of gonorrhoea and are particularly prone to multiple infections. There is evidence, too, of an increasing number of infections resulting from promiscuity among young people. In an investigation by the Co-operative Clinical Group of the Medical Society for the Study of Venereal Diseases a comparison was made of the ages of patients with infectious venereal diseases who attended 147 clinics in the years 1957 and The total number of cases of gonorrhoea treated at these centres rose from 15,308 in 1957 to 17,404 in 1958, an increase of 13-8 per cent. The most marked rise was in the age group 18 to 19 years, the increase being 27 9 per cent for females and 36-3 per cent. for males. The increase for the age group 20 to 24 years was also above the average for the whole series, being 16'4 per cent. for males and 20 1 per cent. for females. At H.M. Prison, Holloway, the consultant venereologist reported that, of 425 known prostitutes admitted during 1959, 35 per cent. were aged between 15 and 20 years and 31 per cent. between 21 and 25. As usual the incidence of venereal diseases was high. 381 of these women were examined and syphilis was diagnosed in six cases and gonorrhoea in 171. Many others had symptoms and signs suggestive of infection but were not observed long enough for final diagnosis. Other Venereal Diseases.-New cases of chancroid increased slightly to 267 as compared with 259 in There were eighty cases of lymphogranuloma venereum as against 77 in Cases of granuloma inguinale decreased from nineteen in 1958 to twelve in Cases of non-gonococcal urethritis in men again showed a considerable increase, as indeed they have year by year since this condition was placed in a separate category in The increase is, however, greater than in previous years, the number having risen from 17,606 in 1958 to 20,227 in 1959 (Appendix, Table A). The number of women with "other conditions needing treatment", many of whom were contacts of men with nongonococcal urethritis, also showed an increase from 12,149 in 1958 to 12,752 in Other Conditions treated at the Clinics.-The venereal disease clinics are places where many anxious patients seek advice, because they have taken risks or because they have symptoms which they fear may be due to infectious diseases. This serves a most useful purpose in bringing to light cases of venereal infection, in dispelling anxiety, and in

4 VENEREAL DISEASES IN ENGLAND AND WALES ensuring treatment for many minor but troublesome complaints. It adds considerably to the burden of work at the clinics but is much to be encouraged. Table A of the Appendix shows that 27,993 new patients attended for diagnosis and treatment of these complaints, and a further 32,704 were examined, tested, and reassured but required no treatment. The equivalent figures for 1958 were 26,711 and 30,712 respectively. The Present Position.-Study of the figures for venereal diseases in 1959 certainly gives no justification for complacency. Gonorrhoea in both sexes and non-gonococcal urethritis in men again show spectacular increases. The significance of the rise in infectious syphilis is a matter for speculation, but the number of cases is still very small. The reasons for the serious increases in gonorrhoea and non-gonococcal urethritis are not clear-cut. Various factors are probably concerned but none emerges as the paramount cause. Immigrants, delinquents, itinerants, and prostitutes all play their part. It seems likely that habitual promiscuity is more widespread than formerly. Medical Officers of Health, doctors at clinics for venereal diseases, social workers and others are especially anxious about sexual promiscuity among young people. For instance, the Medical Officer of Health for the City of Wakefield, in his Annual Report for 1958, stated that it had come to his knowledge that some young girls of 14 years were attending special clinics unknown to their parents. In his area contraceptives had been found to be carried by both boys and girls of 14 years and upwards. He blamed parents for lack of discipline and for failing to make home attractive and to provide the children with an atmosphere of wellbeing, comfort, and affection. If these criticisms are valid for many homes throughout the country and the so-called teenage problems have their roots in unsatisfactory home life, it is not surprising that there is increasing promiscuity and therefore venereal disease among young people. This is a matter which lies outside the immediate scope of preventive medicine but it is one of general concern about which everyone would like more information. The Central Council of Health Education, with the aid of various voluntary organizations, is sponsoring an investigation into the causes of promiscuity among young people. The information collected may well point to the causes of the social sickness of which increasing venereal disease is only one symptom. It is often said that much venereal disease results from ignorance and it is true that the general Appendix Tables A to E overleaf public is not well-informed. Efforts are being made to remedy this deficiency and two recent television programmes, which must have reached large audiences, may help. It seems unlikely, however, that such measures can be more than contributory because moral standards are based upon stable family life and knowledge does not of itself bring virtue. Though our society may seem to be physically and materially strong and healthy, it is a matter for consideration whether its roots in family life may not be suffering from decay. 77 Br J Vener Dis: first published as /sti on 1 March Downloaded from on 25 January 2019 by guest. Protected by copyright.

5 78 BRITISH JOURNAL OF VENEREAL DISEASES APPENDIX TABLE A NUMBER OF CASES (IN ALL STAGES) DEALT WITH FOR THE FIRST TIME AT ANY CENTRE*, Non Total Soft Gonococcal sum of Sex Year Syphilis Chancre Gonorrhoea Urethritis Other Conditionst Columns (Males 2-6 only) , ,811-24,324 57, , ,057-20,005 49, ,790 1,017 20,572-20,476 49, , ,956-22,302 49, , ,215-36,868 64, , ,629-34,123 59, , ,280-42,110 72, , ,912-70,239 1,21, , ,647-53,766 95, , ,006 _ 56,435 91,927 M , ,366 52,526 81,261 A , ,007 _ 55,068 78,487 L Not E Requiring Requiring Treatment Treatment , ,975 10,794 11,607 26,956 69, , ,510 11,552 12,578 25,928 69, , ,242 13,157 13,566 25,619 71, , ,962 13,279 13,071 24,651 68, , ,079 14,269 13,613 24,436 69, , ,377 14,825 14,254 23,514 72, , ,620 16,066 14,332 23,032 76, , ,398 17,606 14,562 21,711 79, , ,964 20,227 15,241 23,160 86, , ,489-14,684 25, , ,882-12,881 23, , ,314-15,068 27, , ,413-20,190 35, , ,043-34,681 52, , ,646-38,566 57, , ,603-41,524 61, , ,431-35,475 56, , ,019-29,314 44,798 F , ,306-27,462 40,138 E , ,121 24,801 34,814 M , ,497 _ 23,840 32,342 A Not L Requiring Requiring E Treatment Treatment , ,089-8,517 12,408 27, , ,585-8,916 11,560 27, , ,021-9,834 10,612 27, , ,574-10,117 9,503 25, , ,766-10,182 9,075 25, , ,011-10,939 8,835 26, , ,761-11,317 9,098 27, , ,489-12,149 9,001 28, , ,380-12,752 9,544 30,353 * Excludes cases transferred from centre to centre. t Including non-gonococcal urethritis up to 1950.

6 VENEREAL DISEASES IN ENGLAND AND WALES TABLE B CASES OF ACQUIRED SYPHILIS IN TABLE A, WITH INFECTIONS OF LESS THAN ONE YEAR, Year Number of Cases Per cent. of Table A Cases Male Female Male Female ,241 2, ,196 2,532 56*2 39* ,949 2, *4 35* ,888 2,030 50* ,226 1, *2 31* ,033 1, * ,986 1,647 49*4 31* ,744 1,494 47*8 30* ,547 1,412 49*1 30* ,029 1, ,023 2, ,470 3, ,159 4,483 58* ,383 4, *2 59 * ,214 5, ,705 6,970 77*6 69* ,750 5, ,603 4, * ,492 2, * ,678 1, , TABLE C CASES OF CONGENITAL SYPHILIS DEALT WITH FOR THE FIRST TIME AT THE TREATMENT CENTRES, Under 1 and 5 and 15 years Year 1 year under 5 under 15 and over Totals years years , , , , , , , , , , , , , , , , , , , , , TABLE D DEATH RATES PER 1,000 LIVE BIRTHS, OF INFANTS UNDER I YEAR CERTIFIED AS DUE TO CONGENITAL SYPHILIS Year Rate Year Rate Year Rate * * * * * *.. Nil *.. Nil *.. Nil * * Rates for years are according to the 1940 classification (5th Revision). For the rates need to be multiplied by the conversion ratio for approximate comparability. * For No in International List (7th Revision). TABLE E DEATHS FROM GENERAL PARALYSIS OF THE INSANE, TABES DORSALIS, AND ANEURYSM OF THE AORTA, 1911 TO 1959 Year General Par- F Tabes Dorsalis Aneurysm of alysis of the Aorta* Insane Males Females Males Females Males Females , , , The averages for the years 1911 to 1939 are based on the 4th Revision of the International List. Figures for the years 1940 to 1959 are according to the 7th Revision. Non-civilian deaths are excluded from September 3, 1939, for males, and from June 1, 1941, for females, to December 31, * For years : "Aneurysm" (Code 96) of the arbitrary rules of assignment. 4th Revision List, based on For years 1940 and after: "Aneurysm of Aorta" (Code 022) of the 7th Revision List, based on assignment by the certifying medical practitioner. 79