Document wq58YozKp98qp6VnLyq81Vb43

iProceebmgs: of tf)C {Eransfoaal 0m iHebtcal #fftcerjs' gtajriatton Issued by the Association. Chamber op Mines building. box 809. Vol. XVIII. OCTOBER and NOVEMBER, 1938. Johannesburg, No. 201 asd 202 The October General Meeting was hold in the There are four main items with which I have Cliumber of Mines Building, -Johannesburg, on to deal in considering this subject of Bantu Thursday, 20th October, 1938, at 8 p.m., Dr. Bvphilis: L. E. Miller (President) in the Chair. 1. The incidence of syphilis among Natives OBITUARY. in South Africa in general and on the The Chairmen said he wished to record our mines in particular. deep and very sincere regret at the death of 2. The serious effects the disease is having Dr. C. J. Scott who, as a member of the Execu on them and the urgent need for adequate tive Committee for many years and President treatment. in 1930, had rendered valuable services lo the Association. Dr. Orensteln, in seconding the motion, 3. The nature of the measures so far taken to combat the disease in South Africa, and moved that a letter of condolence bo sent to Mrs. Scott and her family. A vote of condolence was passed in silence, 4. How the incidence of syphilis can be re duced. all the members standing. 1. Incidence. Figures were quoted at a previous meeting1 to show the ineidence on the There were present 22 members, 0 visitors, and the Secretary, mines. The most valuable oE those were the ones supplied by Dr. Girdwood to the S.A.I.M.R.* The Chairman welcomed the visitors (includ in 1927. The W.R. was performed on specimens ing Dr. Jos. Daneel, Superintendent of the of blood taken from 1,200 boys who had been ltietfontein Hospital, and several Medical passed for service and were about to be sent to Officers of Health of the Reef towns, who had various mines. Of the total number it wns uttended the meeting by invitation) and hoped found that 14-6 per cent, wore positive, the that they would join in the discussions. highest percentage of positives being among The following paper was read:-- Basutoland (29-4 per cent.) and Transvaal (29-5 SYPHILIS--A MAJOR CAUSE OP ILL- per cent.) Busutos. The Wassermann results from Modder Deep, Van Dylc, Geduld and East HEALTH IN NATIVE LABOURERS; AND Gcduld mines were also given,1 where the num SUGGESTIONS FOR MASS TREATMENT. ber of (positives varied from 17.0 per cent, at By S. Y. Humphries, M.A., M.R.C.S., Van Dyk to 40.5 per cent, at East Geduld. For the, sake of interest, I have looked up the ' L.R.C.P. number of positives at Van Dyk and Modder As a junior member I very much appreciate Deep since those figures were given. Out of a the privilege of being allowed to re-introduce total number of 119 taken at Modder Deep from this subject which iB, I think, as important as January, 1937, to the present date, 28 or 23-5 any that has over been considered by this per cent, wore positive; and at Van Dyk, out Association. I want to tfiank Dr. Goldsmith of a total number of 329 taken since February, for reading through parts of my paper and for 1937, 94 or 28-6 per cent, were positive. A W.R. helping me with the framing of the resolutions; is carried out as n routine at Modder Deep and Dr. Orenstcin for providing access to his Van Dyk Hospitals on all severe fractures, eye reference library; and Dr. Aiming and Dr. Gale injuries, contused knees, and several other for providing literature for reference. types of cases in which it is thought that the .122 Proceedings of the Transvaal Mine Medical Officers' Association. presence of syphilis may prejudice u patient's chances of recovery. The figures I have quoted give us a clear idea of the incidence of syphilis among mine Natives. Its incidence amongst Natives of the Union as a whole is less easily assessed, as the prevalence of the disease varies a great deal in different districts. The Natives whose blood was collected for examination at the W.N.L.A.5 were derived from all parts of the Union as well as from the Native protectorates and P.E.A, The following were the percentage of positives in the different tribes:-- East Coast Natives ... ... Pondos .................................... Transvual Basutos .............. Xosas ... ... ... ... British Basutos......................... Bcchuanas . ... ... ... 7*0% 8-5% 29-5% 2-0% 29-4% 22-0% A large proportion of these Natives were pro bably derived from rural areas where syphilis is seldom as prevalentas in towns. Another interesting fact is that there has been an increase in the number of positive Wussermanns in the specimens of blood submitted to the Institute of recent years. Of the total number of speci mens submitted to the Institute in 1927, a positive result was obtained in 20-G per cent.,2 while in 1937 a positive result was obtained in 33-1 per cent.1 This may not, of course, be due to an increaso in the incidence of Native syphilis, as there arc other possible factors which might cause an increase in thq percentage of positive results, but a finding such as this in a country in which so large u proportion of the population consists of Natives, strongly suggests that there is an increase in Native syphilis. It must be conceded that a certain proportion of the Natives from Tropical Africa and from the East Coast in whom the blood show tv positive W.R. arc suffering not from syphilis but from yaws. It is very unlikely that many Basutoland Natives, in whom the percentage of positive Wassermanns is appallingly high, are suffering from yaws, as, to quote from Dr. Scott's paper,4 " Yaws is essentially a disease of warm climates." In another place he says, " The disease docs not spread in cold climates or at high, elevations in the Tropics." In any case, when considering this problem, it matters very little whether yaws is prevalent in the - Union or not. Yaws requires treatment just as much as syphilis, and it would not matter if some cases of yaws were treated under the im pression that they were syphilis as the treatment is the same. The Bantu people appear to be peculiarly susceptible to the invasions of the spiroclmetus and the gonococcus as evidenced by the fact that in the Naimvala district of N. Rhodesia it is esti mated that 80 per cent, of the population are infected with sonic form of V.D., while in the Barotse Province it is believed that 90 per cent, are infected.* Now, as regards this " third disease which stands half-way between yaws and syphilis," of which Dr. Meycrstein has found evidence in Bechuamdand and N-E Zulu!and,7 it probably resembles " Bejel " or non-venereal syphilis, described by Dr. Hudson5 of the American. Mis sion Clinic in the semi-nomud Bedouin. He says it is uon-venercal and acquired in childhood like an exanthem. It fails to respond in typical fashion to anti-syphilitic medication. The dis covery of this new disease in South Africa is no contra-indication to treating syphilis more inten sively. If anything, it is an indication that closer attention should be paid to syphilis and diseases resembling it, as this non-venereal disease may spread among Natives even more rapidly than syphilis itself. I should very much like to know whether any mine medical officer lias come across this disease, as I have never met any form of syphilis that fails to respond to injections of N.A.B. and bismuth. Dr. Gale, the Asst. M.O.H. at Benoni, aptly summarises the position with regard to urban syphilis in his paper which is" to appear shortly in the J'ournul: " The actual number of syphi litics, early and late, among Natives living in most South African towns--as revealed, for instance, by the use of the Wassennann test in sample surveys or in ante-natal clinics--is un doubtedly appallingly high. The lute cases represent the accumulated legacy' of the past- thirty years of inactivity, of tinkering, and of quack treatment. Although most of the syphilis is " latent," there can bo no doubt that it is the basis of much ill-health among Natives--hin dering, for instance, recovery from other diseases --the sum total of which must represent a con siderable economic loss quite apart from its threat to the next generation."5 2. Effects of Syphilis on the Natives. Parran,10 t lie Surgeon General of the United Slates Public Health Service, comparing syphilis with other diseases, concludes that, untreated, it docs more damage than any to the greatest number of individuals, and that quantitatively, in all its forms, it probably lays a heavier burden than any other disoase upon the community. Half the Proceedings of the Transvaal Mine Medical Officers' Association. 123 infections, he points out, occur in the age group you will remember that in a paper read before between 20 and -1>0. Like tuberculosis, it strikes this Association, Dr. Snrtorius revealed the fact tit the most vigorous and productive age: that that pulmonary syphilis in Natives is by no of the wage-earner amt the young mother. There means uncommon. He described 10 eases which is more of it among men, at the rate of (i to lie had seen over a period of two years which every 4. women infected--a fact of particular were mainly drawn from the same mine. importance to the gold mining industry. May 1 remind you of some of the facts that McDaniel, in America,10 studying a series of Dr. Sartorius1- disclosed at that meeting. 0.911 citizens, 1,811 of whom had syphilis, found Quoting from the literature, he showed that that, taking all forms of tlie disease, both early syphilis and tuberculosis work well together, and and late, 40 per cent, of the syphilitics were that syphilis as an active disease has a decidedly unable to do a full day's work. His cases in unfavourable effect on the course of pulmonary cluded an appreciable percentage of negroes. tuberculosis. Beneficial effects were obtained by Among those not infected with syphilis, muny treating the syphilitic element without any other diseases were found, including tuber untoward effect on the tuberculous. It was culosis, cancer, rheumatism, heart disease, pointed out that Natives with syphilis who ure pellagra and a dozen others, and in them the possibly going to get tubercle later will pro number unable to do a full day's work was only bably be benefited by some measure of anti 20 per cent. specific treatment. Among the general signs Harrison, in a personal communication,11 observed in Dr. Sartorius's series of cases, it commenting on the peculiarities of syphilis in was noticed that some cases continued to lose negroes as compared with whites, says, " The weight steadily until anti-specific treatment was chief point which lias struck me in my studies given. Every ease, when put on to this treat of the literature is the proueness of the negro to ment, gained weight; and in every case the gain develop vascular syphilis. Tims J. E. Moore, in his `The Modern Treatment of Syphilis' (1930), .Baltimore, says, ' in late syphilis, the negro is particularly prone to the development of bone in weight and the improvement in the general condition was marked. Another point noticed was the persistence of physical signs in the chest until anti-syphilitic treatment was given. But or cardio-vascular lesions (twice to four times when this was instituted, improvement occurred. as often as the white), and much less likely to develop central nervous system syphilis, especially tabes and paresis, than the white. These are factors of importance in estimating the patient's Two eases with signs of consolidation were sent for X-ray at the W.N.L.A. and came back labelled `` ? T.B." After treatment, they were sent in again, and came back with the report reaction to his infection.1 Stokes's * Modern " Increased shadows.'' Clinical Svphilology,' 1984, Philadelphia, says, Even cases with pleural effusion cleared up ` in 0,420 cases in Baltimore, Turner found 13-9 under anti-syphilitic treatment. per cent, of males and 0-7 per cent, of females to have cardio-vascular disease: one-and-U-half to two times as many negroes as whites have cardio-vascular disease. I'aullin, in 600 cases of heart disease in negroes found 39-3 per cent, to be syphilitic.1 These accord with my own studies of such literature on the subject as I have found in V.D. information and Journ. of American Medical Association." At the previous meeting,1 mention was made of certain pathological conditions which are ac centuated by the presence of syphilis, notably eye conditions, ordinary traumatic wounds and fractures. Besides these there arc, as you will agree, a very large number of clinical conditions for which syphilis is wholly responsible--diseases affecting almost every organ and tissue in the body. Some forms of syphilis are far commoner Surely these results are clear enough proof that syphilis is accentuating lung conditions in Natives. It would obviously be wrong to con tinue neglecting a disease which is suspected to he an accentuating factor in the course of pul monary tuberculosis--the condition that is at present costing the gold mining industry thou sands of pounds in. compensation every year. Yet tuberculosis is only one of the diseases accentuated hv syphilis. .How many others are there that wo know nothing about? In what other undetected ways are Native labourers being incapacitated by syphilis? These will, I think, become apparent only after wo have started to institute really effective treatment. I venture to suggest that our sickness rate will show a marked decrease. Even the number of mine in Natives than they arc in Europeans. Syphilis accidents may be expected to decrease as Native of the lungs, for instance, is described in text labourers, undobilitated by syphilis, will become books on European diseases as very rare, but less easily tired and, with their special senses 12*1 Proceedings of the Transvaal Mine Medical Officers' Association. more acute, will be more quickly able to get out of the way of danger. 3. Nature of the measures so far taken to combat the disease In South Africa. Advances have been made recently in the- campaign against venoronl diseases not only in the Union of South Africa13 but in many other parts of Africa as well, such as Uganda,11 Kenya15 ami Zan zibar.16 Unfortunately, the Annual lleport of the Department of Public Health for the Union13 does not give much valuable information regard ing the actual number of cases being treated for venereal diseases. There is a table in this report headed " Venereal Diseases. Cases Treated and Attendances." This table docs not record the total number of patients that have attended lor treatment throughout tile year, nor the total number of attendances by patients. It mixes the two up inextricably, so that no intel ligible idea can be obtained by any enquiring individual about how much is being done for Native, or, for that matter, for European, or any other syphilis. Under Section 54 of the Public Health Act,17 every person suffering from any venereal disease must attend for treatment and continue to sub mit to treatment until cured or free from such disease in :i communicable form. It is the pre sence of those last four words, " In a communic able form," that allows so much scope for laxity in carrying out the law. Exactly what forms of syphilis, apart from treated syphilis, can anyone sav emphatically are not communicable? Syphilis is dealt with by the Government purely from ft palliative point of view. Its ob ject is to prevent further infection by treating the disease in its communicable form. This obviously means that the Government's policy is to treat open lesions of the skin and mucous membranes, and perhaps a few other syphilitic lesions recognisable on ordinary clinical examina tion that the medical examiner thinks arc trans missible. I think you will agree that a very small percentage of patients whose W.R-. is positive have lesions that are: sufficiently evident to be recognised on ordinary clinical examination. A still smaller number of these would have lesions that nre openly communicable. It therefore follows that by treating only patients with obviously communicable lesions, the vast majority of syphilitics are nob treated at all. The question now arises: How many of these untreated, latent cases of syphilis nre actually capable of transmitting the infection to others? This is a point upon which it is necessary to be absolutely clear. Let us first consider the effects of. syphilis on pregnancy. We know that syphilis in women, however " latent " it may be, unless treated, is liable to cause repeated miscarriages. The liability to miscarriages diminishes with the interval since infection. The sequence in six consecutive pregnancies, says .Letheby Tidy,13 is: 1st pregnancy: early abortion; 2nd pregnancy: miscarriage in the later months; 3rd pregnancy: syphilitic infant; death in a few days; 4th pregnancy: healthy at birth; death in a. few weeks. (Typical congenital syphilis) ; 5th pregnancy: malnutrition only; possibly interstitial keratitis later; and it- is not until we reach the Oth pregnancy that a healthy child is born. The proof that an infected father with latent syphilis is capable of transmitting the infection to the child is not so clearly established, though it is, I think, agreed that there is a strong possibility of this happening. In Denmark,19 where treatment for V.D. is compulsory, a cer tificate of freedom from V.D. is required for marriage, and if either party at the time of con summation was suffering from V.D. in a com municable form, a judicial separation or divorce may he. obtained. It seems strangely ironic that in a country like Denmark, where new infections with syphilis are at the rate of 1-6 per 10,000 of the population per annum, such extremely strict precautions should be regarded as neces sary, whereas in South Africa, where, among Natives, the number of new infections is inesti mable, we are almost happily content to let syphilis take care of itself. In certain progressive townships here, syphilis is being treated intensively, with the object of achieving permanent cures, and I think this is the only reasonable attitude, to take up. Referring to Native syphilis, Harrison,11 says, " 1 certainly advocate treatment of patients with a positive W.R., but no clinical signs, as an insurance especially against catdio-vascular syphilis and syphilis of the supporting and nutri tional structures of the central nervous system. " With regard to the general question of the worth-whileness of tackling the treatment of syphilis in the negro, I would say decidedly ` Yes.' In discussing this question, people seem always to think too much of neuro-svphilis and ioo iittle of eardio-vnscular syphilis. Although I would always prescribe a minimum of forty injections of each type of compound, As. and Bi. Proceedings cf the Transvaal Mine Medical Officers' Association. 125 respectively, to any early case oE syphilis, !l pical boys. I suggest that: it would always be believe that, if every ease of syphilis could have worth while treating syphilis with the object of three months' steady treatment with adequate eventually obtaining a negative W.li. But even doses of As and Bi remedies from the commence in cases m which there is little hope of achiev ment, we should have a very low incidence of ing this result, it is worth while treating the the late effects of syphilis in the community." 4. How the Incidence of Syphilis can be Seduced. It is impossible to dual with this subject from the point of view of the gold disease just the same, .it is now agreed by most syphilologists that treatment with arseuoben- zene plus bismuth is preferable to treatment with arsenohenzeiie alone. mining industry alone. To reduce the disease As syphilis is a national problem, the Govern appreciably, we have to regard it ns a national ment should provide free: drugs, but even if they problem of the first magnitude--every bit ns refuse to do this for the treatment of mine important as the problem of national defence, Natives, ibis should lie no contra-indication to on wlii'ih the Government has just decided to our undertaking more energetic treatment. Thu spend six million pounds. cost of antisvphilitic drugs is by no moans pro A comparison can he drawn between the pro blem we have to face here in treating syphilis and the problem they are confronted with in the hibitory, and there is a large choice of drugs open to us for intravenous, intramuscular and oral administration. United States. In both countries there are The actual number of syphilitics wo should negro populations, mid in both the negro popula tions have in the past been neglected. The main difference is that here the proportion of negro to white is far greater than in America, which makes the problem of dealing with syphilis here more difficult. What Parran10 says about the United States applies in some measure here: ' For the country as a whole wo have carried on a guerilla warfare against syphilis, with attempt to treat on the mines is also debatable. Assuming that 10 per cent, of mine Natives have positive Wnsserniamis, then it follows that about 32.000 mine boys are in need of treatment. To discover these 32.000 at once, it would be neces sary to perform a W.li. on the whole 320,000 1 do not suggest that we sheudd do this. I" suggest that we should regard as our ultimate goal the treatment of every infeclod Native, but that at spirited skirmishes and valiant forays in some present we should fncklc the problem gradually, of the states which show casualties to their by treating all boys whose syphilis wo discover credit. There lias never been a co-ordinated in the course o our ordinary duties. drive against it b_v all the states. . . . It is for Let us suppose that the mine medical officer this reason. I believe, that there is no evidence Lo he found of a general decline in the attackrate of syphilis for the country as n whole." In South Africa it is absolutely essential that there should he a co-ordinated drive, and this should include treatment of the Natives in the British sees a boy at short-weights, or in hospital with a contused knee, and that he notices symptoms suggestive oi syphilis. What I suggest is that he should treat the ease if the W.lt. is positive as thoroughly as he can under the circumstances, with the object of obtaining eventually a nega Protectorates as well as those in 'the towns and rural areas of the Union. It is equally essential that there should ho some co-operative treat ment-card or similar system to enable Natives who travel about to continue their treatment from where they left off. "Unless intensive treatment is undertaken in all parts of South Africa, Natives who have been cured in one locality, for example on the mines, will again contract the disease when they proceed to another locality, as, for instance, when they go home. The actual amount of treatment that could be undertaken on the mines is debatable. It would, naturally, vary with the members of dif ferent Native tribes. As a ride, the stay of tive W.K. " There should be closer co-operation between mine medical officers and. the medical officers of the W.N.L.A. to whom a large number of treated cases arc sent when they arrive from Bietfontein, as well as with M.O.H's. and the officials ol the Native Affairs Department. Many Medical Officers of Health are doing their best to treat infected Native women in the loca tions, and will, no doubt, later, also treat the women on the outlying farms who are frequently responsible for harbouring infection. Bv arrange ment with the .M.O.Hs. it might ho possible for health assistants to he sent out to the miiies fn investigate the sources of freshly-infected Natives. At present there is little effective Nnsas on the mines is short. Shnngaans, on the co-operation between the various medical organi other hniul. usually remain with us for ten sations that treat syphilis. The treatment in months or longer, and the same, applies to tro this country is carried out by District Surgeons, 126 Proceedings of the Transvaal Mine Medical Officers' Association. M.O.Hs., mines, mission-stations tuid hospitals, this would he " chalked up '' on lus card. It bui a Native passing from one treatment-centre would be impressed upon him that he was being to another is not given a card to give informa given the curd for his own good to enable him tion about how much treatment lie lias received to get further treatment for his condition which or the result of his Wassermami Test. was not yet cured. He would be told that he . The result of this lack of system is that if an infected Native leaves one locality for another, desiring to continue treatment, another W.k! has to he taken at the centre to which lie goes. This wastes the time of the medical officer taking the Wassermami, the pathologist, and the patient. Even after the result of the Wassermcuin has been obtained, the medical man treating him has only the hazy idea that the patient can give him of how much treatment has already been given. I have sometimes given boys notes to District Surgeons nearest their homes, with details about their Wassermnnns and so on, but I have done this only in cases in which tho idea has occurred to rue to do so, and there must be hundreds of boys that have been treated earlier on in their contracts and have gone home without a note. This experience must be common to most mine medical officers. If it became an established routine for every syphilitic Native to bu given a card, then cases would not be missed out, and every Native who wanted to continue treatment could do so from where lie left off. On the mines, we can moke antisypliilitic treatment more or less compulsory, hut in the municipalities and rural areas this is imprac ticable. It would, however, be a great help to M.O.Hs. and District Surgeons if some system were established in which they became informed of any syphilitic Natives entering their areas. This could be attained in the case of Natives leaving the mines by co-operation with the Native Affairs Department. Infected hoys leav ing the mines could have their passes marked in a way that I shall describe presently. At present, boys who leave the mines for home need only retain, their passes until they get home, whereas those who leave a mine and sub sequently obtain work on another mine are sometimes issued with new pusses. In either case a boy does not generally retain his puss for very long after his discharge from n mine, so that the mere noting oil a boy's pass of informa tion about Ids W.K. or other particulars would must on no account lose his card, as othewise In: would give his next doctor a great deal of trouble which would delay his treatment. For Natives who intended going home at the ends of their contracts the card would be placed in an envelope addressed to the district surgeon of his district, and given to the boy. Whether lie actually got further treatment after that would depend largely upon himself. .But, in addition to this, every boy suffering from V.'D. would have his pass marked with some symbol distinguishable only by pass officers, compound managers and other necessary officials. Different symbols would be used depending on whether lie was suffering from syphilis, gonorrhoea or chancroid. If the boy wont home, he would probably lose his pass and the symbol would never serve any useful purpose; but if lie went to a pasa office in searcli of further employment, eif her on another mine or in some municipality, the symbol on his pass would be copied on to his new pass. It would inform the doctor who examined him at ihe pass office that lie had a venereal disease, and lie would request to see his card, if the hoy was going to work in that municipality, so that arrangements could he made for him to attend for treatment. If the boy went to another mine, the compound manager would see the symbol on the new pass and inform the mine medical officer that the boy in question laid a venereal disease. The M.M..O. or super intendent would then ask the hoy to show his treatment card which would give full particulars. Such treatment cards as T have described should be issued to all Natives suffering from V.D. in every part of South Africa. They should lie issued to both males and females, and mothers should be given cards for their children. This system, provided clinics wore available in every part of South Africa, would enable every de lected V.D. case to obtain treatment if the patient desired it. If the patient refused to do anything more about it, as doubtless many would, then the Native would at nnv rate have been given a fair chance. not bv itself be a guide for further treatment. In all centres where V.D. was treated, and The method I suggest is as follows: whore cards were issued, there should be Native Every Native who has Y.D.. whether syphilis, aitendants lo explain all that was necessary gonorrhoea, or chancroid, and requires further nhout V.D. to the Native patients, and io em treatment, should bo issued with a treatment phasise the value of the treatment cards. Once card giving all necessary information about liim. the Native people grasped the idea of tho treat Whenever the Native was given an injection. ment card system they would be willing to pro- Proceedings of the Transvaal Mine Medical Officers' Association. 127 <lucc them when ashed for them and would take sively. I have proved fo you by quotations from cure not to lose them. various authorities that syphilis reduces an If the system 1 have outlined were adopted, many of the difficulties mentioned at our last meeting1 about treating syphilis more intensively would vanish. The lact that it would not be individual's capacity to perform a full day's work, that in negroes it is particularly prone to attack the curdio-vasciilar system, that it has a decidedly unfavourable effect on the course of possible to achieve cures in the short periods pulmonary tuberculosis, and that unless it is pro of time that many Natives spend working on perly treated it is often handed on to the next the mines would not matter, as the treatment generation. We know also that it produces would be continued if the patients desired it unfavourable effects on the healing of traumatic after they got home, or wherever they went. wounds, fractures and eye injuries; and I have Later on, when V.D. clinics have been estab pointed out that it probably accentuates the lished more generally throughout the country, it will probably be necessary for the Native Commissioners to bo informed by the Native Affairs Department about boys who have gone home still suffering from syphilis, so that they can be traced through their chiefs, and brought up to a treatment centre. It is no use attempt severity of many other diseases. Though I have no doubt whatever that if we treated syphilis properly we should be repaid many times over, I cannot prove it. A thing like this cannot be proved until the experiment has been made. What we must do, 1 feel, is to persuade the ing to do that until treatment centres have been Government to do its share in reducing the inci established within reasonable reach of most1 dence of the disease, start- a treatment card Natives. system, and treat the disease more effectively It may be argued, as it was by Dr. Orenstein ourselves, at our last meeting1 oil syphilis, that if Natives were given cards for follow-up treatment, they would not trouble to attend for such treatment. I, therefore., move the following resolutions: Resolutions. . 1 do not believe that this is so. In the annual 1. That this Association views with grave report of the Department of Public Health1'1 concern the extreme prevalence of syphilis among there is a statement which suggests that many Natives. It is of the opinion tiiat the disease Natives, if given cards, woidd attend for treat is a serious menace lo the health of Native ment. The report states: labourers, and that, if adequate treatment is "The actual numerical increase recorded in not instituted, it will become a still greater attendances is but one aspect of the increasing menace, ft, therefore, resolves to inform the efficiency of the clinic system. Another is given Chamber of Mines of its opinion and to ask the in the account submitted by medical officers Chamber of Mines to impress upon the Govern and district surgeons from several representative ment the need for immediate effective steps for areas that the erstwhile antipathy of. the Native the reduction of the incidence of the disease. is disappearing. Where previously there existed a deep-rooted suspicion and distrust of European medical methods, there is now appearing a desire for scientific treatment." The report goes on to comment that a larger proportion of cases arc submitting willingly to the complete course of treatment. 2. It resolves to institute a treatment-card system on the mines which will serve as a guide to treatment for Natives passing From one mine to another and' for those who arc going home and will return to the mines later. . 8. In view of the enormous loss lo the industry from the effects of venereal diseases, The propaganda methods suggested by Dr. which are contracted outside the mines, this Peall" at our last meeting for imparting health Association resolves to ask the Chamber of Mines knowledge to mine Natives will, when they come to arrange for free antisyphilitic remedies to be into force, aid considerably in enlightening boys provided by the Government. about the value of V.D. treatment, and the propaganda work that is being initiated bv the Transvaal branch of the S.A. Red Cross will also bo of great value. 4. It is agreed, after obtaining the consent of the Chamber of Mines, to appoint a small sub-committee to discuss with the appropriate Government officials the question of marking the The important, question was raised by Dr. passes.of Natives suffering from venereal disease Orenstein at our last meeting on syphilis1 of with certain symbols. whether the gold mining industry would get value (See amended resolutions as passed at for money if it treated syphilis more inten November meeting, page 184.) 128 Proceedings of the Transvaal Mine Medical Officers' Association. References. 1. Proceedings of Transvaal Mine Medical Officers' Association, Feb., 1937. 2. The S.A.I.M.R. Annual Report for the year elided 31st Doc., 1927. Johannesburg, 1923. I must say at first, Mr. President, that I con sider we are fortunate in having in our Association a member who is not content to let. sueh an important subject as the mass treatment of syphilis rest sine die, and who rightly persists 3. The S.A.I.M.R. Annual Report for tiie year in drawing our attention to flits ravages of this ended 31st Dec., 1937, Johannesburg. disease, and believes that our Association can 4. Proceedings of Transvaal Mine Medical Officers dq more than it lias done in tliu past .in the Association, Feb., 1633. way of treatment and prevention. 5. Northern Rhodesia. Native Affairs Annual Report for the year 1937. Page 48. Lusaka, There can be no question that we all agree with Dr. Humphries that syphilis is rampant 6. Northern Rhodesia. Native Affairs Annual throughout South Africa, and that it undermines Rcgort for the year 1937. Page 102. Lusaka, the health of the Natives in very many ways, and also affects the future population throughout 7. M.eyorstein, Rudolf. " Syphilis in South Africa." ti.A. Med. Journ., 2Sth Nov., 1930. 8. "Bejel": Non-venereal syphilis. Oct., 1930. 3rd 9. G. W. Gale " The Incidence and Control of Venereal Diseases among the Natives of an Urban Area." Awaiting publication in the S.A. Med, Journ. 10- Pnrrnn, Thomas. " Shadow on the Land." New York, 1937. the whole country. The more we study the figures we have at our disposal the more we re alise the colossal extent of the disease, and that, a national campaign, properly organised by the Government, is needed to fight it. The more this disease is looked for the more it is found. Let me give you an example of this: The figures we have just received of the morbidity and mortality of diseases in the Gold Mines and 11. Harrison, L. W. Personal communication, 10th Collieries for August show that on the gold April, 1937. mines there were 205 patients with the final 13. Proceedings of Transvaal Mine Medical Officers' diagnosis of syphilis among some 320,000 boys, Association, March, 1937. whereas on the collieries for the same month 13. Annual Report of the Dept, of Public Health. Year ended 30th June, 1937. Pretoria, 1937. 14. Annual Report of the Medical Dopt. for the year ended 31st Dee., 1937. Uganda Protectorate. 1938. 15. Med. Dept. Ann. Report. 1934. Kenya Colony and Protectorate. Nairobi, 1935. * 1C- Ann. Med. and Sanitary Report for rear ended 31st Dec., 1936. Zanzibur, 1937 ' 17. Nathan A Thornton. " Public Health, Housing and Slums Aots for the Uniun." South Africa' C.N.A. there were 3 such patients amongst 17,345 boys. 1 f the proportions of syphilis in the collieries had been the same as on the gold mines there should have been .18 cuses of syphilis diagnosed instead of 3. I think we can say that the gold mine Natives, on the whole, are of better physique than the colliery Native, and it is because we are able to give more supervision to the health of the mine Native and have easier means of getting our Wasserinanns done that we discover more syphilis than on the coal mines. IS. Tidy, II. .Let-liuby. A Synopsis of Medicine, Bristol, 1930. 19. Anti-venureal Measures in Scandinavia, H.M.J.. lltli June, 1938. 20. Proceedings of Transvaal Mine Medical Officers' Association, Sept., 193B. ] ,043 Wasserinanns were sent in the past 34 years from two hospitals of the Union Corpora tion and 401. were positive--or 37 per cent. Dr. Humphries has brought up so many and important aspecis of a campaign against syphilis that I must confine my remarks to one only of Dp. Goldsmith said: I was President of this the resolutions he has moved. Association in .February, 1937, when a meeting The question of marking passes of infected was held on Preventative Medicine and Hygiene. Natives with some symbol to show they have a Dr. Humphries thou read a short paper on the venereal disease can only he discussed when we advisability of more extensive treatment of have a good knowledge of Native pass regula syphilis in mine Natives--also when the dis tions and passes. In order to make what I have cussion on this subject was continued at the to say clear, I have brought with me three passes meeting in the following month. But after a ' and a tax receipt. good deni of talk it was agreed that the matter Every Native who comes into the Transvaal he further discussed at some future meeting of or O.F.S. to a proclaimed area for the purpose this Society. It was shelved sine din, in fact-. of seeking work must be provided with a travel It is fitting, therefore, that I should re-open ling pass or permit to seek work. In Cape this discussion again. Colony and Natal pusses are not required, a Proceedings of the Transvaal Mine Medical Officers' Association. 129 Native carries liis tax receipt, but a boy leaving To alter u pass so that it shows a reflection on a Natal must have a pass, and women are not re boy's character is not allowed. I found that quired to have passes anywhere. some of the compound managers on the East Tax Receipt. Hand a few years ago had the service contracts of bad or suspicious characters written out in When a Native leaves home he goes to the red ink. This practice was soon stopped by magistrate's office in his district to get a travel Native Affairs as being unauthorised--as casting ling pass or permit to seek work. To obtain this a reflection on a- Native's character. he shows his tax receipt. Here is a Native tax receipt and document of identification. On this is his tax identity number; this number sticks to a Native for life. It is divided up into three by two strokes, and here it is, 176/2/J4G. If it is lost the Native, by giving his chief's name and his father's name to the pass officer in the magistrate's office of the area, can always be traced and the same number is given to him again. He is then given a Travel ling Pass or permit to seek work. .1. Imd an interview with a leading official of the Native Affairs .Department, and asked his opinion on the possibility of marking passes and tax receipts with a symbol (secret symbol only known to the medical profession) to show a boy had V..D. Me very kindly went into the whole question with me, lie said it could not be allowed under the present regulations governing pnsses, and before any pass could be marked with symbols showing a Native had V..D. a new Government regulation would Travelling Pass. have to he passed and proclaimed. It would not This Travelling Pass I have here comes from the office of a magistrate in the Transkcd. It is for the purpose of seeking work on the he long before Natives found out wliat the symbols meant, and that would prevent their employment in many coses. mines within GOO days, but it also has t-lie New regulations must he passed before sym Native's tax registration number, district bols could be used--this is a great pity, as the and area. The holder of this pass got work on Government have right at their hand the the mines within 30 days. He was sent to n simplest wav possible of showing that anv Native pass office, where he obtained (or the mine ob tained for him) liis ordinary pass or service con tract, as it should be called. Here is one, and on this is copied from hiB travelling pass the same numbers of the area, district and his identity number. 'Tins contract is made out in triplicate --(1) employer, (2) Native, (3) filed. has v.:d. ' Also under Section 10, Proc. 150/1934-- (Passes) Tvl. and O.E.S.--No pass shall be issued to any Native apparently suffering from an infectious disease except for the purpose of enabling him to obtain medical attention or fo proceed to n hospital or other institution for Private Boy's Pass. medical treatment. The puss or service contract for boys working However, I should like to show that it for private people is printed in red instead of was not so unreasonable as it seems because black, but it also has the tax identity number, etc., as on the "black" service contract. If a Native loses his pass in a proclaimed area lie is detained for six days until his tax identity numbers are obtained from the district he comes wc have a precedent to go on, and it is this, that Natives who have been in gaol are given a special number on their passes and a description of tlieir finger prints is also given. from before be is given a permit to seek work If the Government does this so as to be able or a service contract. Every Native thus has to control and trace a Native who has been in always on his pass or tax receipt a number by gaol, would it not be possible under altered regu which lie can be traced, and which is put on his lations to allow other figures or symbols indica permit to seek work pass before he can move to ting V.Ds. to be put on passes? obtain work. We hnve, therefore, at hand all .Dr. Goldsmith then read from the Native the machinery necessary to identify the Natives (Urban Areas) Act for Proclaimed Areas No'. we want. What would bo easier than to put a 203 of 1924--as amended--chapter IT. "Eegusymbol at the end of tax identity number to show lutions for Medical Examination," Section 19 that a Native is suffering from a venereal disease to 24, which give unlimited powers to the __a different symbol for different venereal registering officer to cause any Native to be diseases. exnmined by the medical officer when entering, Hut I regret to say there seems to be employed, or residing in a proclaimed area, but great difficulties against putting symbols de unfortunately these powers were rarely exercised, noting disease on boys' pnsses or tax receipts. which was a very great pity. 1(30 Proceedings of the Transvaal Mine Medical Officers' Association. Dr. Williams said: I desire to congratulate C.C. boys provided most of our cases and to show Dr. Humphries on it most thoughtful and that all nations either have or do contract the thought-provoking piece of work, which is re disease with equal facility. Taking 84 random markable, not only for the convineing mass of cases with ++ Wassermanns, 30 per cent, were facts and figures, hut also for the wide and visionary outlook on a problem which is of immense importance to the country as well as to the industry. As Mine Medical Officers with a great number of Natives under our caro, our considered opinion ought to carry some weight, and our figures on the incidence of syphilis amongst mine Native labourers may lend force to the urgency of our plea for somethin" to be done. The spectres of Tuberculosis, Syphilis and Malnutrition that are ever with the Native people cannot be abjured by ignoring them, nor can we afford lo speculate as to whether there C.C. Natives, 29 per cent. Basutos, 14 per cent. Zulus, 13 per cent. Transvaal Basutos, 11 per cent. E.G's. and per cent Swazis. Grouping all sels of figures together, 072 cases were tested for syphilis by the Wnssermann test and 217 were positive, a percentage of 32 per cent. These figures are somewhat terrifying. It is difficult to estimate what percentage of the Native people have been or were infected, but other speakers will doubtless have statistics, and a common estimate may be arrived at. But ti.e position is appalling. will be any malarial gain for us if we sot out to Like Dr. Humphries, I think that such sug urge on immediate attack. But the drive against gestions that the Wnssermann test is unreliable syphilis will be a National one. Those of yon and that there is probably a disease midway who heard, or read. Dr. PcalFs paper on the between yaws and syphilis, are too well known projected activity of the National Council of to be more than a quibble. Such facts in no Social Hygiene will know that the Government way influence the problem in the light of present intends to move in the matter. Our resolutions, knowledge of syphilis. Bub the problem is the which I think it is our patent duty to send, in " follow up " of cases. I must admit that I some shape or form, to the Chamber, will serve t.o stress the necessity for immediate action and indicate our willingness to serve in any capacity the Government thinks lit. " I would like to quote my own figures on thought that the marking of passports with sym bols, or the issue of health passes might bO' practicable, but listening to Dr. Goldsmith's exposition of passport regulations I am prepared to believe that little or nothing can be done along those lines. I would like to suggest that syphilis for I feel that this is the best way of Dr. Humphries abandons his resolution on the supporting 'Dr. Humphries' contentious. During necessity of marking passports, merely indicat the last two years, we have had. nn average com ing to the Chamber our view of the gravity of plement of 1,000 Tropical Natives. All cases the position and our willingness to serve on any coming to hospital for any cause whatsoever sub-committee of the National Council of Social have had their bloods taken for examination for Hygiene, whose duty it will be to evolve the relapsing fever and for the Wnssermann best. 0! plan of attack. ' 301 eases, not apparent syphilis, 37, i.a., .1.2-3 per cent, were positive: of the 37 cases, 31 were -r + . 4 werc-t-, and 2 wcre+-. Tribal incidence, 21 T.N.B. and 10 B.N.P. Dr. Dreosti said he first wished to congratu late Dr. Humphries on his excellent paper and the extremely valuable data collected. The criticisms lie wished io make did not concern the Excluding the eases above, from September. paper but the resolutions put before them. 1937, to September, 193S, 183 obvious venereal He objected fo the phrase " that this Associa eases were treated. Of these, 105 wore syphi tion views with grave concern the prevalence of lis in either the primary or secondary stnges, syphilis amoimst Natives." As far as he cotdd with strong ++ Wnssermann reactions, 18 were gather from the data presented approximately mixed infections (syphilis and gonorrhoea) and 14 per cent, of mine Natives show a positive 00 were gonorrhoea, chiefly in the acute stages Wasserinann reaction and this must include a or with gonococcal epididymitis. In addition to both groups above, 248 bloods were taken in cases other than apparent syphilis. e.f}., delayed healing of wounds, routinely in fracture eases, unresolved pneumonias, eye eases, etc., of these, 57 were positive, i.e., a per fair percentage of positive reactions duo to yaws and not syphilis. At a recent meeting of the Medical Association a^ speaker estimated that 40 per cent, of our European male population is infected with venereal disease, and of this at least 11 per cent, is due to syphilis. The problem of venereal centage of 23 per cent, of which 43 were ++. disease was. therefore, not one of mine Natives 9 were + and 5 + --.. Tribal distribution does to be solved by mine medical officers, but a not help much except lo show that BhpuAok and national problem. Proceedings of the Transvaal Mine Medloal Officers' Association. 131 It seemed that tile only possible solution was and lie felt sure that they would soon learn to the education of both Europeans and Natives to appreciate the value of the card system. They the dangers and infeetivitv of the disease, in the certainly had great faith in salvarsan treat hope that sufferers would conic forward volun ment, which they consider acts like magic. tarily, particularly during the infective stage, for medical treatment or isolation where necessary. Failing this, the only alternative appeared to be compulsory notification .as done at' present for other infectious diseases; early treatment or Dr. L. R. Saayman (Asst. M.O.H., Gerrnis- ton) said he had collected a few figures in the limited time at his disposal from their curative centre at Germiston. isolation under the supervision of the Public Since March, 1038, blood samples for the Health Department or Local Authorities. Wassermann Test were taken from 1,050 cases He failed to see tho object of the fourth resolu tion which proposed marking the passes with symbols and so labelling Natives who have a positive Wassermann reaction. Apart from the many obvious objections, the following appears to be another possible objection. Knowing that the working capacity is con of men, women, children and babies. Those samples were taken at random and not from selected eases in the Germiston Location. The whole group showed 44-4 per cent, ns positive Wassermann. To get a better idea, lie had taken the blood of every expectant mother at the Ante-natal Clinic and they gave a positive Wassermann reaction in 40-5 per cent. Actually siderably reduced, would we engage these labelled " Natives? Is it not natural t-liut we would demand that these Natives be cured before engagement? This appeared to him to he grossly unfair to the Native and, further, if such a pro 227 blood samples had been taken. They had a duplicate card system; one card being given to the patient and one being retained for record purposes. cedure of labelling persons was considered de The follow-up system had also been intro sirable, why confine it to the Native employees duced. Qualified female Native nurses or male only? orderlies were instructed to explain to the In conclusion, he felt that mine medical officers could not, hope to reduce the incidence of venereal disease in mine Natives as long ns foci of infec tion were allowed to exist outside the compounds sufferer and his relations, t-he dangers of neglect ing treatment and of infecting others. Thus if the wife had syphilis, the nurse could usually persuade the husband to come along for ex and in the Native territories. amination and, if necessary, for treatment. Dr. F. C. S. Hlnsbeeck (Medical Officer of Dr. Peall said it was agreed amongst Mine Health, Boodepoort-Mavaisburg) said that he Medical Officers that the question of venereal could assure the meeting that all Medical disease amongst mine Natives was one of Officers of Health were very keenly interested National importance. in syphilis, and that their poor attendance coidd only be ascribed to unavoidable circumstances. Certain Medical Officers of Health had been asked to draw up a memorandum (Dr. Gale, who was present, being one of the doctors con cerned), and he expressed the hope that they would be afforded the opportunity of expressing He thanked Dr. Humphries for again bringing the matter up and congratulated him on tho excellent manner in which he had set forth the various aspects of the subject in his paper. As members had been requested to quote statistics from tho various mine Native hospitals tiieir views on this subject at the meeting of he gave the following figures from Bandfontein. the T.M.M.O.A. to be held in November. Dr. Since February, 1037, 2,500 bloods had been Humphries' paper was an admirable one, and examined for the Wassormami reaction with he was not able to controvert any of the state these results:-- ments made therein. There was no doubt that the efficacy of the card system, which the Medical Officer of Health, Pretoria, had put forward some time ago, should be given a fair 499=20%. gave a + + strongly positive reaction. " 70=2-8%, gave a + reaction. trial. This was not really an innovation, as 93 = 3-7%, gave a + doubtful reaction. seamen suffering from syphilis are supplied with These figures were very comparable to the a treatment card so that the treatment could figures already quoted by other members pre be followed up at other ports of call. sent. The Native, according to his experience, was During the last three months, in connection only too anxious to have anti-syphilis treatment, with an experiment being carried out in treat 132 Proceedings of the Transvaal Mine Medical Officers' Association. ing pneumonia casus with M & B (iSlii, the bloods of ail pneumonia cases had been examined for the Wasscrmann Reaction. This scries of cases again showed 20 per cent, with a + + strongly positive Wassermanns. but be was struck with the fact that although the blood gave a + + reaction the progress of the disease He did not think that cards would serve any useful purpose, except in urban areas. Natives from the territories, even if. willing to make use of the cards and intelligent enough to know wliat to do about it, would find it impossible, in the vast majority of cases, to obtain treatment. It was no earthly use to urge introduction of a was not always seriously interfered with and, measure which one know priori to he unwork therefore, was forced' to draw the conclusion able. Both the Chamber and the Government that a + + reaction did not always have the were unquestionably aware that syphilis plays some significance. a serious role in public health, but exaggeration He was pleased to hear Dr. Dreosti raise the of the case should be avoided. question of venereal disease amongst Europeans. Dr. Orenstein could not see how any sub He had always taken exception to the sug gestion frequently made that venereal disease amongst Europeans was the result of infection from Natives. He did not say that infection from Native to European did not occasionally occur, but this was not the usual method in. which infection was disseminated amongst Europeans. committee which t-lie Association might appoint could make any useful suggestions as to how the problem should ho tackled in a practical manner. The Association should content itself by pre senting to the Government the true state of affairs and pointing out the need for attacking tile problem, without making any suggestions as to liow it should be done. With regard to the resolutions--the fourth one In his opinion, therefore, all the resolutions, was rather drastic. The subject was admittedly except the first one, should fall away. a very important one, hut there was tio neces sity for the public to be stampeded. Many Europeans bad Natives working in the house or garden who had no active disease but gave a -i- -f- strongly positive blood. If this was indi cated on a boy's pass he would most certainly be refused employment. One could not force upon the Natives conditions of supervision whieh Europeans would be unprepared to accept for themselves. The Medical Officer of Health, the Mine Medical Officer and the Public Health Depart ment should agree upon some method of keeping in touch with patients--both European and Native--requiring treatment. He felt that the eradication of venereal disease would be greatly assisted by the education of both Europeans and Natives in these matters. Dr. Orenstein was definitely opposed to the marking of passes indicating that the bearer suffers from syphilis, even though it might be possible to obtain legal sanction for this, which lie seriously doubted. He was opposed to such a measure not only on principle, as applying to one section of the population only, but also on administrative and public heultli grounds. The whole success of the treatment of venereal diseases lies in obtaining the confidence of t-he patient and careful respect for the confidential information which the doctor possesses. De stroy this safeguard and the problem of treat ment becomes infinitely more difficult. Dr. J. Daneel (Medical Superintendent, Rietfontein Hospital), in thanking Dr. Humphries for his very informative paper, said it was an excellent tiling for the subject to be brought Dr. Orenstein stated that the Government t:o the notice of Mine Medical Officers. required no stimulus for the recognition of flic importance of syphilis, but while recognising its importance the Government is ulso faced with many difficulties in the way of carrying through a campaign. Some of these difficulties are dealt with in a pamphlet recently issued by Dr. Gale, and he hoped that copies of this pamphlet would be made available to members of the Associa tion. The legal position requires no alteration. The provisions of the Public Health Act impose compulsion on those who refuse treatment, but As students, we had been taught to classify syphilis as primary, secondary and tertiary, but from the public health point of: view they regard syphilis as infective and non-infective. Also that the primary and secondary Btoges are very infective, but not t-lie tertiary' stage. Active treatment in the infective period would, to u large extent, prevent t-he spread of the disease, and treatment in the non-infectivc stages is mainly instituted as a therapeutic measure for the patient's own benefit. no experienced Public Health Officiul would They knew that com] >1 i cations occur from advocate compulsion ns a general measure. treatment of syphilis, and also rcnlised the Proceedings ol the Transvaal Mine Medical Officers' Association. 133 enormous ramifications of the disease in the to render them non-contagious. Such Natives hospitals and asylums. It was n very grave will marry, infect their children and fill the problem. hospitals and asylums in later years. Jt had been also quoted by Dr. Humphries More easily avnilahle clinics should he that 40 per cent, of citizens, including an appre established, and every Native presenting him ciable percentage of negroes in the U.S.A. were unuble to do a good clay's work. The more he saw of syphilis, the more he realized that a man could not do a full day's work in the tertiary stage, such a man being prematurely aged. The interpretation of the Wassennann reac self for treatment should be issued with a curd indicating the disease, the amount, of treatment, and the date of last treatment. On presentation of the card at any clinic lie could obtnin his appropriate treatment. One felt very strongly that thure was no follow-up treatment at all at present. tion needs a considerable amount of care. He maintained that there was only one thing pos One had also to take into consideration that, sible which gave a repeated sironglv positive re as a whole, there is no reason why anyone under action of the blood (W.ll. ++), and that was treatment should not continue with his work. syphilis. In leprosy, small pox, malaria and Other febrile diseases, a temporary positive reaction (W.Ti. +) may sometimes be obtained, but never a persistently strongly positive (\Y.H. The modern treatment is severe, and not all constitutions can stand it. There is a temporary loss of efficiency during the treatment. + +) reaction. ' Syphilis 1ms a far greater incidence in urban It is known that in tertiary stages, Wasscr- than in rural areas, the detribulized Natives being maun reaction might be + +, +, or negative, exposed to far more temptation and risk of It was also known that there was a laboratory contracting disease. In Pretoria, out of 1,000 error. bloods, 32 per cent, were found to be strongly In his work, before saying any person is suffer positive. The incidence of urban Natives is ing from syphilis, he must get three consecutive round about 40 per cent., and rural 10 per cent, strongly positive Wassorinann reactions; taken to 15 per cent. at reasonable intervals. If t-lic blood shows any He was grateful for the opportunity which of the other reactions and there still remains u susjncion of the existence of: syphilis, a series of provocative injections should be insti had been afforded him of hearing the various impressions at this meeting. tuted before the blood is examined again. The Chairman, in adding his congratulations In the treatment of syphilis, it was extra ordinary the lack of confidence and knowledge on the part of the medical man as to the efficient course to follow. Ho had always main tained that if any patient is accepted for the to those of the other speakers who had joined in the debate, said that Dr. Humphries' paper hud evoked more than the usual amount of discus sion. The subject was one which uffeeted M.M.O's. tremendously in view of the great treatment oE syphilis, the practitioner's eon- damage which syphilis was responsible for, or, science must ultimately be satisfied that the to put it bluntly, the number of shifts lost to treatment lias been thorough, good and suffi the Mining Industry directly and indirectly. cient. From our present knowledge we know tliat we do not treat symptoms, nor the Wassermann reaction, but the disease itself. The latter must he regarded ns a guide. Members bad laid an opportunity of ventilat ing their ideas, and had to pass or reject the resolutions which had been submitted. He moved that the resolutions be held over until the As far os the Native is concerned, when he November meeting. secs his sores and lesions disappear he is satis fied that he is cured, and one has to tell him that his blood is not clean. If one puts medi cine right into liis blood, he will always come and ask for more injections. Ho had felt very strongly on this point--when Natives are sent to his hospital, he felt very guilty when they had to be kept there only for a short time and just Dr, Orensteln seconded, and also congratu lated Dr. Humphries on his paper. It gave him great pleasure to note that a M.M..O. hud taken, up the subject from the wide point of view of the Natives of tlic country, and not merely the anthcap of mine labour. The meeting terminated at 5 p.m. 184 Proceedings of the Transvaal Mine Medical Officers' Association. The November General Meeting was held in ence on a subject with so wide a public health, the Chamber of Mines Building. Johannesburg, aspect, I shall confine my remarks to clarifying on Thursday, 17th November, 1938, at 3 p.m., certain points and emphasising others that Dr. L. E. iVIiller (President) in the chair. have a bearing on the amended resolutions you There were present 21 members, 4 visitors have before you. and the Secretary, As you will observe, I have amended reso The Minutes of Meetings hold 18th August lutions 2 and 3, and .have cut out my original and 15th September (1938) were taken as raid resolution 4, in which it was proposed to mark and confirmed. The Chairman welcomed the Medical Officers of Health present who had attended the meet ing by invitation, and hopped they would again join in the discussions. the passes of natives with symbols. There were several objections to this idea, but the one mentioned by Drs. Poall and Dreosti, viz., that the marking of passes would be a cause of natives being refused employment has convinced me that the resolution should be withdrawn. He called on Dr. S. Y. Humphries to reply to the discussion at the October meeting on his paper " Syphilis--A major cause of Ill-health in Native labourers, and suggestions for mass treatment." Resolution 2 has been altered to malic it compatible with the recommendation of the Society of Medical Officers of Health, and I hope one of their members will explain the travelling-card system proposed. Dr. Humphries read the following resolutions, amended in the light of the previous and present discussions (and carried at the conclusion of the present meeting) :-- AMENDED RESOLUTIONS. Resolution 3 has been altered slightly from: "This Association resolves to ask the Chamber Of Mines to arrange *for free anti syphilitic remedies to be provided by the Gov ernment" to "This Association resolves to ask 1. That this Association views with grave the Chamber of Mines to consider the question concern the extreme prevalence of syphilis of arranging for the Government to supply free among Natives. It is of the opinion that the anti-syphilitic remedies for use on the mines." disease is a serious menaoe to the health of Tiie amended resolution leaves it to the Native labourers, and that, If adequate treat Chamber of Alines to decide the most expedient ment is not Instituted, it will become a still course to adopt. greater menace. It therefore resolves to inform the Chamber of Mines of Its opinion and to ask the Chamber to Impress upon the Government the need for immediate effective steps for the reduction of the incidence of the disease. Non- for a few points requiring clarification. 'First there is the question, of whether the Gov ernment is aware of the urgent need for effec tive steps for the reduction of the incidence of syphilis. It was agreed, I think unanimously, 2. That this Association strongly endorses at the last meeting that syphilis is causing a the recommendation made by the Society of profound degree of disability 'among natives, Medical Officers of Health, and passed by the Lind that something ought to be done about it. Federal Council of the South African Medical Dr. Orenstein has told us that the Govern Association, which reads as follows:-- ment- requires no stimulus for the recognition " The Society reoommends to the Secretary of the importance of syphilis. But I should for Public Health that a suitable travelling like to remind members that while Dr. Orcn- card be drawn up for the use of Y.D. stein's opinion is a very valuable one in this, patients." as in all subjects related to public health, we 3. In view of the enormous loss to the country as a whole from the effects of venereal diseases, this Assosolation resolves to ask the Chamber of Mines to consider the question of arranging for the Government to supply free antl-syphllitlc remedies for use on the mines. must not- lose sight of the fact that he was only expressing an opinion--not stating a fact. If you agree with Dr. Orenstein that the Gov ernment is doing all that it ean possibly do for Bantu syphilis, then you will, of course, throw out my "first resolution. But if, on .the other blind, you agree with me that- the Government Dr. Humphries said.: could do a great deal more for syphilis than it It gives me great pleasure to reopen the dis is doing at present, you will, I hope, support cussion on Bantu syphilis which was started my resolution. last month. As there are several Medical Offi When Dr. Orenstoin says that "the Govern cers of Health present who have come here ment" requires no stimulus, "who does he especially to give us the benefit of their experi mean by "the Government?" I think he Proceedings of the Transvaal Mine Medical Officers' Association. 135 really limans Dr. Cluver. Wo nil know tlint ment do not at present supply free antiisypliilitic Dr. Clover is 011c of tlie most enlightened men remedies for use on t.he mines. Though liy law in South Africa on the subject. But I wonder the mines are entitled to rooeivu free anti vviiat the Cabinet Ministers say when .l)r. syphilitic remedies, there is in< existence at pre Cluvor tells them that syphilis must be more sent between the Union Department of Public intensively treated. I imagine they shrug their Health and the Chamber of Mines a private shoulders and say, ``The problem is immense. agreement, whereby all cases of syphilis It would cost a great deal to do as you sug occurring in native labourers 30 days after en gest."' gagement are treated at the exi>cnse of the If you pass my first resolution, it will mean that the Chamber of Mines, the most progres sive and influential private organisation in mines. I have a letter hero from an official of the Public Health Department defining the position. . South Africa will impress upon the Government Recommendations (1) and (8) were duly the need for immediate effective steps for the seconded bv Dr. Daubcnton, and (12) by Dr. elimination of syphilis. Peal I. " Secondly, there is a point about treatment cards that requires clarification. Dr. Orenstcin says than treatment-cards would serve no use ful purpose, as Natives in the territories, even if willing to make use of their cards, would find it impossible to obtain treatment there. The point 1 want to emphasise is that clinics must be established in the native territories. If the Government do not introduce such clinics they are neglecting their duties towards the native community. The native pays his ,-61 polltax apart from the numerous other taxes that he pays directly or indirectly, and lie is entitled to value for his money. Dr. G. W. Gale (Assit. Benoni) expressed the very keen appreciation of the Medical Officers of Health generally for the invi tation to be present,, nnd said -that in reading the following paper he was deputising for Dr. Aiming (M.O.H., Benoni), who had expressed his siuncere regret at his unavoidable absence: THE TREATMENT AND PREVENTION OF VENEREAL DISEASES IN REEF TOWNS AND IN PRETORIA. Information collected by the Witwalersrand and Pretoria Public Health Consultative Committee. I was very glad to hear Dr. Daneel express The intention of this enquiry is to survey the the opinion that every native presenting him facilities existing in Beef towns and in Pretoria self for treatment should be issued with a card for the prevention of the1 spread of the venereal indicating the disease, the amount of treatment diseases in these towns and for the treatment and the date of the last treatment. The type of persons stiffening with these diseases. of card I had in mind when I first moved the The 12 towns under consideration are liand- resolution on treatmenfc-eardR was a card similar fontein, Krugursdorp, Itoodepoort-Maraisbiirg, to that issued under the Internationa] Agree Johannesburg, Pretoria. Gcvmiston, Boksburg, ment of 1024 for the use of seamen, but modi Benoni, Brakpan, Springs, Nigel and Heidel fied to suit local conditions. berg. This card, two specimens of which ! shall The total population resident within these pass round, has the names of the treatment- Municipal areas is approximately 1,174,320, in centres on the front page, together with the cluding 500,740 Europeans, 326,700 mining identification number of the patient nb each Natives, 200,000 non-mining Natives, and treatment-centre, nnd the diagnosis and stage 47.800 Coloureds and Indians. Approximately of the disease. On pages 2, 3 and 4 are notes one-half of this population is resident within for the guidance of the medical officer, printed the Johannesburg Municipal area as follows: in English and French. Page 5 is for recording 27.1.800 Europeans, 50,(100 mining Natives, the results of laboratory examinations. Pages 144,700 11011-milling Natives, 33,300 Coloureds 6 to 10 are for recording the treatment admin and Indians, giving a total for Johannesburg of istered, with any observations; and page 50 508,SOO. (the back page) lias on it instructions to the seamen, printed in six different languages. This Financial Expenditure on Venereal Disease card could he greatly simplified and modified for Work. the use of natives. No returns have been obtained from Kru- Lastly, there is a point about the third reso gersdorp, Gcriniston, Heidelberg and Roode- lution that I want to make clear. The. Govern poort-Maraisburg regarding expenditure. The 13C Proceedings of the Transvaal Mine Medical Officers' Association. estimated expenditure of the other eight towns for 1038-1930 is 22,010 {Johannesburg 13,872}, estimated refunds from Union Government 0,1142 (Johannesburg 4,350-), leaving a net cost to the eight Municipalities of 12,477 2. One Municipality in Group (2), 17.1 Euro peans, 2,548 non-mining Natives. 3. Two Municipalities in Group (3), one European, 30 non-mining Natives. (Johannesburg 9,522). The main item of ex Ante-Natal Clinics. penditure is in connection with hospital fees, Ante-natal clinics for Europeans and for non- especially preponderant for those Municipalities Europeans are provided at Boksburg, Benoni, whoso clinic services have not been fully de Pretoria, Springs and Gcriniston. In each case veloped as yet. a, routine Wassermann reaction is done, and the Out-patient Venereal Disease Facilities provided by Municipalities. Tho 12 towns may be divided into three groups, according to their arrangements now in force -- 1. Municipalities which provide full clinic ser vices for Europeans and for non-Europeans of both sexes, i.o., 9 Municipalities. percentage of positives in Native females varies from 20 per cent, to 40 per cent. In all these clinics positive cases ore at once referred to the Venereal Disease Clinic for treatment. In. Johannesburg only European ante-natal, clinics are recorded. Where returns have been made from tlio European clinics lit would appear that about 2-1 per cent, of European cases have to be referred io the Venereal 2. Municipalities which provide full clinic Disease Clinics. services for Europeans only and largely de pend on Eietfontein H'ospital for the treat Deaths due to Syphilis. ment of non-Europeans, pality of Johannesburg. i.o., the Munici Deaths during 1937-1938 due to syphilis (Code No. 042). Locomotor Ataxia (302), and 3. Municipalities which provide no clinic ser vices but send all discovered cases to Riot- G.P.i. (308) in all towns except Germiston aud Drakputi' (not recorded1) totalled: -- fonteiu, i.c.. the Municipalities of iioode- Ten European, 113 non-mining Native, 15 poort-Maraisburg and Heidelberg. mine Native and 14 Coloured and Indian In Johannesburg tbe Native population is deaths. Total: 152. catered for by two Municipal clinics each week for Native females, and by the Princess Alice Nursing Home and the Bridgeman `Memorial Hospital for non-Europeans. The death-rates are ns follows: European, 0-02 deaths per 1.000 population non-inining Natives. (M2 deaths per 1.000 population: min ing Natives, 0-00 deaths per 1,000 population; At all Municipal clinics in these towns N.A.B. injections arc given, and other neces sary treatment. All drugs are obtained free Coloureds and Indians, 0-30 deaths per 1.000 population; all non-Europeans, 0-24 deaths per 1,000 population. from Central Medical Stores, Pretoria. Home-visiting and Follow-up Work. In most instances, where non-European, clinics are provided, these arc placed in the locations or at the local General Hospital. All Municipalities except Boodcpoort, Heidel berg, J.irakpan, Krugersdorp and Bandfoiitein report regular follow-up visits to clinic de Facilities for the daily treatment of Gonorrhoea faulters and contacts. In Johannesburg follow iiro provided for non-Europeans in three towns. up work is done by the health inspectors and During the months July-September (inclu health visitors when required. In other towns sive) 1938, in five of the towns included in the totnl of visits paid to Native eases during group (I), with a total non-mining Native July-September, 1938, varies from 50 in one population of 101,000, there were l,19fi new town to 706 in another. cases of syphilis from that section, of the popu lation. Of these 1,106 eases, 104 were chil Average Duration of Attendance of Individual dren. Of the 1,032 adults, 308 were males. Cases at Clinics. Hospital Treatment provided by Municipalities. In each instance this treatment is given a,1: Piietfontein Hospital. The number of cases admitted to this hospital during 1037-1938 was: Various Municipalities report periods varying from 3 to 12 months. Reasons for Default in Attendance at Clinic. Indifference to consequences of neglect of 1. Nine Municipalities in Group (1), 7.1 treatment is given as the main reason by six Europeans, 674 non-mining Natives. Municipalities, change of domicile to another Proceedings of the Transvaal Mine Medical Officers' Association. 137 area by three, and inconvenience of place or 2. During the same period the attendances time of clinic by one Municipality. of syphilitics at clinics run by 8 out of the 9 As the second most frequent rcnsmi Four group (1) Municipalities totalled 2,.1.8G for Euro Municipalities give change of domicile to another area, two give indifference to consei|iienees of neglect, one gives inconvenience of time or place of clinic, and one gives fear of peans anil 12.886 for non-Europeans. At the clinics run by the Municipality in group (2) there were 2,220 European and 801 non-Euro pean attendances by syphilitics. employer. 3. On a basis of three attendances a month Of the other reasons suggested in the ques tionnaire unpleasant sequelae of injections, vomiting, etc.; preference for herbalists, quacks, chemists, etc.--lihesc do not seem to bo of by each individual, there must have been 490 European and 1,521 non-European cases of syphilis attending at the various Municipal clinics during this period. great significance. 4. During .1.937-1938. 243 European, and 3,258 Pass Offioe Medical Examinations. Only one Municipality undertakes these ex aminations. During July-September, 1938, in t-his Municipality 4,248 males were examined; 20 of these (0-5 per cent.) were found to be suffering with venereal disease in a contagious form and were removed to hospital, and 558 others (13-1 per cent.) were referred to the Venereal Disease Clinic for further examination. Only 12 females were examined, of whom five wore found to be suffering with venereal disease in a contagious form, and three others were non-mining Native cases of venereal disease were sent to Diotfontoin Hospital from the .12 towns. 5. Taking these figures in conjunction with the records given above of follow-up work, pro paganda, co-ordination of ante-natal with veneral disease work, etc., it is sug gested that evidence has been presented which discounts the comment that "the natives work ing on tins mines are the only ones in whom any serious attempt is being made to institute effective (anti-venereal disease) measures," referred to the Venereal Disease Clinic for fur Commentary. ther examination. Even though evidence is produced that the These percentages obviously do not express llecf Municipalities, generally speaking, are a true figure of incidence of infection, since the taking active steps to combat venereal disease examinations are made on individuals at hap in their areas, it is apparent that much re hazard intervals, and among males a fair pro mains to be done. There still remain a few portion are coming into town from the country Municipalities whore clinic facilities, and for the first time at the time of examination. especially treatment centres For 11011-mining Propaganda Work. Most Municipalities report propaganda work regarding venereal disease during 1037-1938. 'Mils has included the distribution of pamphlets, poreonal education through individual talks at clinics and during home-visiting, public lectures, the display of films, the distribution of clinic cards giving times of clinics to doctors and chemists, display of posters in public lavatories and workshops, the issue of a duplicate card to clinic attenders, advertising in bioscopes ;and newspapers, personal talks with medical prac titioners, etc. Summary. .1. During the period July-Sepfcemhor (inclu sive), 1938, in the 9 group (1) Municipalities, .167 European and 1,109 non-European new cases of syphilis presented themselves at Muni Natives, held im easily accessible places at suit able times, have not as yet been provided. The incidence of deaths due to syphilis, the high proportion of congenital cases seen at the clinics, the relatively small proportion of Native males attending at the clinics as compared with attendances of Native females--these points suggest that many cases are still failing to get proper treatment. Tile absence of facilities For the daily treat ment of gonorrhoeal infections, except in three towns, is another obvious weakness on the exist ing services. Gonorrhoea in Natives seems to clear up more quickly than it docs in Europeans, and many infected persons go to chemists and quacks for treatment. As a result comparatively few non-European cases come to the clinics at liresent. cipal clinics and 151 European, and 94 non- Six points stand out: -- European cases of gonorrhoea. In the 1 group 1. That there is need for closer collaboration (2) Municipality, 70 European and 191 non- between Hoof lowns and between the mines European new cases of syphilis and 66 new and the Municipalities in providing venereal cases of gonorrhoea arrived at the clinics. disease services. 138 Proceedings of the Transvaal Mine Medical Officers' Association. 2. That cases of venereal disease which that it is "dangerous" to employ a servant who otherwise might be missed are miost frcquently is in regular weekly attendance at a venereal discovcrcd where in addition to good facilities Disease Clinic for an old, latent syphilis. for venereal disease treatment, one or all of the following services are provided: (a) Polyclinics at which .thu general sick attend and are seen bj' the same medical oiliccr who is also attend ing at the Venereal Disease Clinics; (b) Pass Office medical examinations done by the same Medical Officer who is also attending at the Venereal Disease Clinics; (e) Ante-natal Clinics attended by the same medical officer who is also attending at the Venereal Disease Clinics; (d) Dr. Peall, referring to travelling passes, said that many Natives leaving the mines were given curds showing t-he type of work they had done, their rate of wages, and whether they were physically fit. In liis experience these Natives frequently bring t-hese cards back in a good, decent condition, and he therefore fell they could be trusted not tc> lose their travelling treatment cards. follow-up visiting done by trained visitors who Dr. Meiring inquired tho reason for Resolu obtain the confidence of the people and can tion (3) as, after all, the cost; for anti-syphilitic therefore do efficient individual education re remedies was comparatively small. garding venereal disease. Dr. Humphries said this Resolution had been 3. The facilities for .treatment plus propa included more for discussion t-lian with the ganda are likely io achieve better results among object of pushing it through. Not much money a population a considerable proportion of which was at present being spent 011 treating syphilis, is nomadic, even within the individual locations, but if syphilis ware fronted to M10 extent required than any methods of compulsion which can be to get negative Wassermumis, it would involve devised. The effect of tho latter would the industry in greater expense, which should be to arouse strong antagonisms, especi really be a Government liability. He bad moved ally if applied to Natives only, and to the Resolution as a matter of principle, as drive things underground. There is ample evi syphilis was u national problem and should be dence that Natives, as compared with other dealt with hv the Government, races, actually show less tendency to conceal ment and greater readiness to attend regularly for treatment, once the consequences of neglecthave been explained to them by people who can. speak their language, understand their mental attitudes, and thereby gaiin their confidence. Dr. Goldsmith, referring to Resolution (1) "to ask the Chamber of Mines to impress upon the Government the need for immediate effective steps for the reduction of the incidence of the disease," said that- under the Pass Laws for Proclaimed Areas, the Registering Officer had 4. These treatment travelling cards are tremendous powers and could cause any Native essential, and that every case discharged from to be examined by the Medical Officer of Rietfoutein hospital after treatment should be Health, referred by the hospital authorities to the clinic at the patient's place of residence; hut that in referring such cases the hospital should send to the Medical Officer of Health a statement of treatment already given. Would it be possible to add to Resolution (1) that the Chamber also should request, in respect of Proclaimed Areas on the Reef, that facilities be provided for all Natives in that area to receive full treatment for V.D. 5. That, owing to the constant flow of Natives between town and country, it is essential that there should be efficient venereal disease treatment centres in all rural areas, so that treatment- of all cases may be continuous. The establishment of such clinics, and the devising of means whereby the activities of urban clinics may be effectively linked with those of rural clinics, is a function of the Union Some Municipalities did good work, while others were sbu-k. and he therefore moved that the Chamber should draw the Government's attention to the serious menace to health caused by syphilis, and ask the Government and Local Authorities to increase the V.D. clinics with a view to the establishment of uniform, treatment along the Reef. - Health Department acting through rural loe.al Dr. Gale (Assistant M.O.H., Benoni) said authorities and magistrates. that as far as his knowledge went all Munici 0. That as well as providing propaganda to reach the Native people, education is also needed of the employing classes, to disabuse them of the existing ignorant ideas regarding tho significance of the venereal diseases, e.17., palities were endeavouring to establish clinics, but llicv were handicapped by the lack of medical officers. It was only during the last six months that V.D. clinics had been estab lished in Benoni. In the next 12 to 18 months Proceedings of the Transvaal Mine Medical Officers' Association. ISO there would bo centres nt which Natives couhl A groat many Natives carry infection, from attend once a week. Ho did not know vdietber peri-urban areas, which arc outsddc the Public tlie Government could do anything to ginger up Health jurisdiction. The question was very the Municipalities. complicated, and he suggested that the words "which arc contracted outside the mines" in Dr. Hinsbeeck said that, ns n Medical Officer Resolution (3) be omitted. of Health, lie had much pleasure in scr ending the amendment put forward by Dr. Goldsmith. There arc municipalities where better work could bo done, and a little prompting might stimulate such municipalities to greater activity. Dr. Peall, referring to municipal complaints against the mines, said that without the mines the towns would not exist. Dr. Hinsbeeck said that M.O.H's. were fully aware of the situation, ami his object in second ing .Resolution (1) was that Municipalities Dr. J, J. du Pre le Roux (M.O.H., Boksburg) said he was one of the first full-time might be impressed with the necessity for im provements. M.O.lTs. appointed in a Beef town and had The Resolutions (sec p. 134) were then put to also started puss-office examinations similar to the vote and carried. those mentioned by Dr. Gale. Dr. Humphries said Natives did not contract It had to be realised that it was very difficult to organise complete medical services in any area within a year or two, and their full-time M.O.H's. on the Beef were a recent innovation. He thought, in fairness to other towns, that they should bo given time and opportunity to syphilis on mines only and, therefore, it was a national affair and the Government should face Lhc bill. On principle he accepted the amend ments suggested. The Government must realise their responsibilities to mine boys as well as oilicrs. establish their services. It might be unwise, and to a certain extent unfortunate, if the Gov ernment were asked to force the issue, an It was decided to leave the matter to the Executive for necessary action. issue which was receiving every consideration. The Chairman thanked those who had contri buted to the discussions--which lie hoped would Dr. Gale, referring to Bcgolution (3), said bear fruit. that ny medical practitioner could get free drugs; the mine Natives could nob pay, there fore according to a sort of "Gentleman's Agree ment,'' the mining industry paid for them. APPARATUS FOR ESTIMATING C.O. IN THE BLOOD IN THE CASE OF POISONING. The mine Natives go to locations and get syphilis, and the local authorities could there Dr. Orensteln said he had been asked by the fore repudiate responsibility. The local authori Chamber of Mines to exhibit the apparatus, ties regard the mine Natives as a menace, as which was much simpler than the spectroscope they also encourage the illicit brewing of liquor, examination, and was obtainable from Messrs. etc. These problems would not exist were it Sullivan & Co. not for the well-fed full-blooded mine Natives living under conditions of forced celibacy. The meeting terminated at 5.5 p.m. 140> Proceedings of the Transvaal Mine Medical Officers' Association. MACHINE FOR WASHING BEANS AND OTHER VEGETABLES. Through the courtesy of Dr. Goldsmith, a description and diagram of a bean-washing machine designed by Mr. H. J'uc'ld, Compound Manager of East Geduld Mine are hero repro duced. The machine consists of u cone of -$in. iron sheeting swung on two uprights. The cone's capacity is approximately 200 lbs. of beans. Compressed air and water arc led into the cone (ns illustrated) and serve to agitate and wash the beans. Husks, dirt and weevils conic to the surface and arc led away bv an overflow. Heavier debris such as stone and grit sink to the bottom of the cone and pass through a sieve, which is inserted about 3 inches from the cone's apex. After washing for 5 minutes the tap ,below the sieve is opened Allowing the debris to flow away. The process is repeated two or three times, depending on the state of the beans. Finally the cone is tilted over and the washed beans fail out on to a large tray. The machine can also bo used for washing any other vegetables. The cost of the apparatus, made on the mines, is approximately .7. .