1810

Syphilis and the Responsibility ofthe State.

THE LANCET.

L O N D O N: SA TURDA Y, JUNE 28, 1913.

WE publish in another column a plea for the appointmentot a Royal Commission on Venereal Diseases by Sir

MALCOLM MORRIS, who, indeed, has put the case, within

the limitations which he lays down for himself, so simplyand so forcibly that it should require no further support. Theexact terms of reference of such a Commission he does notoutline, and he shrewdly declines at the opening of a

campaign to enter upon controversial topics in respect ofthe control of venereal diseases. He contents himself

with advancing arguments of the strongest sort for the

appointment of a Royal Commission, justifying the demand

by reference to the incalculable ills of syphilis, and we

endorse his position because it seems to us that the

apathy which Sir MALCOLM MORRIS rightly attributes to the

public upon the subject of venereal diseases may also befound to a great extent in the medical mind. We all of us

know the terrible toll of disease, pain, and death exacted ofthe population by syphilis, but we can hardly be said asa profession to have been insistent upon remedial measures

being taken. With the public the reluctance to talk

about such things as syphilis is natural, and if pruderyis carried too ’far it has its origin sometimes in a com-mendable spirit; but it is an unfortunate fact that the

mere preservation of silence upon a subject brings with ita habit of indifference. Things that are not talked

of in the first instance because they are too painful,or because discussion of them at the wrong placeand time or with the wrong people is excessivelyinconvenient, become later forgotten altogether ; laid

aside originally from mingled motives which are not

only respectable but may be respected, they are later not somuch laid aside as forgotten. In these circumstances it

seems to us especially right that the medical professionshould keep before the public the fact that a terrible diseaseis rife among us, against which much could be done byorganised medicine if the public furnished the oppor-

tunities, but against which so far little is attempted.Sir MALCOLM MORRIS has confined his remarks to syphilis

and we propose to do the same. Syphilis and gonorrhoeahave obviously much in common when we are discussingtheir spread, but they are pathologically very different

things, and might well require different machinery for theircontrol. It is now admitted that in some directions

the results of gonorrhœa, especially among innocentlyinfected women, are more disastrous than the results of

syphilis, but the after-effect of any infection with syphilismay be far-reaching to a degree with which no gonorrhœal

infection can compare. It is not that certain appalling cases-

happen, but that any case may be appalling in its.

after-effects as well as hereditary, while the after-effects of-

gonorrhoea are to some extent circumscribed. It is-

quite likely that if a Royal Commission should be-

appointed its terms of reference would include instructions-to consider the prevention of gonorrhoea as well as the.

prevention of syphilis, for in some directions it is plain-that the methods of prevention would be similar; but the-case that can be made out for a national determination to-

do something in the matter of syphilis is overwhelminglystrong. It is undeniable that there is a great deal of

syphilis among us. We do not know how much because

there are no available statistics, and that alone, is.

one reason for bringing together a mass of authoritativeevidence on the subject, that it may be collated, sifted,and its lessons duly learned. It is usual to speak ofsyphilis as having very much declined of late, and uponinquiry it is found that this statement, when made,by medical men, is based upon two things : first,the prevalence in the army is less general, and secondly,the severe cases described in all the text-books, and:

terribly familiar in the minds of medical men of middle-

age, are no longer seen. But we must not allow the public-to be lulled into any sort of comfortable feeling that

nothing need be done because syphilis is dying out.

Inaction cannot be excused on the grounds that the-

evil is righting itself. Let it be granted that syphilis-is on the decrease, the particular circumstances used

to prove the fact have not quite that significance. The-

army is recruited from a far better stock than it used

to be; its whole morale has improvecl, while the goodfeeling between officers and men has been enormouslydeveloped, so that the physical and moral care of

the soldier is now the officers’ charge to a really markedextent.

And if no valuable indications of increasing securityfrom syphilis can be drawn from improvement in the army

statistics, the alteration in the type of disease has, alas,not altered its deadliness. At the time that the horrors-

of tertiary syphilis were more in evidence in our hospitals.a large number of other conditions, now quite well known.to be associated with syphilis, had not such connexion in

any mind. It is probable that these nervous conditions

were in past days not so frequent, for the clinical mani-

festations of many of them were known, while their asso-ciation with syphilis was not suspected. This would not

have been the case if the clinical evidence had been as.

profuse as it now is. But if thirty years ago these nervousconditions were not so frequent, and the ulcerative and

malignant conditions were more frequent, it, would seemthat we have rather a change of type in the disease thana change of quantity to deal with. Here it is significantto recall that we have reached a new era in our know-

ledge of the disease. Within the past few years dis--

coveries have been made which have revolutionised our

methods of diagnosis and treatment. Thus we have-

the best of arguments for a systematised inquiry with aview to national prevention. The inquiry should at one andthe same time inform us as to the extent of a prevalency;.

1811

Nvhich.4_we know to be large, but the measure of which -escapes us in existing conditions, and assist us to formulatea, scheme of control now that our weapons are more

effective. Sir MALCOLM MORRIS insists that before

any systematic control of syphilis can be secured

notification is necessary, and it must be remembered that

the National Insurance Act provides already a half measureof this kind. He would not have the licensing of prostitutesmade any part of such a scheme, and the experience of

foreign countries now points in the same direction.

Eddowes and Others v. The St.

John’s Hospital for Diseases ofthe Skin.

THE action brought recently by three of its former honorary’medical officers against the corporation known as the St.John’s Hospital for Diseases of the Skin is of a nature

fortunately of rare occurrence in the law courts, and theabsence of precedent was responsible for the evident

hesitancy of Mr. Justice PICKFORD with regard to some ofthe issues raised and the remedies sought for. Dr. A.

EDDOWES, Mr. G. W. DAWSON, and Dr. L. F. KNUTHSEN,the three plaintiffs who, supported with success bythe London and Counties Medical Protection Society,raised in the King’s Bench Division the questionwhether the committee of the hospital had exercised towardsthem powers which in law it possessed, were not the onlypersons interested directly and indirectly in the points dis-cussed. Four other members of the staff of the hospitalhad shared their dismissal upon similar alleged grounds,while the whole medical profession was concerned, if less im-

mediately no less vitally, in the upholding of the plaintiffs’’broad contentions. With the actual matters which broughta large number of the medical staff of a particularinstitution into conflict with its board of managementwe do not propose to deal. There was obvious dis-

agreement between them and one of their colleagues. The

fact that there was long-standing friction of a very seriousnature between Dr. MORGAN DOCKRELL and certain of

his fellow practitioners was made public property at thetrial, as was the fact that the committee which inquiredinto the matter adopted Dr. DOCKRELL’S view and gave effectto it in a manner which added emphasis to its finding and,indeed, rendered litigation almost inevitable. The procedureby which, the committee arrived at its conclusion to dispensewith the services of the plaintiffs was one of the points towhich attention was called by the plaintiffs at the trial, butthe fact that they had been dismissed by notice from their

posts as members of the honorary staff of the hospital wasthe principal issue raised on their behalf, and the point towhich Mr. Justice PICKFORD mainly directed his judgment.In delivering it he cleared the ground of other questions bypointing out that he had not got to decide whether the

defendants acted boiaa fide or whether they purported toexercise their powers to the best interests of the corpora-tion. There was not, in short, any allegation of bad faithor corrupt intention made against the governing body.The question upon which the learned judge concentrated

his attention was whether the committee had acted

within its legal powers, and on that point he was against it.He did not find in the articles of association or the rules of

the hospital, or in the general principles applicable, any-thing that would justify dismissal in the circumstances provedto exist. Mr. Justice PICKFORD further made a declaration

that the plaintiffs were entitled to remain members of thecorporation, but refused an injunction, which they askedfor, to restrain the defendants from excluding them fromthe hospital. It was on these grounds that judgment wasgiven for the plaintiffs for sums of £50-damages of a

nominal character awarded in the absence of any evidenceof pecuniary loss upon which accurate assessment of com-pensation could be made-and for costs. L’pon this result

congratulation is due to the plaintiffs and to the colleagueswho shared their dismissal at the hands of the defendants.

What is the position of a member of the staff of a hospitalin the event of questions arising of a serious nature as towhich he finds himself in disagreement with the board of

management ? The action against the governing body of theSt. John’s Hospital for Diseases of the Skin has called

attention to the desirability of the position of the staffs of

hospitals being defined before their appointment in terms

capable of covering all circumstances which are reasonablylikely to occur ; their mutual relations and their relations withthe lay authorities should be made the subject of a writtencontract at the time when the appointment is entered upon.In the case of the St. John’s Hospital for Diseases of theSkin there was a complication arising out of the peculiarconstitution of the corporation owning the hospital, and its

governors in good faith adopted a position as to which theywere held by the learned judge to have been mistaken. Mr.

A. W. WEST, treasurer of St. George’s Hospital, and Sir THOMAS sBARLOW, President of the Royal College of Physicians of

London, were called on behalf of Dr. EDDOWES and his

co-plaintiffs to explain what should be the status of a memberof the staff of the hospital in the absence of definite regula-tion by contract. Neither of these undoubted authorities,approaching the question from separate points of view, had anydoubt as to the permanence of the appointment of physicianon the staff of a hospital in the absence of conditions as tosurrender at a stated age or after a stated period. Limita-

tion in point of time of the tenure of these posts is nowmore common, but that such a tenure could not be deter-

minable by notice was the gist of Sir THOMAS BARLOW’sevidence upon this head. Naturally he admitted that

misconduct would justify dismissal; but this, he pointedout, should only take place after proper inquiry, and thereshould be a tribunal of arbitration for the settlement of

disputes between opposing sections of the staff if there

should be any disagreement to justify such intervention.The desirability of arbitration of an independent characterdoes not appear to have occurred to the committee of the

St. John’s Hospital for Diseases of the Skin, the members ofwhich failed to recognise that, owing to the position occupiedby Dr. DOCKRELL and other matters, they were not the rightpersons to adjudicate upon what amounted to a disputebetween themselves and the plaintiffs. In addition to this,one of their number, who took the chair at their meetings,

appears to have increased rather than diminished the friction