Sex and sisterhood: the nurse’s role in treating sexually transmitted diseases 1917-20

Janet Hargreaves

 

Sexually transmitted diseases attracted Parliamentary attention and action in the second decade of the twentieth century. The recommendation from a 1913 Royal Commission, the subsequent Public Health (Venereal Diseases) Regulations of 1916 and the Venereal Diseases Act of 1917, brought into law the provision of funded, accessible, no-blame treatment for men and women suffering with venereal disease. This ground-breaking innovation revolutionised medical and nursing practice and stimulated a whole new area of research and development. Incentivised by funding, hospital and community clinics were created to meet the clinical demand. Nurses found themselves on the front line of developing this service, which needed a very open minded and sensitive approach, especially for female patients. Drawing on the historiography of a specific nurse’s memoir and on archival sources, this paper seeks to explore the new nursing responsibility for treating venereal disease as the legislation was rolled out.

Venereal disease

Sexually Transmitted Infections (STIs) have been known of for many thousands of years. Until doctors and scientists began to understand the nature of germs, they remained a confusing mixture of symptoms, some of which seemed related to sexual activity.ⁱ

Moral stigma, taken together with poor understanding of diseases’ origins, incomplete tracing of their effects and no curative treatments meant they were greatly feared but often concealed. In the eighteenth century when printed material became more available, those who could pay were faced with a wealth of literature advertising pills and potions which could be discreetly acquired for the euphemistically named ‘secret’ disease. In truth neither the best of physicians nor the worst of quacks had curative powers, so the treatments offered were generally ineffective and often as dangerous as the disease itself.ⁱⁱ For the poor, from the seventeenth century, London offered free treatment at St Thomas and St Bartholomew’s hospitals, and more widely workhouses might have whole wards for their care. However, as the population grew, pressure on services and the lowly status of sufferers meant conditions were appalling, with infected venereal patients and those with the ‘itch’ (scabies) locked in the same ward and often sharing a bed.ⁱⁱⁱ

It was still not clear if there was a single sexually transmitted disease, or distinctly separate ones. With no understanding of microbial infection and no cure, treatments included ointments applied to visible sores, often with highly toxic compounds including mercury, and antiseptic flushing of the urethra or vagina, with highly corrosive liquids. Mercury’s poisonous effects were damaging to the patient, who suffered terrible side effects such as uncontrollable salivation and teeth falling out. Many died of mercury poisoning, rather than venereal disease itself.^iv

As the nineteenth century progressed venereal disease continued to be a significant health problem but remained stigmatised, hidden and under researched. In Britain the study of venereal disease was not included in the medical undergraduate curriculum and no reliable data was collected. Across the world venereal disease was recognised as a major and growing problem, exacerbated by population growth and movement, overcrowding, poverty and especially war. There was a range of approaches to its management from punitive to libertarian but although research continued to try to identify causative organisms, vaccination or cure, progress was all but non-existent.^v

Army and Navy doctors were the most active group in facing the problem: prostitution and increased infection went hand in hand in wartime, in colonial outposts and in garrison towns, not least because the military leadership saw promiscuity as inevitable and tacitly endorsed the use of brothels. The effects of this were a measurable cost in terms of lost manpower so motivation to manage the problem was high. This, along with general moral panic in Victorian society over prostitution and vice, led to a Royal Commission in 1857 and subsequently the Contagious Diseases Acts of 1864, 1866 and 1869. Under these Acts women in towns with a military base could be stopped at will, forcibly examined and imprisoned in a ‘lock’ hospital for mandatory treatment. This deeply unfair legislation, which demonised women without any sanction on men, was vigorously challenged by feminists and libertarians on the grounds of justice, and because it was poorly administered and wholly ineffective.^vi

Vigorous campaigning followed, with the formation of the National Association for the Repeal of the Contagious Diseases Acts. Initially an all-male affair, the Ladies National Association for the Repeal of the Contagious Diseases Act joined the protest led by Josephine Butler.^vii

The Acts were finally, fully repealed in the 1880s but the problem was far from resolved. The first scientific breakthrough came with the identification of the bacteria – Neisseria gonorrhoeae – responsible for gonorrhoea in 1879. Thereafter, an accurate diagnosis was possible, but there remained no cure. Much greater understanding of both gonorrhoea and syphilis was achieved by 1900, but with no medical or public health strategies, the end of the nineteenth century was a depressing one for the people trying to contain venereal disease.^viii

Gonorrhoea was observed to present within days of sexual contact with an infected person. In male patients, discharge and pain were warning signs. This may also have be the case for a woman, but symptoms could be so mild as not to be noticed. If untreated the initial symptoms died down, and both sexes may have thought the danger has passed. At the time, infection for a young man was generally thought to be of minor concern, and in many circles contracting the disease could be construed as a rite of passage to manhood. In the longer term the bacterium tracked up the male urethra and could cause urinary retention. For the woman it reached the reproductive organs, blocking the fallopian tubes to cause infertility, and leading to inflammation of the pelvis. Reaching the joints, often many years after the initial infection, led to arthritis.^ix

Syphilis, in contrast, was shown to have three distinct phases, thus linking several diseases previously thought to be independent, to the original syphilitic infection, well before diagnosis was scientifically provable. Firstly, the presence of syphilis was seen when a sore appeared a few weeks after the infection. Left untreated this cleared up on its own. But by then the infection was chronic, infiltrating body tissues, and the person remained infectious to others. Finally, some years later the infection could manifest in the arteries, tissues such as the tongue, in the heart or in the brain. Neurological invasion ensued, leading to what was then known as general paralysis of the insane.^x

What was even more distressing for patients with Syphilis was the effect on unborn children. Foetuses infected with Syphilis, either through the mother’s already infected state or through the father’s sperm, had no chance of thriving; they either aborted early, were still born or developed prenatal Syphilis, described pejoratively in Burke as ‘extensively and permanently damaged goods’ with a wretched childhood and early death.^xi Gonorrhoea led to chronic pain and infection for the woman and blinded infants at birth as they came into contact with the infection in the birth canal. Both Gonorrhoea and Syphilis led to miscarriages and infertility.^xii

Quite apart from the public health crisis, and the difficulty of maintaining an effective fighting force, venereal disease represented an ideological challenge. The countries of the industrialised west were intent on building empires all over the world. Their narrative was one of white supremacy, justifying the subjugation of indigenous peoples and colonisation of their lands. Despite the combination of medical advances and public health measures making significant inroads into many other infections, venereal disease remained stubbornly untreatable and thus hugely problematic. Far from superior, they revealed the white races to be morally and physically flawed and producing weak, damaged children.^xiii

Such were the cultural norms of the time, it was considered inappropriate to inform women, or indeed in many cases young men, of the risk, as talking about sex was taboo, adding ignorance to the problem. Even once infected, and presenting with life threatening symptoms, doctors tended not to inform women of the cause, making any chance of self-help impossible. Seen as a personal moral failure, people infected were classed as undeserving and were thus often neglected by the voluntary hospital sector. In addition, they risked being disqualified from aid provided by the friendly societies and poor law system. Inevitably, qualified and unqualified practitioners made good money providing discreet, but essentially quack remedies, which exacerbated the problem further.^xiv

Breakthroughs came as the century turned. In 1905 the spirochaete responsible for syphilis was identified which aided greater clarity, for example proving that general paralysis of the insane was the final stage of syphilis. It was quickly followed by the Wassermann diagnostic test in 1906. This revealed not just known cases, but also latent cases with no symptoms, and highlighted the very limited actual curative effect of mercury. Then, in 1909, Paul Ehrlich and his team created ‘Salvarsan 606’. This was seen at first as the long-awaited miracle cure for syphilis, but it only fulfilled this function under the best circumstances and with severe side effects. For gonorrhoea frequent vaginal douches or urethral irrigation over a long period of time with strong disinfectants remained the best chance of weakening and destroying the infection.^xv

Pressure continued to mount in Britain on all fronts for a new, more considered Royal Commission. A major problem for the campaign was a total absence of reliable data. A paper presented at the annual congress of the Royal Institute of Public Health in Dublin, August 1911, offered a depressing summary of the situation. The authors acknowledged that even the data from the military was flawed but suggested that 50% of female sterility after marriage was due to the husband’s gonorrhoea infection and that overall, they conservatively estimated 200,000 new cases of venereal disease per year in London, and around 500,000 in the UK.^xvi

The suffrage movement also took up the cause, seeing it as another example of male double standards and further justification for female enfranchisement. The supporters of women’s suffrage led on many publications, including popular novels that highlighted the dilemmas women faced, and broke taboos by explaining venereal disease to women as well as how they and their children were infected. ^xvii

One of the most notable, high-profile publications wasThe Great Scourge and how to end it, a polemic text produced by Christabel Pankhurst in 1913. This was a journalistic piece, aiming to shock, that asserts the statistics with more authority than they deserve, claiming that 75 – 80% of men were infected with gonorrhoea, which was unprovable at the time. She also repeated emotive language, used elsewhere by campaigners, that venereal disease was akin to racial suicide, and accused the government of hiding vice among the upper classes and enabling prostitution in the military. Amongst this rhetoric, her point was well made: that a hidden problem cannot be tackled, and women should not be kept in ignorance to protect an outdated and hypocritical patriarchy: ‘According to man-made morality, a woman who is immoral is a ‘fallen’ woman and is unfit for respectable society, while an immoral man is simply obeying the dictates of his human nature’. ^xviii

Finally, in this same year and after much prevarication a further Royal Commission on venereal disease was announced. After the inertia following the repeal of the Contagious Diseases Acts, this was the first attempt to face the problems and work out a strategy for managing them. Doctors approached it as a medical problem whereas feminists wanted the wider social issues debated and tackled. The chair, Lord Sydenham, was opposed to the feminist cause and although much was made of women having a voice in this commission, of the fifteen members of the enquiry only three were female, and of the eighty-five people called as witnesses, sixty-six were doctors and just eight were women, one of whom was a feminist. Thus, Sydenham kept a very tight remit, deeming issues such as poverty and housing not relevant.^xix

After three years of enquiry, the Commission concluded that any statistics presented were worthless. The report estimated that around 10% of the population had contracted syphilis, and many more with Gonorrhoea, concluding that venereal disease was a major threat to public health. The report emphasised that gonorrhoea was not a mild infection, but a major illness. It also highlighted the consequential tragedies of congenital syphilis, miscarriage, still birth and infertility. ^xx

The Commission made thirty-five recommendations, mostly around diagnosis and treatment. They gave local authorities the task of setting up pathology labs and negotiating with hospitals to create free diagnostic and treatment services, with no means test or other barriers to attendance such as residence in the area. General Practitioners, who had previously not been allowed to administer Salvarsan, were now included in the medical approach and adverts for over the counter remedies were banned. The exchequer was to cover 75% of costs.^xxi

The subsequent Public Health (Venereal Diseases) Regulations of 1916 set these recommendations in law and the Venereal Disease Act of 1917 went further, insisting that all remedies were to be managed by qualified practitioners, thus outlawing not just adverts but all bogus products.^xxii Collectively, despite the commission’s deliberate failure to address social issues such as housing and poverty, this was a fundamental transformation in the approach to tackling the problem of venereal disease in Britain.

Voluntary hospitals were tasked with delivering many of the recommendations. The West London Hospital offers one example of an institution that welcomed the challenge.

The West London Hospital

Figure 1 Royal College of Nursing Archives, BM/11/13 Boardman post card collection ^xxiii

There is no published history, and very little generally written about the West London Hospital. It opened as the Fulham and Hammersmith General Dispensary, with six beds, in July 1856. This made it a comparatively young addition to the London voluntary hospitals that included, for example, St. Bartholomew and St. Thomas, with their origins in the twelfth and fifteenth centuries. It joined the many other hospitals built in the eighteenth and nineteenth centuries, for example The London and The Middlesex in 1740 and 1745 respectively, and Charing Cross in 1818, that served the constantly growing urban population, and the new medical schools with their need for training, research and a place for the physicians and surgeons to build their reputations.^xxiv

It very quickly outgrew its premises and moved to Hammersmith Road in 1860, reopening as The West of London Hospital and Dispensary, now taking in-patients, most of whom were victims of serious industrial accidents. Finally, in 1863 it became simply the West London Hospital. As a voluntary hospital it relied almost exclusively on charitable donations, including wealthy donors and Royal patronage as well as successful public appeals, which enabled the construction of new wings in 1871, 1883 and 1898 (helped, no doubt, by receiving the Royal Charter in 1894). Nevertheless, it was relatively small, with just 160 beds in 1916.^xxv

There was a nurse training system from the 1880s, but difficulty raising funds led the opening of the Abercorn nurses’ home to be delayed until 1918. A postgraduate college was formed in 1896: undergraduate medical students came later, as did recognition as a centre for general nurse training, after the Nurse Registration Act in 1919. Nurse training ceased in the late 1960s, and it finally closed its doors in 1993 when its services moved to the new Chelsea and Westminster Hospital, Fulham Road. ^xxvi The London Street map shows that the hospital building is now a smart apartment block; however, the Abercorn nurses’ home has retained some of its early intentions as it is now a nursing home.

For the Public Health (Venereal Diseases) Regulations of 1916, the participation of voluntary hospitals was strategically important, but some continued to resist involvement. One reason offered was not wishing to be seen to condone vice and thus offend their pious patrons. Another was a claim that taking the government money broke their charity status, although most had been happy to take such money for TB, child welfare and military patients. These and many other issues, for example regarding remuneration for medical staff, had to be resolved. The voluntary hospitals’ support was needed to be able to provide a service clearly separate from municipal hospitals and workhouses, where patients might fear state surveillance and compulsion. ^xxvii

However, the West London was positive about supporting patients with venereal disease, well before they were compelled to do so. The 1914 registrar report states twenty patients were treated for acquired syphilis and nine for congenital syphilis, three of whom died. Gonorrhoea is not explicitly named in the data here, or elsewhere, but it is reasonable to assume cases have been subsumed into the figures for diseases of the genitourinary organs, and general diseases of women.^xxviii

Building on this experience the Hospital was an early adopter of the scheme, proudly stating in their summary of 1916:

Arising from the report of the Royal Commission on this important subject [Venereal disease] this hospital, amongst others, was appointed under the Local Government Board and London County Council scheme as a centre for the diagnosis and treatment of venereal diseases. From January last, evening clinics have been open upon each week day for patients. The hospital receiving a grant in aid, sufficient, it is hoped, to cover all expenses.^xxix

In the following year the Hospital made the clinic one of its headline achievements, stating that ‘the usefulness of the institution has been still further enhanced.’ They also noted that the large increases in numbers in the out-patient department were due to the expanded venereal disease facilities, and that the West London was now one of the largest centres for diagnosis and treatment in London.^xxx

A nurse’s experience

Molly Morris (later Murphy) was just starting her nursing career as these huge changes in practice were taking place. She arrived at the West London on 20 August 1916.^xxxi She had just completed a probationary year at the Knightwick TB sanatorium in Worcestershire. Once she had passed her three months’ probation, she signed a contract for a three-year training course followed by one year as a staff nurse and remained working at the West London until the end of December 1920. In the 1960s she wrote a memoir, Nurse Molly, which includes detailed recollections of her nursing career.^xxxii

In 1913, when Christabel Pankhurst published The Great Scourge, Molly was a full-time employee of the Women’s Social and Political Union running their office in Sheffield. She was well acquainted with the Pankhurst family, regularly reporting to their head office in London. Its most likely she would have read The Great Scourge, and as a suffragette she would have been more aware than most young women of the controversy surrounding the management of venereal diseases.

The Royal College of Nursing historic journals collection shows that the nursing press reflected an increased interest in the subject and played their part in the call for a propaganda campaign to educate and change attitudes. A search of the full collection from 1900 to 1920, using the key words venereal disease OR Syphilis OR gonorrhoea, revealed that in 1900 there were just ten articles mentioning venereal disease, syphilis, or gonorrhoea, whereas in 1910 this had risen to fifty-four articles. From then on, for the next ten years they ranged from 100 per year, to 209.^xxxiii

An early example is a paper from 1911, which offered a detailed explanation of the then known progress of syphilis and gonorrhoea with adults and children. The moral tone follows the tradition of placing the blame on prostitution, but emphasises that they too are victims, and calls for greater education, particularly for parents to give clear and honest information to their children.^xxxiv

Others included news and science updates, regular coverage of the Royal Commission and its recommendation, factual explanations, and nursing procedures. It is certain that Molly and her nursing colleagues would have read and discussed this determined and revolutionary new approach.

The legislation and new clinics occurred as her training progressed and in 1919, just before she qualified, she was offered a staff nurse post in outpatients, thus giving her the opportunity to develop her skills in this new and growing speciality. She and her colleagues had little to do with the male clinic but were crucial to the female patients.

The clinic was clearly successful, and funding was increased for two evenings, which Molly was involved in running. The clinics were extremely busy: in the sixty-third annual report of 1920 (so reporting on 1919 statistics) there were an additional 1,160 new cases and 10,759 extra outpatients’ attendances, attributed in part to the evening special clinics, and by implication the need for multiple, regular attendances by venereal patients.^xxxv

Persuading people to attend the clinic was aided by the no-blame and no-fee principle, by running evening sessions to make attendance easier, and by not requiring people to be resident in the area, thus offering a greater degree of anonymity. Persuading them to accept the treatment and to keep attending was another matter. None of the treatments available were pleasant, and all required patients to continue to attend for many weeks. A disappointingly low number of patients continued to attend once their symptoms had abated, despite not yet being clear of infection.^xxxvi

In her memoir Molly reflects on hers, and the Sister’s, amazement at the ‘abysmal ignorance’ of venereal disease amongst the public. The findings of the 1913 commission show that this is hardly surprising. Very little accurate information had been available, and even when infected, or facing a severely damaged or dying baby, the true issues were hidden from them. Thus, most knew only anecdotes and old wives’ tales. The nurses’ first job was dispelling this ignorance, helping people to get past the horror and shame they might feel, and to ‘cultivate habits of cleanliness.’^xxxvii

An additional barrier to completing the treatment was that many clinics were poorly run with unsympathetic, or unskilled staff. This was a particular problem for the female patients as very few experienced doctors existed, of whom fewer still were female. Even with the incentives following the Public Health (Venereal Disease) Regulations in 1916, it took time to begin to build up the workforce and there were still chronic shortages in 1920.^xxxviii Thus, the nurses’ job was crucial in bridging the gaps. Patients and staff at the West London were fortunate that the eminent obstetrician, Sir Henry Simpson, led the female venereal disease clinic.^xxxix Molly remembered him as a ‘charming’ man to work for, skilled in communication with his patients and with a good sense of humour.^xl

Molly brought to her role a wealth of life experience. She was the second of seven children and an older sister to four girls. She spent her childhood and teenage years deputising for her mother through times of poverty and illness, caring for her siblings and helping to run the family business in an impoverished district in Salford. She knew how to get along with young people, and with poor working-class women. She was also non-judgemental and had no moral qualms about treating a sex worker with as much respect and worth as a Lady. Thus, she was able to create the frank women-to-women relationship necessary to gain trust and understanding and to keep the women coming back week after week.

The wider services that were needed were developing as fast as they could. The National Council for Combatting Venereal Disease was tasked by the Local Government Board to run a nation-wide propaganda campaign, but this was moralistic in tone, so not always welcome. The social workers who could follow patients up, engaged in the very sensitive process of contact tracing and education, were also still too few.^xliThus the contact within the treatment clinic was absolutely crucial to any hope of success.

The nurse’s role has received no attention in the literature, and yet, particularly for female patients, they were an essential part of the service. This band of invisible workers greeted, supported, encouraged and cared for the hundreds of frightened women and I would argue it was their clinical and emotional skills that helped women to bear the treatment, and keep coming back for more.

For syphilis the nurse might be dressing open sores and supporting the doctor administering the unpleasant injections of Salvarsan. For gonorrhoea there remained no curative agents; the only effective treatment was to flush the infection out with disinfectant. This involved a complex vaginal douche procedure which need to be repeated regularly over several weeks until the infection had gone. A disinfectant, such as perchloride (a strong chorine solution, i.e. bleach) needed to be diluted to the correct level at the correct temperature, then the irrigation needed to be effectively administered to ensure all potentially infected tissue had been exposed to it. This was an intimate, embarrassing and messy procedure that needed managing with the minimum distress to the patient, in a crowded clinic environment, and with scrupulous asepsis to avoid cross contamination of herself, her co-workers, and other patients.^xlii

Figure 2 Millicent Ashdown, A complete System of Nursing (London: J. M. Dent & Sons Ltd, 1917), p. 68.

Every woman, from the experienced sex worker more used to being arrested or shunned than treated with kindness to the most innocent young girl, needed to feel welcome and worthy of time and care.

Patients and staff at the West London were also fortunate to have Miss Neville as matron. The epitome of the hospital matron, she was elderly, sedate and carried an air of ‘natural and trained dignity,’ wearing a black alpaca dress, perfectly starched lace cap, collar, and cuffs.^xliii She was also known to be principled on strict moral grounds, but she fully supported the work of the clinic. Clinical freedom was a fragile and hard-won privilege for nurses in the 1910s, and it is rare to see any challenge to medical authority so a minute in her report book in mid-1919 is significant and worth quoting at length:

the matron recommends that the following recommendations may be considered by the committee or placed before the committee specially dealing with this department [i.e. the venereal disease clinic]: that the mothers or other friends who bring their daughters or other girls for whom they care or try to be responsible or are trying to help, should be allowed to be admitted to the out patients department and have the opportunity of seeing the sister or the nurse in charge of the dept on their first attendance, if the privilege cannot be extended to the subsequent attendances, which in the interests of many of the girls is most advisable. There are many points in connection with the clinic dept which the matron would like to draw attention to, so many improvements could be made to make the work less and be carried out with less friction now the numbers have increased. The matron would be glad to know to whom any recommendations should be made from time to time.^xliv

This convoluted minute, with its repeated words and controlled but pleading tone is out of character with her more usual succinct and direct prose. Miss Neville dedicated all her time to her job. She walked the wards and hospital departments daily, was a shrewd judge of character and nothing escaped her notice. She had directly chosen Molly for the outpatient’s department so saw that this sort of face-to-face public role would suit her. It is fair to assume that the outpatient’s sister and Molly had shared their frustrations with trying to support patients as they were obliged to walk into the clinic and the examination room alone. These frightened young women were unlikely to be able to fully understand what was happening to them or explain to others their situation and treatment, so involving trusted others was key to compliance and success. The nursing staff would know that if they could engage the mothers and friends in the patient’s care, the likelihood of gaining understanding and compliance was greatly increased. However, they clearly had difficulty persuading their medical colleagues to be more innovative in their clinic procedures.

The clinics, such as at the West London, were the start of systematic clinical analysis of venereal diseases, accurate statistics, comprehensive medical education and research. However, change, particularly for gonorrhoea, was slow coming. Twelve years after leaving the West London at the end of 1920, Molly needed her skills again as she nursed a wealthy woman in a private nursing home, where she used the same techniques, she had mastered in outpatients. The advent of the sulphonamides in 1937 and penicillin in the 1940s were the next major breakthrough.

The early 1900s was a significant period in the world-wide battle to understand and contain the ‘loathsome disease’. In Britain government intervention was revolutionary in its approach, but such a blunt instrument required huge changes in medical education and practice, and in public health campaigns. The collaboration and support of the hospitals was crucial. Behind their effort the skilful practice of nurses, such as Molly, was instrumental in turning the clinical recommendations and medical instructions into effective care.

Endnotes