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From Dr. J. P. Walker, M.O.H., Isle of Wight
4e,
PUBLIC HEALTH.
CORRESPONDENCE. The Editor does not accep! responsibilitg /or lhe opinions o/ correspondents.
T H E P R E V E N T I O N OF V E N E R E A L DISEASE. From Dr. SIDNEY BARWISE, M.O.H., Derbyshire.
DEAR S I g , - - T h e correspondence in your columns clearly shows t h a t if we are to extirpate Venereal Diseases, there is room for two societies--one for Combating Venereal Diseases and the other for the Prevention of these diseases. For these diseases above all others the question is, " If preventible, why not prevented ? " They are the easiest diseases to prevent, but amongst the most difficult to cure. I have never had any hesitation in expressing my opinion t h a t the treatment centres established only deal with a small percentage of the cases, and t h a t of the cases treated we know t h a t the bulk will not continue treatment until cured. Personally I do not believe t h a t the distribution of knowledge on the Prevention of Venereal Disease and the use of prophylaxis would plunge our young people into an orgy of licentiousness. Nor will I believe this until it can be shown that we in our profession have a lower standard of morality than the rest of the population. I agree with Colonel Harrison that we should distinguish between the distribution of the means of preventing infection and the mitigation of the consequences of an accomplished act. During the war I have been asked b y several friends to speak to their sons who have been going out to France. The line I have taken is this, t h a t I have urged them to lead a clean life, but have told them t h a t for the sake of the future generation if they have gone wrong they should carry out immediate h'eatment by washing with I in 2,ooo permanganate of potash, wash the meatus thoroughly, then apply 3o per cent. calomel ointment. I a m glad to know t h a t as a result of m y talks these young men have been so disgusted with the whole thing, t h a t they have kept themselves clean. One boy has told me that he purchased the drugs, but was so disgusted t h a t he threw them away, and since m y talk with him has led a pure life. The following figures taken from Dr. Otto May's book, " Prevention of Venereal Diseases " (published by Oxford Medical Press), are most instructive on the point of immediate treatment. The figures are taken from the United States N a v y records : Hours subsequent Percentage oJ infection. to exposure. I ............... o8 5 .............. 1.57 IO .............. 5-14 More than IO . . . . . . . . . . . . 74
JANUARY,
In m y opinion the Society of Medical Officers of Health should approve a circular somewhat on the following lines : Venereal Diseases. " Here should follow a few paragraphs on the baneful effects of these diseases, on the production of blindness, aneurism, stricture, general paralysis of the insane, and tlle effects on the next generation. Then a line pointing out t h a t intercourse is unnecessary for the maintenance of physieal vigour. Prevenfion is Better than Cure. Venereal Diseases can be prevented b y scientific cleanliness. By this is meant if a man has been exposed to the possibility of infection, he should immediately thoroughly wash the parts exposed, especially inside the pipe, with a 1-2,ooo solution of permanganate of potash, afterwards applying a 30 per cent. calomel ointment. The germs of these diseases at first lie on the surface, and we have t h e m a t our mercy. Give them only a few hours, and the permanganate wash and the calomel ointment won't reach t h e m . " I know that the distribution of knowledge of this kind has been most useful, not only in preventing infection, but in preventing youths from going astray. This, too, is the experience amongst the American troops. Information of this kind is widely distributed, and as Colonel Adami pointed out, in National Health for September, 1918, out of 1,367 men for two months in France, only 6 applied for early treatment. Not a single case of venereal disease had been reported amongst 3,267 other men who had also been in France for eight weeks, and only I I early treatments had been given. I suggest in immediate treatment we have a middle course between the prophyla'xis school a~ld the school which is out for locking the stable door when the horse has been stolen. If the latter school will not join us in this reasonable view, we must have two societies, one for the Prevention of Venereal Diseases and another for curing t h e m - if they can. Yours faithfully, SIDNEY BARWISE. From Dr. J. P. WALKER, M.O.H., Isle of Wight.
DEAR S I R , - - I have been asked by Dr. Eustace Hill to sign a letter relating to " Prophylaxis in Venereal Disease," which he proposes to submit to you for insertion in PUBLIC HEALTH. I have informed him t h a t I would ask you to publish also m y reply, which is to the effect t h a t I am unable to agree with him, t h a t we are here primarily as sanitarians, not as moralists, and t h a t when I see a child compelled to go through life blinded from birth owing to ignorance on t~e part of an innocent parent, when I see a devoted mother forced to lead a life of chronic ill- health owing to no fault of hers, or the young widow
I9Z9.
PUBLIC HEALTH.
bereft of her breadwinner owing to a preventable insanity, I think it better to let a hundred guilty ones escape punishment rather than a single innocent individual should be punished in these ways. I t is not necessarily the hardened sinner who becomes the victim of such diseases, but vather the ignorant, the careless, and the innocent are the sufferers therefrom, and so the diseases spread. There are ways of avoiding them, and as medical officers of health we fail in our duty if we do not spread the knowledge of such menas of prevention as are known to assist in preventing them. Yours faithfully, J. P. WALK,In From Dr. J. ROBERTSON, M.O.H. Birmingham.
There is a disadvantage in attempting a correspondence in a monthiy journal, however important the subject, on account of the length of the interval between the issues. I feel, however, that it would be discourteous if, as the original objector, I ceased to reply at this stage. May I, therefore, be allowed in the first instance to recapitulate shortly what I object to ? I n the September number of the Journal it was stated that a notable advance had been made by the Town Council of Warrington in forwarding a letter to the Local Government Board advocating that prophylactic outfits and instructions should be issued free to the general population by total authorities in order to reduce the number of new cases of venereal disease. In the same number of the Journal other papers appeared dealing with this subject. One of these was a letter addressed bY Miss Ettie Rout to the National Council for Combating Venereal Diseases. (The Council's reply has not yet been published.)* Another article was a detailed description of the procedure recommended to men and women for adoption immediately before and immediately after coitus. I believe that such a procedure, if generally adopted, would lead to an increase of promiscuity to such an extent that even if effective as a preventive in certain cases, its adoption would on the whole increase the total volume of venereal disease. But it would do much more. I t would damage the morality of a l a n e number of the men and women of this country who, for one or other reason, are restrained at the present time, but who would lose their self-restraint if general opinion were given to the contention that immorality was safe. None of your correspondents has given information as to the reliability of the method which is advocated. I have been intimately associated with the question of the prevention of venereal disease in the Army during the past four years, both in France and in this country, and prior to that as a Divisional Sanitary Officer I had to look
43
into the question pretty carefully among the troops at home. Until reliable statistical evidence is produced, I should prefer to accept the opinion of medical men who have had opportunities of judging of the effect of these prophylactics, and I should say that of those who are capable of giving sound judgment there is at present an overwhelming majority of medical men who are by no means in favour of the prophylactic " packet " as the best means of preventing venereal disease. W e have not yet got reliable figures from the German Army, where these packets have been used to a laNer extent than in our own Army, but the halfdozen reports which I have seen do not lead me to believe that these packets have been any more successful in warding off venereal disease in the German Army than in our own. The statistical evidence which I have seen on this subject in regard to English and Colonial troops appears to me to need the investigation of a reliable statistician, and I sincerely hope that such investigation will be made, so that our experience during the War may not be lost. I am convinced that the value of the packet has not been proved. But as I have said in my previous letter, I object strongly to the application of a method which might be desirable among soldiers, but which is, in my opinion, extremely undesirable among the civilian population. Surely, nobody who really knows the conditions of life in the Army can fail to appreciate the difference in moral self~control which exists between the man in the Army and the same man in civil life. If you like to put it as Dr. Snell does, I would say that clothes do make an enormous difference. The environment is odifferent, the opportunities and methods of control are entirely different, and many of these methods of control which will be suitable for Army purposes are not necessarily suitable for a civil administration. I do not despair of our being able to reduce venereal disease to a vanishing point by other means. But for the exigencies of the war I am sure that some of these would have been in good working order by now. I t can only be but a short time before some method of notification with compulsion to adopt treatment will be brought into existence, so that cures may be obtained rather than much of the palliative treatment which exists to-day. Yours faithfully, JOHN ROBERTSON.
*The Council's reply has not been received. --ED., P.H. From Sir H. BRYAN D O N K I N .
SIR, The two arguments constantly re-iterated by those who would exclude venereal infections alone
PUBLIC HEALTH.
CORRESPONDENCE. The Editor does not accep! responsibilitg /or lhe opinions o/ correspondents.
T H E P R E V E N T I O N OF V E N E R E A L DISEASE. From Dr. SIDNEY BARWISE, M.O.H., Derbyshire.
DEAR S I g , - - T h e correspondence in your columns clearly shows t h a t if we are to extirpate Venereal Diseases, there is room for two societies--one for Combating Venereal Diseases and the other for the Prevention of these diseases. For these diseases above all others the question is, " If preventible, why not prevented ? " They are the easiest diseases to prevent, but amongst the most difficult to cure. I have never had any hesitation in expressing my opinion t h a t the treatment centres established only deal with a small percentage of the cases, and t h a t of the cases treated we know t h a t the bulk will not continue treatment until cured. Personally I do not believe t h a t the distribution of knowledge on the Prevention of Venereal Disease and the use of prophylaxis would plunge our young people into an orgy of licentiousness. Nor will I believe this until it can be shown that we in our profession have a lower standard of morality than the rest of the population. I agree with Colonel Harrison that we should distinguish between the distribution of the means of preventing infection and the mitigation of the consequences of an accomplished act. During the war I have been asked b y several friends to speak to their sons who have been going out to France. The line I have taken is this, t h a t I have urged them to lead a clean life, but have told them t h a t for the sake of the future generation if they have gone wrong they should carry out immediate h'eatment by washing with I in 2,ooo permanganate of potash, wash the meatus thoroughly, then apply 3o per cent. calomel ointment. I a m glad to know t h a t as a result of m y talks these young men have been so disgusted with the whole thing, t h a t they have kept themselves clean. One boy has told me that he purchased the drugs, but was so disgusted t h a t he threw them away, and since m y talk with him has led a pure life. The following figures taken from Dr. Otto May's book, " Prevention of Venereal Diseases " (published by Oxford Medical Press), are most instructive on the point of immediate treatment. The figures are taken from the United States N a v y records : Hours subsequent Percentage oJ infection. to exposure. I ............... o8 5 .............. 1.57 IO .............. 5-14 More than IO . . . . . . . . . . . . 74
JANUARY,
In m y opinion the Society of Medical Officers of Health should approve a circular somewhat on the following lines : Venereal Diseases. " Here should follow a few paragraphs on the baneful effects of these diseases, on the production of blindness, aneurism, stricture, general paralysis of the insane, and tlle effects on the next generation. Then a line pointing out t h a t intercourse is unnecessary for the maintenance of physieal vigour. Prevenfion is Better than Cure. Venereal Diseases can be prevented b y scientific cleanliness. By this is meant if a man has been exposed to the possibility of infection, he should immediately thoroughly wash the parts exposed, especially inside the pipe, with a 1-2,ooo solution of permanganate of potash, afterwards applying a 30 per cent. calomel ointment. The germs of these diseases at first lie on the surface, and we have t h e m a t our mercy. Give them only a few hours, and the permanganate wash and the calomel ointment won't reach t h e m . " I know that the distribution of knowledge of this kind has been most useful, not only in preventing infection, but in preventing youths from going astray. This, too, is the experience amongst the American troops. Information of this kind is widely distributed, and as Colonel Adami pointed out, in National Health for September, 1918, out of 1,367 men for two months in France, only 6 applied for early treatment. Not a single case of venereal disease had been reported amongst 3,267 other men who had also been in France for eight weeks, and only I I early treatments had been given. I suggest in immediate treatment we have a middle course between the prophyla'xis school a~ld the school which is out for locking the stable door when the horse has been stolen. If the latter school will not join us in this reasonable view, we must have two societies, one for the Prevention of Venereal Diseases and another for curing t h e m - if they can. Yours faithfully, SIDNEY BARWISE. From Dr. J. P. WALKER, M.O.H., Isle of Wight.
DEAR S I R , - - I have been asked by Dr. Eustace Hill to sign a letter relating to " Prophylaxis in Venereal Disease," which he proposes to submit to you for insertion in PUBLIC HEALTH. I have informed him t h a t I would ask you to publish also m y reply, which is to the effect t h a t I am unable to agree with him, t h a t we are here primarily as sanitarians, not as moralists, and t h a t when I see a child compelled to go through life blinded from birth owing to ignorance on t~e part of an innocent parent, when I see a devoted mother forced to lead a life of chronic ill- health owing to no fault of hers, or the young widow
I9Z9.
PUBLIC HEALTH.
bereft of her breadwinner owing to a preventable insanity, I think it better to let a hundred guilty ones escape punishment rather than a single innocent individual should be punished in these ways. I t is not necessarily the hardened sinner who becomes the victim of such diseases, but vather the ignorant, the careless, and the innocent are the sufferers therefrom, and so the diseases spread. There are ways of avoiding them, and as medical officers of health we fail in our duty if we do not spread the knowledge of such menas of prevention as are known to assist in preventing them. Yours faithfully, J. P. WALK,In From Dr. J. ROBERTSON, M.O.H. Birmingham.
There is a disadvantage in attempting a correspondence in a monthiy journal, however important the subject, on account of the length of the interval between the issues. I feel, however, that it would be discourteous if, as the original objector, I ceased to reply at this stage. May I, therefore, be allowed in the first instance to recapitulate shortly what I object to ? I n the September number of the Journal it was stated that a notable advance had been made by the Town Council of Warrington in forwarding a letter to the Local Government Board advocating that prophylactic outfits and instructions should be issued free to the general population by total authorities in order to reduce the number of new cases of venereal disease. In the same number of the Journal other papers appeared dealing with this subject. One of these was a letter addressed bY Miss Ettie Rout to the National Council for Combating Venereal Diseases. (The Council's reply has not yet been published.)* Another article was a detailed description of the procedure recommended to men and women for adoption immediately before and immediately after coitus. I believe that such a procedure, if generally adopted, would lead to an increase of promiscuity to such an extent that even if effective as a preventive in certain cases, its adoption would on the whole increase the total volume of venereal disease. But it would do much more. I t would damage the morality of a l a n e number of the men and women of this country who, for one or other reason, are restrained at the present time, but who would lose their self-restraint if general opinion were given to the contention that immorality was safe. None of your correspondents has given information as to the reliability of the method which is advocated. I have been intimately associated with the question of the prevention of venereal disease in the Army during the past four years, both in France and in this country, and prior to that as a Divisional Sanitary Officer I had to look
43
into the question pretty carefully among the troops at home. Until reliable statistical evidence is produced, I should prefer to accept the opinion of medical men who have had opportunities of judging of the effect of these prophylactics, and I should say that of those who are capable of giving sound judgment there is at present an overwhelming majority of medical men who are by no means in favour of the prophylactic " packet " as the best means of preventing venereal disease. W e have not yet got reliable figures from the German Army, where these packets have been used to a laNer extent than in our own Army, but the halfdozen reports which I have seen do not lead me to believe that these packets have been any more successful in warding off venereal disease in the German Army than in our own. The statistical evidence which I have seen on this subject in regard to English and Colonial troops appears to me to need the investigation of a reliable statistician, and I sincerely hope that such investigation will be made, so that our experience during the War may not be lost. I am convinced that the value of the packet has not been proved. But as I have said in my previous letter, I object strongly to the application of a method which might be desirable among soldiers, but which is, in my opinion, extremely undesirable among the civilian population. Surely, nobody who really knows the conditions of life in the Army can fail to appreciate the difference in moral self~control which exists between the man in the Army and the same man in civil life. If you like to put it as Dr. Snell does, I would say that clothes do make an enormous difference. The environment is odifferent, the opportunities and methods of control are entirely different, and many of these methods of control which will be suitable for Army purposes are not necessarily suitable for a civil administration. I do not despair of our being able to reduce venereal disease to a vanishing point by other means. But for the exigencies of the war I am sure that some of these would have been in good working order by now. I t can only be but a short time before some method of notification with compulsion to adopt treatment will be brought into existence, so that cures may be obtained rather than much of the palliative treatment which exists to-day. Yours faithfully, JOHN ROBERTSON.
*The Council's reply has not been received. --ED., P.H. From Sir H. BRYAN D O N K I N .
SIR, The two arguments constantly re-iterated by those who would exclude venereal infections alone