- Email: [email protected]
CONTROL OF VENEREAL DISEASE.
552
The list, despite all the care taken, may be incomplete, and we should like to receive notice of any corrections that may be necessary.
CONTROL OF VENEREAL DISEASE.
syphilitic women. As a preliminary the following two recommendations were made : (1) Unification of methods of treatment; (2) unification and standardisation of technique in the performance of the Bordet-Wassermann reaction. Dr. Louis Bory, in a communication to the Progrl;s Mcdicat of Jan. 15th, divides cases for consideration into two groups: First, those who present themselves for treatment in the early primary stage before the appearance of a positive blood reaction; and second, those who start treatment subsequent to the development of a positive W.R. As a suitable course of treatment for the first-named group he advocates the following : A preliminary course of an arsphenamine preparation with a total dosage of 3’5 g. for medicaments of the 606 type, and of 4’5 g. for those of the 914 type, the course lasting two months-a month’s rest-and a W.R. ; a second course " de securite" identical with the previous course lasting two months, another month’s rest, and a W.R. Following this an additional treatment with mercury lasting six months. Mercury is given in weekly injections of grey oil or of calomel in courses of two months with a month’s interval between them. At the end of this mercurial treatment a lumbar puncture and examination of cerebro-spinal fluid are performed. The year of treatment having terminated, a year of observation is carried out with periodic examinations of the blood, and a second lumbar puncture. If all these examinations prove negative the patient is allowed to marry at the end of this second year. For those who have not come under treatment until a positive W.R. has developed a second year’s course is prescribed. If at the end of these two years the blood reactions and examinations of the cerebro-spinal fluid prove negative a two years’ period of observation is recommended. During this time regular examinations are performed and a provocative W.R. done at the end of each year. A lumbar puncture terminates the period of observation. If this is negative marriage is permitted. In the opinion of Dr. Bory the same tests should be used for the male as for the female.
Venereal Disease Clinics. atmosphere of discussion enveloping the expediency or possibility of prophylaxis of venereal diseases becomes close and sultry, it is well to remember the development of widely spread and well-organised Ret1wn of the Far East Commission. efforts towards the reduction of these diseases. If we consider that in this country until a few years ago not The Commission appointed by the National Council a single authorised centre was in existence, it becomes for Combating Venereal Diseases and sent out to the obvious that much has already been achieved in a com- Far Eastern ports under the aegis of the Colonial Office paratively short period. The difficulties encountered has completed its itinerary, and will arrive in England were many and in some instances formidable, and the on March 14th. way they have been surmounted in the past gives hope Conference of P7tblic Health Aicthorities. that, if only all parties will work together, enormous A of public health authorities took place conference strides will be made in the eradication of venereal From a study of the list at 5, Cadogan-gardens, London, on March 1st, Lord diseases in the future. of treatment centres approved by the Ministry of Askwith presiding, to consider the prevention of Health under Article III. of the Public Health venereal disease. Dr. A. Mearns Fraser proposed :That, in view of the terrible effects of venereal diseases on the (Venereal Diseases) Regulations, 1916, we note that health of the nation, and especially because of their effects upon there are now in existence 176 recognised centres, at women and children, there is urgent need for health authorities is to both administered to institute active measures to protect the inhabitants of their nearly all of which treatment these diseases. Of these measures by far the districts against men and women. Taking into regard the difficulties most important is education of the public as to the dangers of which still exist, criticism would be out of place, but venereal diseases, as to the manner in which they are spread, and we offer certain suggestions in a spirit of hopeful above all, education in the methods of immediate self-disinfection, commentary. We note that in 31 clinics there are by which venereal diseases can be largely prevented. This is a serious Dr. Fraser said that the Society for the Prevention of no evening sessions for men. Venereal Disease was anxious to induce local authorities industrial classes are usually since the omission, prevented by economic reasons from attending during to make known the methods of self-disinfection to the It is true that in public, and he detailed the action already taken in this the earlier part of the day. certain instances clinics are open on Saturday after- direction by the Portsmouth Health Committee. Dr. noons, but this does not satisfy the need. Every clinic Charles Saunders, in seconding the resolution, said that should be open at least three times a week, and at among the 300,000 inhabitants of West Ham there were hours when the majority of patients can reasonably more than 1000 new known cases of venereal disease expect to attend. Moreover, the provision of irrigation every year. Dr. E. W. Hope, Dr. W. A. Bond, Dr. J. Holroyde, treatment between the actual sessions of the clinics is most important; there are still very many clinics at and other medical officers of health and prominent which this convenience is not afforded. We may hope municipal officers supported the resolution, which was that the next year will see a great improvement in then put to the meeting and carried unanimously with this respect, as well as increased opportunities for the following addendum :Resolved further that this resolution and opinion be forwarded female patients to obtain this valuable adjuvant to health authorities throughout the United Kingdom, with the treatment. request that they take the subject at once into consideration. lIfarriage of Syphilitic Wornen. Sociological Teaching to Medical Students. We have already commented1 on a recent discussion On Tuesday, March lst, the first of a course of at a special meeting of the Societe Francaise de ] on gonorrhoea was delivered at the London Dermatologie et de Syphiligraphie on the marriage oflectures Hospital by Mr. Hugh Lett, director of the Gonorrhceal 1 THE LANCET, Feb. 26th, p. 447. Clinic, who gave an admirable resume of the subject of
WHEN the
553 venereal disease as viewed from the sociological standpoint. He pointed out how necessary it is for medical practitioners to evince such an interest as will enable them to reply with authority and confidence to the inquiries to which, as medical men, they will certainly be subjected. Further, he showed how important it is that medical men should possess such a knowledge, in order that they may be able not only to offer information and guidance but also at times to restrain wellmeaning but ill-considered attempts to reduce venereal disease. Mr. Lett drew a comparison between the prurient and false modesty adopted in the mid-Victorian era and the more wholesome candour which marks the present day, epitomising the activities of the Royal Commission on Venereal Diseases, the National Council for Combating Venereal Diseases, and the Society for the Prevention of Venereal Disease. He explained and dealt in a judicial manner with the controversy concerning immediate self-disinfection and early preventive treatment, ending with a consideration of the difficult subject of notification. Such a lecture, we believe, is something of a novelty in a teaching school, and the example of the London Hospital might well be followed in bringing before medical students and practitioners the necessity for developing a sociological interest in these diseases. If once the sympathy and cooperation of the medical profession as a whole were enlisted it would be a far easier task to influence
I
great reduction in the deaths from pellagra and other diseases is evidently due to some common cause, and this cause seems to be the improvement in the diet proposed in last year’s report, and put into force on May 1st, 1919-namely, an increase of 45 g. of meat and 50 g. of milk daily in the diet of each patient. The importance of this fact is manifest, in view of the doubt recently thrown upon the relationship existing between pellagra and diet, certain investigations having pointed to infection and dysenteric troubles as setiological factors. But the observations of Dr. J. Warnock and Dr. H. W. Dudgeon confirm the impression that pellagra is chiefly associated with defective diet. These should be read in connexion with the special report on pellagra among the Turkish prisoners of war, published by the British War Office, in which the conclusion was reached that lack of sufficient biological value of protein stands in setiological relationship to pellagra, certainly as an exciting factor, and possibly as a determining factor, while the low biological value of the protein of maize was suggested as the reason for the frequency of pellagra among maize consumers. The
from
The Causes
of Insanity.
As usual, pellagra appears as the chief cause of mental disorder in Egypt-or, at all events, as being an associated cause in the production of insanity-and when the different groups are analysed it is found to be equally represented in each. Thus, of the forms of insanity popular opinion. of 52 male and 5 female accused persons-i.e., those accused of crimes-10 of the 52 owed their insanity to LUNACY IN EGYPT. pellagra. Table 5 gives the forms of insanity admitted, and there again it is noteworthy that hashish and THE Twenty-fifth Annual Report on the Government alcohol play an important part, although that part is Hospital for the Insane at Abbasayi and the Eighth small in comparison with pellagra. Epileptic insanity Annual Report on the Asylum at Khanka are, as usual, is also frequent. General paralysis of the insane full of interest, and give evidence of the steady progress occurred in a considerable number of patients, and, which has been made in Egypt in the treatment of the as we have out before, a very large number pointed insane, notwithstanding the very trying experiences of of female patients-in fact, a much larger proportion the last few years. The period covered by the reports of female to male patients-is met with in Egypt than coincides with the financial year 1919-20. The number of in As usual, the large proportion of general England. beds on the establishment is 1581-i.e., 1181 at Abbasayi, paralytics is furnished by the cities, such as Cairo and 400 at Khanka. The admissions, exclusive of transfers Alexandria ; whereas pellagra occurs more commonly between the asylums, reached a total of 919. Besides in the districts. Cairo provides most of the country cases admitted to the two asylums, many patients were cases of insanity due to hashish. Table 9 attempts to admitted to the local hospitals of the Department of the causes of insanity, and suggests the relationship give Public Health. We must once again point out the of heredity to the production of mental disorder ; difficult importance of having other asylums scattered about in as it is in England to obtain any trustworthy history different parts of Egypt. where heredity is concerned, that difficulty is greatly The total number of cases of insanity brought under increased in Egypt among illiterates. Syphilis is given official cognisance during the year is found to be 1098, as a very definite cause, occurring both in men and which, compared with the 1281 in 1918, shows some women, not only producing general paralysis, but also diminution. 635 cases were discharged, of whom 175 other forms of disorder. had recovered, and 26 were found not to be insane; A striking fact as seen from the tables is the 430 cases were handed over to their relatives-while of residence in hospital of patients who length still insane-in most instances because accommodation a considerable number being discharged who recovered, The had been in was needed for new and more acute cases. asylums for seven years and upwards. reduction of 159 in the admissions did not result in any Seclusion had to be resorted to in a fair number of cases, relief of the pressure for room, owing to a reduction of to a great extent upon the crowded condition depending 200 in the number of beds. The old troubles have arisen of the asylum. No mechanical restraint was employed from want of accommodation, there being on the one the year, and hypnotics were used to a during hand a considerable amount of crowding, and on the other limited extent. Five patients sustained fractures from the necessity to discharge many patients who are only, falls or with other patients; one patient struggles apparently, convalescent. Discharge of convalescent sustained a fracture of the humerus, another a fracture patients to their old and in many cases unhealthy of the clavicle. None of the fractures was fatal. Postsurroundings has as usual led to the patients being later mortem examinations were made in only 16 instances. returned under the head of criminals. Again, it has to The staff, both English and Egyptian medical officers, be noticed that there is no real criminal asylum, and has been increased, and has been maintained in its that the majority of the people who are reported to be I
criminally insane
are
sent to
efficiency.
Abbasayi.
Diet and Mental Disease. The death-rate among the insane patients has diminished from 21 per cent. in 1918 to 11’9 per cent. in 1919 ; calculated on the total treated, it has dropped from 13’4 per cent. to 8’2 per cent. The reduction in the deaths affected nearly all causes given in Table 10,
except general paralysis. The greatest reductions as
were
follows :Pellagra .................................... Dysentery and diarrhaea Exhaustion from brain disease and epilepsy ...... Lung and heart disease and tuberculosis .....................
.........
Influenza
.................................
66 25 28 33 30
The Khanka Report. Dr. to Turning Dudgeon’s report at Khanka, it appears that for some considerable part of the year he was taking the place of Dr. Warnock, who was in Europe. Dr. Dudgeon provides interesting tables, showing the rate of admissions, the percentage of pellagra admissions, and the death totals; graphic schemes are given showing these facts in relationship to the Khanka institution. Steady progress is recorded in regard to the farms and the supply of water, and the planting of trees is being carried on satisfactorily. At Khanka are received the more quiet patients, and no rather special class, from whom more work
women-a
The list, despite all the care taken, may be incomplete, and we should like to receive notice of any corrections that may be necessary.
CONTROL OF VENEREAL DISEASE.
syphilitic women. As a preliminary the following two recommendations were made : (1) Unification of methods of treatment; (2) unification and standardisation of technique in the performance of the Bordet-Wassermann reaction. Dr. Louis Bory, in a communication to the Progrl;s Mcdicat of Jan. 15th, divides cases for consideration into two groups: First, those who present themselves for treatment in the early primary stage before the appearance of a positive blood reaction; and second, those who start treatment subsequent to the development of a positive W.R. As a suitable course of treatment for the first-named group he advocates the following : A preliminary course of an arsphenamine preparation with a total dosage of 3’5 g. for medicaments of the 606 type, and of 4’5 g. for those of the 914 type, the course lasting two months-a month’s rest-and a W.R. ; a second course " de securite" identical with the previous course lasting two months, another month’s rest, and a W.R. Following this an additional treatment with mercury lasting six months. Mercury is given in weekly injections of grey oil or of calomel in courses of two months with a month’s interval between them. At the end of this mercurial treatment a lumbar puncture and examination of cerebro-spinal fluid are performed. The year of treatment having terminated, a year of observation is carried out with periodic examinations of the blood, and a second lumbar puncture. If all these examinations prove negative the patient is allowed to marry at the end of this second year. For those who have not come under treatment until a positive W.R. has developed a second year’s course is prescribed. If at the end of these two years the blood reactions and examinations of the cerebro-spinal fluid prove negative a two years’ period of observation is recommended. During this time regular examinations are performed and a provocative W.R. done at the end of each year. A lumbar puncture terminates the period of observation. If this is negative marriage is permitted. In the opinion of Dr. Bory the same tests should be used for the male as for the female.
Venereal Disease Clinics. atmosphere of discussion enveloping the expediency or possibility of prophylaxis of venereal diseases becomes close and sultry, it is well to remember the development of widely spread and well-organised Ret1wn of the Far East Commission. efforts towards the reduction of these diseases. If we consider that in this country until a few years ago not The Commission appointed by the National Council a single authorised centre was in existence, it becomes for Combating Venereal Diseases and sent out to the obvious that much has already been achieved in a com- Far Eastern ports under the aegis of the Colonial Office paratively short period. The difficulties encountered has completed its itinerary, and will arrive in England were many and in some instances formidable, and the on March 14th. way they have been surmounted in the past gives hope Conference of P7tblic Health Aicthorities. that, if only all parties will work together, enormous A of public health authorities took place conference strides will be made in the eradication of venereal From a study of the list at 5, Cadogan-gardens, London, on March 1st, Lord diseases in the future. of treatment centres approved by the Ministry of Askwith presiding, to consider the prevention of Health under Article III. of the Public Health venereal disease. Dr. A. Mearns Fraser proposed :That, in view of the terrible effects of venereal diseases on the (Venereal Diseases) Regulations, 1916, we note that health of the nation, and especially because of their effects upon there are now in existence 176 recognised centres, at women and children, there is urgent need for health authorities is to both administered to institute active measures to protect the inhabitants of their nearly all of which treatment these diseases. Of these measures by far the districts against men and women. Taking into regard the difficulties most important is education of the public as to the dangers of which still exist, criticism would be out of place, but venereal diseases, as to the manner in which they are spread, and we offer certain suggestions in a spirit of hopeful above all, education in the methods of immediate self-disinfection, commentary. We note that in 31 clinics there are by which venereal diseases can be largely prevented. This is a serious Dr. Fraser said that the Society for the Prevention of no evening sessions for men. Venereal Disease was anxious to induce local authorities industrial classes are usually since the omission, prevented by economic reasons from attending during to make known the methods of self-disinfection to the It is true that in public, and he detailed the action already taken in this the earlier part of the day. certain instances clinics are open on Saturday after- direction by the Portsmouth Health Committee. Dr. noons, but this does not satisfy the need. Every clinic Charles Saunders, in seconding the resolution, said that should be open at least three times a week, and at among the 300,000 inhabitants of West Ham there were hours when the majority of patients can reasonably more than 1000 new known cases of venereal disease expect to attend. Moreover, the provision of irrigation every year. Dr. E. W. Hope, Dr. W. A. Bond, Dr. J. Holroyde, treatment between the actual sessions of the clinics is most important; there are still very many clinics at and other medical officers of health and prominent which this convenience is not afforded. We may hope municipal officers supported the resolution, which was that the next year will see a great improvement in then put to the meeting and carried unanimously with this respect, as well as increased opportunities for the following addendum :Resolved further that this resolution and opinion be forwarded female patients to obtain this valuable adjuvant to health authorities throughout the United Kingdom, with the treatment. request that they take the subject at once into consideration. lIfarriage of Syphilitic Wornen. Sociological Teaching to Medical Students. We have already commented1 on a recent discussion On Tuesday, March lst, the first of a course of at a special meeting of the Societe Francaise de ] on gonorrhoea was delivered at the London Dermatologie et de Syphiligraphie on the marriage oflectures Hospital by Mr. Hugh Lett, director of the Gonorrhceal 1 THE LANCET, Feb. 26th, p. 447. Clinic, who gave an admirable resume of the subject of
WHEN the
553 venereal disease as viewed from the sociological standpoint. He pointed out how necessary it is for medical practitioners to evince such an interest as will enable them to reply with authority and confidence to the inquiries to which, as medical men, they will certainly be subjected. Further, he showed how important it is that medical men should possess such a knowledge, in order that they may be able not only to offer information and guidance but also at times to restrain wellmeaning but ill-considered attempts to reduce venereal disease. Mr. Lett drew a comparison between the prurient and false modesty adopted in the mid-Victorian era and the more wholesome candour which marks the present day, epitomising the activities of the Royal Commission on Venereal Diseases, the National Council for Combating Venereal Diseases, and the Society for the Prevention of Venereal Disease. He explained and dealt in a judicial manner with the controversy concerning immediate self-disinfection and early preventive treatment, ending with a consideration of the difficult subject of notification. Such a lecture, we believe, is something of a novelty in a teaching school, and the example of the London Hospital might well be followed in bringing before medical students and practitioners the necessity for developing a sociological interest in these diseases. If once the sympathy and cooperation of the medical profession as a whole were enlisted it would be a far easier task to influence
I
great reduction in the deaths from pellagra and other diseases is evidently due to some common cause, and this cause seems to be the improvement in the diet proposed in last year’s report, and put into force on May 1st, 1919-namely, an increase of 45 g. of meat and 50 g. of milk daily in the diet of each patient. The importance of this fact is manifest, in view of the doubt recently thrown upon the relationship existing between pellagra and diet, certain investigations having pointed to infection and dysenteric troubles as setiological factors. But the observations of Dr. J. Warnock and Dr. H. W. Dudgeon confirm the impression that pellagra is chiefly associated with defective diet. These should be read in connexion with the special report on pellagra among the Turkish prisoners of war, published by the British War Office, in which the conclusion was reached that lack of sufficient biological value of protein stands in setiological relationship to pellagra, certainly as an exciting factor, and possibly as a determining factor, while the low biological value of the protein of maize was suggested as the reason for the frequency of pellagra among maize consumers. The
from
The Causes
of Insanity.
As usual, pellagra appears as the chief cause of mental disorder in Egypt-or, at all events, as being an associated cause in the production of insanity-and when the different groups are analysed it is found to be equally represented in each. Thus, of the forms of insanity popular opinion. of 52 male and 5 female accused persons-i.e., those accused of crimes-10 of the 52 owed their insanity to LUNACY IN EGYPT. pellagra. Table 5 gives the forms of insanity admitted, and there again it is noteworthy that hashish and THE Twenty-fifth Annual Report on the Government alcohol play an important part, although that part is Hospital for the Insane at Abbasayi and the Eighth small in comparison with pellagra. Epileptic insanity Annual Report on the Asylum at Khanka are, as usual, is also frequent. General paralysis of the insane full of interest, and give evidence of the steady progress occurred in a considerable number of patients, and, which has been made in Egypt in the treatment of the as we have out before, a very large number pointed insane, notwithstanding the very trying experiences of of female patients-in fact, a much larger proportion the last few years. The period covered by the reports of female to male patients-is met with in Egypt than coincides with the financial year 1919-20. The number of in As usual, the large proportion of general England. beds on the establishment is 1581-i.e., 1181 at Abbasayi, paralytics is furnished by the cities, such as Cairo and 400 at Khanka. The admissions, exclusive of transfers Alexandria ; whereas pellagra occurs more commonly between the asylums, reached a total of 919. Besides in the districts. Cairo provides most of the country cases admitted to the two asylums, many patients were cases of insanity due to hashish. Table 9 attempts to admitted to the local hospitals of the Department of the causes of insanity, and suggests the relationship give Public Health. We must once again point out the of heredity to the production of mental disorder ; difficult importance of having other asylums scattered about in as it is in England to obtain any trustworthy history different parts of Egypt. where heredity is concerned, that difficulty is greatly The total number of cases of insanity brought under increased in Egypt among illiterates. Syphilis is given official cognisance during the year is found to be 1098, as a very definite cause, occurring both in men and which, compared with the 1281 in 1918, shows some women, not only producing general paralysis, but also diminution. 635 cases were discharged, of whom 175 other forms of disorder. had recovered, and 26 were found not to be insane; A striking fact as seen from the tables is the 430 cases were handed over to their relatives-while of residence in hospital of patients who length still insane-in most instances because accommodation a considerable number being discharged who recovered, The had been in was needed for new and more acute cases. asylums for seven years and upwards. reduction of 159 in the admissions did not result in any Seclusion had to be resorted to in a fair number of cases, relief of the pressure for room, owing to a reduction of to a great extent upon the crowded condition depending 200 in the number of beds. The old troubles have arisen of the asylum. No mechanical restraint was employed from want of accommodation, there being on the one the year, and hypnotics were used to a during hand a considerable amount of crowding, and on the other limited extent. Five patients sustained fractures from the necessity to discharge many patients who are only, falls or with other patients; one patient struggles apparently, convalescent. Discharge of convalescent sustained a fracture of the humerus, another a fracture patients to their old and in many cases unhealthy of the clavicle. None of the fractures was fatal. Postsurroundings has as usual led to the patients being later mortem examinations were made in only 16 instances. returned under the head of criminals. Again, it has to The staff, both English and Egyptian medical officers, be noticed that there is no real criminal asylum, and has been increased, and has been maintained in its that the majority of the people who are reported to be I
criminally insane
are
sent to
efficiency.
Abbasayi.
Diet and Mental Disease. The death-rate among the insane patients has diminished from 21 per cent. in 1918 to 11’9 per cent. in 1919 ; calculated on the total treated, it has dropped from 13’4 per cent. to 8’2 per cent. The reduction in the deaths affected nearly all causes given in Table 10,
except general paralysis. The greatest reductions as
were
follows :Pellagra .................................... Dysentery and diarrhaea Exhaustion from brain disease and epilepsy ...... Lung and heart disease and tuberculosis .....................
.........
Influenza
.................................
66 25 28 33 30
The Khanka Report. Dr. to Turning Dudgeon’s report at Khanka, it appears that for some considerable part of the year he was taking the place of Dr. Warnock, who was in Europe. Dr. Dudgeon provides interesting tables, showing the rate of admissions, the percentage of pellagra admissions, and the death totals; graphic schemes are given showing these facts in relationship to the Khanka institution. Steady progress is recorded in regard to the farms and the supply of water, and the planting of trees is being carried on satisfactorily. At Khanka are received the more quiet patients, and no rather special class, from whom more work
women-a