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THE CONTROL OF VENEREAL DISEASE
510 from the boy’s urine were unstable, precipitating spontaneously in a week or so at 4°C. They were not classified as to light or heavy chains, or Gm type. The serum, examined by starch-gel electrophoresis in urea, showed no evidence of y-globulin fragments. On immunoelectrophoresis, however, it showed more reduplication of the y-globulin arc (similar to that found in normal urine) than does normal serum; but the result was less striking than with the patient’s urine, from which at least six lines were shown in the IgG region. The patient showed no signs of nephropathy apart from 1-2+protein in the urine, and the kidneys were not remarkments
able
at
necropsy.
In any case,
even
in the
most severe case
of
nephrotic syndrome studied, the increase in y-globulin fragments did not approach that found in the agammaglobulina:mic patient. The nature of the defect producing these y-globulin fragments is not known. Although it is remotely possible that this was related to the disease itself, the patient had been receiving a large amount of exogenous y-globulin (Cohn fraction 11) before urine collection. Although shortened half-life of exogenous y-globulin has not been found in agammaglobulinsemia, it is possible that aggregates (which are present in most y-globulin preparations) might have been broken down more quickly. Why a significant portion of this would have been broken down to the large fragment size is not clear, but it might be related to altered reticuloendothelial function due to hepatitis. Janeway and Gitlin8 and Good and Page9 described patients with agammaglobulinxmia who died from hepatitis. One of the two patients described by Good and Page9 was a boy of 4 who had been treated extensively with intramuscular y-globulin, but urinary findings were not commented on. We studied several other agammaglobulinsemics, some who had and some who had not received y-globulin treatment. Our findings in the child described above were not repeated in these patients. Veterans Administration Hospital, Buffalo, New York 14215.
FLOYD A. GREEN.
THE CONTROL OF VENEREAL DISEASE SIR,-It has been urged that the old defence regulation 33B should be revived so that legal compulsion may be used against persons suspected of transmitting venereal diseases if there are two or more informers against them. However, the situation is not comparable to that of over twenty years ago, and today many who would never have dreamed of attending the old venereal-disease clinic come along quite freely from all social classes. In my own department, the figures for new male cases from social classes I, 11, III, iv, and v over the past ten weeks were 66, 375, 531, 121, and 94 respectively, and included some highly cultivated and intelligent people who might well recoil if they thought that they, or still more those whom they recommend also to attend, were even remotely liable to
prosecution. During 1966,
’
551 male homosexuals attended for the first
time, and other clinics may have had higher figures. The incidence of infection, often symptomless, is high among them, and, since they already go in fear of the Law, the addition of new threat would seriously damage that tender plant of confidence which many of us have worked so hard to establish. There will always be the highly promiscuous defaulters of both sexes, a minority constituting an almost insoluble publichealth problem. Here the welfare officer can play an important part, though I agree that her work must be directly channelled by the consultant physician in charge. These patients can be helped in a variety of ways and sometimes trained to visit the clinic if they have cause to suspect infection. At the slightest hint of the Law-for example, after a police raid on their place of employment-they go underground and cease to attend the clinic, sometimes for months. Any attempts to introduce legal compulsion would at once defeat its own ends and vastly a
8. 9.
increase the proportion of false addresses given (at present 15% in my own department) and fabricated case-histories. The present aim is to change and humanise the general attitude towards this whole problem inside and outside the special departments, and more widely through the medium of education. In my view the change proposed conflicts with this approach, and I for one oppose it and would refuse to have anything to do with it. Special Clinic, West London Hospital, London W.6. J. L. FLUKER.
Janeway, C. A., Gitlin, D. in Advances in Pediatrics (edited by S. Z. Levine); vol. 9, p. 105. Chicago, 1957. Good, R. A., Page, A. R. Am. J. med. 1960, 29, 804.
CONTRACEPTIVE ADVICE SIR,-We are the committee of the London
Society of Family Planning Doctors, a professional body open to all doctors interested in contraceptive work in its widest sense. We note the recent unopposed passage of the second reading of the Family Planning Bill, and we are concerned about the recent reports in the lay press of the controversy over policy at the Brook Advisory Centres. We believe that contraceptive advice should not be given without regard to its significance for the patient as an individual, body and mind. We consider that any doctor who prescribes contraceptives requires time and skill to make an of the emotional difficulties that may be associated with the patient’s request for contraceptive advice. At present undergraduates get inadequate training in contraceptive techniques, and little or none in the related emotional problems. Therefore specialised postgraduate training is needed for any doctor advising on contraception, in particular for those doctors who are working with young unmarried people. RITA WALFORD SYLVIA DAWKINS MARY PASMORE POLLOCK JEAN ANN READER ALISON GILES. MARGARET EDGE
assessment
THE ABORTION BILL SiR,-The supporters of Mr. Steel’s Abortion Bill stress the benefits it offers to the mother with an unwanted pregnancy, to society in general, and even, as Dr. Leys writes (Feb. 18, p. 384), to the child who might otherwise survive to find itself unwanted. There is another aspect to all this, however, and it is one that applies to any form of euthanasia. A patient struggling for life or to preserve a pregnancy expects the doctor to try and to go on trying beyond reasonand he usually does. But will he try quite as hard if he has just come from destroying a foetus ? He may think he can keep the two functions separate in his mind, but the unconscious influence will be insidious. Because of this I believe that many of the thinking public will eventually come down against this Bill in its present form, and that, were it passed, most doctors would decline to take part. We should then be left-as elsewhere-with a corps of State abortionists superb as technicians but of negligible calibre as medical men. Is this what we really want ? London W.1.
DAVID LE VAY.
DECIMALS AND THE DAMNED SPOT SIR,-Dr. Eldon’s letter (Feb. 18, p. 391), on the subject of " ten-multiplying " errors, brings to the fore once again the potential confusion and danger of a misplaced decimal point. Tragedies have occurred in the past owing to a tentimes overdose, and will continue to occur, because of the insignificance of this vital dot. It would perhaps be wise, before this country adopts decimal coinage and measurement, to consider the question of using an alternative, and easily recognisable, symbol. A modern linotype printing machine is capable of reproducing
able
at
necropsy.
In any case,
even
in the
most severe case
of
nephrotic syndrome studied, the increase in y-globulin fragments did not approach that found in the agammaglobulina:mic patient. The nature of the defect producing these y-globulin fragments is not known. Although it is remotely possible that this was related to the disease itself, the patient had been receiving a large amount of exogenous y-globulin (Cohn fraction 11) before urine collection. Although shortened half-life of exogenous y-globulin has not been found in agammaglobulinsemia, it is possible that aggregates (which are present in most y-globulin preparations) might have been broken down more quickly. Why a significant portion of this would have been broken down to the large fragment size is not clear, but it might be related to altered reticuloendothelial function due to hepatitis. Janeway and Gitlin8 and Good and Page9 described patients with agammaglobulinxmia who died from hepatitis. One of the two patients described by Good and Page9 was a boy of 4 who had been treated extensively with intramuscular y-globulin, but urinary findings were not commented on. We studied several other agammaglobulinsemics, some who had and some who had not received y-globulin treatment. Our findings in the child described above were not repeated in these patients. Veterans Administration Hospital, Buffalo, New York 14215.
FLOYD A. GREEN.
THE CONTROL OF VENEREAL DISEASE SIR,-It has been urged that the old defence regulation 33B should be revived so that legal compulsion may be used against persons suspected of transmitting venereal diseases if there are two or more informers against them. However, the situation is not comparable to that of over twenty years ago, and today many who would never have dreamed of attending the old venereal-disease clinic come along quite freely from all social classes. In my own department, the figures for new male cases from social classes I, 11, III, iv, and v over the past ten weeks were 66, 375, 531, 121, and 94 respectively, and included some highly cultivated and intelligent people who might well recoil if they thought that they, or still more those whom they recommend also to attend, were even remotely liable to
prosecution. During 1966,
’
551 male homosexuals attended for the first
time, and other clinics may have had higher figures. The incidence of infection, often symptomless, is high among them, and, since they already go in fear of the Law, the addition of new threat would seriously damage that tender plant of confidence which many of us have worked so hard to establish. There will always be the highly promiscuous defaulters of both sexes, a minority constituting an almost insoluble publichealth problem. Here the welfare officer can play an important part, though I agree that her work must be directly channelled by the consultant physician in charge. These patients can be helped in a variety of ways and sometimes trained to visit the clinic if they have cause to suspect infection. At the slightest hint of the Law-for example, after a police raid on their place of employment-they go underground and cease to attend the clinic, sometimes for months. Any attempts to introduce legal compulsion would at once defeat its own ends and vastly a
8. 9.
increase the proportion of false addresses given (at present 15% in my own department) and fabricated case-histories. The present aim is to change and humanise the general attitude towards this whole problem inside and outside the special departments, and more widely through the medium of education. In my view the change proposed conflicts with this approach, and I for one oppose it and would refuse to have anything to do with it. Special Clinic, West London Hospital, London W.6. J. L. FLUKER.
Janeway, C. A., Gitlin, D. in Advances in Pediatrics (edited by S. Z. Levine); vol. 9, p. 105. Chicago, 1957. Good, R. A., Page, A. R. Am. J. med. 1960, 29, 804.
CONTRACEPTIVE ADVICE SIR,-We are the committee of the London
Society of Family Planning Doctors, a professional body open to all doctors interested in contraceptive work in its widest sense. We note the recent unopposed passage of the second reading of the Family Planning Bill, and we are concerned about the recent reports in the lay press of the controversy over policy at the Brook Advisory Centres. We believe that contraceptive advice should not be given without regard to its significance for the patient as an individual, body and mind. We consider that any doctor who prescribes contraceptives requires time and skill to make an of the emotional difficulties that may be associated with the patient’s request for contraceptive advice. At present undergraduates get inadequate training in contraceptive techniques, and little or none in the related emotional problems. Therefore specialised postgraduate training is needed for any doctor advising on contraception, in particular for those doctors who are working with young unmarried people. RITA WALFORD SYLVIA DAWKINS MARY PASMORE POLLOCK JEAN ANN READER ALISON GILES. MARGARET EDGE
assessment
THE ABORTION BILL SiR,-The supporters of Mr. Steel’s Abortion Bill stress the benefits it offers to the mother with an unwanted pregnancy, to society in general, and even, as Dr. Leys writes (Feb. 18, p. 384), to the child who might otherwise survive to find itself unwanted. There is another aspect to all this, however, and it is one that applies to any form of euthanasia. A patient struggling for life or to preserve a pregnancy expects the doctor to try and to go on trying beyond reasonand he usually does. But will he try quite as hard if he has just come from destroying a foetus ? He may think he can keep the two functions separate in his mind, but the unconscious influence will be insidious. Because of this I believe that many of the thinking public will eventually come down against this Bill in its present form, and that, were it passed, most doctors would decline to take part. We should then be left-as elsewhere-with a corps of State abortionists superb as technicians but of negligible calibre as medical men. Is this what we really want ? London W.1.
DAVID LE VAY.
DECIMALS AND THE DAMNED SPOT SIR,-Dr. Eldon’s letter (Feb. 18, p. 391), on the subject of " ten-multiplying " errors, brings to the fore once again the potential confusion and danger of a misplaced decimal point. Tragedies have occurred in the past owing to a tentimes overdose, and will continue to occur, because of the insignificance of this vital dot. It would perhaps be wise, before this country adopts decimal coinage and measurement, to consider the question of using an alternative, and easily recognisable, symbol. A modern linotype printing machine is capable of reproducing