population, together with the enormous cost which would be
thrown upon the present overburdened ratepayers, that even in
June 1921 there was only one in operation (in Manchester), and
only four other possible prospective centres. The London County
Council and many boroughs had refused to adopt this method of
dealing with these diseases, and most thinking people are of
opinion that the onus of keeping clean and thus avoiding the
spread of infection should be thrown on the individual who lays
himself open to infection by promiscuous intercourse. In re-
spect to prophylaxis therefore the policy of the National Council
had entirely failed to deal with the problem, and it was the con-
tention of the S.P.V.D. that the only practical preventive
measure is, " immediate self-disinfection " and that all hindrance
to facilities, such as the law forbidding chemists in England to
sell prophylactics for the specific purpose of rendering an indi-
vidual safe, when contemplating promiscuous sexual intercourse,
should be abolished.
The National Council and its supporters could not deny the fact that immediate self-disinfection, if properly carried out, was an efficient method of prophylaxis; but on moral grounds they strongly objected to its employment, as condoning promiscuous sexual intercourse and thereby leading to increased risk of infec- tion and a false security, because it could never be carried out efficiently by the civil population. Colonel Harrison, adviser to the Ministry of Health, who was responsible for its application in the army, supported the National Council in this contention. He stated that his experience showed that he was wrong in his estimation of the value of self-disinfection as a means of preven- tion of venereal disease in the army, and that it did not meet with the success that he anticipated. On the other hand there is the experience of Sir Archdall Reid, and the equally successful results obtained in the navy by Commander Boyden (see p. 227, Report of Birth-Rate Committee, and Archdall Reid's Prevention of Venereal Diseases, appendix pp. 437-442). Also Capt. Walker's results: " During Aug. and Sept. 1917 (64 days) a little over 5,000 officers and men came on leave to Paris, of whom 1,038 developed venereal disease or about 20 per cent. This closed the leave to Paris. Leave was reopened on Nov. 8 1917. ..." " The actual results from Nov. 8 1917 to March 31 1918 was stated by Capt. Walker to be only 3 % of infections among the men on leave to Paris." This great reduction was the result of prophylactic measures (Public Health, Sept. 1918). Although on a small scale compared with those of Col. Harrison, these results tended to prove that the personal equation plays an all- important part not only in respect to the faith, intelligence and desire of the man who employs self-disinfection as a means of prevention, but in the faith, intelligence and desire of the com- manding officers and medical officers whose duty it is to see that the excellent army instructions, which were promulgated, were enforced and the necessary disinfectants provided. Indeed, had disciplinary measures been adopted and applied both to the individuals who became infected and to the medical officer in charge if carelessness or negligence in carrying out the instruc- tions had been proved, far better results would no doubt have been obtained. Moreover, early detection of the practice of men seeking infection in order to escape service at the front, which became so prevalent as to necessitate classification as " self- inflicted wound," would have been easy and the practice pre- vented. Again, it is argued against chemists being allowed to sell specific prophylactics that it would lead to increase of venereal disease by the assumption of the purchaser that they might serve as a curative agent. Perhaps the strongest argument in favour of the efficacy of the adoption of immediate self-disinfection as the best means of prevention of venereal disease is the fact that at Portsmouth, where Sir Archdall Reid carried on his work, the Medical Officer of Health, Dr. Mearns Fraser, overcame the opposition of clergy and others to this mode of treatment, and advice and information on immediate self-disinfection was in 1921 given there by posters and on application to the Health Department at the town hall.
The policy of the Ministry of Health was thus stated by the Chief Medical Officer of the Ministry of Health:
Facilities are now being provided for disinfection, as well as irrigation and other intermediate treatment, at the various kinds of treatment centres approved by the Ministry and elsewhere under medical supervision (Annual Report, 1920, p. 122).
The experience of the American army, with State control in the United States, supports the view that, to make any system efficient, disciplinary measures and notifications are desirable, but this can only be done when all obstacles to prevention are removed. Ignorance, prejudice and false sentiment must be banished and the public educated to regard venereal disease like any other infective disease:
' Prophylactic treatment stations were established during the war in all the camps and in towns in the vicinity of camps in the United States and in France. These stations were under the supervision of American officers and in charge of carefully trained non-commis- sioned officers. Soldiers were not only instructed in the course of their training that prophylactic treatment does, in many cases, prevent the development of venereal disease but they were also under orders to apply for treatment after having exposed them- selves. If a soldier_ developed venereal disease his record was examined to ascertain whether prophylactic treatment had been taken and if this duty had been omitted, the soldier was subjected to trial by court-martial to ascertain why preventive measures had not been undertaken and to undergo punishment in case neglect became evident. Inquiry into the effectiveness of this system establishes the fact that under favourable conditions, prophylactic treatment was effective in over 90 % of the cases received. It was found that appar- ent failures resulted from four causes: (a) delay in seeking treat- ment; (6) incompetence on the part of the attendant giving the treatment ; (c) previous history of venereal disease indicating a recurrent attack; (d) false statements on the part of the soldier." (" Combating Venereal Disease in Armies, "International Journal of Public Health, published by the League of Red Cross Societies, Jan.-Feb. 1921, vol. ii., No. I.)
State Control. The measures adopted in the United States to control venereal disease are described in the reports of the Public Health Service. These measures are as follows: (i) Notification of cases of venereal disease to the health authorities, the records to be secret; (2) isolation and treatment in detention hospitals of infected persons who are unable or unwilling to take measures to prevent their becoming a menace against others; also measures for the suppression of prostitution; (3) educational measures, including information of the general public concerning the nature and manner of spreading of venereal diseases and the steps to combat them; (4) extension of facilities for early diagno- sis and treatment; (5) prohibition of prescribing by druggists. These principles have been carried into effect in many of the states by rendering persons who are a danger to the public health on account of venereal disease subject to quarantine, and certain standards are laid down which have to be followed before dis- charging patients as non-infectious.
In Pennsylvania the following measures have been adopted. The work of the Department has been divided into three parts: medical, educational, and law enforcement There are certain measures concerning the Medical Department, making for econ- omy and efficiency, which are at variance with those adopted by the British Ministry of Health. These are as follows:
There are 30 public clinics for the treatment of venereal disease, over which the Department of Health has entire supervision and for which it assumes all financial responsibility. In these clinics free treatment is given to those patients whose economic condition will not permit treatment either by private physicians or by clinics charging a fee. Upon entrance to clinics, patients are questioned as to their ability to pay for services. Those able to pay a private physician are referred to outside doctors who are registered with the clinics. If in position to pay only a small sum, they are referred to hospital clinics which charge a nominal fee. Indigent patients are treated free in the state clinics.
Continuance of treatment of a patient is insured by sending a notice to return for treatment. If this does not effect a return, the clinic makes use of the legal machinery at the disposal of the Depart- ment of Health.
Through an Act of the State Legislature passed in 1921, there has been placed at the disposal of the Department of Health a modern 4OO-bed hospital for the care and treatment of syphilitic patients who are menaces to the public health.
Immediate treatment (venereal prophylaxis) for those exposed to disease has been approved by the Pennsylvania State Depart- ment of Health. Prophylaxis as used in the army by means of stations is impractical in civilian life. Tubes containing material for self-disinfection are given the Department's approval, after
