§ LORD WILLOUGHBY DE BROKE rose to call attention to the spread of venereal infection; to ask His Majesty's Government how they propose to utilise recently acquired knowledge with regard to disinfection; and to move for Papers.
§ The noble Lord said: My Lords, venture to call your attention to a subject the importance of which, I think you will agree, it would be very difficult to overestimate. It is important particularly from the view of public health and of national efficiency, and I am bringing the question forward because it is one which requires to be debated in public, even though we do not agree as to the specific remedies. I think that during the whole history of venereal infection there has been a great deal too much secrecy, and, if I may say so, a great deal too much prudery; and the reluctance to face the facts is responsible for a great deal of what undoubtedly is a serious public danger. Ignorance must be no longer deliberately fostered. There is another reason why I draw your Lordships' attention to this subject this afternoon, and that is that I am going to suggest the general lines on which I think the prevention of infection might and ought to proceed. Before getting to that point I should like with your permission to deal, very briefly, with one or two other remedies, some of which have been tried and found wanting, others of which have been suggested but not yet tried, whilst others have been tried and proved to be only a partial success.
§ In approaching this subject it is fair to say that venereal infection is in the main kept alive by promiscuous intercourse between the sexes, together with an ignorance of the consequences, and especially 54 an ignorance of how to avoid those consequences. I am calling attention to these points because the individual whom we are accustomed to speak of as "the man in the street" still remains very ignorant about this great problem. There are many who still think that if we were to revert to the Contagious Diseases Acts, or some of their variants, that culminated in that ill-starred Regulation 40D which has now had to be withdrawn, we should be protecting ourselves and the nation against venereal disease. I should like-to dispose of that point very briefly. Those who suggest going back to the Contagious Diseases Acts, instituting what were known in France as maisons tolérées in fact, inaugurating a system which involves the segregation and medical examination of prostitutes—are advocating a system which has been tried and found wanting. I would advise those who make this suggestion to read Flexner's work on "Prostitution in Europe," in which, after an exhaustive analysis of this system and its variants in different countries in Europe, he summed up absolutely dead against it.
§ The reasons are perfectly obvious. There is one reason which is quite obvious, and it is right to call attention to it, because not many months ago in the House of Commons a responsible Minister spoke about the safety which would accrue to a member of His Majesty's Forces by visiting what I think he called" a clean woman in a maison tolérée." Those who study the subject knew that the difficulty and uncertainty of careful medical examination of women on a scale which would be likely to give protection, presents a practical difficulty which has not yet been overcome. Fresh means may be discovered, but as far as we know, as far as the general public know at present, the medical examination is an exceedingly imperfect test. I will not labour this point, but I must dispose of it because I have heard much about it in private conversation of late. Every woman who gets through the meshes of the medical examination, and some do, will be a source of danger to every man who goes to visit her in the house where she is kept. Another reason why it is impossible to return to anything like the Contagious Diseases Acts is that public opinion to-day, and in my judgment rightly, will not tolerate any discrimination between the sexes in the matter of medical examination. So much for the Contagious Diseases Acts.55
§ There is another means of addressing ourselves to this trouble which comes under the head of moral teaching. Moral teaching would advertise healthy amusements, outdoor games, and all that sort of thing. And quite right. But the object of moral teaching, as I have seen it stated—and perfectly correct—is to bring about a state of public opinion which would culminate in continence before marriage and fidelity after marriage—what is known as extra-marital continence. That may be a consummation devoutly to be wished and certainly to be advocated and preached; at the same time I think your Lordships must agree that we are a very long way from bringing about that state of things; and there is a considerable quantity of venereal infection going on every week. Another point with regard to extra-martial continence is this. Supposing that no husband ever cohabited with any woman except his wife, and that no wife ever cohabited with any man except her own husband, you would still be running a great danger of perpetuating venereal infection unless there is some knowledge of disinfection, because a very great number of married men have been infected since they joined His Majesty's Forces, or during the war, and a great many wives have likewise been infected. In point of fact, infected married men are returning to their wives; uninfected married men are returning to their wives who are infected; unmarried infected of both sexes are contemplating marriage with a view to becoming the fathers and mothers of the next generation, and this is a state of things which cannot be regarded as desirable.
§ I do not wish to belittle for one moment moral teaching in this or in any other regard. I wish to place it on the very highest pinnacle, because I think that we shall find in dealing with this subject in this country that the question of venereal infection is vitally connected with the question of marriage. What I am going to say is only a prophecy, but we must consider that the time may not be very far distant when it will become the fashion in this country to ask for interchanges of health certificates on marriage. That means that sooner or later in this country we shall be obliged to adopt some system of notification for venereal disease, in the same way that we have been obliged to adopt notification for other infectious diseases, in order that the innocent section of the community may be protected. I 56 will not deal at any great length with notification this evening, because it is quite possible that it will be appropriate and useful for your Lordships to consider it when the Ministry of Health Bill comes up from the House of Commons. But I may remind your Lordships of the attitude of the Royal Commission on Venereal Disease which published its Report about, I think, three years ago That Commission laid it down that in their opinion no system of notification should be put in force at the present time—that was three years ago. I am paraphrasing the Report, but I am doing so correctly, and I am speaking in the presence of Lord Sydenham, who will correct me if I am wrong.
§ The Commission went on to say that as soon as we had more knowledge on this subject notification might then be considered. The question naturally arises in one's mind whether we have not now acquired sufficient knowledge to induce us to reconsider the question of notification. In the meantime the Committee on the Ministry of Health Bill in the House of Commons has rejected the idea of notification, while, if I am correctly informed, the National Council for Combating Venereal Disease has approached the Local Government Board with a view to re-opening the question. In mentioning the question of venereal disease and the National Council for combating it, I should like to take this opportunity, as one who has taken some interest in the subject, to pay my personal tribute to Lord Sydenham for all the time, trouble, experience, and skill that he has placed at the disposal of the nation in exploring this very great question.
§ We come now to what is really the most important thing of all—namely, the medical means of dealing with this matter. The medical means naturally divide themselves into prevention and cure. The one great controlling fact with regard to dealing with venereal infection is that the diagnosis and cure of syphilis is advancing with comparatively rapid strides, and we have it on record from certain authorities that if the diagnosis and cure could be correctly applied to those who are affected, and if they can be kept under observation for the requisite time, we should be relatively speaking in a fair way to having mastered the terrible scourge of syphilis in this country. As Colonel Harrison, the medical 57 officer in charge of the military hospital at Rochester Row, in a lecture on venereal disease has told us, the cure of gonorrhea presents very much greater difficulty. I am not speaking of prevention; I am speaking only of cure. He goes on to say that to cure a patient of gonorrhea in the sense of the complete sterilisation in that patient of all the germs of the disease is one of the most difficult, tasks in medicine, and presents a great public problem. I do not suggest that Colonel Harrison would say that it could not be done, but it involves technical skill and care of the very highest degree, and it means keeping a patient under observation for some considerable time. In the old days the form of the disease of which I am speaking used not to be considered nearly so formidable as the syphilitic form, but recent knowledge has shown us that this is not the case. First of all it has been now proved that it is more difficult to cure, and more difficult to deal with, and also that it is quite as prevalent as syphilis. At the same time there is this fact. It is not generally known that in the case of a great number of women it is practically impossible to cure it, and that sometimes a man, but much more often a woman, may unconsciously, even after a scientific cure has been attempted, act as a carrier of the disease for years, and may quite unknowingly, thinking she is cured, communicate it. Therefore the whole physiological aspect of venereal infection points to prevention.
§ In prevention we have recently acquired knowledge of a very encouraging kind, and the form of prevention to which I particularly beg your Lordships' attention this afternoon is that which I, following Dr. Saleeby, shall call "disinfection." That is the term which I believe the medical profession has adopted and taken into the phraseology upon this subject as covering the meaning of what recently have been called prophylaxis on the one hand, and early treatment on the other. In speaking of these two methods I contend, like Dr. Saleeby and other writers whom I have studied, that the term "disinfection" means the use of disinfectants sometimes perhaps before, sometimes immediately after, or at any rate as soon as possible after the act has taken place and before the symptoms declare themselves. As to this, we have some exceedingly encouraging evidence. Disinfection, after all, only means the application to the treatment of venereal disease of the discoveries of 58 Professor Metchnikoff and of the teaching and principles of Pasteur and Lister, which have been applied with such amazing success to modern medicine and modern surgery.
I should like to read what was either written or spoken by that great man Professor Metchnikoff, to whom the whole world owes so much—
The progress of rational hygiene imposes upon physicians the duty of teaching healthy people how to preserve their health. In nothing more advantageously than venereal disease can this prophylactic aim be attained.
These points are put so much better by authorities than I can put them myself that I will read one or two more in favour of the general principle of disinfection. Colonel Harrison explained, in a lecture given recently, that the micro-organisms—or, I suppose, I should be right in calling them germs, though I am not quite sure whether that is technically correct—of both these diseases are some of the most delicate organisms in existence, and, as far as the male is concerned, they are luckily deposited in such a manner and in such a place that they will yield to natural agencies and also to the prompt application of antiseptics. "If this is so," says Colonel Harrison," the chance of infection may be reduced to an infinitesimal amount." I have a mass of figures by which this could be supported, but I will only give one or two. In the American Army there was one group of 2,426 exposures dealt with in early treatment—within one and a-quarter hours after exposure—and there were only two infections. Figures like these are familiar to all who have studied these questions, and I think that those who may be opposed to disinfection from the ethical point of view will at least admit that the value of disinfection from the medical point of view is absolutely incontestable.
It now simply remains for the State and those who are responsible for the health of the nation to settle what means they intend to adopt in order that this disinfection shall be available in its best form to the greatest number of persons. There are two methods of applying disinfection. These methods are not necessarily exclusive of each other; they may even be complementary of each other. There is first the method known nowadays as prophylaxis; and there is, secondly, the method of early treatment. "Prophylaxis" roughly means that the man shall carry the means of disinfection with him; "early treat
ment" means that he shall go as soon as possible after the act to the nearest clinical institution, there to be scientifically treated. Just listen to Colonel Harrison on this—
The ideal method is undoubtedly that in which a man submits himself to treatment by a skilled attendant within one hour of exposure. But promptitude is vitally necessary to success, and if the man is situated where he cannot obtain skilled assistance he should have the means of self-disinfection with him. I hope that before the Army is demobilised we shall have taught it by successful early treatment how to protect itself against venereal disease.
There may be those—I do not suppose there are any members of your Lordships' House, but I believe there are some out of doors—who take exception to disinfection or the prevention of disease in any form. I have heard it stated out of doors by serious people that these diseases are part of the visitation of Divine Providence for breaking the law, and these people—it is a frame of mind you can hardly conceive—do not wish the scourge of venereal infection to be taken away, because they assert that the fear of infection with either of these diseases is the principal factor in making people lead a moral life. I cannot agree with that view. And it is, after all, only an a priori statement at the very best. It may be true or not. We shall never be able to prove how many, if any, have been prevented from promiscuous intercourse with the opposite sex by fear of catching either of these two diseases. If the fear of catching a disease is the principal thing—some say the only thing—which makes certain people lead a moral life, then I suggest that these people rate the power of morality standing by itself very low indeed; it is a very poor compliment to obedience to Divine laws.
§ There is another school of thought which is serious and worthy of profound respect, and we shall probably hear it voiced in your Lordships' House this afternoon; I hope it will be, because I do not wish to speak of it with anything except respect. I have heard this given in evidence, and given with genuine conviction, before the Birthrate Commission. There are those who say that, if anybody were to go to a doctor beforehand with the announced intention of taking the risk of catching the disease that day, the doctor would not be right to give him anything to put in his pocket, or to give him any prescription to take to a chemist; but that 60 the doctor would be morally right if he were to say. "Go out and take the risk, if you like, but only afterwards, if you will come to me, will I give you something which may be a preventive." I cannot see any difference in ethics between a preventive given after the act has taken place and what is substantially the same preventive given a few moments before, or indeed placing the preventive in the hands of the individual in order that he or she may apply it themselves.
§ I may be wrong, but I cannot see any great ethical difference in that; and if you go to the question of ethics or to the question of morals and assert that it is right to go to a clinic after the act has taken place but that it is morally unsound to provide people with the means of disinfection beforehand, then I think that the ethical cause would have a much greater justification if the consequences of the act in the shape of disease were confined to the individual. If the individual were the only person to suffer punishment for wrong doing, then the moral case would be very much stronger; but unfortunately the consequences of the disease are not confined to the individual. Every man or woman who is infected becomes immediately a source of danger to the coming generation, and it is on behalf of the coming generation that I would urge that this process of disinfection should have every possible chance. It is now known that 70 per cent. of the children born with the disease called ophthalmia neonatorum—which is luckily now notifiable and therefore being dealt with—owe their disability to gonorrheal infection before birth; and it has also been estimated that 25 per cent. of the cases of blindness at birth are due to venereal infection. Therefore when you get a man or a woman who may infect everybody with whom he or she comes into contact, and when a large percentage of the next generation may be born blind and not in a position to fulfil the duties of efficient citizenship—to say nothing of the misery and pain they will suffer—I think there is a very strong case indeed, on the ethical side as well as on the score of public health and national efficiency, for doing everything in our power to disseminate this knowledge (as knowledge it is) among our fellow-citizens.
§ I will go back for one moment to prevention being taken only after the act—going to a clinic or to an institution. The 61 advantages of that are those which have been stated by Colonel Harrison in the quotation to which your Lordships were good enough to listen a short while ago. The ideal method, he said, was for a man to go to a clinic or institution within one hour and be treated there by a skilled attendant. That is perfectly sound, but your Lordships will agree with me that there are immense practical difficulties in the way. Dr. Addison said the other day that we should require at least 1,000 clinics. I should have thought that if he had said something like 50,000 clinics he would have been nearer the mark. But however many he wants he has at present only 140; and in the meantime it cannot be too often repeated that venereal infections are going on every hour, every day and every week. Early treatment has no doubt been proved to be successful in the case of the Army and the Navy, where you have men under military or naval diciplines; because then they are obliged to return to amp or on board ship before a certain hour, when the time value comes into play. The importance of the time value was also proved by the experience of the American Army in France, where it was found that the percentage of infection amongst the men who were out of camp on all-night passes was very much greater than it was amongst those who were obliged to return at midnight, or whatever the hour was and were treated at an institution. The time value is of supreme importance.
It seems to me that while we are setting up these clinics, admirable though they-may be, we ought to place in the hands of all our fellow-countrymen the very latest knowledge with regard to the means of disinfection. When I speak of the method of disinfection I am not speaking without the book. I have sent to some of your Lordships copies of remarkable articles in the Lancet of February 8, 1919, by Sir Archibald Reid and Surgeon-Commander Hamilton Boyden. Speaking with regard to the Navy, Sir Archibald Reid said
One of us has been in medical charge of a radically changing body of men generally numbering about 2,000. Up to the end of 1916 venereal disease was common among them in spite of numerous moral lectures, and in spite of adequate provision of what is known as early treatment—that is, disinfection after the contact has returned to quarters. At the beginning of 1917 a new system was instituted; the men were instructed to disinfect themselves immediately after danger had been incurred, just as a surgeon would dis
infect his hands. This procedure is what is known as prophylaxis. It differs from early treatment in that the man carries the disinfectant and uses it immediately.
Surgeon-Commander Boyden said that he commenced the prophylaxis treatment against venereal disease in the Navy in 1907. Writing in 1919 he says—
For the past nine months the method of immediate prophylaxis, by means of the application of a certain very simple solution, has been employed with results as striking as those mentioned above in the case of soldiers. Not one single case of gonorrhea occurred where this method was employed, and only one case of syphilis.
I know I shall be supported by the vast mass of medical opinion on this matter, when I read to your Lordships that they say—
Evidently the time element is of extreme importance. Probably I here is no special virtue in potassium permanganate; any other active antiseptic would be equally effective.
That is the very latest medical testimony as to disinfection. The application, with instructions explaining its use to the men, of a perfectly simple disinfectant would be efficacious.
§ I do not wish to appear to be too sanguine, and I say distinctly that I will not make myself responsible for telling Your Lordships or advising anybody, either in public or in private, that there is an absolutely sure preventive for venereal disease. All these things are relative; but the high degree of the relative value of disinfection up to date is absolutely incontestable; and I bring this matter before your Lordships' House because I trust that this debate will be of use. I urge the noble Viscount who is going to answer me to use his great influence with the Government to treat this knowledge in a scientific manner, and to place it at the disposal of the country. It is not as if the knowledge were confined now to one or two doctors. The knowledge is in the hands of innumerable soldiers and sailors now returning to civilian life; it has appeared in the public, Press. The whole principle of it will be available, more or less, to anybody who reads what takes place in this House this afternoon. The knowledge of it is increasing. It is bound to be bandied about from mouth to mouth, and it will be bandied about, unless the Government take care, in an amateur and haphazard fashion, thereby creating a sense of false security which will probably 63 lead to bad results. Therefore I say that it is the bounden duty of the Government to disseminate this knowledge in a scientific manner, and to handle it in such a way that it shall be available to all intelligent people.
§ I dare say I shall be asked how I am going to do this—whether by advertising in the newspapers or by causing every chemist to put an advertisement in his shop window, to say that he has something which will act as a preventative. I heard that question—it is a very natural one—asked the other day, and I can quote it because it was asked in a public or semipublic place, before the Birth-rate Commission. Sir William Osler was asked that question, and the substance of his answer was that it is the duty of the doctor to supply the knowledge, and that now you have a Health Ministry, and all the rest of the up-to-date State machinery for managing other people's affairs, it is the duty of the State to find means of placing this knowledge at the disposal of the individual. I have not the slightest doubt that it can be done. If there is a will to do it no doubt a way can be found. We have as splendid agency for instructing the country in the National Council for Combating Venereal Disease, and part of their propaganda might be a considered and scientific deliverance of knowledge with regard to disinfection. There are innumerable agencies and means by which it can be done. We are not so bankrupt in ways and means that we cannot find a method of letting the people have this knowledge. I wish to thank your Lordships very much for the exceedingly patient way in which you have listened to what I have had to say. I only wish I could have compressed it a little more, but I have been unable to do so. I beg to move for Papers.
§ LORD SYDENHAM
My Lords, I am certain that the noble Lord who has introduced this most unpleasant subject did so with an earnest desire to assist all who are making efforts to combat this great national danger, and I believe that plain speaking such as he has given us will help to dispel some of the misconceptions that have gathered around this subject on account of its extreme complication. It is not necessary to say a word about the Contagious Diseases Acts, because my Commission examined carefully into them and came to the conclusion that they had not accomplished what they were supposed 64 to have accomplished, and that the great fall in the number of cases in the Army occurred after those Acts had been abolished. Nor need I say a word about maisons tolérées. Apart from any moral considerations they provide no real protection whatever—this, I believe, is the view of foreign authorities—and probably lead to increased infection.
The eminent medical authorities who not long ago pressed very strongly for "simple sanitary measures," the materials for which could be obtained from every chemist, seem to have shifted the ground which they at first took up. They at first seemed to suggest that prophylactic materials should be used before risk of infection was taken, and now they seem to urge that disinfecting packets should be provided for use after risk has been incurred; and in both cases the principle involved is self-disinfection. All depends, however, upon whether the prophylatic or disinfectant is properly used. Even in this outspoken debate it is quite impossible to quote the instructions prepared for individuals, but you may take it from me that they involve a considerable amount of care and precision, which in a great many cases is certain not to be forthcoming. If the instructions are not strictly observed then it may be taken that there will certainly be failure.
A doctor with great experience writes to the British Medical Journal that in five cases of officers he found that the precautions had been carefully taken, and all were infected. When it is remembered that infection must often take place when men are partially intoxicated, the strong probability of a large proportion of failures will be realised. Dr. Robertson, Medical Officer of Health for Birmingham, who also was a member of the Army Sanitary Committee, writes—In my opinion the Army evidence shows that the results are by no means satisfactory—indeed, I would say that where it (the prophylactic packet) has been most carefully put in operation the amount of disease is highest.He quotes the case of thirteen Infantry and one Cavalry Division between August 12 and November 16 last, and shows that the highest incidence of disease occurred where prophylactic packets were used.
The noble Lord relies upon some figures given recently in the Lancet, which he read to the House, and those figures 65 certainly show that potassium permanganate is effective as a disinfectant, and may be more effective than calomel. Permanganate was used about forty years ago in the treatment of venereal disease, but its use as a post risk disinfectant is perhaps new. It is, however, perfectly well known that any effective disinfectant, if used deliberately skilfully, and promptly, can prevent infection, but unless much more information is given than appears in this letter in the Lancet it is quite impossible to accept the figures as proving what the writer intended to prove. Certain other causes may have been at work to reduce and diminish infection, and unless one knew what those causes were one could not build upon those figures. It has been found everywhere that where good lectures have been delivered to the military units and warnings given, and the men advised against the danger and admonished strongly to avoid running risks, the numbers of infections have been very greatly diminished. Colonel Snow, of the American Army, a high authority both on the military and civil side, writes to me that in the United States—A sharp line is drawn between all social and educational measures to prevent exposure and those measures employed after exposure.He goes on to say—The special measure known as the prophylactic packet is distinct from the above, and is not officially or generally approved.He adds that the packet was tried, among other measures, in the United States Army, and this was the experience—It became evident that for various reasons men could not be relied on to use the packet promptly and thoroughly, and the emphasis came to be placed entirely upon the prompt reporting to the regimental infirmary.This was before the war, and the result of the experience which the American authorities gained was that—the War Department was convinced that the packet should have no official status in the enlarged programme for combating venereal disease adopted upon entering the present war.And when America became a belligerent the Secretary of the United States Navy emphatically declared that nothing would induce him to tolerate the use of prophylactic packets. The pre-war Army rate of infection in America was 90 cases per thousand men, which is very high. That was reduced to less than 20 per thousand 66 in the United States and to between 30 and 40 per thousand in France, of course by other methods than the prophylactic packet. Colonel Snow also tells me that his experience in the Army and also as a public, health officer has led him to believe that any measures such as the prophylactic packets will militate against the early discovery and treatment of infected persons. In so far as the packet has a bearing on the moral question its official promulgation seems to me to favour increased sexual promiscuity.
I could give a large number of other opinions of the same kind, and the conclusions to which they lead my mind are these. The medical opinions which the noble Lord has quoted are, of course, perfectly sound from the purely medical point of view. Self-disinfection before exposure to risk, and after exposure to risk if there is not too long a delay (which might be one or two hours) and if it is applied with care and deliberation and promptness, will probably in most cases be perfectly effective; but it must frequently fail because these conditions cannot always be fulfilled, and it is for that reason that the military statistics are so conflicting as they are at present. I do not think anything decisive could be made out from them unless they were examined by a most competent medical statistician who knew all the causes which may have contributed to the fall of the incidence of the disease in a particular case, and could say how far it was due to some particular method and not to another method.
If it were announced by the Government, as the noble Lord appeared to suggest, that protection could be obtained by the use of the prophylactic packet, it must surely have the effect of encouraging recklessness. The effect might be that the number of risks taken by reason of this recklessness would be increased, and, as in a great number of cases the prophylactic packet would fail, the total number of infections might be larger than if the method had never been adopted. The Government, in making such an announcement as is proposed, would take upon itself a very serious responsibility for a feeling of security which present experience does not entirely justify. But that is not quite all. If self-disinfection is to be proclaimed as a specific then it must be applied, of course, to the civil population. As we all know it is far more difficult to deal with 67 the civil population than it is to deal with men in military units and under strict discipline. In the case of the civil population it would be exceedingly difficult to avoid the gratuitous distribution of this prophylactic packet to the poorer classes of the population, and I can hardly believe that any Government would sanction what the United States authorities have unhesitatingly rejected.
I say nothing of the case of women, for that offers peculiar difficulties, which have been much too generally ignored; but I do say this. I strongly feel that there is a distinct moral difference between telling people to go about with disinfecting packets in their pockets, and urging them, if they have fallen into temptation, to take the earliest possible treatment. My council gave earnest consideration to the point and decided to have nothing to do with the former policy. They have done all in their power to let people know that when they have taken any risks they must go to the earliest possible treatment, and that that is the only chance of salvation for them. We do believe that the indiscriminate distribution of these packets among the population must tend to arouse a certain amount of curiosity and might, therefore, lead into vice men who would otherwise recoil from it, by promising an immunity which after all might prove quite illusory. I will say no more on this point, because I hope the most rev. Primate will speak upon it with all the force and authority which he commands.
The noble Lord is quite right in saying that there is an increase of venereal disease going on at the present time. Before the war there were some signs of diminution, but, even so, the effects upon the life and health of the country were most serious. Always after war—and it showed itself after the South African War—there is the certainty of an increase of the disease, and it is the magnitude of the war which makes the danger so very great to us at the present time. As demobilisation proceeds the disease, if it is not checked, may find its way into places and among classes of the population which have hitherto been free from it; and in future we shall have the direst need of the utmost vigour on the part of our people, if we are to restore the prosperity which the war has taken away from us. We cannot afford the economic loss from venereal disease, quite apart from the higher considerations 68 upon which I have just touched. The vast amount of suffering among perfectly innocent persons is shocking to contemplate and we are bound to use any means in our power to control the ravages of this national scourge.
The individual must be made to know that he may not only endanger his own life, but may endanger the lives and the health of several generations to come. That is an appeal which, if it is made in the right way, must undoubtedly, and has been shown to, produce a restraining effect. I should be glad if ministers of religion would be more outspoken on the moral aspect of the matter than they have been in the past. I believe if they got to know more about the real dangers and the means of communication of these diseases they would be able to help materially in the education of the people. Meanwhile, the provision of free treatment centres is progressing, and I am quite certain that the Ministry of Health, when it gets into office, will take up this question with the earnestness which it deserves.
In the United States lately it has been decided that the public health authorities are to take over all measures dealing with disorderly houses and with any causes which tend to spread the disease. I think there is something to be said for that policy and I commend it to the consideration of His Majesty's Government. The weakest part in our machinery, as the noble Lord plainly said, is that we have no means at present of insuring that persons who begin to have treatment shall continue that treatment until they are completely non-infective. In some Australian States legislation has been taken with that object. There is the system of confidential notification which has certainly been partially successful and it deserves to be carefully watched in the future. I believe that our people, when they have sufficient knowledge of the dangers, may demand legislation of that kind, but I am quite certain that it would be useless to attempt such legislation in advance of educated public opinion.
The questions to which the noble Lord has referred, and which he has explained so well, are questions of real and vital national importance. If I disagree with some of his views I believe that the discussion he has raised must tend to do good. We are face 69 to face with a great national danger and we must meet it frankly and fearlessly. We must combat it by every means that medical science has placed in our hands, but we must be most careful that we are on perfectly sure ground and that we do nothing which, by creating a sense of false security, might not only increase infection but might tend to increase public immorality.
THE LORD ARCHBISHOP OF CANTERBURY
Your Lordships have listened with keen interest to the speech with which the noble Lord who introduced this most important subject developed the theory which he holds. I am not quite certain that I realise exactly what it is he desires His Majesty's Government to do. He asks "how they propose to utilise recently acquired knowledge," and then moves for Papers. I do not know exactly what that phrase is meant in this case to cover. No one can have failed to follow with interest his careful and perhaps alarming figures, adduced from very varied sources. Lord Sydenham has to some extent dealt with the general aspect of those statistics, although to tackle them in detail would require a great deal of time and close examination. I suppose we all feel that experience teaches us to be cautious about all statistics, and especially cautious where the subject is one about which the statistics, from the very nature of the case, are derived a great deal from conjecture. It is impossible to be accurate when you are trying to summarise what are the sources from which infection comes. You are at the mercy of those who tell you the story. They may be truthful, but they may deceive you very widely, and undoubtedly those who have investigated the subject most are not those who place the closest reliance upon statistics which the patients themselves give. Statistics are important, but I am not quite sure that they point directly in the direction the noble Lord suggests.
My wish for a few moments is rather to say something about a point which was lightly skated over by the noble Lord in his speech—namely, the danger, and perhaps the impossibility, of separating and dividing the subject into water-tight compartments, separating the technical and medical from the ethical or moral side of the question. In my belief to do so is quite impossible. The two are intertwined and overlap. In almost all social questions 70 they intertwine and overlap, but in this particular case the human frame is so constituted that almost every question connected with the sexual problem is mixed up with problems other than those which are purely and distinctly physical. Although the noble Lord did not do it, a great many of those who are active and vociferous on this subject are pressing upon us that the two things must at all costs be kept apart; that you have to deal with this matter as a physical and medical question, and must not let it be interfered with, or mixed up with, the ethical or moral question. I have before me a letter from a well-known medical man serving in the Army in which he says—Remember that the principles which must underlie the suppression of venereal disease are, first, the complete and absolute separation of the moral from the medical problem.I entirely disagree from that, and feel that even if it were desirable to do so it is practically impossible. I do not think it would be difficult to show the impossibility. Take one simple test and apply it to the statement that the two fields of action are to be kept apart, and that you must not interfere with the action you take on medical grounds because of something which is ethical or moral. Apply a simple test—I think it is a sound test. Supposing we were dealing not with human beings but with animals—foot-and-mouth disease, or canine rabies. You would say that the proper course is extermination; you must kill the mad dog or the diseased cow. But no human being would say that this is what you ought to do with regard to human patients. You at once bring in another consideration altogether. That, I think, is perfectly conclusive as to the impossibility of keeping out the ethical and moral question when you are dealing with the medical side of the problem. It is simply out of the question that we can treat this as a matter to be dealt with by medical science alone, unless that medical science is prepared to take a wider view than the purely physical one.
It will be said of us to-night, and it may be said in support of the noble Lord, "What are you afraid of in the spread of knowledge about these facts?" I am not afraid at all of the spread of knowledge, provided it be given in the right way and by the right persons. The inquiries by the Royal Commission over which Lord Sydenham presided has done very great 71 good, and I myself ant responsible for actually editing papers which give all the information we possibly can, for older and younger people, about the facts which were elicited by this Royal Commission. I am the last to desire that we should fall back upon the kind of ignorance which prevailed, most harmfully, a few years ago, and although the dissemination of knowledge is not without its difficulties it is, I think, rightly disseminated now.
I go a very long way with Lord Willoughby de Broke in that direction. I part company with him, perhaps I misunderstood him, a little further on. There is, first of all, a very obvious danger—not the greatest difficulty, but it is the most obvious—in inculcating self-diagnosis and self-treatment in matters of this kind, because you would be encouraging the particular thing which we set ourselves out to legislate against—namely, the encouragement of quackery, and of treatment without going to the proper medical authorities. The moment you furnish the person who is affected with means, as he thinks and is led to suppose, by which he can doctor himself satisfactorily and take it out of the hands of those who are qualified to advise him you send him to those who will advise lam in a very unsatisfactory way. I think that is a real danger, and one which cannot be overlooked. Lord Sydenham referred to the very interesting paper published a little While ago by Colonel Snow, who is in charge of the control of venereal diseases in the United States Army. He dwells very markedly upon the danger that arises from allowing people to become their own doctors for diagnosis or treatment in this and other matters as well, and he points out how in America real harm has been done in recent years by a process which put into everybody's hands the means of dealing with tubercular disease. Every kind of mischief has been done by people doctoring themselves in a most erroneous way, and he shows how that applies in a greater degree to the problem of venereal disease. He says—It seems to me, both from my experience in the Army and as a public health officer, that any measures which promote self-diagnosis and self-treatment, such as the prophylactic packet, will militate against the early discovery and treatment of infected persons. In so far as encouragement of penny-in-the-slot methods for its distribution, and similar devices, may open the way for increased misinformation and false security, 72 it does involve a serious question and should be opposed on administrative grounds.I think that is a practical difficulty which has to be placed in the very forefront if we are to adopt the line of action which the noble Lord has recommended.
But we are at the present faced by, I think, a much more formidable peril than that. I do not know if your Lordships have observed published rather strangely semi-official documents—I do not know how far they are actually official documents, but they have a certain degree of Local Government Board sanction upon them. These contain the kind of arguments which have been circulated, largely I think by the authorities, to the males and females front New Zealand as to what is now recommended to be the usage in our ordinary civil population. There is an elaborate report or document covering many pages which sets forth with absolute unreserve the most detailed direction for both sexes as regards the mode of applying particular securities. The document then goes on to say that these appliances and remedies of all kinds ought to be gratuitously supplied in every parish to every male or female who may desire them—that is to say, our boys and girls would be encouraged to apply to some public office, I presume, where gratuitously they would obtain protection, or supposed protection, which they were to make use of with a view to indulging without mischief in sexual intercourse. That sounds preposterous, but it is quoted seriously (and it appears in a very serious journal indeed) at great length, and without, at first any very marked and strenuous rebuke. I am glad to say that it was answered by an eminent medical officer in Birmingham, Dr. Robertson, who speaks of the peril we are in, and of the dangers which we are incurring if we allow these kind of recommendations to obtain the slightest currency amongst us. The arguments published in this semi-official way speak of the idea that sexual purity ought to be the rule as a mere fetish not acceptable to mankind in their present stage of moral evolution.
We are face to face with the undisputable fact that this kind of argument and presentment of the case is at the present moment obtaining wide currency, and it is calculated to do almost untold mischief among people who, without much information on these matters, read it. To that kind of argument I take—and I think most 73 of your Lordships would take—an absolute and irreconcilable opposition. The notion that wholesale protection of that kind should be thrust upon people beforehand—boys and girls, and girls just as much as boys cannot in my opinion be too strongly condemned. There is an absolute right and wrong in this matter. You may easily see, running through the whole matter, currency given to the presumption that sexual vice is not only inevitable but is practically universal, and has to be met in the kind of ways that are recommended. Experience has shown both in England and abroad that it is possible to increase immensely the tendency to go wrong by providing in some form or other safeguards against the uncomfortable consequences. It is the old story of the Contagious Diseases Acts. It is the old story in other countries of the maisons tolérées and the rest. I do not want to press the argument against that purely on the part of those specially called upon to give moral and religious teaching. I would rather fall back, as others have in these discussions, upon the calm statement of the subject by men who have studied it scientifically rather than ethically, but who are convinced that, although by certain supposed securities you may diminish. and probably do diminish in some degree, the number of cases and the dangers which would otherwise be run, yet on the other hand you extend the field of danger by encouraging a larger number of people with the thought that they can render themselves immune and take advantage of opportunities without incurring the danger which they would otherwise have to run.
You do not prove your case by merely saying that a certain number of cases have proved effectual. You have to show that this, if effectual, does not tend to encourage a far larger number of people to run the risk which they would not otherwise run. May I quote a sentence from the man who of all others may be most trusted to look at this matter calmly and with an absolutely unequalled wealth of knowledge—I refer to Abraham Flexner. He is clear on that subject. He speaks of creating a certain presumption in favour of the hygienic security of irregular intercourse, and goes on—but as the appetite that it fosters satisfies itself indiscriminately, the result is that bad is simply rendered worse.These are weighty words coming from one who regarded the subject from the scien 74 tific and social point of view. He approached it as a social inquirer and not as an ethical or religious teacher. He says again—Regulation, needless on the score of order, is thus seen to be positively harmful in its bearing on disease. As a system therefore, it runs counter to the modern spirit in ethics, in politics, and in hygiene.I quote that carefully because it is important as showing that those who approach the matter scientifically and with the wealth of material which is at the disposal of that remarkable author are led quite unhesitatingly to the conclusion that you cannot in a wide degree lead people to suppose that they can thus act innocuously without encouraging a much larger number of people to act similarly, and therefore increasing the area of the danger, even if in a certain number of cases you render the individual peril less. I argue that we have a total lack of proof of the effectiveness of prophylaxis as contrasted with earlier treatment. The statistics published by the society over which the noble Lord, Lord Sydenham, presides are, it seems to me, quite conclusive as rendering ineffective—I do not use a stronger word—any argument to the contrary based upon the earlier statistics which were in vogue a year ago.
The very process of the protective treatment given beforehand, not as the noble Lord very acutely described it to the individual, but wholesale, is the real peril of it. You say the individual man goes and asks for this particular protection. The danger is not that that individual man does it, but that a great company of people do it. Published matter oil this subject has been systematically handed round by non-commissioned officers to men going on leave and on other occasions, and I could give instances of my own personal knowledge in which men have explained to rue how they would never have thought about the matter at all had not this been done, and this printed matter put into their hands, and the opportunity offered them of making themselves free beforehand from the danger. That is a very real danger, against which I think we ought on every kind of ground to guard ourselves, and not least on grounds of moral principle. It is absolutely certain that you increase the amount; of wrong-doing in proportion as you render the possible wrongdoers free from the alarm which might be, and so often is, the deterrent. In so doing 75 we run counter to the moral principle which, not religious teachers only, but quiet thinkers of all kinds are trying to inculcate both in medical and other circles among us to-day. Dr. Robertson, of Birmingham, who has already been quoted, in a paper he wrote on the subject says—I am convinced myself that the only true prevention for civilians—and we should all agree to this—is sexual morality. The alternative which is suggested of teaching the use of and supplying prophylactic outfits will more surely destroy the family life of this nation than any other method you could advocate. To destroy the family is to destroy the nation. It was to similar methods that the glory of ancient Rome owed its eclipse.This is a large and vital question. I need hardly say that I feel entirely with the noble Lord who introduced the subject with regard to what he said about certain arguments, which I never hear urged now, but which used to be urged long ago, that nature must be allowed to take its course, and that this is a Divine law, an appointed mode of punishing wrongdoing. That is an argument which I do not come across. At all events, it is an argument which seems to me perfectly easily answerable, and in every sense of the word undesirable and ineffective.
I think it is vital that we remember the inexplicable but at the same time certain connection between the moral and the ethical factors in this problem, both as regards the individual and as regards the community as a whole. It is impossible to rexaggeate the importance of the question. We hold a trust for generations yet unborn, not for medical knowledge and accumulative experience only, but for larger principles besides; and we have to take good heed that, in what we inculcate, or in what we do for the supposed medical gain of the tempted or the diseased, we are not doing something which sets at nought these larger moral questions. We hold that trust as truly as the other for the generations that are to come after us—a trust not merely that we should hand on the accumulated knowledge—medical opinion, often conflicting statistics, very difficult to reconcile one with another, but which it is quite right to collect and propagate, though exceedingly difficult to rely very much upon—but that we should hand on sound principles of moral conduct, those principles upon 76 which the well being of English homes depend. I believe that a discussion like this to-night will do good, but I am sure it would not do good if we did not bear in mind that it is not only a medical question but a moral question too, and that we must look on the ethical aspects of it as well as upon those which deal simply with the physical results.
§ VISCOUNT HALDANE
My Lords, I desire to take a brief part in this debate, because for over six years I had to deal practically with what I think is the real point which has emerged. At the War Office there were the views represented by the Chaplain-General and the Army Chaplains, and the views of the Army Medical Department and its head. My experience was that these views did not come into conflict because of the forbearance of the Army Medical authorities on the one hand, and the good sense shown by the Chaplains' Department on the other.
The controversy really lies within a very narrow compass. It is admitted—I think the three speeches we have heard have been significant in that—that knowledge and the diffusion of knowledge are necessary. It is also, I think, not seriously contested that that knowledge may be applied, or attempted to be applied, in a way that leads to mischief, if we carry it too far. I believe the knowledge itself is valuable; and that it would be well if it were diffused is a proposition which, I think, conflicts very little with what has been said by the most rev. Primate, if we only define the nature of that knowledge. The whole question is how far you carry it and what is to be the application.
I agree with what was said by Lord Sydenham and the most rev. Primate as to the misleading character of attempted applications of that knowledge. I too have studied carefully Mr. Flexner's very remarkable book on prostitution in Europe: It is very instructive to read that book, because it explains why the whole machinery of the Contagious Diseases Acts has been scrapped. He describes as the result of-personal examination the condition of things in Berlin, Vienna, Paris, London, Liverpool, and other cities; and the result of this very detached, highly scientific observer's investigations is that the effect of the Contagious Diseases Act, was simply to lull people into a false security, without any real prevention. He shows, and gives 77 the scientific reason, why anything like complete prevention is impossible under those Acts. In Paris there was some reason to think that in many cases the system of attempted inspection had really tended to spread the disease through contagion. That only shows how a method of applying knowledge which at one time had many supporters has now been completely scrapped and passed by.
Speaking for myself. I think that if some of the methods of prophylaxis, some of the methods of prevention which have been spoken of, were attempted to be put into practice very extensively in the same way you would have the same result of causing people to be misled, and a very grave feeling would be aroused against it, based upon scientific considerations of the kind which Mr. Flexner has put forward. Still, even if you do not go quite so far as Lord Willoughby de Broke did in some things which he suggested, in the main I think he had a strong foundation for his argument. His argument was that much of the evil arises from ignorance, and with adequate knowledge you would prevent, that evil.
Let us see if it is possible to draw a line which would save you from the objections—I think the right objections—which the most rev. Primate has taken to some of the ways of applying that knowledge. We are face to face, in the existence of venereal disease in this country, with a most tremendous evil. People talk as if it were simply the infection of the living. Far worse is the infection of those who never live on account of venereal disease. The pre-natal mortality statistics which have been brought to light are tremendous. I do not think it is an exaggeration to say that if we were free of the evil effects of venereal disease and phthisis upon children before they were born—or rather children who never are born—this nation would have a strengthened vitality which would enable it to undertake almost any burden which even the present situation imposes upon us. It is a tremendous evil, which extends no less to the innocent than to the guilty—more to the innocent than to the guilty; and it is an evil which we are absolutely bound to deal with by every means in our power. I do not think the most rev. Primate has any quarrel with that proposition.
Then we come to the shades of difference of opinion which separate him first, I think, even from Lord Sydenham, and then 78 from Lord Willoughby de Broke. I myself have very great doubts whether there is any tangible distinction between educating people in prevention and educating people in cure. The one is very much the same thing as the other. If you tell people that if they are prompt about it such and such a person will cure them, you tell them what may be very misleading. The disease may crop up again after years of apparent health, and in the meantime innocent people may become infected. To me the solution of this question is that at which we tried to arrive—I do not say that we were altogether successful—in dealing with the matter during my experience of the Army. We had a great deal of knowledge which came from India, and there was very keen interest taken in it on the part of the Army Medical Department and the Army Chaplains. They did not differ very much. The method of the Army Chaplains was not to go into those obnoxious things to which the most, rev. Primate has alluded; not to tell people "If you do this you will save yourself from peril," or "If you do that you will cure yourself after it has matured;" but, without reference to the application, to put them in possession of the facts about the tremendous risks they were running and the tremendous evil which existed.
Ignorance here, as in many other cases, is the cause of the main part of the evil. The way in which the chaplains approached the subject seemed to me to be admirable. They dwelt upon the magnitude of the evil and on the terrific consequences, not only to the individual but, to others who might suffer through him. They did not in the slightest degree fail in their duty of insisting on the moral or spiritual side of the question, but they described the evil. They did not cover it over. They told the men what they had to face. I believe if that sound and wholesome principle were adopted it would serve nearly all the purpose wanted. I know that the Army Medical Department thought those lectures and addresses very admirable indeed. But there was no system of prophylaxis, nor was there any system of telling people to rely upon cure as distinguished from abstention, or at any rate knowledge that they were taking grave physical as well as moral risks.
To my mind the real pith and point of the noble Lord's Motion is that it is a duty 79 on the part of the State—a duty which is as important as the duty of research in various directions—to see that people are warned of the magnitude of this tremendous danger and of the consequences to the whole community if they incur it. If people know enough and have become earnest and serious enough about a subject, they will take care of themselves. It is not necessary, if a man has been warned about the moral as well as the physical side of it, to tell him about this or that particular drug or about this or that particular doctor. He will find that out for himself afterwards. But if you warn him enough to take care of himself in this matter he will do so as he does against other perils of life. I feel the difficulty, as I always have, of trying to be specific in detailed directions given on a different footing. You have only to see from the records what mischief occurred under the Contagious Diseases Act when people thought that if they went to Vienna, or to Berlin, or to Paris they were perfectly safe—a great delusion. The State should see how much better it must be to spread knowledge, and to tell people about the terrible consequences of this evil.
To my mind this debate has been a most valuable one because it has narrowed the question and brought it within a circle. I find myself in the position of agreeing with the substance of the Motion which asks for more knowledge. I find myself in the position of agreeing with Lord Sydenham in thinking that the remedies, if you specify them, are likely to prove in many cases misleading. I find myself in the position of agreeing with the most rev. Primate in thinking it is wrong to overlook that this has a most important and dominating moral side. I do not think I am in conflict with the most rev. Primate here, but I think that in recognising this you can still give knowledge up to a certain point of an important character which will lead people to resort to the best ways of dealing with these things. Notwithstanding what Lord Sydenham said, I feel that prevention, if there must be prevention, is a very important matter. It reduces very much, if it does not obviate.
At the same time, putting all those things together it seems to come to this—that there is a duty on the part of the State to see that people do not go ignorantly into this tremendous abyss. It is supposed that 80 people are not ignorant. They are extraordinarily ignorant, particularly in this field of knowledge, and if their attention were called even to the danger I think it, would be found in many cases it is a danger of which they have been in a large measure ignorant. How to lay down the dividing line exactly I do not know; but I do not think I should find any difficulty, if I were asked about a specific proposition, whether it came on one side of the line or the other. I think there is a great deal to be done in the spread of general knowledge which will lead people, if they so desire, to get more specific knowledge for themselves. That knowledge will be always available; and if the matter is pursued in that spirit, and without a desire to insist on one abstract point of view rather than upon another, I believe it will be found possible for the authorities whose business it is to educate the public in these matters to supply such knowledge and training as will at any rate go a very long way to diminish an evil which is eating at the very heart of the nation.
§ LORD BURNHAM
My Lords, this is not a debate into which any one of your Lordships would wish to enter without cause. I certainly should not; it is obviously too unpleasant. But I think all of us will admit that my noble friend not only acted with his usual courage but with even more than his usual sense of public duty in calling your Lordships' attention to the subject. We have walked too long in darkness in this matter, and we ought to walk much more in the light. I hope the most rev. Primate will forgive me if I say with all respect that I think his speech rather darkened counsel by confusing the moral with the hygienic issues. We had a little of that also in the speech to which we have just listened.
The main reason why I rise is to point out that the information given to the House by my noble friend Lord Sydenham—and endorsed by the most rev. Primate—as to American experience is utterly misleading. A fortnight ago I spent some time with the American Armies in France. I can assure your Lordships that the universal and compulsory rule in every camp and in every locality is to have prophylaxis. There is a prophylactic station in every little village in France and Germany where there is a detachment—even a platoon—of American soldiers.
§ LORD SYDENHAM
Does the noble Lord mean that the prophylactic packet is issued to the American Army, or do the authorities provide prophylactic stations for the treatment of the men?
§ LORD BURNHAM
They do both. I should like to point out that, of course, my noble friend's statement—the statement that he quoted from Colonel Snow—was based on the American experience and practice before the war. I think the noble Lord agrees. I am only telling you what is taking place now; and what is the result? They have reduced venereal disease in the American Army to one-tenth of 1 per cent. We have not taken these measures. We have done a great deal but we have stopped short of those drastic and effective measures, which have enabled America to receive her fighting men back into the United States without any risk of infection, or contagion amongst the civil population. That is a very striking fact when we are comparing the national efficiency of the two countries. We had better bear that in mind, and I add, for testimony which I dare say my noble friend will be interested to hear, that General Pershing, and other Generals whom I met in France and Germany, told me that these measures had been carried out without the smallest objection from any minister of religion either with the American Forces or in the United States. If that is so, it certainly does strengthen the case which my noble friend has presented to your Lordships this afternoon.
We have to bear in mind that there is no nation in the world which upholds a higher standard of sexual morality than the Americans. They are even more particular and meticulous in those matters than we are. In the United States subjects are taboo which are freely discussed in this country, and the rules of social conduct are enforced by public opinion in the States in a way which we cannot claim they are here. Therefore if these measures are sanctioned by the American authorities, as part of the official system, it does a great deal to establish and fortify the arguments used with so much ability by my noble friend to-day. I think your Lordships ought to know this, because if you have out-of-date information given to you it only misleads you as to the real course of events; and although I am sure there is not the smallest intention on the part of my noble friend or the most 82 rev. Primate not to give to you what knowledge they have, it so happened to be an accident that I was able during the last three or four weeks to obtain a great deal of evidence on this matter an opportunity shared by my noble friend the Under Secretary of State for War. I am sure he will confirm all I have said, although I do not know whether he is prepared to make any official statement on the matter, for obvious reasons, because the practice of our military authorities has not been the same.
I do not entirely trust to any system of prevention. For the rest I leave it to a larger publicity. The newspaper Press in the past has been afraid to discuss these matters. I quite admit that there has been a great change since the war. We have conic more in touch with the reality of things, and I ma delighted that we have abandoned those rags of false modesty which have had such terrible effects upon the happiness and well-being of the people. The happiness of the nation, we are told, is in the homes of the people, and we have to contemplate what it means that so large a number of men are coming back to spread contagion and infection, not only to render miserable the lives of those to whom they belong, but to prolong for almost limitless years the effects of their own misconduct—anyhow the effects of their own mistakes. My noble friend has said that there are few people now and certainly none in this House, who think that "just disease to viciousness succeeds." That is not a doctrine which can be maintained in these days. It belongs to the dark ages, because we know that those who suffer most are those who deserve it least. It is not only those who are living but those who are yet to be born, to the third and fourth generation, who carry with them the sequelœ, as the doctors call it of the past, of what their fathers have done.
In those circumstances does not some of the responsibility rest upon your Lordships, and all legislators in this country, if they deliberately prolong that condition of things. I believe that publicity will do a great deal to remove it, and I rather regret the sentence in the Primate's speech, in which, although he agreed that these matters are better discussed, he deplored throwing too much light upon them. I do not think you can throw too much light upon them. I believe we are threatened with a pestilence in this country, not so great perhaps as came after the taking of 83 Constantinople, when the full effects of venereal disease were first felt in Europe. It created a panic then. I do not think there is any need for a panic now, but I believe the danger is a very real one, and I do not think we should neglect any means which will enable us to counter it, and, if not to do away with its effects, at least to make them as small as possible. It is in that spirit that I have intervened in this debate, not only because I wish to impress upon your Lordships what the Americans have done, and are doing to-day, but also because I think it will let those outside know that your Lordships believe that every possible measure ought to be taken to preserve the safety and the health of the people, and the efficiency of the State.
§ LORD DOWNHAM
My Lords, my noble friend who has just spoken said nobody would intervene in this debate unless he had special cause for doing so. My special cause would be that I happened to be Parliamentary Secretary to the Local Government Board when this policy of combating the disease was initiated, and later on, as President of the Local Government Board, I was consulted upon this question of prophylactics and other methods by which we might develop the policy laid down for combating venereal disease. If I might join in the compliment to my noble friend, for the delicate and instructive way in which he has brought forward this subject, I may also say that I cannot help thinking that he left the question which he asked the Government in a singularly obscure condition. If I had happened still to be President of the Local Government Board I should have asked him what it is that he really thought the Government could do, or that the Local Government Board could do, to utilise the recently acquired knowledge with regard to disinfection, and what he thought the local authorities could be compelled to do to utilise and spread that information? That is the question which it seems to me must some day be answered, if we are to continue to discuss this subject.
Most of us know what the policy of the Government is at the present time, and how it is being carried out. We know that there have been set up throughout the country 140 treatment centres, at which treatment is given perfectly free to anybody who finds he is suffering from one of these two diseases, syphilis and gonorrhea; that laboratories are being 84 placed for the use of all properly-qualified medical men, by which the most complete diagnoses of the elements of disease may be obtained, and that all those who have these diseases are invited by various means of information to come to treatment centres as early as possible and to stay there until they are completely cured; that no names are asked, no questions are asked, and the treatment is free. That is the policy which has been initiated. As to how far it has been successful, I would say that, so far as we can tell by figures, last year there were 55,000 new cases altogether treated at the various hospitals. In the London district, which is composed of London itself and the Home Counties stretching right down to Buckinghamshire—with twenty-five hospitals in all giving this free treatment—there were 16,000 new cases, 10,000 men and 6,000 women.
There was rather an important development of this system of treatment indicated in a circular issued last December by the Local Government Board, which invited not only those who actually knew that the disease was about to develop in them, but also those who thought they had committed some action which might possibly, in certain circumstances, lead to one of these diseases, either syphilis or gonorrhea. This was an advance step on the original policy, and I do not think that public opinion anywhere is likely to be shocked by that advance. It is that all those who have any reason whatever to suspect that, in consequence of any action of theirs, they have incurred this terrible penalty, this odious disease, they should if within reach of one of these treatment centres, be able to go there and have that early treatment of which my noble friend has spoken as being one of the surest ways—though not entirely sure—by which they may be immune from the consequences of their action. That has been the policy hitherto.
What is the new policy which I fancy my noble friend advocates? It is that, in addition to what we are doing in respect to curing this disease, the Government itself should cause the local authorities to do one of two things, and possibly both. I will read from the opinion expressed by a physician of great repute, who is one of the champions of the prophylactic treatment. This is what he advocated in a well-known public magazine, the Nineteenth Century—What is needed for this purpose—85 that is, this disinfection—is the provision by the authorities of suitable washing places, which should be attached to every public lavatory in streets, stations and hotels. They should be well lighted, supplied with warm water and kept scrupulously clean, and should be open day and night at all hours. They should be in charge of an attendant responsible for their cleanliness and for keeping the apparatus and medicaments in good order. These are of the simplest; a weak solution of permanganate of potash and a supply of calomel ointment is all that is required.That is one of the treatments recommended.
Now comes the other suggestion which is made with equal force by those who want to develop this policy—the prophylactic or disinfection treatment. That as, that there should be a public supply of packets made up of calomel or permanganate of potash, or something of that kind, and that these packets should be sold, I presume, by Government order or by order of the local authorities, to all those who care to possess them; that information should be spread broadcast that anyone, of any age I suppose, should be able to supply himself or herself with one of these packets, and that, if they did so supply themselves with the packets, in all probability whatever act they commit, they would be immune from either syphilis or gonorrhea. I am not putting that argument as an argument that my noble friend has used. I am putting it as an argument that many have used who are urging this co-called prophylactic treatment. If I were President of the Local Government Board I should ask: is the Local Government Board to be told that it is to address the local authorities and ask them to submit schemes of this nature—of the kind I first mentioned or of the prophylactic packet kind, or both? That is undoubtedly a policy which is being very widely promoted, strongly promoted, by those who believe that you are justified in taking any measures of any kind in stamping out this disease, which I admit is the greatest enemy we have in our midst. It is the enemy of man, the enemy of woman, the enemy of the child, the enemy of the home, the enemy of the nation, and the enemy of the Empire. I think we are justified in taking most remedies, but I am sure we are not justified by public opinion in taking either of these courses.
For my own part, I believe that, after all, we have got to marshal all our forces against this disease. When I say "all 86 our forces" I mean not only medical and surgical and educational, but moral and spiritual also, and I think there is the gravest objection possible to the adoption of any policy of the kind which I have delineated. I believe that public opinion would be aroused against any such policy and that public opinion would never tolerate that there should be this plain offer to all young people of these prophylactic packets, and that officers of the State or of local authorities should, in their different centres, be able to offer them, either free or at a reasonable charge. I believe that that would be a great shock to public opinion, and we are fortified there at all events by the advice given to us by the Secretary of State for the Navy in the United States.
I am not an authority on what has been done in the United States so far as the Army is concerned, but at least I am armed with the circular issued by Mr. Josephus Daniels on the question of the prophylactic packet, and I should like to quote just one passage from the circular, because it thoroughly represents the views which I hold and which. I think many people hold on this subject. In this leaflet of instruction to the officers of the Navy he says—The use of the so-called preventive or prophylactic packet is not authorised and I have been severely criticised in various quarters for my attitude with regard to t his measure. The use of this packet I believe to be immoral; it savours of the panderer; and it is wicked to seem to encourage and approve placing in the hands of the men an appliance which will lead them to think that they may indulge in practices which are not sanctioned by moral, military, or civil law, with impunity, and the use of which would tend to subvert and destroy the very foundations of our moral and Christian beliefs and teachings with regard to these sexual matters.That is practically the same doctrine that has been laid down in the leaflet which we issued at the Local Government Board when I had the honour to be connected with that Department. While we invited all those who had this disease or thought that they had it to go in to be treated, we thought we were fully justified in pointing out to them the great dangers and perils which they ran, and we boldly laid it down, in a circular known as Form 5, that—If every man and woman would lead a moral life, these diseases would at once begin to decline, rapidly. If every lad and man would believe, what is a fact, that chastity is consistent with perfect health, and would have the courage to 87 resist temptation to unchastity, these diseases would rapidly disappear from our midst.It is because I believe that all the moral and religious forces have to be brought to bear in conjunction with our surgical and educational forces that I should deplore any development of our policy on the lines of compelling the State, or the local authorities, to provide these prophylactic remedies, which it seems to me, offered as they would be without any sane or sound advice, would be really putting temptation in the way of the young and making suggestions which had never occurred to them before. I hope that is a policy which neither this House nor the other House will at any time sanction.
§ VISCOUNT SANDHURST
My Lords, perhaps I may now put before your Lordships the views of the Local Government Board, which for the moment I have the honour to represent. In asking your Lordships' attention for a few minutes I cannot be blind to the fact that a most admirable speech has been made by one who is well versed in the ways of the Local Government Board, and who until a short time ago was the President of that Board, which almost does for my reply. I wish to be allowed to join with the various speakers who have addressed your Lordships this evening in saying that. I think the noble Lord who introduced this subject did so in a speech of great moderation and force, and also with a very fitting sense of the gravity of the question he was introducing. No one can possibly doubt the importance of the subject or the gravity of this foul disease, not only upon the population of to-day but on its successors. I do not think the noble Lord's meaning was quite so obscure as appeared to be suggested by my noble friend. It seemed to me, at any rate, that he was wishing to put certain views before your Lordships' House and the public possibly more than advocating them himself. He quoted two or three articles front persons of great distinction with whom, more or less, he desired to associate himself. But his main object, as I understood, was publicity.
I agree with him, and with what many of your Lordships have said, that the first thing we ought to do is as far as possible to publish the dangers or the disadvantages to the present generation and to generations to come. This was dealt upon by the noble Viscount opposite, and perhaps I may venture to remind him that this has 88 been done ever since time Royal Commission, over which Lord Sydenham presided, reported, I think, in 1916. I shall refer to that Report in a moment. On behalf of the Local Government Board I may say that we welcome all knowledge and experience from whatever source it may come. I listened with great interest to everything that has been said by Lord Willoughby de Broke, and if I do not agree with all the conclusions he arrived at I can assure him that I will draw the special attention of the President of the Local Government Board to what he has said.
At the same time I must be quite frank in the short statement I have to make. Several objections have been mentioned as to certain courses suggested in the articles referred to. Lord Willoughby de Broke mentioned, I think, that these two or three gentlemen were persons of unimpeachable, or at any rate great, authority. I have great respect for those authorities, but, as is always the case in matters of this description, it is quite fair to say that on the other side there are gentlemen, no less distinguished, who take the opposite view as to the advisability of the application of certain principles alluded to in the article in the Lancet. I have had a great deal of experience of this sort of thing. I had a melancholy experience of four or five' years of the plague in India, and with other matters more or less cognate in other places, and I have always been amazed, as no doubt your Lordships have been, how the most distinguished experts can differ. The fact of this difference of opinion shows that these matters are still to a certain extent in an experimental stage, and I do not think it would be reasonable to suggest that the Government should advocate for the public at large a remedy or a preventive which cannot be said to be otherwise than in an experimental stage.
First of all comes the question whether these processes really possess that efficiency which their advocates claim for them when they are in the hands of uninstructed persons, and whether they can, as a practical policy, be recommended broadcast on the authority of the Government to the general public. Even supposing that these disinfections are as efficacious as they are said to be, surely much if not everything, must depend upon the method and the time, especially the method, by which they are taken advantage of, and to ensure real benefit it would appear that skilled supervision is necessary. This was 89 referred to by Lord Sydenham. There is also this great fear, from the material point of view, that without this proper supervision a. general sense of security might obtain from the use of these methods which would not be warranted, to say nothing of the fact that many would hold the belief that owing to this supposed security illicit intercourse was being encouraged, or stimulated, by the action of the Government.
This takes us into other considerations which were dealt with by the most rev. Primate, and which I need not dwell on at this moment. It was suggested by Lord Willoughby de Broke that these methods have been authorised, and indeed supplied, by those in charge of the Admiralty and War Office, and with good results. As to that I am not, quite sure, but I gathered that this was what Lord Willoughby de Broke put forward. What. I venture to submit is this. Even if this is so, surely it is very different dealing with a number of men who are under naval or military discipline, and who are obliged to be in their barracks or their quarters by a certain time. No doubt organisation has provided for the proper application of these preventatives. This also must be taken into consideration, that in camps other precautions are resorted to, such as the exclusion of undesirable women and the putting of brothels and streets or even a small town near a camp or cantonment out of bounds, while cleanliness is as far as possible insisted on or inculcated with reiteration. All this should not be lost sight of in considering this question, as aiding such prevention.
There is one other point to which I must draw attention. Lord Sydenham mentioned it but did not pursue it. Supposing that there are these methods of disinfection, how is any system of that kind to be made applicable in the case of the female sex? You cannot serve out packets or anything of that sort to the prostitute. Another thing I would point out is this. It was shown in the Report of the Royal Commission that infection was caused not so much by what are known as professional prostitutes as by a number of unfortunate girls who had gone astray. How are my noble friend's preventives to reach that class? I do not know how otherwise than by the spreading of the knowledge which has been referred to. I am not endeavouring to draw a fancy picture—I am sure my noble friend will 90 acquit me of that—but it has been my duty to put forward these difficulties and objections, and I shall take care that the speech which he has delivered this evening shall be laid before the Minister whom I represent.
Having said this about my noble friend's proposals and the debate generally, I should like to say a word or two as to what the Government is doing. I have not represented this Department before in this House, and I cannot recall that any statement has been made on the subject, but if I do happen to repeat what has been said already I beg your Lordships on this occasion to excuse me. The Royal Commission reported in 1916, and the result was that a very effective propaganda was carried on. Orders and circulars were issued to county and borough councils who were empowered to provide educational lectures, and to diffuse information as rapidly and as vigorously as possible. This was done through the National Council, which arose out of the Royal Commission, The Council's energies have been very great, and there has been a variety of publicity by poster, advertisement, and leaflets drawing attention to the dangers to self and also to posterity, and insisting upon moral responsibility for habits of cleanliness and for the avoidance of the too frequent use of alcohol, and so on. It does not end there. Lecturers have been provided, and leaflets and information, issued to sanitary and Poor Law authorities, to prison doctors and chaplains, to ministers of all religious denominations, to rescue workers, probation officers, midwives and associations of social workers of every description. Here I may add that, in conjunction with the War Office, the National Council have secured the issue to every man on demobilisation of information of this description, which likewise has been distributed among munition workers. That, I think, carries out a great deal of what has been advised this evening—namely, that knowledge should be diffused as vigorously and as widely as possible.
The Government of the day thought so highly of the action and value of the National Council that it has been substantially subsidised, and I believe that is the first time that has occurred to a voluntary society. My noble friend who spoke last referred to the action of the Government in promoting centres or clinics. He has correctly stated the 91 number of patients, but it comes out a little more significantly than my noble friend showed, because there were 470,000 out-patient attendances, and 143,000 bed days. These centres or clinics are provided with the very best attendance free of expense. In the case of a patient who cannot afford to pay his expenses the county council or borough council is allowed under certain regulations to pay his expenses. On the other hand, if it had not been for the war lasting so long no doubt these centres would have been more numerous. There are about 140, but we require a very much larger number. I believe that they are well-organised now, but they should be put in a state of the highest efficiency with officers possessed of the proper knowledge, and with the necessary nurses, and, where females are attended, there should be, if necessary, female doctors. The treatment or advice, as has been pointed out, is confidential. That, I think, plays a considerable and important part in the successful treatment of this disease. What I believe made the quack doctoring, as it was called, and the quack remedies so popular was that the vendors of them put in the forefront of every advertisement—secrecy, secrecy, secrecy.
These centres are not only for the treatment and cure of patients, but they are also for the instruction of medical practitioners, who are advised to visit them, and also for what are known as fifth year men—that is, students—who can thus inform themselves regarding the various ramifications of this horrible disease. In the big towns in every case there is a centre or clinic for diagnosis, but the number of these must be increased. This has been urged on local authorities, and most of them have fallen in with the scheme, but there is still need for speeding up. Immediate treatment is what is so very necessary. There is also need for a further increase in the efficiency of the centres. It has heed suggested that whole-time officers should be engaged who will work under the medical officer of health of the district.
I agree with what was said by the most rev. Primate that the real remedy for this disease is self-control—the self-control which is inculcated by every kind of religion within the Dominions of the King. Of course we all know this, and it is very easy to say and insist upon it. At the 92 same time we must recognise that, human nature being what it is, and in view of the intense seriousness of the problem, people, owing to passion or thoughtlessness, may go astray, and opportunity may be given to guard against results which are disastrous to' the people themselves, and deeply disastrous perhaps to their successors. But there are two conditions of this, namely, that such remedies or treatment shall be furnished in conditions in which they are properly administered and, if properly administered, that they shall be efficient as far as science and organisation can provide, and further, that these facilties shall be as widely made known as it is possible.
The heads under which the Local Government Board at present work are these:—(1) Educational campaign, medical, social, and moral; (2) effective co-operation with the military to reduce or prevent the prevalence of venereal disease among soldiers and its spread during demobilisation; (3) increased facilities for prompt diagnosis provided, as I have shown, by these centres; and (4) early and efficient treatment free to all. Those are the methods that are in use by the Local Government Board, and while I acknowledge the spirit in which my noble friend brought forward his Motion I beg to assure him that the Government are not one whit behind him in energy and solicitude to cope with this terrible evil.
§ LORD WILLOUGHBY DE BROKE
My Lords, I do not intend to persist in my Motion for Papers. After what the noble Viscount has said, and after the debate, I think my object has been attained. I was very grateful to the noble Viscount for one suggestion which he made, which I left out when I first rose to speak. He said "What about the women? "Disinfection with regard to women is just as important—it is even more important—as it is with regard to men. And although you may advocate, and we all approve of—nobody would be found not to approve of—self-control, I suggest to the noble Viscount that he has not heard the last, and the general public and Parliament have not vet heard the last, of self-disinfection. This is a means which is bound to come to the front, it is bound under the discoveries of modern science to be offered and to be available with increased simplicity and 93 with increased facility. It is quite impossible to talk round this question of disinfection or to burke or suppress it. It is bound to reappear.
The point that I was anxious to put before this House is that the Government, as one of the avenues of dealing with venereal infection, should be prepared to deal with it scientifically on the lines of self-disinfection, and that the latest up-to-date knowledge of self-disinfection should from time to time be made available both to inert and to women, and especially to women, in such a way that, if they choose to avail themselves of the known teachings of science, they should be in a position to do so. If the Government are not prepared to do this, if it is not part of their policy, then this knowledge is here, it is in the hands of those who had it supplied to them in the Army and Navy, and it will percolate through society in an imperfect and uninstructed form, and it is much more likely to do harm than it would be if the Government were to place it at the disposal of the individual, if he or she desires to take advantage of it in a scientific and considered manner. Words have been rather put into my mouth as if I had come down here to recommend a whole system by which people would stand at the street corners pressing prophylactic packets into the hands of passers-by, and providing them in a penny-in-the-slot machine.
§ LORD WILLOUGHBY DE BROKE
No, you did not say so, but another noble Lord did. I do not think in the speech I made I mentioned the words "prophylactic packet" once, and my information is that the rather crude form of disinfection which is known as the prophylactic packet will in reasonable time become a back number, and the likelihood is that a much simpler and easier form of disinfection will be found. My object in bringing forward this question was to insist on the scientific study and promulgation of the latest knowledge of disinfection from time to time by the Government in order that it may be available for all those who wish to make use of it.
§ Motion, by leave, withdrawn.