History

Communicable Diseases, Table of Contents

CHAPTER VII

THE VENEREAL DISEASES

STATISTICAL CONSIDERATIONS

That venereal diseases were responsible for greatnoneffectiveness and economic waste to the Army during the World War is shown bythe fact that, of the total primary admissions to sick report on account ofdiseases only, numbering 3,500,000, venereal diseases were the direct causes in357,969 admissions, or 10.2 per cent of the whole. If to this number be addedcases reported as concurrent with other diseases, the total reported venerealincidence would be 383,706.

For admission to hospital, solely on account of venerealdisease, there was a loss of 6,804,818 days from duty. Loss to the service isnot entirely represented in the above figure, principally due to the fact thatit was the practice to return men to their organizations and to a duty status assoon as their physical conditions would permit, further treatment being carriedon in the organization while the soldier was on duty status. Inevitably time waslost for treatment, but was not officially charged as such; and in the case ofsalvarsan treatment for syphilis, carried out during convalescence, moreespecially in the United States, men were returned to the hospital or dispensaryat regular intervals as out-patients, treated and sent back to theirorganizations, usually with a loss of about one-half day per case.

Venereal diseases, as a class, stood second among the mostcommon diseases as a cause of admission to sick report for the Army as a whole,and exceeded the total number of men killed and wounded in action byapproximately 100,000. As a cause of loss of time from duty, disregarding theadditional time unaccounted for, as explained above, the venereal diseases stoodsecond only to influenza, the greatest scourge of the war.

As a cause of permanent disability, requiring discharge fromthe service, venereal diseases ranked fourth among the most common diseases,being exceeded in this respect by, first, tuberculosis, (5.52), second, valvularheart disease (2.59), third, mental deficiency (2.58). For venereal diseases(2.53), the discharge rate was 49.4 per 1,000 strength for total diseases.

There was a marked difference in the discharge rates forwhite and colored enlisted men, as shown in Table 41. The former had a rate of1.41 and the latter 18.36 per 1,000 per annum. The highest rate for any troopsin the entire Army and serving in any country was 35.57 for colored enlisted menserving in the United States. The highest admission rate for American enlistedmen was among the 21,000 stationed in the Philippine Islands. The rate was192.12 per 1,000 strength. The second highest admission rate for enlisted menwas in the United States (134.33) and the lowest in Europe (34.64).

^aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General-Ed.

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The admission rate for the total Army during the war periodwas 86.71, based upon total primary admissions. Venereal diseases wereapproximately five times more common among colored than among white enlistedmen. Among the former there were 95,026 primary admissions (331.62), as comparedwith 250,597 (69.62) among the latter.

TABLE 41.-Venerealdiseases (all). Primary admissions, deaths, discharges for disability, andnoneffectiveness, officers and enlisted men, United States Army, by countries ofoccurrence, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per1,000/font>

	Total mean annual strengths	Admission		Deaths		Discharge for disability		Noneffectiveness
	Total mean annual strengths	Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength	Days lost	Ratios per 1,000 strength
Officers and enlisted men including native troops	4,128,479	357,969	86.71	173	0.04	10,450	2.53	6,804,818	4.52
Total officers and enlisted men, American troops	4,092,457	356,151	87.02	170	.04	10,422	2.55	6,761,087	4.53
Total officers	206,382	3,300	15.99	5	.02	43	.21	105,957	1.41
Total enlisted men, American troops:
White	3,599,527	250,597	69.62	106	.03	5,085	1.41	5,208,880	3.96
Colored	286,548	95,026	331.62	56	.20	5,261	18.36	1,323,424	12.65
Color not stated	---	7,228	---	3	---	33	---	122,826	---
Total	3,886,075	352,851	90.79	165	.04	10,379	2.67	6,655,130	4.69
Total native troops	36,022	1,818	50.46	3	.08	28	.78	43,731	3.33
Total Army in United States including Alaska:
Officers	124,266	1,148	9.24	2	.02	34	.27	42,701	.94
White enlisted	1,965,297	198,727	101.12	66	.03	4,879	2.48	3,619,990	5.05
Colored enlisted	145,826	84,867	581.94	36	.25	5,187	35.57	1,082,759	20.34
Total enlisted	2,111,123	283,594	134.33	102	.05	10,066	4.77	4,702,749	6.10
Total officers and men	2,235,389	284,742	127.37	104	.05	10,100	4.52	4,745,450	5.82
U.S. Army in Europe, excluding Russia:
Officers	73,728	2,043	27.71	2	.03	6	.08	60,083	2.23
White enlisted	1,469,656	41,011	27.91	35	.02	161	.11	1,359,297	2.53
Colored enlisted	122,412	7,032	57.45	18	.15	68	.56	207,661	4.65
Color not stated	---	7,109	---	3	---	18	---	121,026	---
Total enlisted	1,592,068	55,152	34.64	56	.04	247	.16	1,687,984	2.90
Total officers and men	1,665,796	57,195	34.33	58	.03	253	.15	1,748,067	2.88
Officers, other countries	8,388	109	12.99	1	.12	3	.36	3,173	1.04
U.S. Army in Philippine Islands:
White enlisted	16,995	3,062	180.14	2	.12	6	.35	77,195	12.45
Colored enlisted	4,456	1,059	237.66	1	.22	1	.22	24,385	14.99
Total enlisted	21,451	4,121	192.12	3	.14	7	.33	101,580	12.98
U.S. Army in Hawaii:
White enlisted	16,161	813	50.30	---	---	7	.43	25,156	4.26
Colored enlisted	3,319	193	58.15	---	---	---	---	4,690	3.87
Total enlisted	19,480	1,006	51.64	---	---	7	.36	29,846	4.20
U.S. Army in Panama: White enlisted	19,688	1,748	88.78	1	.05	6	.31	30,870	4.26
U.S. Army in other countries not stated:
White enlisted	---	3,211	---	1	---	17	---	73,215	---
Colored enlisted	---	1,448	---	---	---	5	---	916	---
Color not stated	---	107	---	---	---	15	---	1,710	---
Total	14,232	4,766	334.89	1	.07	37	2.60	75,841	14.60
Transports:
White enlisted	97,498	2,025	20.77	1	.01	9	.09	23,157	.65
Colored enlisted	10,535	427	40.53	1	.09	---	---	3,013	.78
Color not stated	---	12	---	---	---	---	---	90	---
Total	108,033	2,464	22.81	2	.02	9	.08	26,260	.67
Native troops:
Philippine Scouts	18,576	680	36.61	---	---	3	.16	17,468	2.58
Hawaiian	5,615	314	55.92	---	---	5	.89	5,788	2.82
Porto Rico	11,831	824	69.64	3	.25	20	1.69	20,475	4.74

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Venereal diseases, at least during their acute stages, arenot among the common killing diseases. Therefore the number of deaths attributedto these causes in the Army during the World War is relatively small. Theduration of the war and the length of service were too short for the most fataltype, syphilis, to show its effects. Table 41 shows that 173 deaths wereattributed to venereal diseases in the total Army during the war. Among these, 5were officers, 106 white enlisted men, and 56 colored enlisted men. Three caseswere charged to native troops, and 3 to enlisted men whose color was not stated.

For a number of years prior to the World War, venerealdiseases constituted a cause for the rejection of applicants for enlistment inthe Army. Since this cause for rejection obviously could not obtain, in so faras the World War Army was concerned, from the first practically all cases ofvenereal diseases were deemed acceptable.¹The number of cases discovered among the inducted men on their physicalexamination after their arrival at Army camps gives a very excellent measuringstick as to the incidence of these diseases among the young adult malepopulation of the United States.

From the beginning of hostilities, in 1917, until May 1,1918, about 1,000,000 men were inducted into the Army.²This is spoken of as the first million and is referred to in Table 42 as P₁.The physical examination blanks used at the time that these men were beinginducted provided but one space for the notation of defects and only the majordefects were noted; therefore, other defects, including venereal diseases, ifnot considered the major defect, were not listed. During the same period,organization was taking place with the draft boards and within the camps. Underthese circumstances, it is to be supposed that the records do not show theoccurrence of venereal disease as fully as was the case subsequently. The secondmillion men, referred to as P₂wascalled between May 1, 1918, and November 11, 1918. On the physical examinationblanks used for the second million men, two spaces were provided for majordefects. Local boards and camp examining boards were well organized and runningsmoothly. The records, therefore, are more complete. This second million was inreality 1,780,000 men, and, as notations shown on the original table²are based upon 1,000,000 men only, figures used in Table 42 are raised bymultiplying those in the original table by 1.8, in order to estimate the totalnumber of cases.

TABLE 42.-Defects found in drafted men-Venerealdisease (all)

Venereal diseases	Group A			Group B			Group C			Group D and Vg					Total
Venereal diseases	P1	P2	P1 and 2	P1	P2	P1 and 2	P1	P2	P1 and 2	P1	P2	P1 and 2	Cl. Vg	Total	Total
Syphilis	2,927	15,130	18,057	---	5	5	12	279	291	1,501	2,745	4,246	4,541	8,787	27,140
Chancroid	952	2,353	3,305	---	2	2	---	54	54	35	198	233	120	353	3,714
Gonorrhea	22,812	72,058	94,870	1	23	24	24	1,458	1,482	490	4,333	4,823	1,135	5,958	102,334
Total	26,691	89,541	116,232	1	30	31	36	1,791	1,827	2,026	7,276	9,302	5,796	15,098	133,188

^aSource of information: Defects Found inDrafted Men. War Department, 1920, 424.^bA-Men selected for full military service. B-Accepted for remediabletreatment. C-Accepted for special or limited service. D-Rejected at camps.Vg-Rejected by local boards. Pi-First million men. P2-second million menand others.

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Since venereal disease was not a disqualifying defect, veryprobably it was not carefully searched for; furthermore, the recorded cases,133,188, were detected upon a quick routine physical examination withoutclinical history or full laboratory facilities.

With the less complete system of recording, 28,754 instancesof venereal disease were reported among the first million drafted men. With themore complete system, as applied in the examination of the second million men, 54,843 cases of venereal disease were recorded by the campexamining boards alone. Taking the second million as an index of occurrence, thegrand total of venereal diseases was shown to be 56.69 per 1,000, or 5.67 percent. Among the 133,188 men with venereal disease reported in the secondmillion, 15,098 were rejected. Venereal diseases accounted for nearly 5.8 percent of all defects and were the third most important cause of defects found incamps.

CHART XXXIII

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If to the cases detected as outlined above we add cases whichcould be detected only by thorough physical examination, including themicroscope for gonorrhea, and the dark-field and complement fixation forsyphilis, the aggregate would be greatly increased. If incoming men broughtvenereal disease into the Army, a study by draft increments should show this.Chart XXXIII is designed to show the relation between the total venerealdiseases by months (lower line) and the draft increments (upper line).

CHART XXXIV

Much has been said relative to the high incidence rate ofvenereal diseases among colored men. Where the number of inducted colored menwas greater than the number of inducted white men, the incidence rate was alsogreater. Chart XXXIV shows the strength trend of white and colored enlisted menin comparison with the trend for venereal diseases. If this be consid-

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ered in conjunction with Chart XXXIII, it becomes apparentthat the proportion of venereal admissions increased as the proportion ofcolored strength to the white strength increased. To assist further in thisvisualization Chart XXXV has been prepared. This chart shows the actual monthlystrengths for white troops, but the monthly strengths for colored troops wereraised to what they would have been if the mean annual strength forthe two races, for the war period, had been the same. The mean annual strengthfor the white troops for the war was to that of the colored troops as 12.805 isto 1. The actual monthly strengths for colored troops were, therefore,multiplied by the factor 12.805 to obtain the raised strength. In the samemanner the

CHART XXXV

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number of admissions for colored troops in the United Statesand Europe were multiplied by this factor to obtain the corrected number ofcases for each month, which was then added to the true monthly admission figuresfor the whites. These figures were used as a basis for the heavy line.

Chart XXXV, considered in conjunction with Charts XXXIII andXXXIV should enable one to visualize the comparative effects of the white andcolored population upon the absolute number of cases of venereal diseasereported. It shows how closely the increase in venereal diseases followed therise in the colored enlisted strength and how nearly the line of cases ofvenereal diseases paralleled the line for colored enlisted strength until thelast peak of mobilization was passed in July. Chart XXXV also shows that coloredenlisted men were inducted later and demobilized earlier than the white enlistedmen; in other words, the average colored soldier was in the military serviceduring a shorter period of time than was the white soldier.

OCCURRENCE IN THE ARMY IN THE UNITED STATES

Since the larger proportion of cases of venereal disease wasimported into the service at the time of the draft, and since active steps weretaken in the latter part of the summer of 1917 to prevent men with venerealdisease from embarking for service abroad,³it is clear why themajority of cases should have been reported in the United States. Table 41 showsthat of the total admissions for venereal diseases in the Army during the war,numbering 357,969, troops serving in the United States contributed 284,742, or79.6 per cent. Whereas the admission rate per 1,000 per annum was 86.71 for theentire Army, the rate at home was 127.37. The admission rate was high for bothwhite and colored enlisted men, being 101.12 and 581.94, respectively; but waslow for officers (9.24). Although the admission rate for white enlisted men wasless than one-fifth that for colored enlisted men, it was about one and one-halftimes the mean ratio of the total Army.

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

In considering the incidence of venereal diseases in theAmerican Expeditionary Forces, particularly when in comparison with theincidence in the Army in the United States, it is necessary to have in mind thefact that every effort was made both in the mobilization camps and at the portsof embarkation to detect all cases of venereal disease among men destined foroverseas prior to their departure from the places mentioned.³

Table 41 shows for the Army in Europe, throughout the WorldWar period, 57,195 primary admissions for venereal disease; the admission ratebeing 34.33 per 1,000 per annum as compared with 127.37 for the Army in theUnited States. Among enlisted men there were approximately five times as manyadmissions in the United States as in the American Expeditionary Forces, with anadmission rate of approximately fifteen times greater at home. White enlistedmen abroad contributed the bulk of the cases, approximately 41,000, and theadmission rate was equal to that of the officers and one-half the rate ofcolored enlisted troops.

The noneffective rate for white enlisted in Europe (2.53) wasapproximately that of officers (2.23) and about one-half the rate at home(5.05). The non-

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effective rate for colored enlisted men, AmericanExpeditionary Forces (4.65), was about one-fourth that of colored enlisted menin the United States (20.34).

These differences are perhaps better shown by comparing theaverage number of days lost per case. Officers in the United States lost on anaverage of 36 days per case, against 33 days in the American ExpeditionaryForces. The average for white enlisted at home was 18 days and abroad 33 days;while for colored enlisted at home the average was 12 days, against 29 days inthe American Expeditionary Forces. The average for the Army at home was 16days, against 31 days abroad.

For white troops serving in Europe-disregarding theabnormally high rates reported in the latter part of 1919 for the AmericanForces in Germany-the peak of admissions occurred in October, 1917. A markeddrop occurred in June, 1918, with low rates subsequent to that time, due atleast in part to the new system of reporting, by which only hospital cases wererecorded on the sick and wounded reports. This same drop was apparent forcolored enlisted men, the rate declining from 228.83 in April to 145.96 in Mayand to 88.54 in June. This lowered incidence rate was not entirely due to thesystem of recording, but was very materially influenced by the prophylacticsystem used in the American Expeditionary Forces.

OCCURRENCE IN OTHER COUNTRIES

The highest admission rate for enlisted American troopsduring the World War was not in the United States, as might have beenpresupposed, due to mobilization influences, but was in the PhilippineDepartment, where very high venereal incidences have been recorded since theyear 1898.⁴ The Philippine rate for American troops during the war was 192.12per 1,000 strength; the United States rate (134.33) held second place. Again,the incidence among colored enlisted men (237.66) was a material factor incausing this high rate; the incidence among white enlisted men in the PhilippineDepartment was 180.14. The venereal disease rate among American troops inthe Hawaiian Department was low (51.64) for both white (50.30) and colored(58.15) men. Native troops serving in their own country showed the lowestvenereal incidence (50.46), with 1,818 cases among a mean strength of 36,022men.

FACTORS INFLUENCING INFECTION

At the outbreak of the World War, the exciting causes of thevenereal diseases were well known and accepted; therefore nothing is to be addedherein along these lines. However, regarding the factors influencing infection,there has been much discussion, and the literature is rich in this material, thepurpose of which was to remove these influences, as far as possible, in orderthat the venereal diseases might be held at lowest ebb. From the Army point ofview, there were certain influencing factors which are worthy of specialconsideration. The most important of these are the incidence of venerealdiseases among the civil population, the influence of age, race, length ofservice, prostitution, and alcoholism. With the exception of the influence onthe Army rate of infection in recruits (to include newly drafted men), thesefactors are interwoven one with the other.

That the source of infection for the Army lies outside of theservice requires no proof, as the opportunity for infection solely within theservice is slight, in

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fact so slight that it need scarcely be mentioned. It is truethat very occasionally venereal infections have occurred and have been reportedas being in line of duty, where, for example, an attendant became infectedduring the care of a patient; but the sum total of these cases is indeed small,and others arising within the service were of about the same rarity.

That race was an important element in the cause of venerealdisease in the Army is shown by reviewing the records from any angle, as thesediseases were far more prevalent among the colored troops. It is not intended toimply that colored men are more susceptible, or that the white soldiers possessa higher degree of immunity to venereal infection; but from the Army standpointthe greater the proportion of colored troops the higher the venereal rate.

Age, in like manner, is an important factor, as venerealdisease is more common among the ages represented by the soldier age group seenduring the World War. In this connection a study by length of service shows thatthe larger number of cases occurred among men with least service, and vice versathe smallest number of cases among those with longer service.

It is a matter of history that prostitution follows in thewake of armies. The soldier does not bring about this condition of loweredmorality, but mobilization attracts women of both clandestine and professionaltypes, and experience has shown that a very large percentage of such females arevenereally infected.

Prostitution, in its relation to armies, was one of the mostextensively studied of the health problems during the war. The calling of wholenations to service altered the conditions that obtained in former wars in whichthere were relatively small fighting forces, preyed upon by the professionalprostitute. The World War greatly enlarged the field for venereal infection.

The dangers resulting from alcoholism were immediatelyappreciated when the United States entered the World War, and Congress empoweredthe President with authority to safeguard the troops against them.⁵

The following table shows admissions, absolute numbers, andratios per 1,000 strength for alcoholism and venereal diseases (all) by yearsfrom 1917 to 1919, for total American troops in the World War:

Alcoholism and venereal disease (all). Primary admissionsamong total American troops during the World War. Absolute numbers and ratios per 1,000 per annum

Year	Alcoholism		Venereal disease
Year	Cases	Rate	Cases	Rate
1917	1,835	2.73	82,299	122.62
1918	2,183	.87	226,875	89.72
1919	1,734	1.75	61,182	61.65

GONOCOCCUS INFECTION

Table 43 shows that the total incidence of primary admissionsfor gonococcus infection during the World War was 251,899. If to this figurecases reported as concurrent diseases (8,403) be added, the total occurrence forthe American Army was 260,302, among a total mean annual strength of 4,128,479officers and men. The strength from which the concurrent cases were reported cannot be determined, therefore these cases are not included in further discussionson the occurrence of gonococcus infection unless specifically mentioned.

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TABLE 43.-Gonococcus infection. Primary admissions, deaths, discharges for disability, and noneffectiveness, officers and enlisted men, United States Army, by countries of occurrence, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000.

	Admissions			Deaths		Discharges for disability		Non-effectiveness
	Total mean annual strengths	Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength	Days lost	Non-effective ratio per 1,000 strength
Officers and enlisted men, including native troops	4,128,479	251,899	61.02	24	0.01	7,027	1.70	3,903,303	2.59
Total officers and men, American troops	4,092,457	250,874	61.30	24	.01	7,021	1.72	3,879,174	2.60
Total officers	206,382	2,027	9.82	2	.01	9	.04	60,922	.81
Total enlisted men, American troops:
White^a	3,599,527	178,322	49.54	20	.01	2,941	.82	3,179,595	2.42
Colored	286,548	66,466	231.95	2	.01	4,067	14.19	568,860	5.44
Color not stated	---	4,059	---	---	---	4	---	69,797	---
Total	3,886,075	248,847	64.03	22	.01	7,012	1.80	3,818,252	2.69
Total native troops	36,022	1,025	28.45	---	---	6	.17	24,129	1.84
Total Army in United States, including Alaska:
Officers	124,266	664	5.34	---	---	7	.06	20,907	.46
White enlisted	1,965,297	149,073	75.84	7	.00	2,863	1.46	2,353,700	3.28
Colored enlisted	145,826	61,901	424.49	1	.01	4,037	27.68	492,884	9.26
Total enlisted	2,111,123	210,974	99.93	8	.00	6,900	3.27	2,846,584	3.70
Total officers and men	2,235,389	211,638	94.67	8	.00	6,907	3.09	2,867,491	3.51
U.S. Army in Europe, excluding Russia:
Officers	73,728	1,301	17.65	2	.03	2	.03	38,442	1.43
White enlisted	1,469,656	23,437	15.95	10	.01	62	.04	724,938	1.35
Colored enlisted	122,412	2,481	20.27	---	---	27	.22	59,130	1.32
Color not stated	---	3,980	---	---	---	4	---	68,982	---
Total enlisted	1,592,068	29,898	18.78	10	.01	93	.06	853,050	1.47
Total officers and men	1,665,796	31,199	18.73	12	.01	95	.06	891,492	1.47
Officers other countries	8,388	62	7.39	---	---	---	---	1,573	.51
U.S. Army in Philippine Islands:^b
White enlisted	16,995	1,359	79.97	1	.06	---	---	37,035	5.97
Colored enlisted	4,456	457	102.56	---	---	---	---	12,139	7.46
Total enlisted	21,451	1,816	84.67	1	.05	---	---	49,174	6.28
U.S. Army in Hawaii:
White enlisted	16,161	588	36.39	---	---	3	.19	17,461	2.96
Colored enlisted	3,319	124	37.36	---	---	---	---	2,278	1.88
Total enlisted	19,480	712	36.55	---	---	3	.15	19,739	2.78
U.S. Army in Panama: White enlisted	19,688	857	43.53	---	---	1	.05	12,835	1.78
U.S. Army in other countries and not stated:
White enlisted^c	---	1,547	---	1	.07	9	---	20,119	---
Colored enlisted^c	---	1,196	---	---	---	3	---	587	---
Color not stated	---	72	---	---	---	---	---	773	---
Total	14,232	2,815	197.80	1	.07	12	.84	21,479	4.14
Transports:
White enlisted	97,498	1,461	14.98	1	.01	3	.03	13,507	.38
Colored enlisted	10,535	307	29.14	1	.09	---	---	1,842	.48
Color not stated	---	7	---	---	---	---	---	42	---
Total	108,033	1,775	16.43	2	.02	3	.03	15,391	.39
Native troops:
Philippine Scouts	18,576	378	20.35	---	---	---	---	10,206	1.51
Hawaiian	5,615	276	49.16	---	---	1	.18	4,614	2.25
Porto Rico	11,831	371	31.36	---	---	5	.42	9,309	2.16

^aIncludes total strength for "othercountries and not stated."
^bIncludes troops in China.
^cSeparate strength for white and colored not available.

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The ratio per 1,000 per annum for primary admissions was61.02 for the total Army. Officers and enlisted men, American troops,contributed 250,874 cases (61.30), of which 2,027 (9.82) were officers. Theremaining cases, 1,025, were among native troops (28.45). The rate of occurrenceamong enlisted men was 64.03 and about five times more common among coloredtroops (231.95) than among the whites (49.54).

Deaths, as would be expected, were very few, a total of 24being reported 20 among white enlisted and 2 each among officers and coloredenlisted men. There were 7,027 officers and men discharged from the service oncertificates of disability on account of gonorrhea, with a discharge rate of1.70 per 1,000 strength. These were cases with complications that unfitted theindividual for the performance of his duties. There were nine officers (0.04),2,941 white enlisted men (0.82), and 4,067 (14.19) colored enlisted men soseparated from the service. It is to be noted that the discharge rate among thecolored enlisted men was about fifteen times greater than among the whiteenlisted men.

The more important influence of gonorrhea on the fightingstrength of the Army is shown in the number of days lost from duty, which was3,903,303, a noneffective rate of 2.59 per 1,000. This disease ranked thirdamong the 30 most common diseases in the Army, from a standpoint ofnoneffectiveness. Officers lost 60,922 days (0.81) and American enlisted men3,818,252 (2.69) days. The noneffective rate among white troops (2.42) wasapproximately one-half (5.44) that of the negro troops. Gonorrhea among thenative troops was consistently less in its various aspects than among Americantroops. The admission rate for the former was 28.45 and no deaths were reported.

OCCURRENCE BY MONTHS

Season, per se, as is well recognized, had no influence onthe prevalence of gonococcus infection; however, a review of the incidence byyears and months shows a marked variation. The annual rates, for example, forthe three years of the war were, respectively, 93.66, 113.30, and 99.93 per 1000strength for enlisted men in the United States as compared with the annual rateof 54.84 for 1916, the year preceding the entering of the United States into thewar. Great variations are revealed in a study by months of occurrence. For whiteenlisted men in the United States during the first month of the war, April,1917, the rate was 61.52, and rose to its peak for this year, in September, to 136.25, concomitant with the mobilization of a large numberof drafted men. In January, 1918, the rate for white enlisted men had fallen to48.29, with a report of 4,412 cases during that month. The mean enlistedstrength was about 1,100,000 men. By July, which was the peak for 1918, the ratehad increased to 133.81, and the mean strength to 1,300,000. There was aprogressive decrease in the ratios until the summer and fall of 1919, when agradual increase brought the trend to 72.32; the end of 1919 found the rateamong white troops 56.27 per 1,000 per annum, with an average for the period of75.84.

Fluctuations were much greater among the colored enlistedmen, and the occurrence among them determined the monthly and annual ratios forgonococcus infections for the Army as a whole. The beginning of the war

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found the admission rate for colored enlisted men at 49.26.This ratio rapidly increased to 408.04 in October, 1917, with the rapid increasein the number of colored drafted men, an increase from 4,870 in April to 21,795in October. January, 1918, had a rate of 230.30 per 1,000 and a mean strength of50,705. The rate increased rapidly throughout the spring and summer, reaching988.38 in August. There was, relatively speaking, a gradual decrease during thefollowing year and in August, 1919, it was 217.85. At the end of 1919 theadmission rate for colored enlisted men decreased to 22.82, these troops beingprincipally of the Regular Army type. The rate for colored enlisted men in theUnited States throughout the war was 424.49 as compared with 75.84 for the white enlisted men.

COMPLICATIONS, SEQUEL?, AND CONCURRENT DISEASES

For the total Army there were among 251,899 primaryadmissions for gonococcus infection a total of 59,896 recorded complications,sequel?, and concurrent diseases. Among the more important were arthritis,epididymitis, prostatitis, lymphadenitis, and associations with other types ofvenereal disease. Among the enlisted men, there were 14,777 cases ofepididymitis, or 5.9 per cent of the total primary admissions were socomplicated. Epididymitis constituted 24.7 per cent of the total complicationsand associated conditions. Arthritis was recorded as a complication in 7,895cases, or 3.1 of the total primary admissions and 13.2 per cent of the totalcomplications and concurrent conditions.

TABLE 44.- Complications, sequel?, and concurrent diseases, among primary admissions for gonococcus infections in the United States Army April 1, 1917, to December 31, 1919

Disease	Cases	Per cent	Per cent of complications and concurrent diseases
Syphilis (all)	4,467	1.8	7.5
Chancroidal infection	4,272	1.7	7.1
Arthritis	7,895	3.1	13.2
Lymphadenitis	3,203	1.2	5.3
Prostate, diseases of	5,850	2.3	9.8
Epididymitis	14,777	5.9	24.7

Among concurrent conditions, syphilis and chancroidalinfection were the most important. Of enlisted men admitted to sick report forgonorrhea, there were 4,467 cases in which syphilis was recorded as anadditional diagnosis. That is, 1.8 per cent of the total primary admissions forgonococcus infection were associated with syphilis, and contributed 7.5 per centof the complications and concurrent diseases. Chancroidal infections werereported in about the same proportions. There were 4,272 such cases, or 1.7 percent of the total admissions to gonococcus infection. Chancroidal infectionsconstituted 7.1 per cent of the total complications and concurrent diseases.

DIAGNOSIS

The diagnosis of gonorrhea in the Army during the warinvolved physical examination and microscopic examination of stained urethralsmears and of cultures. While the majority of men having a purulent urethraldischarge are

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suffering from gonorrhea, one should not forget thatorganisms, other than gonococci, cause urethritis. The possibility of anonspecific infection in the acute stage should always be borne in mind. It isimportant that the presumptive diagnosis made on physical examination alone beconfirmed by microscopic means, since in the Army the line of duty status isdependent upon it. During the war there were 3,444 primary admissions fornonvenereal urethritis, or 0.83 per 1,000 strength. It was more common thanhydrocele, acute or chronic nephritis, and about as common as cystitis. Inproportion to gonorrheal urethritis, it occurred in the ratios of 1 nonspecificto 73 cases of gonorrheal urethritis.

In general, the practice was to look for urethral dischargeduring the regular semimonthly physical examinations and on special occasions.Cases showing discharge were sent to hospital for admission, further examinationand treatment, unless for some particular reason such patients were admitted toa venereal ward or other place of treatment with the presumptive diagnosis ofgonorrheal urethritis.

At the first examination, a note was to be made of the amountof discharge and of the condition of the glans and prepuce, the presence orabsence of chancre and chancroid, and the testicles were to be examined for abeginning epididymitis. Then the two-glass test was to be given for the purposeof determining, first, if the posterior urethra was affected and, second, theamount of pus passed.

The following description is of the two-glass test andmicroscopic examination of the pus as extensively used during the war inpermanent hospitals, segregation camps, and venereal clinics:⁶

The urine passed during gonorrhea appears turbid fromadmixture with pus, and in it are little clumps or masses of desquamatedepithelium. After standing, the pus settles to the bottom of the glass and acloud of mucus appears floating above it. As the patient goes on towardrecovery, the pus disappears, but the hypersecretion of mucus continues andoccasions a cloudiness of the urine, giving it a mucilaginous appearance. Afterthe mucus disappears, the "clap-shreds" persist for months, becauseisolated portions of mucous membrane are not covered with epithelium and arestill secreting pus.

In the two-glass test, if the anterior urethra alone isaffected, the first glass of urine will be cloudy and the second glass clear;but if the posterior urethra is involved both glasses will be turbid from thepresence of pus. This is accounted for by the action of the "cut-off"muscle which forms a barrier between the anterior and posterior urethra. Itprevents pus in the anterior urethra from flowing back into the bladder; so thatin anterior urethritis alone the pus in front of the cut-off muscle is washedout in the first flow of urine, while the last of the urine will flow over aclean surface and remain clear; that is, the first glass will be turbid, thesecond clear. On the other hand, in posterior urethritis, the cut-off muscleholds back the pus, as it does the urine in the bladder, and the pus flowsback into the bladder and renders all the urine turbid. When the urine inposterior urethritis is passed into two glasses, the second glass is turbid aswell as the first. If it is desired to determine the condition of the anteriorurethra in posterior urethritis, it can readily be done by irrigating theanterior urethra with saline solution and collecting the washings in a glass forinspection.

Microscopic examination of pus.-Microscopicexaminations of pus are indispensable, not merely for the establishment of thediagnosis, but also for the observation of the progress and stage of thedisease, for the selection of the appropriate treatment for the differentstages, and finally for the purpose of determining whether the gonococci havebeen eliminated and the patient cured.

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The gonococcus.-The gonococcus is coffee bean orkidney shaped, and usually found in diplococcus form, the flat or slightlyindented side of the organisms facing each other. In pus from acute gonorrheaorganisms are found both within and without the cells, crowded in masses in theleukocytes. The intracellular location of the organisms is of diagnosticimportance, but is not so characteristically seen in pus from chronic cases.

The gonococcus is easily stained with methylene blue orwith most of the other anilin dyes. It is a Gram-negative organism, and for thepurpose of differentiation from other diplococci a Gram stain is necessary. Itis quickly decolorized by Gram's method and can then be counterstained withsafranin or other stain. The Gram stain does not furnish an absolutelycharacteristic differentiation of the gonococcus from all similar cocci, but inpus from the urethra or vagina, or from the eye in cases of acuteconjunctivitis, it may be accepted as a reliable test.

For the absolute differentiation of the gonococcus, culturalmethods are necessary.

In the prodromal stage when the discharge from the meatus isthin and scanty, microscopic examination of smears shows quantities ofdesquamated cylindric epithelial cells and a moderate number of pus cellscontaining clumps of intracellular gonococci. In the ascending stage a largenumber of pus cells, many of them containing gonococci, and a number of freegonococci are to be seen. The stage of decline is indicated by the appearance ofsquamous epithelial cells, showing that the erosions have begun to cicatrizeand have become covered with newly formed epithelium. Clumps of gonococci arealso present, adhering to the epithelium. The pus cells have diminished innumbers and a smaller number of them contain gonococci. As the disease continuesto improve, pus cells amid gonococci disappear, and finally the discharge fromthe meatus is found to be composed only of squamous epithelium, mucus, and anoccasional pus cell, without gonococci.

The diagnosis of gonorrheal arthritis was made upon thefollowing symptoms and signs: The presence of, or a very recent history of,gonorrhea, pain and swelling (effusion) of a joint, commonly unilateral and alarge joint of a lower extremity; fever; chronicity, and poor response totreatment. Paracentesis of the joint was used, but the extent can not be stated.

Gonorrheal ophthalmia had as its basis for diagnosis an acutepurulent conjunctivitis in which the gonococcus was demonstrated; and in the fewclinical records available for examination these patients also had acutegonorrheal urethritis.

Nothing new was developed during the war in the diagnosis ofgonorrheal prostatitis, seminal vesiculitis, cowperitis, epididymitis, and othercommon complications of gonorrhea.

Complement fixation in the diagnosis of gonococcus infectionswas performed sparingly in the laboratories of the base hospitals, generalhospitals, and other permanent or semipermanent institutions. It was not aroutine procedure, but was considered of value when positive results wereobtained. In like manner, cultural methods were reserved for special cases.While necessary for the absolute differentiation of the gonococcus, thesemethods are slow, time consuming, and were considered not necessary in the usualcase of purulent urethritis, especially when a Gram-negative intracellularcoccus had been demonstrated.

PROGNOSIS

The gonococcus is not a great destroyer of life. From theArmy's point of view, prognosis is measured by deaths and discharges of menfrom the service, and by the days lost from duty for men temporarilyincapacitated. Among 251,899 admissions for gonococcus infection there were but24 deaths. A more

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detailed study of these deaths shows such concurrent diseasesas pneumonia, and epidemic meningitis, which in all probability were the actualcauses of death.

It was the policy not to discharge emergency men, who werevenereal patients, from the Army in the United States during demobilization.⁷However, due to many urgent claims for release from military service afterthe armistice began, especially in 1919, and due to the chronicity of manycases, some of which had been under treatment for a long period, it becamenecessary to make exceptions to this rule. Table 43 shows 7,027 men dischargedfrom the Army during the war for disability incident to gonococcus infection.This number constitutes 2.8 per cent of the total primary admissions forgonorrhea. They were discharged on account of complications and may or may nothave been cured of the gonococcus infection. On the whole, the duration ofAmerican participation in the World War was too brief to reveal the outcome ofcases of gonococcus infection.

Virulence of the gonococcus differs in different cases. It isat times noted that when a person has chronic gonorrhea, the gonococci, whentransplanted into the tissues of another person, are not capable of producingsuch virulent inflammatory symptoms as when taken from a fresh case. Thisattenuated virulence explains the fact that in such cases the period ofincubation is comparatively long, the purulent discharge is scanty, the casesoften become chronic, and result in prostatitis and stricture.

Another factor which influences the prognosis of gonorrhea isthe state of the patient's general health. Gonorrhea acquired by personsaffected with phthisis, or who are debilitated from any cause, is apt to run asubacute, but exceedingly protracted, course. Other causes which retard recoverymay be grouped as follows: Posterior urethritis, prostatitis, etc.; reinfectionfrom an urethral gland, seminal vesicle, prostate, etc.; lack of rest; alcoholicindulgence; too vigorous treatment, especially injections which are too strongor too frequently repeated; coitus.

As stated above, the ultimate effects of gonococcus infectioncan not be measured by experience in the Army. Though more than 97 per cent ofthe cases were returned to duty, one can not state how many cases suffered fromrelapse or acute exacerbations among men discharged from the service as cured,or what eventually happened to men with venereal disease discharged fordisability.

Analysis of the average days lost, for officers and enlistedmen, and by countries, shows a great difference when compared one country withanother. This may have been due, in part, to a difference in virulence of theorganism or difference in resistance on the part of the patient; but it isbelieved the principal difference was in the system of management. The averagenumber of days lost from duty per case was 15.4 for the total Army. It was 15.6for American officers and men and 23.5 for native troops. The average amongwhite enlisted was 17.8, and colored enlisted, 8.5. The average for totalofficers was 30 days. This difference is probably explained by the practice ofholding an officer on sick report, once taken tip for gonorrhea, untilapparently cured, while an enlisted man was generally released from hospi-

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tal or sick report as soon as the acute stage or symptoms hadsubsided and he was physically able to do duty. The soldier was restricted tothe military garrison, assigned to a convalescent camp, development battalion,or venereal detachment with his organization. In either case his name wasremoved from the sick list.

As to the difference in race, there was a much largerpercentage of colored drafted men with gonorrhea on entrance into the servicethan of white, and in both incidences the vast majority of cases had passed thevery acute stage of the disease; furthermore, the colored soldier was often veryanxious to be discharged from hospital especially when he was forfeiting his paywhile confined there. These two factors are believed to account for the shorterperiod of hospitalization for gonorrhea among colored soldiers. In the UnitedStates the average for white and colored enlisted men was 15.8 and 7.9 days,respectively; in Europe the average for white enlisted men was 30.9, andcolored, 23.8 days. The longer period in Europe, as compared with the UnitedStates, is accounted for, as above stated, by the fact that cases withcomplications were the ones usually admitted to sick report, while others wereretained with their organizations.

TREATMENT^a

ACUTE GONORRHEA

In order to aid the natural process of repair, the firstessential is rest. No other measure contributes so much to a prompt anduncomplicated recovery as rest in bed during the acute stage of gonorrhea. Thepatient, therefore, should be put to bed and kept there during the ascendingstage of from one to two weeks, or until the discharge becomes mucopurulent andthe burning on urination has disappeared.

In order to keep the urine bland and unirritating and topromote frequent urination, so as to clear the urethra from the products ofinflammation and to expel free organisms that may reinoculate new areas, thepatient in bed should receive from the wardmaster and drink one glass of waterevery hour. The diet should be bland and of a low nitrogen content; highlyseasoned and rich foods should be strictly excluded; cereals, fruit juices,toast and cream with a moderate amount of milk should make the bulk of themeals.

Alkalis and alkaline mineral waters should not be prescribed,because of their effect on the reaction of the urine. An acid reaction of theurine is the best safeguard against a cystitis from bacteria that find their wayinto the bladder. The acidity of the urine will be reduced sufficiently by thefree use of milk and the abstinence from meat. The bowels should be kept openwith aperients, and during the very acute stage a saline cathartic should beadministered every other morning.

Dressings for the purpose of catching the urethral dischargeto keep it from soiling the clothing always should be worn. Severalvarieties may be used: (a) For patients with a long foreskin, the familiargauze butterfly; (b) for patients unable to hold the butterfly, a 4-inch gauzebandage bag with a

^aBased upon "A Manual of Treatment of the Venereal Diseases, for the Use of Medical Officers of the Army". Prepared under the direction of the Surgeon General, 1917.

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little gauze in the bottom, made fresh daily or oftener, or (c)a loose bag, made by cutting off the foot of a stocking, into the bottom ofwhich gauze can be placed to catch the pus. The bags are to be suspended from awaist band. The loose bags permit and encourage a free flow of pus from theurethra, while they prevent retention. Constriction of the penis by dressingswrapped around it should carefully be avoided so as to insure no interferencewith the return circulation. A suspensory bandage should be worn when thepatient is allowed to get up in order to relieve the sensation of dragging onthe spermatic cord and to lessen perhaps the danger of epididymitis.

Oil of sandalwood is soothing and curative to the mucousmembrane; it may be given during the acute stages, but will have little effectowing to dilution from the drinking of large quantities of water. Sandalwood oilshould be administered in capsules in doses of from 0.5 to 1 c.c. three times aday after food. It sometimes disagrees with the digestion, or it may cause anintense pain in the back; when such symptoms occur, it should be discontinued.No copaiba or cubebs should be given in acute gonorrhea; they are serviceableonly in the declining stages.

SEVERE ACUTE URETHRITIS

In very severe urethritis with intense reaction, profusedischarge, and great swelling and edema, it is good judgment to wait for somesubsidence of the symptoms before beginning injections. In the meantime theparts should be kept clean; the penis held in hot water for 15 minutes at a timeevery few hours, and hot sitz baths given every three or four hours to relievedistress. If sitz baths are unobtainable, hot fomentations may be substituted.If pain on urination is very distressing, it may be relieved by an injection,five minutes before urination, of 1 cc. of 1 per cent solution of cocainhydrochlorate or procain. Sandalwood oil diminishes the pain on urination inmost cases, so that the use of a local anesthetic is not often necessary.

Local treatment -In the ascending stage of acuteurethritis and in other acute cases, which do not reach the intensity suggestedin the preceding paragraphs, local treatment by injection may begin at once.

In selecting the drug used for injection, it is necessary tobear in mind the indications for its use, which may be thus formulated: 1. Todestroy the gonococci in all foci within reach as early and completely aspossible. 2. In doing so, to avoid irritation of the mucous membranes, anyexacerbation of the existing inflammation, and everything that has a causticaction on the tissues and all unnecessary pain.

These indications are very well met by the silver proteincompounds of the argyrol and protargol type. The syringe should be all glass, of5 c.c. capacity, with a smooth acorn tip. For injection, solutions in water areused of the following strengths: Argyrol, from 3 to 5 per cent; protargol, from0.25 to 1 per cent. Before injecting, the urine should be passed so as to washout the pus accumulated in the urethral canal. In making injections the tip ofthe syringe should be firmly pressed into the meatus, and the penis should beheld under moderate tension. The solution should be injected with the utmostgentleness. It should be held in the urethra for at least five minutes. If

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injections produce distress, their strength should bereduced. Injections should not be given frequently enough nor sufficientlyconcentrated to cause any irritation of the mucous membrane; an injection whichis too often repeated or is too concentrated prolongs the course of the case. Inpractice it is found that once in two hours is sufficiently often to destroy thegonococci without damaging the inflamed mucous membrane, provided the injectionis carefully given and the solution is not too strong.

SUBACUTE ANTERIOR URETHRITIS

After from 10 days to 3 weeks in those cases that run afavorable course under the treatment with silver proteinates, the acute symptomsdisappear. The discharge becomes watery and scant; microscopic examinationreveals many newly formed desquamated epithelial cells and few or no gonococci;the urine in the first glass becomes clear or slightly turbid, although itcontains many long mucous filaments. If treatment is now discontinued, relapsewith extensive reinfection is certain to occur in from two to three weeks fromthe few gonococci left in the tissues. When the gonorrhea has reached thissubacute stage, the task remains of curing the existing postgonorrheal lesions,which consist of a catarrhal inflammation of the mucous membrane, erosions,periglandular infiltrations, and infiltrations of the submucous tissues. Sincethe silver proteinates only destroy the gonococci and have little effect on theinflammatory processes, it is necessary at this time to treat the existingcatarrh of the mucous membrane with astringent remedies. At this point in theprogress of the disease it is highly desirable to substitute copious irrigationsof the urethra for the hand injections.

Irrigations -The solution best adapted for the doublepurpose of destroying the few remaining gonococci and of acting as an astringentto cure the superficial postgonorrheal lesions of the mucous membrane is silvernitrate in strengths of from 1:3,000 to 1:5,000 of distilled water. Irrigationwith silver nitrate solution acts particularly well in the presence of a clearurine containing shreds of pus or mucous. It may be used every day or everyother day. Potassium permanganate in water solution of the strengths of from 1:3,000 to 1:5,000 is also useful for irrigations. It is especially called forwhen there is a free purulent discharge containing no organisms. A purulentdischarge that arises from the presence of a nongonococcic bacterial urethritisyields to irrigation with mercuric oxycyanide in solution in water in strengthsof from 1:3,000 to 1:5,000. This should never be used if the patient is takingiodide or iodine in any form. The irrigations should be given at temperatures offrom 110? to 115? F.-as hot as can comfortably be borne-and may be repeatedas often as four times in 24 hours.

Technique -The patient should sit well forward on thechair, resting his shoulders against its back, or he may stand. He should hold asmall basin to catch the overflow of the irrigation. The irrigator tip ispressed against the meatus and the anterior urethra distended with fluid. Thenby a short release of pressure of the tip a return flow is allowed. This isrepeated until thorough irrigation of the anterior urethra has been obtained. Ifit is desired to irrigate the posterior urethra, the anterior urethra shouldfirst be washed out. Then

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the tip should be firmly pressed against the meatus and theanterior urethra dilated with fluid. The patient is then instructed to take along breath and to try to urinate; this releases the cut-off muscle and theirrigating fluid flows into the bladder. The bladder is allowed to fill withfluid, but should not be distended beyond the point of comfort. After thebladder is filled, the patient empties it by urination. Should difficulty beexperienced in irrigating the posterior urethra from the meatus, a soft rubbercatheter may be introduced through the cut-off muscle into the posterior urethraand the bladder filled through the catheter. The patient then urinates after thecatheter is removed.

Under the irrigation treatment the urethral discharge ceases,and the shreds disappear from the urine, but before the patient is declaredcured the condition of the prostate and vesicles must be investigated and theurethra must be found to be free from stricture.

It should be borne in mind that it is possible to treat agonorrhea too long, and to cause the discharge to persist by the simpleirritation of injections. In such cases, there will be a secretion free fromgonococci which on squeezing will appear at the meatus as a small, transparent,glycerin-like drop, and which will cause sticking together of the meatus in themorning. In cases manifesting this condition, it is advisable to stop treatmentand to allow the irritation to subside. In consequence, the mucous dischargewill often disappear spontaneously.

ACUTE POSTERIOR URETHRITIS

Severe posterior urethritis demands complete rest in bed andmeasures directed to the relief of the distressing symptoms. All local treatmentof the urethra should be suspended. The nearer the diet approaches to a liquidor milk diet, the better. Abundant water should be taken, but diuretics shouldnot be used, because they cause the too frequent evacuation of an alreadyovertaxed bladder. Saline cathartics should be given every other day to reducecongestion in the pelvis. For the relief of tenesmus and pain, hot sitz baths ofhalf an hour's duration, repeated several times a day, are useful. Alkalies,which favor the growth of bacteria in the bladder by rendering the urinealkaline, are contraindicated, as they are in acute urethritis. Sandalwood oilis not only curative, but soothing and gives relief in many cases. In the severecases morphine should be given to relieve tenesmus and desire to urinate. It isbest to give it in these cases in rectal suppositories.

As a rule, the acute stage of posterior urethritis disappearspromptly, and the cases pass into the condition of mild posterior urethritis,and then should be treated as such.

SUBACUTE POSTERIOR URETHRITIS

In subacute posterior urethritis, treatment is given onprinciples similar to those applicable to subacute anterior urethritis.Solutions are applied to the surface, either by the injection of smallquantities of concentrated solutions or by irrigations of copious quantities ofdilute solutions.

In the first method, a small soft rubber catheter isintroduced just beyond the cut-off muscle, and by means of a small urethralsyringe about 10 drops of 1:500 to 1:100 solution of silver nitrate areintroduced into the posterior

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urethra. This is to be repeated at intervals of one or twodays according to the tolerance of the case. In order to prevent immediateprecipitation of the silver by the urine, the injection should be made with thebladder empty.

Urethrovesical irrigations by the gravity method areparticularly applicable to the treatment of posterior urethritis. They are giventhrough a gravity irrigator elevated 5 to 6 feet above the penis, according tothe technique already described for irrigation. For posterior irrigations, protargol or similar silver protein preparation in the strength of from 1:1,000 to1:250, or silver nitrate from 1:10,000 to 1:4,000, are used. Less effective, butstill useful in some cases, is potassium permanganate, 1:3,000.

As a rule, posterior urethritis extends to the prostate andseminal vesicles, and persistence depends on reinfection from these structures.In every case these structures should be examined and, if necessary, treated.

COMPLICATIONS OF ACUTE GONORRHEA

FOLLICULITIS

The treatment of folliculitis consists in opening the abscessfreely as soon as fluctuation is noticed, evacuating the pus, and allowing it toheal by granulation. It should be opened through a urethroscope from within theurethra, when this is practicable. If incision is done promptly, the occurrenceof a persistent urethral fistula is prevented.

CHORDEE

The patient subject to chordee should empty his bladder justbefore going to bed; should sleep in a cool place, lightly covered; and, toavoid sleeping on his back, should tie a towel around his waist with a knot atthe back. Before going to bed the penis should be given a prolonged immersion inhot water. When the patient wakes with chordee, he should get out of bed andimmerse penis and testicles in cold or hot water, and before going back to bedshould empty the bladder. He should be warned of the danger of"breaking" a chordee. In severe cases sedatives are necessary;potassium bromide, 2.0 gm., or camphor monobromate, 0.3 gm., in the afternoonand before going to bed, are useful; in extreme cases a morphine rectalsuppository may be necessary.

EPIDIDYMITIS

Immediately on the development of epididymitis all injectionsor instrumentation of the urethra must be stopped, the patient be confined tobed, and put on a light diet. The testicles should be elevated by a bandagegoing under them and over the thighs, and hot applications should be made. Hotsitz baths for half an hour three times daily are soothing and hasten recovery.If the symptoms are severe, epididymotomy may be performed. This immediatelyrelieves pain and hastens recovery.

In a few days the acute stage passes. The urethral dischargeis then likely to recur, but local treatment of the urethra must be resumed onlyafter a considerable period of rest and with the greatest caution. A suspensorybandage should be worn until the patient is entirely well. There is in many ofthese cases a chronic inflammatory exudate in the epididymis, which in timeoften disappears. Massage of it may hasten its absorption.

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ACUTE PROSTATITIS

In acute prostatitis the indications are (1) to lessen theseverity of the posterior urethritis; (2) to prevent suppuration of theprostate; (3) if pus forms, to evacuate it promptly by incision.

The patient should be put to bed, sandalwood oiladministered, and, if necessary, the pain and tenesmus controlled by opiumsuppositories. Locally either ice bags or hot poultices are applied to theperineum, a safe guide for the choice between hot and cold applications beingthe amount of comfort which is given to the patient. Hot sitz baths of fromone-half hour to an hour's duration two or three times daily are alwaysindicated. Irrigation of the rectum with hot water for half an hour at a timemay be used instead. A rectal prostatic irrigator, or, in its absence, a returnflow catheter, is introduced into the rectum, and a continuous flow of water ashot as can be borne, is passed through it.

If retention of urine should occur, it may be necessary tointroduce a catheter, but this should be done only when absolutely necessary.Before catheterizing, the urethra should be well irrigated to free it from pus.One c. c. of 2 per cent cocaine solution may be injected into the urethra torelieve pain and facilitate catheterization.

Prostatic abscess -When a very limited area ofsuppuration of the prostate is present, involving perhaps two or three of theprostatic tubules, the temperature is only slightly elevated, and the localsymptoms are not marked. After two or three days the temperature becomes normaland the tenesmus and frequent urination disappear. In such cases an incisioninto the prostate is not required, for the minute abscess generally rupturesinto the urethra and the sinus fills in by granulation.

If, on the contrary, the symptoms do not improve within thefirst week, but the fever continues and chills occur, the local symptoms growworse, and rectal examination shows an increase in the size of the inflamedprostate, it is evidence that an abscess is forming. These symptoms constitutean urgent indication to evacuate the pus; for if the pus is allowed to breakthrough the capsule of the prostate, it will burrow through the tissues and maycause urinary infiltration and pyemia, or, at least, a fistula which will notheal without operation. In these cases immediate surgical measures areindicated. Two operations may be used to evacuate the pus: 1. The prostate maybe exposed by a transverse incision in the perineum, and the collection of pusevacuated without opening the urethra. 2. An incision may be made in theperineal urethra, the mucous membrane of the prostatic urethra broken throughwith the finger, and the pus collection evacuated through the opening thus made.

ACUTE SEMINAL VESICULITIS

The general treatment of acute vesiculitis is the same asthat for acute prostatitis, with which it is usually associated. Injections intothe interior urethra, of course, are contraindicated; but above all things, anyattempt at massaging or stripping the vesicles should be avoided.

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CHRONIC GONORRHEA

CHRONIC ANTERIOR URETHRITIS

Based on the pathologic changes in the tissues, theindications for treatment are: (a) To rid the tissues of gonococci; (b)to cure the catarrhal inflammation in the mucous membrane and promote theformation of squamous epithelium to cover the erosions; (c) to causeabsorption of the submucous infiltration; (d) to restore to normal theintraglandular and periglandular inflamed and infiltrated tissues. Theseindications can be met by irrigations with antiseptic and astringent solutionsand by dilatations of the urethra with sounds and soft bougies.

When general catarrh of the mucous membrane is present andturbidity of glass 1 exists, free irrigation of the urethra and bladder by thegravity method, daily or every second day, using silver nitrate or potassiumpermanganate, soon clears up the diffuse inflammation in the mucous membrane,until the process is no longer general, but is reduced to isolated spots. Thiscondition is denoted by glass 1 being no longer turbid; it does, however, stillcontain the shreds derived from isolated erosions which are not covered byepithelial cells and are still secreting pus, or from the prostatic ducts andMorgagni's crypts. Comma-shaped shreds which are often present are formed bythe secretion from the open mouths of the prostate ducts and Morgagni'scrypts. Gonorrheal shreds floating in clear urine continue until the submucousinfiltrations resolve and the pathologic secretion of the prostate and cryptsdisappears.

In order to promote the absorption of the submucousinfiltration it is necessary to pass steel sounds large enough to distend theurethra fully and put the ring of infiltration on the stretch. Meatotomy may benecessary in order to pass sounds of sufficient size.

The therapeutic effects of the sound can be materiallyincreased by massaging the urethra over it with the fingers. The contents ofMorgagni's crypts can in this way be expressed, and more favorable influenceis exerted on the ring of infiltration in the submucous tissues.

Sounds may be passed too frequently. In cases of soft andrecent infiltration, the intervals should be from four to seven days, alwayswaiting until the reaction following has subsided. In cases of hard, organizedinfiltration the intervals should be a week. If the urethra is acutely inflamedand freely secreting pus, instrumentation is, of course, out of the question.Dilatations should not be started until the urine is clear and contains onlyshreds.

It makes no difference, as far as treatment is concerned,whether the submucous round cell infiltration is soft and recent or whether ithas been transformed into scar tissue; the indications in either case are topromote its absorption by dilatation and pressure. Cases in which a considerablesurface of mucous membrane is involved are unsuitable for dilatation until thecatarrh has been checked by irrigations and the superficial process has beenlocalized in a few spots in the urethra, as denoted by shreds floating in clearurine.

GLANDULAR URETHRITIS

Many intractable cases of gonorrhea lasting for years inspite of constant treatment are caused by a chronic inflammation of Morgagni'scrypts. Such cases show few symptoms, the morning drop at the meatus being themost

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constant. But they are characterized by exacerbations of thedischarge after slight provocation, with a free discharge of pus containinggonococci, which leads the patient to believe that he has acquired a freshinfection. Urethroscopic examination shows the mouths of a few of the crypts tobe open and pouting, with red and slightly elevated edges. In other cases themouths of the crypts are occluded by a growth of epithelium. When the crypts areaffected the gonococci may remain in them for years and the case remaininfectious.

These cases should be treated by dilatations with full-sizedsounds followed by irrigations. When the mouths of the glands are occluded bythe growth of epithelium, dilatation of the urethra opens them and forces outthe purulent secretion. The irrigating fluid enters the cavities and acts on thechronic inflammatory processes within the glands. In that form of inflammationin which the mouths of the glands are held open and the entire crypt isstiffened and inelastic from the periglandular infiltration, dilatations causethe absorption of the infiltrate around the glands and promote a return tonormal condition.

When, after sufficient treatment by dilatations andirrigations, it is found by urethroscopic examination that a few glands stillremain chronically inflamed and suppurating, and are thus foci of infection,these should be destroyed. This can be accomplished by bringing them into viewwith the urethroscope, and introducing a galvanocaustic needle. Thecauterization must be very superficial and rapid; otherwise there will be dangerof stricture formation. Not more than three or four crypts may be destroyed at asitting. It is possible by destroying the glands harboring the gonococci tocure in this way a chronic gonorrhea of years' standing which has resisted allthe other usual forms of treatment.

CHRONIC POSTERIOR URETHRITIS

In the presence of free pus formation urethrovesicalirrigations by the gravity method with a solution of silver nitrate from1:10,000 to 1:4,000 or potassium permanganate, 1:3,000, is the best method ofrapidly reducing the purulent discharge. After the urethra becomes clear, theprostrate and vesicles should be examined, and if found to be diseased must bemassaged in connection with the irrigation. When the urethroscope shows theinfiltrated changes localized to the colliculus, direct applications of from 10to 20 per cent silver nitrate solution should be made once a week through theendoscope. Granulations in the posterior urethra should be treated bycauterizing with strong silver nitrate solution. Small polypi, or granulationson the colliculus may be removed by scissors, forceps, or a galvanocausticpoint. If the utricle is infected it should be injected with silver nitratesolution with a small syringe.

Chronic prostatitis -In almost every case of chronicgonorrheal urethritis the prostate is involved. Chronic prostatitis usuallyoriginates in an attack of acute prostatitis, but it may result from a slow,insidious extension through the prostatic ducts of an infection from theposterior urethra. Aside from its frequency, chronic prostatitis is perhaps themost important complication of gonorrhea, for the reason that the gonococcus,with all its infectious qualities unimpaired, may be retained for years in thediseased tubular glands of the prostate without its presence being suspected.Probably most of the cases in

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which wives are infected with gonorrhea by their husbandscome from uncured prostatitis. Chronic prostatitis is also important on accountof the profound disturbance of the nervous system and the impairment of thesexual function, which it occasionally produces.

The first indication in the treatment of chronic prostatitisis to improve the general condition of the patient by a proper regimen.Constipation is generally a prominent symptom, which is best treated with salinecathartics, because they have some effect in relieving pelvic congestion. Allsorts of erotic excitement should be interdicted on account of their effect ininducing congestion of the prostate. Coitus should not be permitted, bothbecause of its ill effect on the diseased prostate and because of the certaintyof spreading the infection.

The most effective local measure is the emptying of theprostatic tubules of their retained and thickened contents by rectal massage twoor three times weekly. In this procedure both lobes should be massaged fromabove downward and the manipulation should not be very vigorous, the objectbeing to force out the prostatic contents by moderate pressure. Massage of theprostate is not well borne by all patients; and, if it produces irritatingsymptoms, it should not be persisted in. In order to lessen the danger ofepididymitis from prostatic massage, it is advisable to irrigate the urethra andfill the bladder before massage with a solution of silver nitrate from 1: 10,000to 1:4,000 or potassium permanganate 1:3,000.

Treatment by massage and irrigation should be persisted infor from six to eight weeks, or until a microscopic examination of the expressedprostatic secretion shows only a small number of pus cells in the field. Manycases will be found to improve under massage up to a certain point and thenremain stationary. In such instances it is advisable to stop treatment for amonth. If after this intermission the remaining evidences of prostatitis havenot disappeared, another course of massage may be given. Such treatment shouldbe repeated until the pus cells in the expressed prostatic secretion are foundon microscopic examination to be only from four to six in a field, and lecithinbodies are abundant.

While treating chronic prostatitis, it is important not tooverlook the chronic posterior urethritis which nearly always accompanies it.This should be treated by irrigation, dilatation, and other measures, as alreadydescribed.

Chronic seminal vesiculitis -The treatment consists inmassaging and expressing the contents of the vesicles twice a week. Massagingempties the vesicles of their inspissated contents, without forcing the muscularfibers to contract; and, by the relief of distention and the rest thus affordedthem, the muscles recover their tone.

Contraindications to massaging are: (a) The existenceof acute vesiculitis; (b) blood in the expressed material, or (c) excessivetenderness. With these conditions present, there is always danger of setting upan epididymitis.

In chronic vesiculitis the posterior urethra should not beoverlooked, but should receive treatment, with irrigations or instillations orby applications made through the urethroscope as outlined under chronicposterior urethritis. It is desirable not to apply local treatment to theposterior urethra and massage the vesicles at the same sitting, but rather toallow a couple of days to intervene.

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The duration of treatment must be protracted, for it requiresfrom 2 to 12 months to effect a cure. In obstinate cases characterized by markedsexual neurasthenia or intractable gonorrheal rheumatism, free incision into anddrainage of the seminal vesicles may be demanded. This is a procedure requiringexpert skill.

CHANCROIDAL INFECTION

Chancroidal infection, more than gonorrhea or syphilis, is adisease of the careless and uncleanly, relatively uncommon among clean people,and readily prevented.⁶It was the least common of the venerealdiseases in the Army during the war, contributing about 11 per cent.

Being an acute disease and without any known carrier state orcommon chronic complications, chancroid infection played a comparativelyunimportant r?le among men entering the service; there were 3,714 cases amongthe first and second million drafted men examined. (See Table 42.) Of these, 120were discharged as physically unfit for service by the local examining boards,and 233 by the camp examining boards.⁸Therefore, and incontradistinction to syphilis and gonorrhea, the great majority of cases wereacquired by men while in the service. The ratio of chancroid to syphilis andgonococcus infection was 1 to 2 to 6.

There were 39,044 primary admissions for chancroid, with anadmission rate of 9.46 per 1,000 per annum. Of these cases, 105 were dischargedfrom the service on account of disability; loss of time from duty amounted to973,614 days, with a noneffective rate of 0.65 per 1,000 strength. As might bepresumed, chancroid was relatively uncommon among officers, more common amongwhite enlisted men, and with greatest frequency among native and coloredenlisted men. There were 374 primary admissions for officers (1.81), 26,819among white enlisted (7.45), 271 for native (7.52) and 9,937 among coloredenlisted men, with the very high rate of 34.68 per 1,000 strength. More than 60per cent of the discharges following chancroidal infection in the total Armywere among colored enlisted men.

Although not as disabling to the fighting strength of theArmy as either syphilis or gonorrhea, chancroidal infection caused considerablenoneffectiveness. The ratio per 1,000 strength was 0.65 and the average numberof days lost from duty per case was 24.9 as compared with 28.7 for syphilis and15.4 for gonorrhea. The difference in time lost per case was approximately thesame between officers (24.5), white (25.7) and colored (25.3) enlisted men. Theaverage number of days lost among native troops was 23.4. Although the averagenumber of days lost among the enlisted men, white and colored, was about thesame, the noneffective rate was about five times greater for colored enlistedmen.

DIAGNOSIS

The practical diagnosis of chancroidal infection is basedupon the period of incubation and the clinical appearance of the ulcer.Autoinoculation, and cultural and microscopic examinations for the Ducreybacillus, have been used but without encouraging results for routine practice.These methods were known before the war and nothing new and of special valuedeveloped during that time. In view of the vital importance of differentialdiagnosis between

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chancroid and syphilis, and the great importance ofdiagnosing syphilis as coexisting with chancroid, much stress during the war wasplaced on the early and thorough examination of all venereal ulcers to determinewhether or not syphilis was present.⁷

Where sores were concealed it was recommended that thenecessary incision, either dorsal or bilateral be made, in order that the lesionmight be exposed for diagnostic and therapeutic purposes. Moore⁹madea special report on the diagnosis of chancroid, and the effect of prophylaxisupon its incidence in the American Expeditionary Forces. During the 12 monthsending March, 1919, there was afforded opportunity to see over 4,000 venerealcases, among which more than 800 were venereal ulcers. In a selected 10-monthperiod, ending in February, 693 venereal ulcers were encountered. The originaldiagnosis, based on the clinical appearance of the sore and dark-fieldexamination, was chancroid in 379 instances, or 54.5 per cent, and primarysyphilis in 314, or 45.5 per cent. In order to obviate the possibility ofunrecognized syphilis, an effort was made to follow each chancroid case for atleast eight weeks, but, owing to military exigencies, this was possible in only135 cases. Every sore was suspected as being syphilis until proven otherwise,and it was an unalterable rule that dark-field examination should be carried outon every sore for three consecutive days before search for the spirochete wasabandoned. Moore declared that while it had been conclusively demonstrated thatthe bacillus of Ducrey is the cause of chancroid, it is exceedingly hard tofind. In 81 cases, clinically chancroid, in which smears were made, the Ducreybacillus was demonstrated 20 times; while in 61 cases the smears were negative.Cultures on serum blood agar were made 55 times and were positive in only 5instances, proving that these methods of microscopic and cultural diagnosis arenot to be relied upon. A Wassermann test was made when the patient was firstseen, once a week thereafter for the first 8 weeks, and at the middle and end ofthe third month. All of the 135 cases were followed for more than 8 weeks, 97 ofthem for more than 12 weeks.

Autoinoculation proved to be of very little value for tworeasons, according to Moore:⁹ First, because of the difficulty of controllingambulatory patients, who frequently developed large spreading ulcers at the siteof inoculation, which were very difficult to heal, and, second, becauseso-called positive reactions (positive in 24 to 48 hours) can be obtained fromsecondarily infected ulcers in which the spirochete can be demonstrated. A fewexperiments were conducted by Moore in Paris. Five men were selected withclinically typical chancroid, and from the sores three inoculations, about 2inches apart, were made on the left arm. The top inoculation was left as acontrol; the middle one was treated at various intervals after inoculation,ranging from 10 minutes to 2 hours, with calomel ointment well rubbed in forexactly five minutes. The bottom inoculation was treated with tincture of greensoap and warm water at the same intervals and with thorough use for fiveminutes. In all cases, the controls were positive, as was the inoculationtreated with calomel ointment, while the lesion treated with soap and water wasuniformly negative. Therefore, it may be stated that the history of incubation,clinical appearance of the sore, and examinations to determine the presence ofthe Ducrey bacillus

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are no more than suggestive in ruling out primary syphilis.All venereal ulcers should be repeatedly examined by dark-field illuminationbefore local application of antiseptics or the cautery; all patients withchancroid infections should be subjected to frequently repeated Wassermann testsfor several months, to prove the presence or absence of syphilis.

COMPLICATIONS, SEQUEL?, AND CONCURRENT DISEASES

There were 39,044 primary admissions for chancroidalinfection and 7,679 cases reported as concurrent with other diseases, making atotal of 46,723 cases for the total Army during the war. The most common andmore important concurrent diseases were syphilis and gonorrhea. Chancroid wasassociated with syphilis in 3,687 cases, or 8.8 per cent. Gonorrhea was morecommonly so associated; there were 5,221 cases in which gonorrhea and chancroidcoexisted, or 11.11 per cent.

PROGNOSIS

The prognosis of chancroidal infection in the Army, as torecovery, was good. Among 39,044 cases of chancroid, 105 were discharged fromthe service on account of permanent disability, though it is very probable thatcauses other than chancroid were contributory in many of these. Among theprimary admissions there were 4,811 complications and concurrent diseases, withone death; therefore it can be said that chancroidal infection did not increasethe liability to death. Recovery was complete in all cases, with the possibleexception of scars at the site of infection or operation. As to duration of theillness, but few diseases showed such a consistent general average amongofficers and enlisted men.

TREATMENT^a

GENERAL TREATMENT

In order to hasten recovery, the patient with chancroidshould be put to bed, kept clean, and given a nourishing diet. Rest not onlymakes for a prompt healing of the chancroid, but greatly reduces the danger ofbubo. Destructive chancroids are seen in the dirty and debilitated. If patientswith chancroids are kept clean and well nourished, healing is usually prompt,and extensive ulceration very rarely seen.

LOCAL TREATMENT

Abortive treatment.-In a certain proportion of cases ofchancroid, abortive treatment is successful. The principle of all methods ofabortive treatment is to convert the infected ulcer into a sterile one by theuse of some destructive agent. This may be either the actual cautery, or one ofseveral strong chemical caustics.

The thermocautery is doubtless the best agent for thistreatment. Its application is as follows: The ulcer is thoroughly cleaned andwell dried; then the entire area of it is seared with a cherry red cautery.Every particle of diseased tissue must be destroyed. It should be done under ageneral anesthetic, preferably gas.

^aBased upon A Manual of Treatment of the Venereal Diseases, for the Use of Medical Officers of the Army. Prepared underthe direction of the Surgeon General, 1917.

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Chemical cauterization is done as follows: The ulcer is wellcleaned, being first irrigated and then dried. Then a pledget of cotton wet with5 to 10 per cent solution of cocain hydrochlorate or procain is applied to it.After anesthesia is produced the ulcer is dried as thoroughly as possible,preferably with blotting paper, in order to prevent the running of the chemicalssubsequently to be applied. After it has been thoroughly dried, the entiresurface of the ulcer, both edges and base, is touched with pure liquid phenol(carbolic acid) applied on a small cotton swab, care being taken to let noinfected point escape. Then the excess of phenol on the surface is taken up, andnitric acid is applied lightly in the same way. The ulcer should be flushedimmediately with sterile water to stop the action of the acid. Instead of nitricacid a saturated solution of zinc chloride can be used. This is as active acaustic as nitric acid, and its action should be stopped as quickly afterapplication by flushing with water.

After cauterization in any of these ways the wound should bedressed with cold compresses of boric-acid solution or similar bland solution.There results an acute inflammatory reaction, the slough is thrown off, and insuccessful cases a healthy granulating surface is left.

The advantage of these methods of treatment is that, insuccessful cases, healing takes place quickly and the danger of bubo is almosteliminated. Their success depends on thoroughness in destroying the infectedarea. If the procedure fails to do this completely, harm results, because itproduces a larger ulcer, which becomes infected from the focus of disease thathas been left. Attempts at abortive treatment with superficial caustics, such assilver nitrate, are always failures. Attempts at abortive treatment should notbe made unless the prospects of complete destruction of the diseased tissue aregood.

Abortive treatment is contraindicated under the followingconditions: (1) When the diseased area or areas are so extensive or sosituated that the destruction produced by this treatment would result inconsiderable deformity. The chief situation in which it is contraindicated isin chancroid at the meatus. (2) When the inflammatory reaction is already intense andthere is much edema. These would be increased by cauterization. (3) When thereis inguinal adenitis. This would be aggravated by cauterization. (4) In healingchancroids. Here the infection is already under control and nothing would begained by cauterization.

Abortive treatment will, of course, interfere with anyfurther search for spirochetes. For this reason it should never be undertakenuntil every reasonable effort to find the spirochetes has been made. The earlydiagnosis of syphilis is so much more important than the prompt healing of achancroid that efforts to heal the chancroid should be given no considerationuntil the question of diagnosis is settled as far as possible. And aftersuccessful abortive treatment there should be no relaxation in the weeklyWassermann tests or in the clinical observations until syphilis can be finallyruled out.

In all cases, except those favorable for abortive treatment,reliance is placed on cleanliness, the use of antiseptics, and measures topromote healing. The first principle in treating chancroids is to keep them asfree as possible from pus, both to promote healing of the ulcer and to preventinfection of the

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lymphatics. In all cases, for the effect of the heat as muchas for cleaning effect, the patient should hold the penis in hot water for halfan hour several times daily. Then the lesion should be given a copious warmirrigation with boric acid solution or mercuric chloride, 1:10,000, orpotassium permanganate, 1:3,000, or some other nonirritating antisepticsolution. Then the ulcer should be dusted with an antiseptic, such as iodoform(the preferable antiseptic), thymol iodide, calomel, or argyrol. After thisthere should be applied a moist dressing of one of the solutions which are usedfor irrigating the ulcer. In very acute cases a good dressing is one wet withaluminum acetate solution, 1 part of the 8 per cent solution of aluminum acetateto 7 or 15 of water. The dressings must be kept continually moist and changedfrequently enough to prevent accumulation of pus on the ulcer.

When for any reason it is impracticable to keep a wetdressing constantly applied, the next best course to pursue is to dust the ulcerafter irrigation with argyrol crystals or iodoform and then cover it with gauzesspread with petrolatum. Dry powders alone are not good applications forchancroids. They cake into crusts, under which the pus accumulates, and thismaterially increases the risks of infection of the lymphatics and the occurrenceof bubo.

Occasionally in the course of healing of chancroids, thegranulations become sluggish; in such cases, stimulation by the application ofbalsam of Peru works well, or the granulations may be touched occasionally withsilver nitrate. If there is an overgrowth of the unhealthy granulations, theyshould be trimmed off with a knife or razor or seared with a cautery, and thendressed with iodoform and a wet compress.

In chancroids under a greatly swollen or long, tightprepuce, wet dressings can not be used. In these cases prolonged soakings in hotwater several times daily are particularly serviceable. After each soaking thepreputial sac should be cleaned by inserting into it a catheter or a long flatsyringe nozzle and thoroughly irrigating with hot antiseptic solution. After theirrigation there should be injected into the preputial sac from 2 to 4 c. c. ofa suspension of antiseptic powder in oil or glycerine, such as 20 per centcalomel, 10 per cent thymol iodide, or 10 per cent iodoform in oil or glycerine.Of these, 10 per cent iodoform in glycerine is best.

In patients with a long prepuce it is best not to make adorsal slit, if progress can be made without so doing for if a dorsal slit ismade, the whole surface at once becomes chancroidal. Not infrequently in caseswith intense reaction and great swelling no headway can be made while theprepuce is intact; in other cases the reaction becomes so exaggerated that,unless relief of tension is given, sloughing of the prepuce will occur. Underthese conditions a linear slit along the dorsum of the prepuce should be made,and the case then treated as an open chancroid. A complete circumcision shouldnever be attempted until the infection has entirely disappeared.

SUPPURATIVE INGUINAL ADENITIS

Under the usual conditions of treatment of chancroids, whenpatients are not in bed, suppurative inguinal adenitis occurs in from 30 to 50per cent of the cases. But the factors that predispose to bubo are muscularactivity and

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accumulation of pus on the chancroid; so that with patientsin bed and with their chancroids kept free from pus, bubo is a relativelyinfrequent complication.

When bubo threatens, extra care should be used to see thatthere is no absorption of pus from the chancroid; the patient should havecomplete rest, and hot applications should be applied. If fluctuation develops,the hot applications are continued until the gland has fully broken down. Whenit is soft throughout and full of pus, a small incision with a double-edgeknife should be made and the pus evacuated. Iodoform glycerin, 10 per cent, isthen injected into the cavity. The emulsion should be injected three times atthe first sitting. The first two injections run out and the last one remains in.The wound is then bandaged with gauze, moistened with solution of aluminumacetate, 1 part in 7 of water, or boric-acid solution, or some other antisepticsolution. On the following day the wound is emptied by squeezing, and iodoformemulsion injected once and left in. The bandage is then applied, and in five orsix days the wound is closed and healed. If after a week the wound is notclosed, it should be injected again; this will usually result in healing in fiveor six days.

The method of injecting the wound with silver-nitratesolution has been abandoned on account of the pain that it causes and because itis no better than the injection with iodoform.

The plan of encouraging suppuration and evacuating the pusthrough a small incision is satisfactory in most cases when the glands breakdown rapidly. But sometimes suppuration goes on very slowly; and in these casesit is better to make a free incision, evacuate the pus, and dissect or curetteout the partially broken-down remains of the glands. Then the wound is packedwith gauze and allowed to heal by granulation. It is better to avoid this courseif possible, as the subsequent healing takes six or eight weeks and requiresdaily dressing.

It was the practice a few years prior to the World War toendeavor to prevent suppuration in the glands by dissecting them out and tryingto get a clean wound, which was closed by suture. This practice has now beenabandoned because it was found that a solid edema, or elephantiasis, of thepenis and scrotum and inguinal region often followed, in consequence of theobliteration of the lymphatic vessels in the area of the wound. Anotherobjection was that, when patients came to operation, suppuration had nearlyalways begun in the center of the gland, even though no fluctuation was evident;the wound was not aseptic and could not be closed, but had to be left open forthe slow process of healing by granulation.

SYPHILIS

Table 45 shows the occurrence of syphilis in the Army duringthe World War by countries of occurrence for officers and enlisted men. Inaddition to the 67,026 primary admissions, all forms, 9,665 cases were reportedas concurrent with other diseases, making a total of 76,691; that is, with atotal mean strength of 4,128,479 men, 1.85 per cent were admitted to sick reporton account of syphilis.

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TABLE 45.- Syphilis. Primary admissions, deaths, discharges for disability, and noneffectiveness, officers and enlisted men, United States Army, by countries of occurrence, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000

	Total of mean annual strengths	Admissions		Deaths		Discharges for disability		Noneffectiveness
	Total of mean annual strengths	Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength	Days lost	Non- effective ratio per 1,000 strength
Officers and enlisted men, including native troops	4,128,479	67,026	16.24	143	0.03	3,318	0.80	1,927,901	1.28
Total officers and men, American troops	4,092,457	66,504	16.25	140	.03	3,297	.81	1,914,653	1.28
Total officers	206,382	899	4.36	3	.01	33	.16	35,835	.48
Total enlisted men, American troops:
White	3,599,527	45,456	12.63	82	.02	2,104	.58	1,338,950	1.02
Colored	286,548	18,623	64.99	53	.18	1,131	3.95	502,437	4.80
Color not stated	---	1,526	---	2	---	29	---	37,431	---
Total	3,886,075	65,605	16.88	137	.04	3,264	.84	1,878,818	1.32
Total native troops	36,022	522	14.49	3	.08	21	.58	13,248	1.01
Total Army in United States, including Alaska:
Officers	124,266	413	3.32	2	.02	27	.22	19,445	.43
White enlisted	1,965,297	34,915	17.76	56	.03	1,984	1.01	919,290	1.28
Colored enlisted	145,826	16,200	111.09	35	.24	1,089	7.47	407,226	7.65
Total enlisted	2,111,123	51,115	24.21	91	.04	3,073	1.46	1,326,516	1.72
Total officers and men	2,235,389	51,528	23.05	93	.04	3,100	1.39	1,345,961	1.65
U.S. Army in Europe, excluding Russia:
Officers	73,728	454	6.16	---	---	4	.05	15,293	.57
White enlisted	1,469,656	8,672	5.90	24	.02	96	.07	368,875	.68
Colored enlisted	122,412	2,039	16.66	17	.14	41	.33	90,646	2.03
Color not stated	---	1,515	---	2	---	14	---	36,843	---
Total enlisted	1,592,068	12,226	7.68	43	.03	151	.09	496,364	.85
Total officers and men	1,665,796	12,680	7.61	43	.03	155	.09	511,657	.84
Officers, other countries	8,388	32	3.81	1	.12	2	.24	1,097	.36
U.S. Army in Philippine Islands:
White enlisted	16,995	609	35.84	1	.06	5	.29	15,098	2.43
Colored enlisted	4,456	143	32.09	1	.22	---	---	1,842	1.13
Total enlisted	21,451	752	35.06	2	.09	5	.23	16,940	2.16
U.S. Army in Hawaii:
White enlisted	16,161	122	7.55	---	---	4	.25	4,210	.71
Colored enlisted	3,319	47	14.16	---	---	---	---	1,842	1.52
Total enlisted	19,480	169	8.68	---	---	4	.21	6,052	.85
U.S. Army in Panama: White enlisted	19,688	227	14.07	1	.05	2	.10	7,446	1.04
U.S. Army in other countries and not stated:
White enlisted	---	610	---	---	---	8	---	18,040	---
Colored enlisted	---	141	---	---	---	1	---	184	---
Color not stated	---	9	---	---	---	15	---	540	---
Total	14,232	760	53.40	---	---	24	1.69	18,764	3.61
Transports:
White enlisted	97,498	251	2.57	---	---	5	.05	5,991	.17
Colored enlisted	10,535	53	5.03	---	---	---	---	697	.18
Color not stated	---	2	---	---	---	---	---	48	---
Total	108,033	306	2.83	---	---	5	.05	6,736	.17
Native troops:
Philippine Scouts	18,576	195	10.50	---	---	2	.11	4,278	.63
Hawaiian	5,615	23	4.10	---	---	4	.71	989	.48
Porto Rico	11,831	304	25.69	3	.25	15	1.27	7,981	1.85

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The primary admission rate per 1,000 strength was 16.24 forthe total Army and the total days lost from duty was 1,927,901. One hundred andforty-three deaths were charged to syphilis. Since the duration of the war wasshort, the above number of deaths obviously does not represent the toll that wasclaimed by syphilis among soldiers.

The above figures are not intended to represent totalsyphilis in the Army, but only those cases with manifest lesions. Doubtlessthere were many cases that were never recognized. Levin¹⁰ made morethan 10,000 blood tests on troops at Camp Funston, Kans., and at Fort Riley.These tests were made on men from all walks of life. He found the percentage ofsyphilis among officers to be low, with one double-plus reaction in 59 casesexamined. The following table shows the results of this survey, among white andcolored enlisted men:

Comparison of figures obtained in surveys of white and colored men

Troops	Number examined	Known syphilitics	Wassermann	Undoubted syphilitics	Wassermann	Estimated probable syphilitics
		Per cent	Per cent	Per cent	Per cent	Per cent
White	1,577	3.44	4.77	8.21	7.87	16.08
Colored	1,422	1.08	21.80	22.88	13.11	36.00

For the total Army during the war there were 67,026 primaryadmissions for syphilis, of which 899 were officers. White enlisted menfurnished 45,456, and colored enlisted 18,623 cases. The admission rate forofficers was 4.36; for white enlisted men, 12.63; and for colored enlisted men,64.99 per 1,000 strength. Of the deaths recorded, 3 were among officers and 137among enlisted men. White enlisted men contributed 82 and colored enlisted men53 of these deaths, with ratios of 0.02 and 0.18, respectively. This same higherincidence among the colored enlisted men is also shown by discharges fordisability and days lost from duty. The discharge rate for the white was 0.58and for the colored enlisted men 3.95. White enlisted men lost 1,338,950 daysfrom duty and colored enlisted men 502,437. The noneffective rates were,respectively, 1.02 and 4.80. The disease was relatively less common among nativethan among American troops. For the former there were 522 cases (14.49), with 3deaths (0.08), 21 discharges for disability (0.58), and a loss of 13,248 days(1.01) from duty.

OCCURRENCE IN THE ARMY IN THE UNITED STATES

The vast majority of syphilis cases in the Army were reportedin the United States. There were 51,528 primary admissions, with the high rateof 23.05 per 1,000 per annum. This disease was more common among white enlistedmen in the United States (17.76) than in the Army at large (12.63); however,only about one-seventh as common as among the colored enlisted men. Among thelatter there were 16,200 primary admissions, with the high rate of 111.09 per1,000 strength. The majority of deaths, and practically all the discharges fordisability, were recorded for troops serving in the United States. The deathrate among white enlisted men was one-eighth (0.03) that of colored enlisted men(0.24), and the discharge rate was almost in the same proportion.

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Time lost from duty amounted to approximately 900,000 daysfor white enlisted and 400,000 days for colored enlisted, with noneffectiveratios of 1.28 and 7.65 per 1,000, respectively. The average enlisted rate athome was 1.72.

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

As shown in Table 45, syphilis was not as commonly reportedin the American Expeditionary Forces as in the Army in the United States. Therewere 12,680 primary admissions in the former against 51,528 in thelatter. The admission rate in the American Expeditionary Forces was 7.61 per1,000 and 23.05 in the Army in the United States. Syphilis was about twice ascommon among officers abroad as it was at home, the admission ratios being 6.16and 3.32 per 1,000 strength, respectively. It was about one-third as commonamong enlisted men overseas (7.68) as in the United States (24.21); and at homeit was more common among colored (111.09) than among the white enlisted men(17.76). Among colored enlisted men abroad there were 2,039 primary admissions,and among white enlisted men 8,672, with admission ratios of 16.66 and 5.90 per1,000 per annum, respectively.

OCCURRENCE IN OTHER COUNTRIES

Syphilis has been a common disease among American troops inthe Philippines since the first occupation of these islands in 1898. During theWorld War there were 752 primary admissions among the enlisted man, white andcolored, with admission ratios of 35.84 and 32.09, respectively; in thisinstance the rate was higher among white troops than among the colored. It is ofinterest to note that the rate was twice as high as that of the Army at large(16.24). In Hawaii, syphilis was relatively uncommon. There were 169 primaryadmissions among approximately 20,000 enlisted men; the rate was 8.68 per 1,000strength. Syphilis was more prevalent among white troops in Panama than inHawaii; in the former there were 277 cases, with the admission rate of 14.07.The highest rate for enlisted men (53.40) was in a miscellaneous group ofstations that included China, Siberia, Russia, etc. The highest rate among thenative troops was for the Porto Ricans (25.69). Among Philippine Scouts,numbering approximately 19,000, there were 195 cases (10.50). The Hawaiian ratewas the lowest (4.10) recorded for any troops during the war.

DIAGNOSIS

The diagnosis of syphilis in the Army during the war wasconducted along conventional lines and but little new was developed. However,never before were examinations carried out on such a large scale, nor has itbeen possible before to study data in such masses. The outstanding feature indiagnosis was the attempt at the recognition of syphilis as soon as possibleafter infection. This explains the relatively high occurrence of primarysyphilis. Briefly, the methods used were physical examination, examination ofthe ulcer for the Spiroch?ta pallida, and serological methods. Theluetintest was used scarcely at all. The colloidal-gold test and the cell count wereused in selected spinal fluids. The R?ntgen ray was used as an auxiliary incases of suspected visceral syphilis.

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The importance of early diagnosis was frequently emphasizedand, in this regard medical officers were advised by the Surgeon General asfollows:⁷

The matter of prime importance in handling syphilis is toget it at the beginning of the infection. The earlier it is treated the betterare the prospects of cure, and the quicker the soldier can be madenoncontagious and gotten back to duty. It should be the constant effort todiscover syphilis at the earliest possible time, if possible before thedevelopment of a possible Wassermann reaction.

To this end, every sore, whether on thegenitals or elsewhere,that is open to any suspicion of being a chancre should be repeatedly examinedfor spirochetes. No determining weight should be given to the so-calledspecific clinical characteristics of any lesion that might by anypossibility be a chancre. Experience has shown that the typical clinicalcharacteristics of the chancre, aside from indolence-and this may be maskedby another infection-are often lacking. Any excoriations, papule, nodule,crack, herpetic or other erosion no matter how small, may be an initial lesion of syphilis; and such lesions, as well as ulcers about the genitals-andelsewhere, if there is any reason to suspect them or if they are indolent andnot readily to be accounted for-should be searched for spirochetes.

Chancroids in particular should never be accepted asuncomplicated by syphilitic infection. They are likely to have a doubleinfection, and should always be zealously examined for Spiroch?ta pallida. Sometimes,in spite of the most careful search, the spirochetes escape detection inchancroids. For that reason, one can never be sure that a chancroid does nothide a chancre; patients with chancroid, therefore, require watching for thepossibility of syphilis, and, when the spirochetes can not be found, shouldalways have weekly Wassermann tests for three or four weeks until the questionof syphilis can be decided.

Antiseptics, especially mercurials, render the finding of Spiroch?tapallida difficult or impossible, and, because of this, it should be routinepractice to apply no mercurial dressings, or, better, no antiseptic dressings, to suspicious lesions untilthe necessary examinations to exclude Spiroch?tapallida have been made. If any such application has been made toa suspected lesion, the lesion should be thoroughly irrigated with physiologicsodium chloride solution, and a wet dressing of this solution applied for 12hours or more before examining for spirochetes.

In order to aid in discovering the initial lesion at theearliest moment soldiers who have been exposed should be inspected atintervals of a few days for at least three weeks, and also instructed to bethemselves on the watch for suspicious lesions.

Examination for Spiroch?ta pallida and diagnosis -Toobtainthe Spiroch?t?pallid? for examination two procedures are of value. In obtaining them directlyfrom the lesion the surface should be wiped withgauze wet with physiologic sodium chloride solution to remove saprophyticorganisms, especially the Spiroch?tarefringens. The rubbing should leavea clean oozing surface, not bleeding. Light curettement may be necessary in some cases. Moderate squeezing of the lesion will then cause an exudationof lymph from the deeper portions of the tissues. A drop of this lymph is then touched to a cover glass and placed on a slide, or the fluid may becollected in a capillary pipette. It may be preserved for a few hours bysealing the pipette, or the specimen on the slide may be ringed withparaffin or petrolatum and kept on ice for variable periods up to 12 hoursor longer. Delay impairs the validity of the findings, however, and multipliesuncertainties, so that examination should be made at once.

A valuable method, which relieves the observer ofmuch ofthe responsibility for differential diagnosis of the organism, is glandularaspiration. This can be done on prominent nodes in the satellite adenopathyaccompanying the primary lesion. It can also be performed on the indurated base of a suspected chancre. A sterile glasssyringe, of 1 c. c.capacity, fitted with an ordinary stout hypodermic syringe needle, an inch orso in length, is sufficient. The skin over the gland is painted with iodineand the gland palpated and fixed between the thumb and forefinger ofthe left hand. The needle is plunged through the skin into the gland, thepenetration of the capsule being indicated by the moving of the gland underthe finger when the position of the syringe is changed. The gland is thenheld firmly while the needle is manipulated enough to macerate thetissue immediately around the point. Aspi-

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ration will draw a drop or two of tissue juice into theneedle and barrel. The fluid thus obtained is often rich in Spiroch?tapallida. The method is not especially painful, and is easily borne by theaverage patient.

The Spiroch?ta pallida, as obtained for study bythese methods, has a morphology usually easily recognized by the experiencedobserver. It is a regular spiral organism, of from 6 to 15 microns in length,with from 3 to 26 turns. The average length is about twice that of a red bloodcell, and the usual number of turns is from 10 to 20. It is rather slowmoving, which is a distinctive characteristic. A movement in the direction ofthe long axis and a rotating movement are most commonly observed. The organism retains its clear-cut, regular spiral turns exceptionally well,evenat rest-another distinctive characteristic. Long forms bent in the middleare occasionally seen.

From Spiroch?ta refringens, if this is not eliminatedby proper cleansing, the Spiroch?ta pallida is distinguished by thefact that Spiroch?ta refringens is obviously coarser and the turns arefewer and less regular. Spiroch?ta refringens does not keep itscorkscrew shape so well as Spiroch?ta pallida when at rest, and when inmotion moves much more rapidly than the Spiroch?ta pallida. Spiroch?tadentium, seen in mouth preparations, is much more minute than the Spiroch?tapallida. Fibrin spirals have been mistaken for syphilitic spirochetes byinexperienced observers. In general it may be said that while the recognitionof the organism of syphilis is not an affair for the tyro, a moderate amountof experience on the part of the examiner, coupled with the presence of numerousorganisms of the above-described type in a given preparation made under favorableconditions, is sufficient for a diagnosis of syphilis and the institution of appropriatetreatment. Failure to find them, however, is no evidence that the lesion is not syphilis.

In all suspected cases Wassermann tests should be made. Itshould be made a general rule that the first finding of a positive Wassermann reaction should immediatelybe confirmed by a second, but it isnot necessary to delay beginning treatment until the second report is received.For the first 10 days after the appearance of the chancre the Wassermannreaction is usually negative. It is at this critical period that theestablishment of the diagnosis of syphilis by demonstration of the specificspirochetes is of such importance, because it enables us to begin treatmentwhile the infection is still relatively localized and can usually be abortedby thorough treatment. In suspected chancres in which spirochetes can not be foundWassermann tests should be made at intervals of a week, for a month, before it is decided finally that the case is not syphilis. In cases inwhich the spirochetes are found a Wassermann test should be made at theoutset, and if it is not positive should be repeated at weekly intervals for thefirst few weeks to see if, in spite of treatment, it becomes positive. FurtherWassermann tests should be made at about monthly intervals.

In no cases should specific treatment be started until apositive diagnosis of syphilis has been made.

Though the Surgeon General's Office recommended certainlaboratory methods, much latitude was allowed the officers in charge;therefore, methods used by all laboratories were not identical. Particularly wasthis true of laboratories in the United States. In the American ExpeditionaryForces the instructions¹¹ were that a man with asuspicious soreshould be sent to the laboratory of the division, where preparation for stainingand dark-field examinations were to be made by the pathologist, a consultationobtained with the urologist, if feasible, and the man returned at once to hisunit with an immediate report of findings. Local application of mercurialpreparations or cauterization of the sore was forbidden before smears formicroscopic diagnosis were taken, and failure of the microscopic examination todemonstrate Spiroch?ta pallida was not to be regarded as final untilseveral additional smears had been made.

Twenty-eight and four-tenths per cent of the admissions forsyphilis were diagnosed in the primary stage. This was accomplished byexamination of the sore for the Spiroch?ta pallida; 50.4 per cent werediagnosed in the secondary

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stage, accomplished by means of physical examination,confirmation by the results of the Wassermann complement fixation test or somemodification thereof.

No test was considered positive unless there was completeinhibition of hemolysis, except in the early primary cases when less inhibitionwas considered positive in a few cases. Four degrees of reaction are noted inreports from the Army laboratories. A positive reaction is reported asdouble-plus (+ +), and means that there is absolute inhibition of hemolysis. Adoubtful reaction is reported as plus (+) or plus-minus (+ -), the former termindicating that there was over 50 per cent inhibition of hemolysis, the latterthat there was less than 50 per cent inhibition of hemolysis. A negativereaction is reported as minus (-). In most civilian laboratories the resultsof the Wassermann test are reported as four plus (+ + + +), three plus (+ + +),two plus (+ +), plus (+), plus-minus (+ -), and negative (-). The four-plusreaction corresponds to the Army double plus, the three plus and two plus tothe Army plus, the plus and plus-minus to the Army plus-minus.

Although, as generally performed, the Wassermann test is nota true specific reaction, the work of Noguchi¹²and Craig and Nichols¹³ hadproved that, with antigens prepared from pure cultures of Spiroch?ta pallida, complement fixation can be obtained with syphilitic sera, and thatin such instances the reaction is really a specific one, due to antibodies inthe patient's blood serum against the spirochete.

Examination of the cerebrospinal fluid, not only in casespresenting neurological signs and symptoms, but also as an indicator of cure ofthe syphilitic infection, was the practice in the Army. Negative findings in thefluid is a requisite of cure in the Army standard index.

The vast majority of chancres were genital; however,extragenital chancres occurred, and were of special interest to the militaryservice in determining the status of the individual officer or soldier as towhether or not the illness was in line of duty. The number of such cases wasexceedingly small; they were found more commonly among the medical personnel asthe result of infection by patients. Lambie¹⁴made a survey ofapproximately 30,000 Army syphilitic registers and found 139 cases ofextragenital infection.

COMPLICATIONS, SEQUEL?, AND CONCURRENT DISEASES

Since practically no tissue of the human body is immune tothe syphilitic virus, the number of possible complications is large.Complications and sequel?, however, develop relatively slowly and since theaverage length of service per man in the Army during the war was approximately ayear,¹⁵and the average period of time in hospital for syphilis was28.7 days, it is apparent that the Army's World War statistics are of littleinterest in this connection. As previously stated, complicated syphilis, whendetected, was a cause of rejection from military service; however, manyuncomplicated cases were accepted for service. Such complications ascardiovascular syphilis and syphilis of the nervous system were but seldomreported.

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TABLE 46.- Primary admissions,complications, sequel?, and concurrent diseases reported with 12,843 cases ofsyphilis in the United States Army, April 1, 1917, to December 31, 1919

Diseases (primary and secondary)	Number of cases	Diseases (primary and secondary)	Number of cases
Acute articular rheumatism	126	Mental deficiency	95
Chancroidal infection	3,687	Dementia pr?cox	45
Gonococcus infection	7,498	Chorioiditis	56
Arthritis	653	Iritis	307
Leukemia	2	Keratitis	84
Hodgkin's disease	3	Retinitis	34
Anemia, chlorosis	5	Pericarditis	6
Alcoholism, acute or chronic	29	Endocarditis	13
Drug addiction	27	Aortic insufficiency	36
Fracture, faulty union of	17	Aortic stenosis	9
Locomotor ataxia	62	Mitral insufficiency	122
Multiple sclerosis	5	Mitral stenosis	32
Apoplexy	71	Myocarditis and myocardial insufficiency	95
Facial paralysis	15	Angina pectoris	5
Paraplegia	8	Aneurism	12
Paralysis, others	44	Aortitis	42
Epilepsy	66	Tachycardia	41
Neurasthenia	57	Ulcer of the stomach	14
Neuritis	68	Bones, other diseases of
General paralysis of the insane	79	Total	12,843
Duodenal ulcer	8
Cirrhosis of the liver	13
Nephritis:
Acute	32
Chronic	65

PROGNOSIS

For reasons above stated, the World War statistics are of butlittle or no value in determining the prognosis of syphilis. For the total Armyduring the World War there were recorded 51,119 deaths from disease. Forsyphilis, both among primary admissions and concurrent diseases, there were 317deaths; that is, 0.54 per cent. Syphilis ranked twenty-first on the list of themost common causes of death among primary admissions for disease and if allcases, both primary and concurrent, be included, it ranked fifteenth. From themilitary point of view, the prognosis of syphilis was better than, for example,scarlet fever, in that, although there were about one-sixth as many cases ofscarlet fever there were approximately twice as many deaths, while time lostfrom duty was about twice as great per case. As a rule, syphilitics wereadmitted to hospital and held there during the contagious stage and whilephysically disqualified for duty. They were then returned to their organizationsfor prolonged treatment, and but rarely were readmitted to sick report. And asshown under treatment in this chapter, since the course of treatment was a longone, the total interference with duty can not be determined.

From previous experience, especially since 1911, when theArmy syphilitic register was inaugurated, the Surgeon General prescribed astandard cure for syphilis:¹⁶

One year of observation must elapse after all treatment hasbeen stopped. During this year there must be no clinical evidences ofsyphilis, several negative Wassermann reactions and no positive ones. At the end of the year a complete physical and laboratory examination, includingthatof the spinal fluid and a provocative blood Wassermann reaction must benegative. If all these requirements have been fullfilled, the case can beclosed as "cured" and the register sent in.

Among enlisted men, white and colored, during the war therewere treated 19,024 cases of primary, 34,787 cases of secondary, and 10,984cases of tertiary syphilis, but it can not be stated how many were cured. It is difficult tosay

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positively that a patient is cured of syphilis. This mayrequire years of observation, including careful scrutiny at the necropsy tableby a competent pathologist. However, from the military viewpoint it may be saidthat the prognosis of syphilis in the Army during the war, and based upon therecords only, was good, as there were but 143 deaths and 3,318 discharges fordisability among approximately 67,000 cases of syphilis, with an average periodof hospital treatment amounting to 28.7 days.

TREATMENT^a

TREATMENT OF THE CHANCRE

Excision of the chancre is a procedure which theoreticallyshould be useful, on the ground that it removes the important focus ofinfection. And when the location of the chancre is such that its excision willnot cause deformity, surgical excision may be done; but excision of the chancredoes not abort syphilis. The excised chancre should be preserved and sent forlaboratory examination. Until the search for spirochetes is ended, the chancreshould be treated only by cleansing with saline solution and covering with acompress wet with the same solution. As soon as spirochetes are demonstrated,if the chancre is not excised, it should receive an inunction of 33 per centcalomel ointment twice daily for a week; it should be kept clean and protectedby a calomel ointment or some bland protecting dressing.

SYSTEMIC TREATMENT

In the presence of early syphilis, treatment should beimmediately started and vigorously pushed. It should be with both arsphenamine^band mercury. Before beginning there should be a preliminary survey of thepatient's physical condition. Patients with acute febrile diseases or withdiseases of the liver, kidney, or vascular system-when they are nonsyphiliticin origin-should be given arsphenamine with caution.

ARSPHENAMINE^b

There is agreement among syphilographers that the mosteffective time for producing radical results with arsphenamine is in the firstfew weeks of syphilis-best before the Wassermann test becomes positive-andthat arsphenamine should be pushed at this time.

The normal dose should be on the basis of 1 decigram ofarsphenamine for each 30 pounds of body weight, i. e., from 4 to 6 decigramsfor patients of ordinary weight. The first dose should be one-half the normaldose. Administer at intervals of from five to seven days. Six doses constitute acourse.

It is possible that in cases seen before the Wassermann testhas become positive, one such course of arsphenamine combined with mercury maycure. But this is not safe to assume, and, in the light of our past knowledgeof syphilis, it is advised even in these cases to repeat the course ofarsphenamine and mercury treatment at least once after a rest period of fromsix to eight weeks.

^aBased upon A Manual of Treatment of the Venereal Diseasesfor the Use of Medical Officers of the Army. Prepared under thedirection of the Surgeon General, 1917.
^bArsphenamine is the official name now applied to the drug formerly called salvarsan.

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Such patients should be subsequently watched for a year withmonthly Wassermann tests and treated should any evidence of syphilis bediscovered.

In all cases seen after the Wassermann test has becomepositive the first course of treatment should be followed by a second after fourto six weeks' rest. And it is safest to give at least a third similar courseafter an interval of two months even in the most promising of cases.

In all those cases in which a positive Wassermann test or anyother evidence of syphilis remains, further courses of arsphenamine and mercuryshould be given at intervals similar to the foregoing, the persistence intreatment to be determined by the findings in the individual case.

In place of arsphenamine, neoarsphenamine can be used in 50per cent larger doses. It may be somewhat less effective, but the difference isnot sufficient to allow of dogmatic statements on this point.

It may be repeated that the use of arsphenamine is to becombined with that of mercury in the attempt at cure of syphilis; and thatreliance is not to be placed on arsphenamine alone.

PREPARATION AND CARE OF PATIENT

The urine should be examined before each injection ofarsphenamine. Arsphenamine should be given with the patient's stomach empty,or nearly so. The treatments are best given at noon or in the early afternoon,the patient omitting lunch. He should remain quiet for the rest of the day-bestin bed-and should take no food until the next morning.

REACTIONS FROM ARSPHENAMINE

As a rule the administration of arsphenamine is followed byno symptoms whatever. Occasionally, however, reactions occur from it; thesevary in severity from slight, evanescent distress to symptoms of the gravestpoisoning.

To some extent, perhaps, these reactions are due toindividual hypersensitiveness to the drug. There is good reason to believe,however, that the severe reactions are chiefly produced by impurities in thedrug, due to faults in manufacture, or sometimes to oxidation produced bycarelessness in technique of administration.

The reactions may be divided for consideration into early andlate; the early reactions occurring from the very time of injection to 6 or 8hours afterward, and the late occurring from 1 to 4 or 5 days, and,occasionally, even longer afterward.

The early reactions have the symptoms of acute poisonings;the late, symptoms of organic disturbances that have resulted from the sloweraction of a poison.

EARLY REACTIONS

Nausea.-The commonest reaction afterarsphenamine isa feeling of malaise with some nausea from five to seven hours afterward. Notinfrequently this amounts to a chill, followed by slight fever and more or lesssevere vomiting. These symptoms disappear in a few hours.

They do not constitute a contraindication to the further useof the drug, but they should suggest that more care than usual be exercised tosee that,

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before administration, the bowels have been cleaned out andthe stomach is empty and that, afterward, the patient rests without food untilthe next morning.

Febrile reaction -Rarely these reactions are moresevere. The temperature may go to from 101? to 104? F. with headache andgeneral pains, especially of the legs and back, diarrhea as well as nausea andvomiting, and an eruption of urticaria or toxic erythema. The treatment is restin bed and a liquid diet until symptoms have subsided. The pain may becontrolled by a few doses of salicylates. No more arsphenamine should be givenin these cases until several days after all symptoms have disappeared, and anyfurther administration of the drug should be in relatively small doses and atintervals of not less than a week.

Temporary albuminuria -It is not uncommon to find atrace of albumin and a few casts in the next morning's urine after aninjection of arsphenamine. This is not a contraindication to the further use ofthe drug unless the albumin is present in considerable quantity and there aremore than half a dozen casts to the slide.

Immediate acute reaction -The early reaction which inrare cases accompanies or immediately follows the administration of arsphenamineis that of an acute poisoning, characterized by intense congestion fromvasomotor disturbances; this is the so-called anaphylactoid reaction ofarsphenamine. It is probably due to impurities in the drug. In these cases thepatient suddenly-perhaps before the injection is finished-manifestssymptoms of distress. He may first notice a taste of garlic or ether, or of ametallic substance. An erythema appears on the neck and spreads thence over theface, and the jugular pulse is exaggerated and rapid. He complains of faintness;the pulse becomes weak and the respiration labored. The face is puffed andcongested; the pupils dilate; there is a feeling of constriction in the throat;and there may be edema of the glottis, which fortunately is very rarely fatal.There is tightness in the chest, and especially precordial distress. The pulsemay become imperceptible, the patient cyanotic, and syncope may occur.Altogether the picture is extremely alarming in the severe cases, butfortunately the symptoms as a rule quickly improve, and recovery nearly alwaystakes place.

These cases promptly respond to the injection of from 1 to 2c. c. of 1:1,000 solution of adrenalin, which may be repeated at intervals of 20or 30 minutes, if required, until the symptoms subside. In preparation for thisemergency a sterile hypodermic syringe with 2 c. c. of adrenalin solution in itshould always be at hand when arsphenamine is given.

The occurrence of this reaction does not preclude the furtheruse of arsphenamine; but is suggests that careful control of the patient'spreparation should be exercised, that the technique should be reviewed, and thatthe preparation of arsphenamine should be investigated.

LATE REACTIONS

Lowering of general health.-Occasionally during acourse of arsphenamine a patient's general health becomes lowered withoutother evidence of organic disturbance. There is lassitude and, perhaps,headache; the appetite is poor

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and the patient falls off in weight. Such symptoms-likelyto be overlooked because of their insidiousness-should lead to carefulconsideration of the case. Patients who are doing well under specific treatmentshow it in an improvement in their general well-being. If this lowering of thehealth progresses under arsphenamine, it should be discontinued. The patientshould be relieved from duty, placed on a liberal, perhaps forced, diet, giventonics, and his elimination stimulated by abundance of water and the use oflaxatives or cathartics; also he should be carefully examined for otherdiseases.

Erythema and dermatitis -In rare cases, patches ofscarlatiniform erythema develop from 12 to 24 hours after arsphenamine; theseare usually accompanied by evidence of kidney irritation. The appearance ofareas of scarlatiniform erythema is an indication that arsphenamine should bestopped until well after these symptoms have disappeared, and that its furtheruse should be very guarded.

These preliminary manifestations of intoxication usuallydisappear spontaneously in a few days, although rarely they develop into thesevere cases. If arsphenamine is continued in spite of these warnings, thereis likely to develop a universal exfoliative dermatitis with nephritis. Inextreme cases the nephritis is severe, accompanied by high fever, diarrhea andbronchopneumonia, and the result may be fatal. The same measures, to a greaterdegree, are indicated here as already suggested for lesser intoxication-complete rest, support of the patient's strength by anabundant diet, and stimulation of elimination.

Nephritis - Severe nephritis with its sequel? mayoccur without skin symptoms. For this reason the urine should always becarefully watched while arsphenamine is given.

As stated above, a transient albuminuria with a few casts iscommon the next morning after an injection of arsphenamine. If this promptlydisappears, it is not a contraindication to the continuance of the injections.

Again, albuminuria due to syphilitic nephritis is not veryrare. The evidence of the characters of such an albuminuria is that it isquickly benefited by arsphenamine as by other specific treatment.

Persistent evidence of nephritis developing in the course ofarsphenamine administration is another matter. It requires that the course bestopped and not resumed until the nephritis has disappeared; and then thefurther use of the drug must be with extreme caution. If these precautions areneglected the case is likely to develop into one of severe, permanentlydisabling, or fatal type.

Jaundice -In rare cases jaundice occurs in the courseof the use of arsphenamine. It is always a sign of serious intoxication andshould cause immediate, careful attention to be given to the case. Such casesmay go on to acute yellow atrophy of the liver with fatal termination. Theyrequire in the way of treatment measures for overcoming intoxication of thesort already outlined. The larger proportion of jaundice cases are said tofollow neoarsphenamine.

Hemorrhagic encephalitis -This, fortunately, is one ofthe rarest, as it is one of the most serious, of arsphenamine accidents. Thecases begin from two to four days after arsphenamine with severe headache,mental confusion, and dullness; then, usually, convulsions, coma, and death in afew days.

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The pathology of cases succumbing from this type of arsenicalintoxication shows as a rule the following features: There is characteristically anacute hemorrhagic encephalitis with softening of thecerebral tissue and with punctate hemorrhages, especially in the basal ganglia,pons, and medulla, but also involving the cerebral lobes adjacent to the lateralventricles and less frequently the cerebellar tissue. With this is associated anacute ependymitis, especially in the lateral ventricles, with hyperemia andpunctate hemorrhages. There may be general cerebral congestion and edema. Acutenephritis may be present but is not constant. Degenerative lesions maydevelop in the liver, sometimes giving a picture resembling acute yellowatrophy.

Treatment of these cases consists of vigorous elimination,which may include withdrawal of blood, and the intramuscular use of epinephrinin full doses.

Herxheimer reaction -In the presence of syphiliticlesions in vital structures, the administration of arsphenamine which,presumably from the liberation of spirochetal endotoxins, causes a temporaryengorgement of the syphilitic lesion, may produce serious symptoms of pressure,of obstruction, or of other impairment of function. This reaction is mostlikely to occur with early cerebral lesions, producing pressure symptoms, whichmay cause paralysis, coma, and even death. As a rule, while the symptoms arealarming, recovery takes place.

Similar reactions, producing symptoms of a characterdependent on the location of the syphilitic focus, may occur with syphiliticlesions of the viscera, or of the circulatory system, particularly inmyocarditic coronary arteritis and aortitis.

To guard against these accidents, when there is reason tosuspect lesions in any of these structures, particularly in the brain, mercuryand iodide should be vigorously given for several days before arsphenamine isstarted, if the symptoms are not so urgent as to warrant taking the risk of aHerxheimer reaction, and then the use of arsphenamine should be cautiouslybegun, with small doses, and only after two or three injections should fulldoses be given.

In these reactions treatment is symptomatic.

In general, the careful man is likely to attach undueimportance to minor symptoms arising in the course of arsphenamineadministrations, and to be influenced too readily by them to give up its use inthe particular case. On the other hand, a reasonable caution in the face ofsymptomatic warnings of arsphenamine intoxication demands care in its furtheruse in such cases.

RECURRENCES OF NERVE INVOLVEMENT

It is an occasional experience to see, with patients who havehad insufficient treatment with arsphenamine or mercury, a recurrence ofsyphilis in a nerve or the brain or cord, producing symptoms of impairment offunction in the particular structure involved. These recurrences are most likelyto be observed in the auditory or optic nerves, producing more or less damage tohearing and vision. While these are mentioned here, they are not manifestationsof arsphenamine poisoning. They are due to syphilitic infiltrations and occur,as well, in patients who have had no arsphenamine. They require vigorousspecific treatment with mercury, iodide, and arsphenamine-especially thelatter in

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patients who have already had arsphenamine. Of course, whenthese recurrences are cerebral as in the case of involvement of the optic nerve,due care must be exercised with arsphenamine to avoid a Herxheimer reaction.

TECHNIQUE OF ARSPHENAMINE ADMINISTRATION

The fundamental principle of administering any form ofarsphenamine is a rigid asepsis, and only extreme conditions justify itsadministration when this is not obtainable. The apparatus should be boiled for20 minutes. It is important that freshly distilled water be used forarsphenamine solution. Thirty c. c. of water per decigram of arsphenamine is asafe dilution. The ampule should be sterilized by immersion in a strongantiseptic solution, such as mercuric chloride, 1: 1,000, and then should beimmersed in 95 per cent alcohol in order to be sure it is not cracked. If ithas been immersed in mercuric chloride it must be carefully wiped dry before itis opened. It must never be sterilized by boiling.

The drug is first dissolved in about 50 c. c. of water. TheAmerican preparation, arsenobenzol, requires hot water for its solution, and issafely dissolved in hot water. The other preparations dissolve in water at roomtemperature and should not be heated, because of the danger of the formation byheat of highly toxic compounds. The direct solution of arsphenamine is astrongly acid solution, which must be neutralized and diluted before injection.Neutralization is accomplished after all the arsphenamine is dissolved by a 15per cent freshly prepared solution of sodium hydroxide, which should be addeddrop by drop. Arsphenamine is precipitated from the solution by the alkali, butredissolves as soon as the suspension becomes slightly alkaline. The point atwhich this occurs can be gauged with sufficient accuracy if the sodium hydroxideis added carefully and mixed after each drop or two. Since arsphenamine oxidizeseasily, it should not be violently shaken in preparation. As soon as thearsphenamine has redissolved, yielding a clear yellow solution, it may befiltered through wet sterile cotton in a funnel directly into a graduatedcontainer; then warm or cold distilled water is added to the proper dilution andto approximately body temperature. Care must be taken to fill the tube attachedto the container with physiologic sodium chloride solution and to expel all airbubbles before the arsphenamine solution is filtered into the container.

In the event that the arsphenamine precipitates somewhat ondilution, it may be redissolved by another drop or two of the sodium hydroxide.If the preparation has been made too strongly alkaline, a drop of dilutehydrochloric acid may be added and the neutralization repeated. The drug shouldbe administered promptly after preparation, and no more than enough for use onthe patients to be treated at the time should be prepared.

The technique of injection of the solution is comparativelysimple, and the older custom of making an incision to find the vein, with itsresultant scarring, has been abandoned by skillful operators. A variety ofneedles has been proposed, but the Schreiber 18-gauge with thumb guard and aproper adapter, or even a plain needle, will answer all purposes. In difficultcases a finer needle may make it much easier to get in the vein. The skin overthe field of opera-

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tion, preferably in the region of the large cubital veins, issterilized as for a surgical procedure, but if tincture of iodine is employed itis desirable to remove it with alcohol in order that the vein may be more easilyseen. The injection should be given with the patient lying down and the veinsdistended by encircling the arm with a tourniquet.

In nervous patients, local anesthesia may be used toadvantage. The needle is pushed directly through the skin over or to one side ofthe vein and then introduced into the vein. As soon as the blood returns freelythrough the needle, the adapter attached to the tube of the container is fittedto the shoulder of the needle, the tourniquet is released, and the injectionbegun by elevating the container about 2 feet. As a rule assistance isdesirable, since the operator is occupied by keeping the needle in position inthe vein. Failure to enter the vein is apparent by this method, before injectionis begun, through the imperfect flow of blood through the needle. The salinesolution contained in the tube allows sufficient warning of the infiltration ofthe tissues before the arsphenamine solution reaches the needle point. Variousforms of apparatus which inject saline solution as a test before beginning theinjection of the arsphenamine are not essential and are often complicated. Aglass telltale in the rubber tube permits the operator to watch the progress ofthe injection. When the injection is completed, the lowering of the containerbelow the level of the arm before the needle is withdrawn will aspirate a smallamount of blood from the vein and prevent the escape of solution into thetissues.

Recent investigations have shown that the danger fromintoxication with arsphenamine is much greater when it is administered inconcentrated solution or is injected rapidly. For this reason it should be usedin weak dilution and slowly injected.

Infiltrates, if they occur, are usually trivial, provided theoperator has been on his guard. The escape of arsphenamine into the subcutaneoustissues is indicated by a burning sensation, which the patient should be warnedto report. The reaction which ensues when arsphenamine is injected around thevein is inflammatory, with induration and infiltration, and may, if severe,progress to a slough. Arsphenamine infiltrates should be treated by wetdressings, ice bag, and, after inflammatory symptoms subside, by massage andpassive movement. An alarming degree of involvement may subside with practicallyno damage after several weeks or months. Thrombosis of the vein is an infrequentcomplication if the drug has been properly diluted, and should be treated ongeneral indications.

TECHNIQUE OF NEOARSPHENAMINE ADMINISTRATION

The original administration of neoarsphenamine, in dilutionssimilar to those used with arsphenamine, has been greatly simplified by theinjection of the dose in concentrated solution. In this procedure, the dose ofneoarsphenamine is dissolved in 10 c.c. of freshly distilled sterile water atroom temperature-not hot water. The solution is drawn up into an all-glasssyringe and administered as an intravenous injection after the usualpreparations. The method is rapid and extremely convenient, and itsapplicability to difficult cases is apparent.

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The solution of neoarsphenamine, being already neutral,requiresno addition of sodium hydroxid. Care must be taken to avoid infiltrates with theconcentrated solution, but in general infiltrates with neoarsphenamine are aptto be less serious than those with arsphenamine.

The French preparation novarsenobenzol (Billon) was usedalmost exclusively with the American Expeditionary Forces. The results weresatisfactory. It was given in concentrated solution, the ordinary dose in 2 c.c. of water, and the ease of administration of this small injection proved ofgreat practical advantage in the field.

MERCURY

For the cure of syphilis, arsphenamine and mercury should becombined, and at the same time with each course of arsphenamine a vigorouscourse of mercury should be given. This should begin before or at the same timewith or within a few days after the first dose of arsphenamine.

A course of mercury should consist of 9 or 10 weeklyinjections of an insoluble salt, of from 24 to 30 injections of a soluble saltat two-day intervals, or of from 40 to 50 daily inunctions of mercurialointment. The administration of mercury either by inunction or by intramuscularinjection is effective; and in the selection of either method one may beproperly influenced by considerations of convenience and practicability.

INUNCTIONS

If inunctions are used, it is necessary to see that they areproperly performed. Patients can not be trusted to give themselves inunctions;but they can very readily do it for each other by sitting one behind another andhaving each man rub the back of the man in front of him. From 4 to 8 gm. ofmercurial ointment may be used for a daily inunction. It is desirable before theinunction to wipe off the area to be rubbed with alcohol or to wash it lightlywith soap and water and dry. The ointment should be rubbed in slowly and gentlywith the palmar surface for 20 or 30 minutes, or until the ointment ispractically absorbed. Any excess should be allowed to remain on the skin. Aftersix inunctions a day should be skipped and the patient allowed a bath.

In giving inunctions, hairy surfaces and the thin skin ofjoints should be avoided, and the same area should not be used often enough toproduce dermatitis. The two sides of the back furnish the most tolerant areas.The sides of the abdomen and of the chest, and the inner surfaces of the thighs,the arms, and the forearms may all be used.

INJECTIONS

For injections, the preferable insoluble preparations aremercuric salicylate or calomel in oil, or metallic mercury in the form of grayoil. Perhaps the best proportion for the salicylate or calomel suspension is 20gm. (weight) in sterile olive oil or thin liquid petrolatum, enough to make 100c. c. (volume). A good formula for mercurial oil (gray oil) is redistilledmercury, 20 gm.; chlorbutanol, 2 gm.; anhydrous lanolin, 30 c. c. and liquidpetrolatum, enough to make 100 c. c.

The intramuscular dose of calomel, salicylate, and metallicmercury are the same. These three preparations, being of the same strength, havethe advantage of having the same dose. The average dose of either, for an adultman, is 0.06

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gm. weekly; by graduations the dose may be increased to 0.12gm. weekly, or with caution even higher.

The curative action of the injection of soluble salts ofmercury is perhaps less than that of the insoluble. However, they are free fromthe dangers of cumulative effect which are inherent in the insoluble salts; andin emergencies, when there is need to get prompt, certain, and vigorous effectof mercury, they are of great value. Mercuric chloride, mercuric succinimide, ormercuric benzoate are the most useful soluble salts for injections. Goodpreparations are 1 or 2 per cent mercuric chloride or 1 or 2 per cent mercuricsuccinimide with 1 per cent sodium chloride by weight in distilled water. Theaverage dose is 0.015 gm. into the muscle of the buttock every second day.Mercuric benzoate is given in 2 per cent solution with 2.5 per cent sodiumchloride, average dose 0.015 gm. every second day.

The American Expeditionary Forces used as routine treatmentintravenous injection of 1 per cent solution of mercuric cyanide. The averagedose is 1 c. c., representing 0.01 gm. of mercuric cyanide, given daily.

TECHNIQUE OF INJECTIONS

For intramuscular injection, a syringe such as the all-glassL?er hypodermic syringe with a 1?-inch, 20 or 22 gauge needle isused. The needle should have a slip shoulder to permit of its easy detachmentfrom the syringe. Sterilization of the skin with tincture of iodine issufficient; emulsions once sterilized will remain so with reasonable care intheir handling. In military service the syringe and needle should be sterilizedby boiling, or by liquid phenol, and the water or phenol removed by filling thesyringe first with alcohol and then with ether.

The site of the injections is usually in the upper outerquadrant of the buttock, care being taken to avoid the region of the sciaticnerve or the structures about the hip joint. They can also be well given in theupper inner quadrant of the buttocks. Injections are made alternately into eachbuttock.

The needle with the syringe empty should be introduced to itsfull length, and the syringe then detached and filled with the necessary dose.This introduction of any empty needle is a safeguard against making an injectioninto a vein. If the dry needle should be in a vein, on detaching the syringe,blood would well up through it; if the needle remains free from blood, as isnearly always the case, there is reasonable security against introduction into avein.

In general, in order to prevent leakage of the emulsion, itis desirable to introduce the needle on a slight slant in the tissue. This maybe accomplished by drawing downward on the skin of the buttock, which permits avalve action as soon as the needle is withdrawn and the hand released. Theinjection if made slowly is practically painless. The development of infiltratesand nodules of any considerable size, or in any number, during a course ofinjections, is either a reflection on the operator's technique or shows thecase to be unadapted to this form of treatment. When an insoluble salt has beenused, each of these nodules represent encapsulated mercury, and materiallyincreases the danger of cumulative action. Daily massage by the patient willusually reduce them in a short time. If their formation can not be preventedthe patient should be given injections of a soluble salt.

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CARE OF PATIENT WHILE TAKING MERCURY

Mercury as well as arsphenamine throws a burden on thekidneys; and patients under intensive treatment with mercury and arsphenamineshould have the renal functions carefully watched. An examination of the urinefor albumin and casts should be made weekly, and the development of definitenephritis during a course of treatment is an indication to stop. Treatment maybe undertaken again after the nephritis has disappeared, but must be lessvigorous than before and must be carefully watched.

Care of the mouth is a part of the general care which asyphilitic should have. Dental troubles should be looked after and the patientinstructed in the care of the teeth. When a syphilitic patient is sent to thedentist, the dentist should without fail be notified that the patient hassyphilis in order that he may safeguard himself against infection. A dentifriceshould be used, and it is a good plan to have the patients as a routine use anoxidizing mouth wash such as a one-half saturated potassium chorate solution, ora diluted solution of hydrogen peroxide. When the gums are soft or unhealthy, agood astringent application is tincture of myrrh to be painted on two or threetimes daily, after brushing the teeth.

SALIVATION

If salivation occurs, the mouth should be cleaned at shortintervals by washing with hydrogen peroxide solution or half saturated potassiumchlorate solution. Dobell's solution may also be used, and, while lesseffective, it has the advantage of being soothing. Pledgets of cotton or gauzemoistened with boric acid solutions placed between cheeks and teeth givecomfort and get rid of exudate. Atropine is useful, given to the point ofreducing salivary secretion. If the patient has been using inunctions, heshould, in order to get rid of mercury in the skin, be greased with an oil andthen well washed with soap and water and put in fresh clothes. He should have asoft, nutritious diet, be protected from exertions, and given the care forexhausting illness. In particular, he should be given an abundance of water.

ESTIMATING THE COURSE OF CASES

During the early course of syphilis, a Wassermann test shouldbe made at monthly intervals, and after it has apparently become permanentlynegative, it should still be repeated at intervals of two or three months for atleast a year. It should be remembered that the Wassermann test is not likely tobe positive for the first 10 days of the chancre. After it becomes positive, theobtaining of a single subsequent negative reaction means little; it must remainnegative over a period of months to justify the conclusion that it ispermanently negative.

In estimating the effect of treatment on syphilis, notonly the disappearance of specific clinical symptoms and of the positiveWassermann reaction should be considered, but the patient's general well-beingas well. In zeal to sterilize a patient of spirochetes the effect of thetreatment itself on the patient should not be overlooked, and treatment shouldnot be pushed beyond the point at which the patient is able to tolerate itwithout distinct lowering of his general physical tone.

A patient may be regarded as free from the necessity forfurther observations or treatment who, under observation and with Wassermanntests at intervals of two months, has remained free from all evidence ofsyphilis for a year.

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There is room for difference of opinion as to theadvisability of spinal puncture or a provocative injection of salvarsan with asubsequent Wassermann test in every case before discharge. Conservative practicereserves the use of these diagnostic measures to cases in which there arespecial indications.

LATE SYPHILIS

The late manifestations of syphilis in the Army are lesscommon than the early. Gummatous lesions in the skin or bones or elsewhere,which may be cured without leaving any serious damage to the body, do notconstitute a difficult clinical problem. In old cases of this sort there is notthe need for the intensive treatment administered in early cases. These patientsshould have mercury and potassium or sodium iodide until their lesions arecured. How much further treatment should be carried is a matter for judgmentin the individual case. The deep lesions of late syphilis-syphilis of theviscera, of the vascular system, especially of the heart or aorta, and of thecentral nervous system-indicate such serious impairment of the body that thesepatients will not be able to endure the strain of military life in the field. Ifthe lesions in such cases can be controlled, it may be practicable to findduties for which the patients are still fit; otherwise, they should beconsidered for discharge.

REFERENCES

(1) Form No. 11, Provost Marshal General's Office.

(2) Provost Marshal General's Report.

(3) Letter from The Adjutant General of the Army to all Department, National Guard, and National Army Division Commanders, November 15, 1917. Subject: Control of venereal diseases. On file, Record Room, S. G. O., Correspondence File, 726.1 (Venereal) General.

(4) Based on Annual Reports of the Surgeon General, U. S. Army, 1899-1920.

(5) Bulletin No. 45, W. D., July 25, 1917.

(6) Manual of Treatment of the Venereal Diseases, for the Use of Medical Officers of the Army. Prepared under the direction of the Surgeon General of the Army, 1917.

(7) Circular No. 86, W. D., November 25, 1918.

(8) Defects Found in Drafted Men. Washington, Government Printing Office, 1920, 424.

(9) Moore, J. E.: The Diagnosis of Chancroid and the Effect of Prophylaxis upon Its Incidence in the American Expeditionary Forces. Journal of Urology, Baltimore, 1920, iv, No. 2, 169.

(10) Levin, Wm.: The Incidence of Syphilis among White and Colored Troops as Indicated by an Analytical Study of the Wassermann Results in over Ten Thousand Tests. The Journal of Laboratory and Clinical Medicine, St. Louis, 1919-20, v, No. 2, 93.

(11) Manual of Military Urology. Masson et Cie., Paris, 1918, 75.

(12) Noguchi, H.: Serum Diagnosis of Syphilis. J. B. Lippincott Company, Philadelphia, 1913, 3d Ed., 59.

(13) Craig, Charles F., and Nichols, Henry J.: A Study of Complement fixation in Syphilis with Spiroch?ta Culture Antigens. Journal of Experimental Medicine, New York, 1912, xvi, No. 3, 336.

(14) Lambie, John S.: The Prevention of Extragenital Chancres in the Army, Based on a Study of Syphilitic Registers on File at the Army Medical School. The Military Surgeon, Washington, 1922, li, No. 3, 261.

(15) Love, Albert G.: A Brief Summary of the Vital Statistics of the U. S. Army During the World War. The Military Surgeon, Washington, 1922, li, No. 2, 139.

(16) The Management of Syphilis in the Army. Medico-Military Review, S. G. O., Washington, July 15, 1921, ii.