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Chapter VII

Communicable Diseases, Table of Contents

CHAPTER VII

THE VENEREAL DISEASES

STATISTICAL CONSIDERATIONS

That venereal diseases were responsible for great noneffectiveness and economic waste to the Army during the World War is shown by the fact that, of the total primary admissions to sick report on account of diseases only, numbering 3,500,000, venereal diseases were the direct causes in 357,969 admissions, or 10.2 per cent of the whole. If to this number be added cases reported as concurrent with other diseases, the total reported venereal incidence would be 383,706.

For admission to hospital, solely on account of venereal disease, there was a loss of 6,804,818 days from duty. Loss to the service is not entirely represented in the above figure, principally due to the fact that it was the practice to return men to their organizations and to a duty status as soon as their physical conditions would permit, further treatment being carried on in the organization while the soldier was on duty status. Inevitably time was lost for treatment, but was not officially charged as such; and in the case of salvarsan treatment for syphilis, carried out during convalescence, more especially in the United States, men were returned to the hospital or dispensary at regular intervals as out-patients, treated and sent back to their organizations, usually with a loss of about one-half day per case.

Venereal diseases, as a class, stood second among the most common 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 by approximately 100,000. As a cause of loss of time from duty, disregarding the additional time unaccounted for, as explained above, the venereal diseases stood second only to influenza, the greatest scourge of the war.

As a cause of permanent disability, requiring discharge from the service, venereal diseases ranked fourth among the most common diseases, being exceeded in this respect by, first, tuberculosis, (5.52), second, valvular heart 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 for white and colored enlisted men, as shown in Table 41. The former had a rate of 1.41 and the latter 18.36 per 1,000 per annum. The highest rate for any troops in the entire Army and serving in any country was 35.57 for colored enlisted men serving in the United States. The highest admission rate for American enlisted men was among the 21,000 stationed in the Philippine Islands. The rate was 192.12 per 1,000 strength. The second highest admission rate for enlisted men was 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.


264

The admission rate for the total Army during the war period was 86.71, based upon total primary admissions. Venereal diseases were approximately five times more common among colored than among white enlisted men. Among the former there were 95,026 primary admissions (331.62), as compared with 250,597 (69.62) among the latter.

TABLE 41.-Venereal diseases (all). 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/font>

 

Total mean annual strengths


Admission

Deaths

Discharge for disability

Noneffectiveness


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


265

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

For a number of years prior to the World War, venereal diseases constituted a cause for the rejection of applicants for enlistment in the Army. Since this cause for rejection obviously could not obtain, in so far as the World War Army was concerned, from the first practically all cases of venereal diseases were deemed acceptable.1 The number of cases discovered among the inducted men on their physical examination after their arrival at Army camps gives a very excellent measuring stick as to the incidence of these diseases among the young adult male population 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.2 This 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 being inducted provided but one space for the notation of defects and only the major defects were noted; therefore, other defects, including venereal diseases, if not considered the major defect, were not listed. During the same period, organization was taking place with the draft boards and within the camps. Under these circumstances, it is to be supposed that the records do not show the occurrence of venereal disease as fully as was the case subsequently. The second million men, referred to as P2 was called between May 1, 1918, and November 11, 1918. On the physical examination blanks used for the second million men, two spaces were provided for major defects. Local boards and camp examining boards were well organized and running smoothly. The records, therefore, are more complete. This second million was in reality 1,780,000 men, and, as notations shown on the original table2 are based upon 1,000,000 men only, figures used in Table 42 are raised by multiplying those in the original table by 1.8, in order to estimate the total number of cases.

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

Venereal
diseases


Group A

Group B

Group C

Group D and Vg

Total

P1

P2


P1 and 2

P1

P2

P1 and 2

P1

P2

P1 and 2

P1

P2

P1 and 2

Cl. Vg

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 in Drafted Men. War Department, 1920, 424.
b
A-Men selected for full military service. B-Accepted for remediable treatment. C-Accepted for special or limited service. D-Rejected at camps. Vg-Rejected by local boards. Pi-First million men. P2-second million men and others.


266 

Since venereal disease was not a disqualifying defect, very probably it was not carefully searched for; furthermore, the recorded cases, 133,188, were detected upon a quick routine physical examination without clinical history or full laboratory facilities.

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

CHART XXXIII


267

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

CHART XXXIV

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


268

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

CHART XXXV


269

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

Chart XXXV, considered in conjunction with Charts XXXIII and XXXIV should enable one to visualize the comparative effects of the white and colored population upon the absolute number of cases of venereal disease reported. It shows how closely the increase in venereal diseases followed the rise in the colored enlisted strength and how nearly the line of cases of venereal diseases paralleled the line for colored enlisted strength until the last peak of mobilization was passed in July. Chart XXXV also shows that colored enlisted men were inducted later and demobilized earlier than the white enlisted men; in other words, the average colored soldier was in the military service during 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 was imported into the service at the time of the draft, and since active steps were taken in the latter part of the summer of 1917 to prevent men with venereal disease from embarking for service abroad,3 it is clear why the majority of cases should have been reported in the United States. Table 41 shows that 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, or 79.6 per cent. Whereas the admission rate per 1,000 per annum was 86.71 for the entire Army, the rate at home was 127.37. The admission rate was high for both white and colored enlisted men, being 101.12 and 581.94, respectively; but was low for officers (9.24). Although the admission rate for white enlisted men was less than one-fifth that for colored enlisted men, it was about one and one-half times the mean ratio of the total Army.

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

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

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

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


270

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

These differences are perhaps better shown by comparing the average number of days lost per case. Officers in the United States lost on an average of 36 days per case, against 33 days in the American Expeditionary Forces. 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 in the American Expeditionary Forces. The average for the Army at home was 16 days, against 31 days abroad.

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

OCCURRENCE IN OTHER COUNTRIES

The highest admission rate for enlisted American troops during the World War was not in the United States, as might have been presupposed, due to mobilization influences, but was in the Philippine Department, where very high venereal incidences have been recorded since the year 1898.4 The Philippine rate for American troops during the war was 192.12 per 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 in causing this high rate; the incidence among white enlisted men in the Philippine Department was 180.14. The venereal disease rate among American troops in the 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 lowest venereal incidence (50.46), with 1,818 cases among a mean strength of 36,022 men.

FACTORS INFLUENCING INFECTION

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

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


271

fact so slight that it need scarcely be mentioned. It is true that very occasionally venereal infections have occurred and have been reported as being in line of duty, where, for example, an attendant became infected during 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 venereal disease in the Army is shown by reviewing the records from any angle, as these diseases were far more prevalent among the colored troops. It is not intended to imply that colored men are more susceptible, or that the white soldiers possess a higher degree of immunity to venereal infection; but from the Army standpoint the greater the proportion of colored troops the higher the venereal rate.

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

It is a matter of history that prostitution follows in the wake of armies. The soldier does not bring about this condition of lowered morality, but mobilization attracts women of both clandestine and professional types, and experience has shown that a very large percentage of such females are venereally infected.

Prostitution, in its relation to armies, was one of the most extensively studied of the health problems during the war. The calling of whole nations to service altered the conditions that obtained in former wars in which there were relatively small fighting forces, preyed upon by the professional prostitute. The World War greatly enlarged the field for venereal infection.

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

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

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

Year


Alcoholism

Venereal disease


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 admissions for gonococcus infection during the World War was 251,899. If to this figure cases reported as concurrent diseases (8,403) be added, the total occurrence for the American Army was 260,302, among a total mean annual strength of 4,128,479 officers and men. The strength from which the concurrent cases were reported can not be determined, therefore these cases are not included in further discussions on the occurrence of gonococcus infection unless specifically mentioned.


272

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:

 

 

 

 

 

 

 

 

 

    

Whitea

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 enlistedc

---

1,547

---

1

.07

9

---

20,119

---

    

Colored enlistedc

---

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 "other countries 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 was 61.02 for the total Army. Officers and enlisted men, American troops, contributed 250,874 cases (61.30), of which 2,027 (9.82) were officers. The remaining cases, 1,025, were among native troops (28.45). The rate of occurrence among enlisted men was 64.03 and about five times more common among colored troops (231.95) than among the whites (49.54).

Deaths, as would be expected, were very few, a total of 24 being reported 20 among white enlisted and 2 each among officers and colored enlisted men. There were 7,027 officers and men discharged from the service on certificates of disability on account of gonorrhea, with a discharge rate of 1.70 per 1,000 strength. These were cases with complications that unfitted the individual 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 so separated from the service. It is to be noted that the discharge rate among the colored enlisted men was about fifteen times greater than among the white enlisted men.

The more important influence of gonorrhea on the fighting strength of the Army is shown in the number of days lost from duty, which was 3,903,303, a noneffective rate of 2.59 per 1,000. This disease ranked third among the 30 most common diseases in the Army, from a standpoint of noneffectiveness. Officers lost 60,922 days (0.81) and American enlisted men 3,818,252 (2.69) days. The noneffective rate among white troops (2.42) was approximately one-half (5.44) that of the negro troops. Gonorrhea among the native troops was consistently less in its various aspects than among American troops. 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 on the prevalence of gonococcus infection; however, a review of the incidence by years and months shows a marked variation. The annual rates, for example, for the three years of the war were, respectively, 93.66, 113.30, and 99.93 per 1000 strength for enlisted men in the United States as compared with the annual rate of 54.84 for 1916, the year preceding the entering of the United States into the war. Great variations are revealed in a study by months of occurrence. For white enlisted 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 number of drafted men. In January, 1918, the rate for white enlisted men had fallen to 48.29, with a report of 4,412 cases during that month. The mean enlisted strength was about 1,100,000 men. By July, which was the peak for 1918, the rate had increased to 133.81, and the mean strength to 1,300,000. There was a progressive decrease in the ratios until the summer and fall of 1919, when a gradual increase brought the trend to 72.32; the end of 1919 found the rate among white troops 56.27 per 1,000 per annum, with an average for the period of 75.84.

Fluctuations were much greater among the colored enlisted men, and the occurrence among them determined the monthly and annual ratios for gonococcus 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 increase in the number of colored drafted men, an increase from 4,870 in April to 21,795 in October. January, 1918, had a rate of 230.30 per 1,000 and a mean strength of 50,705. The rate increased rapidly throughout the spring and summer, reaching 988.38 in August. There was, relatively speaking, a gradual decrease during the following year and in August, 1919, it was 217.85. At the end of 1919 the admission rate for colored enlisted men decreased to 22.82, these troops being principally of the Regular Army type. The rate for colored enlisted men in the United States throughout the war was 424.49 as compared with 75.84 for the white enlisted men.

COMPLICATIONS, SEQUELÆ, AND CONCURRENT DISEASES

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

TABLE 44.- Complications, sequelæ, 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 chancroidal infection were the most important. Of enlisted men admitted to sick report for gonorrhea, there were 4,467 cases in which syphilis was recorded as an additional diagnosis. That is, 1.8 per cent of the total primary admissions for gonococcus infection were associated with syphilis, and contributed 7.5 per cent of the complications and concurrent diseases. Chancroidal infections were reported in about the same proportions. There were 4,272 such cases, or 1.7 per cent of the total admissions to gonococcus infection. Chancroidal infections constituted 7.1 per cent of the total complications and concurrent diseases.

DIAGNOSIS

The diagnosis of gonorrhea in the Army during the war involved physical examination and microscopic examination of stained urethral smears and of cultures. While the majority of men having a purulent urethral discharge are


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suffering from gonorrhea, one should not forget that organisms, other than gonococci, cause urethritis. The possibility of a nonspecific infection in the acute stage should always be borne in mind. It is important that the presumptive diagnosis made on physical examination alone be confirmed by microscopic means, since in the Army the line of duty status is dependent upon it. During the war there were 3,444 primary admissions for nonvenereal urethritis, or 0.83 per 1,000 strength. It was more common than hydrocele, acute or chronic nephritis, and about as common as cystitis. In proportion to gonorrheal urethritis, it occurred in the ratios of 1 nonspecific to 73 cases of gonorrheal urethritis.

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

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

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

The urine passed during gonorrhea appears turbid from admixture with pus, and in it are little clumps or masses of desquamated epithelium. After standing, the pus settles to the bottom of the glass and a cloud of mucus appears floating above it. As the patient goes on toward recovery, the pus disappears, but the hypersecretion of mucus continues and occasions a cloudiness of the urine, giving it a mucilaginous appearance. After the mucus disappears, the "clap-shreds" persist for months, because isolated portions of mucous membrane are not covered with epithelium and are still secreting pus.

In the two-glass test, if the anterior urethra alone is affected, 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 the presence of pus. This is accounted for by the action of the "cut-off" muscle which forms a barrier between the anterior and posterior urethra. It prevents pus in the anterior urethra from flowing back into the bladder; so that in anterior urethritis alone the pus in front of the cut-off muscle is washed out in the first flow of urine, while the last of the urine will flow over a clean surface and remain clear; that is, the first glass will be turbid, the second clear. On the other hand, in posterior urethritis, the cut-off muscle holds back the pus, as it does the urine in the bladder, and the pus flows back into the bladder and renders all the urine turbid. When the urine in posterior urethritis is passed into two glasses, the second glass is turbid as well as the first. If it is desired to determine the condition of the anterior urethra in posterior urethritis, it can readily be done by irrigating the anterior urethra with saline solution and collecting the washings in a glass for inspection.

Microscopic examination of pus.-Microscopic examinations of pus are indispensable, not merely for the establishment of the diagnosis, but also for the observation of the progress and stage of the disease, for the selection of the appropriate treatment for the different stages, and finally for the purpose of determining whether the gonococci have been eliminated and the patient cured.


276

The gonococcus.-The gonococcus is coffee bean or kidney shaped, and usually found in diplococcus form, the flat or slightly indented side of the organisms facing each other. In pus from acute gonorrhea organisms are found both within and without the cells, crowded in masses in the leukocytes. The intracellular location of the organisms is of diagnostic importance, but is not so characteristically seen in pus from chronic cases.

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

For the absolute differentiation of the gonococcus, cultural methods are necessary.

In the prodromal stage when the discharge from the meatus is thin and scanty, microscopic examination of smears shows quantities of desquamated cylindric epithelial cells and a moderate number of pus cells containing clumps of intracellular gonococci. In the ascending stage a large number of pus cells, many of them containing gonococci, and a number of free gonococci are to be seen. The stage of decline is indicated by the appearance of squamous epithelial cells, showing that the erosions have begun to cicatrize and have become covered with newly formed epithelium. Clumps of gonococci are also present, adhering to the epithelium. The pus cells have diminished in numbers and a smaller number of them contain gonococci. As the disease continues to improve, pus cells amid gonococci disappear, and finally the discharge from the meatus is found to be composed only of squamous epithelium, mucus, and an occasional pus cell, without gonococci.

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

Gonorrheal ophthalmia had as its basis for diagnosis an acute purulent conjunctivitis in which the gonococcus was demonstrated; and in the few clinical records available for examination these patients also had acute gonorrheal urethritis.

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

Complement fixation in the diagnosis of gonococcus infections was performed sparingly in the laboratories of the base hospitals, general hospitals, and other permanent or semipermanent institutions. It was not a routine procedure, but was considered of value when positive results were obtained. In like manner, cultural methods were reserved for special cases. While necessary for the absolute differentiation of the gonococcus, these methods are slow, time consuming, and were considered not necessary in the usual case of purulent urethritis, especially when a Gram-negative intracellular coccus had been demonstrated.

PROGNOSIS

The gonococcus is not a great destroyer of life. From the Army's point of view, prognosis is measured by deaths and discharges of men from the service, and by the days lost from duty for men temporarily incapacitated. Among 251,899 admissions for gonococcus infection there were but 24 deaths. A more


277

detailed study of these deaths shows such concurrent diseases as pneumonia, and epidemic meningitis, which in all probability were the actual causes of death.

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

Virulence of the gonococcus differs in different cases. It is at times noted that when a person has chronic gonorrhea, the gonococci, when transplanted into the tissues of another person, are not capable of producing such virulent inflammatory symptoms as when taken from a fresh case. This attenuated virulence explains the fact that in such cases the period of incubation is comparatively long, the purulent discharge is scanty, the cases often become chronic, and result in prostatitis and stricture.

Another factor which influences the prognosis of gonorrhea is the state of the patient's general health. Gonorrhea acquired by persons affected with phthisis, or who are debilitated from any cause, is apt to run a subacute, but exceedingly protracted, course. Other causes which retard recovery may be grouped as follows: Posterior urethritis, prostatitis, etc.; reinfection from an urethral gland, seminal vesicle, prostate, etc.; lack of rest; alcoholic indulgence; too vigorous treatment, especially injections which are too strong or too frequently repeated; coitus.

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

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


278

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

As to the difference in race, there was a much larger percentage of colored drafted men with gonorrhea on entrance into the service than of white, and in both incidences the vast majority of cases had passed the very acute stage of the disease; furthermore, the colored soldier was often very anxious to be discharged from hospital especially when he was forfeiting his pay while confined there. These two factors are believed to account for the shorter period of hospitalization for gonorrhea among colored soldiers. In the United States 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, and colored, 23.8 days. The longer period in Europe, as compared with the United States, is accounted for, as above stated, by the fact that cases with complications were the ones usually admitted to sick report, while others were retained with their organizations.

TREATMENTa

ACUTE GONORRHEA

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

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

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

Dressings for the purpose of catching the urethral discharge to keep it from soiling the clothing always should be worn. Several varieties may be used: (a) For patients with a long foreskin, the familiar gauze butterfly; (b) for patients unable to hold the butterfly, a 4-inch gauze bandage 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.


279

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 of which gauze can be placed to catch the pus. The bags are to be suspended from a waist band. The loose bags permit and encourage a free flow of pus from the urethra, while they prevent retention. Constriction of the penis by dressings wrapped around it should carefully be avoided so as to insure no interference with the return circulation. A suspensory bandage should be worn when the patient is allowed to get up in order to relieve the sensation of dragging on the spermatic cord and to lessen perhaps the danger of epididymitis.

Oil of sandalwood is soothing and curative to the mucous membrane; it may be given during the acute stages, but will have little effect owing to dilution from the drinking of large quantities of water. Sandalwood oil should be administered in capsules in doses of from 0.5 to 1 c.c. three times a day after food. It sometimes disagrees with the digestion, or it may cause an intense pain in the back; when such symptoms occur, it should be discontinued. No copaiba or cubebs should be given in acute gonorrhea; they are serviceable only in the declining stages.

SEVERE ACUTE URETHRITIS

In very severe urethritis with intense reaction, profuse discharge, and great swelling and edema, it is good judgment to wait for some subsidence of the symptoms before beginning injections. In the meantime the parts should be kept clean; the penis held in hot water for 15 minutes at a time every few hours, and hot sitz baths given every three or four hours to relieve distress. 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 cocain hydrochlorate or procain. Sandalwood oil diminishes the pain on urination in most cases, so that the use of a local anesthetic is not often necessary.

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

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

These indications are very well met by the silver protein compounds of the argyrol and protargol type. The syringe should be all glass, of 5 c.c. capacity, with a smooth acorn tip. For injection, solutions in water are used of the following strengths: Argyrol, from 3 to 5 per cent; protargol, from 0.25 to 1 per cent. Before injecting, the urine should be passed so as to wash out the pus accumulated in the urethral canal. In making injections the tip of the syringe should be firmly pressed into the meatus, and the penis should be held under moderate tension. The solution should be injected with the utmost gentleness. It should be held in the urethra for at least five minutes. If


280

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

SUBACUTE ANTERIOR URETHRITIS

After from 10 days to 3 weeks in those cases that run a favorable course under the treatment with silver proteinates, the acute symptoms disappear. The discharge becomes watery and scant; microscopic examination reveals many newly formed desquamated epithelial cells and few or no gonococci; the urine in the first glass becomes clear or slightly turbid, although it contains many long mucous filaments. If treatment is now discontinued, relapse with extensive reinfection is certain to occur in from two to three weeks from the few gonococci left in the tissues. When the gonorrhea has reached this subacute 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. Since the silver proteinates only destroy the gonococci and have little effect on the inflammatory processes, it is necessary at this time to treat the existing catarrh of the mucous membrane with astringent remedies. At this point in the progress of the disease it is highly desirable to substitute copious irrigations of the urethra for the hand injections.

Irrigations -The solution best adapted for the double purpose of destroying the few remaining gonococci and of acting as an astringent to cure the superficial postgonorrheal lesions of the mucous membrane is silver nitrate in strengths of from 1:3,000 to 1:5,000 of distilled water. Irrigation with silver nitrate solution acts particularly well in the presence of a clear urine containing shreds of pus or mucous. It may be used every day or every other 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 for when there is a free purulent discharge containing no organisms. A purulent discharge that arises from the presence of a nongonococcic bacterial urethritis yields to irrigation with mercuric oxycyanide in solution in water in strengths of from 1:3,000 to 1:5,000. This should never be used if the patient is taking iodide or iodine in any form. The irrigations should be given at temperatures of from 110° to 115° F.-as hot as can comfortably be borne-and may be repeated as often as four times in 24 hours.

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


281

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

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

It should be borne in mind that it is possible to treat a gonorrhea too long, and to cause the discharge to persist by the simple irritation of injections. In such cases, there will be a secretion free from gonococci 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 the morning. In cases manifesting this condition, it is advisable to stop treatment and to allow the irritation to subside. In consequence, the mucous discharge will often disappear spontaneously.

ACUTE POSTERIOR URETHRITIS

Severe posterior urethritis demands complete rest in bed and measures directed to the relief of the distressing symptoms. All local treatment of the urethra should be suspended. The nearer the diet approaches to a liquid or milk diet, the better. Abundant water should be taken, but diuretics should not be used, because they cause the too frequent evacuation of an already overtaxed bladder. Saline cathartics should be given every other day to reduce congestion in the pelvis. For the relief of tenesmus and pain, hot sitz baths of half an hour's duration, repeated several times a day, are useful. Alkalies, which favor the growth of bacteria in the bladder by rendering the urine alkaline, are contraindicated, as they are in acute urethritis. Sandalwood oil is not only curative, but soothing and gives relief in many cases. In the severe cases morphine should be given to relieve tenesmus and desire to urinate. It is best to give it in these cases in rectal suppositories.

As a rule, the acute stage of posterior urethritis disappears promptly, 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 on principles similar to those applicable to subacute anterior urethritis. Solutions are applied to the surface, either by the injection of small quantities of concentrated solutions or by irrigations of copious quantities of dilute solutions.

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


282

urethra. This is to be repeated at intervals of one or two days according to the tolerance of the case. In order to prevent immediate precipitation of the silver by the urine, the injection should be made with the bladder empty.

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

As a rule, posterior urethritis extends to the prostate and seminal 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 abscess freely as soon as fluctuation is noticed, evacuating the pus, and allowing it to heal by granulation. It should be opened through a urethroscope from within the urethra, when this is practicable. If incision is done promptly, the occurrence of a persistent urethral fistula is prevented.

CHORDEE

The patient subject to chordee should empty his bladder just before going to bed; should sleep in a cool place, lightly covered; and, to avoid sleeping on his back, should tie a towel around his waist with a knot at the back. Before going to bed the penis should be given a prolonged immersion in hot water. When the patient wakes with chordee, he should get out of bed and immerse penis and testicles in cold or hot water, and before going back to bed should 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 afternoon and before going to bed, are useful; in extreme cases a morphine rectal suppository may be necessary.

EPIDIDYMITIS

Immediately on the development of epididymitis all injections or instrumentation of the urethra must be stopped, the patient be confined to bed, and put on a light diet. The testicles should be elevated by a bandage going under them and over the thighs, and hot applications should be made. Hot sitz baths for half an hour three times daily are soothing and hasten recovery. If the symptoms are severe, epididymotomy may be performed. This immediately relieves pain and hastens recovery.

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


283

ACUTE PROSTATITIS

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

The patient should be put to bed, sandalwood oil administered, and, if necessary, the pain and tenesmus controlled by opium suppositories. Locally either ice bags or hot poultices are applied to the perineum, a safe guide for the choice between hot and cold applications being the amount of comfort which is given to the patient. Hot sitz baths of from one-half hour to an hour's duration two or three times daily are always indicated. Irrigation of the rectum with hot water for half an hour at a time may be used instead. A rectal prostatic irrigator, or, in its absence, a return flow catheter, is introduced into the rectum, and a continuous flow of water as hot as can be borne, is passed through it.

If retention of urine should occur, it may be necessary to introduce 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 to relieve pain and facilitate catheterization.

Prostatic abscess -When a very limited area of suppuration of the prostate is present, involving perhaps two or three of the prostatic tubules, the temperature is only slightly elevated, and the local symptoms are not marked. After two or three days the temperature becomes normal and the tenesmus and frequent urination disappear. In such cases an incision into the prostate is not required, for the minute abscess generally ruptures into the urethra and the sinus fills in by granulation.

If, on the contrary, the symptoms do not improve within the first week, but the fever continues and chills occur, the local symptoms grow worse, and rectal examination shows an increase in the size of the inflamed prostate, it is evidence that an abscess is forming. These symptoms constitute an urgent indication to evacuate the pus; for if the pus is allowed to break through the capsule of the prostate, it will burrow through the tissues and may cause urinary infiltration and pyemia, or, at least, a fistula which will not heal without operation. In these cases immediate surgical measures are indicated. Two operations may be used to evacuate the pus: 1. The prostate may be exposed by a transverse incision in the perineum, and the collection of pus evacuated without opening the urethra. 2. An incision may be made in the perineal urethra, the mucous membrane of the prostatic urethra broken through with the finger, and the pus collection evacuated through the opening thus made.

ACUTE SEMINAL VESICULITIS

The general treatment of acute vesiculitis is the same as that for acute prostatitis, with which it is usually associated. Injections into the interior urethra, of course, are contraindicated; but above all things, any attempt 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, the indications for treatment are: (a) To rid the tissues of gonococci; (b) to cure the catarrhal inflammation in the mucous membrane and promote the formation of squamous epithelium to cover the erosions; (c) to cause absorption of the submucous infiltration; (d) to restore to normal the intraglandular and periglandular inflamed and infiltrated tissues. These indications can be met by irrigations with antiseptic and astringent solutions and by dilatations of the urethra with sounds and soft bougies.

When general catarrh of the mucous membrane is present and turbidity of glass 1 exists, free irrigation of the urethra and bladder by the gravity method, daily or every second day, using silver nitrate or potassium permanganate, soon clears up the diffuse inflammation in the mucous membrane, until the process is no longer general, but is reduced to isolated spots. This condition is denoted by glass 1 being no longer turbid; it does, however, still contain the shreds derived from isolated erosions which are not covered by epithelial cells and are still secreting pus, or from the prostatic ducts and Morgagni's crypts. Comma-shaped shreds which are often present are formed by the secretion from the open mouths of the prostate ducts and Morgagni's crypts. Gonorrheal shreds floating in clear urine continue until the submucous infiltrations resolve and the pathologic secretion of the prostate and crypts disappears.

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

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

Sounds may be passed too frequently. In cases of soft and recent infiltration, the intervals should be from four to seven days, always waiting until the reaction following has subsided. In cases of hard, organized infiltration the intervals should be a week. If the urethra is acutely inflamed and freely secreting pus, instrumentation is, of course, out of the question. Dilatations should not be started until the urine is clear and contains only shreds.

It makes no difference, as far as treatment is concerned, whether the submucous round cell infiltration is soft and recent or whether it has been transformed into scar tissue; the indications in either case are to promote its absorption by dilatation and pressure. Cases in which a considerable surface of mucous membrane is involved are unsuitable for dilatation until the catarrh has been checked by irrigations and the superficial process has been localized in a few spots in the urethra, as denoted by shreds floating in clear urine.

GLANDULAR URETHRITIS

Many intractable cases of gonorrhea lasting for years in spite of constant treatment are caused by a chronic inflammation of Morgagni's crypts. Such cases show few symptoms, the morning drop at the meatus being the most


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

These cases should be treated by dilatations with full-sized sounds followed by irrigations. When the mouths of the glands are occluded by the growth of epithelium, dilatation of the urethra opens them and forces out the purulent secretion. The irrigating fluid enters the cavities and acts on the chronic inflammatory processes within the glands. In that form of inflammation in which the mouths of the glands are held open and the entire crypt is stiffened and inelastic from the periglandular infiltration, dilatations cause the absorption of the infiltrate around the glands and promote a return to normal condition.

When, after sufficient treatment by dilatations and irrigations, it is found by urethroscopic examination that a few glands still remain chronically inflamed and suppurating, and are thus foci of infection, these should be destroyed. This can be accomplished by bringing them into view with the urethroscope, and introducing a galvanocaustic needle. The cauterization must be very superficial and rapid; otherwise there will be danger of stricture formation. Not more than three or four crypts may be destroyed at a sitting. It is possible by destroying the glands harboring the gonococci to cure in this way a chronic gonorrhea of years' standing which has resisted all the other usual forms of treatment.

CHRONIC POSTERIOR URETHRITIS

In the presence of free pus formation urethrovesical irrigations by the gravity method with a solution of silver nitrate from 1:10,000 to 1:4,000 or potassium permanganate, 1:3,000, is the best method of rapidly reducing the purulent discharge. After the urethra becomes clear, the prostrate and vesicles should be examined, and if found to be diseased must be massaged in connection with the irrigation. When the urethroscope shows the infiltrated changes localized to the colliculus, direct applications of from 10 to 20 per cent silver nitrate solution should be made once a week through the endoscope. Granulations in the posterior urethra should be treated by cauterizing with strong silver nitrate solution. Small polypi, or granulations on the colliculus may be removed by scissors, forceps, or a galvanocaustic point. If the utricle is infected it should be injected with silver nitrate solution with a small syringe.

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


286

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

The first indication in the treatment of chronic prostatitis is to improve the general condition of the patient by a proper regimen. Constipation is generally a prominent symptom, which is best treated with saline cathartics, because they have some effect in relieving pelvic congestion. All sorts of erotic excitement should be interdicted on account of their effect in inducing congestion of the prostate. Coitus should not be permitted, both because of its ill effect on the diseased prostate and because of the certainty of spreading the infection.

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

Treatment by massage and irrigation should be persisted in for from six to eight weeks, or until a microscopic examination of the expressed prostatic secretion shows only a small number of pus cells in the field. Many cases will be found to improve under massage up to a certain point and then remain stationary. In such instances it is advisable to stop treatment for a month. If after this intermission the remaining evidences of prostatitis have not disappeared, another course of massage may be given. Such treatment should be repeated until the pus cells in the expressed prostatic secretion are found on microscopic examination to be only from four to six in a field, and lecithin bodies are abundant.

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

Chronic seminal vesiculitis -The treatment consists in massaging and expressing the contents of the vesicles twice a week. Massaging empties the vesicles of their inspissated contents, without forcing the muscular fibers to contract; and, by the relief of distention and the rest thus afforded them, the muscles recover their tone.

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

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


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The duration of treatment must be protracted, for it requires from 2 to 12 months to effect a cure. In obstinate cases characterized by marked sexual neurasthenia or intractable gonorrheal rheumatism, free incision into and drainage of the seminal vesicles may be demanded. This is a procedure requiring expert skill.

CHANCROIDAL INFECTION

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

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

There were 39,044 primary admissions for chancroid, with an admission rate of 9.46 per 1,000 per annum. Of these cases, 105 were discharged from the service on account of disability; loss of time from duty amounted to 973,614 days, with a noneffective rate of 0.65 per 1,000 strength. As might be presumed, chancroid was relatively uncommon among officers, more common among white enlisted men, and with greatest frequency among native and colored enlisted men. There were 374 primary admissions for officers (1.81), 26,819 among white enlisted (7.45), 271 for native (7.52) and 9,937 among colored enlisted men, with the very high rate of 34.68 per 1,000 strength. More than 60 per cent of the discharges following chancroidal infection in the total Army were among colored enlisted men.

Although not as disabling to the fighting strength of the Army as either syphilis or gonorrhea, chancroidal infection caused considerable noneffectiveness. The ratio per 1,000 strength was 0.65 and the average number of days lost from duty per case was 24.9 as compared with 28.7 for syphilis and 15.4 for gonorrhea. The difference in time lost per case was approximately the same between officers (24.5), white (25.7) and colored (25.3) enlisted men. The average number of days lost among native troops was 23.4. Although the average number of days lost among the enlisted men, white and colored, was about the same, the noneffective rate was about five times greater for colored enlisted men.

DIAGNOSIS

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


288

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

Where sores were concealed it was recommended that the necessary incision, either dorsal or bilateral be made, in order that the lesion might be exposed for diagnostic and therapeutic purposes. Moore9 made a special report on the diagnosis of chancroid, and the effect of prophylaxis upon its incidence in the American Expeditionary Forces. During the 12 months ending March, 1919, there was afforded opportunity to see over 4,000 venereal cases, among which more than 800 were venereal ulcers. In a selected 10-month period, ending in February, 693 venereal ulcers were encountered. The original diagnosis, based on the clinical appearance of the sore and dark-field examination, was chancroid in 379 instances, or 54.5 per cent, and primary syphilis in 314, or 45.5 per cent. In order to obviate the possibility of unrecognized syphilis, an effort was made to follow each chancroid case for at least eight weeks, but, owing to military exigencies, this was possible in only 135 cases. Every sore was suspected as being syphilis until proven otherwise, and it was an unalterable rule that dark-field examination should be carried out on every sore for three consecutive days before search for the spirochete was abandoned. Moore declared that while it had been conclusively demonstrated that the bacillus of Ducrey is the cause of chancroid, it is exceedingly hard to find. In 81 cases, clinically chancroid, in which smears were made, the Ducrey bacillus 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 5 instances, proving that these methods of microscopic and cultural diagnosis are not to be relied upon. A Wassermann test was made when the patient was first seen, once a week thereafter for the first 8 weeks, and at the middle and end of the third month. All of the 135 cases were followed for more than 8 weeks, 97 of them for more than 12 weeks.

Autoinoculation proved to be of very little value for two reasons, according to Moore:9 First, because of the difficulty of controlling ambulatory patients, who frequently developed large spreading ulcers at the site of inoculation, which were very difficult to heal, and, second, because so-called positive reactions (positive in 24 to 48 hours) can be obtained from secondarily infected ulcers in which the spirochete can be demonstrated. A few experiments were conducted by Moore in Paris. Five men were selected with clinically typical chancroid, and from the sores three inoculations, about 2 inches apart, were made on the left arm. The top inoculation was left as a control; the middle one was treated at various intervals after inoculation, ranging from 10 minutes to 2 hours, with calomel ointment well rubbed in for exactly five minutes. The bottom inoculation was treated with tincture of green soap and warm water at the same intervals and with thorough use for five minutes. In all cases, the controls were positive, as was the inoculation treated with calomel ointment, while the lesion treated with soap and water was uniformly negative. Therefore, it may be stated that the history of incubation, clinical appearance of the sore, and examinations to determine the presence of the 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 illumination before local application of antiseptics or the cautery; all patients with chancroid infections should be subjected to frequently repeated Wassermann tests for several months, to prove the presence or absence of syphilis.

COMPLICATIONS, SEQUELÆ, AND CONCURRENT DISEASES

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

PROGNOSIS

The prognosis of chancroidal infection in the Army, as to recovery, was good. Among 39,044 cases of chancroid, 105 were discharged from the service on account of permanent disability, though it is very probable that causes other than chancroid were contributory in many of these. Among the primary admissions there were 4,811 complications and concurrent diseases, with one death; therefore it can be said that chancroidal infection did not increase the liability to death. Recovery was complete in all cases, with the possible exception of scars at the site of infection or operation. As to duration of the illness, but few diseases showed such a consistent general average among officers and enlisted men.

TREATMENTa

GENERAL TREATMENT

In order to hasten recovery, the patient with chancroid should be put to bed, kept clean, and given a nourishing diet. Rest not only makes for a prompt healing of the chancroid, but greatly reduces the danger of bubo. Destructive chancroids are seen in the dirty and debilitated. If patients with 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 of chancroid, abortive treatment is successful. The principle of all methods of abortive treatment is to convert the infected ulcer into a sterile one by the use of some destructive agent. This may be either the actual cautery, or one of several strong chemical caustics.

The thermocautery is doubtless the best agent for this treatment. Its application is as follows: The ulcer is thoroughly cleaned and well 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 a general anesthetic, preferably gas.

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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Chemical cauterization is done as follows: The ulcer is well cleaned, being first irrigated and then dried. Then a pledget of cotton wet with 5 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 chemicals subsequently to be applied. After it has been thoroughly dried, the entire surface 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 no infected point escape. Then the excess of phenol on the surface is taken up, and nitric acid is applied lightly in the same way. The ulcer should be flushed immediately with sterile water to stop the action of the acid. Instead of nitric acid a saturated solution of zinc chloride can be used. This is as active a caustic as nitric acid, and its action should be stopped as quickly after application by flushing with water.

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

The advantage of these methods of treatment is that, in successful cases, healing takes place quickly and the danger of bubo is almost eliminated. Their success depends on thoroughness in destroying the infected area. If the procedure fails to do this completely, harm results, because it produces a larger ulcer, which becomes infected from the focus of disease that has been left. Attempts at abortive treatment with superficial caustics, such as silver nitrate, are always failures. Attempts at abortive treatment should not be made unless the prospects of complete destruction of the diseased tissue are good.

Abortive treatment is contraindicated under the following conditions: (1) When the diseased area or areas are so extensive or so situated that the destruction produced by this treatment would result in considerable deformity. The chief situation in which it is contraindicated is in chancroid at the meatus. (2) When the inflammatory reaction is already intense and there is much edema. These would be increased by cauterization. (3) When there is inguinal adenitis. This would be aggravated by cauterization. (4) In healing chancroids. Here the infection is already under control and nothing would be gained by cauterization.

Abortive treatment will, of course, interfere with any further search for spirochetes. For this reason it should never be undertaken until every reasonable effort to find the spirochetes has been made. The early diagnosis of syphilis is so much more important than the prompt healing of a chancroid that efforts to heal the chancroid should be given no consideration until the question of diagnosis is settled as far as possible. And after successful abortive treatment there should be no relaxation in the weekly Wassermann tests or in the clinical observations until syphilis can be finally ruled out.

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


291

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

When for any reason it is impracticable to keep a wet dressing constantly applied, the next best course to pursue is to dust the ulcer after irrigation with argyrol crystals or iodoform and then cover it with gauzes spread with petrolatum. Dry powders alone are not good applications for chancroids. They cake into crusts, under which the pus accumulates, and this materially increases the risks of infection of the lymphatics and the occurrence of bubo.

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

In chancroids under a greatly swollen or long, tight prepuce, wet dressings can not be used. In these cases prolonged soakings in hot water several times daily are particularly serviceable. After each soaking the preputial sac should be cleaned by inserting into it a catheter or a long flat syringe nozzle and thoroughly irrigating with hot antiseptic solution. After the irrigation there should be injected into the preputial sac from 2 to 4 c. c. of a suspension of antiseptic powder in oil or glycerine, such as 20 per cent calomel, 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 a dorsal slit, if progress can be made without so doing for if a dorsal slit is made, the whole surface at once becomes chancroidal. Not infrequently in cases with intense reaction and great swelling no headway can be made while the prepuce is intact; in other cases the reaction becomes so exaggerated that, unless relief of tension is given, sloughing of the prepuce will occur. Under these 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 should never be attempted until the infection has entirely disappeared.

SUPPURATIVE INGUINAL ADENITIS

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


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accumulation of pus on the chancroid; so that with patients in bed and with their chancroids kept free from pus, bubo is a relatively infrequent complication.

When bubo threatens, extra care should be used to see that there is no absorption of pus from the chancroid; the patient should have complete rest, and hot applications should be applied. If fluctuation develops, the hot applications are continued until the gland has fully broken down. When it is soft throughout and full of pus, a small incision with a double-edge knife should be made and the pus evacuated. Iodoform glycerin, 10 per cent, is then injected into the cavity. The emulsion should be injected three times at the 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 aluminum acetate, 1 part in 7 of water, or boric-acid solution, or some other antiseptic solution. On the following day the wound is emptied by squeezing, and iodoform emulsion injected once and left in. The bandage is then applied, and in five or six days the wound is closed and healed. If after a week the wound is not closed, it should be injected again; this will usually result in healing in five or six days.

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

The plan of encouraging suppuration and evacuating the pus through a small incision is satisfactory in most cases when the glands break down rapidly. But sometimes suppuration goes on very slowly; and in these cases it is better to make a free incision, evacuate the pus, and dissect or curette out the partially broken-down remains of the glands. Then the wound is packed with gauze and allowed to heal by granulation. It is better to avoid this course if possible, as the subsequent healing takes six or eight weeks and requires daily dressing.

It was the practice a few years prior to the World War to endeavor to prevent suppuration in the glands by dissecting them out and trying to get a clean wound, which was closed by suture. This practice has now been abandoned because it was found that a solid edema, or elephantiasis, of the penis and scrotum and inguinal region often followed, in consequence of the obliteration of the lymphatic vessels in the area of the wound. Another objection was that, when patients came to operation, suppuration had nearly always 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 for the slow process of healing by granulation.

SYPHILIS

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

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 for the total Army and the total days lost from duty was 1,927,901. One hundred and forty-three deaths were charged to syphilis. Since the duration of the war was short, the above number of deaths obviously does not represent the toll that was claimed by syphilis among soldiers.

The above figures are not intended to represent total syphilis in the Army, but only those cases with manifest lesions. Doubtless there were many cases that were never recognized. Levin10 made more than 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 of syphilis among officers to be low, with one double-plus reaction in 59 cases examined. The following table shows the results of this survey, among white and colored 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 primary admissions for syphilis, of which 899 were officers. White enlisted men furnished 45,456, and colored enlisted 18,623 cases. The admission rate for officers 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 137 among enlisted men. White enlisted men contributed 82 and colored enlisted men 53 of these deaths, with ratios of 0.02 and 0.18, respectively. This same higher incidence among the colored enlisted men is also shown by discharges for disability and days lost from duty. The discharge rate for the white was 0.58 and for the colored enlisted men 3.95. White enlisted men lost 1,338,950 days from duty and colored enlisted men 502,437. The noneffective rates were, respectively, 1.02 and 4.80. The disease was relatively less common among native than among American troops. For the former there were 522 cases (14.49), with 3 deaths (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 reported in the United States. There were 51,528 primary admissions, with the high rate of 23.05 per 1,000 per annum. This disease was more common among white enlisted men 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 the latter there were 16,200 primary admissions, with the high rate of 111.09 per 1,000 strength. The majority of deaths, and practically all the discharges for disability, were recorded for troops serving in the United States. The death rate 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 days for white enlisted and 400,000 days for colored enlisted, with noneffective ratios of 1.28 and 7.65 per 1,000, respectively. The average enlisted rate at home was 1.72.

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

As shown in Table 45, syphilis was not as commonly reported in the American Expeditionary Forces as in the Army in the United States. There were 12,680 primary admissions in the former against 51,528 in the latter. The admission rate in the American Expeditionary Forces was 7.61 per 1,000 and 23.05 in the Army in the United States. Syphilis was about twice as common among officers abroad as it was at home, the admission ratios being 6.16 and 3.32 per 1,000 strength, respectively. It was about one-third as common among enlisted men overseas (7.68) as in the United States (24.21); and at home it 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 per 1,000 per annum, respectively.

OCCURRENCE IN OTHER COUNTRIES

Syphilis has been a common disease among American troops in the Philippines since the first occupation of these islands in 1898. During the World War there were 752 primary admissions among the enlisted man, white and colored, with admission ratios of 35.84 and 32.09, respectively; in this instance the rate was higher among white troops than among the colored. It is of interest 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 primary admissions among approximately 20,000 enlisted men; the rate was 8.68 per 1,000 strength. Syphilis was more prevalent among white troops in Panama than in Hawaii; 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 of stations that included China, Siberia, Russia, etc. The highest rate among the native troops was for the Porto Ricans (25.69). Among Philippine Scouts, numbering approximately 19,000, there were 195 cases (10.50). The Hawaiian rate was the lowest (4.10) recorded for any troops during the war.

DIAGNOSIS

The diagnosis of syphilis in the Army during the war was conducted along conventional lines and but little new was developed. However, never before were examinations carried out on such a large scale, nor has it been possible before to study data in such masses. The outstanding feature in diagnosis was the attempt at the recognition of syphilis as soon as possible after infection. This explains the relatively high occurrence of primary syphilis. Briefly, the methods used were physical examination, examination of the ulcer for the Spirochæta pallida, and serological methods. The luetin test was used scarcely at all. The colloidal-gold test and the cell count were used in selected spinal fluids. The Röntgen ray was used as an auxiliary in cases of suspected visceral syphilis.


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The importance of early diagnosis was frequently emphasized and, in this regard medical officers were advised by the Surgeon General as follows:7

The matter of prime importance in handling syphilis is to get it at the beginning of the infection. The earlier it is treated the better are the prospects of cure, and the quicker the soldier can be made noncontagious and gotten back to duty. It should be the constant effort to discover syphilis at the earliest possible time, if possible before the development of a possible Wassermann reaction.

To this end, every sore, whether on the genitals or elsewhere, that is open to any suspicion of being a chancre should be repeatedly examined for spirochetes. No determining weight should be given to the so-called specific clinical characteristics of any lesion that might by any possibility be a chancre. Experience has shown that the typical clinical characteristics of the chancre, aside from indolence-and this may be masked by 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-and elsewhere, if there is any reason to suspect them or if they are indolent and not readily to be accounted for-should be searched for spirochetes.

Chancroids in particular should never be accepted as uncomplicated by syphilitic infection. They are likely to have a double infection, and should always be zealously examined for Spirochæta pallida. Sometimes, in spite of the most careful search, the spirochetes escape detection in chancroids. For that reason, one can never be sure that a chancroid does not hide a chancre; patients with chancroid, therefore, require watching for the possibility of syphilis, and, when the spirochetes can not be found, should always have weekly Wassermann tests for three or four weeks until the question of syphilis can be decided.

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

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

Examination for Spirochæta pallida and diagnosis -To obtain the Spirochætæ pallidæ for examination two procedures are of value. In obtaining them directly from the lesion the surface should be wiped with gauze wet with physiologic sodium chloride solution to remove saprophytic organisms, especially the Spirochæta refringens. The rubbing should leave a clean oozing surface, not bleeding. Light curettement may be necessary in some cases. Moderate squeezing of the lesion will then cause an exudation of 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 be collected in a capillary pipette. It may be preserved for a few hours by sealing the pipette, or the specimen on the slide may be ringed with paraffin or petrolatum and kept on ice for variable periods up to 12 hours or longer. Delay impairs the validity of the findings, however, and multiplies uncertainties, so that examination should be made at once.

A valuable method, which relieves the observer of much of the responsibility for differential diagnosis of the organism, is glandular aspiration. This can be done on prominent nodes in the satellite adenopathy accompanying the primary lesion. It can also be performed on the indurated base of a suspected chancre. A sterile glass syringe, of 1 c. c. capacity, fitted with an ordinary stout hypodermic syringe needle, an inch or so in length, is sufficient. The skin over the gland is painted with iodine and the gland palpated and fixed between the thumb and forefinger of the left hand. The needle is plunged through the skin into the gland, the penetration of the capsule being indicated by the moving of the gland under the finger when the position of the syringe is changed. The gland is then held firmly while the needle is manipulated enough to macerate the tissue immediately around the point. Aspi-


297

ration will draw a drop or two of tissue juice into the needle and barrel. The fluid thus obtained is often rich in Spirochæta pallida. The method is not especially painful, and is easily borne by the average patient.

The Spirochæta pallida, as obtained for study by these methods, has a morphology usually easily recognized by the experienced observer. 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 blood cell, and the usual number of turns is from 10 to 20. It is rather slow moving, which is a distinctive characteristic. A movement in the direction of the long axis and a rotating movement are most commonly observed. The organism retains its clear-cut, regular spiral turns exceptionally well, even at rest-another distinctive characteristic. Long forms bent in the middle are occasionally seen.

From Spirochæta refringens, if this is not eliminated by proper cleansing, the Spirochæta pallida is distinguished by the fact that Spirochæta refringens is obviously coarser and the turns are fewer and less regular. Spirochæta refringens does not keep its corkscrew shape so well as Spirochæta pallida when at rest, and when in motion moves much more rapidly than the Spirochæta pallida. Spirochæta dentium, seen in mouth preparations, is much more minute than the Spirochæta pallida. Fibrin spirals have been mistaken for syphilitic spirochetes by inexperienced observers. In general it may be said that while the recognition of the organism of syphilis is not an affair for the tyro, a moderate amount of experience on the part of the examiner, coupled with the presence of numerous organisms of the above-described type in a given preparation made under favorable conditions, is sufficient for a diagnosis of syphilis and the institution of appropriate treatment. Failure to find them, however, is no evidence that the lesion is not syphilis.

In all suspected cases Wassermann tests should be made. It should be made a general rule that the first finding of a positive Wassermann reaction should immediately be confirmed by a second, but it is not necessary to delay beginning treatment until the second report is received. For the first 10 days after the appearance of the chancre the Wassermann reaction is usually negative. It is at this critical period that the establishment of the diagnosis of syphilis by demonstration of the specific spirochetes is of such importance, because it enables us to begin treatment while the infection is still relatively localized and can usually be aborted by thorough treatment. In suspected chancres in which spirochetes can not be found Wassermann 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 in which the spirochetes are found a Wassermann test should be made at the outset, and if it is not positive should be repeated at weekly intervals for the first few weeks to see if, in spite of treatment, it becomes positive. Further Wassermann tests should be made at about monthly intervals.

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

Though the Surgeon General's Office recommended certain laboratory methods, much latitude was allowed the officers in charge; therefore, methods used by all laboratories were not identical. Particularly was this true of laboratories in the United States. In the American Expeditionary Forces the instructions11 were that a man with a suspicious sore should be sent to the laboratory of the division, where preparation for staining and dark-field examinations were to be made by the pathologist, a consultation obtained with the urologist, if feasible, and the man returned at once to his unit with an immediate report of findings. Local application of mercurial preparations or cauterization of the sore was forbidden before smears for microscopic diagnosis were taken, and failure of the microscopic examination to demonstrate Spirochæta pallida was not to be regarded as final until several additional smears had been made.

Twenty-eight and four-tenths per cent of the admissions for syphilis were diagnosed in the primary stage. This was accomplished by examination of the sore for the Spirochæta pallida; 50.4 per cent were diagnosed in the secondary


298

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

No test was considered positive unless there was complete inhibition of hemolysis, except in the early primary cases when less inhibition was considered positive in a few cases. Four degrees of reaction are noted in reports from the Army laboratories. A positive reaction is reported as double-plus (+ +), and means that there is absolute inhibition of hemolysis. A doubtful reaction is reported as plus (+) or plus-minus (+ -), the former term indicating that there was over 50 per cent inhibition of hemolysis, the latter that there was less than 50 per cent inhibition of hemolysis. A negative reaction is reported as minus (-). In most civilian laboratories the results of the Wassermann test are reported as four plus (+ + + +), three plus (+ + +), two plus (+ +), plus (+), plus-minus (+ -), and negative (-). The four-plus reaction corresponds to the Army double plus, the three plus and two plus to the Army plus, the plus and plus-minus to the Army plus-minus.

Although, as generally performed, the Wassermann test is not a true specific reaction, the work of Noguchi12 and Craig and Nichols13 had proved that, with antigens prepared from pure cultures of Spirochæta pallida, complement fixation can be obtained with syphilitic sera, and that in such instances the reaction is really a specific one, due to antibodies in the patient's blood serum against the spirochete.

Examination of the cerebrospinal fluid, not only in cases presenting neurological signs and symptoms, but also as an indicator of cure of the syphilitic infection, was the practice in the Army. Negative findings in the fluid 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 military service in determining the status of the individual officer or soldier as to whether or not the illness was in line of duty. The number of such cases was exceedingly small; they were found more commonly among the medical personnel as the result of infection by patients. Lambie14 made a survey of approximately 30,000 Army syphilitic registers and found 139 cases of extragenital infection.

COMPLICATIONS, SEQUELÆ, AND CONCURRENT DISEASES

Since practically no tissue of the human body is immune to the syphilitic virus, the number of possible complications is large. Complications and sequelæ, however, develop relatively slowly and since the average length of service per man in the Army during the war was approximately a year,15 and the average period of time in hospital for syphilis was 28.7 days, it is apparent that the Army's World War statistics are of little interest in this connection. As previously stated, complicated syphilis, when detected, was a cause of rejection from military service; however, many uncomplicated cases were accepted for service. Such complications as cardiovascular syphilis and syphilis of the nervous system were but seldom reported.


299

TABLE 46.- Primary admissions, complications, sequelæ, and concurrent diseases reported with 12,843 cases of syphilis 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 præcox

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 but little or no value in determining the prognosis of syphilis. For the total Army during the World War there were recorded 51,119 deaths from disease. For syphilis, both among primary admissions and concurrent diseases, there were 317 deaths; that is, 0.54 per cent. Syphilis ranked twenty-first on the list of the most common causes of death among primary admissions for disease and if all cases, both primary and concurrent, be included, it ranked fifteenth. From the military 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 of scarlet fever there were approximately twice as many deaths, while time lost from duty was about twice as great per case. As a rule, syphilitics were admitted to hospital and held there during the contagious stage and while physically disqualified for duty. They were then returned to their organizations for prolonged treatment, and but rarely were readmitted to sick report. And as shown under treatment in this chapter, since the course of treatment was a long one, the total interference with duty can not be determined.

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

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

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


300

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

TREATMENTa

TREATMENT OF THE CHANCRE

Excision of the chancre is a procedure which theoretically should be useful, on the ground that it removes the important focus of infection. And when the location of the chancre is such that its excision will not cause deformity, surgical excision may be done; but excision of the chancre does not abort syphilis. The excised chancre should be preserved and sent for laboratory examination. Until the search for spirochetes is ended, the chancre should be treated only by cleansing with saline solution and covering with a compress 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 cent calomel ointment twice daily for a week; it should be kept clean and protected by a calomel ointment or some bland protecting dressing.

SYSTEMIC TREATMENT

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

ARSPHENAMINEb

There is agreement among syphilographers that the most effective time for producing radical results with arsphenamine is in the first few weeks of syphilis-best before the Wassermann test becomes positive-and that arsphenamine should be pushed at this time.

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

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

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.
bArsphenamine is the official name now applied to the drug formerly called salvarsan.


301

Such patients should be subsequently watched for a year with monthly Wassermann tests and treated should any evidence of syphilis be discovered.

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

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

In place of arsphenamine, neoarsphenamine can be used in 50 per cent larger doses. It may be somewhat less effective, but the difference is not sufficient to allow of dogmatic statements on this point.

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

PREPARATION AND CARE OF PATIENT

The urine should be examined before each injection of arsphenamine. 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-best in bed-and should take no food until the next morning.

REACTIONS FROM ARSPHENAMINE

As a rule the administration of arsphenamine is followed by no symptoms whatever. Occasionally, however, reactions occur from it; these vary in severity from slight, evanescent distress to symptoms of the gravest poisoning.

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

The reactions may be divided for consideration into early and late; the early reactions occurring from the very time of injection to 6 or 8 hours 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 slower action of a poison.

EARLY REACTIONS

Nausea.-The commonest reaction after arsphenamine is a feeling of malaise with some nausea from five to seven hours afterward. Not infrequently this amounts to a chill, followed by slight fever and more or less severe vomiting. These symptoms disappear in a few hours.

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


302

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

Febrile reaction -Rarely these reactions are more severe. The temperature may go to from 101° to 104° F. with headache and general pains, especially of the legs and back, diarrhea as well as nausea and vomiting, and an eruption of urticaria or toxic erythema. The treatment is rest in bed and a liquid diet until symptoms have subsided. The pain may be controlled by a few doses of salicylates. No more arsphenamine should be given in these cases until several days after all symptoms have disappeared, and any further administration of the drug should be in relatively small doses and at intervals of not less than a week.

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

Immediate acute reaction -The early reaction which in rare cases accompanies or immediately follows the administration of arsphenamine is that of an acute poisoning, characterized by intense congestion from vasomotor disturbances; this is the so-called anaphylactoid reaction of arsphenamine. It is probably due to impurities in the drug. In these cases the patient suddenly-perhaps before the injection is finished-manifests symptoms of distress. He may first notice a taste of garlic or ether, or of a metallic substance. An erythema appears on the neck and spreads thence over the face, and the jugular pulse is exaggerated and rapid. He complains of faintness; the pulse becomes weak and the respiration labored. The face is puffed and congested; 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 pulse may become imperceptible, the patient cyanotic, and syncope may occur. Altogether the picture is extremely alarming in the severe cases, but fortunately the symptoms as a rule quickly improve, and recovery nearly always takes place.

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

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

LATE REACTIONS

Lowering of general health.-Occasionally during a course of arsphenamine a patient's general health becomes lowered without other 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-likely to be overlooked because of their insidiousness-should lead to careful consideration of the case. Patients who are doing well under specific treatment show it in an improvement in their general well-being. If this lowering of the health progresses under arsphenamine, it should be discontinued. The patient should be relieved from duty, placed on a liberal, perhaps forced, diet, given tonics, and his elimination stimulated by abundance of water and the use of laxatives or cathartics; also he should be carefully examined for other diseases.

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

These preliminary manifestations of intoxication usually disappear spontaneously in a few days, although rarely they develop into the severe cases. If arsphenamine is continued in spite of these warnings, there is likely to develop a universal exfoliative dermatitis with nephritis. In extreme cases the nephritis is severe, accompanied by high fever, diarrhea and bronchopneumonia, and the result may be fatal. The same measures, to a greater degree, are indicated here as already suggested for lesser intoxication-complete rest, support of the patient's strength by an abundant diet, and stimulation of elimination.

Nephritis - Severe nephritis with its sequelæ may occur without skin symptoms. For this reason the urine should always be carefully watched while arsphenamine is given.

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

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

Persistent evidence of nephritis developing in the course of arsphenamine administration is another matter. It requires that the course be stopped and not resumed until the nephritis has disappeared; and then the further use of the drug must be with extreme caution. If these precautions are neglected the case is likely to develop into one of severe, permanently disabling, or fatal type.

Jaundice -In rare cases jaundice occurs in the course of the use of arsphenamine. It is always a sign of serious intoxication and should cause immediate, careful attention to be given to the case. Such cases may go on to acute yellow atrophy of the liver with fatal termination. They require in the way of treatment measures for overcoming intoxication of the sort already outlined. The larger proportion of jaundice cases are said to follow neoarsphenamine.

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


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

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

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

Similar reactions, producing symptoms of a character dependent on the location of the syphilitic focus, may occur with syphilitic lesions of the viscera, or of the circulatory system, particularly in myocarditic coronary arteritis and aortitis.

To guard against these accidents, when there is reason to suspect lesions in any of these structures, particularly in the brain, mercury and iodide should be vigorously given for several days before arsphenamine is started, if the symptoms are not so urgent as to warrant taking the risk of a Herxheimer reaction, and then the use of arsphenamine should be cautiously begun, with small doses, and only after two or three injections should full doses be given.

In these reactions treatment is symptomatic.

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

RECURRENCES OF NERVE INVOLVEMENT

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


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patients who have already had arsphenamine. Of course, when these 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 of arsphenamine is a rigid asepsis, and only extreme conditions justify its administration when this is not obtainable. The apparatus should be boiled for 20 minutes. It is important that freshly distilled water be used for arsphenamine solution. Thirty c. c. of water per decigram of arsphenamine is a safe dilution. The ampule should be sterilized by immersion in a strong antiseptic solution, such as mercuric chloride, 1: 1,000, and then should be immersed in 95 per cent alcohol in order to be sure it is not cracked. If it has been immersed in mercuric chloride it must be carefully wiped dry before it is opened. It must never be sterilized by boiling.

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

In the event that the arsphenamine precipitates somewhat on dilution, 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 dilute hydrochloric acid may be added and the neutralization repeated. The drug should be administered promptly after preparation, and no more than enough for use on the patients to be treated at the time should be prepared.

The technique of injection of the solution is comparatively simple, and the older custom of making an incision to find the vein, with its resultant scarring, has been abandoned by skillful operators. A variety of needles has been proposed, but the Schreiber 18-gauge with thumb guard and a proper adapter, or even a plain needle, will answer all purposes. In difficult cases a finer needle may make it much easier to get in the vein. The skin over the field of opera-


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

In nervous patients, local anesthesia may be used to advantage. The needle is pushed directly through the skin over or to one side of the vein and then introduced into the vein. As soon as the blood returns freely through the needle, the adapter attached to the tube of the container is fitted to the shoulder of the needle, the tourniquet is released, and the injection begun by elevating the container about 2 feet. As a rule assistance is desirable, since the operator is occupied by keeping the needle in position in the vein. Failure to enter the vein is apparent by this method, before injection is begun, through the imperfect flow of blood through the needle. The saline solution contained in the tube allows sufficient warning of the infiltration of the tissues before the arsphenamine solution reaches the needle point. Various forms of apparatus which inject saline solution as a test before beginning the injection of the arsphenamine are not essential and are often complicated. A glass telltale in the rubber tube permits the operator to watch the progress of the injection. When the injection is completed, the lowering of the container below the level of the arm before the needle is withdrawn will aspirate a small amount of blood from the vein and prevent the escape of solution into the tissues.

Recent investigations have shown that the danger from intoxication with arsphenamine is much greater when it is administered in concentrated solution or is injected rapidly. For this reason it should be used in weak dilution and slowly injected.

Infiltrates, if they occur, are usually trivial, provided the operator has been on his guard. The escape of arsphenamine into the subcutaneous tissues is indicated by a burning sensation, which the patient should be warned to report. The reaction which ensues when arsphenamine is injected around the vein is inflammatory, with induration and infiltration, and may, if severe, progress to a slough. Arsphenamine infiltrates should be treated by wet dressings, ice bag, and, after inflammatory symptoms subside, by massage and passive movement. An alarming degree of involvement may subside with practically no damage after several weeks or months. Thrombosis of the vein is an infrequent complication if the drug has been properly diluted, and should be treated on general indications.

TECHNIQUE OF NEOARSPHENAMINE ADMINISTRATION

The original administration of neoarsphenamine, in dilutions similar to those used with arsphenamine, has been greatly simplified by the injection of the dose in concentrated solution. In this procedure, the dose of neoarsphenamine is dissolved in 10 c.c. of freshly distilled sterile water at room temperature-not hot water. The solution is drawn up into an all-glass syringe and administered as an intravenous injection after the usual preparations. The method is rapid and extremely convenient, and its applicability to difficult cases is apparent.


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The solution of neoarsphenamine, being already neutral, requires no addition of sodium hydroxid. Care must be taken to avoid infiltrates with the concentrated solution, but in general infiltrates with neoarsphenamine are apt to be less serious than those with arsphenamine.

The French preparation novarsenobenzol (Billon) was used almost exclusively with the American Expeditionary Forces. The results were satisfactory. 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 of great practical advantage in the field.

MERCURY

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

A course of mercury should consist of 9 or 10 weekly injections of an insoluble salt, of from 24 to 30 injections of a soluble salt at two-day intervals, or of from 40 to 50 daily inunctions of mercurial ointment. The administration of mercury either by inunction or by intramuscular injection is effective; and in the selection of either method one may be properly influenced by considerations of convenience and practicability.

INUNCTIONS

If inunctions are used, it is necessary to see that they are properly 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 and having each man rub the back of the man in front of him. From 4 to 8 gm. of mercurial ointment may be used for a daily inunction. It is desirable before the inunction to wipe off the area to be rubbed with alcohol or to wash it lightly with soap and water and dry. The ointment should be rubbed in slowly and gently with the palmar surface for 20 or 30 minutes, or until the ointment is practically absorbed. Any excess should be allowed to remain on the skin. After six inunctions a day should be skipped and the patient allowed a bath.

In giving inunctions, hairy surfaces and the thin skin of joints should be avoided, and the same area should not be used often enough to produce 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 are mercuric salicylate or calomel in oil, or metallic mercury in the form of gray oil. Perhaps the best proportion for the salicylate or calomel suspension is 20 gm. (weight) in sterile olive oil or thin liquid petrolatum, enough to make 100 c. c. (volume). A good formula for mercurial oil (gray oil) is redistilled mercury, 20 gm.; chlorbutanol, 2 gm.; anhydrous lanolin, 30 c. c. and liquid petrolatum, enough to make 100 c. c.

The intramuscular dose of calomel, salicylate, and metallic mercury are the same. These three preparations, being of the same strength, have the advantage of having the same dose. The average dose of either, for an adult man, is 0.06


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

The curative action of the injection of soluble salts of mercury is perhaps less than that of the insoluble. However, they are free from the dangers of cumulative effect which are inherent in the insoluble salts; and in emergencies, when there is need to get prompt, certain, and vigorous effect of mercury, they are of great value. Mercuric chloride, mercuric succinimide, or mercuric benzoate are the most useful soluble salts for injections. Good preparations are 1 or 2 per cent mercuric chloride or 1 or 2 per cent mercuric succinimide with 1 per cent sodium chloride by weight in distilled water. The average 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 sodium chloride, average dose 0.015 gm. every second day.

The American Expeditionary Forces used as routine treatment intravenous injection of 1 per cent solution of mercuric cyanide. The average dose 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-glass Lüer hypodermic syringe with a 1½-inch, 20 or 22 gauge needle is used. The needle should have a slip shoulder to permit of its easy detachment from the syringe. Sterilization of the skin with tincture of iodine is sufficient; emulsions once sterilized will remain so with reasonable care in their handling. In military service the syringe and needle should be sterilized by boiling, or by liquid phenol, and the water or phenol removed by filling the syringe first with alcohol and then with ether.

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

The needle with the syringe empty should be introduced to its full length, and the syringe then detached and filled with the necessary dose. This introduction of any empty needle is a safeguard against making an injection into 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 is nearly always the case, there is reasonable security against introduction into a vein.

In general, in order to prevent leakage of the emulsion, it is desirable to introduce the needle on a slight slant in the tissue. This may be accomplished by drawing downward on the skin of the buttock, which permits a valve action as soon as the needle is withdrawn and the hand released. The injection if made slowly is practically painless. The development of infiltrates and nodules of any considerable size, or in any number, during a course of injections, is either a reflection on the operator's technique or shows the case to be unadapted to this form of treatment. When an insoluble salt has been used, each of these nodules represent encapsulated mercury, and materially increases the danger of cumulative action. Daily massage by the patient will usually reduce them in a short time. If their formation can not be prevented the 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 the kidneys; and patients under intensive treatment with mercury and arsphenamine should have the renal functions carefully watched. An examination of the urine for albumin and casts should be made weekly, and the development of definite nephritis during a course of treatment is an indication to stop. Treatment may be undertaken again after the nephritis has disappeared, but must be less vigorous than before and must be carefully watched.

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

SALIVATION

If salivation occurs, the mouth should be cleaned at short intervals by washing with hydrogen peroxide solution or half saturated potassium chlorate solution. Dobell's solution may also be used, and, while less effective, it has the advantage of being soothing. Pledgets of cotton or gauze moistened with boric acid solutions placed between cheeks and teeth give comfort and get rid of exudate. Atropine is useful, given to the point of reducing salivary secretion. If the patient has been using inunctions, he should, in order to get rid of mercury in the skin, be greased with an oil and then well washed with soap and water and put in fresh clothes. He should have a soft, nutritious diet, be protected from exertions, and given the care for exhausting 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 should be made at monthly intervals, and after it has apparently become permanently negative, it should still be repeated at intervals of two or three months for at least a year. It should be remembered that the Wassermann test is not likely to be positive for the first 10 days of the chancre. After it becomes positive, the obtaining of a single subsequent negative reaction means little; it must remain negative over a period of months to justify the conclusion that it is permanently negative.

In estimating the effect of treatment on syphilis, not only the disappearance of specific clinical symptoms and of the positive Wassermann reaction should be considered, but the patient's general well-being as well. In zeal to sterilize a patient of spirochetes the effect of the treatment itself on the patient should not be overlooked, and treatment should not be pushed beyond the point at which the patient is able to tolerate it without distinct lowering of his general physical tone.

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


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There is room for difference of opinion as to the advisability of spinal puncture or a provocative injection of salvarsan with a subsequent Wassermann test in every case before discharge. Conservative practice reserves the use of these diagnostic measures to cases in which there are special indications.

LATE SYPHILIS

The late manifestations of syphilis in the Army are less common 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 not constitute a difficult clinical problem. In old cases of this sort there is not the need for the intensive treatment administered in early cases. These patients should have mercury and potassium or sodium iodide until their lesions are cured. How much further treatment should be carried is a matter for judgment in the individual case. The deep lesions of late syphilis-syphilis of the viscera, of the vascular system, especially of the heart or aorta, and of the central nervous system-indicate such serious impairment of the body that these patients will not be able to endure the strain of military life in the field. If the lesions in such cases can be controlled, it may be practicable to find duties for which the patients are still fit; otherwise, they should be considered 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 Spirochæta 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.