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 Spirocheta 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 Spirochata pallida and diagnosis.-To obtain the Spirochata 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 Spirochata 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 differ ential 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

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

The Spirochata 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 Spirochata refringens is obviously coarser and the turns are fewer and less regular. Spirochæta refringens does not keep its corkscrew shape so well as Spirochata pallida when at rest, and when in motion moves much more rapidly than the Spirochata pallida. Spirochata dentium, seen in mouth preparations, is much more minute than the Spirochata 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 instructions" 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 Spirochata 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 Spirocheta pallida; 50.4 per cent were diagnosed in the secondary

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 fourplus 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 Noguchi 12 and Craig and Nichols 13 had proved that, with antigens prepared from pure cultures of Spirocheta 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. Lambie made a survey of approximately 30,000 Army syphilitic registers and found 139 cases of extragenital infection.

14

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, 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.

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

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

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.

TREATMENT @

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 arsphenamine 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.

ARSPHENAMINE

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.

• Based 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.

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