for this meeting is to establish additional means for drastically reducing the incidence of venereal diseases. As typhoid and smallpox have become unimportant diseases in this country because of unremitting diligence on the part of physicians and health departments, so must venereal disease be relegated to a minor role. Plans for the future must consider not only methods for lowering incidence but also for the maintenance of such ceaseless vigilance that never again will our people be burdened with syphilis and gonorrhea. During the past few years remarkable advances have been made in treatment of syphilis and gonorrhea. These advances have been so far largely on a research basis. The principal agencies directing this research are the National Research Council, the Army and the Navy Medical Departments, and the United States Public Health Service. Preliminary reports have been very encouraging. The later reports which are to be made during this conference may confirm the belief that the physician at last has drugs and procedures adequate to solve the treatment problem. However, no matter how effective they are, these new drugs or new methods of administering old drugs can have little value for reduction of the attack rate of venereal diseases unless persons who are infectious are brought to the physician before they have spread their infections to others. The most desirable, the most effective, and the least expensive approach to venereal disease control is through prevention. A first step in prevention is to find and immediately quarantine individuals with syphilis or gonorrhea before infection can be spread to others. Treatment is the most effective quarantine, since forcible separation of all infected persons from society is a procedure obviously impractical in this country. Prevention through personal prophylaxis, higher moral standards, prostitute repression, and education are all essential, but they are and always will remain secondary to treatment. Our direct responsibility as physicians and health officers is for medical control measures and for dissemination of information about these diseases and their treatment. We recognize the need for and give our support to those programs which are intended to reduce prostitution and provide social welfare services, but their actual operation belongs elsewhere. It is the tradition of physicians and other scientists to search everlastingly for the truth about the ills which plague mankind, and to make that knowledge available to other physicians and to the public. The obligation of physicians and health officers to tell the people the whole truth about venereal disease is as important as with any other communicable disease or hazard to health which requires individual and group cooperation from the general public. The people must know how syphilis and gonorrhea are spread. They must learn how venereal disease may be avoided and cured. Negative action which serves to keep these facts from the public serves to negate human progress. To tell the people the truth is to reaffirm our belief that when free and intelligent men and women are given the facts, they are capable of properly fashioning their destinies. To tell the scientific truth is to provide the strongest reinforcement to the church, to the home, and to the school in their efforts to develop higher standards of sex conduct among all people. The broad dissemination of medical truth about venereal disease is essential if law enforcement and social agencies are to receive full public cooperation. Venereal disease control of the future, so far as the physician and health officers are concerned, must devote a great deal more emphasis to case finding and to public education. It is estimated that about 230,000 new cases of syphilis are being contracted in this country annually. Under existing methods and facilities for case finding we believe that each year only about three-fourths of these infectious cases are discovered and treated by public clinics, by the armed services, and by private physicians. We believe further that less than one-half of those found and treated remain under treatment long enough to insure against infectious relapse. The unfound and untreated one-fourth and the insufficiently treated, lapsed cases are the source of infection for the annually recurring new crop of primary syphilis, and they accumulate year in and year out to form the great reservoir of latent and late syphilis. There is no way of estimating with even reasonable accuracy the incidence of gonorrhea. Let us, however, take the arbitrary minimum ratio of 3 to 1 between gonorrhea and syphilis and assume that nearly a million people contract gonorrhea in this country each year-and this, may I remind you, is the minimum. During the past year private physicians and public clinics reported only 311,795 gonorrheal infections. For purposes of this discussion it is assumed that all of these reported cases received adequate treatment. There must be an extremely large residue of infected persons, therefore, who either receive no treatment at all or who resort to self-treatment. These are the people who keep the chains of gonorrheal infection going. These are the people who must be found and treated. At present there are in the Nation's 3,800 clinics less than 2,000 workers engaged full time in investigating venereal disease contacts reported by the armed services, private physicians, and clinic patients. Additionally, about 6,000 health department nurses and social workers devote part of their time to venereal disease followup. These efforts do not suffice to perform the case finding which is necessary in the control program of the future. A few clinics are doing very fine contact investigation work. The majority are evidently making but slight effort to obtain the names and to locate the contacts of known infectious cases. Unfortunately, in many clinics vastly more time is given to holding old, noninfectious cases than in finding those which are spreading disease throughout the community. The Public Health Service and most State health departments believe that vast improvement must be made in contact investigation before attack rates can be significantly reduced. Further, we believe that the extent of the problem requires that a great many more interviewers and investigators be recruited, trained, and put to work on orderly, well supervised case-finding programs. In cooperation with State health departments and voluntary agencies, the Public Health Service is conducting research investi gations aimed at evolving the most successful methods of interviewing and contact investigation. It is reasonable to expect that these studies may form the basis upon which a well-rounded training program can be established. During this war period one of the major factors in preventing a serious increase in venereal disease has been the information gained from the Selective Service examinations for syphilis, and from the contact reports furnished by the armed services to health departments. Within the past few months Selective Service has more or less ceased to be an active case-finding device, and as more Soldiers and sailors are moved overseas, reports of their contacts in this country will begin to decline. When the war is over new casefinding procedures will be needed. This need will be intensified by sociologic, psychologic, and economic problems of readjustment which will probably be such as to cause a venereal disease problem no less acute than that caused by war itself. Universal compulsory examination is not possible at the present time, so we must search for practical alternatives. Some of the opportunities for serologic and clinical examination for venereal disease which have been suggested and, at least, merit consideration by health officers and by private physicians include: 15,000,000 annual hospital admissions 2,500,000 annual births 1,500,000 annual high school graduations 4,000,000 annual insurance examinations Several million industrial employment medical examinations. Obviously, these are rough estimates containing vast duplication. It is apparent, however, that here are situations where medical examinations are or can be conducted and through which literally millions of opportunities for routine serologic and clinical examinations for venereal disease control can be obtained. These are but a few of the problems and opportunities of venereal disease control today, and in the postwar period of tomorrow. In planning this conference it was felt that these problems and other aspects of venereal disease control could be grouped in four major classifications. Consequently sections were established for each category as follows: 1. Diagnostic and Therapeutic Procedures in Gonorrhea-Chairman, Dr. Rogers Deakin ; Secretary, Senior Surgeon C. J. Van Slyke. 2. Diagnostic and Therapeutic Procedures in Syphilis-Chairman, Dr. A. W. Neilson; Secretary, Surgeon Howard P. Steiger. 3. Epidemiology-Chairman, Dr. N. A. Nelson; Secretary, Lt. Col. Robert Dyar. 4. Education and Community Action-Chairman, Dr. William F. Snow; Secretary, Dr. H. H. Hazen. To these sections I give the following charges: 1. Section on Diagnosis and Therapy of Gonorrhea.-There never have been any reliable figures on the prevalence or incidence of gonorrhea in this country. The most conservative estimate is that the attack rate of gonorrhea among soldiers and sailors is at least three times higher than that of syphilis. Many qualified observers believe that this estimate is too low for the general population. Whatever the actual incidence of gonorrhea, we know there is enough infection to make this disease a serious public health problem. We know also that not enough attention has been paid to the public health control of this disease. We know that our present knowledge of gonorrhea is inadequate. Conflicting theories regarding prevention, diagnosis, and treatment beset us from all sides. It will be the responsibility, therefore, of the section considering diagnosis and treatment of gonorrhea to recommend means to bring system and order out of confusion and conflict. This section will examine all the evidence and, in terms of practical control measures, recommend as nearly as possible precise and definite procedures which may be followed by all official health agencies and through which the essential cooperation of the private physician may be insured. The section will have to consider many questions. In the field of prevention it will need to review the possibility of developing more satisfactory prophylactic agents. In addition to those external agents which may be applied without irritation, the possibility of a systemic approach must be considered, such as oral administration of penicillin-like compounds or some immunizing vaccination procedure. An important preventive topic is how physicians may better utilize their professional prestige in encouraging moral prophylaxis among their patients. Methods should be considered also for convincing both private practitioners and clinics of the supreme importance of obtaining from their patients information about contacts. In this connection it is important to consider how the private physician can make effective use of the health department nurse as his personal agent in following up the infectious contacts of his patients. Better cooperation is also needed from the private physician in reporting cases of gonorrhea coming to his attention. Many very complex problems will face this committee in the field of diagnosis. What are satisfactory diagnostic criteria? Will clinical and epidemiologic evidence suffice? Or must the physician also have laboratory evidence? These are important questions, as are the problems of whether positive spreads alone are sufficient evidence Further, we need to know if there is any difference between the reliability of spreads in male and female patients, and whether there is any difference between male and female with respect to acuteness and chronicity of the disease. Many think cultures are essential in diagnosis. If so, should they be accepted only with carbohydrate fermentation tests? Is sufficient recognition being given to nonpathogenic gonococcus-like organisms which may inhabit the genitourinary tract? In this connection, the possibility of confusion is illustrated by a recent study of 293 males selected more or less at random from a prison population. Of this group, gonococci were found in 3 men, while other Neisserian forms were found in 22. The possibility of developing still other tests may be discussed, 641013°46-2 complement fixation, for example, or an effective skin test. Many physicians are also interested in the development of more satisfactory methods for differential diagnosis of gonorrheal arthritis. Gonorrhea therapy today is in a state of flux. It is difficult even to think about, much less to discuss anything other than penicillin. It is important, therefore, to bear in mind that the final timedosage relationships have not yet been established. Any present method of therapy must give way promptly to improved schedules, methods, and treatment agents, antibiotic or otherwise, as soon as these have proved their worth. What safeguards will this section recommend against the masking of syphilis by treatment of gonorrhea with agents which may prevent development of syphilis symptoms and yet are inadequate to arrest the disease? Assuming that penicillin or a similar effective and innocuous drug becomes available in sufficient quantity and at a reasonable cost, health officers will welcome this section's views as to whether it should be distributed freely to all physicians for treatment of their gonorrhea patients. Will it be advisable for the physician to use this free penicillin for gonorrhea treatment on the basis of any possible diagnosis or should he withhold treatment until diagnosis has been confirmed beyond reasonable doubt? These questions may be of paramount importance very soon. The whole field of treatment of gonorrheal complications needs to be surveyed by this section, and, finally, the section will wish to include in its deliberations the question of criteria of cure. 2. Section on Diagnosis and Treatment of Syphilis.-It will be your duty and responsibility to weigh with utmost care the available evidence on new treatment drugs and methods and to decide which are to be recommended for use by the physician in private practice and for use in clinics and hospitals. It will be your duty to recommend in general terms how the drugs are to be distributed and utilized so that treatment will be available to every person with syphilis in this Nation regardless of economic status, race, age, or place of residence. This must be done with the least possible disturbance to the traditional relationships between the private physician and his patient, and between Federal, State, and local health departments in their accepted spheres of public responsibility. If you believe that further research and observation are necessary before general use of the new drugs and treatment methods can be urged, you should make specific recommendations. Equally important in your deliberations will be the question of diagnosis of syphilis. It is obvious that successful new treatment schemes are of limited value to public health unless infected persons are found early in the infectious stage and brought to an effective treatment source. It is of the utmost importance that we institute a program of case finding vastly larger in scope and effectiveness than now practiced. Consideration of the case-finding problem is the responsibility of the section on epidemiology, but diagnosis and case finding are closely related. Large-scale case finding is handicapped so long as our major diagnostic technic for syphilis is regarded by the public as inconvenient. A radically improved test would solve many problems in |