ministration of the initial course of 100,000 units, and an increasing proportion of such cases is being treated on an outpatient status. There is no reason to take up hospital beds with such patients. If cure is not obtained by the initial course within a period of a week, it is advised that the patient then be admitted to a hospital, where careful study for complicating urologic conditions is carried out. A second course of 200,000 units is given. In the very patients who are not cured by this second course of penicillin, administration of a subsequent series totaling 500,000 units is advised. To date (October 1944), no instance of failure of anterior or posterior gonorrheal infection to be cured by this regimen has been reported. It is difficult to appreciate the enormity of this advance until one has experienced the administrational and medical difficulties of caring for the large residum of resistant gonorrhea which was encountered under sulfonamide and local therapy. Such men constituted a serious problem in military medicine and in discipline. This problem no longer exists.

III. Diagnosis and Treatment of VD in the Armies

Certain difficulties in the diagnosis and treatment of venereal diseases become accentuated by conditions obtaining in the combat zone. For various reasons which need not be outlined here, adequately trained personnel and sufficient technical facilities for the accurate and prompt diagnosis of venereal diseases are difficult to provide in hospitals in the Army zone which are receiving large numbers of surgical casualties.

On the basis of plans made some months prior to D-day, therefore, the following general scheme of management is being employed within the Army areas in ETO, and is, it is believed, resulting in greatly improved accuracy of diagnosis and effectiveness of treatment. All patients with penile ulcers, or with gonorrhea which has resisted an initial course of 100,000 units of penicillin, are evacuated immediately to a venereal disease treatment center, usually established in a convalescent hospital. This special treatment facility is staffed by a medical officer with experience and ability in the diagnosis and treatment of venereal diseases, and adequate laboratory facilities for diagnosis are maintained, using personnel detached from the Army Medical Laboratory. The standard of professional care in such patients is greatly superior to that which is afforded when the diagnosis and treatment of venereal disease, particularly of penile ulcers, is divided among a number of hospitals. Increase in the case load can readily be met because patients can be quartered in tents or barracks, and do not require, except in special instances, all the facilities of an Evacuation Station or General Hospital. It is needless to point out that the availability of penicillin therapy greatly increases the effectiveness of such an installation. With provision of personnel and facilities for accurate diagnosis, the standard of management of venereal diseases is in every respect comparable with the best afforded in civilian or fixed Army hospitals, and with much lessening of the patient load which must be carried by Field or Evacuation Hospitals, and with avoidance of the necessity of evacuating patients farther to the rear in the line of communications by reason of venereal diseases.

IV. Determination of Cure. Follow-up of Penicillin-treated Syphilis With increasing use of short-term methods of treatment for syphilis, the necessity for better methods of follow-up has been brought into sharp focus in the European Theater of Operations. Adequate follow-up is an absolute and inescapable responsibility, especially when new and relatively less established methods of treatment are employed.

a. Complete dependence upon unit medical officers for the carrying out of follow-up serologic tests after completion of standard therapy, intensive arsenotherapy, or penicillin therapy, will not be successful. This is due to a number of factors entirely unrelated to the interest and energy of the medical officer: His duties and responsibilities are large and varied; he is expected to be conversant with a bewildering array of circular letters, bulletins and directives (some of which he may never have seen); regular access to medical records under field conditions may be difficult or impossible to maintain. He needs and deserves all the help that can be afforded from headquarters. Certain methods have been employed in ETO, in collaboration with the Medical Records Division, as follows:

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→ (1) After completion of the cerebrospinal fluid and physical examinations and the blood Kahn test which is required when the standard 6-month therapy is finished, or after 6 months of observation following intensive arsenotherapy or penicillin therapy for syphilis, the syphilis register is sent to the Medical Records Division, Office of the Chief Surgeon, for review and safekeeping. It is there subjected to summarization and review to determine the adequacy of treatment. If treatment is inadequate or the result not satisfactory, or if a procedure essential for the protection of the patient has not been done, the register is returned to the unit with a request for the indicated examination or suggestions for further treatment. Registers which are satisfactory, but on which further follow-up serologic tests are required, are held for safekeeping, and requests for the tests are submitted to the Commanding Officer of the unit of the patient at the proper time. Registers of patients in whom the treatments and periods of observation for cure are adequate are immediately sent to The Surgeon General with recommendation for closure.

In general, 25 to 30 percent of registers are returned to the patients' units immediately for essential data or further treatment, 25 to 30 percent are held in the Medical Records Division for followup tests as they become due, and 40 to 50 percent are sent to the Office of The Surgeon General. Under such a system, it is to be emphasized that in one-fourth to one-third of the patients, a deficiency in laboratory studies or in treatment is corrected immediately rather than allowing the deficiency to persist until the register would be submitted for closure under the ordinary procedure. In addition, prompt information as to the current effectiveness of the management of venereal diseases in the Theater is available, and opportunity for acquainting medical officers with acceptable methods is afforded.

(2) An individual record of treatment form, to be carried by the patient, was introduced in the European Theater of Operations in March 1943. This has subsequently been replaced by Form 78a

issued by the Office of The Surgeon General. It is difficult to estimate accurately the success of such a form. It is my feeling that it falls short of expectations in influencing continuity of treatment or performance of follow-up examinations. However, it does give the intelligent and interested soldier an opportunity to obtain such treatment or follow-up studies and, on this basis alone, its continuance seems worth while.

(3) The names of all patients who have received penicillin therapy for syphilis in ETO are submitted monthly by the hospital concerned to the Office of the Chief Surgeon, ETO, and are there tabulated and carded according to months, for requests for followup serologic tests. At the proper time, a request for a quantitative Kahn is sent out through command channels. Considerable experience was gained with such a central follow-up system in connection with intensive arsenotherapy, and it is believed that it will enable us to protect men under our jurisdiction against undetected relapse, and also indicate promptly any significant incidence of failures from the schedule of treatment now in use.

(4) Preservation of the syphilis register:-From the standpoint of future evaluation of adequacy of treatment, nothing is more important to the soldier with syphilis than the preservation and safekeeping of his syphilis register. For this reason it has been the policy in ETO to keep these registers on file in the Office of the Chief Surgeon after the spinal fluid and other examinations have been done, even though further serologic tests may be necessary. Such a system is possible only in a Theater which is relatively compact and where communication lines are not too long. It will at times result in delay in the taking of serologic tests when the soldier in question cannot be located promptly, but has thus far proved of the greatest advantage in maintaining more adequate follow-up, and in preventing loss of a record of vital importance, the syphilis register.

There are many other problems concerning which we need information. The diagnosis of chancroid, for instance, is not satisfactory; it remains a waste basket group dependent on the establishment of findings ruling out other disease. More information is needed concerning the essential follow-up procedures after penicillin therapy of gonorrhea. Are elaborate tests of cure at all necessary? As yet we have not encountered any significant weight of evidence that they are.

A critical problem is the one which has arisen from the circumstance that, in the treatment of gonorrhea with penicillin, we are inevitably subjecting an unknown number of patients to the risk of temporary suppression of signs of a coincident early syphilis infection. It has been recommended that all patients with gonorrhea be subjected to a serologic test for syphilis 3 months after penicillin therapy. However, it remains to be seen whether or not this is adequate, and every precaution must be taken to insure that a significant number of patients do not slip through the net with undetected syphilis.

Colonel Sternberg has addressed this conference regarding the plans which the Army and the Public Health Service have made for the detection of venereal disease and determination of cure, and insurance of such further treatment as may be necessary in

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soldiers being discharged from the service. I believe the plan which has been evolved is workable. Certainly the protection of the soldier and the community against undetected or uncured venereal disease is an absolute obligation upon the military and civilian medical service of the country. It is my belief that most medical officers in foreign Theaters of Operation would be exceedingly loathe to employ an essentially experimental method of treatment for syphilis, such as penicillin, unless there was good assurance that our patients would be protected from possible treatment failures after they have passed from our control. To those of us who cut our syphilologic teeth, so to speak, in the two decades after World War I, the results of inadequate treatment and failures of follow-up in discharged soldiers were a disconcerting object lesson. The knowledge and facilities for the prevention of the tragedies of late syphilis are available. They must be applied.

It is hoped that this brief resume has indicated that the Army Medical Service in the European Theater of Operations is motivated by a keen determination that the standard of medical and surgical practice for the men for whose health we are responsible shall be the highest obtainable, and that methods of treatment of proved value shall be applied without delay. We are appreciative of and greatly dependent upon the efforts of investigators in the Zone of the Interior who have contributed so greatly toward the revolution in the therapy of venereal diseases which has occurred during the past 2 years. By the development of more effective and less toxic methods of treatment for the fighting soldier, a considerable increase in the efficiency of the Armies has been effected. This is a real contribution for which we in the armed services are profoundly grateful.

The Chairman: The subject will be continued by Lieutenant Colonel Paul Padget, of the Army of the United States.

U.S. ARMY EXPERIENCES IN VENEREAL DISEASE

CONTROL IN THE EUROPEAN THEATER OF
OPERATIONS

PAUL PADGET, Lieutenant Colonel, M. C.,
Army of the United States

As has been brought out in the previous discussion, the purpose of this conference is to consider ways and means for dealing with problems which will be presented by the venereal diseases in the difficult period which will follow the present war. I well remember that in the first draft of these remarks I wrote, "The problems which will be presented by the venereal diseases in the United States following the present war," but only a moment of consideration was required to see the fallacy of so narrowly limiting the concept. The venereal diseases will be, as they have always been, a world problem, and with the conditions which we may anticipate to obtain in the postwar world, with tremendous shiftings of large population groups and with travel between and intercourse among the various peoples of the world on a scale so far unprecedented, we may take for granted that the venereal disease problem will be international, and we in the United States may base our plans upon that concept.

Not the least important part of that concept is the fact that our soldiers returning from long tours of duty overseas will be something like entering aliens so far as disease problems are concerned. Please do not misunderstand me; I have no desire to enter into, much less become a partisan to one side or the other of the controversy initiated when Dorothy Parker suggested that the returning soldier will be, as the Reader's Digest put it, "a stranger." The social readjustment of the returning soldier is in itself a problem with which this conference might well concern itself, but in the narrower field which I choose to consider we must view the returning soldier as a new problem so far as the possibility of disease transmission is concerned. He has been in contact with an alien population for a long period, regardless of military control, has been exposed to the communicable diseases characteristic of those people, and has suffered them in proportion to their prevalence in that population. Among the large body of men who eventually will return to the United States from Europe there will be a number who have acquired a venereal disease. This fact and its possible significance to the public health of the people of the United States must be carefully considered.

It is this idea, therefore, which promoted the inclusion of the present discussion in the program of this conference. It was felt that the experiences which we have sustained in venereal disease control in the European Theater of Operations might be of interest to this conference for two reasons: (1) Because of the public health problem posed by the returning soldier, and (2) because perhaps in some small way the experiences which we encountered when a large body of soldiers was moved from the United States to the United Kingdom and eventually to Europe, may point toward the problems which may be encountered when that same body of soldiers retrace their steps.

The venereal disease control program in the European Theater of Operations (E.T.O.U.S.A., familiarly known as ETOUSA) got under way in the summer of 1942, and became a full-time venture in September of that year with my assignment as Venereal Disease Control Officer. Since that time, the program which has been developed represents the collaborative effort of many people to all of whom I should like, did time permit, to give due credit by name. As it is, they consider me as their spokesman, here to attempt briefly to give you a picture of the problems which we have encountered, the accomplishments we have achieved, and the failures we have suffered.

The loss of military manpower caused by the venereal diseases may be minimized in two ways: First by the prevention of infection, and second by the use of treatment methods which reduce loss of military effectiveness from those infections which have occurred. This essentially bicameral nature of the problem was recognized in ETOUSA; and in the organization of the Office of the Chief Surgeon the problems of treatment were assigned to the Division of Professional Services, while preventive measures were developed in the Division of Preventive Medicine. Without in the least attempting to discount the important contributions which have been made by new developments in treatment in reducing the manpower cost of the venereal diseases, this discussion will be devoted entirely