TABLE OF CONTENTS. 
Page 
1* Organization of the Program in Cooperation with Medical and 
Allied Professions and Lay organizations *-> 
2, Administration of the Program ......... 1 
a, A Division of Venereal Disease Control, 1 
b, Direction by a Venereal Disease Control Officer 1 
c. Duties of Venereal Disease Control Officer, 2 
d. Auxilliary Personnel in The Division of Venereal Disease 
Control . . 3 
3, Treatment Services, 3 
a. General Principles 3 
4-, Definition of Beneficiary of Public Clinic Service A 
5, Definition of Physical Quality of Clinic Service 4- 
6, Clinic Conduct 4- 
7, Clinic Personnel, 5 
8, Clinic Equipment 5 
9, Hospital Services , 6 
10, Gonorrhea 6 
a. Diagnosis 6 
b. Treatment of Gonorrhea 7 
c. Tests of Cure 8 
11, Syphilis. . . , 8 
a. Diagnosis 
(1) Primary Syphilis 8 
(2) Secondary Syphilis 9 
(3) Latent Syphilis,. 10 
(4.) Syphilis and Pregnancy 10 
(5) Congenital Syphilis, 10 
(6) Late Syphilis. 11 
b. Management of Syphilis, . 11 
c. Treatment of Primary, Secondary, or Latent Syphilis • . • • 12 
12, Chancroid 14* 
0 
I Page 
13# Lymphogranuloma Venereum 16 
14* Granuloma Inguinale ......... 17 
15* Case-Holding and Case-Finding ... ......... 19 
a* General Considerations. 19 
b, Case-Holding. ...... ..... 20 
c, Case-Finding, 20 
16, Information and Education . ;21 
a. Professional 21 
b. Public 22 
c. Patient Education . • • • 23 
4 
17, The Charlatan, and The Unethical Pharmacist and Physician • • • -23 
IB, Prostitution 24 
19# Classification of the Venereal Diseases 2B 
20, Cbmmunity Venereal Disease Control Cornells 29 
21, Suggested Clinic Monthly Itepqrt Form, 30 
II TB - PH - PREY MED 4 
THE PRINCIPLES OF VENEREAL DISEASE CONTROL 
PUBLIC HEALTH AND WELFARE TECHNICAL BULLETIN 
PH m GHQ SCAP APO 500 
June 1947 
1« Organization of the Program in Cooperation with Medical and Allied 
Professions and Lay Organizations• 
In the organization of a national venereal disease control program for Japan, 
careful attention should be given to the part to be played by the medical and 
allied professions and lay organizations. Although the Ministry, with the direction 
and supervision of the Public Health and Welfare Section, SOAP, must determine the 
scope and define the content of the program and administer many of the details, the 
private practitioner, the local and prefectural medical societies, the hospital, 
nursing, welfare and voluntary public health agencies, the public schools, medical 
schools, and a variety of other agencies, will have specific duties to perform in 
the actual application of many of the control procedures. Unless they are informed 
as to the Ministry's plan and are in general sympathy with its principles, they 
will either fail to assist to the full extent of their capacities or, In ignorance 
of the aims of the control program, may work at cross purposes to the eventual 
detriment of the public welfare. 
Interested, active, and well-informed voluntary organizations can be of 
invaluable assistance in securing public support for the program, and in extending 
the health department's channels of the public information and education. It is 
doubtless to the disadvantage of many prefectural programs that not enough atten- 
tion is paid to this matter of public relations. 
Organizations of the general public, that is, non-professional groups, are 
very important in the last analysis. The greatest stimulus to the reluctant or 
uninspired public health worker is the persistent demand and continuous interest 
of the people he is paid to serve. 
2, Administration of the Program 
a, A Division of Venereal Disease Control, Venereal disease control 
should be a function of a separate section in the prefectural health department. 
In Japan venereal diseases are too outstanding a problem to be grouped with other 
infectious diseases. Where it is impracticable to make venereal diseases control 
a separate section, it should be the function of a subsection, with a high degree of 
autonomy, in the section of communicable disease control or its equivalent. 
b, Direction by a Venereal Disease Control Officer. Whether there is a 
section or a sub-section of venereal disease control, the program should be direct- 
ed by a venereal diseases control officer who his entire time to the duties 
1 of his office. This officer should be the best trained clinically., should be , 
amenable to further training, and should have the best knowledge of modern venereal 
disease control methods* ■ 
c, The duties of the venereal disease control officer should include as 
a minimum the following-: 
(1) * The definition of the alms, purposes, and policies of the venereal 
disease control program. Since it will be his responsibility to carry out the pro- 
gram, under the direction and supervision of the Military Government Health Officer, 
he should administer that part of it with which the section of venereal disease 
control is directly involved; that is, he should have administrative supervision 
over all of the‘Work cf the section and over all of its personnel. 
(2) The collection and analysis of morbidity data. Future planning, 
the need for more personnel, supplies, equipment and financial aid are all depend- 
ent upon the gathering and presentation of accurate statistics. As the extent and 
prevalence of venereal disease become recognized, additional facilities will be 
easier to acquire. It is important, that the venereal disease control officer keep 
himself informed, through the study of statistics, as to the results of the program 
and as to any progress which is being made toward the control of thd venereal di- 
seases. , The actual collection and analysis of all morbidity data are the function 
of a section of vital statistics in the health departments. In such cases, however, 
the venereal disease control officer should be permitted to prescribe, the data to 
be, collected for his purposes, and the scope of their analyses. He should have the 
fullest cooperation of the section of vital statistics in the planning and conduct 
of special studies, particularly as they pertain to analyses of treatment, case- 
finding and case-holding performance of clinics and other treatment sources. Cer- 
tain statistical data must be available to the prefectural V,D,C,D, each month, 
so that he can submit his monthly report of Venereal Disease Control Activities 
to the V.D,C,0, in the Ministry, 
(3) The establishment of effective cooperation with physicians in 
private practice, through conferences with local medical societies, provision of 
consultation services, by the health bureau clinics distribution of effective and 
helpful medical literature, provision of prefpctural laboratory services and such 
other assistance as will lead to the willing participation of physicians in the 
health bureau1s program, , , 
(4) The development of cordial relations not only with the public but 
with special scientific groups. He should conduct a continuous campaign of sound 
public education in venereal disease control. He should be the liaison officer 
between the health bureau and the several agencies which will share in the develop- 
ment of the program. 
. ‘ ' • _ •* • ♦ * ’ • ‘ ’ \ ' t 
(5) Administrative consultation to other units \7ithin the health 
bureau, such as the.sections of. laboratories, maternal and child health, anti-tuber- 
culosis, Ho should have considerable voice in the determination of what emphasis 
is. to be placed upon^those parts of the program which may be administered by these 
. .sections in order, that ohe service may not overbalance the other, and in order that 
one section may not work at cross-purposes with another to the embarrassment of 
both and to the confusion of the public. (6) The organization and supervision of venereal disease clinics. The 
health bureau should conduct sufficient in-patient and out-patient facilities to 
adequately serve the population of the prefecture. The prefectural. V.D.C.O. must 
either conduct these clinics personally, or supervise the work of the clinicians 
■who are operating the clinics. Methods used should be as approved by.the Military 
Government Health Officer and the Public Health & Welfare Section of SCAT, 
(7) The organization and supervision of epidemiologic and followup 
services for clinics and private physicians. 
(?) Study and control of the efficiency of venereal disease clinics 
in terms of contact tracing, efficacious treatment, and case holding. 
d. Auxiliary Personnel in the Section of Venereal Disease Control, The 
venereal disease control officer should be supported by such administrative assist- 
ants, professional consultants, case-holding and case-finding personnel,and cleri- 
cal staff as the execution of the program may demand. To whatever extent the pro- 
gram can be expanded from time to time, more nearly to approach the ideal, the 
staff of the section should be increased to permit the effective execution of the 
expanded program. 
3, Treatment Services 
a, General Principles 
(l) The provision of adequate public treatment services is a basic 
necessity for venereal disease control in Japan, As has been demonstrated in other 
countries, the level of venereal disease control work is raised in direct proportioi 
to the number of public facilities available. It is a matter of readily verified 
fact that most of the infected who seek treatment at public clinics are either on 
relief or are managing a precarious independent existence. Many are young people 
with small earning capacities, if they work at all. It is not likely that many 
patients in Japan at this time are seeking free care at public agencies in spite of 
being able to pay for private care. The treatment of the venereal diseases, and 
especially of syphilis, is time consuming and, at private practitioners1 rates, is 
expensive. Those of the infected who can afford long continued medical care at the 
hands of private physicians will not often be found in public clinics where the 
danger of recognition is great, where long periods of waiting are the rule, where 
mass methods may leave little room for close patient-physician relationships, and 
where a multitude of other embarrassments and inconveniences must too often be 
tolerated. The more talk that is heard as to who will pay for the patients care, 
the poorer the medical care will be. 
(2) The venereal diseases are communicable diseases. The right of 
the community to protect itself against exposure to communicable disease is recog- 
nized wherever there is civilization. In providing public treatment for the indi- 
gent infected with venereal disease, the community exercises a prerogative consis- 
tent with this right to protect itself. It is only in the public clinic that the 
large mass of the economically handicapped can be given efficient service at a 
price which the community can afford to pay. The provision of adequate treatment 
is vastly more than the simple introduction of medication into the patient. Con- 
sultation, case-holding and case-finding services are important functions of vener- 
eal disease control which could hardly be provided for the great number of the 
medically indigent in any other way than through organized clinic services. 4>» Definition of Beneficiary of Public Clinic Service. 
Diagnostic and treatment facilities should be provided for: 
a. The diagnosis and emergency treatment of all persons who apply. .. All 
contagious patients must.be considered a community hazard and treated until non- 
communicable • 
W All patients referred by private physicians either for continued 
treatment or for consultation. 
c. All patients unable to pay for private medical care. 
5# Definition of Physical Quality of Clinic Service. 
Clinics should be so located as to be easy of access and of maximum convenient 
to the population of the areas which they are to serve* The number of clinic . 
sessions should be such as*to meet the needs of the area without overcrowding or 
unreasonable delay* Night sessions should be held if necessary and at such hours 
as' to prevent loss of time from work to employed patients* Special attention 
should be paid to special conditions, such as advanced pregnancy, the need of a 
patient to catch a bus, to return to work, or to return to children left at home. 
Health Bureau Clinics should be held in clean, well-lighted, well-ventilated 
rooms, so located and arranged as to offer adequate privacy but not to imply iso- 
lation (as of a communicable disease), nor segregation (as of undesirable people). 
The physical arrangements should be such as to insure privacy in history-taking, 
physical examination and treatment, to provide adequate waiting-room and toilet i 
facilities, and to contribute to the self-respect of. the patient. In other ?/ords, 
the' accessibility and the physical'character of the clinic should be such as to 
invite and encourage regularity of attendance; not to discourage it or to imply 
that any treatment at‘all, no matter how disreputable the environment in which it 
is administered, is good enough for, the venerally infected. 
Children are preferably handled in a family clinic with the late afternoon 
or Saturday morning hours. Their mothers should be treated for their venereal 
infections during these same sessions, and prenatal and, pediatric care when nece- 
ssary should also be available in these family clinics. 
6, Conduct of Clinics 
a. Clinic sessions and hours should be well.publicized. Patients should 
be examined in the order in which they appear at the clinic, although exceptions 
may be made for a very sick patient, mothers with several small children, or a 
working person with only a short time off from, his job, .'The other patients who 
were not taken in turn .should understand why another patient,was seen.ahead of 
them, . 
b. The general atmosphere of the clinic is of major' importance...and shoulc 
be felt the moment the patient enters. All patients..should be..treated y/ith .courte- 
sy; professional dignity must never be violated, and a friendly,, business-like 
attitude should prevail in which the patient feels a respect toward, the physician 
and nurse in their professional capacities,- .... • ' r  c, A sincere,interact in each patient and a kindly manner, should be main- 
tained regardless of the patient1s economic, social position, educational level, or 
personal appearance* Public health venereal disease clinics treat patients in such 
a way that the majority of patients are very desirou of carrying out every medical 
or epidemiologic directive given to -them by the clinician or the nurse. 
d. Good manners are a first requirement in a professional service dealing 
with the public, A display of haste, loud voices, and impersonal handling of pa- 
tients such as is common in prostitute hospitals should not be tolerated for the 
general public. Remarks should be directed to the person concerned and.not to the 
entire clinic. Irrelevant conversation should never be indulged in during clinic 
hours. Pood should never be prepared, or eaten in the clinic. 
0. Modern venereal disease clinics in health centers are noted for their 
cleanliness, quietness, efficiency and gentle handling of patients. In a public 
health venereal disease clinic patients should be made to feel welcome. In these 
respects the clinic nurse has the main responsibility, .By her deportment, bearing, 
and kind reception of each patient, the nurse sots the tone of the entire clinic, ' 
f. The most important public health teaching is done while, the patient 
is in.the clinic. Every patient will respond to a clear explanation of his parti- 
cular case with more enthusiastic cooperation. The tactful handling of each pa- 
tient and careful instruction while in the clinic are most effective ip case con- 
trol and eliminate the necessity for much correspondence and hone visits. 
7. Clinic Personnel 
a. All clinic personnel should be technically qualified for the parti- 
cular functions which they must perform. 
bf. Minimal clinic personnel should consist of (1) a qualified physician 
who is a graduate of a recognized medical school, who has had at least 6 months of 
special training under supervision, in the management of the venereal diseases, and 
who has a tactful and sympathetic personality and a particular interest in the 
venereal diseases and their relation to the public health; (2) a qualified techni- 
cal nurse who should assist the physician in the technical aspects of clinic opera- 
tion, the routing of patients through the clinic, the entry of clinical notes of a 
routine nature, etc; and (3) a clerk, (female)y who should keep clinic records and 
statistics, attend to the clerical aspects of the follow-up system, and attend to 
the clinic .correspondence. To this fixed minimum of intramural personnel there 
should be added such assistants in all of the categories as may be necessary to the 
efficient, and effective operation of the clinic- without undue waste of the pa- 
tients1 time and case-holding and case-finding personnel as may be adequate to the 
problem with which the clinic is confronted, • • - 
8,• Clinic Equipment 
\ ‘ j. • ». / 
a. Clinic equipment should be adequate to- the proper and efficient han* 
dling of the patient, his adequate physical examination-, and his competent treat- 
ment, Adequate facilities should be available for the collection of specimens for 
examination in the laboratory-and in the clinic for the immediate examination of 
smears, chancre serum (by dark-field), urine, unless adequate laboratory service 
is available close at hand. Lack of .dark-fieId substages in many prefectures will 
necessitate sending capillary tube specimens of serum from,suspected chancres to 
t he ne are st laborat ory having'a dark-fieId’micro scope, b, History, physical examination and treatment record. Clinic records 
should provide for recording the patient1s medical history, the results of an 
adequate physical examination, treatments given, reactions to treatment, tests for 
cure, and the condition of the patient at the time of any interruption of his con- 
nection with the clinic whether because of cure, the further need for treatment, 
transfer to treatment elsewhere, or unauthorized discontinuance of treatment. The 
record should provide, further, for recording the identity of all of the patient’s 
contacts and the result of their follow-up. 
9* Hospital Services 
a. Hospitalization should be provided, at the discretion of the clinic 
chief, for patients with open lesions of early syphilis under certain circum- 
stances, particularly in case of infectious relapse or for the recalcitrant or 
promiscuous patient, or when there are unusual home or social conditions. It 
should also be provided for lumbar puncture if this service cannot properly be 
provided in the clinic, or when there are circumstances which make it advisable 
to have the patient under hospital control. 
b. Only those hospitals should be used that belong to the national, 
prefcctural, or municipal governments. Hospitals that are partially or totally 
controlled by private or special interests should not be used by the health 
bureaus. 
10, Gonorrhea 
a • Diagnosis 
(l) In the Male: 
(a) Cultural evidence of the presence of the gonococcus is 
adequate, in itself, for the diagnosis of a gonococcal infection. Cultural evi- 
dence is defined as including those fermentation tests which differentiate bet- 
ween the gonococcus and other members of the groups of gram-negative diplococci 
which resemble the gonococcus. 
(b) A diagnosis of gonorrhea may also be made in the male, 
under the following throe conditions; 
1 If intracellular, gram-negative diplococci which re- 
semble the gonococcus are found in smears from the male genito-urinary tract, and 
if the history of the infection or the clinical evidence is presumptive of gono- 
coccal infection. 
12 If extracellular organisms are found in typical 
during the earliest hours of an acute infection, and the history or clinical find- 
ings are presumptive of gonorrhea, clinical diagnosis of gonorrhea may be made and 
the case treated as such. Smears should be made at frequent intervals thereafter 
as intracellular organisms may be found at a later date (especially in a case 
which does not respond to sulfonamide therapy). 
1 A clinical diagnosis should be made in the presence of 
a suggestive history and suspicious clinical findings, confirmatory laboratory 
findings being lacking, and the patient treated as if he had gonorrhea. Repeated 
search should be made for the gonococcus thereafter, however• (c) If the diagnosis of gonorrhea has been made elsewhere, on 
the basis of evidence.which would have been'acceptable to the dine if the patient 
had first been seen.in the clinic, that diagnosis may be accepted and the patient 
treated for gonorrhea, if necessary, even though gonococci can no longer be found. 
(2) In the Female: 
. - . ‘ (a) Laboratory confirmation of diagnosis, whether by smear 
or culture, is relatively easy in acute infections in'either male or female* 
In chronic infections in women, however.' even repeated cultures may be negative. 
and♦ if the patient*is to have the advantage of prompt treatment, the diagnosis 
will have to be made clinically if a history of exposure or of promiscuous sexual 
intercourse is obtained. 
(b) Specimens for either smear or culture should be taken 
from the urethra after thorough massage of the para-urethral (Skene1s) glands, 
and from the cervix after thorough cleasing of the vagina with dry gauze or 
cotton swabs and manipulation’of the cervix between the blades of a bivalve 
speculum. Specimens collected from the urethra withbut prior massage of the para- 
urethral glands, or from the cervix without first cleansing the vagina and remov- 
ing any cervical plug, will usually be highly contaminated with overgrowing organ- 
isms or contain no gonococci. 
(c) The patient*s history should include an account of the 
symptoms which she has or has had, such as dysuria (not'common), vaginal discharge 
vulvar pruritis, pelvic inflammation (including abdominal surgery), Bartholin 
abscess or-.cyst, acute “arthritis, and menstrual disturbances not otherwise ade- 
quately accounted for. It should further include any history of exposure to a 
known gonococcal infection, of sexual promiscuity, or of having infected another 
person with gonorrhea. The mother of an infant with gonococcal opthalmia 
neonatorum, for instance, may usually bo assumed to be the source of the infantfs 
infection. 
b, Treatment of Gonoirhe a: 
(1) Penicillin, when it is available, is the treatment of choice* 
When Penicillin sodium is given in normal saline or distilled water, it may be 
given as follows: 
First dose - 0 hours —— 100,000 units intramuscularly in 
buttock 
Second dose - 2 hours — 100,000 units intramuscularly in 
buttock 
Third dose - K hours — 100,000 units intramuscularly in 
buttock 
The above treatment should cure about 9A% of the patient's. Those who are not 
cured should be given another course doubling the dosage of the drug. Use a 
different lot of penicillin if possible. 
(2) Where penicillin is not available, sulfathiazole or sulfadiazin 
should be used as follows; 1 gram (2 tablets) four or five times a day for five 
days. The drug is given every four hours. The patient should drink a glass of 
water each time the drug is taken, and should consume at least three quarts of 
fluids daily, ; 
7 (3) The patient may improve clinically under this regime and labo- 
ratory reports may appear to be negative, but unless the clinician is satisfied 
that the patient is cured, it is better to wait three days and then repeat the 
course of the drug. 
(4-) Sulfonamides should not be given intravenously. Vaccines should 
not be used. Douches, washing, and irrigation apparatus should be removed from 
the clinics and not used in the future. They are of no value in the treatment of 
gcnbrrhoa. They may do harm. Topical applications are useless. Modern treatment 
is systemic and by chemo-therapy. The clinicians time is too valuable to waste in 
useless procedures which do not "keep the patient clean", and which have no meii- 
cal value. 
c. Tests of Cure: 
(l) Three negative cultures obtained at 4-8 hour (or weekly) inter- 
vals plus a negative culture obtained after a menstrual period are satisfactory 
evidences of cure in the female. The longer the observation period, the better. 
The patient is examined several times during a three-month period. If all tests 
are negative during this period, the patient may be considered cured. 
(2) If cultures are not available, reliance must be placed on 
smears. The clinician should remember that in the diagnosis of chronic gonorrhea, 
especially in women, smears are notoriously unreliable. Laboratory samples must 
bo obtained carefully from secretion expressed from Skenefs, Bartholin’s, and the 
endocervical glands. The gonococcus will not be found on the surface of the 
mucous membranes. 
(3) Patients treated for gonorrhea, especially those treated with 
penicillin, should receive a serologic test for syphilis once a week for a month, 
and once a month for the next three months. The possibility of masking primary 
syphilis with penicillin used in the treatment of gonorrhea should be kept in mind 
11, Syphilis 
a. Diagnosis 
(1) Primary Syphilis 
(a) Any genital sore in male or female is possible primary 
syphilis until proved to bo otherwise. 
(b) Any indolent lesion anywhere on the body (especially lips, 
tonsils, fingers) which fails to heal in two weeks may be primary syphilis. 
{c) The diagnosis of primary syphilis is a laboratory, not 
a clinical procedure. 
(d) Suspected primary syphilis should not be treated locally - 
until repeated dark-fields are negative. 
(e) Antisyphilitic treatment must not be given on suspicion 
alone. The diagnosis must bo proven. Once treatment is begun, it must be carrie 
through until 4-0 arsenicals and at least 30 heavy metals have been given. '(f) There is reason for urgent hast in diagnosis; hours 
countI 
(g) The diagnostic procedures are as follows: 
1 Dark-field of surface serum; if negative, repeat at 
least three times on consecutive days before local treatment# 
2 If surface dark-field is negative, do dark-field of 
aspirated serum from lesion*s base, or, dark-field of aspirated material from the 
regional lymph node* 
2 If you have no dark-field microscope,•send the 
patient at once to someone who has; or send a capillary tube specimen to the neares 
laboratory that has a dark-field substage. 
£ Do serologic test on all patients with open.lesion 
at first visit# If any of these tests are positive, treat at once. If all are 
negative — - 
jj Do serologic test follow-up for 3 months, weekly for 
first month, every 2 weeks"thereafter. 
• (h) No physician who has not actually had training and 
experience in the recognition of Spirochaeta pallida should attempt the diagnosis 
of syphilis by the dark-field; too many serious errors are likely to be made. This 
is especially trud of lesions in the mouth whore organisms resembling Spirochaeta 
pallida are frequently found, A diagnosis of syphilis made by dark-field from 
preparations taken from the mouth, should never be made. 
(2) Secondary Syphilis: 
(a) Do blood serologic follow-up (3 months) on any lesion 
which was possibly primary syphilis. 
(b) For any generalized skin eruption - DO A SEROLOGIC TEST, 
(c) For any sore mputh or throat which does not heal in 10 
days - DO A SEROLOGIC TEST. 
# 
(d) For any unexplained patchy loss of hair - DO A SEROLOGIC 
TEST. 
(e) For any iritis or neuroretinitis - DO A SEROLOGIC TEST, 
(f) For any vague bone pains or polyarticular arthralgia — 
”acute, subacute, or chronic infectious arthritis” * DO A SEROLOGIC TEST. 
(g) Lift the top from a papular lesion and examine the serum 
by dark-field. It is highly desirable to recognize the approach of the open, 
infectious stage of secondary syphilis before it develops—hence, the serologic 
follow-up advised is maxim #1# The next five maxims call attention to the five 
common manifestations of secondary syphilis—generalized skin eruptions, mucosal 
lesions, alopecia, iritis and arthralgia, although others, much less common, do 
occur. Ninety-*flvo percent of all patients with secondary syphilis will present one or a combination of these five jponifestations. Unfortunately, the lesions 
of secondary syphilis may either be completely lacking or so trivial and evanescent 
as to be overlooked by patient and physician alike. Further, unless blood tests 
are made, the fact that the lesions are due to syphilis may be entirely missed, 
and some other diagnosis made. 
(h) 'Fortunately, the properly performed serologic test has its 
highest negative value during the secondary stage of syphilis. It is always 
positive (100 percent). If it is negative, there is practical assurance that the 
patient lias some other disease. On the other hand, it must be remembered that a 
patient may have a positive blood test as the result of an old infection with 
syphilis, and at the same time have any one of the above signs or symptoms as the 
result of concurrent condition, not syphilis. The history of exposure or the 
history of a primary lesion may help to settle the question. 
(3) Latent Syphilis; All syphilitic infections are latent at some 
time, and most of the time until ultimate break-down occurs. There is no way to 
rocognize latent syphilis except by serologic tests. 
(4) Syphilis and Pregnancy: 
(a) Few syphilitic pregnant women have lesions, and history 
and physical examination are nearly worthless as aids in making the diagnosis in 
this group. The diagnosis can be made in most cases only by serologic tests, 
Eyery pregnant woman should have at least one and preferably two serologic tests 
for syphilis during pregnancy. One test should be taken during the early months 
of pregnancy and another about the seventh or eighth month. 
(b) If proper treatment is begun before the 16th week of 
pregnancy, the infected mother can be assured of a baby free from syphilis in 
almost every case. Treatment must be adequate and continuous throughout pregnancy, 
and should be continued to completion, A careful history for any reactions to the 
previous treatment must be elicited before each succeeding treatment. Urine speci- 
mens should be checked frequently for signs of renal damage. 
(c) Pregnancy usually causes the signs and symptoms of syphili; 
to become less obvious. Most pregnant women with syphilis are unaware of the di- 
sease and have no signs or symptoms. Treatment is almost al?/ays well tolerated 
and the clinician will not encounter any special trouble if the reaction to each 
previous treatment is carefully noted. 
(5) Congenital Syphilis: 
(a) Syphilis should be suspected in every baby of a known 
syphilitic mother, whether or not she was treated before or during pregnancy. 
(b) Syphilis should bo suspected in puny, ill-nourished, 
wizened infants who "won’t gain”, in infants with skin rashes of any type, in 
those with snuffles or those with "psoudoparalysis". 
(c) In older children, syphilis should be suspected if there 
is "pink eye" (it may bo interstitial keratitis), deafness unless clearly middle 
ear, hydrarthrosis of the knees (Glutton’s joints), osteomyelitis, and peculiar 
second dentition. Check suspicion by serologic test of both child and other 
members of its family. 
10 (d) If the facilities are available, make a dark-field examina- 
tion of scrapings from the wall of the unbilical vein. The finding of Spirochaeta 
pallida establishes the diagnosis at the earliest possible moment. : 
(e) If quantitative serologic tests can" be made, do. quantita- 
tive serologic tests on the cord blood and an. the infant* s blood at X, 2, A, 6$. 8, 
and 12 weeks of life and at intervals thereafter for at least the first 2 years4 ■- 
If the child does not have syphilis,vthe titer will decrease and usually become 
negative before the end of 8 or 12 weeks. If the child has syphilis, the titer may 
rise, or. it nay fall at first and then rise. 
(f) If titration cannot bo done, it nay be assumed that a 
positive serologic tost of the infant* s blood after 8 weeks to 3 months means 
syphilis. If the test is negative at 3 months,-it should be repeated at 6 months, 
1 year, and 2 years. If all these tests remain negative, the child certainly has 
escaped infection with syphilis, ■ 
(g) Roentgenograms of .the infant1 s long bones, at the age of 2 
weeks nay establish the diagnosis if there is characteristic evidence of syphilitic 
osteochondritis at the epiepyseal lines. Negative findings do not exclude the 'j 
possibility of syphilis. Interpretation of the roentgenograms must be made by an 
experienced roentgenologist, since deposits of bismuth (if the mother has been 
treated with bismuth) nay make differential diagnosis difficult, 
t 
(6) Late Syphilis: 
(a) Late .syphilis nay attack any part of the body. Its mani>- 
fostations arc so numerous and its differential diagnosis so difficult, clinically, 
that it has well earned the name of ’’Great Imitator”, It is impossible, outside 
of a voluminous textbook, to discuss the diagnosis of late syphilis adequately. 
b. Management of Syphilis 
(1) General Principles: In general, no treatment should be given 
nntil the diagnosis is made either by dark-field or confirmed by serologic tests. 
No therapeutic tests should bo used. If. under the pressure of a post unusual and 
extreme emergency, treatment for a lesion suspected of being a chancre must be 
begun before laboratory confirmation of the diagnosis can be obtained* (or if 
treatment has been begun elsewhere without adequate diagnosis^. such treatment 
should conform fully to the scheme for early syphilis and must be carried through 
to completion as if a positive diagnosis of syphilis had been made. 
(2) Where adequate supplies of penicillin are available, syphilis is 
now treated in Rapid Treatment Centers, For a period of less than two weeks the 
patient is hospitalized and given combined treatment with mapharsen, bismuth and 
penicillin. Various amounts of these drugs are used but at least 5 injections of 
mapharsen, 3 injections of bismuth and 2,000,000 units of penicillin are given, dur- 
ing the patients period of hospitalization. The penicillin is given in divided 
doses, every 3 hours night and day until the entire amount has been given, ..As can 
be seen, this regime necessitates adequate supplies of penicillin, sufficient in- 
patient facilities, and trained nursing and medical personnel. Where this treat- 
ment regime can be instituted the follow-up problem on lapsed cases is nil. In 
Japan, at this time, it is obvious that Rapid Treatment -Centers are not feasible. In some instances, such as patients who are pregnant and too near tern to institute 
the usual treatment regine, it may be possible to hospitalize the expectant mother 
and institute treatment with penicillin, mapharsen, and bismuth. However, most 
patients at the present time will have to be treated with mapharsen and bismuth 
according to the schedule given in this manual. 
(3) Treatment should be begun with an arsenical in early and latent 
syphilis but with bismuth in cardiovascular syphilis and certain forms of central 
nervous syphilis. The preferred arsenical, outside of clinics with well-trained 
medical personnel, is arsenoxide (mapharsen). Under expert direction, arsphenamine 
or other arsenicals may be employed* The preferred bismuth preparation is bismuth 
subsalicylate in oil. 
(4) Each treatment should be recorded upon the patient* s clinic 
record, including the date, form of drug, dose given, and any reaction noted. 
(5) It cannot be too strongly emphasized that clocklike calendar 
regularity of treatment without long or short variation or lapses, is critically 
important both to control of infectiousness and cure. Every effort should be made 
to impress this fact upon all of the clinic personnel on every occasion. 
(6) Emphasis should be placed upon the need for the completion, by 
each patient, of the full treatment schedule in the time called for by the type of 
infection which he presents. The results of serologic tests should not be permitte 
to interfere with this schedule of treatment, ’’Treatment to noninfectiousness” 
only, should never be accepted as the objective of any clinic in any case. 
(7) The infectiousness of syphilis is not to be predicted upon the 
results of blood tests but upon the total time, course, laboratory tests, physical 
inspection, and treatment summation of the case. 
c. Treatment of Primary, Secondary or Latent Syphilis 
(l) All patients started on treatment will receive the full course 
of 40 arsenicals and at least 30 bismuth injections. 
(2) A negative serologic test for syphilis (STS) will not be used af 
a reason for stopping treatment before 40 arsenicals and 30 heavy metals have been 
given. 
(3) Any patient who becomes delinquent before receiving 20 arsenica? 
and 20 bismuth injections must be considered infectious and must be returned to 
treatment according to the directive SCAPIN 153 which classifies venereal diseases 
with other communicable diseases. 
« 
(4) If old arsphenamine is used, the dosage will be 0,3 grams and 
will be given only once a week. 
(5) If neoarsphenamine is used, the dosage will be 0,45 grams, and 
will bo given only once a week. 
(6) Hfepharsen is an arsenical drug that has been used in place of 
Arsphenamine (Salvarsan) and Neoarsphenamine (Neosalvarsan), It is less toxic thar 
the other arsenicals and is just as effective even when given in one-tenth the a- 
mount of Neoarsphenamine. (7) It must be thoroughly aerated when it is mixed, and it should be 
injected ihto the vein quickly in twenty seconds or less, 
(8) If Mapharsen and Bismuth Subsalicylate are used, the following 
schedule will be adhered to: 
Week 
Mapharsen 0.04 
gms 
to 0,06 
gms, TWICE a 
week. 
Bismuth Subsalicylate 0,2 gms 
(I'scc) intramuscularly once 
a week 
1 
ti 
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2 
il 
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3 
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ii 
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it 
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4 
n 
ti 
it 
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it 
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5 
it 
it 
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6 
II 
n 
it 
it 
it 
Omit Bismuth 
7 
II 
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8 
II 
ii 
ii 
ti 
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9 
II 
ii 
ii 
ti 
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10 
II 
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11 
Omit Mapharsen 
Bismuth 
Subsalicylate 0,2 gms, ONCE o week 
12 
ii 
ii 
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it 
n 
13 
M 
ii 
ii 
it 
ii 
it 
U 
II 
n 
ii 
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ti 
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15 
tl 
n 
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ti 
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16 
Mapharsen 0,04 
gms 
to 0,06 
gms. Twice a week. 
Omit Bismuth 
17 
ti 
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It 
ti 
ti 
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18 
n 
n 
It 
n 
ti 
ti it 
19 
n 
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II 
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ti n 
20 
ti 
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ti ti 
21 
Mapharsen 0,04 
gms 
to 0,06 
gms. Twice a 
week. 
Bismuth Subsalicylate 0,2 gras, 
intramuscularly once a week. 
22 
ti 
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it 
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23 
n 
it 
it 
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it 
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24 
tt 
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it 
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25 
26 
27 
28 
29 
*30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
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4 
Total Treatment: 
40 Arsenicals, 30 heavy metals 
• Recheck the blood test every 3 months for the first year after treatment, 
every six months the second year and at yearly intervals thereafter. 
An examination of the spinal fluid should be- made -within the first 6 months 
following treatment. . ,:r »-'• 
If the blood test, after having been negative* becotnes positive and stays 
positive, (in the absences of other causes such as acute infectious diseases, 
vaccinations, immunizations), the patient should be retreated, 
(9) Treatment ’in late latent syphilis should begin with a series of 
injections of bismuth subsalicylate. Thereafter, arsenicals and bismuth are given 
in alternate courses at weekly intervals. Example; Bismuth for 10 weeks, arsoni- 
cals for 10 weeks and repeat until 30 arsenicals and 4-0 injections of bismuth have 
been given, 
(10) The treatment of LATE Syphilis must be individualized according 
to the existing type of organic pathology. 
12. Chancroid- 
a. Definition 
(1) ..Chancroid (soft chancre) is a localized venereal disease caused 
by the Hemophilus ducreyi/ transmitted only by direct contact, and characterized 
by painful single or multiple genital ulcers, often complicated by suppurating 
inguinal bubo. The incubation period is usually 2 to 5 days, but may be longer. 
b. Epidemiology 
(1) The disease occurs primarily among peoples that live on a low 
hygienic level. There are undoubtedly symptomless carriers, usually female. 
c. Course 
(1) The disease begins as a vesicopustule which breaks down rapidly. 
The pustule soon ruptures, leaving a sharply circumscribed, shallow ulceration. 
The edges may become- ragged and undermined. The base is moist and covered with 
necrotic, grayish exudate. When this is removed, an unwren base of purulent 
granulation tissue is revealed. The lesion is surrounded by erythema and is 
usually very painful. Multiple lesions may develop rapidly by auto-inoculation. 
Induration is usually absent in untreated lesions, but boggy induration may be 
present if local treatment has been applied. 
(2) The lesions occur in the following sites in order of frequency: 
in the male-prepuce, frenun, shaft, anus; in the female-labia, clitoris, fourchettc 
vestibule, anus, and cervix. Spread by auto-inoculation may take place anywhere ii 
the perigenital zone. 
(3) Regional adenitis frequently develops within a few days to 2 
weeks* The bubo is usually large, unilateral, soft, fluctuant, acutely inflamed, 
and tender. Untreated, it has a tendency to rupture at a single point. However, 
it may subside without suppuration when the patient is treated with sulfonamides. M Phimosis and paraphimosis may occur. There is a tendency to 
spontaneous healing, both of genital lesions and of bubo, with scar formation. 
Systemic reactions are mild or absent, 
d, Diagnosis 
(1) All patients with penile ulcers of any description should be 
admitted to a hospital for diagnosis and treatment. If this is not practicable 
the physician must be sure that the patient understands and will observe isolation 
technique, 
(2) Since primary syphilis may clinically resemble chancroid, and 
since mixed infections of these two diseases may occur (thechancre appearing in 
the chancroid), the diagnosis of syphilis must be confirmed or ruled out by 
laboratory tests, 
(3) A blood serologic test for syphilis should be made on admission. 
repeated once a week for the first month, and at monthly intervals for 3 months. 
unless a diagnosis of syphilis is established earlier. 
(4-) The diagnosis of chancroid may be aided by the laboratory exami- 
nation of stained smears from the lesion, or by culture of pus from the lesion or 
the bubo, 
e, Treatment 
(1) C hemot herapy 
(a) Systemic. Sulfadiazine or sulfathiazole should be admini- 
stered in all cases. One gram four times a day until the lesion is healed is 
recommended. Where adequate hospital service is available, the drug is given every 
four hours, night and day for one week. 
(b) Local. Nothing but cleanliness (soap and water) is neces- 
sary. Keep the ulcers clean and dry. 
(2) Surgical Treatment 
(a) The bubo should never be incised. If fluctuation is pre- 
sent, aseptic aspiration with a 16-gauge needle is recommended; this may be re- 
peated if necessary. Sulfadiazine ointment should be applied to the puncture 
wound, 
(b) Bilarked phimosis or paraphimosis may be treated by immersion 
and soaking in hot magnesium sulfate or saline solutions during systemic sulfonamid 
therapy. Circumcision or dorsal slit is undesirable and is rarely necessary, 
f, Prophylaxis 
t 
(1) Personal cleanliness is important, 
(2) Caution: All patients receiving sulfonamides should consume 
at least 3000cc of fluid daily. 13* Lymphogranuloma Venereum 
a. Definition 
(1) Lymphogranuloma venereum (also known as lymphogranuloma 
inguinale, 4th venereal disease, Nicholas-Favres Disease, lymphopathia venereum, 
and by numerous other names) is a systemic virus disease, acquired venereally, and 
characterized by a small evanescent herpetiform initial lesion frequently followed 
by regional lymphangitis and adenitis* 
b. Epidemiology 
(1) The disease is generally acquired through sex contact* The 
existence of asymptomatic carriers is suggested by the numerous individuals 
with positive Frei tests without clinical signs or symptoms of the diseased ' 
c. Course - 
(1) The disease usually begins as a trivial and transitory*, painless, 
small erosion, papule, or herpetiform vesicle or ulcer, of the penis, vulva, vagina, 
peri-anal area, or anal or rectal canal which frequently escapes the patient*s 
notice* • T 
(2) The invasion of the lymph nodes usually occurs from 10 to 30 
days after infection. Inguinal adenitis is often bilateral and occasionally sub- 
sides without suppuration. During this stage, constitutional symptoms (prostration, 
malaise, fever, meningitis, meningo-encephalitis, or other bizarre manifestations) 
may be observed. The lymph nodes may fuse to the skin. Multiple areas of soften- 
ing occur in the matted nodes followed by break-down and the development of numer- 
ous sinuses. Extensive scarring accompanies healing. The anorectal -syndrome is 
more frequently found in the female and is characterized by rectal pain, discharge 
of blood and pus from the anus, a tendency toward extreme chronicity, and the 
production of rectal strictures, 
d. Diagnosis 
(1) A positive Frei reaction cannot bo relied upon absolutely to 
establish the lymphograriulomatous nature of any clinical condition, since it is 
known that, in untreated infections with lymphogranuloma venereum, skin sensitivity 
persists for many years, probably for a lifetime, A positive test, therefore, nay 
only mean that the patient has had lymphogranuloma venereum at some time in the 
past, rather than his present symptoms being caused by this' disease. False posi- 
tive -Frei reactions may occur in other related virus infections, 
(2) A diagnosis of lymphogranuloma venereum should not be*made on 
the basis of a positive Frei reaction in the absence of clinical signs* 
(3) A negative Frei reaction in the presence of a clinically suspi- 
cious lesion of at least thPee weeks1 duration is of value in excluding the diag- 
nosis of lymphogranuloma venereum. 
(4) The complement fixation test for lymphogranuloma venereum is no 
longer in the experimental stage, but is still not available for general use. e, Differential Diagnosis 
(l) Lymphogranuloma venereum must be differentiated from malignant 
tumors, Hodgkin1s disease, tularemia, amebic proctitis, tuberculosis, meninto- 
cncephalitis, pyogenic infections, plague, chancroidal bubo, granuloma inguinale, 
and syphilis. Syphilis should be ruled out by dark field examinations of material 
from genital lesions or regional lymph nodes and by serologic examination which 
should be repeated monthly for at least three months. Low titre positive serologic 
tests for syphilis may occur in this disease. 
f, Treatment 
(1) Local, The fluctuant nodes may be aspirated; but incision 
and drainage should not be used. Radical excision is inadvisable because of the 
risk of lymphatic obstruction and chronic swelling of the penis, scrotum, or vulva, 
(2) Chemotherapy, Sulfadiazine should be administered in a dose 
of 1 gram three times daily for 21 days. 
(3) Surgical, Patients with late complications who do'not re- 
spond to sulfonamide therapy, should be handled in the following manner? 
(a) Rectal Stricture, Prolonged gentle dilatation, prefer- 
ably manual. Colostomy should not be performed unless dilation is impossible, be- 
cause of location of the stricture, or has failed, 
(b) Peri-rectal abscess. Surgical incision and drainage, 
(c) Fistula-in-ano, Should be excised where possible, 
14. Granuloma Inguinale 
a. Definition 
(l) Granuloma inguinale is a chronic disease due to infection with 
a Donovan body, which is possibly of bacterial nature. It is a mildly contagious, 
progressive disease, characterized by a sharply defined, granulomatous, usually 
painless, initial lesion, involving the skin of the genital or inguinal region, 
and spreading gradually by continuity or contiguity. Rarely, it is a systemic 
disease involving bones, joints, and viscera. Granuloma inguinale is a distinct 
disease entity and should not be confused with lymphogranuloma venereum. 
b. Epidemiology 
(l) Some doubt exists concerning the manner of spread of granuloma 
inguinale. The consensus is that it is venereally acquired and that its communi- 
cability is low. There appears to be marked differences in racial and individual 
susceptibility. 
c. Course 
(1) The disease starts as a vesicle, papule or nodule. The surface 
epithelium becomes excoriated or eroded, leaving an ulcer with a beefy red granular 
base. An early lesion may be a clean, raised, velvety, smooth tuft of granulation 
17 tissue, situated at the mucocutaneous border of the vaginal orifice,*at the pre- 
putial orifice, or on the glans or inner surface of the prepuce. The margin of 
the lesion is sharply defined, The granulation tissue, if traumatized, bleeds 
easily. The lesions are not painful unless grossly secondarily infected. There 
is very little tendency to spontaneous healing, -The lesions spread by continuity 
or contiguity; Extension is often slow. There is a predilection for'moist con- 
tact surfaces, particularly in the cruroscrotal folds, the groins, and the cleft 
and folds of the buttocks. The advancing border of the lesion has characteristic, 
rolled edges, the granulation tissue piling over onto the bordering epithelial 
surface, 
(2) The ulcerative process may remain more or less stationary for 
many years. Secondary elephantoid enlargement of penis, scrotum, or labia may 
occur. The lesions may heal with scar formation at one margin and progress at 
another. There are three types of lesions: exuberant, ulcerative and cicatricialt 
(3) Ultimately, narked impairment of general health may occur, end- 
ing in extreme cachexia and death, 
d. Diagnosis 
(1) The clinical appearance of a chronic ulcerative process involv- 
ing the skin of the groin and genital areas, without involvement of the lymph 
nodes-, is characteristic of the disease. The demonstration of Donovan bodies 
confirms the diagnosis, 
* (2) For this demonstration spreads should bo made from scrapings or 
punch biopsy of clean granulation tissue, and stained by Wright or Giemsa stain. 
Histologic study of tissue sections taken by biopsy from a peripheral area of 
diseased tissue may demonstrate the pathognomonic large colls with cystic spaces 
containing Donovan bodies, 
(3) Lymphogranuloma venereum, chancroid, carcinoma and syphilis 
should be considered in the differential diagnosis, and appropriate, diagnostic 
tests should be performed, A blood serologic test for syphilis should be made 
weekly the first month and at monthly intervals for 3 months unless a diagnosis 
of syphilis is established earlier, 
e, Treatment 
P 4 
* (l) Fuadin (a complex antimony compound). This drug is also known 
as neoantimosan and stibophen, It is supplied in ampules containing 6,4 percent 
solution (0,06-4 gm fuadin, 1 grain, in lee), Fuadin solution is given intramuscu- 
larly, The first throe doses of 1,5 cc, 3*5 cc, and 5 cc are given on successive 
days, followed by 5 cc two or three times weekly, until complete healing has taken 
place; and, in order to prevent relapse, continued at weekly intervals fo!r 6 . 
months after complete healing. The most commonly reported toxic sytnptom is vomit- 
ing, Rarely, joint and muscle pains may appear. If any toxic symptom occurs, the 
dose should be reduced, 
(2) Antimony and potassium tartrate (tartar emetic). If there is 
no response to* fuadin therapy after 6 weeks of treatment, antimony and potassium 
tartrate should be administered. This preparation contains about 36 percent anti- 
mony, One percent solution should bo freshly prepared using supplies of sterile distilled water or physiological saline. The solution should be perfectly clear 
and free from sediment. It is sterilized by gentle boiling for 5 minutes. Solu- 
tion should not bo autoclaved. The drug is best tolerated 2 to 3 hours after a 
light meal. It is administered intravenously and should bo given slowly. Since 
the solution is very irritating, the needle should be wiped off with a sterile 
sponge and there should be no extravasation. The patient should remain recumbent 
for at least an hour after treatment. The first dose is 3 cc (0,03 gm tartrate). 
Provided no untoward reaction occurs, subsequent doses are given on alternate days 
and are increased on each occasion by 3 cc (0,03 gm tartrate), until the maximum 
individual dose of 12 cc (0.12 gm tartrate) is reached. If no toxic reaction 
appears the maximum tolerated dose may bo given 3 times weekly for 15 doses. The 
toxic effects of antimony and potassium tartrate include coughing immediately 
upon injection, which is not important; nausea, vomiting, dizziness, and collapse. 
Transient electrocardiographic changes without corresponding clinical manifesta- 
tions have been reported. If a toxic reaction other than coughing occurs during 
administration, the injection should be stopped at once. Following any toxic 
effect, the subsequent dose or doses should be reduced or omitted according to 
the circumstances, 
(3) Healing under antimony is enhanced by adequate concomitant 
treatment of gross secondary infection. This nay bo accomplished by local appli- 
cation of daily wet dressings with weak solutions of potassium permanganate or 
sodium perborate. Penicillin given intramuscularly every 3 hours, in injections 
of 10,000 units each, in a total dosage of 400,000 units, is also recommended 
fcr the treatment of secondary infection, 
(4) X-ray therapy combined with chemotherapy has yielded promising 
results, 
(5) Surgical excision of the entire diseased area may be necessary 
as a last resort. If used, it must be followed by chemotherapy, 
15# Case-Holding and Case-Finding 
a• General Considsrations 
(1) Gonorrhea and syphilis are communicable diseases, and every 
new patient admitted to a treatment service offers to the personnel a double 
challenge in case-holding and case-finding. These diseases are communicable, 
however, under very limited conditions, and their communicability may vary or 
disappear with the passage of time or with treatment. Both diseases nay be 
clinically asymptomatic end still be communicable or potentially so. Communicable 
relapse of syphilis and reinfection with gonorrhea are common® /in otherwise non- 
communicable infection with syphilis in a female may become communicable to the 
infant in pregnancy. Congenital infections are ordinarily communicable only in 
infancy. Incubation periods are variable and histories of sexual exposure are 
often indefinite or unreliable. Infectiousness is not easily established by 
ordinary physical examination; it is likely to be ephemeral, and it is never to 
be taken lightly since the unexpected may always happen, 
(2) Competent medical evaluation of every case is essential to 
intelligent case-holding and case-finding. It should be obvious, therefore, that 
those who are to render these services must understand the diseases with which 
they are to work and must be frequently in consultation with the chief of the 
treating agency. Reasonably adequate training should be given to all those who 
are to do this work. 
19 (3) Sympathy, tact, ability to work with patients, and a roal in-• 
terest in venereal disease control are essential in those who are to do case- 
holding and case-finding. It is important, therefore, that this personnel should 
be selected with these qualities foremost in mind. 
b. Case-Holding . I 
(l) Case-holding is essential if the patient’s infection is to be 
kept lander control until it is cured. It is useless, however, to employ a case- 
holding staff if the fundamental causes of neglect of\ treatment are ignored. Some 
of these are failure to explain the disease, its treatment and its communicability 
to the patient; failure to take the patient’s economic problems and job into ac- 
count; transportation difficulties; rough or discourteous handling of the patient 
in the clinic; lack of privacy in the clinic; dirty, crowded, unattractive clinic 
quarters; poor technics which cause pain, reactions and resentment; inadequate co- 
operation between related clinic services, the hospital proper, and the venereal 
disease clinic, so that infections discovered in one service fail to roach the 
attention of the venereal disease clinic. 
(2) An effective case-holding service will be constantly on the 
watch for neglect on the part of the clinic or other treating agency to cooperate 
with the patient. It should be the ultimate objective of every case-holding ser- 
vice so completely to solve all of those problems ¥;hich lead to premature interrup- 
tion of treatment that only those patients who are mentally unable to cooperate or 
who are obviously antisocial in their behavior need be referred to the health de- 
partment for control. Except for the truly nonoooporative, every patient which 
the treating agency finds it necessary to report to the health department for con- 
trol should be looked upon as a clinic failure in case-holding 
c, Case-Finding 
(1) Case-finding is not an objective in itself, ‘±f it is to be of 
any benefit to the community it must lead to one or more of three conclusions; 
(l) Better information as to the provalance or incidence of infection in the 
community, either for the purpose of stimulating support for an improved control 
program, or as a measure of the effectiveness of a program; (2) The protection 
of the public health and the promotion of the public safety, as in the discovery 
of communicable infection or of cardiovascular or neurosyphilis in those who hold 
lives in their hands and (3) the treatment of the infected. 
(2) Mass blood-testing, in some industries for example, is too 
often used for the purpose of weeding out infected employees who promptly become 
candidates for discharge from employment. Food-handlers and domestics, in parti- 
cular, are singled out for blood tests on the completely false premise that in- 
fected food-handlers, because of their occupation, are more dangerous than other 
persons to the public health. These are abuses of a case-finding procedure which 
protect nobody and which are almost certain, eventually, to bring this case-finding 
procedure Into disrepute. 
(3) It is of the utmost importance, therefore, that the health 
department do all that it can to see to it that any case-finding procedure is used 
with an intelligent and legitimate objective in mind. 
(4) Case-finding procedures- may be divided into three main groups: 
(a) Mass blood testing; (b) direct epidemiologic investigation, starting with a known infection; and (c) public education, through which those who may have been 
exposed are encouraged to seek medical advice. 
(5) Direct epidemiologic investigation — Direct epidemiologic 
investigation, starting with a knovm infection, is probably the most productive 
method of case-finding, at least so far as the discovery of communicable infections 
is concerned. It is when case-finding is initiated by the discovery of a patient 
with a recently acquired infection that the greatest promise is offered for 
communicable disease control. 
(6) For these reasons, direct epidemiologic investigation is best 
carried out by representatives of the treating agency, in the name of the treat- 
ing agency. Only the patient can supply the information by which his contacts 
may be identified. The clinic follow-up worker has the confidence of the patient 
and will often be able to obtain the patient1s active assistance in bringing the 
contacts to medical attention. In many cases more than one contact must be in- 
vestigated although not all of them will be found to be infected. It is much 
less disturbing to those who must be approached that the approach is made by a 
representative of a medical agency. There is then an implication of the confiden- 
tial relationship which is commonly accepted as characteristic of medical agencies* 
This softens the blow and makes the investigation a medical, rather than a public, 
and possibly punitive one. 
16. Information and Education 
a. Professional 
(l) Medical - The control of the venereal diseases will depend, in 
great measure, upon how well the medical profession is informed and trained in the 
management of these diseases. Whether the physician is engaged in the private 
practice of medicine, in the treatment of patients in a venereal disease clinic, 
in medical teaching, or as a health officer, it is he who will make the diagnosis 
and treat the patient or conceive and direct the control program. It is a matter 
of fundamental principle, therefore, that the prefectural health department give 
adequate attention, in the development of its venereal disease program, to the 
following procedures in medical information and education. 
(2) The modification of the curriculum of the medical school toward 
better instruction in the public health aspects of venereal disease control. The 
required course should consider general methods and interpretations, control of 
infectiousness, standard diagnostic and treatment procedures in early and latent 
syphilis and gonorrhea, the general management of late syphilis, prevention of 
of cardiovascular and congenital syphilis and neuro-syphilis, prevention of the 
serious complications of gonococcal infection, the use of drugs, and precise 
instruction in the details of technic with emphasis on indications, reactions and 
contraindications. Most important of all is the inculcation of modern, sound, 
basic public health principles, Prefectural health departments have on unusual 
opportunity, through their close contact with the faculties of medical schools in 
their prefectures to stimulate medical schools to greater effort and efficiency 
in teaching venereal disease control. 
(3) Postgraduate instruction of practicing physicians. Although 
this is secondary to better instruction of the medical student, it nonetheless 
is of great importance. Postgraduate instruction will have to be carried out 
21 locally by meetings of the prefectural medical societies# It will also be carried 
out on a national basis through the Ministry. 
(4-) The dissemination of informative literature to private physi- 
cians: This is essential. The material used should be so selected that it will 
aid them in their private practices. It will help to secure their active coopera- 
tion in the control program. 
(5) Allied professions. Provision should be made, also, for the 
training and information of nurses, social workers, and public health workers both 
in training schools and by postgraduate instruction along lines analogous to those 
followed in the information and training of undergraduate and graduate medical 
students and practicing physicians. It is from this group that clinic nurses, 
follow-up workers, health education personnel, and others who will function in 
one way or another in venereal disease control, will be recruited# It is as im- 
portant that they, as well as physicians, understand the venereal diseases and 
control procedures. 
b. Public 
(1) Intelligent public understanding of the venereal diseases and 
the objectives of the venereal disease control program is essential to public 
support of the program and to effective public use of the diagnostic and treatment 
facilities ?/hich are available# It stimulates the activities of the public offi- 
cials# Effective and persistent public education not only accelerates case-finding 
and improve case-holding, but it also may be counted upon to inhibit exposure and 
to encourage prophylaxis against infection# 
(2) Virtually all media of public communication — the, press, radio, 
motion pictures, lectures, publications, exhibits — are as available and as 
effective in venereal disease education as in any other field of public health. 
(3) Great care should be taken to give the public the unvarnished 
facts* Over-dramatization should be strictly avoided, for the facts are astonish- 
ing enough* Over-dramatization and exaggeration lead, eventually, to loss of 
public confidence in the health department when the truth becomes known* They 
also lead to hasty and ill-advised public response. Too many persons will be 
denied or removed from employment if too much emphasis is placed upon the com- 
municability of the venereal diseases without adequate definition of when and 
how they are communicable. It is dangerous to put too much emphasis upon the 
blood test as an end in itself. It should be made clear that a blood test should 
form part of every general physical examination, or that a careful examination, 
including a blood test, should bo made if there may have been exposure to an 
infection. 
(4.) Ambiguity and statements which may be misinterpreted should be 
avoided.,- Statistics should not be complicated, or require interpretations of 
which the audience to be reached is incapable# They should be Pud justed to the 
conditions in the area,to be reached. Statistics ¥/hich describe conditions which 
exist in one part of the country may not be at all applicable to conditions in 
other areas. If data aro used which represent average conditions over the country 
at large, it should be made clear that they are average, and how they correspond 
with the local situation. c, Patient Education 
(l) Physicians in charge of venereal disease clinics as well as 
private physicians doing venereal disease work have a professional obligation to 
provide venereal disease patients with the basic facts about these diseases, how 
they are contracted, diagnosed and treated, and how they may be avoided and kept 
from spreading. 
(2) Contact tracing and the prevention of re-infection will be 
greatly facilitated by realistic and intelligently applied patient education. All 
members of the clinic staff who come into contact with patients or suspects must 
be thoroughly trained in the essential facts of venereal disease diagnosis, treat- 
ment, epidemiology and prevention. 
17, The Charlatan, and The Unethical Phafaacist and Physician 
a. It is known that a large number of people are treated, or drugs are 
prescribed and dispensed for their infections, by unethical drug clerks. Charla- 
tans and unethical physicians, also, treat many patients, especially in the larger 
cities. Since none of these is trained in the diagnosis or treatment of the 
venereal diseases or competent or equipped to evaluate a cure, every effort should 
bo made to protect the infected from this dangerous e xploitation. 
b* When legislation has boon enacted, the health department should make 
such observations as may be necessary to see that it is observed, and should re- 
port any violations to the proper enforcement authority. It may be necessary in 
some cases to send health department inspectors to certain drug stores to discover 
whether the law is being obeyed. 
c. The Charlatan usually violates medical practice laws already in 
existence. His control is a matter of lav; enforcement rather than of the enact- 
ment of new legislation. The function of the health department in the control 
of the charlatan is to call him to the attention of the proper enforcement agency 
whenever it can be discovered that he is practicing in the community. 
d. The control of the unethical physician is a problem for the medical 
profession. What may be Considered as unethical practice is often a matter of 
degree of mismanagement, The old-fashioned ”clap-doctor” does not bother with the 
refinements of correct diagnosis. He treats the patient as long as payments are 
forthcoming or for a specified period for a specified sum, ofte:.. payable in ad- 
vance, He is more interested in what he can collect than in the excellence of 
his management of the disease, although he must enjoy a certain amount of success 
in symptomatic cure at least, to acquire his large clientele. In the long run, 
however, except that he bleeds the patient financially, ho probably is no more 
dangerous to the public health than the physician who uses legitimate treatment 
procedures unintelligently and who is satisfied with symptomatic cure, The pro- 
blem is largely one of convincing all physicians that if they are to treat vene- 
real disease at all, they should know what they are doing find should treat and 
evaluate cure according to the best methods available. 
e. The protection of the public against the exploitation of all three, 
charlatan and unethical or careless physician and drug clerk, may be advanced, 
also, through public health education. If the public becomes adequately informed 
as to the proper methods to be used in the diagnosis, treatment, and determination 
23 of cure of the venereal diseases, the infected may be better able to determine at 
once whether they are in the hands of a physician who knows what he is doing. It 
should be the constant effort, therefore, of every health department to inform 
the public as rapidly as possible upon these matters. Every patient seen by an 
ethical treatment source should be thoroughly instructed in the difference bet- 
ween g6od and poor management of venereal infections, for informed and we11-treat- 
ed patients make excellent salesmen among their infected friends* 
IB, Prostitution 
, , ' a. The economic, political and social aspects of prostitution are well 
known. Prostitution is largely a Social Welfare problem for all of society. 
Actually, only the infectious disease aspects of prostitution are medical, al- 
though as good citizens, doctors must admit that prostitution, in addition to 
being medically harmful, is also ethically and socially ?/rong. 
b. It is well know that prostitutes are recruited almost entirely from 
the lowest economic levels of society. They are mainly daughters of homos where 
there has Been too little food, too little clothing, inadequate shelter, insuffi- 
cient forms of decent recreation, and too little opportunity to acquire an averrge 
education. In short these women have had too little of all the good things'of 
life. In addition they usually come from homos where there has been marital dis- 
cord, homes that have been broken up, or whore as children, they received insuffi- 
cient parental affection and guidance. 
c. While we pity any woman who must earn her living in this manner, 
we must realize that prostitution is an antisocial, evon if a still legal pursuit 
in Japan, It cannot be considered an honorable or responsible occupation for a 
woman. The fact that certain women are prostitutes, lowers the status of all- 
women, No little girl grows up with the ideal of becoming a prostitute. It is 
a last choice occupation. 
d. Prostitution should not be dignified with the term "Profession", 
or son® euphemistic term like 11 Angels of the Night", It is actually an antisocial 
sweated occupation which does more damage to more people and is of greater cost ■ 
to all society than the occasional burglar or other criminal. Such organizations 
as”prostitute unions" or "mutual benefit associations", are really a mark of 
shame and disrespect to unions of honest workers who are doing socially useful 
work in. their communities. 
.e. No democratic country must find the solution to its economic pro- 
blems at the expense of its poorest people. The question of how these women are 
going to live is an economic and social welfare problem, not a medical one. They 
cannot be permitted to infect the entire, population just so they can live, any- 
more, than society could allow other antisocial individuals to operate at the ex- 
pense of the welfare of society. Therefore, while we nay be sympathetic with the 
plight of all people in low economic levels, we cannot permit any of them to 
operate at the expense of society, because they endanger the health and welfare 
of the community. 
f, It is understood that the main individuals at fault are the owners 
and managers of brothels, and patrons of prostitutes. In every country there are 
always disreputable characters who will try every device, if they see the oppor- 
tunity to make money at it, even though society nay suffer. Whenever those individuals crop up, society has to see that they are put down. Commercial pros- 
titution must be made unprofitable• Prostitutes, since they do endanger the 
community, must be detained, reoriented, reeducated, taught useful occupations and 
treated medically to cure their diseases# 
g. It has been firmly established throughout the world that, given the 
opportunity, most prostitutes are amenable to reorientation and rehabilitation 
and can become socially acceptable members of modern society. 
h. Failure to control the sources of infection in any campaign against 
the venereal diseases, favors the spread of these diseases# It is known that 
many persons who are infected with gonorrhea, syphilis and chancroid acquire 
their infections from prostitutes or from persons who have been infected by those 
practicing prostitution. 
i# It is generally accepted that the licensing or toleration of prosti- 
tution and of agencies promoting prostitution, or the segregation of prostitutes 
in special areas, increased the opportunities and accessibility of prostitutes 
and the volume of their promiscuity. The streetwalker who must hunt for each 
patron can only infect about three or four individuals a night, while the prosti- 
tute in a brothel can easily infect thirty or forty individuals. 
j, No health department should ever engage in the medical supervision 
of prostitutes. If it does, it is open to criticism medically, and for becoming 
a supervisory partner in an anti-social, commercial venture. If brothel owners 
feel it would be beneficial for their business to have their employees examined 
at intervals, it is purely a commercial device without medical basis. Any honest 
medical study on these prostitutes would leave the brothel keeper with no prosti- 
tutes to carry on his business# As was said by a French medical officer in a 
position of great responsibility, speaking of routine examinations of prostitutes, 
"If the doctor is good, the system is bad; if the doctor is poor, the system is . 
dreadful; and we know what kind of doctors make their living off prostitutes”. 
No health department physician should be placed in this category. 
k* Infection is too difficult to detect by any system of routine 
examination, and exposure between examinations is too frequent to make the proce- 
dure effective. No epidemiologic procedure in the hands of the health officer 
can solve this problem. Even when it is possible to trace an infection to a 
particular girl in a specific house, the incubation period (of syphilis at least) 
is so long that many infections will have been caused by a busy prostitute before 
the health officer can even start the epidemiologic process. Prostitutes often 
may show improvement under present treatment, but they will still be infectious 
when they return to their occupation. 
1, An observation and isolation period of at least six weeks, during 
which time additional clinical and laboratory examinations are made, is necessary 
before a patient can be said to be probably free from venereal disease infections. 
Even then the clinician cannot be certain of his diagnosis. Periodic examinations 
alone as a means of reducing the infectivity of promiscuous persons are known to 
be medically useless. Such procedures give a false sense of security to the 
public and further indoctrinate them with the fallacious idea that prostitutes 
are the only ones who have venereal diseases. jn#. The routine periodic examination of prostitutes-cannot bo recom- 
mended, but as long as health departments in Japan still engage in this practice,, 
they,should be aware of the following factors: 
A 
(1) Periodic examinations of prostitutes as a means of controlling 
venereal disease has long been known to be medically worthless and utterly futile# 
This is the opinion of the world*s best university and Public Health Physicians# 
(2) The enormous amount of venereal disease in Japan today is the 
best proof of the failure of this system. 
(3) No epidemiologic or clinical procedure in the hands of any 
health, officer '-can control the infectious spread into the community by prostitutes 
(4.) Prostitution cannot be controlled by medical means alone# It 
is the duty of the health officer to show the public that the suppression of 
prostitution is a function of the police and courts. To do this, the police and 
courts have to work on the basis of a law which prohibits prostitution and its 
allied activities, that is, oY/ning or managing brothels, procuring, and even.those 
patronizing brothels# 
(5) Wherever routine examinations of prostitutes are done it will 
be found that a low professional level exists# Good physicians will n6t do this 
work, knowing its uselessness and the corruption that invariably creeps in# 
(6) Health departments who do this work are obvious examples of 
deterioration,and degeneration# 
(?) Such health departments can be seen to do nothing for the 
public, but end by devoting their entire attention to a small segment of the 
population—the prostitutes, who are actually some brothel keepers private 
employees# 
* , > 
(8) In view of the lack of funds, facilities, and supplies it is 
difficult to justify useless work on prostitutes, when useful work could be done 
on the general population who have a greater chance to stay cured once they are 
properly treated# ‘ 
. (9) More reasons for not engaging in this work could be given, a 
partial list is as follows: 
(a) The Health department becomes a supervisory partner in an 
antisocial, commercial venture# 
. (b) It fosters the idea that prostitution is approved by the 
Health Department# 
(c) It continues the •rroneous notion that prostitutes can bo 
kept from infecting their patrons by any system of medical examinations. 
(d) It encourages use of brothels# 
(e) It focuses attention on the erroneous idea that only 
prostitutes have venereal disease# (f) Infection is often too difficult to detect in a single 
examination. * 
(g) Prostitutes use various measures to escape detection 
(urinating, douches, sulfonamides). 
(h) Laboratory tests are partially dependent on the proper 
collection of material by the clinician. In chronic gonorrhea the organisms are 
deep in the smaller mucus glands, and if this material is not expressed, the 
smears will be useless. * ■ 
(i) Some laboratory tests are inconclusive. Smears and cul- 
tures are not reliable in chronic gonorrheal endocervicitis. 
... , (j) Laboratory tests are not infallible, but only as good as 
thfc person doing the test. 
(k) Some laboratory tests take more than one day to perform, 
(l) Laboratory tests may be negative during the incubation 
period of the disease. • 
(m) In syphilis the incubation period nay be as long as six 
or eight weeks. 
(n) If the primary lesion is small and not detected, twelve 
weeks nay elapse before secondary signs appear, 
(o) A busy prostitute could be theoretically free from disease 
when examined, become infected by her first patron, and thereafter infect most of 
the succeeding customers until the next examination — if she is not overlooked 
at this tine, 
(p) Repeated studies on unselocted groups of prostitutes have 
shown from 50% - 90% to be infected with one or more venereal diseases. 
(q) Any routine examination which fails to find infections in 
one-half to nine-tenths of the examinees therefore is missing many infections and 
allowing then to return to infect more people, 
(r) Routine examinations and treatment of prostitutes is 
therefore non-productive work. Even the few who are diagnosed and treated soon 
Becon® reinfected, ■ The main accomplishment is probably a penal job of keeping the 
prostitute from infecting others during the period of isolation, - 
n. Every health department must make clear the distinction between its 
function and that of the police department* Law enforcement is a police problem 
dhd not a function of the health department; The police apprehend law breakers 
or suspects, the health department uses persuasion and voluntary methods to 
encourage the attendance of persons possibly infected with diseases. While the 
health department is responsible for controlling all the infections it is possible 
to trace .through epidemiologic processes, it is most unreasonable to make the 
health department solely responsible for the control of the'sources of disease, 
and then to express surprise and indignation upon discovering-that the health department, working alone, has been unable to do much about putting the owners 
and managers of brothels and the procurers out of business. 
o. The police and court authorities are responsible for the enforcement 
of whatever laws exist regarding prostitution. Health departments will cooperate 
with tho above branches of government in the carrying out of the medical aspects 
of these laws. That is to say public health agencies will examine, diagnose and 
treat persons apprehended by the police as well as all individuals who apply 
voluntarily for service. The apprehension or sentencing of persons who break the 
laws is not the concern of the health department. The nature of the punishment 
should be determined’without consideration of the element of infection. 
p. Little will be accomplished so long as the health officer remains 
the only stimulus to police activity. When the police are required by law to take 
effective action, they will attack the problem from the direction of ridding the 
community of all infectious persons whether on the streets or in brothels. It is 
a function of the health officer to persuade tho public that this is a police pro- 
blem and not one of epidemiology to any practical extent. If the health department 
allows itself or is forced to take over the function of the police, it will degen- 
erate eventually into the same "protective0 agency that tho police in some places 
are alleged to have become, 
q. The Venereal Disease Control program should be redirected to the 
finding and treating of these diseases in the general population. All members of 
society including prostitutes, waitresses, hostesses, dance hall girls, etc., will 
be gladly accepted for diagnostic and treatment services, as individuals. However, 
routine examinations of any special groups are not done by public agencies in 
countries where there are modern venereal disease control programs. 
19. Classification of tho Venereal Diseases 
a. Syphilis 
(1) Primary - (chancre present) 
(a) Dark field positive Sero Negative 
(b) Dark field negative Sero Positive 
(c) Dark field positive Sero Positive 
(2) Secondary - (skin eruption, mucus patches, condylomata lata, 
patchy alopoocias, generalized adenopathy, arthalgia,. irites, may all be present 
either in combinations or alone). The blood test is always positive. 
(3) Early Latent (No objective signs or symptoms, Cerebrospinal 
fluid negative, within 4 years of the .initial infection, serology is positive), 
(4) Late Latent Syphilis (Same criteria as above but of more than 
4 years duration)• ‘ • 
(5) Late Syphilis (State type, Example; C.N.S, Cardiovascular, 
Bono, Cutaneous, other Visceral). 
(6) Congenital b, Gonorrhea 
(1) Acute - duration less than 3 months 
(2) Chronic - duration more than 3 months 
(3) Ophthalmia 
c, Chancroid 
d, Lymphogranuloma Venereum 
e, Granuloma Inguinale 
20* Community Venereal Disease Control Councils 
In order to bring about the public action necessary to develop and main- 
tain effective local conditions and practices in support of the medical control 
program, committees must often be mobilized and organized. There were in previous 
years several organized groups in Japan who were interested in venereal disease 
control. Remnants of these groups may still exist. However, in many areas there 
were no such groups, and it will be necessary to organize them from the beginning. 
It will be helpful in the solving of all public health problems if committees of 
laymen aro organized to study ways and methods for the community to act on these 
matters. In some places these groups may be limited to a city or village. In 
other areas there may be one group for the entire prefecture. 
In the absence of any existing organization of the general public to 
study and act upon community venereal disease control problems, the following 
procedure is recommended: 
a. Under the auspices of a few civic minded individuals or groups, call 
together representatives of the following groups; School system, labor union 
organization, local government, newspapers, welfare agencies, church groups, 
medical society, law enforcement agency, and any other groups who should be in- 
terested within this field, members of professional and business groups. 
b. Representatives of these groups, meeting with the prefectural vene- 
real disease control officer, present and discuss the local venereal disease pro- 
blems. The group is then asked to cooperate in planning a solution for this 
problem, 
c. A small executive committee should be chosen, and to encourage 
continuous interest in their activity, it has been found useful to break the 
larger group into the following sections: Law enforcement, social welfare, 
health education and information, medical services and group participation. 
The prefectural venereal disease control officer uses these sections to 
improve control work in these fields, especially in health education and informa- 
tion, He is present so that the community representatives can make him aware and 
keep him cognizant of the public demands and possible need for extension of vene- 
real disease control facilities. No community action campaign is successful in 
the long run, unless it reaches and motivates the average man, or woman. It is 
his health with which we are concerned and his cooperation obviously should be 
secured. Education alone will not suffice, active public participation is required. 
29 CLINIC MONTHLY REPORT 
CUn/c _ 
Prefecture_ 
For THE MONTH OF IQ 
City, town or village_ 
Syphilis 
Gonorrhea 
Chan- 
croid J 
ALL 
OTHER 
VfNtREAL 
DISEASES 
Patient Load 
Pr/~ Second*Early Late , Congen- 
MARY ARY LATENT LATENT LATE ITAL 
Acute Chronic 
/ Cases carried 
OVER FROM 
PREVIOUS MONTH 
| Croup A* 
A Others 
Total. 
2. NswCases^pre- 
VIOUSLY TRSATEDEY 
THIS OR ANY OTHER 
CUNIC OR PRIVATE 
PHYSICIAN 
IMale 
Group A* 
_ Others 
Total 
Total 
Addi- 
tions 
this 
MONTH 
3. Readmissions and 
CASES PREVIOUSLY 
TREATED BY ANY OTHER 
CLINIC OR PRIVATE PHT\ 
-SfCtAN BUTMBW TO THIS 
Male 
aj Group A* 
i. Others 
r Total 
& Cases discharged 
AS CURED 
DURING MONTH 
I Male 
Croup A* 
Others 
Total 
SUB- 
TRACT 
TI0NS 
Cases referred 
toother care 
Male 
I Group A* 
Others 
Total 
6 Cases that discon- 
tinued TREATMENT 
WITHOUT PERMISSION 
THE ENTIRE MONTH 
Male 
I [Group A*. 
j£ Others 
Total 
Bal- 
ance 
END OF 
MONTH 
7 Total patient 
load at end of 
MONTH 
lTIM(l*$MINUs(t*S*6) 
Male 
| Group A* 
j Others 
Total 
8. Number of persons 
EXAMINED AND FOUND 
flu I Male I 
POSITIVE t 
7. |male] 
Negative^.■■ f 
Total , 
3 Number of injections 
and treatments 
Injections of 
ARSBNICALS BISMUTH PENICILLIN 
Treatments 
\Male [ 
Total . 
10 Number of laboratory tests 
Serologic Tests 
Blood TSpinal Fluid 
fbsiT/YE 
Hesaws 
Total 
Dark Field Examinations 
All kinds of tests 
,l' Contacts 
Number reported 
Number examined, found infected 
Number examined, not infected 
Number of visits for contact tracing 
12. Total number of visits to clinic for treatment.; observation or advice/by all patients for all venereal diseases 
13. Number of visits for delinquent cases 
| /(t. Number, of delinquent patient*™ treatment 
US. Total lapsed cases all V. D 
Case finding 
FOP. ALL V D 
Voluntary 
Referred by 
PRIVATE PHYSICIAN 
Drought by police 
Referred by 
PUBLIC CLINIC 
By contact 
TRACING 
Compulsory prosti 
-tute examination 
All others 
Date 19 
Submitted by 
Title 
All CLINICS TREATING VENEREAL DISEASES REQUIRED TO SUBMIT THIS form IN DUPLICATE BySTH. DAY OF each SUCCEEDINGMONTH 
* Group A includes prostitutes in brothels, street walkers and all other prostitutes 
5757 - 8 7-47 - 64ENGR-20C