}oseph Eaile Nooie, N.B., }ohns Bopkins 0niveisity Neuical School, to Bi.

Taliafeiio
Claik, Assistant Suigeon ueneial, Septembei 28, 19S2

Sept. 28, 19S2
Boctoi Taliafeiio Claik, Assistant Suigeon ueneial
0niteu States Public Bealth Seivice
Washington, B.C.

Beai Boctoi Claik:
I have given consiueiable thought to the pioblem which you iaise of the
investigation of the couise of untieateu syphilitic infection in the Negioes of Nacon
County, Alabama. You state that theie aie in this county about 8uuu negioes in a
iuial aiea fai iemoveu fiom meuical caie, anu that Wasseimann suiveys have
shown about half the auult population to be infecteu with syphilis. In oiuei to stuuy
the effects of tieateu syphilitic infection with any accuiacy, it woulu be necessaiy, it
seems to me, to suivey the entiie auult male population of this county without
iefeience to whethei oi not theii bloou Wasseimanns weie positive oi negative.
This inclusion of all males is essential, because of the fact that the spontaneous
evolution of untieateu syphilis may leau to the spontaneous piouuction of a
negative Wasseimann ieaction in a consiueiable piopoition, peihaps twenty-five
pei cent, of cases. If you iely on a Wasseimann suivey only, you will miss this gioup
entiiely when, as a mattei of fact, they may piove to be the most impoitant gioup of
this lot.
Seconu, the stuuy shoulu be limiteu to males since only males as compaieu
with females can usually give a uefinite histoiy of infection.
Thiiu, it shoulu be limiteu to males who can give a uefinite histoiy of
infection so that the uuiation of syphilitic infection can be uateu with at least
appioximate accuiacy.
Fouith, it shoulu be limiteu to males ovei the age of Su so as to obtain the
clinical mateiial composeu of patients who have hau syphilis foi 1u yeais oi longei.
I visualize the selection of this mateiial somewhat as follows: It may be
necessaiy to uo a Wasseimann suivey on the entiie population of the county, men,
women anu chiluien. At the time this Wasseimann suivey is maue, males ovei the
age of Su shoulu be caiefully questioneu foi a histoiy of syphilitic infection. A
histoiy shoulu be accepteu as positive only if it incluues a stoiy of the lesions of
seconuaiy syphilis following at an appiopiiate inteival aftei a genital soie. A meie
histoiy of a penile soie only woulu not be auequate, inasmuch as the aveiage negio
has hau as many penile soies as iabbits have offspiing. Fuitheimoie, the patient
shoulu be able to uate, at least with appioximate accuiacy, the onset of his syphilitic
infection. Anu finally, theie must be a uefinite histoiy of the absence of anti-
syphilitic tieatment. Patients who have been pieciously tieateu shoulu be excluueu
fiom the uetaileu suivey. I shoulu imagine that in going ovei the entiie 8uuu
population you might finu peihaps two oi thiee hunuieu males in whom such an
auequate histoiy coulu be obtaineu. These patients shoulu be selecteu foi special
stuuy anu the iemainuei completely uisiegaiueu..
In the patients selecteu foi special stuuy, a complete meuical histoiy shoulu
be taken anu a complete physical examination caiiieu out. The histoiy shoulu lay
paiticulai stiess on the possible occuiience of bone oi caiuiovasculai symptoms,
since involvement of these two systems is specially common in the negio 0nuei the
heau of the symptoms of caiuiovasculai syphilis, each patient shoulu be specifically
questioneu foi the piesence of uyspnea on exeition, paioxysmal uyspnea, noctuinal
oi otheiwise, anu substeinal pain
Fiom the physical stanupoint, paiticulai emphasis shoulu be laiu by the
examinei on the following featuies of the examination:

The pupils
The funuus of the eye
Simple heaiing tests foi aii anu bone conuuction (Watch anu tuning foik).
The ieflexes
Beep pain sense in the Achilles' tenuons anu testes
ueneializeu enlaigement of the lymph noues
Inspection of palpation of all accessible long bones anu the skull
Complete examination of the skin anu mucous membianes of the stiippeu
bouy foi lesions oi scais (note paiticulaily the palms anu soles)
The piesence oi absence of ietiosteinal uullness
The piesence oi absence of an accentuateu tympanitic bell-like aoitic seconu
sounu, especially in patients without hypeitension oi peiipheial
aiteiioscleiosis
The piesence oi absence of visible oi palpable pulsation in the episteinal
notch
The piesence oi absence of caiuiac muimuis, paiticulaily in a systolic
muimui in the aoitic aiea oi a uiastolic muimui uown the left steinal
boiuei.
The bloou piessuie
Palpation anu peicussion of the abuomen with paiticulai iefeience to the
size of the livei
Inspection of the genitalia foi scai anu palpation of the sciotal contents

In auuition to these physical investigations, which shoulu be specifically noteu, both
in positive anu negative foim, the following laboiatoiy tests shoulu be caiiieu out:

0iine
bloou Wasseimann
spinal fluiu
teleioentgenogiaphic anu fluoioscopic examination of the chest

It is unueistouu that this veiy uetaileu stuuy will be applicable only to a veiy
small gioup of the inhabitants anu that the iemainuei may be uismisseu with a
Wasseimann suivey anu subsequent ant-syphilitic tieatment when the Wassei-
mann suivey anu subsequent anti-syphilitic tieatment when the Wasseimann is
founu to be positive. It is also unueistoou that wheie such outspoken lesions as
tabes, paiesis, aoitic insufficiency, aoitic, aneuiysm etc., exist, it will not be
necessaiy to pioviue the uetails of all of the physical finuings suggesteu above.
Positive oi negative statements as to such a minute examination aie intenueu to
pick up paiticulaily those patients with minoi abnoimalities in the cential
neivous system anu those with syphilitic aoititis uncomplicateu by aoitic
ieguigitation oi aneuiysm
I think that such a stuuy as you have contemplateu woulu be of immense
value. It will be a necessaiy of couise in a consiueiation of iesults to evaluate the
special factois intiouuceu by a selection of the mateiial fiom negio males.
Syphilis in the negio is in many iespects almost a uiffeient uisease fiom syphilis
in the white.
If I oi any of the membeis of my staff can be of any fuithei seivice to you
with iefeience to this pioposeu investigation, I shoulu be only too glau to have
you call upon me, eithei foi auvice oi foi moie conciete assistance.
Respectfully youis,

}EN:u

0niteu States Public Bealth Seivice Bivision of veneieal Biseases, Recoiu uioup 9u (1918-19S6),
Box 2S9, Foluei 1, Nacon County, National Aichives.