september 2011

“Ethically impossiblE”

STD Research in Guatemala 

from 1946 to 1948
About the cover:

Detail taken from historical map

Complete map shown above

Author: Schrader; Vivien St Martin, L.

Date: 1937

Short Title: Mexique

Publisher: Librairie Hachette, Paris

Type: Atlas Map

Images copyright © 2000 by Cartography Associates

David Rumsey Historical Map Collection

www.davidrumsey.com
Washington, D.C.

September 2011

www.bioethics.gov

Presidential Commission 

for the Study of Bioethical Issues

“Ethically Impossible”

STD Research in Guatemala 

from 1946 to 1948
“Ethically Impossible” STD Research in Guatemala from 1946-1948

iiii

About the Presidential Commission for

the Study of BIOETHICAL Issues

The Presidential Commission for the Study of Bioethical Issues (the Commission) 

is an advisory panel of the nation’s leaders in medicine, science, ethics, religion, 

law, and engineering. The Commission advises the President on bioethical issues 

arising from advances in biomedicine and related areas of science and technology. 

The Commission seeks to identify and promote policies and practices that 

ensure scientific research, health care delivery, and technological innovation are 

conducted in a socially and ethically responsible manner.

For more information about the Commission, please see www.bioethics.gov.
iii

Contents

PREFACE ........................................................................................................ 1

BACKGROUND .............................................................................................. 9

Terre Haute Prison Experiments, 1943-1944 ................................................ 13

Implementing the Experiments .................................................................. 20

Developments in the Science and Prevention of Sexually Transmitted Diseases ... 23

GUATEMALA EXPERIMENTS 1946-1948 .................................................... 27

Initial Experiment Design ........................................................................... 28

Treatment Programs and Goodwill Efforts................................................... 32

Serological Experiments .............................................................................. 36

Penitentiary............................................................................................ 37

Children................................................................................................. 38

Leprosarium............................................................................................ 40

Psychiatric Hospital ................................................................................. 41

Intentional Exposure Experiments............................................................... 41

Overview................................................................................................ 41

Gonorrhea Experiments............................................................................ 43

Syphilis Experiments ................................................................................ 52

Chancroid Experiments............................................................................ 69

Winding Down the Guatemala Experiments................................................ 70

Extension of the Grant ............................................................................ 70

Disposition of the Laboratory .................................................................... 71

Race and Secrecy during the Guatemala Experiments................................... 72

Issues of Race........................................................................................... 72

Concerns about Secrecy............................................................................. 74

THE POST-CUTLER CONTINUATION OF THE GUATEMALA

EXPERIMENTS AND FINAL REPORTs 1948-1955 ....................................... 81

Serology Experiments.................................................................................. 82

Continuing Observations............................................................................ 83

PUBLICATION OF THE GUATEMALA DATA ............................................. 85

AFTERWORD ............................................................................................... 87

REVIEWING ETHICAL STANDARDS IN CONTEXT ................................. 91

Current Human Research Protections and Ethical Requirements of Our Own 

Time.......................................................................................................... 92

Longstanding Ethical Principles .................................................................. 93

Contemporaneous Standards for Ethical Research in 1946-1948 .................. 97

Evaluating General Mitigating Arguments..................................................101

Evaluating Historically Specific Mitigating Arguments............................... 104
“Ethically Impossible” STD Research in Guatemala from 1946-1948

iv

The Guatemala Experiments—Looking Back, Looking Ahead, and 

Apportioning Blame ..................................................................................107

TABLES AND FIGURES ..............................................................................109

Table 1: The Cutler Documents.................................................................. 110

Table 2: Individuals Involved in the STD Experiments in Guatemala...........112

Table 3: Timeline of all Guatemala Experiments ......................................... 116

Table 4: Subject and Population Specific Data ............................................. 118

Figure 1: Organizational Chart of the Office of Scientific Research and 

Development ............................................................................................ 120

Figure 2: Organizational Chart of the National Research Council ...............121

Figure 3: Organizational Chart for the U.S. Public Health Service, 1946 ....... 122

Figure 4: Organizational Chart for the National Advisory Health Council, 

December 1946 ........................................................................................ 123

Figure 5: Organizational Chart for the Syphilis Study Section .................... 124

Figure 6: Intentional Exposure Experiments Goals over Time......................125

Figure 7: Intentional Exposure Experiments over Time............................... 126

Figure 8: Methods of Exposure over Time.................................................. 127

GLOSSARY OF KEY TERMS........................................................................ 129

APPENDICES................................................................................................137

Appendix I: Waiver Form Proposed in Preparation for the Terre Haute 

Experiments ............................................................................................. 138

Appendix II: Chancroid Experiment Report Excerpt ...................................141

Appendix III: Investigation Methods ..........................................................142

Research in Guatemala............................................................................146

Advisors to the Investigation.....................................................................146

Targeted Interviews.................................................................................148

Staff Delegation to Guatemala ................................................................148

Translation ............................................................................................148

Appendix IV: Subject Database Methods ..................................................... 149

Creation of Subject Database...................................................................149

Subject Database Quality Control ............................................................ 151

Limitations ............................................................................................ 153

Figures 6, 7, and 8..................................................................................154

Appendix V: Suggestions for Further Reading ............................................. 155

ENDNOTES.................................................................................................. 159

INDEX ..........................................................................................................201
v

Presidential Commission for the Study of Bioethical Issues

President Barack Obama

The White House

1600 Pennsylvania Avenue, NW

Washington, DC 20500

Dear Mr. President:

On behalf of the Presidential Commission for the Study of Bioethical Issues, we present to you 

this report, “Ethically Impossible”: STD Research in Guatemala from 1946 to 1948. In response 

to your request of November 24, 2010, the Commission oversaw a thorough fact-finding 

investigation into the specifics of the U.S. Public Health Service-led studies in Guatemala 

involving the intentional exposure and infection of vulnerable populations. 

Following a nine-month intensive investigation, the Commission has concluded that the 

Guatemala experiments involved gross violations of ethics as judged against both the standards 

of today and the researchers’ own understanding of applicable contemporaneous practices. It is 

the Commission’s firm belief that many of the actions undertaken in Guatemala were especially 

egregious moral wrongs because many of the individuals involved held positions of public 

institutional responsibility.

The best thing we can do as a country when faced with a dark chapter is to bring it to light. 

The Commission has worked hard to provide an unvarnished ethical analysis to both honor the 

victims and make sure events such as these never happen again. 

The Commission is also working to fulfill your other charge on human subjects research—a 

review of domestic and international contemporary human subjects protection rules and 

standards, to ensure federally funded scientific studies are conducted ethically—and will submit 

a report to you in December. 

The Commission is honored by the trust you have placed in us and grateful for the opportunity 

to serve you and the nation in this way.

Sincerely,

Amy Gutmann, Ph.D. James Wagner, Ph.D.

Chair Vice-Chair

1425 New York Avenue, NW, Suite C-100, Washington, DC 20005

Phone 202-233-3960 Fax 202-233-3990 www.bioethics.gov
“Ethically Impossible” STD Research in Guatemala from 1946-1948

vi
vii

PRESIDENTIAL COMMISSION FOR THE STUDY OF BIOETHICAL ISSUES

AMY GUTMANN, PH.D., CHAIR

President and Christopher H. Browne

Distinguished Professor of Political Science, University of Pennsylvania

JAMES W. WAGNER, PH.D., VICE CHAIR

President, Emory University

YOLANDA ALI, M.B.A.

Michael J. Fox Foundation

Founder’s Council; 

Emory Neurosciences

Community Advisory Board

ANITA L. ALLEN, J.D., PH.D.

Henry R. Silverman Professor of Law 

and Professor of Philosophy 

University of Pennsylvania Law School

JOHN D. ARRAS, PH.D.

Porterfield Professor of Biomedical

Ethics, Professor of Philosophy,

University of Virginia

BARBARA F. ATKINSON, M.D.

Executive Vice Chancellor,

University of Kansas Medical Center; 

Executive Dean, University of 

Kansas School of Medicine

NITA A. FARAHANY, J.D., PH.D.

Leah Kaplan Visiting Professor in 

Human Rights, Stanford Law School

Associate Professor of Law; 

Associate Professor of Philosophy

Vanderbilt University

ALEXANDER G. GARZA, M.D., M.P.H.

Assistant Secretary, Office of Health

Affairs; Chief Medical Officer, 

Department of Homeland Security

CHRISTINE GRADY, R.N., PH.D.

Acting Chief of the Department of 

Bioethics, National Institutes of 

Health Clinical Center

STEPHEN L. HAUSER, M.D.

Robert A. Fishman Distinguished 

Professor and Chair of the Department 

of Neurology, University of California, 

San Francisco

RAJU S. KUCHERLAPATI, PH.D.

Paul C. Cabot Professor, Department 

of Genetics, Harvard Medical School; 

Professor, Department of Medicine, 

Brigham and Women’s Hospital

NELSON L. MICHAEL, M.D., PH.D.

Colonel, Medical Corps, U.S. Army; 

Director, Division of Retrovirology; 

Walter Reed Army Institute of Research; 

U.S. Military HIV Research Program

DANIEL P. SULMASY, M.D., PH.D., FACP

Kilbride-Clinton Professor of Medicine 

and Ethics, Department of Medicine 

and Divinity School; Associate Director, 

The MacLean Center for Clinical Medical 

Ethics, University of Chicago
“Ethically Impossible” STD Research in Guatemala from 1946-1948

viii

PRESIDENTIAL COMMISSION FOR THE STUDY OF BIOETHICAL ISSUES 

staff* and consultants

Executive Director

Valerie H. Bonham, J.D.

Deputy Director

Debbie Banks Forrest, M.P.P.

Communications Director

Hillary Wicai Viers, M.S.J.

Senior Advisors

Paul Lombardo, Ph.D., J.D.

Jonathan D. Moreno, Ph.D.

Jeremy Sugarman, M.D., M.P.H., M.A.

Research Staff

Eleanor Celeste, B.A. 

Tom Cinq-Mars, B.A.

Brian C. Eiler, J.D.

Michelle Groman, J.D.

Chris Havasy, Sc.B.

Holly Fernandez Lynch, J.D., 

 M. Bioethics

Debra Mathews, Ph.D.

Eleanor E. Mayer, J.D., M. Bioethics

David G. Miller, Ph.D.

Anne Pierson, J.D.

Jason L. Schwartz, A.M., M. Bioethics

Kayte Spector-Bagdady, J.D., 

 M. Bioethics

Victoria Wilbur, B.A.

Consultants

Burness Communications

Kathi E. Hanna, M.S., Ph.D.

Jonathan Zenilman, M.D.

Committee and Staff Affairs

Judith E. Crawford

Esther Yoo, B.A.

Fellows and Interns

Laura Biron, Ph.D.

Michael Grippaldi, B.S.

Magdalina Gugucheva, B.A.

Casey Nicol, B.S.

Tuua Ruutiainen, B.A. 

Michael Tennison, M.A.

David Tester, Ph.D.

Ilana Yurkiewicz, B.S.

*Includes former and part-time staff
ix

Acknowledgements

The Commission is grateful to the many individuals who contributed their time, 

energy, and insight to this investigation. The Commission extends its thanks to 

the historians, scholars, archivists, and agency officials who helped it find and 

synthesize the records and documents necessary to fully describe these events. 

It is impossible to name each person here, but the Commission offers its 

particular thanks to Suzanne Junod, Susan Lederer, Richard Mandel, Robert 

F. Moore, Betty Murgolo, John Parascandola, Richard Peuser, Andrew Pope, 

Martin Rangel, John Rees, Susan Reverby, Rob Richards, Nancy Terry, Paul 

Theerman, and Wanda Williams. The Commission also extends a special 

thanks to Jonathan Zenilman, Epidemiology Director at the Johns Hopkins 

Center for Sexually Transmitted Infections Research and Prevention, for his 

assistance in interpreting the research records.

Finally, the Commission is enormously indebted to its talented staff for their 

unwavering dedication to conducting a thorough and comprehensive investigation 

into this complex set of events in a short period of time. The Commission extends 

a special thanks to Executive Director Valerie Bonham, for her passion and tireless 

commitment to bringing the truth to light, Senior Advisors Paul Lombardo and 

Jonathan Moreno, for their wisdom and expertise, and lead staff on the investigation Brian Eiler, Eleanor Mayer, and Kayte Spector-Bagdady, whose drive for 

excellence inspired us all.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

x
1

PREFACE 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

2

On October 1, 2010, President Barack Obama telephoned President 

Álvaro Colom of Guatemala to extend an apology to the people of 

Guatemala for medical research supported by the United States and conducted in Guatemala between 1946 and 1948. Some of the research involved 

deliberate infection of people with sexually transmitted diseases (“STDs”)1

without their consent. Subjects were exposed to syphilis, gonorrhea, and 

chancroid, and included prisoners, soldiers from several parts of the army, 

patients in a state-run psychiatric hospital, and commercial sex workers. 

Serology experiments that did not involve intentional exposure to infection, which continued through 1953, also were performed in these groups, 

as well as with children from state-run schools, an orphanage, and several 

rural towns. President Obama expressed “deep regret” for the research and 

affirmed the U.S. government’s “unwavering commitment to ensure that all 

human medical studies conducted today meet exacting” standards for the 

protection of human subjects.2

Kathleen Sebelius, Secretary of the U.S. Department of Health and Human 

Services (DHHS), and Hillary Rodham Clinton, Secretary of the Department of State, immediately issued a joint apology to the government of 

Guatemala and the survivors and descendants of those affected. Calling the 

experiments “clearly unethical,” Secretaries Sebelius and Clinton amplified 

the President’s statements of regret and apologized “to all the individuals 

who were affected by such abhorrent research practices.”3 In the spirit of 

openness and freedom of inquiry needed to restore trust and repair the 

damage created by these revelations, the Secretaries indicated that the U.S. 

government would launch an independent inquiry into the events. They also 

announced plans for the Presidential Commission for the Study of Bioethical 

Issues (the “Commission”), with input from international experts, to undertake a thorough review of human subjects protections to “ensure that all 

[U.S.-sponsored] human medical research conducted around the globe today 

meets rigorous ethical standards.”4

The outrage that the U.S. government registered with these announcements 

echoed around the globe. For some, the story was reminiscent of the infamous 

U.S. Public Health Service (PHS) Study of Untreated Syphilis (also known 

as the “Tuskegee Syphilis Study”), in which nearly 400 African American 

men with syphilis in Alabama were left untreated for nearly 30 years while 
preface

3

U.S. government researchers observed the progress of their infections.5 The 

similarities between the two cases were stark. The cases arose from the same 

laboratory of the Public Health Service, the Venereal Disease Research Laboratory (VDRL), involved some of the same researchers, and focused, in part, 

on the same disease. Both cases also involved deliberate efforts to deceive 

experimental subjects and the wider community that might have objected 

to the work. But other factors distinguished the research in Guatemala from 

that conducted in Tuskegee. The research in Guatemala ended long before 

the work in Tuskegee stopped and took place over a much shorter period. 

Subjects in Guatemala were deliberately exposed to infections, were members 

of different populations, and were citizens of a foreign country. 

As additional details about the research emerged, President Obama directed 

the Commission to undertake both a forward-looking assessment of research 

ethics and an historical review of events that occurred in Guatemala between 

1946 and 1948.6 On November 24, 2010, he charged the Commission, beginning in January 2011, to “oversee a thorough fact-finding investigation into 

the specifics” of the Guatemala research.7

 The President also charged the 

Commission to undertake “...a thorough review of [current] human subjects 

protection to determine if federal regulations and international standards 

adequately guard the health and well-being of participants in scientific studies 

supported by the federal government.”8

The Commission began its work in January 2011. It held three public 

meetings addressing the President’s requests. During these meetings, the 

Commission heard from experts in law, history, medicine, and ethics, and 

received testimony from members of the public. With dual responsibilities 

to give a full and fair accounting of events largely hidden from history for 

nearly 65 years and also provide an assessment of the current system, the 

Commission decided to publish two reports. This is the first report, a historical account and ethical assessment of the Guatemala experiments. It aims 

to uncover and contextualize as much as can be known at this time about 

the experiments that took place nearly 65 years ago. It also aims to inform 

current and continuing efforts to protect the rights and welfare of the subjects 

of U.S.-sponsored or -conducted research. The second report on this topic, to 

be published in late 2011, will address contemporary standards for protecting 

human research subjects around the world. 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

4

Many unanswered questions drove the Commission’s work at the outset of 

its historical review and throughout the investigation process. Among the 

overarching questions to be examined were:

•	 What occurred in Guatemala between 1946 and 1948 involving a series of 

STD exposure studies funded by the U.S. PHS?

•	 To what extent were U.S. government officials and others in the medical 

research establishment at that time aware of the research protocols and to 

what extent did they actively facilitate or assist in them?

•	 What was the historical context in which these studies were done?

•	 How did the studies comport with or diverge from the relevant medical and 

ethical standards and conventions of the time?9

In seeking to answer these questions, the Commission cast a wide net. It 

began with the original records documenting the Guatemala activities found 

by Wellesley College professor Dr. Susan M. Reverby at the University of 

Pittsburgh in June 2003.10 Dr. John C. Cutler, who directed the studies in 

Guatemala and later served as a faculty member at the University of Pittsburgh, donated the records to the university in 1990. Dr. Reverby had 

presented her findings from these records at a May 2010 meeting of the 

American Association for the History of Medicine.11 Thereafter, she contacted 

Dr. David Sencer, former Director of the Centers for Disease Control and 

Prevention (CDC), who notified the CDC of this information. Upon learning 

of these records, the CDC immediately undertook a review of them at the 

university. In September 2010, the university contacted the CDC to request 

the transfer of the material to the federal government, and the documents 

were subsequently transferred to the U.S. National Archives and Records 

Administration.12 The National Archives provided the Commission with 

copies of these records in December 2010.

The Commission also sought information from other government and 

nongovernmental sources. Staff independently reviewed documents in nine 

archives, including the National Archives and the University of Pittsburgh 

Archives, and three libraries, including the library of the Pan American 

Health Organization (PAHO) headquarters. PAHO’s predecessor organization, the Pan American Sanitary Bureau (PASB), sponsored the research 
preface

5

in Guatemala through a National Institute of Health grant funded by the 

PHS Venereal Disease Division and its VDRL, which later became part of 

the CDC.

13 The Commission sought documents from several government 

agencies, including the U.S. Departments of Defense and Veterans Affairs. 

Documents were requested from the government of Guatemala as well, 

though none were received.14

In total, the Commission reviewed more than 125,000 pages of original 

records. It collected tens of thousands of pages of relevant archival records 

and examined more than 550 published sources. The Commission focused 

its review on the period between 1935 and 1956, starting 10 years before the 

first known planning for the Guatemala experiments began and continuing 

through the year after Dr. Cutler finalized his last retrospective report on 

the experiments. Collected documents and publications are maintained in 

the Commission’s archives. These records will be provided to the National 

Archives for future researchers. 

With the passage of over six decades, the evidence available to document 

the events is limited. Moreover, much of the available information was 

written retrospectively by Dr. Cutler years after the experiments were actually 

conducted. Some of these retrospective accounts include inaccurate data or 

incomplete descriptions of experiments. The documentary evidence is in some 

cases scattered and incomplete. This Commission report was prepared, and 

should be read, with an awareness of the inherent limitations of fact finding 

based in large part on one person’s recollections, particularly those of one who 

played a primary role in the research.15

At the outset of the Commission’s investigation, Commission Chair Amy 

Gutmann and Commission Executive Director Valerie Bonham met with 

Vice President Rafael Espada of Guatemala, and they shared their respective plans to lose no time in undertaking thorough investigations to be made 

public.16 Several Commission staff members later traveled to Guatemala in 

May 2011 to meet with the separate commission charged by the government 

of Guatemala to investigate the experiments and to visit the Central American 

Archives in Guatemala City and relevant historical sites.17

When the Commission began its inquiry, all agreed that—judging from what 

they had learned to date—the intentional exposure research conducted in 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

6

Guatemala between 1946 and 1948 was clearly and grievously wrong. The 

Commission’s aim in conducting a more comprehensive historical investigation was to fully uncover the facts surrounding the experiments and offer a 

fair-minded and unvarnished ethical assessment. 

In sum, the PASB18 and VDRL activities in Guatemala led by Dr. Cutler 

took place from approximately July 1946 to December 1948, with follow-up 

work continuing through 1953.19 PASB built and supplied a venereal disease 

research laboratory in Guatemala City to support the work and negotiated 

agreements that gave the researchers authority to work with officials and institutions across the Guatemalan government, including public health service 

treatment centers for venereal diseases, government hospitals, medical installations and officers of the military, institutions caring for orphans and the 

insane, and the penal system. Many aspects of the research were collaborative. Costs were borne by the PASB (for administration, travel, construction, 

and supplies), the U.S. Public Health Service Venereal Disease Division 

(providing and paying directly for staff and supplies as well as funding the 

grant issued from the Research Grants Office of the then U.S. National Institute of Health), and the government of Guatemala (directly funding staff and 

supplying facilities). 

The studies encompassed research on three STDs—syphilis, gonorrhea, 

and chancroid—and involved the intentional exposure20 to STDs of 1,308 

research subjects from three populations: prisoners, soldiers, and psychiatric 

patients.21 Of the 1,308 subjects exposed to an STD, the researchers documented some form of treatment for 678 subjects.22 Commercial sex workers,23

who in most cases were also intentionally infected with STDs, were used 

to transmit disease. In addition, to improve diagnostics, the researchers 

conducted diagnostic testing of 5,128 subjects24 including soldiers, prisoners, 

psychiatric patients, children,25 leprosy patients,26 and Air Force personnel at 

the U.S. base in Guatemala.27 This diagnostic testing, which included blood 

draws as well as lumbar and cisternal punctures,28 continued through 1953.29

Most of the information about the experiments in Guatemala available to the 

Commission comes from the records Dr. Cutler donated to the University of 

Pittsburgh Archives Service Center (the Cutler Documents). The documents 

include several final reports on the STD experiments authored in the 1950s 
preface

7

(see Table 1). Institutional leaders of the PHS, the National Research Council 

(NRC), the National Institute of Health, and the Director and Assistant 

Director of the VDRL, as well as leading academic scientists encouraged and 

supported the work. Research staff for the Guatemala experiments included 

leaders and senior medical personnel of the government of Guatemala, for 

example, directors of the national Public Health Service Venereal Disease 

Section, the national psychiatric hospital, the national orphanage, and the Army 

medical department (see Table 2). The records show that these events involved 

many officials and researchers in the United States as well as Guatemala. The 

records reveal the unconscionable ways in which the researchers sometimes used 

people as a mere means to advance what Dr. Cutler sometimes called “pure 

science,”30 hidden from public scrutiny in the United States. 

The history of U.S.-supported experimentation undertaken to advance 

medical knowledge and protect national security is complex with evolving 

ethical standards and norms.31 Nonetheless, the experiments in Guatemala 

starkly reveal that, despite awareness on the part of government officials 

and independent medical experts of then existing basic ethical standards 

to protect against using individuals as a mere means to serve scientific and 

government ends, those standards were violated. The events in Guatemala 

serve as a cautionary tale of how the quest for scientific knowledge without 

regard to relevant ethical standards can blind researchers to the humanity of 

the people they enlist into research. 

Arising in response to cases such as these, today’s requirements for the protection of human subjects in U.S.-funded research are expressed in the medical 

ethics literature and through government regulations and international covenants and declarations, all of which share certain standards and principles. 

Obtaining informed consent of subjects is a cornerstone ethical requirement. 

So too are requirements for minimization of risks, a reasonable balance of 

risks and benefits, sound scientific justification, protection of privacy and 

confidentiality, and special protections for those who are especially vulnerable, including minors and those with impaired decision making.32 While 

research is sometimes still done with vulnerable populations, using deliberate 

exposure and infection, and without informed consent, such studies have to 

be carefully justified, reviewed, and approved often with additional protections added.33    
“Ethically Impossible” STD Research in Guatemala from 1946-1948

8

None of the principles and requirements reflected in the standards noted 

above were satisfied in the Guatemala experiments. And several—if not all—

of these principles were known by the researchers in Guatemala at the time. 

Their behavior in a similar case—just two years earlier in the United States—

and contemporaneous correspondence shows understanding of, and disregard 

for, generally accepted moral principles such as respect for human dignity in 

the course of their work in Guatemala. For these reasons, the Commission 

finds that many of the actions of the researchers were morally wrong and the 

individual researchers and institutional officials were morally blameworthy.
background I

9

BACKGROUND 
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

10

i

n april 1947, New York Times science 

editor Waldemar Kaempffert published 

a note describing an intentional exposure 

syphilis prophylaxis (prevention) experiment in rabbits that off ered great promise to 

reduce spread of the disease, if only similar 

research could be conducted in humans.34

Th e investigators that conducted that experiment, which included colleagues of Dr. John 

c. cutler from the relatively small world of 

venereal disease researchers, had shown that 

penicillin injected within a few days after 

exposure could prevent syphilis infections.35

but, Kaempff ert observed, it would be “ethically impossible” to undertake such 

research and “shoot living syphilis germs into human bodies.”36 Th erefore, it 

might be years before similar conclusions could be drawn for human beings.37

Kaempff ert’s article was of particular interest to Dr. cutler and his colleagues, 

who had been planning precisely the same type of experiment for months, and 

were about to begin doing just what Kaempff ert described as being ethically 

impossible with prisoners and psychiatric patients in Guatemala.38

STDs were long a concern of the u.S. 

government. in 1938, u.S. Surgeon 

General Th omas parran testifi ed before 

congress in support of proposed legislation to expand funding for public 

health prevention efforts and scientific 

research in this fi eld.39 “men and munitions” were needed in the battle against 

syphilis and other STDs, such as gonorrhea.40 Dr. parran sought support for the 

phS to complete “studies, investigations 

and demonstrations which are necessary to develop more eff ective measures 

of prevention, treatment and control of 

venereal diseases... [so that] science will 

Published: April 27, 1947

Copyright © The New York Times

thomas Parran

From the National Library of Medicine

Waldemar Kaempffert. Notes on Science: 

Syphilis Preventive. New York Times. 

April 27, 1947.
background I

11

give us a much more effective method of 

treatment than we now have.”41

Dr. Parran also emphasized the need for more 

funds to train the doctors who would man 

the front lines against STDs, which posed a 

major threat to members of the military, as 

well as the general population. Operating 

without such funding “would be like sending 

a battleship to sea with untrained officers and 

crew aboard,” said Dr. Parran.42

New developments in STD treatment and 

prophylaxis were overdue. At the beginning of World War II the same system of 

chemical prophylaxis had been in use in the 

U.S. Army and Navy for about 30 years.43

The procedure required men to begin by 

urinating and washing with soap and water. 

They then injected a silver proteinate into 

their penises to prevent gonorrhea and 

rubbed a calomel ointment over their penis 

and pubic region to prevent syphilis.44

These methods had been adopted based on 

“poorly controlled and relatively unconvincing statistical studies carried out in the 

field.”45 Speaking of the need to re-evaluate 

the regimen of prophylaxis followed by 

the armed services, STD expert Dr. John 

F. Mahoney, then head of PHS/VDRL in 

Staten Island, New York, said, “[t]he prevention of the primary invasion of the male by 

the syphilis spirochete, as a means of minimizing the loss of effectiveness which is 

incident to established disease, still constitutes one of the most pressing problems of 

military medicine.”46

STD Treatment options

The modern era for the treatment 

of syphilis began in 1909 when 

Dr. Paul Ehrlich developed 

salvarsan, an arsenic-based 

compound. Bismuth used in 

combination with either mercury 

or arsenic-based compounds 

became a popular treatment 

for syphilis in the early 1920s, 

though patients found it 

complicated, time consuming, 

and even toxic. Arsenical 

therapy remained the primary 

treatment for syphilis until after 

1943 when the effectiveness of 

penicillin was demonstrated. In 

1938, sulfanilamide became the 

first reliable method of curing 

gonorrhea. Sulfonamides were 

still being used to treat gonorrhea 

when the U.S. involvement in the 

Second World War began in 1941.

John F. Mahoney

From the Lasker Foundation 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

12

When World War II began, scientists, physicians, and public health officials 

considered the steps needed to address STDs occurring in troops in wartime. 

Dr. Joseph Earle Moore, Chairman of the NRC47 Subcommittee on 

Venereal Diseases, wrote that he expected, 

“approximately 350,000 fresh infections 

with gonorrhea [in the Armed Forces], 

[which] will account for 7,000,000 lost man 

days per year, the equivalent of putting out 

of action for a full year the entire strength of 

two full armored divisions or of ten aircraft 

carriers.”48 Dr. Moore estimated that the 

cost of treating the anticipated infections 

would be $34 million (approximately $440 

million today, adjusted for inflation).49

President Franklin D. Roosevelt’s newly 

established Office of Scientific Research and 

Development (OSRD) (see Figure 1) and 

its Committee on Medical Research (CMR)50 provided STD researchers an 

unprecedented opportunity to mobilize federal funds to mitigate these threats.51

The OSRD served “to initiate and support a research program [to] utilize the 

scientific personnel and resources of the nation” and “to aid and coordinate 

the research activities carried on by other governmental Departments and 

Agencies.”52 Within the Office, the CMR’s primary charge was to focus on 

“medical problems affecting 

national defense.”53 Through these 

new entities, the U.S. government 

substantially increased the amount 

of money available for medical 

research in a short period of time.54

In addition to chairing the NRC

Subc om m it tee on Venere a l 

Diseases (see Figure 2), Dr. Moore 

directed the Venereal Disease 

Division at Johns Hopkins University and served as advisor to the Above and Above Right: Venereal Disease Posters

From the National Library of Medicine
background I

13

Surgeons General of the U.S. Army, Navy, and PHS on STD control.55 NRC

committees provided initial screening of proposals submitted to the CMR, 

which recommended approval or disapproval to Dr. Vannevar Bush, the OSRD 

Director.56 Later, Moore chaired the 1946 study section that approved the 

Guatemala research. Dr. Moore’s comments were made in support of a proposal 

to the CMR for a new program of clinical 

research to study chemical prophylaxis for 

gonorrhea. The study would be carried out 

with “human volunteers” and would occur 

in a prison. While initially proposed by 

university-based researchers, PHS researchers, 

including Dr. Cutler, conducted the research 

in 1943 and 1944.

Terre Haute Prison Experiments, 

1943-1944

The Terre Haute Experiments, which were 

done at the U.S. Penitentiary in Terre 

Haute, Indiana, provide important comparisons and contrasts with the experiments 

conducted several years later in Guatemala. The Terre Haute experiments were 

conducted and supported by many of the 

same people involved in the Guatemala 

experiments, including Dr. Cutler, Dr. John 

F. Mahoney, Dr. Thomas Parran, Dr. Joseph 

Earle Moore, and Dr. Cassius J. Van Slyke. 

The Terre Haute experiments had the same 

goals as the Guatemala experiments (i.e., to 

find a suitable STD prophylaxis) and had a 

similar study design. 

Planning for the experiments began 

in October 1942,57 when Dr. Charles M. Carpenter, a researcher at the 

University of Rochester School of Medicine and Dentistry, contacted Dr. 

Moore to ask about possible support for conducting gonorrhea prophylaxis 

Top: Cassius Van Slyke

From the National Library of Medicine

Bottom: Joseph Moore

From Louis Fabian Bachrach 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

14

research in humans following intentional exposure to Neisseria gonorrhoeae, 

the bacterium that causes gonorrhea. Dr. Moore forwarded the question to 

Dr. A.N. Richards, CMR Chair.58 Dr. Richards promptly responded that 

human experimentation was “not only desirable but necessary in the study 

of many of the problems of war medicine which confront us.”59 Dr. Richards 

emphasized strict constraints for informed consent: 

“When any risks are involved, volunteers only should be utilized as 

subjects, and these only after the risks have been fully explained 

and after signed statements have been obtained which shall prove 

that the volunteer offered his services with full knowledge and 

that claims for damages will be waived. An accurate record should 

be kept of the terms in which the risks were described.”60

Dr. Moore subsequently organized a meeting of the NRC Subcommittee on 

Venereal Diseases,61 at which Dr. Carpenter and his fellow researcher Dr. 

Alfred M. Cohn, from the New York City Department of Health, discussed 

their ideas. The NRC Subcommittee62 agreed that Dr. Moore, as Chairman, 

should “attempt to obtain official government backing...through the Surgeons 

General of the Army, Navy, and Public Health Service, the Committee on 

Medical Research, and OSRD.”63

Dr. Moore succeeded in his efforts. In November and early December 1942, 

leaders from the PHS, the Army, and the Navy endorsed the proposal that 

Dr. Carpenter had initiated, so long as “volunteers” only were exposed to 

infection. Dr. Thomas Parran, PHS Surgeon General, explained his support:

“Because of the great prevalence of gonorrhea and its importance in 

the production of noneffective [sic] man-days both in the armed 

forces and civilian population, I believe that the human inoculation experiments proposed by Doctor Carpenter are justifiable if 

the human subjects are selected on a voluntary basis.”64

Colonel John A. Rogers, Executive Officer of the U.S. Army Medical Corps 

agreed “that the National Research Council [should] undertake an investigation in search of an effective prophylaxis and improved treatment for gonorrheal 

infections, using selected human volunteers.”65 “Any progress in this field,” he 

explained, “will have a direct bearing on the conservation of manpower engaged 
background I

15

in war work of any character and it is hoped it will be possible for the [National 

Research] Council to undertake such an investigation.” The Surgeon General 

of the U.S. Navy, Dr. Ross T. McIntire, also concurred, emphasizing that “the 

incidence of gonorrhea in the armed forces and the lost manpower resulting therefrom constitutes a problem of major military importance.”66 Consequently, he 

observed, “[t]he crucial experiment in the development of new prophylactic agents 

against gonorrhea lies in the experimental inoculation of human volunteers.”67

Dr. Moore’s Subcommittee on Venereal Diseases, this time with CMR head 

Dr. A.N. Richards,68 met again in early December 1942.69 It approved the 

proposal and recommended that Moore organize a conference with members 

he selected to further specify details of the experiment and the accompanying risks.70 Dr. Richards urged Dr. Moore to convene the conference group 

“immediately.”71

Dr. Moore’s conference group met promptly at the end of December to 

formulate specific plans.72 Its proposal included a detailed research protocol, a 

clear set of goals, and a participant waiver form that outlined the procedures 

and the risks associated with the experiments.73 The project would “study the 

effectiveness of two types of prophylaxis against gonorrhea: (1) the protective 

action of sulfonamide compounds taken by mouth before exposure to the 

disease, and (2) the prophylactic action of chemical agents applied locally to 

the genital tract after exposure to the disease.”74

Consistent with the opinions of the Surgeons General, Dr. Carpenter stated 

that “[o]nly volunteers are acceptable.”75 The proposed waiver form explicitly 

described the procedures involved and risks associated with the experiment.76

It used colloquial terms (“clap,” “strain,” and “running ranges”) for gonorrhea in addition to medical language, and stated that individuals would be 

exposed to infection by “applying the germ to the end of the penis.”77 The 

form included an explanation of risks, including the fact that not all subjects 

would respond to “modern treatment methods” and that complications could 

arise from being treated with older methods. It also detailed the side effects 

of the “modern treatment.”78 According to the form, an inmate had to waive 

liability and the officer in charge had to give permission before the inmate 

could volunteer for the experiment.79
“Ethically Impossible” STD Research in Guatemala from 1946-1948

16

The issue of the ethical and legal permissibility of intentionally exposing 

humans to STDs remained unsettled. Dr. O.H. Perry Pepper, Chairman 

of the NRC Committee on Medicine,80 asked members about the experiment. Dr. James E. Paullin, President of the American Medical Association81

and one of the committee members, argued that eventually the details of the 

experiment would “fall in the hands of a very unscrupulous lawyer” and the 

waivers signed by the subjects would not constitute sufficient legal protection for those involved.82 As a result, he voted not to approve the experiment, 

despite the fact that he supported its scientific value. Another member that 

endorsed the scientific merit of the experiments, Dr. Arthur Bloomfield, questioned “the public relations” aspect of the research.83

With NRC members raising doubts about the work, Dr. Moore met in 

January 1943 with another group that included CMR head Richards and 

OSRD attorney James B. Donovan.84 At that conference, Dr. Richards 

reported that he had discussed the matter with Dr. Vannevar Bush, OSRD 

Director, who also questioned the legality of the experiments and the potential for adverse public reaction.85 Among other issues, New York State law 

constraints raised concerns about the original plan to proceed in a state 

prison.86 Donovan suggested the possibility of using federal prisoners, Army 

prisoners, or conscientious objectors as an alternative.87 The group agreed that 

if OSRD approved the experiments on scientific grounds, it would contact the 

U.S. Solicitor General to seek additional legal advice.88

With the groundwork thus laid, Dr. Moore’s subcommittee finalized a 

proposal for OSRD in February 1943. The proposal emphasized the importance of the research to the war effort and outlined the prophylactic methods 

then used in the U.S. Armed Forces.89 The subcommittee noted that the 

chemical prophylaxis administered at the time was highly unsatisfactory 

for the men90 because it was “embarrassing, revelatory to fellow soldiers and 

sailors, mildly uncomfortable, time-consuming, and messy.”91

The subcommittee recommended that the experiments be conducted in men 

in state prisons and city jails for several reasons.92 First, they were isolated 

from women. The subcommittee emphasized that the volunteers needed to 

live “under conditions which prevent sexual intercourse for approximately 

6 months.”93 In addition, prisoners would be under medical supervision for 
background I

17

the required time period.94 The subcommittee speculated that prisoners also 

wanted to help win the war and so would participate out of patriotism.95

The prison environment also provided readily available medical facilities.96

Finally, the subcommittee observed that because many prisoners had previously contracted gonorrhea, they might be less concerned about the risks 

associated with the experiment.97

In describing the subcommittee’s proposal, Dr. Moore explained that the 

group rejected other potential populations for several reasons.98 Both soldiers 

and people living in psychiatric institutions were considered unacceptable 

experimental populations. According to the subcommittee, military personnel 

could not be used because they could not be subjected to sexual isolation, and 

the U.S. Armed Forces would not want military personnel to take time from 

training or combat in order to participate in the experiment.99 Individuals 

housed in psychiatric institutions were also deemed unacceptable. Dr. Moore 

explained: “[t]his population group has never been seriously considered, since 

it is clearly undesirable to subject to any experimental procedure persons incapable of providing voluntary consent.”100

The subcommittee asked CMR to address two issues about the experiments: 

(1) “legality” and (2) “expediency,” which seems to have been a reference to 

potentially adverse public opinion.101 Despite these questions, Moore relayed 

the subcommittee’s view that stated that the experiment was legal, despite 

some potentially contrary state statutes,102 and that public opinion would likely 

be on the side of “any sound scientific proposal” combating STDs.103 It also 

noted that an experiment involving infected men and non-infected commercial 

sex workers had been reported in 1939 both in the popular press (by journalist 

Paul de Kruif) and in the Journal of the Oklahoma State Medical Association,

104

without ensuing public outcry.105 In that experiment, commercial sex workers 

who were not infected with gonorrhea were given a pre-exposure prophylaxis 

and then had sexual intercourse with men infected with gonorrhea (at the 

request of the researchers—the experiment was not purely observational).106

The subcommittee recommended that the CMR approve the proposal.107

Later that month, OSRD investigated the legality of the experiments. Dr. 

Bush contacted Assistant Solicitor General Oscar Cox, who discussed the 

matter with Attorney General Francis Biddle.108 Cox and Biddle agreed that: 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

18

“The problem is not a legal one, but political in nature. There should 

be no question of the legality of the experiments, in the absence of 

specific provisions of law to the contrary. While the experiments 

might be held to be technical violations of law in a particular jurisdiction, any criminal prosecution should be easily defended.”109

Cox furthermore dismissed the political risks; he argued that the experiments 

should not be hampered by such criticism in a “time of war.”110

A little more than two weeks after submitting the NRC subcommittee 

proposal to OSRD, Dr. Moore contacted James Bennett, Director of the 

Bureau of Prisons, because Dr. Bush favored the use of federal, rather than 

state, prisoners in the experiment.111 After receiving Dr. Moore’s “detailed 

statement of the proposed plan of procedure,”112 Bennett endorsed the 

proposal with a few conditions.113 Researchers should not promise pardons or 

commutations of sentences as an incentive to volunteer,114 though he agreed 

that the parole board would probably consider their involvement in the 

research when the inmates were eligible for parole.115 The volunteers could be 

paid $100 each for participation,116 but Bennett questioned the effect of some 

receiving these benefits on prisoners not selected for participation. He told Dr. 

Moore to conduct the experiments in secret “to protect the general morale of 

the several [prison] institutions.”117

With the Bureau of Prisons on board, the leadership of the National Academy 

of Sciences (NAS) and NRC, its operating agency, responded to questioning 

from Dr. Bush about the legality and ethics of the experiment. In March 

1943, Dr. Frank B. Jewett, NAS President and head of Bell Telephone Laboratories, and Dr. Ross G. Harrison, NRC Chairman and Professor Emeritus 

at Yale University, wrote to Dr. Bush, who had asked the scientists “whether 

the Academy and Council, having considered the possibility of public reaction, are willing to encounter the risk in view of the results attainable.”118

Drs. Jewett and Harrison declined to speak for either NAS or NRC, but 

they offered Dr. Bush their “personal opinions in [their] official capacities.”119

With that qualification, both men endorsed the experiments, noting that 

attitudes toward STDs had become more progressive and that the public 

had an interest in protecting men in the armed services.120 These facts, they 

suggested, could help explain the experiment if questions about intentionally 

infecting prisoners were raised later.121
background I

19

With collective support from the highest echelons of the nation’s medical 

establishment, and with the concurrence of the Attorney General, Dr. Bush 

approved the experiment in early March.122 Only four federal prisons had 

appropriate medical facilities.123 The federal penitentiaries in Terre Haute, 

Atlanta, New York State, and Leavenworth were all considered, but Terre 

Haute had the best medical facilities.124 Dr. Parran had already identified the 

high-quality medical facilities available as one of the benefits of conducting 

the experiment in a federal prison,125 and Terre Haute offered the best option 

for capitalizing on that benefit. 

Dr. Bush directed that PHS conduct the experiment rather than the university-based research team of Drs. Carpenter and Cohn.126 Where previously 

the PHS role was limited, like that of the U.S. Army and Navy, to simply 

endorsing the scientific merit and opining on ethical and legal limitations 

of Moore’s NRC proposal and the university-based research, it now became 

the lead for the work. In April 1943, Dr. R.A. Vonderlehr, a PHS Assistant 

Surgeon General, wrote to Dr. Moore regarding PHS’s new role.127 A PHS 

investigator leading the experiments would also assure support from the 

Bureau of Prisons. He explained: 

“Mr. James Bennett of the Bureau of Prisons has lost interest in the 

proposed project...Mr. Bennett thinks a great deal of the Public 

Health Service and if we assure him that the investigation will be 

done by regular officers in our Service I believe he will show much 

more interest than he has evinced in recent weeks.”128

Within PHS, responsibility for conducting the research fell to the VDRL. The 

VDRL arose in 1927 under the PHS Venereal Disease Division, led by Dr. 

Thomas Parran, who later became the Surgeon General.129 A small laboratory 

was set up within the U.S. Marine Hospital in Staten Island, New York, that 

conducted laboratory experiments for the purpose of studying methods of 

treating syphilis, and gonorrhea.130 Clinical studies were also undertaken 

with the cooperation of the hospital staff.131

Dr. John F. Mahoney led the laboratory, with Dr. Cassius J. Van Slyke serving as 

the Associate Director.132 Dr. Mahoney, a 1914 graduate of Marquette University School of Medicine, had joined PHS in 1917 as a scientific assistant.133 In 

1918, he was commissioned as an Assistant Surgeon in the PHS Commissioned 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

20

Corps. 134 Dr. Mahoney 

was assigned to the Staten 

Island Marine Hospital and 

became director of VDRL

in 1929.135

Dr. Van Slyke, a 1928 graduate of the University of 

Minnesota medical school, 

joined the VDRL at Staten 

Island in 1936, after eight 

years of practicing general medicine. He served in Staten Island until August 

1944, when he moved to be the Assistant Chief of the PHS Venereal Disease 

Division in Washington, D.C.

Dr. Mahoney submitted a formal proposal to OSRD/CMR in June 1943.136

Dr. Mahoney’s proposal indicates that OSRD and PHS split the costs of the 

experiments.137 The budget requested for the first year of the experiment was 

$45,200,138 which included salary support for one physician and two bacteriologists in addition to “two medical officers and one bacteriologist to be 

assigned” from the PHS.139

Implementing the Experiments

Work at Terre Haute began in September 1943 under Dr. Mahoney’s leadership in Staten Island, and his young associate, Dr. Cutler, at the prison.140

Dr. Cutler, age 28, was relatively new to PHS, having joined in 1942, the 

year after his graduation from Western Reserve University Medical School 

in Cleveland.141 After serving a year as a medical officer with the U.S. Coast 

Guard, Dr. Cutler moved to the VDRL in Staten Island in early 1943.142 Dr. 

Henrik Blum, another junior PHS officer assigned to the VDRL, went with 

Dr. Cutler to Terre Haute to help conduct the experiments.143

The investigators required that participants be at least 21 years old and 

provide “[a]ssurance that the volunteer possessed a thorough understanding 

of the purpose underlying the study and the possible risks involved.”144 At 

the conclusion of the experiments, participants received $100, a certificate of 

merit, and a letter of commendation to the parole board.145 The documents 

do not indicate whether the prisoners were told ahead of time that they would 

Staten Island Marine Hospital From the National Library of Medicine
background I

21

receive a letter of commendation for the parole board, but Bennett’s disapproval of such inducements suggests they were not.146

In total, 241 prisoners participated in the experiments, which ended in 

1944.147 The first stage of the experiment required the investigators to develop 

a consistent technique for producing gonorrhea in subjects. Dr. Mahoney, 

Dr. Cutler, and their staff began efforts to infect subjects through artificial 

exposure in October 1943, a year after Dr. Carpenter first proposed the work 

to Dr. Moore.148 All subjects were inoculated with bacteria deposited into the 

end of the penis.149 The researchers tried a variety of strains and concentrations of gonorrhea.150 At least some of the strains were gathered from local 

commercial sex workers who were examined by Dr. Blum after they had been 

arrested in Terre Haute by local police.151

Five months after beginning work to intentionally induce gonorrhea infection, the researchers faced serious challenges. Dr. Mahoney, as project leader, 

reported to Dr. Moore’s NRC subcommittee, which retained at least indirect, 

if not direct, oversight responsibility for the work.152 He explained that the 

researchers were unable to consistently produce infection in the prison volunteers and opined that further research was not likely to succeed.153 He asked 

whether the experiments should be discontinued, and if not, whether they 

should be recalibrated to focus on other issues.154

Despite Dr. Mahoney’s concerns, the NRC subcommittee favored continuing 

the experiments. At its February 1944 meeting, the group concluded:

“The opportunity for a study of experimental gonococcal infection 

in human volunteers and its relationship to the chemical prophylaxis of gonorrhea has never previously arisen on the present scale 

and with the termination of this experiment is unlikely to arise 

again unless under the impetus of a future war.”155

With the exigency of war, and after a year and a half of intense effort, the 

scientific establishment represented at NRC directed Dr. Mahoney and PHS 

to continue the work. Under Dr. Mahoney’s guidance, Dr. Cutler set about 

finding a reliable method to infect the prisoners. Results continued to be poor. 

A conference group convened again, this time in Terre Haute, in April 1944, 

to “review all circumstances in connection with the study of prophylaxis in 

gonorrhea...in progress in the Terre Haute institution.”156 The attendees157 of 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

22

the conference agreed that the investigators should try one more approach, 

involving particular “colony types” of gonorrhea, and decided that if that 

did not work it was probably time to discontinue the study.158 Each infection 

method yielded unsatisfactory results. 

In June 1944, Dr. Mahoney reported to Dr. Moore’s subcommittee that he 

would not be continuing the work.159 Describing his feelings about this decision later, Dr. Cutler referred to what a “blow” it had been “to discontinue the 

Terre Haute project.”160 The experiments ended a month later in July 1944, 

10 months after they began. Dr. Mahoney attributed this decision to the 

inability to reliably induce infection. In his final report, he concluded: “In 

spite of the use of different strains of Neisseria gonorrhea, modifications in 

methods of cultivating the organism and of inoculation, it was found impossible to infect with a degree of regularity which would be required in the 

testing of prophylactic agents.”161

A draft of a history of the OSRD, written in 1946, explains, “[e]fforts were 

made to produce experimental gonorrhea in these volunteers by almost every 

conceivable expedient except by the intraurethral inoculation of pus taken directly 

from the cervix or urethra of infected females or by the natural method of infection – sexual intercourse” (emphasis added).162 OSRD’s document includes no 

comment on whether the “natural method of infection,” which was pursued 

in Guatemala in 1947, would be an appropriate next step. But it did observe 

that the scientific questions pursued in Terre Haute remained unanswered. 

“It is still unknown,” the document states, “whether any prophylactic agent, 

including the silver proteinate the armed forces have used for thirty-five years, 

[has] any value in the prevention of this disease.”163

Drs. Mahoney, Van Slyke, Cutler, and Blum published the results of the 

experiments in the American Journal of Syphilis and Gonorrhea in January 

1946, around the same time that plans for work in Guatemala were developing.164 The researchers concluded that “[n]one of the exposure techniques 

employed proved capable of producing disease with a consistency considered 

to be adequate for a study of experimental prophylaxis.”165 They did, however, 

note “the most effective method of conveying infection to volunteers was...

the direct transference of secretions from the infected patient to the urethra 

of normal volunteers.”166 They also observed “a significantly lower rate of 
background I

23

experimental infections in those patients with a history of previous gonorrheal infection.”167

The experiments in Terre Haute presaged the work in Guatemala in a number 

of ways. They demonstrated how military and science leaders actively sought 

improved methods to combat STDs and their willingness to endorse experiments using human volunteers to improve STD prophylaxis.168 They also 

provided a scientific impetus for the experiments in Guatemala; the inability 

to develop a reliable method for gonorrheal infection in Terre Haute left 

the researchers unable to address their primary research goal, more effective 

prophylaxis, and wondering about alternative infection strategies. The investigators and reviewing committee viewed the Terre Haute experiments as a 

rare opportunity, and both Dr. Cutler and Dr. Mahoney viewed the work as 

unfinished. The chance to do additional experiments in Guatemala presented 

an unexpected and welcome opportunity. 

The Terre Haute research offered an important precedent for exploring and 

applying ethical constraints related to individual consent. These considerations did not constrain the later research in Guatemala. Conducting the 

experiments in Guatemala provided an opportunity to work with reduced 

concern for some of the key obstacles associated with the Terre Haute experiments: fear of adverse legal consequences and bad publicity.169

Developments in the Science 

and Prevention of Sexually 

Transmitted Diseases

In June 1943, as he submitted plans for the 

Terre Haute experiments to OSRD/CMR, 

V DRL chief Dr. John Mahoney began 

studying the effects of penicillin on syphilis 

in human subjects.170 Through a limited fourperson human trial with colleagues Drs. R.C. 

Arnold and Ad Harris, both of whom worked 

at the VDRL, the researchers showed that 

eight days of penicillin use caused “a more or 

less rapid and complete disappearance” of the Richard C. Arnold

From the National Library of Medicine 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

24

disease.171 The conventional arsenic therapy generally required 18 months to 

complete and had many unpredictable side effects.172

As Dr. Cutler was beginning research in Terre Haute in October 1943, Dr. 

Mahoney announced these results to a “jam-packed session” at the American Public Health Association’s annual meeting. The initial results were so 

promising that one researcher called the work “probably the most significant 

paper ever presented in the medical field.”173 Dr. Mahoney, in collaboration 

with Dr. Moore and several others comprising the newly established NRC

Penicillin Panel, quickly began a much larger clinical trial involving 1,400 

subjects.174 Eight months later, in June 1944, the U.S. Army adopted penicillin as its standard treatment for syphilis.175 In September 1944, Drs. Moore 

and Mahoney and their colleagues published results for the larger trial that 

confirmed their earlier findings.176

Despite this success, many questions remained. Researchers wondered 

whether penicillin therapy left subjects immune to further infection or at risk 

of re-infection with the same or a different strain of the disease.177 Uncertainty 

lingered too about penicillin’s long-term effectiveness. Blood tests showed that 

penicillin eliminated syphilis spirochetes (a type of bacterium) in the short 

term, but could not confirm whether the disease disappeared entirely.178

Researchers and policy makers alike were also seeking to improve methods 

to prevent syphilis with post-exposure prophylaxis. Describing these facts in 

his 1955 “Final Syphilis Report,” Dr. Cutler reported that Drs. Mahoney 

and Arnold felt that a prophylaxis consisting of a simple orvus-mapharsen 

wash might meet with more acceptance than the calomel ointment, which 

at the time was routinely prescribed. Animal studies conducted in the laboratory repeatedly showed orvus-mapharsen’s effectiveness.179 Furthermore, 

Drs. Arnold, Cutler, and another researcher, Dr. Sacha Levitan, a PHS Senior 

Surgeon, conducted “small scale studies” of the orvus-mapharsen solution 

on “ships where relatively high rate [sic] of venereal infection was expected 

among the crews.”180 But these results were inconclusive.181 Consequently, Dr. 

Cutler later reported, they felt that small controlled experiments on individuals “exposed to a high risk of infection” were required to determine if 

orvus-mapharsen could be effective, “particularly in the Armed Services.”182
background I

25

Similarly, as Dr. Cutler wrote in his 1952 

Experimental Studies in Gonorrhea report, 

Drs. Mahoney and Arnold hoped that 

the orvus-mapharsen prophylaxis would 

also prove effective for gonorrhea.183 Postexposure prophylaxis regimens to prevent 

gonorrhea during WWII involved a solution 

of silver proteinate injected directly into 

the urethra that, like the calomel solution 

for syphilis prophylaxis, did not appeal 

to servicemen.184 Furthermore, animal 

testing was unhelpful because gonorrhea 

produced in a rabbit’s eye or chick embryo 

lacked appropriate comparability to the 

male urethra. Drs. Mahoney and Arnold, 

Dr. Cutler said, wanted to test orvusmapharsen’s effectiveness in man.185 Dr. 

Cutler later explained that a large-scale field 

study of orvus-mapharsen would have included many men and a long period 

of observation, and therefore a carefully controlled study in a small group was 

deemed advisable.186 The VDRL found an opportunity to undertake this work 

in 1946 in Guatemala.

STD Prophylaxis Options

Orvus-mapharsen: a substance 

made up of 1 percent orvus 

[alkyl aryl sulfate] and 0.15 

percent mapharsen in aqueous 

solution and was supposed 

to be applied after sexual 

intercourse to prevent infection. 

Calomel: a substance used by 

the U.S. Army and Navy as a 

post-exposure prophylaxis for 

syphilis.

Silver proteinate: the active 

ingredient in one of the postexposure prophylaxis regimens 

used for gonorrhea.
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

26

Key

1 honor Guard barracks 

2 Psychiatric hospital

3 orphanage

4 venereal Disease and Sexual 

 Prophylaxis hospital (vDSPh)

5 Penitentiary

6 Military hospital

Map of Guatemala city and 

Map of Guatemala city center

The original map is held at the University 

of Chicago Library’s Map Collection

Guatemala City

“Highlands”

Totonicapan

Puerto de 

San José

 Serology experiments

2

3

5

4

6

1
preface

27

GUATEMALA EXPERIMENTS 

1946-1948 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

28

This section contains graphic medical descriptions of artificially inoculating humans 

with STDs. It may not be appropriate for all readers. This information has been 

included for completeness of the historical record.

Initial Experiment Design

The Terre Haute experiments had shown the difficulty of reliably producing 

infection, at least for gonorrhea, through artificial inoculation. Dr. Mahoney 

later observed in the Journal of Venereal Disease Information (July 1947) that 

undertaking research in Guatemala offered new opportunities unavailable in 

the United States:

“It has been considered impractical to work out, under postwar 

conditions in the United States, the solution of certain phases 

concerned with the prevention and treatment of syphilis. These 

problems are largely concerned with the development of an effective prophylactic agent for both gonorrhea and syphilis and the 

prolonged observation of patients treated with penicillin for early 

syphilis. Because of the relatively fixed character of the population 

and because of the highly cooperative attitude of the officials, both 

civil and military, an experimental laboratory in Guatemala City 

has been established...”187

Dr. Cutler, who was 31 years old when he 

traveled to Guatemala to lead the work in 

August 1946, emphasized the scientific merit 

of working where “normal exposure” could 

be easily replicated.188 Dr. Cutler wrote later 

that the idea for the research in Guatemala 

originated with Dr. Juan Funes, a Guatemalan 

physician who worked as a one-year fellow with 

Drs. Mahoney, Arnold, and Cutler at the VDRL

in Staten Island in 1945.189 In Guatemala, 

the legality of commercial sex work and the 

requirement for sex workers to undergo health 

inspection at medical clinics, the main one of which was supervised by Dr. 

Funes, presented “the possibility of carrying out carefully controlled studies 

John C. Cutler

From the National Library of Medicine
GUATEMALA EXPERIMENTS 1946-1948 II

29

there.”190 The researchers decided to study orvus-mapharsen prophylaxis (an 

aqueous solution made up of 1-percent orvus [alkyl aryl sulfate] and 0.15-

percent mapharsen that was supposed to be applied after sexual intercourse 

to prevent infection)191 in cooperation with the Guatemalan Venereal Disease 

Control Department (which Dr. Funes directed) and the Penitenciaría 

Central (Penitentiary) “where exposure of volunteers to infected prostitutes 

would provide the testing opportunities.”192 Following prisoners, a contained 

and restricted population, after they had sexual intercourse with commercial 

sex workers known to be infected with STDs, promised to establish a “rapid 

and unequivocal answer as to the value of various prophylactic techniques” 

through the preferred technique of “normal exposure.”193

Other factors may have also influenced the decision to locate the research 

in Guatemala. The pre-existing relationship between the United States and 

Guatemala included aid for the provision of medical services and development 

of public health services. The Office of Inter-American Affairs, which brought 

fellows like Dr. Funes to the United States to study, and its predecessor, the 

Office of the Coordinator of Inter-American Affairs,194 supported construction of a 300-bed general hospital in Guatemala City in 1944.195 In addition, 

the presence of other U.S. medical researchers working in Guatemala ensured 

that the researchers would not be alone in their efforts. 

With Guatemala identified as a research location, the VDRL needed a way 

to pay for the research. During the war, OSRD and CMR had served to 

coordinate and fund an expanded system to support scientific and biomedical 

research.196 As these war-time activities began winding down, federal 

policymakers, spurred in part by Surgeon General Thomas Parran and NIH

Director R.E. Dyer, shifted authority to PHS and NIH, whose Congressional 

mandates changed considerably in 1944197 (see Figure 3.) The enactment of the 

Public Health Service Act, on July 1, 1944, created a PHS grant system under 

the Surgeon General and authorized the National Advisory Health Council 

(NAHC) (see Figure 4) to recommend projects to be funded.198 The NAHC

was a longstanding government committee of federal and nonfederal scientific 

advisors established in 1902 as the Advisory Board for the Hygienic Laboratory 

of the Public Health Service,199 the precursor to the NIH.

200
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

30

nahc had served since at least 1930 to advise the government on both fi eld 

and laboratory research activities of the phS.201 in September 1944, cmR 

accepted a proposal by nih Director Dyer to transfer control of cmR and 

its nRc reviewing committees to phS.202 in 1945, oSRD medical research 

contracts began transferring to the phS grant system.203 a new system for 

federally funded biomedical research emerged, housed at nih, in which 

oSRD contracts were converted into phS grants.204 Th e assistant chief of 

the Venereal Disease Division, and former VDRl associate Director, Dr. 

cassius J. Van Slyke, became chief of the new nih Research Grants offi ce.205

phS leadership established a dual-review structure for evaluating funding 

applications, borrowed in part from the war-time structure of oSRD/cmR 

and its advisory nRc committees.206 Study sections (serving a similar function as the nRc committees), composed of independent, usually civilian, 

peer scientists and representatives from the army, navy, Veterans administration, and phS, made recommendations about the applications’ scientifi c merit 

and an advisory council, also comprised of independent scientists, considered 

policy implications in addition to evaluating questions of scientifi c merit.207

Th e Surgeon General made fi nal funding decisions.208

The first study section 

established under this 

new structure was the 

Syphilis Study Section 

(see figure 5), formerly 

the penicillin panel of 

the nRc Subcommittee 

on Venereal Diseases 

and renamed by Dr. 

parran in December 

1945.209 it began work 

i n e a r l y 19 4 6 a n d 

reviewed the proposal for research in Guatemala as one of 30 projects considered at its fi rst meeting on february 7-8, 1946.210 Dr. Joseph moore, from 

Johns hopkins university and chair of the nRc Subcommittee on Venereal 

Diseases, chaired the group, which included 11 other members. 

Syphilis Study Section, 1947

From the National Institutes of Health, 

Department of Health and Human Services 
GUATEMALA EXPERIMENTS 1946-1948 II

31

They were: 

•	 Dr. David E. Price, U.S. PHS Venereal Disease Division; 

•	 Dr. Harry Eagle, U.S. PHS Hospital in Baltimore and the 

Venereal Disease Research Laboratory at Johns Hopkins University; 

•	 Dr. John R. Heller, chief of the PHS Venereal Disease Division and 

Dr. Van Slyke’s most recent former supervisor; 

•	 Dr. John F. Mahoney, who continued to direct the VRDL

in Staten Island;211

•	 Dr. Lowell J. Reed, Johns Hopkins University; 

•	 Dr. John H. Stokes, University of Pennsylvania; 

•	 Dr. Harry C. Solomon, Harvard University; 

•	 Dr. Thomas B. Turner, Johns Hopkins University; 

•	 Major L.N. Altshuler, U.S. Army; 

•	 Cdr. George W. Mast, U.S. Navy; and 

•	 Dr. Bascom Johnson, Veterans Administration.212

The study section approved the proposal for “the Guatemala study dealing 

with the experimental transmission of syphilis to human volunteers and 

improved methods of prophylaxis,”213 and recommended it to the NAHC

for funding.214 On March 8-9, 1946, PHS Deputy Surgeon General Warren 

Draper presided over the NAHC meeting that recommended funding the 

proposal.215 Funded shortly thereafter as “Research Grant No. 65 (RG-65)” 

for “a grant to the Pan American Sanitary Bureau for investigation into 

venereal disease to be held in Guatemala,” the funding recommendation 

of $110,450 “was different from others in that funds were provided by the 

Venereal Disease Division with mechanics of processing to be handled by 

the [NIH] Research Grants Office.” 216 In other words, the funding for this 

research came not from general NIH Research Grants Office monies but 

specifically from VDRL funds.217

Following the NAHC meeting, Surgeon General Thomas Parran approved 

the grant, and the funds were transferred to the PASB, which started work 

in Guatemala in April 1946 (see Table 3).218 Construction began on a new 

“Venereal Disease Research Laboratory” to support the work.219 Dr. Cutler 

arrived in August 1946.220 Dr. Joseph Spoto, Assistant Chief of the Venereal 

Disease Division, also on assignment to PASB for research,221 met him on 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

32

arrival and briefed him on the construction efforts to date.222 Dr. Spoto also 

introduced Dr. Cutler to many Guatemalan officials who would facilitate 

the work.223 The two met with officials at Guatemala’s Dirección General de 

Sanidad Pública (Ministry of Public Health), as well as with the “chiefs” of 

the Ejército Nacional de la Revolución (National Army of the Revolution) 

(Guatemalan Army).224 Dr. Cutler also met with the Minister in charge of the 

Penitentiary and reported that “[a]ll of those concerned” at the Penitentiary 

were indeed “very anxious” for the research to begin.225 Additional PHS staff 

soon joined Dr. Cutler in Guatemala, including Dr. Sacha Levitan, a Senior 

Surgeon who served as the Assistant Director of the Guatemala project, Dr. 

Elliot Harlow, an Assistant Surgeon, Joseph Portnoy, a serologist, and Alice 

Walker and Virginia Lee Harding, bacteriologists.226

To facilitate the work, PASB officials signed agreements for “cooperative working 

arrangements”227 with the Ministers of Health, War, and “Gobernación” [Interior] under whose jurisdiction the Penitenciaría Central (the Penitentiary) 

fell.228 According to Dr. Cutler, these agreements gave the researchers authority 

to work with officials and institutions across the Guatemalan government, 

including “the medical and other authorities of the public health service rapid 

treatment center for venereal diseases, in the governmental hospitals, with 

medical installations and officers of the military, with institutions caring for 

the orphans and the insane, and with the penal system.”229 Writing in 1955, Dr. 

Cutler explained that many different activities were contemplated, including: 

assessing the prevalence of STDs in the country; developing an improved 

system of STD control through personnel training; establishing prophylactic, 

diagnostic, and treatment facilities; investigating and refining diagnosis and 

treatment; and prophylactic experiments.230 The researchers were to train local 

personnel to take over the new PASB VDRL-constructed research laboratory as 

a Guatemalan government facility in the future.231

Treatment Programs and Goodwill Efforts

After Dr. Cutler met with leaders of the Guatemalan Army in August, they 

asked the researchers to set up a “treatment program” for the Hospital Militar 

(Military Hospital).232 With the support of Dr. Spoto, in whom Dr. Mahoney 

vested great confidence,233 and Dr. Funes, the former VDRL fellow, Dr. 

Cutler argued to Dr. Mahoney that treatment programs should start in order 
GUATEMALA EXPERIMENTS 1946-1948 II

33

to earn “complete cooperation” for the future inoculation work.234 While Dr. 

Mahoney expressed some doubts, both Drs. Cutler and Spoto were anxious to 

provide a treatment program to the Guatemalan Army.235 The program began 

and, eventually, approximately 309 soldiers received some form of STD treatment, such as penicillin or salvarsan. Of these 309, 242 were soldiers whom 

the researchers intentionally exposed to infection during the STD experiments at one point or another.236

In October, Dr. Mahoney wrote to Dr. Cutler:

“Your show is already attracting rather wide and favorable attention 

up here. We are frequently asked as to the progress of your work. 

Doctor T.B. Turner of Johns Hopkins wants us to check on the 

pathogenicity in man of the rabbit spirochete; Doctor Neurath of 

Duke would like to have us follow patients with his verification 

procedure; [Surgeon General] Doctor Parran and probably Doctor 

Moore might drop in for a visit after the first of the year.”237

While supervisors and colleagues in the United States were awaiting opportunities to do additional research, Dr. Cutler was continuing to develop 

relations with the Guatemalan authorities. In November, Dr. Cutler asked 

Dr. Mahoney to provide the Guatemalan Army with penicillin, which was in 

short supply, for its own needs on a reimbursable basis. Dr. Mahoney rejected 

this request, warning against “entering into a too comprehensive program 

which may involve the use of more of the drug than we are able to procure.”238 

Dr. Cutler agreed and promised to use the penicillin sparingly so as to leave it 

available for “demonstration programs and to build goodwill.”239

Treatment During Diagnostic Testing

The researchers conducted diagnostic testing for syphilis, gonorrhea, and chancroid 

among 5,128 subjects including sex workers, soldiers, prisoners, orphans, schoolchildren, 

leprosarium patients, and U.S. servicemen.

Out of the subjects involved in the Guatemala experiments, the researchers provided 

some form of STD treatment for 820 of them. While some of the subjects involved in 

the diagnostic testing were also involved in the intentional exposure experiments, at least 

142 subjects who were not exposed to an STD by the researchers were given some form 

of treatment.
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

34

by December, Dr. constantino alvarez b., Division chief at the Guatemalan ministry of health, requested that Dr. cutler “inform us in great 

detail of the penicillin treatment for syphilis; given that many chief physicians of the departmental health units have been directing their enquiries 

for more information to this Division.”240 Dr. cutler replied with a “general 

treatment plan for each syphilis stage” in which penicillin had been shown 

to be “truly valuable.”241 Dr. carlos E. Tejeda, chief of the Guatemalan 

army medical Department, later wrote a letter to Dr. cutler in June 1947 

“beseeching you to draw 

up an Emergency Venereal 

Disease prophylaxis plan 

for [the military medical 

D e p a r t m e nt], w h i c h 

would be implemented 

in the national army as 

soon as possible.”242 Dr. 

cutler complied with a 

“prophylactic plan for the 

Guatemalan army,” which 

included an educational 

program; a prophylactic 

program of condoms, silver proteinate solution, and ointment; and methods 

for implementation of the prophylactic program.243 in July, an article of Dr. 

cutler lecturing the first convention of military Doctors on the “prophylactic venerological emergency plan for the army of the Revolution” appeared 

in one of the local papers.244

in the penitentiary, Dr. cutler reported that “ready acceptance of our group” 

followed from the establishment of diagnostic and treatment programs (“a 

program of care for venereal disease which they have lacked in the past”).245

Th e treatment program, he said in January 1947, was “worthwhile” and “fully 

justifi ed” to promote the prophylaxis experiments.246

While Dr. cutler planned to start a “program of prophylaxis for all contacts 

that took place at the penitentiary,” he suggested to Dr. mahoney that 

they would only “use placebo.” Th e intent of the placebo program was to 

“accustom[] the inmates to the use of prophylaxis so there will be no diffi culty 

Dr. cutler lecturing the First convention of Military Doctors in July 1947 

From the Diario de Centro America 
GUATEMALA EXPERIMENTS 1946-1948 II

35

in carrying on with our own compound [orvus-mapharsen] at the proper 

time.”247 While further specifics of the Penitentiary program are unclear, 

records show that 139 prisoners received some form of treatment for an STD. 

Of these, 92 were prisoners whom the researchers intentionally exposed.248

Later, when Dr. Cutler departed from Guatemala in 1948, the Director of 

Medical Services for the Penitentiary, Dr. Roberto Robles Chinchilla, wrote 

to give Dr. Cutler “our everlasting gratitude which will remain for ever [sic] in 

our hearts, because of your noble and gentlemanly way with which you have 

alleviated the sufferings of the guards and prisoners of this penitentiary.”249

While Dr. Cutler did not discuss the treatment program in the Asilo de Alienados (Psychiatric Hospital) in his final reports, records show that the researchers 

treated a total of 334 psychiatric subjects for an STD. Of them, 328 were 

subjects whom the researchers intentionally exposed at one point or another.250

The researchers fostered goodwill and cooperation in other ways as well. In 

January 1947, Dr. Cutler arranged for serology testing supplies to be sent from 

the VDRL on Staten Island to the Ministry of Public Health in Guatemala.251

The researchers also provided training for Guatemalan laboratory personnel and 

established collaborative and mutually beneficial professional relationships with 

many Guatemalan medical personnel. Among these, the researchers developed 

a particularly close rapport with Dr. Carlos E. Tejeda, Colonel and Chief of 

the Guatemalan Army Medical Department. Dr. Tejeda visited Dr. Mahoney 

on Staten Island in October 1946, shortly after Dr. Cutler arrived, and later 

worked with the researchers on all three of the inoculation experiments.252 After 

Dr. Tejeda’s visit to New York, Dr. Cutler confided to Dr. Mahoney that Dr. 

Tejeda “appreciated [Dr. Mahoney’s] attention” and was “very much interested 

in our study.”253 Consequently, the researchers were “counting on real cooperation from the [Guatemalan] Army.”254 When Dr. Tejeda’s wife fell ill that 

autumn, Dr. Cutler relayed his and Dr. Spoto’s opinion that “it [would] be a 

very good move” for PHS to supply Dr. Tejeda with the scarce medication his 

wife needed, which they did, “although it did arrive too late.”255

In addition, in the Psychiatric Hospital, the researchers developed a close 

relationship with the director, Dr. Carlos Salvado. He later received an offer 

to work as a fellow in the United States, and also became a paid employee 

of the Venereal Disease Division to facilitate “continuing observations” of 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

36

the experimental subjects.256 Dr. Hector Aragon, 

the director of the Hospicio Nacional de Guatemala (the Orphanage), who in addition worked in 

the Psychiatric Hospital,257 also developed a relationship with the researchers. He published with 

the researchers and gave a speech on the diagnostic experiments in the orphanage at the Second 

Congress of Venereal Diseases in Central America 

held in Guatemala City in 1948.258

Serological Experiments

To ensure reliable syphilis diagnoses and to assist 

their colleagues in the Guatemalan government 

to improve public health, the researchers began 

serology testing (a diagnostic tool to detect antibodies indicative of infection) in November 1946. The investigators focused 

primarily on the effectiveness of four specific blood tests: the Kahn, Mazzini, 

Kolmer, and VDRL slide tests.259 For these serology tests, blood was drawn 

and subjected to one or more different syphilis testing methods that would 

indicate whether the blood contained antibodies against syphilis. If antibodies were present, the conclusion was 

that a subject had either an active syphilitic infection or a previous infection.260

Lumbar punctures were sometimes 

conducted to confirm the results of blood 

tests or to look for infection in the spinal 

fluid that might not have been found 

using blood tests.261

Serology testing began in the Penitentiary 

on November 7, 1946.262 The researchers 

also conducted serological research in the 

Guatemalan Army and Psychiatric Hospital. 

Efforts to develop reliable serological testing 

would confound the group for several years 

and their serology work in Guatemala 

Hector Aragon

“Tribute to Dr. Aragon on his Golden 

Anniversary in the Profession”

Published in the Prensa Libre 

newspaper on December 4, 1971. 

The Daily Journal Archive, Historical 

Archives, CIRMA

The Venereal Disease and Sexual Prophylaxis 

Hospital, Guatemala City, 2011
GUATEMALA EXPERIMENTS 1946-1948 II

37

continued through 1953, well after Dr. 

Cutler left the country in 1948.263

Several days after beginning the 

work in the Penitentiary, Dr. Cutler 

reported traveling to the “lowlands” 

for a “preliminary venereal disease 

survey” in children.264 In December, 

he described doing small-scale serologic 

work in the Hospital de Profilaxis (Venereal Disease and Sexual Prophylaxis 

Hospital) (VDSPH), a hospital directed 

by Dr. Funes, Dr. Cutler’s colleague 

who originally suggested the research in 

Guatemala.265

In total, the researchers, including cooperating Guatemalan officials, conducted 

syphilis serology experiments on Guatemalan prisoners, children, psychiatric 

patients, and leprosy patients. Blood 

speci men s f rom U. S. Ai r Forc e 

personnel stationed in Guatemala were also used to compare results between 

Guatemalan and U.S. populations.266 There is no record of any of the subjects 

involved in the serology experiments consenting to any of the procedures 

performed by investigators.267

Penitentiary

Overall, 842 prisoners were involved in diagnostic testing for STDs, which 

included gonorrhea and chancroid, and the researchers discovered high rates 

of false positives for syphilis.268 Dr. Cutler concluded that either syphilis 

affected a much higher portion of the Guatemalan population than expected, 

or that other “factors...operative in the population different from those 

experienced in the United States or in Northern Europe” explained the 

results.269 A high base rate of syphilis in the population would have limited 

the researchers’ ability to conduct planned prophylaxis experiments.270 Dr. 

Cutler later explained “[t]he serologic findings posed a real problem.”271

Subject Profile: Carlos

Carlos, a male prisoner at Guatemala 

City’s Penitenciaría Central in 1947, 

contracted syphilis before he was 

enrolled in the PHS experiments. He 

noticed a chancre during the summer 

of the preceding year, and a blood test 

confirmed that he had syphilis. 

In September 1946, Carlos 

was treated with injections of 

Neosalvarsan, as well as 11 injections 

of bismuth (standard of care for 

the time). Although Carlos was 

asymptomatic when he arrived at the 

Penitentiary, dark-field microscopy 

showed that he still had syphilis. 

Carlos was treated by the researchers 

with 3,400,000 units of penicillin over 

the course of a week, and his blood 

tests showed dramatic improvement 

during the following two months.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

38

The researchers also soon encountered problems obtaining cooperation from 

the prisoners. The “Indians,” Dr. Cutler reported to Dr. Mahoney in January 

1947, had “very widespread prejudice against frequent withdrawals of blood,” 

which Dr. Cutler attributed to them being “uneducated and superstitious.”272

As Dr. Cutler later explained:

“Most of [the prisoners] believed that they were being weakened 

by the weekly or biweekly withdrawals of 10 cc. of blood and 

complained that they were getting insufficient food to replace it. 

The fear of what they saw was much more important to them than 

the potential damage which might be done by syphilis years later 

and could not be countered by promises of or actual administration of penicillin for syphilis and iron tablets to replace blood. In 

their minds there was no connection between the loss of a ‘large 

tube of blood’ and the possible benefits of a small pill.”273

The prisoners’ lack of cooperation also threatened the researchers’ ability to 

proceed with the project.274 The researchers’ plan for prophylaxis research 

“as originally conceived at the prison could not be carried out,” Dr. Cutler 

later wrote.275

Children

Serology testing in children began sometime before June 1947276 and ended 

in summer 1949.277 The researchers conducted physical examinations, blood 

draws, and, in some cases, lumbar punctures, on 1,384 Guatemalan children 

between 1 and 18 years of age.278 Children came from the Orphanage, a school 

at Port of San José, Totonicapan, and the “highlands” of Guatemala.279 Testing 

children below the age of sexual maturity, Dr. Cutler later explained, ensured 

the opportunity for conclusive evidence of false positivity for any testing 

regimen, because subjects presumably would have acquired the disease congenitally rather than sexually, and congenital syphilis was distinguishable.280

There is no record of any of these children being inoculated or exposed to any 

STD. There is also no record that the children knew that they were a part 

of an experiment or had an individual parent or guardian consent on their 

behalf. Guatemalan government officials were aware of, and supported, the 

research.281 At the Orphanage, the director, Dr. Aragon, collaborated as a 
GUATEMALA EXPERIMENTS 1946-1948 II

39

researcher and co-author on the publication later describing the work.282 The 

Ministry of Public Health also supported the research. 

Serological testing began with schoolchildren in Port of San José, Guatemala, 

followed closely by children in the Orphanage.283 Many of the 151 children tested 

in Port of San José exhibited symptoms of malaria. Indeed, Dr. Cutler later sent 

blood and blood smears from approximately 300 children to Dr. Willard Wright, 

Chief of the Division of Tropical Diseases at NIH, for the laboratory’s ongoing 

malaria study in Guatemala.284 To Dr. Mahoney, Dr. Cutler relayed that treating 

the children for malaria was “to [the researchers’] advantage”:

“In drawing blood from these children it is to our advantage to give 

them some medicine, for that reason we are planning to give them 

Aralen [an antimalarial drug] to treat the group found infected 

with malaria and at the same time we shall arrange for all of the 

children to receive a weekly prophylactic dose.”285

The researchers conducted clinical exams of the children’s mouths, skin, 

lymph nodes, and, in boys, the genitals.286 Two children in the Port of San 

José were identified with congenital syphilis, one symptomatic and one 

asymptomatic. Other children with clear or ambiguous seropositive reactions never manifested further clinical symptoms.287 Several months later, 

after compiling preliminary results on the children in the Port of San José, 

Dr. Cutler reported that “it is very evident to us that the cardiolipin test [i.e. 

the VDRL or Kolmer test] is much more nearly specific than the Kahn or 

Mazzini techniques [which utilized lipoidal antigens].”288

Serology research, including clinical examinations, in the Orphanage 

involved significantly more children, approximately 515.289 In April 1948, 

the researchers presented preliminary serological findings at the Second 

Congress of Venereal Diseases in Central America held in Guatemala City, 

which Dr. Arnold also attended.290 The Director of the Orphanage reviewed 

results and described the efforts taken within the institution to care for the 

children.291 To the researchers, the children in the Orphanage made an ideal 

study population for many reasons. Most of the children had never had sexual 

contact, thereby preventing the sexual spreading of syphilis, the facility was 

in excellent condition, and the children were accustomed to routine medical 

examinations and treatment. The Orphanage also had a large, stable, and 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

40

easily accessible population. The Orphanage generated and meticulously 

maintained medical records for each child from the moment of admittance, 

facilitating screening for previous infection or other complicating factors.292

Three children showed serologic patterns highly suggestive of syphilis. The 

researchers treated all three with penicillin and the children showed a slight 

decline in serologic titer the following year, though none became seronegative.293 Eighty-nine children demonstrated some level of serologically positive 

reaction, but only 55 received a clinical work-up.294 Forty-nine children then 

underwent lumbar punctures for further diagnosis.295

Additional experiments involving 441 “Ladino” children between the ages of 

5 and 14 years from the highlands of Guatemala, and 277 “Indian” children 

between the ages of 6 and 14 years from Totonicapan, Guatemala were also 

undertaken.296 These children were involved in blood serology testing only; 

no lumbar punctures were reported.297

Although Dr. Cutler’s rationale—at least in part—for testing children 

appeared to be to validate serological methods for prophylaxis research, 

the exposure experiments in the Penitentiary in May 1947 began before the 

research in children started,298 and was over in September 1948,299 long 

before the testing in children ended in 1949.300 Furthermore, Dr. Cutler 

later changed his mind about the utility of the experiments in children. In 

1955 he concluded that effective validation of the serological test methods 

needed to come from comparisons with better matched populations to the 

prophylaxis experiments, that is, “an adult group coming from the same 

society as the prisoners.”301

Leprosarium

The researchers conducted serological experiments with 51 leprosy patients, 

nearly the entire population of a leprosarium just outside of Guatemala 

City.302 Given the high rates of false positive serologic tests for syphilis seen in 

other Guatemalan populations, along with published reports of false positive 

reactions in leprosy patients, the investigators sought to examine serologic 

tests for syphilis when both factors—disease state and nationality—were 

combined.303 The researchers did not find any clinical evidence of syphilis, 

but positive serologic results appeared higher than in other Guatemalan 
GUATEMALA EXPERIMENTS 1946-1948 II

41

populations. The researchers attributed this finding to the leprosy itself 

causing false positive results for syphilis.304

Psychiatric Hospital

The researchers also conducted serologic research in the Psychiatric Hospital 

of Guatemala.305 Dr. Carlos Salvado, the director of the Psychiatric Hospital 

(whom the U.S. government later paid to complete follow-up work after Dr. 

Cutler left) invited the group to begin serologic screening of patients and new 

admissions. Dr. Cutler later explained that this presented an opportunity for 

the researchers to do regular and repeated serologic screening in a defined 

population of adults over time.306 A total of 642 psychiatric subjects were 

involved in STD (syphilis, gonorrhea, and chancroid) diagnostic research, 

many of whom were engaged repeatedly for different interventions.307 In 

addition to blood testing and lumbar punctures, the researchers performed 

hundreds of cisternal punctures on psychiatric patients for serological 

purposes.308 Writing in 1955, Dr. Cutler claimed to need these data from the 

Psychiatric Hospital because of failure in the children experiments.309

The serological testing in the Psychiatric Hospital continued after Dr. Cutler 

left Guatemala. Drs. Funes and Salvado managed continuing observations 

for PHS and shipped samples back to the United States for analysis. Blood 

draws and lumbar punctures continued in approximately 250 subjects from 

the institution,310 several of whom tested positive for syphilis.311 Treatment 

was not documented. These observations continued through at least 1953.312

Intentional Exposure Experiments

Overview

Six months after Dr. Cutler arrived in Guatemala, the intentional exposure and 

prophylaxis experiments began. They continued from February 1947 through 

October 1948.313 In total, Dr. Cutler reported 32 gonorrhea experiments,314

17 syphilis experiments,315 and one chancroid experiment316 (see Table 4).317 A

total of 1,308 people including commercial sex workers, soldiers, prisoners, and 

psychiatric patients were involved in the exposure experiments.318 The ages of 

subjects involved in the exposure experiments ranged from 10 to 72 years, with 

the average subject being in his/her 20s.319 Of that group, 678 individuals can 

be documented as receiving some form of treatment.320
“Ethically Impossible” STD Research in Guatemala from 1946-1948

42

The original plan for the Guatemala experiments—what Dr. Cutler argued 

brought them to Guatemala initially—was to test the orvus-mapharsen 

prophylaxis wash as a prophylaxis for syphilis in prisoners exposed to 

infected commercial sex workers. The purpose was to develop more effective preventative tools for U.S. military personnel. This experiment never 

happened.321 Instead, the researchers faced difficulties in diagnosing syphilis, 

reliably inducing infection (through the use of commercial sex workers), and 

procuring a compliant subject population. The experiments, upon review, 

appear to lack logical progression: baseline experiments for background 

infection rates were conducted after prophylaxis experiments began and new 

experiments were started before the results for pilot experiments were known 

(see Figure 6).322 Intentional exposure experiments began in the Guatemalan 

Army and focused almost equally on efforts to infect as efforts to test a 

prophylaxis for gonorrhea. As in Terre Haute, the researchers never mastered 

a technique with which to infect subjects. 

The majority of the intentional exposure experiments took place in the Guatemalan Army on 60 different days and involved gonorrhea and chancroid. 

The researchers conducted gonorrhea, chancroid, and syphilis experiments 

at the Psychiatric Hospital on 33 different days. Intentional exposures in the 

Penitentiary were relatively few, occurring on 24 different days, and were 

limited to syphilis.323 While Dr. Cutler’s retrospective reports suggest a logical 

progression in the experiments from one population to the next, and from 

one type of experiment to another, this step-wise progression is often absent 

from the contemporaneous records and the aggregate data he collected (see 

Figure 7).

Dr. Cutler’s contemporaneous records note 83 deaths during the course of 

the experiments.324 The exact relationship between the experimental procedures and the subject deaths is unclear. When Dr. Cutler wrote his 1955 

Final Syphilis Report, he noted a “steady loss of patients by death” that he 

attributed primarily to tuberculosis and to the fact that “both acute and 

chronically ill patients” were used.325 The researchers planned “to perform 

autopsies on all patients so that special spirochetal and histologic experiments could be made.”326
GUATEMALA EXPERIMENTS 1946-1948 II

43

Gonorrhea Experiments

Overview

Intentional exposure gonorrhea experiments 

involved approximately 582 people including 

at least four commercial sex workers and 518 

soldiers from February 1947 to July 1948, 

psychiatric patients from June 1948 through 

September 1948, and ten additional subjects 

during the same period whose background 

is unknown. Of the subjects exposed to 

gonorrhea (an STD caused by the bacterium Neisseria gonorrhoeae), available records 

document only 237 receiving any form of 

treatment.327 The primary purpose of the 

gonorrhea experiments in the Guatemalan 

Army was to test the effectiveness of different 

prophylaxis measures including the orvusmapharsen solution, a 10-percent argyrol 

(i.e., silver) intra-urethral instillation, the U.S. Army “pro kit,” and oral penicillin.328 The experiments in the Psychiatric Hospital appear to have been 

primarily observational (i.e., no prophylaxis or treatment was tested).

The researchers required “ample supplies of pus” carrying the gonorrhea 

bacteria for their gonorrhea experiments. To obtain such samples, they turned 

to patients “under arsenical treatment for syphilis” at the Military Hospital.329

There, the researchers sought to infect the syphilis patients with gonorrhea in 

order to create a “reservoir of infect[i]on” from which to draw.330

In his 1952 retrospective summary of their work, the Experimental Studies 

in Gonorrhea report, Dr. Cutler wrote that all experimental infections 

were treated with penicillin in the form of injections of 300,000 units of 

a repository delayed-absorption preparation.331 However, the researchers’ 

contemporaneous records reveal that some of the subjects they infected 

received treatment with a bismuth-arsenic combination,332 and many of the 

subjects were never treated at all.333

Gonorrhea is a contagious 

disease caused by the bacterium 

Neisseria gonorrhoeae. Similar to 

syphilis, gonorrhea is transmitted 

largely through sexual contact 

and can also be spread from 

mother to fetus during pregnancy. 

Symptoms may vary depending 

on the gender of the individual 

infected. Signs of infection in 

men include a burning sensation 

during urination, or a white, 

yellow, or green discharge from 

the penis. Women on the other 

hand, exhibit either mild or no 

symptoms at all. Gonorrhea 

can be cured by antibiotics, but 

there are currently an increasing 

number of drug-resistant strains 

that are difficult to treat.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

44

Guatemalan Army and Commercial Sex Workers

On February 15, 1947, the researchers began intentional exposure experiments 

with gonorrhea.334 Unlike serological testing for syphilis, with its associated false-positive complications, diagnostic testing for gonorrhea was more 

straightforward and reliable.335 In total, 518 soldiers were exposed to gonorrhea, 202 of whom received some form of treatment.336

The research in the Guatemalan Army began, Dr. Cutler later explained, as a 

“result of the interest of the medical department” of the Guatemalan Army.337

The researchers established relationships with local physicians in the military 

to support their work. Some of these Guatemalan researchers were involved in 

the syphilis work as well. Dr. Raul Maza of the Military Hospital was involved 

in both the syphilis and gonorrhea experiments,338 and Col. Juan Oliva of the 

Guardia de Honor (Honor Guard) worked on the syphilis experiments.339

Gonorrhea experiments among the Guatemalan Army continued through 

July 1948.340 Methods of infection included sexual exposure, superficial 

inoculation into the penis, deep inoculation into the penis, and superficial 

inoculation following sexual exposure. Subjects included men in the Military Hospital, the Honor Guard,341 and the Second Army Company of 

Riflemen.342 The average age of the soldiers involved was 22 years old.343

Many also held the lowest rank of private.344

Often, the soldiers involved in the experiments were isolated under careful 

control and supervision during the experiment.345 No discussion of compensation for the soldiers is included in Dr. Cutler’s reports, beyond some 

purchasing of clothing by PHS Senior Surgeon Dr. Levitan for the “volunteers.”346 Many of the soldiers were also noted as having been given Arginol 

(a herbal supplement designed to facilitate erections) in conjunction with the 

sexual intercourse experiments.347

There is no evidence that the soldiers gave consent for the experiments. Indirect evidence from June 1947 shows that the subjects at the time were not, in 

fact, “volunteers.”348 As Dr. Mahoney explained to Dr. Cutler: “[t]he use of 

volunteer groups rather than the type which is being employed would be more 

than satisfactory. Our budget will stand for almost any fee for volunteers 

which you consider to be advisable” (emphasis added).349
GUATEMALA EXPERIMENTS 1946-1948 II

45

Normal Exposure

Dr. Cutler’s contemporaneous notes identify 

four commercial sex workers who were used 

in “normal exposure” gonorrhea experiments 

on two different days in which they had sexual 

intercourse with soldiers (Dr. Cutler did not 

include the first two days experiments in his 

final gonorrhea report and also reported that 

12 sex workers were involved).350 Commercial sex workers were also involved in artificial 

inoculation exposure experiments after sexual 

intercourse (discussed below) on 13 different 

days.351 Both Dr. Luis Galich, the head of the 

Ministry of Public Health, and Dr. Juan Funes, by that time the Chief of Medicine at VDSPH, referred infected commercial sex workers from VDSPH to Dr. 

Cutler.352 Their assistance was advantageous because, Dr. Cutler reported in 

1952, “[c]ontrary to what might be expected, it proved extremely difficult to 

obtain prostitutes willing to serve under experimental conditions.”353

Dr. Funes was the physician responsible for the medical supervision of the 

commercial sex workers and the STD rapid treatment centers “where all 

venereal disease patients could be hospitalized for free treatment.”354 Detailed 

Guatemalan regulations, a copy of which Dr. Cutler retained in his personal 

papers,355 required commercial sex workers be at least 18 years old, register 

with the Sexual Prophylaxis and Venereal Diseases Section356 of the government, and report twice weekly for an examination at a local Venereal Disease 

Control Clinic.357 Women infected with syphilis, gonorrhea, or chancroid 

were prohibited from working as commercial sex workers, but treatment, 

which was based primarily on arsenical drugs, was provided at no cost.358

There is no record in any of the available documents that the women 

consented to being a part of the experiments or had any idea that they 

were infected with STDs by the researchers.359 Medical records reflect that 

at least one commercial sex worker used in these prophylaxis experiments 

was 16 years old, contrary to applicable law.360 Several of the women were 

also given alcohol before the experiments. While documents stated that men 

Dr. Luis Galich

“Gallery of future Presidential contenders: 

We now offer readers the Mayor of the 

capital, Luis Fernando Galich.” 

Published in Diario La Hora on May 11, 1962. 

The Daily Journal, Historical Archives, CIRMA 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

46

occasionally received alcohol to “lower resistance to infection,”361 no reason is 

stated for giving alcohol to the commercial sex workers.

At least four of the sex workers presented 

with naturally occurring gonorrhea, but Dr. 

Cutler concluded that it was “impossible 

to wait for chance of infection with gonorrhea.”362 The researchers artificially inoculated 

four commercial sex workers several times.363

Some contemporaneous notes for gonorrhea 

experiments show $25 payments to commercial sex workers for particular experiments,364

although the majority of the notes do not 

document any compensation.365

The researchers artificially inoculated 

commercial sex workers with gonorrhea 

by moistening a cotton-tipped swab with 

pus from an acute case of gonorrheal 

urethritis in the male, inserting the swab 

into the woman’s cervix and “swabb[ing] it 

around...with considerable vigor.”366 All of 

the commercial sex workers infected in this 

manner reportedly contracted the disease. 

None “showed evidence of acute infection 

such as a rich outpouring of thick yellow pus from the cervix or by signs of 

pelvic inflammatory disease...[but] all of them showed evidence of infection 

by cervical discharge and excessive accumulation of secretion in the vagina,” 

and all were culture-positive.367 Dr. Cutler later made at least one note 

saying that two of the women involved in the experiments “were eventually 

treated,”368 but detailed treatment records, like those that exist for the other 

subject populations, do not exist for the commercial sex workers.

The first gonorrhea experiment, on February 15, 1947, tested the effectiveness of Dr. Arnold’s penicillin/POB (a preparation of penicillin in a medium 

of peanut oil and beeswax to ensure a slow steady release prophylaxis) in 

a placebo-controlled trial of 15 men who were exposed to commercial sex 

Subject Profile: 

Maria Luisa

Maria Luisa was a commercial sex 

worker who went to the VDSPH, 

directed by Dr. Funes, on March 

13, 1947. She tested positive for 

gonorrhea when she arrived at the 

hospital and was subsequently 

referred by Dr. Funes to Dr. Cutler. 

On March 15, 1947, Maria Luisa was 

paid $25 and had sexual contact 

with seven men. During the following 

year, Maria Luisa was inoculated 11 

different times with many different 

strains of gonorrhea. While infected 

with gonorrhea she had 105 sexual 

contacts. 

There is no evidence that Maria 

Luisa received any treatment for 

her acute gonorrhea during the 

experiments.
GUATEMALA EXPERIMENTS 1946-1948 II

47

workers known to be infected.369 As Dr. Cutler later wrote “ideally, a prophylactic should be tested under normal conditions.”370 Dr. Arnold was there to 

oversee this work. He had arrived in Guatemala sometime before February 

10, and left approximately 10 days later, arriving home in time to write Dr. 

Cutler on February 27. 

Before the experiment began, Dr. Cutler specifically designated which soldiers 

were to receive the prophylaxis and which were to receive the placebo, but 

several men’s roles were reversed on the day of the trial.371 The commercial 

sex workers were instructed not to douche on the day of the experiment and 

were not permitted to wash between episodes of sexual intercourse with the 

men.372 In later experiments, the researchers confirmed that the commercial 

sex workers were infected before the prophylaxis tests began, but in the first 

experiment, Dr. Cutler was unable to confirm infection status at the time of 

exposure because “the girls were quite apprehensive.”373

For this first intentional exposure experiment, Dr. Cutler recorded the length 

of time the soldiers engaged in sexual intercourse, and he examined each man 

afterward for “evidence of vaginal secretion and ejaculation” to “assure that 

contact had actually taken place.”374 Dr. Cutler also recorded when the subject 

did not ejaculate.375 While the goal of this first experiment was to “permit 

the exposure of a large group of men to infected prostitutes to determine the 

normal rate of infection with gonorrhea,”376 none of the men involved in the 

experiment contracted gonorrhea. Dr. Cutler did not report this first experiment in his 1952 Experimental Studies in Gonorrhea report summary.377

After Dr. Arnold’s visit in February,378 Drs. Heller, Van Slyke, and Mahoney 

traveled to Guatemala in April 1947.379 Dr. Cutler worked hard to entice and 

impress these senior PHS leaders. In January, Dr. Cutler had written Dr. 

Mahoney to tell him about eight cases of Pinto (a skin disease caused by a 

spirochete indistinguishable from Treponema pallidum) that Dr. Mahoney 

could review on his visit for use in rabbit experiments.380 Dr. Cutler withheld 

treatment for three months so Dr. Mahoney would have such an opportunity: “we hope to be able to take you to the finca [estate] to see the cases of 

Pinto and then to give them Penicillin after having taken biopsies for rabbit 

inoculations. The cases were most interesting and I am sure that you will 

enjoy the trip.”381  
“Ethically Impossible” STD Research in Guatemala from 1946-1948

48

The visiting physicians observed the intentional exposure experiments. Dr. 

Van Slyke complained that Dr. Cutler had not confirmed that the commercial 

sex workers were in fact infected with gonorrhea at the time of exposure.382

Discussing these concerns later, Dr. Arnold suggested that Dr. Cutler not 

“put on any more shows unless you are sure of everything” so as to avoid “an 

unfavorable impression.” Alternatively, Dr. Arnold suggested that Dr. Cutler 

“do a little blanket stretching.”383

In addition, the volume and frequency of exposures to the commercial sex 

workers raised some concern. Dr. Cutler’s superiors advised that the commercial sex workers should have sexual intercourse with men several hours 

apart384 or just several times a day385 to maximize transmission rates. But the 

sex workers involved in the experiments had intercourse with different men 

sometimes less than a minute apart, seeing a large number of men in a very 

short time.386 For example, one commercial sex worker whom the researchers 

infected with gonorrhea had contact with eight soldiers387 in 71 minutes.388

Transmission rates remained low. According to Dr. Cutler’s final report, in 

total in the Guatemalan Army, only five infections resulted from 138 exposures of 93 men (5.4 percent) to 12 commercial sex workers over the course of 

the normal exposure experiments which ended in July 1948.389

Artificial Inoculation

Shortly after beginning the sexual intercourse experiments to induce gonorrhea infection, the researchers also began “artificial inoculation” experiments, 

mirroring techniques employed in Terre Haute (see Figure 8). The researchers 

conducted these artificial inoculation gonorrhea experiments in the Guatemalan Army beginning in April 1947 (two months after they started the 

sexual intercourse experiments).390 They employed two procedures for artificial inoculation: “superficial” and “deep” inoculation. The swabs used in 

superficial inoculation were from the bacterial laboratory. For deep inoculation, the researchers used toothpicks wrapped in a small amount of cotton. 

For both procedures, the swab was moistened with pus from an “acute case of 

gonorrhea in the male.”391 In a superficial inoculation: 
GUATEMALA EXPERIMENTS 1946-1948 II

49

“[T]he penis was grasped just distal to the sulcus between the left 

thumb and forefinger of the physician so that the mucosa of the 

fossa navicularis was averted and so that the urethra distal to a 

point 2-4 mm. from the meatus was occluded. With the right 

hand the physician carefully, and with some force, rolled the large 

inoculating swab over the mucosa so as to try to contaminate the 

entire fossa navicularis.”392

For the deep inoculation method, “the toothpick swab was...inserted about 

1⁄2 [inch] into the urethra, and carefully rubbed over the mucous membrane, 

so much so as to cause pain.”393

Describing early results to Dr. Mahoney on May 17, 1947, Dr. Cutler explained:

“On Friday, May the 9th, we performed another experiment inoculating six patients with pus and treating three of them. As of May 

15, one of the controls showed positive culture, the second showed 

considerable discharge with extra-cellular organisms, while the 

third shows considerabl[e] discharge which is microscopically 

negative thus far. That reminds me of the patients at Terre Haute 

some of whom showed such a discharge for a few days before we 

were able to make the diagnosis, while others might show for a few 

days after inoculation extra or intra cellular organisms but remain 

culturally negative and not develope [sic] the infection. None of 

the treated patients thus far shows any evidence of a take.”394

In the same letter, Dr. Cutler also described the researchers’ first success 

using commercial sex workers for “normal exposure” from the months prior 

(“[w]e have had the first success with the normal exposure with one patient 

of six showing positive results”). But, Dr. Cutler continued to voice concerns 

about the effectiveness of that method of transmission.395

Writing to Dr. Arnold on June 5, 1947, following eight sexual intercourse 

experiments, Dr. Cutler observed that infection by “natural exposure with 

these men is rather low.”396 On June 22, after one additional sexual intercourse 

experiment, Dr. Cutler reported to Dr. Mahoney on his continued findings:
“Ethically Impossible” STD Research in Guatemala from 1946-1948

50

“In the last gonorrhea experiment utilizing natural exposure we 

used two girls over a four night period with four men exposed 

to them. Each man had as many contacts as he wanted during 

the evening so that the tota[l] time of exposure averaged over ten 

minutes with most men having two and some three exposures. 

There was no doubt of the presence of the gonococci in the women, 

as that was proven culturally twice each night, but after two weeks 

of observation no infection developed in any of 16 men. It may 

be that the infection had gone too long in the sources, so that we 

are getting ready now to expose our men to the infection as early 

in its course as possible. At the same time, or in the next run we 

shall use alcohol again, for to date our only success has come in 

the case of a man who had alcohol prior to exposure. It seems that 

clandestine affairs, with respect to gonorrhea, are far safer than 

ever before imagined.”397

In response, Dr. Mahoney, whose doubts about the feasibility of intentional 

infection contributed to the decision to terminate the Terre Haute work,398

advised his junior colleague on June 30 to follow a contact only (i.e., sexual 

intercourse) regimen: “we are anxiously awaiting your report of the transmission experiments utilizing contact only. This is of vital importance if we are 

to carry out the studies outlined.”399 By August, Dr. Mahoney had advised 

Dr. Cutler that “[i]t is becoming obvious also that experimental infection 

cannot be produced with sufficient frequency to assure an adequate background for a study of prophylaxis. Because of the circumstances your opinion 

as to the advisability of discontinuing the gonorrhea phase of the project for 

the time being would be appreciated.”400 Dr. Cutler responded that “we might 

well continue [the experiments] a while longer to get as much information as 

possible now that we have a set up here.”401

Despite Dr. Mahoney’s concerns, the researchers increased the number of artificial inoculation experiments relative to the sexual intercourse experiments 

beginning in August. While the researchers conducted 13 sexual intercourse 

experiments and eight artificial inoculation experiments between February 

and July 1947, they conducted nine sexual intercourse experiments and 32 

artificial inoculation experiments between August 1947 and July 1948.402
GUATEMALA EXPERIMENTS 1946-1948 II

51

Explaining his choice to begin artificial inoculation methods later in 1952, 

Dr. Cutler noted, “[a]s a result of the experience of several authors, it was 

decided to carry out an evaluation of prophylactic methods using artificial 

means of inoculation.”403 Dr. Cutler pointed out that Dr. Tejeda had many 

patients in the Guatemalan Army who had artificially inoculated themselves 

in order to get out of official duties: “[t]he technique commonly used was to 

take by the end of a match from an acute case and to insert the contaminated 

end of the match into the urethra of the solider desiring to infect himself.”404

Dr. Cutler also cited the Terre Haute experiments in his 1952 report as 

evidence that the method “could cause infection,”405 despite concerns about 

the effectiveness of this form of inoculation research raised in 1944.406

In the control groups, Dr. Cutler reported rates of approximately 50 percent 

infection with the superficial inoculation method, and 97.8 percent with 

the deep inoculation method.407 He concluded that these numbers showed 

that a prophylactic agent tested against a superficially inoculated subject 

was “subjected to a very severe test indeed.”408 If a prophylactic agent could 

withstand an otherwise 54-percent rate of infection, he argued, it “should be 

expected to show up well” when subjected to the “less-severe test of routine 

risk of infection.”409

By September 1947, Dr. Cutler also decided to conduct several experiments 

using artificial inoculation after sexual intercourse. With this method, the 

men had sexual intercourse with a commercial sex worker, and immediately 

following intercourse, “while the penis was still partially engorged and while 

the fluid of the ejaculate was at the meatus,” the inoculation was performed 

to “simulate more nearly the natural conditions.”410 This type of experiment 

occurred on 13 different days, but the results did not differ significantly to artificial inoculation without sexual intercourse.411 The researchers completed their 

gonorrhea experiments with subjects in the Guatemalan Army in July 1948.412

Psychiatric Hospital

The researchers conducted gonorrhea intentional exposure experiments in 

the Psychiatric Hospital from June to September 1948.413 These experiments 

involved a total of approximately 50 subjects, 32 of whom received some form 

of treatment.414 They included inoculation in the subjects’ rectum, urethra, 

and/or eyes.415 One female subject who was identified as having a terminal 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

52

illness died four days after the researchers 

inoculated her, without receiving any treatment for the gonorrhea or syphilis with 

which the researchers had infected her.416

Syphilis Experiments

Overview

The researchers conducted intentional exposure experiments involving syphilis, the 

STD caused by the bacterium Treponema 

pallidum, with 688 subjects, including 

commercial sex workers, prisoners, and 

psychiatric patients from May 1947 through 

October 1948.417 The primary purpose of 

these experiments was to study the clinical effectiveness of the orvus-mapharsen 

prophylaxis that Drs. Arnold and Mahoney 

proved effective in rabbits.418 Other types of 

prophylaxis tested were the Army “pro kit” 

(a topical preparation containing calomel, 

sulfathiazole, white petrolatum, light 

mineral oil, and cetyl alcohol), parenterally 

administered preparations (e.g., POB), and 

oral penicillin in pill or liquid form.419

The researchers used several different strains 

of infectious material for the syphilis experiments.420 They used rabbits as the source of 

most of the strains,421 but they also tested 

strains taken directly from humans (“human 

passage material”) because of questions about 

the impact of rabbit passage on the pathogenicity of Treponema pallidum and 

conviction that “the ultimate value of a prophylactic agent depended upon the 

ability to protect man against the infection in man.”422 These methods exposed 

subjects to additional health risks for human-to-human pathogens in addition to 

the syphilis and any number of zoonotic pathogens from the rabbit strains. 

Subject Profile: berta

Berta was a female patient in the 

Psychiatric Hospital. Her age and 

the illness that brought her to the 

hospital are unknown. 

In February 1948, Berta was 

injected in her left arm with 

syphilis. A month later, she 

developed scabies (an itchy skin 

infection caused by a mite). Several 

weeks later, Dr. Cutler noted that 

she had also developed red bumps 

where he had injected her arm, 

lesions on her arms and legs, and 

her skin was beginning to waste 

away from her body. Berta was 

not treated for syphilis until three 

months after her injection. 

Soon after, on August 23, Dr. 

Cutler wrote that Berta appeared 

as if she was going to die, but he 

did not specify why. That same 

day he put gonorrheal pus from 

another male subject into both 

of Berta’s eyes, as well as in 

her urethra and rectum. He also 

re-infected her with syphilis. 

Several days later, Berta’s 

eyes were filled with pus from 

the gonorrhea, and she was 

bleeding from her urethra. 

On August 27, Berta died.
GUATEMALA EXPERIMENTS 1946-1948 II

53

To harvest the human passage material, Dr. Cutler used exudate (infectious 

fluid) from selected subjects with previously infected penile or skin chancres, 

some of which was obtained from 

patients in the local hospitals, including 

the Military Hospital where Dr. Raul 

Maza worked. Dr. Cutler then excised 

the cutaneous chancres, sometimes by 

full “circumcision,” under local anesthesia.423 He explained in his Final 

Syphilis Report that treatment for 

the donor’s syphilis was sometimes 

provided immediately after removal 

of the chancre but that at other times 

“treatment was delayed to study the healing of operative wounds in syphilitic 

patients.”424 The material was then ground up and made into an emulsion. 

The “street strain” inoculum was a mixture of material collected from three 

different soldiers.425

The researchers used three types of intramuscular penicillin injections for treatment: an aqueous solution of the sodium or potassium salt of penicillin G; 

POB; or Duracillin, the procaine salt of penicillin in a peanut oil base.426 While 

some of the subjects exposed to syphilis were not treated absent clinical evidence 

of disease (e.g., the development of a chancre), 388 out of 688 subjects exposed 

were treated in some fashion.427 These treatment practices varied, however, and 

the efficacy of the different approaches was not fully known at the time. The 

researchers recorded few adverse events related directly to the penicillin treatment, but they noted that at least one subject died after receiving penicillin.428

Penitentiary

When the researchers began work in the Penitentiary in early fall 1946, they 

limited their work to “good will” screening and treatment, plus serology and 

placebo prophylaxis, until May 10, 1947, when the group began intentional 

exposure experiments.429 In total, 219 prisoners were included in these experiments through exposure to infected commercial sex workers and/or artificial 

Syphilis is a contagious disease caused 

by the bacterium Treponema pallidum. 

Although it is mainly transmitted through 

sexual contact, syphilis can also be 

transmitted from mother to fetus during 

pregnancy. The disease is mainly 

characterized by sores, but can also 

cause a wide variety of symptoms that 

vary depending on the state of the disease 

(primary, secondary, latent, and tertiary). 

Syphilis can be diagnosed through a blood 

test or an examination of the bacteria 

found in the infectious sore. If caught 

early, syphilis can easily be treated with 

an antibiotic, such as penicillin.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

54

inoculations with infectious material, between May 1947 and September 

1948.430 Only 92 of the 219 people exposed received some form of treatment.431 In contrast to the experiments with soldiers and psychiatric patients, 

the prisoners were exposed to commercial sex workers and artificial inoculation with relatively less invasive injection methods.432

Prison inmates were viewed as an isolated population that could be used for 

“normal exposure” to STDs (i.e., sexual intercourse). There is no record of the 

men in the Penitentiary either consenting to be involved in an experiment 

or understanding that an experiment was taking place. Moreover, evidence 

suggests that some prisoners objected to participation. As Dr. Cutler later 

explained, “relationships between prisoners and experimenters” made it 

impossible to secure serum from dry lesions due to the prisoners’ “strenuous 

objection to the pain.”433

A large portion of the prison population consisted of indigenous Guatemalans, referred to in correspondence as “Indians.” Writing to Dr. Arnold about 

this group shortly after he arrived in August 1946, Dr. Cutler relayed Dr. 

Spoto’s view that the experiments need not be explained to the “Indians.”434

“Likewise,” Dr. Cutler continued, “our payment for the males will be considerably less than we had originally planned.”435 Still, the researchers undertook 

various methods to deceive the prisoners about their research aims during, 

and possibly after, the experiments. In January 1947, Dr. Cutler advised Dr. 

Mahoney of several steps planned with “all concerned” to “allay fears and 

suspicions” about the research:

“So far as the work in the prison goes, it appears that it will have 

to be carried out as a scheme of prophylaxis for everyone, using 

a placebo where indicated. To increase the number of exposures 

we shall bring in the sourcs [sic] of infection [the commercial 

sex workers] as indicated along with some not infected so as to 

allay fears and suspicion. In that way, we shall be able to avoid 

political repercussions which are even now in the air as the papers 

are complaining about conditions in the prison now. It is quite 

probable that we shall pay the men either nothing or a pack of 

cigarettes or some soap or other items for each extraction of blood. 

We have had many conferences about this matter and the scheme 
GUATEMALA EXPERIMENTS 1946-1948 II

55

mentioned above seems to be the one acceptable to all concerned 

and is one which offers the least risk of any trouble.”436

Notwithstanding these plans, Dr. Cutler’s records reflect that only 13 of the 

23 experiments involved sexual intercourse—the rest involved injection as 

an artificial exposure technique.437 Writing in 1955 about the goals of the 

Penitentiary inoculation work, Dr. Cutler explained the purpose as seeking 

to identify an effective serologic test and answer several additional questions (only one of which concerned prophylaxis, and none of which involved 

orvus-mapharsen):

•	 What types of clinical and serologic changes might result from the injection 

of rabbit testicular syphilomata (versus human);438

•	 Whether superinfection was possible;439

•	 Whether virulence of the disease could be lost due to length of infection in 

the rabbit donor;440

•	 Whether animal passage material “so attenuated or altered the bacterium that 

it [] lost the ability to penetrate the human mucus membrane,” leading the 

researchers to design an experiment to “pass the material through man”;441

•	 What was the effectiveness of “abortive penicillin therapy”442 and intramuscular 

penicillin prophylaxis;443 and 

•	 Whether treated subjects with early or late latent syphilis could be reinfected.444

The individual reports of the injection experiments, later found in the final 1955 

report, include research data collected for addressing each of these questions.

Despite ongoing concern about serological testing and its reliability as an indicator of infection, the researchers began syphilis experiments with commercial 

sex workers and prisoners in May 1947 shortly after Drs. Mahoney, Heller 

and Van Slyke visited.445 Writing in 1955, Dr. Cutler described the commercial sex workers who served the penitentiary populations as the “lowest in the 

social scale of local prostitutes and most frequently infected with syphilis and 

gonorrhea,”446 but Dr. Cutler inoculated some of the commercial sex workers 

directly through intra-cervical injection of rabbit testicular syphilomata.447

Shortly thereafter, these women had sexual contact with 12 inmates. None of 

the prisoners developed clinical symptoms of infection, but complete serologic 

follow-up was impossible due to the prisoners’ objections to the collection 

of blood.448 As in the first two gonorrhea experiments, this first syphilis 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

56

experiment in the Penitentiary was not included in the summary chronology 

in Dr. Cutler’s Final Syphilis Report. Dr. Cutler later wrote that the commercial sex workers were to be paid by the researchers for their services,449 but no 

contemporaneous records document compensation.

Dr. Cutler argued in his final report that “it became necessary to develop a 

different mode of attack” from the sexual intercourse exposure for inoculating 

the prisoners due to the small number of men available for the experiment 

and the scientific difficulties they were facing.450 But researchers began intracutaneous inoculation of prisoners on May 14,451 just days after the first failed 

“normal exposure” experiment. Prisoners were given intracutaneous injections 

of syphilitic material into the distal border of the foreskin and/or anterior 

aspect of the right forearm.452

The researchers achieved a 96.8-percent transmission rate in the first artificial 

inoculation prison experiment via injection.453 But, “[i]n view of the importance of gaining information as rapidly as possible,” the researchers decided 

to begin the next experiment “without waiting to determine the outcome” 

of the first.454 The researchers also used the same needle “repeatedly” and 

“without sterilization of any kind from one patient to the next.”455 The practices significantly raised the risk of infection and other adverse health effects 

for individual subjects. 

The original plan to test orvus-mapharsen prophylaxis through the “normal 

exposure” of sexual intercourse between an infected woman and an uninfected man in the Penitentiary was never implemented. 

Psychiatric Hospital 

In January 1947, four months before beginning any intentional exposure 

experiments in the Penitentiary, and a month before beginning intentional 

exposure experiments in the Guatemalan Army, Dr. Cutler advised Dr. 

Mahoney about supplementing the original research design to include 

experiments “such as inoculation” at the National Psychiatric Hospital of 

Guatemala.456 The decision to undertake intentional exposure experiments 

there met with some resistance from Dr. Cutler’s supervisors, who raised 

concern about possible adverse public reaction. In April 1947, before any 

intentional syphilis exposure experiments began in either the Penitentiary or 
GUATEMALA EXPERIMENTS 1946-1948 II

57

Psychiatric Hospital, Dr. Arnold wrote to Dr. Cutler that he was “a bit, in fact 

more than a bit, leary [sic] of the experiment with the insane people” as they 

“cannot give consent” and “do not know what is going on...”457 Dr. Arnold 

appeared primarily concerned about exposure to criticism, because if “some 

goody organization got wind of the work, they would raise a lot of smoke.”458

He continued that:

“I think the soldiers would be best or the prisoners for they can give 

consent. Maybe I’m too conservative. A lot depends on the medical 

officer and the reaction of the supt. of the ins. hosp. [sic] Also how 

many knew what was going on [sic]. I realize that a [subject] or a 

dozen could be infected, develop the disease and be cured before 

anything could be suspected. The penicillin could be a Rx [treatment] for the insanity, your first study could be done in a short time 

and none would be the wiser. In the report, I see no reason to say 

where the work was done and the type of volunteer. You know the 

setup best, but be sure that all angles have been covered.”459

Writing in 1955 in his Final 

Syphilis Report, Dr. Cutler cast 

the choice to move to the Psychiatric Hospital as a reaction to 

problems in the Penitentiary, 

particularly the prisoners’ objections to the blood draws that were 

critical to assessing infection.460

“As work in the penitentiary 

grew less attractive,” he wrote, 

the researchers “shifted [their] 

major activity to the asylum.”461

However, the first intentional 

exposure experiments in the Psychiatric Hospital occurred only three days 

after the first intentional exposure experiment in the Penitentiary (May 10 

and 13, respectively).462 And, the Penitentiary work continued for almost a 

year and a half after the work in the Psychiatric Hospital began. A total of 

446 psychiatric patients were involved in the intentional syphilis exposure 

experiments, 294 of whom received some form of treatment.463

The syphilitic rash of a 22-year-old female psychiatric subject 

who was exposed to syphilis twice and received some treatment.

From the National Archives and Records Administration 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

58

Dr. Cutler said they chose subjects in the Psychiatric Hospital based on 

“custodial considerations” such as expected date of release and absence of 

homosexual behavior, but there are several examples of the researchers intentionally exposing men they also noted to be “active homosexuals.”464 It is 

possible that the subjects involved in the experiment spread syphilis beyond 

the experimental boundaries through homosexual contact,465 but Dr. Cutler 

dismissed this possibility in his 1955 Final Syphilis Report. He reported 

observing no clinical evidence of syphilis spread in this manner.466

Dr. Carlos Salvado, the Director of the Psychiatric Hospital, collaborated 

on the syphilis and gonorrhea experiments and made staff available to assist 

the researchers.467 Dr. Cutler credited Dr. Salvado with suggesting use of 

the psychiatric patients in experiments “since we had available a certain and 

sure cure for syphilis....”468 Dr. Cutler added that “[r]esponsible medical officials representing all groups concerned” together decided to undertake the 

syphilis inoculation experiments at the Psychiatric Hospital. Dr. Cutler justified this decision by pointing out that “[m]embers representing the VDRL

had previous experience in inoculation of volunteers both with gonorrhea 

and syphilis,” after which he cited the Terre Haute experiments as well as 

an “unpublished observation” he made with Dr. Arnold “on inoculation of 

volunteers with Nichols strain T. pallidum obtained from rabbit testicular 

syphilomata quick frozen and maintained in solid carbon dioxide refrigeration.”469 Dr. Cutler argued that “organizations concerned” had been involved 

in malaria470 and infectious hepatitis inoculation experiments,471 “so that 

there was a large background of experiences in the methods of working in 

human inoculation and with the safeguards for the individuals concerned.”472

Such an opportunity, the researchers believed, would “provide conclusive 

answers to a large number of questions of great importance, not only in the 

matter of prophylaxis but also concerning progress of national and international 

control of venereal disease then in action or proposed for the future.”473 Once 

in the Psychiatric Hospital, questions to which “conclusive answers could be 

expected to be found,” Dr. Cutler later wrote, included the following:

•	 Whether the orvus-mapharsen prophylaxis was effective in the prevention 

of syphilis;

•	 How the orvus-mapharsen prophylaxis compared with those in use at the time;
GUATEMALA EXPERIMENTS 1946-1948 II

59

•	 Whether oral penicillin was effective as a prophylaxis;

•	 Whether reinfection could take place following treatment and its clinical 

course; and

•	 Whether reinfection or superinfection could take place in treated or untreated 

latent or late syphilis.474

Psychiatric Hospital staff assisted during the experiments on an “irregular yet 

constant” basis.475 Dr. Salvado objected to having the researchers make supplementary payments to compensate Psychiatric Hospital staff, but he permitted 

the researchers to share the occasional pack of American cigarettes or a few 

extra dollars.476 Workers at the hospital notified the researchers of deaths, helped 

at autopsies, and aided experiments with large groups of subjects.477

When the researchers began at the Psychiatric Hospital, Dr. Cutler proposed 

to shift the $1,500 originally intended to pay prison volunteers478 to provide 

“for the benefit of the institution rather than for the individual.”479 At the 

direction of Dr. Salvado and “the Sister in charge,” a refrigerator in which 

to store drugs, a sound projector, and some metal plates and cups were 

provided.480 Dr. Cutler confirms in his report that these items were purchased 

for the hospital, but it appears from correspondence that the items were later 

sold to the hospital at cost.481 As compensation to subjects, the researchers 

provided cigarettes for “patient management.”482

The researchers also provided medication for psychiatric patients for the 

specific purpose of aiding their own serological testing needs. In a February 

6, 1948 letter to Dr. Mahoney, Dr. Cutler explained:

“We are having to order large quantities of [d]ilantin in order to 

protect ourselves. They had started treating the epileptics at the 

asylum with intravenous magnesium sulfate which caused thrombosis of the veins so that we are beginning to be unable to get 

blood samples. Out of self interest we agreed to furnish Dilantin 

to treat all of the patients in whom we are interested.”483

Dr. Cutler’s Final Syphilis Report makes no mention of this rationale but 

instead notes “the project provided much-needed anticonvulsant drugs, particularly Dilantin, for the large part of the patient population which was epileptic 

and for which funds previously had been insufficient to provide drugs.”484
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

60

no evidence indicates that the psychiatric subjects gave consent or understood 

that they were involved in an experiment. indeed, when writing about the fi rst 

experiment in the psychiatric hospital Dr. cutler wrote to Dr. mahoney that 

this female patient in the Psychiatric hospital was 

exposed to syphilis twice and was treated with penicillin. 

She also was involved in the serological testing for 

syphilis. her age and original diagnosis, and reason for 

hospital treatment, are unknown.

this female patient in the Psychiatric hospital was 

exposed to syphilis twice and was treated with penicillin. 

She also was involved in the serological testing for 

syphilis. her age and original diagnosis, and reason for 

hospital treatment, are unknown.

this 25-year-old female patient in the Psychiatric 

hospital was exposed to syphilis once with no record 

of treatment. She also was involved in the serological 

testing for syphilis. her original diagnosis, and reason for 

hospital treatment, are unknown. records indicate that 

she was released. 

this 16-year-old female patient in the Psychiatric 

hospital was exposed to syphilis twice and was treated 

with penicillin. She also was involved in the serological 

testing for syphilis. her original diagnosis, and reason for 

hospital treatment, are unknown. records indicate that 

the patient was “uncooperative.” 

From the National Archives and Records Administration
GUATEMALA EXPERIMENTS 1946-1948 II

61

“[a]s you can imagine we are all holding our breaths, and we are explaining 

to the patients and others concerned with but a few key exceptions that the 

treatment is a new one utilizing serum followed by penicillin. This double talk 

keeps me hopping at times.”485

There are also several noted examples of psychiatric patients actively objecting 

to the experiments. For example, one subject “fled the room” after being 

subjected to scarification of the penis, and he was not found for several 

hours.486 Dr. Cutler reported further that it was difficult to examine the 

women’s abdomens, breasts, or backs “as a result of local prejudices against 

male viewing of the body, even by physicians...”487 Dr. Cutler also admitted 

that under their “stated studies” there was “no good reason which could be 

offered [to the women] to explain the necessity for complete examinations.”488

Therefore, he wrote, “[i]t was unfortunately not feasible to attempt mucosal 

inoculation in the female genitalia to compare the male with the female.”489

Injection and Contact Method

In May 1947, the researchers began their 

artificial inoculation syphilis experiments in the Psychiatric Hospital with 

two different exposure methods using the 

injection technique that was employed 

in the Penitentiary as well, and the 

“contact” method that Drs. Mahoney 

and Arnold used previously in rabbit 

experiments.490 Dr. Arnold had explained 

how best to expose the subjects via 

contact method in a letter to Dr. Cutler 

in April.491 Dr. Cutler used this method 

because both he and Dr. Mahoney felt that it was the procedure most “closely 

approximating” normal sexual intercourse.492 During the “contact method”:

“[A] cotton pledget was placed at the frenum and moistened with 

varying amounts of suspension and at intervals, dependent upon 

the experiment. The pledget was moistened by dropping the fluid 

through a 25 gauge needle onto the pledget. The foreskin was 

replaced to normal position concealing the pledget entirely.”493

This is the syphilitic chancre of a female psychiatric 

subject who was exposed to syphilis twice, received 

some treatment, and later passed away.

From the National Archives and 

Records Administration 
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

62

Dr. cutler later reported a 17.9-percent transmission rate for this method.494

Scarifi cation and Abrasion

on September 24, 1947, after six 

contact and injection experiments 

in the psychiatric hospital, the 

researchers began abrading the 

membranes of psychiatric subjects’ 

penises to improve the syphilis 

transmission rate.495 but, like the 

artifi cial gonorrhea inoculations, 

this technique raised some serious 

doubts with Dr. cutler’s supervisors at the VDRl. on September 

8, Dr. mahoney reminded Dr. 

cutler “we have delayed setting 

up a fi eld trial of the prophylactic 

agent in the hope that the Guatemala work would give precise data 

which would support, even in a 

small way, the experimental fi ndings in animals.”496 Dr. mahoney 

felt that both scarifi cation and abrasion were “drastic,” were “beyond the range 

of natural transmission and [would] not serve as a basis for the study of a locally 

applied prophylactic agent.”497 Dr. mahoney told Dr. cutler “unless we can 

transmit the infection readily and without recourse to scarifi cation or direct 

implantation, the possibilities of studying the subject are not bright.”498

in another letter the same day, Dr. mahoney continued:

“i wish you would give some thought to the future of the work 

in Guatemala. in the event of the prophylaxis angle proving to 

be impossible of resolution, we will have left only the serology 

study and the work in penicillin therapy. We would surely have 

diffi culty in selling an expensive project of this kind to the public 

health Service.”499

this male patient in the Psychiatric hospital was exposed to 

syphilis twice and was treated with penicillin. he also was 

involved in the serological testing for syphilis. his age and original 

diagnosis, and reason for hospital treatment, are unknown. 

From the National Archives and Records Administration 
GUATEMALA EXPERIMENTS 1946-1948 II

63

On September 18, Dr. Cutler wrote Dr. 

Mahoney that the “vast amount of fundamental work to be done in experimental 

syphilis in man and in serology” should 

make it “easy to justify continuation of the 

study even though we are not able to study 

simple prophylaxis as originally planned.”500

He emphasized the unusual opportunity 

presented in Guatemala for “pure science”:

“With the opportunity offered here to 

study syphilis from the standpoint of 

pure science just as Chesney studied 

it in the rabbit it should be possible 

to justify the project in the event 

of the impossibility of resolution of 

the prophylactic program. But we 

feel that we shall be able to subject 

prophylaxis to a severe trial. Along 

the same line of thought of investigation in pure science I shall have a 

chance later to do a survey on a small 

group of pure Indians being worked 

[on] by the Carnegie Institution. If 

any interesting findings result it may 

give us new leads for investigation on 

a purely scientific basis.”501

Dr. Cutler disregarded his supervisor’s 

objections to scarification and abrasion. He 

argued instead that “we shall be able to study 

prophylaxis by other methods to subject it to 

much more severe tests than those occurring 

normally.”502 Dr. Cutler wrote in correspondence to Dr. Mahoney that “[t]he 

low incidence of infection following natural exposure indicates that the test to 

which the [prophylaxis] method was submitted is much more drastic than that 

occurring under conditions of normal exposure.”503

Subject Profile: celso

Celso was a male patient in the 

Psychiatric Hospital. His age and 

the illness that brought him to the 

hospital are unknown. 

Celso was involved in two syphilis 

experiments in 1947 where an 

emulsion containing syphilis 

was applied to his penis. In 

one experiment he received a 

prophylaxis of penicillin and in the 

other he received no prophylaxis. 

Celso was enrolled in his third 

and final experiment in January 

1948. As part of this experiment, 

Celso’s penis was abraded and then 

syphilis was applied. In March and 

April 1948, Celso exhibited multiple 

clinical symptoms of syphilis. 

In May 1948, Celso was treated 

with penicillin, but subsequent 

examinations in June 1948 

determined his case had developed 

into secondary stage syphilis. There 

is no record of additional treatment.

In June 1949, Dr. Cutler’s notes 

state Celso died as a result of a 

lobotomy and that an autopsy was 

performed. However, a letter was 

sent to Dr. Cutler in 1952 that said 

Celso was alive and he had no 

clinical symptoms of syphilis. It is 

unclear which record is accurate.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

64

Dr. Cutler justified his “heroic challenge methods”504 in the Final Syphilis 

Report as a means to provide more rigorous experimentation:

“It was realized at the outset that the mechanical abrasion would 

probably be more severe than that occurring naturally and might 

permit more ready penetration of the organisms. But it was felt 

that under such circumstances any agent to be tested for prophylactic value would be subjected to a more severe test condition 

than that occurring naturally.”505

He offered a parallel rationale for the artificial exposure techniques in his 

Experimental Studies in Gonorrhea report:

“A comparison between the rate of infection of (5/93) 5.4% 

following normal exposure to an infected female and (47/87) 54% 

following superficial inoculation indicates that a prophylactic 

agent tested against superficially inoculated patients is subjected 

to a very severe test indeed, so that a preparation found to be 

effective under these circumstances should be expected to show 

up well when subjected to the less-severe test of routine risk of 

infection.”506

In addition, based on observations of “reddened and battered-looking” 

penises, Dr. Cutler concluded that there was “probably a good deal of 

penile trauma during intercourse with breaks in the membrane.”507 Dr. 

Cutler reasoned that the infection with syphilis might be dependent on 

these “breaks in the continuity of the mucous membrane” and that “any 

method of inoculation which destroyed the continuity of the skin or mucous 

membrane might offer a more nearly physiological approach to the problem 

of bringing about experimental infection.”508 Dr. Cutler made this argument justifying scarification to both Dr. Arnold509 and Dr. Mahoney510 in 

September. Later, in a historical review of STD control (written in 1989), Dr. 

Cutler concluded, “studies on human inoculation with syphilis demonstrated 

the value of intact, healthy skin and mucous membrane in preventing infection.”511 The evidence he cited for this assertion was “a conversation with JM

Funes, MD (December 1947).”512

The researchers continued to employ the contact method after they had begun 

abrasion because “[a]s yet there was doubt as to the advisability of utilizing a 
GUATEMALA EXPERIMENTS 1946-1948 II

65

method of inoculation involving damage to [the] mucous membrane in testing 

prophylaxis.”513 Dr. Cutler responded to Dr. Mahoney’s concerns with assurance that “within the next few days we hope to have the prophylaxis study 

in syphilis under way as originally planned.” He concluded that “[w]e know 

nothing of infection following scarification, but it is my own feeling that we 

have underestimated the importance of the breaks in the continuity of the 

mucous membrane in the invasion of the spirochete.”514

However, by November, Dr. Cutler concluded that abrasion was “the only 

practicable method” of prophylaxis testing “approximating normal sexual 

exposure...”515 When locally applying syphilitic material to the abraded 

mucous membrane of the penis:

“[T]he foreskin was retracted and the glans placed on a stretch 

over the forefinger of the left hand of the physician. Using the 

long end of a 20 gauge, long-bevel hypodermic needle held in the 

right hand, the dorsal surface of the glans just distal to the coronal 

sulcus was lightly abraded over an area of about 2 x 5 mm. We 

tried to stop the abrasion short of drawing blood or serum, barely 

removing the surface layer, but not infrequently small bleeding 

points could be noted. The abraded area was covered with...[a] 

cotton pledget [soaked in Treponema pallidum].”516

Dr. Cutler later reported that the researchers achieved a 91.6-percent transmission rate through this mode of inoculation, which was considerably greater 

than the rate following sexual intercourse. Dr. Cutler concluded that this 

method of inoculation should therefore “provide a most severe test of clinical 

efficacy of any prophylactic agent.”517

During a related mode of infection, the “multiple pressure technique”:

“The inoculation was performed over the deltoid region...one or 

two drops of the spirochetal emulsion was allowed to drop on the 

surface. Through this drop, and using a sterile sewing needle or 

small-gauge hypodermic needle a series of 2-30 strokes was made 

by the technic [sic] utilized for smallpox vaccination and the material was allowed to dry. An attempt was made not to penetrate the 

dermis or to draw blood.”518
“Ethically Impossible” STD Research in Guatemala from 1946-1948

66

After the subject was abraded and inoculum applied as described above, a 

small amount of the prophylactic was “placed in the meatus” and the rest 

of the material was “thoroughly rubbed into the glans, foreskin, shaft of the 

penis, and onto the pubic hair by the physician.”519

As “[c]omplete results of any given experimental procedure were not available 

for at least 4 months following inoculation,” Dr. Cutler wrote: 

“With limited time available for completion of the project it was 

thus not feasible to delay four months between each experimental 

run so as to plan successive experiments on the basis of knowledge 

gained from the predecessors. Thus it was necessary to anticipate 

results upon bases of early observations and to move ahead on 

the strength of incomplete experimental data with knowledge that 

final analysis would be made of the completed work so that any 

errors in the early hypothesis would be shown up.”520

Oral Contagion and Cisternal Punctures

The researchers also decided to undertake other types of inoculation in the 

Psychiatric Hospital, including oral ingestion of syphilitic material. For this 

work, the researchers were curious about the ability of the syphilis spirochete 

Cisternal Puncture

Seven women in the Psychiatric Hospital were 

exposed to syphilis via cisternal puncture, the 

injection of syphilis into the spinal fluid from 

the back of the skull.

Dr. Cutler wrote in his Final Syphilis Report 

that the reason they inoculated the women 

in this fashion was to determine the 

effectiveness of the “blood-spinal-fluid” 

barrier, as well as to attempt to “shock” the 

women out of their epilepsy. 

Two of the women subjected to cisternal puncture developed headaches and one lost the 

use of her legs for a period of time. Five of the seven women were eventually treated, one 

received penicillin only as a prophylaxis, and one never received any penicillin. One of the 

women who received penicillin later died.

Diagram of a cisternal puncture.

From Alexander G. Reeves, M.D. and Rand S. Swenson, 

M.D., Ph.D., “Disorders of the Nervous System”
GUATEMALA EXPERIMENTS 1946-1948 II

67

to penetrate the intact mucous membrane of the gastrointestinal system to 

clarify “the problem of oral contagion through kissing and oro-genital sexual 

contacts.”521 To test this question: “[a] mixture of testicular tissue and supernatant fluid was well mixed. One cc. of this mixture was placed in a small 

beaker to which was added 20 ccs of distilled water. The patient was given the 

dose to swallow...”522

The researchers also sought to determine the effectiveness of the “blood-spinalfluid barrier” in preventing Treponema pallidum “between the systems”523 and 

“directly into the central nervous system,”524 and to do so, they performed 

“hundreds” of cisternal punctures for diagnostic purposes, and several for 

intentional exposure.525 According to Dr. Cutler in 1955, “deteriorated and 

debilitated epileptics” were given intracisternal inoculation as:

“it was hoped that by shock of inoculation it might be possible to 

influence favorably their epilepsy. This experiment was undertaken 

at the expressed desire of the clinical director [Carlos Salvado] in 

hopes that he might be able to do something for these women who 

had been completely resistant to all types of anticonvulsive therapy. 

All of these were so uncontrollable that they had inflicted serious 

injuries upon themselves such as burns leading to contractures, 

blindness, wounds, etc., as a result of the loss of consciousness and 

motor activity due to epileptic attacks.”526

To accomplish the intentional exposure experiment:

“A cisternal puncture was made and about 10 ccs. of spinal fluid was 

removed. The syringe was withdrawn from the spinal needle, and 

the syringe containing the emulsion introduced 0.1 cc of emulsion. 

Some of the patients fluid was used (about 5 ccs.) to wash the spinal 

needle to ensure a complete dose of the spirochetes.”527

Cisternal puncture, which involves the withdrawal of cerebral spinal fluid 

from the back of the skull, is particularly dangerous because of its proximity 

to the brain stem.528 It would have been unclear at the time what types of 

reactions would occur from injection of foreign material, let alone infectious 

material, into the cerebral spinal fluid. Dr. Cutler was at least aware of some 

risk; he specifically mentioned in his 1955 report that even with all of the 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

68

punctures he performed, “none resulted fatally...”529 Moreover, Dr. Cutler 

admitted that some subjects experienced “a simple bacterial meningitis” manifested by headaches and stiffness of the neck.530 The inoculum made from 

lesions of other syphilitic subjects “was certain to contain secondary bacterial invaders...,” he said.531 Dr. Cutler reported that the symptoms subsided 

within a few days.532 Several cisternal puncture subjects developed secondary 

syphilis and neurosyphilis, and one subject lost the use of her legs for over 

two months.533

Fellow researcher William Curth, when he was in Guatemala in the 1930s, 

deemed it “unwise” to attempt any type of spinal puncture “[o]wing to the 

many superstitions of the Indians.”534 Dr. Cutler reported in 1955, however, 

that the Psychiatric Hospital subjects “minded the procedure so little” that they 

lined up “day after day” for the puncture, to receive the reward of two packs of 

cigarettes.535 There is no contemporaneous evidence to support this claim.

In February 1948, Surgeon General Thomas Parran, who supported the work 

in Guatemala, was replaced by Dr. Leonard Scheele. Dr. Mahoney told Dr. 

Cutler that they had “lost a very good friend and that it appears to be advisable to get our ducks in line.”536 Because of that, Dr. Mahoney said, “we 

feel that the Guatemala project should be brought to the innocuous stage as 

rapidly as possible.”537

The researchers, however, continued with syphilis experiments in the 

Psychiatric Hospital through October 1948. They moved beyond their 

original questions and began testing issues such as the validity of accidental 

needle stick procedures for needles exposed to syphilis in clinics in the United 

States.538 One subject underwent scarification followed by injection into the 

dorsum of the penis in hopes of producing a representative chancre specifically 

for the purpose of taking photographs.539 In July, the researchers conducted 

one of the last Psychiatric Hospital intentional exposure experiments, which 

involved inoculating, through “a number of different techniques,” all of the 

subjects who had been protected by a prophylaxis or had simply failed to 

become infected in previous experiments.540
GUATEMALA EXPERIMENTS 1946-1948 II

69

Chancroid Experiments

Overview

The researchers conducted experiments 

involving chancroid (the STD caused 

by the bacterium Haemophilus ducreyi) 

on 133 subjects in the Psychiatric 

Hospital and Army in October 1948. 

These experiments occurred several months 

after Dr. Mahoney informed Dr. Cutler 

that he would not renew the Guatemala 

grant.541 Cutaneous inoculation of the 

arms and back was the exposure method 

used.542 The primary goal of the chancroid experiments was to test the orvusmapharsen prophylaxis, as Dr. Cutler felt it had held up well against syphilis 

and gonorrhea.543 The researchers treated the soldiers they infected (131) with 

sulfathiazole (one gram per day for five days). Of the 133 subjects exposed to 

chancroid, 131 received some form of treatment.544

Psychiatric Hospital

The researchers conducted three 

chancroid experiments in the 

Psychiatric Hospital from October 

10-12, 1948.545 The researchers 

used 41 subjects in total, treating 

39 of them.546 They tested the 

orvus-mapharsen prophylaxis as 

compared to the U.S. Army pro 

kit.547 Methods of inoculation were 

tested mostly on women’s forearms 

and shoulders by scarification with 

a needle.  Of note, one group of three women was inoculated three times in 

the arms before an infection occured.548 Dr. Cutler noted that two of the 

women inoculated with chancroid in this experiment later died, one just 13 

days after inoculation.549  

Chancroid is a bacterial disease 

caused by Haemophilus ducreyi. 

It is spread through sexual contact. 

Signs of infection begin with the 

development of a small bump 

that transforms into an ulcer. It is 

diagnosed by examining the ulcers 

and checking for swollen lymph 

nodes. There is no blood test available 

to check for infection. Chancroid is 

treated with antibiotics and large 

lymph nodes can be drained with a 

needle or local surgery.

The injection site of a female psychiatric subject who was 

exposed to syphilis three times and received some treatment.

From the National Archives and Records Administration 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

70

Guatemalan Army

In October 1948, the researchers began 

testing the orvus-mapharsen prophylaxis 

for prevention of chancroidal infection 

in the Guatemalan Army.550 Dr. Cutler 

had discussed this work with Dr. Tejeda 

in August and received approval to start 

work on chancroid as soon as the cultured 

material was available. For the rest of the 

soldiers, the researchers compared the orvusmapharsen prophylaxis to the standard U.S. 

Army pro kit with 81 soldiers, all of whom 

were then treated.551 They inoculated each 

soldier in three sites simultaneously: on two 

of the sites they tested a prophylaxis, and on 

one site they did not apply a prophylaxis so 

the subject could serve as his own control.552

To infect the men, half-inch scratches were 

made by a hypodermic needle, just deep 

enough to draw blood.553 Dr. Tejeda made 

the right arm scratch, Dr. Levitan made the left arm scratch, and Dr. Maza 

scratched the shoulder554 (see Appendix II). After the scratches were made, 

0.01cc of chancroidal inoculum “was placed on the abraided [sic] area and gently 

rubbed in by the flat surface of another needle.”555 After one, two, or four hours, 

the different prophylaxes were applied. Dr. Cutler noted in his Chancroid Experiment report that the researchers also took “moving pictures of patients with 

chancroid inoculation.”556

Winding Down the Guatemala Experiments

Extension of the Grant 

As the date of the Guatemala grant expiration approached, Dr. Cutler began to 

address what would happen to both the work and the facilities after his departure. He focused on ensuring that there would be sufficient time and money 

to complete the ongoing research and follow up. Dr. Mahoney’s letters, on the 

other hand, focused on an orderly winding down of the “terminal phases of the 

Guatemala study.”557

patient Profile: mario

Mario was a soldier in the 

Guatemalan Army’s Honor Guard. 

His age was not recorded. 

In March 1947 Mario was one of the 

soldiers who had sexual contact with 

commercial sex workers who had 

been inoculated with gonorrhea; he 

was then given a placebo treatment 

of 0.1cc sterile distilled water. 

On October 23, 1948, researchers 

applied cultured chancroid material 

to scratches on Mario’s arms and 

shoulder. Mario’s right arm was then 

washed with orvus-mapharsen for 

30 seconds; his left was washed 

with the standard U.S. Army pro kit. 

The next day, all three sites were 

swollen and indurated. Mario was 

treated with sulfathiazole ointment 

for five days.
GUATEMALA EXPERIMENTS 1946-1948 II

71

Funding to support the Guatemala research ran through June 1948, but 

the Research Grants Office at NIH, on request from the PASB, authorized 

continued work in Guatemala until the end of December, without additional 

funding.558 Dr. Cutler urged Dr. Mahoney to seek additional financial support 

for the work, arguing “because of the importance of the study and because 

of our responsibility to the patients, it should be possible to justify a small 

grant for the second year to avoid any possible repercussions in the event of 

the complete expenditure of the present grant.”559 Dr. Mahoney dismissed that 

suggestion as “a new grant has some drawback in that it will require a progress 

report dealing with the work which has been accomplished. This we might not 

care to do at the present time.”560 Alternatively, Dr. Mahoney suggested that 

Dr. Cutler re-apportion the funds to carry out the essential follow-up services 

for two years.561

Disposition of the Laboratory

Dr. Cutler was also concerned about the fate of the laboratory facilities. He 

wrote to Dr. Mahoney in June 1948 to argue that they should leave the laboratory intact so that the Ministry of Public Health could continue to use 

the facility: “[i]n view of the wholehearted cooperation that we have received 

officially and unofficially from the Guatemala Medical profession and government Agencies and in view of the fact that we may later want to return for 

other work and will want to continue to enjoy the same cooperative relationship I feel that it would be a mistake not to leave the laboratory fully 

equipped and functioning upon our departure.”562 Dr. Cutler also requested 

that Dr. Abel Paredes Luna, a Guatemalan Public Health Service physician 

who worked with PASB, receive a fellowship at Staten Island and be given the 

opportunity to study with Dr. Mahoney.563

The Ministry of Public Health was also eager to continue the relationship. It 

expressed an interest in taking over the facility in the event that PASB did 

not want to continue to occupy it, and Dr. Luis Galich, who was the head 

of the Ministry of Public Health, discussed the matter with PASB personnel 

on several occasions, including during a trip to Washington in June 1948.564

PASB Assistant Director John Murdock, for his part, agreed that long-term 

support for public health activities in Guatemala was always envisioned. “From 

the very beginning of the Project,” Dr. Murdock wrote to Dr. Cutler in June 

1948, “the staff at the [PASB] headquarters has felt that on the completion of 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

72

the research in which you are presently engaged, the Bureau in cooperation 

with health authorities of Guatemala would utilize the Laboratory as a training 

center for serologists and technicians and for standardization of other laboratories in Central America.” Dr. Mahoney was equally enthusiastic, arguing that 

“this culmination is the most desirable possible and...the laboratory should be 

capable of extending a helpful service in the future.”565 Dr. Mahoney assisted 

in this regard, as is explained further in this report below, by identifying and 

facilitating the move of Ms. Genevieve Stout from the PHS to PASB to manage 

the laboratory in Guatemala after Dr. Cutler left. 

Race and Secrecy during the Guatemala Experiments

Issues of Race

Dr. Cutler did not discuss the race of his experimental subjects as an ethical 

issue in his correspondence or reports, but race, as understood in that era, 

was clearly an important component of the Guatemala experiments. At the 

time, many physicians believed that syphilis affected different races differently. For example, Surgeon General Thomas Parran, described syphilis as 

being “biologically different” in African Americans, and said that African 

American women “remain[ed] infectious two and one-half times as long as 

the white woman.”566 In addition, the belief in some quarters that African 

Americans were sexually promiscuous was used to bolster arguments that 

African Americans were more likely to contract syphilis, and against treating 

the disease in that population.567 These convictions played a role in the PHS 

Tuskegee Syphilis Study, in which Dr. Cutler also was involved as a primary 

researcher in the 1950s.568 At Tuskegee, PHS doctors told syphilitic African 

American men from Macon County, Alabama, that they would receive free 

health care for their “bad blood.” While doctors monitored the progress of the 

disease, the PHS doctors provided no treatment during the span of the experiment (1932-1972). The belief that syphilis was widespread among African 

Americans provided justification for the experiment to continue long after 

penicillin was proved to cure syphilis: “[a]s sickness replaced health as the 

normal condition of the [African American] race, something was lost from 

the sense of horror and urgency with which physicians had defined disease.”569

While Dr. Cutler never discusses sexual promiscuity in his final reports, 

he does partially account for the low gonorrhea transmission rate by the 
GUATEMALA EXPERIMENTS 1946-1948 II

73

“duration of coitus” in the “culture group” involved in the Guatemalan 

Army experiments: 

“The average length of exposure of this culture group to a prostitute 

is very short, according to experience of military physicians of the 

country so that it seems that the experimental group probably did 

not experience an unusually short period of contact as a result of 

the experimental conditions. With longer periods of sexual fore 

play and sexual intercourse it is probable that there would be an 

increased flow of vaginal and cervical secretions. Theoretically this 

might bring greater quantities of the organism into contact with 

the male urethra and for a longer period of time. In view of the 

fact that the duration of coitus does vary in different cultural and 

socio-economic groups this factor may possibly play a part as one 

of the variable determinants of the rate of infection.”570

In the 1930s, U.S. researchers also speculated that syphilis affected some 

Latin Americans differently from Caucasian North Americans or Europeans 

and that “clinical lesions of syphilis found in the Central American Indian 

and the Mixture of Indian-European or Indian-European-Negro are different 

from those found in the white European.”571 Some physicians believed that 

syphilis originated in Central America, leading the indigenous population 

to acquire immunity to it.572 Just as U.S. researchers linked high rates of 

syphilis in African Americans with sexual promiscuity, W. Curth’s Syphilis in 

the Highlands of Guatemala concludes:

“Sanitation is primitive in these towns and villages and most of 

the Ladinos and Indians alike live in extreme simplicity. Overindulgence in alcoholic liquors is common among the men of both 

races. Sexual promiscuity is said to be very prevalent among the 

Ladinos [‘Indian-Spanish crosses’], whereas, we were informed on 

good authority that the Mayan Indians preserve a remarkably pure 

family life when at home but that their sexual life on the plantations is apt to be lax.”573

Dr. Cutler mentioned in his Final Syphilis Report that he did not have access 

to ethnological information regarding their subjects, although he believed 

Guatemala City to be “approximately 85% Indian...”574 He added that “it was 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

74

our observation too, that many of our patients had the classic, pure Indian 

features indicating little or no mixture [with other races].”575 Dr. Spoto, the 

PHS onchocerciasis researcher, told Dr. Cutler that he need not explain 

the experiments at all to the “Indians” in the Penitentiary “as they are only 

confused by explanations and knowing what is happening.”576 Dr. Mahoney 

observed upon his visit to Guatemala City and his trip to the city of Chichicastenango that he did “not think much of the natives.”577

Despite the pervasive belief that the effects of syphilis varied among races, 

and despite the underlying beliefs about the indigenous population that the 

researchers may have harbored, Dr. Cutler concluded in his Final Syphilis 

Report that the researchers found no evidence of “‘racial immunity’ in the 

Central American Indian.”578 He speculated that the authors of earlier articles claiming that such immunity existed had instead encountered the same 

serology-testing problems that the researchers experienced and were interpreting their diagnostic false positives incorrectly.579

Concerns about Secrecy

The Cutler Documents specifically elucidate contemporaneous efforts to limit 

knowledge about the experiments. “[a]s a result of experience elsewhere,” 

Dr. Cutler wrote in 1955, “it was deemed advisable, from the point of view 

of public and personnel relations, to work so that as few people as possible 

know the experimental procedure.”580 In February 1947, the same month the 

researchers began sexual intercourse experiments in the Guatemalan Army, 

G. Robert Coatney, a PHS malariologist, wrote Dr. Cutler about Surgeon 

General Parran’s interest in his work.

“I saw Doctor Parran on Friday [February 14] and he wanted to 

know if I had had a chance to visit your project. Since the answer 

was yes, he asked me to tell him about it and I did so to the best of 

my ability. He was familiar with all the arrangements and wanted 

to be brought up to date on what progress had been made. As you 

well know, he is very much interested in the project and a merry 

twinkle came into his eye when he said, ‘You know, we couldn’t 

do such an experiment in this country.’”581
GUATEMALA EXPERIMENTS 1946-1948 II

75

In May 1947, Dr. Cutler pointed Dr. Mahoney to a “Note on Science” that 

appeared in the April 27 New York Times regarding a new scientific advancement 

by syphilologist Dr. Harry Eagle (member of the Syphilis Study Section that 

approved the Guatemala project) and others.582 The New York Times note read:

“Drs. Harry Eagle, Harold J. Magnuson and Ralph Fleischman 

of the United States Public Health Service, the Johns Hopkins 

School of Hygiene and the University of North Carolina have 

discovered that small doses of penicillin injected within a few 

days after exposure, prevent syphilis from developing. This case 

holds good for rabbits, but no tests on human beings have yet been 

made. To settle the human issue quickly it would be necessary to 

shoot living syphilis germs into human bodies, just as Dr. Eagle 

shot them into rabbits. Since this is ethically impossible, it may take 

years to gather the information needed” (emphasis added).583

Waldemar Kaempffert, the New York Times science editor, authored the 

note.584 Between the time when the note was published and when Dr. Cutler 

called Dr. Mahoney’s attention to it, the researchers in Guatemala had 

begun injecting “living syphilis germs into human bodies”585—exactly what 

Kaempffert had asserted was “ethically impossible.”

Eight days after the publication of the note in the New York Times, Dr. 

Mahoney wrote Dr. Cutler to say that Dr. Van Slyke had made a “hurried 

trip from Washington” to tell Dr. Mahoney that the same physician discussed 

in the note, Dr. Eagle, was, despite the conclusion in the New York Times:

“...about to complain to the Surgeon General [Parran] that I have 

not been extremely enthusiastic about allowing him to enter the 

Guatemala study. As you may know, he has done considerable 

animal work in prophylaxis in syphilis by use of penicillin and 

can only prove the thesis by a human experiment.”586

Dr. Mahoney opposed allowing Dr. Eagle to join Dr. Cutler in Guatemala 

because he “could not see wherein a study of that kind would have other than 

an academic value if an injection technique was employed....”587 In addition, 

Dr. Mahoney “thought it would be of still less importance if an oral preparation of penicillin was to be studied as a prophylactic agent.”588
“Ethically Impossible” STD Research in Guatemala from 1946-1948

76

When Dr. Cutler highlighted the New York Times report on Dr. Eagle’s work 

to Dr. Mahoney, he noted that it “went on to speculate on the method of 

proving his hypothesis in humans and said, ‘that such work could not ethically be carried out’ (as I remember the quotation). Then in the Journal of 

the American Medical Association appeared a notice about the grant to the 

Pan American Sanitary Bureau for the study of syphilis.”589 Knowing that 

Kaempffert had just written that the Guatemala protocol was “ethically 

impossible,” Dr. Cutler confided to Dr. Mahoney that:

“It is becoming just as clear to us as it appears to be to you that it 

would not be advisable to have too many people concerned with 

this work in order to keep down talk and premature writing. I

hope that it would be possible to keep the work strictly in your 

hands without necessity for outside advisors or workers other than 

those who fit into your program and who can be trusted not to 

talk. We are just a little bit concerned about the possibility of 

having anything said about our program that would adversely 

affect its continuation.”590

Also in May of 1947, Dr. Mahoney told Dr. 

Cutler that he had “gather[ed] the impression” that Dr. John Heller, who had joined 

Drs. Mahoney and Van Slyke in touring 

the Guatemala work the previous month, 

“would feel considerably more secure if we 

were to set up an advisory group of leading 

figures in the world of science to serve as a 

background for the study.”591 Dr. Mahoney 

said “I have never been a believer in this 

type of thing and I do not think that an 

advisory committee would help us greatly,” 

but he admitted that they “might have to 

defer to political expediency.”592 Dr. Mahoney went on to say, “[t]here are 

several men whom I would not mind being associated with the work,” but 

that there were “several other leading figures” that he thought “would be a 

distinct detriment.”593

John R. Heller

From the National Library of Medicine 
GUATEMALA EXPERIMENTS 1946-1948 II

77

On June 22, 1947 (after artificial inoculation with gonorrhea and syphilis had 

begun in the Guatemalan Army, Penitentiary, and the Psychiatric Hospital), Dr. 

Cutler wrote to Dr. Mahoney “personally and unofficially” with several questions. Dr. Cutler first emphasized to Dr. Mahoney the staff’s desire to conduct 

prophylaxis work, and the belief that the treatment work undertaken in the 

Penitentiary had supplied the necessary groundwork to secure “volunteers”:

“When the program was originally set up it was the plan to get the 

volunteers at the prison and pay them. You are well acquainted with 

the reasons why it was not thus carried out. Drs. Funes, Harlow and 

I have considered the matter carefully and feel that on the basis of 

our experience to date and [of] our work at the penitentiary which 

has resulted, we feel, in confidence in us, that we might approach 

the colo[nel] [Tejeda] and then the prisoners to secure volunteers 

first for more carefully [con]trolled gonorrhea work and then on 

syphilis. I feel that I can appri[illegible] colonel and the prisoners 

now on a more or less personal basis with [dis]cussion of our army 

experience and say that we still have unanswer[ed] [questions] which 

could be answered there. Doing it openly instead of [illegible] as we 

had considered would, we feel, give us much more mate [illegible] 

time in which to take advantage of it . . . . It is unfortunate that we 

have to work in such a guarded, even subterranean way, but it seems 

to be very necessary.”594

Writing back, Dr. Mahoney endorsed the proposal, saying that the use of 

volunteers other than the type employed up to that point would be “more 

than satisfactory,” as “our budget would stand for almost any fee for volunteers which you consider to be advisable.”595

The second concern Dr. Cutler highlighted for Dr. Mahoney in the June 22 

letter involved the replacement of Dr. Hugh Cumming by Dr. Fred Soper as 

the Director of PASB. Dr. Cutler asked Dr. Mahoney about the “extent of Dr. 

Soper’s knowledge of our project”596 and told Dr. Mahoney that when Dr. Soper 

arrived on July 7, apparently to visit in Guatemala, Dr. Cutler would inform 

him “the less he talks the better.”597 Responding to Dr. Cutler, Dr. Mahoney 

said that he had never met Dr. Soper himself and told Dr. Cutler “[y]ou will 

have to be guided by your own impressions as to freedom in discussing the 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

78

work.” Dr. Mahoney did point out, however, that Dr. Soper was the responsible 

official of the study and as such was “entitled to complete confidence.”598

In the same letter, Dr. Cutler also cautioned that, as Dr. Mahoney knew, “it 

is imperative that the least possible be known and said about this project, for 

a few words to the wrong person here, or even at home, might wreck it or 

parts of it.”599 Dr. Cutler told Dr. Mahoney that his staff had found that there 

had been “more talk here than we like” and that knowledge of the work had 

turned up in “queer places.”600 Dr. Cutler said that he believed the whole staff 

realized the confidential nature of the project but that husbands and wives 

also knew about the project, and with the “frequent social gatherings at which 

especially interesting topics may be discussed,” it was “quite a temptation to 

talk more than is wise.”601

Dr. Cutler told Dr. Mahoney that the “four of us in our project”602 had 

discussed the matter and felt that “we should do all possible to keep knowledge of our project restricted.”603 To that end, Dr. Cutler requested permission 

from Dr. Mahoney to send the “detailed reports and discussions of our work 

directly to you and not through any other person here.”604 While the NIH

Division of Research Grants under Dr. Van Slyke did not require more than 

annual reports from its researchers,605 PASB required monthly progress 

reports from the Guatemala staff.606 In order to fulfill this requirement, Dr. 

Cutler suggested that they could send PASB “the barest summaries of our 

progress.”607 Dr. Cutler also had sent monthly progress reports to VDRL on 

Staten Island,608 but in June he requested that he might send these monthly 

reports directly to Dr. Mahoney and not through any other person in Guatemala. Dr. Cutler also told Dr. Mahoney that “any letters directly respecting 

our work” could be sent to him through “APO [Army/Air Force Post Office] 

if not urgent” or sent to him at the Ministry of Public Health.609

“In regard to the amount of gossip which the work in Guatemala had engendered,” Dr. Mahoney later assured Dr. Cutler, “we are doing our utmost 

here to restrict our own conversations and those of others bearing upon the 

matter.”610 Dr. Mahoney had “been aware of considerable conversation and 

discussion” that was “being carried out in rather high places, much of which 

has not helped the work greatly.”611 Dr. Mahoney advised Dr. Cutler that they 

were forwarding all of Dr. Cutler’s reports to Dr. Heller “in a way which we 
GUATEMALA EXPERIMENTS 1946-1948 II

79

hope will prevent their being read by unauthorized persons.”612 Dr. Mahoney 

added, however, that he hoped Dr. Cutler would “not hesitate to stop the 

experimental work in the event of there being so undue amount of interest 

in that phase of the study.” Dr. Mahoney felt that “[i]t would be preferable to 

delay the work than to risk the development of an antagonistic atmosphere.”613

The intentional exposure experiments continued for 16 months longer.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

80
81

THE POST-CUTLER CONTINUATION

OF THE GUATEMALA EXPERIMENTS 

AND FINAL REPORTS

1948-1955
“Ethically Impossible” STD Research in Guatemala from 1946-1948

82

After Dr. Cutler left Guatemala in December 1948, several investigators 

continued with discrete aspects of the work he had begun. Genevieve 

Stout conducted a series of serology experiments that, while similar to Dr. 

Cutler’s serology work, functioned as stand-alone experiments that she (and 

others) published independently.614 Dr. Juan Funes, Chief of the Venereal 

Disease Section at the Guatemalan National Department of Health, and Dr. 

Carlos Salvado, the Director of the Psychiatric Hospital, carried out follow 

up on subsets of the subjects enrolled in the serology and intentional exposure 

experiments. Despite the time spent in Guatemala and the continuing observations of subjects that were funded, the Guatemala intentional exposure data 

were never published directly by any of the researchers.

Serology Experiments

PASB hired Genevieve Stout (on leave from 

PHS) in 1948 “to continue the laboratory as 

a training center for serologists and technicians” and to “promote the standardization of 

serological techniques of other laboratories in 

Central America and Panama.”615 PASB and 

the Ministry of Public Health agreed to make 

the new project a joint endeavor and planned 

to enter into a two-year contract to establish 

the new laboratory.616 “Dr. Galich...agreed 

to assign the entire personnel of the present 

serological laboratory of Sanidad Pública 

[the Ministry of Public Health] to this laboratory and to pay their salaries,” and PASB

agreed to provide funding for a number of staff members as well.617 Stout was 

instrumental in establishing the new venture; she arrived in August 1948 to 

“activate the Venereal Disease Laboratory and Training Center for Central 

America” and remained in Guatemala until August 1951.618

Stout and her staff conducted a number of serological experiments.619 They 

primarily worked in six recently established laboratories across Central America, 

and in at least one experiment they worked with a total of 11 different laboratories.620 Many of the experiments directed by Stout sought to standardize the 

Kahn Standard and VDRL slide test in use at these laboratories.621

Genevieve Stout at a convention of the 

Montana Society of Medical Technologists, 

1953 From Leo Carper
Post-Cutler Continuation of the Guatemala Studies: 1948–1953 III

83

Continuing Observations

PHS hired two Guatemalan physicians, Drs. Funes and Salvado, to continue 

“the observation of certain of the patient groups” after Dr. Cutler left Guatemala in 1948.622 These appointments offered the opportunity to advance the 

scientists’ careers. As Dr. Mahoney observed, “[w]e have always felt that it 

would be expedient to do everything possible to push Funes to the fore as the 

leading Central American syphilologist. I am sure that this will be worthwhile in the event of the broad program of venereal disease control work being 

developed in Central America.”623 Dr. Salvado also received a fellowship in 

the United States at that time.624

Dr. Funes’s staff continued to collect data on residents of the Orphanage, 

inmates of the Penitentiary, individuals from the Psychiatric Hospital, 

schoolchildren, and the members of “various Indian tribes in the vicinity of 

Guatemala” who had participated in the experiments.625 Dr. Funes’s U.S. 

government personnel files indicate that he was hired to “advise concerning the 

clinical examinations of treated patients, their re-treatment as may be required, 

the collection of blood specimens for serologic examinations at periodic intervals, the preparation and shipment of all blood specimens collected for serologic 

examination” to the United States, and “the submission of such reports as may 

be necessary for the completion of the study of this patient group.”626

Dr. Funes’s staff collected samples from subjects and, as agreed, shipped them 

to the United States for analysis.627 Based on the one report available in the 

Cutler Documents, they followed approximately 248 people from the mental 

institution, completing 243 blood draws and 170 lumbar punctures.628 Several 

of those subjects tested positive for syphilis during the follow-up experiments.629 The subjects from the Psychiatric Hospital were followed until at 

least 1953.630 The published work resulting from the Guatemala experiments 

also indicates that Dr. Funes continued to do serological testing on the children at the Orphanage until at least 1949.631
“Ethically Impossible” STD Research in Guatemala from 1946-1948

84
85

PUBLICATION OF THE 

GUATEMALA DATA
“Ethically Impossible” STD Research in Guatemala from 1946-1948

86

After leaving Guatemala, Dr. Cutler joined a World Health Organization 

(WHO) Disease Demonstration Team and moved to India. From April 

1949 to July 1950, the team worked to establish a “venereal-disease control 

demonstration” in various parts of the country and teach advanced methods 

of control for STDs.632 Over the next several years, while continuing to serve 

as a PHS officer and earning a master’s degree in public health from Johns 

Hopkins University at the same time, Dr. Cutler prepared his final reports 

on the STD studies in Guatemala.633 The Chancroid Experiment report is 

undated, but Dr. Cutler sent this document to the Director of the VDRL

in Chamblee, Georgia, in September 1952. Dr. Cutler asked the Director to keep the report confidential.634 Dr. Cutler’s Experimental Studies in 

Gonorrhea report is dated October 1952. He marked it as “SECRET-CONFIDENTIAL” and edited out identifying details.635 The Final Syphilis Report 

is dated November 1955. No evidence shows that the syphilis or ghonorrhea 

reports were provided to anyone.636

While the results of the serological experiments were published in several 

different articles,637 and the intentional exposure experiments were referred 

to indirectly in later publications,638 the Commission found no evidence 

that Dr. Cutler’s final reports or the results of the exposure and prophylaxis 

experiments were submitted for peer review or published. There are several 

published examples in which Dr. Cutler discusses data from these experiments but misleadingly cites another published study. In these cases, the 

published study cited does not actually support the data presented.639 In addition, the Guatemala experiments are notably absent from historical reviews of 

STD research authored by the researchers.640

An enormous amount of money, time, and effort went into the Guatemala 

experiments, and the exact motivations for hiding the results is unclear, 

particularly because the VDRL researchers published widely on their research 

activities, including other STD intentional inoculation experiments during 

the time and the serology results from Guatemala.641
87

afterword
“Ethically Impossible” STD Research in Guatemala from 1946-1948

88

Many of the key investigators involved in this case continued to work in 

medical research and clinical care after the experiments ended. Dr. 

Cutler continued his career with PHS through the 1950s and much of the 

1960s, during which time he held several positions of note. During his time 

working in the PHS Venereal Disease Division from 1951 to 1954, Dr. Cutler, 

along with Dr. Sidney Olansky, became a lead researcher for the ongoing PHS 

study of syphilis among rural African Americans in Tuskegee, Alabama.642

In 1955, as Acting Chief of the PHS Venereal Disease Division, Dr. Cutler 

supervised a syphilis study that used prisoner subjects at Sing Sing State 

Prison in New York.643 In 1961, Dr. Cutler became Assistant Director and 

later Deputy Director of PASB.

644

In 1967, Dr. Cutler retired from PHS and joined the faculty at the University of Pittsburgh, where in 1968 and 1969, he served as the Acting Dean of 

the Graduate School of Public Health.645 While at Pittsburgh, he remained 

engaged in research concerning the prophylaxis of STDs. Dr. Cutler received 

a contract from the U.S. Agency for International Development in 1970 to 

study the use of a vaginal contraceptive, Conceptrol Cream, as a prophylaxis 

against gonorrhea.646 Although early versions of the proposal called for clinical studies outside the United States in countries such as Jamaica, Taiwan, 

and Guatemala, the award was granted only for a local field trial in Allegheny 

County, Pennsylvania.647 Dr. Cutler died on February 8, 2003.648

Dr. Richard Arnold remained with VRDL until 1951, when he became 

Chief of Technical Services at the National Heart Institute within NIH.

649

In 1959, Dr. Arnold rose to the position of PHS Assistant Surgeon General 

for Personnel and Training.650 He retired from PHS in 1963 and joined 

the Missouri State Health Department, where he later became the Medical 

Director for the Missouri Crippled Children’s Service.651 Dr. Arnold died on 

October 17, 1992.652

Dr. Juan Funes remained Chief of the Venereal Disease Section of the Guatemalan Department of Health.653 He also remained a special consultant of the 

Venereal Disease Division of the U.S. PHS from 1948 to 1956.654 By 1950 

Dr. Funes had become Vice-Chairman of the WHO Syphilis Study Commission.655 In 1954, he became Chief of the National Anti-Venereal Campaign 

of Guatemala.656
afterword V

89

Dr. John Mahoney remained the director of the VDRL until 1950, when he 

retired from the PHS and became New York City Health Commissioner. He 

continued to serve the PHS as an uncompensated special consultant until his 

death in February 1957.657

Surgeon General Thomas Parran retired from the PHS in 1948 and became 

the first head of the Graduate School of Public Health at the University of 

Pittsburgh. After his retirement, Dr. Parran continued to serve in both paid 

and unpaid consulting positions to the U.S. government. He also remained a 

leader in the international and public health fields, serving on many national 

boards and commissions. Dr. Parran died on February 16, 1968.658

Dr. Van Slyke left the Division of Research Grants in August 1948 to 

become director of the newly-established National Heart Institute. He served 

there until December 1952, when he became Associate Director (for extramural programs) of the National Institutes of Health. He retired from the 

PHS in 1959. He continued to serve the PHS as a paid consultant through 

1963. In 1957, he received the Albert Lasker Award of the American Public 

Health Association “for distinguished contributions to the nation’s health in 

advancing the foundations of public health progress—medical research and 

staff training.”659
“Ethically Impossible” STD Research in Guatemala from 1946-1948

90
91

REVIEWING ETHICAL STANDARDS 

IN CONTEXT 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

92

I

n the Commission’s view, the Guatemala experiments involved unconscionable violations of ethics, even as judged against the researchers’ own 

understanding of the practices and requirements of medical ethics of the day. 

Many of their actions disregarded principles widely accepted as applicable 

across time, as well as the standards of our own time that are embodied 

in the ethics and regulation of biomedical research today. The Guatemala 

experiments could not be approved under the current system for protecting 

human subjects in U.S.-funded research. Widely discussed cases in the postWorld War II era with some similar features have led to a greater appreciation 

and articulation of the moral principles underlying medical research. A clear 

consensus has emerged that medical research must not undermine the very 

human flourishing it seeks to advance in future patients. The Guatemala 

experiments and other troubling violations of this norm that have come to 

light in the last 60 years truly shock the conscience, precisely because of their 

medical context.660

Current Human Research Protections and Ethical Requirements of Our 

Own Time

The standards of ethical human subjects research today are expressed in the 

medical ethics literature and through government regulations and international covenants and declarations. All of these documents share certain 

principles. Informed consent, called for by the principles of autonomy and 

dignity, is a cornerstone, as are requirements for minimization of risks, a 

reasonable balance of risks and benefits, sound scientific justification, protection of privacy and confidentiality, and special protections for those who are 

especially vulnerable, including minors, prisoners, and those with impaired 

decision making.661 Crucially, a careful and accountable independent review 

is required prior to the initiation of clinical research. 

None of these elements were satisfied in Guatemala. As the Commission’s 

investigation shows, there is no evidence that consent was sought or obtained 

from the individual subjects who were the subjects of the research.662 On 

the contrary, there were examples of active deceit.663 Individual experiments 

appeared to have been haphazardly designed and initiated with little apparent 

appreciation for the relative risks and benefits to research subjects or the articulation of a sound scientific justification for particular research designs.664
reviewing ethical standards in context VI

93

Many of the experiments, particularly those involving intentional exposure to 

syphilis, gonorrhea, or chancroid, would fail to satisfy any serious assessment 

of risks to individual subjects in medical research. 

The research specifically included populations that are currently recognized as 

vulnerable and thereby deserving of additional safeguards to ensure adequate 

protection for human subjects. Prison inmates, institutionalized and mentally 

disabled individuals, and children were among the groups most frequently 

included in the Guatemala experiments. Federal regulations, international 

codes, and the ethics literature today all acknowledge that research involving 

these groups raises unique issues requiring additional attention.665 These 

requirements recognize the challenges in ensuring adequate informed consent 

in vulnerable populations as well as the risk that members of these groups could 

be unjustly included primarily as convenient sources of research subjects. 

The researchers in Guatemala and their immediate supervisors at the VDRL

appear to have had considerable latitude in the design and conduct of individual experiments, with little evidence of substantive independent review 

for the conduct of the research. On the contrary, substantial evidence reflects 

efforts by the researchers to limit knowledge of the Guatemala activities as 

much as possible to colleagues predisposed to support it.666 The experimenters 

in Guatemala, both those from the United States and their local colleagues, 

consistently failed to act in accordance with our contemporary understanding 

of human rights and morality in the context of research. 

Longstanding Ethical Principles

In the Commission’s view, the Guatemala experiments involved gross violations of ethics as judged not only in light of modern human research ethics, 

but also against the researchers’ own understanding of medical ethics practices and requirements of the day. The Commission believes not only that 

there were moral wrongs carried out in Guatemala, but also that some of 

the participants were morally culpable and blameworthy for these wrongs. 

Admittedly, making moral judgments about past actions and agents is not a 

straightforward process and is not without its hazards. In this case, however, 

the usual challenges associated with making moral judgments about the 

past are not substantial obstacles for the Commission in reaching its conclusions because many of the actions undertaken in Guatemala were especially 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

94

egregious moral wrongs and because many of the individuals involved held 

positions of public institutional responsibility.

Careful consideration of the ways these actions violated ethical principles both 

honors the memory of these victims and helps ensure that society learns from 

these offenses. To that end, the Commission turns to a set of fundamental 

moral commitments that find expression in moral philosophy, theological 

traditions, and more highly specified codes, rules, and regulations. An ethical 

assessment of the Guatemala experiments does not, strictly speaking, require 

a comprehensive set of ethical principles, which would be more usefully 

invoked to evaluate experiments that do not so blatantly violate widely recognized fundamentals. Instead, for the purpose of creating a structure upon 

which to evaluate past violations and in order to help inform future practices, 

the Commission elucidates three longstanding and widely accepted moral 

principles of particular relevance to the Guatemala experiments. These moral 

principles are also fitting to guide current conduct, with exceptions allowed 

only with stringent justification. Each of these three principles is necessary, 

but no single principle is alone sufficient for the justification of an experiment 

involving human subjects.

1) One ought to treat people fairly and with respect. 

Treating persons fairly and with respect prohibits choosing more vulnerable 

people upon whom to experiment when research could be done with less 

vulnerable populations. This principle also requires special steps and precautions to protect those who cannot protect themselves or give informed consent 

under any circumstances. Vulnerable groups should not disproportionately 

bear the burdens of research. The violation of this principle of respect becomes 

all the more serious an offense when the risks of research are imposed on 

vulnerable populations without their consent, or on those who are both 

vulnerable and incapable of providing consent. As stated in the first sentence 

of the Nuremberg Code, “the voluntary consent of the human subject is absolutely essential.”667

The Guatemala research targeted some of the most vulnerable groups in any 

society (prisoners, conscripted soldiers, institutionalized psychiatric patients, 

and children), and also was conducted in an underdeveloped country with 

pervasive social inequalities that exacerbated their vulnerabilities. Such 
reviewing ethical standards in context VI

95

populations are given special protections in modern society because of their 

limited abilities to protect their own interests. The ethical requirement of 

consent is intended specifically to enable persons to be treated respectfully 

and in accord with their understanding of their interests, and in more limited 

cases according to the judgment of those who are in the best position to speak 

for them. In the Guatemala experiments the most vulnerable populations 

appear to have been targeted specifically because of their inability to protect 

themselves or to have others represent their interests. As explained below, even 

at that time there was a basic conception of voluntary consent and an understanding of differential vulnerability in various populations. Not only is there 

no record of consent to participation in the experiments, there are also several 

examples of active deceit on the part of the researchers. 

2) One ought not to subject people to harm or the risk of harm, even with 

their consent, unless the risk is reasonable and there is a proportionate 

humanitarian benefit to be obtained. 

Morally sound scientific research involving human subjects includes this 

humanitarian principle: the degree of risk should be minimized and never 

be disproportionate to the humanitarian importance of the problem to be 

solved by the experiment. This principle was recognized in the Nuremberg 

Code: experiments on human subjects that risk harm “should be such as to 

yield fruitful results for the good of society, unprocurable by other methods 

or means of study, and not random and unnecessary in nature.”668 Careful 

and scientifically sound research design is a sine qua non of medical ethics, 

without which it is unethical to ask persons to submit themselves as experimental subjects.

The Guatemala experiments were not carefully designed by either current or 

contemporaneous understandings of appropriate scientific methods: modes 

of transmission were used that supervisors warned would not withstand scrutiny, and data were altered or excised before inclusion in summary reports. 

Aggravating the failure to ensure valid methodology is the fact that not all of 

the patients given STDs were treated, making the risks clearly unreasonable. 

Therefore, not only did the researchers put their subjects at gratuitous risk, 

including risk of death in some cases, through this faulty scientific design, a 

violation of the prohibition against unjustifiable harm, but the unreliability 

of the data produced in this fashion further degrades the subjects’ sacrifices. 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

96

3) One ought not to treat people as mere means to the ends of others. 

Subjects involved in experiments must not be treated as mere means to the 

ends of researchers or supervisors.669 It follows that researchers must obtain 

the informed consent of individuals before experimenting on them as a necessary, but not sufficient, condition. Informed consent also rules out deception, 

unless individuals are informed and agree to be part of a practice that may 

entail deception. In that case they are not treated as mere means, as they have 

been informed and have agreed to be part of a practice that includes potentially justifiable deception. Without this condition another critical element of 

the Nuremberg Code cannot be satisfied, that the experimental subject must 

be free to withdraw from the study at any time.

The individuals involved in the Guatemala experiments were used as mere 

means to further the ends of researchers and those responsible for their caretaking in a way that seems to ignore even the rudimentary consideration they 

should have been granted as human beings. Even a praiseworthy goal (in this 

case, finding effective prevention of STDs) does not justify the use of persons 

as mere means to that goal. Sophisticated expressions of moral philosophy 

and governmental or professional codes of research ethics are built upon the 

recognition of violations of human dignity, violations that characterize many 

of the practices involved in these experiments. The researchers and government officials who were involved in these experiments, both in the United 

States and in Guatemala, acted in ways that violated basic moral norms. 

Morally serious persons may disagree about the specific articulation of the 

elements of a list of principles such as those described above, and about their 

ultimate moral justification. As guides to conduct, they admit to exceptions 

and are subject to interpretation and application. Nonetheless, the Commission 

finds that, to a shocking degree, actions undertaken as part of the Guatemala 

experiments unjustifiably and often grossly violated the widely shared, basic 

sense of human decency encoded in such principled elements of the moral 

life.670 Although much of the discussion that follows draws upon a fine-grained 

historical examination of formalized research practices and norms at that time, 

the Commission does not want to lose sight of a more basic point: many of the 

actions performed as part of the Guatemala project were unconscionable and 

those responsible for those actions were morally blameworthy. 
reviewing ethical standards in context VI

97

Contemporaneous Standards for Ethical Research in 1946-1948 

The norms of medical ethics for a given era are often difficult to identify 

in detail. They are a complex mixture of written statements, practices, and 

attitudes. The era in which the research in Guatemala occurred was certainly 

one in which ethical standards were in flux. The medical experimenters of the 

years immediately following World War II were swimming in a sea of change 

that, several decades later, produced decisive shifts in the tides of moral 

awareness and regulation. Retrospective moral judgments can therefore be 

hazardous. With the passage of time, the accumulation of experience, and the 

luxury of reflection, it can be easy to feel morally superior to our predecessors.

Despite these challenges, it is possible to develop and apply a standard for 

moral judgments about past actions and, to some degree, to conclude that 

actions and actors were blameworthy. In the case of the Guatemala experiments, retrospective moral judgment is facilitated by a rich historical record 

of the experimenters’ own words and behavior in the years prior to the 

onset of these studies, behavior that expressed and endorsed a self-imposed 

moral metric that can be held against their activities. What bears particular 

emphasis is that this historical record includes not only practices but also selfindicting statements by the researchers themselves. 

To be sure, these investigators were operating within a culture of medical 

research that often treated moral norms pragmatically, primarily as defenses 

against meddling “do-gooders” who would impinge upon their all-important 

work, rather than as genuine moral imperatives based upon respect for persons. 

In 1947, such an attitude might have characterized the majority of medical 

researchers and, indeed, some researchers might still harbor such views today. 

Nonetheless, during this period basic tenets bearing on informed consent and 

risk reduction were beginning to be widely recognized and followed in practice. Many researchers, especially public health investigators, were familiar 

with Walter Reed’s yellow fever experiments at the turn of the century during 

which Spanish workers were recruited and agreed to be exposed to mosquitoes 

to test the theory that the insects carried yellow fever.671 Legal standards articulated early in the 20th century included an individual’s right to determine 

what shall be done with his or her body, although acceptance and application 

of these norms diffused slowly within the medical profession.672
“Ethically Impossible” STD Research in Guatemala from 1946-1948

98

Writing after a thorough historical review of practices during this time 

period, the President’s Advisory Committee on Human Radiation Experiments (the “Radiation Experiments Committee”) reached a set of equivocal 

conclusions. On one hand, the Radiation Experiments Committee found 

that, “as early as 1944 it was conventional for physicians and other biomedical scientists to obtain consent from healthy subjects of research.”673

However, the Committee also found that “physicians engaged in clinical 

research [i.e., research on sick patients, not healthy volunteers] generally did 

not obtain consent from patient-subjects” even when the experiment offered 

no prospect of direct benefit to the patient.674 Nonetheless, it was “common 

for physicians to be concerned about risk in conducting research on patientsubjects and, in the absence of a prospect of offsetting medical benefit, to 

restrict research uses of patients to what were considered low- or minimalrisk interventions.”675 Subsequent concerns that physician-investigators 

underestimated risks to patient-subjects contributed to the establishment of 

independent review mechanisms. 

By mid-century, these early examples of informed consent and risk-assessment 

practices, while not often phrased as such, were common for experiments 

involving healthy subjects like prisoners, soldiers, and conscientious objectors.676 In particular, the Terre Haute researchers and their superiors—who 

included some of the same individuals as the experiments in Guatemala—

carefully considered and adopted strict requirements for individual consent 

and voluntariness for the research they conducted in 1943 and 1944.677 In 

1946, VDRL researchers Drs. Mahoney, Cutler, Van Slyke, and Blum also 

recognized a need to use only “volunteers” as experimental subjects, and 

then only after providing adequate information about risks for a prospective 

participant to make an informed choice. Writing in the American Journal 

of Syphilis, Gonorrhea, and Venereal Diseases about their work with prisoners 

at Terre Haute, the doctors insisted that participants must possess “a thorough understanding of the purpose underlying the study and the possible 

risks involved.”678 Other researchers engaged in intentional infection research 

expressed similar sentiments.679 Of course, it is impossible to know whether 

these sentiments were largely intended to avert public disapproval.

The period between 1946 and 1948 was an especially important time in the 

development of human research ethics. During these years, the Nuremberg 
reviewing ethical standards in context VI

99

Medical Tribunal considered charges against 23 physicians and bureaucrats 

accused of complicity in concentration camp experiments, many of which 

were geared to support the Third Reich’s war effort.680 A key witness for the 

prosecution was Dr. Andrew C. Ivy, a leading U.S. medical researcher who 

served as a vice president at the University of Illinois and as former scientific director of the Naval Medical Research Institute in Bethesda, Maryland. 

Dr. Ivy was a consultant designated by the American Medical Association 

to assist the prosecutors.681 Around the time the trial began in 1946, Dr. Ivy 

prepared a report to articulate ethical and legal conventions, or “rules,” for 

human experimentation. Historians have argued that the preparation of this 

report was prompted by the Nazis’ defense lawyers’ surprisingly disconcerting 

arguments regarding questionable conduct of human research in the United 

States, particularly research conducted in prisons.682

The American Medical Association accepted the report of Dr. Ivy and his 

collaborator, Dr. Leo Alexander, and its House of Delegates adopted it in 

December 1946. The Journal of the American Medical Association published 

the statement in early January 1947.683 The rules emphasized voluntary and 

informed consent, as well as avoidance of inappropriate risk. First: 

“Consent of the human subject must be obtained. All subjects 

must have been volunteers in the absence of coercion in any 

form. Before volunteering the subjects have been informed of the 

hazards, if any...”684

And, second: 

“The experiment must be conducted...so as to avoid all unnecessary 

physical and mental suffering and injury, and...there is no a priori 

reason to believe that death or disabling injury will occur, except 

in such experiments as those on Yellow Fever where the experimenters serve as subjects along with non-scientific personnel.”685

In May 1947, Dr. Ivy, describing his assessment of the Nazi doctors’ medical 

experiments in the newsletter of the Federation of State Medical Boards, 

concluded that the activities “were crimes because they were performed on 

prisoners without their consent and in complete disregard for their human 

rights. They were not conducted so as to avoid unnecessary pain and suffering, 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

100

death being the premeditated outcome in a number of these experiments.”686

In fact, however, those who were later convicted in the Nazi doctors’ trial 

were found guilty of participation in mass slaughter, not for violations of 

medical ethics. 

Writing in The New York Times in April 1947 about syphilis research, journalist Waldemar Kaempffert, reported that any plan to “shoot living syphilis 

germs into human bodies” to advance science would be “ethically impossible.” Yet human testing of the very kind described in the note as “ethically 

impossible” was about to begin in Guatemala. Upon reading the New 

York Times article, Dr. Cutler called it to the attention of his superior Dr. 

Mahoney, VDRL Director. In his letter to Dr. Mahoney, Dr. Cutler expressed 

his concern that, in light of the unqualified ethical statement made in 

Kaempffert’s article, a recent public notice regarding the Guatemala research 

would draw undesirable criticism. Dr. Cutler also emphasized the need to 

increase secrecy and limit information about the program to those “who can 

be trusted not to talk.”687

Kaempffert’s New York Times article and the concern it engendered on Dr. 

Cutler’s part illustrate the tensions that were created as a result of evolving 

research ethics standards in the period immediately following World War II. 

The rules subsequently issued by the Nuremberg court in its judgment on 

the Nazi doctors’ case in August 1947, now famously called “The Nuremberg 

Code,” largely echo Drs. Ivy and Alexander’s original formulation.688 First, 

the court found that “the voluntary consent of the human subject is absolutely 

essential.”689 The court emphasized the need for careful attention to risks and 

rigorous commitment to individual participant welfare. Experiments should 

be conducted “so as to avoid all unnecessary physical and mental suffering and 

injury,” the court ruled, and be “not random and unnecessary in nature.”690

Furthermore, “[n]o experiments should be conducted where there is an a priori

reason to believe that death or disabling injury will occur, except, perhaps, in 

those experiments where the experimental physicians also serve as subjects.” 

Like Dr. Ivy and the American Medical Association, the tribunal asserted 

that its rules were already understood and followed by all ethical medical 

researchers everywhere in the world.691 However, more recent scholarship has 

disclosed that these assertions were at the very least highly exaggerated.692 It 

would be more accurate to state that these rules were available in the culture 
reviewing ethical standards in context VI

101

of medicine, as is clear from the fact that Dr. Ivy was able to identify them 

and the American Medical Association promulgated them, although they 

were not understood and appreciated as fully as they are today. Certainly, the 

evidence suggests that the physicians and officials responsible for the Guatemala experiments recognized that these rules were in circulation and had 

some appreciation of their implications for research, as Dr. Cutler’s reaction 

to the Kaempffert article shows. As medical professionals and public officials, 

they had a moral and professional duty to recognize these rules and to appreciate their implications for research practices.

Yet the physicians and officials responsible for the Guatemala experiments 

violated all of these requirements. Not only was there no evidence of voluntary consent by the subjects, but also they were clearly exposed to the risk of 

serious physical harm posed by contracting various diseases. Specific correspondence and other records show that some subjects were exposed to, and 

sometimes suffered, significant injury when treatment and available medicines 

could have prevented such harms.693 Compounding these issues was the fact 

that even had risks been reasonable, there was no proportionate humanitarian 

benefit to be gained, as the experiments were not designed in a scientifically or 

morally responsible fashion. There is no evidence that any of the researchers 

volunteered to subject themselves to the experiments, a condition that we 

might today view as quaint and irrelevant but which was not uncommon at 

the time and would at least have established that they were willing to consent 

to the risks to which they exposed others without seeking their consent. 

Evaluating General Mitigating Arguments

Mitigating factors can moderate or reduce the blame deserved by individual 

actors, as well as confound the determination of individual blameworthiness, 

independent of judgments regarding the rightness or wrongness of the actions 

themselves. Mitigating conditions of a general nature include:

•	 Non-negligent factual ignorance;

•	 Culturally induced ignorance about relevant moral considerations;

•	 Evolution in the interpretation and specification of moral principles; and

•	 Indeterminacy in an organization’s division of labor, with the result that 

it is unclear who has responsibility for implementing the commitments of 

the organization.694
“Ethically Impossible” STD Research in Guatemala from 1946-1948

102

Examining these four potentially mitigating conditions in the context of 

the Guatemala research, the Commission finds, first, that the researchers 

were well aware of the factual circumstances. While much may have been 

unknown about the prevention and treatment of the STDs being studied in 

Guatemala, the devastating impact of the diseases themselves on individuals 

and communities was well understood. It was exactly this knowledge of the 

consequences of STD infection that motivated the researchers to pursue this 

research program despite the ethical objections they knew would be voiced if 

others learned of their work.695

It is true that during the period 1946 to 1948 the interpretation and specification of research ethics principles were evolving. However, these researchers 

constituted a small and coherent professional network that had previously 

engaged in analogous studies in the United States. The de facto standards that 

they applied in the Terre Haute prison, particularly with respect to written 

consent, stand in stark contrast to those in the Guatemala experiments. The 

extensive attention given in the former case to questions regarding research 

involving intentional infection with STDs, consent procedures, and unique 

issues related to research in prisons provides clear evidence that the Guatemala 

investigators were familiar with such concerns. Although the interpretation 

and specification of moral principles may have been gradually evolving during 

this period, the Terre Haute work indicates that these concepts were not unfamiliar to the researchers. In this sense, the defense of culturally induced moral 

ignorance is inadequate. 

There is another sense of culturally induced moral ignorance, one that may 

have stemmed from the small circle of researchers themselves. Perhaps they 

believed that culturally available moral concerns were not binding on them 

because they took their research to be more important than respecting the 

readily available human subjects, obtaining their consent, and avoiding needless harm. They might have known that these were moral concerns to which 

the public expected them to adhere, hence their efforts at secrecy so as not to 

be subject to criticism from their own medical colleagues and from the public. 

But even if they took these moral concerns as purely practical side constraints, 

to be evaded if at all possible, this does not lessen their culpability. Indeed, it 

makes them more arrogant, for they then would not have the excuse of ignorance or compulsion. We may find this conclusion especially disconcerting 
reviewing ethical standards in context VI

103

when those who cannot be excused are physicians and public officials who are 

dedicated to finding cures for serious diseases. Nonetheless, they bear moral 

responsibility when they put their actions and their science above moral rules 

on the ground that their science is more important than the rules. Neither a 

bioethics commission nor the American people should accept such an excuse.

Again, the documentary evidence indicates that the investigative team in 

Guatemala recognized the relevant moral considerations—even if these moral 

considerations were devalued by some as mere defensive measures against bad 

publicity. And, given their positions of scientific and medical responsibility, 

they could and should be held culpable for a failure to recognize the moral 

considerations of their work. Yet these concerns were routinely ignored or 

dismissed in favor of the continued pursuit of new scientific knowledge with 

minimal external interference.696 An appreciation of possible objections to 

their work on moral grounds (whether they agreed with these objections or 

not), and the practical consequences of those objections for the future of the 

activities in Guatemala, is reflected clearly in the extensive interest in minimizing knowledge of the research program beyond a small circle of insiders 

associated with the VDRL.

697

Why was Guatemala found to be such an opportune environment for these 

excesses? Among the relevant factors was surely the eager cooperation of 

Guatemalan authorities. As well, it is difficult to ignore the possibility that 

class, ethnic, and racial differences were among the factors that numbed the 

researchers to the larger moral context of their work. It is plausible that once 

they initiated the research program, the researchers became increasingly 

inured to the ethical violations of which they were a part. Not only was the 

VDRL itself a limited circle of insiders, the researchers in Guatemala operated as a still smaller, mutually reinforcing group culture far from home, 

distant from peers, and in a very different societal environment from that of 

the United States. These factors may have contributed to a collective numbing 

to ethical norms, a hypothesis that may help to explain the conduct of the 

researchers but by no means excuses it.

It cannot be said, however, that the chain of command was faulty with 

respect to professional responsibility in the context of the Guatemala 

research. Despite the physical distance between the research sites and the 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

104

relevant U.S. administrative entities responsible for oversight, correspondence between Dr. Cutler and his superiors at the VDRL demonstrates a 

clearly defined, well-understood hierarchy regarding the design and conduct 

of the research. Complementing this correspondence are references to site 

visits conducted by more senior officials in PHS and evidence of the Surgeon 

General’s own knowledge of the work being conducted under his administrative purview. Rather than a faulty chain of command, there was a failure of 

both professional and institutional leadership in disregarding the excesses of 

the Guatemala experiments.

Evaluating Historically Specific Mitigating Arguments

There are other, more historically specific arguments that might also be 

offered to explain the actions of and potentially mitigate the culpability of 

the physicians and government officials who participated in the Guatemala 

experiments: 

•	 That the experiments were conducted for national security purposes and 

therefore the conventional standards of medical ethics could be waived; 

•	 That there was a powerful public health need for such experiments due to 

the prevalence of STDs such that the balance of risk and benefit justified the 

effort, however much it might compromise individual rights; and 

•	 That although the conditions set out by Dr. Ivy of the AMA were cited as 

conventional, in fact, at the time, understanding of the moral norms for 

research by scientists and others was evolving and rules and principles were 

just beginning to be codified. 

The Radiation Experiments Commission addressed the national security 

defense when it found that “for the period 1944 to 1974 there is no evidence 

that any government statement or policy on research involving human 

subjects contained a provision permitting a waiver of consent requirements 

for national security reasons.”698 However, there is evidence that government 

agencies in this period decided not to disclose certain experiments to the 

public for fear of government embarrassment and potential legal liability. 

It could be argued that the case of ionizing radiation experiments differed 

from that of STDs because the latter were of immediate and pressing concern 
reviewing ethical standards in context VI

105

for military readiness, as had been shown during World War II.

699 Experiments involving ionizing radiation were highly speculative and the benefits 

remote, whereas the need for improvements in the treatment and prevention 

of STDs was intense700 and, especially with the advent of penicillin, seemingly 

within reach. But the Guatemala experiments were initiated after the war had 

ended and while the country was at peace, so there was no immediate military necessity in the form of an existential threat to the United States. A more 

plausible argument is that there was a pressing public health need to address 

these human scourges that had caused, and continued to cause, vast suffering 

throughout the world.

There is no question that campaigns for the eradication of dire threats to 

the public health have often been justifiably aggressive, in accordance with a 

strongly utilitarian moral philosophy. However, not all threats to the public 

health are so grave that any and all interventions may be justified by a crude 

utilitarianism. Whether the threat to public health posed by a particular 

disease outbreak is severe enough to justify aggressive tactics that temporarily 

suspend our usual ethical norms is itself an important question of ethics and 

policy.701 Only after such an assessment is decided in favor of suspending our 

usual ethical norms should the question be considered whether there is sufficient justification for selecting one location or population to be subjected to 

overriding typical rights. 

Moreover, when the public health activity in question is experimental (as was 

the case in Guatemala), the justificatory bar must be set still higher in order 

to comply with the principles and requirements of research involving human 

subjects. The corresponding ethical burden to justify the selection of locations and populations is considerably greater in the context of human subjects 

research. In research, one justification for selecting a certain site or population 

could be that the disease does not occur with adequate frequency in other 

places to make experimental work feasible elsewhere. This was one of the 

justifications for the location of the Tuskegee syphilis study. Again, however, 

the rationale for place or population selection does not excuse experimenters 

from other ethical requirements, such as informed consent, and limiting foreseeable harm, requirements that were grievously and notoriously violated in 

the Tuskegee experiment and elsewhere. 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

106

No such justification was available in the Guatemala experiments. Rather, it 

is likely that the Guatemalan sites were chosen precisely because they would 

be out of public view in the United States and beyond the reach of our laws 

and research norms. The subjects may have been viewed as powerless and 

easily available; and local authorities were not merely cooperative but enthusiastic partners. In Guatemala, the diseases were not especially endemic to 

the local community, as was the case in Tuskegee.702 Given the focus of the 

Guatemala research on prophylaxis and diagnosis, the majority of the subjects 

were not already infected, again unlike Tuskegee. A “methodological” justification was the opportunity to use commercial sex workers—whose work 

was legal in Guatemala but not in the United States—as vectors to study 

STDs “as acquired in the usual manner.”703 A possible remaining but clearly 

unacceptable explanation for choosing Guatemala would reflect the notion 

that the Guatemalans were a suitable, if not preferable, experimental population by virtue of poverty, ethnicity, race, remoteness, national status, or some 

combination of these factors. Stated differently, the commercial sex workers, 

prisoners, psychiatric patients, and soldiers may have been seen as convenient 

and, on the whole, captive. But convenience, however expedient, is by itself no 

moral justification, as the Belmont Report cogently concluded decades later.704

The fact that local authorities in Guatemala made their institutions available to 

the U.S. researchers similarly fails to provide any moral justification. Perhaps 

the U.S. officials and physicians convinced themselves that the Guatemala 

authorities somehow represented the interests of the potential subjects, an 

argument that is hardly plausible under the circumstances, and in any case not 

one that was forthrightly stated or likely to be persuasive upon scrutiny. The 

materials available to the Commission provide only limited insight into the 

decision-making processes of the Guatemalan health authorities and government officials, but the U.S. researchers had ample authority, experience, and 

opportunity to have prevented moral wrongs from occurring, independent of 

the decisions and actions of their Guatemalan partners. The cooperation by 

the Guatemalan health authorities and government officials fails to provide 

moral justification for the actions of Dr. Cutler and others. Rather, cooperation 

by Guatemalan health authorities and government officials also reveals their 

culpability in allowing these wrongs to be perpetrated.
reviewing ethical standards in context VI

107

One final view that some suggest might mitigate the moral culpability of the 

participants, though it will not excuse it, is that the ethical conventions of 

that era were evolving and were frequently violated in practice. On this view, 

it would be unfair to hold certain researchers to standards to which many 

researchers did not abide. Depending on the stakes involved, we might not 

require professionals to place themselves at substantial personal risk, including 

compromising their career prospects, in order to change the status quo by 

insisting on certain ethical norms. Here it is important to distinguish between 

moral heroism, which is not morally required of an individual, although it is 

praiseworthy, and simply the act of standing up against a bad practice. The 

failure to stand up to a bad practice cannot be excused. In this case the stakes 

for failing to stand up to practices as bad as those in the Guatemala experiments were high indeed. They extended not only to the dignity but also to 

the health and well-being of highly vulnerable persons. The discussions about 

using different techniques of exposure to pathogens of one group or another 

suggest that the vulnerability of their subjects was apparent to these investigators.705 Additionally, the doctors involved were not all subordinate or junior 

in their status; some were in positions of high responsibility in government. 

Their failure to exercise moral leadership cannot be excused, and their failure 

led to practices that were so wrong as to be fairly characterized as heinous. 

Those who committed these actions were not under any unusual pressure to 

do so. They thought that they were above the rules, and went to some lengths 

to shield themselves from normal institutionally imposed scrutiny.

The Guatemala Experiments—Looking Back, Looking Ahead, and 

Apportioning Blame

The Guatemala case differs from some potentially analogous cases in the postWorld War II period in ways that facilitate the process of reaching moral 

judgments. This comprehensive discovery and review of historical documents 

reveal a great deal of discussion among the protagonists that demonstrates 

their awareness of relevant ethical considerations and the corresponding reactions that would follow if their activities became widely known. This is true 

even during a time of evolution of interpretation and specification of moral 

principles in human research. In other words, the contemporaneous actions 

and words of the principal actors constitute their own moral indictment. 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

108

As a direct result of the decisions and actions of the PHS researchers and 

their superiors, profoundly vulnerable persons, some in the saddest and most 

despairing states, had their bodies systematically and repeatedly violated. An 

intense and uncritical commitment to advancing knowledge under convenient 

conditions does not account for the suspension of moral sensitivity that 

should have been stimulated by the suffering of their fellow persons, suffering 

that the researchers themselves in some cases grievously aggravated. 

It is clear that many of the actions undertaken within the Guatemala 

experiments were morally wrong. The Commission further concludes that 

the individuals who approved, conducted, facilitated, and funded these 

experiments are morally culpable to various degrees for these wrongs. The 

Commission reaches these conclusions on the basis of basic moral principles, 

the moral norms that were articulated at the time, the strikingly contrasting 

practices in Terre Haute, and the statements of the protagonists themselves 

during the period of work in Guatemala. Our moral norms today also 

endorse this judgment for reasons fully compatible with the norms—and the 

reasoning supporting them—that were available to the researchers and public 

officials involved in the Guatemalan experiments. This is not a judgment that 

the Commission reaches lightly, but one that it feels compelled to reach by the 

facts of the case and by the logic of the moral argument.

Although some individuals are more blameworthy than others, the blame for 

this episode cannot be said to fall solely on the shoulders of one or two individuals. The unconscionable events that unfolded in Guatemala in the years 

1946 to 1948 also represented an institutional failure of the sort that modern 

requirements of transparency and accountability are designed to prevent. In 

the final analysis, institutions are comprised of individuals who, however 

flawed, are expected to exercise sound judgment in the pursuit of their institutional mission. This is all the more true and important when those individuals 

hold privileged and powerful roles as professionals and public officials. One 

lesson of the Guatemala experiments, never to take ethics for granted, let 

alone confuse ethical principles with burdensome obstacles to be overcome 

or evaded, is a sobering one for our own and all subsequent generations. We 

should be ever vigilant to ensure that such reprehensible exploitation of our 

fellow human beings is never repeated. 
tables and figures VII

109

TABLES AND FIGURES 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

110

Table 1: The Cutler Documents

Document Name Date Description Distribution Conclusions

Correspondence Aug. 1946–

Nov. 1948

Hundreds of written 

exchanges regarding 

a variety of topics, 

including letters on 

formal letterhead 

as well as informal 

discussions among 

colleagues

Includes 

correspondence 

between Drs. Cutler, 

Arnold, Mahoney, 

Tejeda, and many 

other affiliates of the 

study

N/A

Experimental

Logbooks

Various The two “Daily 

Laboratory” notebooks 

contain handwritten 

lists of subjects and 

potential subjects 

alongside the results 

of various tests

The two “Studies 

in the Military” 

notebooks vary in their 

contents

Unknown N/A

Subject Note Cards Various Individual records 

of subjects in the 

Penitentiary and 

Psychiatric Hospital 

Unknown N/A

Photographs Various A total of 594 photos 

were taken, including 

372 photos of infected 

subjects from the 

Psychiatric Hospital 

and Penitentiary, 

215 portraits taken 

of subjects in the 

Psychiatric Hospital, 

and seven photos 

of prophylactic 

procedures

Dr. Heller was 

“interested in having 

photographic records 

...”

Photographs were also 

taken so Dr. Mahoney 

could “have all 

information necessary 

to do any talking that 

you desire” 

Dr. Ingalls H. Simmons 

asked the PHS team 

for photographs “of 

the common venereal 

lesions for the Army 

teaching program,” 

and Dr. Cutler sent 

“photographs of typical 

venereal lesions” to Dr. 

Simmons to be used for 

“teaching filmstrips”

N/A
tables and figures VII

111

Document Name Date Description Distribution Conclusions

Chancroid 

Experiment

Undated, but 

Dr. Cutler 

sent the 

document 

to the 

Director of 

the Venereal 

Disease 

Research 

Laboratory 

at Chamblee, 

Georgia, in 

Sept. 1952

Describes the 

effectiveness of the 

orvus-mapharsen 

prophylaxis 

Sent to the Director of 

the VDRL at Chamblee, 

Georgia, but with 

some information 

from an original 

draft censored; the 

Director was asked 

to “handle and 

treat this document 

as confidential” 

(emphasis in original) 

Orvus-mapharsen 

prophylaxis was not 

effective

Experimental Studies 

in Gonorrhea

Oct. 29, 

1952

Describes the 

effectiveness, 

side effects, and 

drawbacks of 

prophylactic methods 

(10% argyrol solution, 

the U.S. Army pro kit, 

penicillin, and orvusmapharsen)

Marked as “SECRETCONFIDENTIAL” with 

some identifying 

details masked (e.g., 

identities of physicians 

involved)

No evidence that Dr. 

Cutler shared this 

report with anyone

All tested prophylactic 

methods were 

effective, but the 

orvus-mapharsen 

solution was found to 

be the best option

Final Syphilis Report Feb. 24, 

1955

Describes different 

methods of 

prophylaxis against 

syphilis

Describes effects of 

penicillin in treatment 

of syphilis

Describes use of 

serology testing

Describes 

understanding of 

syphilis in man

Not marked 

“confidential,” and no 

indication from the 

documents that Dr. 

Cutler did not intend 

it to circulate, but 

also no record that Dr. 

Cutler ever provided 

this report to any 

outside party

The highest degree 

of prophylactic 

effectiveness was 

obtained with either 

orvus-mapharsen, 

calomel ointment, 

oral penicillin, 

or intravenous 

mapharsen

Penicillin almost 

invariably cured 

primary and 

secondary syphilis

No specific serology 

conclusions 

were made

Various observations 

of syphilis in man were 

recorded
“Ethically Impossible” STD Research in Guatemala from 1946-1948

112

Name affiliation title Known Role in 

Guatemala Experiments

Aguilar, Casta Luis Guatemala Ministry of 

Public Health

Director of Research 

Laboratory

Guatemalan government 

participant in the syphilis 

experiments

Co-author of orvus-mapharsen 

study in sex workers with Dr. 

Funes

Aragon, Dr. Hector National Orphanage of 

Guatemala

Director Approved the serological 

experiments

Published on serological data 

with the researchers and spoke 

on the topic at the Second 

Congress of Venereal Diseases 

in Central America in 1948

Arnold, Dr. Richard C. U.S. Public Health 

Service (USPHS), 

Venereal Disease 

Research Laboratory 

(VDRL), Staten Island, 

New York

Senior Surgeon, USPHS

Director of Syphilis 

Research, VDRL 

(1939-1951)

Secondary supervisor of the 

experiments

Received Dr. Cutler’s reports on 

the experiments

Visited the Guatemala site at 

least two times, 1947 and 1948

Chinchilla, Dr. 

Roberto Robles

Central Penitentiary, 

Guatemala City

Director of Medical 

Services

Guatemalan government 

participant

Wrote Dr. Cutler thank you 

letter that was included in Dr. 

Cutler’s Final Syphilis Report

Cutler, Dr. John C. USPHS / PASB, 

Guatemala

Senior Surgeon, USPHS

Director, STD Research 

in Guatemala

Principal on-site investigator, 

Guatemala

Leader of the intentional 

exposure experiments

Eagle, Dr. Harry USPHS / National 

Institute of Health (NIH), 

Syphilis Study Section

Member, Syphilis Study 

Section

Commissioned Officer, 

USPHS (1936-1961)

Director, Laboratory of 

Experimental Therapeutics 

and Venereal Disease 

Research Laboratory, 

Johns Hopkins School 

of Hygiene and Public 

Health and the Public 

Health Service Hospital in 

Baltimore (1936-1948)

Member of the Syphilis Study 

Section that approved the 

Guatemala research grant

Requested to do own 

prophylaxis research on 

subjects in Guatemala

Table 2: Individuals Involved in the STD Experiments in Guatemala
tables and figures VII

113

Name affiliation title Known Role in 

Guatemala Experiments

Funes, Dr. Juan M. Guatemala Ministry of 

Public Health

Chief, Venereal Disease 

Section, National 

Department of Health

Special Consultant with the 

Venereal Disease Division, 

Bureau of State Services, 

USPHS (1948-1956)

Proposed that the researchers 

go to Guatemala while a Fellow 

at the VDRL

Involved in the referral of sex 

workers with STDs from the 

Venereal Disease and Sexual 

Prophylaxis Hospital (VDSPH) 

to Dr. Cutler

Active participant in exposure 

experiments 

Continued to collect data on 

individuals involved in the VDRL 

experiments until 1953

Funes, Rolando Guatemala Ministry of 

Public Health

Serologist Guatemalan government 

participant in the syphilis 

experiments

Galich, Dr. Luis Guatemala Ministry of 

Public Health

Director Involved in the referral of sex 

workers with STDs from the 

VDSPH to Dr. Cutler

Oversaw transfer of laboratory 

from the researchers to the 

Guatemalan government

Sought and received permission 

for VDRL to use serology data 

in 1948 

Harding, Virginia Lee USPHS / PASB, 

Guatemala

Bacteriologist, USPHS Worked in laboratory

Harlow, Dr. Elliot USPHS / PASB, 

Guatemala

Assistant Surgeon, USPHS Assisted with the intentional 

exposure experiments

Heller, Dr. John R. USPHS Chief, Venereal Disease 

Division (1943-1948)

Member of the Syphilis Study 

Section that approved the 

Guatemala research grant

Requested photographs be 

taken during the experiments

Received Dr. Cutler’s reports on 

the experiments

Visited the Guatemala site at 

least once in April 1947

Levitan, Dr. Sacha USPHS / PASB, 

Guatemala

Senior Surgeon, USPHS

Assistant Director, STD 

Research in Guatemala

Active participant in the 

intentional exposure experiments

Luna, Dr. Abel 

Paredes

Guatemala Ministry of 

Public Health

Physician for the 

Guatemalan Public Health 

Service and PASB

After Guatemala experiment 

given fellowship on Staten Island 

and studied with Dr. Mahoney

continued
“Ethically Impossible” STD Research in Guatemala from 1946-1948

114

Name affiliation title Known Role in 

Guatemala Experiments

Mahoney, Dr. John F. USPHS, VDRL, NIH, 

Syphilis Study Section

Director, VDRL (1929-1949) Member of the Syphilis Study 

Section that approved the 

Guatemala research grant

Primary supervisor of the 

experiments

Received Cutler’s reports on 

the experiments

Visited the Guatemala site at 

least once in April 1947

Maza, Dr. Raul Guatemala National 

Army of the Revolution

Military Hospital

Active in intentional exposure 

experiments 

Moore, Dr. Joseph E. NIH, Syphilis Study 

Section

Chairman of the National 

Research Council, 

Subcommittee on 

Venereal Diseases

Chairman, Syphilis Study 

Section

Associate Professor, Johns 

Hopkins University 

Chairman of the Syphilis Study 

Section that approved the 

Guatemala research grant

Advised Committee on Medical 

Research on the importance of 

prophylactic research

Oliva, Dr. Joseph Guatemala National 

Army of the Revolution

Colonel Participant in the syphilis 

experiments

Parran, Dr. Thomas USPHS U.S. Surgeon General 

(1936-1948)

Granted final approval for the 

Guatemala research grant

Portnoy, Joseph USPHS / PASB, 

Guatemala

Serologist, USPHS

Chief, Laboratory 

Guatemala City, USPHS 

(Sept. 1946-Apr. 1948)

Participant in the syphilis 

experiments

Salvado, Dr. Carlos Guatemala National 

Psychiatric Hospital

Hospital Director

Special Consultant with the 

Venereal Disease Division, 

Bureau of State Services, 

USPHS with supervision 

by PASB (Dec. 1948-May 

1950)

Invited the researchers to do 

experiments in the Psychiatric 

Hospital

Active participant in the 

intentional exposure 

experiments

Involved in the continuation of 

data collection from subjects 

until 1953

Spoto, Dr. Joseph USPHS / PASB, 

Guatemala and USPHS, 

Washington DC

Assistant Chief, Venereal 

Disease Division, USPHS 

(1947-1948)

Chief, PASB Guatemala 

Office (1945-1946)

Facilitated PASB construction 

and other activities at start of 

research

Introduced researchers to 

Guatemalan officials who 

assisted in the experiments

Table 2: Individuals Involved in the STD Experiments in Guatemala
tables and figures VII

115

Name affiliation title Known Role in 

Guatemala Experiments

Stout, Genevieve USPHS / PASB, 

Guatemala

Serologist, USPHS

Director, Venereal Disease 

Laboratory and Training 

Center, Guatemala City, 

Guatemala (Aug. 1948-

Aug. 1951)

Led PASB laboratory after Dr. 

Cutler’s departure

Did further work in serology in 

the Guatemalan population

Tejeda, Dr. Carlos E. Guatemala National 

Army of the Revolution

Colonel, Chief of the Army 

Medical Department

Active participant in intentional 

exposure experiments

Involved in the continuation of 

data collection from subjects 

until 1953

Van Slyke, Dr. 

Cassius J.

USPHS, NIH Medical Director, USPHS

Chief, Research Grants 

Office, NIH (1946-1948)

Approved the Guatemala 

research grant

Visited the Guatemala site at 

least once in April 1947

Walker, Alice USPHS / PASB, 

Guatemala

Bacteriologist, USPHS Worked in laboratory
“Ethically Impossible” STD Research in Guatemala from 1946-1948

116

1946

Month Location Test

Feb. NIH Syphilis Study Section recommends STD research in 

Guatemala

Mar. National Advisory Health Council meeting that approved the 

proposal that became “Research Grant No.65 (RG-65)”

Apr. PASB starts project

Aug. Dr. Cutler arrives in Guatemala

PASB officials sign agreements with the Guatemalan government

Army 

Penitentiary

Treatment programs begin

Nov. Penitentiary Serology Studies begin

Dec. “The Surgeon General [Parran] has become keenly interested in 

the Guatemala project.”

1947

Feb. Army Gonorrhea First intentional exposure experiment

Dr. Arnold visits Guatemala

Apr. Drs. Mahoney, Heller and Van Slyke visit Guatemala

New York Times says human intentional infection syphilis 

experiments “ethically impossible”

Army Gonorrhea First artificial inoculation (deep inoculation) experiment

May Penitentiary Syphilis First normal exposure experiment involving sex workers

Hospital Syphilis First artificial inoculation experiment

Penitentiary Syphilis First artificial inoculation experiment

School children Serology Studies begin

Orphanage Serology Studies begin

June Dr. Cutler concerned that the wrong person finding out about the 

experiments “might wreck it or parts of it” and proposes to start 

sending “barest summaries of our progress” to PASB

Aug. Hospital Syphilis First abrasion experiment

Sept. Dr. Mahoney tells Dr. Cutler that the abrasion methods are 

“drastic”

Table 3: Timeline of all Guatemala Experiments
tables and figures VII

117

1948

month location test

Apr. Second Congress of Venereal Diseases in Central America; 

Dr. Arnold visits and presents

June Original end date of RG-65(c); extension granted

July Army Gonorrhea Last experiment

Aug. Stout arrives to manage the Venereal Disease Laboratory and 

Training Center

Sept. Dr. Mahoney refuses to consider an extension of the grant

Penitentiary Syphilis Last experiment

Oct. Hospital Chancroid Artificial inoculation experiment

Army Chancroid Artificial inoculation experiment

Dec. End of RG-65(c) extension; Dr. Cutler leaves Guatemala

1949

Aug. Orphanage Serology Study ends

1951

Aug. Stout leaves Guatemala

1952

Sept. Chancroid Experiment report distributed

Oct. Experimental Studies in Gonorrhea report prepared

1953

Apr. Hospital Serology Dr. Cutler receives specimens from Dr. Funes taken from 

ongoing observations

1955

Feb. Final Syphilis Report prepared
“Ethically Impossible” STD Research in Guatemala from 1946-1948

118

Commercial sex 

workers

soldiers prisoners2 orphans, 

schoolchildren, 

“indian,” 

and

“ladino” 

children

Leprosarium 

Patients

Psychiatric 

Patients

U.S. 

Servicemen in 

Guatemala

Not

specified3

TOTAL

Subjects Identified Either by Aggregate or by Name in the Cutler Documents and Corresponding Articles4

Number of 

Subjects

14 1017 976 1384 51 716 23 1359 5540

Age 

Range, 

Mean 

(Mode)5

16-18

17 (16, 18)

10-72

22 (20)

15-62

29 (22)

1-18

Not 

available

Not 

available

14-58

29 (17)

Not 

available

19-45

27 (19)

Range: 

1-72

Not 

available

Subjects Involved in Diagnostic Testing

Number of 

Subjects

14 897 842 1384 51 642 23 1275 5128

Subjects Receiving Some Form of Treatment for an STD

Number of 

Subjects

06 309 139 3 Not 

available

334 Not 

available

35 820

Subjects Exposed to Any STDs7

/Number of Subjects Exposed Who Received Some Form of Treatment for an STD8

Gonorrhea 4/0 518/202 0 N/A N/A 50/32 N/A 10/3 582/237

Syphilis 5/0 0 219/92 N/A N/A 446/294 N/A 18/2 688/388

Chancroid 0 81/81 0 N/A N/A 41/39 N/A 11/11 133/131

Total 

Subjects

6/0 558/242 219/92 N/A N/A 486/328 N/A 39/16 1308/678

1 For methods and limitations, please see “Appendix IV: Subject Database Methods.” 2 These numbers include several prison guards. 3 Includes women referred by Dr. Funes, Dr. Galich, or the Venereal Disease and Sexual Prophylaxis Hospital, 

where commercial sex workers were required to report twice a week for STD testing and treatment. 4 Including persons who may have been listed in the Cutler Documents for non-research purposes (e.g., general 

medical care, referred for enrollment, etc.). 5 Age range, mean, and mode based on age numbers that were available. Not all ages of subjects were recorded and 

available in the Cutler Documents. 6 There were no clear treatment data available for any of the commercial sex workers. 7 Includes all subjects exposed to an STD, whether or not additional data indicate the subject was in fact infected 

with the STD. 8 Includes all subjects who were exposed to an STD and received some form of treatment, whether or not 

additional data indicate the subject was in fact infected with the STD. While some subjects were exposed to an 

STD multiple times, they were included in the “treatment” column if they received treatment for any exposure 

even once. In the case of syphilis, the Commission considered penicillin given within 21 days of exposure to be 

a prophylaxis, and penicillin given 21 days after exposure to be a treatment. For more information please see 

“Appendix IX: Subject Database Methods.”

Table 4: Subject and Population Specific Data1
tables and figures VII

119

Commercial sex 

workers

guatemalan

army

Penitentiary Orphans and

Schoolchildren

Psychiatric Hospital

Methods of Inoculation

Gonorrhea Swabbing 

of cervix

Sexual contact with 

infected commercial sex 

workers

Inoculation inside 

the penis

Inoculation inside the 

penis after sexual 

exposure

None None Inoculation inside 

the urethra 

Inoculation of 

the rectum

Inoculation of the eyes

Syphilis Injection 

of cervix

None Sexual contact with 

infected commercial 

sex workers

Injection

None Injection

Inoculation by contact 

with the penis

Abrasion of skin 

and penis

Oral ingestion

Cisternal puncture

Chancroid None Abrasion and rubbing 

in of inoculum on arms 

and back

None None Abrasion and rubbing 

in of inoculum on arms 

and back
“Ethically Impossible” STD Research in Guatemala from 1946-1948

120

Figure 1: Organizational Chart of the Office of Scientific Research 

and Development

Office of Scientific Research and Development

(Vannevar Bush, Director)

National Defense 

Research Committee

Committee on Medical 

Research 

(A.N. Richards, 

Chairman) 

Sources: First Draft of Proposed C.M.R. Chapter for Irvin Stewart’s Administrative History of OSRD. (1945, January 

12). PCSBI HSPI Archives, NARA-II_0000354; Lockwood, J.S. (1946, August). War-time activities of the National 

Research Council and the Committee on Medical Research; with particular reference to team-work on studies of 

wounds and burns. Annals of Surgery 124(2):314-315. 

Lewis H. Weed 

Vice-Chairman

(Johns Hopkins University)

Rear Admiral 

Harold W. Smith

(U.S. Navy)

Brig. Gen. 

James S. Simmons

(U.S. Army)

R.E. Dyer

(NIH Director)

A.B. Hastings

(Harvard University)

A.R. Dochez

(Columbia University)
tables and figures VII

121

Committee on Medicine

(O.H. Perry Pepper, Chairman)

Subcommittee 

on Venereal Diseases

(Joseph Earle Moore, Chairman)

National Research Council

(Ross G. Harrison, Chairman)

Division of Medical Sciences

(Lewis H. Weed, Chairman)

Charles W. Clarke

(New York City Department 

of Health)

Oscar F. Cox

(Boston Medical Dispensary)

Russell Herrold

(University of Illinois)

John F. Mahoney

(VDRL)

Nels Nelson

(Baltimore City Health Department)

John H. Stokes

(University of Pennsylvania)

Figure 2: Organizational Chart of the National Research Council

Sources: Lewis H. Weed to Charles Taft. (1943, November 6). Correspondence. PCSBI HSPI Archives, 

NAS_0000458; O.H. Perry Pepper to E.H. Cushing. (1942, May 29). Correspondence. PCSBI HSPI Archives, 

NAS_0000540; E.H. Cushing to Robert L. Dickinson. (1942, December 9). Correspondence. PCSBI HSPI Archives, 

NAS_0000446.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

122

Public Health Service

(Thomas Parran, 

Surgeon General)

Federal 

Security 

Agency

Bureau of State Services

(L.R. Thompson, Chief)

National Institute of Health

(R.E. Dyer, Director)

(Cassius J. Van Slyke, 

Research Grants)

Venereal Disease Division

(John R. Heller, Chief)

Clinical and Laboratory 

Research Branch

Venereal Disease 

Research Laboratory

(John F. Mahoney, 

Director)

Office of 

the Surgeon 

General

Bureau of 

Medical 

Services

Industrial 

Hygiene 

Division

State 

Relations 

Division

Hospital 

Facilities 

Division

Tuberculosis 

Division

Operations 

Branch

Nursing 

Branch

Technical 

Aids 

Branch

Figure 3: Organizational Chart for the U.S. Public Health Service, 1946

Sources: Public Health Service Act of 1944, Public Law No. 78-410, 58 Stat. 682.; Training Division, Communicable 

Disease Center, U.S. Public Health Service. (1947, January 15). Organization and Functions of the U.S. Public Health 

Service. PCSBI HSPI Archives, NARA-SE_0000148.; PCSBI HSPI Archives, MISC_0000909.; Federal Security 

Agency Notice of Personnel Action (1946). PCSBI HSPI Archives, NPRC_0001673.
tables and figures VII

123

Capt. O.L. Burton 

(U.S. Navy) 

Gordon M. Fair

(Harvard University)

Edwin B. Fred 

(University of Wisconsin)

A. Baird Hastings

(Harvard University)

Carl S. Marvel

(University of Illinois)

Kenneth F. Maxcy

(Johns Hopkins University)

Karl F. Meyer

(University of California, San Francisco)

Lowell J. Reed

(Johns Hopkins University)

John H. Musser

(Tulane University)

Harry S. Mustard

(Columbia University)

William C. Rose

(University of Illinois)

Henry F. Vaughn

(University of Michigan)

Harry W. Schoening 

(U.S. Department of Agriculture) 

Col. Karl R. Lundeberg 

(U.S. Army)

R.E. Dyer 

(NIH Director)

National Advisory 

Health Council

(Warren Draper, 

Chairman)

Figure 4: Organizational Chart for the National Advisory Health 

Council, December 1946

Sources: National Advisory Health Council Meeting, U.S. Public Health Service. (1946, March 8 and 9). PCSBI 

HSPI Archives, NARA-II_0000544; Van Slyke, C.J. (1946, December 13). New horizons in medical research. 

Science 104(2711): 567.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

124

Figure 5: Organizational Chart for the Syphilis Study Section

Source: Van Slyke, C.J. (1946, December 13). New horizons in medical research. Science 104(2711):567.

Major L.N. Altshuler 

(U.S. Army)

Harry Eagle

(PHS, Johns Hopkins University)

John R. Heller

(PHS)

Bascom Johnson

(Veterans Administration)

John F. Mahoney

(VDRL)

George W. Mast

(U.S. Navy)

David E. Price

(PHS)

Lowell J. Reed 

(Johns Hopkins University)

Harry C. Solomon

(Harvard University)

John H. Stokes

(University of Pennsylvania) 

Thomas B. Turner

(Johns Hopkins University) 

Syphilis Study Section

(Joseph Earle Moore, 

Chairman)
tables and figures VII

125

Figure 6: Intentional Exposure Experiments Goals over Time

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

GONORRHEA SYPHILIS CHANCROID KEY

Army

Penitentiary

Psychiatric 

Hospital

Unknown 

Population

Line Indicates

Date of Event

e.g. Feb.15

TransmissionProphylaxisUnknownTransmissionProphylaxisRe-infection/SuperinfectionOther/UnknownTransmissionProphylaxisUnknown

1947 1948
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

126

Figure 7: intentional Exposure Experiments over time

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

GONORRHEA SYPHILIS CHANCROID

ArmyPenitentiaryPsychiatricHospitalUnknownArmyPenitentiaryPsychiatricHospitalArmyPenitentiaryPsychiatricHospital

1947 1948

KEY

Line Indicates

Date of Event

e.g. Feb.15
tables and figures VII

127

Figure 8: Methods of Exposure over Time

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

Contact with RectumContact with EyesDeep InoculationSuperficialInoculationCisternal PunctureScarificationof PenisIngestionContact with PenisInjectionUnknown

GONORRHEA SYPHILIS

CANCROIDAbrasion of Arm 

KEY

Army

Penitentiary

Psychiatric 

Hospital

Unknown 

Population

Line Indicates

Date of Event

e.g. Feb.15 1947 1948

CSW (GONORRHEA

& SYPHILIS)
“Ethically Impossible” STD Research in Guatemala from 1946-1948

128
129

GLOSSARY OF KEY TERMS
“Ethically Impossible” STD Research in Guatemala from 1946-1948

130

abscess – a collection of pus that typically causes swelling and inflammation 

around it. 

abrasion – scraping the surface of the skin in order to facilitate disease 

transmission. 

alkyl aryl sulfate – a sulfur-based component of orvus-mapharsen. 

antibody – a protein that is generated by the body’s immune system when 

foreign substances, called antigens, are recognized.

anticonvulsant – a medication used to treat or prevent seizures. 

argyrol solution – an antiseptic containing a compound of protein and silver.

bismuth – a metallic element similar to arsenic that is often used in pharmaceutical compounds.

brain stem – the part of the brain that connects the spinal cord to the forebrain and cerebrum.

calomel ointment – a substance used by the U.S. Army and Navy as a postexposure prophylaxis for syphilis.

cerebrospinal fluid – a clear liquid that is secreted from the blood into the 

ventricles of the brain and serves to maintain uniform pressure within the 

brain and the spinal cord.

cervix – the opening of the uterus.

chancre – an ulcer that forms at the site of infection in the primary stages of 

syphilis.

chancroid – a bacterial disease caused by Haemophilus ducreyi that is spread 

through sexual contact. The disease is characterized by bumps that transform 

into ulcers.

chemical prophylaxis – a chemical agent used as a protective or preventative 

treatment against disease.

chemotherapy – the use of chemical agents in the treatment of a disease. 
glossary of key terms VIII

131

cisternal puncture (a kind of spinal tap) – the withdrawal of cerebral spinal 

fluid from the back of the skull.

congenital syphilis – a bacterial disease caused by Treponema pallidum that is 

transferred from mother to child through pregnancy or at birth. 

conjunctiva – a clear membrane that lines the inside of the eyelid and covers 

the eyeball.

cutaneous – relating to the skin.

distal – far from the center of the body.

dorsum of the penis – the upper surface of the penis.

Duracillin – the procaine salt of penicillin in a peanut oil base.

foreskin – skin that covers the head of the penis. 

fossa navicularum – the dilated portion of the urethra in the head of the 

penis.

frenum (plural of frenulum) of the penis – elastic band of tissue that 

connects the glans of the penis to the foreskin and helps retract the foreskin 

from the glans. 

Frew strain – one of the strains of infectious material used by Dr. Cutler and 

his colleagues for the syphilis experiments.

glans of the penis – head of the penis.

gonorrhea – a contagious disease caused by the bacterium Neisseria gonorrhoeae. It is transmitted largely through sexual contact with an infected 

individual. 

histologic – relating to microscopic anatomy, such as body tissues and cells.

hunterian chancre – another term for a “typical” chancre caused by syphilis—i.e., one that is solitary, round or oval, and has a firm base, a convex 

surface, and a hemorrhagic border.

immunity – resistance to a particular disease.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

132

inoculate – to introduce an organism into the body such as bacteria. 

inoculum – a substance used for inoculation. 

intracutaneous – administered by entering the skin.

intraurethral – introduced into the urethra.

intravenous – administered by introducing into a vein.

Kahn test – one of the serological tests for syphilis used by Dr. Cutler and 

his colleagues.

leprosarium – a hospital for leprosy patients.

leprosy (Hansen’s disease) – a chronic bacterial infection caused by Mycobacterium leprae characterized by skin lesions. 

lesion – an abnormal change to a part of the body, particularly one that is 

circumscribed and well-defined, caused by infection or injury, .

lumbar puncture (a kind of spinal tap) – a puncture of the space between 

the vertebrae in the lower back to extract cerebrospinal fluid.

malaria – a parasitic disease spread by mosquitoes and characterized by periodic bouts of fever and chills.

Mazzini test – one of the serological tests for syphilis used by Dr. Cutler and 

his colleagues.

meatus – the opening of the urethra.

meningitis – a disease caused by the inflammation of the membranes 

covering the brain and spinal cord known as the meninges. This disease can 

be caused by either viruses or bacteria. The bacterial variety is typically more 

severe. Meningitis is characterized by fever, headache, and a stiff neck, and is 

sometimes fatal. 

microbiologist – a scientist who specializes in the branch of biology dealing 

with microscopic organisms.

mucosa – mucous membrane.
glossary of key terms VIII

133

Neisseria gonorrhoeae – the bacterium that causes gonorrhea.

Nichols strain – one of the strains of infectious material used by Dr. Cutler 

and his colleagues for the syphilis experiments.

onchocerciasis (River Blindness) – a parasitic disease spread by the black fly 

that is characterized by blindness.

orvus-mapharsen – made up of 1% orvus (alkyl aryl sulfate0 and 0.15% 

mapharsen in aqueous solution and was supposed to be applied after sexual 

intercourse to prevent infection. 

pelvic inflammatory disease – an infection of the uterus, fallopian tubes, and 

other reproductive organs that can cause abdominal pain, ectopic pregnancy, 

and infertility.

penicillin – an antibiotic either obtained through Penicillium molds or 

produced synthetically that is used to treat various diseases and infections.

penile – relating to or affecting the penis.

pinto – a bacterial infection caused by Treponema pallidum carateum. 

placebo – an inactive substance given instead of treatment, often used as a 

control in a pharmaceutical experiment.

pledget – small, absorbent piece of material used to cover a wound or sore on 

the body.

POB – a preparation of penicillin in a medium of peanut oil and beeswax to 

ensure a slow steady release. 

post-exposure prophylaxis – a prophylaxis designed for use after exposure to 

an infection. 

preventive medical measures – the word used to describe these measures 

was “prophylaxis.” This term included the steps taken after sexual exposure, 

such as washing and applying medicinal ointment containing mercury and/or 

arsenical compounds that would forestall “seroconversion,” the systemic infection evidenced by appearance of antibodies to the bacteria in the bloodstream. 

prophylaxis – a measure taken as a preventative for a disease or condition. 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

134

rectum – the portion of the intestine between the colon and the anus.

salvarsan – an arsenic-based compound used in the treatment of syphilis.

serological – having to do with blood serum, particularly with regards to its 

reactions and properties.

serologists – scientists who specialize in the reactions and properties of blood 

serum.

seronegative – having a negative serum reaction, particularly with regard to 

a test for a particular antibody.

seropositive – having a positive result from a serological test for a disease, in 

this case syphilis. 

serum – a clear fluid that is left over from blood plasma after clotting factors 

(such as fibrinogen) have been removed through the process of clot formation.

sexually transmitted diseases (STDs) – diseases that are spread through 

sexual contact (vaginal, oral, or anal).

silver proteinate – the active ingredient in one of the post-exposure prophylaxis regimens used for gonorrhea.

spirochetal – caused by or consisting of spirochetes.

spirochete – a spiral-shaped bacterium. Syphilis is among the diseases caused 

by spirochetes. 

submucosal – introduced beneath a mucous membrane.

sulfonamide compounds (including sulfanilamide and sulfathiazole) 

– an early antimicrobial drug used to treat gonorrhea before the advent of 

penicillin.

sulcus (or coronal) of the penis – a groove in the surface of the penis.

super-infect – to infect with an additional strain of a disease already present.

symptomatic – having symptoms associated with a disease.
glossary of key terms VIII

135

syphilis – a contagious disease caused by the bacterium Treponema pallidum. 

It is mainly spread through sexual contact and is characterized by both recognizable and unrecognizable sores. 

syphilomata (plural of syphiloma) – a tumor caused by infection with 

syphilis.

syphilologist – a physician who specializes in the study of syphilis.

Treponema pallidum – the bacterium that causes syphilis.

tuberculosis – a bacterial infection caused by Mycobacterium tuberculosis; 

characterized by coughing up blood, weakness and fatigue, fever, chills, and 

night sweats. 

typhus – a potentially lethal disease transmitted through fleas and lice, 

caused by a type of bacteria.

urethra – canal that removes urine from the bladder and, in men, also allows 

for the passage of semen out of the body.

vector – an organism, such as a mosquito, that transmits a disease-causing 

pathogen.

zoonotic pathogen – an infection of a human from an animal source. 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

136
137

APPENDICES
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

138

appendix i: Waiver Form proposed in preparation for the terre haute 

Experiments

Statement of Explanation of the Experiment and its Risks to Tentative Volunteers. (n.d.) Reproduced in Minutes of 

a Conference on Human Experimentation in Gonorrhea Held Under the Auspices of the Subcommittee on Venereal 

Diseases. (1942, December 29). PCSBI HSPI Archives, NARA-II_0000173-76.
iX

139

appEnDiX i
“EThically impoSSiblE” STD Research in Guatemala from 1946-1948

140

appendix i: Waiver Form proposed in preparation for the terre haute 

Experiments
iX

141

appEnDiX ii

appendix ii: chancroid Experiment Report Excerpt

Chancroid Experiment. Report. PCSBI HSPI Archives, CTLR-0000978.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

142

Appendix III: Investigation Methods

Commission staff broadly searched for relevant documents from 1935, 10 

years preceding the initial planning for the work in Guatemala, through 

1956, one year after Dr. Cutler finished preparing the final report on the 

studies. Secondary literature and additional records from after this time 

specifically related to Dr. Cutler, intentional exposure, and STD research 

were also examined. The Commission staff worked with archivists, historians, 

government officials, and scholars from across the country. 

Searches were undertaken in:

•	 Johns Hopkins Medical Institutions, Baltimore, MD

•	 National Archives and Records Administration, various locations:

•	 College Park, MD 

•	 Morrow, GA

•	 St. Louis, MO

•	 National Academy of Sciences, Washington, DC

•	 National Library of Medicine, Bethesda, MD

•	 New York City Municipal Archives, New York, NY

•	 Pan American Health Organization Headquarters Library, Washington, DC

•	 University of Minnesota, Minneapolis, MN

•	 University of Pennsylvania, University Archives and Records Center, 

Philadelphia, PA

•	 University of Pittsburgh Archives, Pittsburgh, PA

•	 University of Virginia Library, Charlottesville, VA

Additionally, Commission staff specifically requested documents from 

selected government agencies and non-governmental organizations as follows:

The Center for Mesoamerican Research (CIRMA): historical materials or 

photographs related to U.S. Public Health Service activities or personnel in 

Guatemala in the 1940s. 

Missouri State Archives: records related to Dr. Richard C. Arnold. 

National Archives and Records Administration: records related to the experiments 

conducted in Guatemala by U.S. PHS officers between 1946-1948; any documents relating to the Federal Security Administration, Bureau of State Services, 

U.S. PHS, Venereal Disease Division between 1935-1955, and personnel records 
IX

143

appendix III

for: L.N. Altshuler, Casta Luis Aguilar, Richard C. Arnold, Theodore J. Bauer, 

Frederick J. Brady, Opal Christopherson, G. Robert Coatney, Hugh Cumming 

Sr., John C. Cutler, Harry Eagle, Juan M. Funes, Virginia Lee Harding, Elliot L. 

Harlow, Ad Harris, John R. Heller, Bascom Johnson Jr., Henry C. Miller, Sacha 

Levitan, John F. Mahoney, George W. Mast, William J. McNally Jr., Joseph 

Earle Moore, John R. Murdoch, Thomas Parran, David E. Price, Joseph Portnoy, 

Lowell J. Reed, Carlos A. Salvado, Harry C. Solomon, Fred L. Soper, Joseph S. 

Spoto, John H. Stokes, Genevieve W. Stout, James D. Thayer, Thomas B. Turner, 

Cassius J. Van Slyke, Alice Walker, and Margaret R. Zwalley.

Office of Research Information Systems, National Institutes of Health (NIH): all 

records related to the experiments conducted in Guatemala by U.S. PHS officers 

between 1946-1948, including any records relating to the funding of Research 

Grant 65, 65 (c) by the NIH Division of Research Grants.

Pan American Health Organization (PAHO): all records related to the experiments conducted in Guatemala by U.S. PHS officers between 1946-1948, 

under the auspices of the Pan-American Sanitary Bureau (a predecessor organization to PAHO).

United States Agency for International Development: any and all records 

related to grants issued to, and grant applications received from, Dr. John 

Cutler.

U.S. Departments of Defense, Energy, State, and Veterans Affairs: all records 

during the time period of issue related to:

1. STD experiments conducted by U.S. PHS officers in Guatemala between 

1946-1948; 

2. Clinical studies funded, approved, facilitated, or coordinated by the U.S. 

government that:

a. related to STD research;

b. involved the use of vulnerable subject populations;

c. were conducted or partially conducted outside of the United States; or

d. involved the use of intentional infection protocols;

3. Ethical standards and conventions of human subject experimentation, 

particularly those that fall between the time frame of 1935-1955; or
“Ethically Impossible” STD Research in Guatemala from 1946-1948

144

4. Collaboration between the agency and the U.S. PHS, particularly with 

regard to activities that:

a. related to STD research;

b. involved the use of vulnerable subject populations;

c. were conducted or partially conducted outside of the United States; or

d. involved the use of intentional infection protocols.

U.S. Department of Justice: all records that relate to the use of prisoners as 

subjects in clinical trials, particularly those trials that were conducted at the 

Federal Penitentiary at Terre Haute (1942-1943) and at Sing Sing Correctional Facility (1954-56). 

U.S. Public Health Service Commissioned Officers Association: records 

related to any living U.S. PHS officers who may have had a firsthand knowledge of the U.S. PHS Venereal Disease Research Laboratory during the time 

period that the STD experiments were underway in Guatemala.

In total, Commission staff reviewed over 125,000 pages of original records, 

550 secondary sources and publications, and collected thousands of relevant 

documents. The collected documents of the Commission investigation are 

organized as follows:

PCSBI-HSPI record group 1 – National Archives and Records Administration (NARA): NARA Southeast Region (Morrow, GA)

•	 NARA record group 442 – Records of Dr. John C. Cutler

•	 NARA record group 442 – Records of the U.S. PHS

PCSBI-HSPI record group 2 – NARA-II facility (College Park, MD)

•	 NARA record group 59 – General Records of the Department of State

•	 NARA record group 84 – Records of the Foreign Service of the 

Department of State

•	 NARA record group 220 – Records of the Advisory Commission on 

Human Radiation Experiments

•	 NARA record group 227 – Records of the Office of Scientific Research 

and Development

•	 NARA record group 229 – Office of Inter American Affairs 

•	 NARA record group 443 – Records of the NIH Division of Research 

Grants
IX

145

appendix iii

PCSBI-HSPI record group 3 – NARA Personnel Record Center (St. 

Louis, MO)

•	 U.S. government personnel records for: Richard C. Arnold, Theodore 

J. Bauer, Frederick J. Brady, G. Robert Coatney, Hugh Cumming, Sr., 

John C. Cutler, Harry Eagle, Juan M. Funes, Elliot L. Harlow, John R. 

Heller, Bascom Johnson, Jr., Sacha Levitan, John F. Mahoney, George 

W. Mast, William J. McNally, Jr., Joseph Earle Moore, Thomas Parran, 

Joseph Portnoy, Lowell J. Reed, Carlos A. Salvado, Harry C. Solomon, 

Fred L. Soper, Joseph S. Spoto, John H. Stokes, Genevieve W. Stout, 

Thomas B. Turner, and Cassius J. Van Slyke

PCSBI-HSPI record group 4 - Pan American Health Organization Headquarters Library (Washington, DC)

•	 World Health Organization publications

•	 Pan American Sanitary Bureau publications

PCSBI-HSPI record group 5 – National Academy of Sciences (Washington, DC)

•	 Records of the Advisory Committees to the Surgeons General of the 

War and Navy Departments and U.S. Public Health Service Records 

Group (also known as the Military Medicine Committees)

•	 Records of the National Research Council Division of Medical Sciences

•	 National Academy of Sciences – National Research Council Central 

Policy Files Records Group

PCSBI-HSPI record group 6 – National Library of Medicine, National 

Institutes of Health (Washington, DC)

•	 Files of Dr. Fred Soper

•	 Files of Dr. John C. Cutler

•	 Files of Dr. Thomas Parran

•	 Files of PHS Office of the Historian

PCSBI-HSPI record group 7 – Alan Mason Chesney Archives of The 

Johns Hopkins Medical Institutions (Baltimore, MD)

•	 Thomas B. Turner Collection

•	 Biographical File – Dr. John C. Cutler

•	 Biographical File – Dr. Harry Eagle

•	 Biographical File – Dr. Joseph Earle Moore
“Ethically Impossible” STD Research in Guatemala from 1946-1948

146

PCSBI-HSPI record group 8 – University of Pennsylvania, University 

Archives and Records Center (Philadelphia, PA )

•	 Papers of Dr. A.N. Richards

PCSBI-HSPI record group 9 – University of Pittsburgh (Pittsburgh, PA)

•	 Dr. Thomas Parran Collection

PCSBI-HSPI record group 10 – University of Minnesota, Social Welfare 

History Archives (Minneapolis, MN)

•	 Archives of the American Social Health Association

PCSBI-HSPI record group 11 – Various Records Compiled by U.S. 

government agencies in Response to PCSBI Document Requests

•	 Documents from the U.S. Agency for International Development

•	 Documents from the U.S. Department of Defense

•	 Documents from the U.S. Department of Justice

•	 Documents from the U.S. Department of Veterans Affairs

PCSBI-HSPI record group 12 – Miscellaneous Documents

•	 Documents collected from various sources not otherwise listed above, 

including: NIH, Office of Research Information Systems; the Center for 

Mesoamerican Research; and historical press clippings from Guatemala

Research in Guatemala

Martin Rangel, an archaeologist and freelance social science researcher in 

Guatemala, assisted the Commission in the collection of historical press articles and published materials relevant to the intentional exposure experiments.

Those materials are kept within the PCSBI HSPI archives. 

Advisors to the Investigation

Over the course of the investigation, the Commission was invaluably served 

by its three Senior Advisors: Dr. Paul Lombardo, Bobby Lee Cook Professor 

of Law, Georgia State University; Dr. Jonathan D. Moreno, David and 

Lyn Silfen University Professor of Ethics, Professor of Medical Ethics and 

Health Policy, of History and Sociology of Science, and of Philosophy at the 

University of Pennsylvania; and Dr. Jeremy Sugarman, Harvey M. Meyerhoff 

Professor of Bioethics and Medicine at Johns Hopkins University. Their leadership and expertise helped guide the investigation and proved a great asset 

in writing the report. 
IX

147

appendix iii

The Commission also received significant input and valuable advice from 

Dr. Jonathan Zenilman, Professor, Division of Infectious Diseases, Johns 

Hopkins School of Medicine, and Johns Hopkins School of Public Health, 

who served as a technical consultant to the investigation.

Commission staff also benefited from the assistance and advice of many 

outside experts and informal advisors. In many cases, these experts in the 

fields of history, bioethics, archival research, medicine, medical research, and 

law volunteered many hours of their time to meet with Commission staff 

members to share their insights and often the results of their own independent 

research. These individuals include:

•	 Linnea Anderson – Interim Archivist, Social Welfare History Archives, 

University of Minnesota 

•	 Dan Guttman, Ph.D. – former Executive Director, Advisory Committee on 

the Human Radiation Experiments.

•	 Stephen J. Greenberg, Ph.D. – Coordinator of Public Services, History of 

Medicine Division, National Library of Medicine

•	 James H. Jones, Ph.D. – author, Bad Blood: The Tuskegee Syphilis Experiments

(1976)

•	 Suzanne Junod, Ph.D. – Historian, FDA History Office

•	 Susan Lederer, Ph.D. – Robert Turell Professor of Medical History and 

Bioethics, University of Wisconsin

•	 Richard Mandel, Ph.D. – Lead Technical Information Specialist, NIH

Executive Secretariat

•	 Robert Martensen, M.D., Ph.D. – Director, NIH Office of History

•	 Nancy McCall – Director, Alan Mason Chesney Medical Archives of The 

Johns Hopkins Medical Institutions

•	 Robert F. Moore – Historian/Consultant, Office of Research Information 

Systems, National Institutes of Health

•	 John Parascandola, Ph.D. – U.S. Public Health Service Historian (retired)

•	 Katrina Pearson – Office of Research Information Systems, NIH

•	 Richard Peuser – Assistant Chief, National Archives and Records 

Administration

•	 John Rees – Curator, National Library of Medicine

•	 Susan Reverby, Ph.D. – Marion Butler McLean Professor in the History of 

Ideas and Professor of Women’s and Gender Studies, Wellesley College

•	 Paul Theerman, Ph.D. – Head of Archives, National Library of Medicine
“Ethically Impossible” STD Research in Guatemala from 1946-1948

148

Targeted Interviews

Commission staff conducted a series of informal interviews for background 

information on the STD experiments in Guatemala with individuals who 

knew Dr. Cutler. The interviews were conducted by phone. A full listing of 

those interviewed follows:

Dr. Donald S. Burke

Dr. Michael E. Dalmat

Ms. Lois G. Michaels

Dr. Jerry Michael

Dr. David Sencer

Dr. Michael Utidjian

Staff Delegation to Guatemala 

At Guatemalan Vice President Dr. Rafael Espada’s invitation, a small delegation of Commission staff members visited Guatemala from April 30 to May 

3, 2011. They met with Vice President Espada and the government of Guatemala’s investigation commission, toured the Central American Archives, and 

visited relevant historical sites. The visit served to introduce the Commission’s 

work to the members of the Guatemalan commission and gather information 

about their activities. It also enabled staff to gain a better understanding of 

the context in which the research proceeded. The Commission staff delegation included Valerie Bonham, Brian Eiler, Dr. Paul Lombardo, and Kayte 

Spector-Bagdady. 

Translation

Among the records collected and reviewed over the course of the investigation 

were many Spanish language documents. These documents included 

correspondence between U.S. PHS officers and Guatemalan officials, published 

works of scientific scholarship, press articles, and selected pages from laboratory 

notebooks. Relevant documents were translated by an independent translator, 

Cetra Language Solutions of Elkins Park, Pennsylvania. The translated 

documents are kept within the PCSBI HSPI archives. 
IX

149

appendix iv

Appendix IV: Subject Database Methods 

In order to specifically identify the number of individuals involved in the 

research, and better understand what happened to them, the nearly 10,000 

pages from the Cutler Documents were read and analyzed with a particular 

focus on information about individual research subjects. Commission staff 

created a comprehensive database of individual subject information from 

these records. 

Creation of Subject Database

A great deal of historical research was done to help interpret the Cutler Documents. The Commission relied heavily on Modern Clinical Syphilology (1944) 

by John H. Stokes, Herman Beerman, and Norman R. Ingraham, which 

was considered the definitive text on syphilis at the time. In addition, the 

Commission consulted regularly with Dr. Jonathan Zenilman, Chief of the 

Infectious Diseases Division of the Johns Hopkins Bayview Medical Center.

For data extraction and analysis purposes, the data sources were divided into 

two categories: research notebooks and additional archive documents. 

Research Notebooks

The Cutler Documents include four research notebooks, two laboratory notebooks (Notebooks 1 and 2), and two clinical notebooks (Notebooks 3 and 

4). The laboratory notebooks primarily contain laboratory test results. The 

clinical notebooks primarily contain research subject histories and clinical 

notes. All notebooks contain entries written in both English and Spanish.

The primary data of interest included patient profile information (e.g., name, 

age, subject number, study population), inoculation data, treatment data, 

and information that independently raised ethical concerns (e.g., evidence of 

deceit on the part of the researchers or resistance on the part of the subjects).

Based on a detailed reading of Notebook 1 and a review of Notebooks 2, 3, 

and 4, an initial coding scheme was developed to capture relevant information from the notebooks in an Excel database. Four coders then used the 

preliminary coding scheme to code a sample of about 10 pages from each of 

the four notebooks. Following each preliminary coding trial, the data were 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

150

discussed and the codes refined with input from Dr. Zenilman. Once the 

preliminary coding and revisions were complete, double coding began, with 

two coders working on the laboratory notebooks and two on the clinical 

notebooks (the coders working on the clinical notebooks had moderate to 

high Spanish fluency). Each pair of coders worked through a number of pages 

of their notebook independently, then met to reconcile their coding. One 

member of each team maintained the master database with reconciled data. 

The coding scheme was revised iteratively, as new information was encountered that was not being adequately captured. When the coding scheme was 

revised, previously coded data were recoded to reflect the revised scheme.

The rules employed during coding included:

•	 Use one line for each entry about each person per date. Simple direct Spanish 

translation permitted (e.g., “orinas” in the data source became “urines” in the 

database)

•	 Long or complex Spanish translations should be preceded in the database by 

‘[Translation]’

•	 Where handwriting cannot be interpreted, denote as ‘[illegible]’

•	 Where handwriting is difficult to interpret, use brackets [] to denote coder’s 

interpretation of entry

•	 Coding test results

•	 N (any variation) = negative

•	 P (any variation) = positive

•	 D (any variation) = doubtful

•	 WP = weakly positive

•	 QNS = quantity not sufficient

•	 If there is a N, D, or WP and a P on the same line, code as “conflicting”

•	 If there is a N and a D on the same line code as “negative”

A detailed data interpretation and coding key is available upon request.

Additional Cutler Documents

Additional Cutler Documents included Dr. Cutler’s final research reports, 

photographs, correspondence, individual experiment files, and about a dozen 

miscellaneous documents.706 There were also approximately 7,000 research 

subject note cards. Overall, the content of these data sources was much less 
IX

151

appendix iv

rich than that of the Research Notebooks, with the possible exception of 

the subject note cards. There was a tremendous amount of variation in the 

contents of the note cards, with some cards containing nothing but a name 

or subject number and some cards containing detailed clinical notes about a 

named individual.

All of these documents were single-coded, meaning that only one person 

coded any given document. Each coder’s work was regularly audited for 

faithful recording of data from the source documents, appropriate application of the coding scheme, and consistency.

Subject Database Quality Control

Once all sources were coded, separate databases were combined into one master 

Subject Database, with over 30,000 lines of data on over 5,000 individual 

subjects. The database was checked for obvious coding errors (e.g., a name 

where a date should be, mode of inoculation where a test result should be) and 

corrected where necessary. The Subject Database was saved and archived.

In order to identify the total number of subjects involved in the studies, as 

well as information about inoculation and treatment, further quality control 

of the database began. The first step was to review the names, where possible, 

in an effort to ensure that any given individual was only counted once. A

new column was created (“Full Name Clean”) to hold the best assessment 

of an individual’s name in cases where ambiguity existed. A paradigmatic 

case is one where one (or many) line includes information on A. Gomes and 

another line (or many) includes data on A. Gomez. In this instance, if it was 

found that a second piece of information (subject number, date, population, 

age, or experiment number) on each individual matched, those two lines of 

data were assumed to be on the same individual. All lines with information 

on that individual were then assigned either the majority name or the most 

logical name—in our example, all lines would be assigned the name of “A. 

Gomez” in the Full Name Clean column. The First Name and Last Name 

columns were always left untouched, changing the name only in the Full 

Name Clean column.

If a line of data could not be assigned to a unique individual, the data were 

not included in our subsequent calculations.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

152

In order to enable calculation of the number of subjects exposed to syphilis, 

gonorrhea, and chancroid, an additional column was added to the database: 

“STD Exposure.” Based on data available about each unique individual, the 

STD Exposure column was populated with the disease used in exposure, for 

those individuals who were exposed. Frequently the disease involved in the 

exposure was explicit, but in instances where it was not, the disease was determined based on knowledge about the exposure methods used for each disease 

and the populations in which various experiments were conducted, based on 

the retrospective reports that Dr. Cutler authored on the experiments.

In a second round of data review, an attempt was made to fill in missing 

but known data (e.g., if there are 12 lines about A. Gomez—per the Full 

Name Clean column—and one of them lists age, age was filled in for all 

corresponding lines about him). In cases where an individual’s population 

(Commercial Sex Worker, Prisoner, Psychiatric Patient, Soldier) was missing, 

an effort was made to determine the population by comparing the date and 

nature of the experiment in which the individual was involved with the timeline of all of the experiments (assembled from Dr. Cutler’s final reports.) 

In cases where there was an obvious conflict between the database and Dr. 

Cutler’s reports (e.g., chancroid inoculation in a population not reported 

by Dr. Cutler to have been involved in chancroid experiments), the original 

archive documents were checked and the data verified or corrected. There were 

a number of commercial sex workers who were mentioned in the documents 

and were referred to Dr. Cutler for potential involvement in the inoculation 

studies, but who never participated. These individuals were identified as a 

discrete population (“Referred by VDSPH”) and included in the database, 

but in all cases, the only data available for these individuals were gonorrhea 

test results. The database was also double checked for individuals who have 

the exact same name in the Full Name Clean column, but were clearly not the 

same person (e.g., A. Gomez who was in the prison and A. Gomez who was 

in the mental health hospital), to ensure that both individuals were counted.

Challenges in distinguishing between penicillin used as a prophylaxis for 

syphilis following exposure and penicillin used as a treatment for diagnosed 

syphilis infection arose. After consulting with Dr. Zenilman, the following 

standard was applied: as the incubation period of syphilis for lesion development is mean 21 days, all dosages of penicillin before 21 days were 
IX

153

appendix iv

considered prophylactic in nature, and all dosages after 21 days were considered treatment.

In all cases, where no data were available or reasonably interpretable, the cell 

was left with “nd,” denoting no data.

Limitations

Limitations inevitably attach to trying to interpret and analyze incomplete 

and decades-old data sources. The documents contained a mix of English 

and Spanish written by multiple individuals with varying levels of fluency, 

proficiency with spelling, and penmanship. They reflect inconsistency in the 

spelling of individuals’ names and assigning the subject numbers, further 

complicating this investigation; for example, on one page, an individual’s 

name would be recorded as “Gomez,” but the next entry referencing the same 

person might be noted as “Gomes,” likewise for “J.O. Hernandez” and “Jorge 

Oscar Hernandez.” 

In addition, though Dr. Cutler’s final reports provide some information on 

timing and some experimental details, they are not comprehensive, as, for 

example, there are experimental results in the Research Notebooks that were 

not mentioned in the final reports. Conversely, Dr. Cutler includes over 10 

experiments in his Final Syphilis Report for which the Commission did not find 

corroborating evidence in the contemporaneous laboratory or clinical notes. For 

example, Dr. Cutler describes a superficial inoculation gonorrhea experiment in 

the Guatemalan Army on May 9, 1947, but there are no additional subject data 

available in the Cutler Documents to evidence this experiment.707 The reason 

for this discrepancy is unclear; however, there is reason to believe that the 

Commission is not in possession of all of the clinical notes from the Guatemala 

experiments. For example, one of the clinical notebooks includes an instruction 

to please “[s]ee Miss [Alice] Walker’s record book.”708 This referenced notebook 

is not among those included in the Cutler Documents.

Additionally, the experiments described in these documents were conducted 

in the 1940s, at a time when diagnosis and treatment methods for STDs 

were not as settled as they are today, and the syphilis organism was poorly 

understood. Sixty-five years later, it is difficult to know what the researchers 

thought and understood about the diseases they were working with and the 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

154

tests they were conducting. Given this, the Commission did not attempt 

to identify how many people were clinically infected or how many people 

received adequate treatment. In the case of syphilis, for example, the serological testing conducted was unreliable and highly dependent on the skill, 

precise method, and consistency of an individual laboratory and the quality 

of the clinical assessment. As a result, the database focuses on the number of 

individuals exposed to, rather than infected with, STD. 

Lastly, due to time and resource constraints, research records deemed of greatest 

significance, specifically the majority of the clinical and laboratory notebooks, 

were double-coded (meaning by two or more people), but the majority of 

records were single-coded. Periodic audits were conducted of all work. 

Figures 6, 7, and 8

Figures 6, 7, and 8 were created using amalgamated data from the Subject 

Database derived from the Cutler Documents. As Dr. Cutler’s retrospective 

counts of his experiments are inconsistent, these figures are based on an independent count of days on which intentional exposure to STD occurred for 

an individual or population. This exposure day count excludes days on which 

commercial sex workers alone were exposed, as Dr. Cutler did not consider 

these instances “experiments” or the sex workers as “subjects.”
IX

155

appendix v

Appendix V: Suggestions for Further Reading

Advisory Committee on Human Radiation Experiments. (1996). Final 

Report of the Advisory Committee on Human Radiation Experiments. New York: 

Oxford University Press. 

Annas, G.J., Glantz, L.H., and B.F. Katz. (1977). Informed Consent to Human 

Experimentation: The Subject’s Dilemma. Cambridge: Ballinger.

Annas, G.J., and M.A. Grodin. (1992). The Nazi Doctors and the Nuremberg 

Code. New York: Oxford University Press. 

Altman, L.K. (1986). Who Goes First? The Story of Self-Experimentation in 

Medicine. New York: Random House.

Beecher, H.K. (1966). Ethics and clinical research. The New England Journal 

of Medicine 274(24):1354-1360.

Beecher, H.K. (1959). Report to the Council: Experimentation in man. 

Journal of the American Medical Association 69(5):461-478.

Beauchamp, T.L., and J.F. Childress. (2001). Principles of Biomedical Ethics. 

New York: Oxford University Press. 

Brandt, A.M. (1993). No Magic Bullet: A Social History of Venereal Disease in 

the United States Since 1880. Oxford: Oxford University Press.

Emanuel, E.J., Grady, C., Crouch, R.A., Lie, R.K., Miller, F.G., and D. 

Wendler. (2008). The Oxford Textbook of Clinical Research Ethics. New York: 

Oxford University Press.

Faden, R.R. and T.L. Beauchamp. (1986). A History and Theory of Informed 

Consent. New York: Oxford University Press.

Grodin, M.A., and L.H. Glantz. (1994). Children as Research Subjects: Science, 

Ethics, and Law. New York: Oxford University Press.

Harkness, J.M., Lederer, S.E., and D. Wikler. (2001). Laying ethical foundations for clinical research. Bulletin of the World Health Organization 79(4): 

365-366.

Hornblum, A.M. (1998). Acres of Skin: Human Experiments at Holmesburg 

Prison. New York: Routledge.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

156

Jones, J.H. (1993). Bad Blood: The Tuskegee Syphilis Experiment. New York: 

The Free Press.

Kahn, J.P., Mastroianni, A.C., and J. Sugarman. (1998). Beyond Consent: 

Seeking Justice in Research. New York: Oxford University Press. 

Katz, J. (1972). Experimentation with Human Beings: The Authority of the Investigator, Subject, Professions and State in the Human Experimentation Process. 

New York: Russell Sage Foundation.

Kraut, A.M. (2003). Goldberger’s War: The Life and Work of a Public Health 

Crusader. New York: Hill and Wang.

Lederer, S.E. (1995). Subjected to Science: Human Experimentation in America 

before the Second World War. Baltimore, Maryland: Johns Hopkins University 

Press. 

Levine, C.R., Grady, C., Hammerschmidt, D., Eckenwiler, L., and J. 

Sugarman. (2004). The limitations of ‘vulnerability’ as a protection for 

human research participants. American Journal of Bioethics 4(3):44-49.

Levine, R.J. (1988). Ethics and Regulation of Clinical Research. New Haven, 

Connecticut: Yale University Press. 

Lombardo, P.A. (2009). Tracking chromosomes, castrating dwarves: Uninformed consent and eugenic research. Ethics and Medicine 25(3):149-164.

Lombardo, P.A. (2003). “Of Utmost National Urgency”: The Lynchburg 

Colony Hepatitis Study, 1942. In Moreno, J.D. (Ed.). (2003). In the Wake 

of Terror: Medicine and Morality in a Time of Crisis. Cambridge: MIT Press.

Marks, H.M. (1997). The Progress of Experiment: Science and Therapeutic 

Reform in the United States, 1900-1990. New York: Cambridge University 

Press.

Mastroianni, A.C., and J.P. Kahn. Special Issue: Advisory Committee on 

Human Radiation Experiments.” Kennedy Institute of Ethics Journal 6(3): 

ix-322. 

Moreno, J.D. (1999). Undue Risk: Secret State Experiments on Humans. New 

York: W.H. Freeman and Company.
IX

157

appendix v

Moreno, J.D. (1998). Regulation of research on the decisionally impaired: 

History and gaps in the current regulatory system. Journal of Health Care Law 

and Policy (1):1-21.

Parascandola, J. (2008). Sex, Sin, and Science: A History of Syphilis in America. 

Westport: Praeger.

Parran, T. (1937). Shadow on the Land. New York: Reynal & Hitchcock.

The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1976). Report and Recommendations: Research 

Involving Prisoners. Washington, D.C.: Department of Health, Education, and 

Welfare.

The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1978). The Belmont Report: Ethical Principles 

and Guidelines for the Protection of Human Subjects of Research. Washington, 

D.C.: Department of Health, Education, and Welfare.

Reverby, S.M. (2000). Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study. 

Chapel Hill: University of North Carolina Press.

Ross, L.F. (2006). Children in Medical Research: Access versus Protection. New 

York: Oxford University Press.

Rothman, D.J. (2008). Strangers at the Bedside: A History of How Law and 

Bioethics Transformed Medical Decision Making. New Brunswick: Aldine 

Transaction.

Tucker, T. (2006). The Great Starvation Experiment: The Heroic Men who 

Starved so that Millions Could Live. New York: The Free Press.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

158
159

ENDNOTES
“Ethically Impossible” STD Research in Guatemala from 1946-1948

160

1 Throughout this report, the Commission uses contemporary language (e.g., “STDs” instead of “venereal 

diseases”) as opposed to the terminology used in the recovered historical documents, except when directly 

quoting from those materials. Dr. Susan M. Reverby, of Wellesley College, notified the U.S. government 

about the events involving the intentional exposure to STDs in the summer of 2010. 

2 Read-out of the President’s Call with Guatemalan President Colom. (2010, October 1). Available at http://

www.whitehouse.gov/the-press-office/2010/10/01/read-out-presidents-call-with-guatemalan-presidentcolom (accessed July 22, 2011). 

3 Joint Statement by Secretaries Clinton and Sebelius on a 1946-1948 Study. (2010, October 1). Available at 

http://www.hhs.gov/news/press/2010pres/10/20101001a.html (accessed July 22, 2011).

4 Ibid.

5 Caplan, A. (2010, October 1). “Horrific medical tests of past raise concerns for today,” MSNBC. Available 

at http://www.msnbc.msn.com/id/39463624/ns/health-health_care/t/horrific-medical-tests-past-raiseconcerns-today/ (accessed August 10, 2011). (“The impact of Tuskegee experiment has had a lasting effect 

on the lack of trust and suspicion minorities have about medical research... Many African-Americans 

believe that the government let doctors give people syphilis. While that did not happen in Tuskegee, the 

revelation of the Guatemalan research is a stark reminder that racism and indifference to the weak and 

the vulnerable did permit incredible abuses.”) Landau, E. (2010, October 1). “Studies show ‘dark chapter’ 

of medical research,” CNN. Available at http://www.cnn.com/ 2010/HEALTH/10/01/guatemala.syphilis.

tuskegee/index.html?iref=allsearch (accessed August 30, 2011).

6 Previously, the historical review was to be performed by the Institute of Medicine of the U.S. National 

Academies. The assignment moved to the Commission as more facts came to light. On November 24, 2010, 

the Academies explained: “Since receiving the request from [D]HHS, we have learned that at the time 

of the 1940s Guatemala study at least five individuals served simultaneously on the National Institutes 

of Health Study Section on Syphilis and the National Research Council’s Subcommittee on Venereal 

Diseases. The same individual served as chair of both groups. Because of these overlapping appointments 

between our institution and a body involved in the federal government’s syphilis research program, the 

National Academies should not conduct this historical review.” National Academies Statement on the 

1940s Guatemalan Syphilis Studies. (2010, November 24). Available at http://www8.nationalacademies.

org/onpinews/newsitem.aspx?RecordID=20101124. 

7 Memorandum from President Barack Obama to Dr. Amy Gutmann, Chair, Presidential Commission for 

the Study of Bioethical Issues. (2010, November 24). Available at http://www.bioethics.gov/documents/

Human-Subjects-Protection-Letter-from-President-Obama-11.24.10.pdf (accessed July 22, 2011). 

8 Ibid.

9 Testimony of Executive Director Valerie H. Bonham to Commission, March 1, 2011.

10 Personal communication, Susan Reverby, Wellesley College, to Brian Eiler, Commission staff, August 3, 

2011. Speaking to the Boston Globe in October 2010, Dr. Reverby described her discovery: “I expected to 

find something on Tuskegee...There was nothing. What he left behind were these records from the Guatemala study.” When Dr. Reverby “happened upon the documents” she “was just completely blown away.” 

As she described in the interview: “I was floored.” Smith, S. (2010). Wellesley Professor unearths a horror: 

Syphilis experiments in Guatemala. The Boston Globe. October 2, 2010. Available at http://articles.boston.

com/2010-10-02/news/29290885_1 _reprehensible-research-susan-m-reverby-syphilis-experiments (accessed September 8, 2011). 

11 Reverby, S.M. (2010, May 2). ‘Normal Exposure’ and Inoculation Syphilis: PHS ‘Tuskegee’ Doctors in 

Guatemala, 1946-48 and at Sing Sing Prison, Ossining, New York, 1953-54. Paper presented at the annual 

meeting of the American Association for the History of Medicine, Mayo Clinic, Rochester, MN. 

12 National Archives Press Release. (2011, March 28). Available at http://www.archives.gov/press/pressreleases/2011/nr11-94.html (accessed September 7, 2011).

13 For a history of the VDRL, see Parascandola, J. (2001). John Mahoney and the introduction of penicillin 

to treat syphilis. Pharmacy in History 43:3-13. In 1948 VDRL moved from its home in Staten Island, New 

York, to Chamblee, Georgia. See VDRL cooperates with state laboratories. (1954). Public Health Reports 

69 (2): 202. In 1957, VDRL, along with the rest of the PHS Venereal Disease Division, was absorbed by 
endnotes X

161

the Communicable Disease Center, and the functions of the VDRL were transferred to Atlanta, Georgia. 

Etheridge, E.W. (1992). Sentinel for Health: A History of the Centers for Disease Control. Berkeley, 

California: University of California Press, pp. 88-89. The Communicable Disease Center was renamed 

the Center for Disease Control in 1970 and was renamed again in 1992 as the Centers for Disease 

Control and Prevention, while maintaining the acronym CDC. CDC Office of the Associate Director for 

Communication. (2011, July 7). Available at http://www.cdc.gov/about/history/timeline.htm (accessed 

August 30, 2011). The U.S. Public Health Service’s venereal disease control and laboratory activities now 

operate as part of CDC’s Division of STD Prevention within the National Center for HIV/AIDS, Viral 

Hepatitis, STD, and TB Prevention.

14 The Commission requested information when it visited Guatemala April 30 to May 3, 2011, and again 

after Guatemalan media reported that the government of Guatemala had identified living victims of the 

research. A regulation passed in Guatemala on May 1, 2011 precluded release of all records relating to 

the Guatemalan government’s investigation prior to release of its final investigation report. Guatemala 

government Resolution Number 131-2011. Presidential Commission for the Study of Bioethical Issues 

Human Subjects Protections I (PCSBI HSPI) Archives, MISC_0000638. While unable to obtain specific 

records, Commission staff met with the Directors of the three Guatemalan Archives, Ana Carla Ericastilla 

(Central American Archives), Marco Tulio Alvarez (Peace Archives), and Gustavo Meono Brenner 

(Police Archives). They confirmed to the Commission staff that numerous records had been found in Guatemala substantiating the information from the Cutler Documents and also providing additional evidence 

surrounding the conduct of the experiments. The Guatemalan media has also reported that the government of Guatemala possesses records from the national hospital, the former Department of Public Health, 

and the psychiatric hospital. Villasenor, C.M. (2010, November 25). Archivo General de CA resguardará 

expediente de experimentos de EE. UU. Prensa Libre. (2010, November 11). Archivos de hospital mental 

no se destruyeron en 1960. Prensa Libre.

15 The Commission identified only one living person with first-hand knowledge of the events, though her 

recollection is limited and she was able to offer no specifics. The documents indicate that Mrs. John C. 

(Eliese S.) Cutler lived and worked with Dr. Cutler in Guatemala from 1946 into 1948. Commission staff 

contacted Mrs. Cutler, but she declined to speak with the staff. She did, however, send a letter to the 

Commission, writing: “I have no recollection of any such medical testing other than that conducted in the 

mental institution.” Personal communication, Eliese S. Cutler to Valerie Bonham. (2011, June 25). PCSBI 

HSPI Archives, MISC_0000523. 

16 Meeting, February 11, 2011. Vice President Espada was invited to speak at two Commission meetings 

held during the investigation, but regrettably for both parties, unanticipated events prevented him from 

traveling. 

17 While unable to obtain specific records during its trip, the Commission was later aided by the work of an 

independent researcher in Guatemala, Mr. Martin Rangel, who provided relevant contemporaneous reports 

from Guatemalan media. 

18 Beginning in 1924, PASB was the principal coordinating entity of international health activities in the 

Americas. During the time period of the STD studies in Guatemala, the PASB was closely linked with 

the U.S. PHS. In 1946, the PHS assigned “practically all of the professional staff of the Bureau.” In 

1947 and 1948, the PHS paid for the salaries of the PASB Assistant Director, the Chiefs of the Lima and 

Guatemala Zone Offices as well as officers and personnel assigned to special projects of the PHS. The 

two organizations shared the same leader, the U.S. Surgeon General, until 1936. (Hugh S. Cumming Sr., 

assumed the position of PASB Director when he took office as U.S. Surgeon General in 1920. In 1936, he 

retired as Surgeon General but remained PASB Director until 1947.) Fred L. Soper. (n.d.). Report of the 

Director of the Pan-American Sanitary Bureau to the Member Governments of the Pan American Sanitary 

Organization: January 1947-April 1950, p. 30. PCSBI HSPI Archives, PAHO_0000486. In 1949, the 

PASB became the Regional Office of the Americas of the World Health Organization, an arm of the Pan 

American Sanitary Organization, which is today known as the Pan American Health Organization. Cueto, 

M. (2007). The Value of Health: A History of the Pan American Health Organization. Washington, DC:

Pan American Health Organization, pp. 63-108.

19 RG-65, awarded July 1946; RG-65(C), awarded July 1947, and extended to December 1948. Funding 

through 1953 was provided by PHS to several Guatemalan researchers. See, e.g., Juan M. Funes Personnel 

Files. (1948, December 10). PCSBI HSPI Archives, NPRC_0000807.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

162

20 It is important to recognize that “exposure” to an STD is not the same as “infection” with an STD. Subjects who were exposed to an STD by the researchers ran the risk of becoming infected with that STD, but 

many of the subjects that were exposed to an STD were not infected.

21 PCSBI. (2011). Subject Database. This number represents the number of separate individuals exposed at 

least one time. Some individuals were exposed more than once.

22 Ibid. 

23 All of the sex workers employed for the research were women. 

24 PCSBI. (2011). Subject Database.

25 The available records show that the researchers did not inoculate the children in the orphanage or school 

with STDs.

26 Stout, G.W., Cutler, J.C. (1951, September). Serology problems (syphilis) in Central America. Journal of 

Venereal Disease Information, 32(7): 238-239; Portnoy, J., Galvez, R., Cutler, J.C. (1952). Clinical and 

serologic studies with reference to syphilis in Guatemala, Central America. III. Studies of comparative 

performance of the Kahn, Kolmer, Mazzini, and VDRL slide tests among leprosy patients. American 

Journal of Syphilis, Gonorrhea, and Venereal Diseases 36(3):566-570.

27 Falcone, V.H., Harris, A., Olansky, S., Salvado, C., Cutler, J.C. (1953). A study of the Neurath Inhibition 

Phenomenon in the serodiagnosis of syphilis. American Journal of Syphilis, Gonorrhea, and Venereal 

Diseases 37(3):264-272.

28 A lumbar or cisternal puncture is the removal of cerebrospinal fluid through a needle inserted between two 

vertebrae in the lower back (lumbar) or into the base of the skull (cisternal).

29 Report on Serologic Follow-up on Patients Done at CDC in 1953, Samples sent from Guatemala. (1953.) 

PCSBI HSPI Archives, CTLR_0001436.

30 John Cutler to John Mahoney. (1947, September 18). Correspondence. PCSBI HSPI Archives, 

CTLR_0001231.

31 Advisory Committee on Human Radiation Experiments. (1996). Final Report of the Advisory Committee 

on Human Radiation Experiments. New York: Oxford University Press; Moreno, J.D. (1999). Undue Risk: 

Secret State Experiments on Humans. New York: W.H. Freeman & Co.; Faden, R.R., Beauchamp, T.L. 

(1986). A History and Theory of Informed Consent. New York: Oxford University Press; Rothman, D.J. 

(1991). Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision 

Making. New Brunswick: Aldine Transaction.

32 See, e.g., World Medical Association. (1964). Code of Ethics of the World Medical Association: Declaration of Helsinki. Helsinki, Finland: World Medical Association; Drug Amendments of 1962, Public 

Law No. 87-781 (1962), codified at 21 U.S.C. 355 (requiring informed consent in certain FDA-regulated 

research); 21 C.F.R. 50 (same); National Research Act of 1974, Public Law No. 93-348 (1974), codified at 

42 U.S.C. 218 (requiring informed consent and independent review in HHS-sponsored research); 45 C.F.R. 

46 (same); Emanuel, E.J., Wendler, D., Grady, C. (2000). What makes clinical research ethical? JAMA

283(20):2701-2711.

33 See 45 CFR 46, Subparts B-D (allowing for research on vulnerable populations, including prisoners 

and children, provided additional protections are in place); 45 C.F.R. § 46.116(d) (allowing for waiver of 

informed consent when: the research involves no more than minimal risk, the waiver will not adversely 

affect subjects’ rights and welfare, the research could not practicably be conducted without the waiver, 

and, where appropriate, subjects are provided with additional information after participation). Today, 

intentional infection research is used for a variety of purposes, including proof of microbial pathogenicity, 

definition of protective antigens, identification of factors that influence disease acquisition and severity, 

assessment of vaccine efficacy, demonstration of infection-derived immunity, identification of protective 

immune responses, and refinement of vaccine formulation, schedule, and delivery. Kotloff, K.L. (2003). 

Human challenge studies with infectious agents. Journal of Investigative Medicine 51(Supp.): S6-S7. See 

also Cohen, M.S., Cannon, J.G. (1994). Human experimentation with Neisseria gonorrhoeae: Rationale, 

methods, and implications for the biology of infection and vaccine development. Journal of Infectious 

Diseases. 169:532-537 (providing an example of recent intentional infection research in gonorrhea).

34 Kaempffert, W. (1947). Notes on science: Syphilis prevention. New York Times. April 27.
endnotes X

163

35 Ibid.

36 Ibid. 

37 Ibid. 

38 Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clinical notebook. 

PCSBI HSPI Archives, CTLR_0000620.

39 La Follette-Bulwinkle Act (Venereal Diseases), Public Law No. 75-540; 75 Cong. Ch. 267; 52 Stat. 439 

(May 24, 1938). The Act made provisions for “establishing and maintaining adequate measures for 

prevention, treatment and control of VD [and] for the purpose of making studies, investigations and 

demonstrations to develop more effective measures for prevention, treatment, and control.”

40 U.S. Congress. House. Committee on Interstate and Foreign Commerce. Hearings on Investigation and 

Control of Venereal Diseases. 75th Congress, 3rd Session, April 12-14, 1938, at 143.

41 Ibid, at 144.

42 Ibid.

43 Draft of Committee on Medical Research History, Section on Venereal Disease attached to February 

25, 1946, Memorandum from E. Cowles Andrus to Chester S. Keefer. (n.d.). PCSBI HSPI Archives,

NARA-II_0000414. Indeed, only a year later, in 1944, the Army decided it could no longer use arsenical 

and bismuth treatment for the treatment of syphilis, given combat conditions, and sought advice 

from the Subcommittee on Venereal Diseases on how best to administer penicillin as an alternative 

treatment. Penicillin Conference Under the Auspices of the U.S. Public Health Service, Food and Drug 

Administration, and National Research Council. March 27, 1946, at 158. 

44 Ibid.

45 Ibid, PCSBI HSPI Archives, NARA-II_0000415.

46 Mahoney, J.F. (1936). An experimental resurvey of the basic factors concerned in prophylaxis in syphilis. 

The Military Surgeon 78-79:351.

47 The National Research Council (NRC) was organized in 1916 as an arm of the National Academy of 

Sciences by the National Academy of Sciences, under its congressional charter. In 1918, President 

Woodrow Wilson established the Council as a standing organization by Executive Order. Executive Order 

No. 2859, May 11, 1918. 

48 Joseph Moore to A.N. Richards. (1943, February 1). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000176.

49 Ibid. 

50 The membership of the CMR included Dr. A.N. Richards, Chairman; Rear Admiral Harold W. Smith 

(Navy); Brig. Gen. James S. Simmons (Army); Dr. R.E. Dyer (PHS); Dr. A.B. Hastings (Harvard 

University), and Dr. A.R. Dochez (Cloumbia University). First Draft of Proposed C.M.R. Chapter for 

Irvin Stewart’s Administrative History of OSRD. (1945, January 12). PCSBI HSPI Archives, NARAII_0000354; Lockwood, J.S. (1946, August). War-time activities of the National Research Council and the 

Committee on Medical Research; With particular reference to team-work on studies of wounds and burns. 

Annals of Surgery 124(2):314-315. 

51 First Draft of Proposed C.M.R. Chapter for Irvin Stewart’s Administrative History of OSRD, 12 Jan. 1945, 

PCSBI HSPI Archives, NARA-II_0000354; Executive Order. (June 28, 1941).

52 Ibid 

53 Ibid 

54 Rothman, D.J., op cit., pp. 30-31.

55 Joseph Earle Moore Obituary. (1958). British Journal of Venereal Disease 34:58-59. When he died, 

Moore’s memorial emphasized that he had devoted his “whole professional career...to the study and 

treatment of syphilis”; Thomas, H.M. (1960). Memorial: Joseph Earle Moore, MD. Transactions of the 

American Clinical and Climatological Association 71: xlix-l; Curriculum Vitae – Joseph Earle Moore, 

M.D. (n.d.). PCSBI HSPI Archives, JHU_0000035.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

164

56 Fox, D.M. (1987). The politics of the NIH Extramural Program, 1937-1950. Journal of the History of 

Medicine and Allied Sciences 42(4):452. 

57 Joseph Moore to A.N. Richards (1942, October 6). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000346. 

58 Ibid. 

59 A.N. Richards to Joseph Moore. (1942, October 9). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000346. 

60 Ibid. 

61 Minutes of a Conference on Chemical Prophylaxis. (1942, November 18). PCSBI HSPI Archives, NARAII_0000332. The Subcommittee on Venereal Diseases was formed within NRC on June 7, 1940, to make 

“general recommendations to The Surgeons General of the Army and the Navy concerning the prevention 

and treatment of the venereal diseases.” See Padget, P. Diagnosis and treatment of the venereal diseases. 

In Coates, J.B. (Ed.). (1963). Internal Medicine in World War II, Volume II: Infectious Diseases. Washington, D.C.: Office of the Surgeon General, Department of the Army, p. 410.

62 The Subcommittee consisted of Drs. Joseph E. Moore, Charles W. Clarke, Oscar F. Cox, Russell Herrold, 

John F. Mahoney, Nels Nelson, and John H. Stokes; E.H. Cushing to Robert L. Dickinson. (1942, 

December 9). Correspondence. PCSBI HSPI Archives, NAS_0000446.

63 Minutes of a Conference on Chemical Prophylaxis (1942, November 18). PCSBI HSPI Archives, 

NARA-II_0000334. 

64 Thomas Parran to Lewis H. Weed. (1942, November 19). Correspondence. PCSBI HSPI Archives, NARAII_0000284. Of note, Dr. Parran, former President of the American Neisserian Medical Society, may well 

have been familiar with the case of Albert Neisser, famous for his discovery of the bacterium that causes 

gonorrhea, who was fined by the government of Prussia for infecting prostitutes with syphilis without 

their knowledge or consent in 1898. Vollman, J., Winau, R. (1996). The Prussian regulation of 1900: Early 

ethical standards for human experimentation in Germany. IRB: Ethics and Human Research 18: 9-10. 

Kampmeier, R.H. (1984). Section I: The years of the American Neisserian Medical Society, 1934-1942. 

Sexually Transmitted Diseases 11(3):193.

65 John A. Rogers to Lewis H. Weed. (1942, December 4). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000283.

66 Ross T. McIntire to Lewis H. Weed. (1942, December 5). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000282.

67 Ibid. 

68 The CMR consisted of, aside from Dr. Richards, Dr. Lewis H. Weed (Vice-Chairman), Rear Admiral Harold 

W. Smith (Navy), Brig. Gen. James S. Simmons (Army), Dr. R.E. Dyer (PHS), Dr. A.B. Hastings (Harvard 

University), and Dr. A.R. Dochez (Columbia University). First Draft of Proposed C.M.R. Chapter for Irvin 

Stewart’s Administrative History of OSRD. (1945, January 12). PCSBI HSPI Archives, NARA-II_0000354. 

69 Minutes of the Seventeenth Meeting of the Subcommittee on Venereal Diseases – National Research 

Council. (1942, December 1). PCSBI HSPI Archives, NARA-II_0000342. 

70 Ibid; O.H. Perry Pepper to Lewis H. Weed. (1942, December 14). Correspondence. PCSBI HSPI Archives 

NAS_0000707. 

71 A.N. Richards to Joseph E. Moore. (1942, December 12). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000136. 

72 The conference group consisted of: 1) Drs. Joseph Earle Moore, Oscar Cox, and Russell Herrold (from 

the Subcommittee on Venereal Diseases), 2) Drs. Alfred Cohn and Theodore Rosenthal (from the New 

York City Health Department), 3) Drs. James H. Lade and M. deMello (from the New York State Health 

Department), 4) Dr. Charles M. Carpenter (University of Rochester), 5) Dr. C. Phillip Miller (University 

of Chicago), 6) Drs. O.H. Perry Pepper, T.R. Forbes, G.A. Carden, and Wilbur Davison (NRC), 7) 

Dr. Lowell J. Reed (Johns Hopkins University), 8) Dr. Hugo Muench (International Health Division, 

Rockefeller Foundation), 9) Lt. Col. T.B. Turner, Maj. Gaylord W. Anderson, Maj. Thomas H. Sternberg, 

Maj. Robert Dyar, and Capt. Robert H. Reidel (U.S. Army), 10) Lt. J.F. Shronts and Cmdr. R.W. Mussen, 

R.N., British Liaison Officer (U.S. Navy), and 11) Dr. R.A. Vonderlehr (U.S. PHS).
endnotes X

165

73 Minutes of a Conference on Human Experimentation in Gonorrhea Held Under the Auspices of the 

Subcommittee on Venereal Diseases and Exhibit B to Same. (1942, December 29). PCSBI HSPI Archives, 

NARA-II_0000157-175.

74 Dr. Carpenter’s statement on The Evaluation of Prophylactic Agents and Procedures in the Prevention of 

Gonorrhea. (n.d.). PCSBI HSPI Archives, NARA-II_0000162. 

75 Proposed Plan of Procedure in the Study of Chemical Prophylaxis in Human Volunteers among Prison 

Inmates, reproduced in Minutes of a Conference on Human Experimentation in Gonorrhea Held Under 

the Auspices of the Subcommittee on Venereal Diseases. (1942, December 29). PCSBI HSPI Archives,

NARA-II_0000168. The extensive consent form (called a “waiver”) described the procedures and risks 

of the study in considerable detail, which suggests that the Subcommittee did want the “volunteers” to 

understand the study in which they were participating. 

76 Statement of Explanation of the Experiment and Its Risks to Tentative Volunteers, (n.d.), reproduced 

in Minutes of a Conference on Human Experimentation in Gonorrhea Held Under the Auspices of the 

Subcommittee on Venereal Diseases. (1942, December 29). PCSBI HSPI Archives, NARA-II_0000173. 

More specific evidence that this or a similar form was used in Terre Haute has not been located, but an oral 

history of the career of Dr. Henrik Blum, one of the PHS medical officers who ran the experiments, affirms 

that the prisoners were informed about the nature of the study. Dr. Blum had other criticisms of the Terre 

Haute experiments, but he stated that there was “[n]o question about” whether the prisoners were “aware of 

what was being done.” Crawford, C. (1999). Henrik Blum, M.D., M.P.H., “Equity for the Public’s Health: 

Contra Costa Health Officer; Professor, UC School of Public Health; WHO Fieldworker.” An oral history 

conducted in 1997 by Caroline Crawford, Regional Oral History Office, The Bancroft Library, University 

of California, Berkeley. Available at http://www.archive.org/stream/equity pubhealth00blumrich/ 

equitypubhealth00blumrich_djvu.txt (accessed May 16, 2011). 

77 Statement of Explanation of the Experiment and Its Risks to Tentative Volunteers, (n.d.), reproduced 

in Minutes of a Conference on Human Experimentation in Gonorrhea Held Under the Auspices of the 

Subcommittee on Venereal Diseases. (1942, December 29). PCSBI HSPI Archives, NARA-II_0000173.

78 Ibid, PCSBI HSPI Archives, NARA-II_0000174.

79 Ibid. 

80 The Committee on Medicine was one of eight major committees that made up the NRC’s Division of 

Medical Sciences in 1941. First Draft of Proposed C.M.R. Chapter for Irvin Stewart’s Administrative 

History of OSRD. (1945, January 12). PCSBI HSPI Archives, NARA-II_0000354-56. 

81 American Medical Association. Our History: Full List of Annual Meetings and Presidents. Available 

at http://www.ama-assn.org/ama/pub/about-ama/our-history/full-list-annual-meetings-presidents.page 

(accessed August 26, 2011). 

82 James E. Paullin to O.H. Perry Pepper. (1942, January 13). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000264.

83 Arthur L. Bloomfield to O.H. Perry Pepper. (1943, January 11). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000266. Arthur L. Bloomfield was Professor of Medicine and Executive of the Department 

of Medicine at Stanford University. Cox, A.J., Hilgard, E.R., Rytand, D.A. (1962, September). Arthur L. 

Bloomfield 1888-1962. California Medicine 97(3): 91-192. 

84 Inter-Office Memorandum by J. B. Donovan regarding January 22, 1943 Conference. (n.d.). PCSBI HSPI 

Archives, NARA-II_0000150. 

85 Memorandum of a Conference of the Prophylaxis of Gonorrhea in Human Volunteers. (1943, January 23). 

PCSBI HSPI Archives, NARA-II_0000227-228. 

86 New York State law read: “no person shall do ‘any act detrimental to the health of any human being.’” See 

Inter-Office Memorandum by J. B. Donovan regarding January 22, 1943 Conference. (n.d.) PCSBI HSPI 

Archives, NARA-II_0000151.

87 Moreno, J.D., op cit., p. 26, describing the widespread use of conscientious objectors in human subject 

experiments.

88 Memorandum of a Conference of the Prophylaxis of Gonorrhea in Human Volunteers. (1943, January 23). 

PCSBI HSPI Archives, NARA-II_0000227-228. 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

166

89 Joseph E. Moore to A.N. Richards. (1943, February 1). Correspondence. PCSBI HSPI Archives 

NARA-II_0000178. 

90 Neither birth control nor STD prophylaxis was provided to women in the Armed Forces in 1942. See 

Considerations for Utilizing Women on a Station. (n.d.). PCSBI HSPI Archives, NAS_0000511.

91 Joseph E. Moore to A.N. Richards. (1943, February 1). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000177. 

92 Ibid. PCSBI HSPI Archives, NARA-II_0000184-85. 

93 Ibid. PCSBI HSPI Archives, NARA-II_0000183. While there is some discussion of homosexual sex among 

prisoners, the assumption was that most of the men were not sexually active while in prison. Proposed 

Plan of Procedure in the Study of Chemical Prophylaxis in Human Volunteers among Prison Inmates, 

reproduced in Minutes of a Conference on Human Experimentation in Gonorrhea Held Under the Auspices 

of the Subcommittee on Venereal Diseases. (1942, December 29). PCSBI HSPI Archives, NARAII_0000169. The various benefits of conducting research among prisoners had not gone unnoticed by other 

investigators; by the middle of the 20th century, a substantial number of medical experiments had been 

conducted in the United States using prisoners as subjects. Widespread prison research in the United States 

continued into the 1970s. See Bonham, V.H., Moreno, J.D. (2008). Research with captive populations: 

Prisoners, students, and soldiers. In Emanuel, E.E., et al. (Eds.). The Oxford Textbook of Clinical Research 

Ethics. New York: Oxford University Press, pp. 461-474; Moreno, J.D., op cit.; Harkness, J.M. (1996). 

Research Behind Bars: A History of Nontherapeutic Research on American Prisoners, Ph.D. dissertation, 

University of Wisconsin-Madison. 

94 Joseph E. Moore to A.N. Richards. (1943, February 1). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000183. 

95 Ibid, PCSBI HSPI Archives, NARA-II_0000184-85. 

96 Ibid. 

97 Ibid. 

98 Ibid, PCSBI HSPI Archives, NARA-II_0000184. 

99 Ibid. Subsequent discussion between NRC and the Surgeon General of the Navy yielded the same result for 

different reasons. Military personnel were rejected, in part, because of the “impossibility of deliberately 

exposing military personnel to infection even when volunteering....” Lewis H. Weed to Ross G. Harrison. 

(1943, March 2). Correspondence. PCSBI HSPI Archives, NARA-II_0000249. 

100 Joseph E. Moore to A.N. Richards. (1943, February 1). Correspondence. PCSBI HSPI Archives, NARAII_0000184. This statement establishes an important consideration, later disregarded, for not including 

psychiatric institution patients in STD research. It is unclear if Dr. Moore knew, or approved, the later use 

in Guatemala of individuals in the psychiatric hospital. Evidence shows that the initial plan for Guatemala, 

as presented to Moore and others in the Syphilis Study Section in March 1946, included use of prisoners 

only. John Cutler, Final Syphilis Report. (1955, February 24). PCSBI HSPI Archives, CTLR_0000643; 

John Cutler to John Mahoney (1947, January 7). Correspondence. PCSBI HSPI Archives, CTLR_0001039.

101 Joseph E. Moore to A.N. Richards. (1943, February 1). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000185-86. 

102 Ibid, PCSBI HSPI Archives, NARA-II_0000185. 

103 Ibid, PCSBI HSPI Archives, NARA-II_0000186. 

104 Porter, H.H., et al. (1939). Social diseases at the crossroads. Journal of the Oklahoma State Medical 

Association 32: 54-61.

105 Joseph E. Moore to A.N. Richards. (1943, February 1). Correspondence. PCSBI HSPI Archives, NARAII_0000185-86. Some have suggested that few people actually saw either of those articles. See Harkness, 

J.M., op cit., pp.124-25. 

106 Porter, H.H., op cit., pp. 54-61.

107 Joseph E. Moore to A.N. Richards. (1942, February 1). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000186. 
endnotes X

167

108 James B. Donovan to Irvin Stewart. (1943, February 17). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000221. 

109 Ibid. 

110 Ibid. 

111 Joseph E. Moore to James V. Bennett. (1943, February 18). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000156.

112 Ibid, PCSBI HSPI Archives, NARA-II_0000155.

113 James V. Bennett to Joseph E. Moore. (1943, February 26). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000188. 

114 Ibid. It was not uncommon to offer pardons or reduced sentences to prisoners participating in human 

experiments in prisons in the United States during the first half of the 20th century. Harkness, J.M., op cit., 

pp. 14-72.

115 James V. Bennett to Joseph E. Moore. (1943, February 26). Correspondence. PCSBI HSPI Archives, 

NARA-II_0000188.

116 Ibid. 

117 Ibid. 

118 Frank B. Jewett and Ross G. Harrison to Vannevar Bush. (1943, March 5). Correspondence. PCSBI HSPI 

Archives, NARA-II_0000190. 

119 Ibid. The designation of “personal opinion” in an “official capacity” is ambiguous, and no further 

explanation is contained in the available records. 

120 Ibid. 

121 Ibid, PCSBI HSPI Archives, NARA-II_0000190-192.

122 On March 6, 1943, a note on a memorandum of a conversation with Joseph E. Moore states “Dr. Bush read 

this and approves. The V. D. prophylaxis studies can go ahead...” Unsigned conversation of March 5, 1943, 

with Joseph E. Moore. (1943, March 6). Correspondence. PCSBI HSPI Archives, NARA-II_0000146.

123 Ibid. 

124 Ibid. 

125 R.A. Vonderlehr to F.M. King. (1943, February 24). Correspondence. PCSBI HSPI Archives, 

NLM_0000716. 

126 Dr. Bush may have felt also that research conducted directly by the U.S. government would face less 

public scrutiny. Unsigned conversation of March 5, 1943, with Joseph E. Moore. (1943, March 6). 

Correspondence. PCSBI HSPI Archives, NARA-II_0000146-47. See also letter from Joseph E. Moore 

to Thomas Parran, reproduced in Minutes of a Conference on Human Experimentation in Gonorrhea 

Held under the Auspices of the Subcommittee on Venereal Diseases. (1943, March 12). PCSBI HSPI 

Archives, NAS_0002328-36. These minutes show some internal conflict as Dr. Parran, the PHS Surgeon 

General, disfavored the proposal initially. He noted that PHS was not technically responsible for the care of 

federal prisoners. PHS provided personnel to the Bureau of Prisons so it could staff its medical facilities, 

and PHS was “responsible only for the professional competence of the personnel and the standards of 

professional care in the prisons.” Memorandum from Thomas Parran to R.A. Vonderlehr. (1943, March 11). 

Correspondence. PCSBI HSPI Archives, NAS_0002342. Dr. Parran’s concern appears to have resolved, 

however, since these materials show that Dr. Vonderlehr subsequently offered substantial support for the 

project. 

127 R.A. Vonderlehr to J.F. Mahoney. (1943, April 15). Correspondence. PCSBI HSPI Archives, 

NLM_0000712. 

128 Ibid. 

129 Parascandola, J. (2001). Op cit., p. 7.

130 Ibid. U.S. Marine Hospitals were operated throughout the country by the PHS. The Marine Hospital 

Service, which traces its roots back to a 1798 law, was organized as a national organization in 1870. 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

168

Originally established to provide medical treatment to merchant seamen in American ports, it grew to 

become the U.S. Public Health Service, a uniformed service of the U.S. government charged with duties 

that involved the research, prevention, control, diagnosis, and treatment of human illness throughout the 

United States. Parascandola, J. (1998). Public Health Service. In Kurian, G.T. (Ed.) A Historical Guide to 

the U.S. Government. New York: Oxford University Press, pp. 487-493.

131 Parascandola, J. (2001). Op cit., p. 7. 

132 Biographical Sketch, Dr. Cassius J. Van Slyke. (n.d.). PCSBI HSPI Archives, NPRC_0002846.

133 Parascandola, J. (2001). Op cit, p. 7. 

134 Ibid. 

135 Ibid. 

136 Proposal for Contract in Medical Research Pertaining to National Defense. (1943, June 25). PCSBI 

HSPI Archives, NARA-II_0000583; Cassius J. Van Slyke Personnel Files. (Various dates). PCSBI HSPI 

Archives, NPRC_0002844-57.

137 Ibid, PCSBI HSPI Archives, NARA-II_0000585. 

138 Approximately $590,000 today, when adjusted for inflation. 

139 Proposal for Contract in Medical Research Pertaining to National Defense. (1943, June 25). PCSBI HSPI 

Archives, NARA-II_0000584. 

140 Report to Subcommittee on Venereal Diseases. (1943, November 11). PCSBI HSPI Archives, 

NAS_0003530; Draft of CMR History, Section on Venereal Disease attached to February 25, 1946 

Memorandum from E. Cowles Andrus to Chester S. Keefer. (n.d.). PCSBI HSPI Archives, NARAII_0000419; Cutler Award Citation. (n.d.). PCSBI HSPI Archives, MISC_0000341. 

141 Dr. John C. Cutler, CV. (n.d.). PCSBI HSPI Archives, MISC_0000409. 

142 Ibid. 

143 Henrik Blum, M.D., M.P.H., op cit. 

144 Mahoney, J.F., Van Slyke, C.J., Cutler, J.C., Blum, H.L. (1946, January). Experimental gonococcic 

urethritis in human volunteers. American Journal of Syphilis, Gonorrhea, and Venereal Disease 30:3. 

145 Reports to a Conference Held Under the Auspices of the Subcommittee on Venereal Diseases 9 February 

1944, on the Chemical Prophylaxis of Venereal Disease. (1944, February 9). PCSBI HSPI Archives, 

NAS_0003112. 

146 The Department of Justice was unable to locate any records pertaining to this research. E-mail from Mala 

Adiga, Counsel to the Associate Attorney General, U.S. Department of Justice, to Brian Eiler, Senior 

Policy and Research Analyst, Presidential Commission for the Study of Bioethical Issues. (2011, June 6). 

PCSBI HSPI Archives, DOJ_0000098.

147 Report to Subcommittee on Venereal Diseases. (1943, November 11). PCSBI HSPI Archives, 

NAS_0003531; Mahoney, J.F., Van Slyke, C.J., Cutler, J.C., Blum, H.L. (1946). Op cit.

148 Report to Subcommittee on Venereal Diseases. (1943, November 11). PCSBI HSPI Archives, 

NAS_0003531.

149 Minutes of the Twenty-First Meeting of the Subcommittee on Venereal Diseases. (1943, November 

11). PCSBI HSPI Archives, NAS_0002782; Reports to a Conference Held Under the Auspices of the 

Subcommittee on Venereal Diseases 9 February 1944, on the Chemical Prophylaxis of Venereal Disease. 

(1944, February 9). PCSBI HSPI Archives, NAS_0003114-17. 

150 Reports to a Conference Held Under the Auspices of the Subcommittee on Venereal Diseases, op cit. 

151 In an oral history conducted with Dr. Henrik Blum in 1997, he stated that it was his job to “examine[] 

prostitutes to find gonorrhea bugs to bring fresh bugs in because it was part of our experiment.” According 

to Dr. Blum, the prostitutes had been “picked up by the police. Terre Haute was a town famous for its 

prostitution because it was the soft coal mining center. The miners came to Terre Haute for recreation--R 

& R, rest and recreation.” Henrik Blum, M.D., M.P.H., op cit. 
endnotes X

169

152 Minutes of a Conference on Chemical Prophylaxis of Venereal Diseases. (1944, February 9). PCSBI HSPI 

Archives, NAS_0002070. 

153 Reports to a Conference Held Under the Auspices of the Subcommittee on Venereal Diseases 9 February 

1944, on the Chemical Prophylaxis of Venereal Disease. (1944, February 9). PCSBI HSPI Archives, 

NAS_0003113. 

154 Ibid. 

155 Minutes of a Conference on Chemical Prophylaxis of Venereal Diseases. (1944, February 9). PCSBI HSPI 

Archives, NAS_0002072. 

156 Minutes of a Conference on the Prevention of Gonococcal Infection in Experimentally Infected Human 

Male Volunteers. (1944, April 4). PCSBI HSPI Archives, NAS_0002089. 

157 The conference was attended by: 1) Dr. Oscar F. Cox, Dr. Phillip Miller, and Dr. Russell Herrold (from the 

NRC), 2) Dr. Marion R. King, Dr. R.O. Settle, and Warden E.B. Swope (from the Bureau of Prisons), and 3) 

Drs. Mahoney, Van Slyke, Cutler, and Blum, and Mr. Harold Hirschhorn and Miss Millicent R. Chapman 

(from the PHS). Minutes of a Conference on the Prevention of Gonococcal Infection in Experimentally 

Infected Human Male Volunteers, (1944, April 4). PCSBI HSPI Archives, NAS_0002089. 

158 Ibid, PCSBI HSPI Archives, NAS_0002090. 

159 Minutes of the Twenty Third Meeting, Subcommittee on Venereal Diseases of the Committee on 

Medicine. (1944, June 29). PCSBI HSPI Archives, NAS_0002108. 

160 John Cutler to John F. Mahoney. (1947, September 20). Correspondence. PCSBI HSPI Archives, 

CTLR_0001225. 

161 Final Report, Prevention of Gonococcal Infection in Experimentally Infected Human Volunteers. (1944, 

July 1). PCSBI HSPI Archives, NAS_0003656. 

162 Draft of CMR History, Section on Venereal Disease attached to Feb. 25, 1946 Memorandum from E. 

Cowles Andrus to Chester S. Keefer. (n.d.). PCSBI HSPI Archives, NARA-II_0000419. The Venereal 

Disease section of the draft was written by a team directed by Dr. Joseph E. Moore. 

163 Ibid, PCSBI HSPI Archives, NARA-II_0000420.

164 Mahoney, J.F., Van Slyke, C.J., Cutler, J.C., Blum, H.L. (1946). Op cit. The journal was the official 

publication of the American Neisserian Medical Society and later the American Venereal Disease 

Association. Kampmeier, R.H. (1974, September). Historical note. Journal of the American Venereal 

Disease Association 1(1): 8-9. 

165 Mahoney, J.F., Van Slyke, C.J., Cutler, J.C., Blum, H.L. (1946). Op cit., p. 32.

166 Ibid. 

167 Ibid, p. 33.

168 Since the 18th century, researchers have reported inoculating human subjects, often including themselves, 

with syphilis, gonorrhea, and chancroid to evaluate questions regarding the nature of these diseases, 

contagion, immunity, and the like. Weyers, W. (2003). The Abuse of Man: An Illustrated History of 

Dubious Medical Experimentation. New York: Ardor Scribendi, pp. 19-40; Magnuson, H.J., et al. (1956). 

Inoculation syphilis in human volunteers. Medicine 35(1):35-41; Hill, J. (1943). Experimental infection 

with Neisseria gonorrhoeae. American Journal of Syphilis, Gonorrhea, and Venereal Diseases 27:733-

762. The first reported STD inoculation study supported by the U.S. government identified in the course of 

the Commission’s review was published in 1943, “done under a contract, recommended by the Committee 

on Medical Research, between the Office of Scientific Research and Development and the University of 

Georgia School of Medicine.” Human subjects were inoculated in the thigh with chancroid bacterium 

in order to evaluate the efficacy of various prophylactics. Greenblatt, R.B., et al. (1943). Experimental 

prophylaxis of Chancroid Disease. American Journal of Syphilis, Gonorrhea, and Venereal Disease 27: 

30-43; Greenblatt, R.B., et al. (1944). The experimental prophylaxis of Chancroid Disease – II. American 

Journal of Syphilis, Gonorrhea, and Venereal Disease 28:165-178.

169 These concerns followed the researchers to Guatemala, however, as evidenced by some of their efforts to 

limit and restrict access to information about the work.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

170

170 This work also proceeded under the auspices of NRC and OSRD. Mahoney, J.F., Arnold, R.C., Harris, A. 

(1943). Penicillin treatment of early syphilis: A preliminary report. American Journal of Public Health 

and the Nation’s Health 33(12):1390; Parascandola, J. (2008). Sex, Sin, and Science: A History of Syphilis 

in America. Westport, CT: Praeger, 129.

171 Mahoney, J.F., Arnold, R.C., Harris, A. (1943). Op cit., p. 1390; New Magic Bullet. (1943). TIME 

Magazine, October. 

172 Before the development of penicillin, options for treating syphilis included mercury, arsenic, bismuth, 

iodides, and sodium thiosulphate. There were several types of arsenical drugs, with varying efficacies 

and toxicities. Salvarsan proved the most toxic and thus was generally replaced by neoarsphenamine, 

sulpharsphenamine, and silverarsphenamine. Callis, H.A. (1929). Comparative therapy in syphilis. Journal 

of the National Medication Association 21(2):61-63. However, none of these drugs were completely 

effective, particularly in the late stages of disease. The larger issue was associated adverse events, 

including dermatitis, argyria, kidney irritation, and injury to blood, blood-forming organs, and cerebral 

vessels. 

173 New Magic Bullet. (1943). TIME Magazine, October. In 1943, state health departments in the United States 

reported cases of primary and secondary syphilis at a rate 63.8 per 100,000. Ten years later, once penicillin 

had been made available and widely adopted throughout the United States, cases of primary and secondary 

syphilis dropped over 90 percent to a rate of 5.6 per 100,000. CDC. (1998). Sexually Transmitted Disease 

Surveillance 1997. CDC: Prevention, Division STD Prevention, 65.

174 Moore, J.E., Mahoney, J.F., et al. (1944). The treatment of early syphilis with penicillin: A preliminary 

report of 1,418 cases. Journal of the American Medical Association 126(2):67-73. The experiment began in 

September 1943. 

175 Parascandola, J. (2008). Op cit., p. 129-130. There was debate about how much penicillin to use in the 

treatment of syphilis in 1944, as evidenced by discussion at a Penicillin Conference chaired by Dr. Moore 

and held under the auspices of PHS, the Food and Drug Administration (FDA), and NRC a couple of years 

later. Dr. Mahoney et al. used 1.2 million units of penicillin over seven and a half days in their first four 

cases. Mahoney, J.F., Arnold, R.C., Harris, A. (1943). Op cit., p. 1390. According to the discussion at the 

Penicillin Conference, the Armed Forces, with the advice of the Subcommittee on Venereal Diseases, 

doubled that when it implemented penicillin treatment for syphilis in 1944, using 2.4 million units in seven 

and a half days. Penicillin Conference Under the Auspices of the U.S. Public Health Service, Food and 

Drug Administration, and National Research Council. March 27, 1946, at 158-159. 

176 Moore, J.E., Mahoney, J.F., et al. (1944). Op cit. In response to Mahoney and Arnold’s preliminary results, 

a Penicillin Panel was formed under the auspices of OSRD and the Subcommittee on Venereal Diseases. 

The Panel initially consisted of Drs. Moore and Mahoney; Commander Walter Schwartz, U.S. Navy; 

Lieutenant Colonel Thomas Sternberg, U.S. Army Medical Corps; and Dr. Barry Wood. Dr. John Heller, 

Medical Director in charge of the Venereal Disease Division, was later added to the Panel. As discussed 

below, the Penicillin Panel was renamed the Syphilis Study Section in 1946. Fox, D.M. (1987). The politics 

of the NIH Extramural Program, 1937-1950. Journal of the History of Medicine and Allied Sciences

42(4):458-459. 

177 In addition, while syphilis is typically only contagious in its first stage, rapid treatment with penicillin may 

make people susceptible to new infections and put them once again in a transmissible stage.

178 National Research Council – U.S. Public Health Service. (1946). Transcript: Meeting of Penicillin 

Investigators, National Academy of Science, Washington, D.C; John Cutler. (1955, February 24). Final 

Syphilis Report. PCSBI HSPI Archives, CTLR_0000892.

179 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000639.

180 Ibid.

181 Ibid. The results do not appear to have been published. 

182 Ibid. 

183 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001279.

184 Ibid, PCSBI HSPI Archives, CTLR_0001278.
endnotes X

171

185 Ibid, PCSBI HSPI Archives, CTLR_0001279. This was briefly mentioned in a paper presented by Dr. 

Paul D. Rosahn of Yale University at a meeting of Penicillin Investigators, sponsored by PHS and NRC 

February 7-8, 1946. Drs. J.E. Moore and J.H. Stokes, who presided over the meeting, also addressed the 

question during the general discussion portion of the meeting on the morning of February 7. National 

Research Council – U.S. Public Health Service. (1946). Transcript: Meeting of Penicillin Investigators, 

National Academy of Science, Washington, D.C. 

186 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001279.

187 Mahoney, J.F. (1947, July). Some significant aspects of venereal disease research: Work of the Venereal 

Disease Research Laboratory, Staten Island, N.Y. Journal of Venereal Disease Information 28(7):129.

188 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000640.

189 Ibid, PCSBI HSPI Archives, CTLR_0000639-40. Dr. Funes visited the VDRL under the auspices of the 

Office of Inter-American Affairs (OIAA). The United States created OIAA in 1941 to develop commercial 

and cultural relations between North and South America. The OIAA’s name was changed in 1945 to 

“Coordinator of Inter American Affairs.” Official Personnel Folder: Juan M. Funes, “Special Consultant 

Appointment Recommendation.” (1948, December 10). PCSBI HSPI Archives, NPRC_0000807; John 

Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000639-40; National 

Archives. (1945). Executive Orders Disposition Tables: Franklin D. Roosevelt-1945. Available at http://

www.archives.gov/federal-register/executive-orders/1945-roosevelt.html (accessed May 16, 2011); National 

Archives. (n.d.). Records of the Office of Inter-American Affairs. Available at http://www.archives.gov/

research/holocaust/finding-aid/civilian/rg-229.html (accessed May 16, 2011).

190 John Cutler (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000639-40.

191 There are many scientific terms required to describe the experiments in Guatemala. Please see the 

Glossary of Key Terms at the end of the report for further detail.

192 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000643.

193 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001279; John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, 

CTLR_0000640. The researchers categorized sexual intercourse as “normal exposure” to STDs. Dr. 

Mahoney had long advocated that best practice in syphilis research, at least in rabbits, would “require[]” 

the intact maintenance of the exposed penile membrane to preserve “whatever mechanical or biological 

defense mechanisms may be inherent thereto.” See Mahoney, J. F. (1936). An experimental resurvey of the 

basic factors concerned in prophylaxis in syphilis. The Military Surgeon 352-53. This approach stood in 

contrast to the use of “scarification” of the membrane to cause infection (that Dr. Cutler later employed) 

as such method “permits an unnatural freedom of ingress for the organism.” Ibid. Discussing animal 

inoculation in preparation for the Terre Haute study, Dr. Mahoney again argued that the most favorable 

method of inoculation was that which most closely “simulated the method of inoculation in human beings 

exposed by sexual intercourse, i.e., the simple contact of an emulsion of T. pallidum with an unbroken 

mucous surface.” Moore, J.E. (1942, March 23). Memorandum: Conference on Chemical Prophylaxis of 

Venereal Diseases. PCSBI HSPI Archives, NAS_0003411. Dr. Mahoney also reiterated the sentiment that 

scarification and artificial implementation were “drastic...[and] beyond the range of natural transmission” 

in a letter to Dr. Cutler in 1947. John Mahoney to John Cutler. (1947, September 8). Correspondence. 

PCSBI HSPI Archives, CTLR_0001234. Despite his supervisor Mahoney’s stated preferences, Dr. Cutler 

would defend his scarification and other techniques beyond sexual intercourse when inducing infection 

through sexual intercourse in Guatemala proved difficult. John Cutler to John Mahoney. (1947, September 

18). PCSBI HSPI Archives, CTLR_0001231.

194 The Office was established by Executive Order in July 1941 to promote “the spirit of cooperation between 

the Americas in the interest of Hemisphere defense.” Executive Order 8840, July 30, 1941. 

195 Vought, R.L. (1946). The administration of an Inter-American Cooperative Health Program. Public Administration Review 6(1):49; Silva-Lizama, E. (2000). History of dermatology in Guatemala. International 

Journal of Dermatology 39(4):305-311. That hospital, called Roosevelt Hospital (after President Franklin 

D. Roosevelt) continues to serve as one of two major public hospitals providing free care in the country. 

Additionally, the presence of the U.S. military base in Guatemala provided Dr. Cutler and the researchers 

with supplies and equipment through their Army Transport Service and Army Post Office. John Cutler to 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

172

John Mahoney. (1946, November 22). Correspondence. PCSBI HSPI Archives, CTLR_0001254; John Cutler to John Mahoney. (1947, January 7). Correspondence. PCSBI HSPI Archives, CTLR_0001037; Richard 

Arnold to John Cutler. (1947, February 27). Correspondence. PCSBI HSPI Archives, CTLR_0001056; 

Richard Arnold to John Cutler. (1947, April 18). Correspondence. PCSBI HSPI Archives, CTLR_0001113; 

Ad Harris to John Cutler. (1947, April 21). Correspondence. PCSBI HSPI Archives, CTLR_0001114; John 

Cutler to John Mahoney. (1947, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001241.

196 Rothman, D.J., op cit., pp. 30-31.

197 Fox, D.M., op cit., pp. 454-455 discussing the legislation that allowed the PHS to make grants-in-aid.

198 Public Health Service Act of 1944, Public Law No. 78-410, 58 Stat. 682; see also Fox, D.M., op cit., p. 

454. Before passage of the Public Health Service Act of 1944, the Public Health Service had more limited 

authority to provide aid to states and issue grants-in-aid to combat specific medical illnesses under several 

different statutes. See e.g., Venereal Disease Control Act of 1938, 40 Stat. 886. May 24, 1938; National 

Cancer Institute Act of 1937, Public Law No. 75-244. August 5, 1937. See also Statement, National 

Advisory Health Council. (1945). Science 102(2640):113, describing new authority of NAHC under the 

Public Health Service Act of 1944 and Surgeon General Parran’s statement regarding that new authority. 

199 Public Health and Marine-Hospital Service Act, Public Law No. 57-236, 32 Stat. 712. July 1, 1902.

200 Ransdell Act, Public Law No. 71-251, 46 Stat. 379. May 26, 1930, reorganizing and designating the 

Hygienic Laboratory as the National Institute of Health. The Advisory Board was renamed the National 

Advisory Health Council in 1930. Public-Health Activities Act, Public Law No. 71-106, 46 Stat. 150. April 

9, 1930. See also Statement, The National Institute of Health. (1930). Science 72(1861): 214-215, describing 

how the Hygienic Laboratory became the National Institute of Health. 

201 Meeting of the National Advisory Health Council. (1931). Science 73(1894): 412-413. 

202 National Institutes of Health, Division of Research Grants. (1996). Division of Research Grants: A Half 

Century of Peer Review Alexandria, Virginia: National Institutes of Health, p. 12.

203 Fox, D.M., op cit., p. 456.

204 Ibid, p. 457; Division of Research Grants, op cit., pp. 16-22, describing the transfer of OSRD contracts to 

the Research Grants Office. See also Public Health Service Act of 1944, Public Law No. 78-410, 58 Stat. 

682; Strickland, S.P. (1989). The Story of the NIH Grants Program. Lanham, Maryland: University Press 

of America, p. 18, describing how the Division of Research Grants arose as a peacetime replacement for 

OSRD and CMR.

205 Fox, D.M., op cit., p. 457. Dr. Van Slyke, with Drs. Parran and Heller, favored a process to maximize 

investigator independence. The award process should be accompanied, Dr. Van Slyke stated, by “complete 

acceptance of a basic tenet of the philosophy upon which the scientific method rests: The integrity and 

independence of the research worker and his freedom from control, direction, regimentation and outside 

interference.” See Van Slyke, C.J. (1946, December 13). New horizons in medical research. Science

104(2711):559-562. See also Strickland, S.P., op cit., p. 22, describing the “grant-contracts” that Drs. Parran 

and Van Slyke favored as OSRD contracts were transferred to the NIH grant system. In the January 1948 

introduction to a Public Health Reports supplement, which indexed research awards, Dr. Van Slyke further 

explained: “wide latitude is allowed the responsible scientific investigator in the use of research grants 

funds. Recipients of awards are given complete freedom to conduct projects in whatever ways they choose. 

They are requested to make only such reports as will assure the government that the money being spent for 

their research is wisely and carefully used.” U.S. Public Health Service. (1948). Research Grants Awarded 

by Public Health Service, supplement No. 205. Washington, DC: U.S. Government Printing Office. PCSBI 

HSPI Archives, MISC_0000037.

206 Van Slyke, C.J., op cit., p. 559; Fox, D.M., op cit., p. 457; Strickland, S.P., op cit., p. 19.

207 Van Slyke, C.J., op cit., p. 559. See also Allen, E.M. (1980). Historical view: Early years of NIH research 

grants. NIH Alumni Association Newsletter 2(2): 6-8. 

208 Public Health Service Act of 1944, Public Law No. 78-410, 58 Stat. 692, §301(d); Van Slyke, C.J., op cit., 

p. 562. 

209 Fox, D.M., op cit., pp. 458-459, citing a December 1945 letter from Dr. Parran to the Federal Security 

Agency administrator. See also Committee on Medical Research and Public Health Service. (1946). The 

treatment of early syphilis with penicillin: A joint statement. JAMA 131(4): 265-266, describing the role of 
endnotes X

173

the NRC Penicillin Panel and the transfer of its responsibilities to the NIH Syphilis Study Section “with 

the same membership” plus two clinicians and a biostatician. 

210 The Syphilis Study Section convened to “hear papers and progress reports of the syphilis and penicillin 

investigations.” See Ernest Allen to R.E. Dyer. (1946, March 8). Correspondence. PCSBI HSPI Archives,

NARA-II_0000129. No specific protocols or applications considered by the group, including those for the 

Guatemala research, could be located.

211 There is no evidence that Dr. Mahoney, an architect and supervisor of the Guatemala work, recused 

himself from reviewing the project.

212 The membership list comes from a December 1946 publication of then NIH Research Grants Division 

Lead, Dr. C.J. Van Slyke. See Van Slyke, C.J., op cit., p. 567. An earlier publication authored by the OSRD 

CMR and the PHS in May 1946 suggests a slightly different membership, composed of: Dr. J.W. Ferree 

(Navy), Dr. John F. Mahoney (Subcommittee on Venereal Diseases), Dr. Joseph E. Moore (Subcommittee 

on Venereal Diseases), Dr. Walter Schwartz (Navy), Dr. Harry C. Solomon (Harvard University), Dr. T.H. 

Sternberg (Army), Dr. John H. Stokes (University of Pennsylvania), and Dr. W.B. Wood, Jr. (Committee on 

Chemotherapeutics and Other Agents). See Committee on Medical Research and Public Health Service, op 

cit., p. 265. 

213 This description of the study is from a final letter from Chairman Moore to Dr. C.J. Van Slyke, with a 

copy to the entire Study Section, during deliberation of the reauthorization of the original grant. Joseph E. 

Moore to C.J. Van Slyke. (1947, May 26). Correspondence. PCSBI HSPI Archives, NARA-II_0000036. 

214 An abstract for this work was included in a group of “all new projects” circulated to members of the 

NAHC for review prior to its March meeting, but the abstracts have not been located. See Ernest Allen to 

R.E. Dyer. (1946, March 8). Correspondence. PCSBI HSPI Archives, NARA-II_0000129. See Van Slyke, 

C.J., op cit., pp. 556, 564. See also Fox, D.M., op cit., p. 450. 

215 Other members who were present at the NAHC meeting March 8-9, 1946 were: Gordon M. Fair (Harvard 

University), A. Baird Hastings (Harvard University), Carl S. Marvel (University of Illinois), Kenneth F. 

Maxcy (Johns Hopkins University), Karl F. Meyer (University of California, San Francisco), Harry S. 

Mustard (Columbia University), William C. Rose (University of Illinois), Henry F. Vaughan (University 

of Michigan), Harry W. Schoening (U.S. Department of Agriculture), Capt. O.L. Burton (U.S. Navy), 

R.E. Dyer (NIH Director), Col. Karl R. Lundeberg (U.S. Army). Absent members were Edwin B. Fred 

(University of Wisconsin), Lowell J. Reed (Johns Hopkins University), and John H. Musser (Tulane 

University). National Advisory Health Council Meeting, U.S. Public Health Service. (1946, March 8 and 

9). PCSBI HSPI Archives, NARA-II_0000544; Van Slyke, C.J., op cit., pp. 559-567.

216 Minutes of the National Advisory Health Council Meeting. (1946, March 8-9). PCSBI HSPI Archives, 

NARA-II_0000546. Meeting minutes show that this grant award was unusual in other ways. NAHC 

considered 30 grant applications during its two-day meeting, and meeting minutes list each proposal with 

the name of an institution as a grantee and the name of an individual as the principal investigator. The 

only exception is RG-65, which simply names “Guatemala” as the grantee and “Pan American Union” 

as the investigator. In addition, the amount recommended for RG-65 was conspicuously large, over five 

times greater than any other grant approved during the meeting. Just over a year later, on May 14-15, 1947, 

Dr. Parran presided over another NAHC meeting that recommended a continuing grant, RG-65(C), in 

the amount of $105,800, the largest amount for any grant recommended at the meeting. Members present 

at the May 14-15 meeting were George Baehr, Gordon Fair, A. Baird Hastings, Carl S. Marvel, Karl F. 

Meyer, John H. Musser, Harry S. Mustard, Henry F. Vaughan, Cpt. O.L. Burton, Col. Karl R. Lundeberg, 

Harry W. Schoening, and R.E. Dyer. Also present were non-members Deputy Surgeon General James A. 

Crabtree, C.J. Van Slyke, Ernest Allen, John D. Porterfield, David E. Price, and Mary Switzer (Assistant 

to the Administrator, Federal Security Agency). PCSBI HSPI Archives, NARA-II_0000473-74; Medical 

Research Grants. (1947, April 26). JAMA 17(133): 1289 (which reported, “of the 193 grants that supplement 

existing funds of universities and other research institutions, the largest, $105,800 was recommended for a 

study of syphilis by the Pan American Sanitary Bureau”). 

217 In addition, PHS sent down materials and supplies. C.H. Morrison to John Cutler. (1946, November 4). 

Correspondence. PCSBI HSPI Archives, CTLR_0001262. The precise amount awarded and paid out 

for RG-65, 65(c) is unclear. Public Health Reports Supplement No. 205, revised shows that the total 

amount actually awarded for Grant 65, 65(c) as of August 31, 1948 was $171,950 ($44, 300 less than 

the total amount recommended by the NAHC). U.S. Public Health Service. (1948), Research Grants 

Awarded by PHS, Public Health Reports, Supplement No. 205, revised. p. 38. PCSBI HSPI Archives, 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

174

MISC_0000907. In addition to the grants funds that the PHS awarded to PASB, the PHS paid the salaries 

of five of researchers working on the STD studies in 1948 (John C. Cutler, Virginia Lee Harding, Sacha 

Levitan, Joseph Portnoy, and Alice Walker), worth $23,585.91 in services in kind. PASB. PASB Statement 

of Services in kind. (n.d.). PCSBI HSPI Archives PAHO_0000577-78. PASB salary records were not 

available for 1946 or 1947, but a conservative estimate for the combined years of 1946 and 1947 would be a 

$27,500 PHS contribution of services in kind. Combining these figures, the estimated amount that the PHS 

provided to PASB in direct funding and services for the purpose of conducting STD research in Guatemala 

is $223,032.91.

218 Pan American Sanitary Organization Executive Committee. Final Report of the Fourth Meeting of the 

Executive Committee of the Pan American Sanitary Bureau (1948, May 3-13). p. 9. PCSBI HSPI Archives, 

PITT_0000182.

219 Describing the construction in a 1951 publication, PASB serologist Genevieve Stout, on detail from the 

U.S. PHS, explained that it was “for the purpose of conducting an investigation of the serologic picture 

presented by the people in that area.” Stout, G.W., Cutler, J.C. (1951). Serology problems (syphilis) in 

Central America. Journal of Venereal Disease Information 32(7): 237.

220 Unsigned [John Cutler] to Richard Arnold. (1946, August 21). Correspondence. PCSBI HSPI Archives, 

CTLR_0001215.

221 Dr. Spoto was doing work in Guatemala on onchocerciasis (a parasitic disease that causes blindness). 

Working with Guatemala’s Dirección General de Sanidad Pública, Spoto and his colleagues examined 

more than 1,000 infected people around Guatemala City beginning in 1945. Clark, W.B. (1947). Ocular 

onchocerciasis in Guatemala: An investigation of 1,215 natives infected with onchocerca volvulus. 

Transactions of the American Ophthalmological Society 45:461-501.

222 Unsigned [John Cutler] to R.C. Arnold. (1946, August 21). Correspondence. PCSBI HSPI Archives, 

CTLR_0001215.

223 John Cutler to John Mahoney. (1946, September 3). Correspondence. PCSBI HSPI Archives, 

CTLR_0001213.

224 Ibid.

225 John Cutler to John Mahoney. (1946, October 1). Correspondence. PCSBI HSPI Archives, CTLR_0001210.

226 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000629. Joseph 

Portnoy followed in September 1946, Dr. Harlow arrived in winter 1947, and Dr. Levitan joined in 

spring 1947. John Cutler to John Mahoney (1946, September 3). Correspondence. PCSBI HSPI Archives, 

CTLR_0001213; John Cutler to John Mahoney. (1947, September 21). Correspondence. PCSBI HSPI 

Archives, CTLR_0001225; John Cutler to John Mahoney. (1947, February 4). Correspondence. PCSBI 

HSPI Archives, CTLR_0001047.

227 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000641. 

Agreements and “commitments” were also referred to in contemporaneous Cutler correspondence. 

See e.g., John Cutler to John Mahoney. (1946, September 3). Correspondence. PCSBI HSPI Archives 

CTLR_0001213; and John Cutler to John Mahoney. (1947, September 20). Correspondence. PCSBI HSPI 

Archives, CTLR_0001225. Copies of these agreements were not included in the Cutler Documents and 

have not been located. Searches were conducted in the PAHO archives and the National Archives.

228 While the agreements may have given the researchers the authority claimed, it is clear that some of the 

specifics, e.g., use of “orphans and the insane,” were undertaken well after his arrival in August 1946. 

See, e.g., John Cutler to John Mahoney. (1947, January 7). Correspondence. PCSBI HSPI Archives, 

CTLR_0001039. John Cutler to John Mahoney. (1946, September 3). Correspondence. PCSBI HSPI 

Archives, CTLR_0001213.

229 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000642. Dr. 

Cutler added that they would have access to “excellent facilities for close follow-up on syphilis” in the 

Military Hospital and Penitentiary. John Cutler to John Mahoney. (1946, September 3). Correspondence. 

PCSBI HSPI Archives, CTLR_0001213.

230 Ibid. While these agreements could not be located, requests were made to PAHO (the successor 

organization of PASB) and the U.S. government.
endnotes X

175

231 John Cutler. Final Syphilis Report. (1955, February 24). PCSBI HSPI Archives, CTLR_0000641.

232 John Cutler to John Mahoney. (1946, September 3). Correspondence. PCSBI HSPI Archives, 

CTLR_0001213.

233 In 1946 Dr. Mahoney told Dr. Cutler: “I have the highest regard for [Spoto’s] judgement and ability...” John 

Mahoney to John Cutler. (1946, November 18). Correspondence. PCSBI HSPI Archives, CTLR_0001194. 

234 John Cutler to John Mahoney. (1946, October 17). Correspondence. PCSBI HSPI Archives, 

CTLR_0001208.

235 John Cutler to John Mahoney. (1946, November 12). Correspondence. PCSBI HSPI Archives, 

CTLR_0001196.

236 PCSBI. (2011). Subject Database.

237 John Mahoney to John Cutler. (1946, October 15). Correspondence. PCSBI HSPI Archives, 

CTLR_0001200.

238 John Mahoney to John Cutler. (1946, November 18). Correspondence. PCSBI HSPI Archives,

CTLR_0001195.

239 John Cutler to John Mahoney. (1946, November 30). Correspondence. PCSBI HSPI Archives, 

CTLR_0001192.

240 [Translation]. Constantino Alvarez B. to John Cutler. (1946, December 26). Correspondence. PCSBI HSPI 

Archives, CTLR_0001068.

241 [Translation]. John Cutler to Constantino Alvarez B. (1947, January 13). Correspondence. PCSBI HSPI 

Archives, CTLR_0001068.

242 [Translation]. Carlos Tejeda to John Cutler. (1947, June 17). Correspondence. PCSBI HSPI Archives, 

CTLR_0001075.

243 John Cutler to Carlos Tejeda. (1947, June 26). Correspondence. PCSBI HSPI Archives, CTLR_0001072-73.

244 [Translation]. (1947). Primera Asamblea de Cirujanos Militares. Diario de Centro America. July 17, 1947. 

245 John Cutler to John Mahoney. (1947, January 20). Correspondence. PCSBI HSPI Archives, 

CTLR_0001041. 

246 Ibid.

247 Ibid. In his 1955 Final Syphilis Report, Dr. Cutler noted that the researchers instituted a serologic 

screening program for all new prison admissions, and set up a system of “prophylaxis” for prisoners 

having sexual contact with a woman other than a wife. John Cutler. (1955, February 24). Final Syphilis 

Report. PCSBI HSPI Archives, CTLR_0000644. However, the January 20, 1947 letter from Dr. Cutler to 

Dr. Mahoney suggests that a comprehensive prophylaxis program was placebo-based. John Cutler to John 

Mahoney. (1947, January 20). Correspondence. PCSBI HSPI Archives, CTLR_0001041.

248 PCSBI. (2011). Subject Database.

249 John Cutler. (1955, February 24). Final Syphilis Report, PCSBI HSPI Archives, CTLR_0000628. Dr. 

Robles was also listed as a “Guatemalan Government Participant” in the syphilis experiments in Dr. 

Cutler’s Final Syphilis Report. Ibid, PCSBI HSPI Archives, CTLR_0000629-30.

250 PCSBI. (2011). Subject Database.

251 John Cutler to John Mahoney (1947, January 10). Correspondence. PCSBI HSPI Archives, 

CTLR_0001040; John Mahoney to John Cutler (1947, January 20). Correspondence. PCSBI HSPI 

Archives, CTLR_0001049. 

252 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea Report. PCSBI HSPI Archives, 

CTLR_0001356; John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, 

CTLR_0000629; John Cutler. (n.d.). Chancroid Experiment Report. PCSBI HSPI Archives, 

CTLR_0000947.

253 John Cutler to John Mahoney. (1946, November 5). Correspondence. PCSBI HSPI Archives, 

CTLR_0001198.

254 John Cutler to John Mahoney. (1946, November 5). Correspondence. PCSBI HSPI Archives, 

CTLR_0001198.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

176

255 Ibid; John Cutler to John F. Mahoney. (1946, November 30). Correspondence. PCSBI HSPI Archives, 

CTLR_0001192.

256 John F. Mahoney to John Cutler. (1948, June 21). Correspondence. PCSBI HSPI Archives, CTLR_0001143; 

Falcone, H.H., Harris, A., Olansky, S., Salvado, C., Cutler, J.C. (1953). A study of the Neurath 

Inhibition Phenomenon in the serodiagnosis of syphilis. American Journal of Syphilis, Gonorrhea, and 

Venereal Diseases 37(3): 264-272. Memorandum to Mr. Gustavo An[i]rada to Mr. C.H. Morrison re: 

Pay-Consultants; Doctors Funes and Salvado. (1950, April 5). Correspondence. PCSBI HSPI Archives, 

NPRC_0001964.

257 Dr. Aragon was appointed director of the Orphanage in January 1946. Nuevo Director del Hospicio 

Nacional. (1946). Diario de Centro America, January 24. Dr. Aragon was the director at the Orphanage 

until 1951 when he was transferred. Homenaje al Doctor Aragon en sus bodas de oro profesionales. (1971). 

El Imparcial. December 4.

258 Stout, G.W., Cutler, J.C., op cit., p. 237; see generally Aragon, H.A. (1948, October). Estudio de la sifilis y 

pruebas de la serologia en el Hospicio Nacional de Guatemala. Salubridad y Asistencia; Levitan, S., et al. 

(1952, July). Clinical and serologic studies with reference to syphilis in Guatemala, Central America: I. 

Studies of comparative performance of the Kahn, Kolmer, Mazzini, and VDRL slide tests as carried out in 

the National Orphanage. American Journal of Syphilis, Gonorrhea, and Venereal Diseases 36:379. 

259 At the completion of the research Dr. Cutler concluded that the Kahn and Mazzini tests yielded yield high 

numbers of false positives whereas the Kolmer and VDRL slide tests had better specificity (accuracy). 

Funes, J.M., Cutler, J.C., Levitan, S., Portnoy, J., Funes, R. (1953). Estudios serológicos y clínicos con 

referencia a la sífilis in Guatemala, Centro America:II. Observaciones efectuadas en un grupo de niños de 

escuela en el Puerto de San José. Boletín de la Oficina Sanitaria Panamericana 34(1):14-18. The first two 

methods using lipoidal antigens resulted in significant numbers of false positives because the antibodies 

reacting with the antigen are not specific to syphilis. In fact, these antibodies can be present in numerous 

other conditions, including malaria and leprosy. Kahn, R.L. (1972). Syphilis serology with lipoidal antigen: 

The meaning of positive reactions. Journal of the National Medical Association 64(2):117-121. While 

cardiolipin antigens are also non-specific for syphilis, Dr. Cutler’s Final Syphilis Report cites a lower level 

of false positives through empirical testing: “flocculation tests using crude lipoidal antigen [the Kahn and 

Mazzini tests]...give a much higher rate of serological positivity than complement fixation tests using 

crude lipoidal or cardiolipin-lecithin antigens [the Kolmer test], or flocculation tests using cardiolipinlecithin antigens [the VDRL slide test].” John Cutler. Final Syphilis Report. (1955, February 24). PCSBI 

HSPI Archives, CTLR_0000675.

260 Dugdale, D.C. (2009, December 1). National Library of Medicine and National Institutes of Health. 

Medline Plus, Serology. Available at http://www.nlm.nih.gov/medlineplus/ency/article/003511.htm. 

261 Dugdale, D.C. (2009, December 1). National Library of Medicine and National Institutes of Health. 

Medline Plus, Cerebral spinal fluid (CSF) collection. Available at http://www.nlm.nih.gov/medlineplus/

ency/ article/003428.htm. (accessed September 8, 2011). Contemporaneous literature discusses the 

“fundamental importance” of spinal fluid examination in the detection of syphilis: “a guide to the effect of 

and need for treatment in both early and late neurosyphilis, the examination of the spinal fluid has become 

indispensable, and failure to insist on the test may rank as culpable negligence.” Stokes, J.H., Beerman, 

H., Ingraham, N.R. (1944). Modern Clinical Syphilology: Diagnosis, Treatment, Case Study. Philadelphia: 

W.B. Saunders Company, pp. 1094-1114.

262 John Cutler to John F. Mahoney. (1946, November 12). Correspondence. PCSBI HSPI Archives, 

CTLR_0001196.

263 Stout, G.W. (1962). Personnel Files, Nomination for Departmental Honor Award. PCSBI HSPI Archives, 

PCSBI HSPI Archives, NPRC_0002555.

264 John Cutler to John F. Mahoney. (1946, November 12). Correspondence. PCSBI HSPI Archives, 

CTLR_0001196.

265 John Cutler to John F. Mahoney. (1946, December 6). Correspondence. PCSBI HSPI Archives, 

CTLR_0001253. The VDSPH was a hospital primarily for commercial sex workers in Guatemala who 

were required by law to report to Prophylactic Dispensaries twice a week for physical exams. Reglamento 

de la Seccion de profilaxia y de enfermedades venéreas: Leyes conexas con el mismo. (1938, June). 

PCSBI HSPI Archives, CTLR_0001692-1693. Dr. Funes “was responsible for medical supervision of 
endnotes X

177

prostitution and of all rapid treatment centers where all venereal disease patients could be hospitalized 

for free treatment.” John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, 

CTLR_0000640. Dr. Cutler also performed several syphilis serology tests for the U.S. Air Base in San 

José, Guatemala, on men stationed there. John Cutler to the Commanding Officer, U.S.A. Air Base, San 

José Guatemala. (1946, December 21). Correspondence. PCSBI HSPI Archives, CTLR_0001245.

266 Blood samples from the Air Force were used for a study on the “Neurath inhibition phenomenon,” which 

was developed to aid in the serodiagnosis of syphilis. Originally tested by the VDRL Staten Island, the 

Neurath procedure was then carried out by the researchers in Guatemala “on a number of individuals in a 

population group giving a high percentage of positive reactions...” Blood specimens for this study were 

obtained from children in the Orphanage, school children in San José, and syphilitic adults in Guatemala 

City. U.S. men stationed at the Air Force Base in Guatemala were used as a control “to demonstrate 

whether reagents used and the performance of the procedure in Guatemala would elicit the same type of 

results as those obtained when the tests were performed in this country on individuals in the United States 

population.” Falcone, V.H., et al., op cit., pp. 264-265, 269. 

267 Insofar as the serology experiments were part of medical care, conventional practices in the United States 

would not have mandated any written or formalized consent for testing. Faden, R.R., Beauchamp, T.L. 

(2009). The concept of informed consent. In Vaughn, L. (Ed.). (2009). Bioethics: Principles, Issues, and 

Cases. New York: Oxford University Press, p. 146. However, while available records show three children 

in the Orphanage received treatment for congenital syphilis, there is no record of treatment for the other 

children. Levitan, S., et al., op. cit., pp. 380-381.

268 PCSBI. (2011). Subject Database.

269 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000643.

270 There were still outstanding questions regarding whether persons with untreated syphilis were resistant to 

infection with a different strain of syphilis, or whether persons with treated latent syphilis were immune 

to reinfection. If both of those questions held true, and many of the prisoners had syphilis already, there 

would be few men that would make adequate prophylaxis subjects. John Cutler. (1955, February 24). Final 

Syphilis Report. PCSBI HSPI Archives, CTLR_0000646.

271 Ibid. 

272 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000648.

273 Ibid.

274 However, it does not appear as though the prisoners were subjected to more invasive serological testing 

methods used by the researchers later in other populations, such as lumbar or intra cisternal punctures.

275 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000652.

276 It is not clear when the research began, however Dr. Cutler wrote to Dr. Arnold in June 1947 to tell him 

they were going to San José to “work again” with the children. In the same letter, Dr. Cutler explained 

that testing in the Orphanage was more preliminary (“We have begun with the orphanage, but have barely 

touched it, so that there is nothing to report”). Unsigned [John Cutler] to Richard Arnold. (1947, June 5). 

Correspondence. PCSBI HSPI Archives, CTLR_0001240.

277 Ibid; PCSBI HSPI Archives, CTLR_0001240; Levitan, S., et al., op cit., p. 379. Data analysis continued 

until the early 1950s. Stout, G.W., op cit.

278 This number is made up of 515 children from the Orphanage, 151 children from the Port of San José, 277 

“Indian” children from Totonicapan, and 441 “Ladino” children from the “highlands” of Guatemala. Stout, 

G.W., op cit., p. 238.

279 Ibid, pp. 238-239.

280 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000649. Dr. 

Cutler’s records do not reflect why congenital syphilis would be readily apparent to the researchers, but 

there are many clinical symptoms of congenital syphilis that differentiate from sexually acquired syphilis. 

Stokes, J.H., op cit., pp. 1094-1114. Dr. Funes repeated this rational in his article on the children, arguing 

that “to study false positive reactions to the serologic tests, it is necessary to select a group that is not 

sexually mature and in which the probability of acquired syphilis is minimal” [translation]. Funes, J.M., et 

al., op cit., pp.14-18.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

178

281 Funes, J.M. (1949, enero). Avances venereológicos en la sección correspondiente de la Dirección General 

de Sanidad Pública de Guatemala. Boletín de la Oficina Sanitaria Panamericana 28(1):48-49.

282 Aragon, H.A. (1948, October). Estudio de la sífilis y pruebas de la serología en el Hospicio Nacional de 

Guatemala. Salubridad y Asistencia: 187-190.

283 The investigators reported that this was funded in part by the PHS grant to PASB, RG-65/65(C). Funes, 

J.M., et al., op cit.

284 John Cutler to Willard H. Wright. (1948, February 13). Correspondence. PCSBI HSPI Archives, 

CTLR_0001173; This data was later published in Wright, W.H., Dobrovolny, C.G. (1953). Experiments 

in the control of schistosomiasis in Brazil. Public Health Reports 68(12):1156-1160. Willard H. Wright 

to John Cutler. (1948, February 18). Correspondence. PCSBI HSPI Archives, CTLR_0001174. Dr. Funes 

similarly writes of sending blood samples from school-aged children from Puerto de San Jose to the 

Laboratory of Tropical Disease in the United States for further analysis of suspected malaria. Funes, J.M., 

et al. (1953). Estudios serológicos y clínicos con referencia a la sífilis en Guatemala, Centro America: II. 

Observaciones efectuadas en un grupo de ninos de Escuela en el Puerto de San José. Boletín de la Oficina 

Sanitaria Panamericana 34(1):15. In mid-1948, the government of Guatemala, in cooperation with the 

U.S. Public Health Service and the Pan American Sanitary Bureau, began a large-scale malaria study in 

various locations across Guatemala. Schmidt, L.H. and Coatney, G.R. (1955). Review of investigations 

in malaria chemotherapy (U.S.A. 1946 to 1954). American Journal of Tropical Medicine and Hygiene

4(2):208-216; Dobrovolny, C.G., et al. (1953). Chloroquine and chlorguanide as suppressants of malaria 

in Guatemala. American Journal of Tropical Medicine and Hygiene 2(5): 808-845. Dr. Charles S. 

Dobrovolny, a parasitologist at the Tropical Disease Laboratory at NIH and a commissioned officer, 

was assigned to PASB for the malaria study in Guatemala. PASB Statement of Service in Kind. (n.d.). 

PCSBI HSPI Archives, PAHO_0000578; Wright, W.H., Dobrovolny, C.G., op cit. Dr. Dobrovolny and 

his supervisor in the malaria studies, Dr. Coatney, published a paper in 1953 detailing their malaria 

surveys and treatment studies across Guatemala. Dobrovolny, C.G., White, W.C., and Coatney, G.R. 

(1953). Chloroquine and chlorguanide as suppressants of malaria in Guatemala. American Journal of 

Tropical Medicine and Hygiene, 808-845. Dr. Coatney was the same physician who had discussed his 

observations of the Guatemala experiments with Dr. Parran and who wrote to Dr. Cutler in the winter of 

1947 to inform him of Dr. Parran’s “merry” reaction as described in the section on “Race and Secrecy in 

the Guatemala Experiments: Issues of Secrecy.” G. Robert Coatney to John C. Cutler. (1947, February 17). 

Correspondence. PCSBI HSPI Archives, CTLR_0001051.

285 John Cutler to John F. Mahoney (1947, June 6). Correspondence. PCSBI HSPI Archives, CTLR_0001070.

286 Funes, J.M., et al., op cit.

287 Ibid. There is no information indicating whether the children with confirmed syphilis were treated. 

288 [Unsigned] John Cutler to J. F. Mahoney. (1947, September 18). Correspondence. PCSBI HSPI Archives, 

CTLR_0001228. Completed research was published in 1953. Funes, J.M., Cutler, J.C., Levitan, S., Portnoy, 

J., Funes, R. Estudios serológicos y clínicos con referencia a la sífilis in Guatemala, Centro America: II. 

Observaciones efectuadas en un grupo de niños de escuela en el Puerto de San José. Boletín de la Oficina 

Sanitaria Panamericana 14-18.

289 There are conflicting data in some of the articles regarding how many children were involved from the 

Orphanage, as well as their ages. Stout et al. reported that 515 children were involved, confirmed by the 

report from the director of the Orphanage, ages 1 to 18 years. Dr. Levitan et al. reported that 438 children 

were involved, ages 6 to 16. The reason for the discrepancies is unclear. See Stout, G.W., op cit., p. 238; but 

see Levitan, S., et al., op cit., p. 379. In published reports, the Ministry of Public Health is credited with 

sponsoring the study which was also “aided by a grant from the United States Public Health Service to the 

Pan-American Sanitary Bureau.” Levitan, S. et al., op cit., p. 379. 

290 The Second Congress of Venereal Diseases in Central America, “an event that is singularly momentous 

for the country of Guatemala with regard to the fight against widely extended diseases,” ran from April 

26-May 1, 1948. [Translation]. (1948). Segundo Congreso de Venereologia el 25: Asistiran Observados de 

los Estados Unidos, Mexico y Cuba y Paises Centroamericanos. El Imparcial. April 5, 1948. The United 

States, Cuba, Mexico, Panama, and the republics of Central America were all participants. The organizing 

committee of the Second Congress included Drs. Galich, Funes, Aguilar, Tejeda, and Cutler. (1947). 

Guatemala sera sede del II Congress de Venereologia. El Imparcial. April 29, 1947. Dr. Arnold requested 

to Dr. Cutler that any papers the researchers wanted to present there be forwarded to VDRL Staten Island 
endnotes X

179

for approval. R.C. Arnold to John Cutler. (1947, December 30). Correspondence. PCSBI HSPI Archives, 

CTLR_0001108. The topics of the congress included: “a) Valuation of penicillin in the treatment of 

syphilis; b) Evaluation of semi-intensive 20-day arsenotherapy; c) Study of the action of sodium, salicylate 

in the treatment of venereal lymphogranuloma and appreciation of other methods of treatment; d) Results 

obtained on the repressive system of prostitution in general and related studies on its economic aspect; e) 

Evaluation of the probability of marriage among syphilitics treated with intensive systems; f) Venereal 

disease in infancy; g) Open topics always related to the general topics” [Translation]. Other topics to be 

addressed by sub-committees included: “a) Social and legislative problems; b) Gonorrhea; c) Psychiatry of 

prostitution; d) Neurosyphilis; e) Serology; f) Intensive treatment; g) Other venereal diseases; h) Venereal 

diseases and infancy; i) Penicillin therapy” [Translation]. (1948). Segundo Congreso de Venereologia 

el 25: Asistiran Observados de los Estados Unidos, Mexico y Cuba y Paises Centroamericanos. El 

Imparcial. April 5, 1948. Attendants included Drs. Arnold and Spoto as well as “[f]our American doctors 

representing the army, navy, military and civil aviation...” [Translation]. (1948). Un acontecimiento sera 

el Congreso de Venereologia: Eminencias medicas de otros paises concurriran, ademas. Diario de Centro 

America. (April 15, 1948), p. 7. Pan American Sanitary Bureau. (1948). Expenditure Breakdown: Calendar 

Year 1948. PCSBI HSPI Archives, PAHO_0000568. Dr. Galich reported at this Congress that “trials or 

tests with penicillin are being conducted, up to now with the outstanding results, to prove conclusively 

that primary syphilis can be cured with only one ampoule or dose, just as is done in the United States 

seemingly with great success. [Translation]. (1948). Sistemas de Diagnostico al Congreso de Venereas. El 

Imparcial. April 29, 1948. 

291 Aragon, H.A. (1948). Estudio de la sifilis y pruebas de la serologia en el Hospicio Nacional de Guatemala. 

Salubridad y Asistencia 20:187-190.

292 Ibid, p. 187.

293 Levitan, S., et al., op cit., pp. 380-381.

294 Ibid. (“By the time that 55 [children], called at random, had been checked, in addition to the 3 seropositive 

children, it was believed that a sufficient number of study cases had been assembled.”) Thus, 34 children 

who had some sort of doubtful seropositive result were not examined further for clinical manifestations of 

syphilis.

295 None of the 89 seroreactors exhibited obvious further clinical symptoms of syphilis during the observation 

period. In their study, the investigators concluded that the Kolmer and VDRL tests were best for routine 

use “under conditions such as exist in the region from which this group is drawn.” Levitan, S., et al., op 

cit., p. 387. Lumbar punctures at the time would have been considered standard of care for diagnosis of 

syphilis. The risks associated with such a lumbar puncture include a post-procedure headache, which 

may be accompanied by nausea, vomiting, and dizziness. The children also faced the risk of experiencing 

radiating back pain, serious bleeding, and rarely infectious meningitis or brainstem herniation from this 

procedure, though there was no documentation of adverse events. Mayo Clinic. (2010). Lumbar puncture 

(spinal tap) – Definition. Available at http://www.mayoclinic.com/health/lumbar-puncture/MY00982 

(accessed May 27, 2011). 

296 Stout, G.W., op cit., p. 239.

297 Ibid.

298 Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clinical Notebook. 

PCSBI HSPI Archives, CTLR_0000620.

299 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000704.

300 Unsigned [John Cutler] on PASB letterhead to Richard Arnold. (1947, June 5). PCSBI HSPI Archives, 

CTLR_0001240; Levitan, S. et al., op cit., p. 379. Data analysis continued until the early 1950s. Stout, 

G.W., op cit.

301 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000649.

302 While the study results were published in 1952, the dates of the research are not clear. The VDRL team for 

this work also included Ramiro Galvez (a bacteriologist from the VDRL stationed in Georgia). Portnoy, J., 

et al. (1952). Op cit., pp. 566-70.

303 Portnoy, J., et al., op cit.

304 Ibid.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

180

305 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000649. A 

contemporaneous newspaper article noted that the Psychiatric Hospital “is far from possessing all the 

characteristics inherent in a first-rate institution; nevertheless, as far as the scientific and material, little 

by little modifications and reforms have been introduced that have converted it into something of a bit of 

paradise in comparison to what it was three decades ago, when the institution merited the name ‘house 

of the insane,’ as it was nothing more than a place in which to pile all those who for any reason could be 

qualified as crazy.” (1947). Servivio Quirurgico para el Hospital de Neuro-Psiquiatria. Diario de Centro 

America. July 21, 1947. 

306 Ibid.

307 PCSBI. (2011). Subject Database.

308 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000669.

309 It is unclear whether the leprosy study could have provided a useful comparison. Furthermore, as with 

his retrospective claims about the decision to begin testing in children, the timeline for this statement is 

questionable. Intentional exposure work (requiring accompanying serological diagnostic testing) began in 

the Psychiatric Hospital in May 1947. John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI 

Archives, CTLR_0000694.

310 Cutler Documents (1953). Report on Serologic Follow-up on Patients Done at CDC in 1953, Samples sent 

from Guatemala. PCSBI HSPI Archives, CTLR_0001433-76. These numbers are rough as there are subject 

data missing making an exact count impossible (e.g., for some subjects only the subject number [without 

a name] is included; as there are several subjects with the same number it is impossible to tell whether it is 

the same subject being tested twice or the data represents two different subjects).

311 See, e.g., Cutler Documents. (1953). Report on Serologic Follow-up on Patients Done at CDC in 1953, 

Samples sent from Guatemala. PCSBI HSPI Archives, CTLR_0001436.

312 Ibid.

313 PCSBI. (2011). Subject Database.

314 Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clinical notebook. 

PCSBI HSPI Archives, CTLR_0000611. Dr. Cutler’s retrospective counts of his experiments, however, are 

inconsistent. According to his contemporaneous notes, subjects were exposed to gonorrhea on 67 different 

days. PCSBI. (2011). Subject Database.

315 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000694-

746. Dr. Cutler’s retrospective counts of his experiments, however, are inconsistent. According to his 

contemporaneous notes, subjects were exposed to syphilis on 52 different days. PCSBI. (2011). Subject 

Database.

316 John Cutler. (n.d.). Chancroid Experiment. Report. PCSBI HSPI Archives, CTLR_0000947. Dr. Cutler’s 

retrospective counts of his experiments, however, are inconsistent. According to his contemporaneous 

notes, subjects were exposed to chancroid on four different days. PCSBI. (2011). Subject Database. 

317 Dr. Cutler’s count of experiments is incomplete as it does not include several experiments conducted to 

assess infection methods and many individual observational inoculations presumably were excluded as 

they were not part of a larger controlled study. See, e.g., John Cutler. (1955, February 24). Final Syphilis 

Report. PCSBI HSPI Archives, CTLR_0000885; and Cutler Documents. Insane Asylum Asilo Des 

Alienados and Prison Patient Records. (various Dates). Subjects Note Card. PCSBI HSPI Archives, 

CTLR_0004157. In addition, the contemporaneous notes Dr. Cutler took often contradict the data included 

in the reports he later wrote. See, e.g., Cutler Documents. (1947). [Subjects names]. Subjects Note Cards 

and Lists. PCSBI HSPI Archives, CTLR_0001806, CTLR_0001809, CTLR_0001810, CTLR_0001812, 

CTLR_0001813, CTLR_0001816; but see John Cutler. (1952, October 29). Experimental Studies in 

Gonorrhea. Report. PCSBI HSPI Archives, CTLR_0001299. For this reason, the Commission report will 

discuss days of experiments rather than number of experiments for accuracy. This day count will not 

include days on which commercial sex workers were infected as Dr. Cutler did not consider these instances 

experiments or the sex workers as subjects.

318 PCSBI. (2011). Subject Database. “Exposure” to an STD is not the same as being “infected” with an STD. 

Subjects who were exposed to an STD by the researchers ran the risk of becoming infected with that 

STD—however many of the subjects that were exposed to an STD were not in fact infected.
endnotes X

181

319 PCSBI. (2011). Subject Database. Overall, there were 18 subjects involved in the intentional exposure 

experiments who were under the age of 18 (including a 10 and 15-year-old soldier, a 16-year-old sex 

worker, a 15-year-old prisoner, and 14 psychiatric patients ranging in age from 14 to 17). The youngest 

subject involved in the STD exposure experiments was a 10-year-old soldier who was a member of the 

Honor Guard. As part of the experiments, he had sexual intercourse three times with a commercial sex 

worker infected with gonorrhea and was superficially inoculated in his penis with gonorrhea-infected 

pus once. The subject’s age was recorded in two separate places. Cutler Documents. (1947). Gonorrhea 

Experiment #1. Clinical notes, protocols, and subject note cards. PCSBI HSPI Archives, CTLR_0001738, 

CTLR_0001743, CTLR_0001748, CTLR_0001769, CTLR_0001770; Cutler Documents. (1947-

1948). Guatemala Journal Studies with the Military (GC). Clinical notebook. PCSBI HSPI Archives, 

CTLR_0000561; and Cutler Documents. (1947-1948). Gonorrhea Experiments: Military. Lists and clinical 

notes. PCSBI HSPI Archives, CTLR_0001971. Studies have shown that sexual intercourse before the age 

of 13 is possible. CDC. (2010, June 4). Youth Risk Behavior Surveillance-United States, 2009. Available at 

http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf (accessed August 10, 2011).

320 This is according to contemporaneous Cutler notes. PCSBI. (2011). Subject Database. While treatment 

with penicillin or sulfathiazole was recorded for many of the subjects, some of the subjects involved were 

released or escaped before treatment; homosexual contacts may have spread the disease further than the 

researchers charted; and some subjects not showing clinical manifestations of the disease were never 

treated, despite testing positive.

321 For the original plan of Dr. Cutler’s study, see Section “Initial Study Design.”

322 In addition, some studies were designed in a way that subjects in the active arm of the experiment, (testing 

the prophylaxis), were given a less effective form of inoculation than the control arm, thus making the 

prophylaxis appear more effective (see, e.g., experiment 31 in which the researchers used superficial 

inoculation for the active arm, but deep inoculation for the control group—a method they knew to be more 

likely to transfer gonorrhea). Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military 

(GC). Clinical notebook. PCSBI HSPI Archives, CTLR_0000602. 

323 PCSBI. (2011). Subject Database.

324 Ibid. This number excludes several subjects for whom the records reflect confusion as to whether the 

subject died or not. See, e.g. Cutler Documents. (n.d.). Penitentiary, Alphabetical Lists of Patients by 

Number. PCSBI HSPI Archives, CTLR_0001500. Seventy-six of the 83 subjects that the researchers 

recorded as having passed away were involved in the STD exposure experiments. 

325 These deaths occurred “either during the inoculation stage, during the active phase of the disease, 

or post treatment.” John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, 

CTLR_0000672.

326 Ibid. The researchers offered staff at the Psychiatric Hospital “a few extra dollars” to notify them of subject 

deaths so that autopsies could be performed. John Cutler. (1955, February 24). Final Syphilis Report. 

PCSBI HSPI Archives, CTLR_0000674. This practice is consistent with the PHS/Venereal Disease 

Division activities in the Tuskegee Syphilis Study, where Dr. R.A. Vonderlehr coordinated with a wide 

variety of agencies and individuals, including Dr. Eugene Dibble, a physician at the Tuskegee Institute to 

whom he offered a PHS appointment, to ensure that researchers were notified of subject deaths to facilitate 

autopsies. Jones, J.H. (1993). Bad Blood: The Tuskegee Syphilis Experiment. New York: The Free Press, 

pp. 132-150. No autopsy reports were found in the Cutler Documents, but there are records of tissue 

samples from seven subjects being sent to Dr. James D. Thayer at the Venereal Disease Experimental 

Laboratory in Chapel Hill, North Carolina in April 1957. The Venereal Disease Experimental Laboratory 

was part of the PHS Venereal Disease Branch and was also associated with the University of North 

Carolina, Chapel Hill. John Cutler to L.L. Ashburn. (1957, January 7). Correspondence. PCSBI HSPI 

Archives, CTLR 0001531; L.L. Ashburn to James Thayer. (1957, April 3). PCSBI HSPI Archives, CTLR 

000152.

327 PCSBI. (2011). Subject Database.

328 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001299.

329 Ibid, PCSBI HSPI Archives, CTLR_0001285.

330 John Cutler to R.C. Arnold. (1947, September 16). Correspondence. PCSBI HSPI Archives, 

CTLR_0001230.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

182

331 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001285. This dosage meets the standard of care treatment for gonorrhea at the time. Perkins G.E., 

Brewster, H.N. (1947). Penicillin in the treatment of gonorrhea in women: Results of treatment as reported 

and by twelve co-operating venereal-disease clinics in Massachusetts during 1945. New England Journal 

of Medicine 236(8):280.

332 See e.g., Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC), Notebook 4. 

Clinical notebook. PCSBI HSPI Archives, CTLR_0000505.

333 PCSBI. (2011). Subject Database.

334 Cutler Documents. (1947). Gonorrheal experiment #1. Clinical notes, protocols, and subject notecards. 

PCSBI HSPI Archives, CTLR_0001736-79.

335 Gram staining and culture were used, sometimes individually and sometimes together, to detect the 

bacteria that causes gonorrhea. The Gram stain test required samples from swabs of the urethra (in males) 

or cervix (in females) to be stained and microscopically examined for Neisseria gonorrhoeae. Although 

Gram stain tests are relatively accurate for males, they are only accurate in 40 percent to 60 percent of 

infected females. The bacterial culture test, which was more accurate but also more time consuming, 

required the samples to be placed onto culture medium specific for Neisseria gonorrhoeae to determine 

if the bacteria was present. Oxtoby, M., et al. (1982). Potential shortcuts in the laboratory diagnosis of 

gonorrhea: a single stain for smears and nonremoval of cervical secretions before obtaining test specimens 

Sexually transmitted diseases. 9(2):59-62. 

336 PCSBI. (2011). Subject Database.

337 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001285.

338 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001356; John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, 

CTLR_0000629.

339 While no syphilis experiments were actually conducted in the Guatemalan Army, Dr. Cutler still listed 

these men as participants in his Final Syphilis Report. It is possible that they became involved as they 

were overseeing syphilitic patients of their own. In addition, some syphilis human passage material (i.e., 

chancres) was taken from Guatemalan Army patients. John Cutler, Final Syphilis Report. (1955, February 

24). PCSBI HSPI Archives, CTLR_0000629.

340 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001302.

341 Unsigned [John Cutler] to Richard Arnold. (1947, September 16). Correspondence. PCSBI HSPI Archives,

CTLR_0001230. The Guardia de Honor (Presidential Honor Guard) was a unit created for the President of 

Guatemala’s personal protection. Gleijeses, P. (1991). Shattered Hope: the Guatemalan Revolution and the 

United States, 1944-1954. Princeton, N.J.: Princeton University Press, p. 16.

342 See, e.g., Cutler Documents. (1948, June 28-29). Guatemala Journal Studies with the Military (GC). 

Clinical notebook. PCSBI HSPI Archives, CTLR_0000602.

343 PCSBI. (2011). Subject Database.

344 See, e.g., Cutler Documents. (1947, February 14). Gonorrheal experiment #1. Clinical notes, protocols, and 

subject note cards. PCSBI HSPI Archives, CTLR_0001749-1778.

345 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001280.

346 John Cutler to John Mahoney. (1947, September 16). Correspondence. PCSBI HSPI Archives, 

CTLR_0001126.

347 See, e.g., Cutler Documents. (1947-1948). Gonorrhea Experiments: Military. Lists and clinical notes. 

PCSBI HSPI Archives, CTLR_0001878. 

348 John Mahoney to John Cutler. (1947, June 30). Correspondence. PCSBI HSPI Archives, CTLR_0001078.

349 Ibid.
endnotes X

183

350 See Cutler Documents. (1947). Gonorrheal experiment #1. PCSBI HSPI Archives, CTLR_0001736-79 

and Cutler Documents. (1947). Gonorrheal experiment #2. Clinical notes and subject note cards. PCSBI 

HSPI Archives, CTLR_0001780-1801; but see John Cutler. (1952, October 29). Experimental studies in 

Gonorrhea. Report. PCSBI HSPI Archives, CTLR_0001299. 

351 PCSBI. (2011). Subject Database.

352 The Venereal Disease and Sexual Prophylaxis Hospital still stands today in Guatemala City and a 

delegation from the Commission visited it in May 2011. A 1937 plaque on the building dedicated it to three 

people including Mr. John D. Rockefeller and Dr. Hugh S. Cumming, former U.S. Surgeon General (1920-

1936) and PASB Director from 1937 to 1947.

353 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001279-80.

354 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000640.

355 The copy he retained was of the regulations in 1938. It is not clear how the regulations changed, if at all, 

before Dr. Cutler undertook his experiments. 

356 Reglamento de la Seccion de profilaxia y de enfermedades venéreas: Leyes conexas con el mismo. (1938 

June). PCSBI HSPI Archives, CTLR_0001691.

357 Ibid, PCSBI HSPI Archives, CTLR_0001686-735.

358 Ibid, PCSBI HSPI Archives, CTLR_0001692; Funes, J.M. (1949, enero). Avances venereológicos en la 

sección correspondiente de la Dirección General de Sanidad Pública de Guatemala. Boletín de la Oficina 

Sanitaria Panamericana 28(1):46. The treatment with arsenical drugs was not related to the U.S. PHS STD 

experiments, which predominently used penicillin as a treatment.

359 The intentional infection procedures are discussed below. 

360 Cutler Documents. (1947). Gonorrheal experiment #1. Clinical notes, protocols, and subject note cards. 

PCSBI HSPI Archives, CTLR_0001737.

361 However, “[i]t was not feasible to carry on further studies with respect to alcohol on rate of infection.” 

John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001287. 

362 Ibid. 

363 PCSBI. (2011). Subject Database. 

364 This payment was documented on one day for one experiment involving multiple exposures. Cutler 

Documents. (1947). Gonorrheal experiment #2. Clinical notes and subject note cards. PCSBI HSPI 

Archives, CTLR_0001781-97. In 1947, $25 had the same buying power as $253 in 2011.

365 See, e.g., Cutler Documents. (various dates). Gonorreal experiment #1. Clinical notes, protocols, and 

subject note cards. PCSBI HSPI Archives, CTLR_0001736-1800. 

366 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001280.

367 Ibid.

368 Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clinical notebook. 

PCSBI HSPI Archives, CTLR_0000620.

369 Cutler Documents. (1947). Gonorrheal Experiment #1. Clinical notes, protocols, and subject note cards. 

PCSBI Archives, CTLR_0001736-79. The placebo used in most experiments was an injection of 0.5 cc of 

sterile, distilled water. See, e.g., Ibid, PCSBI HSPI Archives CTLR_0001751.

370 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001286.

371 It is unclear from Dr. Cutler’s notes whether these deviations were intentional. See Cutler Documents. 

(1947). Gonorrheal Experiment #1. Clinical notes, protocols, and subject note cards. PCSBI HSPI 

Archives, CTLR_0001749-78. 

372 Referred to as “exposures” by Dr. Cutler. John Cutler. (1952, October 29). Experimental Studies in 

Gonorrhea. Report. PCSBI HSPI Archives, CTLR_0001280.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

184

373 Cutler Documents. (1947). Gonorrheal Experiment #1. Clinical notes, protocols, and subject note cards. 

PCSBI HSPI Archives, CTLR_0001749-78. The failure to confirm that the sex workers were infected at the 

time of the experiment may have undermined the validity of the study.

374 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001280.

375 See Cutler Documents. (1947). Gonorrheal Experiment #1. Clinical notes, protocols, and subject note 

cards. PCSBI HSPI Archives, CTLR_0001761-75.

376 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives 

CTLR_0001286.

377 Ibid, PCSBI HSPI Archives, CTLR_0001299.

378 John Mahoney to John Cutler. (1947, February 10). Correspondence. PCSBI HSPI Archives, 

CTLR_0001048.

379 John Cutler to John Mahoney. (1947, March 12). Correspondence. PCSBI HSPI Archives, CTLR_0001054.

380 John Cutler to John Mahoney. (1947, January 2). Correspondence. PCSBI HSPI Archives, CTLR_0001034.

381 John Cutler to John Mahoney. (1947, January 7). Correspondence. PCSBI HSPI Archives, CTLR_0001037. 

After the trip, Dr. Arnold wrote to Dr. Cutler that the rabbit inoculations were a failure and that none 

exhibited pinto. Richard Arnold to John Cutler. (1947, April 10). Correspondence. PCSBI HSPI Archives, 

CTLR_0001037.

382 Richard Arnold to John Cutler (1947, April 10). Correspondence. PCSBI HSPI Archives, CTLR_0001190.

383 Ibid. Most likely meaning that Dr. Cutler should stretch the truth. 

384 Ibid.

385 Richard Arnold to John Cutler. (1947, April, 11). Correspondence. PCSBI HSPI Archives, CTLR_0001061.

386 Culter Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clnical notebook. 

PCSBI HSPI Archives, CTLR_0000513.

387 Cutler Documents. (1947). Gonorrheal Experiment #4. Clinical notes and subject note cards. PCSBI HSPI 

Archives, CTLR_0001823; Guatemala Journal Studies with the Military (GC). Clinical notebook. PCSBI 

HSP I Archives, CTLR_0000513. 

388 Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clinical notebook. 

PCSBI HSP I Archives, CTLR_0000513. 

389 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001299. Dr. Cutler published that result nearly three decades later: “[s]tudies in gonorrhea have 

indicated that the risk to the male in contact with an infected female is roughly one in 20 for a single 

contact.” Dr. Cutler cites an “[u]npublished observation” by Dr. Funes and himself for this data. Cutler, J.C. 

et al. (1973, February). Op cit., p. 89.

390 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001299-1302.

391 Ibid, PCSBI HSPI Archives, CTLR_0001282.

392 Ibid, PCSBI HSPI Archives, CTLR_0001283.

393 Ibid.

394 John Cutler to John Mahoney. (1947, May 17). Correspondence. PCSBI HSPI Archives, CTLR_0001121.

395 Ibid, PCSBI HSPI Archives, CTLR_0001121-22.

396 Unsigned [John Cutler] on PASB letterhead to Richard Arnold. (1947, June 5). Correspondence. PCSBI 

HSPI Archives, CTLR_0001240.

397 John Cutler to John F. Mahoney. (1947, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001242.

398 Reports to a Conference Held Under the Auspices of the Subcommittee on Venereal Diseases 9 February 

1944, on the Chemical Prophylaxis of Venereal Disease. (1944, February 9). PCSBI HSPI Archives, 

NAS_0003113-18. 
endnotes X

185

399 John Mahoney to John Cutler. (1947, June 30). Correspondence. PCSBI HSPI Archives, CTLR_0001077. 

However, Mahoney’s opinion with regard to artificial inoculation reflects some uncertainly as well. Mahoney, J.F., Van Slyke, C.J., Cutler, J.C., Blum, H.L. (1946). Op cit., 24. Dr. Mahoney’s stated preference 

for “contact” methods as a mode of inoculation apparently applied to both the gonorrhea and syphilis 

studies, as described in “Syphilis Experiments: Psychiatric Hospital: Scarification and Abrasion” section 

regarding the contact method for syphilis transmissions, and in his syphilis research in rabbits. Mahoney, 

J. (1936). An experimental resurvey of the basic factors concerned in prophylaxis in syphilis. The Military 

Surgeon 352-353.

400 John Mahoney to John Cutler. (1947, August 11). Correspondence. PCSBI HSPI Archives, CTLR_0001086. 

Dr. Mahoney sent this letter to Dr. Cutler through the Director of PASB, and forwarded to Assistant 

Director, John Murdock.

401 John Cutler to John Mahoney. (1947, August 25). Correspondence. PCSBI HSPI Archives, 

CTLR_0001085.

402 PCSBI. (2011). Subject Database. Separate experiments for this section are defined as a group of exposures 

done with the same population and the same STD on the same day. How Dr. Cutler defined his own use of 

numbering the experiments is unclear, and he does not account for all of his data.

403 It is not clear to whom the term “authors” refers, as it appears that only Dr. Cutler wrote up the 

Experimental Studies in Gonorrhea report. In the report, after the word “authors,” a citation is added to 

the Terre Haute article, “Experimental Gonococci Urethritis in Human Volunteers” by Drs. Mahoney, Van 

Slyke, Cutler, and Blum. John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. 

PCSBI HSPI Archives, CTLR_0001286.

404 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001286.

405 Ibid, PCSBI HSPI Archives, CTLR_0001288.

406 Minutes of the Twenty-First Meeting of the Subcommittee on Venereal Diseases. (1943, November 

11). PCSBI HSPI Archives, NAS_0002782; Reports to a Conference Held Under the Auspices of the 

Subcommittee on Venereal Diseases 9 February 1944, on the Chemical Prophylaxis of Venereal Disease. 

(1944, February 9). PCSBI HSPI Archives, NAS_0003114-18. 

407 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001303-4.

408 Ibid, PCSBI HSPI Archives, CTLR_0001290.

409 Ibid. 

410 Ibid, PCSBI HSPI Archives, CTLR_0001286.

411 PCSBI. (2011). Subject Database.

412 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. CTLR_0001302. In 1948, 

after Dr. Cutler concluded that sexual intercourse experiments with sex workers were ineffective for 

experimental transmission of disease, Dr. Funes and Casta Luz Aguilar (who succeeded Dr. Galich as 

the Chief of the Guatemalan Ministry for Public Health) decided to test the effectiveness of the orvusmapharsen prophylaxis in sex workers. While Dr. Arnold and Dr. Mahoney concluded in their 1948 animal 

study of orvus-mapharsen that “the preparation should be suitable for use in a douche” for women, Dr. 

Funes and Aguilar decided to test its use as a post-coital prophylactic douche in female commercial sex 

workers “under legal supervision” in a Guatemalan brothel [translation]. In their published article, they 

argued that commercial sex-regulating bureaus and agencies in the Americas relied too heavily on the 

condom (which clients of sex workers often refused to use) to both protect sex workers and prevent the 

spread of the disease. Dr. Funes and Aguilar used six sex workers in the experiment that “had previously 

been followed for a long time by the first author [Dr. Funes]...” [translation]. These are possibly some 

of the same women used in the U.S. PHS normal exposure experiments, although it is unclear. After 

recording the women’s sexual activities for six months, Dr. Funes and Aguilar determined that use of 

the orvus-mapharsen douche produced a decrease in the incidence of gonorrhea. There is no record of 

them intentionally inoculating the sex workers for this experiment; however, if these women had been 

used in the U.S. PHS’s normal exposure experiments, they may have already been inoculated for those 

purposes. There is also no record of the researchers determining the rates of STD infection in the men with 
“Ethically Impossible” STD Research in Guatemala from 1946-1948

186

whom the sex workers had contact, indeed “precise observations were not made” of the women’s sexual 

contacts [translation]. Arnold, R.C., Mahoney, J.F. (1948). Local prophylaxis in experimental syphilis of 

the rabbit. Journal of Venereal Disease Information 29:138-41; Funes, J. Aguilar, C.L. (1952 agosto). La 

solución de mafarside-orvus en la profilaxis de la blenorragia de la mujer. Boletín de la Oficina Sanitaria 

Panamericana 33(2):121-125. Dr. Cutler discussed this study in a later article on STD prophlaxis; however, 

he added “[s]tudies involving the exposure of non-infected volunteers to infected contacts in order to 

observe relative rates of protection have become increasingly difficult, due to the rigid medical research 

ethics now operative.” Cutler, J.C., et al., (1973). Op cit., p. 89.

413 PCSBI. (2011). Subject Database.

414 Ibid.

415 The idea to infect in subjects’ eyes possibly came from Dr. Arnold’s letter in which he had written to Dr. 

Cutler about another experiment “that could be done” involving “the actual infection or [an] attempt to 

infect the eye with [gonococcal] pus...” He was curious whether the eye became infected easily as “[j]ust 

a thought for the future.” Richard Arnold to John Cutler. (1947, April 19). Correspondence. PCSBI HSPI 

Archives, CTLR_0001220.

416 Cutler Documents. Insane Asylum Asilo de Alienados and Prison Patient Records. (Various dates) Subject 

note cards. PCSBI HSPI Archives, CTLR_0004155-57; Cutler Documents. (1947-1948) Guatemala 

Journal Studies with the Military (GC). Clinical notebook. PCSBI HSPI Archives, CTLR_0000617; Cutler 

Documents. (1948, February 8). Asylum Asilo de Alienados and Prison Patient Records. (Various dates) 

Subject note cards. PCSBI HSPI Archives, CTLR_0004158. 

417 PCSBI. (2011). Subject Database.

418 Arnold, R.C., Mahoney, J.F. (1948, May). Op cit., pp. 138-141; John Cutler. (1955, February 24). Final 

Syphilis Report. PCSBI HSPI Archives, CTLR_0000759.

419 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000782.

420 These strains include the Nichols strain, the Frew Strain, and a “street strain” of Dr. Cutler’s own making. 

John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000684-86. 

421 Treponema pallidum cannot be maintained adequately in culture and can only be maintained in the testes 

of rabbits. To produce Treponema pallidum for research purposes, rabbits are inoculated intra-testicularly 

with the organism and, after a month, are killed. Emulsions are then prepared from the testes. The 

researchers had “access to large quantities of the organism more or less at will” because “an animal colony 

was maintained at the VDRL Staten Island to use in experimental work.” See John Cutler. (1955, February 

24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000688.

422 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000711.

423 Ibid, PCSBI HSPI Archives, CTLR_0000675.

424 Ibid, PCSBI HSPI Archives, CTLR_0000687.

425 Ibid, PCSBI HSPI Archives, CTLR_0000686.

426 As of 1946, as evidenced by a statement by Dr. Moore at a Penicillin Conference held under the Auspices 

of the U.S. PHS, FDA, and NRC, the U.S. Armed Forces were treating patients with syphilis with 

2.4 million units of penicillin, but data indicated that amount was insufficient. As a result, penicillin 

researchers were testing other amounts, as high as 9.6 million units, but there were insufficient data 

to determine which amount was most effective. Penicillin Conference Under the Auspices of the U.S. 

Public Health Service, Food and Drug Administration, and National Research Council. March 27, 1946, 

at 158-159. The researchers defined “adequate” treatment as ≥ 3,400,000 units of penicillin administered 

over seven to eight days, with aqueous preparations every two hours and 12 to 24 hours for the POB and 

Duracillin, which fit within the standard of care guidelines at the time. Crawford, G.M. (1947). Syphilis. 

New England Journal of Medicine 236(8):283. 

427 PCSBI. (2011). Subject Database. Several patients in the Psychiatric Hospital without serological or clinical 

evidence of syphilis were also treated with penicillin “for political reasons only (emphasis in original).” 

See, e.g, Cutler Documents. Insane Asylum Asilo de Alienados and Prison Patient Records. (Various 

dates). Subject note cards. PCSBI HSPI Archives, CTLR_00006321.
endnotes X

187

428 It was not clear that his death was caused by penicillin; the subject “developed status epileptiaus during 

the course of therapy with aqueous penicillin for primary syphilis on the 6th day, and despite efforts to 

control the condition, died,” but, Dr. Cutler reported, the subject had a history of severe epileptic attacks 

prior to his exposure to penicillin during the experiment. John Cutler. (1955, February 24). Final Syphilis 

Report. PCSBI HSPI Archives, CTLR_0000748. Dr. Cutler and his staff also made a number of clinical 

observations in the Final Syphilis Report. With regard to lesions, the researchers found that: “...it can be 

said that absence of lesion signifies with a high degree of certainly the absence of infection. This statement 

had subsequently been confirmed with respect to the group of patients initially treated for latent syphilis 

or late symptomatic syphilis in the Sing Sing study.” John Cutler. (1955, February 24). Final Syphilis 

Report. PCSBI HSPI Archives, CTLR_0000925. As Dr. Cutler points out in his Final Syphilis Report, he 

was also involved in the U.S. PHS-sponsored Sing Sing Correctional Facility study conducted from 1953 

to 1954. To develop a syphilis vaccine, researchers inoculated volunteers with a very high level of syphilis 

spirochetes. Investigators discussed “the study, the objectives, and the details of its day-to-day conduct” 

with the volunteers. Patients received follow-up for a year (monthly checkups) through the study and 

then were treated as part of the general “syphilitic” prison population. The details of this research were 

widely published in the medical and popular press. Syphilis vaccine gains: Sing Sing tests held raising 

hopes for finding preventive. (1954). New York Times, December, 9; Sing Sing study confirms rabbit tests. 

(1955, February). Public Health Reports (1896-1970), 70(2):214; Magnuson, H., et al. (1956, February). 

Inoculation syphilis in human volunteers. Medicine 35(1):33-82; Reverby, S. (2009). Examining Tuskegee: 

The Infamous Syphilis Study and its Legacy. Chapel Hill: University of North Carolina Press, p. 146.

429 This date is taken from the day that two commercial sex workers were exposed to syphilis via intracervical injection on May 10, 1947 “to send to the penitentiary as part of the study to determine normal 

rate of infections.” Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). 

Clinical notebook. PCSBI HSPI Archives, CTLR_0000620. While there are no contemporaneous clinical 

notes of Penitentiary subjects having sexual intercourse with sex workers on that date and it is not included 

in the summary section of the Final Syphilis Report, Dr. Cutler does discuss this “risk of infection” study 

in the “Immunity” section of his final report. John Cutler. (1955, February 24). Final Syphilis Report. 

PCSBI HSPI Archives, CTLR_0000885.

430 PCSBI. (2011). Subject Database. Five prison guards were also included in the researchers’ intentional 

exposure experiments (see, e.g., Cutler Documents. Insane Asylum Asilo de Alienados and Prison Patient 

Records. (Various dates). Subject note cards. PCSBI HSPI Archives, CTLR_0003401); for the sake of 

brevity, they will be included with the data of the “prisoners.”

431 PCSBI. (2011). Subject Database.

432 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000662.

433 Ibid. PCSBI HSPI Archives, CTLR_0000667.

434 Unsigned [John Cutler] to Richard Arnold. (1946, August 21). Correspondence. PCSBI HSPI Archives,

CTLR_0001215.

435 Ibid.

436 John Cutler to John Mahoney. (1947, January 7). Correspondence. PCSBI HSPI Archives, CTLR_0001039. 

When Dr. Cutler wrote that the papers were already complaining about prison conditions, he is probably 

referring to articles such as the one published later that year reporting that “the prison system in 

Guatemala, like the infamous Bastille to the French and the horrible Romada to the Venezuelans, has 

not fulfilled the purpose outlined by national law, but has been a pit for vengeance, for suffering and for 

crime that has served dictators in satisfying their basest instincts on defenseless enemies, who in reality 

have been the best friends of democratic institutions and the joyful march to civilization and culture” 

[translation]. Editorial. (1947, August, 9). La Reforma Penitenciaria. Diario de Centro America.

437 PCSBI. (2011). Subject Database. There is one day on which the method of exposure is unclear.

438 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000723.

439 Ibid, PCSBI HSPI Archives, CTLR_0000724.

440 Ibid, PCSBI HSPI Archives, CTLR_0000699.

441 Ibid.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

188

442 Ibid, PCSBI HSPI Archives, CTLR_0000704. The contemporaneous literature defines the “abortive cure” 

of syphilis as “essentially the systematic speculative under-estimation of the amount of treatment required 

by the seronegative primary stage,” which was a dated treatment from the turn of the century. Stokes, J.H., 

Beerman, H., Ingraham, N. R. (1944). Modern Clinical Syphilology: Diagnosis, Treatment, Case Study.

Philadelphia: W.B. Saunders Company, pp. 1094-1114.

443 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000731.

444 Ibid, PCSBI HSPI Archives, CTLR_0000741.

445 See Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clinical notebook. 

PCSBI HSPI Archives CTLR_0000620 and John Cutler. (1955, February 24). Final Syphilis Report. 

PCSBI HSPI Archives CTLR_0000885.

446 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000640.

447 Ibid, PCSBI HSPI Archives, CTLR_0000885. 

448 Ibid, PCSBI HSPI Archives, CTLR_0000648. The researchers were having such a difficult time causing 

infections through the sex workers that Dr. Harlow conveyed his amusement to Dr. Mahoney that the only 

person they managed to infect in the prison was the “prisoner-secretary” of the Penitentiary hospital who 

“had contact” with “one of our female hirelings whom we thought was non-infected.” Dr. Harlow “could 

not help laughing at the irony of the situation” and even asked the secretary not to take sulfa or penicillin 

as treatment which “he unfortunately had access to.” The next day the discharge and symptoms abated 

and Dr. Harlow “fear[ed] he may have treated himself.” John Cutler. (1955, February 24). Final Syphilis 

Report. PCSBI HSPI Archives, CTLR_0000762.

449 Ibid, PCSBI HSPI Archives, CTLR_0000640.

450 Ibid, PCSBI HSPI Archives, CTLR_0000762.

451 Ibid, PCSBI HSPI Archives, CTLR_0000722-23.

452 Ibid, PCSBI HSPI Archives, CTLR_0000699.

453 Ibid, PCSBI HSPI Archives, CTLR_0000764.

454 Ibid, PCSBI HSPI Archives, CTLR_0000696. It is also possible that they wanted to avoid giving the 

prisoners time to speak with each other and the opportunity to decline to participate in future experiments.

455 Dr. Cutler did not later report any evidence of transmission of jaundice or other infection. John Cutler. 

(1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000679.

456 John Cutler to John Mahoney. (1947, January 7). Correspondence. PCSBI HSPI Archives, CTLR_0001039. 

457 Richard Arnold to John Cutler. (194[7], April 19). Correspondence. PCSBI HSPI Archives, 

CTLR_0001220. This letter is originally dated April 19, 1948, however it is clear that this was a typo from 

context (e.g., the discussion about Joseph Portnoy’s salary letter that Dr. Cutler forwarded to them on April 

10, 1947) and that the letter should have been dated April 19, 1947. See e.g., John Cutler to John Mahoney. 

(1947, April 10). Correspondence. PCSBI HSPI Archives, CTLR_0001059.

458 Richard Arnold to John Cutler. (1947, April 19). PCSBI HSPI Archives, CTLR_0001220.

459 Ibid.

460 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000648.

461 Ibid, PCSBI HSPI Archives, CTLR_0000658.

462 PCSBI. (2011). Subject Database.

463 Ibid. This data also includes at least one nurse who worked at the Psychiatric Institution who was exposed 

to syphilis twice through injection. Cutler Documents. (1948, May 9). Asilo de Alienados: Immune 

Experiment No 14. Protocols. PCSBI HSPI Archives, CTLR_0002224; Cutler Documents. Insane Asylum 

Asilo des Alienados and Prison Patient Records. (various dates). Subject Notecard. PCSBI HSPI Archives, 

CTLR_0003885.

464 See, e.g., Cutler Documents. (n.d.). Insane Asylum Asilo de Alienados and Prison Patient Records. 

(Various dates). Subject note cards. PCSBI HSPI Archives CTLR_0002635. 
endnotes X

189

465 “[I]t was known by the staff that homosexual practices were very common.” John Cutler. (1955, February 

24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000659. 

466 “It is worth mentioning that although supervision of the patients within the institutions was minimal and 

although it was known by the staff that homosexual practices were very common (several epidemics of 

homosexual gonorrhea were treated) no clinical evidence of syphilis by this route was observed.” John 

Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000659. 

467 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001356; John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, 

CTLR_0000629.

468 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000653.

469 It is not clear to what study Dr. Cutler is referring.

470 Dr. Cutler is possibly referencing the Stateville prison study of 1942, in which 432 inmates in the Illinois 

Federal Penitentiary in Stateville were intentionally infected with malaria, while confined for 18 months 

in a segregated part of the prison, through a mosquito vector. Informed consent was obtained from each 

subject. Five days after exposure, the subjects were treated with an experimental intervention. Comfort, N. 

(2009, September). The prisoner as model organism: Malaria research at Stateville Penitentiary,” Studies in 

History and Philosophy of Biological and Biomedical Science 40(3):190–203.

471 Dr. Cutler is possibly referencing the Lynchburg Colony studies conducted during World War I at the 

Virginia Colony for the Epileptic and Feebleminded, where 190 patients between the ages of 15 and 57 

were given the “Rockefeller vaccine,” known to cause hepatitis and jaundice in a significant number of 

administrations, so the military could use the data on infectious hepatitis occurrences and treatment in the 

relevant arenas of war. See Lombardo, P.A. (2004). ‘Of Utmost Urgency’: The Lynchburg Colony Hepatitis 

Study, 1942. In Moreno, J.D. (Ed.). In the Wake of Terror: Medicine and Morality in a Time of Crisis.

Cambridge: MIT Press, pp. 3-15.

472 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000655.

473 Ibid, PCSBI HSPI Archives, CTLR_0000654.

474 Ibid.

475 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000673.

476 Ibid, PCSBI HSPI Archives, CTLR_0000673-74.

477 Ibid, PCSBI HSPI Archives, CTLR_0000674.

478 John Cutler to John Mahoney (1948, May 19). Correspondence. PCSBI HSPI Archives, CTLR_0001141.

479 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000657.

480 John Cutler to John Mahoney (1948, May 19). Correspondence. PCSBI HSPI Archives, CTLR_0001141.

481 See, John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000552; 

but see John Cutler to [Fred L. Soper] Director, Pan American Sanitary Bureau. (1948, November 15). 

Correspondence. PCSBI HSPI Archives, CTLR_0001172.

482 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000673.

483 John Cutler to John Mahoney. (1948, February 6). Correspondence. PCSBI HSPI Archives, 

CTLR_0001139. 

484 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000652.

485 John Cutler to Richard Arnold. (1947, June 5). Correspondence. PCSBI HSPI Archives, CTLR_0001240.

486 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000706. Also, 

many subjects were noted as being “uncooperative.” See, e.g. Cutler Documents. Insane Asylum Asilo 

Des Alienados and Prison Patient Records. (Various dates). Subject Note Card. PCSBI HSPI Archives, 

CTLR_0005103.

487 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000657.

488 Ibid, PCSBI HSPI Archives, CTLR_0000666.

489 Ibid, PCSBI HSPI Archives, CTLR_0000845.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

190

490 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000694.

491 Richard Arnold to John Cutler. (1947, April 11). Correspondence. PCSBI HSPI Archives, CTLR_0001061.

492 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000766.

493 Ibid, PCSBI HSPI Archives, CTLR_0000679.

494 Ibid, PCSBI HSPI Archives, CTLR_0000766.

495 Ibid, PCSBI HSPI Archives, CTLR_0000706.

496 John Mahoney to John Cutler. (1947, September 8). Correspondence. PCSBI HSPI Archives,

CTLR_0001234. He was most likely referring to his published work on the effectiveness of the orvusmapharsen prophylaxis in rabbits. Arnold, R.C., Mahoney, J.F. (1948, May). Local prophylaxis in 

experimental syphilis of the rabbit. The Journal of Venereal Disease Information 29:138-141.

497 John Mahoney to John Cutler. (1947, September 8). Correspondence. PCSBI HSPI Archives, 

CTLR_0001234. Dr. Mahoney had been arguing that the contact method of syphilis inoculation (i.e., with 

a pledget soaked in syphilis spirochetes placed upon intact skin) was the best practice in syphilis research. 

See Mahoney, J. (1936, May). An experimental resurvey of the basic factors concerned in prophylaxis in 

syphilis. The Military Surgeon 352-353.

498 John Mahoney to John Cutler. (1947, September 8). Correspondence. PCSBI HSPI Archives, 

CTLR_0001234.

499 In addition, in order to perform “a comprehensive study of the reliability of serology as a diagnostic 

instrument among aboriginal peoples in tropical America,” it “would require a different approach than 

the one being used at the present.” They would “be obligated to canvass the South and Central American 

natives, the Mexican Indians, the Indian tribes in the United States and, finally, the southern negro.” This 

type of study would require “mobile teams capable of doing medical work as well as serology,” and Dr. 

Mahoney was “not at all sure that we could make the necessary financial arrangements.” John Mahoney to 

John Cutler (1947, September 8). Correspondence. PCSBI HSPI Archives, CTLR_0001233.

500 John Cutler to John Mahoney. (1947, September 18). Correspondence. PCSBI HSPI Archives, 

CTLR_0001231.

501 Ibid. Between 1924 and 1927, Drs. Alan Chesney and Jarold Kemp, both of the Johns Hopkins University 

Department of Medicine, published a series of articles regarding syphilis experiments done on rabbits. The 

experiments included reinoculation and reinfection, treatment with arsphenamine, and the relationship 

between the dose of inoculum given and the incubation period of the infection induced. Chesney, A.M., 

Kemp, J.E. (1924). Experimental observations on the “cure” of syphilis in the rabbit with arsphenamine. 

Journal of Experimental Medicine 39(4):553-564; Chesney, A.M., Kemp, J.E. (1925). Studies in 

experimental syphilis: I. The influence of the size of inoculum on the course of experimental syphilis in 

the rabbit. Journal of Experimental Medicine 41(4):479-485; Chesney, A.M., Kemp, J.E. (1925). Studies in 

experimental syphilis: II. The influence of a non-specific inflammatory reaction upon the development of 

the chancre. Journal of Experimental Medicine 41(4):487-502; Chesney, A.M., Kemp, J.E. (1925). Studies 

in experimental syphilis: III. Further observations on the possibility of cure of syphilis in the rabbit with 

arsphenamine. Journal of Experimental Medicine 42(1):17-31; Chesney, A.M., Kemp, J.E. (1925). Studies 

in experimental syphilis: IV. The survival of Treponema pallidum in the internal organs of treated and 

untreated rabbits. Journal of Experimental Medicine 42(1): 33-42; Chesney, A.M., Kemp, J.E. (1926). 

Studies in experimental syphilis: VI. On variations in the response of treated rabbits to reinoculation; and 

on cryptogenetic reinfection with syphilis. Journal of Experimental Medicine 44(5):589-606; Chesney, 

A.M., Kemp, J.E. (1927). Studies in experimental syphilis: VII. Reinoculation of treated and untreated 

syphilitic rabbits with heterologous strains of Treponema pallidum. Journal of Experimental Medicine

46(2):223-237.

502 John Cutler to John Mahoney. (1947, September 18). Correspondence. PCSBI HSPI Archives, 

CTLR_0001231.

503 Ibid, PCSBI HSPI Archives, CTLR_0001229. Dr. Mahoney had already addressed this heroic challenge 

method counterargument in his Terre Haute publication, and he pointed out that the “usefulness of the 

experimental approach” required “that the experimental routine reasonably approximate the mode of 

transmission which is operative in female to male infection of human beings—this, in order that the 

burden placed upon the prophylactic agent might not be greatly in excess of that imposed by natural 

exposure (emphasis added).” Mahoney, J.F., et al. (1946). Op cit., 3.
endnotes X

191

504 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000933. 

“Challenge methods” is a term used to describe intentional infection studies. Which involve deliberately 

inducing infection in order to study preventative measures and disease pathogenesis. Though 

controversial, challenge experiments are still conducted today. Some ethicists have argued that they 

are not necessarily unethical and that they may be ethically justified when conducted by competent 

investigators and according to scientifically sound protocols that incorporate safeguards to ensure the 

safety of volunteers. Miller, F.G., Grady, C. (2001). The ethical challenge of infection-inducing challenge 

experiments. Clinical Infectious Diseases 33(7):1028-1033.

505 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000701.

506 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001290.

507 John Cutler to Richard Arnold. (1947, September 16). Correspondence. PCSBI HSPI Archives, 

CTLR_0001230. 

508 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000727.

509 John Cutler to Richard Arnold. (1947, September 16). Correspondence. PCSBI HSPI Archives, 

CTLR_0001230. 

510 John Cutler to John Mahoney. (1947, September 18). Correspondence. PCSBI HSPI Archives, 

CTLR_0001228.

511 John Cutler. (1989, June). Stemming the AIDS epidemic: Drawing on past experience with VD control. 

Consultant 26(6):62-63.

512 Ibid.

513 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000705.

514 John Cutler to John Mahoney. (1947, September 18). Correspondence. PCSBI HSPI Archives, 

CTLR_0001228.

515 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000734.

516 Ibid, PCSBI HSPI Archives, CTLR_0000680.

517 Ibid, PCSBI HSPI Archives, CTLR_0000763.

518 Ibid, PCSBI HSPI Archives, CTLR_0000680.

519 Ibid, PCSBI HSPI Archives, CTLR_0000712.

520 Ibid, PCSBI HSPI Archives, CTLR_0000729. In other words, Dr. Cutler decided that instead of allowing 

the time necessary for future experiments to build on knowledge gained from the first experiments, the 

researchers should assume results based on incomplete data and move forward with new experiments 

nonetheless. 

521 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000728.

522 Ibid, PCSBI HSPI Archives, CTLR_0000681.

523 Ibid, PCSBI HSPI Archives, CTLR_0000705.

524 Ibid, PCSBI HSPI Archives, CTLR_0000836.

525 Ibid, PCSBI HSPI Archives, CTLR_0000669.

526 Ibid, PCSBI HSPI Archives, CTLR_0000732.

527 Ibid, PCSBI HSPI Archives, CTLR_0000681.

528 Medline. (n.d.). Cerebral spinal fluid (CSF) collection. Available at http://www.nlm.nih.gov/ medlineplus/

ency/article/003428.htm (accessed May 11, 2011). Damage to the brain stem can cause loss of control over 

autonomic functions such as breathing, digestion, and heartbeat, and a mishap would result in death. The 

University Hospital. (n.d.). Anatomy of the Brain. Available at http://www.theuniversity hospital.com/

stroke/anatomy.htm (accessed May 11, 2011).

529 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000669.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

192

530 Ibid, PCSBI HSPI Archives, CTLR_0000793.

531 Ibid.

532 Ibid.

533 Cutler Documents. Insane Asylum Asilo de Alienados and Prison Patient Records. (Various dates). Subject 

note cards. PCSBI HSPI Archives, CTLR_0005823, CTLR_0005777.

534 Curth, W. (1933). Syphilis in the highlands of Guatemala. American Journal of Syphilis 2(xvii):166.

535 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000669.

536 John Mahoney to John Cutler. (1948, February 19). Correspondence. PCSBI HSPI Archives, 

CTLR_0001223.

537 Ibid. It is not clear from the letter what the “innocuous stage” of the Guatemala project would have 

included.

538 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000718.

539 Ibid, PCSBI HSPI Archives, CTLR_0000744.

540 Ibid, PCSBI HSPI Archives, CTLR_0000746.

541 John Mahoney to John Cutler. (1948, June 21). Correspondence. PCSBI HSPI Archives, CTLR_0001143.

542 Risks involved in the application of chancroid in this manner include painful pustular lesions and redness 

of the skin. Al-Tawfiq, J.A., et al. (1998). Standardization of the experimental model of Haemophilus 

ducreyi infection in human subjects. Journal of Infectious Diseases 178(6):1684–1687; Heyman, H. (1950). 

Chancroid. In Harrison, T.R., et al. (Eds.). Principles of Internal Medicine. Philadelphia: The Blakiston 

Company, pp. 861-863..

543 John Cutler. (n.d.). Chancroid Experiment. Report. PCSBI HSPI Archives, CTLR_0000969.

544 PCSBI. (2011). Subject Database.

545 See, e.g. Cutler Documents. (1947-1948) Guatemala Journal Studies with the Military (GC). Clinical 

notebook. PCSBI HSPI Archives, CTLR_0000621-22.

546 PCSBI. (2011). Subject Database.

547 John Cutler. (n.d.). Chancroid Experiment. Report. PCSBI HSPI Archives, CTLR_0000947.

548 Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clinical notebook. 

PCSBI HSPI Archives, CTLR_0000621-622.

549 Ibid, PCSBI HSPI Archives, CTLR_0000621.

550 John Cutler. (n.d.). Chancroid Experiment. Report. PCSBI HSPI Archives, CTLR_0000969.

551 PCSBI. (2011). Subject Database.

552 John Cutler. (n.d.). Chancroid Experiment. Report. PCSBI HSPI Archives, CTLR_0000969.

553 Ibid.

554 The names of the physicians are included in the original draft of the Chancroid Experiment report, but 

are then crossed out by hand and not included in the final draft. (See Appendix II: Chancroid Experiment 

Report). Ibid, PCSBI HSPI Archives, CTLR_0000980.

555 Ibid, PCSBI HSPI Archives, CTLR_0000970.

556 Ibid, PCSBI HSPI Archives, CTLR_0000967. This film was not in the University of Pittsburgh Archives 

and has not been located. 

557 John Mahoney to John Cutler. (1948, June 21). Correspondence. PCSBI HSPI Archives, CTLR_0001143.

558 Ernest Allen to John Murdock. (1948, June 28). Correspondence. PCSBI HSPI Archives, CTLR_0001182.

559 John Cutler to John Mahoney, forwarded by William J. McAnally, Jr. (1948, August 26). Correspondence. 

PCSBI HSPI Archives, CTLR_0001163.

560 John Mahoney to John Cutler, forwarded by [Fred L. Soper] Director, Pan-American Sanitary Bureau. 

(1948, September 3). Correspondence. PCSBI HSPI Archives, CTLR_0001161.
endnotes X

193

561 Ibid.

562 John Cutler to John Mahoney. (1948, June 21). Correspondence. PCSBI HSPI Archives, CTLR_0001142.

563 John Cutler to John Mahoney. (1948, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001144.

564 John Murdock to John Cutler, forwarded by William J. McAnally, Jr. (1948, June 30). Correspondence. 

PCSBI HSPI Archives, CTLR_0001151.

565 John Mahoney to John Cutler. (1948, July 16). Correspondence. PCSBI HSPI Archives, CTLR_0001148.

566 Parran, T. (1937). Shadow on the Land. New York: Reynal & Hitchcock, p. 175.

567 Ibid.

568 Dr. Cutler led the Tuskegee Syphilis Study in conjunction with Dr. Sidney Olansky and Dr. Stanley 

Schuman. Reverby, S. (2009). Op cit., p.69.

569 Jones, J.H. (1993) Bad Blood: The Tuskegee Syphilis Experiment. New York: The Free Press, p. 28.

570 John Cutler. (1952, October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, 

CTLR_0001287-88.

571 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000852. Dr. 

Cutler cites to: Shattuck. G.C. (1930). Preliminary communication on syphilis in Yucatan. American 

Journal of Tropical Medicine and Hygiene S1-10(3):177-182.; Curth, W. (1933). Op cit.; and Shattuck, G.C. 

(1933). Syphilis in Yucatan and related immunological questions.

572 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000852.

573 Curth, W. (1933). Op cit. This article is cited by Dr. Cutler in his Final Syphilis Report.

574 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000809.

575 Ibid, PCSBI HSPI Archives, CTLR_0000809. When Commission staff traveled to Guatemala and spoke 

with the Guatemalan Commission investigating these experiments, the Guatemalan Commission informed 

them that words used to describe the indigenous population in contemporaneous documents (that the 

Guatemalan Commission possesses) were derogatory and offensive. 

576 Unsigned [John Cutler] to Richard Arnold. (1946, August 21). Correspondence. PCSBI HSPI Archives,

CTLR_0001215.

577 Richard Arnold to John Cutler. (1947, April 10). Correspondence. PCSBI HSPI Archives, CTLR_0001190.

578 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000858.

579 Ibid, PCSBI HSPI Archives, CTLR_0000809.

580 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR_0000655.

581 G. Robert Coatney to John Cutler. (1947, February 17). Correspondence. PCSBI HSPI Archives, 

CTLR_0001051 

582 John Cutler to John Mahoney. (1947, May 17). Correspondence. PCSBI HSPI Archives, CTLR_0001122.

583 Kaempffert, W. (1947). Notes on science: syphilis prevention. New York Times, April 27. Several months 

before the New York Times publication, Dr. Eagle had been working with the Surgeon General of the U.S. 

Navy, Rear Admiral Clifford A. Swanson, on testing an oral penicillin prophylaxis in the Navy stemming 

from the above research. Surgeon General Swanson wrote to the NRC that “we are very much interested 

in the possibility of trying [penicillin by mouth] in the Navy on an experimental basis.” He solicited “[s]

uggestions for setting up the experiment...if the Council considers that this can be accomplished without 

seriously jeopardizing the health of the men involved” [emphasis added]. Clifford A. Swanson to Lewis 

H. Weed. (1947, February 13). Correspondence. PCSBI HSPI Archives, NAS_0001991. As described 

in a 1949 article, Eagle did indeed conduct this research in “a small body of military personnel with an 

extraordinarily high morbidity of gonorrhea.” This study did not involve artificial exposure. In fact, “no 

attempt was made to ascertain whether the men had been exposed.” Instead, subjects were divided into 

an experimental group, who received a single tablet of penicillin each time they returned from leave, and 

a control group, who received a placebo. Eagle then compared the general rate of infection of both groups 

over two 24-week periods. Eagle, H. (1949). The prophylactic use of penicillin. Trans Assoc Am Physicians

62:59-60.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

194

584 Waldemar B. Kaempffert Dies; Science Editor of The Times, 79. (1956). New York Times, November 28. 

PCSBI HSPI Archives, MISC_0000070.

585 Kaempffert, W. (1947). Notes on science: syphilis prevention. New York Times, April 27..

586 John Mahoney to John Cutler. (1947, May 5). Correspondence. PCSBI HSPI Archives, CTLR_0001243.

587 Most likely because the prophylaxis was intended to be included in the Army pro kit for soldiers 

to treat themselves, which would rule out injections. John Mahoney to John Cutler. (1947, May 5). 

Correspondence. PCSBI HSPI Archives, CTLR_0001243. It is also worth noting that Drs. Arnold and 

Mahoney had first discovered the use of the orvus-mapharsen prophylaxis, a competitor to the use of 

penicillin as a prophylaxis. Arnold, R.C., Mahoney, J.F. (1948). Local prophylaxis in experimental syphilis 

of the rabbit. Journal of Venereal Disease Information 29(5):138-41. 

588 John Mahoney to John Cutler. (1947, May 5). Correspondence. PCSBI HSPI Archives, CTLR_0001243. 

Dr. Mahoney does not specifically say in this letter why he thought that an oral preparation of penicillin 

was less important; however, he most likely was concerned about the use of penicillin as a prophylaxis 

creating penicillin-resistant bacteria. As Dr. Cutler discussed in the Experimental Studies in Gonorrhea 

report, “the fact that patients may become, or be sensitive to penicillin and the danger inherent in creating 

a penicillin-resistant bacterial flora in the patient that might later prove pathogenic...suggests that it is 

inadvisable to use oral penicillin as a mass prophylaxis against venereal disease.” John Cutler. (1952, 

October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, CTLR_0001298.

589 John Cutler to John Mahoney. (1947, May 17). Correspondence. PCSBI HSPI Archives, CTLR_0001122.

590 Ibid.

591 John Mahoney to John Cutler. (1947, May 5). Correspondence. PCSBI HSPI Archives, CTLR_0001243. 

There is no further information in the Cutler Documents regarding the formation of an advisory group.

592 Ibid. 

593 Ibid. 

594 John Cutler to John Mahoney. (1947, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001242.

595 John Mahoney to John Cutler. (1947, June 30). Correspondence. PCSBI HSPI Archives, CTLR_0001078.

596 John Cutler to John Mahoney. (1947, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001241.

597 Ibid.

598 John Mahoney to John Cutler. (1947, June 30). Correspondence. PCSBI HSPI Archives, CTLR_0001077. 

It appears that this confidence was indeed later entrusted, as in a later letter written by Dr. Soper, he lauds 

Dr. Cutler’s excellent job leading the Venereal Disease Program in Guatemala, which included studies in 

“transmission, serology and treatment of venereal diseases.” Dr. Soper goes on to say that “[d]uring [Dr. 

Cutler’s] detail in Guatemala, which required not only technical skill but the ability to deal with authorities 

and handle patients under extremely difficult conditions, he conducted his work in an outstanding manner, 

got along well with every one, and demonstrated his administrative capacity.” Fred L. Soper to Ernest L. 

Stubbins. (1950, April 20). Correspondence. PCSBI HSPI Archives, JHU_0000007.

599 John Cutler to John Mahoney. (1947, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001241.

600 Ibid.

601 Ibid.

602 It is not clear who Dr. Cutler is including in the four. In addition to himself, Dr. Levitan, and Dr. Harlow, 

he is also possibly including Dr. Spoto. 

603 John Cutler to John Mahoney. (1947, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001241.

604 Ibid.

605 Strickland, S.P. (1989). Op cit. 

606 John R. Murdock to John Cutler, forwarded by William J. McAnally, Jr. (1947, December 26). 

Correspondence. PCSBI HSPI Archives, CTLR_0001102.

607 John Cutler to John Mahoney. (1947, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001241.
endnotes X

195

608 See e.g., John Cutler to John Mahoney. (1947, February 4). Correspondence. PCSBI HSPI Archives,

CTLR_0001047. Copies of these reports were not included in the Cutler Documents.

609 John Cutler to John Mahoney. (1947, June 22). Correspondence. PCSBI HSPI Archives, CTLR_0001241.

610 John Mahoney to John Cutler. (1947, June 30). Correspondence. PCSBI HSPI Archives, CTLR_0001077.

611 Ibid.

612 Ibid.

613 Ibid.

614 Stout, G.W., Guzmán, M., Scrimshaw, N.S. (1952, marzo). Reacciones serológicas para sífilis 

presuntamente positivas falsas en la América Central. Boletín de la Oficina Sanitaria Panamericana 32(3): 

206-213; Stout, G.W., Guzmán, M., Scrimshaw, N.S. (1952, junio). Reacciones serológicas para sífilis 

presuntamente positivas falsas en la América Central: II. Relación con el acido ascórbico, riboflavina, 

fosfatasa alcalina, carotina y vitaminas A y E en el suero sanguíneo. Boletín de la Oficina Sanitaria 

Panamericana 32(6): 521-526; Stout, G.W., Méndez, J., Guzmán, M., Scrimshaw, N.S. (1952, agosto). 

Reacciones serológicas para sífilis presuntamente positivas falsas en la América Central: III. Relación con 

el contenido de proteina, albumina y globulina en el suero. Boletín de la Oficina Sanitaria Panamericana

33(2):110-115; Stout, G.W., Aguirre, F., Scrimshaw, N.S. (1953, enero). Reacciones serológicas para sífilis 

presuntamente positivas falsas en la América Central: IV. Relación con las reacciones positivas a la prueba 

de floculación de cefalina colesterol (hanger). Boletín de la Oficina Sanitaria Panamericana 34(1): 9-13.

615 John R. Murdock to William J. McAnally, Jr.. (1948, July 26). Correspondence. PCSBI HSPI Archives, 

CTLR_0001155; Report of the Director of the Pan American Sanitary Bureau to the Member Governments 

of the Pan American Sanitary Organization. (n.d.). PCSBI HSPI Archives, NLM_0000033. Dr. Stout 

was a microbiologist who had worked with Dr. Mahoney at Staten Island and had, prior to joining 

Mahoney’s team, been in charge of the Serological Department for the Navy at Bethesda. Genevieve 

W. Stout Personnel Files, Nomination for Departmental Honor Award, 1962. PCSBI HSPI Archives, 

NPRC_0002573.

616 John R. Murdock to William J. McAnally, Jr. (1948, July 26). Correspondence. PCSBI HSPI Archives, 

CTLR_0001155-56; Stout, G.W., Cutler, J.C. (1951). Serology problems (syphilis) in Central America. 

Journal of Venereal Disease Information 7(32): 240.

617 John R. Murdock to William J. McAnally, Jr. (1948, July 26). Correspondence, PCSBI HSPI Archives, 

CTLR_0001155-56.

618 Stout, G.W. Personnel Files, Nomination for Departmental Honor Award, 1962, PCSBI HSPI Archives, 

NPRC_0002555; Pan American Sanitary Bureau. (1948). Expenditure Breakdown: Calendar Year 1948. 

PCSBI HSPI Archives HSPI, PAHO_0000574.

619 Thome, J.V. (1955, agosto). Encuestas serológicas centroamericanas realizadas durante los años 1950, 1951, 

1952, y 1953. Boletín de la Oficina Sanitaria Panamericana 39(2):131-145.

620 Ibid.

621 Ibid. One of Stout’s articles indicates that did serological testing in Guatemala, El Salvador, Costa Rica, 

and Panama. Stout, G.W., Cutler, J.C. (1951). Op cit,. p. 240. This work was conducted in conjunction 

with investigators in the United States. The VDRL in Chamblee, Georgia, the institute to which Funes’s 

continuing observation samples were sent, co-sponsored the studies, and “the PASB solicited the 

cooperation of the United States Public Health Service to have the VDRL in Chamblee...serve as a 

co-control lab” for at least two of the studies. Thome, J.V., op cit., pp.131-145. Their results showed a high 

incidence of false-positive reactions in most of the countries involved (Panama, like the United States, did 

not show the elevated incidence of false-positives), which mirrored the staff’s prior results. Stout, G.W., 

Cutler, J.C. (1951). Op. cit., p.240. 

622 John Mahoney to John Cutler. (1948, June 21). Correspondence. PCSBI HSPI Archives, CTLR_0001143; 

Memorandum to Gustavo An[i]rada to C.H. Morrison re: Pay-Consultants; Doctors Funes and Salvado. 

(1950, April 5). Correspondence. PCSBI HSPI Archives, NPRC_0001964. Dr. Carlos A. Salvado received 

a “special research” fellowship from the Public Health Service to study Psychiatry at New Jersey State 

Hospital in 1949. Research Grants Awarded by the Public Health Service. Supplement 205 Public Health 

Reports. (1950). PCSBI HSPI Archives, MISC_0000900.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

196

623 John Mahoney to John Cutler. (1948, July 26). Correspondence. PCSBI HSPI Archives, CTLR_0001157.

624 John Cutler to Fred L. Soper, forwarded by William J. McAnally, Jr. (1948, August 27). Correspondence. 

PCSBI HSPI Archives, CTLR_0001183.

625 John Cutler to John Mahoney, forwarded by William J. McAnally, Jr. (1948, August 26). Correspondence. 

PCSBI HSPI Archives, CTLR_0001162; Juan M. Funes Personnel Files. (1948, December 10). PCSBI 

HSPI Archives, NPRC_0000807.

626 Ibid.

627 Report on Serologic Follow-up on Patients Done at CDC in 1953, Samples sent from Guatemala. (n.d.). 

PCSBI HSPI Archives, CTLR_0001466.

628 Ibid, PCSBI HSPI Archives, CTLR_0001433-76. These numbers are rough as there are data missing for 

many patients, which makes an exact count impossible (e.g., for some patients only the patient number 

[without a name] is included; as there are several patients with the same number it is impossible to tell 

whether it is the same patient being tested twice or two different patients).

629 See, e.g., Report on Serologic Follow-up on Patients Done at CDC in 1953, Samples sent from Guatemala. 

(n.d.). PCSBI HSPI Archives, CTLR_0001436.

630 This is the latest date for which there is evidence of samples sent to the VDRL at Chamblee, Georgia.

631 Levitan, S., et al. (1952). Op. cit, pp. 379-387.

632 John Cutler. (1950, September 1). Summary Report of the WHO Venereal Disease Demonstration Team in 

India, PCSBI HSPI Archives, MISC_0000426.

633 John Cutler, Curriculum Vitae. (1990, February). PCSBI HSPI Archives, UOFM_0000021.

634 John Cutler. (n.d.). Chancroid Experiment, Report. PCSBI HSPI Archives, CTLR_0001003.

635 E.g., the country in which the experiment was conducted and the physicians involved. John Cutler. (1952, 

October 29). Experimental Studies in Gonorrhea. Report. PCSBI Archives, CTLR_0001278-79.

636 John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, CTLR 0000632.

637 Aragon, H.A., (1948, October). Estudio de la sifilis y pruebas de la serologia en el Hospicio Nacional de 

Guatemala. Salubridad y Asistencia; Stout, G.W., Cutler, J.C. (1951). Op cit., pp. 238-239; Levitan, S., et al. 

(1952, July). Op cit.; Funes, J.M., et al., (1953). Op cit., pp. 14-18; Portnoy, J., Galvez, R., Cutler, J.C. (1952). 

Op cit., pp. 566-570; Falcone, V.H., Harris, A., Olansky, S., Salvado, C., Cutler, J.C. (1953). Op cit.

638 Cutler, J.C., et al. (1972, February). Studies on development of a vaginal preparation providing both 

prophylaxis against venereal disease, other genital infections, and contraception. I. Venereal disease 

prophylaxis, past experience, present status and plans for future studies. Military Medicine 138(2):89; 

Cutler, J.C. (1989, June). Op cit., p. 63.

639 For example, Cutler cites a Funes orvus-mapharsen study on sex workers as support for the statement 

that “the male’s risk for [gonorrheal] infection through vaginal contact was only one in 20 contacts” in 

several of his articles. See e.g., Cutler, J.C., (1989, June). Op cit., pp. 60-61. This Funes study, however, did 

not include data from male contacts and just followed the rate of infection of the sex workers. Funes, J., 

Aguilar, C.L. (1952 agosto). La solución de mafarside-orvus en la profilaxis de la blenorragia de la mujer. 

Boletín de la Oficina Sanitaria Panamericana 33(2):121-125. The Studies in Gonorrhea Report does draw 

this 1 in 20 conclusion from the Guatemala data. John Cutler. (1952, October 29). Experimental Studies in 

Gonorrhea. Report. PCSBI HSPI Archives, CTLR_0001303.

640 See, e.g., Arnold, R.C., Cutler, J.C., Wright, R.D., Levitan, S. (1952). Studies in penicillin treatment of 

syphilis – from 1943 to 1950. Public Health Reports 67(1):78-89; Cutler, J.C. (1972). Prophylaxis in the 

venereal diseases. Medical Clinics of North America 56(5): 1211-1216; and Cutler, J.C., Arnold, R.C. 

(1988). Venereal disease control by health departments in the past: Lessons for the present. American 

Journal of Public Health 78(4):372-376. As Dr. Cutler concluded in 1973, however: “[a]lthough both 

syphilis and gonorrhea are accepted as completely curable in the early stages, they are certainly never 

trivial, and rarely self-limiting. It is highly questionable whether it would be acceptable to deliberately 

expose volunteers to the risk of such infection. The required experimental circumstances, i.e. of deliberate 

sexual intercourse by volunteers with a person known to have active gonorrhea and/or infectious syphilis 
endnotes X

197

present problems of social, political, and ethical concern, which must be weighed against national 

attitudes and practices and the seriousness of the problem to be studied.” In addition, Cutler continues 

that Terre Haute and Sing Sing could be carried out with volunteer cooperation “because of the certainty 

of cure and consequent low risk to the patient, and because of the fact that the technique for infection 

was experimental inoculation,” presumably as opposed to sexual intercourse. Cutler, J.C., et al. (1972, 

February). Op cit., p. 90.

641 See, e.g., Mahoney, J.F., Van Slyke, C.J., Cutler, J.C., Blum, H.L. (1946). Op cit. John Cutler. (1952, 

October 29). Experimental Studies in Gonorrhea. Report. PCSBI HSPI Archives, CTLR_0001286; 

Magnuson, H.J., et al. (1956). Inoculation syphilis in human volunteers. Medicine 35(1):33-82. In addition, 

the VDRL staff went back to publishing regarding syphilis prophylaxis in rabbits. See, e.g., Arnold, R.C., 

Cutler, J.C. (1956). Experimental studies to develop local prophylactic agents against syphilis. British 

Journal of Venereal Disease 32(1):34-35.

642 Reverby, S. (2009). Op cit., p. 144; John Cutler, Curriculum Vitae. (1990 February). PCSBI HSPI Archives, 

UOFM_0000020.

643 “Syphilis vaccine gains.” (1954). New York Times, December 9. 

644 John Cutler, Curriculum Vitae. (February 1990). PCSBI HSPI Archives, UOFM_0000020.

645 Ibid. 

646 Project for the Development of a Combined Agent for Disease Prophylaxis and Contraception. PCSBI 

HSPI Archives, NLM_0001832.

647 Contract No. AID/csd-2822. (1971, December 8). Allegheny County Field Efficacy Trial of ProphylaxisContraceptive Compound, Experimental Design Document. PCSBI HSPI Archives, NLM_000240. In 

this study, female subjects were selected from local STD clinics, and were self-identified as high risk of 

contracting an STD by “repeated visits for treatment at this clinic.” In the experiment, a health educator 

interviewed patients, the purpose of the trial was explained, and if the patients agreed to participate, they 

were asked to sign a consent form. No intentional infection protocol was employed. Singh, B., Cutler, J. 

(1979). Vaginal contraceptives for prophylaxis against sexually transmissible diseases. Workshop on New 

Developments in Vaginal Contraception, Guatemala City, Guatemala, April 25-27, 1979.

648 Ackerman, J. (2003). Obituary: John Charles Cutler / Pioneer in Preventing Sexual Diseases. Pittsburgh 

Post-Gazette. February 12. Available at http://www.post-gazette.com/obituaries/20030212cutler0212p3.

asp (accessed Sept. 1, 2011). 

649 Richard Arnold personnel form. (n.d.). PCSBI HSPI Archives, NPRC_0000132.

650 Ibid. 

651 Roster of Workshop Consultants (n.d.). PCSBI HSPI Archives, NLM_0001920.

652 Richard C. Arnold Obituary. (n.d.). PCSBI HSPI Archives, MISC_000319.

653 See Funes, J., et al. (1953). Serological and clinical studies of syphilis in guatemala, central america: 

Part 2, observations of a group of schoolchildren in Puerto San Jose. Pan-American Sanitation Bulletin

34(1):14-18.

654 Juan M. Funes Personnel Files, Notification of Personnel Action. (1956). PCSBI HSPI Archives, 

NPRC_0000799.

655 Venereal Disease Control. (1950, Oct. 14). JAMA 7(144): 556.

656 Wilcox, R.R. (1954). A WHO Study of Treatment Schedules of Treatment Schedule for Early Syphilis in 

use Throughout the World. World Health Organization Bulletin, 10: 579-617.

657 John F. Mahoney Obituary. (1957). PCSBI HSPI Archives, MISC_0000071.

658 T. Parran Personel File, PCSBI HSPI Archives, NPRC_0001601-662.

659 Cassius J. Van Slyke Personnel Files. (Various dates). PCSBI HSPI Archives, NPRC_0002844-57.

660 For other examples, see Beecher, H.K. (1966). Ethics and clinical research. New England Journal of 

Medicine 274(24):1354-1360.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

198

661 See Drug Amendments of 1962, Public Law No. 87-781 (1962), codified at 21 U.S.C. 355 (requiring 

informed consent in certain FDA-regulated research); 21 C.F.R. 50 (same); National Research Act of 1974, 

Public Law No. 93-348 (1974), codified at 42 U.S.C. 218 (requiring informed consent and independent 

review in HHS-sponsored research); 45 C.F.R. 46 (same); Emanuel, E.J., Wendler, D., Grady, C. (2000). 

What makes clinical research ethical? JAMA 283(20):2701-2711; World Medical Association. (1964). Code 

of Ethics of the World Medical Association: Declaration of Helsinki. Helsinki, Finland: World Medical 

Association.

662 See Section “Guatemala Experiments 1946-48” in this report.

663 See Section “Guatemala Experiments 1946-48: Race and Secrecy in the Guatemala Experiments: Issues 

of Secrecy.”

664 See Section “Guatemala Experiments 1946-48: Intentional Exposure Experiments: Overview.”

665 45 C.F.R. 46, Subparts B, C, D; Council for International Organizations and Medical Sciences and World 

Health Organization. (2002). International Ethical Guidelines for Biomedical Research involving Human 

Subjects. Geneva: World Health Organization, pp. 64-66; The National Commission for the Protection of 

Human Subjects of Biomedical and Behavioral Research. (1978). The Belmont Report: Ethical Principles 

and Guidelines for the Protection of Human Subjects of Research. Washington, D.C.: Department of 

Health, Education, and Welfare, DHEW Publication OS 78-0012; Ruof, M.C. (2004). Vulnerability, 

vulnerable populations, and policy. Kennedy Institute of Ethics Journal 14(4):411-425; Levine, R.J. (1988). 

Ethics and Regulation of Clinical Research, 2nd ed. New Haven: Yale University Press.

666 See Section “Guatemala Experiments 1946-48: Race and Secrecy in the Guatemala Experiments: Issues 

of Secrecy.”

667 The Nuremberg Code. (1949). In Trials of War Criminals Before the Nuremberg Military Tribunals Under 

Control Council Law No. 10, Volume 2. Washington, D.C.: U.S. Government Printing Office, pp. 181-182.

668 Ibid.

669 See, e.g., Kant, I. (1959). Foundations of the Metaphysics of Morals, trans. Lewis White Beck. 

Indianapolis: Bobbs-Merrill Company, pp. 37-42.

670 For prominent discussions of bioethical principles and moral rules, Beauchamp, T.L., Childress, J.F. 

(2001). Principles of Biomedical Ethics. New York: Oxford University Press; Gert, B., Culver, C.M., 

Clouser, K.D. (Eds.) (1997). Bioethics: A Return to Fundamentals. New York: Oxford University Press. 

The Advisory Committee on Human Radiation Experiments (1995) alludes to these rules as well.

671 de Kruif, P. (1926). Microbe Hunters. New York: Harcourt, pp. 303-325.

672 Schloendorff v. Society of N.Y. Hospital, 211 N.Y. 125, 129, 105 N.E. 92, 93 (1914) (“Every human being 

of adult years and sound mind has a right to determine what shall be done with his own body.”); Katz, J. 

(1984). The Silent World of Doctor and Patient. New York: The Free Press. See also Lederer, S.E. (1995). 

Subjected to Science: Human Experimentation in America before the Second World War. Baltimore: Johns 

Hopkins University Press. 

673 Advisory Committee on Human Radiation Experiments. (1996). Final Report of the Advisory Committee 

on Human Radiation Experiments. New York: Oxford University Press, p. 502.

674 Ibid. See also Beecher, H.K. Op. cit.

675 Advisory Committee on Human Radiation Experiments, op cit., p. 502.

676 Moreno, J.D., Hurt, V. (1996). How the Atomic Energy Commission discovered ‘informed consent.’ 

In DeVries, R., Subedie, J. (Eds.). Bioethics and Society: Constructing the Ethical Enterprise. Upper 

Saddle River, N.J.: Prentice Hall; Bonham, V.H., Moreno, J.D. (2008). Research with captive populations: 

Prisoners, students, and soldiers. In Emanuel, E.J., et al. (Eds.). The Oxford Textbook of Clinical Research 

Ethics. New York: Oxford University Press, pp. 461-474; Harkness, J.M. (1996). Research Behind Bars: A 

History of Nontherapeutic Research on American Prisoners, Ph.D. dissertation, University of WisconsinMadison, pp. 102-110 discussing Nathan Leopold’s experiences in the Stateville malaria experiments; 

Ethics governing the service of prisoners as subjects in medical experiments: Report of a committee 

appointed by Governor Dwight H. Green of Illinois. (1948). JAMA 136(7):457-458. 

677 Advisory Committee on Human Radiation Experiments, op cit., pp. 53-54.
endnotes X

199

678 Mahoney, J.F., Van Slyke, C.J., Cutler, J.C., Blum, H.L. (1946). Experimental gonococcic urethritis in 

human volunteers. American Journal of Syphilis, Gonorrhea, and Venereal Diseases 30:3.

679 See, e.g., Akrawi, F. (1949). Is bejel syphilis? British Journal of Venereal Disease 25:119; Alving, A.S., 

et al. (1948). Procedures used at Stateville Penitentiary for the testing of potential antimalarial agents. 

Journal of Clinical Investigation 27:2-5; Rein, C.R., Kent, J.F. (1947). False positive tests for syphilis: A 

study of their incidence in sporozite-induced vivax malaria. JAMA 133(14):1001-1003. 

680 Advisory Committee on Human Radiation Experiments, op cit., p. 92, n.2; Lifton, R.J., (1986). The Nazi 

Doctors: Medical Killing and the Psychology of Genocide. New York, Basic Books; Proctor, R. (1988). 

Racial Hygiene: Medicine Under the Nazis. Cambridge, MA: Harvard University Press.

681 American Medical Association, Board of Trustees. Minutes of the May 1946 meeting, pp. 156-157.

682 Moreno, J.D. (2000). Undue Risk: Secret State Experiments on Humans. New York: Routledge, pp. 63-71.

683 Coventry, W.A. (1947). Report of the Reference Committee on Miscellaneous Business, proceedings of the 

House of Delegates Meeting, 9-11 Dec. 1946. JAMA 133(1): 35.

684 Advisory Committee on Human Radiation Experiments, op cit., p. 76.

685 Ibid. Of course, conventions such as the Hippocratic Oath, which is widely known to admonish physicians to 

“abstain from all intentional wrong-doing and harm,” informed the understanding of a physician’s duties well 

before the written declarations of the mid 20th century. See Rieser, S.J., Dyck, A.J., Curran, W.J. (Eds.). (1977). 

Ethics in Medicine: Historical Perspectives and Contemporary Concerns. Cambridge, MA: MIT Press, p. 5. 

686 Ivy, A.C. (1947, May). Nazi war crimes of a medical nature. Federation Bulletin 33:133. Ivy also discussed 

his views several months earlier at an annual meeting of the Federation of State Medical Boards of the United 

States in February 1947. See Advisory Committee on Human Radiation Experiments, op cit., p. 93, n.5.

687 John C. Cutler to John F. Mahoney. (1947, May 17). Correspondence. PCSBI HSPI Archives, 

CTLR_0001122.

688 United States v. Karl Brandt et al. (1949). The Medical Case, Trials of War Criminals before the Nuremberg 

Military Tribunals under Control Council Law No. 10. Washington, D.C.: U.S. Government Printing Office.

689 Ibid. 

690 Ibid.

691 The veracity of this claim was challenged by many developments in the history of human subjects research 

in the decades that followed. See, e.g., Beecher, H.K., op cit. Scholars have argued that the Nuremberg 

Code itself had little if any effect on mainstream researchers in the United States until the 1960s. See 

Faden, R.R., Lederer, S.E., Moreno, J.D. (1996). US medical researchers, the Nuremberg Doctors 

Trial, and the Nuremberg Code: A review of findings of the Advisory Committee on Human Radiation 

Experiments. JAMA 276(20):1667-1671. 

692 Moreno, J.D. (2000). Op cit., pp. 64-80.

693 See Section “Guatemala Experiments 1946-1948: Syphilis Experiments: Overview.” 

694 Advisory Committee on Human Radiation Experiments, op cit., pp. 121-124.

695 See Section “Background: Developments in the Science of Sexually Transmitted Disease.” As Parran 

pointed out: “You know, we couldn’t do such an experiment in this country.” G. Robert Coatney to John C. 

Cutler. (1947, February 17). Correspondence. PCSBI HSPI Archives, CTLR_0001051. See also Moreno, 

J.D. (2000). Op cit., pp. 28-32.

696 As noted, it may be that the researchers viewed moral concerns not as meaningful requirements but rather 

as pragmatic boundaries beyond which they might receive unwanted attention from the press, the public, 

or government. See, e.g., Katz, J. (1972). Experimentation with Human Beings: The Authority of the 

Investigator, Subject, Professions, and State in the Human Experimentation Process. New York: Russell 

Sage Foundation. 

697 See Section “Guatemala Experiments 1946-1948: Race and Secrey During the Guatemala Experiments: 

Issues of Secrecy.” 

698 Advisory Committee on Human Radiation Experiments, op cit., p. 501.
“Ethically Impossible” STD Research in Guatemala from 1946-1948

200

699 Brandt, A.M. (1987). No Magic Bullet: A Social History of Venereal Disease in the United States Since 

1880. New York: Oxford University Press.

700 See section “Background.” 

701 See, e.g., Jonas, H. (1969). Philosophical reflections on experimenting with human subjects. Daedalus

98(2):219-247; Arras, J.D. (2005). Rationing vaccine during an avian influenza pandemic: Why it won’t be 

easy. Yale Journal of Biology and Medicine 78:287-300.

702 Indeed, a high rate of infection within a local population would make a prophylaxis study ill-suited 

to that locality, since researchers primarily sought uninfected subjects in order to test methods to 

prevent infection. John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives, 

CTLR_0000646. 

703 See Section “Guatemala Experiments 1946-1948: Initial Experiment Design.” 

704 The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. 

(1978). The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects 

of Research. Washington, D.C.: Department of Health, Education, and Welfare, DHEW Publication OS 

78-0012.

705 See Section “Guatemala Experiments 1946-1948: Syphilis Experiments: Psychiatric Hospital: 

Scarification and Abrasion.”

706 For a complete list of documents, please see Table I: The Cutler Documents. 

707 See John Cutler. (1955, February 24). Final Syphilis Report. PCSBI HSPI Archives CTLR_0001299; but 

see PCSBI. (2011). Subject Database.

708 Cutler Documents. (1947-1948). Guatemala Journal Studies with the Military (GC). Clinical notebook. 

PCSBI HSPI Archives CTLR_ 0000516.
201

A

abrasion, 62, 63, 64, 65, 116, 

119, 130, 185, 200

Advisory Committee on 

Human Radiation 

Experiments, 98, 155, 

156, 162, 198, 199

Aguilar, Casta Luis, 112, 143, 

178, 185, 186, 196

Alexander, Leo, 99, 100

Altshuler, L.N., 31, 124, 143

American Medical 

Association, 76, 99, 100, 

101, 155, 165, 170, 199

Anderson, Gaylord W., 164

Andrus, E. Cowles, 163, 168, 

169

Aragon, Hector, 36, 38, 112, 

176, 178, 179, 196

argyrol, 43, 111, 130

Arnold, Richard C., 23, 24, 

25, 28, 39, 46, 47, 48, 49, 

52, 54, 57, 58, 61, 88, 

110, 112, 116, 117, 142, 

143, 145, 170, 172, 174, 

177, 178, 179, 181, 182, 

184, 185, 186, 187, 188, 

189, 190, 191, 193, 194, 

196, 197

artificial inoculation, 28, 45, 

48, 50, 51, 54, 56, 61, 77, 

116, 117, 185

Asilo de Alienados 

(Psychiatric Hospital), 26, 

35, 186, 187, 188, 192

B

Baehr, George, 173

Belmont Report, 106, 157, 

198, 200

Bennett, James, 18, 19, 21, 

167

bismuth, 37, 43, 130, 163, 

170

Bloomfield, Arthur L., 16, 

165

Blum, Henrik, 20, 21, 22, 

98, 165, 168, 169, 185, 

197, 199

Burton, O.L., 123, 173

Bush, Vannevar, 13, 16, 17, 

18, 19, 120, 167

C

calomel, 11, 24, 25, 52, 111, 

130

Carden, George A., 164

Carpenter, Charles M., 13, 

14, 15, 19, 21, 164, 165

Chapman, Millicent R., 169

Chesney, Allen M., 63, 145, 

147, 190

children, iii, 2, 6, 37, 38, 39, 

40, 41, 83, 88, 93, 94, 

116, 118, 155, 157, 162, 

177, 178, 179, 180

Chinchilla, Roberto Robles, 

35, 112

cisternal puncture, 66, 67, 68, 

119, 131, 162

Clarke, Charles W., 121, 164

Coatney, G. Robert, 74, 143, 

145, 178, 193, 199

Cohn, Alfred M., 14, 19, 164

commercial sex workers, 2, 6, 

17, 21, 29, 41, 42, 43, 44, 

45, 46, 47, 48, 49, 52, 53, 

54, 55, 56, 70, 106, 118, 

119, 152, 154, 176, 180, 

185, 187

Committee on Medical 

Research (CMR), 12, 13, 

14, 15, 16, 17, 20, 23, 29, 

30, 114, 120, 163, 164, 

168, 169, 172, 173

contact method, 61, 64, 185, 

190

Cox, Oscar F., 17, 18, 121, 

164, 165, 169

Crabtree, James A., 173

Cumming, Hugh S., 77, 143, 

145, 161, 183

Curth, William, 68, 73, 192, 

193

Cushing, E.H., 121, 164

Index

Italic numbers indicate pages bearing illustrations
202

Cutler, John C., iv, 4, 5, 6, 7, 

10, 13, 20, 21, 22, 23, 24, 

25, 28, 31, 32, 33, 34, 

35, 37, 38, 39, 40, 41, 42, 

43, 44, 45, 46, 47, 48, 49, 

50, 51, 52, 53, 54, 55, 56, 

57, 58, 59, 60, 61, 62, 63, 

64, 65, 66, 67, 68, 69, 70, 

71, 72, 73, 74, 75, 76, 77, 

78, 79, 82, 83, 86, 88, 98, 

100, 101, 104, 106, 110, 

111, 112, 113, 114, 115, 

116, 117, 118, 131, 132, 

133, 142, 143, 144, 145, 

148, 149, 150, 152, 153, 

154, 161, 162, 163, 166, 

168, 169, 170, 171, 172, 

173, 174, 175, 176, 177, 

178, 179, 180, 181, 182, 

183, 184, 185, 186, 187, 

188, 189, 190, 191, 192, 

193, 194, 195, 196, 197, 

199, 200

D

deep inoculation, 44, 48, 49, 

51, 116, 181

Dilantin, 59

Dirección General de Sanidad 

Pública (Ministry of 

Public Health), 32, 174, 

178, 183

Dochez, A.R., 120, 163, 164

Donovan, James B., 16, 165, 

167

Duracillin, 53, 131, 186

Dyer, R.E., 29, 30, 120, 122, 

123, 163, 164, 173

E

Eagle, Harry, 31, 75, 76, 112, 

124, 143, 145, 193

Ejército Nacional de la 

Revolución (National 

Army of the Revolution) 

(Guatemalan Army), 32

F

Fair, Gordon M., 123, 173

Fleischman, Ralph, 75

Forbes, T.R., 164

Fred, Edwin B., 123, 173

Frew strain, 131, 186

Funes, Juan M., 28, 29, 32, 

37, 41, 45, 46, 64, 77, 

82, 83, 88, 112, 113, 117, 

118, 143, 145, 161, 171, 

176, 177, 178, 183, 184, 

185, 186, 195, 196, 197

Funes, Rolando, 113, 176, 

178

G

Galich, Luis, 45, 71, 82, 113, 

118, 178, 179, 185

Galvez, Ramiro, 162, 179, 

196

Guardia de Honor (Honor 

Guard), 44, 182

H

Haemophilus ducreyi, 69, 

130, 192

Harding, Virginia Lee, 32, 

113, 143, 174

Harlow, Elliot, 32, 77, 113, 

143, 145, 174, 188, 194

Harrison, Ross G., 18, 121, 

166, 167, 192

Harvard University, 31, 120, 

123, 124, 163, 164, 173, 

199

Hastings, A.B., 120, 123, 

163, 164, 173

Heller, John R., 31, 47, 55, 

76, 78, 110, 113, 116, 

122, 124, 143, 145, 170, 

172

Herrold, Russell, 121, 164, 

169

Hirschhorn, Harold, 169

Hospicio Nacional de 

Guatemala (National 

Orphanage of Guatemala), 

26, 36, 176, 178, 179, 

196

Hospital de Profilaxis 

(Venereal Disease and 

Sexual Prophylaxis 

Hospital) (VDSPH), 36, 

37

Hospital Militar (Military 

Hospital), 32

I

intravenous mapharsen, 111

Ivy, Andrew C., 99, 100, 101, 

104, 199

J

Jewett, Frank B., 18, 167

Johns Hopkins University, 12, 

30, 31, 86, 114, 120, 123, 

124, 146, 156, 164, 173, 

190, 198

Johnson, Bascom, 31, 124, 

143, 145
203

K

Kaempffert, Waldemar, 10, 

75, 76, 100, 101, 162, 

193, 194

Kahn test, 36, 132, 162, 176

Keefer, Chester S., 163, 168, 

169

Kemp, Jarold, 190

King, F.M., 167

King, Marion R., 169

Kolmer test, 36, 39, 162, 

176, 179

L

Leprosarium, iii, 40, 118

Levitan, Sacha, 24, 32, 44, 

70, 113, 143, 145, 174, 

176, 177, 178, 179, 194, 

196

lumbar puncture, 132, 179

Lundeberg, Karl R., 123, 173

M

Magnuson, Harold J., 75, 

169, 187, 197

Mahoney, John F., 11, 13, 19, 

20, 21, 22, 23, 24, 25, 28, 

31, 32, 33, 34, 35, 38, 39, 

44, 47, 49, 50, 52, 54, 55, 

56, 59, 60, 61, 62, 63, 65, 

68, 69, 70, 71, 72, 74, 75, 

76, 77, 78, 79, 83, 89, 98, 

100, 110, 113, 114, 116, 

117, 121, 122, 124, 143, 

145, 160, 162, 163, 164, 

166, 167, 168, 169, 170, 

171, 172, 173, 174, 175, 

176, 178, 182, 184, 185, 

186, 187, 188, 189, 190, 

191, 192, 193, 194, 195, 

196, 197, 199

Marvel, Carl S., 123, 173

Mast, George W., 31, 124, 

143, 145

Maxcy, Kenneth F., 123, 173

Maza, Raul, 44, 53, 70, 114

Mazzini test, 36, 132, 162, 

176

McAnally, Jr., William J., 

192, 193, 194, 195, 196

McIntire, Ross T., 15, 164

Meyer, Karl F., 123, 173

Miller, C. Phillip, 164, 169

Moore, Joseph Earle, 12, 13, 

14, 15, 16, 17, 18, 19, 21, 

22, 24, 30, 33, 143, 145, 

163, 164, 166, 167, 169, 

170, 171, 173, 186

Murdock, John R., 71, 185, 

192, 193, 194, 195

Musser, John H., 123, 173

Mustard, Harry S., 123, 173

N

National Advisory Health 

Council (NAHC), iv, 29, 

30, 31, 116, 123, 172, 

173

National Commission for 

the Protection of Human 

Subjects of Biomedical 

and Behavioral Research, 

157, 198, 200

National Institute(s) of 

Health (NIH), 5, 6, 7, 29, 

30, 31, 39, 71, 78, 88, 89, 

112, 114, 115, 116, 120, 

122, 123, 143, 144, 145, 

146, 147, 160, 164, 170, 

172, 173, 176, 178

National Research Council 

(NRC), 7, 12, 13, 14, 16, 

18, 19, 21, 24, 30, 145, 

160, 163, 164, 165, 166, 

169, 170, 171, 173, 186, 

193

Neisseria gonorrhoeae, 14, 

43, 131, 133, 162, 169, 

182

Nelson, Nels, 121, 164

Nichols strain, 58, 133, 186

normal exposure, 28, 29, 45, 

48, 49, 54, 56, 63, 64, 

116, 160, 171, 185

Nuremberg Code, 94, 95, 96, 

100, 155, 198, 199

Nuremberg Medical Tribunal, 

98

O

Office of Inter-American 

Affairs (OIAA), 29, 171

Office of Scientific Research 

and Development 

(OSRD), iv, 12, 13, 14, 

16, 17, 18, 20, 22, 23, 29, 

30, 120, 144, 163, 164, 

165, 169, 170, 172, 173

Office of the Coordinator of 

Inter-American Affairs, 29

Olansky, Sidney, 88, 162, 

176, 193, 196

Oliva, Juan, 44, 114

orphans, 6, 32, 33, 118, 119, 

174

orvus-mapharsen, 24, 25, 29, 

35, 42, 43, 52, 55, 56, 

58, 69, 70, 111, 112, 130, 

133, 185, 190, 194, 196
204

P

Pan American Health 

Organization (PAHO), 

4, 143, 161, 174, 178, 

179, 195

Pan American Sanitary 

Bureau (PASB), 4, 6, 31, 

32, 71, 72, 77, 78, 82, 88, 

112, 113, 114, 115, 116, 

161, 174, 178, 179, 183, 

184, 185, 195

Paredes Luna, Abel, 71, 113

Parran, Thomas, 10, 11, 13, 

14, 19, 29, 30, 31, 33, 68, 

72, 74, 75, 89, 114, 116, 

122, 143, 145, 146, 157, 

164, 167, 172, 173, 178, 

193, 197, 199

Paullin, James E., 16, 165

penicillin, 10, 11, 23, 24, 28, 

30, 33, 34, 37, 38, 40, 43, 

46, 47, 52, 53, 55, 57, 59, 

60, 61, 62, 63, 66, 72, 75, 

105, 111, 118, 131, 133, 

134, 152, 160, 163, 170, 

171, 172, 173, 179, 181, 

182, 183, 186, 187, 188, 

193, 194, 196

Penicillin Panel, 24, 30, 170, 

173

Penitenciaría Central 

(Penitentiary), 26, 29, 

32, 37

Pepper, O.H. Perry, 16, 121, 

164, 165

POB, 46, 52, 53, 133, 186

Porterfield, John D., vii, 173

Portnoy, Joseph, 32, 114, 

143, 145, 162, 174, 176, 

178, 179, 188, 196

Price, David E., 31, 124, 143, 

173

prisoners, 2, 6, 10, 16, 17, 

18, 20, 21, 29, 33, 35, 37, 

38, 40, 41, 42, 52, 53, 54, 

55, 56, 57, 77, 92, 94, 98, 

99, 106, 144, 157, 162, 

165, 166, 167, 175, 177, 

187, 188, 198

pro kit, 43, 52, 69, 70, 111, 

194

Public Health Service (PHS), 

2, 4, 5, 7, 10, 11, 13, 14, 

19, 20, 21, 24, 29, 30, 

31, 32, 35, 37, 41, 44, 47, 

72, 74, 82, 83, 86, 88, 89, 

104, 108, 110, 124, 142, 

143, 144, 145, 148, 160, 

161, 163, 164, 165, 167, 

169, 170, 171, 172, 173, 

174, 178, 181, 183, 185, 

186, 187

R

Reed, Lowell J., 31, 123, 124, 

143, 145, 164, 173

Reed, Walter, vii, 97

Reidel, Robert H., 164

Reverby, Susan M., ix, 4, 147, 

157, 160, 187, 193, 197

Richards, A.N., 14, 15, 16, 

120, 146, 163, 164, 166

Rockefeller, John D., 183

Rogers, John A., 14, 164

Roosevelt, Franklin D., 12, 

171

Rosahn, Paul D., 171

Rose, William C., 123, 173

S

Salvado, Carlos, 35, 41, 58, 

59, 67, 82, 83, 114, 143, 

145, 162, 176, 195, 196

salvarsan, 11, 33, 134, 170

scarification, 61, 62, 63, 64, 

65, 68, 69, 171, 185, 200

Scheele, Leonard, 68

Schoening, Harry W., 123, 

173

Schuman, Stanley, 193

Schwartz, Walter, 170, 173

Second Congress of Venereal 

Diseases in Central 

American, 39, 112, 117, 

178

Settle, R.O., 169

silver proteinate, 11, 22, 25, 

34, 134

Simmons, Ingalls H., 110

Simmons, James S., 120, 163, 

164

Smith, Harold W., 120, 163, 

164

soldiers, 2, 6, 16, 17, 33, 41, 

43, 44, 45, 47, 53, 54, 57, 

69, 70, 94, 98, 106, 118, 

166, 194, 198

Solomon, Harry C., 31, 124, 

143, 145, 173

Soper, Fred L., 77, 78, 143, 

145, 161, 189, 192, 194, 

196

spinal puncture, 68

Spoto, Joseph, 31, 32, 33, 35, 

54, 74, 114, 143, 145, 

174, 175, 179, 194
205

Sternberg, Thomas H., 164, 

170, 173

Stewart, Irvin, 120, 163, 164, 

165, 167

Stokes, John H., 31, 121, 

124, 143, 145, 149, 164, 

171, 173, 176, 177, 188

Stout, Genevieve, 72, 82, 

115, 117, 143, 145, 162, 

174, 176, 177, 178, 179, 

195, 196

“street strain”, 53, 186

Subcommittee on Venereal 

Diseases, 12, 14, 15, 30, 

114, 138, 160, 163, 164, 

165, 166, 167, 168, 169, 

170, 173, 184, 185

sulfanilamide, 11, 134

sulfathiazole, 52, 69, 70, 134, 

181

sulfonamide, 11, 15, 134

superficial inoculation, 44, 

48, 51, 64, 153, 181

Switzer, Mary, 173

Swope, E.B., 169

Syphilis Study Section, iv, 30, 

75, 112, 113, 114, 116, 

124, 166, 170, 173

T

Tejeda, Carlos, 34, 35, 51, 

70, 77, 110, 115, 175, 

178

Treponema pallidum, 47, 52, 

53, 65, 67, 131, 133, 135, 

186, 190

Turner, Thomas B., 31, 33, 

124, 143, 145, 164

Tuskegee Syphilis Study, 2, 

72, 157, 181, 193

U

University of North Carolina, 

75, 157, 181, 187

University of Pennsylvania, 

vii, 31, 121, 124, 142, 

146, 173

University of Pittsburgh, 4, 6, 

88, 89, 142, 146, 192

University of Rochester, 13, 

164

V

Van Slyke, Cassius J., 13, 19, 

20, 22, 30, 31, 47, 48, 55, 

75, 76, 78, 89, 98, 115, 

116, 122, 123, 124, 143, 

145, 168, 169, 172, 173, 

185, 197, 199

Vaughn, Henry F., 123

VDRL test, 36, 39, 82, 176, 

179

Venereal Disease Control 

Clinic, 45

Venereal Disease Laboratory 

and Training Center, 82, 

115, 117

Venereal Disease Research 

Laboratory (VDRL), 3, 5, 

6, 7, 11, 19, 20, 23, 25, 

28, 29, 30, 31, 32, 35, 36, 

39, 58, 62, 78, 82, 86, 

89, 93, 98, 100, 103, 104, 

111, 112, 113, 114, 121, 

124, 144, 160, 161, 162, 

171, 176, 177, 178, 179, 

186, 195, 196, 197

Vonderlehr, R.A., 19, 167, 

181

W

Walker, Alice, 32, 115, 143, 

153, 174

Weed, Lewis H., 120, 121, 

164, 166, 193

Wood, Barry, 170, 173

Wright, Willard, 39, 178
206

presidential commission for the Study of bioethical issues

1425 new york avenue nW, Suite c-100

Washington, D.c. 20005

(202) 233-3960

www.bioethics.gov