BASIC CONCEPT IN THE MANAGEMENT OF A VENEREAL CASE
by Major M. P. Vora M.B., D.V.D.
Hon. Senior Venereologist, St. George’s Hospital, Bombay.
Current Medical Practice
A monthly journal devoted to modern medicine and surgery.
Volume Number- 3, Number - 12 of December 1959.
Page no. 713 to 716.
Venereologists are few and far between even in large cities like Bombay. They are even rarer in the mofussils. Besides, the vast majority of our patients belong to low income groups and cannot afford expensive services of a specialist. It is reasonable to assume that the management of a venereal case is usually in the hands of a general practitioner.
Management of a venereal case is a subject of great importance and forms a significant part of a general practitioner’s requirements. However, both the diagnosis and the treatment of these cases, one regrets to note, have not been up to a standard. These are common afflictions, curable by comparatively simple methods which are almost entirely within the scope of a general practitioner. For a success adequate and painstaking history and physical examination of the patient are essential. The practitioner should have a good working knowledge not only of general medicine but also of surgery, gynaecology, urology, sexology, dermatology, psychology and venereology.
Keenly aware of these facts, an attempt is made to find out, from personal experience, what a great practitioner often forgets to do or neglects to observe in a management of a venereal case.
To begin with, he must discard the old- fashioned attitude and adopt in its place a sympathetic and humane one towards these patients. He must not confuse sexuality, which is natural to humanity, with sensuality. Great tact and consideration in dealing with these patients are necessary. All venereal diseases are not so simple in their management as is often taken for granted. They involve very complicated procedures and some inherent implications.
The most important point in the management of these diseases is to make sure of the diagnosis and confirm it before the treatment is started. Treatment of a venereal case without diagnosis is prohibited in the practice of venereology.
How often does a practitioner try to verify the diagnosis of a genital ulcer? He often presumes it to be a chancre or a chancroid and institutes treatment in his eagerness to give immediate relief to the patient. He should remember that the spot diagnosis of a genital lesion as a chancre or chancroid from clinical examination alone is impracticable and at time disastrous. It is arrived at by a process of exclusion and invariably confirmed by laboratory tests.
How often is the diagnosis of gonorrhoea verified in a patient with urethral signs and symptoms? Frequently, one does not make sure whether there is any discharge and whether it comes from the urethra or the subpreputial sac. It is then assumed to be a case of gonorrhoea and specific treatment is commenced. Such a procedure is neither fair to the patient nor to the practitioner in the modern scientific era.
The most important consideration is of the various implications inherent in the diagnosis of these diseases. How often does one try to ascertain whether or not the other sexual partner, i.e. wife if he is married, has been exposed to the risk of infection either during the incubation period or after the appearance of the first symptom? The next is the question of the likely source of infection and of other contacts. These aspects should not be dismissed cursorily but pursued with a firm determination. One must always be conscious of one’s responsibility relative to the prevention and spread of venereal diseases. Unless a practitioner, attending upon a patient with early syphilis or gonorrhoea, attempts to find out and treat the source of his patient’s disease and to protect his intimate contacts, he may have to assume the responsibility for other infections and spread of venereal diseases in the community. Careful and detailed instructions to the patient will often enlist his cooperation in bringing in exposed sexual partners and protecting members of his family.
Education of the patient relative to these diseases as infectious, is essential. During his first interview, he should enlighten his patient about the potential seriousness of the disease, the necessity of early and effective treatment, the importance of his cooperation in achieving success, avoiding sexual contacts till he is cured or made non-infectious and finally how to prevent infection in the future if he happens to be exposed to the risk of infection.
When a patient comes with a genital ulcer, the first question to determine is whether or not it is syphilitic in origin. The ulcer is cleaned with normal saline and a drop of blood serum from the lesion is taken and examined for T. pallidum under dark-field microscopy. If such a facility is not available in his office, the serum should be collected in a capillary tube and the sealed tube is sent to the nearest laboratory for examination. A serologic test for syphilis should be done as a routine in every patient. If there is secondary infection or painful inguinal adenitis, the patient should be given a sulpha drug g. one, four or five times a day orally for 5 to 6 days. This controls secondary infection and helps to prevent bubo-formation; at the same time, it does not interfere with the investigations or the course of concomitant syphilis.
The complaint of a ‘urethral discharge’ by the male is a symptom often of obscure origin. It must be remembered that all patients who come with this complaint are not necessarily the victims of gonorrhoea which is all easy to presume. On the contrary, most of them mean thereby something else. Whenever such a complaint is reported, it is reasonable to keep a suspicion and think of gonorrhoea; but this presumption has to be confirmed and verified in every case by examination of smears and at times cultures. Diagnosis must come before specific treatment.
Successful outcome in the treatment of gonorrhoea depends on the observance of certain basic rules with regards to the use of drugs employed and the choice of procedures of treatment. In using sulpha drugs, the accuracy of bacterial diagnosis, the duration and the extent of infection, adequate dosage over an adequate period so as to maintain an effective blood concentration of the drug for the requisite period are important points to bear in mind. For a case of acute fresh gonorrhoea, sulphadiazine or sulphathiazole gm one, four of five times a day orally for 5 – 6 days or 400,000 units of procaine penicillin fortified I.M. is considered adequate. In long standing or complicated gonorrhoea, the focus of primary infection should not be neglected. Here no amount of powerful drugs would cure the infection unless local therapy consisting of urethral lavage, dilatations, prostatic massage, etc. have been employed in addition, at the same time. These measures help to promote drainage and permit the successful application of chemotherapy. A course of treatment may have to be repeated. Importance of complete eradication of the primary focus of infection must not be lost sight of in relieving the symptoms such as arthritis or epididymorchitis. In treating gonorrhoea with penicillin, there is a danger of masking syphilis or modifying its course if a double infection has been contracted at about the same time. Many failures in the treatment of gonorrhoea and subsequent complications can easily be avoided by having thorough understanding of these basic principles.
Any inflammation of the eye of a newly born infant within two weeks from the date of birth should arouse suspicion of ophthalmia neonatorum, and the preventive aspect by adopting appropriate treatment immediately, should not be overlooked to protect the child from blindness. Investigation of the mother for the detection of infection should not be neglected.
From the clinical point, the practitioner must think of syphilis in terms of a systemic disease which is almost always active and slowly progressive; it may show itself at any time in one or more ways in any tissue of the body. He must remember that the course of syphilis does not invariably run true to type. He must discard the tendency to think of syphilis only in terms of disease of the genitals or the skin. His index of suspicion must be high as to the possible role of syphilis in chronic diseases appearing many years after the onset of infection. It must be emphasized again that a detailed history and careful physical examination of the patient are valuable.
The value and necessity of laboratory diagnosis in early syphilis must be clearly understood. One should know the great advantage of dark-field microscopy over the customary blood test for syphilis in early and accurate diagnosis of syphilis. He must remember that a delay of a few days in arriving at a diagnosis of syphilis may impair the patient’s chance of a complete cure and increase the opportunity for dissemination of infection both in the individual and the community.
The most important need is the knowledge of the value the blood tests have in the diagnosis of syphilis and the interpretation of their results. The value of any serologic test in the diagnosis of syphilis is dependent on its sensitivity and specificity; however, neither the sensitivity nor the specificity is absolute in spite of the modern techniques. Hence the results of the test should always be considered in conjunction with the history and clinical findings. He should remember that a negative blood test in the course of treatment does not necessarily indicate that the patient is cured and the quantitative serologic tests are valuable in assessing the response to treatment. When the blood test for syphilis is positive but is not supported by history or clinical signs, a diagnosis of syphilis should not be made at once on the strength of a single serologic positivity nor the antisyphilitic treatment instituted in haste ordinarily. There is therefore, a great need for the greatest caution before accepting an unexpected serologic positivity as incontrovertible proof of syphilis.
In the field of syphilotherapy, the practitioner must know what constitutes an adequate treatment for a given stage of syphilis and evils of under- and irregular treatment specially in the early stage. It makes the vital organs more vulnerable to the infection and often leads to crippling nervous and cardiovascular disabilities. The physician must bear in mind that in syphilis, a prolonged study is absolutely necessary in the evaluation of a new drug. At least, a few years must elapse subsequent to treatment before final estimate and evaluation of a new drug in syphilis can be made. Hence it is advisable for him to combine the advantages of a new drug with a portion of the proved method of treatment, which has stood the tests of time. From this point of view, it is good to use penicillin-arseno-bismuth therapy in early syphilis.
The objects of treatment of early syphilis are to render the patient rapidly non-contagious and to effect complete eradication of the infection in the shortest time. Hence intensive treatment as far as practicable should be given. In sero-negative primary syphilis, 4.5 mega units of procaine penicillin I.M. for 8 days and in sero-positive primary and early secondary stage, 6 mega units for 10 days are considered necessary. In addition, one unit course of Mepharside (0.5 gm total) I.V. and bismuth (2 gm total) I.M. for ten weeks should be given. In late syphilis, it is essential to exclude any serious lesion of the cardiovascular or nervous system, before active treatment is instituted. Here the objects of treatment are to relieve the patient and arrest the progress of the disease; therefore leisurely rather than intensive schedules of treatment are preferred. In using antisyphilitic drugs every care must be taken to avoid untoward reactions, by careful examination and interrogation of the patient before each injection; for a severe reaction may follow occasionally any drug.
The conception of abortive treatment of syphilis is not new but its value is doubtful. The short-term results may appear very impressive, but one has observed patients treated in this way, long enough and carefully to know whether its effect is merely to suppress the early signs of infection. It’s quite unsound, ineffective and often harmful. Its use is a violation of a fundamental principle and it should always be regarded as an undesirable expedient. The administration of such a treatment to anxious patients necessitates a considerable period of observation, testing and anxiety which could be normally limited to three months at the most.
It is of the utmost importance to get blood tests for syphilis done as a routine in every pregnant woman at the end of the 4 th, 6 th, and 8 th month of pregnancy. For the prevention of congenital syphilis depends on the detection and adequate treatment of maternal syphilis at the earliest moment. It is advisable to give a course of treatment during two subsequent pregnancies irrespective of her blood test reports to assure a healthy child. Results with penicillin treatment are found to be quite satisfactory. Once the diagnosis of congenital syphilis is made, the investigation of the mother and other members of the family should not be omitted.
When the practitioner is asked to advise on the fitness for marriage of a syphilitic person, he should be very cautious in estimating the risk of transmission of syphilis or its ill effects on the progeny. Neither unqualified pessimism nor careless optimism can be justified on his part.
When the treatment of the disease is completed, an adequate observation and proper tests of cure to make certain that the infection has been truly and really eradicated, are essential in every case. But they are often overlooked or neglected. Surveillance of these patients is absolutely necessary. A number of tragedies are frequently met with for want of compliance with this simple rule. A case of chancriod should be kept under observation for 3 to 4 months during which regular physical examination of the patient and serologic tests for syphilis are carried out. A case of acute gonorrhoea should have a follow-up for a period of 3 to 4 months, during which various tests for the cure of gonorrhoea, including serologic tests for syphilis, are performed. A case of early syphilis treated, needs an observation of at least two years, during which regular physical examination, blood tests, at least two examinations of cerebrospinal fluid, check up of the central nervous and cardiovascular systems, are to be completed before the patient can be given up as cured and a bill of clean health can be issued.
If the practitioner would bear in mind and resolve to put in practice the fundamental principles involved in the management of a venereal case, he would do an immense service to the public at large and make a valuable contribution towards the eradication of this scourge from the society; for, at present, an average venereal patient seems to be convinced with the erroneous idea that he can be cured by one or two shots and needs no other care or consideration.