PROOFS OF CURE IN GONORRHOEA
M. P. Vora, M.B.B.S.
The Medical Bulletin
Vol. IX, No.5 of 1 st March, 1941; Pages: 153-158
The question of ‘Cure’ of gonorrhoea is a common topic in the practitioner’s daily work and is, indeed, not of minor importance. When can one safely pronounce a patient, suffering from gonococcal infection, as cured? Obviously the answer is not an easy one. The word cure is used differently to mean symptomatic cure, apparent or clinical cure and bacteriological cure. The cure in the sense of the former two is possible in every case within a short period. Bacteriological cure, an ideal cure, which should be aimed at in every case, is obtainable in cases early and with few complications such as prostatitis, vesiculitis, epididymitis, salpingitis etc. In chronic and complicated cases, it is rather difficult, and it becomes more so on account of the long and tedious treatment, prolonged and irksome tests of cure, and the cost thereof. It also requires the fullest co-operation between the patient and the doctor. It is unfortunate that, in spite of the recent advances in the medical science, while one can definitely pronounce a clinical cure, it is very difficult to say positively and decisively that bacteriological cure or a thorough and complete cure has been effected. At the same time it is very hard to lay down an absolute standard of cure which can be applied rigidly to all cases. It is difficult in the male and doubly so in the female. “As to the presence of gonococci the question can only be answered categorically. A man may be well and normal in clinical sense and still may harbour latent gonococci in his genital tract, which may become activated when deposited on a virgin soil. The lapse of time will tell better than the most exact series of tests, whether or not the element of infectiousness has been completely removed from the patient”. One has, therefore, to use the greatest thoroughness and judgment and to allow sufficient time to pass before telling a patient that he or she is ‘cured’; otherwise the doctor would fail to discharge his obligations that are imposed upon him.
Even A VERY EARLY CASE, WHEN UNDER PROPER TREATMENT, MAY NEED AS MUCH AS EIGHT WEEKS, PROBABLY MORE BUUT NOT LESS, FOR A THOROUGH CURE. Older the infection or more complications in the disease, longer will be the period of treatment, and more difficult becomes the complete cure. This holds good notwithstanding the recent chemotherapeutic advance, which has helped not only to reduce the period and the cost of the treatment, but also to carry out the whole course of treatment rapidly, more successfully and with least complications. All the same, the importance of local treatment in the complete eradication of infection, must not be lost sight of. To establish a cure, it is essential that certain standard tests should be passed by every person. They are proceeded more or less on the same lines in both sexes. For all practical purposes the following plan may be adopted for general guidance.
I. Male Infection
The conditions to be examined for a cure of male infection. (A) where the anterior urethra alone is involved and (B) where the whole urethra is involved. Though the nature and the scope of examination do not vary greatly in the two, this division seems more appropriate and convenient to the present day when early cases with anterior urethritis only are not uncommon. In these cases, the tests of cure need not be gone through relatively easily and in a short time.
Smears are made from the above material, stained with gram’s stain and examined carefully for the presence of pus cells and gram-negative intra and extra cellular diplococci. At the same time cultures are made on a suitable medium and watched for the growth of the organism. As regards the examination of the urinary deposit, one should make a point to examine the fresh urine; for gonococci autolyse and disappear from the stale or alkaline samples.
(ii) 1 in 4000 Pilocarpin Hydrochloride solution 10c.c.
(iii) 5% Protargol solution 10 c.c.
Since the disease comes under observation late there is likelihood of the involvement not only of the whole urethra but also of some other organs. In the chronic disease, where prostate vesicle, epididymis etc are affected, it is not often possible to procure complete cure, on the account of the irrevocable nature if the changes that are wrought in the organs. Complicated cases therefore, the organs which have undergone considerable changes, cannot be expected to return back to complete normal state. The tests of cure are naturally more extensive and critical and take longer period. Some extra tests, in addition to the tests described above, require to be satisfied in these cases.
Semen are made stained and examined for pus cells and gonococci. Cultures are also made from these materials are examined.
If the primary tests i.e. test No. 1, 2, 3 and 5 are found satisfactory immediately after the suspension of treatment, a provisional assurance that the disease is ‘nearing a cure’ should be given. If, in these tests, any doubt arises as to the presence of infection, a further course of treatment should be prescribed and the tests of cure should be repeated at a later date till the requirements are satisfied. After one to two month’s rest from treatment the patient is examined again. If the test No. 1, 2, 3, 4, and 5 i.e. clinical, microscopic, cultural, provocative and urethroscopic examinations, are found satisfactory, one may declare a patient ‘clinically cured’. At this stage, the patient may be allowed to resume his ordinary habits of life and asked to report himself again for examination three to four months subsequent to the suspension of the treatment. If no signs and symptoms of the disease are apparent during this probationary period and the repetition of tests is found again negative, the use of condom or some such protection, during sexual intercourse, (if the person is married) for the first few times, should be advised. A complete failure to demonstrate any evidence of the presence of infection in a patient after these elaborate and repeated procedures, is a proof of complete ‘cure’ has been effected. But the evidence after all is circumstantial and one cannot be too sure bacteriologically. Does this mean that one can deal lightly and impatiently with the cure of gonorrhoea simply out of mere pessimism? That can by no means be fair. The disease is infectious and as such it is our duty to exhaust all the means that are available to achieve the ideal end.
II. F emale Infection
The conditions to be examined for a cure of the female infection: -
When the primary tests, i.e. test No. 1, 2, and 4 are found satisfactory after the cessation of treatment, the patient may be assured that the disease is ‘nearing a cure’. The test should be repeated monthly during ensuing three months within 24 hours after the cessation of menses, the last time, the test being supplemented by the provocative dose of vaccine and by the retention of glycerine plug into the vagina. If these examinations, i.e. clinical, microscopic, cultural, urethroscopic and provocative, are negative the patient may be declared ‘clinically cured’. When six to nine months have gone without any sign, the previous findings are automatically confirmed. After all these elaborate tests are passed repeatedly, she may be considered completely cured.
My thanks are due to Dr. W. N. Welinkar, Specialist in Venereal Diseases, Sir J.J. Hospital, Bombay, who kindly read through this article and made important suggestions.