by Major. M. P. Vora, M.B.B.S., D.V.D.,

Ex-Hon. Senior Venereologist,

St. George’s Hospital, Bombay.

The Indian Practitioner

(A Monthly Journal of Medicine, Surgery & Public Health)

Volume No. XX, Number 11 of November 1967.

Page No. 707 to 713.


A paradox without a parallel in the history of communicable diseases control is the continuance of the spread of syphilis and gonorrhoea unabated, despite the great sensitivity and susceptibility of Treponema pallidum and Neisserian gonococcus to penicillin, and the simplicity and speediness of the modern treatment. The steep rise with renewed vigour in these diseases, all over the world, as can be noted from recent and reliable reports, is a stark and shocking reality. This is now a major problem for public health authorities everywhere. It is very disheartening from the point of public health and equally disturbing to those with a casual approach to sex.


To be cured of syphilis or gonorrhoea, they must be diagnosed promptly and accurately, treated adequately and their “cures” confirmed subsequently by bacteriologic and serologic follow- up tests. The fundamental reason for the failure to check the spread is that physicians have simply failed to find out and treat infected persons rapidly enough to halt their spread. The primary responsibility in checking the spread is the prompt discovery of every existing infection and preventing equally promptly its spread. Every case of infectious syphilis or gonorrhoea, which could lead to an epidemic, must be regarded as a medical urgency. A physician in private practice is the key- figure in detecting venereal diseases in early stages; for most of these patients approach him first and seek advice and treatment from him. He has, however, still to come up to a standard to become a part of the control team in a nation-wide effort. Physicians who undertake to treat these diseases, must adopt scientific approach to the problem and develop certain standard and basic procedures, which are essential for the control of V.D. Unless they do so, they can never hope to discharge their responsibilities to themselves and to the public at large. Sincerity without competence is dangerous.


The management of a venereal case is not so simple as is often taken for granted. It requires an adequate and painstaking history and careful physical examination of the patient; it also involves complicated procedures and some inherent implications, which must be thoroughly grasped. Briefly they are:




When a patient seeks an advice for a genital ulcer, the most important point to determine is, whether or not it is syphilitic. For this, one must desist from temptations to prescribe antiseptic applications to the sore or treatment which would interfere with the detection of Tr. pallidum in the sore. Use of antibiotics at this stage delays the accurate diagnosis, and institution of proper treatment. The ulcer should be cleaned with normal saline and a drop of blood –serum from the lesion is taken and examined for Tr. pallidum under dark – field microscopy by which it is possible to diagnose syphilis several weeks before the S.T.S. becomes positive. At the same time, a smear is made for Ducrey’s bacillus, if chancroid is suspected. A serologic test for syphilis should be done as a routine in every case. If the ulcer is secondarily infected, or painful inguinal lymphadenitis is present, the patient should be given sulpha drugs, one gm. four to five times a day orally, for five to seven days, depending on the severity of the condition. This controls the secondary infection, prevents bubo formation, and at the same time, does not militate against the early and accurate diagnosis of syphilis. If the bubo is soft and fluctuating, it should be aspirated rather than cut open for rapid recovery.


The complaint of a urethral discharge or burning micturition, is a symptom of obscure origin many times. Whenever such a compliant is reported, it is reasonable to maintain a high index of suspicion, and think of gonorrhoea, but this suspicion has to be confirmed or ruled out by adequate physical examination of the patient and bacteriological examination of smears of urethral discharge, urine and cultures. On this very fact will depend appropriate treatment and other essential procedures. However, it is common knowledge, that no attempt is made to find out, if there is any purulent discharge, whether it comes from the urethra or subpreputial sac, or if there is any additional lesion, leave aside the etiologic agent.


When a patient complains of a painful inguinal swelling, one should always inquire and search for a genital lesion as a precursor, and attempt to arrive at a reasonable diagnosis, before the institution of any specific treatment. Frequent tendencies to prescribe penicillin injections in one’s eagerness to give quick relief to the patient, is harmful in the long run, and must be resisted at all costs. It destroys the only available evidence of early and accurate diagnosis, which is of utmost importance in planning the line of action.


Presence of any one of venereal diseases should make one search for other infections, because more than one may be acquired at a single contact. Hence, the tendency to neglect a careful and adequate physical examination in these patients, is strongly depreciated.


Educating the public with regard to these diseases is a very useful weapon against the spread of these diseases. At present, there is a good deal of ignorance, superstition, secrecy and prejudice on the part of general public. Because of the mode of transmission of infections, the word V.D. has long been a taboo in most homes. Few schools or institutions offer any trust-worthy information on the subject. Ignorance which is maintained by continued silence, hampers the struggle for the control of V.D. It is ignorance, which leads patients to conceal first signs and symptoms of these diseases, to try self-medication on their friend’s advice or to go for quacks for treatment and finally to accept disappearance of early signs and symptoms as “cure”. Year after year, ignorance has swollen the reservoir of infection, endangering the health of the nation. This conspiracy of silence must be ended. Every patient need to be told, about the potential seriousness of these diseases, their infectious nature, to avoid sexual contact till he is cured or made non-infectious, dangers of inadequate or irregular treatment, its latent nature, its effects on the marital partner or future progeny, and finally how to prevent these infections in the future, if he ever happens to expose himself to the risk of infection. A special emphasis must be placed on the fact, that disappearance of signs and symptoms does not mean ‘cure’, and that he must leave himself in the hands of the doctor, till he is definitely told, that his infection is completely eradicated. This basic lack of knowledge about diseases among people, coupled with easy access to contraceptives, and increasingly casual sexual behaviour, creates a climate, in which venereal diseases can spread like wild raging fire over the world. No physician, however, hard pressed to time should lose the golden opportunity to educate his patient on the subject. Every individual- may it be a man or a woman- urgently needs authentic information on the subject to forestall his or her co-operation in halting the spread of infection.


How often does a physician try to ascertain, whether or not the other sexual partner i.e. the wife or husband, if the patient is married, has been exposed to the risk of infection, and to find out the likely source of infection, and other contacts? These aspects should not be dismissed lightly, but pursued with tact and firm determination. Case-tracing is a tough, vital and demanding job for a medical social worker or epidemiologist, whose specialised task is to trace, as speedily as possible, the chain of venereal infection from patient to patient until all contacts have been unearthed, investigated and treated. The most usual and common questions asked are: “What about the person you caught it from. and what about the people whom you may have given it, before coming here”? The worker has to know the names of all the people with whom the established case had contacts. However, this is all kept strictly confidential. The roster of contacts serves to determine all possible links, in the continued chain of infection, and permits working both ways from the established case. The main object of this inquiry is that the worker can help these contacts, before the disease permanently damages their health, and they can spread it to others. Epidemiologists have to struggle very hard and incessantly to break the chain of infection, as quickly as possible. Adequate epidemiological control could contribute much to the reduction in the incidence of these diseases. However, experience indicates that this is seldom done outside recognised clinics. It is true that the practitioner has to face many obstacles to contact investigations of a venereal case such as lack of time, patient’s non –co-operation, deliberate lies or denial of exposure, and unproductive nature of the female’s physical and bacteriological examination, particularly in chronic gonorrhoea. However, the trouble is worth taking. If a physician in private practice will do his part, in finding the source and contacts of his patient, and placing them under treatment, the incidence of these diseases- there is no doubt- will be naturally reduced to a great extent. Frequent failure to trace the source of infection is the most important single defect in halting the spread of V.D.


In dealing with venereal diseases, it is of utmost importance that the treatment is followed to completion. Lapses in treatment are common among these patients, and repeated follow-ups are necessary. Venereal diseases can be cured easily by proper, regular and adequate treatment. Irregular or inadequate treatment, especially in the early stages of these infections, has merely suppressive or relieving effect for the time being, often results in the emergence of resistant strains of organisms, and damage to the vital organs of the body, producing crippling permanent disabilities at a future date. Most of the patients lack patience and wish for “all right” for the moment. In their ignorance, they often consider it unnecessary to continue attendance and treatment, when all the visible signs and symptoms have disappeared. They do not know the significance of latency or carrier stage of these diseases, which become inwardly active and damage vital organs of the body. Because of the failure on the part of most of these patients, to complete regular and adequate treatment and subsequent tests of cure, it has now become an accepted procedure, to employ a technique to achieve, what is called ‘case- holding’. It is for the practitioners treating these diseases, to impress on their patients the urgent need for their co-operation and to induce them to comply with the necessary treatment and tests of cure.


The great importance of this principle in treating venereal diseases cannot be overstated. Can a therapy, which is hit-or-miss type, or without an accurate diagnosis, be pardonable to scientifically trained physicians? Indiscriminate use of drugs, or promiscuous therapeutics must be avoided at all costs, in the treatment of V.D. It deprives the patient of his body- defence build-up, promotes emergence of resistant strains of organism, and makes vital organs of the body more susceptible to the attacks of the infection. As the result a good opportunity for early diagnosis and permanent cure is simply wasted, and subclinical infections are let lose, to spread in the community. Anti-venereal drugs must be prescribed only when called for, in adequate dosage, over an adequate period, to maintain an effective blood-level, for the requisite period. Experience indicates that this principle is very often violated to the detriment of the patient’s health and the public health. A physician, who is desirous of treating these cases efficiently must get himself well acquainted with modern therapeutics in venereology. It would be a great misfortune for a patient to be treated by an ignorant physician. Rational therapeutics aim to treat the cause and not merely to relieve the symptoms of a disease. To obey the percepts of therapeutic rationality, the physician must avoid treating the symptoms alone, when there is a way to attack cause.


A successful outcome in the treatment of gonorrhoea depends on the accurate bacterial confirmation, the sex of the patient, duration and extent of the infection, the presence of complications, choice of drugs and procedures of treatment. For a fresh case of acute gonorrhoea in the male, sulphadiazine 1 gm., four or five times a day orally for five to six days or procain penicillin G 400,000 units I.M. daily, for three consecutive days, is considered adequate. For an acute fresh gonorrhoea in the female, the amount of treatment should be doubled as a general rule. When penicillin is given for gonorrhoea, there is a danger of masking syphilis or modifying its early course, if double infection has been contracted at the same time. In long-lasting or complicated gonorrhoea, mere chemotherapy will not eradicate the infection unless local therapy such as urethral dilatations, prostatic massage, etc. are employed at the same time, in addition to chemotherapy. However, these measures must not be employed until the acute process has completely subsided. Chronic or complicated gonorrhoea would need three times the amount of treatment that is considered adequate for an acute fresh case. It is futile to depend on penicillin for a cure of non-gonococcal urethritis. While treating gonococcal arthritis or epididymo-orchitis, the treatment of the primary focus of infection and contact investigations must be overlooked.


One must bear in mind that healing of the chancre does not mean cure of syphilis. A case of primary syphilis needs at least 6 mega units and late secondary syphilis 9 mega units of procain penicillin-G, administered in ten and fifteen days respectively. Serious complications of syphilis and gonorrhoea and their late sequelae can be prevented, if every case is adequately treated in the early stages of infection.


Tests of cure are very essential in every case of V.D. treated. Treatment, however, perfect and at the hands of an expert, is not a guarantee of a real and permanent cure, in every case, unless it is followed by periodic physical check-ups and laboratory tests, spread over a certain period. In absence of a full bacteriologic and serologic follow-up of these patients, one is likely to enlarge, the pool of infected persons in the society. Hence one must not neglect this vital procedure, when the treatment is completed. A physician who wishes for the future well-being of his patient ought to be, specially particular about these tests, for the ultimate health of his patient and his family depends on the results of these tests. The absolute necessity for the most careful observation over a period must be stressed.


A case of chancroid needs to be observed for 3 to 4 months, the maximum incubation period for syphilis. During this period, searching physical examination of the patient, and serologic test for syphilis, preferably quantitative, have to be carried out at regular intervals, to exclude the possibility of syphilitic infection.


A case of acute fresh gonorrhoea should have a follow-up for a similar period, during which various tests, for the cure of gonorrhoea, including the serologic test for syphilis are to be carried out. Urine held for about 4-5 hours should be free from ‘threads’, pus cells and gonococci. Presence of more than five pus cells per microscopic field H.P. is an indication of continued inflammation. Secretions from accessory sexual glands need to be examined and cultured for the confirmation of cure.


A case of early syphilis treated needs an observation period of at least two years, during which time, regular physical examination of the patient, blood test for syphilis, examination of cerebrospinal fluid, and full check up of the cardiovascular and nervous system are to be carried out, before the patient can be declared as cured. Sero-negativity within six months of treatment is considered satisfactory in early syphilis. A steady rise in titre of the serologic test for syphilis indicates either failure of the treatment or an impending relapse of the infection. Increase in proteins and lymphocytes in the C.S.F. indicates early neurosyphilis, which can only be detected by timely examination of the C.S. fluid. Even though the blood serology is consistently negative, the C.S.F. must be examined at the end of six months.


As these patients need a surveillance or observation period extending from four to twenty-four months, when they have to undergo a series of tests, proper and accurate records have to be kept, for evaluation of effects of treatment, to understand the serologic trends, and to be able to declare the patient “cured”. Up-to-date records of results of tests performed from time-to-time, which can be seen at a glance, are of great help in deciding the patient cured of his infection. Without reference to this record, it will not be possible to offer a clean bill of health to the patient. A physician who declares his venereal patient cured, on the strength of a single examination- may it be comprehensive- makes a serious mistake. It is not possible to declare a V.D. patient cured on the strength of a single examination either physical, bacteriological or serological, or the combination of all. “Cure” must be based on the results of a series of observations on physical health, bacteriologic and serologic tests.


How many physicians are aware of these implications and procedures, and honestly carry them out while treating venereal cases? Its answer is superfluous and needs no comment. To prevent a disaster of great magnitude, it is considered necessary to galvanize them out of their somewhat ‘laisse faire’ attitude towards the problem of V.D. control. During the past few years, the treatment of venereal diseases has been greatly simplified. It should now be the responsibility of the general practitioner rather than the specialist to treat numerous venereal patients who seek his advice and aid. Nevertheless, it cannot be strongly emphasized that successful management of V.D. continues to depend on the closest attention to the details of the fundamental principles in the diagnosis and treatment of V.D. by both the physician and the patient alike. It has been found that a specific remedy does not ensure eradication of a disease, and that the inefficient use of the remedy may readily lead to drug resistant forms of disease, as well as to multiplication of symptomless carriers of the infection. This is one of the reasons for the increase in the incidence of venereal diseases. Control of contagious diseases depends on complete cure of the infected individuals, along with detection of the sources of the disease and their treatment along with other contact cases. Until full control measures are effected by complying with the basic principles in the treatment of venereal diseases, the spread of these diseases is likely to continue unabated. What is required is the clear understanding of the problem and resolute action on the part of every physician – of – first- contact.