by M.P.Vora, M.B.B.S.
The Grant Medical College Magazine
Volume No. XLII, Number. 2 of March 1941.
Page No. 110 to 117
Venereal sores or genital ulcers resulting from sexual intercourse present various appearances and used to be classified as ‘hard’ and ‘soft’ sores in the former days when one used to be content to observe symptoms. Now, when the methods of diagnosis have far advanced, one would not be justified to wait for diagnosis till symptoms develop, and would naturally be eager to diagnose them bacteriologically and to classify them more scientifically into two classes ‘Syphilitic’ and ‘Non-syphilitic’. The effects of the latter are strictly local while those of the former, general and lasting. For this reason the terms syphilitic and non-syphilitic sores are more appropriate than the loose terms ‘soft’ and ‘hard’ sores. The chief question that should occur in the mind on seeing a venereal sore is whether or not it is syphilitic; for syphilitic leaves irreparable damage to vital organs of the body, if not detected in time. In syphilis, early diagnosis is of great importance. The sooner the diagnosis is made greater the chances of complete cure and shorter the treatment. The earlier the lesion is seen, the less does it present the true and characteristic hardness of syphilitic chancre. It is in such an early and atypical lesion that an accurate diagnosis is essential and is often difficult if clinical data alone are to be relied on. But it can be easily achieved with the recognition of Trepenoma pallidum in the serum from the sore. Non-syphilitic sores, on the contrary, are not due to Trepenoma pallidum, whatever else the casual organism may be, whether Ducrey’s bacillus, Staphylococcus, Streptococcus, non-syphilitic spirochaetes or filterable virus. They are of local importance and may spread, at the most, to the nearest lymph glands. Once they are proved to be non-specific it becomes relatively unimportant.
In taking the clinical history, in cases of venereal sores, the following points should be noted: Age, sex, married or unmarried, extra-marital sexual intercourse, date of last exposure to infection, the date of appearance of the disease, and any treatment done.
Mode of infection is usually by sexual intercourse with an infected person. The infection may however be transmitted by other means than sexual congress. Infection of the fingers of the doctors and nurses, during their attendance on syphilitic patients is not uncommon.
Incubation period- The primary syphilitic lesion follows exposure to infection by an average period which varies from 15 days to 21 days. It may be, however, as short as 10 days and as long as 10 weeks.
Site- Syphilitic sores may occur on any part of the body but they are most common on the genitals. In men, the favourite sites are the coronal sulcus, mucous membrane of the prepuce, frenum, skin of the penis, scrotum or groin, glans penis, etc. in the female they are found in the labia majora, labia minora, clitoris, vaginal wall, fornix, cervix, pubis, etc. In women, the chancre often escapes notice and it is often necessary to wait for secondary symptoms before diagnosis can be made.
Primary syphilitic lesion (Chancre) -An abrasion is usually present at the site of inoculation of Tr. pallidum. Any abrasion on the genitals subsequent to an exposure to infection must be considered as potentially syphilitic until proved otherwise. Hardness which one is inclined to feel before diagnosis is a late sign and must not be given undue importance in the early stage of the disease. Primary lesion begins as an abrasion or as a red spot. At times there may be complete omission of the early lesion. It then gradually goes into a papule or vesicle which in turn increases in size and develops into an ulcer. The ulcer has well-defined circular or oval outline which it retains during its spread. It is surrounded by a pink zone varying in width from 2 to 3 mm. It is quiet, indolent, not painful or tender and it may remain so during the whole of its course. It does not bleed easily and the discharge is small and serous. When it heals it does not leave a scar. As the ulcer becomes older, fibrous tissue gets deposited in and around the base of the ulcer giving rise to induration which is so typical of this infection; but it is not appreciable of the lesion on the glans penis. Induration is well marked in chancres situated on the skin or at the mucocutaneous junction, i.e. sore at the mouth of the prepuce. The zone of induration which surrounds the ulcer and gives it the appearance of being embedded in the tissues, remains for some time even when the ulcer is healed. Induration can easily be elicited by passing a finger gently from the healthy tissue over the edge of ulcer when one feels elevation and india-rubbery consistence. The primary syphilitic lesion is usually single though its multiplicity does not exclude the infection. Shortly after the appearance of primary lesion, there is a characteristic enlargement of the nearest lymph glands which are felt hard, discrete, painless under the skin (‘shotty’). There is no sign of acute inflammation. This is all true- it should be remembered- only of an uncomplicated syphilitic sore; any additional infection may easily change the appearance completely. An acute painful ulcer may result, discharging abundant purulent discharge; the painless glands may become painful and tender and later on develop into fluctuating buboes and then suppurate. In some cases this typical glandular enlargement may be absent however, but this failure to find enlarged glands should not weigh against the diagnosis. Suppuration in the nearest glands also does not eliminate syphilis. Occasionally the primary lesion may not be seen, i.e. intraurethral sore, sore in fornices or on the cervix.
These are the main characters of the primary lesion, but clinically there is not a single character which is not subjected to fallacy. When all the fallacies are taken into consideration it becomes apparent how difficult it is to pass a definite opinion on early genital sore. It would be wise policy not to give decided opinion that it is not syphilitic until repeated dark ground examination and blood test are negative and a few months have passed from the date of exposure to infection. One pathognomonic sign in all these chancres is the presence of T. pallidum.
(i) A Chancroid or soft sore commences as an abrasion and is due to infection by Ducrey’s strepto-bacillus after sexual intercourse. The infection is local and may involve the lymph glands draining the area of the sore. It affects men more commonly than women. Incubation period is short and varies from 1 to 3 days. The favourite sites in order of frequency are frenum, the undersurface of the prepuce, balano-preputial fold the glans penis, fossa navicularis, in the male and, labia majora and minora, perineum in the female. Chancroid, as they are usually multiple, may appear as early as 24 hours after the exposure to infection. To begin with they are usually small superficial ulcers with thin, red, undermined and irregular edges. They enlarge rapidly and form irregular ulcers. There is absence of typical induration. The floor of the ulcer is covered with yellowish necrotic material and emits purulent discharge. The margin of the ulcer is ragged and bleeds easily. The ulcer is auto-inoculable. The condition is painful from the beginning when there is superadded pyogenic infection- as is often the case- ulcer takes a very virulent form and may destroy a large area of tissue if prompt and energetic treatment is not instituted. Chancroidal ulceration is associated with painful, tender lymphadenitis which later on develops into buboes and suppurates. The whole process is one of acute inflammation. Diagnosis can be based on the following points.
Short incubation period, multiplicity and superficiality of the lesion, pain, tenderness, loss of tissue, irregular undermined edges; painful lymph nodes, rapid spread, absence of Trepenoma pallidum in the serum from the sore and Positive Rienstiernas Test.
A good rule to follow is to remember that every soft sore or chancroid may conceal a chancre and be on the look out. The earliest sign, i.e. the presence of Trep. Pallidum often fails, for the organism is present in the serum and not in the purulent discharge.
Rienstierna’s Test- An intra-cutaneous injection of 0.2c.c of the dead suspension of Ducrey’s bacillus is followed in, from 24 to 48 hours, by a red halo or blister at the site of the injection. The test becomes positive when the ulcer becomes 8 days old and remains so for years. It shows that patient had or has a chancroid.
(ii) Granuloma Inquinale or Venereum- It is an infective and granulomatous condition of the pudenda, found in the tropics and conveyed by sexual contact. Its exact cause is doubtful. According to Donovan, it is caused by ‘Calymmatobacterium granulomatis’; while E.L. Walker believes Bacillus Mucosus Capsulatus as the causative organism. Incubation period varies from 2 to 8days. The disease commences as a nodular thickening of the skin on the genitals, the usual sites being on the penis, labia minora and groin. It then excoriates and breaks down forming an ulcer. It advances in two ways: by continuous eccentric peripheral extension, and by auto-infection of the opposing surface. It shows distinct predilection for warm and moist surfaces, particularly the folds between the scrotum and thighs and labia. Its spread is very slow and concurrent with the spread, there is dense scar formation. In the female, the disease primarily attacks the crura of the clitoris, then extending into the vagina, over the labia and along the flexors of the thighs. In the male, the disease may spread over the penis, glans, scrotum or groin. The ulceration is relatively not deep and emits watery discharge with peculiar offensive odour. The floor of the ulcer is covered by greyish necrotic material. The disease slowly extends and continues for years. It is known by its chronicity and extensive cicatrization. It is entirely local but in the process of cicatrization, the lymphatics get blocked with the result pseudo-elephantiasis of the genitalia. The early ulceration may be mistaken for a chancre or chancroids but the disappointing results of purely local treatment should make one think the possibility of the lesion being granuloma venereum. Its early diagnosis or recognition is important because it is amenable only to antimonial compounds, no other remedial treatment being of much avail.
(iii) Climatic Bubo or Lymphogranulomatosis Inguinalis- The disease is transmitted by sexual contact and is caused by the infection with a filterable ultramicroscopic virus. The incubation period i.e. the time which elapses between the time of sexual congress and the appearance of primary lesion, varies from a few days to a three weeks. The primary lesion is a small herpitiform vesicle or an ulcer circular in shape. The tiny lesion may be single or multiple and has neither induration nor pain nor tenderness. It is often transitory and heals spontaneously without leaving a scar. It may occur on any part of the genitals, the commonest site being the coronal sulcus in the male and the fourchette or the posterior vaginal wall in the female. The lesion is looked upon as a mere abrasion evanescent, and is no longer visible at the time patient comes under observation for adenitis. Intensity and severity of adenitis varies in different cases. The earliest symptom complained of may be some stiffness or aching in the groin on walking. At the beginning there is a single discrete enlarged gland, freely moveable under the skin, slightly tender on pressure and unassociated with any charges in the overlying skin. The infection gradually involves and spreads to the whole group of inguinal lymph glands. In the early period, these glands resemble the early syphilitic glands; but as the time passes, these glands increase in size till they reach a certain size when they either retrogress ending the process or develop ‘slowly’ over many weeks to go on to suppuration. The whole process is very chronic and indolent lasting many months. Prior to softening of the glands, periadenitis is marked and the mass becomes fixed and adherent to the overlying skin, which takes a purple colour. The adenitis may be either unilateral or bilateral. Associated enlargement of the iliac glands is common and invariable. Suppuration, when it occurs, is very characteristic and particularly pathognomonic picture of this disease; but it does not occur in all the cases of adenitis. Some cases take up milder course or may show considerable enlargement and yet resolve. The swollen mass of the glands break down with a number of foci of suppuration and form multiple fistulae. There is no ulceration about the mouths of these fistulae. The lips of these openings are simple, not infiltrated; they do not show either undermining or button-like granulation tissue. The discharge from these openings is small and tenacious. Some cases may develop troublesome recurrent lymphatics with elephantiasis of the penis and the scrotum, recurrent attacks of fever and arthralgia or stricture of the rectum. The genito-anal-rectal syndrome or Esthiomine is common in women in whom the primary sore is commonly situated in the posterior part of the vulva towards the fourchette, with the result that the inguinal glands may be missed altogether while the glands situated in the pelvis are involved and undergo the same pathological changes as in the inguinal bubo. Hence genital elephantiasis, rectal stricture and ano-vulval hypertrophy and ulceration are frequently met with in women.
Frei’s Test- is specific for this disease. Frei’s Antigen 0.1cc. is injected intracuteneously on the outside of the forearm and a corresponding area on the other arm by normal saline as a control (use same quantity of saline). The result is read after 48 hours. A positive test shows an inflammatory dome-shaped area ½ cm. in diameter and a surrounding area of red zone.
I wish to record my sincere thanks to Dr. W.N. Welinkar, L.R.C.P., M.R.C.S., ( Eng.) and Dr. J.D. Bilimoria, M.R.C.P.E., D.P.H. ( Eng.) for their suggestions and encouragement.