TREATMENT OF VENEREAL SORES
M. P. Vora, M.B.B.S., Venereal Dept., J.J. Hospital, Bombay
The Medical Bulletin
Vol. VIII, No.14 of 20 th July, 1940; Pages: 465-470
V enereal Sores, (ulcers on the genitalia as a result of sexual intercourse) used to be classified as ‘hard’ and ‘soft’ sores in the olden days. Now that the methods of diagnosis have undergone a considerable change, one would not like to wait for diagnosis till symptoms develop and would further like to classify the sores more scientifically as ‘syphilitic’ and ‘non-syphilitic’. The effects of the latter are purely local and more serious. It is on this account that the terms syphilitic and non-syphilitic are preferable to more loosely applied terms ‘hard’ and ‘soft’ sores.
From the treatment point of view, the syphilitic sores may be divided into two groups i.e., (i) uncomplicated and (ii) complicated; while the non-syphilitic sores into three groups i.e., (i) chancroid (ii) granuloma venereum and (iii) primary lesion of the climatic bubo.
In syphilis, early diagnosis is of paramount importance to cut short the period of infectivity and to assure the patient not only of symptomatic and serologic cure but also of ‘biological’ cure. It need hardly be stressed that during the period of incubation which precedes the onset of induration of the chancre, the Treponema pallidum can be found in the serum from the sore and it, therefore, behoves every medical man to examine carefully and promptly the suspected material from the genital sore under dark ground examination, as the earlier this is done and the treatment begun, greater the chances of ‘cure’. It must be remembered that where antiseptics have been applied to the sore, the spirochetes migrate into the deeper issues and so a negative result is often obtained, whereas if the sore is dressed only with saline before examination, numerous spirochetes will be found. For this reason potent antiseptics must be avoided until at least three successive specimens of serum from the sore have been carefully examined for Treponema pallidum. During this period of investigation applications of hot saline dressings (either normal 0.9% or hypertonic 5%) are extremely good. They not only relieve pain and keep the part clean but also help to heal. Another useful dressing is the frequent application and rubbing in the sore of sulphur sublimate powder; for it does not interfere with the finding of organism in the serum from the edge of the wound. It cannot be too strongly impressed that the medical man should do well to advise the patient even though the sore is found Treponema-negative, to get blood examined for Wassermann Reaction or Kahn Test, thrice, at monthly interval, the last blood test being done about 4-5 days after the provocative dose (0.3 gm. N.A.B. intravenously). It would help to detect the infection early and to ensure against late disastrous sequelae. Once the routine examination is finished, the local treatment of the sore consists in virtually following the ordinary principles of surgical dressing i.e. rest to the part, securing good drainage, frequent application of heat, baths keeping the ulcer and the surrounding area clean, application of dressings and stimulating growth, attention to the diet, bowels and general health of the patient.
When the ulcer is hidden under the prepuce and the flow of discharge is interfered with, due to tight prepuce, the exposure of the glans penis and the ulcer is essential both from the point of diagnosis and treatment. If free flow of the discharge is not secured buboes are apt to develop. The exposure may be detected by either of the following ways. – (1) Dorsal slit or incision (2) V-shaped incision.
From the day previous to the operation, the patient is kept on the following mixture for a few days. It helps to deaden the sense of pain and to check painful erections.
Pot. Bromide gr.30
Aqua chloroform ad ǯi
mft.mist. ǯi T.D.S.
Camphor monobromate gr. 10
In a cachet at bed time.
Application of ice or ethyl chloride at the root of the penis will check impending erections. This is especially helpful during night.
Before operation anaesthesia either general or local is essential. Block anaesthesia if properly given is convenient and satisfactory. It is a simple operation but needs careful technic to avoid annoyance during operation. Subpreputial irrigation is given, skin of the part and the surrounding area is cleaned and sterilized with the application of Tr. Iodine. A 10 or 20 c.c. syringe is filled with 2% Novocain solution to which a drop or two of Liq. Adrenaline Hydrochlor – are added. Two wheals are raised, one on either side of the base of the penis, just medial to and below the pubic spine. Holding the penis out, the needle is passed through these wheals in succession and advanced deeply infiltrating the solution on each side of the suspensary ligament, in close contact with the body of the penis, as it emerges from the angle of the symphysis. About 2 to 3 c.c solution should be injected around each dorsal nerve. Then the needle is directed beneath the skin, and a collar of ½” root of the penis distributing about 100 c.c solution. In an adult about 15 c.c. solution is sufficient. Care should be taken constantly not to inject Novocain solution into the vein. Allow few minutes to pass. When the part becomes anaesthetic, the prepuce is cut with a knife or a pair of scissors, the lower blade of which is guided by a director passed between the glans penis and the prepuce. The incision is carried back to expose the coronal sulcus. If there is anybleeding vessel it should be lgatured. When the local condition improves and at a later stage, the redundant skin may be removed and the operation of circumcision completed.
In cases where the operation of dorsal slitting is refused, four-hourly subpreputial irrigation with hot antiseptic solutions, and frequent hot baths in hypertonic saline may be prescribed.
T reatment of Syphilitic Sores
Treatment may be preventive, abortive and curative. The curative treatment may be further be divided into (1) specific (2) general and (3) local. It is the local treatment that will be considered here and consists of application of either wet, dry or oily dressings.
Wet-dressing – sore is cleaned with hydrogen peroxide, the surrounding area is cleaned and sterilized with rectified spirit or spirit biniodide (1-2000) and the gauze soaked in either of the following lotions is applied to the sore and bandaged.
Picric Acid aqueous solution 1%; Acriflavin solution 1-1000; Carbolic Acid lotion 1-60; H.P. lotion 1-2000.
Dddddry-dressing – sore is cleaned as above and one of the following powders applied to the sore. To be effective it should be applied frequently and thoroughly.
Oily dressings:- (1) Ung. Hydrag. Subchloride (20% calomel ointment). (2) Butesin picratte ointment (Abbot Lab). (3) Flavogel (Glaxo Lab.)
One of the above dressings may be applied according to one’s chooooice and loking. Healing of a large ulcer may be accelerated by one or two injections of ‘N.A.B.’, Mapharside or Neosalvarsan. Cleanliness is all that is necessary in these cases.
When the syphilitic sore is complicated by sepsis, chancroid or an ulceration of granuloma venereum type, the treatment of such an ulcer becomes a difficult problem and depends on the early recognition of the disturbing element. In good many cases, the care based on ordinary surgical lines should give satisfactory results. Local cleanliness, good drainage, frequent hot baths or fomentations and dressings are very useful. Ulcer is cleaned with hydrogen peroxide and the area around it with rectified spirit, and one of the wet-dressings applied daily. Where the ulcer is very unclean, eusol bath and dressing should prove very valuable; but it must be stopped as soon as the ulcer becomes clean and healthy and usual dressing instituted. Where the above treatment is found ineffective, one of the following methods may be tried with success. (i) Cautery (ii) Vaccine or Protein shock therapy (iii) Sulphanilamide preparation (iv) Tartar emetic or its compounds. (v) Injections of N.A.B.
The specific treatment, of course, has to be given in both cases – complicated or non-complicated.
T reatment of Non-syphilitic Sores :
(1) Chancroid (2) Granuloma venereum (3) Primary lesion of Climatic Bubo.
Ulcers specially of mixed infection spread rapidly and become phagedenic. It should be the usual practice to see the ulcer daily and to watch the effects of treatment. Before it assumes phagedenic character, and destroys a large area of the tissue, a prompt and energetic treatment should be adopted. When under treatment chancroids heal in about three or four weeks; and its persistence after the time is strongly in favour of there being syphilitic infection in addition. Chemical Cauterization may be tried in such cases.
T reatment of Common Complications:
Lig. Arsenicalis 1 part.
Vinum Ipecac 1 part.
Spirit Rectified 2 parts.
Acid Salicylic 1 part.
Acetic Acid 8 parts.
If the growth is a big one, shaving the masses, and then touching the bases with cautery either electric or chemical may be tried. Application of solid copper sulphate is also very good aand may be repeated at a week’s interval. While applying causties usual precautions should be taken.
The following powders are very useful for dusting the parts and to keep them dry.
Boric acid aa
mft. pulv. for dusting
Bismuth subgallate 2 parts.
Zinc oxide 1 part.
Mag. Carb. Levis 2 parts.
Starch 3 parts.
mft. pulv. for dusting
Parts should be cleaned with some antiseptic lotion (Potassium permanganate 1 in 2000 to 6000) and then dried and dusted freely with one of the above powders.
The treatment that has been described here is found by experience to be both safe and efficacious in majority of cases. Each case however must be treated on its own merits. Following a fixed routine in all cases is not without dangers. The medical man should use his wise judgement and practical experience and change the treatment to suit his wants. If this is not done in time, not only the patient’s health but also the doctor’s reputation will suffer.
I wish to record my sincere thanks to Dr. W. N. Welinkar, Dr. J. D. Billimoria and Dr. F.C. D’Souza for their valuable suggestions and encouragement.