PREVENTION OF VENEREAL DISEASES
By
M. P. Vora, M.B.B.S., St. George’s Hospital, Bombay
The Medical Bulletin
Vol. XII, No.2 of 15 th Jan, 1944; Pages: 19-24
The importance of prevention of venereal diseases cannot be over-rated. It becomes greater on account of the war which is known to increase its incidence. It would be just and befitting to be conversant with this subject in view of frequent question, how can Venereal Disease be prevented? The modern medical science lays more stress on the prevention of a preventable disease then its cure by treatment. The function of the medical man to-day is not only to treat disease, but to prevent disease and to offer to clients sound and helpful advice that will make life more pleasant and comfortable.
Conventional indifference on moral or religious grounds will be unjustifiable. To preach universal continence is easy, however, its observance is not often within the reach of every body. The difficulties of sexual abstinence are at times real and worth appreciating. Some of those who compose the society are constitutionally unfit for the task of abstinence. One should not be, therefore, reluctant to recognise the limitations of their power to control their desire in the face of difficulties, which the present day civilization and social conditions often put forward. Moralists may say what they like; medical consideration and human understanding rather than any intention of encouraging the promiscuous intercourse or persons of easy virtue, are of paramount interest in pleading to be well acquainted with this matter.
It should be thoroughly understood at the outset, that there is no infallible way, save abstinence, of avoiding venereal disease. Continence and self-control are the only sure methods of preventing infection. One should, therefore, try one’s best to avoid temptations. If one feels diffident of one’s success, one should remember that passion without caution at the helm may steer on to rocks and render one a hopeless wreck. Even after all the precautions, success cannot be guaranteed, and the after-results may be worse than those involved in the struggle to repress sexual desire.
Venereal diseases belong to a group of preventable diseases. They are almost, if not quite, completely preventable, a fact which has been proved and confirmed by fairly long experience. Infection can be avoided in a great proportion of cases by taking certain precautions. Methodical application of physical and chemical prophylaxis would reduce its incidence enormously. Self disinfection is not likely to be very efficacious. The use of prophylaxis is based on the fact that every sexual exposure is a potential source of infection, that skilful application by a trained person or under the expert guidance is essential, and that the prophylactic measures are applied before the germs have had sufficient time to enter the body tissues. In this way not only syphilis or gonorrhoea and chancroid as well, may be prevented. To be successful, prophylaxis must be applied properly and immediately or within hour’s interval after the exposure to the infection i.e. “the first exposure and not the last of an all night session”. Then and then alone the application is most effective. It effectiveness rapidly deteriorates as the interval between the exposure and the prophylaxis lengthens. Chances of infection following exposure increase if there is any break, how-so-ever small it may be in the continuity of the skin or mucous membrane. Easily abraidable skin or mucous surface, as in the case of tight foreskin or prepuce is decidedly most susceptible to infection. Circumcised foreskin, therefore, is to be preferred both from the point of avoiding and preventing infection.
Venereal diseases are often attended, in their earliest stages, by so little discomfort so as to appear very insignificant and this is especially true in syphilis. It is therefore all the more necessary to report at once to the doctor if anything unusual is noticed in the first twelve weeks following exposure to infection. It should be borne in mind that the disinfection, however immediate it may be, does not invariably prevent infection: failures may occur especially when it is not carries out carefully. Inebriate conditions are therefore to be avoided at all costs. Prophylactic measures may prevent the appearance of the primary sore but not the infection so that those who use them should resort to blood tests afterwards to make certain that they do not develop syphilis later on. It needs hardly to state that the method of disinfection is often useful for prevention but not for cure of any of the venereal diseases.
Preventive measures (for males) may be divided into
A - (1) Protective sheath through which germs can not pass. ‘Durex Protective or the like when properly and carefully ed is capable of preventing both giving and taking infection. But owing to the faulty circumstances in which it is often used, it is not easy to mange very effectively. It deprives the user of the sense of actual touch, which is held essential by many people. It is also common to meet with accidents of slipping, tearing etc. The cases of infection even after the use of condoms are met with such as pubic or scrotal chancres. If it is used in addition to local disinfection it should help to great extent in the prevention of infection. Condoms should be tested both before and after the use.
B - (1) It is advisable to urinate immediately after the coitus. Urination should be forcible and the flow of urine should be interrupted a few times by closing the meatus of the urethra. If urination is not possible, anterior urethral should be washed out with potassium permanganate solution 1 in 2000 to 4000, half a dozen times.
(2) Immediate and thorough disinfection of the whole genitalia, first with soap and water, second with some antiseptic solution and lastly with calomel ointment.
A basin of warm water and absorbent cotton wool or gauze is used for washing. Soap should be thoroughly applied to the whole area including the penis, scrotum, pubis, and adjacent areas of both thighs and the perineum. Special attention should be paid to wash and clean the different folds and creases of the skin. It should be done carefully spending at least 4 to 5 minutes. The foreskin, the frenum and it sides; coronal groove and the scrotum need special attention. This washing assists in the prevention of chancroids. When the washing is over, the whole area and all the parts should be washed with some antiseptic solution (1-2000, Pot. permang. H.P., of Mercury, Lysol or Dettol). The parts are then dried thoroughly and one drachm of 4 cc of a freshly prepared 2% solution of Protorgal or 10% solution of Argyrol in water is injected into the urethra and retained there by compressing lips of the meatus: at the same time the shaft of the penis is massaged gently towards the root , so that all the parts of the urethra come in contact with this solution. To avoid the difficulty of having a freshly made solution, one may use Collosal Argentum, 1 in 2000 (Crooks0 or Urosalv (C.D.C.) or Norgol jelly. After about 15 minutes interval, the injected solution or jelly is allowed to come out by removing the pressure on the meatus. Having done this ½ to 1 drachm or 1 to 2 gms of 33% calomel ointment is rubbed thoroughly on the penis, and the surrounding area. About 8 to 10 minutes should be spent in this rubbing. Special care must be taken of the prepuce, the frenum, the meatus, and the coronary groove. The scrotum and the surrounding areas should also be rubbed with the ointment, and some portion of the ointment should be introduced in the mouth of the urethra. Genitalia is then covered with toilet or wax paper just to protect clothes from soiling. It is necessary not to pass urine or not to wash the parts for 4 to 5 hours, thus allowing antiseptics to remain in contact with the tissues for sometime. Soap and water protect against chancroids, and partially against syphilis. Protorgal or Argyrol protects against gonorrhoea, and calomel ointment against syphilis.
Theoretically, V.D. prophylaxis should be equally applicable to the females. The same procedure as in the case of males may be used in a slightly modified form. But its effectiveness is often doubtful due to inaccessibility of certain parts. Self disinfection is almost impossible on account of natural differences. Satisfactory disinfection is only possible with the help of a trained person, just before the time of contact, antiseptic tablets like Bircon tablet on jelly, Milsan jelly, or calomel ointment or failing all this simple lubricant like Vaseline may be used. Care should be taken to extend the application high up to the cervix. After the connection she should be made to urinate. She is then placed in the lithotomy position on the gynaec table; her genitalia and adjacent area are thoroughly washed with soap and water. A copious douche of water, 4 pints, at 100° F to 110° F temperature is given. This is to be followed by another antiseptic douche of 4 pints H.P. lotion 1 in 2ooo, or Biniodide of mercury 1 in 2000, or Pot. permang. 1 in 2000, may be used for the prupose. All he parts and the surrounding area are washed with the same antiseptic lotion. Then all the parts and surrounding areas are dried by cotton-wool by means of a bivalve vaginal speculum and a swab holding forceps, the entire vagina and cervix are dried and painted with 2 % Protorgal or 10% Argyrol solution, freshly made. Special attention should be given to different folds, fornices, cervix, Skene’s ducts, Bartholin’s ducts, and the urethra. All these parts should get in touch with this solution, and remain in that condition for about 5 to 7 minutes. Solution should be injected into the urethra so as to distend it, and held there for the same period by asking the person to place her finger against the urinary meatus. Once again the vagina and vulva are douched with a small quantity of sterile water and dried well with a piece of gauze. Having done this, 33% calomel ointment is to be applied very carefully to the whole surface. Care needs to be taken to apply it to the cervix, vagina and its folds, and recesses, surrounding areas etc. 10 to 15 minutes should be devoted to this application. About one drachm of 4 gms. of the ointment, maximum quantity that it is allowed, should be used for vagina. Cover the external parts with wax paper and advise the patient to allow the ointment to remain for several hours before washing the parts.
The discussion of V.D. prophylaxis would not be complete without reference to the scope and usefulness of arsphenamine and sulphanilamide prophylaxis in the prevention of V.D.
Arsphenamine prophylaxis in syphilis - Because primary seronegative syphilis can be treated more successfully or effectively and with less amount of treatment than the secondary or seropositive syphilis, one is led naturally to the belief that still less treatment would be required if one can start treatment immediately after the infection i.e. before the appearance of the sore. This is rather an objectionable procedure and unwise too. The chances of escape from infection, even after exposures are not trifle, and the prospects of radical cure are excellent even when the first evidence of infection develops i.e. in the primary seronegative stage or early seropositive stage. The effect of prophylaxis whether with one or several injections of neoarsphenamine must not be suppression only but complete eradication of the infection. Though such prophylaxis may keep the patient free from syphilitic manifestations, and may show his blood Wassermann reaction negative, for several years, it is not likely to protect him, is he is really infected, from the late manifestations. Patient may subsequently develop grave late lesions, involving vital organs of the body, such as the nervous or cardiovascular system. Apart from the risk of using a toxic drug, both the physician and the patient are in the dilemma of not knowing if the patient would have escaped infection, provided nothing was done. This is bound to lead to a constant uncertainty later on. On account of these reasons, it is far better for the exposed person to keep himself under the expert medical supervision for some time, say 3 to 4 months, than to submit to arsphenamine prophylaxis straightaway. During this period of observation, he should report , on the first appearance of a suspicious lesion, for dark-field examinations; further he should get his blood Wassermann done, if the former examinations are negative, at bi-weekly intervals. Examination of the partner if possible, is worth suggesting and is likely to be helpful. Certainly, it would be sound withhold specific treatment until definite diagnosis of syphilis is arrived at.
However, if one chooses this type of prophylaxis for certain reasons, it should consist of not one or two injections but of at least one full course, i.e., ten injections each of neoarsphenamine and bismuth, in adequate dosage, given regularly at 5 day intervals. Adoption of this procedure implies the certainty of infection. The patient must therefore considered as syphilitic for all practical purposes, and treated and followed as any other syphilitic patient. Folllow-up should extend over five years and consist of blood tests every month during the first year, bimonthly during the second year, and yearly afterwards. The patient should be examined thoroughly from time to time and should have at least, one examination of the cerebrospinal fluid at the end of two years.
Suphanilamide prophylaxis for gonorrhoea, chancroids and lymphogranuloma venereum - if this carried out in association with the local measures of prophylaxis, there is nothing (except intolerance) that could possibly contraindicate the procedure. Sulfathiazole or Sulfadiazine is the preparation of choice. However, the present opinion is swinging in favour of Sulfadiazine. It should be given doses evenly spread over three to five days. Some may consider its use superfluous and would like to reserve it for abortive purposes rather than for prophylaxis. Its advisability in the females, in whom proper disinfection is difficult, is worth exploring. It should prove valuable in the prevention of infection and its propagation. If this type of prophylaxis is used, further follow up to determine freedom from infection, (especially gonococcal) will be necessary. As regards the scope for this procedure one would not like to commit oneself till sufficient evidence is available.
Arthur and Derman studied in a unit of Negro troops series of exposures to contacts. Sulfathiazole prophylaxis was instituted the morning after exposure. It consisted of 3,2, and 1 gm. after breakfast, lunch and supper respectively. Out of 384 exposures in 259 men, not followed with drug, 42 resulted in infection, 9 having primary syphilis. Out of 199 exposures in 152 men, followed by sulfathiazole prophylaxis, one developed chancroid and five syphilis. The rate of infection per thousand exposures to venereal disease was 109 for those not taking the drug after contact, while it was 30 for those who received the drug. This clearly shows that Sulfathiazole is a valuable adjunct to the routine prophylaxis against venereal diseases. Its use becomes all the more necessary where routine prophylaxis has been omitted.
M. Joses studied the results of Sulfathiazole in U.S. Navy. He treated 150 cases, who had taken no precautions whatsoever and reports that not a single case of chancroid or gonorrhoea had developed in them. He advocates 3gms. at 8 A.M., 2 gms. at noon and at 6P.M. next day.
Outfit for disinfection
Two basins of water and antiseptic lotion
Soap and water
Antiseptic tablets or liquid - Potassium permanganate tablet 5gms. in a
pint of water given in 1 in 2000 solution. Hydrag perchlore 8.75 gms.
tablets in a pint of water give 1 in 1000 solution. Lysol one drachm to a
pint.
Silver salt solution - Protrgal 2%, Argyrol 10% freshly made. Instead, one
may use Collosal Argentum 1 in 2000 (Crooks) Uroslav (C.D.C.) or
Nargol jelly.
30 to 33% Calomel ointment
U.S. Army Formula
Calomel 30 parts
Adeps Benzoatus 65 parts
Cera alba 5 parts
U.S. Navy Formula
Calomel 30 parts
Phenol 3 parts
Camphor 2 parts
Anhydrous Linolin 39 parts
Adeps Benzoatus 20 parts
Bee wax 3 parts.
Complete douche can preferably all glass with tubing, nozzle. All glass
urethral syringes with Janet point, 5 to 10 c.c. capacity.
Bivalve vaginal speculum, swab holding forceps, Playfair’s dressing forceps,
Uterine forceps, Female urethral speculum etc.
Cotton swabs, vaginal tampons, gauze, cotton wool, wax paper etc.
Quninie sulph gr.5
Hydrarg perchlore gr. 1/100
Ol theobrome gr. 15.
mft. One pessary for insertion in the vagina as directed.
Complete sets are available in the market by different firms such as,
‘Immediate Disinfection’ by Holborn Surgical Co., Frank Kidd and so
on.