TREATMENT OF VENEREAL SORES

By

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

Syrup ʒi

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.

• Treatment of an uncomplicated syphilitic sore : -

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.

• Calomel and sulphur sublimate in equal parts.

• Calomel and calamine in equal parts.

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.

• Treatment of a complicated syphilitic sore: -

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.

• Cautery – electrical or chemical. The chemical agents usually employed for cauterizing the ulcers are pure Carbolic acid, Camphenol (equal parts of camphor and carbolic acid crystals), Copper sulphate, Nitric Acid pure etc. Of these phenol and Camphenol are the best because their caustic action is not accompanied by pain or severe inflammatory reaction. Moreover, they do not need any anaesthesia. The area surrounding the ulcer is protected by the application of soft paraffin and the surface of the ulcer is touched with the cotton wool mounted on the end of a broomstick and soaked in one of the above agents. If there is excess of Carbolic acid it may be removed by a swab soaked in rectified spirit. Keep the part and ulcer dry both before and after the application of carbolic acid. Having done this, usual dry or wet dressing may be applied and continued. In some case, application of solid copper sulphate proves successful but it is very painful and irritating. It should be preceded by local anaesthesia. Milder than this is the 4 hourly applications of 25% solution of copper sulphate for a day, followed by daily dusting with iodoform powder.

• Vaccine or Protein Shock Therapy : - A course of six injections of Dmelcos (M&B) or Mixed Special Chancroid Vaccine (Union Drug Comp.) starting with ½ c.c and gradually increased to 2 to 3 c.c. intravenously at two to three days’ intervals, will prove effective especially where chancroidal complication is predominating. Two or three injections of sterilized skimmed milk, 5 to 8 c.c. in the buttock, may be tried as an alternative.

• Sulphanilamide preparations should prove very useful where septic element is predominant. It may be given orally or by injection (Septanilam, Glaxo Lab. Or M&B. 693 7 ½ Gr. Tablets, two T.D.S.) or Soluseptasine M&B., Prontosil Bayer, Streptocide Sol., Evans. Parentral Therapy is more efficient. During the time when sulphanilamide preparation is being given the usual dietietic precautions should be observed and the administration of arsenical preparations like N.A.B. should be avoided for fear of overburdening the liver and the kidneys.

• Tartar Emetic and its compounds :- When other methods of treatment fail, this method succeeds. Daily application of 1% Tartar Emetic solution to the sore course of six intravenous injections of 1% Tartar Emetic solution, commencing with 5 c.c. increasing each time by 1 c.c. until 10 c.c. and given at three day-intervals, will prove very efficacious. Fouadin (Bayer) Anthimoline (M&B) are the compounds of Antimony for intramuscular use.

• Healing of large syphilitic ulcers may be accelerated by a few injections of N.A.B. or some other similar preparation. Local application of N.A.B. Powder or its solution to the ulcer may be tried especially where non-specific spirochetal infection is in abundance. When the ulcer begins to heal, epithelization may be hurried by application of red lotion. Scarlet red ointment, or Pallidol to the sore.

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.

• Chancroid – As soon as the possibility of syphilitic infection is excluded, it may be treated very much on the same line as the mixed syphilitic sore with the exception of the specific treatment. During investigation, sulphur powder or hypertonic saline bath and dressing, good drainage etc. are very helpful. Ulcer is cleaned with hydrogen peroxide and one of the wet dressings applied daily to the sore. In addition, a course of a few intravenous injrctions either of Dmelcos or Mixed Special Chancre Vaccine starting with ½ c.c. and increased to 3 c.c. and given at two or three days’ intervals, may be tried with splendid results. Where pyogenic infection is preponderating two injections of Soluseptasine or Prontosil, given in a week may be tried. Milk injections occasionally yield encouraging results. Disappointing results of the above treatment should make one think of the granuloma venereum and to start local application of compresses soaked in 1 per cent Tartar Emetic solution and to try a course of six intravenous injections of 1 % tartar emetic solution, starting with 5 c.c. and gradually increased to 10 c.c. and given on every alternate day. Exposure to ultraviolet rays may be considered in certain cases.

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.

• Granuloma Venereum – Most cases respond well to the local application of 1 % Tartar emetic solution and a course of six to eight injections of 1 % Tartar emetic solution given intravenously at 3-day interval. A commencing dose of 5 c.c is given and is gradually increased to 10 c.c. One should be careful to detect Arthralgia which is set up in some cases and to stop injections. Other preparations may be tried.

• Primary lesion of climatic Bubo – It is small and transitory lesion. It either passes unnoticed or heals spontaneously and rarely needs any special treatment except cleanliness.

T reatment of Common Complications:

• P himosis – proper cleanliness, drainage, subpreputial irrigations, dorsal slitting or circumcision.

• Paraphimosis – Applications of saturated Mag. Sulph. Compress; when the swelling is gone down, apply some lubricant to the part and using a little pressure, try to reduce. Where ulceration is threatened and a constricting ring is present the ring must be incised carefully and the circumcision undertaken later on.

• Phagedena – Daily supervision of the ulcer, a good drainage and the dressing, frequent hot baths in hypertonic saline, slitting, Vaccine therapy or Sulphanilamide preparation, where necrosis is present. Eusol bath and dressing milk injections etc. may be tried.

• Bubo – It can be prevented by properly establishing the drainage of the sore. When the patient complains of pain and tenderness in the lymph glands it can be aborted by intensive treatment i.e. injections of vaccine or Sulphanilamide, fomentation drainage and rest. When the bubo softens and fluctuates aspirations followed by an injection of a few c.c.s of 1 inn 10 to 20 solution of tincture iodine, is superior to the more customary incision, and drainage. Skin is painted with Tincture Iodine and a needle No. 18 guage is passed into the cavity of the bubo through a healthy and independent part of the skin. After completely removing the contents, the cavity is filled with Tr. Iodine solution and the needle is drawn out. Puncture is sealed with Collodion and a pad applied to the groin. The patient is advised to have rest in bed. If the bubo fills again, it should be aspirated. In the majority of cases two or three aspirations will suffice. When suppuration has taken place and abscess is pointing, an incision should be made at the most dependent area in the direction of the important structures.

• Papillomata or venereal Warts – The parts must be kept scruptously clean and dry at all times. Success of the treatment will depend on this simple but very essential practice. Small growths will disappear by applying the following paint:

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.

Zinc oxide

Boric acid aa

Bismuth Subgallate

mft. pulv. for dusting

Alum powder

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.

• Climatic Bubo – Treatment of this complication is very disappointing. Numerous Therapeutic methods have been employed but none of them has proved very satisfactory. In spite of the treatment disease runs a very chronic course. One of the following treatments may prove useful.

• T.A.B. Vaccine or Dmelcos intravenously at 3 days’ interval.

• Milk 3, 5, 7, 9 c.c. intragluteally.

• Antimony compound, stipenyl, neostibosan.

• X-ray application.

• Sulphanilamide ultramild

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.

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