Gonorrhea: A Film in For Physicians in Technicolor (USPHS, 1943)

[Music] In diagnosing gonorrhea, we are concerned
not only with the clinical and epidemiologic evidence but laboratory evidence as well.
All physicians however may not be equipped for laboratory diagnosis. In such circumstances it is wise to act on
a provisional diagnosis based on history and symptoms while waiting for laboratory confirmation. True diagnosis rests on finding the gonococcus
by study of cultures and smears or, to use the word that is gaining preference, spreads.
Since facilities for culture study are not available to all physicians, many must depend
upon the spread alone. In any case, our concern is to secure material
for laboratory study. The profuse discharge of acute gonorrhea makes this a simple routine
matter both in the male and in the female. However, a thick spread makes study difficult,
so special care should be taken to make the spread for gram-staining thin and uniform.
This is best accomplished by rolling the material in the manner shown here. The story is quite different in chronic gonorrhea
in both sexes when the perfuse discharge is not present. Then it is often extremely difficult
to secure material for study. Yet here, careful diagnosis is most important.
Chronic gonorrhea is a focus of infection and a constant source of new cases of gonorrhea. As diagnosticians, we must be familiar with
those structures where the gonococcus may be found and with the techniques for stripping
them. In the male, these structures that harbor
the gonococcus are the urethra, the prostate, Cowper’s glands and the seminal vesicles. Stripping these structures will yield material
for study. Of course it is realized that procedures for stripping these structures are dangerous
in the presence of acute gonorrhea and that they belong only to the chronic stage of the
disease and among the tests for cure. Stripping the urethra is a simple and familiar procedure. The prostate, however, being highly susceptible to trauma, requires gentle and correct massage. The safest and least painful method is to
pass the finger well up over the lateral lobe, bringing it down in a direction parallel to
the midline. After both lobes are thus emptied, the finger
is pressed well up beyond the median sulcus of the prostate and brought several times
from there to the anterior extremity of the gland. In this form of massage, the dangers of complications
are reduced. The patient’s comfort is perhaps the best guide as to the degree of pressure
to be used. Wisdom will always err on the side of gentleness.
Cowper’s glands through manipulation, may also yield material for study. To find the gland, the tip of the finger is
drawn down over the arch of the pubic bone, about one-half inch to the side of the midline. As it drops from the edge of the bone it will,
particularly in thin patients, fall into a triangular depression. The gland is easily
felt by rolling the intervening tissues between the finger and the thumb. Gently rolling the
tissue will express secretor lurking in the glands. The seminal vesicles when stripped also provide
material for study. However since the prostatic secretion always contains pus when the seminal
vesicles are infected, it is rarely necessary to strip them. Stripping is resorted to when vesiculitis
is suspected, but the physician should wait until the acute stage of the disease has passed
and the chronic stage has been reached. Only then can digital expression of the vesicles be done safely. To strip the vesicles, extend the finger beyond
the prostate and to the side of the midline and bring it downward and toward the midline
as shown here. With the use of these techniques, material
for spreads and cultures may be obtained from the urethra, the prostate, Cowper’s glands
and the seminal vesicles. Secretions obtained by stripping any of these
glands are collected in sterile broth for cultural studies and stained for microscopic
examination. Of course, preparation of the material for
laboratory study presents no problem when the specimen is ample. However, stripping the urethra, the prostate and Cowper’s glands may at times yield only a scanty discharge
and in such cases the following method may be used to prepare material for study. After stripping the various structures, secure
the first half ounce of urine voided. Then centrifuge the urine; And invert the tube, so that the urine flows
out leaving the sediment in the tip of the tube. Then place a very small amount of normal salt solution in the tube; And shake well so that the sediment is suspended
in it. Then centrifuge again. Invert the tube and obtain sediment from its
tip for examination. This material is subjected to spread examination
and where available, culture studies. So much for the male. Now to secure material for study in chronic
gonorrhea in the female. Material may be obtained from the urethra,
from the endocervical glands and from Skene’s and Bartholin’s glands. To secure material for study from the urethra,
the urethral meatus is wiped with cotton to remove vulva secretions. The gloved finger is then inserted into the
vagina and the urethra is stripped from above downward, the external meatus being pressed
rather firmly against the pubic bone. A small cotton wrapped applicator is inserted
about half an inch into the urethra. The applicator should secure enough material for stain and culture. Secretor from Skene’s glands is expressed
by the procedure just described. No additional massage or manipulation is necessary. In obtaining
secretor from Bartholin’s glands, first wipe the area of the duct with cotton. Then insert the index finger a short way into
the vagina and place the thumb on the outer side of the labia majora. The intervening
tissue is then gently squeezed. When secretion is obtained in this way, it
is usually too scanty to be secured on an applicator. The flat end of a toothpick or
a platinum loop is better suited for this purpose. In obtaining material from the cervix, it
is well to remember that in the chronic stage of the disease, the gonococci are deep in
the endocervical glands and usually not in the plug of mucus filling the canal. Thus
it is best to cleanse this canal with cotton held in a sponge forceps. Then make firm pressure on the cervix with
blades of a bivalve speculum; And obtain the material thus expressed for
study. If spreads of these secretions are thin and
uniform, examination will be facilitated. If we rely on the techniques described, we
will find that material for test and study is always available. All of these materials from the male and the
female can of course be used both for cultures and spreads. Mastery of these techniques will help provide
laboratory evidence for diagnosis, and what is equally important: laboratory confirmation of cure. But as the laboratory checks the clinical
symptoms and general treatment, so in the case of chronic gonorrhea in the female, the
clinical symptoms and case history must be used as a check on the laboratory. This is necessary because in chronic gonorrhea
in women, the gonococcus will sometimes escape detection by both the gram stain and the culture. Consequently when the history is suspicious
and symptoms persist, the laboratory must be challenged, perhaps repudiated. In the case of the female with chronic gonorrhea,
we must be guided by epidemiologic and clinical evidence as well as by laboratory evidence.
If symptoms and history point to the gonococcus, treatment is definitely in order. To withhold treatment is to risk new infections
and grave complications for the patient. In any case, the procedure of treating on
suspicion cannot be challenged. We all know patients who come for exam and they never
return. We know that often we have a positive diagnosis from the laboratory but no patient. To treat on suspicion, to warn at once that
an infectious disease may be present and to urge the patient to act accordingly, is to
move towards gonorrhea control. Certainly where infectious diseases are concerned,
every physician feels that his responsibility extends beyond his patient. It extends to
the people the patient may infect. Since diagnosis is an integral part of the
patient’s first visit and this first encounter with the physician has a profound influence
on the patient’s later behavior, it may be in order to discuss further at this point, the patient and his doctor. Effective venereal disease control and good
case holding rest on the doctor-patient relationship and require that the patient be considered
as a total medical problem. The patient must be given an understanding
of the nature of his problem and he must be given an objective, which will impel him to
continue treatment. The patient may have syphilis. There may be
other complications. Certainly in a patient with gonorrheal infection, syphilis must be
considered. Ideally, the history of gonorrhea case follows
these general lines. The patient usually comes to the doctor’s office three to six days after exposure, when the symptoms appear. Following the examination, the doctor takes material for a spread. He also takes a blood test for syphilis as part of the physical examination. It is too early to check for a syphilitic
infection which may have been contracted when gonorrhea was contracted. But the doctor explains
that the danger of such an infection exists. If possible, the doctor then gets the name
of the contact and speaks of bringing her under treatment. He also explains the nature
of the disease to the patient, in language that the patient can understand. The patient returns in three days for a second examination and to learn the laboratory findings. Let us assume that the findings of the test
for syphilis are negative. The smear, however, is positive. Since treatment began with the first visit,
the doctor now simply checks the progress of the disease. Seven days later, the symptoms of most patients will have vanished. But now enough time may have elapsed for penile lesions to appear
if the patient also contracted syphilis. The doctor looks for lesions and if he finds
them, does a darkfield test at once. Let us assume that no lesions are found at this time. The patient returns again in seven days for two reasons; so that the doctor can check the gonorrhea cure and look for penile lesions
again. We assume that again, no lesions are found.
The patient returns and is reexamined for infectious lesions at weekly intervals for
three weeks. Thereafter, every two weeks for another six weeks. A second blood test is part of the final examination. We have thus completed a three-month period of observation. The course of action described here has given the patient the fullest possible
protection. His gonorrhea cure has been determined, the
physician has also determined whether or not there was a syphilitic infection. The results
are good case holding and effective venereal disease control. These are objectives that must be attained.
We know only too well that they will never come to us from the laboratory but only from
an appreciation of human relationships. When we speak of chemotherapy, we speak of
the weapon with which a change in history has been wrought. We speak of a swift, sure
and inexpensive cure for gonorrhea. Chemotherapy in gonorrhea has made difficult
and painful local treatment unnecessary except in the small number of patients who do not
respond to such medication. It is a great boon to the private physician,
to clinics carrying heavy caseloads, often with extremely limited personnel and of course
it is a great boon to the patient. In discussing this new treatment, it may be
well to recall an era of the past in order to dispose of it permanently for the future. Sulfanilamide was the first sulfa drug used
in the treatment of gonorrhea. Although toxic reactions were frequent and sometimes grave, it continued in use for a time because a better substitute was not yet found. Because to tens of thousands infected with
gonorrhea, it offered the promise of a swift cure, a swift return to the jobs from which
the disease had taken them. This early sulfanilamide compound held out a hope to gonorrhea sufferers. But sulfanilamide produced toxic reactions
in many patients and created numerous asymptomatic carriers. Laboratories focused their attention
on finding a safer and more effective chemotherapeutic agent. New sulfa drugs were produced rapidly. Drugs
superior to sulfanilamide. As these more effective drugs appeared, leading clinicians and the
United States Public Health Service abandoned sulfanilamide. But sulfanilamide had been widely publicized and so it gave way, but slowly, to the more effective, safer drugs. Doctors continued to prescribe it. Patients
continued to ask for it. But there is no place for sulfanilamide in the treatment of gonorrhea. Today, the drug of choice is sulfathiazole. But research and experience indicate that
it may be entirely supplanted by penicillin. The toxicity of penicillin is negligible. The toxicity of sulfathiazole is low and the
reactions are mild. Rarely does the patient find it impossible to consume enough of the
drug to bring about a cure. Even when low blood concentrations are maintained,
the relatively high cure rate is achieved. Of course, there are a few people who cannot
tolerate any of the sulfa drugs in any concentration and so all patients must be watched. This is no drug to be sold over a counter withouta prescription. Twenty grams is the recommended dosage for
a single course of treatment; four grams a day for five days. However, if this first course of sulfathiazole
fails to bring about a cure, medication should be discontinued for seven to ten days and then a second course of treatment given. A number of patients will not be cured. Penicillin
should be considered. Penicillin therapy of gonorrhea may mock or delay symptoms of syphilis. Patient observation should be continued over three months. A special precaution against transmitting
a possible chronic infection, the physician should insist that a condom be used at every
sexual contact for three months after disappearance of symptoms. With the aid of these drugs, we can in a short
time make gonorrhea a comparatively rare disease. Prophylaxis is the other
great ally of gonorrhea control. Civilian and military health authorities now recognize its value and urge its widespread use. To make descriptions of approved techniques
available to physicians, these publications have been prepared and are furnished on request.
The greatest safety and preventive measures other than continence, belongs to the condom. But improper use of the condom destroys its value. Instruction of the patient is part of the
physician’s role in implementing prophylaxis. Common habits such as using a condom only
at the end of intercourse should be condemned. The patient should also be warned to put on
the condom before his hand comes into contact with the woman’s genitalia, lest he carry
the infection to his own organs before intercourse is begun These and other points need to be impressed
on the patient. The pamphlet shown is intended for lay education and can also be secured
from the United States Public Health Service. The prophylactic packet is sometimes effective
but here again, the patient needs instruction as to its proper use. Chemical prophylaxis
is most effective when administered under medical supervision. When administered soon after exposure, it is at least 90 percent effective. Prophylactic measures are not as easily applied
in women. Nor are they considered to be as efficacious. There is no doubt that widespread use of prophylaxis will aid materially in controlling gonorrhea. Education of the public so that people will
not go to the quack but to the licensed physician; early diagnosis by the physician; correct
use of prophylaxis. Sulfathiazole, penicillin: these things are weapons in the hands of the medical profession. And most important in gonorrhea therapy, let
us remember this; a laboratory is not infallible. Clinical and epidemiologic findings are ample
grounds for treatment. If we use them as a basis for treatment, we
will eradicate many infections that in the past filtered through the diagnostic net. Certainly sulfathiazole and penicillin are
a promise and a challenge to the medical profession; an opportunity to wipe out one of our oldest
diseases, and an opportunity to save millions of man days lost to industry and the armed
forces. To prevent a great loss to the nation’s health
and strength. [ Music ]


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