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[music] [man climbs out of red work truck and begins walking away.] [a female switchboard operator is shown turning away from the switchboard and touching her head as though it aches.] [a police officer leaves headquarters.] [narrator:] 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 ona 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 [?] 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 profuse 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 harborthe 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. [animated images of male genitalia and the procedure for obtaining samples of discharge for testing are shown.] the prostate however, being highly susceptibleto trauma, requires gentle and correct massage. the safest and least painful method is topass the finger well up over the lateral lobe, bringing it down in a direction parallel to the midline. [animated presentation of the described procedure.]
after both lobes are thus emptied, the finger is passed well up beyond the median sulcus of the prostate and brought several timesfrom 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 isdrawn 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 gland. [the described procedure is shown through animation.] 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 vesiculitisis 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, materialfor 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. [a nude man bends over an examining table, then stands up for further attention from the physician.] 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, securethe first half ounce of urine voided. [the male patient and the doctor are in the examining room. the doctor is handling the urine specimen.] then, centrifuge the urine... [the doctor is hand-cranking a centrifuge.] and invert the tube, so that the urine flowsout leaving the sediment in the tip of the tube. then place a very small amount of normal salt solution in the tube,
[the physician carries out the described steps.] 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. [the doctor continues carrying out the described procedures.] this material is subjected to spread examination and where available, culture studies. so much for the male. now to secure material for study in chronicgonorrhea in the female. [an animated image of internal female pelvic organs is shown.]
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 vulval secretions. [the described procedure is shown using animated images.] the gloved finger is then inserted into the vagina and the urethra is stripped from above downward, the external meatus being pressedrather 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. [an animated sequence shows the described procedure.] secretor from skene's glands is expressedby 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. [the procedure is demonstrated using animated images.] 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, itis usually too scanty to be secured on an applicator. the flat end of a toothpick ora platinum loop is better suited for this purpose. [the animated demonstration of the procedure continues.] in obtaining material from the cervix, itis well to remember that in the chronic stage of the disease, the gonococci are deep inthe 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. [the procedure is demonstrated.] then make firm pressure on the cervix withblades of a bivalve speculum;
and obtain the material thus expressed forstudy. [animation changes to live action as a pair of hands are shown handling the sample.] if spreads of these secretions are thin anduniform, examination will be facilitated. if we rely on the techniques described, wewill 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. [a cylindrical container with the sample is shown.] mastery of these techniques will help provide laboratory evidence for diagnosis, and what is equally important: laboratory confirmation of cure.
[a female laboratory worker is shown testing samples,] but, as the laboratory checks the clinicalsymptoms 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 suspiciousand 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. [a physician appears to be reviewing lab reports with a female patient, asking questions to which she replies.] to withhold treatment is to risk new infections and grave complications for the patient. in any case, the procedure of treating onsuspicion cannot be challenged. we all know patients who come for examination and never return. we know that often we have a positive diagnosis from the laboratory, but no patient. [the doctor is now seated in his office with a male patient.] to treat on suspicion, to warn at once thatan infectious disease may be present
and to urge the patient to act accordingly, is to move towards gonorrhea control. [the male patient puts on his hat and leaves. a nurse comes in to speak to the doctor.] 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. [the male patient who has just left the office walks away with a woman who was standing outside the building.] since diagnosis is an integral part of thepatient'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 goodcase-holding rests on the doctor-patient relationship and require that the patient be consideredas 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 secondexamination and to learn the laboratory findings. let us assume that the findings of the testfor 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 findsthem, 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 froman 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 bewell to recall an era of the past, in order to dispose of it permanently for the future. sulfonilamide was the first sulfa drug usedin 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 withgonorrhea, it offered the promise of a swift cure, a swift return to the jobs from whichthe disease had taken them. this early sulfonamide compound held out a hope to gonorrhea sufferers. [a cross-section of people, wearing suits, work clothes, and uniforms, assembles in a line.] but sulfanilamide produced toxic reactionsin 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. patientscontinued 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 thatit may be entirely supplanted by penicillin. the toxicity of penicillin is negligible.
the toxicity of sulfathiazole is low and thereactions 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, a 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, without a 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. as special precaution against transmittinga 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 shorttime make gonorrhea a comparatively rare disease. [people are shown walking, arriving at their jobs, and conducting their usual daily business.]
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 thephysician's role in implementing prophylaxis. common habits such as using a condom onlyat 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 carrythe 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 willnot go to the quack, but to the licensed physician...
early diagnosis by the physician; correctuse of prophylaxis; sulfathiazole; penicillin... these things are weapons in the hands of the medical profession. and most important in gonorrhea therapy, letus remember this: a laboratory is not infallible. clinical and epidemiologic findings are amplegrounds for treatment. if we use them as a basis for treatment, wewill eradicate many infections that in the past filtered through the diagnostic net. certainly sulfathiazole and penicillin area promise and a challenge to the medical profession, an opportunity to wipe out one of our oldestdiseases, and an opportunity to save millions of man-days lost to industry and the armedforces...
to prevent a great loss to the nation's health and strength.
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