War Surgery and Medicine
GENERAL OUTLINE OF TREATMENT
GENERAL OUTLINE OF TREATMENT
The discovery of the action of the sulphonamide group of drugs greatly simplified the treatment of gonorrhoea during the early part of the war.
It meant that, in the majority of cases, the infection was overcome before it could involve the posterior urethra with its attendant glands, and therefore the laborious and relatively ineffective local treatments that a chronic posterior case demands were avoided.page 611
A small proportion became chronic, despite sulphonamides—a proportion which steadily increased as time progressed, owing to the increased use of the drug and consequent resistance.
In these cases treatment relapsed to the well-tried methods of the First World War—namely, daily irrigations, prostatic massage, urethral instillations, etc. The average hospital stay for these cases was at least three times that of those which responded promptly to sulphonamides.
Later on when sulphonamide resistance increased to frightening proportions penicillin became available in large enough quantities to be used as routine treatment, greatly simplifying the task of combating the enormous rises in incidence in Italy in 1943 and 1944.
Non-specific urethritis was a problem. The frankly purulent discharge, devoid of all organisms at first, soon became full of secondary invaders, and the posterior urethra and glands were quickly involved despite full doses of sulphonamides. Some gradually cleared up with local therapy; others defied all treatment for months, even years.
Soft sore, fairly common in Egypt, healed promptly on sulphonamide and was no problem.
An interesting sidelight on the use of the sulphonamides in hot Cairo weather in a tented hospital was the lack of toxic effects. No cases of sulphonamide oliguria occurred and only a very small number of photosensitive skin rashes.
This disease was not diagnosed nor treatment commenced until a positive dark ground examination and/or a positive complement fixation test (Wasserman or Kahn), repeated if necessary, had been obtained.
The current standard treatment was adopted in 2 NZEF from 1940. It comprised courses of ten weekly injections of neoarsphenamine, commencing with 0.45 gm. and continuing with 0.60 given concurrently with bismuth intramuscularly, 0.2 gm. each injection. At the termination of each course a serum complement fixation test was done, and the number of courses given depended on when the blood became sero-negative, three further courses being given after this. An interval of four weeks was made between courses.
Sulpharsphenamine was used at first to save the trouble of intravenous injection, but was soon discarded as being too painful.
Final tests of cure consisted of a complement fixation test on the cerebro-spinal fluid at the completion of the last course and six-monthly blood serum tests for two years.page 612
The patient was retained in camp hospital until non-infective (usually two to four weeks), then discharged to reception depot for the rest of his first course.
In these early days the Division was in the Western Desert and gross sources of infection were out of reach. As a result, of the small number of men being treated for syphilis the majority were base personnel, and, from the centralised VD hospital, their treatment could be efficiently and regularly given; but after the return of the Division at the end of 1940 the incidence rose and it soon became obvious that, to ensure continuity of treatment, some arrangements had to be made for treatment to be given by field medical units, a central authority at Base being responsible for seeing that it was carried out.
Thus men were returned to their unit after their first course, and specially trained officers in their nearest field ambulance gave them their injections and arranged for their final tests of cure at a suitable hospital.
In 1943 there was a modification in the treatment, oxoarsphenamine (mapharside) being used in an attempt to obviate what we now know as homologous serum jaundice. At the time the picture was very confused, there having been at the end of 1942 a severe epidemic of infectious hepatitis amongst all Middle East troops, and the drug was suspect as the cause of syringe-transmitted jaundice. Finally extremely strict sterilisation of syringes and needles eliminated the serum jaundice.
In August 1944 a tremendous advance was made when sufficient penicillin became available for it to be used in the treatment of syphilis. In a course lasting only seven and a half days 2.4 mega units of penicillin was injected in doses of 40,000 units every three hours. Later it was found that 2,400,000 units was insufficient to effect a complete cure in all cases, and, if checks by monthly quantitative Kahn tests were not satisfactory, a further course of penicillin was given. In July 1945 the course was amended to 30,000 units two-hourly for seven days.
A positive diagnosis was made only in those cases of urethral discharge in which gonococci were seen in the stained smear, all other cases being diagnosed as non-specific urethritis.
Sulphapyridine was the only antibiotic available early in the war, and the standard treatment was 5 gm. a day for seven days, the pills being administered by an orderly every four hours. In these early days of sulphonamide administration very few strains of gonococci had developed sulphonamide resistance, and nearly all cases cleared up clinically under this regime.page 613
They were transferred to Base Reception Depot as soon as the discharge had ceased and were seen at regular intervals until three months had elapsed, when final tests of cure were applied and had to be satisfactory before the patient was crossed off the VD roll. These tests comprised a serum complement fixation test, prostatic examination and smear, and anterior urethroscopy.
The small minority who did not clear up on exhibition of sulphapyridine were retained in camp hospital as chronic gonorrhoea, and were treated by irrigations, instillations, prostatic massage, and sometimes TAB vaccine fever therapy. These cases provided the biggest problem, and their treatment often dragged on for months or years.
The proportion of sulphonamide-resistant cases gradually increased as the war progressed. In August 1943, following a direction from GHQ MEF, the treatment of simple clinical gonorrhoea by an RMO within unit lines was authorised, using sulphathiazole or sulphapyridine, but it was found more satisfactory, partly due to complications developing, for such cases from Base to be admitted to VD Treatment Centres as hitherto.
At the beginning of the Italian campaign, notably in the Naples area at the beginning of 1944, treatment of gonorrhoea began to produce serious difficulties owing to the appearance of sulphonamide-resistant strains of gonococcus. In 2 NZEF the number of uncured cases of gonorrhoea, involving hospital treatment, grew rapidly.
Until penicillin was made available to it in Italy the Mobile Unit treated 326 cases of gonorrhoea with sulphathiazole and sodium citrate between October 1943 and August 1944, with 181 relapsing cases. The patients dosed themselves with the drugs in their own unit lines, and failure to observe the instructions may have accounted for some of the relapses, apart from the sulphonamide resistance built up by the gonococcus in Italy. For relapsed cases the only recourse was to evacuate them to 3 NZ General Hospital, Bari, where 101 Treatment Centre was attached, for intravenous TAB vaccine therapy. In May 1944 penicillin was made available for resistant cases only, a dose of 60,000 units being given in injections of 5000 units three-hourly. The course was very successful, especially when washes of acriflavine were introduced to prevent symbiotic organisms from the prepuce invading the inflamed urethra and causing a residual urethritis. In September 1944 permission was given to use penicillin for all fresh cases of gonorrhoea, 100,000 units being given in five injections. The relapse rate dropped markedly, and of 644 cases treated from September 1944 to July 1945 only 41 relapsed.
In contrast to the First World War, there was a relatively high proportion of the cases of urethritis which were classed as nonspecific, or more correctly as non-gonococcal. (A War Office instruction of 5 October 1940 stated that cases of urethritis other than those in which the gonococcus was found, and other than those in which history of special treatment and common sense pointed to the gonococcus as the infecting agent, were to be diagnosed as ‘urethritis non-venereal’, and that the patient was to be given the benefit of any doubt.)
These cases, in which the diagnostic smears usually showed profuse pus with no organisms, were a difficult problem. Secondary invaders appeared in quantity when the disease became chronic, and the gleety urethral discharge resisted all the usual local treatments. Complications such as epididymitis, prostatitis, etc., were frequently seen. Eventually, however, over a period of months the discharge cleared up. The final tests of cure were the same as for gonorrhoea.
All genital sores were regarded as syphilitic until disproved as such by three dark ground examinations. If negative they were called soft sore and, in fact, did clinically fall into one group, although B. Ducrey was never recovered because of inaccessibility of laboratory facilities. Later the terminology was changed to penile sore, venereal.
All cleared dramatically on a total of 40 gm. of sulphapyridine, given four-hourly over ten days.
In Italy it was found that healing of the lesion was hastened when the usual eusol washes and dressings were supplemented by iodoform and eusol powders, and eusol and acriflavine were alternated every two days as washes. A serum complement fixation test was done three months later to make certain that syphilitic infection was not present.
Men who reported to a treatment centre suspecting they had venereal disease, but which could not be confirmed by clinical examination, proved a problem in the later stages of the Italian campaign. These neurotic outpatients often expected to be given treatment, but this was refused where a thorough examination, supplemented by anterior urethroscopy, proved negative. Explanation page 615 and reassurance generally gave heartening results and allayed the neurotic's fears, whereas the giving of unnecessary treatment might have cemented in the neurotic's mind the belief that he had contracted venereal disease.
VD Treatment, J Force
VD treatment at 6 NZ General Hospital followed in the main the directive issued by DDMS BCOF. In the revised instructions of early 1948 the treatment for syphilis was by a combination of penicillin and arsenic and bismuth as follows:
Penicillin: 4 mega units by three-hourly intramuscular injections of 50,000 units each over ten days.
Arsenic and bismuth:
2nd day—NAB 0.3 gm., Bismol 0.2 gm.
5th day—NAB 0.45 gm., Bismol 0.2 gm.
9th day—NAB 0.6 gm., Bismol 0.2 gm.
After discharge from hospital, by unit MO—
Weekly for eight weeks—NAB 0.6 gm., Bismol 0.2 gm.
Thus the total dosage by eleven injections was NAB 6.15 gm. and Bismol 2.2 gm.
In the instructions treatment of uncomplicated gonorrhoea and urethritis was by 250,000 units of penicillin given by five three-hourly doses of 50,000 units each. Sulphonamide drugs could also be used.
Frequently strains of gonococci resistant to penicillin and sulphonamides were found. These cases often became chronic, and prostatitis developed. Large doses of penicillin were sometimes necessary, and the old-time practice of irrigation was often used.
In March 1948 the OC VD Wing, 6 NZ General Hospital, reported that a number of gonorrhoea cases treated with penicillin alone, and whose symptoms had rapidly disappeared, were being found to have chronic prostatitis, and he said: ‘It would seem that the standard treatment as set out in the BCOF instructions, though adequate for halting the symptoms, in many cases is not sufficient to prevent prostatitis developing. I would advocate the addition of sulphonamide drugs as a routine to the treatment of all cases of gonorrhoea. It is interesting to note that cases of chronic prostatitis persisting for many months are responding to treatment with TAB. The vaccine is given in doses of 50 million organisms intravenously page 616 and at the same time penicillin and/or sulphonamide drugs are administered.’
The period of hospitalisation was slightly increased and this was found to lower the relapse rate, which earlier was 10 per cent. The average case of acute gonorrhoea remained three to four weeks in hospital, and the average case of acute urethritis remained four to five weeks. In a check it was found that relapses occurred in 19 per cent of all cases treated at 6 NZ General Hospital, whereas 59 per cent of New Zealand soldiers treated at other hospitals were subsequently found to have a relapse or chronic disease. There seems to have been only one relapse detected in the treatment for syphilis.
functioning of 102 nz mobile vdtc in 1944–45
Personnel: Medical Officer in charge; a WO II; a sergeant; a lance-corporal (clerk, i/c records); 2 treatment orderlies; 1 general duty orderly; ASC attached, consisting of 4 drivers.
Vehicles: 1 15–cwt. truck, MO's vehicle; 1 water cart; 1 3–ton truck fitted out as a laboratory with cupboards, etc.; 1 3–ton truck for equipment.
Tentage: 1 hospital cover; 1 180–pounder for MO's use; 1 180–pounder for examination room and laboratory; 1 180–pounder for office and QM store.
Organisation for handling cases:
There was a strong necessity for such a routine set-up, whereby cases pass smoothly from one department to another, and in which (where there are large numbers to be treated) the full personnel of the unit is actively engaged. With one man performing a routine test, very soon the man becomes highly expert, e.g., at staining a smear and reading it.
Siting: The unit was invariably sited next to the Sick MDS, and for rations was served from the MDS cookhouse.