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THE MEDICAL WORLD

Considerable attention is now being devoted to the etiology, pathology and treatment of asthma. Laboratory tests are being made in an effort to discover the cause or causes. Clinical study is made to ferret out the pathogenesis of the disease. Therapeutic study aims to suggest an etiology by means of the therapeutic test. Asthma is not a simple, plain disease. Its many complexities and treatments add greatly to the problem of fixing a definite etiology and tracing a pathogenesis.

The characteristic sounds emanating from the lungs are ascribed to a large variety of conditions, as follows:

1. Spasm of bronchial muscles. And an atonic or paralytic form-paralysis of circular fibres.

2. Vasomotor neurosis, producing urticaria-like swelling of the mucous membrane.

3. Hereditary neuropathic tendency and vasomotor ataxia.

4. Spasm of the bronchial muscles and inflammatory swelling or vasomotor swelling.

5. Spasm at attack and atonic condition at intervals.

6. Eosinophilic diathesis, producing a non-inflammatory hyperemia.

7. Exudative bronchiolitis.

8. Anaphylaxis-antigen-antibody formation, but without protection that should be afforded by the antibodies.

9. Allergy or sensitiveness to different food proteins, producing biochemical changes on entering the circulation.

10. Allergy to plant emanation or pollens, producing seasonal asthma-rose cold, hay asthma, etc.

11. Allergy to animal emanation, the blood of some persons containing specific precipitins for the albumin of the animal in question.

12. Imperfect metabolism, leading to toxemia.

13. Bacterial infection, producing winter asthma.

14. Fatigue toxemia, or fatigue neurosis. 15. Syphilis of the lung.

16. Peribronchial thickening or certain forms of fibrous tuberculosis.

17. Certain forms of tuberculosis with great resisting power on the part of the patient where wear and tear go hand-inhand with repair.

Which of these conditions are primary and which secondary has not been determined.

Treatment, of course, has been directed to all of these conditions. Antispasmodics of all kinds have been used with great success, altho eventually each one loses its effectiveness for the given patient and then recourse must be had to a different one.

Alteratives have been used, with excel

lent results in many cases, but eventually they too lose their value for the particular

case.

Vaccines, phylacogen, serobacterins, etc., have done remarkably well in cases due to or complicated with bacterial infections.

General tonic treatment has done much for many run-down and toxemic asthmatics, coupled with thoro eliminative measures.

Specific diseases that also affect the lung as well as other parts of the body are promptly relieved by appropriate treatment directed to the disease.

For some years clinicians and laboratory investigators have given considerable time and attention to discovering the relationship of normal and foreign protein and other substances to the etiology of asthma. The examination now of an asthmatic has gotten to be quite a systematic affair. First is a general laboratory examination of urine and sputum, and blood for Wassermann test. Then tests are made for food and pollen sensitiveness. Next autogenous or stock vaccine is used if there is marked expectoration or mixed infection. It is well to use it in any case. In addition to the tests for food and pollen sensitiveness and the use of the appropriate remedy, the injection of "foreign" protein (that is, a kind not existing in the human body) is of great value.

Tests for food and pollen sensitiveness are easily made. The pollen testing material is supplied in powder form. The patient should be comfortably seated in a chair with his two arms bared, resting in front of him on a table or other support. The skin of the patient's forearms is carefully cleansed with alcohol. At three dif ferent spots about two inches apart the skin is lightly scratched to remove the surface epithelium, but not deeply enough to draw blood. The upper arm is treated similarly. With a sterile applicator of some kind (a sterilized wooden toothpick is used by some) place a small quantity of the pollen powder on one of the abraded surfaces. With another applicator place a drop of a 1/10 decinormal sodium hydroxide solution. Be careful in the making of this solution to have it right. A good way is to make a decinormal solution of the sodium hy droxide, and then to 10 parts of this add 90 parts of distilled water.

Five of the six abraded spots on the patient's arm are to be used for testing with five different pollens or proteins, and the

The

sixth one is to be used as a control. proteins are supplied in solution. One drop of the solution is dropped on the abraded spot selected for the test. The sodium hydroxide solution is not used on the proteins in solution. It is only used on the dried pollens. On the control spot nothing is applied or else a drop of distilled water is used. The other arm is treated similarly.

When a positive reaction occurs a very irregular ragged area of redness forms around the area of inoculation. It resembles a mosquito bite, with elevation, white crest and erythematous areola. This occurs within five minutes in a positive case, according to Dr. Alexander Sterling, who has done much of this work in Jefferson Hospital in this city. Two layers of sterile gauze are bound on the arms before the patient is dismissed.

By the means given above, ten tests can be performed on a patient at one time. The tests are repeated a week later with ten other proteins. Any number of proteins can be tested on the patient. Among the substances that may be tested with in this manner for possible allergy reactions are ragweed, goldenrod, egg yolk, egg albumin, milk, casein, cheese, herring, beef, chicken, lamb, pork, wheat, corn, rice, potato, barley, cocoa, radish, beet, cabbage and onion. In addition tests are also made with horse serum, cat's hair, dog's hair, and horse hair.

In case a positive result is obtained with any of these, desensitization is attempted. This is done by means of a very dilute solution of the agent producing the reaction. Inject hypodermically 5 drops of a 1 to 10,000 dilution of the agent every two or three days, increasing the amount at every third or fourth injection. At the end of two weeks the dilution may be made 1 to 8,000 or 1 to 6,000 and the dose reduced and then raised as before. This can be continued with increasing strength until the patient does not react to a large injection of the full strength solution. Afterward repeat the skin test with this particular proteid to learn if a cure is effected.

After a positive result is secured the patient is only cured of allergy in regard to that particular proteid, pollen or other substance. He may require treatment for a number of them.

Sterling has been very successful with the use of the foreign protein. He has injected mustard and rape protein, either alone or mixed. Good results have been

obtained, altho the reaction was gotten from a food proteid, pollen, etc.

Drugs also are useful. In the attack adrenalin chloride relieves the spasm. Sterling says use only 1 or 2 minims, that the results will be as good as with 10 minims. That may be true of cases that have not had adrenalin injected previously. But we have had patients that required 25 minims injected hypodermically in order to get relief.

Sterling tried the effect of pituitrin on 10 patients, 1 mil being injected in each. The result was a severe paroxysm of asthma. The injection of 1 mil of adrenalin relieved them. This may point to hyperpituitary action as the basis of asthma.

Other drugs that have been injected hypodermically for the arrest of the paroxysm are scopolamine, dionin, morphine, atropine, aspidospermin (% grain), and quebrachoid. Sterling sometimes has patients drink a glass of hot water every hour for two days a week. He also gives a series of twelve injections of sodium cacodylate, injecting hypodermically 72 grains every two days. As a sedative he prescribes sodium bromide, 10 to 20 grains; tincture of belladonna, 1 to 2 minims; and Fowler's solution, 5 to 10 drops, in water three or four times a day.

Dr. William A. Swalm uses frequently a mixture consisting of Fowler's solution, 2 drams; Hare's anti-asthmatic elixir, 4 drams; glykeron, 4 drams, and elixir lactopeptine to make 4 ounces. He gives a teaspoonful every three hours.

Another useful combination is a pill composed of lobelin, 1/128 grain; apomorphin, 1/64 grain; strychnine, 1/128 grain; and hyoscine sulphate, 1/2000 grain. One pill may be administered every fifteen minutes until relief occurs, then continued every three hours or as needed.

Benzyl benzoate is an antispasmodic, given in one-grain doses in solution. It is giving good results in some cases.

Dr. Benjamin Ulanski gave one patient auto-condensation treatment, using a pad on front and back of chest. The patient was relieved for six months.

Aspirin and all the other salicylates are contraindicated in asthmatics, altho they

can stand 10 grain doses.

EDITOR MEDICAL WORLD:-Please find inclosed check for $4.00 to pay my subscription for four years. I can't get along without THE WORLD. expect to read it as long as I can read. E. E. EDDY, M. D. Redwood, N. Y., Dec. 5, 1919.

Trachoma.

The various health authorities thruout this country, in their work of eradicating disease and making the world safe for humanity, are uncovering considerable trachoma in various places. It is endemic in several parts of the country, notably in the Kentucky mountains, Ohio, Florida, Alabama, etc. It is also finding its way from its center of focus to neighboring areas. It is always more or less prevalent in our large cities. The physicians in all these places should take these cases in hand and institute appropriate treatment.

Trachoma is an inflammation of the conjunctiva, contagious in nature and spreads by continuity over the conjunctiva of eyelids and eyeball. It also spreads over the cornea of the eye, showing the condition called pannus, evidenced by a gray film of tissue with blood vessels showing as fine red lines. It is a slowly progressive (chronic) disease, marked by papillæ. In the course of time thickening of the conjunctiva takes place. It is usually present in both eyes, tho one eye may be affected more than the other.

The patient usually complains of sensitiveness to the light, the eyes water very considerably, the lids stick together, and he suffers pain. The fear of the light causes him to keep his eyelids closed. A patient with a corneal ulcer may have pain, watery eye, inflammation of conjunctiva, etc., which must not be mistaken for trachoma. When the lids are thickened, the eyes are less likely to be opened widely. Upon everting the lid, by turning the lower part of the lid upward over the tarsal cartilage, the conjunctiva is seen to be very red and thickened and studded with papillæ.

In one form there is a development of papillæ or elevations on the surface of the conjunctiva, which therefore appears velvety. If the papillæ are large the conjunctiva appears studded with coarse granules, small nodules, or even with raspberrylike projections. These are found on the tarsal conjunctiva.

In the second form occur the trachoma granules. They are gray, translucent, roundish granules, showing thru the most superficial layers of the conjunctiva, which they push up to form hemispherical swellings. Because of their translucent, seemingly gelatinous character, they have been likened to the eggs of frog spawn or to grains of boiled sago. They are found prin

cipally in the retrotarsal fold, in which they may be in such numbers that when the lower lid is drawn down the fold projects as an elastic swelling, at the summit of which are seen the granules sometimes arranged in rows like a string of pearls.

To bring into view the granules in the upper retrotarsal fold, push the fold down. To do this, hold across the upper part of the upper eyelid a slender wooden or metal applicator, wooden preferably, so that it can be burned later to avoid carrying infection to others. Carefully and gently take hold of the edge of the lid and turn it up over the applicator. Then press the upper part of the eyelid down., In very thickened lids have the patient hold his head back, then lift up the lid and look under it. A flashlight or some other bright light may be needed to help see the under surface of the lid, tho in daytime take your patient to the window and diffuse daylight will permit you to see the conjunctiva. The granules on the tarsal conjunctiva may be hidden by the conjunctiva.

Both papillæ and granules are found in the same patient.

The conjunctiva of the eyeball is usually inflamed, the blood vessels standing out prominently. The conjunctiva discharges a yellowish, purulent secretion, more abundant in the early stages. In old cases it is scanty.

In late stages the conjunctiva becomes quite thickened to a certain point, when cicatrization takes place, followed by contraction. This causes the trachoma to cease its activity. The cicatrices begin as fine, whitish lines. They increase in number and form a network. These slowly contract until the conjunctiva is pale, thin and smooth.

Pannus is a result of the spread of the trachoma over the cornea. It begins at the corneoscleral margin and spreads toward the center. As usually seen, it consists of

Ulcers of the cornea may develop. The ulcers may be found on the pannus or at its edge. Trachoma may invade the lacrymal sac.

In some cases trachoma exists a long time before giving rise to symptoms. An acute form may occur, with violent inflammation, pain, etc. This form is rare.

Treatment consists in the application to the trachomatous areas of the lids of 2 per cent. silver nitrate solution in the acute inflammatory stage. Keep it off the cornea if not diseased. This should be applied once a day. Continue this treatment until the inflammation has subsided and the secretion has diminished, probably for several weeks. Do not continue it too long lest argyrosis ensue.

Then apply blue stick (copper sulphate). The copper sulphate is made into a cone shape, the lid is held up or away from the eyelid or preferably everted, and the copper sulphate rubbed thoroly over the trachomatous area. This should be done once a day; less often as improvement occurs. Copper sulphate is especially useful in old, thickened cases. It should be continued until all trace of the hypertrophy has been eradicated and the conjunctiva is smooth.

The pain of the applications may be avoided by the use of cocaine beforehand, by incorporating orthoform in the copper stick, and by applying cold compresses to the eyes after the treatment.

As improvement progresses a stick of alum may be substituted. Some patients or members of their family can be shown how to use the copper stick. Or an ointment can be prescribed of 2 to 1 per cent. of copper sulphate or of 10 per cent. copper citrate which can be used by the patient. A 10 per cent. solution of copper sulphate in glycerin can be used. This is to be diluted with 60 parts of water and dropped into the eye three or four times a day. Reduce the amount of water frequently. The watery solution must be made fresh daily. The strength of this latter solution may be increased as fast as the patient can stand it.

For cicatricial contraction of the conjunctiva use 1 or 2 per cent. white or yellow mercurial precipitate ointment in the conjunctival sac.

If relapse occurs, with acute inflammation, resume treatment with silver nitrate solution.

When the conjunctiva is very much thickened the lids should be rolled with Knapp's

roller forceps, using general anesthesia. Cold compresses and boric acid irrigations are then used for a few days. After the rolling resume the medical treatment, preferably the blue stick applications. Very severe cases require very vigorous treatment. If the pannus does not clear up as a result of the treatment of the lids, the copper may be applied to the pannus.

Cures have been reported by the use of high frequency currents.

An effort has been made to develop a vaccine from the material expressed from trachomatous granules. The material is rubbed up in a mortar with normal salt solution and injected hypodermically. Improvement is said to have occurred in ten days. Croftan1 recovered staphylococcus aureus from trachomatous granules with which he made a vaccine that cured trachoma. The disease might yield to autotherapy.2

We have heard recently of the use of lactic acid bacilli, supplied by grinding a lactic acid tablet and dusting the powder into the eye. It is said to have been successful.

Caution must be exercised in the handling of these patients on account of the contagious nature of the disease. Be sure to use antiseptics on your hands after treating the patient and warn him to be careful, for himself and for others.

1American Journal of Clinical Medicine, December, 1919.

*See article by Dr. Charles H. Duncan in this Issue.

BUSINESS TALK TO DOCTORS

These Talks are intended to present in a plain and direct way the general principles of a physician's business life. The investment of savings is a feature of every man's business life. A physician's work is removed from the business world, and his mind is occupied by science and the humaniHence ties rather than by business propositions. physicians have been easily duped by financial schemers of all sorts. WORLD readers have been abundantly warned in this department and hundreds of thousands of dollars have doubtless been saved to the profession thereby.

The best and cheapest way that we know of to get information concerning the numerous concerns that are asking the public to buy their stock is to send $1 to the Financial World, 29 Broadway, New York, N. Y., for a ten-weeks' trial subscription. Then as a subscriber you have the privilege of using their Subscribers' Service-that is, you can write them for information concerning any offered investment, and get the advantage of their long experience and excellent facilities in the realm of finance.

We have before us the circular of a large stock and bond selling house-brokers. On carefully examining it we find that the bonds we would like to buy yield only a low rate of interest, 2 to 5 per cent., such as United States government bonds, state and municipal bonds. municipal bonds.

Their prime advantage

is safety, and the interest is regularly paid. These are the gilt-edge securities-they are securities, not weaklings. But these are so much in demand that the yield of interest is smaller than many others that are offered. Many school and road bonds are offered in various sections of the country.

A large interest is offered on foreign government bonds, ranging from 5% to 834 per cent. Undoubtedly the financiers do not hold them in as high repute as the American bonds or their price would be higher. We will list a few herewith:

EDITOR MEDICAL WORLD:-Am inclosing the sum of $4 for 4 years' subscription to THE MEDICAL WORLD, as my subscription expires some time next month. Again I want to say that I consider THE MEDICAL WORLD the best medical journal for any physician and surgeon, and the Business Talks to Doctors are of more value than most physicians estimate. I have saved many a dollar by taking your advice and I would have saved more had Ï taken the advice sooner. Success to you. I noted in your last journal of the exposure of the Houston Bank & Trust Co.'s advertisements of fake oil stock. I received a lot of their literature this fall, but it went into the waste basket. Long life and success to you; but don't discontinue the Business Talks to Doctors. Sincerely yours,

DR. J. A. RICHMOND.

832 Seventeenth St., Denver, Colo.

Some of the railroad stocks and bonds of this country are not now in good standing. The final disposition of the railroads by the government is yet uncertain, and precarious stocks suffer accordingly. A recent issue of The Financial World gives a list of stocks and bonds owned by the late exPresident Theodore Roosevelt, and some of them were called "worthless" by that paper. So you see even a man like Roosevelt could fail in the selection of good investments.