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Sulfonamide Suppository in The Treatment of Acute Gonorrhea in Women
SULFONAMIDE SUPPOSITORY IN THE TREATMENT OF ACUTE GONORRHEA IN WOMEN WILLIAM BICKERS,
M.D.,
RICHMOND, VA.
(From the Department of Gynecology, MedWal College of Virginia) IS well known that ambulatory treatment of acute gonorrhea has always been I Tattended by a large incidence of compl.ications, including Bartholin abscess, chronic Skenitis, salpingitis, and endocervicitis. Nevertheless, economic considerations still demand ambulatory treatment in many patients, and this study was made on such a group. The last two years have seen many publications describing the treatment of acute gonorrhea by the oral administration of sulfonamide. It is interesting to note that the urologist has been more enthusiastic about his clinical results than has the gynecologist. This may be due to the chemotherapeutic effect of the drug passing over the male urethra after being excreted by the kidney. In this out-patient service, 25 cases of acute gonorrhea were observed and proved by history, laboratory, and pelvic examination. These patients were treated by the oral administration of sulfonamide, 80 gr. daily for the first three days, an.d 60 gr. thereafter for two weeks. Bi-weekly examinations of the blood and urethral and cervical smears were taken. In this group, treated as described, without any looal therapy, one patient had a negative smear at the end of one week; 3 patients had negative smears at the end of two weeks. The other 21 patients had clinical and laboratory evidence .of gonorrhea when the seventeen-day course of therapy was completed. Eighteen of the 25 cases could be followed for three months. Dur· ing this period 3 of them developed a Bartholin's abscess, 4 developed evidence of salpingitis, 16 had a persistent endocervicitis, and 6 had a subacute Skenitis. It could not be concluded from the results in this series that sulfonamide administered orally, in the absence of other treatment, was a satisfactory means of treating gonorrhea in women. Two young girls, aged 4 and 9, were seen with acute Neisserian vaginitis. They were treated with 40 and 30 gr. of sulfonamide, respectively, administered for a period of seventeen days. No laboratory or clinical change in the vaginitis could be seen at the end of the treatment. After being disappointed by the oral administration of the drug, we observed an· other series of patients with acute gonorrhea, using the drug locally. Insufflation of the powder was first used but promptly discarded because the powder has a tendency to cake in the vaginal vault, and does not come into contact with the urethra and vaginal introitus. The sulfonamide then was incorporated in a boroglyceride base, using 20 gr. of sulfonamide and 10 gr. of lactose in the suppository. Twenty· five patients suffering from acute gonorrhea were treated by the insertion of one sulfonamide suppository high into the vaginal vault three times a day. These patients were treated for seventeen days, smears from the urethra and cervix being taken biweekly. It was noted that the symptoms of dysuria and purulent leucorrhea disappeared in 12 of the patients on the third day. Smears from the urethra and cervix were negative in all 25 patients at the end of one week. It was possible to follow 21 of the 25 for a period of three months. Nineteen patients were symptom-free without evidence of urethritis, and there were no cases of bartholinitis. There was not a single ease of salpingitis. One patient, at three months, had an acute gonorrhea which could be traee
WI:t-.'XELSTEIN:
ENDOMETRIAL BIOPSIES
163
Two cases of acute vaginitis in children were seen. Local treatment by insertion of sulfonamide suppository resulted in laboratory and clinical cure within the seventeen-day treatment period. A careful review of the literature failed to show any report on blood levels of sulfonamide, following the introduction of the drug into the vagina. Twenty-five adult patients treated by the vaginal route were studied at the end of one week, during which time the adult patients had each received 420 gr. of sulfonamide, and the children had each received 280 gr. The blood levels varied from a trace to 4 mg. per 100 c.c. of blood. The higher concentrations were found in children with acute vaginitis. Obviously, the clinical result could not be attributed to the drug which was absorbed. It does demonstrate again that the vaginal mucosa is an absorptive organ, and therefore, care should be exercised in the intro.duction of new drugs. CO~CIXSIONS
1. Oral administration of sulfonamide for the treatment of acute gonorrhea in women has little if any value. 2. Sulfonamide locally in the form of boroglyceride suppository probably has real value in the prevention of complications and cure of infection. 3. Sulfonamide is absorbed from the vaginal mucosa in varying degrees, the degree of absorption being more apparent in patients with aeute vaginitis. 807 '\VEST Ji'RANKI,IN STREET
SIMPLIFIED SUCTION FOR OBTAINING ENDOMET-RIAL BIOPSIES I1. B. WINKELSTEIN, M.D., NEw YoRK, N.Y. (From. the Btuyvesant Polyclinic) value of endometrial biopsy in gynecologic and endoerine diagnosis is obTHE vious, even though Israel and Mazerl believe that tlm removal of small pieces of tissue is of no value, e3pecially in suspected malignancy. Various types of in· struments, however, have been devised for the removal of such specimens from the uterus with minimal danger and discomfort to the patient. These include a tiny curette (Hoffmannz), an endometrial punch (Lorincz and DaviHa), and the more commonly used cannula with the closed end and the side opening, the biopsy curette (Klingler and Burch4; Novak5; Randalls). ~Iodifieations of the latter instrument have been made by Kurzrok, Wilson and Cassidy.' With the punch or biopsy curette, in order that the portion of the endometrium be removed and not lost in the uterine cavity, suction is applied. This pulls the tissue back into thoo hollow shaft of the instrument, and allows the operator to remove three or four sections without with· drawing the instrument from the uterus. Suction may be applied either with a glass or metal syringe, equipped with a three-way stopcock ( 8), or with an electric pump, similar to a breast pump, and connected to the curette by means of a suction bottle and rubber tubing (!J ). Both of these methods possess disadvantages. The former requires the use of both hands in manipulating the syringe, gives an intermittent type of suction, and possesses an added hazard, in that the operator, forgetting to turn the stopcock be· fore closing the syringe, forces both air and the tissue specimen back into the uterine cavity. 'rhe particular disadvantages of the latter method lie in its ex· cessive bulk and unwieldiness, together with its inherent power to ruin the specimen by excessive amounts of suction. Since the above methods are not satisfactory, the following simple means of applying either negative or positive pressure to the biopsy curette is recommended. The apparatus consists essentially of a metal Luer nipple to fit the machined end of the curette, a length of thick-walled rubber tubing, and a DeVries aspirator bulb, the end of which is modified so that it can be held firmly between the lips and
M.D.,
RICHMOND, VA.
(From the Department of Gynecology, MedWal College of Virginia) IS well known that ambulatory treatment of acute gonorrhea has always been I Tattended by a large incidence of compl.ications, including Bartholin abscess, chronic Skenitis, salpingitis, and endocervicitis. Nevertheless, economic considerations still demand ambulatory treatment in many patients, and this study was made on such a group. The last two years have seen many publications describing the treatment of acute gonorrhea by the oral administration of sulfonamide. It is interesting to note that the urologist has been more enthusiastic about his clinical results than has the gynecologist. This may be due to the chemotherapeutic effect of the drug passing over the male urethra after being excreted by the kidney. In this out-patient service, 25 cases of acute gonorrhea were observed and proved by history, laboratory, and pelvic examination. These patients were treated by the oral administration of sulfonamide, 80 gr. daily for the first three days, an.d 60 gr. thereafter for two weeks. Bi-weekly examinations of the blood and urethral and cervical smears were taken. In this group, treated as described, without any looal therapy, one patient had a negative smear at the end of one week; 3 patients had negative smears at the end of two weeks. The other 21 patients had clinical and laboratory evidence .of gonorrhea when the seventeen-day course of therapy was completed. Eighteen of the 25 cases could be followed for three months. Dur· ing this period 3 of them developed a Bartholin's abscess, 4 developed evidence of salpingitis, 16 had a persistent endocervicitis, and 6 had a subacute Skenitis. It could not be concluded from the results in this series that sulfonamide administered orally, in the absence of other treatment, was a satisfactory means of treating gonorrhea in women. Two young girls, aged 4 and 9, were seen with acute Neisserian vaginitis. They were treated with 40 and 30 gr. of sulfonamide, respectively, administered for a period of seventeen days. No laboratory or clinical change in the vaginitis could be seen at the end of the treatment. After being disappointed by the oral administration of the drug, we observed an· other series of patients with acute gonorrhea, using the drug locally. Insufflation of the powder was first used but promptly discarded because the powder has a tendency to cake in the vaginal vault, and does not come into contact with the urethra and vaginal introitus. The sulfonamide then was incorporated in a boroglyceride base, using 20 gr. of sulfonamide and 10 gr. of lactose in the suppository. Twenty· five patients suffering from acute gonorrhea were treated by the insertion of one sulfonamide suppository high into the vaginal vault three times a day. These patients were treated for seventeen days, smears from the urethra and cervix being taken biweekly. It was noted that the symptoms of dysuria and purulent leucorrhea disappeared in 12 of the patients on the third day. Smears from the urethra and cervix were negative in all 25 patients at the end of one week. It was possible to follow 21 of the 25 for a period of three months. Nineteen patients were symptom-free without evidence of urethritis, and there were no cases of bartholinitis. There was not a single ease of salpingitis. One patient, at three months, had an acute gonorrhea which could be traee
WI:t-.'XELSTEIN:
ENDOMETRIAL BIOPSIES
163
Two cases of acute vaginitis in children were seen. Local treatment by insertion of sulfonamide suppository resulted in laboratory and clinical cure within the seventeen-day treatment period. A careful review of the literature failed to show any report on blood levels of sulfonamide, following the introduction of the drug into the vagina. Twenty-five adult patients treated by the vaginal route were studied at the end of one week, during which time the adult patients had each received 420 gr. of sulfonamide, and the children had each received 280 gr. The blood levels varied from a trace to 4 mg. per 100 c.c. of blood. The higher concentrations were found in children with acute vaginitis. Obviously, the clinical result could not be attributed to the drug which was absorbed. It does demonstrate again that the vaginal mucosa is an absorptive organ, and therefore, care should be exercised in the intro.duction of new drugs. CO~CIXSIONS
1. Oral administration of sulfonamide for the treatment of acute gonorrhea in women has little if any value. 2. Sulfonamide locally in the form of boroglyceride suppository probably has real value in the prevention of complications and cure of infection. 3. Sulfonamide is absorbed from the vaginal mucosa in varying degrees, the degree of absorption being more apparent in patients with aeute vaginitis. 807 '\VEST Ji'RANKI,IN STREET
SIMPLIFIED SUCTION FOR OBTAINING ENDOMET-RIAL BIOPSIES I1. B. WINKELSTEIN, M.D., NEw YoRK, N.Y. (From. the Btuyvesant Polyclinic) value of endometrial biopsy in gynecologic and endoerine diagnosis is obTHE vious, even though Israel and Mazerl believe that tlm removal of small pieces of tissue is of no value, e3pecially in suspected malignancy. Various types of in· struments, however, have been devised for the removal of such specimens from the uterus with minimal danger and discomfort to the patient. These include a tiny curette (Hoffmannz), an endometrial punch (Lorincz and DaviHa), and the more commonly used cannula with the closed end and the side opening, the biopsy curette (Klingler and Burch4; Novak5; Randalls). ~Iodifieations of the latter instrument have been made by Kurzrok, Wilson and Cassidy.' With the punch or biopsy curette, in order that the portion of the endometrium be removed and not lost in the uterine cavity, suction is applied. This pulls the tissue back into thoo hollow shaft of the instrument, and allows the operator to remove three or four sections without with· drawing the instrument from the uterus. Suction may be applied either with a glass or metal syringe, equipped with a three-way stopcock ( 8), or with an electric pump, similar to a breast pump, and connected to the curette by means of a suction bottle and rubber tubing (!J ). Both of these methods possess disadvantages. The former requires the use of both hands in manipulating the syringe, gives an intermittent type of suction, and possesses an added hazard, in that the operator, forgetting to turn the stopcock be· fore closing the syringe, forces both air and the tissue specimen back into the uterine cavity. 'rhe particular disadvantages of the latter method lie in its ex· cessive bulk and unwieldiness, together with its inherent power to ruin the specimen by excessive amounts of suction. Since the above methods are not satisfactory, the following simple means of applying either negative or positive pressure to the biopsy curette is recommended. The apparatus consists essentially of a metal Luer nipple to fit the machined end of the curette, a length of thick-walled rubber tubing, and a DeVries aspirator bulb, the end of which is modified so that it can be held firmly between the lips and