THE MANAGEMENT OF CANCER OF THE BREAST

Radical mastectomy is excellent only for cases of operable breast cancer in which the tumor is limited to the breast or to the nodes in the axilla. That there is metastasis to the internal mammary lymph nodes in a high proportion of cases has been “overlooked” for many years. Also it is probable that metastasis occurs to the supraclavicular lymph nodes more often than is suspected. Hence the extended radical mastectomy operation leaves much to be desired. There has been no significant improvement in recent years in the mortality rate of mammary cancer.Simple mastectomy and thorough adequate postoperative radiation therapy have much to offer.Treatment of “operable” breast cancer should be a cooperative effort of surgeon, radiation therapist and pathologist.     

THE USE OF BANTHINE IN THE TREATMENT OF DIGESTIVE DISTURBANCES

Banthine® was used in the treatment of patients with various diseases, organic and functional, of the gastrointestinal tract. Good response was obtained in a high proportion of cases of duodenal, stomal and gastric ulcer, and of hypertrophic gastritis. In some instances, patients who did not have good response at first were relieved later when the size of doses and the dosage schedule were adjusted to fit their particular needs.Some patients “felt so well” during Banthine therapy that they departed from prescribed diet and violated injunctions against use of alcohol and tobacco, and symptoms recurred.Nine patients with history of recurrent bouts of pain from ulcer for several years took small doses of Banthine constantly, or occasionally at times of stress, as a prophylactic measure after the symptoms were relieved by therapeutic doses. None of them had recurrence while following the prophylactic regimen.In most of the cases of peptic ulcer in which the response was recorded as “poor,” it was because distressing side-effects dictated discontinuance of the drug. Several elderly male patients had severe urinary retention. Paralytic ileus developed postoperatively in one patient who was receiving Banthine. Less severe side reactions—dry mouth, blurring of vision, urinary slowing — were for the most part transient.Few patients with functional indigestion, chronic non-specific colitis or regional enteritis were relieved. Most of the patients with functional indigestion reported exacerbation of symptoms when Banthine was given. This was believed to be based on emotional reaction to the hypomotility induced by the drug.     

THE USE OF SILICONES IN DERMATOLOGY

A cosmetically acceptable lotion containing a silicone protectant, a keratolytic, a bacteriocidal agent and antipruritic substances, was clinically tested in 208 persons with various dermatoses.Twenty-four-hour closed patch tests on humans and intradermal tests in laboratory animals indicate the lotion not to be a sensitizer.Subacute and chronic housewives'' eczema and contact dermatitis of the hands, uncomplicated “diaper rash,” periaural dermatitis due to excessive moisture, and certain hyperkeratotic dermatoses responded satisfactorily to the use of the lotion.     

SCINTIGRAMS OF THE THYROID GLAND—The Diagnosis of Morphologic Abnormalities with I131

Functioning thyroid tissue containing sufficient radioiodine can be visualized by scanning the gland with a directional scintillation counter.⁴ This visual representation of the gland is called a “scintigram.” Scintigrams have been invaluable in the detection and study of both “toxic” and non-functioning nodules, diffuse enlargement in hyperthyroidism and the subsequent reduction in gland size after treatment, carcinoma, and aberrant thyroid tissue.     

THE ANESTHETIST IN THE PRACTICE OF MEDICINE

In this age of specialization it is often difficult for the patient to determine who “his doctor” is. In the circumstances of anesthesia and surgery, the professional services of both physicians, the anesthetist and the surgeon, are highly integrated and the lines of responsibility must be clearly established. In the particularly close associations between anesthetist, surgeon and patient there is an urgent need for the application of scientific method in order to facilitate communication, improve the approach to the solution of problems, and enhance the welfare of the patient.     

THE THORNY CHILD

Too many physicians—and parents—hide behind the overworked excuse that “Johnny is just going through a stage.” If the remark is inaccurate a great disservice can be done to both mother and child, and ultimately to society. The well oriented physician would no more permit a young mother to unwittingly feel “guilty” because her two-year-old “little stinker” behaves like a two-year-old little stinker than he would casually reassure when a ten-year-old behaves as though he were two.Actually much of the unpleasant behavior of children is quite normal. If physicians would help all young mothers to recognize this without dismissing abnormal behavior, it would do much to avert the overwhelming sense of inadequacy that so many modern young mothers feel—especially with their first baby. If they can be made comfortable with their first the others usually come easily. Many physicians who care for children are not trained in the rudiments of developmental behavior. By means of a simple outline and drawing of “the thorny child” even the least of the experts can better understand some of the chronologic variations in developmental behavior.     

REPAIR OF NERVE INJURIES IN THE HAND

Loss of sensation in a finger due to industrial injury is of rather high incidence as a cause of disability. In many cases “finger blindness” can be prevented by nerve repair immediately after injury. Over a period of three years at a clinic for treatment of industrial injuries, primary nerve repair resulted in 95 per cent of cases in usefully functioning digits.     

STRETCHING OF THE SCIATIC NERVE—A Means of Relieving Postoperative Pain Following Removal of Ruptured Lumbar Intervertebral Discs

Stretching the sciatic nerve for the relief of “sciatica” was frequently employed before 1900 and was subsequently abandoned, probably because it was done without sufficient scrutiny of the indications. The procedure has recently been employed in cases in which “sciatica” remains following the operative removal of ruptured intervertebral discs, and it has been instrumental in relieving postoperative “sciatica” when the cause was the formation of adhesions about the lumbar nerve roots. If the nerve root is compressed by recurrent disc protrusion or by adjacent bone, the manipulation usually increases the pain, a phenomenon that has been helpful from a diagnostic standpoint.     

PATHOLOGY AND THE PATHOLOGIST IN THE CANCER PROGRAM

Cancer as one of the most important human diseases does not present as formidable a problem as infectious disease did a century ago. The diversified cancer program, combining voluntary and governmental agencies in support of research, education and coordinated teamwork in the clinical care of the patient, presents a varied although unified approach to the problem that has never before been available for the study of any single human disease. Pathology, with its applied methods from the basic sciences, has a singular role in the scientific aspect of the cancer program. Representing a new specialty in medicine and embodying an inquiring approach to the study of human disease, pathology has a leading role to play. The pathologist, assuming the new role of “pathologist-physician” brings to the clinical care of the cancer patient the most precise methods of cancer diagnosis. The “pathologist-physician” should be a pivotal member of the “clinical team” in the immediate diagnosis, care and treatment of the cancer patient.     

Organization of the Mitochondrial Apoptotic BAK Pore: OLIGOMERIZATION OF THE BAK HOMODIMERS*

The multidomain pro-apoptotic Bcl-2 family proteins BAK and BAX are believed to form large oligomeric pores in the mitochondrial outer membrane during apoptosis. Formation of these pores results in the release of apoptotic factors including cytochrome c from the intermembrane space into the cytoplasm, where they initiate the cascade of events that lead to cell death. Using the site-directed spin labeling method of electron paramagnetic resonance (EPR) spectroscopy, we have determined the conformational changes that occur in BAK when the protein targets to the membrane and forms pores. The data showed that helices α1 and α6 disengage from the rest of the domain, leaving helices α2-α5 as a folded unit. Helices α2-α5 were shown to form a dimeric structure, which is structurally homologous to the recently reported BAX “BH3-in-groove homodimer.” Furthermore, the EPR data and a chemical cross-linking study demonstrated the existence of a hitherto unknown interface between BAK BH3-in-groove homodimers in the oligomeric BAK. This novel interface involves the C termini of α3 and α5 helices. The results provide further insights into the organization of the BAK oligomeric pores by the BAK homodimers during mitochondrial apoptosis, enabling the proposal of a BAK-induced lipidic pore with the topography of a “worm hole.”     

THE IMPORTANCE OF POTASSIUM AFTER OPERATION

A deficiency of potassium in a patient after operation is manifest clinically by anorexia, malaise, apathy, weakness, abdominal distention and hypochloremia.Many patients who have had a prolonged disturbance in nutrition may have a “subclinical” hypopotassemia.Prophylaxis by means of replacement of the potassium excreted daily in the urine is the ideal treatment.When the clinical picture of potassium deficit develops, the amount of the potassium ion needed for replacement should be calculated on the basis of the total amount of water in the body of the patient.     

THE CONCEPT OF CONTINUATION EDUCATION IN MEDICINE

The rapid increase in quantity and complexity of medical knowledge requires a redefinition of the educational aims of schools of medicine. The four formal years in medical school must be regarded as only the first four years of a “forty-year medical educational experience” and these four years must be devoted in the main to teaching principles of health and disease. There, then, must follow well-planned, realistic programs of continuation education, not in lieu of, but in addition to already established formal programs of postgraduate education.     

THE SURGICAL TREATMENT OF MELANOMA

Some melanomas arise from compound and junctional nevi. Since there is a relatively high incidence of malignant diseases on the soles of the feet and the genitalia, routine removal of nevi developing in those areas is recommended.“Juvenile melanomas” are active, cellular nevi occurring in prepubertal children. The clinical course is probably benign.The tenet of excision and dissection in continuity where feasible of the primary melanoma and the regional lymph nodes is reemphasized. When continuous dissection is not possible, regional node dissection is recommended as a separate procedure.Major amputations for melanomas of the extremities are not recommended for the usual case.     

A THEORY OF THE GENESIS OF BREAST DUCT PAPILLOMA

While it is not the intent to argue that papilloma never develops in the conventionally accepted manner (proliferative growth from the wall of a pre-existing cavity) a new, perhaps alternative, genesis is suggested. The concept is that, beginning with the usual lobular structure of the breast, first by hyperplasia and then by coalescence of alveoli, seen earliest at the periphery of the lobule, spaces appear between the content of the lobule and the wall. By confluence of these spaces a larger cystic cavity is formed. Coalescence of alveoli through the body of the central mass, in the same way as at the periphery, develops the familiar pattern of “papilloma.” Following the earlier hyperplasia, regressive changes appear and may go on to complete disintegration of the papillary mass, leaving a smooth-walled cavity.     

THE USE OF ANTITHYROID DRUGS

The preoperative use of antithyroid drugs is mandatory if surgical treatment of complicated hyperthyroidism is contemplated. Six months to a year may be required for suitable preparation.The long-term use of antithyroid drugs is less effective for the “cure” of hyperthyroidism than is operation or the use of radioactive iodine.Propyl and methyl thiouracil are the antithyroid drugs of choice.Either of these thiouracil derivatives is capable of producing leukopenia.The antithyroid drugs exert no favorable effect on exophthalmos.The antithyroid drugs are suitable for the control of hyperthyroidism during pregnancy. The patient probably should not be kept hypothyroid during pregnancy but rather in a state of mild hyperthyroidism.     

MALIGNANT LYMPHOMA OF THE COLON AND RECTUM—Roentgen Diagnosis

The filling defects of a particular lymphosarcoma of the colon or rectum may present an appearance identical to that of a carcinoma in the same location. In general, lymphosarcomas tend to be longer, more distensible, less sharply demarcated, more frequently polypoid, and to feel larger as palpable masses. The filling defects are infrequently of the annular “napkin ring” appearance, and occasionally the involved segment is dilated.     

THE USE OF ANTABUS IN THE THERAPY OF ALCOHOLIC PATIENTS

Preliminary studies on the effects of antabus (tetraethylthiuram disulfide) in the therapy of alcoholic patients indicate that it is very valuable in providing a “chemical foundation” for sobriety, even in those with a severe, long term drinking problem. In the first 30 patients treated, a favorable degree of control of the alcoholism has been effected in approximately 80 per cent. When taken regularly the drug maintains in the patient a very high degree of sensitivity to alcohol, quickly producing a number of very distressing bodily reactions whenever even very small amounts of spirits are ingested. Because of its potential dangers, antabus should be used only after thorough clinical and laboratory studies in properly staffed institutions. It is contraindicated in individuals with existing major psychosis or drug addiction and must be used only with caution in patients with diabetes mellitus, cardiovascular disease, goiter, pregnancy, epilepsy, asthma, and hepatic disease. Antabus therapy should be considered only one aspect of the total treatment program for the alcoholic patient.     

THE TREATMENT OF MEDIASTINAL TUMORS

Because there can be no certainty of diagnosis without it, thoracotomy is indicated in cases in which there is roentgenographic evidence of mediastinal tumor. “Watchful waiting” is considered unwise because the tumor may be malignant when first observed or may later undergo malignant change. Even if the lesion is and remains benign, an increase in the size of the mass may cause obstructive pressures necessitating operation ultimately. Moreover, infection and inflammation may develop at the site during prolonged observation, making operation more difficult.The hazards of thoracotomy, which have been greatly reduced in the last few years, are less than the hazards of waiting.     

PSYCHIATRY AND THE LAW

In Rex vs. Arnold (1724) it was held that to avail himself of the defense of insanity “a man must be totally deprived of his understanding and memory, so as not to know what he is doing, no more than an infant, a brute, or a wild beast.” Although there has been some modification of this formula in most jurisdictions, the courts still operate under the McNaghten Rule (1843) which is no more logical and actually is more difficult to apply. That such a situation exists in 1956 is a reflection on the indifference of society—and particularly the courts which it elects—as well as on the failure of modern psychiatry to communicate its viewpoint to society. If we are to correct the sad formulae of the “right and wrong” and “policeman at the elbow” tests, we must have more study and better methods of communication in this area.A similar state of confusion exists in the methods of commitment of mentally ill people to psychiatric hospitals. The methods prescribed by law are archaic and cruel—and again reflect the failure of modern psychiatry to communicate its understanding to the legislatures and courts.There are many other areas of conflict between law (which looks to the past for its insights) and psychiatry (which seeks for its concepts in the current scientific advances).     

THE USE OF RADIOACTIVE IODINE IN THE TREATMENT OF GRAVES' DISEASE

Fifty patients with uncomplicated Graves'' disease were treated with radioactive iodine (I₁₃₁). Twenty-six patients who were followed for one year or longer are the basis of this report. Twenty-five are now euthyroid; only one is not completely well.The total dose of radioiodine administered varied from 0.5 to 10 millicuries. The average length of time necessary for return to a euthyroid state was from three to four months.Hypometabolism developed in three patients, and in one the signs and symptoms of myxedema developed. No other complications ensued. One patient who apparently relapsed had complete return to normal after further iodine administration.The determination of the uptake of radioactive iodine by the thyroid gland is a useful diagnostic procedure in differentiating conditions simulating hyperthyroidism.Following treatment with radioactive iodine, the thyroid gland becomes smaller, the uptake of iodine by the gland is reduced, and the level of organic iodine in the plasma becomes normal.In acute thyroiditis, in spite of a high basal metabolic rate, high content of organic iodine in the plasma and other evidences of “hyperthyroidism,” the uptake of I₁₃₁ has been very low.