NONSURGICAL TREATMENT OF CONVERGENT STRABISMUS

It is generally agreed that surgical treatment of convergent strabismus should be withheld until all other less traumatic approaches have proved ineffectual. There are four categories of nonsurgical treatment.One is psychiatric. Too often psychiatric problems in the causation of convergent strabismus are either overlooked or unrecognized.Another is the proper employment of optical devices. For example, spectacle lenses to eliminate the need for excessive accommodation with its associated convergence excess, and the employment of prisms in the lenses to permit the two eyes to see as a unit even though they may not be properly anatomically oriented.Another kind of treatment is orthoptics, the use of exercises and rather complex optical equipment in a laboratory to train the patient in coordination between the two eyes.Treatment with drugs is based on the fact that certain drugs reduce the effort necessary for accommodation (much as eye-glasses do) and therefore lessen the stimulus toward convergence which may possibly tend toward the development of convergent strabismus.     

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 MANAGEMENT OF CHYLOTHORAX

Chylothorax is readily diagnosed from the characteristic qualities of the effusion. Treatment should initially be conservative, consisting of multiple aspirations followed, if necessary, by suction drainage.Approximately half of the patients will not respond to these measures, and direct ligation and division of the duct is necessary for cure. This operation is most readily carried out through the right chest, the thoracic duct being ligated just above the diaphragm. In cases in which the duct is surrounded by tumor, radiotherapy to the mediastinum is often successful in controlling the reaccumulation of chyle, but irradiation is generally not recommended until after a tissue diagnosis has been made by thoracotomy.Nutritional problems are often concomitants of chylothorax.     

SURGICAL TREATMENT OF CONVERGENT STRABISMUS

In convergent strabismus, glasses, visual training and exercises are often helpful, but operation is usually needed in addition to produce a functional or cosmetic cure.Babies who are born cross-eyed should be examined early and nonsurgical treatment started so that proper visual appreciation will be developed in both eyes.Children in whom strabismus develops some time after birth (usually between 18 months and six years of age) should be examined with atropine, glasses prescribed when indicated and full medical treatment instituted. If those measures fail, operation should be done on one or both eyes, the operation depending on the magnitude of the deviation.     

THE PRACTICAL MANAGEMENT OF DIZZINESS

The problem of dizziness is greatly simplified if: (1) A definite routine is followed in the history taking and the steps of the examination; (2) the examination is done in two stages; and (3) a simple classification is used in cases of dizziness of vestibular origin whereby three groups are distinguished on the basis of localization of the origin. The etiologic diagnosis is thereby narrowed down to a relatively few possibilities.The treatment consists of measures to relieve the symptoms and to reverse the underlying disease which produced the symptoms.