ADVANCED NEOPLASTIC DISEASE—Treatment with 5-Fluorouracil and Irradiation

One hundred and twelve patients with far advanced, inoperable neoplastic disease were treated by a method utilizing the simultaneous administration of the pyrimidine antagonist, 5-fluorouracil, and ionizing irradiation to an estimated tumor dose of 2,000 roentgen units. Seventy-seven of them had periods of objective regression of tumor of three months or more.The data presented suggest that either there may be an additive effect when the two modes of therapy are used simultaneously or one mode of therapy may potentiate the antitumor effect of the other.     

NEISSERIAN CONJUNCTIVITIS—Treatment with Penicillin

Data on treatment of 45 patients with Neisserian conjunctivitis demonstrate that penicillin is a reliable therapeutic agent in this disease. Exudate must be frequently flushed out of the conjunctival sac to prevent corneal ulcer and endophthalmitis. Penicillin may be administered intramuscularly or topically, in solution.The use of penicillin solution topically has been demonstrated to be superior to intramuscular penicillin in some cases, and to be adequate in all cases, even when saline solution irrigations are the only other therapy.     

COCCIDIOIDOMYCOSIS—Treatment with Isonicotinic Acid Hydrazide

Since coccidioidal granulomas are histologically indistinguishable from tuberculous granulomas, a long course of isonicotinic acid hydrazide therapy was tried experimentally in three cases of coccidioidomycosis, with good results. In two cases the disease was far advanced and prognosis poor before INH therapy was begun. In one case the disease was mild and symptoms abated after a short course of small doses of INH. It recurred when INH therapy was discontinued, and again resolved when larger doses of INH were given over a longer period.INH seemed to have an effect on appetite also, although the patients were taking B-complex vitamins both before and during INH treatment. The three patients ill with coccidioidomycosis averaged a weight gain of four and a half pounds a month during the period of INH therapy. Six well persons who were underweight and lacked appetite were given INH without other drugs, and they then had an increase in appetite and in weight.     

EMESIS AND HICCOUGH—Treatment with Chlorpromazine

Thorazine was very effective in the control of vomiting, regardless of cause, in 20 cases in which it was used. It stopped hiccough in five of seven patients treated and partially controlled it in the other two. The drug was more effective when given intramuscularly than orally. Use of the drug intravenously was observed in one case; shock occurred soon after injection.     

WHIPLASH INJURIES—Diagnosis and Treatment

Whiplash injury may extend far beyond the neck, and may involve even the soft tissues of the pelvis. For permanent recovery, all the injuries must be evaluated and treated together.When impact from the rear snaps the head back and then forward, posterior subluxations in the cervical spine cause anterior-posterior narrowing of the intervertebral foramina, which may result in injury to the cervical nerve roots. Impact at the front, causing hyperflexion followed by hyperextension, has a similar effect although usually not as severe. Resulting symptoms may not appear until two or three weeks later, when irritative lesions have developed because of hemorrhage or swelling. Mild or progressive degenerative changes may cause no symptoms but may predispose the affected area to injury following some slight trauma. Capsular ligaments of the lateral intervertebral joints are especially liable to whiplash injury which may give rise to scars and adhesions that compress spinal nerves. Sympathetic system involvement may cause reflex and referred pain.Detailed neurologic, roentgen and electromyographic studies may be necessary for proper evaluation of injuries. Seemingly psychosomatic pain or disability is likely to have some physical basis in whiplash injuries.In 33 patients with whiplash injury, some recently injured and some chronically disabled with persistent symptoms, good results were observed following hydromassage, hot packs, joint mobilization exercises and, in a few, cervical or pelvic traction.     

SPASTICITY—Its Nature and Treatment

There are a number of physiological means of relaxing spasticity, including active resistive exercise, cold hydrotherapy, heat, electrical stimulation of antagonistic muscles, passive stretch in diagonal movement patterns, and the Von Bechterew reflex. Although none of them will cure spasticity, temporary relaxation may permit a patient to achieve better functioning of an affected joint. The choice of procedure will depend on the nature of the lesion and the muscular distribution of the spasticity.     

SUBCLINICAL HYPOTHYROIDISM—Recognition and Treatment

Often patients in whom there is little to suggest myxedema or cretinism have subclinical hypothyroidism. Once the condition is suspected, it can be diagnosed by determination of protein-bound iodine and, if the PBI is low, by response to therapy with thyroid hormone.Patients in the following categories should have protein-bound iodine determination: Those having (1) a history of previous treatment for hypothyroidism; (2) suboptimal development in children; (3) ovarian dysfunction, infertility, habitual abortion or unusual menopausal disorders; (4) symptoms of malaise and debility, such as undue fatigue, somnolence, mental asthenia and anxiety; (5) unexplained anemia; (6) colloid goiter, adenomatous goiter and cancer of the thyroid gland.If hypothyroidism is diagnosed, administration of thyroid hormone in increasing amounts, as determined by serial serum PBI tests, should be carried out indefinitely. Instruction of the patient is essential.     

ONYCHOMYCOSIS OF THE FEET—Treatment with Griseofulvin

Griseofulvin, a new orally administered antifungal antibiotic which has proved to be effective for the treatment of a wide variety of superficial fungus infections of man, was used in the treatment of 51 patients with infections of the toenails due to T. rubrum. Thirty-four of the patients were treated with griseofulvin alone and seven were treated with griseofulvin combined with surgical avulsion of all involved toenails. The remaining ten had bilateral infections, and avulsion was done on one foot but not the other before griseofulvin therapy was begun.Of 34 patients who were treated with griseofulvin alone, few had complete cure even after prolonged treatment. Some nails showed improvement for a time, then no further gain; some showed no improvement; some showed resistant wedges of infection which penetrated proximally toward the posterior nail fold.In the instances of surgical avulsion, clinically normal nails regrew during griseofulvin therapy. This simple procedure, with thorough removal of all underlying keratinous debris, apparently did away with foci of possible reinfection.The results of the study indicated that surgical avulsion of the toenails in combination with griseofulvin therapy is an effective and practical method of treating onychomycosis of the toenails due to T. rubrum.     

TRIIODOTHYRONINE—Clinical Effects in Patients with Suboptimal Response to Other Thyroid Preparations

Thirty patients with evidence of hypometabolism or a clinically related condition were given triiodothyronine after suboptimal response to thyroxin or desiccated thyroid. DL- and L-isomers of triiodothyronine were used and compared. Thirteen patients (43.3 per cent) were improved and 17 (56.6 per cent) were unimproved or became worse. Side effects occurred in 9 of 34 trials (26 per cent), and could not always be eliminated by decreasing the dosage. The highest percentage of good response occurred in a small group (four of five) who received a combination of desiccated thyroid or thyroxin with supplemental triiodothyronine. Despite careful analysis of the data, no basis was found on which to predict which patients would receive benefit from the triiodothyronine. However, the occasional improvement, sometimes dramatic, suggested that a therapeutic trial with triiodothyronine in difficult or unresponsive cases of hypometabolism or hypothyroidism is justified.     

HIRSCHSPRUNG'S DISEASE—The Clinical Differentiation and Treatment of Children with Hirschsprung's Disease and Pseudo-Hirschsprung's Disease

Hirschsprung''s disease is marked by constipation from the time of birth, with the development, if uncorrected, of a protuberant abdomen and flared costal margins. The rectal ampulla is empty and the abdomen is filled with fecal masses. Pain is not prominent. Flatus is passed in large amounts. Encopresis does not occur. Barium enema shows the characteristic narrowed distal rectal segment and biopsy of the rectum shows absence of the ganglion cells of the myenteric plexus.Treatment is operative resection of the distal narrow segment and a primary anastomosis.Hirschsprung''s disease may be mimicked in children with:1. Psychogenic constipation—pseudo-Hirschsprung''s disease. Unlike Hirschsprung''s disease, symptoms do not appear at birth, encopresis is common, and the barium enema shows no narrow distal segment.2. Mental retardation and cerebral defect.3. Corrected imperforate anus—on the basis of stenosis, imperfect innervation or poor habit training.4. Cretinism—with severe constipation and intestinal dilatation perhaps the presenting symptoms.Treatment of these four groups of children with severe constipation not due to Hirschsprung''s disease is:For Group 1, open discussion with parent and child. Assumption by the physician of full control of the details of treatment, and relegation of parent to the role of the physician''s agent in following the prescribed regimen.For Group 2, an enema regimen. Whereas fairly rapid restoration (and then persistence) of normal bowel habit can be expected in Group 1, the basic defects in Group 2 may require indefinite continuation of treatment.For Group 3, regular enema regimen, in the less severe cases—one identical with that used in Group 1, and dilatation of strictures or anoplasty.In Group 4, thyroid hormone therapy relieves the constipation of hypothyroidism and causes reversion of radiographic changes in the colon and rectum.     

HEMANGIOMAS—Histologic Structure,and Treatment

Hemangiomas are considered tumors originating in blood vessels and are classified as ectatic and hyperplastic. Controversy regarding active therapy occurs in the case of strawberry hemangiomas which are hyperplastic capillary hemangiomas. Although they may clear up spontaneously, on rare occasions they may predispose to grave sequelae. Port-wine stain hemangiomas should never be treated with x-ray or radium.     

MALFUNCTIONING POSTGASTRECTOMY STOMA—Diagnosis and Treatment

Individualization in the treatment of patients with malfunctioning gastrojejunostomy stomas is paramount. Prompt surgical intervention in critically ill patients is necessary to save life.In the early postoperative phase, the use of barium studies is disappointing and very seldom gives information as to the actual site of the obstruction.In surgical treatment, operation directly upon the stoma should be avoided as much as possible. The release of small bowel obstruction, the reduction of intussusception or the correction of retraction of the jejunum through the mesocolon can be accomplished readily. Double or single jejunostomy for feeding and decompression are all that is necessary in cases in which no cause can be found for obstruction at or below the stoma.In a patient with peptic ulcer, the use of enteroenterostomy below the stoma is unphysiological and will predispose to gastrojejunal ulcer at a later date.     

NONALLERGIC ASTHMA—Differential Diagnosis and Treatment

A classification of asthma into allergic and nonallergic has gained support from the more recent studies on the underlying causes of the disease.The majority of instances of nonallergic asthma occur after middle life and result from recurrent infections of the upper and lower respiratory tract. Status asthmaticus is a frequent complication of infectious asthma.Chronic and intractable asthma may be present also in a patient with allergic asthma complicated by a superimposed infection of the sinuses, bronchi and lungs.There are many secondary or precipitating causes that may bring on asthmatic paroxysms. The most important of these are acute respiratory infections, mechanical and chemical irritants, autonomic imbalance, hormonal deficiencies and psychogenic influences. These secondary causes play a more important role in nonallergic asthma because of the greater tendency to chronicity in this form of the disease.The effective treatment of chronic asthma depends largely on the successful control of the secondary or precipitating causes of the asthmatic attacks.The introduction of the antibiotics and corticosteroids in the treatment of infectious asthma has supplied potent weapons to combat the disease. The use of these therapeutic agents makes possible the control of two of the important pathologic lesions of asthma—bronchial infection and bronchial inflammation.At present combined antibiotic and cortisone or hydrocortisone therapy of asthma seems to be the most rational method of preventing the disease from becoming chronic and intractable. Their value in infectious asthma is due to their anti-infective and antiflammatory action.When prolonged treatment is essential, combined therapy also lessens the dangers arising from the presence of masked infections.     

POSTOPERATIVE ESOPHAGEAL COMPLICATIONS—Prevention and Treatment

Postoperative esophagitis and stricture formation may be more serious than the disease for which operation was done.The best treatment is prevention by avoiding use of a nasogastric tube if possible. If it has to be used, the tube should have a small lumen and be removed as soon as possible.When surgical operation is necessary, the cardioesophageal junction should not be sacrificed unless it is absolutely necessary to do so.Conservative treatment if begun early can minimize or prevent the development of esophagitis and subsequent stricture formation.