Management of Drug Abuse

The management of complications from drug abuse demands a variety of skills from airway management to control of seizures and shock. Several reviews have addressed the issues of general resuscitation and toxidromes.
The purpose of Drug rehab is to present a series of management strategies for the emergency physician or other clinical personnel caring for patients with acute complications from drug abuse. Immediate interventions (e.g., resuscitation and stabilization), secondary interventions (e.g., emergency care after the patient is stable), as well as diagnostic workup (e.g., laboratory data, imaging), and disposition of the patient are discussed. This is proposes a variety of treatment approaches based on a review of the pertinent literature and clinical experience. A general treatment approach based on symptom complex (i.e., seizures, coma, hyperthermia) is presented since initial management decisions frequently have to be made without the benefit of a reliable history. This is followed by a brief review of the each particular drug of abuse (i.e., psychostimulants, opiates, hallucinogens).
It should be emphasized that the adverse reaction to a drug may depend on the unique characteristics of an individual (i.e., presence of cardiovascular disease) as well as the type of drug abused. These protocols serve as guidelines only and an individualized approach to management should be made whenever possible. In the setting of drug overdose, coma usually reflects global depression of the brain’s cerebral cortex. This can be a direct effect of the drug on specific neurotransmitters or receptors or an indirect process such as trauma or asphyxia. Treatment deals largely with maintaining a functional airway, the administration of potential antidotes, and evaluation for underlying medical conditions. The following section describes the Drug rehab thats appropriate use of antidotes and the approach to the patient with a decreased level of consciousness from drug abuse.
Level vs. content of consciousness: It is often useful to distinguish between the level and the content of consciousness. Alertness and wakefulness refer to the level of consciousness; awareness is a reflection of the content of consciousness. In referring to coma, stupor, and lethargy here we address the level of consciousness as it applies to the drug-abusing patient along a clinical spectrum with deep coma on one end, stupor in the middle, and lethargy representing a mildly decreased level of consciousness. Agitation, delirium, and psychosis are addressed in a subsequent section with a greater focus on content of consciousness, i.e., presence or absence of hallucinations, paranoia, severe depression, etc. Attributes of a good antidote The ideal antidote should be safe, effective, rapidly acting, and easy to administer. It should also have low abuse potential, and act as long as the intoxicating drug.
The following standard antidotes are of potentially great benefit and little harm in all patients. Thiamine: Thiamine is an important cofactor for several metabolic enzymes that are vital for the metabolism of carbohydrates and for the proper function of the pentose–phosphate pathway.When thiamine is absent or deficient, Wernicke’s encephalopathy, classically described as a triad of oculomotor abnormalities, ataxia, and global confusion, may result. Although Wernicke’s is rare, empiric treatment for this disease is safe, inexpensive (wholesale price of 100 mg of thiamine is approximately $1), and cost-effective.

Nimodipine: Cocaine is known to decrease reuptake of serotonin, which is believed to play a
role in cocaine-induced headaches and may be associated with cocaine-induced vasoconstriction.
Rothrock et al. reported on three cases of amphetamine-related stroke: in one case a 35-year-old abuser had 20 episodes of transient right hemiparesis occurring within minutes of inhaling methamphetamine; later he developed permanent right hemiparesis. In animal studies,
intravenous methamphetamine administration has resulted in narrowing of the middle cerebral
artery branches within 19 min.While the pharmacologic approaches to cerebral vasospasm are varied, the calcium-channel blocker nimodipine has been used widely with proven efficacy in preventing vasospasm associated with hemorrhagic stroke.No studies looking at this issue in the setting of drug-induced hemorrhagic stroke exist. Although two animal studies found that nimodipine potentiated the toxicity of cocaine and amphetamines in rats, it is felt that in selected
patients the risk–benefit ratio may favor nimodipine administration. Such populations may include the drug-abusing patient who is experiencing transient ischemic attacks closely temporally related to substance abuse or who has had a documented subarachnoid hemorrhage associated with cerebral vasospasm. Recent reports suggest no benefit of nifedipine in ischemic strokes of any type.

OTHER HORMONAL DISORDERS

Finally, we turn to the common endocrine glands that occasionally produce a disease. Many people are concerned about the function of the thyroid gland. This endocrine organ, located at the base of the neck just below the “Adam’s apple” (larynx) is an important regulator of the metabolism of the body. Its overactivity results in characteristic symptoms, such as a rapid pulse, bulging of the eyes, nervousness, tremor, and diarrhea.
Tumors of the thyroid gland, as well as the overproduction of the brain hormone stimulating the gland to produce excessive amounts of thyroid hormone may cause these problems. Blood tests are available to determine the level of thyroxine, the major hormone, as well as others circulating in the system.
Although stress may be a precipitating factor in the development of hyperthyroidism, a failure to respond to the recommended change in lifestyle with increased rest and physical exercise, should lead a person to seek medical counsel, as surgery is occasionally indicated.
Many more people are concerned about underactivity of the thyroid gland. This is often blamed for obesity but in reality is seldom the cause. A tendency to fluid retention, sluggishness, drying of the skin, constipation, and fluid retention should lead one to seek the appropriate blood tests and accurate diagnosis. The typical patient with advanced hypothyroidism, called myxedema, becomes very complacent, with subdued emotional responses and dull mental processes. This so-called “bovine placidity” is much less distressing to its possessor than to the patient’s associates.
Neurologic syndromes are occasionally mimicked by hypothyroidism. They normally clear rapidly with replacement therapy. Many different forms of thyroid medications are available, but should not be used unless a definite deficiency is diagnosed. In such case full hormone replacement becomes necessary, usually for life.

TRACE MINERALS

Many trace minerals are known to be essential to physiologic processes. It is not known in all cases that supplementation of these can cure specific diseases, but a few of the common sources are listed below. Zinc is widely distributed in foods, particularly breads, cereals, lentils, beans, and rice. This nutrient is essential to growth, as well as in repair and healing processes. Copper is abundant in raisins, whole grain cereals, dried legumes, and nuts. It also plays a role in blood production, tissue metabolism, bone development, and nerve function.
Cobalt is a component of vitamin B12 and comes from a variety of sources. Called hydroxycobalamin, vitamin B12 is a vital ingredient in blood cell formation as well as healthy nerve function. Deficiency of B12 produces the disorder pernicious anemia. Vitamin B12 is found in many animal products, such as milk, eggs, and cheese. It is absorbed in the small intestine (ileum), and requires a protein intrinsic factor for complete absorption. Intrinsic factor is found in the stomach. It is often deficient in people who have chronic gastritis or those who have had the major part of the stomach removed by surgery. Total vegetarians should be sure that their diet includes some vitamin B 12. Many breakfast cereals, soy milks, and meat substitutes are fortified with 12. It is available in tablet form. One microgram is sufficient for daily protection.
On the other hand, many vegans have gone for years without evidence of vitamin B12 deficiency. There is a urine test that can determine any presence of B12 deficiency. It is called urinary homocysteine and methylmalonic acid.
Both of these substances are metabolites of vitamin B12. Together with serum B12 measurements, these analyses are effective in screening vegetarians for any trace of B12 deficiency before problems appear. The anemia of vitamin B12 deficiency is macrocytic, meaning that the red blood cells are unusually large. More serious are the nerve and spinal cord disorders that develop. Neurologic signs include loss of position and vibration sensation, combined with sensations of numbness and tingling. Later, serious impairment of gait and bladder (sphincter) control are seen. Some of these symptoms may persist long after vitamin 12 is again replenished. Moreover, this neurologic damage may occur before any evidence of anemia, making diagnosis very difficult in early stages. Prevention is the watchword for vitamin B12 disorders.
Selenium, like vitamin E, protects against cellular damage and lowers the risk of cancer. Cereal grains are good sources of this mineral also. Manganese and magnesium affect a host of enzyme systems. They likewise come from whole grain cereals, as well as many vegetables. Nickel, silicon, fluorine, and many other minerals are also important to the body. Whole grain cereals are a major source of Chromium. It is also found in Brewer’s yeast. This mineral helps to improve glucose tolerance and is an important preventive against the development of diabetes.

VITAMIN DEFICIENCIES 2

Vitamin B6 deficiency is seen occasionally in individuals who eat very few plant foods. Seizures occur in babies fed formulas deficient in B6. This has especially been a problem when a relatively high kidney excretion develops during pregnancy, while a mother was given high dose supplements. A number of drugs interfere with vitamin B6 utilization, such as isoniazid, used in the treatment of tuberculosis. Eating a natural varied diet, it is not difficult to get plenty of pyridoxine. It is the vegetable source of vitamin B6. Scurvy is another vitamin deficiency with worldwide prevalence as well as a colorful history. This condition is caused by a deficiency of ascorbic acid, also called vitamin C. It was a common cause of mortality in sailors during the fifteenth and sixteenth centuries. James Lind, a British naval surgeon, developed a simple cure in 1747 by giving the sailors two oranges and one lemon every day. Their swollen gums, weakness, and bleeding tendencies responded dramatically, giving rise to the nickname, “Limeys.” In more recent times scurvy appears more commonly in alcoholics, food faddists, and the impoverished elderly living on a grossly unbalanced diet.
The principal manifestations of scurvy are hemorrhages in the skin, swollen and bleeding gums, aching muscles, fatigue, and emotional changes. These symptoms appear after two months of depletion. Appearing occasionally in children, scurvy produces tenderness and swelling in the legs. Extreme pain may be present. Finally, after the teeth erupt, swollen gums and bleeding develops. Skeletal changes show signs of growth retardation. In some cases of a vitamin-D deficiency syndrome, rickets, may co-exist.
A carefully taken feeding history is helpful for the diagnosis of infantile scurvy. After 46 months of age any infant fed solely with the bottle, using only boiled cow’s milk or a milk substitute, may develop this disease. Fresh orange juice or another dietary source of vitamin C is rapidly curative. Extremely high supplements of ascorbic acid are seldom necessary. They may produce an abnormal dependency, based on the development of increased excretion originating in the kidneys to compensate for this superabundance.
Large doses of vitamin C can also inactivate vitamin B12. That, at times, unfavorably affects reproduction. Vitamin A is primarily manufactured by the conversion of dietary betacarotene into the active form, retinol. One of the first symptoms of vitamin A deficiency is inability to see in reduced light (night blindness). A later change in the eye is the presence of dryness, xerophthalmia. The conjunctiva becomes opaque, the secretion of tears decreases, then a sticky secretion appears over the cornea, called the Bitot spot. This mark has the appearance of a flake of meringue. Further destruction of the cornea may occur, leading eventually to blindness.
In treating the acute disease, a supplement of vitamin A is recommended. The prevention of deficiency using a balanced diet containing green and yellow vegetables, fresh fruit, and vitamin-supplemented milk is entirely adequate. Green and yellow foods such as carrots, cantaloupe, squash, and dark green leafy vegetables are considered excellent sources for this vitamin.
A high intake of carotene appears in adults using carrot juice or a similar food concentrate excessively. Carotenemia may color the skin, but should not be confused with jaundice. It is considered harmless and will subside when the carotene intake is reduced. Hypervitaminosis A, on the other hand, can produce an acute toxicity. In infants, it presents as drowsiness, vomiting,
and other signs of increased intracranial pressure. Adults commonly develop a headache within hours after any injection of a toxic dose. Blurred vision, nausea, vomiting, or drowsiness may also develop. The skin peels and hair loss occurs. With chronic ingestion of high doses, liver changes resembling cirrhosis are seen. Psychiatric side effects manifest themselves, but prognosis is good when vitamin A ingestion ceases.
Vitamin E is the common name of a group of related fat-soluble vitamin, called tocopherols. They vary in their potency, with the alpha form being thought most active. A number of animals develop a Vitamin E deficiency syndrome, with deterioration in the muscle fibers, impaired reproduction, or anemia. Clinically, these insufficiencies are rare in adults. When the diet contains enough polyunsaturated fatty acids, plenty of dietary vitamin B is usually available. Unfortunately, optimistic expectations of many researchers have been disappointed in spite of the literature proclaiming the miracleworking powers of this vitamin. We do not know for certain whether vitamin B supplementation can favorably affect physical endurance, cardiac status, sexual potency, or longevity in individuals with normal blood levels of Vitamin B (tocopherols).
A number of vitamins affect the production of blood or its proper coagulation. Vitamin K is present in most edible vegetables, particularly the green leafy ones. A similar vitamin is also produced by intestinal bacteria. The gradual accumulation of vitamin K levels in a newborn baby explains easily why ancient recommendation for an eight-day circumcision was made to the Jews. Hemorrhagic disease of the newborn as well as in adults is prevented by proper blood levels of this vitamin. Vitamin B12, folic acid, and iron are also closely related to blood production and have been discussed in Chapter 4, dealing with the circulatory system.

VITAMIN DEFICIENCIES 1

Although definite diseases can be associated with the excess intake of certain vitamins, these are seldom seen on a large scale. Much more common are the deficiencies described below. Pellagra is a disease caused by the deficiency of niacin, one of the B vitamins. The name is derived from the rough skin characteristically seen crusting around the hands and neck. Painful burning of the mouth, shaking of the body, and less commonly, mental disturbances can result. Pellagra was common in the United States in the early 1900’s. A healthful diet was discovered to be curative. One of the essential amino acids, tryptophan, is converted into nicotinic acid, a counterpart of niacin. Deficiency of other nutrients sometimes complicates the disease. Individuals subsisting on a diet primarily of corn are predisposed to pellagra, since corn protein is low in tryptophan and most of the milling removes the vitamin.
Classically pellagra is characterized by the “three D’s” — diarrhea, dermatitis, and dementia. Certain earlier symptoms may develop, however, including loss of appetite, indigestion, weakness, burning in the mouth, and insomnia. Pellagra most commonly appears in the spring or early summer, when the dietary deficiencies of winter combines with renewed exposure to the sun seems to precipitate the outbreak. The skin problems begin to look much like a sunburn. Burning may be intense. Sun-exposed areas, such as the neck, arms, and hands are affected most commonly. Later the skin becomes brownish in color, then rough and scaly. Soreness of the mouth is typical, with inflammation of the tongue. Diarrhea may or may not be present. Mental disturbances usually begin with episodes of nervousness and tremor. Later there occurs confusion, depression, or even delirium.
Early replacement of the B-complex vitamin with high doses of niacinamide is recommended. This related substance does not cause unpleasant vascular flushing like nicotinic acid does. Most people can take them orally. As symptoms subside, all vitamins should all be obtained from a wellbalanced, varied diet of natural foods.
Thiamine Deficiency, called Beriberi, has been known to western medical science since the seventeenth century. Recognized first in the Orient, beriberi has been associated with a deficiency of thiamine. It commonly appears when the diet exclusively consists of polished rice. Cases are occasionally encountered in the United States, particularly in infants and in alcoholics. Three main types of this disease are identified. A chronic form called “dry beriberi” causes tenderness in the calf muscles and weakness in the legs. The acute form, “wet beriberi”, is characterized by cardiovascular changes, with edema, congestion of the lungs, and heart failure. In alcoholics, the brain damage may be irreversible. Beriberi in infants continues to be a health problem in the Far East, where a child may lose his voice, develop heart failure, or gastrointestinal changes with vomiting and constipation.
Adequate nutrition for the breast-feeding mother is particularly important for its prevention. The therapeutic response to Thiamine in infants and adults with beriberi involving the heart is dramatic. A rapid transition, however, should be made from vitamin supplementation to a diet containing adequate wheat germ, rice polishings, or whole grain cereals. This disease is entirely preventable, and reflects one of many conditions following the wake of the industrial revolution.
Riboflavin deficiency is still common in many developing countries. In the Unites States there appears to be a correlation between low income and riboflavin intake. Milk and certain vegetables are good sources of riboflavin. However, when the milk is exposed to direct sunlight a considerable amount of this vitamin is destroyed. Riboflavin is reduced when the food is treated
with alkali, such as we find in certain preservatives and the use of soda. Lack of riboflavin usually results in sores, developing at the corners of the mouth, inflammation of the tongue, and sore throat. Late findings affect the nerves, as well as the blood, with the development of anemia. Replacement of the vitamin rapidly reduces these changes.

MALNUTRITION

Although over-nutrition so characteristic of obesity could be considered a type of malnutrition, such diagnosis is usually reserved for the deficiency syndromes. In all parts of the world various deficiencies of vitamins, minerals, protein, or calories can be seen. Deficiencies are naturally more prevalent in countries where food supply is limited and poverty abounds. Careful analysis
of food intake and any form of intemperance—such as manifested in alcohol consumption, bizarre food practices, food faddism, or the abuse of drugs— are productive to evaluate these conditions. Repeated closely spaced pregnancies and psychological disturbances manifested by a change in food intake should be assessed. Chronic infection, anorexia, or diarrhea likewise may profoundly affect the nutrient balance.
Measurement of height and weight should never be omitted. These are the most commonly used measurements of growth in children and adolescents. Other body measurements include skin fold thickness, head circumference, and biochemical tests measuring blood levels of various nutrients, such as proteins, vitamins and minerals. At times, therapeutic trials of replacement nutrients play a role in the diagnosis of deficiencies. In general, however, nutrient stores must be depleted before low blood levels of any nutrients are found. Changes in the body chemistry and functional neurologic defects occur late in the course of a deficiency. Take a careful history for invaluable help in the initial phase of treatment. Then combine this with a high index of suspicion for various nutrient-related disorders. In spite of modern technology and transportation, there are still large areas in our world where famine is epidemic. In fact, the risk of mass starvation in many countries is all too real, and often associated with other diseases. Body changes during the starvation reflect physiologic attempts to adapt to undernutrition. Fat stores are utilized first in order to spare structural protein. Thus, body fat diminishes more rapidly than does muscle. Extensive losses occur later in other organs, especially the liver and intestines. Fortunately, the central nervous system and circulation maintain themselves, whatever the cost to less essential parts of the organism. The person during starvation also conserves calories by reducing his output of energy. Voluntary physical activity decreases, as does the metabolic rate. A semi-starved patient complains of feeling tired, irritable, and depressed. He may also show lack of ambition, and narrowing of interests, then develops muscle soreness and cramps. The hair begins to fall out, andcuts and wounds heal slowly. Cold temperatures are poorly tolerated.
Ultimately, the individual looks haggard, pale, and emaciated. At times swelling (edema), particularly of the eyelids and cheeks appear, masking the degree of weight loss. The pulse weakens and the eyes become dull, looking like unglazed porcelain. Without relief and too often alone, the hapless victim of starvation then dies on the street of some large city.
The rehabilitation diet for patients recovering from starvation must begin with small quantities of the simplest food, taken at frequent intervals. A natural diet is preferable to the use of “predigested” end products. Vitamin and protein supplementation are ordinarily unnecessary. General dietary allowances should be approximately 100% of those recommended on the basis of the patient’s “desirable” weight. Recovery from starvation, however, advances at a very slow pace. Weakness, fatigability and muscle aches, as well as depression, may persist for weeks to months. Recovery of strength and working capacity is slow. Eventually, recovery is sure, and a life has been saved.
Protein Calorie Malnutrition is another type of disorder seen in early childhood. One such syndrome, called kwashiorkor, appears most commonly between the ages of one and three years. This tragic disorder occurs frequently in Africa in children displaced from their mother’s breast by subsequent pregnancies. Conditioning factors, such as diarrhea, parasites, and skin rash may be seen. Edema is the principal sign. It is associated with low serum proteins. The child’s face may appear round and moon-like. The hair changes with lightening of color, straightening of curly hair, and stripes of lightened color that attest to oscillating levels of good and poor nutrition in the past.
The other major type of malnutrition is called nutritional marasmus. This compares with severe semi-starvation in adults. It most commonly affects infants during the first year of life. The most conspicuous features in marasmus are wasting of muscle and fat, with growth retardation. Affected infants appear prematurely old, and often suffer from vitamin deficiency. Both types of malnutrition respond to a careful feeding regimen of simple foods, given first at frequent intervals, containing both adequate protein and calories.

WATER RETENTION

Adults who suddenly increase their body weight may have an increase in fatty (adipose) tissue, accumulation of fluid (edema) or both disorders. Weight gain in excess of two pounds per day usually implies excess fluid retention. It is easy to confirm this by comparing the body weight in the morning and then again in the evening. Weight gains of less than two pounds during one day usually will subside by the following morning. Fluid retention may disclose increased salt and water intake or decreased sodium and water secretion.
Checking weight changes from morning to evening often provides early evidence of disease. Dietary indiscretion, the use of diuretics, excessive intake of licorice root, or a cortisol-type drug preparation may also be responsible. A special type of fluid retention called cyclic edema occurs predominantly in women. This is characterized by periodic episodes of fluid retention, frequently accompanied by distention of the abdomen, Patients may weigh several pounds more in the evening than in the morning. Although there is some relation to the menstrual cycle, evidence suggests also that psychological and hormonal factors may be related. The treatment of cyclic edema includes restriction in salt intake, rest in the feet elevated (supine) position for several hours during the day, and the use of elastic stockings.

Careful medical work-up is sometimes indicated to evaluate underlying causes.

HYPOGLYCEMIA

Low blood sugar, usually called hypoglycemia, has many causes. The most common one relates to our fast-paced lifestyle. Excessive sugar intake, frequent snacking, and caffeine or cola beverages contribute to this frequent malady. When the blood glucose level falls rapidly, emergency “fight-orflight” stress responses take over. The individual feels weak, very hungry, and frequently becomes irrational. Emotional reactions to hypoglycemic episodes vary from agitated to angry, depressed to suicidal. Personalities change rapidly, but return to normal function with some form of food.
Rather than frequent feedings such as the “six meal a day” diet, I recommend the following regimen: First, begin the day with a wholesome, hearty breakfast. Some whole grain cereal, bread, nut butter, or fruit makes a great way to start the day. Avoid coffee and frequent snacks. They both aggravate any tendency to low blood sugar. Mealtimes should be at regular intervals, usually five or six hours apart. Stress factors can affect hypoglycemia. Exercise is a great way to reduce or relieve stress. Try for an hour or two of extra sleep at night. Or find a weekend for a refreshing minivacation.
Careful testing of your blood, including the five-hour Glucose Tolerance Test (GTT), may help your medical advisor to “fine-tune” your dietary and lifestyle regimen. Most individuals can overcome this metabolic imbalance, particularly the so-called reactive hypoglycemia. This type comes several hours after a meal or sugar-rich snack. It responds very well to the remedies mentioned above. Rarely, tumors of the pancreas may produce abnormal secretions of insulin. In such case the symptoms of hypoglycemia occur during a fast, often early in the morning. Removal of the tumor is necessary to cure this uncommon condition. Finally, diabetes mellitus may be associated with hypoglycemia. It occurs in the context of early diabetes, erroneously termed borderline. Overdoses of insulin will produce hypoglycemia. They occur during vigorous exercise or at night. Adjusting the insulin dosage along with dietary modification will level the blood glucose fluctuations in all but the most “brittle” diabetics.

DIABETES MELLITUS 2

This is associated first of all by the achieving and maintaining of an ideal body weight. Our third goal is the prevention or delay of the specific complications associated with diseases of the eye, kidney, and nerves. Finally, we try to stem the accelerating atherosclerosis to which the diabetic is particularly liable. Success in these therapies depends on how well the patient has been instructed and his conscientiousness in following directions. The avoidance of cigarette smoking, with regular daily exercise, the monitoring of the urine and blood sugar, cholesterol and triglycerides, blood pressure and body weight are all imperative. Basically, however, the treatment of diabetes revolves around an appropriate diet.
The dietary treatment must meet the basic nutritional requirements. These are usually the same as those of a nondiabetic patient and, of course, to be acceptable, taste, variety, economy, and other nutritional factors should be considered. The prevention of high blood sugar occurring after a meal is important to avoid aggravating the symptoms. On the other hand, if a person is taking insulin it is important to provide enough calories of the right type to prevent hypoglycemic reactions. Ideal body weight should be achieved as soon as possible. In order to delay the atherosclerotic complications, the diet should be low enough in fat and animal products to normalize the serum cholesterol and triglyceride levels.
The basic caloric requirement is dictated by age, ideal weight, physical activity, climate, and the patient’ s occupation. An approximate calculation can be obtained by multiplying the ideal weight in pounds by ten. Individuals who are less active or past middle age should reduce their calories somewhat. Meals should be regular, usually spaced 5-6 hours apart. They are ideally limited to two or three meals a day, the latter especially for those taking insulin. I recommend taking the greater number of calories at breakfast, in order to provide energy during the active part of the day. Suppers should be light, eaten several hours before going to bed.
Careful regulation of the insulin level can usually avoid the necessity of a bedtime snack. The fat content of the diet should definitely be reduced from the 40% eaten by the average American. Protein should also be reduced slightly. The remaining calories should be obtained from complex
carbohydrates. This can lower the insulin requirement dramatically, and in many maturity onset diabetics, make a need for the needle entirely unnecessary. Some dietary suggestions for diabetics, as used in my institution, are presented in the accompanying tables. Insulin therapy is usually necessary for diabetes of juvenile onset. Several types are available, having fast, intermediate, and long duration of action.
Most of the insulin used in the United States today contains 100 units per milliliter. This has helped considerably to standardize the syringes and simplify the self-administration of this hormone. Regular or crystalline insulin is the shortest acting and is usually used for emergencies. Its duration of action is 6 to 8 hours. Intermediate acting insulins, such as NPH or Lente have a peak effect in 8-12 hours and usually last for 24. The longer-acting insulins are seldom used. At times, a second small dose of intermediate insulin before bedtime is preferable to increasing the daily dose.
It is preferable to have a small amount of sugar spill in the urine during the day than achieve such rigid glucose control as to render the patient hungry all the time or prone to hypoglycemic reactions. Be sure to rotate the sites of injections and use sterile techniques in the administration of all insulin hormones. Although many diabetic patients develop antibodies to the insulin used, only a few, about 0.1% will develop insulin resistance. A regular exercise program helps, in combination with the low fat diet, to lower daily insulin requirement. Using the more convenient but less physiologic oral diabetic pills should be discouraged, because of numerous side effects, particularly an increased acceleration of vascular complications. Hope is definitely on the way for patients with diabetes, who will eat properly, exercise regularly, and keep their weight under control.

DIABETES MELLITUS 1

We now turn to the common problems of metabolism that can often be treated, controlled, or prevented in a home setting. Knowledge of sugar diabetes is important, because of its high prevalence. This disease has been recognized from antiquity. Both Greek and Chinese writings have mentioned it; and in the sixteenth century Paracelsus initiated the study of the chemistry of diabetic urine. The word mellitus, introduced by Thomas Willis one hundred years later, describes the sweetness of the diabetic urine, “as if imbued with honey.” This rapidly led to a dietary approach to this disease, until finally Langerhans, a medical student, in 1869 described the islets in the pancreas where the basic production of insulin occurs. Two Canadians, Banting and Best, finally prepared the extract from dog pancreas that was capable of reducing the elevated blood glucose level. A fascinating long history of discoveries marks the approaches to understanding and treating this common disorder.
It is estimated that there are about 200 million diabetics in the world and approximately 4.2 million in the United States. This disease is more frequent in older people. Hence, as the population grows and becomes older, diabetes will continue to increase. With treatment, the life expectancy of the diabetic is increasing, and since inheritance is an important factor, the more diabetics that have children, the greater will be the prevalence of this disease, Obesity is also on the rise and appears to precipitate diabetes among those predisposed to it.
Next to obesity and thyroid disorders, diabetes is the third most common problem in metabolism. Interrelated are the metabolic or hormone, and vascular or long-termed components of this disease. The latter consist of an accelerated arteriosclerosis that leads to premature aging and particularly affects the eyes and the kidneys. Gangrene of the foot, arteriosclerotic heart disease, blindness, and kidney failure (uremia) are the most frequent manifestations of the vascular syndrome. Statistically, the diabetic is faced, not only with a decreased life expectancy, but also with the eventual possibility of disabling complications.
The early detection of diabetes first involves a high index of suspicion. This disease is two and half times more frequent in relatives of known diabetics. Furthermore, 85% of diabetic patients were or are overweight. Four out of five diabetics are over 45 years of age. Mothers who deliver large babies have a high potential for the development of diabetes.The simplest screening test for this disorder is a urinalysis for sugar.
Measurement of the blood sugar (glucose) level in the fasting patient should also be encouraged as a screening tool. The five-hour Glucose Tolerance Test is less commonly performed for diabetes, but is usually used to diagnose and evaluate hypoglycemia. Pathologic changes occur with the passage of time in diabetes, and seem accelerated by failure to control this disease. The
islets of Langerhans in the pancreas typically deteriorate, resulting in the lack of insulin production. Atherosclerosis occurs earlier in a diabetic patient, often leading to coronary artery disease and stroke as the most frequent cause of death. These also occur from the lack of insulin production. The eyes show changes after 10 to 1 5 years of diabetes. Small retinal hemorrhages, dilated sacs in the weakened blood vessel (aneurysms), and waxy patches (exudates) develop.
Later a dangerous type of new blood vessel forms, then further hemorrhages and gradual or sudden loss of vision. Although marvelous advances in the diagnosis and treatment of these visual complications have been made, diabetic eye disease remains the second most frequent cause of blindness in the United States. Increased tendencies toward cataract formation also occur. In the kidney, characteristic damage to the filtering unit (glomerulus) progresses to destroy renal function. Infections of the kidney and urinary tract are common, and many patients go on to develop high blood pressure, serious loss of protein, and later kidney failure.
The symptoms of diabetes, as mentioned above, are multiple. Increased fatigability and weakness is common. The diagnosis is frequently suggested by history of increased thirst (polydipsia), increased urination (polyuria), and excessive hunger (polyphagia) in association with weight loss. Long standing disease is reflected in the pathologic changes mentioned above.
Two typical types of diabetes mellitus are seen. The juvenile onset type is characterized by a rapid onset, with instable diabetes, associated with loss of weight and strength, irritability, and the three “polys” mentioned above.
Insulin therapy is mandatory in this type of patient and long-term medical counseling is needed. The second type of diabetes is termed maturity onset. Frequently symptoms are minimal or absent at first. Weight loss or weight gain may be present. These may be increased tendency to urinary infections or Vaginitis. Blurred or decreased vision, anemia, loss of sensation, or other neurologic problems may send the patient to the physician. Since many patients are obese, the reduction of weight associated with a careful diet can bring a return of health to most people who will cooperate with simple health principles.
The treatment of diabetes involves several basic principles. Doctors aim to correct the underlying metabolic abnormalities and thereby reduce diabetic symptoms.

SYMPTOMS RELATED TO THE ENDOCRINE SYSTEM

We now present a few common symptoms and the possible relationships to specific endocrine diseases. Clinical experience is certainly important in interpreting these relationships. Nevertheless, the suspicion that there is something wrong is often the first step toward an accurate diagnosis.
Weakness and increased fatigability are without doubt the most frequent symptom of adults seeking medical diagnosis. In the majority, these complaints derive primarily from emotional or psychological disturbances. When hormone abnormalities are suspected, one should inquire first whether the symptoms have been accompanied by weight loss. If so, insufficiency of the adrenal gland, overactivity of the thyroid, and diabetes mellitus should be considered.
Adrenal insufficiency is usually accompanied by increased pigmentation, low blood pressure, and perhaps salt craving. Hyperthyroidism is suggested by goiter (enlargement of the thyroid gland), bulging eye changes, tremor, and heat intolerance. Sugar diabetes is usually accompanied by excessive urination and increased thirst. Without weight loss, but with symptoms of weakness and fatigability one could consider underactive thyroid, underactive pituitary gland, overactive parathyroid gland with high calcium levels, and hypersecretions of aldosterone, another hormone from the adrenal gland regulating the salt balance. The first of these are associated with hypoactive reflexes, intolerance to cold, dry skin. Hypopituitarism is suggested by delayed or absent menstrual cycle, impotence, decreased tolerance to cold, hypoglycemia, and low blood pressure. Hyperparathyroidism is usually associated with bone pain, kidney stones, and increased urination. Elevated aldosterone levels are accompanied by high blood pressure, muscle weakness, and signs of potassium depletion.
Menstrual irregularities are associated with four major hormone disturbances. Primary failure of the ovaries prior to a natural menopause is characterized by hot flushes, weight gain, emotional instability. Secondary ovarian failure, associated with reduced stimulating hormones from the
pituitary gland is often related to diseases in the thyroid or adrenal.
Underactive thyroid gland is often associated with excessive menstruation, as well as decreased flow. The final, but much more rare syndrome is seen in conjunction with adrenal gland dysfunction. The menstrual irregularities in this case are usually associated with increased muscle development, increased body hair (hirsutism) and other signs of masculinization. The use of birth control pills should always be investigated as a cause of menstrual irregularity.
Breast changes are also commonly associated with hormone disorders. Enlargement of the breast in males (gynecomastia) occurs normally at puberty and may persist through adolescence. Rarely, hormone-secreting tumors of the adrenal gland or testes may also produce these problems.
Several varieties of drugs may cause breast changes as well. Abnormal lactation (galactorrhea) is sometimes observed in-patients with tumors of the pituitary gland. A number of drugs, including some antihypertensive and tranquilizing preparations may also produce this problem. Hypertension may also be associated with hormone disorders, although it is more commonly related to stress, salt intake, and obesity. Cushing’s syndrome or adrenal gland excess can definitely cause high blood pressure and should be considered if unusual obesity, associated with a tendency to bruising, is present. An episodic hypertension is caused by secretion from the adrenal medullary tumor called pheochromocytoma. The picture of rapid heart rate, nervousness, sweating, although classic, is infrequent. Increased secretion of the parathyroid hormone or the adrenal hormone aldosterone can also cause hypertension, and should be excluded in complete diagnosis of the problem.
Obesity suggests the possibility of a hormone disturbance, but it is usually caused by habitually increased food intake or deep-seated emotional problems. Diabetes should definitely be investigated and excluded in the presence of obesity, particularly in adults. Thyroid disorders are commonly related and can be evaluated with simple blood measurements. One must also
consider the possibility of problems induced by hormone administration, as we see the frequent prescribing of cortisone preparations, thyroid or sex hormone in nonspecific therapies for varying symptoms. These so-called iatrogenic (physician caused) problems can often be improved by the discontinuance of the offending drug.

URINARY RETENTION

Inability to void may develop abruptly, but is usually preceded by a history of diminished size and force of the urinary system, hesitancy, nocturnal urination, and dribbling. Many of these individuals are older men, having developed gradual prostate enlargement, but scarring and stricture from infection in the urinary tract can also produce these symptoms.
One of the most important ways of relieving these conditions, short of actual surgical cure, is the use of the urinary catheter. Unless the obstruction is severe this soft, flexible tube with a rounded end can be passed successfully into the bladder in most people. The catheter should be sterilized, the opening of the urethra (meatus) cleansed carefully with antiseptic solution, and with appropriate lubrication the catheter passed gently into the bladder. Usually relief is obtained and this technique is easily learned at home thus allowing either for the necessary time to seek medical care or a chronic relief in older patients deemed unsuitable for surgery.
The Foley catheter, which contains an inflatable balloon, can be used for indwelling drainage of the bladder. This, connected to a closed, sterile system of collection can provide comfort for a longer time. However, infection mayresult from the presence of this foreign substance after only two to three days.
In association with gentle catheter placement techniques, bladder irrigation may be learned. Different patients require varying intervals between catheter change and this can often be prolonged by the use of irrigating solutions. Some of these inhibit bacterial formation and others improve patency of the catheter by reducing bladder sludge. All instrumentation of the bladder may produce hematuria or the presence of blood. Persistence of this and other urinary symptoms should cause a patient to seek counsel from a competent physician.
Although the urinary tract is complex and mysterious it is usually amenable to simple home remedies. The early use of these preventive measures can frequently restore health before chronic illness or disability becomes a problem.

KIDNEY FAILURE

Failure of the kidneys to form urine properly can be either of an acute or chronic nature. The acute types are called nephritis, referring to the inflammation of the functional kidney complex. This may occur in conjunction with a Strep. throat or other bacterial infection. At times it develops suddenly, associated with protein loss, edema, and high blood pressure. These cases need to be evaluated with laboratory tests and medical expertise. But several simple approaches are helpful.
First of all it is important to recognize the influence of diet on kidney function. Many years ago it was discovered that a high protein diet predisposes to kidney complications. For this reason it is wise to avoid an excess of animal products, particularly flesh foods. Adequate fluid intake is
also important. In treating these symptoms hot packs as well as hydration will be beneficial.
Chronic failure of the kidneys frequently produces metabolic disturbances in water, sodium, potassium, calcium, and acid-base balance. The onset of renal failure is usually insidious. Excessive formation of urine and passage of urine at night may be only signs at first. Later a patient complains of feeling weak, fatiguing easily, sleeping poorly, and becoming slightly breathless. The appetite is lost and there is a bad taste in the mouth. Nausea, especially in the morning or anemia may be present. With increasing kidney failure, a person becomes lethargic, may develop twitching of the limbs, hemorrhages, and eventually develops a breath with an odor of urine, dry skin, and if not treated may progress into a coma and die. Therapy of kidney failure demands an early determination of the cause.
The role of dietary protein is very important. To reduce the blood urea accumulation a good quality protein is used with restriction in quantity to around 20 gm. daily. Sweating treatments may help eliminate toxins through the pores. The most efficacious are usually the hot blanket pack or steam bath. However, the latter is not advised (contraindicated) in severe hypertension.
Scientific research has offered a number of artificial approaches to kidney disease, such as dialysis of the blood (hemodialysis) or abdominal (peritoneal) fluid, and even transplants from a healthy donor. All of these have hazards, however, and if approached early and controlled, many cases of chronic kidney failure can be arrested.

Involuntary loss of urine is a very troublesome symptom

This may occur in children and when associated with bed-wetting is usually termed enuresis. Up to 4-5 years of age this may be quite common, and when persistent usually indicates some psychological distress. Congenital defects in the formation of the urinary organs may contribute to this disorder, and they can be evaluated with a specific x-ray study, the intravenous pyelogram.
Most cases of childhood incontinence subside with the passage of years. Women of childbearing age may have incontinence after the delivery of a large baby. Or with successive pregnancies, the support of the bladder and urethra may be weakened, producing a hernia or prolapse called a cystocele. Often this is associated with stress incontinence on sneezing, coughing, or straining. The Kegel exercises described in the chapter on gynecology are often helpful in alleviating these symptoms. If persistent anatomic defect is demonstrated, surgical repair may be indicated to restore continence and alleviate the anxiety that inhibits social interaction.
Men seldom have incontinence until advanced age. This may occur at times after operations such as a prostatectomy. If the incontinence does not improve during convalescence it should be evaluated by a urologist since research centers have developed a number of surgical approaches to this troublesome problem. Mechanical devices to preserve social acceptance and self-confidence are also available.

URINARY INFECTION

Bacterial infections of the urinary tract are extremely common. Some are also notoriously resistant to treatment and thus likely to reoccur. Yet the majority of persons with urinary tract infections are unaware of it. On other occasions, infections take the form of an acute disease usually with characteristic symptoms. The commonest symptoms are pain on urination, urinary frequency, and a strong urge to void. More serious infections may produce fever, pain in the bladder region, or over the kidneys.
Many different causes can produce infection. The commonest of these come from the group of gram negative bacteria (such as E. coli) inhabiting the digestive tract. Cultures of the urine can usually pinpoint the exact offender. Most of the time these coliform bacteria gain access to the bladder through the urethra. Under normal circumstances the urine in the bladder is sterile and large numbers of bacteria can be cleared rapidly in both humans and animals. Slight physiologic alterations, however, may permit survival of as few as ten microorganisms, which multiply rapidly, then persist for prolonged periods. Some associated conditions that may contribute to the formation of urinary infections are as follows: One to four percent of females from childhood to the childbearing age may harbor bacteria in the bladder or urethra, sometimes without the presence of symptoms. In men urinary infections are quite rare below the age 50. Four to eight percent of pregnant women may have infections, some of them without symptoms. Diabetes is another contributing factor, particularly when sugar is present in the urine.
Any impediment to the free flow of urine—tumor, stricture, or stones— results in distention of the kidney and greatly increased frequency of urinary infection.
In fact, the reflux of urine in the bladder cavity up to the ureter occurring during voiding will contribute to more infections, particularly children. Infection of the lower urinary passages is sometimes initiated by bacteria carried on catheters or other instruments passed into the urethra and bladder. Sterile technique in catheter insertion can help to reduce this risk. Kidney diseases with resulting high blood pressure may also contribute at times to the lowered defense against infection. Once the diagnosis has been established, treatment can be begun at home.
The fluid intake should be increased, usually with water as well as Vitamin C or cranberry juice to render the urine more acid. A special protein found in cranberries and blueberries can combat most urinary tract infection by causing the causative germs to lose their grip on the bladder wall. Thus, the infective organisms become more amenable to bladder rinse-out with normal urination.
One glass of liquid per hour up to 12-16 cups per day is recommended. In at least half such cases, the urinary infection will clear itself, with symptoms subsiding over 24-48 hours. Increasing blood flow to the urinary organs, these hydrotherapy treatments aid the body in natural resistance to infection and the clearing of disease. Persistence of symptoms or the underlying presence of diabetes, high blood pressure, or chronic kidney disease should be evaluated with appropriate urine tests, cultures, and medical counsel.

URINARY STONES

Stones in the kidney or ureters may occur at any age, but are more common in the third and fourth decades. These calculi may be single or multiple, firmly lodged or free. Kidney stones often cause pain, produce blood in the urine, and symptoms of vague abdominal distress. Occasionally, even when large, stones may occur without symptoms, while causing serious and
insidious kidney damage.
Characteristically, as mentioned above, renal calculi cause severe, sharp flank pain, which is often acute in onset and present intermittently. A small stone being passed in the ureter creates painful colic and the patient usually moves about restlessly, vainly seeking relief. Blood is frequently present in the urine, but at times requires the microscope for its detection. Physical findings may be entirely normal, although tenderness, muscle spasm, or even a lump may be felt in the location.
It is important to search for the original cause of the stone, then attempt to correct it. Most stones after bladder passage can be analyzed to determine their composition. Some are composed of calcium salts; others of oxalate crystals, and less commonly uric acid or cystine may precipitate to form stones. Each of these causes needs to be ascertained in order to correct the
diet, avoiding future recurrence.
One of the commonest situations that sets the environment for an attack of colic is inadequate fluid intake. Normally our kidneys require at least one and a half to two quarts of fluid a day! That will maintain urine volume at diluted concentrations, to avoid the precipitation of these salts. A high consumption of milk may result in calcium precipitation and the formation of a stone. Ice cream, cheese, and soft drinks such as cola beverages, and foods high in oxalic acid may provide the situation where stones begin to crystallize.
Uric acid stones usually result from a high intake of purines, found in meats, particularly sweetbreads, and other flesh foods obtained from animal organs. Uric acid calculi are usually seen in combination with other symptoms of gout, a metabolic disease traditionally associated with indulgence in rich foods and alcohol. A discriminating, well-balanced diet associated with adequate fluid will usually bring relief to patients who form uric acid stones frequently.
The treatment of colic in the urinary tract usually begins at home. Drink a high intake of water, at least one glass of liquid hourly, and begin immediately. Urinary acidifying agents are helpful to deter stones of calcium or oxalate composition, while for uric acid stones the urine should be alkalinized. Vitamin C and cranberry juice are both good acidifying agents for the urine, and are also helpful in treating urinary infections. Diuretic herbs, such as Buchu tea may also be helpful, when combined with a high volume of fluids.
Relief of acute urinary pain can be obtained in a hot tub bath, or with intensely hot fomentations applied to the flank and hip region. At times when flank pain is severe, the treatments will not only modify the pain, but through reflex pathways may help to relax the ureter and alleviate the spasm. Most often the smaller stones (calculi) will pass down into the bladder, where they are then excreted. Since obstruction in the urinary tract can progressively damage the kidney, as well as be painfully disabling, any urinary stones that do not resolve promptly should be evaluated be a competent physician.
Newer diagnostic techniques using x-ray contrast, and cystoscopic basket stone retrieval, water immersion shock (sound) wave lithotripsy, and other types of surgery may be necessary to save the kidneys from permanent harm.

The PREVENTION of MALIGNANCY

Based upon the evidence currently available, it is my conviction that a rational plan can be designed to prevent most types of cancer. Summed up in one word, moderation, the preventive approach involves several factors:
Your diet should be simple, utilizing natural foods as much as possible. Adequate amounts of fruit, fresh vegetables, and whole grain cereals should be included together with some nuts and natural sources of dietary fats, such as olives, avocados, and a most sparing use of vegetable oil. Any excess of oil, sugar, salt, or any single food, especially refined ones, in the diet should be shunned.
The low-fat vegetarian diet has been associated clearly with an increased resistance to many types of cancer. When individuals abstain from milk and eggs, as well as meat, the cancer risk becomes even lower. Naturally these total vegetarians must have a considerable knowledge of nutrition in order to maintain balanced nutrition, and provide optimum vitamin and mineral intake to maintain excellent health. Thousands of discriminating consumers, however, are rapidly adopting a vegetarian lifestyle as fast as they are able to learn how to select and prepare the foods. In this change is found the key to preventing not only many cancers, but also atherosclerosis and numerous other diseases.
Reasonable amounts of exercise should be obtained daily for a lifestyle that is low in occupational stress, while satisfying and productive. A moderate exposure to sunlight prevents detrimental premalignant skin changes that many acquire as their skin ages. The use of a broad-brimmed hat, sunscreen lotions, and avoidance of excessive sun bathing can bring about vibrant health, without wearing out or prematurely aging the dwelling of skin we live in.
Temperance advocates for many years have proclaimed the key to prevent one most common cancer. Those who abstain completely from tobacco smoke, and even avoid settings where the involuntary inhalation of stale secondhand smoke is required, will reduce their risk of lung cancer dramatically. Even ex-smokers who quit before a cancer develops, have a much lower rate than the devotee who continues to use cigarettes. Although pipes and cigars may produce less lung cancer, they’re stronger forms of tobacco still show malignant potential in cancer of the lip, tongue, throat, and larynx far too often.
Chronic use of alcohol increases the risk of cancer in the breast and liver, as well as seriously irritating the stomach and several other organs. Exposure to drugs of all kinds, including sex hormones, antibiotics, anticancer agents, and coal tar preparations can increase the incidence of malignancies in many organs. True temperance requires us to dispense entirely with all things hurtful, and use in moderation those things healthful. This principle of moderation can help to prevent many cancers.
Routine physical examinations and periodic self-examination of the breasts and skin, with careful observation for the symptoms of cancer described above can detect abnormal lesions in the earliest possible stage, when surgical removal is a possibility. A regular annual physical should usually include the annual Pap smear, a biennial sigmoidoscopic examination, together with the appropriate laboratory testing for additional aid in early diagnosis. On the other hand, it may just give satisfying reassurance concerning one’s state of health.

SKIN CANCER

Although more skin cancers are seen than malignancies involving any other organ, this is least commonly a cause of cancer death. Inasmuch as the lesion can be seen with the naked eye in an early stage, the potential for cure is well over 90%. It is thought that the single most important factor in the cause of skin cancer is chronic exposure to ultraviolet light of the sunburn wavelength (UV-B). Individuals who are intensely pigmented are quite well protected from these rays. Fair-complexioned individuals and albinos should especially use sunscreen preparations. All should avoid unnecessary exposure to x-rays, coal tar products, and arsenic preparations known to be carcinogens.
Seventy-five percent of all skin cancers are of the basal cell carcinoma type. These rarely metastasize, but are locally invasive. The cancer typically begins as a noninflamed, smooth, waxy nodule. Usually a number of small blood vessels are visible near the surface. These nodules often ulcerate and form a crust. Biopsy and excision will confirm the diagnosis; as well as treat the lesion. Simple excision gives the best cosmetic results. Liquid nitrogen may be used for local freezing, called cryosurgery. In combination with curettage or electrocautery, a cure rate of more than 95% may be expected.
Squamous cell carcinoma is the second most common type, developing also from the surface layer of the skin, but having more propensity to metastasize. Most of these lesions are painless. They show up with firm, red plaques, displaying visible scales on the surface. They may arise from preexisting solar keratoses, premalignant lesions developing from repeated sunburn. Treatment is similar to that of basal cell lesions described above, namely removal.
Malignant melanoma is the most deadly type of skin cancer. They also are related to excessive sunburn and exposure. Pigmented moles are among the most common growths on the skin of humans. Some of these ultimately may change in their color, size, or hair pattern, which is often an early sign of their malignancy. Irregularities in surface pattern and varying colors are characteristic of the melanoma. Shades of red, white, or blue (no patriotism here) and other mixtures of brown and black, may indicate the development of this cancer.
Melanomas should always be removed with wide excision, since their propensity to spread to other organs, such as the liver, eye, and other areas of the skin is great. Therapy utilizing the immune mechanism (immunotherapy) has been used widely in the treatment of metastatic melanoma. Although still experimental these approaches offer an exciting alternative with less cost in toxicity to the individual. BCG vaccine, used for years to prevent tuberculosis, has found its place in the treatment of these melanomas with encouraging results in many cases.

LEUKEMIA

Cancer involving the blood and bone marrow is most often seen in children. Several types of leukemia are described, based upon the type of blood cells involved and their appearance under the microscope. Samples from the blood and bone marrow are usually compared. Ionizing radiation, whether from nuclear sources or x-ray therapy, is clearly associated with an increased incidence of these leukemias. Chemical agents, such as the anticancer drugs and occupational exposure to benzal have been associated with increased leukemia. Some hereditary factors have
also been linked with this disease.
Most interesting is the firmly established viral theory in relation to acute leukemia. In rodents, fowls, cats, and monkeys certain viruses are known to cause leukemia when experimentally inoculated. These animals can pass viruses to their offspring through the ovum or shed it in their milk or other secretions, thereby transmitting it to unaffected animals. Again it makes one wonder how much leukemia may actually be transmitted to human beings through the use of animal foods, such as meat, eggs or milk. Milk is increasingly suspect for cancer viruses, especially the bovine leukemia virus (BLV) and the bovine immunodeficiency virus (BIV, a relative of HIV).
A disease in chickens (fowl leukosis) is estimated to affect up to 15% of the birds used for food, and many cases escape the casual inspection at the mass production slaughterhouse. The virus definitely passes into the egg, and can infect a baby chick even before hatching. It would take very high or prolonged cooking temperatures to be sure the virus was inactivated in eggs used for food. In spite of the fact that the common treatment of leukemia today is with cellular poisons (cytotoxic drugs), it is my hope that a much more physiologic treatment will soon become available, and, in the right setting be demonstrated as superior.
Combining a proper diet with the judicious use of fever therapy should induce the appropriate antibodies to aid in virus destruction and the maintenance of health, as well as a decrease in complications. This type of therapy has been used with increasing success in the treatment of related tumors, such as Hodgkin’s disease, chronic lymphocytic leukemia, and some other lymphomas. These closely related malignancies all seem to have a common viral origin. Thus, they should respond to the intermittent induction of high fever, However, it must be given in a controlled setting for safety.

LUNG CANCER

Cancer of the lung is the most common cancer in men and increasing rapidly among women in the United States. There are a number of types of lung cancer, but the most common is called bronchogenic, since it originates in the bronchial tubes. By far, the most common cause of lung cancer is tobacco smoking with the risk directly proportionate to the number of cigarettes smoked and the amount of inhaling. It appears that in the tobacco tar, we find not only benz-0-pyrene, but also dozens of other cancerproducing chemicals, as well as other substances that sensitize the tissues to the destructive action of these agents. Over a period of years the hapless smoker accumulates an increasing amount of tar, until some of the lining cells, which at first increase in number as a protective measure, finally become transformed into malignant cells, which invade local tissues and eventually metastasize.
Extensive research on tobacco was sponsored by The American Cancer Society. Also, momentous publications by the recent Surgeon General of the United States, especially his dynamic governmental Report on Smoking and Health, underscore clearly the detrimental effects of tobacco use and its potential for producing malignancy in vital organs. In spite of many medical and surgical advances in the treatment of advanced cancer, lung cancer still takes the lives of about 95% of its victims. Tragically, most cases are discovered too late for any hope of cure, although this disease is almost entirely preventable.
An individual developing cancer of the lung may have no symptoms at all until the cancer is far advanced. Others develop a cough that may be confused with the smoker’s cough of chronic bronchitis. At times the expectorated mucous may contain blood, a rather late sign in the development of this cancer. Some unfortunate cases have spread to involve vital blood vessels, the brain, or bones before adequate diagnosis has been made. Occasionally, the removal of the lung or part of a lobe may eradicate the tumor early enough to effect a cure.