Max M. Montgomery

THE MUCOCUTANEOUS LESIONS OF REITER'S SYNDROME

Excerpt In recent years we have observed a number of patients with Reiters syndrome. Although the triad of urethritis, conjunctivitis and arthritis is now rather well known, the high incidence of ...

Adrenocorticotropin and cortisone in the treatment of severe Reiter's syndrome.

Excerpt Reiters syndrome, a condition of undetermined etiology, is manifested by urethritis, conjunctivitis and arthritis, and in its moderate and severe forms follows a characteristic course over...

Certain Aspects of ACTH and Cortisone Therapy in Older Patients with Rheumatoid Arthritis

Accumulated experience in the treatment of rheumatoid arthritis patients with ACTH and cortisone has shown that these substances are not curative but in full dosage produce a suppressive effect on the inflammatory process, a marked analgesic effect and a euphoria and sense of well being. 1–4 The full suppressive effect, after a time, is usually associated with evidences of hyperadrenocorticism: moon facies similar to that of Cushing’s syndrome, and development of skin striae, acne, obesity, etc., which may be so marked as to necessitate discontinuance of therapy. Lower dosage schedules may be well tolerated with only slight sideeffects, though suppression of the manifestations of rheumatoid arthritis may not be complete. 5 One must adjust the dosage so that something of a “physiological” effect is obtained without production of the overdosage effects. ACTH and cortisone therapy should be used as an adjunct to other treatment. There is no unanimity of opinion regarding indication for its use in patients of any age with rheumatoid arthritis. Some clinicians have definite opinions as to the type of patient who should receive these substances, but modifying factors determine selection of the individual patient for such treatment. Age is one of these factors. Cortisone is administered intramuscularly in a daily dose or orally in divided doses every 6 or 8 hours; 100 mg. daily is considered a suppressive dose and this amount over a period of time usually produces the well known syndrome of Cushing’s disease “in miniature.” One may be able to maintain suppression of the rheumatoid process by slightly lower doses, and 62.5 mg. is usually considered the lower limit of the suppressive dosage range. Low dosage schedules for maintenance have been advocated by Ward, Slocumb, Polley, Lowman and Hench and range down to 37.5 mg., with an occasional patient getting only 25 mg. daily in divided doses. 6 ACTH can be given intramuscularly or intravenously. The regular-type ACTH must be administered intramuscularly every 6 hours. There is now available an intramuscular type of ACTH which can be administered once daily. The suppressive dosage can be considered as 60 to 100 I.U. daily in divided doses, while the maintenance dosage ranges from 60 I.U. down to 10 I.U. daily in divided doses. ACTH can be given intravenously in 500 cc. of 5 percent dextrose solution over 8-to 12-hour period and is effective in 1/10 to 1/5 the intramuscular dosage. Old age has been considered by some as a relative contraindication to prolonged ACTH and cortisone therapy. 7 Chronological age limits are of little value, as some patients are biologically younger at 75 years than others at 55 years of age. Many rheumatoid arthritis patients in mid-life are prematurely old and for practical purposes are aged. In considering the subject, a number of questions such as the following come to mind: 1) Should ACTH and cortisone be used in the treatment of any condition in the aged? If so, 2) should they be used only for short periods of 7 to 10 days? 3) Should they be used for prolonged periods? 4) Should they be used in full suppressive dosage? 5) Should they be used in very low dosage? At this time these questions cannot be answered with an unequivocal yes or no. Numerous variables make practically every patient an individual problem. It is the impression of many physicians that older patients tolerate these substances, especially cortisone, as well as or better than younger individuals. There would appear to be no valid reason to withhold indicated therapy just because the patient has reached a certain age. Undesirable side-effects occur and are frequently severe in the elderly, so one should have a good indication before initiating therapy. The treatment period should be as short as necessary to accomplish the purpose, and the dosage should be kept as low as possible. There are certain contraindications about which there is agreement, such as

Acute Gonococcal Arthritis: Clinical Findings Presented by 28 Patients Observed in Recent Years.

Excerpt In the past few years, the idea that gonococcal arthritis has become a rarity and that only young women and homosexual males are affected has been quite generally accepted. At the Universit...

The teaching of internal medicine: the evaluation of lectures and lecturers: a discussion of results of a study by faculty and students at the University of Illinois College of Medicine.

Excerpt INTRODUCTION The esteem with which medical educators have looked upon lectures has shown a considerable decline during the course of the past century. In their biography of William Henry We...