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Editor - Captain L. B. Marshall, MC, USN j 



Vol. 22 Friday, 4 September 1953 No. 5 



TABLE OF CONTENTS 

Treatment of Aneurysms of the Circle of Willis 2 

Surgical Management of Cerebritis 3 

Intraspinal Neoplasms in the Cervical Region 5 

High Cervical Chordotomy 6 

Infected Cystic Disease of the Lung 7 

Kaposi's Sarcoma 9 

Familial Pheochr omocytoma „ 11 

Prolapsing Ureterocele 13 

Beriberi Heart Disease 14 

Treatment of Addison's Disease 15 

Hypertension and Coronary Occlusion 16 

Chronic Barbiturate Intoxication 17 

X-ray Therapy of Peripheral Tuberculous Lymphadenitis 18 

Problems in Ocular Prosthetics 20 

Dental Caries Control 22 

Memorandum on Noise Measurement 24 

Scientific Papers for The 1954 Aero-Medical Association Meeting .... 25 

Medico-Military Training Program 25 

Course of Instruction in Submarine Medicine 26 

From the Note Book 27 

Water and salt requirements (BuMed Inst. 6260. 2) 30 

NROTC physical examinations (BuMed Notice 6120) 30 

Morbidity Report, MED 6310-2 (BuMed Inst. 6310. 1A) 30 

Attendance at scientific meetings {BuMed Inst. 1321.2) 31 

Report of Preventive Medicine Activities (BuMed Inst. 6200. 6) 31 

Tissue homografts (BuMed Inst. 6460, 3) , 31 

Roster Report of the Medical Corps (BuMed Notice 1080) 32 

PREVENTIVE MEDICINE SECTION 32 




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Medical News Letter, Vol. 22, No. 5 



Policy 

The U.S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical De- 
partment of the Regular Navy and Naval Reserve to timely up-to-date items 
of official and professional interest relative to medicine, dentistry, and 
allied sciences. The amount of information used is only that necessary to 
inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be nor 
susceptible to use by any officer as a substitute for any item or article in 
its original form. All readers of the News Letter are urged to obtain the 
original of those items of particular interest to the individual. 

****** 
Treatment of Aneurysms of the Circle of Willis 



The prognosis of spontaneous subarachnoidal hemorrhage caused by 
rupture of aneurysms on the circle of Willis has been the object of several 
recent investigations. It is evident from the figures presented that the 
prognosis of these aneurysms once they have started to bleed is very serious, 
between 35 and 50% of the patients dying from the effects of the initial hemor- 
rhage. A considerable portion of those dying during the initial attack do so 
within the first 48 hours (according to Dandy's figures, about 50%) and about 
half of these die within the first 24 hours. 

Recurrent bleeding occurs in a large number of patients who survive 
the initial attack. The percentage of recurrent bleeding shows rather wide 
variations in different statistics, from 20% reported by Hyland up to 50% 
reported by Hamby. All agree, however, that the mortality attending 
secondary hemorrhage is even greater than in the initial bleeding, and 
mortality figures up to 70 and 80% have been reported. 

Two quite different problems are involved in the treatment of intra- 
cranial aneurysms. The first and most pressing question is what kind of 
surgery, if any, should be performed on aneurysms in the acute stage of 
hemorrhage. The second problem, which appears to be much easier to 
solve, is what should be done to prevent recurrent bleeding. Unfortunately, 
the statistics so far published do not distinguish between these two problems, 
and the results of various procedures are assessed regardless of the stage 
of the aneurysm in relation to leakage. 

In the stage of acute hemorrhage an aneurysm is a very grave condi- 
tion entailing great danger to life and to function in case the patient should 
survive. It may be said in consequence that considerable surgical risk may 
be justified if the mortality attending the first attack of subarachnoidal hem- 
orrhage can thereby be materially reduced. However, the timing of the 



Medical News Letter, Vol. 22, No. 5 



3 



operation is a factor of such great importance that without information on 
this point no conclusions at all are possible concerning the result. Among 
the large number of cases reported in the literature such information is 
available only in isolated instances. 

The authors' material shows that of 15 patients operated on between a 
few hours up to 22 days after onset of hemorrhage, 8 died. Good recoveries 
followed in 6 cases and in 1 case hemiplegia set in gradually the day after 
operation and became permanent. 

The authors' impression from these experiences is that (1) when mas- 
sive hemorrhage has occurred, no operation is likely to save the patient, 
and that as a rule it is useless to operate unless the patient survives the 
first 2 days, and (2) the circulation of the brain is profoundly disturbed 
during the first 2 or 3 weeks following hemorrhage, and this disturbance is 
the result of both the increase in intracranial pressure, and the vasocon- 
striction almost invariably present in these cases. Unless some method 
can be found to eliminate vasoconstriction after the neck of the aneurysm 
has been clipped, it is probably better to abide by conservative treatment. 
The authors are, at present, experimenting with papaverine and permanent 
perfusion of the superior cervical ganglion as recommended by Poppen, but 
whether either or both of these methods will contribute materially to reduce 
the hazards of early operation cannot yet be determined. It is perhaps also 
possible that by postponing the operation until such time as the vasoconstric- 
tion begins to subside spontaneously the dangers of the operation may be re- 
duced. This would appear to be about 3 weeks after hemorrhage as found 
by Ecker and Riemenschneider , a view that is also supported by the authors' 
experiences. 

Operations after the patient has recovered from the initial hemorrhage 
are to be considered as a prophylactic measure aimed at preventing further 
hemorrhage. Clipping of the neck of the aneurysm is the best method for 
this purpose. Mortality and morbidity, when this operation is performed 3 
to 4 weeks after the last attack of bleeding, is very low and protection against 
future hemorrhage is excellent. (J. Neurosurg. , July 1953, G. Norlen and 
H. Olivecrona, Stockholm, Sweden) 

* * ^ * * # 

Surgical Management of Cerebritis Complicating 
Penetrating Wounds of the B rain 

One of the most disheartening complications of penetrating wounds of 
the brain is the development of cerebritis which is commonly accompanied 
by formation of a cerebral fungus. Experiences in World War II and in the 
Korean War have shown that earliest possible definitive neurosurgical care 
of patients with penetrating wounds of the brain should be considered the 
largest single factor in the prevention of such cerebritis. 



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Medical News Letter, Vol. 22, No. 5 



Cerebritis as a sequel of penetrating wounds of the brain may be in- 
duced by delayed surgical intervention, or by the retention of debris, de- 
vitalized tissue, and bone fragments. Improper wound closure or faulty 
healing may then lead to the formation of a cerebral fungus. Though there 
are many proposed regimens for handling cerebral fungi, the management 
of frank cerebritis has seldom been approached surgically. This article 
proposes a method of "open" surgical treatment of fulminating, fungating 
cerebritis based on the experiences of one of the authors in the Okinawa 
Campaign (1945) and on joint experiences in the Korean conflict. The em- 
ployment of this method has been associated with a reduction of mortality 
and morbidity and has been an essential factor in lessening the ultimate 
neurological deficit. 

The method of choice in the management of penetrating missile wounds 
of the brain is earliest possible definitive neurosurgical intervention with 
radical debridement, removal of all devitalised tissue, and primary closure 
of the dura mater and scalp. The early phase of the Korean War presented 
the opportunity to see patients with fulminating, fungating cerebritis as a 
sequel of untreated, or inadequately treated, missile wounds of the brain. 
Although all patients in this series had received adequate dosages of anti- 
biotics from the very beginning, cerebritis developed in association with 
the prolonged retention within the cranial cavity of devitalized tissue, clots, 
and bone fragments. The marked increase in the neurological deficit and 
the high mortality in those who were subjected to surgical resection of the 
area of cerebritis and primary closure, led the authors to adopt the "open" 
method of treatment which is described in this article. Its employment, 
however, has been reserved for previously untreated missile wounds with 
fulminating, fungating cerebritis and for those patients in whom such cere- 
britis had developed following inadequate debridement and closure. 

Of the 15 patients in the authors' series who had been operated on prior 
to institution of open therapy, 13 presented an infected fungus or a draining 
sinus which led through small openings in the scalp and dura mater to a large 
underlying area of cerebritis. The remaining 2 were operated on because 
of bulging flap and other signs of increased intracranial pressure. When the 
suspected cerebritis was found, it was resected and subjected to open ther- 
apy. 

Two patients in the series had accompanying lacerations of the sagittal 
sinus. In 1 the laceration was anatomically complete with thrombosis of the 
distal and proximal openings into the sinus. In the other there was lacera- 
tion of the sinus with thrombosis proximal to the tear. The thrombus was 
evacuated and the laceration was repaired by primary suture and gelfoam. 

The presence of ventricular penetration may complicate an existing 
cerebritis or fungus, but should not deter the institution of open therapy. 
Ten patients in this series presented ventricular perforations at the time of 
first operation at the Neurosurgical Center at the Tokyo Army Hospital. 



Medical News Letter, Vol. 22, No. 5 



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The duration of open treatment varies from 3 to 82 days with an over- 
all average of 24 days. Though early closure is most desirable, prolonged 
open therapy is believed to be justified by ultimate cure of an otherwise hope- 
less situation. 

Definitive resection at time of creation of the open wound is advanta- 
geous though not always feasible. In some instances further demarcation of 
nonviable brain necessitates intervat'resection. In this series 7 patients re- 
quired from 1 to 3 interval resections. In 4 patients, from 1 to 4 minor 
procedures for scalp closure were necessitated by failure of scalp healing 
without recurrence of fungus or cerebritis. (J. Neurosurg. , July 1953, 
A. M. Meirowsky and G. R. Harsh III) 

$$$$$$ 
Intraspinal Neoplasms in the Cervical Region 

This article summarizes the clinical and pathologic features in 179 
cases of intraspinal neoplasms in the cervical region in which surgical 
treatment was utilized. Excluded from this series of cases were intra- 
cranial and thoracic intraspinal tumors that appeared to involve only 
secondarily the cervical segments of the spinal cord. 

These neoplasms consisted of 64 neurilemmomas , 41 meningiomas, 
41 gliomas, and 33 miscellaneous tumors. Sixty-eight tumors were intra- 
dural, 46 intramedullary, and 16 extradural; the remaining 49 lesions could 
be termed "dumbbell tumors. " 

Patients who had meningiomas were usually older than those who had 
neurilemmomas; the latter were usually older than those who had gliomas. 
The average preoperative duration of symptoms was 40.9 months. Ependy- 
momas, however, produced symptoms for 51 months on the average. 

Sixty percent of the patients experienced distinctive pain as the initial 
symptom. Pain was valuable in suggesting the presence of an intraspinal 
tumor and important in a determination of the level of the tumor; the pres- 
ence or absence of pain and its character were related remotely, if at all, 
to the type of tumor. 

The reflexes were altered in all but 10 cases. The tendon reflexes in 
the upper extremities were diminished in 67% of the cases of intermedullary 
tumor, while 20% of neurilemmomas and only 12% of meningiomas were as- 
sociated with such changes in reflexes. Weakness and sensory disturbances 
could be demonstrated in the vast majority of patients, of whom an appreciable 
number had signs deceptively limited to the lower extremities. Stiff neck, 
tenderness over the cervical region of the spinal column, and a palpable 
mass in the neck were often present and suggested the cervical region as 
the site of the neoplasm. 



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Medical News Letter, Vol. 22, No. 5 



Clinical features have been described that ordinarily are not expected 
to be associated with intraspinal tumors. Such features appear to be related 
to the anatomic characteristics of the cervical portion of the spinal cord, 
including its proximity to the intracranial contents. 

Lumbar puncture with manometric studies and examination of the cere- 
brospinal fluid disclosed either a dynamic block or a value for protein of 
more than 40 rag. per 100 cc. or both in all but 6 of the cases in which 
these tests were performed. (J. Neurosurg. , July 1953, J. H. Webb, W. 
McK. Craig, and J. W. Kernohan) 

High Cervical Chordotomy 

This is a preliminary report made on a group of 12 consecutive cases, 
with far-advanced malignant diseases associated with severe intractable 
pain not controlled by surgery, roentgen therapy, or narcotics. In these 
patients the bilateral operation was performed between the first and second 
cervical segments. As the purpose of this study was to prove that the bi- 
lateral one-stage high cervical chordotomy was feasible, there was no 
selection of patients as to etiology of pain, location of pain, or life expect- 
ancy. The only criteria was that the pain be below the fourth cervical der- 
matome. Patients were operated upon in varying degrees of debilitation; 
with neurosurgical deficits, both motor and sensory; with urinary and fecal 
incontinence; and in varying stages of narcotic addiction. 

This series demonstrates that the bilateral high cervical chordotomy 
performed at a single stage is a practical operation. Although there was 
1 death, 16 days after surgery from renal failure, there were no deaths 
which could be attributed directly to the surgical procedure and no patient 
showed signs of respiratory embarrassment. The operative morbidity was 
considerably less than that usually seen following dorsal chordotomy. Al- 
though early in this series all patients were bedfast for periods of from 7 
to 10 days, the more recent ones were allowed up on the second or third 
day and were discharged within a week's time. Postoperative pain was con- 
fined to some headache for 1 or Z days, associated with pain and stiffness of 
the neck. 

The signs of damage to neighboring pathways, as an aftermath of the 
incision in the cord, were almost negligible. There were no patients in 
whom motor weakness has been produced, nor were neurological deficits 
existing prior to operation accentuated. A single patient exhibited absence 
of sweating on one side of the face, but there were no instances of classical 
Horner's syndrome. 

As with bilateral chordotomies elsewhere, sphincter incontinence was 
the major postoperative complication. Only 1 patient who had not had incon- 
tinence prior to operation developed a lasting bladder sphincter incontinence. 



Medical News Letter, Vol. 22, No. 5 



7 



In this patient, there was extensive involvement of the pelvis by carcinoma, 
which undoubtedly played an important role in the failure to regain bladder 
control. There was a temporary loss of sphincter control lasting up to 10 
days in 4 additional patients, all but 1 of whom had extensive pelvic disease. 
There is little doubt that the instances of sphincter incontinence were directly 
related to involvement of the pelvic viscera and lumbosacral plexus. 
(Surgery, Aug. 1953, G. E. Roulhac) 

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Infected Cystic Disease of the Lung 

Infections of areas of the lung containing multiple small cysts gives 
rise to a definite chain of events, and to certain recognizable changes. 
Treatment is excision of the involved pulmonary tissue, and cure is the 
usual result. Although there are many articles on pulmonary cysts prac- 
tically no attention has been given to the problem of superimposed infection 
of cystic areas. In this article the clinical problem as seen in 26 cases 
during the last 5 years is discussed. 

Of the 26 cases, 9 had had resections of the involved areas. Two had 
exploratory thoracotomies and were found to have too extensive involvement 
of the lungs to permit resection. In the others the diagnosis was made on 
the basis of history and roentgen ray studies. The 9 patients in whom re- 
sections were done had their disease limited to one lobe, or a portion of it. 
In every instance there was evidence of multiple cysts with obvious infection 
in them, and in the adjacent tissue. The rest of the lung appeared normal. 
In 1 instance, the disease was confined to the lower segments of the. lower 
left lobe and the upper segment was normal. 

Acute pneumonitis marked the onset of symptoms in practically all 
of the authors' patients. At that time the diagnosis was always pneumonia. 
Roentgenograms showed shadows that were consistent with the diagnosis 
of virus pneumonia, but in a few instances there were radiolucent areas 
which suggested the presence of cysts. Under the usual care for pneumonia 
symptoms subsided, but in all instances there was little evidence of change 
in the roentgen appearance. This persistence of a shadow in the roentgeno- 
gram supported the diagnosis of virus pneumonia, and it was not until many 
weeks later that the persistence of the roentgen ray changes indicated that 
this diagnosis would not suffice. Following the subsidence of the acute symp- 
toms suggesting pneumonia, the patients continued to cough and most of them 
raised sputum. In a few instances blood was mixed with the sputum, or 
coughed up in small quantities. Some of the patients had localized chest 
pain. Fever and malaise were less common. 

Solitary cysts, found on routine roentgenograms, or producing symp- 
toms, are readily removed and the result is good. Infected solitary cysts 
have been frequently confused with abscesses, or even empyema. In the 



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Medical News Letter, Vol. 22, No. 5 



past, when abscesses were only drained, to confuse an infected cyst with a 
simple abscess was most disappointing, and many papers were written about 
them. Pulmonary cysts which rupture and give rise to spontaneous pneumo- 
thorax are readily removed, or otherwise treated, with excellent results. 
Even cases in which there are multiple or bilateral cysts are amenable to 
surgery, and the chances for great improvement are good. Only in those 
rare instances where there is a true diffuse cystic condition of both lungs, 
with minute or large cysts, is the prognosis hopeless. 

The pathogenesis of pulmonary cysts has been discussed in the litera- 
ture from every angle, and the authors have no desire to enter the debate. 
Whether the condition described as infected cystic disease is the result of 
infection of a congenitally cystic area of the lung, or is an area of chronic 
pneumonitis with cystic changes as a result of the infection, the authors can- 
not say. Most of the sections from the areas of cystic disease which they 
have removed at operation have shown multiple small cysts, lined with 
columnar epithelium resembling the lining of bronchi. The authors are 
aware of the observation of Potts and his associates on the development of 
pulmonary cysts in the lungs of infants following recovery from staphylo- 
coccus pneumonia, but they are solitary cysts, and of considerable size. 
The authors believe that the areas of small cysts which they have encoun- 
tered, and found to be infected, are congenital in origin. Whether or not a 
pulmonary cyst is of some other origin it is well known that when they be- 
come infected, they rarely, if ever, return to their former state. It would 
seem that congenitally abnormal tissue is less resistant to infection than is 
normal tissue. Another patient with a diagnosis of infected cystic disease 
of the lung on whom the authors operated was found to have chronic pneu- 
monitis involving the lingula of the left upper lobe. The entire lobe was 
without pigment and appeared to be fetal. Microscopic studies confirmed 
this impression. One factor that would seem to hinder the natural defense 
of the cystic area, or of fetal lung, is the absence of functioning cilia. In 
both areas there was absence of recognizable bronchioles, and terminal 
bronchi. 

There can be little difference of opinion as to the treatment of infected 
cystic disease. Excision, with salvage of as much normal lung tissue as 
possible, seems obvious. There is no evidence that cystic tissue, once in- 
fected, can completely lose this infection, or long escape reinfection. And 
any patient who harbors such a lesion cannot hope for restitution to normal 
with his lungs intact. 

In establishing the diagnosis the most important point is awareness of 
the possibility of the lesion being present. With this in mind more and more 
cases of chronic localized pneumonitis will be found to be due to infected 
cystic disease. Since this paper was -presented, 10 more patients with in- 
fected cystic disease of the lung have been treated by pulmonary resection 
with good results in all. (Dis. Chest, Aug. 1953, R. H. Meade and R. A. 
Rasmus sen) 



Medical News Letter, Vol. 22, No. 5 



9 



Kaposi's Sarcoma 



A small brown, blue, or red macule is generally the first manifesta- 
tion of Kaposi's sarcoma or angioreticulomatosis. Nodules and plaques 
subsequently develop and both are present in most fully developed cases; 
occasionally only one type is present or one may predominate. The nodules 
are firm and vary from a few millimeters to 2 or 3 cm. in diameter. They 
may be few in number or may be quite numerous. Babes having observed 
450 in 1 patient. The tumors may be discrete, or several may coalesce to 
form large masses. They, as well as the plaques, tend to be bluish, bluish 
red, or reddish brown in color. The plaques, which are usually well de- 
marcated, may be small or may reach a size of 20 cm. or more. In the 
early stages these are only slightly indurated, but as the lesions age the in- 
duration increases. Telangiectases may be present in the skin overlying 
the tumors. Nodules and plaques have been observed developing in areas of 
purpura. Lesions simulating cysts, bullae, and lymphangioma circum- 
scriptum have been reported, as have deeper angiomatous tumors resem- 
bling simple angioma and granuloma pyogenicum. In rare instances the 
disease may appear in the form of tumors from the start {the "d'amblee" 
variety). 

The eruption usually begins on the hands and feet, more frequently the 
latter. However, it may start anywhere on the body. The disease tends to 
be unilateral early in its course, later becoming bilateral. The lesions may 
be few in number and localized to one area or there may be extensive involve- 
ment not only of the extremities but also of the face, trunk, and the visible 
mucous membranes. 

A common feature of Kaposi's sarcoma is swelling of the extremities. 
This may be the first evidence of the disease. In some cases the pitting 
edema stops abruptly just below the knee or elbow so that the leg and foot or 
the forearm is markedly enlarged while the thigh and arm are of normal size. 
In others the entire extremity may be involved. The cause of this type of 
swelling, which resembles that due to congestive heart failure, is unknown. 

The multiple theories as to the nature of Kaposi's sarcoma have been 
divided into four main groups by Choisser and Ramsey: (1) neoplasm, (2) 
infectious granuloma, (3) infectious granuloma with neoplastic potentialities, 
and {4) reticuloendothelial hyperplasia. There has been little mention in the 
American literature of the interesting investigations of Greco and collabora- 
tors, who studied Kaposi's sarcoma in several members of the same family 
and concluded that the disease had an infectious, mycotic origin. They called 
it a myco-hemo-angio-endothelitis with colliquative dermo-epidermic reac- 
tion and named the pathogenic fungus Cryptococcus hoematicon. European 
investigators, however, have been unable to confirm Greco's findings. At 
present it is generally believed that the disease is a neoplasm, some main- 
taining that it is primary and others that it is secondary to chronic hyper- 
plastic inflammation and granuloma. Among those who believe that the dis- 



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Medical News Letter, Vol. 22, No. 5 



ease is a neoplasm, considerable difference of opinion exists as to the cell 
of origin. This, to a large extent, is due to the varied histologic pictures 
which may be observed. 

As pointed out by MacKee and Cipollaro, in the early stages the patho- 
logic process tends to be inflammatory, with dilatation of blood vessels and 
lymphatics, edema, hemorrhage, and a perivascular infiltrate of round cells, 
connective tissue cells, and some plasma cells. . Later the granulomatous 
element may predominate, proliferation of small vessels and connective 
tissue being added. In the late stage the neoplastic features are most marked 
and, depending on whether the vascular or the connective tissue elements 
predominate, the picture may be that of an angioma, granuloma, lymphangioma, 
fibroma, spindle cell sarcoma, or angiosarcoma. The pathologic changes 
which occur in the viscera are the same as those in the skin. Sachs, Azulay, 
and Convit, on the basis of their histopathologic studies, have suggested that 
glomus tumor, granuloma pyogenicum, and Kaposi's sarcoma are all angio- 
blastomas. They further concluded that Kaposi's sarcoma may be subclassi- 
fied as a systemic angiosarcomatosis. 

Diagnosis on the basis of the history and clinical appearance of the 
cutaneous lesions is relatively easy. When the tumors are few in number, 
involve unusual sites or do not have the typical appearance, differentiation 
from various benign and malignant tumors such as angioma, angiosarcoma, 
granuloma pyogenicum, and lymphoblastoma may require histologic studies. 
The majority of individuals with visceral lesions present no symptoms refer- 
able to them and in most cases the lesions are discovered at autopsy. How- 
ever, hemorrhage, diarrhea, abdominal pain, intussusception, and emaciation 
may be manifestations of the disease. It is in such cases that cutaneous tumors 
may supply the clue as to the nature of the internal disorder. 

X-ray therapy is almost universally accepted as the treatment of choice 
for Kaposi's sarcoma. Most lesions respond promptly to doses of 75 r, un- 
altered, at weekly intervals. Large doses are not recommended. 

New lesions continue to appear, treatment serving primarily to in- 
crease the comfort of the patient. Even without treatment, as pointed out 
by Grinspan, macular, infiltrative, and tumoral lesions will occasionally 
disappear spontaneously, leaving an atrophic scar and pigmentation. 
Generally the individual lesions do not produce symptoms, but when a great 
many are grouped on one extremity and there is considerable edema, or 
when ulceration develops (usually after trauma), there may be discomfort 
and impairment of function. 

As summed up by MacKee and Cipollaro, the course of the disease is 
generally slow but at times it may be rapidly progressive. Their studies 
indicated that the average duration is from 5 to 10 years, with death gener- 
ally due to intercurrent disease or some complication but often the result of 
hemorrhage and emaciation secondary to visceral involvement. (Postgradu- 
ate Medicine, Aug. 1953, F. Ronchese and A, B. Kern) 



Medical News Letter, Vol. 22, No. 5 



11 



Familial Pheochromocytoma 

Satisfactory surgical treatment of pheochromocytoma requires that 
the surgeon be mindful of certain pathologic characteristics of these tumors. 
Although pheochromocytoma is usually found as a single, encapsulated, be- 
nign tumor located in one adrenal gland, exceptions occur in all these re- 
spects. In other words, tumors of this type may be multiple, malignant, 
bilateral, and located elsewhere than in an adrenal gland. Because of the 
relative infrequency of these tumors, it is difficult to state definitely the 
exact percentage of cases in which these variations from the usual findings 
may be encountered. However, they occur with sufficient frequency so that 
the surgeon should perform an operation for this type of tumor in such a 
manner that regardless of the findings a satisfactory surgical procedure 
can be conducted. Although various approaches have been employed to ex- 
pose the adrenal glands, including posterolumbar, transthoracic, and 
thoracicoabdominal, a high transverse, slightly curved abdominal in- 
cision has proved most satisfactory in the authors' experience. Fortunate- 
ly, the patient who has pheochromocytoma is almost invariably thin, and 
an approach of this type affords not only ready simultaneous access to both 
adrenal glands but also permits thorough general abdominal exploration if 
the tumor is not situated in the adrenal glands. 

Both adrenal glands should be explored in every case, as there is no 
way of being certain prior to operation whether or not bilateral tumors are 
present. Likewise, search for a tumor in a possible ectopic location within 
the abdomen should be a routine procedure. These tumors also have been 
found in rare instances in the thorax or even in the neck. Palpation of and 
pressure on, the tumor should be minimized during its removal because of 
serious vasopressor effects which may result from these manipulations. 
Blood supply of the tumor should be interrupted as soon as possible during 
removal of the tumor. It is most unusual that an adequate amount of adrenal 
tissue cannot be preserved, even when bilateral tumors are present, but 
care should always be exercised in this regard. In case of any question 
concerning the adequacy of adrenal tissue which is preserved, prompt sub- 
stitution therapy is most important: If the patient has had sustained hyper- 
tension before operation, blood pressure should fall precipitously after 
removal of all tumor tissue. If such a drop in pressure does not occur after 
removal of a tumor, the presence of additional tumor tissue should be sus- 
pected. A pharmacologic test performed at this time with one of the vaso- 
depressant agents, such as phentolamine, may afford valuable additional 
evidence concerning the persistence of tumor tissue. 

It is of interest that from the anatomic and pathologic standpoints the 
tumors in the 3 cases reported were similar, but the clinical manifestations 
were different. In each case, both adrenal glands were involved, and the 
tumors on each side consisted of multiple nodules. Although the total amount 



12 



Medical News Letter, Vol. 22, No. 5 



of tumor tissue varied somewhat, being greatest in Case 2 and least in Case 
3, the first patient presented the clinical syndrome of fulminating malignant 
hypertension with severe retinopathy, the second presented the picture of a 
chronic hypertension of moderate severity with intermittent attacks which 
were at least suggestive of hyperadrenalism, and the third patient had no 
hypertension and his symptoms were minimal. It is unlikely that the third 
patient would have sought medical aid or that the diagnosis would have been 
made if tumor had not been diagnosed and removed successfully from his 2 
sisters. It is probable that the father of these 3 patients died of pheochromo- 
cytoma. His history of hypertension with attacks of palpitation, headache, 
excessive sweating, and weakness was very suggestive of pheochromocytoma. 

The authors' experiences with these 3 patients emphasize the importance 
of controlling hypera'drenalism during operations for these tumors and of 
continued close observation of the patients during the immediate postopera- 
tive period with immediate institution of substitution therapy with epinephrine 
and arterenol if symptoms of shock develop. 

The second patient was of particular interest in that after removal of 
the tumors there was no remaining cortical adrenal tissue, as far as could 
be determined at the time of operation. In spite of the fact that the clinical 
picture of adrenal cortex insufficiency developed subsequently, this was com- 
pletely controlled by continued therapy with cortisone and desoxycorticosterone 
acetate. It was of further interest that with the aid of this substitution therapy, 
this patient subsequently went through a pregnancy and was delivered of a nor- 
mal child without untoward incident, in spite of the fact that the delivery re- 
quired manipulation with forceps because of the occipitoposterior position 
of the child. Such an occurrence has been reported previously in patients 
with Addison's disease. 

So far as the authors know, this is the first report of the diagnosis and 
successful removal of bilateral pheochromocytomas from 3 members of the 
same family, 2 sisters and a brother. Likewise, to the best of their know- 
ledge, there has been no previous report of the successful surgical removal 
of bilateral pheochromocytomas in a single operation. (Arch. Surg. , July 
1953, G. M. Roth, N. C. Hightower, Jr., N. W. Barker, and J. T. Priestley) 

****** 
Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U.S. Navy Medical School, National Naval Medical 
Center, Bethesda 14, Maryland, giving full name, rank, corps, and old and 
new addresses. 



****** 



Medical News Letter, Vol. 22, No. 5 



13 



Prolapsing Ureterocele 

Ureterocele, or intravesical cyst of the ureter, is an intravesical bal- 
looning of the distal end of the ureter with involvement of all the component 
layers of the ureteral wall although the involvement of the middle coat is 
usually minimal. 

Ureterocele is a relatively common lesion to the urologist. It has been 
estimated that ureterocele will be present in 1 of each 30 complete genito- 
urinary studies in children. The size of the ureterocele will vary greatly; 
it may measure less than 1 cm. or may fill the entire bladder. Approxi- 
mately 15% of all cases of ureterocele are bilateral, with right- and left- 
sided involvement being about equal. The lesion is estimated to be four 
times more frequent in the female than in the male. In one half of these 
cases there are other co-existent urogenital tract anomalies. In redupli- 
cated upper urinary tracts two-thirds of the cases of ureterocele involve 
the ureter which drains the upper pelvis. 

The symptoms of ureterocele are largely those of ureteral obstruc- 
tion which, if allowed to persist, usually result in hydro-ureteronephrosis. 
The presence of the ureterocele and its complicating pathological changes 
is easily demonstrated by a complete urologic survey. Excretory urogra- 
phy will present the so-called classical "cobra head" or "spring onion" 
filling defect in the lower end of the ureter. Commonly associated com- 
plications are most often stasis, infection, and calculus formation, with 
the latter complication occurring in from 4 to 5% of all cases. 

Prolapse of an ureterocele is not common. Emmett and Logan in 1944 
surveyed the literature and collected 37 cases, recording 1 additional case 
at the time. Twenty-five of the thirty-eight cases occurred in adults and 
13 occurred in children less than 15 years of age. In the same year Kickham 
and Birdsall and Abernethy each presented an additional single case, bringing 
the total to 41. Hurwitz, and McDonough in 1945 reported the forty-second 
case. Ortmayer, Koester, and Stetler in 1946 presented the forty-third 
case. Ingerslev in 1947 and Adams in 1949 presented the forty-fourth and 
forty-fifth cases, and Merricks and Herbst in 1950 presented the forty- sixth 
case. All cases reported were in females. This is not unusual owing to the 
limitations imposed by the male anatomy. Of the 13 children reviewed and 
reported by Emmett and Logan, there was a variation in ages between 13 
days and 14 years. In this group of children only 5 of 1 3 survived operation. 

Ureterocele, if the prolapsing type, in addition to the symptoms and 
complications associated with simple ureterocele, is further complicated 
by producing varying degrees of vesical neck obstruction. Gangrenous 
changes of the prolapsed mass must also be considered. In differentiating 
prolapsed ureterocele from prolapse of the ureter it is only necessary to 
observe that in ureterocele there is a'definite ballooning out of the smooth 
mucosal surface, whereas in ureteral prolapse there is only an eversion of 
the mucosa. 



14 



Medical News Letter, Vol. 22, No. 5 



A case of prolapsing ureterocele is presented in an 11 -month-old 
white female. The literature was reviewed and insofar as can be deter- 
mined this appears to be the forty-seventh reported case. Surgical cor- 
rection was instituted in the form of an ureter onephrectomy and extra- 
urethral excision of the ureterocele. Complete continence of urine has 
been maintained. (J. Urol. , Aug. 1953, L. M. Orr and J. B. Glanton) 

* >|i % s|c # 9f 

Beriberi Heart Disease 

Notwithstanding the fact that the occurrence of cardiac beriberi now 
is well recognized in several countries, it still is described among the rare 
types of heart disease in most of the modern textbooks of cardiology. How- 
ever, in view of the authors' experience in Brazil, they have reason to be- 
lieve that is is not such an unusual condition and that the apparent infrequency 
of beriberi heart disease is due to the fact that many cases are not recog- 
nized as such and are often confused with other more common and well- 
known types of heart disease. 

During a 3-year period since the authors' attention was directed to 
this problem, beriberi heart disease has been identified in a series of 22 
patients including occasional instances in which other associated etiologic 
factors were encountered. 

Although thiamine deficiency among oriental populations is usually due 
to an inadequate diet, most cases of beriberi heart disease in this hemi- 
sphere occur as a result of chronic alcoholism. All the authors' patients 
were heavy drinkers, and only 50% had a history of an associated dietary 
deficiency. However, there was no evidence of malnutrition in any instance, 
because of the high caloric content of the alcoholic beverages consumed. 
Because the incidence of chronic alcoholism is far greater than that of beri- 
beri heart disease, it is evident that other associated factors such as physi- 
cal exertion, infectious diseases, thyrotoxicosis, pregnancy, and so forth 
must also play a role. At any rate the so-called alcoholic myocarditis, 
which was formerly believed to be due to the direct effects of alcohol on the 
heart, is not accepted by the most recent investigators. The excessive in- 
take of alcohol predisposes to beriberi by inducing thiamine deficiency which 
is the primary factor in this condition. That alcohol does not play a direct 
role in this disease has been proved by the complete reversal of the clinical 
picture following the administration of large doses of thiamine to patients 
who maintain their usual intake of alcohol. Furthermore, many cases have 
been observed in which the development of cardiac failure occurs for the 
first time, following a period of several weeks or even months of total ab- 
stinence from alcohol. This is usually seen in individuals with digestive 
disturbances which undoubtedly maintain the thiamine deficiency. 



Medical News Letter, Vol. 22, No. 5 15 



Edema was the earliest and most frequent clinical manifestation. Vari- 
able degrees of dyspnea occurred in 20 cases during the course of cardiac 
failure, although it appeared as an initial symptom in 2 cases. A certain 
lability of the pulse rate was an interesting feature, particularly a transient 
bradycardia which usually appeared at the onset of clinical improvement. 
Blood pressure variations were observed, particularly a transient hyper- 
tension during the course of heart failure. Clinical signs of polyneuritis 
were present in all but 2 cases and were rarely of clinical significance. 
The main roentgenologic and electrocardiographic features are analyzed, 
emphasizing their reversibility on thiamine treatment. The occasional, 
diagnostic difficulties in distinguishing cardiac beriberi from hypertensive 
and arteriosclerotic heart disease are pointed out. 

There were 6 deaths in the present series caused by heart failure. 
Five cases came to autopsy and -were all confirmed as representing instances 
of thiamine deficiency. 

Considering the fact that the unfavorable prognosis of beriberi heart ' 
disease in certain cases is due to the prolonged duration of thiamine defi- 
ciency leading to an irreversible myocardial fibrosis, the early recognition 
of this condition is emphasized, because appropriate therapeutic measures 
at this time may result in a complete cure. (Am. Heart J , Aug. 1953, 
A. B. Benchimol and P. Schlesinger, Rio de Janeiro, Brazil) 

# # * # & # 



Treatment of Addison's Disease 



An aqueous, microcrystalline suspension of the trimethylacetate ester 
of desoxycorticosterone was utilized in the maintenance treatment of 45 pa- 
tients with chronic adrenal cortical insufficiency. Intramuscular injection 
of this compound produced effective electrolyte regulation, as demonstrated 
by metabolic balance studies, within 24 to 48 hours; the duration of action of 
a single intramuscular dose ranged from 4 to 8 weeks, with an average dura- 
tion of 5 to 6 weeks. Optimal therapeutic control, however, was obtained by 
injection of maintenance doses at 30 -day intervals. This schedule provided 
excellent control of body weight, blood pressure, hydration, and cardiovas- 
cular function. 

Studies were carried out on patients with classic signs and symptoms 
of Addison's disease and a small group of subjects with carcinoma of the 
prostate who had been previously subjected to complete bilateral adrenalec- 
tomy. Patients were studied on the metabolism ward and in the out-patient 
endocrine clinic of the Peter Bent Brigham Hospital. Procedures utilized 
in the measurement of electrolyte balance, hematocrit, and blood urea ni- 
trogen were described previously. Heart size was determined from 7-foot 
postero-anterior chest films taken during average inspiration; measurements 
were based on height-weight standards as described by Ungerleider. 



16 



Medical News Letter, Vol. 22, No. 5 



Prior to the initiation of treatment with the trimethylacetate ester, 37 
of these patients had been maintained by repeated implantations of desoxy- 
corticosterone acetate pellets; the remaining 8 had received daily injections 
of DCA in oil. The most informative index, both for patients and physicians 
was the body- weight curve. A chart of daily weights, recorded on a printed 
form supplied to all patients, was submitted at intervals of 2 to 4 weeks. 
This procedure proved exceedingly helpful in assessing both initial and 
maintenance dosage levels. 

The maintenance of body weight, blood pressure, hydration, and car- 
diovascular function during continued treatment with this compound was 
uniformly consistent. It is a pertinent fact that the great majority of pa- 
tients in this series indicated a definite preference for this method of 
desoxycorticosterone administration. Its advantages over other techniques 
of dosage are: (a) infrequent injections; (b) flexibility of dosage schedules; 
(c) avoidance of the minor surgical procedure involved in the implantation 
of pellets; and (d) constant control, especially in comparison with the final 
4 to 8 weeks of pellet therapy, during which time fatigability and muscular 
weakness are common. It is the authors' opinion that this technique of 
desoxycorticosterone administration currently constitutes the method of 
choice in the majority of patients. (J. Clin. Endocrinol. , Aug. 1953, 
G. W. Thorn, D. Jenkins, W. L. Arons, and T. F. Frawley) 

£ sjs # * J}C * 

Hyp erte nsion and Coronary Occlusion 

Ever since coronary occlusion became a well recognized clinical entity, 
many writers have suggested that hypertension was a common antecedent of 
the condition in both men and women, and a significant factor in its etiology. 

It is the author's opinion that the conclusions formerly reached con- 
cerning the relationship of hypertension to coronary occlusion are not valid. 
"High" systolic and diastolic blood pressures have been found in a majority 
of persons 60 years of age and older. Readings previously believed to be 
abnormal are too common to be considered so now. New definitions of hy- 
pertension, according to the age and sex of the patients, are evidently 
necessary. Because the average blood pressure rises with age and varies 
with sex, it is not reasonable to use the same definition of hypertension, for 
example, 150/90, or 150/96, or 160/ J.00 for all ages, and for both men and 
women. 

Using recently established limits of hypertension as the basis for a 
new study, the author re-examined the problem of the relationship between 
hypertension and coronary occlusion. Six hundred consecutive patients with 
coronary occlusion, seen in private practice, were studied. Five hundred 



Medical News Letter, Vol. 22, No. 5 



17 



were men and one hundred were women, all under the age of 65. Patients 
over 64 were not included in this study, solely because the newly established 
blood pressure limits had not been determined for individuals beyond that age. 

The blood pressure which had been present before the coronary occlu- 
sion occurred was the criterion. (The borderline cases were not considered 
in this report. ) 

Men sustain coronary occlusion much more frequently than women, and 
at an earlier age. 

The frequency of hypertension in the men averaged 27.2%, and increased 
only slightly, if at all, with age. More than 70% had had a normal blood 
pressure before the onset of the coronary occlusion. Hypertension, there- 
fore, is not the all-important factor in the causation of coronary occlusion 
in men. This conclusion differs from that of any reported studies on the 
relationship of increased blood pressure to the onset of coronary occlusion. 

Seventy-one percent of the women had had hypertension preceding the 
attack. In women who sustain coronary occlusion, therefore, hypertension 
is a significant etiologic factor. 

The results of a recent post-mortem study confirmed the author's 
clinical findings: hypertension did not appear to be a factor in producing 
coronary disease and occlusion among men, but was a definite factor in its 
causation among women. 

The possible effects of the serum cholesterol, the Sf 12-2-lipoprotein 
fraction, and the sex hormones on atherosclerosis and hypertension are 
briefly discussed. These fields of investigation hold particular promise for 
the treatment and prevention of coronary disease in men and of hypertension 
in women. {Circulation, Aug. 1953, A. M. Master) 

$$$$$$ 



Chronic Barbiturate Intoxicat ion 

Investigations of chronic barbiturate intoxication have yielded con- 
siderable information on physiological functioning, intellectual impairment, 
and personality changes during the course of addiction. This study is an 
attempt to add to this information by delineating several aspects of readi- 
ness to respond (motivation) and muscular coordination during the course 
of chronic intoxication with certain barbiturates and during the periods of 
withdrawal of drugs and of recovery from the drug effects. 

Clinical studies from the Addiction Research Center, Public Health 
Service Hospital, Lexington, Ky. , have amply shown that acute or chronic 
intoxication with large amounts of barbiturates (secobarbital, pentobarbital, 
and amobarbital) produces nystagmus, incoordination, ataxia in gait and 
station, and coarse tremors of the hands. The muscular incoordination of 
intoxicated persons is so obvious that the measures obtained in the present 



18 



Medical News Letter, Vol. 22, No. 5 



study were recorded mainly for purposes of quantification and comparison. 
However, the effects of changing motivations upon the disorganized be- 
havior observed during intoxication and withdrawal have not been investi- 
gated. 

Ten male patient volunteers, addicted to barbiturates upon arrival at 
the Public Health Service Hospital, Lexington, Ky. , were maintained on 
large doses of secobarbital (Seconal) for periods ranging from 35 to 90 days. 
Reaction times to visual stimuli and quantified measures of muscular coor- 
dination were taken (a) during the last week of addiction (intoxication), (b) 
after abrupt withdrawal of the drug, and (c) after recovery from drug 
effects. 

Great loss of coordination was found during intoxication and during 
the first 8 days of the withdrawal period, with gradual improvement con- 
tinuing through the remaining 10 days. Reaction time was found to be very 
greatly impaired during intoxication and early in the withdrawal period; but, 
unlike coordination, it showed significant improvement soon after withdrawal 
and thereafter gradually returned to the control level. 

Differences in reaction time corresponding to various foreperiods, or 
delay times, were evaluated as motivational differences; i. e. , they were 
evaluated as differences in ability to develop a "set" or a "readiness to 
respond. " Ins ensitivity to changes in foreperiods was found during intoxi- 
cation. Sensitivity increased after withdrawal of the drug and was appar- 
ently normal after 3 to 5 months of enforced abstinence. 

In view of the observed severe muscular incoordination and lack of 
ability to acquire and maintain readiness to respond, it was concluded that 
the general behavior of chronic barbiturate users is very severely impaired. 
They lack the ability to prepare for and react efficiently in performing man- 
ipulative tasks. It appears, moreover, that they could not anticipate emer- 
gencies and that they would be very unsafe machine operators. (Arch. 
Neurol. & Psychiat. , Aug. 1953, H. E. Hill and R. E. Belleville) 

# * * * * * 

X-ray Therap y of Peripheral Tuberculous Lymphadenitis 

Peripheral tuberculous lymphadenitis frequently causes greater anxiety 
than the threat or actual existence of tuberculous pulmonary disease. This 
is especially true when the adenitis becomes fluctuant and drains. Even 
though the adenitis is only one manifestation of a systemic tuberculous in- 
fection, most patients will not accept the idea that, given enough time, the 
adenitis will usually regress and heal without direct intervention as the sys- 
temic disease improves. Usually, therefore, some form of specific therapy 
is attempted. 



Medical News Letter, Vol. 22, No. 5 



19 



Before streptomycin became available, several forms of therapy were 
used, for tuberculous lymphadenitis. The most common methods of treat- 
ment were surgical excision, surgical drainage by needle aspiration or in- 
cision, ultraviolet irradiation, and x-ray irradiation. 

Treatment of tuberculous lymphadenitis by drainage through an incision 
or by aspiration is frequently complicated by the formation of chronic drain- 
ing sinuses. With these methods, the results are not predictable and the 
healing process may take many months or even years. 

Although the advent of streptomycin provided the first real promise of 
successful therapy, it has become apparent that, because of toxicity and the 
emergence of drug-resistant tubercle bacilli, the drug has some limitations 
in the treatment of tuberculosis. Streptomycin should be used in combination 
with other forms of therapy and in the right case at the right time. Ideally, 
streptomycin should be used inthe treatment of tuberculous lymphadenitis 
in those patients with concomitant pulmonary or nonpulmonary tuberculosis 
which requires antimicrobial therapy at that time. The same principles 
would be applicable to isoniazid and other new drugs. Of the alternative 
methods available for therapy, the use of x-ray is considered in this report. 

This report is based upon the study of 65 patients with tuberculous 
lymphadenitis who received treatment exclusively with technically adequate 
dosages of x-ray irradiation. 

Of the 65 patients, 29 were male and 36 were female. The youngest 
patient treated was 2 years old and the oldest was 49 years old. The 
greatest number of patients, 33, were in the 13- to 19-age group. 

The clinical impression of tuberculous lymphadenitis was based upon 
the presence of painless swelling of the lymph nodes, usually chronic, with- 
out evidence of local nontuberculous infection and without clinical or labora- 
tory findings suggestive of other causes of lymphadenopathy. 

Thirty-eight patients had other forms of tuberculosis in addition to the 
clinical picture of lymphadenitis as described above. Thirty-one of these 
had active pulmonary tuberculosis. These included 1 patient with tubercu- 
lous salpingitis and 1 with active Pott's disease in addition to the pulmonary 
disease. Six patients had associated arrested pulmonary tuberculosis. One 
of the thirty-eight had tuberculous inguinal lymphadenitis associated with 
tuberculosis of the knee, without pulmonary tuberculosis. 

Twenty- seven patients did not have associated tuberculous infection in 
other locations. In 4 of these, biopsy and histologic examination of the 
lesion confirmed the clinical impression of tuberculous etiology. Five pa- 
tients had positive Mantoux tests as the only additional finding. Eighteen 
had the previously described clinical picture as the sole basis for diagnosis. 

Many of the patients had more than one area involved and treated. The 
areas sometimes differed with respect to the nature of the lesions and the 
results of therapy. For the purpose of analysis, each field was considered 
as a separate unit. 



20 



Medical News Letter, Vol. 22, No. 5 



The total number of fields treated was 87. Of these, 79 were cervical 
and 8 were noncervical. The latter were: draining sinus on the chest wall, 
3 fields; draining sinus in the axilla, 3 fields; inguinal draining sinus, 1 field; 
and enlarged, hard, inguinal nodes, 1 field. 

The results of x-ray treatment of 65 patients with tuberculous lymph- 
adenitis representing 87 fields during an 8-year period are described. The 
techniques varied in some degree but all were of the intermittent, low-dosage 
variety, the average frequency of treatment being once a week. The over-all 
results showed a 35% average healing rate when the nodes were hard, and a 
63% average healing rate when the nodes were fluctuant with or without drain- 
age. No significant, permanent, deleterious effects of irradiation were 
noted. (Am. Rev. Tuber c. , Aug. 1953, J.N. Aceto, K. Kasuga, and S. S. 
Sanderson) 

****** 

■ 

Problems in Ocular Prosthetics 

In the authors' clinic the prosthetist and surgeon have been able to 
work closely together. This cooperative arrangement and the opportunity 
for a fairly broad experience with a variety of prosthetic problems has 
fostered an appreciation of the interdependence of the surgeon and technician. 

The need for prosthetics may already exist or will exist as the result 
of an impending surgical procedure. If satisfactory cosmetic results may 
be added to a physiologically sound operation, the necessary additional 
surgical steps should be taken. The best possible care should be given while 
healing takes place. The prosthesis, in any case, should be engineered to 
the best abilities of the pr osthetists , with guidance of the surgeon if neces- 
sary. Cosmetically it should create an illusion that the patient's eye is still 
present and normal (as far as possible). The final result should be comfort- 
able and should protect the health of the socket and adjacent tissues. It 
should spare the patient all possible emotional discomfort. The best course 
of care of the socket and prosthesis should be established for each patient. 
And, finally, the patient should be told that the shape of the prosthesis can 
and should be adjusted to expected changes in the shape of the socket. 

The authors have studied these points individually and as they relate 
to and affect each other. They are discussed, generally, as they have been 
observed in several hundred cases during the past 8 years and especially as 
seen in the records of 128 cases during the past 2 years. 

Three factors appear to be beyond control at the present time. One is 
a product of the age and related physical condition of the patient. Most chil- 
dren can be given comfortable prostheses which fill the sockets and shape 
the adjacent tissue to normal appearance. They are likely, also, to have 
somewhat better motility of the prosthesis than those operated at a later 
age. Beyond 10 or 12 years of age, imperfections in prominence, contour 



Medical News Letter, Vol. 22, No. 5 



21 



of the lid margin, depth of the supra-orbital fold, et cetera, occur more 
commonly, until in senility the majority of persons are extremely difficult 
to fit satisfactorily. On the other hand, one of the observations which im- 
pressed the authors most was the fact that aging had little effect upon the 
cosmetic appearance of cases which had been operated in childhood, and 
fitted and refitted properly. 

The second factor is trauma preceding surgical enucleation. Ob- 
viously, such changes as loss of lid tissue complicate the prosthetic fitting. 

The third factor is the unpredictable variations in healing. Some of 
these variations may be anticipated on the basis of attention to surgical de- 
tail. The authors noted that patients with both eyes removed present simi- 
lar problems on both sides when both operations are performed within a 
short period of time. And again the same surgeon, operating upon different 
patients in an age group, can have different results. This may point sus- 
piciously toward differences in tonicity of tissue or differences in the forma- 
tion and nature of scar tissue in some individuals. In any case, care in the 
details of surgery must be stressed. 

The surgeon's choice of type of operation for eye removal has widened 
somewhat in recent years. For surgery limited to the globe, there are now 
6 different basic procedures in use over the country: (1) Enucleation (simple), 
(2) enucleation with ball implant, (3) enucleation with muscle cone exposed 
implant, (4) enucleation with muscle cone buried implant, (5) evisceration 
(simple), and (6) evisceration with buried implant. 

Postoperative care in most of the types of eye surgery discussed is 
well known to all surgeons. There is a preference for pressure dressings 
for 5 days following surgery of the integrated or buried muscle cone im- 
plants. Also, in these two types it is desirable to use conformers, which 
are furnished by the manufacturers, until the prosthesis is fitted. The need 
for the conformer in the buried type is not so much to shape the socket as to 
protect the lid conjunctiva from the clipped eye lashes and to keep the mei- 
bomian glands functioning properly. 

The technician has 5 contributions to make to prosthetics. He must 
"engineer" the shape of the prosthesis to mirror, in as many respects as 
possible, the form and motility of the patient's remaining eye. He must 
fill the socket comfortably and in a manner which will assure the health of 
the tissues. He must create illusions with colorations of the eye which will 
help hide any remaining form defect. He must create with texture and color 
the impression of living tissue to the extent that the eye is accepted as the 
patient's own in spite of other defects which cannot be hidden. He must use 
all care in the handling of his materials to guarantee the least danger of 
sensitivity to the plastic and to assure all possible permanence. 

Manipulation of the form of the prosthesis to force the lids and other 
structures into the desired positions is the most important part of the fitting 
procedure. Many technicians are not well versed in this phase of the work. 



22 



Medical News Letter, Vol. 22, No. 5 



Because such is likely to be the case for some time, it would be ideal if the 
surgeon could offer constructive criticisms on any fitting problems which 
arise. 

Some problems cannot be fully solved in every case. In a few they can- 
not be solved at all. Both the surgeon and the prosthetist must be prepared 
to compromise on the final result, if necessary. 

It must be emphasized that correction of one fault may reveal another. 
Correction of the second may reveal a third, and so on. The final result is 
achieved when the cosmetically most acceptable compromise is reached. (J. 
Iowa State M. Soc. , Aug. 1953, L. Allen, A. E. Braley, and H. Webster) 

>(c # 4 * sfc s(S 

Dental Caries Control 



It is generally believed by most research workers that dental caries 
is caused by acids formed as a result of the action of micro-organisms on 
carbohydrates. The process is characterized by decalcification of the in- 
organic portion of the tooth and is accompanied or followed by disintegration 
of the organic matrix. Theoretical considerations and some experimental 
data indicate that all caries is derived from the diet. Furthermore, the only 
portion of the diet that may be effective in the caries process is that which 
is available on the tooth surface after the food is ingested. The acids are 
formed on the tooth surface, and, if they are not neutralized by the saliva 
or otherwise destroyed, decalcification of the tooth will proceed. 

On this basis it is obvious that in order to control dental caries one 
must prevent the acid from forming, produce conditions under which the 
acids will be destroyed before harm results, or make the tooth itself more 
resistant to the action of the acids. All of the methods that have been suc- 
cessful so far in the restriction of dental caries have conformed to one or 
more of these fundamental concepts. For example, the use of fluorides and 
soluble oxalates have been shown either to make the tooth more resistant to 
acids or to have actually restricted dental caries. The elimination of fer- 
mentable carbohydrate from the diet and increasing the natural neutralizing 
influences of the mouth have been partially successful in the restriction of 
dental caries. 

From theoretical aspects of the problem, one of the most effective ways 
of preventing dental caries would be.by the use of enzyme inhibitors. Insofar 
as the acids which attack the tooth surface are derived from sugars by en- 
zyme action, one should be able to block the formation of acid by the use of 
compounds that would inactivate the enzymes concerned. Such compounds as 
vitamin K, urea, ammonia, and a host of others are known to interrupt the 
chain of reactions which are necessary for the production of acids. In fact, 
there are literally hundreds of compounds of this nature which might be 
classified as enzyme inhibitors or antienzymes. The main difficulty involved, 



Medical News Letter, Vol. 22, No. 5 



23 



however, is a practical and effective method of application. It is obvious 
that, in order for the glycolytic reactions to be inhibited, the enzyme in- 
hibitors must be present at the time the fermentable carbohydrate is pres- 
ent. This means that the inhibitor may be incorporated into the sugar that 
is ingested; it could be placed in the mouth immediately before, after, or 
during the consumption of sugar; or it may be fastened to the tooth surface 
in some manner so that it will be present when sugars are ingested. A com- 
pound suitable for incorporation in the sugar at the refinery would be highly 
desirable, but to date no such compound has been reported in the literature. 

It has been noted by many investigators that the carious lesion always 
occurs under what is commonly called the dental or mucinous plaque. The 
dental plaque is consistently present on the unclean surfaces of the teeth. 
It is difficult to remove and by the usual oral hygiene procedures can be 
cleaned only from those surfaces accessible to the toothbrush. It has been 
suggested many times that caries could be controlled if the dental plaque 
could be prevented from accumulating on the tooth surface, or if the dental 
plaque could be removed completely by means of oral hygiene procedures. 

In 1949 it was suggested that if the dental plaque could not be elimin- 
ated or modified so as to be harmless it might serve as an agent for the 
retention of enzyme inhibitors on the tooth surface. The plaque is protein 
in nature and it is known that various stains will attach themselves to pro- 
tein. This being the case, one might borrow the concept of chemotherapy 
from Ehrlich and incorporate an enzyme inhibitor into the molecule of a 
substance that would attach itself to the plaque. If compounds could be 
found that would absorb, adsorb, or otherwise attach themselves to the 
plaque, and at the same time be powerful enzyme inhibitors either in situ 
or by being gradually released from the plaque, these compounds could be 
incorporated into an effective therapeutic mouthwash or dentifrice. 

Certain characteristics of the compound are desirable. In the first 
place, it must be effective in the prevention of acid formation from sugar, 
and it must attach itself to the plaque and should remain active for a period 
of several hours. It should be relatively nontoxic and it should be colorless. 
Furthermore, it should not be unpleasant to the taste, and it should be read- 
ily available. 

When it became apparent that compounds could be found that would be- 
come attached to dental plaques and remain after washing with water, it was 
of interest to determine whether or not the compounds would remain effective 
in the mouth. 

Investigation of several hundred compounds indicated that, although 
most antiseptics, many aldehydes, ketones, and anionic and cationic deter- 
gents, and other types of compounds would prevent the formation of acid in 
sugar- saliva mixtures, very few would become attached to the plaque and 
remain active after washing with water. 



24 



Medical News Letter, Vol. 22, No. 5 



To date about 10 compounds have been found which will become attached 
to the plaque material in effective concentrations and resist washing with 
water. Of these, 3 have been incorporated into dentifrices or mouthwashes 
and have been tested in vivo. In each case the results have been favorable. 
Two of these, sodium N-lauroyl sarcosinate and sodium dehydroacetate, 
are now under test clinically. After 9 months of this clinical test, it was 
found Jhat both compounds were still effective in blocking acid formation 
below what has been considered the harmful level. This dividing line is 
empirical and is based primarily on laboratory evidence. No accurate es- 
timates concerning the effect of these compounds on clinical caries can be 
made, but it would be interesting to speculate on the possible results. If 
the dangerous acidity is pH 5.5 and the carious process is an all-or-none 
proposition, then there should be no appreciable differences in the caries - 
inhibiting action of the two compounds. However, if this is not the case, 
they might possibly develop a difference, as one of the compounds depres- 
sed the formation of acid to a greater extent. 

If it is assumed that acid on the tooth surfaces is the immediate cause 
of dental caries, then dentifrices or mouthwashes containing sodium N-lauroyl 
sarcosinate, sodium dehydroacetate, penicillin, and other compounds which 
behave in the same manner should be truly therapeutic in the prevention of 
dental caries. (J. Dent. Research, Aug. 1953, L. S. Fosdick, J. C. Calandra, 
R. Q. Blackwell, and J. H. Burrill) 

****** 
Memorandum on Noise Measurement 

During the course of the program in noise presented as a part of the 
United States Navy Fifth Annual Industrial Health Conference, 17-23 April 
1953 in Los Angeles, the extreme interest in the noise problem on the part 
of those in attendance was evidenced by the numerous questions raised. 
Some questions were of the type not readily answered at that time and a rep- 
resentative from the U.S. Navy Medical Research Laboratory at New London 
volunteered to supply information which would be of assistance in some of 
the problems encountered. 

The problems in noise which appeared to be of most concern were: 
(a) Methods of measuring noise levels encountered in working areas and in 
audiometric testing areas, (b) Lack of information regarding noise limits 
in working areas and in audiometric testing areas, (c) Lack of information 
regarding the frequency spectrum of noise, (d) Methods of constructing 
sound-proofed testing rooms. 

This memorandum report has been written in an attempt to supply 
answers to these, questions and more important, to acquaint naval personnel 
with current publications which could be of assistance in studying and con- 
trolling noise conditions. (Medical Research Laboratory, New London, Conn. , 
Memorandum Report 53-11, Project NM 003 041. 34, 24 July 1953) 



Medical News Letter, Vol. 22, No. 5 



25 



Scientific Papers for 
Th e 1954 Aero-Medical Association Meeting 

The Silver Anniversary, or twenty-fifth annual meeting, of the Asso- 
ciation will be held at the Statler Hotel, Washington, D. C. on 29, 30, and 
31 March 1954. It is hoped that this meeting will be marked by the best 
scientific presentations in the history of the Association. 

In order to firm up the best possible program at an early date, Flight 
Surgeons who desire to make presentations to the Aero-Medical Association 
are requested to submit the titles of their papers to Captain C. P. Phoebus 
(MC) USN, Office of Naval Research (Code 439), Department of the Navy, 
Washington 25, D. C. , as soon as possible. Captain Phoebus is the Navy 
member of the Scientific Program Committee for the 1954 meeting. 

Colonel Robert J. Benford USAF (MC) is the Chairman of the Scien- 
tific Program Committee and has indicated that the scientific presentations 
will be limited to 15 minutes each. In addition, each speaker will be asked 
to designate a qualified person to discuss his paper. The discussant, who 
will be listed in the program, will be limited to 3 minutes and should re- 
ceive a preliminary draft of the paper at least 30 days before the meeting. 
The various papers will be grouped into related areas on the program after 
the presentations have been judged acceptable by the committee. (AvMed 
Div, BuMed) 

Medico-Military Training Program 

The second course to provide active duty for training in medico-mili- 
tary matters will be conducted October 12-24, 1953 at the U.S. Naval Medical 
School, National Naval Medical Center, Bethesda, Md. This course is simi- 
lar to the one conducted during March 1953 and has been generally acclaimed 
by those who attended. 

The first week of this program will be devoted to the Medical Reserve 
Program and Medical Department of the Navy in general, presenting recent 
advances in military medicine and surgery, including aviation, submarine, 
and field medicine. 

The second week will be devoted to the problems likely to be confronted 
and recommended defensive techniques to be employed by medical and dental 
officers against bacterial, chemical, and radiological action. The subjects 
will be presented by speakers of outstanding prominence in their specialties; 
hence, a most interesting and informative program is assured. 

Reserve Medical, Dental, Medical Service, Nurse, and Hospital Corps 
officers residing in the 1st, 3rd, 4th 5th, 6th, 8th, and 9th Naval Districts 
and the Potomac River Naval Command who desire to attend this course 
should submit their request for 14 days training duty to the Commandant's 



26 



Medical News Letter, Vol. 22, No. 5 



office at the earliest practicable date. The above-named districts have been 
assigned a quota for this course. 

It is desired to invite reserve personnel's attention to the fact that 
acceptance of orders to attend this course WILL NOT, in any way, increase 
the possibility of call to extended active duty. Therefore, personnel con- 
cerned are encouraged to take advantage of the opportunity to attend this 
course. (ResDiv, BuMed) 

# if 3|c >jc 3J; s)c 

Course of Instruction in Submarine Medicine 



On October 12, 1953 the next class in submarine and diving medicine 
will convene. The course consists of two separate periods of instruction: 

(a) 2-1/2 months' diving training at the Naval School, Deep Sea Diving fol- 
lowed by related medical instruction at the Experimental Diving Unit. Both 
of these activities are located at the Naval Gun Factory, Washington, D. C. 

(b) 6 months' instruction at the Submarine School for line officers (January- 
June 1954 class) supplemented with interfused medical instruction in sub- 
marine medicine at the Medical Research Laboratory. Both of these act- 
ivities are located at the U.S. Naval Submarine Base, New London, Conn. 
Comfortable BOQ and family quarters are available to students and their 
families for this period. 

The next class will be limited to 6 medical officers of the Regular 
Navy and Reserve with rank not above Lieutenant Commander, Applicants 
must be physically qualified in accordance with Arts. 15-29 and 15-30, 
Manual of the Medical Department and completed standard Form 88 should 
accompany the application. The service agreement for this course has re- 
cently been reduced by BuMed Instruction 1520. 3A, dated 22 July 1953. 

On completion of training, graduates are generally assigned a 2-year 
tour of sea duty as staff medical officers to the various submarine squad- 
rons located at Pearl Harbor, San Diego, New London, Norfolk, or Key 
West or to certain amphibious organizations in Coronado, Calif, and Little 
Creek, Va. Qualification to wear the submarine medical insignia can be 
acquired 1 year following graduation upon fulfillment of the requirements 
of Art. C-7309, BuPers Manual. Subsequent shore duty assignment may 
or may not include duty at submarine, diving, and medical research act- 
ivities, or clinical assignments depending upon the desires of the individual 
and the needs of the Service. During the past 2 years 2 submarine medical 
officers have received an academic year's course of instruction in atomic 
medicine in preparation for duty with the forthcoming nuclear submarine 
program. Most of the submarine medical officer assignments, both afloat 
and ashore entitle the incumbent to extra compensation in accordance with 
Arts. A-4302 and 4303, BuPers Manual. 



Medical News Letter, Vol. 22, No. 5 



27 



Radical changes in future submarine design, advancing operational 
developments, and improvements in the techniques of submarine escape, 
deep sea diving, and underwater demolition activities offer challenging 
physiological, psychological, and human engineering problems. Toxico- 
logical and disease control studies peculiar to the submarine service offer 
excellent background training for future assignments to industrial medicine, 
preventive medicine, physiology, and medical research. The duties of a 
submarine medical officer are by no means confined to these highly special- 
ized problems. The clinical care of submarine personnel and their de- 
pendents in well-equipped submarine tenders and bases offer ample general 
medical and surgical practice with especially good opportunities for clinical 
specialization in otolaryngology, clinical psychology, and psychiatry. 

Application for this course should be made by official correspondence 
to the Chief of the Bureau of Medicine and Surgery enclosing standard Form 
88 and the following service agreement: "I agree to remain on active duty 
for 9 months following the period of service for which I am currently ob- 
ligated, or for 18 months following completion of this course, whichever 
is longer." (SubMedDiv, BuMed) 

****** 
From the Note Book 

1. Rear Admiral JLamont Pugh, Surgeon General of the Navy, during 
the period August 26 through September 2, 1953, inspected informally the 
Navy Medical Department facilities located in the San Diego area, at Bar- 
stow, Inyokern, and Monterey, Calif., and at Hawthorne, Nev. ( TIO, BuMed) 

2. Doctor Howard T. Karsner, Medical Research Advisor to the Sur- 
geon General of the Navy participated in the meetings of the North Carolina 
Heart Association held Sept 3-4, 1953, at Winston-Salem. Dr. Karsner, on 
invitation of the Association, will conduct two clinico-pathological conferences 
and will give a lecture on, "The Pathogenesis of Arteriosclerosis. " (TIO, 
BuMed) 

3. A Bureau of Medicine and Surgery scientific exhibit entitled, 
"Electroencephalography in Combat Head Injuries, " was displayed during 
the Third International Congress of Electroencephalography and Clinical 
Neurophysiology, Aug 22-23, 1953, at Boston, Mass. (TIO, BuMed) 

4. Twenty-four recent graduates of civilian dental schools have ac- 
cepted Naval Dental Internships. The new Dental Interns have been appointed 
Lieutenants (junior grade) in the Dental Corps, USNR, and began their 
training, of 12 months' duration, on July 1, 1953, at naval hospitals 
approved for intern training by the American Dental Association. (TIO, 
BuMed) 



Medical News Letter, Vol. 22, No. 5 



5. The Legion of Merit with Combat "V" was presented to Commander 
William E. Ludwick (DC) USN, Head of the Dental Branch, Research Divi- 
sion and Head of the Dental Branch, Biological Sciences Division, Office of 
Naval Research, on Aug. 4, 1953. Appropriate presentation ceremonies 
were held in the offices of Rear Admiral C. M. Bolster, Chief of Naval 
Research, who presented the award. (TIO, BuMed) 

6. The Executive Council of the Association of Military Surgeons has 
voted to submit the name of Captain L. H. Newhouser (MC) USN as joint re- 
cipient of the Gorgas Award for 1953. 

7. The relative- value of electroencephalography, pneumoencepha- 
lography, ventriculography, and angiography in the diagnosis of 200 cases 
of intracranial mass lesions is discussed in the Journal of Neurosurgery, 
July 1953, F. A. Martin, J. E. Webster, and E. S. Gurdjian. 

8. Limitations in the use of gamma globulin in poliomyelitis are dis- 
cussed in the American Journal of the Medical Sciences, Aug. 1953, W. 
McD. Hammon. 

9. The "MIF" stain preservation technic for the identification of in- 
testinal protozoa is described in the American Journal of Tropical Medicine 
and Hygiene, July 1953, Capt. J. J. Sapero (MC) USN and D. K. Lawless, 
HMC, USN. 

10. Bilateral adrenalectomy has been used in patients whose carcinoma 
of the prostate gland and symptoms have not been controlled by prostatic sur- 
gery, revision of the obstructive vesical neck, estrogens, bilateral orchiec- 
tomy, with and without deep x-ray therapy. (J. Urol. , Aug. 1953, W. J, 
Baker) 

11. A technic of cardiac resuscitation is described in detail including 
artificial respiration, cardiac massage, intravenous fluids, and blood, drugs, 
and defibrillation by means of electric shock. (J. A. M. A. , 8 Aug. 1953, S. E, 
Leeds) 

12. Developments in the treatment of skin lesions by surgical abrasion 
are discussed under 3 main groups: traumatic and surgical scars; pitting, 
secondary to acute dermal infections; and pigmentation, congenital and ac- 
quired. (Plastic & Reconstructive Surgery, July 1953, P. C. Iverson) 

13. Thirty- one consecutive cases of infants dying suddenly while in 
apparent good health and with gross necropsy findings insufficient to explain 
death were studied microscopically. In all cases there were microscopic 
inflammatory lesions in the upper and lower respiratory tracts. There were 



Medical News Letter, Vol. 22, No. 5 



29 



vascular changes in the respiratory tract and other organs. The spleen, 
lymph nodes, and thymus showed characteristic reaction. The presence 
of these changes is regarded as evidence that death resulted from a ful- 
minating respiratory disease. (Am. J. Path. , July-Aug. , 1953, J. Werne 
and I. Garrow) 

14. A study of a group of patients with pulmonary tuberculosis was 
undertaken to observe the effect of testosterone on the twenty-fourth hour 
urinary excretion of the 17-ketosteroids and the clinical effects of testos- 
terone. (Am. Rev. Tuberc. , Aug. 1953, S. Cohen, B. Hayrabetian, and 
E. Li. Sevringhaus) 

15. With the view of contributing to the etiology, diagnosis, treat- 
ment, and mortality factors, 116 consecutive cases of intussusception have 
been reviewed and analyzed. (Arch. Surg. , July 1953, D. L. Thurston, J. 
Holowach, and E. E. McCoy) 

16. CDR C, G. Calderwood (MC) USN was recently elected to Fellow- 
ship in the American College of Surgeons. The following naval medical 
officers have recently been certified in their specialties by American Boards: 
CDR R. A. Phillips (MC) USN, American Board of Clinical Chemistry; 

CDR A. L. Schultz (MC) USN, American Board of Neurological Surgery; 
CDR J. L, Yon (MC) USN, American Board of Surgery; LT W. C. Hearin, 
Jr. , (MC) USNR, LT W. C. Pallas (MC) USNR, LT P. R. Rand (MC) USNR, 
LT JG E. J. Crawford, Jr. (MC) USNR, and LTJG G. J. Geanuracos (MC) 
USNR, American Board of Obstetrics and Gynecology; LT H. C. MacMillan 
(MC) USNR and LTJG A. Steward, Jr. (MC) USNR, American Board of 
Internal Medicine; and LT J. W. Wahl (MC) USNR, American Board of 
Otolaryngology. (TIO, BuMed) 

17. Cases of subacute deltoid bursitis showing calcium deposits were 
given injections of 1,000 meg. of vitamin Bj2 with most encouraging, and 
in some cases, dramatic, results. (Indust. Med. & Surg. , Aug. 1953, I. S. 
Klemes) 

18. A brief outline of the specific use of antibiotics and sulfonamides 
appears in the University of Michigan Medical Bulletin, July 1953, A.I. 
Braude. 

19. The diagnosis and prevention of bacterial endocarditis is discussed 
in Circulation, Aug. 1953, A. L. Bloomfield. 

20. Two cases of autopsy-proved truncus arteriosus and right aortic 
arch in which the pulmonary arteries arose directly from a single vessel are 
reported. (Am. Heart J. , Aug. 1953, R. D. Rowe and P. Vlad) 



30 



Medical News Letter, Vol. 22, No. 5 



BUMED INSTRUCTION 6260. 2 27 July 1953 

From: Chief, Bureau of Medicine and Surgery 
To: All Ships and Stations 

Subj: Water and s-alt requirements for personnel working in hot 
environments and hot climates 

This instruction provides information on water and salt (sodium chloride) 
requirements for personnel subjected to high environmental temperatures. 

****** 

BUMED NOTICE 6120 28 July 1953 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical and /or Dental Officers 

Regularly Assigned 

Subj: Errors and omissions in physical examinations in the case of 

applicants for officers' training courses and/or periodic exam- 
inations for such programs as the NROTC 

Ref: (a) Chap. 15, ManMedDept 
(b) BuMed Inst. 6120. 2 

This notice is promulgated for information and guidance of medical and 
dental examiners conducting physical examinations in the case of appli- 
cants for all officers' training courses. 

BUMED INSTRUCTION 6310. 1A 3 Aug 1953 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical Personnel Regularly 

Assigned 

Subj: Morbidity Report, MED 6310-2; preparation and submission 

This instruction consolidates existing directives and prescribes the proce- 
dure for the preparation and submission of Morbidity Report. BuMed C/L 
50-79, 51-62, 51-125, 51-131, and BuMed Inst. 6310.1 are cancelled. 



1$; s£c 5p sfc j}; ifc 



Medical News Letter, Vol. 22, No. 5 



31 



BUMED INSTRUCTION 1321. 2 4 Aug 1953 

From: Chief, Bureau of Medicine and Surgery 

To: Activities Under BuMed Management Control and Financial 

Responsibility 

Subj: Attendance at meetings of scientific, technical, professional, or 
similar organizations 

Ref: (a) SecNav Inst. 7200.2 
(b) BuPers Inst. 1321. 2 

This instruction establishes the prerequisites for attendance by military and 
civilian personnel of the Medical Department of the Navy at meetings of 
scientific, technical, professional, or similar organizations to comply with 
the provisions of references (a) and (b). BuMed ltr BuMed-233 L.20-1 dated 
30 April 1951 and BuMed Inst. 12230. 1 are cancelled. 

iff Hf $ $ * sjc 

BUMED INSTRUCTION 6200. 6 10 Aug 1953 

From: Chief, Bureau of Medicine and Surgery 

To: Preventive Medicine Units, and Fleet Epidemic Disease Control 

Units 

Subj: Monthly Report of Preventive Medicine Activities 

This instruction describes a monthly report to be prepared by preventive 
medicine units and fleet epidemic disease control units. BuMed ltr BuMed- 
7211 A16/P3-3 of 19 Oct 1949 addressed to Preventive Medicine Units Nos. 
2, 3, 4, 5, and 6, is hereby cancelled. 

****** 

BUMED INSTRUCTION 6460. 3 11 Aug 1953 

From: Chief, Bureau of Medicine and Surgery 
To: All Naval Hospitals 

Subj: Tissue homografts, follow-up studies concerning 

This instruction promulgates instructions concerning follow-up studies in 
patients who have received tissue homografts in naval medical facilities. 



32 Medical News Letter, Vol. 22, No. 5 

BUMED NOTICE 1080 13 Aug 1953 



From: Chief, Bureau of Medicine and Surgery 

To: All Naval Hospitals, Hospital Ships, and Medical Units Functioning 

in Hospitals of Other Government Agencies 

Subj: Roster Report of the Medical Corps (Med-1080-3) 

Ref: (a) Art. 23-32, ManMedDept 

This notice is promulgated to invite attention of addressees to discrepancies 
in the preparation of subject report relative to reporting staff medical offi- 
cers who are on the sick list. 

>$; .j^s jfc sQc 3$; 



S&togfo PREVENTIVE MEDICINE SECTION 



Recent Findings From Studies on Seasickness 
(Motion Sickness) 

A comparison of the duration of the aftersensation following the ad- 
ministration of angular accelerations (cupulometry) was made of normal 
and seasick-prone persons. The parallel- swing examination was also used. 

It appeared that objective abnormalities of the labyrinth were present 
in every chronically seasick patient investigated with these methods. Only 
the small group of neurotics in whom the affection is completely psychic in 
nature forms an exception to this rule. In the chronically seasick, the ab- 
normalities may be of two kinds: 

1. Those in whom the duration of the aftersensation following the ad- 
ministration of angular accelerations is particularly long. There are vaso- 
vegetative reactions in the sense of a rise of the endocranial blood pressure, 
measured in the central retinal artery after examination on the parallel 
swing. Persons showing these abnormalities are regarded as the specific 
seasick. This group comprises about 80% of the total number of seasick. 



Medical News Letter, Vol. 22, No. 5 



33 



2. Those in whom there is an uncertainty in the after sensations , or 
an unequal sensitivity of the two labyrinths, which the author attributes to 
a deficiency. These are indications of the existence of a vestibular dys- 
function. Persons showing these characteristics are called the unspecific 
seasick. About 20% belong to this group. 

Atropine and dimenhydrinate were found to diminish the duration of the 
after sensations centrally while the sensitivity in the peripheral organ re- 
mains the same. Atropine was found to decrease the vasolability mentioned; 
dimenhydrinate either did not influence it or increased it to a slight degree. 

The following course of events is postulated: (1) The maculae stimu- 
late the stellate ganglion, which causes a constriction of the endocranial 
vessels. This becomes manifest in a rise of the endocranial blood pressure. 
Due to the vascular spasm, the blood supply to the labyrinths is insufficient, 
resulting in unequal stimuli centrally. (2) These centrally conducted stim- 
uli, together with possible optic and proprioceptive stimuli, cause an over- 
straining of the aspecific stimulative system (reticular formation), resulting 
in the nausea syndrome. 

The technical methods used in this experiment are set forth in detail. 
(Acta Oto-Laryngologica, Supplementum CVIII, 1953, G. DeWit, University 
of Utrecht, The Netherlands and Surgeon Lt. Cdr, , Royal Netherlands Naval 
Reserve) 

Venereal Disease Control 

Laboratories Now Receiving Specimens for TPI Test 

The treponemal immobilization test, also known as the TPI test and 
the Nelson test, is being performed at the Hawaiian Medical Laboratory, 
APO 957, c/o Postmaster, San Francisco, Calif. All activities in the 
Pacific area- -including Alaska, the States of California, Oregon, and 
Washington, and forces afloat- - should submit specimens to this laboratory. 

All other areas will be served by the TPI Laboratory, Naval Medical 
School, National Naval Medical Center, Bethesda, Md. 

Specimens should be submitted in accordance with the instructions 
contained in BuMed C/L 51-29 until the forthcoming BuMed instruction 
dealing with the TPI test is promulgated. 

$ sje s{c 3(e j{c £ 

Oral Penicillin Prophylaxis 

A review of morbidity reports reveals that of all ships and stations of 
the U.S. Navy (more than 2,00.0 activities), 50 demonstrate a definite need 
for increased emphasis on their venereal disease control program. 



34 



Medical News Letter, Vol. 22, No. 5 



The incidence of venereal disease is indicative of the size of the reser- 
voir of infection in the population with whom naval personnel have contact 
while on liberty, and of failure on the part of those who have been exposed 
to employ adequate prophylactic measures. This failure is not entirely at- 
tributable to the exposed personnel; the command can play an important part 
by its educational program, and by motivating individuals to protect them- 
selves. Commands should encourage the use of oral penicillin prophylaxis, 
a proved and effective measure, by making it readily available for the asking, 
without fear of being punished, directly or indirectly. Almost without ex- 
ception, ships and stations in foreign areas with high venereal disease rates 
have failed to practice some of these measures. 

The Navy adopted oral penicillin as a prophylaxis against gonorrhea in 
foreign areas of high incidence only after extensive studies over a period of 
nearly 4 years, in conjunction with the Subcommittee on Venereal Diseases, 
Division of Medical Sciences of the National Research Council and with the 
National Institutes of Health. The Subcommittee on Venereal Diseases of 
the National Research Council has recommended such use to the Navy and, 
in fact, has repeatedly urged all the Armed Forces to use it for this pur- 
pose in all areas. Some of the points given careful consideration in the 
studies were: 

1. The possibility of producing organisms resistant to penicillin. No 
evidence has been found to indicate that there has been any significant in- 
crease in the number of resistant organisms because of the oral use of this 
antibiotic, and no resistant strains of gonococci have been identified. 

2. The possibility of masking the symptoms of early syphilis. The 
Subcommittee believes that there is virtually no likelihood of this with the 
small amount of penicillin used orally for prophylaxis. Careful follow-up 
of naval personnel who have taken part in the oral penicillin studies has 
substantiated this belief. 

3. The occurrence of reactions to penicillin. During the Navy studies, 
oral penicillin was found to have relatively few antigenic qualities. From 
statistical data on reactions to all forms of penicillin, it would appear that 
as the antibiotic becomes more and more refined and as less antigenic 
vehicles are employed, the ratio of reactions to the units of penicillin used 
decreases. 

If oral penicillin is made readily available and the men are motivated 
to its use and assured that there will be no form of punishment for those who 
report infection, they will be much more likely to protect themselves and 
the command may achieve dramatic declines in the incidence of venereal 
dis ease. 

$ * $ $ 3{e $ 

The printing of this publication has been approved by the Director of 
the Bureau of the Budget, June 23, 1952. 



Medical News Letter, Vol. 22, No. 5 35 

Industrial Medicine 

Exposure to Paint-Stripping Compounds 

Paint stripping of naval military aircraft, which must be done when- 
ever the craft come in for major overhaul or the paint film shows signs of 
corrosion, presents a number of safety and health problems. The primer 
and lacquer finish must be removed and the metal surface cleaned and pre- 
pared for repainting. The paint skin is removed by chemical means. A 
commonly used paint- stripping compound is formulation 52-R-15 (Aer), 
which is a thick mixture of complex composition. It contains many toxic 
and highly irritant ingredients. Of particular significance to the medical 
officer and the industrial hygienist is the fact that it contains significant 
amounts of dichlorom ethane, die hloro ethyl ether, phenolic s, ammonia, 
and potassium hydroxide. 

The compound is generously applied with brushes to the surfaces to be 
stripped of paint and is allowed to remain in contact with the paint for about 
15 minutes. Then, as the paint film loosens, another coat of stripper is 
applied and a stream of water is directed at the work while the operator 
brushes the loose paint and excess stripper downward so that it falls to the 
deck. At the naval air station reporting the operation, the climate permits 
the processing of the fuselage and wings out of doors; the smaller compo- 
nents are processed on benches under indoor or semioutdoor conditions. 

The vapors generated in the operation are unpleasantly odoriferous 
and on prolonged exposures are nauseating. Direct contact of the skin with 
the stripper must be prevented to avoid serious chemical burns. Paint 
stripper splashed in the eyes, even with immediate medical treatment, 
produces a burn which is very painful and incapacitating and which heals 
slowly. The slimy mixture of stripped paint and the stripping compound 
deposited on the deck is very slippery, and consequently the footing is in- 
secure and there is an ever-present hazard of falls. Because of large 
amounts of hot water and steam used, the working environment is quite humid. 

Some of the measures for the protection of the workers are, of course, 
obvious. Vaporproof goggles must be supplied, and the wearing of them on 
the job strictly enforced. Rubber boots, gloves, and coveralls must be pro- 
vided. To assure firmer footing NAS Alameda has developed a spike-studded 
sole that is attached to an elastic band so that it can be slipped over the rub- 
ber boot. The protective equipment should be frequently inspected for deter- 
ioration because the paint stripper attacks and damages rubber. For obvious 
reasons, there should be available a means for thoroughly drying the pro- 
tective equipment for the next day's wear. 

The problem of establishing safe limits of exposure to various vapors 
generated during application of the paint stripper is complex. There are 
present, simultaneously, in the air which the worker breathes: 



36 



Medical News Letter, Vol. 22, No. 5 



1. Dichloromethane- -maximum allowable concentration given by dif- 
ferent authorities as from 200 to 500 p. p. m. 

2. Dichloroethyl ether--m. a. c. 10 to 15 p. p.m. 

3. Phenols --probable m. a. c. of 5 p. p. m. 

4. Ammonia- -m. a. c. 100 p. p.m. 

Each of these has its own poisonous characteristics and its unique physio- 
logical effect on the body. That there is a marked synergism in this com- 
bination of vapors is demonstrated by the fact that nausea and loss of appetite, 
the most frequent complaints, occur when none of the maximum allowable 
concentrations mentioned are exceeded. 

Downdraft ventilation of stripping tables in the indoor shop should be 
effective in eliminating most of these toxic vapors, and when this ventila- 
tion is of sufficiently. great capacity it may be applicable to semioutdoor 
work on pieces of medium size. The greatest exposures, however, occur 
during the outdoor stripping of fuselage and other large surfaces, and a 
really practical method of controlling such exposures has yet to be dis- 
covered. The use of respirators does reduce exposures, but also reduces 
the rate of production. The wearing of respirators in addition to other 
safety gear places the workers under a tremendous handicap, and strict 
enforcement of this requirement has resulted in an increased labor turnover. 

Tuberculosis Control 

Tuberculosis Mo rtality in the United States, 1950 

Final 1950 tuberculosis mortality statistics (by residence) are now 
available from the National Office of Vital Statistics, Public Health Serv- 
ice, for each State and the District of Columbia. The tuberculosis death 
rates (all forms) ranged from a low of 6. 2 per 100,000 population for 
Wyoming to a high of 59.6 per 100,000 for Arizona. 

The over-all geographic pattern of tuberculosis mortality for 1950 
resembled that for 1949. The States having highest mortality were con- 
fined largely to the South, Southwest, and East while the States with the 
lowest rates were generally those in the northwestern and north central 
parts of the country. 

The year 1950 completes a decade of striking reductions in the tuber- 
culosis death rate. For the continental United States, the death rate drop- 
ped from an average of 45.8 per 100,000 population for the 3-year period 
1939-41 to 22.5 in 1950, a decline of 50.9%, whereas in the preceding 
decade the tuberculosis death rate declined 35.6%. 

Although these declines are impressive, the numbers of deaths re- 
main high for a disease whose cause and manner of prevention have been 
well known for over half a century. 



Medical News Letter, Vol. 22, No. 5 



37 



Furthermore, the decline in the annual number of new cases of tuber- 
culosis reported during recent years has been slight compared with the de- 
cline in mortality. That the number of newly reported cases remains high, 
despite the rapid decline in death rates, underscores the fact that efforts to 
wipe out tuberculosis must continue to have high priority among public health 
problems. (Pub. Health Rep. , June 1953] 

Training and Visual Aids 

Experimental Use of Health Slogans on Paper Cups 



Another channel for the distribution of health information in the Navy 
is being put into use with the placing of orders for paper cups having health 
slogans and cartoon-type illustrations printed on the sides. It is believed 
that this medium of health education will have similar value to the safety- 
slogan cups which have found wide application in industry. 

The initial supply of the printed cups, which are to be in the 7 -ounce 
size, will be used in vending machines in overseas Navy exchanges, vessels 
of the Military Sea Transportation Service, and vessels being supplied by 
the naval supply centers at Oakland and Norfolk. The activities receiving 
the cups have been requested to submit the reactions of patrons and any 
other information regarding the acceptability of this use of health slogans 
in order to assist the Bureau of Medicine and Surgery in an evaluation of 
this experiment. It is planned to use the cups for 1 year before a decision 
is made to put them into wider use in the Navy or to discontinue them. 

General Sanitation 

Food Sanitation 



L,T W. H. Cope (MC) USN, recently assigned to Preventive Medicine 
Unit No. 2, has sent in these notes of interest to the Navy on the occurrence 
of food-borne diseases: 

Attention is being focused on efforts to decrease the incidence of food- 
borne diseases throughout the Navy. Such outbreaks of disease are occurring 
also in civilian communities throughout the country in spite of increasing 
knowledge of the proper handling of food. It is believed that the great major- 
ity of outbreaks are preventable and can be traced to carelessness and im- 
proper knowledge concerning sanitary practices. The following summary 
has been prepared partly from data concerning food- and water-borne dis- 
ease outbreaks in 1952, reported by C. C. Dauer, M. D. , in the Public 
Health Reports, July 1953. 



38 



Medical News Letter, Vol. 22, No. 5 



Sixty-nine disease outbreaks were reported in various units of the 
Armed Forces in the continental United States in 1952. A total of 3,833 
persons were affected. Thirty- s even, or more than half of these out- 
breaks were classified as food poisoning. 

Poultry and eggs were important as sources or vehicles of infection. 
In 39 outbreaks involving chicken or turkey, Salmonella infection was proved 
or suspected in a large proportion. Many Salmonella infections throughout 
the country were also traced to a powdered egg-yolk product. These re- 
ports indicate very clearly that fowl and eggs constitute a large reservoir 
of infection and emphasize the need for more effective measures to prevent 
transmission of the infection to man. 

Laboratory evidence of the presence of staphylococci in food was 
available in 32 outbreaks of food poisoning. Epidemiological investigations 
indicated this type of food poisoning in 45 additional outbreaks. Of these 77 
outbreaks, cream-filled pastry was involved in 15; ham in 21; poultry in 10; 
and salads in 10. In 28, or approximately one-third of the 77 outbreaks, 
lack of refrigeration or inadequate refrigeration was considered to have been 
an important factor. In 5 of the outbreaks, a food-service worker was found 
to have an infection on his hand. In 3 a food- service worker had a throat in- 
fection, and in 5 food-service procedures were considered to be unsatisfac- 
tory. 

There was a great increase of typhoid fever cases in the United States 
during 1952 compared with the preceding year. In 4 instances carriers had 
prepared food eaten by the persons who became ill. Water was suspected of 
being the vehicle of infection in 2 outbreaks, but laboratory evidence was 
lacking. Contaminated well water was shown to be the source of infection 
in 2 other outbreaks. 

A number of severe outbreaks of streptococcal infections were re- 
ported. Epidemiological investigations of 1 group of 82 cases which occur- 
red in a hospital indicated that the outbreak was food-borne, but the specific 
item of food was not identified. A group of 81 cases of streptococcal sore 
throat was reported among persons who had eaten warmed-over stew. 
Streptococcus viridans was isolated from a purulent discharge from the 
thumb of the cook and from the throats of the ill persons. 

Investigations of food-borne outbreaks of disease in 1952 repeatedly 
showed that the importance of properly storing and refrigerating food and 
of food-service workers keeping their hands clean was not fully appreciated. 
It is apparent that expensive equipment and elaborate procedures do not 
assure wholesome food. Food stored promptly in the cheapest icebox is 
less likely to cause illness than food placed in the most elaborate refriger- 
ator after a few hours' exposure at room temperature. 

Four items of the greatest importance in the prevention of food poi- 
soning are: 

(1) Prepared food should be kept either hot at 140° F. or above, or 
cold at 50° F. or below. The practice of allowing excessive time for food to 



Medical News Letter, Vol, 22, No. 5 



39 



cool to room temperature before refrigerating is not considered to be a safe 
or necessary procedure. (Preventive Medicine Division suggests that this 
is dependent upon the size of the container and refrigerating capacity of the 
storage space. It is suggested that, where large containers (which should 
never be over 3" deep) of food are involved, they be permitted to cool not 
more than 30 minutes to an hour before being placed in the refrigerator. 
Stirring at 15-20 minute intervals will insure cooling throughout the mass 
of food. This procedure allows for loss of excessive heat prior to refrig- 
eration, but may not necessarily permit reduction to actual room tempera- 
ture). 

(2) All persons engaged in handling food must practice strict personal 
hygiene. Facilities to permit frequent washing of the hands must be made 
easily available to these persons. 

(3) A daily inspection of all food-service workers must be made by a 
medical officer or his qualified representative. 

(4) During the summer months the preparation of highly perishable 
foods (c ream -filled pastries, chicken or turkey sandwiches, et cetera) 
should be avoided. 

(A summary of food-borne illness outbreaks in the Navy in 1950, 1951, 
and 1952 will appear in the next Preventive Medicine Section of the Medical 
News Letter. ) 

$ $ ]|C $ $ $ 

Symposium on Advanced-Base Water Supply and Sanitation 

The Bureau of Yards and Docks is sponsoring a symposium on advanced- 
base water supply and sanitation, to be held at Port Hueneme, Calif. , on 7, 
8, and 9 October. The objective of the symposium is to explore and discuss 
military requirements, problems, and current and future development per- 
taining to water supply and how it is affected by related field sanitation. 
Topics tentatively listed for discussion are the military problem, desalting, 
purification, sanitation, and polar and arid water supply. 

Specialists in the field of sanitary engineering from the Army, Navy, 
Air Force, and industry will be on the program. Among the speakers will 
be Captain O. L. Burton (MC) USN, Director of the Preventive Medicine 
Division of the Bureau of Medicine and Surgery; Dr. J. Harrell Morris of 
Harvard University; Professor E. N. Kemler of the University of Minnesota; 
Professor W. F. Langlier of the University of California; and Dr. Abel Wol- 
man of Johns Hopkins University. Lieutenant Commander F. E. Stewart 
(MSC) USN, Head of the Sanitation Section of the Preventive Medicine Divi- 
sion, will demonstrate a kit for testing the pH and chlorine concentration of 
water, especially adaptable for field use. 



40 



Medical News Letter, Vol. 22, No. 5 



It is urged that all interested personnel of the Navy Medical Depart- 
ment plan to attend. The U.S. Naval Civil Engineering Research and Eval- 
uation Laboratory at Port Hueneme will arrange for reservations and 
transportation from Los Angeles upon request. 

$ $ $ sjc $ )(c 

Survival of Organis ms in Dressing Made With Dried Eggs 

Not all Salmonellae and staphylococci inoculated into cooked salad 
dressing made with dried eggs are destroyed at the pH of the basic formu- 
la, or any palatable variation, but these pH's do not provide a favorable medium 
for the growth of pathogenic organisms. 

"Cooking dried egg in salad dressing for one-half minute or to a tem- 
perature of 84° to 86° C. destroys food poisoning organisms which are likely 
to be found in dried eggs or introduced into them by food handlers. " (Public 
Health Engineering Abstracts, May 1953, in a report on an article by T. C. 
Kintner and M. Mangel in Food Research, Jan. -Feb. 1953) 



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