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Full text of "United States Navy Medical News Letter Vol. 25, No. 11, 10 June 1955"

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NavMed 369 




Editor - Captain L. B. Marshall, MC, USN (RET) 



Vol. 25 



Friday, 10 June 1955 



No. 11 



TABLE OF CONTENTS 



Residency Training in the Navy 2 

Diagnosis of Hemolytic Transfusion Reactions 3 

Epidemic of Infectious Hepatitis ^ 

Musculoskeletal Chest Pain 

Treatment of Cardiac Arrest 8 

Oral Penicillin Prophylaxis of Streptococcal Infections 9 

Reducing Salivary Lactobacillus Counts 12 

Toothbrushing Procedure for Orthodontic Patients 14 

Clinical Experience with Intravenous Infusion of Emulsified Fat 17 

Combined Steroids to Suppress Lactation 18 

20 

Household Goods 

TV Production -- "The Lifeline" 

Training Opportunities for Naval Reserve Personnel 21 

From the Note Book 24 

Board Certifications 

Clinical Records for VA Patients (BuMed Notice 5212) 27 

Industrial Relations Institute {BuMed Notice 12,000) 27 

Unit Pricing of MD Property (BuMed Inst. 7320. 3) 27 

P REVENTIVE MEDICINE DIVISION 

28 

Notes on Salk Poliomyelitis Vaccine 

29 

Poliomyelitis (continued) 7 

Differential Diagnosis of Diffuse Pulmonary Infiltrations 36 

Gastroenteritis Studies in Egypt . 38 



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Medical News Letter, Vol. 25, No. 11 



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. 

****** 
Notice 

Due to the critical shortage of medical officers, the Chief, Bureau of 
Medicine and Surgery, has recommended, and the Chief of Naval Personnel 
has concurred, that Reserve medical officers now on active duty who desire 
to submit requests for extension of their active duty for a period of three 
months or more will be given favorable consideration. 

****** 
Residency Training in the Navy 



The results of previous notices concerning residency training have b 
most gratifying. However, applications are still desired from Regular 
officers and those Reserve officers who have completed their obligated 
service under the Universal Military Training and Service Act, as amended, 
in the following specialties : Internal Medicine, Radiology, Pathology, Ped- 
iatrics (opening in Pediatrics at Chelsea, Oakland, and Philadelphia), 
Urology, and Otolaryngology (Philadelphia only). 

It is now the desire of the Bureau of Medicine and Surgery to continue 
a resident in training without interruption until he has completed the formal 
training requirements leading to certification by an American Specialty 
Board. This procedure will be strictly adhered to in every case where the 
needs of the Service permit and providing the officer shows satisfactory 
progress as a resident. (ProfDiv, BuMed) 



een 



*****# 



Medical News Letter, Vol, 25, No. 11 



Diag nosis of Hemolytic Transfusion Reactions 

In most instances, the clinical picture of hemolytic transfusion 
reactions is characteristic and permits a diagnosis without great difficulty. 
However, at least three reasons justify preoccupation with this subject: 
(1) There are cases in which the clinical manifestations are obscured by 
the underlying disease; (2) The characteristic clinical picture of a hemo- 
lytic transfusion reaction is not always fully developed; and (3) Some 
clinicians have a tendency to blame on transfusions all complications of 
diseases following a transfusion. Fortunately, laboratory tests may help 
to establish the correct diagnosis, providing they are employed properly 
and at the proper time. 

The aid of the laboratory is essential in at least three situations 
for the correct diagnosis of hemolytic transfusion reactions: (1) Asympto- 
matic hemolytic transfusion reaction. Clinical symptoms, such as typical 
anginal precordial pain, severe lumbar distress, and chill followed by drop 
in blood pressure, are frequently the first indications of a hemolytic pro- 
cess. However, the absence of these signs and symptoms does not exclude 
a hemolytic transfusion reaction. Hemolytic reactions have occurred even 
in the absence of clinical manifestations, although there was definite proof 
that incompatible blood was administered; in one patient, the only clinical 
manifestation was urticaria which is usually believed to be characteristic 
of an allergic reaction; (2) Hemolytic transfusion reaction simulated by 
underlying disease; and {3) Hemolytic transfusion reaction obscured by the 
underlying disease. 

The following conditions are also included: progressive renal failure 
which may be a part of the transfusion reaction, but which may also be a 
part of the underlying disease or a complication of a surgical operation; 
acute liver insufficiency with jaundice; acute anemia; hemoglobinuric 
nephrosis due to causes other than transfusion-hemolysis and resulting 
from shock or hemorrhage; progressive azotemia resulting from massive 
gastrointestinal hemorrhage; jaundice following massive pulmonary infarc- 
tion, et cetera. The changes in the blood of patients with hemolytic trans- 
fusion reactions which are responsible for the various clinical manifesta- 
tions described in the preceding sentence are: intravascular hemolysis 
followed by hemoglobinemia, hemoglobinuria, bilirubinemia, and bilirub- 
inuria; rise in nonprotein nitrogen and its fractions, indicative of renal 
failure secondary to hemoglobinuric nephrosis. Intravascular hemolysis 
demonstrable by these tests in transfusion reactions is, in most instances, 
the result of destruction of injected red cells by the isoantibody of the rec 
ient, or sometimes the result of destruction of the red cells of the recipi 
by the antibody of the injected blood. The authors' discussion deals main 
with recognition of hemolytic transfusion reactions of this nature. Intra- 
vascular hemolysis may also occur when the transfused blood contains 



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Medical News Letter, Vol. 25, No. 11 



a large amount of free hemoglobin, or excessively fragile cells (inadequately 
preserved or over-aged blood). Renal or hepatic failure, or both, may be 
caused by various factors. These are some of the reasons why a transfusion 
may be blamed for events it did not cause and, vice versa, why a diagnosis 
of a hemolytic transfusion reaction may be missed. 

What steps are to be taken in order to make possible a complete inves- 
tigation of transfusion reactions if and when they occur? The following 
measures appeared to be indispensable: (1) Every pre-transfusion specimen 
must be saved for a period of at least 10 days, together with the pilot tube 
of the blood that was crossmatched for the recipient; (2) After administra- 
tion of blood, the bottle should be returned to the blood bank; (3) When a 
transfusion reaction is reported or suspected, a specimen of blood of the 
recipient must be obtained immediately, one part of which is placed into a 
tube containing an anticoagulant, while the rest is used as clotted blood for 
tests; (4) A specimen of urine must be obtained immediately; (5) Additional 
specimens of urine should be collected and measured as indicated. 

Laboratory tests are listed to be utilized for recognition of hemolytic 
transfusion reactions. The following tests are carried out immediately: 
(1) Donor and recipient are retyped (ABO group, Rh type); (2) Crossmatch- 
ing tests are repeated with pre-transfusion and post-transfusion specimens, 
using in both instances a sensitive high-protein crossmatch as well as the 
indirect antiglobulin test. If all tests are negative but there is good reason 
to suspect a hemolytic transfusion reaction, a crossmatching test with enzyme- 
treated red cells of the donor is done. (3) The supernatant plasma of the post- 
transfusion specimen is examined with the naked eye, and chemically, for 
the presence of free hemoglobin. (4) A drop of the non-clotted blood is 
examined under the microscope for presence of small agglutinates resulting 
from intravascular agglutination. (5) Serum bilirubin and urea nitrogen are 
determined on pre-transfusion and post-transfusion specimens, and these 
tests are repeated at 24-hour intervals if a hemolytic transfusion reaction 
has occurred. (6) Urine specimens are tested for free hemoglobin, red 
cells, and red-cell casts. (7) The few drops of blood always remaining in 
the bottle should be tested for ABO group and Rh typeinorder to be sure 
that no confusion has taken place between identity of the pilot tube and the 
actual blood contained in the bottle. Another portion of the remaining blood 
should be used for study of possible bacterial contamination. A table lists 
tests that furnish corroborative evidence and further insight int6 the mech- 
anism of hemolytic transfusion reactions. 

If all tests give negative results, one can exclude a hemolytic trans- 
fusion reaction. If positive results have been obtained, the identification 
of the antibody responsible must be approached by the usual methods. In 
some instances, when a hemolytic transfusion reaction is suspected, one 
must also investigate the possibility that this was due, not to incompatibility 



Medical News Letter, Vol. 25, No. 11 



5 



of the blood factor, but to other causes of hemolysis such as inadequate 
preservation of blood (improper temperature of storage) or simultaneous 
administration with the blood of incompatible solutions such as distilled 
water or glucose in water. It is, therefore, highly desirable that records 
of the administration of blood contain a definite statement as to the solu- 
tions that have been administered with it, or that have been passed through 
the same set of tubing either before or after administration of the blood. 

Once a hemolytic transfusion reaction has occurred, follow-up tests 
are useful and important for management of the patient and evaluation of 
the effectiveness of therapy. 

There is no single method that can insure freedom of hemolytic 
transfusion reactions or their early recognition once they have occurred. 
Meticulously done pre-transfusion tests, adequate controls, a well-organized 
system of record keeping, and a high index of suspicion regarding sequelae 
of blood transfusions, are indispensable. Eternal vigilance is the premium 
that must be paid to collect dividends in safe blood transfusions. (Davidsohn, I. , 
and Stern, K. , Diagnosis of Hemolytic Transfusion Reactions: Am. J. Clin. 
Path. , 25: 381-392, April 1955) 



# 5|S * # * * 



Epi dem ic of Infectious Hepatitis 

Studies on the viral hepatitides of man have aroused increasing interest 
in the past few years, and several studies of epidemics of infectious hepatitis 
have been recorded. The present report is concerned with a brief review 
of the literature pertinent to the problem and with recording an epidemio- 
logical study with particular reference to delineation of high-risk groups 
in an open community outbreak. In addition, some observations on the 
effect of normal human serum gamma globulin in protecting exposed sus- 
ceptible s under field conditions is presented and the proper application of 
this material in open community outbreaks considered. 

From June 1951 to September 1952, an epidemic of infectious hepatitis 
occurred in Dalton and Whitfield Counties, Georgia, totalling 335 reported 
cases. The epidemiologic study which was done is summarized. 

Practicing physicians in the epidemic area were contacted and apprised 
of the purposes of the study. They were requested to report all cases of 
infectious hepatitis to the Health Department by card or telephone. All cases 
were then visited by a physician-epidemiologist or a nurse-epidemiologist, 
and detailed data concerning the illness were collected on a prepared form. 
Included were: onset date; symptoms and signs; history of injections within 
6 months; antecedent, coincident, or subsequent cases in the family or en- 
vironment; animal and insect contacts; food, water, milk, and ice-cream 
supplies; and school or occupation. Data were analyzed from these forms. 



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Medical News Letter, Vol. 25, No. 11 



Data on an outbreak of infectious hepatitis, which spread through a 
community by person-to-person contact over a period of 15 months involvi 
ing 335 persons in 260 families, is presented. Striking selection of the 
younger age groups was noted, and examination of appropriate attack rates 
indicated that the school and family groups were the chief loci of dissem- 
ination of the virus. 

Gamma globulin was shown to afford a high degree of protection of 
exposed susceptibles under field conditions when administered in doses 
approximating 0. Olcc. per pound of body weight more than seven days 
before the appearance of symptoms. 

In future epidemics, it would seem that efforts at control should 
proceed from these facts, and that gamma globulin should be administered 
to persons in high-risk groups, namely, to school and family contacts of 
cases. It is likely that a significant degree of control could be achieved 
even if administration of the material were restricted to persons in these 
groups under the age of 20. Prior studies have indicated that special 
attention should also be given to the protection of pregnant and postmeno- 
pausal women. 

Further studies, in any event, should attempt to develop practical 
methods for control of epidemics of infectious hepatitis, and the avail- 
ability of a substance which is effective in protecting exposed susceptibles 
under field conditions; The magnitude of the problem raised by the fre- 
quency and prolonged courses of such epidemics, together with the 
frequently widespread and prolonged morbidity resulting from the disease, 
underline the importance of such studies as pointed out in this article. 
{Barondess, J. A. , et al. , Epidemic of Infectious Hepatitis: Arch. Int 
Med. , 95: 633-643, May 1955) 

****** 
Musculoskeletal Chest Pain 

Of 60 referred patients with myocardial infarction, either acute or 
old, 8 had persistent chest pain. One patient with chest pain had pain in 
the shoulder and hand, in addition; 2 other patients in this series had 
developed the shoulder-hand syndrome without chest pain. 

The onset of the chest pain occurred within the first two weeks 
following myocardial infarction in 6 of the 8 patients, 3 months later in 
one, and 6 months later in another. The pain was located in the left pre- 
cordium in 6 patients, and spread to the entire anterior chest wall in 2 
patients. The postinfarction pain was located in the same area as the 
pain of the acute infarction in one-half of the patients. The onset of the 
pain was gradual, and its duration varied from 30 minutes to several days, 



Medical News Letter, Vol. 25, No. 11 



7 



usually about 1 to 2 hours. It was most often described by the patient as 
a steady, dull, aching, or pressing pain. The intensity of the pain was 
usually mild to moderate. However, in 2 patients in whom the pain came 
on within the first week after infarction, it was so severe that opiates 
were required for relief. The episodes of pain recurred intermittently 
during a period of time varying from one month to 3 years. 

There was no specific relationship to generalized physical exertion 
except that the pain was likely to occur toward the end of the day when the 
patient felt fatigued. In 5 of the 8 patients, the pain was worse when lying 
down, especially if lying on the left shoulder. Seven of the patients could 
relate either the onset or the aggravation of the pain to a specific move- 
ment of the body or arm; 4 to the raising of the arms above the head; and 
3 to a turning or twisting motion of the body. Although none described a 
pleuritic pain, in 3 patients the pain was made slightly worse by taking a 
deep breath. Nitroglycerin had no effect on the pain in any of the patients, 
and in none of them did physical exertion reproduce the pain. 

Six of the 8 patients were found to have localized areas of muscle 
tenderness within the area of the pains. However, the exact spontaneous 
pain was not reproduced by pressure. Reproduction of the spontaneous 
pain was accomplished in all but one patient, either by raising the arms 
high over the head or by twisting the body. 

Three of the 8 patients had angina pectoris occurring after myo- 
cardial infarction. Two of them were unable to differentiate the attacks 
of angina from the skeletal chest pain until after the exercise test separat- 
ed the short-lived anginal pain from the prolonged skeletal pain. Another 
noted that his skeletal pain became much more severe during periods of 
increasingly frequent attacks of nocturnal angina. 

Rinzler and Travell have shown that local procaine infiltration, or 
topical ethyl chloride spray, may dramatically benefit this type of local 
pain; these measures were not deemed necessary in the patients in this 
series. Reassurance that the pain was not serious, local heat, and anal- 
gesics allayed the anxiety concerning the pain and reduced its intensity, 
although most of the patients continued to have milder discomfort at less 
frequent intervals. 

The persistence of chest pain for months after the disappearance of 
evidence of tissue destruction following myocardial infarction distinguishes 
this pain from that of acute infarction. However, when the pain comes on 
within the first week after an infarction, the differential diagnosis between 
skeletal pain and a second infarction or coronary insufficiency is difficult. 
The lack of specific relationship of the pain to exertion, the absence of 
electrocardiographic changes during the pain, the absence of response to 
nitroglycerin, and its reproduction by arm or body motion, clearly differ- 
entiate it from angina pectoris. 



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Medical News Letter, Vol. 25, No. 11 



Skeletal chest pain following myocardial infarction is almost uniform- 
ly interpreted by patients as serious cardiac pain, and because of the dif- 
ficulties of differential diagnosis, physicians are apt to be misled in like 
fashion. Therefore, the importance of this pain is its differentiation from 
myocardial infarction and angina pectoris. This can be accomplished by 
applying those measures in history-taking and observation which elucidate 
skeletal pain. (Edwards, W. L. J. , Musculoskeletal Chest Pain Following 
Myocardial Infarction: Am. Heart J. , 49:713-717, May 1955) 

****** 



Treatment of Cardiac Arrest and Slow Ventricular 
Rates in Complete A-V Heart B lock 

Few dependable drugs are available for increasing the ventricular 
rate in complete A-V heart block during prolonged sinus pauses, and follow- 
ing periods of cardiac arrest occurring in association with anesthesia and 
other states. Epinephrine (and occasionally other sympathomimetic drugs) 
and Isuprel are used to increase the idioventricular rate, but are not always 
dependable and may, at times, manifest serious untoward effects. In states 
where the slow heart rates are associated with increased vagal tone, a 
wider spectrum of drugs is available: e. i. , parasympatholytic drugs (atro- 
pine, Banthine) and sympathomimetic drugs (ephedrine, Paredrine, and 
others). The cardiac slowing that occurs under many conditions may, 
however, be the result of a combination of several factors, namely depres- 
sion of the conducting tissue in the cardiac muscle, varying degrees of 
increased vagal tone, or a combination of both factors. In such cases, 
the drugs mentioned above will either be ineffectual or only partially 
effective. 

The object of this presentation is to report the effects of sodium 
lactate (molar and half molar) solutions: (1) in restoring ventricular beat- 
ing during repeated episodes of cardiac standstill of Stokes-Adams seizures; 
(2) during episodes of cardiac arrest of other etiologies; (3) in increasing 
the ventricular rates in states accompanied by slow heart rates; e. g,., 
varying grades of partial A-V heart block and sinus bradycardia; and (4) 
in increasing the rate of ventricular beating in complete A-V heart block. 
These effects have, insofar as the authors know, not been previously 
reported. 

The therapy of episodes of cardiac arrest, ventricular standstill during 
Stokes-Adams seizures, the slow idioventricular rhythm of complete A-V heart 
block, the slow ventricular rates of partial A-V heart block and sinus brady- 
cardia by the administration of molar and half molar sodium lactate is reported. 

After epinephrine, Neosynephrine and atropine were without effect in 
restoring the ventricular beating during repeated, prolonged periods of 
ventricular standstill in a case of Stokes -Adams syndrome. Molar and 



Medical News Letter, Vol. 25, No. 11 



9 



half -molar sodium lactate, administered intravenously, restored the heart 
beat on 10 separate occasions. After 2 hours, the heart continued to beat 
spontaneously for several hours. In the case of terminal cardiac arrest, 
the intracardiac injection of sodium lactate temporarily restored ventricu- 
lar beating. 

Sodium lactate was administered to three cases of complete A-V heart 
block. In one of these, the patient presented a ventricular rate of 15 per 
minute, widened QRS complexes, and a state of shock. Sodium lactate 
increased the ventricular rate to 60 per minute and increased the blood 
pressure to 120 to 140 systolic with resultant marked improvement in the 
patient's clinical state. The widened QRS complexes were significantly 
narrowed. Decrease in the rate of administration or cessation of admin- 
istration of the lactate solution on two separate occasions resulted in a 
return of the electrocardiogram to the control rate of 15 per minute. After 
5 hours of administration, the ventricular rate had increased to 60 per 
minute and was maintained without further lactate administration. About 
one hour later, normal sinus rhythm was restored. 

In a second case of complete A-V heart block, the ventricular and 
atrial rates were significantly increased following the administration of 
sodium lactate. In a third case of complete A-V block, with occasional 
normally conducted beats, the complete A-V heart block was abolished 
and the idioventricular beats were entirely replaced by normally conducted 
beats. 

Sodium lactate appears to have marked qualities of increasing cardiac 
rhythmicity while possessing little or no pressor action. Observations in 
the human subject and in the experimental animal suggest that this solution 
possesses qualities that should be of help in the prevention and therapy of 
sudden cardiac standstill. In addition, it did not produce dangerous ectopic 
rhythms. 

The dose, method of administration, and fate of the sodium lactate 
in the body is discussed; the possible mechanisms by which the sodium 
lactate produces the effects described are outlined. (Bellet, S. , Wasserman, F. , 
and Brody, J.I. , Treatment of Cardiac Arrest and Slow Ventricular Rates 
in Complete A-V Heart Block: Circulation, _11_: 685-699, May 1955) 



****** 



Oral Pen icillin Prophylaxis of Streptococcal Infections 

Because of the lack of other effective control measures and its reporte 
success in the prevention of recurrent rheumatic fever in civilian groups, 
investigations into the use of oral penicillin for the prophylaxis of epidemic 
streptococcal infections among naval personnel were begun in 1951. The 
initial study demonstrated that a 100, 000 -unit tablet of oral penicillin once 
daily was highly effective in preventing men from developing streptococcal 



10 



Medical News Letter, Vol. 25, No. 11 



infections under conditions of considerable risk. The purpose of this report 
is to summarize additional investigations made in Navy recruit populations 
and to report some previously unreported data. With one exception, all 
studies in the Navy have been carried out by the Naval Medical Research 
Unit No. 4. 

Commercial buffered tablets of penicillin G have been employed in 
studies having two general objectives: (1) to learn the smallest dose that 
would effectively suppress epidemics; and (2) to learn the smallest dose 
practicable for use in prophylaxis that would eliminate group A strep- 
tococci from a maximum number of carriers. It was foreseen that under 
some circumstances continuous prophylaxis over a considerable period 
of time might be necessary. For economic reasons, because the involved 
populations might number in the hundreds of thousands during full mob- 
ilization, the minimum effective dose was sought. It was also thought that, 
under some conditions, it might be possible to cause a more or less pro- 
longed interruption of an epidemic by a short course of penicillin which 
would eliminate streptococci from most carriers. 

Both controlled studies and experiments with mass prophylaxis have 
been made. In most studies, groups of recruits were cultured before and 
after a variable period of administration of the several doses of penicillin. 
The purpose was to learn how effective penicillin had been in preventing 
the development of a positive throat culture or in converting a positive 
throat culture to a consistently negative culture. In controlled studies, 
serial cultures were taken at weekly or more frequent intervals and the 
results are in terms of persistently positive or negative cultures. In 
mass prophylaxis experiments, only the results of single cultures taken 
before, during, and after prophylaxis were considered. 

It appeared that all doses employed had some efficacy in converting 
the throat culture from positive to negative. It was not until a dose of 
375, 000 units daily was reached, however, that a marked decline in the 
incidence of carriers resulted. A dose of 500, 000 units daily for 10-21 
days eliminated streptococci from the throat culture in 97. 2% of 138 men 
with positive cultures for group A streptococci prior to prophylaxis. 

Experiments in mass prophylaxis with oral penicillin in military 
populations have been made by three other groups of investigators. Gezon, 
et al. , compared once daily doses of 125, 000 units of penicillin with 0. 5 gm 
of sulfadiazine. Both were effective in reducing the incidence of strepto- 
coccal infection. Wannamaker, et al. , also reported on the efficacy of 
various doses and preparations of penicillin in eliminating streptococci 
from carriers. Pertinent to the present report was the observation that 
a dose of 250, 000 units once daily for 10 days was not highly effective 
Doses of 500, 000 units or 1, 000, 000 units twice daily did not appear to be 
more effective than was the 250, 000 units twice-a-day regimen in Navy 
recruits. Large doses given for only 5 days were relatively ineffective in 
comparison with the results of the same dose continued for 10 days. 



Medical News Letter, Vol. 25, No. 11 



11 



The studies of Bernstein, et al. , in Air Force recruits are most 
comparable to studies made in Navy recruits with a dose of 250,000 units 
twice daily. Both 5- and 10-day regimens were tried. Results showed the 
10-day regimen to be the most effective; it closely paralleled the results 
obtained with 14- and 21 -day regimens in Navy recruits. The type 3 strep- 
tococcus responsible for the epidemic in Air Force recruits persisted 
through a 10-day period of prophylaxis in all recruits, as did the type 19 
streptococcus in Navy recruits during 1954. On the theory that recurrence 
of an epidemic might stem from incoming recruits, prophylaxis was con- 
tinued in about half of newly arrived men. Results were inconclusive but 
the authors expressed an opinion that epidemic recurrence more probably 
stemmed from uneradicated sources on the post than from new recruits. 

Once virulent strains have been introduced, rapid spread occurs 
from old recruits to new recruits. During epidemics, a high percentage 
of recruits completing training are carriers and may spread the epidemic 
into other populations to which they are assigned. In the Navy, a majority 
of the population in service schools {secondary training) is derived directly 
from the several recruit training centers. If epidemic streptococcal infec- 
tions are occurring at any one of the recruit centers, a direct pathway of 
spread into the several service schools exists. Because these schools are 
located on posts where recruit training is also done, epidemics originating 
in recruits on one post may reach recruits at another post via the transfer 
of large numbers of men into the service schools. 

Because epidemics can quickly be brought under control with a rel- 
atively short course of oral penicillin, and the effects can be expected to 
persist to some degree after prophylaxis is stopped, it would seem more 
practical that a diligent search be maintained for first evidences of the 
beginning of epidemics and that control be maintained by intermittent 
courses. This is particularly true because it appears that it may not be 
necessary to prevent all streptococcal infections to maintain a continued 
suppression of rheumatic fever. Under circumstances where epidemics 
rapidly recur, it may prove practical to maintain suppression by contin- 
uous administration of 50,000 units of oral penicillin once daily. 

In general, however, continuous prophylaxis with small doses is 
undesirable unless administration can be strictly supervised by responsible 
individuals. In these studies, both supervisors and recipients were reluc- 
tant to adhere to the program after the epidemic was ended. There is also 
a greater risk of causing emergence of a penicillin- resistant strain of 
group A streptococcus --if such exists. Men known to have had previous 
attacks of rheumatic fever should probably receive continuous prophylaxis 
throughout their stay in training camps or schools. For this, a long-acting, 
parenteral penicillin preparation is probably preferable to oral penicillin. 

When men known to have had previous sensitivity reactions to penicil- 
lin are exempted, the risk of mass prophylaxis with oral penicillin is 



12 



Medical News Letter, Vol. 25, No. 11 



negligible. An occasional severe reaction will probably have to be antic- 
ipated but the risk appears to be minimal in comparison with the risk of 
individuals developing serious complications or sequelae if epidemics of 
streptococcal infections are allowed to go uncontrolled. There seems little 
possibility that penicillin-resistant strains of streptococci will emerge if 
mass penicillin prophylaxis is continued. 

Epidemics of streptococcal infection in military populations can be 
prevented by continuous administration of oral penicillin in a dosage as 
small as 50, 000 units per day. They can be abruptly terminated by a 
dosage of 250, 000 units of oral penicillin twice daily. If continued for 10 
days or more, this dose will eliminate the streptococcus from the throats 
of a majority of carriers. 

Suppression or termination of epidemics of streptococcal infections 
with penicillin is attended by a reduction or termination of rheumatic fever 
and other complications. Intermittent 10-day courses of 500, 000 units of 
oral penicillin daily, if spaced at short intervals, will probably almost 
completely prevent rheumatic fever even though limited recurrences of 
epidemic streptococcal infections occur between courses. 

The results of these studies should be applicable to civilian popula- 
tions and provide a means for the control of epidemic streptococcal infec- 
tions in children's institutions and schools. 

Penicillin prophylaxis is not considered a desirable or final answer 
to the problem of control of epidemic streptococcal infections. Rather, it 
is an interim measure, the judicious use of which will allow the emergency 
control of demonstrated epidemics of streptococcal infections and which is 
economically and administratively feasible. 

A knowledge of the epidemiology of streptococcal infections in the 
population for which prophylaxis is considered is essential for its intelligent 
use. (Seal, J. R. , CDR MC USN, Oral Penicillin Prophylaxis of Strepto- 
coccal Infections: Am. J. Pub. Health, 45: 662-672, May 1955) 

****** 



Reducing Salivary Lactobacillus Counts 



Consistently high counts of salivary lactobacilli have been found to be 
closely related to concurrent dental caries activity. Consistently low counts 
of salivary lactobacilli have been found to be associated with little or no 
concurrent activity of dental caries. 

Periodic counts of salivary lactobacilli have been used for some years 
by the Caries Control Laboratory of the University of Michigan School of 
Dentistry in the diagnosis of dental caries activity. Lactobacillus counts 
have also been used to determine the effectiveness of a dietary treatment 
(the elimination of sucrose and the reduction of other carbohydrates) in 
arresting dental caries activity. 



Medical News Letter, Vol. 25, No. 11 



13 



In October 1944, the Ohio State University College of Dentistry 
established a Caries Control Laboratory patterned closely after the Mich- 
igan Laboratory. The technic of making salivary Lactobacillus counts 
has been kept identical with that used at Michigan, therefore, the results 
of the two laboratories are comparable. The recommended low carbo- 
hydrate diets used in the Ohio Laboratory have been varied somewhat 
from those originally recommended at Michigan, but both laboratories 
have consistently recommended the elimination of sucrose from the diet 
and the reduction of other carbohydrates for periods of several weeks. 

This report is a supplement to the 1948 report, and includes data 
from the Ohio Laboratory records from October 1944 to June 1953. Briefly, 
the procedure for diagnosis and treatment of active dental caries has been 
as follows: 

Two stimulated saliva specimens are collected on consecutive days 
before the subject eats or brushes the teeth, and lactobacillus counts are 
made in the manner developed in the Michigan Laboratory. A patient who 
has a salivary lactobacillus count of over 10, 000 per cubic centimeter of 
saliva is regarded as caries active. For this patient, it is recommended 
that carious areas be repaired immediately. The patient is then instructed 
to follow, for a period of two weeks, a diet free of sucrose and low in other 
carbohydrates (as near as possible to 100 gm. of carbohydrate a day). This 
diet is referred to as PlanI diet and is free of bread, potatoes, and high 
carbohydrate fruits and vegetables, as well as of sucrose. Careful adher- 
ence to this diet will nearly always result in a reduction of the salivary 
lactobacillus count to practically zero. At the end of a two-week period on 
Plan I diet, a count of salivary lactobacilli is made and the patient is instruct- 
ed to change to Plan II diet. This is Plan I diet with the addition of some 
bread and some fruits and vegetables with a higher content of carbohydrate. 
At the end of two weeks of Plan II diet, another salivary lactobacillus count 
is made. If the count has remained low, the patient is instructed to change 
to Plan III diet. This consists of Plan I diet with the addition of bread, un- 
restricted fruits and vegetables, and the equivalent of one teaspoonful of 
sugar per day, if desired. After a two-week period of Plan III diet, the 
salivary lactobacillus count is determined, and if it is low the patient is 
allowed to change to Plan IV diet. This is a nearly unrestricted diet. 
However, the patient is instructed to keep sugar consumption low if he 
wishes to avoid a subsequent increase in the salivary lactobacillus count 
with its resultant resumption of dental caries activity. 

The Laboratory intends to follow each patient with periodic lacto- 
bacillus counts for a period of at least two years after the initial dietary 
treatment has been completed. Any increase in the counts is followed by 
recommendations to the patient to restrict sugar consumption. 

The Ohio State University Dental Caries Control Laboratory has, 
over a period of 8 years, made salivary lactobacillus counts on 1089 patients. 



14 



Medical News Letter, Vol. 25, No. 11 



Of this number, 811 individuals had over 10, 000 lactobacilli per cubic 
centimeter of saliva at the time of the initial counts. Two hundred and 
seventy-eight had salivary Lactobacillus counts of less than 5000. Of the 
278, 101 subsequently had increased counts. Of the caries-active individ- 
uals, 410 completed two weeks of the Plan I diet with low counts. Of these, 
318 completed Plan II with low counts. Of the 318, 225 completed Plan III 
with low counts. One hundred and forty-two continued to have low counts 
after two weeks of Plan IV diet. Ninety-one of 126 individuals checked 
had low counts after 6 months on Plan IV. Fifty-three of 75 individuals 
checked had low counts after one year on Plan IV diet. Twenty-five of 
34 individuals checked had low counts after two years on Plan IV diet. 
Fourteen of 23 individuals checked had low counts after three or more 
years on Plan IV diet. The results compare favorably with those published 
by Jay. (Kitchin, P. C. , and Permar, D. , Results of an Eight-Year Study 
of the Effectiveness of Carbohydrate Restriction in Reducing Salivary Lacto- 
bacillus Counts : J. Dent. Res., 34_: 89-93, February 1955) 

****** 



Toothbrushing Procedure for Orthodontic Patient! 



Attempts have been made throughout history to clean the teeth, although 
the toothbrush as now known was developed in the last century. A review of 
the literature on toothbrushing reveals the following techniques which have 
possible implications for the orthodontic patient: Haphazard Method, Fones 
Method, Roll Method, Charters Method, Stillman Method, Physiologic 
Method, and Miscellaneous Methods. 

The first thing that comes to mind when considering toothbrushing 
is that, if properly done, it will reduce the incidence of caries. Miller 
formed the chemicoparasitic theory of dental caries which is now generally 
accepted. According to this concept, caries is caused by an acid disintegra- 
tion of the inorganic part of the tooth by acids which are formed from bac- 
terial action on carbohydrates. The organic remainder of the tooth is then 
removed by proteolytic action of the same or different bacteria. This theory 
was strengthened by the work of Williams who demonstrated the presence of 
bacterial plaques which confine this action on specific areas of the teeth. 

All of the caries control measures that are discussed should be used 
in order to keep the formation of new caries to a minimum. 

Toothbrushing is equally important in maintaining a normal gingiva 
during orthodontic treatment. The orthodontic appliance interferes with 
the normal stimulation which the periodontium should receive by the excur- 
sion of food during mastication. Also, the accumulated debris, that lodges 
around orthodontic appliances not properly cleansed by brushing, acts as 



Medical News Letter, Vol. 25, No. 11 



15 



an irritant to the supporting structures of the teeth. This irritant will 
produce an inflammation of the gingiva. Local periodontal disturbances 
are caused by inflammation. 

The author does not recommend any particular type of dentifrice 
but follows the lead of the American Council of Dental Therapeutics of 
the American Dental Association which no longer evaluates dentifrices 
that do not claim caries -inhibitory factors. Those dentifrices containing 
chlorophyll, penicillin, urea, and ammonium compounds are placed by 
this council in a category requiring more investigation before their effec- 
tiveness can be accurately evaluated. More and more medicated denti- 
frices are appearing and although bacterial numbers can be reduced 
immediately after brushing, this inhibition is transient and the numbers 
of bacteria soon increase after brushing. The medicated dentifrices give 
the patient a sense of security so that he tends to be careless in other 
caries control measures. A dentrifice has three primary functions: 
(1) to increase the effectiveness of the brushing by containing an abrasive 
substance that will help to dislodge food particles and to polish the tooth 
surface; (2) to make the brushing procedure more enjoyable (for this reason 
a pleasant flavor is important); and (3) to reduce the surface tension of the 
saliva so that particles of debris may be removed more readily. Conse- 
quently, as long as the patient uses a dentifrice that is not harmful, the 
author does not recommend a change. He tells his patients that an intel- 
ligent application of "elbow grease" on the handle of the toothbrush is 
more important than the particular brand of toothpaste or powder that is 
used. 

The basic technique used calls for the use of the small soft-bristled 
brush. With this type of brush, the teeth can be adequately cleansed and 
the damage that can be inflicted is minimized. One of these brushes is 
furnished to each patient and one kept in the office for the patient's use. 
A toothpaste is also furnished as paste is easier to apply to the brush and 
is not as likely to become spilled in the office as toothpowder. The patient 
receives his first instruction in toothbrushing technique as soon as the 
excess cement is removed from the first bands that are placed. 

The technique used is basically the Roll technique. Toothpaste is 
applied to a new toothbrush and the technique is demonstrated in the mouth 
with the patient looking in a mirror. For demonstration purposes, the 
buccal surface of the upper left premolar region is selected as the stroke 
here is typical and easy for a right-handed patient to see. 

The brush is placed with the tip of the bristles at the mucogingival 
junction and with the sides of the brush in contact with the soft tissue. The 
brush then is brought down over the buccal surfaces of the teeth with a rotary 
motion in which the ends of the bristles move the farthest and the base of the 
bristle in the handle moves the least. As the brush sweeps over the free 
gingiva, it is vibrated mesiodistally so that the bristles go into the buccal 



16 



Medical News Letter, Vol. 25, No. 11 



embrasures and clean that area. Then the stroke is continued over the 
bands and tooth surface. This type of brushing removes particularly the 
debris in that area between the free margin of the gingiva and the ortho- 
dontic appliance. This is the area of the tooth surface most amenable to 
toothbrushing as a preventive measure for periodontal disturbances and 
caries. 



The patient practices this technique until he becomes proficient at 
it in this area. Then a definite sequence of areas to brush is given to the 
patient. Because the lingual surfaces of the teeth usually are poorly 
brushed, the author recommends that they be brushed first. The teeth 
are brushed by starting with the most posterior tooth on the upper left side. 
The position of brush and the stroke are the same as described for the 
buccal surface of the teeth. When the lingual surface of the posterior 
teeth has been cleansed, the patient moves the brush to the lingual surface 
of the anterior teeth. Here is is necessary to hold the long axis of the 
brush parallel to the long axis of the teeth. However, a similar type of 
motion is used with a downward and forward roll. When this has been done, 
the brushing is continued on around the arch to the lingual surface of the last 
molar on the right side. Then the upper buccal surface is done as previous- 
ly described, starting with the most posterior tooth on the left side and 
going around the arch to the right. Then the patient starts with the lingual 
of the lower left area, and goes around the arch to the lingual on the right 
side. Next he starts on the buccal surface of the lower left side, and moves 
around to the right. Finally, he brushes the occlusal surface with a back 
and forth stroke. 

Oral hygiene has not been adequately described in the orthodontic 
literature. The importance of toothbrushing has been repeatedly empha- 
sized, but how the teeth should be brushed, when the teeth should be brushed, 
and why the teeth should be brushed, have been neglected. A number of tech- 
niques of brushing the teeth are advocated for the patient without orthodontic 
appliances in place. This article presents a specific toothbrushing technique 
for orthodontic patients. 

Just how much effect toothbrushing has on the incidence of caries 
is questionable. However, the cavities that occur on the cervical portions 
of the teeth can be prevented by proper cleansing. The teeth should be 
brushed soon after eating in order to obtain the maximum benefits of tooth- 
brushing. There are other methods of caries prevention that must not be 
ignored. They include restriction of sugar in the diet, use of fluorides, 
proper band construction, proper band cementation, et cetera. Toothbrushing 
is equally important in preventing immediate and future periodontal distur- 
bances, and halitosis. Tooth brushing has certain psychologic and esthetic 
values as well. 

The patient must be properly motivated or he may be one of the many 
who will not make the required effort to maintain a clean mouth. Consequently, 



Medical News Letter, Vol. 25, No. 11 



17 



certain psychologic principles must be followed in instructing the patient 
about oral hygiene measures. (Woods, G. A. Jr., Toothbrushing Procedure 
for Orthodontic Patients: Am. J. Orthodontics, 41: 370-383, May 1955) 



% # * * * * 



C lini cal Experience with Intravenous Infusion of Emulsified Fat 

The utilization of intravenous fat, the methods by which it leaves the 
blood, and its effect upon hepatic function have been studied. The present 
report concerns the results of 1466 infusions of fat emulsions in 426 patients 
and represents the larger part of the authors' clinical experience with fat 
emulsions during the period from September 1950 to July 1954. 

The incidence of thermogenic responses to the infusion of emulsified 
fat has been one of the major difficulties that has confronted workers in 
this field At the present time there is still uncertainty about the origin 
of these pyrogens and their mode of operation. When these clinical studies 
were begun it was believed that pyrogenicity resulted in large part from 
contamination of raw materials. Consequently, many different sources of 
a given oil, as well as different oils, were used and considerable effort was 
made to eliminate possible sources of contamination and to remove traces 
of contaminants by chemical and physical purification. This effort has been 
continued, using both natural and synthetic oils. 

The authors found it necessary to evaluate numerous natural and 
synthetic emulsifying agents and triglycerides in the laboratory; those which 
appeared promising were eventually tested in the clinic. For these reasons, 
a large number of different batches of emulsions have been prepared, tested 
in animals, and finally, applied clinically. During the period covered by this 
report, more than 1000 different experimental and clinical emulsions have 
been prepared, and of these, 151 have been used in patients. 

The data presented summarize the clinical observations made by the 
authors. Preclinical testing of the emulsions included infusion intraven- 
ously into three species of animals-rats, dogs, and rabbits-plus micro- 
scopic examination of the emulsion using the phase microscope. Emulsions 
were also tested for sterility. The details of these studies are given in a 
separate report. Emulsions which passed all preclinical tests were then 
used in patients. In using the emulsions in man, if any particular batch 
gave rise to a series of reactions, it was discarded. Similarly, if any 
individual patient reacted severely to administration of fat infusions, he 
was usually given no further infusions. 

A temperature rise of more than two degrees, a chill, or any obvious 
reaction has always been considered adequate reason for stopping an infu- 
sion On the other hand, if a given patient tolerated the infusions well, he 
may have been infused daily for several weeks. For these reasons, the 



18 



Medical News Letter, Vol. 25, No. 11 



data are weighted favorably. Using these methods, the authors found that 
approximately 100 infusions in at least 25 patients are required to gain an 
adequate evaluation of the clinical usefulness of any particular type of emul- 
sion. Clinical testing of this sort has been, and still is, necessary to 
determine the final behavior of any particular emulsion or batch of emulsion 
because, to date, it is impossible to predict the clinical result on the basis 
of laboratory and animal experimentation. 

Almost all of the 426 patients in these studies were ill and in need of 
caloric supplementation. All but a few were being treated on the wards of 
the Massachusetts General Hospital, and these few were patients in other 
local hospitals. The group as a whole, therefore, constitutes a reasonable 
cross section of severely ill patients in a large general hospital. Almost 
every common type of disease that might be associated with acute or chronic 
starvation is represented, but the majority were suffering from gastrointes- 
tinal tract neoplastic disease or intra-abdominal infection. 

Emulsions containing 10 to 15% of coconut, olive, peanut, and cotton- 
seed oils, and synthetic triolein have been used. 

Data pertaining to such reactions as pyrogenicity, blood pressure, 
pulse, and chills are presented. The collected data are analyzed in regard 
to the over-all effect of type of oil, concentration of oil, concentration of 
emulsifiers, presence of synthetic emulsifiers, quantitative and qualitative 
serum protein abnormalities of patients, and the effects of an antihistaminic 
on these reactions. 

Ninety-one percent of the cottonseed oil infusions, 86% of the coconut 
oil infusions, 82% of the olive oil infusions, 85% of the coconut oil-olive 
oil infusions, 83% of the peanut oil infusions, 76% of the synthetic triolein 
infusions were without pyrogen reaction. If temperature rises of 2. 0° F are 
excluded, the percentage of successful infusions rises appreciably to 97% 
for emulsions of cottonseed oil and 94% for emulsions of synthetic triolein. 
A small number of other unfavorable reactions occasionally observed are 
discussed in detail, especially as they pertain to the intrinsic colloid char- 
acter of fat emulsions. 

Substantial progress has been made toward the solution of the problems 
associated with the availability and use of emulsions of fat that can be given 
satisfactorily by vein. (Waddell, W. R. , et al. , Clinical Experience with 
Intravenous Infusion of Emulsified Fat: J. Lab. & Clin. Med , 45-697-709 
May 1955) ' 

Combined Steroids to Supp ress Lactation 

With an increasing number of patients who cannot or will not nurse 
their babies, the physician finds himself more and more in need of a simple 



Medical News Letter, Vol. 25, No, 11 



19 



method of suppressing lactation and preventing the discomfort of breast 
engorgement during the puerperium. Prior to the advent of hormonal 
therapy, the only widely used treatment was breast binders with suppor- 
tive analgesics. Both doctors and patients have objected to this method. 
Parker points out that a tight breast binder can seriously limit respiratory 
excursions and, if improperly applied, increase the likelihood of mammary 
abscess. Patients complain of the mastalgia of the breast engorgement, 
the discomfort and inconvenience of the breast binders, and the frequent 
failure of the binding to prevent lactation. 

On the assumption that a combined estrogen-androgen might offer 
the benefits of both and the side effects of neither, Premarin with methyl- 
testosterone was employed in 267 cases to inhibit lactation in the puer- 
perium. In the belief that this method offers a workable solution, this 
report is added to the literature. 

The 267 cases in this series from the author's general practice were 
patients in whom post-partum lactation was not desired. In only 6 of the 
cases was suppression advised because of inadequate breast tissue, inverted 
nipples, severe post-partum bleeding, or severe pre-eclampsia. The re- 
maining 261, for various reasons, requested to bottle feed their babies. 

The dosage regimen was three tablets every 4 hours for five doses. 
The first dose of Premarin with methyltestosterone was administered 
immediately on the patient's return to her bed from the recovery room, 
usually about 45 minutes after delivery. Reich states that, in estrogen 
therapy, the success of therapy varies inversely with the length of time 
between parturition and initiation of treatment. As this observation had 
been found to hold true in the author's experience with estrogen, *the com- 
bined steroids were administered as soon as possible after delivery. In 
only two cases was the dosage delayed. In one, a case of post-partum 
bleeding immediately after delivery, the drug was withheld for 12 hours. 
In the second case, because of a nursing error, the patient did not receive 
her first dose for 8 hours. Both patients developed engorgement of the 
breasts. 

In no case was it necessary to prescribe additional amounts of the 

drug. 

Besides a brassiere to support the pendulous breasts, supplemental 
therapy was unnecessary. The brassiere was used only during the 5 days 
of hospital stay. On discharge, the patient was told that its further use 
was unnecessary. Saline purges, restriction of fluids, local applications 
to the breast, and analgesics were not required. 

The efficacy of this method of therapy was evaluated on these criteria: 
(1) prevention of the discomfort and mastalgia of breast engorgement, (2) 
permanent inhibition of lactation; and (3) absence of untoward symptoms 
referable to the drug therapy. 



20 



Medical News Letter, Vol. 25, No. 11 



One hundred and sixty- six patients (62. 4%) who had no breast engorge- 
ment or untoward symptoms from the medication were considered to have 
had excellent results. Those who noticed a full but not painful sensation 
in the breasts were classified as having mild breast engorgement and were 
considered to have had good results. Ninety-one patients (33. 8%) fell into 
this category. Ten patients (3. 8%) with a full sensation and a slight lactor- 
rhea were classified as having moderate breast engorgement and considered 
to have only fair results. These symptoms occurred on the sixth or seventh 
day post-partum. A patient with painful breasts (severe engorgement) re- 
currence of lactation, or untoward side effects, would have been considered 
to have had poor results. No patient warranted this classification. There 
was no nausea or vomiting, virilization, breast abscess, or excessive 
vaginal lochia, or bleeding after withdrawal of the drug. Menses returned 
after the normal interval of about 6 weeks. Of notable importance was the 
absence of mental depression in the puerperium. This was believed to be 
due to the combined effects of estrogen and androgen. 

In this series, the success of Premarin with methyltestosterone to 
suppress breast engorgement and lactation was most gratifying. Its use 
provided a simple scheme of therapy that was fully effective in 96. 2% of 
the cases. (Fiskio, P. W. , Combined Steriods to Suppress Lactation- 



GP > H : 70-72, May 1955) 



****** 
Household Goods 



Have you just received orders to sea duty or duty overseas? If so, 
you may request non-temporary storage of those household goods which ' 
you do not desire to take to your new duty station. Approval for requests 
for non-temporary storage depends, however, on whether space is avail- 
able. Non-temporary storage may not be available at the designated ship- 
ping activity arranging for shipment of your household goods. Therefore, 
the goods may have to be packed, crated, and shipped to one of the desig- 
nated non-temporary storage activities. 

If commercial transportation is utilized in placing your household 
goods in non-temporary storage, no further shipment is authorized under 
identical orders except in instances when you are ordered to places where 
shipment of household goods and dependents' travel is prohibited. In these 
instances, re-shipment may be authorized from non-temporary storage to 
the duty station provided a certificate is obtained from the overseas area 
commander to the effect that shipment of household goods or dependents' 
travel will not be authorized within 20 weeks. 

If re- shipment is contemplated, this certificate should be obtained 
prior to shipment to non-temporary storage since the certificate is the 



Medical News Letter, Vol. 25, No. 11 



21 



official document which will be used to support re-shipment upon receipt 
of approval for shipment of household goods or dependents' travel. 

Non-temporary storage may be requested in connection with retire- 
ment including temporary disability retirement or transfer to the fleet 
reserve or fleet Marine Corps reserve. You may avail yourself of this 
right only in those instances where non-temporary storage is available 
at point of origin. If commercial transportation is involved in placing 
household goods in non-temporary storage, no further shipment is auth- 
orized at Government expense. 

Non-temporary storage is also authorized upon being detached from 
a permanent duty station and ordered to temporary duty. This right is 
limited, in most instances, to non-temporary storage at point of origin 
since temporary duty orders do not entitle you to shipment of the permanent 
weight allowance except under orders to temporary duty in connection with 
tie building, fitting -out or conversion of a vessel or temporary duty pend- 
ing assignment aboard or to a vessel 

If multiple shipments to your duty station and non-temporary storage 
are desired, contact your shipping officer to determine your entitlement. 
If such shipments are approved by your shipping officer, carefully check 
the inventories covering both shipments to ensure that the goods required 
at the overseas duty station are not included on the inventories covering 
shipment to non-temporary storage. (BUSANDA, Monthly Newsletter, 
April 1955) 

****** 
T V Production -- "The Lifeline" 

On 16 May 1955, Medic TV Productions telecast "The Lifeline," 
a film made aboard the Hospital Ship USS Haven. In a letter to the Surgeon 
General, the Production Manager expressed the deep appreciation of the 
company for the cooperation and fine assistance extended by the officers 
and crew during the filming of this production, and the hope that the pic- 
ture would be an honor and credit to the U. S. Navy and would reflect the 
great spirit exemplified by the entire staff of the USS Haven. 

****** 

Ac ti v e Duty Training Opportunities for Naval Reserve 
Personnel During Fiscal Year 1956 

The Chief of Naval Personnel has promulgated information concerning 
active duty for training ashore for Naval Reserve officer and enlisted per- 
sonnel during f iscal Year 1956. 



22 



Medical News Letter, Vol. 25, No. 11 



Special courses of instruction, designed to aid in keeping Reserve 
medical personnel not on active duty abreast of recent advancements in 
military and naval medicine, have been established as listed below. 

Eligible Reserve medical personnel, including those attached to pay 
units of the Naval Reserve, are encouraged to take advantage of the oppor- 
tunity to attend one of these courses in a pay status. Quotas, providing 
for pay and authorized allowances for personnel in a non-drill pay status, 
have been assigned each naval district. Contingent upon non-availability' 
of funds, active duty may be performed without pay. Detailed information 
concerning these courses may be obtained from District Commandants. 

Seminar for Commanding Officers, Naval Reserve Medical Companies 
{Six days) Will convene in the Bureau of Medicine and Surgery, Navy Depart 
ment, Washington 25, D C. on 31 October 1955. All naval districts have 
been assigned a quota for this seminar. 

Medical Military Training . (Twelve days) U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Md. ; 3 October 1955 and 12 Marc 
1956. Chief, Naval Air Reserve Training, Potomac River Naval Command 
and all naval districts, less 11th, 12th, and 13th, have beenas signed quotas. 
Officer personnel only. 

Insect and Rodent Prevention and Control . (Fourteen days) Preven- 
tive Medicine Unit No. 1, Naval Air Station, Jacksonville, Fla. ; first 
Wednesday of each month. Chief, Naval Air Reserve Training, Potomac 
River Naval Command and all naval districts, less 11th, 12th, and 13th, 
have been assigned quotas. Male officer and enlisted personnel only. 

On-the-Job Training in Submarine Medicine. (Fourteen days) Naval 
Medical Research Laboratory, Naval Submarine Base, New London, Conn. 
First Monday in August - November 1955 and February - May 1956. Dis- 
tricts 1, 3, 4, 5, 6, 8, and 9 have been assigned quotas. Medical and 
Medical Service Corps officers only. 

On-the-Job Training in Medical Research . (Fourteen days) Naval 
Medical Research Laboratory, New London, Conn. Earliest possible 
date Fiscal year 1956. Districts 1 and 3 have been assigned quotas. 

Aviation Medical Equipment Laboratory, Naval Air Material Center, 
Philadelphia, Penn. Earliest possible date Fiscal Year 1956. Districts 
4 and 5 have been assigned quotas. 

Aviation Medical Acceleration Laboratory, Naval Air Development 
Center, Johnsville, Penn. ,4-18 July and 1-15-29 August 1955. Dis- 
tricts 1, 3, 4, 5, and 9 have been assigned quotas. 



Medical News Letter, Vol. 25, No. 11 



23 



Naval School of Aviation Medicine, Naval Air Station, Pensacola, 
Fla. Earliest possible date Fiscal Year 1956. Districts 6 and 8 have been 
assigned quotas. 

Diving Unit, Naval Gun Factory, Washington, D. C. Earliest possible 
date Fiscal Year 1956. Potomac River Naval Command only has been 
assigned a quota. 

Naval Medical Research Unit No. 1, University of California, Berkeley, 
Calif. Earliest possible date Fiscal Year 1956. Districts 12 and 13 have 
been assigned quotas. 

Eligible are Ensigns, 1995 (Medical) who have successfully completed 
first year of medical school and who manifest an interest in medical research 
and development. 

Clinical Clerkship Training. (Sixty days) At U. S. Naval Teaching 
Hospitals designated by the Chief, Bureau of Medicine and Surgery. Earliest 
possible date Fiscal Year 1956. Potomac River Naval Command and all 
naval districts have been assigned quotas. Eligible are Ensigns, 1995 who 
have completed at least their second year in medical school. Each officer 
is eligible for only one tour of this training. 

Special Weap ons, Isotopes and Military Medicine . (Five days) Naval 
Station, Treasure Island, Calif. , 27 February 1956. Quotas have been 
assigned districts 11, 12, and 13. Male and female officer personnel only. 

Malariol ogy and Insect Control. (Fourteen days) Naval Air Station, 
Alameda, Calif. First and third Wednesday of each month. Quotas have 
been assigned districts 11, 12, and 13. Male officer and enlisted person- 
nel only. 

Field Medicine. (Fourteen days) Camp Pendleton, Oceanside, Calif. , 
15 August and 10 October 1955. Quotas, have been assigned districts 1 1, 12, 
and 13. Male officer and enlisted personnel only. 

O n-the-Job Training, (fourteen days) Any suitable training medical 
facility. Reporting date to be arranged between the Commandant, trainee, 
and Commanding Officer of the training facility. Quotas have been assigned 
all districts. Male and female officer personnel. 

On-the-Job Training . fourteen days) Any suitable Naval medical 
facility as determined by the cognizant Commandant, preferably, a naval 
hospital. Quotas have been assigned Potomac River Naval Command and 
all naval districts. Eligible are Reserve enlisted personnel in training for 
a change to hospital corps rating (Group X). Personnel must have completed 
their initial recruit training in accordance with current instructions. 
(ResDiv, BuMed) 



24 



Medical News Letter, Vol. 25, No. 11 



From the Note Book 

1 The symposium of the Surgeon General of the Navy with high ranking 
medical and dental officers of the Navy and the Naval Reserve was held 
at the National Naval Medical Center, Bethesda, June 1 - 3, 1955. Rear 
Admiral B. E. Bradley, MC USN, Deputy and Assistant Chief of the Navy's 
Bureau of Medicine and Surgery, served as Chairman. 

A principal feature of this symposium was a series of panels, or 
round table discussions, which provided opportunity for the conferees to 
discuss with each other and with representatives of the Bureau of Medicine 
and Surgery, their views, problems, and possible solutions. The medical 
panels were attended by fleet, force, type and staff medical officers; 
district medical officers; and commanding officers of naval hospitals. 
Conducted simultaneously with the medical panels was a series of dental 
panels and panels on research and Reserve activities. Attending the 
dental panels were fleet, force and staff dental officers; the inspectors of 
Naval dental activities, Pacific and Atlantic Coasts; district dental officers; 
the commanding officer of the Naval Dental School, Bethesda; and command- 
ing officers of Naval dental clinics. Commanding officers and officers-in- 
charge of Naval research laboratories attended the research panels, and 
the Assistants to District Medical Officers (Medical Reserve Program) 
attended the Reserve panel discussions. (TIO, BuMed) 

2 Rear Admiral W. P. Dana, MC USN, Assistant Chief for Aviation and 
Operational Medicine and Assistant Chief for Research and Medical Military 
Specialites, represented the Bureau of Medicine and Surgery during an 
Office of Naval Research-sponsored visit to LOBUND Institute, South Bend, 
Ind. , May 24 - 25, 1955. The visit provided an opportunity to observe the 
present status of research with germ -free animals at the Institute; the 
problems involved in large-scale production, maintenance, and utilization 
of germ-free animals; and the other aspects of the long-range approach to 
germ-free animal research. (TIO, BuMed) 

3 CDR H. S. Etter, MC USN, Director of the Special Weapons Defense 
Division, Bureau of Medicine and Surgery, participated in a panel discussion 
of 'Atomic Bomb Injury, Prevention and Treatment" at a meeting of the 
Blair County (Pennsylvania) Medical Society and Civil Defense officials in 
Altoona, Penn. , on May 24, 1955. 

The coordinator for the discussion was Rear Admiral C. F. Behrens, 
6th Naval District, Charleston, S. C. Captain D. W Miller, MC USN, 
Chief of Surgery at the Naval Hospital, Newport, R. I. , was also a dis- 
cussant. (TIO, BuMed) 



Medical News Letter, Vol. 25, No. 11 



25 



4 The staff of Navy Medical Research Unit #3, Cairo, Egypt, par- 
ticipated in the Vth Middle East Medical Assembly, Beirut, Lebanon. 
Six papers were read by members of the staff. Exhibits dealing with the 
diagnosis of brucellosis, schistosomiasis, and urinary tract malignancy 
were also shown. (NAMRU 3) 

5 The American College of Radiology has prepared a pamphlet giving 
a brief introduction to radiology. The information is presented in terms 
and explanation suitable for the information of the patient and others who 
may be interested and who are not familiar with professional terms. 
(DMO, 6th ND) 

6 A new edition of a directory of services and facilities available to 
cancer patients throughout the United States has been issued by the Public 
Health Service. The directory, "Cancer Services and Facilities in the 
United States, 1954", compiled by the National Cancer Institute, can be 
purchased from the Superintendent of Documents, Government Printing 
Office, Washington 25, D. C. , for 45 cents a copy. ( P. H. S. , Dept. , 

H. E. W. ) 

7 Special mechanisms by which the body destroys drugs and other 
"foreign" compounds, have been discovered, revealing that the body has 
systems of "counter agents" that attack and inactivate drugs. The counter 
agents are contained in little- studied liver microsomes, tiny particles of 
the body's cells too small to be seen even with a microscope. This dis- 
covery stems from research on the fate of drugs in the body being conducted 
by the Public Health Service's National Heart Institute, National Institutes 
of Health, Bethesda, Md. (P. H. S. , Dept. , H. E. W. ) 

8 A report of 141 cases of primary serofibrinous pleural effusion in 
young adult white men indicates the tuberculous nature of this form of 
pleurisy and emphasizes the importance of adequate, immediate treatment 
and long -continued observation to prevent relapse. (Am. Rev. Tuberc. , 
May 1955; LtCol W. H. Roper, MC USA, J.J. Waring, M. D. ) 

9 The treatment of subacute bacterial endocarditis is discussed and 

the need for early intensive and prolonged treatment stressed. (Am. J. Med. , 
April 1955; I. A. Feder, M. D. ) 

10 An analysis of the failures in a series of 400 consecutive patients 
undergoing resections for pulmonary tuberculosis is presented in J. Thoracic 
Surg., April 1955; R.J. Schlosser, M. D. , F.I. Jarvis, M. D. 



****** 



Medical News Letter, Vol. 25, No. 11 



Board Certifications - Inactive Dut y Officers 

American Board of Anesthes iology 

LTJG Richard G. Ellis (MC) USNR 
LT Alfred T. Wagner (MC) USNR 

American Board of Dermatology and Sy philology 
LT Edwin M. Hamlin (MC) USNR 
LT Harry L. Wechsler (MC) USNR 

American Board of Gastroentero logy 

CAPT John H. Willard (MC) USNR 

American Board of Internal Medicin e 

LTJG Keehn "W" Berry, Jr. (MC) USNR 
LT William G. Donald, Jr. (MC) USNR 
LTJG Buford Hall, Jr. (MC) USNR 
LTJG Fred "Z" Havens, Jr. (MC) USNR 
LT Leo E. Hollister (MC) USNR 
LT Harold P. Johnson, Jr. (MC) USNR 
LCDR James W. Leathe rman (MC) USNR 
LTJG William M. Luikart (MC) USNR 
LTJG Antonio V. Mascatello (MC) USNR 
LCDR Herbert C. Moffitt, Jr. (MC) USNR 
LT Richard H. Saunders, Jr. (MC) USNR 
LTJG Roy F. Saxon, Jr. (MC) USNR 
LTJG Roy S. Sheffield (MC) USNR 
LT Edward B. Wells (MC) USNR 
LTJG Richard S. Wilbur (MC) USNR • 

American Board of Internal Medicine and Gastroent erology 
LT John W. Fmdley, Jr. (MC) USNR 

American Board of Neurological Surg ery 

LT Lawrence H. Arnstein (MC) USNR 
LT Edward D. Horning (MC) USNR 
LTJG Martin P. Sayers (MC) USNR 
LTJG Charles D. Scheibert (MC) USNR 

American Board of Ophthalmology 

LTJG Paul St. Cyr Blak (MC) USNR 
LT Robert F. Merchant (MC) USNR 
LCDR Wixom S. Sibley (MC) USNR 
(to be continued in the next issue of the Medical News Letter) 



Medical News Letter, Vol. 25, No. 11 



27 



BUMED NOTICE 5212 13 Ma V 1955 

From: Chief, Bureau of Medicine and Surgery 

To: All Naval Hospitals and Stations Having Infirmaries 

Subj: Transfer of certain medical records to GSA Records Center 

Ref: (a) ManMedDept, Art 23-303 (6) (d), item 617- 

This Notice advises that the VA Records Center, Columbus, O. , is disestab- 
lished; clinical records for VA patients hospitalized in Navy medical facil- 
ities should be held temporarily before forwarding to GSA Records Center. 

****** 

BUMED NOTICE 12000 16 Ma ^ 1955 

From: Chief, Bureau of Medicine and Surgery 
To: National Naval Medical Center 
Naval Hospitals (continental) 

Subj: Industrial Relations Institute Schedule for Fiscal Year 1956, 
information concerning 

Ref: (a) NCPI 230. 15-7 

This Notice announces the Industrial Relations Institute Schedule for the 
fiscal year 1956. This Institute is further described in reference (a). 

****** 

BUMED INSTRUCTION 7320. 3 25 Ma V 1955 

From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Medical /Dental Personnel Regularly 
Assigned 

Subj: Unit pricing of Medical Department property; accounting procedures 

Ref: (a) NavComp Man, Vol 3, Ch 6 
(b) ManMedDept, Art 25-3 

This Instruction reaffirms a uniform accounting procedure for establishing 
and maintaining unit prices of property under the cognizance of BuMed. 



28 



Medical News Letter, Vol. 25, No. 11 



| MM MM mm mmm m ■ 



PREVENTIVE MEDICINE SECTION 



Communicable Disease Control 

Notes on Salk Poliomyelitis V accine 

Plans for the immunization of dependent children of Navy and Marine 
Corps personnel on active duty with Salk poliomyelitis vaccine have been 
announced in ALSTAOUT 1 of 19 April 1955, and ALSTACON 3 of 3 May 1955. 
Detailed instructions on the distribution and use of this vaccine are being 
prepared and will reach the field by the time commercially available vaccine 
is delivered to the Armed Forces for distribution. 

It was expected that all dependent children in the first and second 
grades of schools in the continental United States, Hawaii, and Alaska 
would receive the vaccine in the program being conducted by the National 
Foundation for Infantile Paralysis. At the request of the Armed Forces, 
the Assistant Secretary of Defense (Health and Medical) asked the Found- 
ation also to provide enough vaccine for dependent children in the same 
grades of schools in overseas areas other than Hawaii and Alaska. An affir- 
mative reply has been received but the delivery date of the vaccine is still 
unknown. It will be distributed immediately upon receipt in amounts suf- 
ficient for the first two immunizing doses for the first and second grade 
school children indicated in requisitions submitted in accordance with 
ALSTAOUT I. 

Since early March, Armed Forces Medical Procurement personnel 
have maintained contact with the manufacturers of poliomyelitis vaccine 
in regard to plans for commercial distribution. Through radio and the 
press, most readers will be aware of the changing plans since efficacy of 
the vaccine was announced and it was licensed on 12 April 1955. At this 
writing, all commercially available vaccine will be subject to allocation 
by the Poliomyelitis Vaccine Advisory Committee of the Department of 
Health, Education, and Welfare. It is expected that initial allocation to 
the Armed Forces will be made on the basis of a ratio between the number 
of dependent children aged 5 through 9 and the total number of children in 
the United States of this age. (This is the same plan being used for each 
of the 48 states. ) Subsequently, allocations will be made in accordance 



Medical News Letter, Vol. 25, No. 11 



29 



with other age priorities recommended by the Advisory Committee until 
all children aged 1 through 19 years, for whom immunization is desired, 

have been supplied. 

Because of the National Allocation Plan and the necessity for central 
procurement by the Armed Forces, it is not expected that any efforts which 
may have been made by field activities in attempting local procurement, by 
or on behalf of dependents, will prove successful. In the event dependents 
do obtain vaccine locally through any source other than the National Found- 
ation for Infantile Paralysis, it will be deducted from the amount allocated 
to the Armed Forces and, in turn, from the supply of the local activity. 

Only a very small quantity of vaccine was delivered to the Armed 
Forces on contracts negotiated prior to the allocation plan. This was sent 
to the Philippines. Information is J not now available as to when regular 
deliveries of vaccine will begin under the allocation plan. From estimates 
of commercial production potentialities, however, it will probably be late 
fall or winter before supplies will be available to complete the immuniza- 
tion of children in first age-priority groups. 

There seems little likelihood that production will permit immunization 
of any appreciable percentage of children in other age groups before the end 
of the poliomyelitis "season. " 



****** 



Pol iomyelitis 

(This section concerning the clinical aspects of poliomyelitis is the contin- 
uation of a review prepared by Members of the Commission on Viral Infec- 
tions of the Armed Forces Epidemiological Board as a revision of Army 
Technical Bulletin Medical No. 193, "Poliomyelitis. " Certain editorial 
changes --principally deletions of details of medical and orthopedic care-, 
have been made in adopting it for the publication in the U. S. Navy Medical 
News Letter. ) 

Cli nical Features. Various clinical and subclinical forms of polio- 
myelitis infection are recognized as (1) inapparent infection, which is by 
far the commonest form and actually represents the absence of symptoms 
and signs during a period in which virus is present in and excreted from 
the body and in which antibodies develop; (2) the minor illness or abortive 
form, characterized by nonspecific symptoms; (3) the major illness which 
rrlaTbe paralytic or nonparalytic and may appear either unheralded or as 
the second phase of the classical biphasic (dromedary) course of poliomye- 
litis; and (4) the so-called straggling type most often seen in adults. 

The incubation period is variable and may be shorter than is usually 
supposed, averaging from 3 to 8 days for the abortive case, and 9 to 13 



30 



Medical News Letter, Vol. 25, No. 11 



for the nonparalytic and paralytic cases; extreme ranges may be from 3 
to 35 days. Difficulty in estimating the incubation period results partly 
from the fact that first phase symptoms may be slight or absent in the 
frank case, but when they do occur it is logical to consider them as mark- 
ing the onset of the disease. 

The minor illness (which may or may not be followed by the major 
illness) consists of a brief febrile episode without signs referable to the 
central nervous system, but in which sore throat, headache, anorexia, 
vomiting, abdominal pain, and other nonspecific symptoms may be present. 
In such cases, the diagnosis can be only a presumptive one based largely 
on epidemiological circumstances. Such cases have been estimated to 
account for from 4 to 8% of those patients who become infected with a given 
type of virus, but there is also reason to believe that in some epidemics 
they may range up to 25%. 

The major illness is heralded by the symptoms and signs just mentioned 
as well as by those of central nervous system involvement, which include: 
stiff neck and back which may progress to weakness or paralysis of a muscle 
or various groups of muscles. It has been estimated that in the U. S. A. less 
than 2% of those persons infected with poliomyelitis virus acquire a major 
illness, and in this sense one can regard the development of paralysis in 
this disease as a complication. 

The symptomatology in children and adults differs sufficiently to 
warrant the use of the terms adult and childhood types of clinical poliomye- 
litis. In the childhood type the onset of either the minor or major illness 
is apt to be sudden in approximately 80% of the cases with fever as high 
as 102° or 103°. The biphasic form of the disease is more common in 
childhood, the early symptoms consisting of sore throat, vomiting, and 
headache; the late symptoms consisting of headache, vomiting, stiff neck, 
and stiff back, which appear rather rapidly, sometimes tenderness in the' 
limbs or abdomen, and, in rare instances, diarrhea. After one or more 
days of fever of the second phase, weakness or paralysis of various muscles 
may appear. 

In the adult type the onset is apt to be more insidious than in the child- 
hood type and the biphasic form is less common. The patient is restless 
and uneasy and complains of stiffness of the muscles which he thinks he can 
resolve by exercising. He may at the same time be afebrile. Other common 
symptoms are malaise, listlessness, mild intermittent headache, anorexia, 
vague pains or stiffne'ss in the extremities, generalized tremulousness, and 
localized areas of hyperesthesia and paresthesia. Often pain in the back 
may be quite severe. These symptoms may persist for several days, 
occasionally even for a week or more, before the onset of fever becomes 
appreciable (greater than 100. 5°). During this period it may be difficult 
to reach a decision as to whether or not the patient is really ill, although 



Medical News Letter, Vol. 25, No. 11 



31 



the importance of early diagnosis is obvious, if only for the sake of avoid- 
ing excessively fatiguing or exhausting work or exercise. 

In both childhood and adult types, a large variety of other signs and 
symptoms may be encountered early in the illness. These include transient 
personality changes, emotional lability, extreme irritability which may be 
followed by listlessness, lassitude, drowsiness, and even coma. Convul- 
sions are rare but may occur. Dizziness which is not a true vertigo but a 
lightheadedness is not uncommon. Shaking chills are rare and are more 
apt to occur in the bulbar form of the disease. 

Clinical varieties of encephalomyelitis are recognized to occur in 
this disease. All poliomyelitis cases have lesions of varying extent in the 
spinal cord, brainstem, cerebellar nuclei and motor area. The clinical 
forms are due to dominance of the lesions. These forms are spinal para - 
lyt ic poliomyelitis ; bulbar poliomyelitis; and encephalitis in poliomyelitis. 
In the spinal form, paralysis usually develops after 1 to 4 days of nonpara- 
lytic illness characterized by the aforementioned symptoms. On the other 
hand, paralysis may be the first manifestation of illness. Muscle pain 
may become more prominent with the onset of paralysis which is of a 
flaccid or lower motor-neuron type and is characteristically asymmetrical 
in distribution but may have any distribution. The muscles commonly para- 
lyzed in order of frequency are those of the legs, arms, back, and thorax 
(including the intercostals and diaphragm). Paralysis of the muscles of 
respiration may occur. 

In bulbar poliomyelitis , paralysis of one or more muscle groups 
innervated by the cranial nerves, especially those of the soft palate and 
pharynx, occurs, and this gives rise to dysphagia, dyspnea, and nasal 
speech. Paralysis, of the muscles of the face, tongue, jaw, and eye may 
also occur. Its most serious manifestations are involvement of the circula- 
tory or respiratory centers. These may develop with great rapidity and 
are of grave prognosis. Practically all acute deaths from poliomyelitis 
are attributable to bulbar involvement. 

E ncephalitis in Poliomyelitis . So-called encephalitic manifestations 
suc h as drowsiness, coma, and tremors are sometimes observed and may 
be common. Patients with coma show no pathological lesions that are not 
found in patients without coma. Biochemical disturbances in the blood, 
rather than special "encephalitic lesions", may be responsible for the 
clinical signs of so-called "polio -encephalitis. " 

Clinical Course. The usual febrile course of the major illness seldom 
exceeds 4 to 10 days, about 5 days of fever is an average. As fever falls 
the prognosis regarding further spread of paralysis improves. 

Diagnosis. Poliomyelitis should perhaps be considered first when 
paralysis of one or more muscles develops (without accompanying sensory 
changes) in the course of an acute illness. Actually, paralytic poliomyelitis 



32 



Medical News Letter, Vol. 25, No. 11 



does not, as a rule, offer great difficulties in diagnosis. The medical 
officer's problem here is, rather, to be on the alert to diagnose the onset 
of respiratory difficulties in order that he may act immediately. Nonpara- 
lytic poliomyelitis , on the other hand, is not easily diagnosed although " 
during an epidemic of poliomyelitis the aseptic meningitis syndrome is 
usually caused by infection with poliomyelitis virus. 

The juvenile patient at the onset of the minor illness or the abortive 
disease presents the nonspecific picture of a mildly ill child with listless- 
ness, pallor, fever, and some redness of the pharynx. In the beginning of 
the major illness , whether paralytic or nonparalytic, the situation may be 
similar until stiffness of the neck, back, and hamstrings appear. Back 
stiffness is best elicited by asking the patient to "kiss his knees" while 
sitting up in bed with his knees naturally flexed. This is difficult or pain- 
ful to attempt if the back is stiff. Tightness of the hamstrings, and stiff- 
ness, spasm, and tightness of other muscle groups may be present. In 
some patients muscle spasm persists undiminished long after the acute 
illness has subsided and, sometimes, in the absence of any muscle weak- 
ness. 

Another early sign, which is helpful, is head drop in which the head 
falls back limply in a position of hyper extension if the patient is lifted from 
the bed with one's hands placed under his shoulders. This sign may also 
be present in pneumonia or meningitis but in the obvious absence of these 
it is useful in early poliomyelitis. 

Reflexes are often normal and active in the early stages and in the 
nonparalytic case usually remain so. Before the onset of paralysis there 
is often a loss or diminution of superficial abdominal and spinal reflexes, 
but hyperactivity of deep reflexes with an occasional positive Babinski sign. 
The latter quickly diminish or disappear as paralysis appears. Often, 
reflex changes presage paralysis of a specific limb. Thus, the loss of 
the right lower abdominal reflex and a hyperactive or diminished right 
knee jerk may precede paralysis of the right leg by 12 to 24 hours. As 
weakness progresses, deep reflexes disappear and in widespread para- 
lysis, both superficial and deep reflexes may be lost. 

In spinal poliomyelitis, respiratory difficulties may arise as the 
result of weakness or paralysis of the intercostals, diaphragm and abdom- 
inal muscles. Muscle spasm and shortening of these muscles may also 
interfere with respiration in the absence of actual weakness. If the inter- 
costals are weak and the diaphragm normal, there is little widening of the 
intercostal space and the rib cage is depressed at the insertion of the dia- 
phragm. If the diaphragm is weak and the breathing is thoracic, widening 
of the intercostal spaces and flaring of the costal margin and the use of 
accessory respiratory muscles is noted. One or both sides of the thorax 
and/or diaphragm may be affected, causing difficulty in coughing, difficulty 



Medical News Letter, Vol. 25, No. 11 



33 



in bringing up mucus secretions, and obstruction of the airway. As res- 
piratory failure progresses, apprehension and cyanosis appear; respira- 
tion becomes more and more shallow, but a regular rhythm is maintained 
(unlike the situation in central respiratory failure in bulbar poliomyelitis). 
Other autonomic nervous system signs include localized areas of sweating 
and vascular abnormalities in the skin. 

In bulbar poliomyelitis , the cranial nerve nuclei are the most fre- 
quently attacked, next the respiratory centers in the medulla, and least 
often the medullary vasomotor centers. The 10th cranial nerve nuclei are 
involved most often, resulting in paralysis of the pharynx, the soft palate, 
and the vocal cords. Nasal voice, hoarseness, increased accumulation of 
secretions in the oropharynx, difficulty in swallowing, and occasionally, 
regurgitation of fluid through the nose may develop. Paralysis of the facial 
nerve is also frequently observed. In patients in whom the medullary res- 
piratory centers are involved, irregularity in rhythm and depth of respira- 
tions are the first signs to appear. Increased restlessness, anxiety, inability 
to sleep, rapid pulse rate, and a rise in blood pressure may occur before 
cyanosis is detectable. Respiratory failure may occur with alarming sudden- 
ness and progress rapidly with increased periods of apnea, Cheyne-Stokes 
respiration, confusion, delirium, coma, and death. The temperature and 
pulse rise terminally, and the blood pressure may rise, or fall to shock 
levels. A few patients develop severe circulatory collapse due to vasomotor 
center involvement, with little or no cranial nerve weakness, and at first, 
no respiratory failure. This is a highly fatal form of the disease in which 
the patients have a characteristic appearance: the face has a dusky, flushed 
appearance, and the lips are cherry red. The pulse is rapid, 150 to ZOO per 
minute, often irregular, and difficult to palpate. The blood pressure is 
variable, but in children it is more apt to be elevated; a small pulse pres- 
sure, sometimes as low as 10 mm of mercury is characteristic. Shock, 
pulmonary edema, and varying degrees of respiratory failure precede death. 

Differe ntial Diagnosis. Sporadic cases of nonparalytic poliomyelitis 
cannot be distinguished clinically from other forms of aseptic meningitis. 
Nevertheless, the presence of marked back stiffness, pain, and hyperesthe- 
sia in a patient with aseptic meningitis, especially in the summer or autumn, 
is more likely to be caused by poliomyelitis than by other viruses except 
where certain of the arthropod-borne viral encephalitides are endemic or 
epidemic. Both mumps meningoencephalitis and lymphocytic choriomenin- 
gitis are primarily winter or spring diseases and both can be diagnosed 
serologically if acute and convalescent phase sera are available. In the 
absence of parotitis, a history of exposure to mumps is helpful. In both, 
the spinal fluid cell count is apt to be higher than in poliomyelitis. Lepto- 
spiral meningitis can be diagnosed by serologic means. Infections with 
Coxsackie virus, both epidemic pleurodynia (Bornholm disease) and aseptic 



34 



Medical News Letter, Vol. 25, No. 11 



meningitis have the same seasonal incidence as poliomyelitis and may 
produce a similar clinical picture. Infectious mononucleosis can be 
distinguished by the blood picture and a positive heterophile agglutination 
test. 

Paralytic poliomyelitis and encephalitis in poliomyelitis must be 
differentiated from the arthropod-borne enc ephali tides which occur at the 
same season and sometimes in the same area. With the latter, enceph- 
alitic signs usually dominate the picture and may be the first to appear. 
Paralysis of the limbs is less common than in poliomyelitis, is more apt 
to be spastic than flaccid, and when it occurs, is almost invariably pre- 
ceded by encephalitic signs. Serological tests are usually available to 
establish the diagnosis of the recognized arthropod-borne viral enceph- 
alitides. 

Infectious polyneuritis (Guillain-Barre' disease), tuberculous menin- 
gitis, coccidioidomycoidal meningitis, acute rheumatic fever, acute osteo- 
myelitis, and acute appendicitis may also be confused with poliomyelitis. 
In the first-mentioned disease, it should be recalled that both sensory and 
motor changes appear in the affected areas and albumino -cytologic dissocia- 
tion occurs early after onset. In epidemic times, it is also necessary to 
consider hysteria in the differential diagnosis. 

Specific Laboratory Procedures . In those patients with physical signs 
of central nervous system involvement, the spinal fluid examination is 
usually positive, whereas in those poliomyelitis cases without central 
nervous system signs it is nearly always negative. However, in .a small 
percentage of frank cases of paralytic poliomyelitis and even in fatal cases 
the spinal fluid cell count is not elevated. A positive spinal fluid examina- 
tion is the presence of an elevation of leukocytes in the spinal fluid, above 
8 to 10 cells per cu. ml. The usual range in poliomyelitis is 50 to 300, 
although counts higher than 1000 sometimes, though rarely, occur. If 
the cell count is higher than 400, one should consider the possibility of 
some other type of meningo- encephalomyelitis infection. Characteristically, 
the cells in poliomyelitis are largely polymorphonuclears in the first 24 hour's 
but there is a rapid shift to mononuclears (lymphoid cells) thereafter. At 
first the protein content may be normal or slightly elevated, 35 to 60 mg. 
per cu. ml. , increasing during the second and third weeks at a time when 
the cell count has returned to normal. Thus, in late poliomyelitis, the 
spinal fluid findings resemble those in the Guillain-Barre' syndrome. 

The blood shows no characteristic abnormalities although moderate 
leukocytosis is not uncommon in the acute phase. If the total white count 
is higher than 15, 000 per cu. ml. one should look for complications or 
possibly question the diagnosis of poliomyelitis. 

Isolation of virus from throat and rectal swabs or stools*, using tissue 
culture methods, can be carried out by special viral diagnostic laboratories. 



Medical News Letter, Vol. 25, No. 11 



35 



The same is true of serological diagnosis by neutralization and complement 
fixation tests using acute and convalescent phase serum specimens. These 
are still largely research tools which should become more available in the 
future. 

(ED: It is usually worthwhile to determine the virus type in any 
severe or unusual outbreak. The Bureau of Medicine and Surgery should 
be contacted for instructions. ) 

Treatment. There is no specific treatment, no antibiotic or chemo- 
therapeutic agent which has any effect in controlling the spread of the virus 
within the body. Neither convalescent serum nor gamma globulin, when 
used therapeutically, alters the course of the disease. This is not surpris- 
ing because usually the patient already has produced antibodies to his own 
strain of virus by the time of onset of the major illness. Medical treatment 
comes down to general supportive measures and the anticipation and hand- 
ling of complications. 

In the early stages of a mild illness, suspected to be poliomyelitis, 
it is unwise to subject the patient to unnecessary procedures which come 
under the heading of trauma or stress, for these may influence the course 
of the disease unfavorably. Under this category, are long ambulance rides, 
the shift to the new hospital environment, multiple injections, et cetera. For 
this reason it is advised that mildly ill patients be kept at home in bed, provided 
that they c an have constant medical supervision and that, should paralysis (of 
an y type) develop, they can be readily transported to a hospital. 

Prognosis. During the acute illness the extent of paralysis cannot be 
predicted! As long as fever persists, there is a possibility that paralysis 
may develop or extend, but once the temperature has returned to normal, 
the development of paralysis is rare. The overall mortality varies in differ- 
ent epidemics but is usually around 4%. It is always much higher in the 
bulbar form of the disease, particularly in patients having respiratory com- 
plications. Age is also a conditioning factor, i. e. , more severe paralysis, 
a higher incidence of respiratory muscle paralysis, or a higher incidence 
of the bulbar form increases the mortality in older age groups. 

Recovery from paralysis occurs in some degree in most patients and 
is complete in many. Cranial nerve paralyses show the greatest tendency 
to recovery; if the patient with bulbar poliomyelitis does not die in the acute 
state, virtually complete return of those functions with bulbar innervation 
can be expected. The recovery of strength in individual peripheral muscles 
begins promptly after the acute phase. During the first 3 months, with 
adequate therapy, a muscle recovers approximately 60% of the total strength 
that it can ever recover. During the first 6 months, 80% of anticipated recov- 
ery occurs. Thereafter, muscular strength continues to increase at a slow 
rate until the culmination of a period of approximately 18 months following 



36 



Medic al News Letter, Vol. 25, No. II 



the occurrence of the acute phase. The final score depends on the degree 
of irreversible nerve cell damage; therefore, some muscles may show no 
recovery or never improve beyond 10 or 12% of normal function, while 
others recover 100% of normal strength. 

(to be concluded in an early issue of the Medical News Letter) 

****** 

Industrial Medicine 

Differential Diagnosis of Diffuse Pulmonary Infiltrations 

Although it is easy to establish the presence of diffuse pulmonary 
infiltrations by roentgenograms, to determine the underlying cause may be 
difficult. In addition to roentgenograms, the importance of a careful med- 
ical history and physical examination is stressed. Laboratory facilities 
should be available and full use should be made of them in arriving at a 
diagnosis. 

Pulmonary Tuberculosis . The careful preparation of both family 
and patient histories is of the greatest importance in diagnosing this con- 
dition. 

Miliary Tuberculosis . Three diagnostic procedures are followed: 
namely, liver biopsy, bone marrow biopsy, and ophthalmoscopic inspec- 
tion of the retina. 

Chemical Pneumonitis. This condition usually develops within a few 
hours following aspiration or ingestion of certain chemicals. Patients 
should be removed as quickly as possible from further exposure to aspira- 
tion of the irritant substances. Ingested irritant substances should also 
be removed from the gastrointestinal tract. 

Periarteritis Nodosa. This condition is believed to be either a post- 
infection disease or due to a filterable virus. The disease may produce 
a moderate thickening and prominence of the hilar shadows and is usually 
accompanied by an eosinophilia. Diagnosis is very difficult unless a biopsy 
of a subcutaneous node is done. 

Bronchopneumonia. In most cases, the inflammatory process occurs 
in patchy or confluent areas usually scattered throughout both lungs with 
maximum involvement usually occurring at the bases. The infection is 



Medical News Letter, Vol. 25, No. 11 



37 



usually a mixed one but many cases are caused by pneumonococci. Early 
recognition of the causative agent is very important in order that proper 
therapy may be instituted. 

Pneumoconiosis. The principal dusts which injure the lungs contain 
silica. Workers in cement and ceramic industries, miners of silica mate- 
rials, sand blasters, and those engaged in manufacturing some abrasive 
soaps are most commonly affected because of their exposure to silica 
dusts. Naval industrial activities have a successful preventive program 
for pneumoconiosis, i. e. , the use of coverings, hoods, and masks in 
hazardous dusty areas. 

Pulmonary Carcinosis. Pulmonary carcinoma often presents a dif- 
ficult diagnostic problem. One should not lose sight of the fact that the 
primary neoplasm may be in the stomach, rectum, thyroid, breast, or 
genito- urinary tract. 

Fungus Infestation. This condition may be caused by any one of a 
number of fungi. The roentgenograms present no distinctive clinical pic- 
ture. Diagnosis may be confirmed by demonstrating the fungus itself and 
by positive skin tests. Most fungus infections of the lungs respond quite 
favorably to iodides, sulfonamides, antibiotics, and vaccine therapy 
(moniliasis, blastomycosis, histoplasmosis, coccidioidomycosis, actino- 
mycosis, and aspergillosis). 

Sarcoidosis. This is a disease of unknown etiology. No specific 
therapy is known although several cases have been known to respond to 
streptomycin and cortisone therapy. 

Hodgkin's Disease. This disease usually begins in the cervical 
lymph nodes and spreads to the entire reticular endothelial system. A 
steadily progressive anemia develops. There may be a Pel-Ebstein type 
of fever. Diagnosis is made by biopsy of a lymph node. The histopathology 
consists of Sternberg-Reed cells, numerous eosinophils and increased 
fibrotic stroma of the node. The clinical course usually terminates fatally 
in 3 to 5 years. 

Loffler's Syndrome. The cause of this condition is not clearly 
defined^ It is characterized by transitory pulmonary infiltrations, a 
benign course and eosinophilia. The eosinophils may reach 65%. It is 
difficult to differentiate from other pulmonary diseases. Treatment may 
be either blood transfusions or cortisone. Symptomatic treatment should 
be given for any existing allergic state. The prognosis is good. 



38 



Medical News Letter, Vol. 25, No, 11 



Cystic Disease of the Lungs , The etiology of this disease is not 
clear. Some solitary cysts may reach an enormous size. The honeycomb 
or polycystic variety involves both lungs and is quite rare. Roentgenologic 
examination is the best method of diagnosis. 

Pulmonary Granulomatosis . The clinical symptoms are those of res- 
piratory distress. Cyanosis and clubbing of the fingers may be present. 
Roentgenograms characteristically show diffuse nodular shadows which 
gradually develop into a ground glass appearance. Cortisone therapy may 
be beneficial in some cases. The course is usually progressive and even- 
tually, death results from right heart failure. {John B. Andosca, and 
Albert M. Moloney, Boston, Mass. , Postgraduate Medicine, January 1955} 

* # # * $ * 

General Sanitation 



Epidemiological Study of Gastroenteritis in Eg ypt: 
Human Enteric Pathogens on Me at 

The high incidence of gastroenteritis in the Middle East prompted 
an epidemiological investigation of shigellosis and salmonellosis in Egypt. 
The specific objective was to determine more precisely the role of fresh 
meats, as sold to the general public, in the transmission of diarrheal 
diseases. 

Two hundred and fifty samples of meat were purchased from 53 open, 
unscreened butcher shops in the Cairo area during the period from October 
1951 through January 1952. These shops, located in the poorer districts 
of the city, were representative of those serving a major portion of the 
population. 

In general, there are two types of retail butcher shops in Cairo. 
A small number in the central metropolitan area are thoroughly modern 
in equipment and sanitation. These are usually part of exclusive grocery 
stores and serve a limited clientele. Shops serving the middle and poorer 
classes of people, on the other hand, are open and unscreened and usually 
border directly on sidewalks and streets. Carcasses are hung around the 
three walls and often across the front where they are exposed to contam- 
ination by customers, dust, and flies. It is estimated that only one-third 
of the shops have any means of refrigeration. This usually consists of 
an ice chest used only for storage of small cuts from carcasses on display. 
The close proximity of meat shops to garbage accumulations and to indis- 
criminately depostied human feces provides ideal conditions for flyborne 
contamination of the carcasses. 



Medical News Letter, Vol. 25, No. 11 39 



All the common cuts of beef, veal, lamb, and pork were included 
in the study. Pork, however, is an infrequently consumed item of food 
in this region and, consequently, is sold in few shops. Selections of the 
types and cuts of meat, with the exception of pork, were made as uniformly 
as possible from the various shops. Usually, 6 or 8 samples were bought 
from several shops in a single day. Meat markets were graded arbitrarily 
as to sanitation standards and refrigeration facilities. The meat samples 
were wrapped individually in paper, brought to the laboratory within an 
hour of purchase, and examined bacteriologically. 

Enteric pathogens were isolated from 21 (8. 4%) of the 250 samples. 
Two of the samples yielded 2 pathogens each, bringing the total number 
of isolations to 23. 

Of the 23 isolations, 14 {60. 8%) were identified as belonging to the 
Shigella group. Of these, 8 were Flexner strains, 4 were S. sonnei, and 
2 were S. dysenteriae 2. The remaining 9 isolations (39. 2%) belonged to 
the Salmonella group. Of these, 2 were S. typhi ; 1, J3. paratyphi A_; 
1, S. paratyphi B; 4, S. dublin ; and 1, S. muenchen. 

— Other non-lactose -fermenting organisms isolated from the meat 
samples were identified so far as feasible. All 250 of the samples yielded 
Escherichia coli. Random samples of E. coli strains were tested for their 
"INVIC" reactions for an indication of their probable source. Forty percent 
were found to be of Type I. Among the species of Proteus isolated, P. 
morganii was most common. The others, in order of frequency, were 
P. mirabilis, P. vulgaris , and P. rettgeri . Paracolon organisms were 
present in 31. 6% of the samples. Three strains of Bethesda paracolons 
were identified from among these. 

One hundred and seventy of the samples came from shops with no 
refrigeration, and 80 from shops with refrigeration. The percentage of 
samples found to be positive for known pathogens was approximately the 
same in both groups. 

It is believed that this is the first report of enteric organisms of 
human origin being found on fresh meat. Surveys similar to this one, 
conducted in other countries, have revealed as many as 13 different 
Salmonella species but these were probably of animal origin. 

Human infection could occur through mechanical transfer of human 
enteric pathogens present in raw (retail) meat either to the mouth or to 
other foodstuffs. Infection could occur also through consumption of meat 
in which the organisms have survived inadequate cooking. That cooking 
does not always provide complete protection has been shown in several 
outbreaks of food poisoning in which the causative organisms were recov- 
ered from both cooked and uncooked portions of meat. It has been pointed 
out that the penetration of heat into meat is slow and that the interior often 
may not reach sterilization temperature. This fact is of particular importance 



40 



Medical News Letter, Vol. 25, No, 11 



in countries such as Egypt where some of the meat dishes are not cooked 
thoroughly and outbreaks of food poisoning, attributed to meat, are not 
uncommon. (Thomas M. Floyd, Joseph R. Baranski, and Mohamed 
El-Gannani, U.S. Naval Medical Research Unit No. 3, Cairo, Egypt, 1952) 

****** 



Change of Addres s 

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

****** 

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



****** 



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