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NavMed 369 




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



Vol. 27 Friday, 6 January 1956 No. 1 



TABLE OF CONTENTS 

Penicillin Prophylaxis of Gonorrhea 2 

CB 1348 in Malignant Lymphoma 3 

Chronic Ulcerative Colitis in Children 5 

Tuberculosis of the Breast 7 

Postoperative Hypoparathyroidism 9 

Decontamination of Anesthesia Apparatus . . . . 12 

Intestinal Obstruction Caused by Adhesions 14 

Rupture of the Pregnant Uterus 15 

Carcinoma of the Urinary Tract - Medicolegal Aspects 17 

Leprosy - Pathologic Changes in 20 

Applications Desired for Graduate Medical Training . 23 

Accreditation Problems 24 

Board Certifications • 25 

From the Note Book 26 

Recruiting Statistics (BuMed Notice 6120) ••• • 27 

Retirement of Records (BuMed Notice 5212) . 28 

Hearing Conservation Program (BuMed Inst. 6260. 6) 28 

Defrayment of Travel and Perdiem Expenses (BuMed Notice 1520) .... 28 

Aviation Physiology Training Program (BuMed Inst. 3740. 1) 29 

Poliomyelitis Vaccine, Salk, Distribution and Use(BuMed Inst. 6230. 8) • 29 

Graduate and Postgraduate Training (BuMed Inst. 1520. 2C) 30 

MEDICAL RESERVE SE CTION 

Outstanding Naval Reserve Medical Companies Commended 30 

Active Duty Training for West Coast Medical Department Officers. . . 31 

PREVENTIV E MEDICINE SECTION 

Research in Infectious Diseases .... 32 Insect and Rodent Control • • • 38 

Training in Occupational Medicine .. 35 Efficiency, Membrane Filter . 39 

Pneumonic Plague . 36 Foreign Animal Diseases ... . 40 



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Medical News Letter, Vol. 27, No. 1 



Polic y 

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 Person- 
nel has concurred, that Reserve medical officers now on active duty who 
desire to submit requests for extension of their active duty at their 
present stations for a period of three months or more will be given favor- 
able consideration. BuPers Instruction 1926. IB applies. 

****** 
Penicillin Prophylaxis of Gonorrhea 

BuMedlnst. 6222. 3B of 25 October 1954 has been interpreted by many 
as prohibiting the use of oral penicillin for the prevention of gonorrhea. 
This interpretation is incorrect. Medical officers are at liberty to use 
this chemoprophylaxis as they desire and should not refuse it to those 
who request it only on the basis of this instruction. 

For the reasons set forth in this instruction, major emphasis on 
the prevention of venereal diseases should not be focused on chemopro- 
phylaxis, since oral penicillin has been shown to be effective only in the 
prevention of gonorrhea, whereas the real medical department problem 
is bound up with other venereal diseases. 

The printing of this publication has been approved by the Director 
of the Bureau of the Budget, 16 May 1955. 



Medical News Letter, Vol. 27, No. 1 



3 



CB 1 348 in Malignant Lymphoma 

Everett, Roberts, and Ross synthesized a series of water-soluble 
aromatic nitrogen mustards one of which, p-(di-2-chlorethylamino)- 
phenylbutyxic acid (CB 1348), was found to be a powerful inhibitor of 
the transplanted Walker rat tumor 256 and was submitted for clinical 
trial. 

Ninety-three patients suffering from advanced carcinoma and from 
lymphomas have been treated with CB 1348 since September 1952. This 
report concerns only the cases of malignant lymphoma of which there 
were 76. Fourteen of these have been omitted from the report because 
the diagnosis was in doubt, because of inadequate follow-up, or because 
incomplete treatment was given. The 62 remaining cases include 23 of 
Hodgkin's disease, 20 of lymphocytic lymphoma (including 8 cases of 
chronic lymphocytic leukemia), 1 1 of reticulum -cell sarcoma, 6 of follicular 
lymphoma, and 1 each of generalized exfoliative erythrodermia and mycosis 
fungoides. 

Administration was usually by mouth, but a few patients received the 
sodium salt intravenously, either alone or in addition to oral therapy. 

The disadvantages of existing methods of treatment of the lymphomas 
are well known. A preparation of similar efficacy but lacking the side- 
effects and toxic properties of existing cytotoxic drugs would find a place 
in therapeutics. To some extent, CB 1348 fulfills these requirements. It 
is relatively free from side-effects, and from the limited experience of 
the authors, it is at least as effective as any other method in follicular 
lymphoma and in lymphocytic lymphoma. In the latter group particularly, 
treatment by conventional agents is often unsuccessful because dosage is 
limited by thrombocytopenia, or in the subleukemic group by low leuko- 
cyte counts; yet CB 1348 has been used successfully in these circumstances. 
In Hodgkin's disease, the proportion of patients who responded well is 
small, but useful remissions have been obtained — in two instances, better 
than those following T. E. M. CB 1348 is safer than T. E. M. ; this is 
especially important when repeated courses are required for it is rarely 
safe to give more than three courses of T. E. M. Unexpected and irreversible 
bone-marrow damage following previously well tolerated doses of T. E. M. 
is not uncommon even when the blood picture is apparently normal before 
treatment. With CB 1348, up to six courses have been given safely. Severe 
bone-marrow damage can follow CB 1348 administration, but it is usually 
the result either of excessive dosage or of treating patients with impaired 
bone -marrow function. 

The dosage likely to cause bone-marrow damage almost always lies 
well outside the therapeutic range — at any rate for first courses. For 
these reasons, the authors believe that CB 1348 deserves further trial 
in the treatment of malignant lymphoma. 



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Medical News Letter, Vol. 27, No. 1 



CB 1348 may be safely used in routine therapy if simple precautions 
are taken to avoid damaging the bone marrow. The marrow is espe_ially 
vulnerable (1) shortly after a course of treatment with ionizing radiations 
or cytotoxic drugs, including CB 1348 itself; (2) when it is infiltrated with 
lymphomatous tissue; and (3) when it is hypoplastic as a result of long- 
standing and usually extensively treated disease. CB 1348 should, there- 
fore, not be used within four weeks of the end of a full course of radiation 
therapy or chemotherapy. 

When small doses of palliative x-radiation have been given over 
small fields remote from foci of bone marrow, the neutrophil and platelet 
counts will not usually be depressed and chemotherapy may be safely started. 
If one or both of these counts are depressed, treatment should be postponed 
until normal counts are obtained, usually one or two weeks later. Whether 
treatment has been given or not, persistently low neutrophil and platelet 
counts or peripheral lymphocytosis should lead to suspicion of bone-marrow 
infiltration. Marrow puncture should be performed in these cases. If 
lymphocytic infiltration is present, as is frequently the case in lympho- 
cytic lymphoma and sometimes in follicular lymphoma, CB 1348 may be 
given, but at less than standard dosage. In some cases of Hodgkin's 
disease, when marrow cannot be obtained from several sites by aspira- 
tion, trephine specimens may show extensive fibrosis. These cases are 
not suitable for chemotherapy. 

The standard daily dose is 0. 2 mg. per kg. ; the whole dose is given 
at once and no special precautions are necessary. When lymphocytic infil- 
tration of the bone-marrow is present or when the marrow is hypoplastic, 
the daily dose should not exceed 0. 1 mg. per kg. Out-patient supervision 
is satisfactory in the less seriously ill patients, but during treatment, 
approximately weekly visits are essential so that hemoglobin estimation 
and total and differential leucocyte counts can be performed; routine 
platelet counts may be omitted provided skin and mucous membranes 
are inspected for hemorrhagic phenomena. It is not safe to leave a patient 
for more than two weeks without clinical and hematological examination, 
and it is helpful to plot the blood counts at each attendance on a chart 
on which temperature, weight, and spleen size may also be recorded. 

Clinical improvement is usually evident in the third week of treat- 
ment, but a four-weeks trial is necessary before giving up treatment as 
ineffective. Administration need not be discontinued as soon as the neutro- 
phil count begins to fall, but it should be remembered that the fall may 
continue for 10 days after the last dose, and that as the total dose approaches 
6. 5 mg. per kg. there is a real risk of causing irreversible bone-marrow 
damage. An average course at 0.2 mg. per kg. per day might last 4 weeks 
(5. 6 mg. per kg. ). If maintenance therapy is contemplated in patients who 
show slowly progressive improvement during the initial weeks of treatment, 



Medical News Letter, Vol. 27, No. 1 



5 



who tolerate the drug well, and whose blood picture remains stable, the 
maintenance dose should not exceed 0, 1 mg. per kg. per day, and may well 
be kept 0. 03 mg. per kg. It is probable that short courses of treatment 
carry less risk than maintenance therapy. Both methods have been effec- 
tive, but it is possible that continuing therapy may give an illusion of 
"maintenance" to a remission that would have proceeded without further 
treatment. (Galton, D. A.G, , et al. , Clinical Trials of p-{DI-2 -Chloro- 
ethylamino)-Phenylbutyric Acid (CB 1348) in Malignant Lymphoma: Brit. 
M. J. , 4949 : 1172-1176, November 12, 1955) 

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Ch ronic Ulcerative Colitis in Children 

One hundred twenty-two cases of ulcerative colitis in children seen 
at the Mayo Clinic between January 1944 and January 1954 are reviewed. 
The article concerns particularly the roentgen aspects of the condition. 
In each case, some combination of clinical, roentgenologic, and procto- 
scopic evidence of idiopathic chronic ulcerative colitis was present. 
Amebiasis and tuberculous ulcerative colitis have been excluded from 
this study. 

Chronic ulcerative colitis occurs almost twice as often among boys 
as among girls; 76 of the 122 children were boys. The cases were divided 
rather arbitrarily into groups based on the age of the patient: birth to 4 
years, eleven cases; 5 to 9 years, twenty-eight cases; 10 through 15 years, 
83 cases. The disease occurs with increasing frequency up to 15 years of 
age. Early adolescence appears to be a particularly dangerous time 
because of rapid progression of the disease and severe changes in short 
periods. 

The onset of chronic ulcerative colitis in childhood may be gradual 
and insidious or it may be sudden. Its type has a bearing on the roent- 
genologic findings, because if there is a rather sharp onset of bloody 
diarrhea, extensive roentgen changes may be apparent within less than 
two weeks. 

Bloody diarrhea is characteristic of the disease and with few excep- 
tions is present in every case. Frequently, the onset is related to some 
inflammatory episode involving the respiratory tract. 

Of equal value with the roentgenologic study is the proctosigmoido - 
scopic examination. The correlation between the proctoscopic findings 
and the roentgenologic manifestations of early disease is very good. Rarely 
(3 cases) , will the roentgenologic findings be negative if the proctoscope 
shows evidence of ulcerative colitis. Similarly, positive roentgenographic 
evidence of disease is uncommon (6 cases) in the face of negative findings. 



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Medical News Letter, Vol. 27, No. 1 



Apparently, no time lag exists between the proctoscopic diagnosis of 
chronic ulcerative colitis and the roentgenologic diagnosis. A careful 
review of the cases reported in this article reveals no significant difference 
in the diagnostic results of these procedures; it serves only to emphasize 
the necessity of both examinations. 

The types of ulcerative colitis have been described by Weber and 
Bargen. Type 1 is the most frequently encountered form of the disease, 
with roentgenologic findings and proctoscopic changes beginning in the 
rectum and progressing orad. In Type 2, there is roentgenologic evidence 
of the disease, but the proctoscopic manifestations are either equivocal or 
lacking. Type 3 reveals an unusual proctoscopic appearance with a peculiar 
mucosal pattern and ulcers in the rectum and sigmoid. These patients fre- 
quently show roentgenologic evidence of disease in the right side of the 
colon and normal appearing areas in other segments. In 5 cases, ulcera- 
tive colitis, Type 3, was suggested by the proctoscopist. These cases 
presented an unusual mucosal pattern with ulcers in the rectum and sigmoid 
apparent on proctoscopy. The roentgen examination revealed definite evidence 
of chronic ulcerative colitis primarily in the right portion of the colon. 

Weber has said that the roentgen manifestations of all forms of ulcer- 
ative colitis reflect the gross morphologic changes produced by the patho- 
logic process in the size, shape, and contour of the part of the intestine 
affected. 

The roentgen examination of the colon for evidence of chronic ulcera- 
tive colitis consists of roentgenoscopy during administration of a barium 
enema and of evaluation of changes apparent on a roentgenogram obtained 
after evacuation. The roentgen diagnosis should be based on a correlation 
of these findings. 

The roentgenoscopic manifestations of chronic ulcerative colitis in 
children are no different than they are in the adult. The changes depend 
entirely on the degree of involvement of the bowel and the stage of the 
disease. Briefly^ the recognizable findings are narrowing and shortening 
of the bowel; thickening of the wall, determined by palpation ; polypoid 
hyperplasia; and destruction of the mucous membrane. These manifes- 
tations are those of moderately advanced chronic ulcerative colitis rather 
than of early or minimal involvement. 

It is not difficult to explain the association of regional enteritis and 
the development of a roentgenographic pattern in the colon which is indis- 
tinguishable from chronic ulcerative colitis. Occasionally, however, the 
roentgenologist will be confronted with the typical roentgenographic mani- 
festations of ulcerative colitis, although the clinical story will not be con- 
sistent with the disease and the proctoscopist will be unable to confirm 
its presence. Two such cases occurred in the present series: one patient 
had nephritis with edema and ascites, and the other cystic fibrosis of the 



Medical News Letter, Vol. 27, No. 1 



7 



pancreas. It should be noted that any condition that may produce edema 
or superficial erosion of the mucous membrane can simulate the roent- 
genologic criteria for the diagnosis of chronic ulcerative colitis. As 
pointed out, chronic ulcerative colitis tends to be more severe in children 
from 10 to 15 years of age. Changes in the bowel, evident on roentgeno- 
logic examination, are more marked and complications are more frequent. 
The disease is rare in infants. The younger the child, the better the 
chance of both clinical and roentgenologic improvement. 

The differences between chronic ulcerative colitis of idiopathic 
origin in adults and in children are minor. The disease manifests itself 
in the same fashion and the same roentgenologic criteria for diagnosis 
apply. 

Both the proctoscopist and the radiologist provide valuable diagnostic 
information to the clinician. Diagnosis depends on correlation of clinical, 
proctoscopic, and roentgenologic information. 

More chance of recovery appears if the disease is detected early 
in a child, and the authors are of the opinion that in the prepuberty group 
there appears to be less roentgenologic evidence of complications. Chronic 
ulcerative colitis in children, while a formidable disease, may be suscep- 
tible to control if detected early and managed carefully. (Hodgson, J. R. , 
Kennedy, R, L.J, , The Roentgenologic Aspects of Chronic Ulcerative 
Colitis in Children: Radiology, 65_: 671-678, November 1955) 

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Tuberculosis of the Breast 



Tuberculosis of the breast is reviewed and experience with 10 
cases at the New York Hospital-Cornell Medical Center presented. 

The majority of the cases reported in the literature have been des- 
cribed as occurring in the child-bearing age. In this group, from 20 to 40 
years of age, tuberculosis is most prevalent. In the present series of 10 
cases, 3 patients were more than 60 years of age (the oldest was 72), 3 
patients were between 45 and 50 years, and 4 patients were between the 
ages of 20 and 44 years. Deaver and McFarland reported that 70% of their 
patients were from 20 to 5,0 years of age. Schipley and Spencer stated that 
the average age of their patients was 44 years. 

In the past, large numbers of cases of breast tuberculosis have 
been incorrectly classified as primary. This is an unfortunate misnomer, 
for most of these lesions were undoubtedly secondary to a focus elsewhere 
in the body and reached the breast by one of several routes which are des- 
cribed. While it is true that the breast may be the only organ showing 
clinical evidence of tuberculosis, absolute proof that the primary disease 



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Medical News Letter, Vol. 27, No. 1 



began in the breast is possible only if a complete autopsy shows the tuber- 
culous lesion to be the oldest tuberculous process in the body. No proof 
was offered in these so-called primary cases other than that the patient 
was in apparently good health and had no previous history of active tuber- 
culous infection. It is the author's opinion that primary tuberculosis of 
the breast is extremely uncommon and should be reserved for the rare 
instance in -which direct inoculation of the breast occurs from an infected 
needle or instrument. 

Tuberculosis of the breast is Usually unilateral and in only a few 
instances have both breasts been involved. This is in contrast to the 
usual tendency of the tubercle bacillus to affect each of bilateral organs 
(lung, kidney, fallopian tube, epididymis). It confirms the view that tuber- 
culous mastitis rarely results from a hematogenous infection. The follow- 
ing types of tuberculous mastitis have been described: nodular (discrete 
disseminated, or confluent); sclerosing type; and atypical types. 

The most frequent initial symptom of tuberculous mastitis is a 
painless lump. This has been noted in 65 to 75% of the cases reported. 
The lump gradually increases in size and may or may not become fixed 
to the skin. Pain is an infrequent initial symptom but may occur later in 
the disease in the course of abscess formation. Axillary lymph node 
enlargement is present in 50 to 75% of the patients and frequently may 
precede the development of the breast swelling. The disease progresses, 
if untreated, for a period of several months and an abscess may form 
which either ruptures or is incised, resulting in the formation of draining 
sinuses. Occasionally, secondary infection with pyogenic organisms 
produces a more acute course. 

In the sclerosing type, the mass becomes hard and fixed to the skin 
and deeper structures. Depending on its proximity to the central portion 
of the breast, the process may cause retraction of the nipple. 

Tuberculous mastitis may occur in patients who appear in apparent 
good health despite the fact that unrecognized foci of tuberculosis may be 
present in other parts of the body. The upper outer quadrant of the breast 
is most frequently involved due to the proximity of the axillary lymph 
nodes from which retrograde lymphatic extension occurs. However, any 
portion of the breast may be affected, including the central portion under 
the nipple. A nontender nodular mass is usually the first sign detected. 
Redness and tenderness of the skin overlying the mass are signs that 
develop if the condition progresses to abscess formation. Deaver and 
McFarland have described retraction of the nipple in approximately one- 
third of 79 cases. Discharge from the nipple is not a frequent sign. 
Fistulae occur in approximately one-third of the cases. 

The appearance of the breast depends on the type and extent of the 
underlying disease. In the nodular type, no enlargement of the breast 



Medical News Letter, Vol. 27, No. 1 



9 



may be discernible, whereas, in the confluent type, the involved breast 
may appear enlarged. Fluctuation with abscess formation and redness 
of the skin is found in patients who present themselves late in the course 
of the disease. In the sclerosing type, the breast may appear smaller 
and retraction of the skin and fixation to the deeper structures may be 
apparent. 

Because of the rarity of tuberculosis of the breast, its similarity 
to other conditions which involve the breast, and the fact that it is seldom 
correctly diagnosed preoperatively, the several other conditions for 
which tuberculosis is mistaken ai briefly mentioned. 

Before tuberculous mastitis has progressed to the stage of sinus 
formation and when only a lump is palpable in the breast, it may be mis- 
taken for carcinoma, a fibro- epithelial type of tumor, chronic cystic 
mastitis, pyogenic mastitis, gumma, sarcoma, or actinomycosis. Car- 
cinoma has been most frequently diagnosed in patients with tuberculous 
mastitis, particularly in the sclerosing type, but also in the nodular type 
when fixation of the skin and axillary adenopathy are present. 

The differential diagnosis of tuberculosis from other breast lesions 
is not simple. Biopsy for histologic study and complete bacteriologic 
examination afford the only dependable means of accurate diagnosis. 

In addition to the local treatment of tuberculous mastitis, such 
general measures as proper rest, diet, and a careful search for other 
foci of tuberculosis are of importance. Treatment for tuberculous mas- 
titis should include a pre- and postoperative course of antituberculous 
drugs and local excision of all tuberculous tissue including axillary lymph 
nodes, if present. If the diagnosis of tuberculosis is made postopera- 
tively, the patient should receive a course of antituberculous drugs and 
be reoperated upon if all tuberculous tissue has not been initially removed. 
{Schaeffer, G. , Tuberculosis of the Breast: Am. Rev. Tuberc. , 72: 810- 
822, December 1955) 

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Postoperative Hypoparathyroidism 

Fifty cases of surgically induced hypoparathyroidism are reported. 
The data have been obtained from the authors' personal experiences incident 
to the care of recent patients, some of which extended for as long as 28 
years. Many of the latter group have been recently examined, The authors 
have been especially interested in studying the late effects of the disease 
as seen in some of these patients in whom the disorder has persisted for 
many years. The results of this study have suggested the need for review 
of relevant embryologic, anatomic, and physiologic considerations, and for 



10 



Medical News Letter, Vol. 27, No. 1 



re -examination of current clinical concepts related to parathyroid 
deficiency. Review of the pertinent literature suggests that parathyroid 
dysfunction following surgery is tacitly regarded as usually being transient 
and, in any case, as presenting no particular problem in management, 
should it prove permanent. Reference is made to complications which may 
develop with improper management, the implication being that these occur 
infrequently and are indications of neglect on the part of the responsible 
physician. The authors' experience has been to the contrary; permanent 
parathyroid deficiency following thyroid surgery is not infrequent. Manage- 
ment of these patients is often difficult, and incapacitating complications 
are not uncommon even in patients under medical surveillance. Failure 
to note permanent hypoparathyroidism among a large group of patients 
who have had thyroid surgery performed can have two possible explanations: 
the postoperative follow-up has failed in thoroughness, or has not extended 
for a long enough time. 

Onset of clinical hypoparathyroidism occurred most often during the 
week following operation. Tingling, paresthesias, and numbness of the 
fingers and toes were the most common presenting symptoms. Tonic 
spasms of the fingers and toes (carpopedal spasm) and evidence of increased 
neuromuscular irritability (Trousseau's, Chvostek's •and Erb's signs) 
were present at this time, or soon appeared. Tightness and stiffness of 
other muscle groups, a feeling of restriction of freedom of inspiration and 
expiration, hyperventilation, and laryngospasm occurred much less fre- 
quently and later. 

In a patient who has recently undergone thyroid surgery, the appear- 
ance of these symptoms and signs is pathognomonic of parathyroid insuf- 
ficiency. Laboratory determinations done at the onset showed depression 
of the serum calcium, elevation of the serum phosphorous, and decreased 
or absent calcium in the urine as determined by the Sulkowitch test. Fur- 
ther confirmation of the diagnosis is provided by the prompt disappearance 
of the symptoms when calcium is administered intravenously. 

Differentiation from tetany caused by other disorders, that is, tetany 
of the newborn, osteomalacia, infantile rickets, chronic steatorrhea, preg- 
nancy, renal failure when acidosis is corrected, loss of gastric juice, 
sodium bicarbonate therapy, or hyperventilation or from nonsurgical hypo- 
parathyroidism is rarely difficult because of the clear cut history. Occasion- 
ally, a problem is presented in differential diagnosis by the development of 
the symptoms and signs of tetany unassociated with recent thyroid surgery. 
Of more importance is the recognition of hypoparathyroidism, surgical or 
nonsurgical, as the cause of cataracts, convulsive episodes, mental 
deterioration, and psychosis. Patients with these late sequelae may have 
none of the typical symptoms or signs which have been discussed. 

Infrequently, the onset of the hypoparathyroid state will be announced 
by the rapid development of frightening respiratory difficulty resulting in 



Medical News Letter, Vol. 27, No. 1 



11 



frantic efforts by the patient to increase pulmonary ventilation, leading 
to rapid shallow respiration and aggravation of all symptoms. Intravenous 
calcium administration (calcium chloride or gluconate 10 ml. of a 10% 
solution) results in prompt correction of the hyperpneic state and improve- 
ment of the more common tingling, muscle cramps, paresthesias, numb- 
ness, and signs of increased neuromuscular irritability. This improvement 
results from the interruption of a vicious cycle. By raising the ionized 
serum calcium level, psychic and organic factors leading to neuro-muscular 
excitability and spasm are corrected, resulting in slower and deeper respira- 
tions leading to correction of the respiratory alkalosis. In the unusually 
severe case, it may be necessary to repeat this dose one or more times 
until satisfactory control has been obtained with definitive therapy. 

Parathormone may be useful, although it is rarely necessary during 
this early period. Its continued use results in a refractory state within a 
few weeks or months so that even large doses will have no effect. This 
fact, combined with its relatively high cost, makes parathormone of little 
practical importance in the management of this disorder. 

Vitamin D£ (50,000 to 200, 000 units daily) and oral calcium (calcium 
lactate powder 5 to 15 gm, daily) should be started as soon as the diagnosis 
is made. Various preparations of both these medications are available 
and are equally effective. The correct dosages are determined by follow- 
ing the patient's course, serum calcium, and phosphorous levels. After 
control of the parathyroid deficiency has been achieved, serum determina- 
tions will be required only infrequently but must be continued throughout 
the patient's life if the disorder proves permanent. 

In addition to vitamin D2 and calcium, it is most important to place 
the patient on a low phosphorous diet. Intake of meat, fish, whole grain 
cereals, and dairy products, all relatively high in phosphorous, should 
be limited to basic requirements. 

Because of its relatively high cost, dihydrotachysterol (A. T. 10) 
should be reserved for the exceptional case which cannot be managed with 
vitamin D2, calcium, and diet. The effect of dihydrotachysterol is about 
midway between parathormone and vitamin T>2> that is, while having more 
effect on the kidney than vitamin it has less than parathormone, more 

effect on calcium absorption than parathormone, but less than vitamin 
Before a decision is made that dihydrotachysterol is required, an adequately 
supervised trial with vitamin D;>, calcium, and low phosphorous diet should 
be extended a week or more, employing the maximum indicated doses. 

After satisfactory control has been achieved as indicated by the 
absence of signs and symptoms and normal serum calcium and phosphorous 
values, the primary responsibility for management must be shifted to the 
patient. He must be carefully oriented regarding the nature of his problem 
and painstakingly instructed in its management. Proper regulation is ob- 
tained by taking sufficient medication so that no signs or symptoms of 



12 



Medical News Letter, Vol. 27, No. 1 



tetany are present. The use of the Sulkowitch test provides real assis- 
tance to the patient. Satisfactory control exists if an early morning urine 
specimen shows a f- precipitate. If none is present, the serum calcium 
is low and the dosage of medications should be increases; a / / f pre- , 
cipitate indicates overtreatment and dosages should be decreased. One 
of the greatest values of the Sulkowitch test is in preventing overtreatment. 
In order to assure adequate management, it is necessary to obtain periodic 
serum calcium and phosphorous levels for as long as the disorder persists. 
Of importance, is periodic re-evaluation by an informed physician. The 
patient with permanent hypoparathyroidism is to be regarded as having a 
lifelong metabolic disease in every sense as serious as diabetes mellitus 
and requiring equally assiduous attention to the details of management. 
(Buckwalter, J. A. , et al. , Postoperative Hypoparathyroidism: Surg. 
Gynec. & Obst. , 101: 657-666, December 1955) 

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Decontamination of Anesthesia Apparatus 

The decontamination of rubber parts of anesthesia machines, includ- 
ing the- face -mask, ,tubing, and breathing bag, is often inadequate or 
occasionally entirely neglected in an effort to meet a busy surgical schedule 
A soap- and -water rinse is most commonly used and soaking in alcohol is 
sometimes employed. To meet the demands of a busy surgical service, a 
method of cleansing anesthesia apparatus must be available which is simple 
rapid, effective, and noninjurious to the patient or apparatus. 

This article presents the results of a bacteriologic survey of anesthe 
sia equipment and a practical method of decontamination. Three phases of 
the study were: (1) development of standard technique for culturing parts of 
the gas machines while doing a general bacterial survey of the current 
method of cleansing; (2) general bacterial survey of gas equipment after 
slight modification of the existing cleansing method; and (3) limited bac- 
terial survey of such gas equipment after final modification of the existing 
cleansing method. 

Before this study was undertaken, the current cleansing method 
consisted of rinsing the face-mask, the inspiratory and expiratory tubing, , 
and the breathing bag in soap and water, then hanging them up to dry. 
Endotracheal tubes, suction catheters, and oral -pharyngeal airways were 
also washed in soap and water, the lumens being cleaned with appropriate 
brushes, and then placed in Zephiran solution, 1:1000, for 12 hours befori 
being used again. All of the equipment was washed in the same container, 
the same soapy solution often being used for as many as from four to six 
different sets of equipment. 



Medical News Letter, Vol. 27, No. 1 



13 



Early in the study, it was noted that the apparatus which had been 
soaked in Zephiran solution never grew any organisms. The author then 
sought a method of limited soaking which would eliminate most of the organ- 
isms demonstrated. Accordingly, the 5-minute Zephiran (1:1000) soak was 
tried. The best spectrum s of bacterial growth resulted from culturing the 
inspiratory and expiratory tubing and the breathing bag. These items 
were, therefore, chosen for further study in order to evaluate the effec- 
tiveness of the five -minute Zephiran soak. 

In comparing tabulated results, the author found almost complete 
disappearance of organisms after the five -minute Zephiran soak. This 
occurred in spite of the fact that on several occasions the same Zephiran 
solution was used for as many as four sets of tubing and breathing bags. 
The cultures were allowed to incubate for three days at room temperature 
after the original incubation period at35°C. , because it has been demon- 
strated that organisms not growing at35°C. , frequently will do so at room 
temperature. Alcaligenes faecalis was the most prominent of the few organ- 
isms which grew under this method. It is felt that this organism may well 
be a resistant contaminant present in the reservoir of diluted Zephiran 
prepared for the study. This contaminant has been found to grow in 1:1000 
Zephiran solution at room temperature. This same organism has also 
been demonstrated in various other Zephiran reservoirs in the hospital. 

Aside from the alpha -hemolytic streptococci and micrococci groups, 
the organisms found in this study, which are not inhabitants of the normal 
pharynx, were Ale, faecalis , Ps. aeruginosa , and B. subtilis. All of 
these organisms are commonly found in feces and have been known to 
produce resistant geni to -urinary tract infections. Ps. aeruginosa is 
commonly found mixed with streptococci and staphylococci and has been 
found in pure culture in abscesses in different parts of the body, especially 
in the middle ear. Cases of endocarditis and pneumonia have been reported 
where Ps, aeruginosa seemed to be the sole responsible microorganism. 
Spontaneous infection with B. subtilis in man may produce a panophthal- 
mitis. 

Because the above common contaminants are ubiquitous in dust and 
water, and may at any time become pathogenic, the use of Zephiran, 
1:1000, is suggested for their elimination. The method is rapid, cheap, 
effective, and permits early and continuous re -use of limited quantities 
of expendable rubber equipment. No injury to either patient or anesthesia 
equipment was demonstrated with this cleansing method. (Gross, G. L. , 
Decontamination of Anesthesia Apparatus: Anesthesiology, 16: 903-909, 
November 1955) 



# % $ age :{£ $ 



14 



Medical News Letter, Vol. 27 No. 1 
Intestinal Obstruction Caused by Adhesions 



This report presents a review of the authors' experience in manage- 
ment of obstructions caused by adhesions, and discusses this problem 
briefly. All cases of adhesive obstruction are included whether intestinal 
obstruction was the illness that necessitated hospital admission or whether 
it developed secondarily in the course of another disease. 

The diagnosis was confirmedby operation or autopsy in 274 cases 
(70.6%). In 114 cases (29. 4%) treated by conservative decompression, it 
was the clinical impression at the time — plus a current review of available 
records and roentgenograms — that established the diagnosis. 

Obstructions were caused by adhesions of three types: postoperative 
adhesions, inflammatory adhesions (without antecedent surgery) and 
congenital bands. Most frequent were occlusions due to postoperative 
adhesions ; 79. 4% of cases were of this type. Operations on the large bowel, 
appendectomies, and operations for intestinal obstruction were the most 
common preceding surgical procedures. Inflammatory adhesions were 
responsible for 17. 8% of obstructions. Less common causes in the order 
of importance were pelvic inflammatory disease, regional enteritis, chole- 
cystitis, and ulcerative colitis. Congenital bands accounted for only 2. 8% 
of all adhesive obstructions. 

The small bowel is considerably more susceptible to obstruction by 
adhesions than is the colon, as is evident from the distribution of cases. 
The majority (88.4%) were small bowel obstructions. Only 8. 0% were 
colic occlusions, and 3. 6% of cases were of the mixed variety with obstruc- 
tion simultaneously of both colon and small bowel. 

The type of adhesions causing obstruction also influenced the location 
of the obstruction. Thus, large bowel and mixed obstructions were com- 
mon in the groups due to inflammatory adhesions (30. 5%) or congenital 
bands (22. 3%) but were uncommon (6. 8%) in the group of obstructions 
caused by postoperative adhesions. 

The average age of patients was 45.9 years, and 68. 6% were 60 
years of age or younger. That patients in extremes of life were not exempt 
is evident, for 14 patients were less than one year old and 8 were over 80 
years old. 

The reports of McKittrick and Dennis, as well as the authors' results, 
indicate the necessity for early diagnosis and institution of appropriate 
treatment promptly in intestinal obstruction. The utilization of routine 
abdominal roentgenograms early in the course of all unexplained abdominal 
conditions may be helpful in this regard, as intestinal distension may be 
detected thereby when clinical abdominal distension is absent. Diagnosis 
and institution of treatment of obstruction before the disease is over 24 
hours old offers the best prognosis. If this advantage is to be gained, the 
diagnosis must usually be made or suspected by the first physician in 
attendance. 



Medical News Letter, Vol. 27, No. 1 



15 



The type of treatment to be employed in adhesive obstructions is a 
final consideration. Most of the recent efforts to further improve results 
in the treatment of intestinal obstruction have been directed toward early 
operation. 

Based on the conclusions, the following plan for the management 
of adhesive obstructions has been adopted in this clinic: 

1. All patients with findings suggestive or indicative of strangula- 
tion obstruction, or wherein coexisting abdominal conditions are 
compelling factors for immediate surgery, are operated upon as soon 
as they can be prepared. With few exceptions, patients who have large 
bowel obstructions with distension are operated upon without delay. 
Transverse colostomy is performed if the obstruction is not relieved 
by division of adhesive bands. Primary resection and anastomosis 

in the face of large bowel distension is not recommended. 

2. In remaining patients, a trial of intestinal intubation is carried 
out. Conservative treatment is interrupted at any time if signs sugges- 
ting strangulation develop. At the end of a 12 -hour period, abdominal 
roentgenograms are repeated and the patient's status is re-evaluated. 

If no real progress has been made in the relief of distension, conser- 
vative treatment is interrupted and operation carried out. Conservative 
decompression is continued if no signs or symptoms of strangulation 
obstruction develop and improvement is progressive. (Perry, J. F. Jr., 
Smith, G. A. , Yonehiro, E.G., Intestinal Obstruction Caused by Ad- 
hesions: Ann. Surg., 1_42: 810-816, November 1955) 

****#;{£ 

Rupture of the Preg nant Uterus 

From May 1931 to July 1953, there were 52 ruptures of the pregnant 
uterus among 71, 483 delivered patients, an incidence of 0. 07% which 
represents one of the higher rates among the reported incidences of other 
institutions. Undoubtedly, instances of uterine rupture have occurred 
which were not diagnosed correctly and which were mistakenly consid- 
ered to be postpartum hemorrhage and shock due to other causes and in 
a subsequent pregnancy the uterus may have ruptured again or the lacera- 
tion may have extended sufficiently to permit detection. 

The ruptures of the uterus incident to childbirth were customarily 
classified as noncesarean ruptures and cesarean or postsurgery ruptures. 
In this series of 52 cases, 37 ruptures of the uterus were classified as 
noncesarean ruptures of which 31 cases were traumatic and 6 cases were 



t 



16 



Medical News Letter, Vol. 27, No. 1 



spontaneous, and induced or traumatic ruptures. In this series of 52 
cases, 37 ruptures of the uterus were classified as noncesarean rup- 
tures of which 31 cases were traumatic and 6 cases were spontaneous. 
Fifteen cases were considered postcesarean ruptures, of which only one 
instance of traumatic rupture was noted. Such a classification properly 
emphasized the unknown integrity of the surgical scar, but on the other 
hand, it failed to stress uterine scarring sustained during previous for- 
ceps deliveries, intrauterine manipulations, curettages, et cetera. 
Another method of classification divided uterine rupture into complete 
and incomplete ruptures depending upon whether or not the peritoneum 
remained intact. The location and extent were of greater importance, 
however, because rupture and fatal hemorrhage occurred and still remained 
within the confines of the peritoneum. 

The signs and symptoms of uterine rupture varied according to its 
type and location. In this series, the classical signs and symptoms of 
rupture, as abdominal pain and tenderness, cessation of labor, and shock 
were noted only in the spontaneous uterine ruptures. The majority of 
patients with traumatic ruptures were anesthetized or given sedation and 
the classical clinical picture was masked. Immediate postpartum hemor- 
rhage and shock were the characteristic signs in 90% of the patients in 
the traumatic group. Forty percent of the patients with postsurgery 
uterine ruptures gave no evidence of impending or actual rupture of the 
uterus. 

The prime requisite for successful management was early diagnosis 
and active treatment, consisting of adequate blood and fluid replacement, 
surgical intervention, and liberal use of antibiotics postoperatively. The 
procedure of choice was hysterectomy, complete or incomplete, which 
was performed in 40 cases (77%). The uterus was packed in 5 cases; 
in an additional 3 cases, the uterine packing was augmented by clamping 
the uterine arteries as a terminal procedure. In 2 instances of separation 
of a previous cesarean scar, successful repair was accomplished. 

It is evident that every obstetrical procedure or condition is asso- 
ciated with an irreducible minimal hazard of uterine rupture and it is 
also evident that most uterine ruptures are produced by failure to heed 
time -tested indications and conditions required for every obstetrical 
procedure. Using the strictest criteria in analyzing the 52 cases, one 
may speculate that the 31 traumatic uterine ruptures (88%) in the non- 
cesarean group would have preventable factors. 

From 1931 to 1953, there were 52 cases (0.07%) of rupture of the 
pregnant uterus among 71,483 delivered patients. The associated maternal 
mortality was 15% and the uncorrected fetal mortality was 50%. 

Uterine rupture remains a serious surgical emergency but there 
were no maternal deaths in the 21 ruptures which occurred from 1942 



Medical News Letter, Vol. 27, No. 1 17 

to 1953. The contributing factor s in the reduction were the following: 
better understanding of the physiology of labor, hospital delivery, earlier 
diagnosis, more adequate blood and fluid replacement, immediate surgical 
intervention, and employment of antibiotics. 

Forty-five percent of the traumatic uterine ruptures resulted from 
version and extraction. Stricter adherence to the indications and conditions 
required for the obstetrical procedure and the more liberal use of cesarean 
section were the most important factors in prevention of ruptures. 

Fifteen cases of uterine rupture occurred in patients with previous 
sections, this being 1. 0% of the patients with a previous section who came 
to term. The policy of once a section always a section is strongly advised. 

Prevention by the properly selected obstetrical operation is better 
than treatment. When a rupture of the uterus is suspected, the manage- 
ment of choice is early diagnosis by manual exploration of the uterine cavity 
and visual inspection of the vagina, cervix, and lower uterine segment, 
judicious blood and fluid replacement, and surgical treatment. In most 
instances, a subtotal hysterectomy offers the most rapid control of hemor- 
rhage with minimal trauma. (Bak, T. F. , Hayden, G. E. , Rupture of the 
Pregnant Uterus: Am. J. Obst. & Gynec. , 7£:96l-971 ) November 1955) 

Ca rcinoma of the Urinary Tract - M edicolegal Aspects 

The role of trauma in the production of cancer has always been a 
moot subject. Too many "traumatic cancers" have recently appeared in 
medicolegal literature, despite the fact that there is no association between 
a single trauma and the development of cancer. The relation of trauma 
and cancer in most litigated cases has been overshadowed by the importance 
placed on the theory that aggravation of an existing tumor may occur as a 
result of trauma. 

The industrial specialist, like the industrial physician, is well aware 
that the average person is prone to blame his present affliction upon an 
alleged accident or so-called occupational disease. No matter how intel- 
ligently the problem may be approached, there is often great difficulty in 
determining just what is to be regarded as cause and what may be attri- 
buted to mere coincidence. 

Once it is established that an accident has occurred "as a result of" 
or "arising out of" employment, it becomes necessary to consider whether 
the accident, injury, or disease would have happened to the patient on the 
street, at home, or anywhere outside his occupational environment. In 
other words, a causal relation must be established or ruled out. To 
evaluate causal relationship properly, it is well to bear in mind that the 



18 



Medical News Letter, Vol. 27, No. 1 



question of causation automatically arises when, as a result of the clai- 
mant's testimony, he alleges that the accident or exposure caused the 
present affliction and complaint. He also claims that prior to the alleged 
injury he had no symptoms nor had he any disease process. Obviously, 
in a case of cancer the injured person honestly believes that it would be 
impossible for the disease to have existed prior to the alleged accident 
or injury. 

Frequently, in attempting to evaluate causal relationship, the 
decision is influenced by one of the tenets of the law, "In dubio pro laeso, " 
which means "In doubt, always favor the injured. " This attitude is unjust 
and in no way aids in the solution of this universal problem. It is not fair 
for any verdict to be given on a basis of sympathy and such a decision 
should never be tolerated. 

To evaluate the causal relation of trauma to a malignant tumor 
claimed to be associated therewith, certain postulates must be fulfilled. 
No possible relation of injury to the development of cancer can be fulfilled 
in any hypothetical case without such an evaluation. The following criteria 
have been established for evaluating the possible relation of an injury to the 
development of cancer: (1) authenticity and adequacy of the trauma; (2} 
previous integrity of the wounded part; (3) origin of tumor at exact point 
of injury; (4) reasonable time lapse between injury and appearance of the 
tumor; and {5} positive diagnosis of presence and type of tumor. 

These criteria or postulates are the basic factors in establishing 
and assessing the possible responsibility of an injury for the development 
of cancer. Yet frequently, as a result of an inadequate history, inadequate 
medical records, faulty examination, faulty microscopic interpretation or 
illogical evaluation of causal relations, a neoplastic disease may be inter- 
preted as causally related to trauma. 

The author's opinion is that, as pointed out by Mock and Ellis, in 
any case in which cancer is claimed to have been caused by an accidental 
injury or trauma^the following postulates be answered: (1) a definite des- 
cription by the reporting surgeon of the trauma at the time it was sustained; 
(2) definite proof by every possible means of examination at the time the 
injury was sustained that no tumor already existed at the site of the truama; 
and (3) definite signs and symptoms of a pathologic process continuing at 
the site of the trauma until a malignant tumor appeared and was positively 
diagnosed. * 

Aggravation of a tumor by trauma is always a much discussed subject 
in compensation cases. The granting of an award in such instances seems 
reasonable when there is no doubt that the trauma accelerates the patholo- 
gic process, or when certain complications have arisen that would not have 
occurred in the progress of the disease had not the alleged injury been 
sustained. At no time was the law intended to protect or insure the worker 



Medical News Letter, Vol. 27, No. 1 



19 



against cancer that is not the result of causes in his occupational environ- 
ment. The factor of aggravation constantly confuses the issue in cases 
of cancer as well as of other diseases. For this reason, it is well to be 
familiar with exactly what is meant by aggravation. Ewing stated that 
aggravation exists when "an injury hastens the death of a patient . . . 
but when, however, the trauma merely leads somewhat prematurely to 
complications which are inevitable in the course of the disease and which 
are about to occur in the normal course, it is inequitable to assume that 
any aggravation has occurred , . . unless the trauma introduces into 
the course of the disease something which does not belong there and which 
works to the disadvantage of the patient, aggravation may not properly 
be assumed. " 

Assuming that there is no deliberate attempt at deception, it is well 
to keep in mind that tumors are often present for years before they are 
recognized. Further, even though the injured person was examined at 
the time of the alleged injury without a tumor's having been detected, the 
possibility of its having been present cannot be excluded. Of even greater 
significance, is the fact that certain tumors are prone to remain latent 
and unrecognized. In fact, the primary site of such a tumor can often be 
determined only by postmortem examination. This is especially true of 
tumors (carcinoma) of the thyroid, the male breast, the prostate, the 
kidney, and the testicle. Such tumors metastasize in a bizarre fashion, 
remote from the primary growth, and frequently involve the skeleton. 

Often, it has been noted that a person with a silent or unnoticed 
tumor (especially a testicular tumor) seems more liable to injury at the 
tumor site. In addition to the tendency of injuries to occur in the tumor- 
bearing area, there seems to be intensification of the subjective symptoms 
and local effects of the injury. Such tumors, e.g. , tumors of the testicle, 
produce such local conditions as increased bulk, fixation in the organ, 
adherence to the skin, and deep structures, and often some inflammatory 
reaction. Under these circumstances, a simple blow, twist or pressure is 
often capable of injuring the tissues and causing pain and hemorrhage, 
whereas, under normal circumstances the effect of the same simple blow, 
twist, or pressure on normal tissues would have been nil. This predis- 
position is called "traumatic determination. " Ewing once said, "Traumas 
reveal more malignant tumors than they cause. " Pack described this 
phenomenon as "a strange paradox that injury to a part of the body con- 
taining an unknown tumor may be an accident beneficial to the patient, 
as it sometimes leads to the discovery of the tumor at a time when cure 
is still possible. " Because of such phenomena, it is always well to remem- 
ber that whenever an apparently trivial injury is said to have produced 
some peculiar and exaggerated effect and a tumor is later discovered, the 
tumor probably antedated the injury. 



20 



Medical News Letter, Vol. 27, No. 1 



The author offers postulates which he hopes will help to evaluate 
the role of trauma in neoplastic disease. In all cases of trauma, careful 
study is indicated in order to establish, as far as possible, a causative 
relation to the occupational environment. fWershub, L. P. , Medicolegal 
Aspects of Carcinoma of the Urinary Tract: J. Internat. Coll Surgeons, 
XXIV: 562-566, November 1955) 

$ $ $ s{s $ $ 

Leprosy - Pathologic Changes In 

This presentation records the gross and microscopic changes 
observed in necropsy material from leprosy patients. Fifty consecutive 
necropsies performed at the National Leprosarium at Carville, La. , 
are reviewed. 

All of the 50 cases presented in this study concerned patients at 
the National Leprosarium where 46 of the gross necropsies were performed. 
The remaining 4 gross necropsies were performed at the New Orleans U.S. 
Public Health Service Hospital, where the tissues from the 50 cases were 
studied microscopically and the clinical data analyzed. 

Routine sections were made of heart, lung, spleen, liver, adrenal 
gland, kidney, testis, epididymis, skin, peripheral nerves (usually ulnar), 
gastrointestinal tract, lymph node, thyroid gland, pituitary body, bone, 
bonemarrow, eye, brain, and spinal cord. Tissues were removed from 
additional sites when indicated. All of the tissues were fixed in 10% 
formalin. Routine hematoxylin and eosin stains, as well as acid-fast 
stains, were made of all tissues. The acid-fast quality of Myco. leprae 
is more difficult to demonstrate than that of Mycobacterium tuberculosis, 
and in the authors' experience, the Fite-Cambre-Turner technique is 
superior to other modifications of the Ziehl-Neelsen stain. Bennhold's 
congo red and the crystal violet stains gave the most satisfactory results 
for demonstration of amyloid. Mallory's trichrome stain was useful in 
evaluating late testicular changes. 

During the 5-1/2 years covered by this study (September 1948 
through April 1954) the average census at the National Leprosarium was 
385 patients. Seven percent of these were considered to have leprosy of 
the tuberculoid type and the majority of the remaining were considered to 
be of lepromatous type. Of the 50 cases in this series, 48 were of lepro- 
matous type and 2 were of tuberculoid type. Therefore, this review is 
essentially one of lepromatous leprosy. In addition to being the predominant 
type at the National Leprosarium ; it is also the type most frequently seen in 
the United States. The 50 cases represent 92. 6% of all the deaths that 
occurred at the National Leprosarium during the 5-1/2 year study. 



1 



Medical News Letter, Vol. 27, No. 1 21 

Thirty-four of the patients were men and 16 were women, giving 
a 2:1 ratio which is approximately the figure given for the sex distribution 
of leprosy throughout the world. The race was listed as white in 29 cases, 
Mexican in 10, colored in 8, and Chinese, Japanese, and Filipino, respec- 
tively, in the 3 remaining cases. 

The average age at the time of death was 58. 8 years, the youngest 
patient being 31 and the oldest 79 years. The average length of life from 
the onset of obvious signs and symptoms of leprosy was 20 years. Five 
of the patients gave a family history of leprosy in one or more relatives. 

In the sections describing the gross and microscopic findings, many 
of the observations are of necessity composite. Upon inspection of the 
body, the disfigurement of the nose, eyes, extremities, and skin was 
quite obvious. Corneal opacities were frequent and in some cases the eyes 
had been enucleated. "Saddle" nose deformity of varying degrees usually 
was present. The ear lobes were often enlarged and redundant. The eye- 
brows and eyelashes were sparse, especially laterally, and some patients 
had none at all. Considerable induration of the facial skin and underlying 
tissues resulted in the typical leonine facies of leprosy. 

The skin lesions varied considerably depending upon the activity of 
the disease at the time of death. Areas of irregular pigmentation, old 
scars from burns or lepromatous nodules, and a diffuse atrophy of skin 
over wide areas of the body with thin "onion skin" wrinkling, were seen. 
Hypopigmented areas were frequent in the skin of deeply pigmented persons. 
A few patients presented, sometimes, raised erythematous areas of appar- 
ently active lesions. 

Obvious deformities of the hands and feet often were present with 
resorption of bone and shortening of fingers, toes, and sometimes other 
bones. Usually, the shortened finger or toe had a small distorted nail 
remaining at its tip for the digits in fact seldom "fall off" as in the cica- 
trizing disease ainhum, but rather undergo a progressive resorption 
from the tip. Many patients had trophic ulcers of the extremities and 
some had had previous amputations. Muscle atrophy, especially of the 
interossei of the hands, was prominent in many cases with marked nerve 
involvement. Usually, the ulnar nerves were palpably enlarged. Testicular 
atrophy was usually quite marked. Several cases presented gynecomastia. 

It must be remembered that the pattern of lepromatous leprosy is 
presented as seen in necropsies at the National Leprosarium in the United 
States, and that the pattern of leprosy in many other parts of the world is 
quite different. It should also be recalled that in the natural history of the 
disease the tendency is toward spontaneous remission after many years. 
The so-called "burned-out" cases may reveal few or no organisms and 
are left only with the residual neural and other tissue damage as described 



22 



Medical News Letter, Vol. 27, No. 1 



in many of the present cases. One of the oldest patients in this series 
became blind from leprous changes in 1898, 8 years after the clinical 
onset of leprosy. He refused virtually all specific therapy except for 
sporadic doses of chaulmoogra oil totalling approximately 1000 cc. 
Several years prior to death, over 60 years after the onset of his lep- 
rosy, skin scrapings were positive only occasionally. No organisms 
were demonstrable at necropsy. 

It should be pointed out that 30 of these patients (60%) received 
sulfone therapy for at least 2 years, and 10 patients received sulfone 
therapy for a shorter period. It is believed that this treatment has, to 
some extent, influenced the pattern of the disease in some of these patients. 
Undeniably beneficial effects are produced clinically by the sulfones, as re- 
ported recently by Chang, Wolcott, and Doull. However, they pointed out 
that bacteriologic improvement may lag behind clinical improvement for 
years. Skin scrapings were positive clinically just prior to death in 23 
of the 30 patients who received sulfone therapy for at least 2 years. As 
mentioned, Myco . leprae was demonstrable also in necropsy tissues in 
22 of these cases. Moreover, it is believed that, if additional multiple 
sections of skin and nerve had been taken, organisms would have been 
found in a higher percentage of cases. 

As seen by the average duration of life of 20 years after the recorded 
onset of obvious signs and symptoms, leprosy per se is not a rapidly 
fatal disease. Also, the average age at the time of death of just under 
59 years is less than 10 years below that of the population as a whole. 
In only one patient in this series was widespread leprosy itself consid- 
ered to be a major factor in the immediate cause of death. However, 
the disabling features of leprosy often were seen, as in the contractures, 
resorbed digits, neurotrophic ulcers, renal insufficiency, and blindness. 

While leprosy was not an immediate cause of death, it very frequent- 
ly produced secondary changes which in turn were responsible eventually 
for the patient's demise. Thus, in 38% of the cases, amyloidosis of the 
kidney secondary to the leprous infection produced renal insufficiency 
with uremia, often coma, bronchopneumonia and/or pulmonary edema, 
and death. The cause of death in another 14% was active pulmonary tuber- 
culosis to which the patient might have been predisposed by the debilitating 
effects of the leprous infection. It might be assumed then, that in approx- 
imately 50% of the cases, leprosy was indirectly responsible for death. 
In the other 50%, diseases to which any person might succumb, such as 
neoplasms and myocardial infarction, were the causes of death. 

From the descriptions, it can be seen that few tissues in the body 
were free from demonstrable involvement by lepromatous leprosy at 
necropsy. The principal ones not involved included the lower respiratory 
tract, the heart and great vessels, the gastrointestinal tract, the central 



Medical News Letter, Vol. 27, No. 1 



23 



nervous system, and the female reproductive organs. Isolated instances 
of involvement of most of these sites have been reported in the literature, 
but their occurrence must be exceedingly uncommon. Viscera, such as 
spleen, liver, and adrenal gland contained lepromatous lesions in one - 
third of the cases in this series. In 6 of the 10 patients believed to be 
clinically arrested (12 consecutive negative skin scrapings) organisms 
were demonstrated at necropsy. 

A striking feature secondary to leprosy in these patients was the 
frequency with which amyloid was seen (almost one-half of the cases). 
When the kidney was involved by amyloidosis, it usually was very markedly 
altered and resulted in marked renal insufficiency which was incompatible 
with life. The pathogenesis of the deposition of amyloid, while obviously 
related to the leprous infection of the body in general, still remains theo- 
retical. (Powell, C. S. , Swan, L. L. , Leprosy: Pathologic Changes Ob- 
served in Fifty Consecutive Necropsies : Am. J. Path., XXXI: 1131-1141, 
November -Dec ember 1955) 

3{t 5{c S^I l^C ijc 

Applications Desired for Graduate Medical Training 

1. Applications are desired for residency training in all specialties. 
Eligible are Regular officers and Reserves who have completed their Sel- 
ective Service obligations, or will accept a Regular Navy commission. 
Hospitals approved for residency training are: U.S. Naval Hospitals, 
Bethesda, Md. ; Chelsea, Mass. ; Great Lakes, 111. ; Oakland, Calif. ; 
San Diego, Calif. ; Philadelphia, Pa. ; Portsmouth, Va. ; and St. Albans, 
N. Y. 

2. Letters of application should be addressed to the Chief of the Bureau 
of Medicine and Surgery via official channels, and should contain an ade- 
quate service agreement in accordance with BuMed Instruction 1520. 7 

of 4 August 1954. 

3. The following are excerpts from a letter sent to all Navy Interns by 
the Surgeon General: 

"Interns who will remain on active duty under the provisions of the 
Universal Military Training and Service Act, as amended, will be 
eligible for consideration for assignment to residency training duty 
upon completion of Selective Service military requirements, or 
immediately upon acceptance of a Regular Navy commission. Regu- 
lar officers may fulfill their Selective Service requirements con- 
currently with the period of obligated time required after completion 



24 



Medical News Letter, Vol. 27, No. 1 



of training. As you may be aware, Navy interns are eligible to 
make application for transfer to the Regular Navy after completion 
of six months of internship. In this regard, those officers trans- 
ferring to the Regular Service should make application for a com- 
mission not later than the end of January 1956. The administrative 
procedures needed to process an application are somewhat time 
consuming, and early application will insure completion of these 
procedures prior to termination of internship. 

Those of you who have completed your Selective Service active duty 
may apply for residency training to commence upon termination of 
internship. While all applications for residency training should be 
for one year at a time, it is expected that those officers whose 
progress is satisfactory will be permitted to complete the required 
formal training without interruption. Every effort will be made to 
accomplish this insofar as Service needs will permit. It is expected 
that vacancies will be available in all specialties by 1 July 1956, and 
application for training maybe made at once. For training received 
in a naval hospital, you are required to serve on active duty one year 
for each year of training received. Training in civilian institutions 
requires a two-year obligated service agreement for the first year 
of training received, and one year of obligated service for each 
successive year. During Navy sponsored civilian training, medical 
officers continue to draw the full pay and allowances of their rank 
with, of course, the cost of tuition and fees being borne by the Navy 
Department. " (ProfDiv, BuMed^ 

****** 

Accreditation Probl ems 

How complete do the minutes of the various departmental and staff 
meetings have to be? In general monthly meetings, does a case which 
is presented have to be recorded in the minutes? Does the general dis- 
cussion of the case and subject being discussed have to be recorded? 

The minutes of discussions at medical staff meetings, departmental 
meetings, clinico -pathological conferences and, in fact, any clinical meet- 
ing should be concisely recorded and reveal a thorough review and analysis 
of the clinical work done in the hospital. The minutes should include a 
brief clinical abstract and pertinent discussion on any case whether it be 
selected death, unimproved case, infection, complication, error in diag- 
nosis or result of treatment on a patient in the hospital at the time of the 
meeting or recently discharged. 



Medical News Letter, Vol. 27, No. 1 



25 



We cannot tolerate minutes which read — 
"A case of peripheral vascular disease was reported . . . Meeting 
adjourned. " 

(Babcock, K. B. , Accreditation Problems: Hospitals, 22:32, November 1955) 

$ $ !(S $ 3fc # 

B oard Certifications 

American Board of Anesthesio l ogy 

L,T William R. Stilwell (MC) USNR (Active) 

American Board of D e r matology and Syphilology 
L,T John J. Downey (MC) USN 

Am erican Board of Intern al M edicine 

LTJG Charles F. Forester (MC) USNR (Inactive) 

American Board of Obstetr ic s and G y necology 
LCT31Tjohn~P. Marty~(MC) USNR (Active) 

American Board of Ophthalmology 

LT Robert A. Ballou (MCjljSNR (Active) 
L.CDR Lockland V. Tyler, Jr. (MC) USN 

American Board of Pathology 

LCDR Sholom S. Barron (MC) USNR (Active) 

American Boa rd o f Pediatrics 

ITt" Thomas B. Delaney (MC) USN 

American Boa rd of Preven tive Medicine 
CAPT Allan S. Chrisman (MC) USN 
CAPT Lloyd B. Shone (MC) USN 

American Board of Surgery 

~LT^ohlTir. _ D~riscon~(MC) USNR (Active) 
CDR Robert W. Mackie (MC) USN 
CDR Everett J. Schmitz (MC) USNR (Active) 
CDR George T. VanPetten (MC) USN 



i^C 3§f ■$£ j{5 -flC 



26 



Medical News Letter, Vol. 27, No. 1 



From the Note Book 

1. Rear Admiral R. W. Malone, DC USN, Assistant Chief for Dentistry 
and Chief of the Dental Division, Bureau of Medicine and Surgery, accom- 
panied Doctor F. B. Berry, Assistant Secretary of Defense (Health and 
Medical) and his civilian advisory group on a visit to medical and dental 
activities in military installations of the Caribbean area and Florida. 
(TIO, BuMed) 

2. The Navy Department was recently awarded an impressive bronze 
plaque by the National Committee on Films for Safety for the Bureau of 
Medicine and Surgery film entitled: "Breathe and Live. " (MN-7498a) 
The film was accorded highest honors in the occupational field for non- 
theatrical films on safety produced or released in 1954. The original 
award is now on display at the Naval Photographic Center, Naval Air 
Station, Anacostia, D. C. (BuMed Info. Memo) 

3. The U.S. Naval Hospital, San Diego, Calif. , has been approved for 
the establishment of a course of instruction in Urological Technic for hos- 
pital corpsmen. The firstclass willbe convenedin January 1956. (TIO, BuMed) 

4. In November 1954, the Dental Division made an initial distribution 
of 20, 000 copies of a 50, 000 printing of the booklet, "The Care of Your 
Teeth and the Prevention of Dental Disease, NavMed P-5039. " Now, just 
a year later, all but 9000 copies of the original 50, 000 are gone, and there 
are back orders totaling 15,000. An additional printing has been ordered. 
It is evident that Navy dental officers are using this booklet to "spread the 
word" of the value of oral hygiene and how to attain it. (TIO, BuMed) 

5. A selection board is tentatively scheduled to convene at the Navy 
Department, Washington, D. C. , on or about February 7, 1956, to recom- 
mend Naval Reserve Officers of the Medical, Dental, and Medical Service 
Corps on inactive duty for promotion to Captain, (TIO, BuMed) 

6. SecNav Instruction 5420. 70 of November 30, 1955, transmits Depart- 
ment of Defense Instruction 5136. 7 of November 25, 1955, which estab- 
lishes a Department of Defense Dental Advisory Committee under the 
Assistant Secretary of Defense (Health and Medical). This committee 
shall advise and assist the Assistant Secretary of Defense (Health and 
Medical) in the development and implementation of Department of Defense 
policies, plans, and programs required to provide adequate, efficient, and 
economical dental care and services for Armed Forces. (TIO, BuMed) 



Medical News Letter, Vol. 27, No. 1 



27 



7. Experience with prescalene and deep cervical lymph node biopsy in 
50 consecutive cases with previously undiagnosed intrathoracic lesion is 
reviewed in Surg. Gynec. Obst. , December 1955; R. G. Connor, M. D. 

8. In a series of 100 cases of Dupuytren's contracture, it has been 
found that the site and degree of the lesions, the choice of treatment and 
the surgical technique constitute the most important factors in prognosis. 
Complete removal of palmar fascia, including the palmar and digital lesion, 
appears to be the most effective treatment. J. Bone & Joint Surg. , Dec- 
ember 1955; Raoul Tubiana, Paris, France. 

9. Data presented in this article and increasing experience indicate that 
the properly selected patient with cirrhosis of the liver does not constitute 
an unfavorable surgical risk, provided the, diagnosis is made in advance 
and proper precautions are taken before, during, and after the operation. 
Arch. Surg., December 1955; D. Cayer, M. D. , M. F. Sohmer, M. D. 

10. A rapid simple method for estimating the CO content of blood is 
described, whereby the CO is liberated from the c a rb oxyhemoglobin by one 
reagent and determined calorimetrically by drawing the CO through another 
reagent in a commercially available sampling tube. {J, Lab. & Clin. Med. , 
December 1955; H. I. Chinn, PhD., et al. ) 

11. The medicolegal aspects of chemical tests of alcoholic intoxication 
are discussed in Canadian Services Medical Journal, December 1955; 

I. M. Rabinowitch. 

12. Characteristics desirable in a topical anesthetic for ophthalmic pro- 
cedures are discussed in Am. J. Ophth. , November 1955; J. G. Linn, Jr. 



M. D. , LTJG E. K. Vey, MC USNR. 



BUMED NOTICE 6120 



8 December 1955 



From : 
To: 



Chief, Bureau of Medicine and Surgery 

All Ships and Stations Having Medical Personnel Regularly 
Assigned 



Subj: 



NavMed-X (Recruiting Statistics); submission of 



Ref: 



(a) Art. 23-15, ManMed 



This notice advises field activities of the latest revision of NavMed-X to be 
used in submission of the annual report required by reference (a). 



28 Medical News Letter, Vol. 27, No. 1 

BUMED NOTICE 5212 9 December 1955 



From: Chief, Bureau of Medicine and Surgery 

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

Subj: Retirement of medical and dental records to Naval Records 
Management Center, Garden City, New York 



Ref: (a) Art. 23-303, ManMed 



This notice advises that medical and dental records are not to be shipped to 
the Naval Records Management Center, Garden City, New York, after 31 Dec- 
ember 1955. Such records are to be held temporarily by addressees for for- 
warding to the Naval Records Management Center, St. Louis, Mo. .after 1 June, "56. 



ijf!, ?fc sjc sjc sfe sfc 

BUMED INSTRUCTION 6260. 6 13 December 1955 

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

Subj: Hearing conservation program 

Encl: (1) Outline of Hearing Conservation Program 

(2) Glossary of Terms 

(3) Bibliography 

This instruction provides a general guide for the establishment and imple- 
mentation of uniform and effective hearing conservation programs through- 
out the Naval Establishment. The basic elements of a program designed 
to prevent hearing loss in personnel employed in areas of high noise 
intensity are outlined in enclosure (1). Enclosure (2) is added to promote 
uniformity in terms used in reporting on hearing conservation programs. 
Enclosure (3) is a source of further detailed information pertinent to this 
program. 



$ * * * # sf: 



BUMED NOTICE 1520 15 December 1955 



From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Officers of the Medical Corps Regularly 
Assigned 



Medical News Letter, Vol. 27, No. 1 



29 



Subj: Guidelines for Bureau defrayment of travel and perdiem expenses 
for medical officers attending civilian short courses 

This notice provides guidelines for the attendance of medical officers at 
civilian sponsored short courses, seminars, etc. 

* * # * Sft * 

BUMED INSTRUCTIO N 3740. 1 16 December 1955 

From: Chief, Bureau of Medicine and Surgery 

To: All Stations Having Physiology Training Devices and/or Ejection 
Seat Trainers 

Subj: Aviation Physiology Training Program; augmentation of current 
instruction in 

Ref: (a) OpNavInst 3740. 3A, Subj: Aviation Physiology Training 
Program 

The purpose of this instruction is to provide professional guidance to 
flight surgeons in carrying out the provisions of reference (a). 

****** 

BUMED INSTRUCTION 6230. 8 Sup I 16 December 1955 

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

■ 

Subj: Poliomyelitis vaccine, Salk; distribution and use of in the 
continental United States 

Ref: (a) BuMedlnst 6230. 8 of 1 6 September 1955 

{h\ BuMed disp 0220102 of December 1955, same subj (NOTAL) 

This instruction supplements previous instructions by promulgation of 
policies concerning distribution and use of poliomyelitis vaccine {FSN 
IN62790) within the continental United States. 

****** 



! 



30 



Medical News Letter, Vol. 27, No. 1 



BUMED INSTRUCTION 1520. 2C 19 December 1955 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Dental Corps Personnel Regularly 
Assigned 

Subj: Graduate and postgraduate training for officers of the Dental Corps, 
U.S. Navy and U.S. Naval Reserve on active duty. 

Ref: (a) Art 6-82, ManMed 

This instruction informs all officers of the Dental Corps, U. S. Navy and 
U. S. Naval Reserve, on active duty concerning graduate and postgraduate 
training, 

BuMed Instruction 1520. 2B of 10 November 1954 is canceled. 



MEDICAL RESERVE SECTION 



Outstanding Naval Reserve Medical 
Companies Com mended 

Seven Naval Reserve Medical Companies were selected as outstand- 
ing in their respective Naval Districts for fiscal year 1955, and, in recog- 
nition of this, each Commanding Officer received a commendatory letter 
from Vice Admiral J. L. Holloway Jr. , USN Chief of Naval Personnel. 
In forwarding these commendations, the Surgeon General extended his 
congratulations to each Commanding Officer and the members for their 
noteworthy achievement during fiscal year 1955. 

The selected Naval Reserve Medical Companies, their Commanding 
Officers, and addresses follow: 

First Naval District Third Naval District 




NavRes Medical Co. 1-3 
Captain E. H. Drake MC USNR 
58 Deering St. , Portland Me. 



NavRes Medical Co. 3-2 

Captain R. E. Meek MC USNR 

N. Y. Hospital, 52 5 E. 68th St. NYC. 



Medical News Letter, Vol. 27, No. 1 



31 



Fourth Naval District 



Eighth Naval District 



NavRes Medical Co. 4-16 

LCDR Wm.M. Fischbach MC USNR 

5203 Delhi Pike 

Cincinnati 38, Ohio 



* NavRes Medical Co. 8-2 
Captain J. S. Webb Jr. , MC USNR 
Baptist Hospital 

2700 Napoleon Ave, New Orleans, La. 



Sixth Naval District 

NavRes Medical Co. 6-3 

LCDR L. D. Hagaman MC USNR 

Boone, N. C. 



Ninth Naval District 

* NavRes Medical Co. 9-4 
Captain R. E. Duncan MC USNR 
909 Argyle Building, Kansas Cy. Mo. 



Twelfth Naval District 



NavRes Medical Co. 12-5 
LCDR J. M. Yalon MSC USNR 
Rm. 309 Federal Office Bldg. 
San Francisco, 2, Calif. 



* A salute and special recognition to Medical Companies 8-2 and 9-4 for 
attaining this outstanding evaluation for the second consecutive year! 

$ sje !fc $ ajc $ 

Active Duty Training for West Coast Medical Department Officers 

A 5-day course in Special Weapons, Isotopes, and Military Medicine 
is scheduled to convene at U.S. Naval Station, Treasure Island, San Fran- 
cisco, Calif. , Monday 27 February 1956, and continue through 2 March 1956. 

This course will present an up-to-date review of problems and infor- 
mation relating to various medical aspects of special weapons and radioactive 
isotopes with primary emphasis on their application to military and naval 
medicine and civil defense. 

Subjects will be presented by speakers of outstanding prominence in 
their specialties; hence, it is assured that the presentation will be interesting 
and informative to all Medical Department officers. 

Rear Admiral Eugene R. Hering MC USN(Ret)will lecture on "Field 
Medicine with the Fleet Marine Force. " 

Quotas for this course have been authorized for Districts II, 12, & 13. 
All Naval Reserve Medical Department officers, male and female, are 
eligible to attend. No security clearance is required. 



32 



Medical News Letter, Vol. 27, No. 1 



WljjfiR} PREVENTIVE MEDICINE SECTION 



Recent Research in Infectious Diseases 

The following four abstracts, printed in the Proceedings of the 28th Annual 
Meeting of the Central Society for Clinical Research, are of particular 
interest to Medical Department personnel interested in infectious diseases. 



2. Studies on the Environmental Disse mi nation and Aerial Tran smission 
of Tubercle Bacilli 



The mechanism of environmental dispersion of tubercle bacilli and 
its influence upon the development of pulmonary tuberculosis is incom- 
pletely understood. The hypothesis generally accepted is that primary 
pulmonary tuberculosis is an air -borne infection resulting from the inhala- 
tion of particles sufficiently small to reach and be retained in the alveoli. 
The particle size distribution of aerosols dispersed by tuberculous patients 
and the factors which influence their production, pathogenicity, and sur- 
vival in the environment are unknown. The objective of this study was 
to acquire data which would provide a consistent explanation of the mode 
of transmission of tuberculosis. 

Quantitative bacterial air and surface -sampling techniques of proved 
efficiency were used in hospital wards and in an experimental room to 
assess the presence of the infectious particles in the air and upon surfaces 
and fabrics, and to measure their survival rate. The patients in these 
environments were bacteriologically confirmed open cases of pulmonary 
tuberculosis. The 640 cubic foot experimental chamber simulated con- 
ditions which occur in natural spread of air-borne disease through control 
of temperature and relative humidity. Careful study of 1254 samples of 
air, surfaces, dust, and bedding in rooms occupied by sputum -positive 
tuberculous patients failed to reveal any virulent tubercle bacilli, even 
when the patients were actively coughing. In five instances, avirulent 
acid-fast bacilli were isolated in these experiments. 

Studies on the survival of artificially generated aerosols of Myco - 
bacterium phlei revealed that these acid-fast bacilli failed to survive in 



Medical News Letter, Vol. 27, No. 1 



33 



the air beyond several hours at any relative humidity; furthermore, a 
relative humidity of 30% was most lethal. Earlier studies using a labora- 
tory strain of human tubercle bacilli (H37Rv) demonstrated that these 
organisms, when suspended in various vehicles and deposited as droplets 
upon glass surfaces, failed to survive beyond 37 days at any relative humid- 
ity. Identical results have been obtained in recent studies utilizing the 
acid-fast bacilli naturally present in sputum from tuberculous patients. 

These results suggest that persisting environmental contamination 
with infectious particles is not a common hazard associated with pulmonary 
tuberculosis, and that when inhalation infection does occur, it follows the 
coincidence of specific conditions not yet defined. (Abramson, S. , Lester, 
Wm. Jr. ) 

15. Epidemiology of Influenza as Revealed by Serum Pools from Various 
Age Groups 

In previous communications to the Society, it was shown that serum 
pooL collected by random sampling from individuals of all ages reveal 
changes in titer of antibodies against influenza virus corresponding to the 
occurrence of outbreaks of that disease. Low levels of antibody against 
the causative virus are present prior to an outbreak and a distinct rise in 
average titer follows an outbreak. The levels at which antibodies persist 
between outbreaks likewise were demonstrated. For the past three years, 
sera of infants and children were collected and divided into pools according 
to age. Pools of serum of adolescents, young adults, and individuals over 
40 years of age also were collected. The antibody content of all of these 
'pools against representative strains of influenza virus was determined. 

In agreement with reports of Francis and others, the authors find 
antibodies against swine influenza virus only in adult sera. In their serum 
pools, antibodies against PR -8, Type A, isolated in 1934, were not found 
in any significant titer in children born after the year 1944. Antibodies 
against the Lee strain of Type B isolated in 1940 were not found in the 
pooled sera of children born after 1945, whereas antihemagglutinins 
against more recently isolated Type B strains were found in children born 
in more recent years. The A prime viruses, prevalent since 1946, have 
caused outbreaks as recently as 1953. Antibodies against these viruses 
are found in the sera of nearly all children. 

It seems possible by analysis of the antibody content of sera collected 
by age groups to determine when a given virus strain ceased to be present 
in a community and when new virus strains appeared. 

The authors' findings suggest that recent influenza outbreaks occurred 
as a result of appearance of virus strains of new antigenic patterns rather 
than by reappearance of older strains after loss of population resistance. 



34 



Medical News Letter, Vol. 27, No. 1 



The findings in the sera of children indicate a decided lack of resistance 
to the older influenza viruses. The possibility exists that reappearance 
of one of these strains in virulent form could readily attack a large segment 
of the younger generation. (Broun, G. O. , Schmidt, R, R. , Murry, F. , 
Oligschlaeger, D. ) 

33. The Association of APC Virus es with Respiratory Illness in a Student 
Population 

Filterable agents, presumably viruses, which produce degeneration 
of tissue culture growth of human carcinoma cells (strain HeLa), human 
embryonic lung, and monkey kidney have been isolated from presumably 
normal human tonsils and adenoids grown in tissue culture, and from 
throat washings of patients with respiratory illnesses. Studies of the 
immunology and host range have indicated that they were similar to a new 
group of agents isolated by Werner and Hilliman and Huebner and associates, 
and designated APC (adenoid-pharyngeal-conjunctival) agents. 

To determine the frequency with which these agents were associated 
with sporadic illness in a student population, throat washings or throat 
swabs from 168 febrile infirmary admissions were inoculated into HeJLa 
cultures. Serial passages in tissue culture were made when suggestive 
or definite degeneration was observed. Complement fixation tests by a 
plate method have been carried out thus far on 71 paired serum samples 
from such individuals. Illnesses studied were predominantly respiratory. 

A cytopathogenic agent was obtained from 23 students. On the basis 
of the type of degeneration and rise in complement fixation titer, 8 were 
classified as belonging to the APC group. Six appeared to be herpes sim- 
plex, 3 mumps, 1 chicken pox, and 5 are as yet unidentified. Five other 
individuals with negative isolations had infections associated in the APC 
group on the basis of a fourfold or greater rise in complement fixation 
titer. Thus, 8. 5% (14) of the 168 patients studied have had illnesses assoc- 
iated with APC viruses. The clinical diagnoses in these patients were: 
acute upper respiratory infection, 5; pharyngitis and/or tonsillitis, 8; 
primary atypical pneumonia, 1; bronchitis, 1. Only 1 patient had con- 
junctivitis. No distinctive feature of the cases studied thus far has per- 
mitted a clinical diagnosis of an APC infection. These results will be 
compared with those obtained in military populations. (Evans, A. S. , 
Morse, H. ) 

53. A Rationale for Mo dification of Infl ue nza Virus Vaccines Derived 
from Experiments in Man 

Strains of influenza viruses A and B have varied antigenically from 
year to year since the original strain of each type was identified. Yet but 



Medical News Letter, Vol. 27, No. 1 



35 



in a single instance was it found that vaccine made from strains isolated 
in previous years (1934 and 1943) failed to induce antibody to, or protec- 
tion against, the prevailing virus. The results of the present studies, in 
which over 1000 persons in three age groups were vaccinated with one of 
eight experimental vaccines, demonstrate that antibodies against strains 
of influenza A-prime isolated from 1947 to 1955 are still induced by ade- 
quate amounts of vaccine prepared with a 1947 strain (FMI). In contrast, 
antibodies to recent strains of influenza B are relatively low following 
vaccination with a 1940 virus (Lee). Hence, it would appear logical and 
timely to alter the vaccine formula by adding a recent strain of influenza 
B, but not of influenza A-prime. 

In addition, the results of vaccine experiments in children, military 
recruits, and persons over 30 years demonstrate that excellent antibody 
response to viruses prevalent during the childhood of each of these cohorts 
of the population may be achieved by giving strains encountered after child- 
hood. However, in order to induce antibody against strains not previously 
experienced, those viruses must be included in a vaccine. Therefore, to 
achieve for all ages by vaccination that broad spectrum of antibodies char- 
acteristic of the older segment of our population whose resistance to influ- 
enza is greatest, a polyvalent vaccine composed of swine (1931), PR8 
(1934), FMI (1947) strains of influenza A, and Lee (1940) and Great Lakes 
(1954) strains of influenza B is required. (Hennessy, A. V. , Davenport, 
F. M. ) 

(Proceedings of the Central Society for Clinical Research: J. Lab. 8t 
Clin. Med. ,46:791; 799-800; 812-813; 826; November 1955) 

-jf 

Training in Occup ational Medicine 

Applications are invited from regular naval medical corps officers, 
up to and including the rank of commander, for postgraduate training in 
preventive and occupational medicine. 

The training may be requested in a school of medicine or school of 
public health. The school from which such training is requested shall be 
one accredited for graduate study by either the Council on Medical Educa- 
tion and Hospitals of the American Medical Association or the American 
Public Health Association, in accordance with the jurisdictions of these 
accrediting agencies. 

Medical officers are needed for duty in naval industrial activities 
who are especially qualified and have had formal training in the field of 
preventive and occupational medicine. 



36 



Medical News Letter, Vol. 27, No. 1 



Pneu monic Plague 

(A summary of Army Technical Bulletin Medical No. 124, "Plague, " 
appeared in the Preventive Medicine Section of the November 18 issue 
of the U.S. Navy Medical News Letter. The following discussion of 
pneumonic plague consists of a revision of paragraph 13 of Army Tech- 
nical Bulletin Medical No. 47. Certain minor editorial changes were 
necessary in adapting the revision to Navy use. ) 

Pneumonic plague occurs as a primary infection or as a secondary 
complication of the bubonic form of plague. Primary pneumonic plague 
begins with fever and chilliness followed within 4 to 20 hours by a scantily 
productive cough yielding frothy, bloody sputum. Fever continues, and 
weakness, prostration, cyanosis, and dyspnea develop rapidly and are out 
of proportion to the pulmonary involvement found by physical examination 
and roentgenography. Rapid progression of the disease in untreated cases 
almost invariably ends in death in 48 to 72 hours; treatment with strepto- 
mycin and broad spectrum antibiotics within the first 24 hours after the 
onset of fever is life saving, but delay in treatment greatly lessens the 
chances of survival. The sputum contains great numbers of plague bacilli. 
Pleural pain is usually not severe, and physical signs of frank consolida- 
tion of the lungs are generally not present. Peripheral blood shows a 
marked polymorphonuclear leukocytosis. Hemorrhages, into either the 
skin or subcutaneous tissues, may appear. Approximately 5% of patients 
with the bubonic form develop secondary plague pneumonia. A positive 
diagnosis can be made hy demonstrating the etiological agent in the sputum 
or blood in the primary pneumonic form and also in the buboes in the sec- 
ondary form. 

Primary pneumonic plague results from discharges from the res- 
piratory tract of patients with the pneumonic form, either primary or 
secondary. Secondary plague pneumonia develops in cases of bubonic 
plague contracted from infected fleas. 

Transmission is by direct contact with an infected individual or 
indirectly from articles contaminated with discharges from the respira- 
tory tract of such a person. The organisms may also gain entrance to 
the respiratory tract in the handling of the carcasses of infected rodents. 
Although, infection usually takes place through the respiratory tract, 
the conjunctiva may also be a portal of entry. 

The incubation period in bubonic plague is between 2 and 10 days, 
usually 3 to 4 days. In primary pneumonic plague, it may be as short as 
2 to 3 days, but all contacts must be observed for 8 days. As long as 
the etiological agent is present in discharges from the respiratory tract, 
the disease must be considered communicable during the period of acute 
symptoms. 



Medical News Letter, Vol. 27, No. 1 



37 



Susceptibility is general, but an attack of plague confers immunity 
for a number of years. Some degree of active immunity results from 
vaccination, although frequent booster inoculations are required to main- 
tain such resistance. 

Outbreaks of pneumonic plague occur periodically in certain regions 
where bubonic plague, is endemic (i. e, , in modern times in Manchuria, 
Madagascar, South Africa, and occasionally elsewhere). Reasons for 
outbreaks are poorly understood, but climatologic and sociologic condi- 
tions are thought to contribute. Secondary plague pneumonia in a patient 
with flea -transmitted infection begins the man-to-man cycle of pneumonic 
epidemics. The incidence of fleaborne bubonic plague in man is related 
directly to the plague incidence in rodents in the immediate environment. 
The species of rodent which act as the reservoir of the disease vary in 
different regions. In the United States, plague is endemic in various 
species of rodents in the Pacific and Mountain States. In South America, 
it occurs in Venezuela, Guiana, the coastal region of Brazil, the northern 
part of Argentina, Paraguay, Bolivia, Peru, and Ecuador. In Africa, 
endemic areas are widely distributed and include the west coast, South 
Africa, East Africa, the Belgian Congo, a band in the north from Morocco 
to the Nile delta, and Madagascar. In the Middle East, it occurs in Syria, 
Iran, and Iraq. The disease is found in all parts of India, Ceylon, Burma, 
Thailand, Indo-China, Malaya, and the Malay Archipelago. It is endemic 
in much of the coastal area of China, throughout Manchuria, and also 
in scattered areas of the interior. Other foci exist in Hawaii, New Cal- 
edonia, and the Azores. 

The rapidly fatal outcome of pneumonic plague in individual patients 
and the explosive nature of the outbreaks demand immediate institution 
of therapeutic and control measures, often before bacterial confirmation 
is effected. 

1. Isolation should be carried out until plague bacilli are no longer 
present in discharges from the respiratory tract. Because of the extremely 
high communic ability during the period of acute symptoms, all attendants 
should be provided with gowns, goggles, masks, and rubber gloves which 
should be worn when in contact with the patient as well as when disposing 

of articles contaminated with infective discharges. The improved type of 
face mask, consisting of a singly layer of cotton flannel filter fabric, 
covered on each side with a single ply of gauze, should be used. 

Articles should not be removed from the environment of the patient 
unless disinfected by boiling or an equivalent method and terminal dis- 
infection is necessary. The bodies of persons dying of plague should be 
handled only under strict aseptic precautions. 

2. Quarantine. Contacts of cases of pneumonic plague must be 
held in strict quarantine for 8 days with careful periodic observation and 



38 



Medical News Letter, Vol. 27, No. 1 



recording of temperature every 4-6 hours. Contacts developing fever 
are immediately isolated and given specific therapy. 

3. Immunization . In the face of an epidemic, or when the threat is 
appreciable, all persons in the region should be immunized or reimmunized. 
Special attention should be given medical attendants. 

4. Investigation of Source of Infection . In pneumonic plague, search 
should be made for other human cases to which the patient may have been 
exposed. The local rodent population should be examined for evidence of 
plague, and antirat measures should be intensified. 

5. General Measures . Because effective flea and rodent control 
measures are important in preventing bubonic and septicemic plague, such 
measures indirectly reduce the chance of an outbreak of pneumonic plague. 
Direct man-to-man spread of pneumonic plague is controlled by quarantine 
of the region, prompt isolation of all patients and contacts, early treatment 
df cases, and immunization of the population at risk. 

Department of Defense Standards for 
Insect and Rodent Control 

The new look in the Navy's insect and rodent control program has 
been further freshened by the recent issuance of Department of Defense 
vector and economic pest control standards (BuDocksInst 6250. 3 of 
31 October 1955). These standards were promulgated to ensure the safe, 
efficient, and economical control of insects, rodents, and other pests 
that are injurious to health and morale, cause discomfort to personnel, 
and destroy property at military installations. 

The principal requirements established by these standards are for: 

1. The establishment and conduct of a scheduled preventive program 
of pest control as a part of the installation "maintenance" management 
program. 

2. Use of only standard issue pesticides of known composition and 
origin and standard dispersal equipment. 

3. Use of only certified personnel for the accomplishment of pest 
control operations. 

4. Provision of protective devices and clothing wherever control 
operations require their use. 

5. Provision of means for safe storage and transportation of poten- 
tially toxic formulations. 

6. Maintenance of adequate records of operations and costs. 

7. Review of all pest control contracts by higher authority to ensure 
safety, quality of work, and provision for control operations at a level of 



Medical News Letter, Vol. 27, No. 1 



39 



effectiveness at or above that which is obtainable by the use of installation 
personnel. 

Procedures for ensuring conformity with these new standards will 
be promulgated for management activities of the Bureau of Medicine and 
Surgery as soon as is feasible, 

^ ^ ^ ^ ^ ^ 

R apid Identification of Enteric Organism s 
on Membrane Filters 



The following summary of an article concerning eyperiments testing 
the efficiency of the membrane filter (MF) in the differentiation of enteric 
organisms by their colonial appearance on the filter was abstracted from 
the September 1955 report of Preventive Medicine Unit Number 8. Requests 
for copies of the complete paper may be addressed to: Preven tive Medicine 
Unit, Number 8, Navy No, 3923, c/oFPO, San Francisco, Calif. 

"The use of the membrane filter in the rapid primary isolation of 
enteric pathogens is described. A tentative identification of Shigella and 
Salmonella organisms from rectal swabs can be established on the average 
in 10 hours, using serological group typing of colonies on MF. 

A nutrient indicator inhibitor (Nil) broth was used as the primary 
isolating medium for the MF technique. 

Rectal swabs were obtained and processed from 134 nondiarrheal 
individuals and 19 patients with diarrhea. Individual isolated colonies were 
obtained from 109 of the nondiarrheal specimens and from specimens from 
15 of the 19 persons with gastrointestinal disturbances. 

Differentiation between Escherichia coli and other enteric organisms 
was made by observing differences in size and color. The E. coli colonies 
were orange while the other enteric organisms appeared either colorless 
or bluish-green. The E^ coli colonies were usually larger than the other 
enteric organisms after the same period of incubation. 

Approximately 70% of the clear or bluish-green colonies, when studied 
further, were found to be noncoliform organisms. 

Experiments are presently in progress on the application of the mem- 
brane filter technique in field surveys of food handlers for the identification of 
enteric pathogen carriers and also in the study of the Paracolobactrum 
group of organisms. " (Bloom, H. J. , Cobb, J. M. , Rapid Identification 
of Enteric Organisms on Membrane Filters. Submitted to Am. J. Clin. 
Path. , for publication. > 



sjs >je :{« ^ % 



40 



Medical News Letter, Vol. 27, No. 1 



Foreign Animal Diseases 



The U. S. Livestock Sanitary Association has recently published 
a 270 -page report entitled "Foreign Animal Diseases, Their Prevention, 
Diagnosis, and Control. " The book's information — particularly that con- 
cerning diseases transmissible from animals to man — should be useful to 
medical officers and other Medical Department personnel. 

Detailed knowledge of each disease concerning changes, diagnosis, 
prognosis, and epizootiology, control, and public health aspects, is included. 
The report also deals with insect vectors, the part they play in spreading 
certain diseases, and measures for effective control. Illustrations and 
photographs covering 28 diseases as well as references are included. A 
limited number of copies of this report are available to activities with a 
legitimate need, upon request, from the Bureau of Medicine and Surgery, 
attention: Code 72. 



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. 



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