THE SURGEONS I

J U L. - 1 9 5 2

V 0 L U M E - VII

NUMBER - 7

A FAR EAST PERIODICAL.

MEDICAL ,AND UNC OF ARMr APO 500 SEftTlftN#52HQ-fEC, MEDICAL SERVICES INFORMATION

Volume VII - Number 7 Circular JULY 1952 Headquarters Far East Command Medical Section Letter APO 500

ADMINISTRATIVE

Army Medical Service Observes 177th Anniversary, 27 July ..... 100

Distinguished Service Cross Awarded Posthumously AMEDS Soldier* . 101 Know Your Caduceus 101 Impregnation of Clothing With Miticides and Use of Insect Repellents 102 Malaria Therapy « • 102 Awards to Amy Medical Service Personnel 103 Recent Department of the Army and FEC Publications 105

ARMY MEDICAL SERVICE OBSERVES 177TH ANNIVERSARY,* 27 JULY

In a letter to the Continental Congress dated 21 July the post. Surgeon General Church was replaced by- 1775, General George Washington, Commander-in-Chief John Morgan, MD, who, counselled by General Washing- of the Continental Army, requested an organized med- ton and with the assistance of his subordinate med- ical service for his amy of 20,000 men maintaining ical officers, drafted the first hospital regula- that "the lives and health of both officers and men tions. A chapter of these regulations on treatment so much depend on a due regulation of this depart- of the sick gave information which would still be ment." On 27 July 1775, the Continental Congress considered as good common sense. passed a bill providing for "an Hospital" or Hospi- tal Department, with personnel to include a chief The achievements of the Army Medical Service are surgeon, one apothecary and 23 subordinate person- many; its rosters are studded with the names of out- nel. standing physicians and pioneers in the field of med- icine—Kelser, Beaumont, Waterhouse, Lovell, Vedder, The Hospital Department faced many and myriad diffi- Letterman, Hammond, Reed, Gorgas, Billings, Darnall. culties. They were called upon to serve in the war Brigadier General Raymond A. Kelser, besides discov- of 1812, for example, with a medical provision of ering a vaccine for the dread cattle disease, rinder- one surgeon and two assistants for each of the thir- pest, was responsible for determining the mode of teen additional regiments. In that war, as in the transmission of equine encephalomyelitis. Colonel Revolutionary War, surgical practice was at a mini- Edward B. Vedder discovered the cause of beriberi, mum. Anesthetics were not in use and blood-letting thereby giving a new lease on life to millions whose was still considered a cure-all. At that time, "the food consisted principally of rice. Colonel Vedder more blood expended the better the wounds of the vis- was also one of the leading research scientists in cera, provided life was not extinguished when the the field of deficiency diseases. Other outstand- hemorrhage had stopped," was the prevailing attitude ing contributors to the growth of Army medicine in- of surgeons. In both these wars medical service for cluded an army surgeon, Benjamin Waterhouse, who,in the sick was a greater problem than the care of the 1800, brought smallpox vaccine to the United States. wounded; there were more deaths from disease and From it grew the widespread practice of vaccination wound infection than from enemy action. which has practically removed smallpox from America.

From this unpretentious beginning, lacking in the The year 1821 brought William Beaumont, one of the precedents and centralized control of medical facil- Army's most famous medical officers, to the fore- ities and limited by a demand for strict economy,the ground. Called on to treat a young half-breed who Hospital Department progressed to the present highly had been accidentally shot in the abdomen, Surgeon organized and coordinated scheme of military medical Beaumont took the patient to his own home where he service. The early discoveries, the application of nursed him back to health. However, the wound left practical sanitary measures and the medical practic- a fistula which never completely healed, thus enab- es of the Army Medical Service have not only pro- ling Beaumont to observe the process of digestion. longed the life of its own personnel but that of all people of the civilized world as well. In 1836, Army Surgeon General Joseph Lovell estab- lished a collection of medical books that later be- came known as the Surgeon General's Library. Still The first "Surgeon General" was Benjamin Church, MD, later it was changed to the Army Medical Library and and he carried the somewhat aweseme title of Direc- finally, this year, it became the Armed Forces Med- tor General and Physician-in-Chief of the Continen- ical Library. It has grown to be the greatest col- tal Army. In the same year of his appointment to lection of medical reference books in the country.

100 During the Civil War, Surgeon Jonathan Lotte man won Army Dental Corps and the Army Nurse Corps, and the prominence by devising the present day system for establishment of a surgical hospital at Washington speedy evacuation of the wounded; in 1862 Surgeon Barracks, forerunner of the present Walter Reed Army General.William A. Hammond established the Amy Med- Medical Center. ical Museum to house gross material, instruments and * other items of significance in medical history. To- Then there was Surgeon John S. Billings who pioneered day the Museum possesses over 5,000 specimens of in the study of the ill effects of overcrowding, and gross tissue and the largest collection of micro- Major Carl R. Darnall who originated the process of scopes in the world. The institution is the only purifying drinking water by liquid chlorination. The one of its kind in the world open to the public. application of Major Darnall's work is now world-wide in scope and probably has saved as many lives as any Perhaps the Amy Medical Service achievement best other medical achievement. known to the general public is the discovery by Maj- or Walter Reed and his associates of the mode of Today, Army Medical Service personnel are continuing, transmission of yellow fever in 1900. Major Reed's each in his own way, to make outstanding contribu- work was the foundation for Brigadier General Wil- tions to the field of medicine. A compilation and liam C. Gorgas whose work in preventive medicine evaluation of these contributions will, undoubtedly, made possible the construction of the Panama Canal. further the art of medical science. Whether in com- bat or out, they are dedicated to the task of safe- In the same decade, General Sternberg materially ad- guarding and restoring the health of the individual vanced the study of bacteriology in this country. soldier as the best means of "conserving America's He was also responsible for the organization of the fighting strength."

DISTINGUISHED SERVICE CROSS AWARDED POSTHUMOUSLY AMEDS SOLDIER

For extraordinary heroism in action against the en- a medical aidman with Medical Company, 38th Infantry emy in Korea, an officer and three enlisted men re- Regiment, 2d Infantry Division, accompanied a force cently were awarded the Distinguished Service Cross, assaulting an enemy-held hill near Pia-ri. Wounded posthumously, according to Eighth Army Order. One early in the attack and in great pain, Private Tren- of the enlisted men was a member of the Army Medi- holm forced himself to his feet and rendered aid to cal Service. two other wounded men. While attempting to evacu- ate the second man for further treatment, he was On September 12, 1951, Private Richard R. Trenholm, killed by a burst of enemy fire.

KNOW YOUR CADUCEUS

In the Amy of the United States the dess of health. While Aesculapius was treating a care and treatment of the sick and the patient one day a snake entered the tent and en- promotion of health generally has for twined about his walking stick, thus conferring up- many years been carried on under the on him the gift of wisdom. symbol or sign of the caduceus. The serpent was sacred to nearly all the gods, both Investigations indicate that the cadu- Egyptian and Grecian. It represented immortality ceus had its origin in civilizations or renovation of life and vigor, typified by the much earlier than the Greek and that it symbolized periodical change of its skin. In various places certain vague groups of mystic or magic processes the serpent represented knowledge and culture, whioh in the cult of prehistoric men were anterior shrewdness and wisdom, freedom from disease. to medicine, in our sense, but certainly inclusive of it. In the earlier Babalonian figurations the The caduceus, with entwined serpents, frequently ap- caduceus is not an emblem but a god in itselfj in peared on the title pages of medical books published others it is carried in the hand of gods or goddes- in the 16th Century. One of these printers used ses as a sign and symbol of supernatural power. the caduceus without the wings but a dove hovers This staff in its oldest form was a rod ending in overhead and the complete emblem includes a Greek two prongs entwined into a knot. inscriptions "Be ye therefore wise as serpents and harmless as doves." This is perhaps the first in- Apollo, the Sun-god, carried a staff or magic wand stance in which the caduceus of Hermes is associa- which exercised influence over the living and the ted with medicine. The physician to King Henry dead. Apollo, first victor of the Olympic games, VIII was the first to employ the caduceus in his was not only a great athlete but was also god of the crest. healing art, "physician and seer," "health giver," "averter of evil," and "physician of the soul." In 1857 Army Regulations directed that the caduceus be part of the army insignia for hospital stewards. Apollo gave his wand to Hermes (Mercury) in exchange In 1902 uniform specifications directed that the for a lyre. Hermes, while carrying this wand came caduceus, as we know it, the staff around which are upon two serpents knotted together. While fighting, entwined two serpents and at the head of staff two he separated them with his wand. Mythologists ex- outstretched wings, be worn as a collar ornament of plain this as the time the serpents were substituted Medical Service personnel. Army Regulations provide for the entwined rod. A pair of wings was sometimes that the caduceus be the only article of the uniform attached to the top of the staff in token of the peouliar to the Medical Service to symbolize the non- speed of Hemes as a messenger. ccmbatant functions of the Service, and of its neu- tral status on the battlefield under the Convention Aesculapius, Apollo's son, became the lengendary of Geneva, 1864. Greek god of medicine. In the temple erected to him he effected cures and prescribed remedies to the (Adapted from Army Medical Bulletin, No. 32, July sick in dreams. His daughter, Hygeia, was the god- 1935).

101 IMPREGNATION OF CLOTHING WITH MITICIDES AND USE OF INSECT REPELLENTS

The program of prevention of epidemic hemorrhagic tive after two scrubbings with soap and cold water. fever in Korea by impregnation of clothing with miti- Hot water laundering removes the miticide more rap- cides and the use of insect repellents as an indiv- idly and should not be used for laundering treated idual protective measure have resulted in numerous clothing. After the uniforms have been laundered requests for information on techniques of applica- three times in cold water, they should be reimpreg- tion of the impregnant and use of the repellent. nated.

Quartermaster issue anti-mite fluid is compounded Mien impregnation of the uniform by total immersion under various formulations but consists essentially in the miticidal solution cannot be practiced, the of a mixture of equal portions of dibutylphthallate individual may secure protection by use of insect and benzyl benzoate, plus an emulsifying agent. One repellent. This repellent for individual use is gallon of this mixture in 17 gallons of water will available in two ounce bottles supplied by the QM. make enough solution to impregnate 50 herringbone The liquid should be applied by hand to the exposed twill uniforms and pairs of socks. surfaces of the skin, on the face, forehead, neck, behind the ears, ankles, legs, wrists, hands and The procedure for applying the miticide is as fol- arms. It should be applied in a similar manner to lows : the edges of the cloth surrounding openings into the clothing such as the bottoms of the sleeves and trou- 1. Prepare the dipping solution in an oil drum with sers, the fly, front opening and neck line. top removed or other similar container on the basis of one gallon of the miticide per 17 gallons of wa- Miticidal fluids can be applied using sprayers of a ter. A stick long enough to reach the bottom should proper type. As a general rule, impregnation by to- be kept in tiie drum 30 that the mixture may be kept tal immersion is the preferred treatment because in- stirred thoroughly during the dipping operation. A adequate treatment often follows from use of the second oil drum or similar container should be placed wrong type of spray equipment. If sprayers are used, adjacent to the first drum to receive the excess wa- they must be of a type that delivers large coarse ter wrung from the clothing. Station a man at each droplets that will actually wet the cloth and not drum. drift away as mist. A uniform should be covered with at least two ounces of miticide to insure pro- 2. Form the men into a line, each carrying his uni- per protection. form and socks. Each man should stop briefly at the first drum, immerse his clothing long enough for it Emulsion treatments are easily applied in QM mobile to be saturated thoroughly with the solution, and laundries and such treatment is to be preferred when then with the assistance of the man stationed at the large amounts of mite proof clothing are to be is- second drum, wring out the excess solution into the sued. As mobile laundries utilize centrifugal ex- drum. The liquid collecting in the second drum tractors which remove more liquid from the clothing should be returned as it accumulates to the first them would drip out in ordinary line drying, higher container. concentrations of the miticide are necessary. Clo- thing should be weighed before treatment and after 3. Hang up the clothing to dry, taking care to pro- centrifuging to determine the amount of liquid re- tect it from rain while it is still wet with the im- tained. The concentration of the emulsion should pregnant. As soon as the clothing is dry, it is be adjusted so that each uniform takas up from 2 to ready to wear. 2.5 ounces of the miticide. Drying should be accom- plished at temperatures less than 160 F. to prevent Under conditions of field use, a treated uniform loss of impregnant thru volatilization. will withstand prolonged soaking resulting from rain or wading in fresh or salt water. The impregnant is References TB MED 31, dtd 21 Jem 48, Scrub Typhus removed slowly by laundering but still will be effec- Fever.

MALARIA THERAPY

Section II, SGO Circular No. 110, dated 3 July 1952, scribed. The presence of anemia does not preclude is quoted for information and guidemce of all medi- the use of primaquine in the treatment of malaria. cal officers: "Primaquine is effective in destroying the tissue "Studies at the present time indicate that the ad- phases of the malaria parasite but is relatively in- ministration of primaquine in doses of 15 milligrams effective against the 'blood stages of the organism daily for 14 consecutive days will markedly reduce and should therefore be used in combination with the relapse rate of Korean Malaria (Vivax Malaria) chloroquine for the treatment of acute attacks of and there has been no apparent toxicity from prima- Vivax Malaria. quine when given in doses of 15 milligrams once daily for 14 days. Two large groups of troops were treated with this regimen while on a full duty sta- "In treating the acute attacks, the following regi- tus and no toxic effects were manifested. However, men is reoommended: when administering primaquine, one must be cognisant of its potential toxicity which might result in herao Chloroquine, 3 doses of 0.3 grams (base) during lytic anemia, bone marrow depression, methemoglobin- the first 24 hours and then 0.3 grams (base) once emia and abdominal pain. Primaquine in higher dos- daily for 2 days. age levels may produoe hemolytic anemia in Negroes more readily than in Caucasians but this has not Primaquine is given simultaneously in single daily been observed when 15 milligrams daily has been pre- doses of 15 milligrams for 14 consecutive days."

102 AWARDS TO ARMY MEDICAL SERVICE PERSONNEL

The following additional Army Medical Service personnel have been awarded the Distinguished Service Cross, Silver Star, Legion of Merit, Soldier's Medal, Bronze Star Medal with "V", Bronze Star Medal or Commendation Ribbon for exceptional bravery in face of the enemy and meritorious service during the Korean conflict. These names are taken from the MRU Roster prepared as of 18 April 1952.

[DISTINGUISHED SERVICE CROSS ; LEGION OF MERIT Landers, Charles, M/Sgt Lange, Philip F., 1st Lt., MC Roton, Franklin D., Pvt Cirlot, Joseph S., Lt Col, MC Leddy, John R., Cpl Dredge, Thomas E., Lt Col, MC Love, Frederick E., Pvt French, Sanford V., Col, MC Martin, Veil B., FFC Glove, Richard P., Lt Col, MC McCord, Robert G., PFC Markowitz, Isidor, Lt Col, MC McDonald, Jerome, Cpl : SILVER STAR Page, Thomas N., Col, MC McGuire, Daniel T., PFC Rogers, James T., Lt Col, MC UcRuer, Alexander, Sgt adams, Floyd D., Jr., Pvt Mendoz, Pete, Cpl Anderson, Victor I, Cpl [ SOLDIER'S MEDAL Miller, ndger M., Capt, DC Atencio, Jonn R., FFC Miller, Richard, PFC Baker, Jimmie, Sgt Ackerman, Robert C., PFC Millican, Loman C., PFC Beckingham, Theodore, Cpl McCowan, Ralph L., Sgt Mills, Gerald 7.'., Sgt Blansett, Joe C., Cpl Ming, Paul E., SFC Milton, Trent E., PFC Brakeman, William n., PFC Snow, David R., PFC Morfey, Donald L., PFC Brooks, John R., 1st Lt, MC Morris, Carson, L., Cpl Brown, Clarence J., Sgt Olivera, David M., Cpl Buckley, John M., PFC BRONZE STAR MEDAL with "V" | Patillo, Paul 3., PFC Council, John B. Jr., PFC Peters, Fdward D., Sgt Cratty, James W., Sgt Allen, Lloyd B., Sgt Prato, Charles, Sgt Csepp, Jack J., PFC Anderson, Frederick, Sgt Quiring, Donald R., PFC William Cpl Davidson, W ilbur L., Cpl Bacon, L., Quiroz, Rafael, Jr., Cpl r Cpl Dixon, Douglas 0., PFC Barker, Cecil H., Jr., Rich, Lewis, J., Sgt PFC Dobbins, Ernest, Jr., PFC Bell, Fred, Robichaud, Richard, Cpl Dougherty, Eugene G., Cpl Bellair, Lloyd, PFC Rogers, John D., Cpl Bossman, Edward L., Cpl Dowdy, Marvin L., Pvt Rogers, Robert E., Capt, MSC Ellis, David M., Cpl Briggs, James H., PFC Rosa, Jesus, Sgt James R., 2d MSC Eshelman, Richard C., Cpl Brown, Scherf, Donald D., PFC Obed Cpl Ford, Henry, Sgt Brown, N., Scott, Lowell, PFC Goodman, Harry A., Sgt Bryant, Charlie, Sgt Selph, William W., Cpl Granados, Nicandor, PFC Calvo, Sam, Cpl Sloth, Dale N., PFC Greene, John T., PFC Ceccato, Robert, PFC Smith, Thomas L., Cpl Gudmundson, Hjalmar, 1st Lt, MC Coen, George D., PFC Swerdi, Thomas, Cpl Gundlach, Raymond W., Sgt Colantonio, Fred, PFC Templeton, Herbert, PFC Kenyon, Eugene P.. Cpl Collom, Glenn M., PFC Tesler, Irving, PFC Knezevich, William, Sgt Conger, Jack D., Cpl Thomas, Earl L., PFC Lawton, Ora V., Sgt Crawford, Charles R., PFC Thomas Ira L., Sgt Mahue, Aurius J., Jr., Cpl Cronkhite, Linniel, Cpl Thompson, Silas, PFC Cummings, Frank May, Leslie E., PFC C., PFC Thornton, Jimmie H., Pvt McCowan, Ralph, Sgt Donnelly, William J., Cpl Torres, Melquiades, Sgt Eves, Robert J., PFC Neagle, Paul E., 1st Lt, MSC Tucker, Lowell G., PFC Novak, Martin T., PFC Feigelson, Herschel, Sgt Velasco, Spifanio, Cpl Fina, David R., PFC Olsen, David J., PFC Vining, Robert A., Cpl Fisher, Frank PFC Orrach, George A., Sgt T., Walker, Donald D., Cpl Fitzwater, Carl S., PFC Packard, Stanley W., Sgt Wellman, LelandJ., PFC Douglas PFC Eugene B., Sgt Giebeler, R., Wheaton, Howard H., PFC Palermo, Cpl Pickerel, Robert A., PFC Glover, Earl H., Wisniewski, Raymond, PFC Plessis, Joseph H., PFC Goodin, William L., Cpl Withee, James F., Cpl Kenneth Cpl Pryne, Harvey S., PFC Gordon, V., Lauris D., Capt, I.IC Ramirez, Frank, Cpl Graves, STkR Grubinskas, Charles, Cpl BRONZE MEDAL] Ramos, Ralph, Sgt • Guy, Edward 1st MC Rapine, Lonnis D., Cpl J., Lt, Abate, Sgt Hall, Robert K., Cpl Valentino, J., Rhodes, Edmond A., 2d Lt, MSC Abbott, William L., Maj., VO Earl A., PFC Romano, Florentine, Sgt Hille, Adair, Victor R., Sgt Scheffler, Elmer H., Pvt Hulett, Wilbur J., Pvt Adelman, Robert A., PFC Seaborn, Larry, PFC Hul'sey, Thomas C., PFC Allen, Lloyd B,, Sgt Smith, Ernest C., Pvt Jackson, Leon, Cpl Anderson, Samuel R., Li/Sgt Takanishi, Morito, Cpl Jeffrey, Tennis H., Sgt Arredondo, Stanley, PFC Tidwell, Vernon H., PFC Johnson, Stephen C., Sgt Atkins, John, Capt, MSC Vega, Charles B., PFC Johnson, William H., 1st Lt., MC Avery, William G., Maj., MC Waas, Richard, Cpl Johnson, William H., 1st Lt,, MC Barmore, John Lucia, Maj., MC Webster, George D., Capt, MC King, Robert L., PFC Barrett, Roy D., Cpl Whitt, John, Jr., PFC Kocjancich, Edward., Cpl Bass, John, Capt, MSC Winter, Wilbert L., Cpl Kurucz, Steve J., PFC Baumgartner, Loran, Capt., MSC Wright, William L., Cpl Landeros, Manuel, PFC Baxter, Roland A., Cpl

103 BRONZE STAR MEDAL (CONTD) Magri, Joseph E., SFC Tempi©, Merlin F., M/Sgt Makely, George P., M/Sgt Thomason, Eugene A., Capt, MC Bazemore, William F., Sgt Marlette, Robert H., Maj, DC Titus, Elbert D., SFC Beach, Prince D., Lt Col, MC Marshall, Linn F., Capt, MSC Trenholra, Richard R., Pvt Beard, Earl P., Cpl Martin, Charles E., Capt, MSC Tucek, Arthur R., Capt, MSC Beers, Leo E., SFC Matthews, John T., Maj, MSC Turner, Robert E., M/Sgt Bowman, Charles J., SFC Mauk, Ralph B., M/Sgt Vanderwende, Cornel, Sgt Bradshaw, O’Donald, Cpl May, Frank L., 1st Lt, MC Walter, Florence A., Capt, ARC Britton, George T., Lt Col, MC Mazzola, Russell E., Cpl Weidenkopf, Stanley, Lt Col, MSC Brown, Jesse F., Lt Col, MC McGonigle, John F., Capt, MC Weisman, Eugene J., Capt, DC Brown, William G., Sgt McLean, Donald T., Sgt Wells, Charles H., Capt, MC Bryan, Joseph L., SFC Meltzor, Daniel, Capt, MSC White, James, PFC Wilkins, Sgt Capasso, Salvatore, Maj., MSC Merrihew, Donald R., Capt, MC Truman, Donald Cappy, Andrew Louis, Maj., MSC Messenger, Andrew L., Capt, MC Windsor, F., Sgt Cartwright, Thomas, Capt, DC Miller, Charles H., Cpl Wittlif, Charles L., Capt, MSC Chalfant, George A., Capt., MC Moraitis, Constanti, 1st Lt, MC Wolf, Donald C., Sgt Young, Chardack, William M., Maj., MC Moran, Kenneth J., SFC John T., Maj, MSC Cirlot, Joseph S., Lt Col, MSC Morgan, Hathan T., Sgt Zola, Seymour P., Capt, MC Clawson, Carroll K., Capt, MC Morrell, Rathan E., 1st Lt, MSC Coe, Charles A., Jr., Maj, MC Morrison, Cecil E., Sgt MSC Mulford, Todd M., Lt Col, MC Cohen, Stanley, Capt, Addington, Robert E., Cpl Nebe, Frederick M., Lt Col, MC Cole, Richard K., Jr., Capt, MSC Donald D.A., Cpl Remeth, Ernest A., 1st Lt, MSC Anderson, Collazo, Arcadio, Sgt Donald A., MSC Nocella, Pearl P., Capt, ARC Anidon, Capt, Condo, Richard L., Capt, MC Anselmi, Sgt Rorem, Leroy K., Capt, MSC Donald, Crouch, William L., Sgt Augustus, A., Capt, MSC John Sgt Charles Cutler, Morton T., Capt, MSC Rorris, H., aune, Jerald 0., Sgt Olsen, Earl M., Capt, MSC Dailey, Dayton H., Cpl Norval L., SFC Omori, Harry I,, Capt, DC Bannister, Dailey, John J., Cpl Beasley, Cecil Cpl Patten, John Capt, MC M., Daniels, Leon L., SFC C., Bentley, Alfred Peck, Willard L., M/Sgt H., M/Sgt Davis, Ray C., Sgt Berman, Joseph, Capt, MSC MSC Pitnu, Anthony J., Sgt Deakins, John A., Capt, Blakely, Burward L., Maj, Plotkin,.Alexander, PFC MSC Dekle, Marion, Sgt Blount, Alvin V., Jr., Capt, MC 2d Lt, Delagarza, Carlos G., MSC Potter, Delbert, PFC Boardman, Vernon R., Sgt George Demorset, Paul L., Pvt Potter, H,, Sgt Bonczyk, Henry J., SFC Capt, MSC Ramsey, Foster Maj, MSC Dodge, Harry Weeks, G., Brown, Gordon T., SFC Capt, MC Riley, Maj, MC Dudney, Rewton E., John W., Burns, George F., Cpl Johnnie, Riley, Winifred WMSC Dunn, Sgt G.,-Capt, Cappelletti, John D., SFC A., Wonsham B., Capt, MSC Ellis, Vernon Sgt Roberson, Casciano, Anthony A., Sgt DC Roberts, Herbert SFC Evans, Robert H., Maj, G., Casetta, Gerald Lee, Cpl 2d MSC Fort, Daniel W., Cpl Roberts, William W., Lt, Castiglia, Jerry, Cpl Capt, Henry Cpl Fraticelll, Eddie, MSC Robinson, B., Cobb, Jack N., 1st Lt., MSC Jose MC Fulner, Adam C., SFC Rodriguez, M., Maj, Coe, Charles A., Maj, MSC Rogers, James MC Gaham, Thomas A., PFC T., Lt Col, Cooper, Charles E., Sgt Nathan, Ross, Richard H., Lt Col, MC Galanski, M/Sgt Cotrell, Gerald F., Sgt Kenneth 1st Lt, MSC Russell, Charles A., PFC Garls, D., Cruikshank, Paul H., Cpl Cpl Maj, MC Gentry, James D., Ruth, Charles J., Daab, Vernon J., Raymond, PFC Gotham, Joseph W., SFC Saenz, SFC Daughton, Jack E., Sgt Sgt Schaap, Howard PFC Grandfield, Robert, C., Debruhl, Max H., Cpl John A., M/Sgt Greene, John T., Pvt Schneider, Decker, Evelyn, 1st Lt, ARC Robert MSC Scott, Claude A., Maj, MC Gregg, A., Capt, Dedionisio, Carl L., SFC Irving J., M/Sgt Russel Jr., 1st MSC Guerin, Scott, Lt, Dier, Rorbert, Sgt Donald Shoe, Charles H., Pvt Guptan, E., Sgt Elliott, Charles E., Sgt Capt, ARC Gwinn, Frank W., Maj, MC Siems, Florence, Elliott, Pete, Sgt Sgt Hannon, Joseph L., Capt, MC Sims, Merle M., Erwin, William D., Sgt Skelly, D., Sgt Harris, Bertie C., Sgt Charles Evans, George D., Jr., Sgt MC Deward E., Hays, Jack M., Capt, Smith, Sgt Evans, Robert H., Maj, DC George Heaton, Stanley B., Cpl Smith, A., SFC Farina, Ernest, SFC MC Harold SFC Hepsh, Harold, 1st Lt, Smith, E., Faught, William V., Cpl Harry Capt, Maj, DC Hbss, J., MSC Smith, Louis T., Faulkner, George,Jr., Sgt Hidaka, MC Orne Lt MSC Harry T., Maj, Smith, D., Col, Fields, James S., Capt, MSC James Maj, DC Coy SFC Hill, J., Smock, E., Fisher, Alfred S., SFC Hotsenpiller, Harry, Maj, MSC Smull, Helen K., Capt, ARC Fitzpatrick, Paul, Cpl Hunter, George W., II, C 0 1, MSC Snodgross, D. C., Cpl Fleming, John I., M/Sgt Hurrell, William M., SFC Sondag, Roger H., Capt, DC Frada, Louis G., M/Sgt William Capt, Jenkins, Douglas J., Sgt Sonnier, Jr., MC Freeling, Raymond L., SFC Southerland, 1st Lt, MC Johnson, William H., 1st Lt, MC Fred W., Futsler, Robert L., Sgt Herbert SFC Souza, Ronald D., Cpl Jones, A., Ganong, William F., 1st Lt., MC Spainhour, Cpl Keele, John C., Jr., Lt Col, MSC Russell, Gasbarro, Sam, M/Sgt Stewart, Price C., Maj, MSC Kellen, Robert D., Sgt Geiger, Kenneth G., Cpl Charles Stinson, Robert L., Capt, MSC Kinnely, R., Capt, MSC Gillenwater, Kent L., Maj, MSC Stone, Sidney M., Jr., M/Sgt Lamp, Clifford, SFC Glasscock, Thomas T., Maj, MC Leonard, Wesley E., Maj, MC Stouffer, Jay E., Capt, MSC Gray, William, Sgt Antonio Jr., Sgt Stout, John, Sgt Limas, L., Griffin, John J., 1st Lt., MSC Lucas, John C., Jr., Capt, MC Stovall, Sidney L., Lt Col, MC Joseph J., Jr., M/Sgt Stropes, Lloyd R., Lt Col, MC Maciel, (To Mackoy, Don, PFC Taylor, Melvin, SFC be cont'd next issue)

104 RECENT DEPARTMENT OF THE ARMY AND FEC PUBLICATIONS

- AR 140-300, 5 May 52: Organized Reserve Corps DA Cir 54, 26 Jun 52: Sec V - Detection and Correc- Order into the Active Military Service of the tion of Physical Abnormalities United States DA Cir 55, 1 Jul 52: Sec II - Basic Course in Avia- AR 210-22, 6 Jun 52: Installations - Emergency Ex- tion Medicine pansion Planning DA Cir 56, 2 Jul 52: Sec IV - Limiting Date on Re- AR 40-630, 12 Jun 52: Medical Service - Subsistence ceipt of Interservice Transfer Applications in Hospital Messes DA Cir 59, 8 Jul 52: Rates, Fees and Monetary Value AR 40-105, C-l, 26 Jun 52:) Medical Service - Stand- of Hospital Rations for Army Medical Service Ac- AR 40-105, C-2, 10 Jul 52:) ards of Physical Examin- tivities. Sec III - Rates for Medical Care in ation for Commissions or Warrant in Regular Amy, Army Medical Treatment Facilities, Fiscal Tear

National Guard of the United States, Army of the 1953. Sec IV - Rates for Subsistence Furnished United States, and Organized Reserves by Army Hospital Messes to other than Pay Pa- AR 40-635, C-l, 10 Jul 52: Medical Service - Medi- tients, Fiscal Year 1953 cal Services Account AR 600-450, C-4, 10 Jul 52: Personnel - Separation for Physical Disability ATT 8-16, C-l, 9 Jun 52: Training Test for Veter- inary General Hospital,CZ (T/O&E 8-750) ATT 8-17, C-l, 9 Jun 52: Training Test for Station SR 40-440-10, 5-Jun 52: Medical Service - Army Area Hospitals, CZ (T/O&Es 8-561, 8-562, 8-563, 8-564,, Medical Laboratories Reports and Records 8-565, 8-566, and 8-567) SR 31-360-50, 12 Jun 52: Subsistence Supply - Com- ATT 8-19, C-l, 9 Jun 52: Training Test for General missaries - Reimbursable Issues to Army Medical Hospitals, CZ (T/OAEs 8-551, 8-552 and 8-553) Treatment Facilities ATT 8-21, C-l, 9 Jun 52: Training Test for Medical SR 40-630-1, 12 Jun 52: Medical Service - Subsist- Depot, CZ (T/O&E 8-187A) ence in Hospital Messes ATT 8-22, 4 Jun 52: Training Test for Medical Com- ffi 40-635-2, C-l, 10 Jul 52: Medical Services - pany, Infantry Regiment, Airborne (T/OAE 8-37) Accounting for Medical Services

SR 600-450-5, C-2, 10 Jul 52: Personnel - Evalua- tion and Separation for Physical Disability T/a 80-10, 19 Mar 52: United States Army, Korea - Sec II - Medical TB 10-A-301, VA Technical Bulletin, 29 Apr 52: Ex- aminations for Determinations of Auditory Acuity TB May 52: Hepatitis - 206, 16 Viral GO 47, 5 May 52: Sec II Meritorious Unit Commend- MED TB MED 237, 6 Jun 52: Collection and Preparation ation - Para 1. The 106th VFID. Para 12. The of Specimens Medical Laboratory, 8217th AU for Shipment to Medical Laborator- GO 9 May 52: Sec I - Armed Forces Medical Li- ies 49, TC 15, 25 Mar 52: brary, Washington, D. C. Artificial Respiration GO 53, 29 May 52: Meritorious Unit Commendation - Para 4 - The 121st Evac Hospital (Srabl), Para 15- The Mobile Army Surgical Hospital, 8209th AU, HQ FEC Cir 16, 1 Jul 52: Physical Examination of (then 1st MASH Hosp), Para 16 - The Mobile Army Japanese Personnel Utilized by the United States Surgical Hospital, 8225th AU Forces, Japan

TECHNICAL

Hyperinsulinism 105 The Dental Use of Ice Cartridges 108 Medical Collapse Measures, in the Treatment of Pulmonary Tuberculosis 108

Preliminary Report on the Effect of Cortone in the Treatment of Patients With Viral Hepatitis .... 110

HYPERINSULINISM G. R. Brosius, 1st Lt, MC, Medical Service, Osaka Army Hospital

might be defined as the state fact that spontaneous hypoglycemia might be recog- produced by excessive amounts of insulin in nized by symptoms resembling those which result from HYPERINSULINISMthe body whether the insulin is exogenous or excessive doses of insulin. In 1924 he wrote, "When endogenous in origin. Spontaneous hypoglycemia I saw the insulin reaction of diabetic patients, I denotes a depression of the blood sugar to abnormal- realized I had seen many patients not taking insulin ly low level which occurs without the administration who had complained of the same symptoms," i.e., hun- of exogenous insulin. ger, weakness and anxiety neurosis. On the basis of symptomatology correlated with blood sugar determin- ation, Harris established the presence of spontan- Seale Harris was the first to call attention to the eous hypoglycemia in a number of patients. In 1927

105 Wilder first showed the disorder that could result disturbances of the sympathetic nervous system usu- from hyperinsulinism. He demonstrated the presence ally predominate. These include sweating, flushing, of large quantities of insulin in the liver metasta- pallor, numbness of the circumoral region, nausea, ses of a patient with carcinoma of the islands of chilliness, hunger, epigastric pain, trembling, dir- Langerhans. zinass, weakness, elevated blood pressure, palpita- tion and syncope (some people feel these symptoms Hypoglycemia associated with anatomical lesion: may be due entirely to the secondary discharge of adrenalin). A. Hyperinsulinism Evidence of disturbance of the central nervous sys- 1. Pancreatic islet cell adenoma tem is usually seen in more severe attaoks and are 2. Pancreatic islet cell carcinoma attributed to the hypoglycemia per se and are as 3. Diffuse hypertrophy of pancreatic tissue follows: restlessness, thick speech, diplopia, oc- ular palsies, episodes suggesting petit mal, posi- B. Hepatic disease tive Babinski, tonic or clonic muscle spasms, con- vulsions and in extreme oases coma and death. 1. Toxic hepatitis 2. Fatty liver Psychiatric manifestations may occur in either mild 3. Diffuse carcinomatosis or severe attacks and consist of emotional instabil- 4. Ascending cholangitis ity, apprehension, difficulty in concentration, dis- 5. Von Gierke's disease orientation, amnesia, negativism, mania and uncon- sciousness. The electro-encephalogram frequently C. Hypopituitarism shows focal and widespread dysrhythmia which is us- ually transient but may persist for days or even 1. Destructive lesions as chromophobe adenoma weeks. 2. Atrophy or infection When the symptomatology is considered, it is easy D. Adrenal cortical insufficiency to understand why these patients often find their way to psychiatrists and neurologists before reach- 1. Tuberculous granuloma ing internists. Kepler recorded the various diag- 2. Primary atrophy nosis made in 21 cases of hypoglycemia. Among these 3. Destructive neoplasm were hysteria, alcoholic intoxication, acute confu- 4. Amyloid disease sional state, brain tumor, epilepsy and encephali- tis. The epigastric pain, fatigue and hunger which E. Hypothyroidism is relieved by food may be confused with peptic ul- cer. F. Lesions of the central nervous system (thalamic) Diagnosis: Hypoglyoemia without demonstrable origin To establish a diagnosis of spontaneous hypoglycemia, A. Increased secretion of insulin by normal islet it is essential to demonstrate a depression in the cells due to autonomic inbalance blood sugar level. It is of equal importance to es- tablish the cause. Since the periods of hypoglycem- B. Decreased secretion of anterior pituitary or ia are often transient, various means must be used adrenal cortical steroids for their detection, (l) A fasting blood sugar be- fore breakfast is important though it is often nor- C. Excessive oxidation of carbohydrate in severe mal. (2) If possible, a blood sugar determination muscular work should be made at the onset of an attack. If the attack is convulsive in nature, the blood sugar to- D. Pregnancy or lactation ward the end of the episode may be normal or eleva- ted. (3) The glucose tolerance is of use only in E. Idiopathic those patients in whom a fasting blood sugar is nor- mal or when it is impossible to get a specimen at Clinical Picture: the onset of an attack (the curve may be normal, flat or diabetic in form during the first 2-3 hours, The pattern of the clinical picture is extremely but if the blood sugar falls below 50 mg percent, 3, varied, but in one person the symptoms tend to recur, 4, or 6 hours after the stimulating dose of glucose though they may vary in severity. Attacks usually and particularly if it is associated with the devel- occur before breakfast or several hours after any opment of characteristic symptoms,the diagnosis is meal and are frequently precipitated by physical ex- established.) (4) When hypoglycemia is not demon- ertion. Attacks are apt to be more frequent and se- strated by these means, a 24-hour fast should be in- vere during menstruation. They may last but a few stituted and blood sugar determination made at 12, minutes and terminate spontaneously or after the in- 18 and 24 hours. gestion of food. On the other hand, they may be se- vere and last for hours and even days and prove re- The relative frequency of the various causes of sistant to treatment. Occasionally an attack ends spontaneous hypoglycemia have been analyzed and ac- fatally. The blood sugar at which symptoms appear cording to Conn, 90% of all cases result from one varies, some patients are asymptomatic until levels of three causes: (l) Functional hypoglycemia, (2) below 40 mg percent and others present classical Hyperinsulinism with demonstrable pancreatic lesion, symptoms with blood sugar from 50-60 mg percent. and (3) Organic disease of the livqr.

The symptomatology is closely related to the nervous The typical glucose tolerance curve in hyperinsulin- system. In fact, the subjective and objective signs ism due to islet cell tumor is characterized by (a) of this disease are almost entirely attributable to subnormal lasting level, (b) peak rarely exceeds the effects of hypoglycemia on the central and sym- 120 mg percent, and (c) returns to subnormal values pathetic nervous systems. In early and mild attacks, within two hours. These values are usually main-

106 tained throughout the 3rd, 4th and 5th hours. In In Simmond's disease due to destruction, atrophy or functional nervous disorders, (a) the fasting blood degeneration of the anterior pituitary, it is not sugar is usually normal, (bj the one hour specimen surprising that with the removal of a potent insulin is usually slightly higher than the normal post ci- opposing gland, hypoglycemia may occur. This is & bal range, and (c) at the end of the 2nd and 3rd relatively unimportant feature of the disease when hours, hypoglycemia occurs with a tendency to spon- compared with the symptoms of senile decay. Ex- taneous return by the 4th or 5th hours. In liver treme destruction of the anterior pituitary by tumor disease, the glucose tolerance curve begins witlT a growth such as a chromphobe adenoma may result in subnormal level but rapidly rises to hypoglycemia disturbance of the blood sugar level. Here again levels followed by a slow return to normal during the hypoglycemia is but a small part of the symptoms the day and subnormal levels after a fast of more produced by such a tumor. than 12 hours. Hypoglycemia of a mild degree is an uncommon finding From the standpoint of management, the chief prob- in a patient with hypothyroidism. It is rarely of lem of diagnosis is to differentiate organic from significant severity to cause spontaneous hypogly- functional hyperinsulinism. A differential diagno- cemia. sis of the three important causes of spontaneous hy- poglycemia should not be difficult if one carefully Organic disease of the nervous system - although hy- evaluates the (l) fasting blood sugar, (2) glucose perglycemia is more common when the base of the brain tolerance test, (3) liver function studies, and (4) is involved, low blood sugar values are occasionally history and clinical courses. seen in schizophrenia and subdural hemorrhage. Exercise, if prolonged as in a marathon race, may As already mentioned, in functional hyperinsulinism, cause low blood sugar level. The degree is usually the fasting blood sugar is normal. It is abnormally not severe. It is due to rapid depletion of sugar low (50 mg percent or less) in hepatic disease or is- in the circulation and unusual reduction in the gly- demonstrated that the fast- let tumor. If it can be cogen reserves. Lactation, renal glycosuria and se- blood is 50 ing sugar below mg percent, functional vere malnutrition,such as seen in anorexia nervosa, hyperinsulinism can be ruled out. may be complicated by hypoglycemia. In each in- stance the underlying cause is deprivation of nour- When the glucose tolerance curves of hepatic disease ishment to the organism. and pancreatic islet tumor are compared,although the fasting of both the remainder of the are low, curves Treatment falls logically under three headings: (a) are entirely different. The pancreatic tumor is lil© the acute attack, (b) conservative measures to pre- but set to low the normal curve is down a level. In vent attacks, and (c) surgical measures. the hepatic type, the hypoglycemia fasting sugar is followed by a high plateau diabetic type of curve. The treatment of the acute attack is identical to that used in hypoglycemia induced by overdosage of In functional hyperinsulinism, the hypoglycemia at- insulin. Briefly, it consists of any form of glu- prandially. Why should this tacks come on post occur cose if the attack is mild. Should the attack be at this time? is an of nor- It probably exaggeration severe, 0.5 to 1.0 cc Epinephrine may arouse the pa- mal response. As the blood sugar rises, it serves tient enough to take food by mouth or it may be nec- stimulus to insulin production. The as a pancreas essary to give I.V. glucose. Twenty mg of glucose is extremely sensitive to the normal insulinogenic or corn syrup dissolved in 8 oz of warm water given to stimulus and this is probably due autonomic ner- rectally ha3 served in an emergency when sterile vous system inbalance. The blood sugar level falls solutions are not available. too far but the adrenal mechanism is efficient and brings it up quickly. For the prevention of attacks, diet is effective in bringing relief to many patients with functional hy- In the case of the islet tumor, they complain of pre- poglycemia. Conn goes so far as to say that in breakfast as as post prandial attacks,so the functional hyperinsulinism, if a trial of this diet history of both makes one think of organic hyperin- for a week does not give relief, the diagnosis is sulinism. Attacks tend to become worse with time not correct. It is useless in cases of islet cell and may be precipitated by a missed meal. What caus- tumors and should be abandoned in favor of surgery es the hepatic form to have a diabetic type of glu- as soon as the diagnosis is made. The quickly ab- cose tolerance curve? Their ability to oxidize glu- sorbable carbohydrate foods are of value in correc- cose is normal but the part of the blood sugar that tion of the acute attaok but because of the stimu- should be stored in the liver as glycogen doesn't lating effect which they have on the secretion of get in so it stays in the blood giving what looks insulin and because of the increased insulin sensi- like a diabetic curve. This type of individual tivity which follows their use, they are to be avoid- hasn't been storing enough sugar as glycogen so his ed. The carbohydrate content of the diet should not blood eventually falls. When it gets to the point exceed 75 gn and is best provided in slowly absorb- where the adrenal is stimulated to put out glycogen, able forms such as cereals, bread, vegetables and there isn't any glycogen available, so the blood fruits such as bananas and apples. A liberal pro- sugar keeps going down to hypoglycemic level. These tein quota is advooated by Conn (120-140 gm). The people therefore have a history of pre-breakfast at- glucose derived from protein is slowly released and tacks and the only time during the day when they may apparently has no apparent stimulating effect on pro- get attacks is when they miss one or more meals. In duction of insulin. Fat is allowed in liberal quan- the patients with no obvious evidence of liver dis- tities. The diet should be divided into six feed- ease, the function studies are of course helpful. ings. Undernourishment is to be avoided as weight loss exaggerates the symptoms. Physioal exercise, be- Deficiency of the adrenal cortex may cause hypogly- cause of its blood sugar lowering effect, should be cemia. The clinical features of Addison's disease restricted. should remove the danger of confusing this disease with hyperinsulinism in most cases. Hypoglycemia, Surgery is indicated in the treatment when a thorough though uncommon in this condition, may be the immed- trial of conservative treatment fails to prevent at- iate cause of death. tacks of hypoglycemia and hepatic, adrenal and pit-

107 uitary lesions are excluded as the cause. If the di- prove beneficial. Treatment is therefore limited agnosis is believed to be hyperinsulinism due to or- to direct restoration of blood sugar. In cases re- ganic lesion of the islands of Langerhans, surgical sulting from disease of biliary tract or liver,treat- intervention should not be delayed since the fre- ment should be directed toward correcting the under- quent feedings necessary to ward off attacks often lying disorder. In liver disease, unlike functional lead to the development of obesity which adds to the hyperinsulinism, a high carbohydrate diet is more difficulties of surgical treatment. Adenomas also beneficial than a reduction in carbohydrates. A lib- tend to undergo malignant changes early so they eral protein intake fortifies against further damage should be operated upon as soon as the diagnosis is to the liver. It is particularly important to give, well established. these patients a meal before going to bed. In the majority of cases, there is nothing we can do about Spontaneous hypoglycemia, due to lesions of the pit- degenerative liver disease. There is one relatively uitary or adrenal, is not significantly benefited rare occurrence where hepatic hypoglycemia is based by extracts of these glands now generally available, on .ascending cholangitis. If the gall bladder is although ACTH in early hypopituitarism, and corti- the source of infection, its removal may bring about sone in Addison's disease with hypoglycemia, may a remarkable return of liver function.

THE DENTAL USE OF ICE CARTRIDGES Lt Colonel Arnold H. Feldman, DC, Dental Surgeon, Ryukyus Command

— ONVENIENT size cylinders of ice for dental pur- be used when there is a possibility of the syringe ' poses can be made from cartridges in which lo- or ice water making contact with a hyperemic tooth. C cal anesthetic is dispensed. These cylinders may be directed to the desired area by means The use of ice cartridges in testing the vitality of of a modified,cartridge-type hypodermic syringe. the pulps is simple, convenient and expedient. The ice is merely directed on the individual tooth be- These syringes may be used as an adjunct in testing ing tested. A definite advantage of this technic is the vitality of the pulp and also as an aid in the that the tooth need not undergo a sudden shock as elimination of pain dhring the administration of a may be experienced by some of the other methods. local anesthetic. Moreover, the application is confined to the indiv- idual tooth. The equipment necessary for the preparation of ice cartridges includes a refrigerator with a freezing As an adjunct in the elimination of pain during the compartment, a cartridge-type hypodermic syringe, administration of a local anesthetic, ice cartridges and some used local anesthetic cartridges. are of especial use with young patients. The mouth is first rinsed and the area of needle insertion The syringe is modified by increasing the opening touched with Tincture of Iodine. The cartridge,with through the hub to slightly less than the inside ice extruding, is then placed in contact with the diameter of an anesthetic cartridge. The rubber tissue at this point and held under slight pressure stopper at the hub end of the cartridge is discard- from the plunger for about one minute. The area is ed. The stopper at the plunger end is retained. again touched with Tincture of Iodine and the local After cleansing the tube, it is filled with water anesthetic is then administered in the usual manner. and placed upright in a small cup or container and stored in the freezing compartment of the refriger- ator. Children are especially appreciative of this technic. Let the child feel the cold of the cartridge. Tell When an ice cartridge is needed, it is removed from him that you are going to put a popsicle in his the refrigerator and held in the closed palm of the mouth and only the tooth is to be put to sleep. Keep hand until a film of water forms on the inside sur- up a steady stream of conversation while the ice is face of the glass tube - usually five to ten seconds. being applied and during the injection of the local The cartridge is now placed in the modified syringe anesthetic. You can perfect yourself to the extent with the rubber stopper next to the plunger and is that the child and the adult, too, undergo a minimum directed either to the tooth to be tested or to the amount of discomfort during the administration of a area of needle insertion. This technic should not local anesthetic.

MEDICAL COLLAPSE MEASURES IN THE TREATMENT OF PULMONARY TUBERCULOSIS* Major C. B. Pramuk, MC, 279th General Hospital, APO 53

chemotherapy has moved into the lime- A comparison of the two methods is most interesting. light in the control of pulmonary tuberculosis Pneumothorax is usually reserved for those cases of in recent years, and resection has found a def- "cooled off," unilateral tuberculosis, with cavita- \LTHOUGHinite place in the treatment of this tion in the apical, or subapical regions of "the lung. disease, "medical collapse measures" must still be considered On the other hand, pneumoperitoneum can be institu- as vital adjuncts when the phthisiologist plans his ted earlier, and in extensive bilateral disease that therapeutic attack in any particular case. The much is not obviously hopeless. It has proven efficacious older and classic method, artificial pneumothorax, in the closure of cavities at all lung levels, al- and the more recent artificial pneumoperitoneum,with though results are generally better in ameliorating or without the addition of temporary phrenic crush, lower lobe disease. are the most noteworthy methods. Pneumothorax at present has few adherents and the procedure should be reserved for highly selected *This paper was presented at the Eighth Army Confer- cases. The contraindications to pneumothorax are ence on Chest Disease, 20 February 1952. more numerous than in pneumoperitoneum, noting,how-

108 ever, that the presence of any "downhill," non-tuber- age which is vital in the resolution of tuberculous culous condition would be self-evident in the unde- disease, and tne early closure of cavitation obviates sirability and futility of the initiation of any col- the thick-walled lesion which will later require thor- lapse measure whatsoever. Far advanced fibroid tu- acoplasty or a resection. berculous disease falls in the same category. Un- controllable abdominal hernia and dense peritoneal Comparison of the two forms of therapy used in 200 or pleural adhesions offer the principal barrier to cases of each type during the year 1951 revealed the pneumoperitoneum. following:

Pneumothorax carries the following two groups of com- (a) Pneumoperitoneum proved the easier to induce plications, the operative and the late. Of the for- and to follow up. Fluoroscopic control was not as mer, pleural shock (of debatable pathogenesis, but a vital a factor, although it still remained, a desir- definite entity to be considered), mediastinal einphys able procedure. ema, lung rupture, broncho-pleural fistula, and ten- sion pneumothorax following rupturo of an emphysema- (b) Pneumothorax did, however, in approximately 75% tous bleb, are commonly seen. Of the late complica- of the cases that were successfully induced, reveal tions, the most frequent and troubling are pleural a favorable trend. Cavity closure was somewhat more effusion, empyema, and the inexpansile lung. dramatic than in pneumoperitoneum, as a rule. ’Sputum conversion, on the average, turned from positive to Pneumoperitoneum, on the other hand, has a much more negative in a shorter period of time. It must be limited set of complications, tuberculous peritoni- borne in mind, however, that of the cases in which tis and ascites occurring in approximately one per- both forms of therapy were instituted, the average cent of cases under treatment. Pelvic inflammatory case treated with pneumoperitoneum was definitely disease is questionably more frequent when a patient more serious, often being in the far advanced group. is under this type of therapy. Nausea and pain can- This conforms with the indications for each type of not be classified as complications, however, they therapy outlined earlier in this paper. must be mentioned as factors, which, at times, lead one to elect cessation of the treatment. It is the (c) Streptomycin was not used in all cases, but relative lack of complications in pneumoperitoneum about equally in both groups. Therefore comparisons that has influenced many to turn their attention to of its influence in this series are not possible ex- this form of therapy. cept to note its influence was approximately equal in both of Complications common to both are air embolism and types procedure. subcutaneous emphysema. Air embolism, often fatal, (d) observations supported, generally, the is rare whereas subcutaneous emphysema occurs a great Our con- deal more frequently, but is of no particular conse- clusions drawn by many others in regard to the com- in In quence. plications these collapse measures. pneumo- thorax, the complications outnumbered those of pneu- moperitoneum approximately The following advantages of pneumoperitoneum over five to one. pneumothorax must be kept in mind: In view of the fact that this paper favors pneumoper- it might (a) The mental attitude of a patient is given a sub- itoneum, be interesting to add a brief note on the mechanism of this form of collapse stantial "boost" when positive therapy is initiated. measures. With the introduction of a very minute amount of air (even a few the peritoneal cavity, the (b) The ease of institution of pneumoperitoneum, c.c.), into pressure turns from a to a one. and the facility of refills (without the use of novo- negative positive caine, usually), allays much of the apprehension on This pressure change transmits its effect to the the part of the patient. thorax, altering momentarily the intrapleural pres- sure. Physiology is not permanently affected in the (c) The treatment is reversible; the same definite- Some degree of ly cannot be said for pneumothorax. No difficulty least. selective collapse is thereby obtained, the diseased tissue tending to undergo col- is encountered in restarting if temporarily stopped lapse more readily than the The by either doctor or patient for reasons of their healthy lung tissue. motion of the also is volume own. diaphragm limited, lung is reduced (on the average 10-15%), and the lung is put to rest. Following the induction of pneumoper- (d) In basal lesions, and cavitation in that area, itoneum with approximately 500cc of air, and repeated pneumoperitoneum may be particularly efficacious, once or twice a few days apart, maintenance is usual- especially if a temporary phrenic crush is added. ly kept with refills averaging 1000 weekly. In reference to the latter, it seems best to reserve cc this additional measure for unilateral pathology SUMMARY: The selection therapeutic (phrenic crush is often permanent, although not so of collapse pro- cedures in the treatment of pulmonary tuberculosis intended), and to those cases particularly resistant to diaphragmatic elevation. should be highly individual, pneumoperitoneum being much safer, carrying fewer complications, and extreme- efficacious in a wider of than (e) A moderate degree of pleural adhesions may be ly variety cases pneu- mothorax. present, yet in spite of these, pneumoperitoneum often effects satisfactory resolution of lesions. Although patients were followed for a relatively Of course, this does not hold for all cases, or in short period, experience with pneumothorax and pneu- the treatment of fibroid tuberculosis. The same moperitoneum substantially approximated the conclu- type of adhesions, however, are invariably a defin- sions of many groups treating pulmonary tuberculosis ite"stumbling block" in the acquisition of a satis- in the United States. factory pneumothorax "pocket." Reference: "Artificial Pneumoperitoneum in the Treat- (f) Earlier use of pneumoperitoneum (possible be- ment of Pulmonary Tuberculosis," John L. Elliott, MD, cause of the lack of danger of atelectasis and the FCCP, and Emil Blair, LID, Savannah, Georgia, Diseases previously mentioned complications), enhances drain- of the Chest, November, 1951.

109 FRELIMINARY REPORT ON THE EFFECT OF CORTOKE IN THE TREATMENT OF PATIENTS WITH VIRAL HEPATITIS Lt Colonel Tyron E. Huber, MC, Capt Paul E. Lacy, MC, and Capt Andrew T. Wiley, MC., all of U. S. Army Hospital, 8168th Army Unit, Medical Service

TREATMENT of hepatitis, either of the so- Other investigators have utilized gamma globulin called infectious or the serum type, has been either as an agent of prevention or attenuation in largely symptomatic and based upon two princi- the treatment of infectious hepatitis. In a recent THEples, bed rest and diet. For the vast majority report Stokes^reviewed the results using 0.01 ml. of patients with hepatitis this therapeutic regime gamma globulin per pound of body weight in three in- is entirely satisfactory and the patient usually stitutional epidemics. A single injection of glob- makes an uneventful recovery. However, there remain ulin apparently caused protection in the inoculated a number of basic and fundamental scientific ques- groups for as long as nine months despite continued tions, for the greater part unanswered, relative to intimate exposure to cases of hepatitis in the con- the implementation of these two principles in the trol groups. Stokes believed this protection to be treatment of patients with hepatitis. For instance, the result of a passive-active immunization. there are no definite scientific data on the length and beneficial effects of bed rest or how long a con- With the announcement by Henchl8Hn the spring of valescence is required. Likewise, we.have no ade- 1949 that ACTH and cortisone appeared to be benefi- quate scientific data to prove whether the high cal- cial in the treatment of patients with rheumatoid oric, high carbohydrate, high vitamin, high protein, arthritis and other allied conditions, we were im- and low fat diet, so much in vogue during World War mediately impressed with the effects that ACTH and II, is the most advantageous diet to be employed in cortisone apparently produced in appetite and re- tne treatment of patients with hepatitis. Until sulting weight gain. Of the 21 patients flench these basic fundamental questions are answered, the treated with ACTH and cortisone, 20 had increased problem of evaluating any therapeutic regimen in the appetites. The increase was very marked in 11 pa- treatment of hepatitis will continue to be a most tients whose appetites became "tremendous or insa- difficult one. tiable," and when one patient was allowed to eat ad lib, he consuned 6,000 calories in one day. One pa- For the past three years we have undertaken a study tient gained 14 lbs in 22 days; another patient to determine the effectiveness, if any, of the newer gained 19 lbs in 32 days; and still another gained drugs in our rapidly expanding armamentarium of ther- 26 lbs in 33 days. These patients experienced two apeutics in the treatment of hepatitis. Although types of weight gain. In one type the nutritional the mortality rate has been recorded by and gain was steady, progressive, and proportionate to others as being from '0.2% to 0.5%, actually a very the increased appetite and did not dimish rapidly low mortality rate when compared with other diseases, when’cortisone was discontinued. In the other type we are nevertheless relatively helpless to alter a the weight gain resul-ted in retention of fluids,was process that usually continues on to death when a often not accompanied with increased appetite, and patient with hepatitis begins to deteriorate and lap- often disappeared shortly after cortisone was dis- ses into hepatic coma. Recourse to intravenous glu- continued. However, it was not always easy to dis- cose is the generally accepted therapeutic approach tinguish between the two types or to estimate how in such patients. Obviously this procedure leaves much of the increased weight was nutritional until much to be desired clinically and from a therapeutic the use of cortisone was discontinued in each pa- standpoint may be even deleterious if there has been tient. sufficient damage to the hepatic cells to impede phosphorylation and utilization of the glucose. It has been our clinical impression that as long as In a search for a specific therapeutic agent, the hepatitis patient did not develop nausea, vomit- administered aureomycin in acute viral hepatitis and ing, or aversion to food, and continued to eat, the reported little, if any, effect on the duration of eventual outcome was usually favorable. Moreover, the acute symptoms or persistence of abnormal labor- of the two basic principles involved in the conven- atory findings. Recently there has been a resurgence tional form of treatment, namely bed rest and ade- of interest in the use of aureomycin in several dif- quate diet, the latter has appeared to us to be the C3) ferent types of liver disease. Gyorgy has report- most important. If the effects of increased appe- ed that aureomycin apparently was capable of delay- tite and improved nutrition, which Hench had report- ing the onset of massive dietary necrosis of the ed following use of cortisone in patients with rheum- liver in experimental animals. The mode of action atoid arthritis, could be produced in patients with of aureomycin is not clear, but it has been postu- hepatitis, then an agent would be available which lated that aureomycin suppresses the growth of in- might possibly alter those processes usually leading testinal flora, thus preventing the elaboration of to deterioration and death. Yet, however attractive bacterial metabolic products which the injured liver this thought might appear, we were immediately cog- is theoretically unable to properly detoxify. More- nizant of a potential therapeutic paradox. For Hench over, there has been some evidence that aureomycin had observed in 1929 that patients with rheumatoid possesses a rather narrow spectrum of antiviral ac- arthritis who developed jaundice seemed to experience tivity. The most promising results from aureomycin improvement in their state of rheumatoid arthritis. therapy appear to be in cases in which there is im- In an attempt to explain this phenomenon, Hench had pending hepatic coma. W) However, the results from hypothesized some normally occurring product improp- aureomycin therapy in the treatment of acute infec- erly detoxified by a damaged liver, which caused a tious hepatitis have been disappointing. beneficial effect on rheumatoid arthritis. If this altered metabolic product was cortisone, then corti- desoxycorticosterone in cases of in- sone therapy would probably be ineffective in hepa- fectious hepatitis with evidence of improvement in titis where there is obvious hepatic involvement. tne protracted forms of that disease. However, Hench had also reported in 1931 that preg- nancy improved the rheumatoid state, yet there is ACTH to one case of homologous serum no constant pathology of the liver in the pregnant hepatitis which caused an immediate improvement in state. In spite of these theoretical considerations, the clinical condition of the patient as well as tne mute fact remained that patients given cortisone restoration of the liver function tests to within developed "tremendous and insatiable appetites" and normal limits. did gain weight. Therefore, we felt that a short- 110 terra preliminary trial with cortisone was certainly may possibly play a more dominant role in the reduc- worthy of clinical investigation in patients with tion in urinary 17-ketosteroid excretion than is viral hepatitis. Merck and Company kindly made avail- commonly supposed, for reported a marked able enough Cortone* to treat five patients with vi- decrease in the urinary 17-ketosteroid excretion dur- ral hepatitis. ing acute starvation for as short a period of time as four days. In order that this study of viral hepatitis could bo undertaken with a homogeneous group of patients, A diet consisting of 400 grams oarbohydrate, 155 those patients with obvious serum transmitted hepa- grams protein, and 120 grams fat, totaling 3,320 titis, with Weil's disease, syphilis, malaria, ty- calories daily, was prescribed for all patients in phoid fever, yellow fever, tuberculosis, "chemical addition to multivitamin tablets and 3 grams of and biological hepatitis," and amebic hepatitis, as Brewer's yeast daily. The patients were removed well as patients with infectious mononucleosis, were from bed rest when each had attained normal appetite, excluded. Eight groups of ten patients each were when the liver was no longer tender or enlarged, and given one of the following forms of therapy: when tne icterus index and other laboratory tests approached normality. The patients were then allow- Group A - Adrenal cortical extract, 10 cc.daily for ed one week of full activity about the hospital. The 7 days (providing approximately 2 mg. of laboratory studies were repeated and if there had cortisone daily according to Thorn). been no significant change in the patient's condi- tion or in the laboratory studies, the patient was Group B - Adrenal cortical extract, 20 cc. daily for discharged and returned to full duty. The entire 7 days (providing 4 mg. of cortisone group of patients was placed on one large medical daily according to Thorn). ward of the hospital under the supervision of the same physician, nurse, and enlisted personnel. Group C - Adrenalin, 0.3 cc. 1:1000 dilution, plain, for 7 days with a hope that this drug It appeared that the group treated with Cortone dis- would provoke stimulation of the adrenal played a more rapid fall of icterus index during the oortex through the pituitary-adrenal axis. week of treatment and during subsequent weeks than any of the other groups and, that of all the other Group D - Progesterone, 10 mg. daily for 7 days. therapeutic agents employed in this investigation, only the groups treated with progesterone (10 mg. Group E - Progesterone, 20 mg. daily for 7 days. daily and 20 mg. daily) exhibited a significant de- The progesterone was administered on the crease in icterus index. However, we were aware supposition that a portion of that drug that at least three sources of error were present might be transformed into a corticoid. in this clinical investigation:

Group F - Immune globulin in massive doses, 10 cc. 1. All of the groups were not treated simultan- daily for 7 days with a hope that a suf- eously since the arrival of the Cortone was ficient titre of neutralizing antibodies unfortunately delayed and this group was would be available to attenuate or modi- treated separately at a later date. fy the course of the disease through neutralization of the virus of infectious 2. We intentionally selected the most severe hepatitis. case of hepatitis for administration of Cor- tone for, having such a limited amount of Group G - 1,000 cc. 10% glucose in water I.V. daily Cortone available, we could ill afford to ex- for 7 days. pend Cortone on patients with only a mild dis- ease. Group H - 4 cc. normal saline intramuscularly for 7 days. This group served as control 3. The number of patients in all of the treatment group. groups except the Cortone-treated group was 10 and in the Cortone group, 5. We realized Group I - Finally, only 5 patients were given 100 that the patients treated in each group rep- mg. of Cortone daily for 7 days. resented entirely too few cases for signifi- cant statistical analysis. Detailed laboratory studies were accomplished on each of the patients but will not be reported here Therefore, the following clinical investigation was inasmuch as those studies do not add significantly devised in which four groups each of 100 patients to our knowledge of hepatitis as previously docu- would be treated with the following therapeutic mented, except that the urinary 17-ketosteroid ex- agents: cretion was found to be in the lower limits of nor- mal early in the disease and to increase slightly Group A - Progesterone, 10 mg. daily, until clini- after recovery from hepatitis regardless of type of cal recovery resulted. treatment instituted. It would, indeed, be tempting to interpret this low level of urinary 17-ketoster- Group B - Progesterone, 20 mg. daily, until clini- oid excretion as an indication of lowered adrenal cal recovery resulted. activity as hypothesized by Webster**? However, the urinary 17-ketosteroid excretion probably depends Group C - Normal saline, 4 cc intramuscularly daily, on a number of different factors in addition to the until clinical recovery resulted. total amount of adrenal cortical hormone produced and the total metabolic status of the individual pa- Group D - Cortope, 100 mg. daily for the first 7 tient. In viral hepatitis tie element of starvation days, then 50 mg. daily until ambulation was begun, and then 25 mg. daily for 2-5 days. ♦This material (Cortone Acetate) was supplied through the generosity of Elmer Alpert, Manager, Clin- M.D., We were particularly interested in determining if ical Research, Merck and Company, Rahway, New Jersey. cortisone or progesterrkie would cause significant increases in appetite as evidenced by weight gains of illness. The Cortone-treated group remained on and daily food intake in ounces. Therefore, we es- the average, one extra day prior to initiation of tablished a system whereby the weight of each tray treatment in order that preliminary glucose toler- of each patient was carefully weighed before leaving ance tests and psychiatric evaluations could be ob- the ward diet kitchen and upon its return. Thus, tained prior to the initiation of Cortone therapy. the difference represented the amount of food con- Inasmuch as there are only 70 patients in this pre- sumed in ounces for each meal. All patients were liminary report treated with Cortone and 89 patients encouraged to eat as much as th,ey desired, and often in the progesterone 10 mg. daily group, 90 patients as many as three separate servings were consumed at in the progesterone 20 mg. daily group, as well as breakfast and lunch, but seldom at the evening meal. 90 patients in the control group, we believe that All in-between meal consumption of food was likewise the groups will probably be comparable, except for recorded and a grand total for each patient was pos- Che additional day of hospitalization required for ted in his chart daily. Likewise, each patient was the Cortone-treated group, when the goal of 100 pa- weighed each day at the same time, in the same amount tients in each group is reached, at which time all of clothes, on the same scales, by the same ward per- the data assembled will be subjected to critical sonnel and recorded in the patient's chart. The sme statistical analysis. precautions were taken as in the original investiga- tion to insure that a homogeneous group of viral hep- atitis patients was studied. They were placed in TA3LS 1 the respective groups according to their admission to the hospital. Likewise, the same officer, nurse, Proges- Proges- Cor- and enlisted personnel as were present with the orig- Saline terone terone tone inal investigation were retained on the same ward (4 cc) (20 mg) (10 mg) during this investigation. The same criteria for Days of illness before ambulation, convalescence, and discharge as in the admission 9.7 9.95 9.38 10.62 original investigation were continued. Days of jaundice before admission 4.34 3.90 3.67 4.10 Since four out of five patients treated with Cortone Days in hospital before in the first investigation had displayed a transit- treatment 3.6 3.14 3.26 4.30 ory glycosuria, we attempted to exclude by urinaly- Days of treatment 19.3 19.70 19.20 21.63 ses, fasting blood sugar determinations, glucose tol- Days of illness after erance tests, as well as by family histories, the treatment started 42.7 44.20 43.21 45.50 potential diabetics from the Cortone-treated group. Total duration of Likewise, by careful histories and physical examina- illness 54.7 55.90 54.93 59.94

Table 2 records the average icterus index and average serum bilirubin of the four treatment groups the day before treatment and at weekly intervals thereafter.

TABLE 2

Icterus Index -1 +7 +14 4-21 4-28 4-35 4-42 4-49

Saline (4cc) 45.9 25.10 16.20 11.60 10.10 9.30 8.8 9.6 Progesterone (20 rag) 50.20 28.20 19.10 14.90 12.30 10.63 9.9 9.2 Progesterone (10 mg) 50.20 27.40 19.0 13.90 12.40 10.97 10.4 10.4 Cortone 61.89 23.06 15.74 14.70 11.52 9.97 8.92 8.52

Serum Bilirubin

Saline (4cc) 7.10 3.46 2.15 1.41 1.13 0.96 0.93 0.98 Progesterone (20 mg) 7.55 4.14 2.57 1.97 1.44 1.15 1.06 1.05 Progesterone (10 mg) 7.63 4.22 2.66 1.83 1.45 1.27 1.23 1.20 Cortone 8.90 3.13 2.05 1.84 1.38 1.10 0.98 0.91

tions, those individuals with hepatitis who displaced Table 3. records the weight gained during the treat- obvious or potential hypertension, gastric ulcers, ment period and total weight gained during entire and unstable emotional backgrounds were excluded hospitalization of the four treatment groups. It is from the group. Finally, a psychiatric evaluation apparent that the Cortone-treated group gained more by the staff psychiatrist was obtained on each of weight during treatment as well as throughout the the individuals in the Cortone-treated group prior entire hospitalization period. to administration of Cortone. TABLE 3 From the data obtained, it appeared that the Cortone- treated group maintained an average total daily in- Weight Gained Total take at a consistently higher level -than the other During Weight three groups. Treatment Gained

Table 1 records the days of jaundice before admis- Normal saline ( 4 cc) 5.22 7.49 sion to the hospital, days in the hospital before Progesterone (20 mg) 4.91 7.40 treatment was begun, days of treatment, days of ill- Progesterone (10 mg) 5.29 7.91 ness after treatment was started, and total duration Cortone 7.15 9.26 Discussion of Some of the Clinical Aspects of Cor- iently severe to warrant discontinuing the drug. One tone Therapy in the Treatment of Hepatitis. case treated with Cortone developed a frank cataton- ic schizophrenia eight days following completion of The three major effects of Cortone therapy is the treatment. However, during the same period two pa- treatment of hepatitis are: tients in the control group developed major psycho-

ses . There was an earlier and more striking ameliora- Summary tion of the symptoms of hepatitis, such as nausea, abdominal discomfort, malaise and depression after It would appear that the Cortone-treated group dis- the first few days of Cortone treatment, than would played an earlier and more striking amelioration cf normally be expected in the patients treated with symptoms, a more rapid return of appetite and defin- bed rest and an adequate diet. itely increased weight gain, as well as earlier and more rapid clearing of the jaundiced state, than A rapid return of the appetite to normal or above would normally be expected in patients with hepati- normal levels occurred. Although an increased appe- tis treated with bed rest and an adequate diet. tite is characteristic of the recovery stage of hep- atitis, the patient treated with Cortone experiences However, we do not desire to create the impression a tremendously increased appetite much earlier than that all cases of hepatitis should be treated with would be expected under the conventional form of Cortone, for as we.3 mentioned previously, the vast therapy. majority of patients with hepatitis will respond to the conventional therapeutic regimen. Nevertheless, A more rapid decrease in clinical jaundice fol- Cortone would appear to be particularly helpful in lows the institution of Cortone treatment and the de- the treatment of severe cases of hepatitis or in crease begins earlier than would bo anticipated in those cases of hepatitis that deteriorate under con- the normal clinical course of this disease. ventional therapy.

The four main side effects we have observed are as follows:

Fluid Retention: It was necessary to reduce the REFERENCES: dosage of Cortone to 50 mg. daily at the end of the (1) Neefe, J.R: Results of hepatic tests in chron- first week in order to control edema which involves ic hepatitis without jaundice; correlation the face and sometimes the ankles. with clinical course and liver biopsy find- ings, Gastroenterology 7:1, 1946. Withdrawal Symptoms: Colbert("Jhas mentioned the (2-) Shaffer, J.M., Farquhar, J.D., Stokes, Joseph, recurrence of symptoms following the abrupt with- Jr., Sborov, V.M.: Studies on the use of drawal of ACTH in 5 cases of viral hepatitis. Rifken aureomycin in hepatic disease; aureomycin has likewise reported clinical relapse following sud- therapy in acute viral hepatitis, .American den discontinuance of corticotropin or cotisone in 4 Journal of ‘‘“edical Sciences 220:1, 1950. patients with acute homologous serum hepatitis. We (3) Gyorgy, P., Stokes, J. Jr., Goldblatt, H., Pop- observed this same rebound phenomenon in the origin- per, H. : Journal Experimental Medicine 93: al investigation in 5 patients with viral hepatitis 513, 1951. that were treated with Cortone. In those cases we (4) Goldbloom, R.S., Stergmann, F.j Gastroenterology' observed an actual increase in the icterus index and 18:93, 1951. serum bilirubin as well as the return of clinical (5) Buchmann, P., Schulze-Buschoff, H.: Adrenal symptomatology when Cortone was precipitiously with- Cortex hormone in treatment of jaundice, Mod- drawn. Before the present series of 70 cases of vi- izenische Klinik, Munich, 44:881, 1949. ral hepatitis treated with Cortone was undertaken, (6) Thorn, G.W., Forsham, P.H., Frawley, T.F., Hill, we investigated several treatment schedules, includ- S.R., Ruch, M., Staehelin, D., Wilson, D.L.: ing those suggested by Hench. We finally adopted The clinical usefulness of ACTH and Cortisone, the treatment schedule of reducing the 100 mg. daily The New England Journal of Medicine 242:865, dose of Cortone to 50 mg. per day at the end of the 1950. fired; week in order to control edema. The 50 mg. (7) Stokos, J. Jr., Farquhar, T.D., Drake, M.E., daily dose of Cortone was continued until the time Capps, R.B., Ward, C.S. Jr., Kitts, A.W.: of ambulation, when a further reduction to 25 mg. Infectious hepatitis; duration of protection per day was continued for an additional 2 to 5 days. by gamma globulin, J.A.M.A. 147:714, 1951. We have reduced to a minimum these rebound phenomena (8) Hench, P.S., Kendall, E.C., Slocumb, C.H., since the adoption of this treatment schedule for Palley, H.F.: Effects of cortisone acetate the Cortone-treated group. and pituitary ACTH on rheumatoid arthritis, rheumatic fever and certain other conditions, Glycosuria: Approximately 50$ of the patients Archives of Internal Medicine 85:545, 1950. treated with Cortone exhibited a transient glycosur- (9) Webster, J .J .: Adrenal Cortex in liver disease, ia. In the majority of the patients the glycosuria Annals of Internal Medicine 33:854, 1950. was mild and disappeared when treatment was Complet- (10) Landau, R.L.: Diagnostic significance and lab- ed; however, one case displayed hyperglycemia and oratory methods in determination of 17 ketos- heavy glocosuria which persisted for four weeks teroids, American Journal of Clinical Path- after completion of treatment, but did not require ology, 19:424, 1949. insulin therapy. During this same period one pa- (11) Colbert, J.W. Jr., Holland, J.F., Heissler, I., tient in the control group developed a severe case Knowlton, M.: The use of ACTH in acute viral of diabetes requiring large doses of insulin. hepatitis, The New England Journal of Medicine, 245:172, 1951. (12) Rifkin, H., Marks, L.J., Hammerman, D.J., Blum- Psychiatric Disorders: Several of the Cortone- enthal, M.J., Weis, A., Weingarten, B.: Use treated patients complained of nervousness, sleep- of Corticotropin and Cortisone in acute horao- lessness, and an ill-defined sense of oppression logus serum hepatitis, Archives of Internal during treatment and in two cases this was suffic- Medicine 89:32, 1952.

113 HEALTH OF ARMY TROOPS, FEG

/per iooo \ Admission Rate( all causes), u,S. Army Personnel, Far East Command \per year)

1952 1951

Adraissions per 1,000 troops per annum, Army personnel, for the four-week pefiod ending 28 May 1952 were as follows: FEC JAPAN KOREA PHILCOM(AF) RYCOM

All Causes 571 568 587 279 340 Diseases 450 496 439 246 287 Injuries 102 72 119 33 52 Battle Casualties 19 0 29 0 0 Psychiatric 22 14 26 8.2 9 Common Respiratory Diseases and Flu 96 138 79 82 48 Primary Atypical Pneumonia 2.6 1.4 3.3 0 0 Bacillary' Dysentery .18 0 .28 0 0 Amebiasis .69 1.3 .39 0 1 Malaria, new 15 0 19 8.2 2 Infectious Hepatitis 5.7 5.7 5.3 0 15 Dermatophytosis 6.7 4.2 7.6 0 12 Rheumatic Fever .40 .12 .56 0 0 Venereal Diseases 246 274* 238 205 157

DAILY NON-EFFECTIVE RATE

All Causes 17 32 10 30 8.2

Health of the Far East Command for the month of May low last year’s rate at this time. Measles, mumps, 1952 refers to Army personnel only. hepatitis, respiratory diseases, and pneumonia all showed strong declines while hemorrhagic fever, mal- ADMISSION RATES: aria, venereal diseases, and psychiatric conditions increased in incidence. Despite the rise for FEC, All Causes: The general health of the command re- the disease rate for Japan was down slightly. mained good during May 1952, with no epidemics re- ported and no unusual incidence of digestive tract Nonbattle Injuries: Admissions in this category infections. The admission rate to hospital and rose 15$ during May to a rate of 102 per 1000 per quarters for "all causes" was relatively unchanged, annum. Again, the rate for Japan countered the over- with a Far East Command rate of 571 per 1000 troop all FEC pattern and showed a decline of 4$. The rate strength. This is 35$ fewer admissions than during for Korea was up by 20$. Approximately one out of the same month last year. every 14 admissions in the nonbattle injury group resulted from automobile accidents and one out of Disease: A very slight increase in the disease in- every 10 resulted from athletic injuries. A compar- cidence was noted. Total admission rate for all ison of the admission rates for Korea and Japan is disease was 450 per 1000 per annum, a figure 30$ be- shown below:

114 ADMISSION RATES with last year's pattern in whioh the peak was reach- Motor Vehicle Accidents Athletic Injuries ed in J une.) ~TMT tforea Japan mr~ Korea Japan Venereal Disease: Rates for both white and colored Jan 6.9 9.0 2.9 2.3 1.6 3.4 troops increased in the same ratio during May, both Feb 7.9 10.7 3.3 2.9 .9 6.2 rising 1 over the previous month's rate. FEC's Mar 6.3 8.1 3.7 4.5 2.7 7.1 white rate was 199 per 1000 per annum; colored, 602; Apr 7.4 9.1 5.0 6.6 6.5 7.3 and overall, 246. Korea, RYCOM, and PHILCOM (AF) May 8.4 10.7 4.2 10.9 11.9 9.8 reported heavy increases; in Japan the increase was slight (only 2$). Divisional rates for Korea and Battle Casualties: Admissions from combat wounds Japan are as follows: and injuries were virtually unchanged, with a rate Ko- 0—4-KAY 1952 - ~i— deaths in FEC during May. Thus, while the hospital deaths rose during the month, principally as the re- sult of nonbattle injuries, the total death figure was 13$ below that for April.

EPIDEMIC HEMORRHAGIC FEVER:

Cases of this disease which appeared again in April continued to increase during May, as reflected on the following chart:

INCIDEI ICE OF HEMORRHAGIC FEVER i ]—

’ * 19E3 |Y e C JWM RTEI , WEE <3,. 1131.- JE

Psychiatric: A sharp increase in psychiatric admis- sions was reported in Korea (24$), while the Japan rate showed a drop of 7$. The Korean rate of 26 per 1000 per annum, while running below last year's rate at this time, represents the highest incidence re- ported thus far in 1952. (Provisional figures for June show rate increases in both Japan and Korea.)

Malaria: The normal seasonal trend continued during May, reaching a rate of 13 per 1000 per annum, just double last month's rate and virtually the same as the incidence recorded in May 1951. (Provisional June figures show a continued rise, also in keeping

115 DISEASE, &- liiiiliiBliiillililiiitmtm NON-BATTLE INJURY BATTLE CASUALTY memMmwi (per IOOO per year) U.S. ARMY PERSONNEL, F.E.C

disease non battle inj. battle cas.

HOSPITALIZATION: (These data cover all patients. Army, Air Force and others.)

The bed status as of 28 May 1952 was as follows: Average Beds Occupied All Patients Army Patients Designated Operating Army USA? Havy Beds Beds Hospitals Hospitals Hospitals

Japan 13,250 10,335 3,543 121 3 Korea 5,400 5,258 2,375 4 56 P3ILC0M (AF) 0 0 0 37 0 RYCOM 400 347 194 0 _0 F2C 19,050 15,940 6,112 152 59

In Korea, there were 11,700 PsW operating beds, 5,710 of which were occupied by PsW and 1,439 occupied by civilian internees.

The percent of designated beds and operating beds in Army hospitals occupied as of 28 May 1952 was as fol- lows : Percent of Designated Beds Occupied Percent of Operating Beds Occupied

Japan 27 34 Korea 44 45 RYCOM 49 56

FEC 32 38

Tabulated below is the number of patients evacuated from the major commands during the four report weeks ending 28 May 1952: Evacuated to the Zone of Interior Other United Nations Amy Personnel Evacuated Personnel Otho rs • Total to Their Homelands

Japan 509 45 554 45 PHILCOM (AF) 2 0 2 - 25 23 48 RYCOU —

FEC 536 ♦ 68 604 45

♦Includea 15 Amy patients hospitalised in USAF hospitals

Litter bearers carry wounded soldier of the 23rd Infantry Regi- ment, 2d Infantry Division, to 2d Battalion forward aid station as battle for possession of "Old Baldy" continues in Korea.

116 The Chief Surgeon extends an invitation to all Far East

Command medical personnel of the U. S. Army, Navy and Air Force, or of the United Nations, to prepare and forward with view to publication, articles of professional or administrative nature. It is assumed that editorial privilege is granted unless author states otherwise.

Capt. Charles A. Copeland, MSC EDITOR