NA V MED P-5088

Vol. 49 Friday, 10 February 1967 No. 3

Surgeons General of the Past (The fifth in a series of brief biographies) Doctor William Maxwell Wood was born 27 May 1809 in Baltimore, Md., was graduated from the University of Maryland School of Medicine, and was commissioned an Assistant Surgeon in the U.S. Navy 16 May 1829. His unusual, colorful, and varied service career included duty aboard vessels involved in the suppression of piracy and interrup­ tion of the slave trade, as well as activities in the Seminole Indian War, the Mexican War and the Civil War. As Fleet Surgeon of the Pacific Fleet he furnished American naval authorities with the ear­ liest possible information on the outbreak of the Mexican War, thus enabling the Navy to seize Cali­ fornia for the United States. He was aboard the USS SAN JACINTO when the East Indian Squadron ar­ ranged commercial relations with Siam and negotiat­ ed for trading ports with China and Japan in 1853. He was attached to a three-vessel squadron which protected American interests against Chinese anti­ foreign feeling at Canton in 1856, being present during the attack on and destruction of the Canton­ ese forts. From 1862 to 1864 he served as Fleet Surgeon for a blockading squadron, attached to the flagship USS MINNESOTA. On 1 July 1869, he was appointed Chief, Bureau of Medicine and Surgery by President Grant. He became the first occupant of the office to be designated Surgeon General when that title was prescribed in an appro­ priation act of 3 March 1871 which also gave him the rank of Commodore. Doctor Wood was placed on the Retired List 27 May 1871 but served as Sur­ geon General until 25 October of that year. During his administration legislation was passed which grouped medical officers in a separate and distinct staff corps with grades established by law; and the naval hospital at Mare Island, California was built. On 1 April 1873 he went into full retirement, and he died at his home in Owing Mills, Baltimore County, Md., on 1 March 1880. United States Navy MEDICAL NEWS LETTER

Vol. 49 Friday, 10 February 1967 No.3

Vice Admiral Robert B. Brown MC USN Surgeon General Rear Admiral R. 0. Canada MC USN Deputy Surgeon General Captain W. F. Pierce MC USN (Ret), Editor William A. Kline, Managing Editor Contributing Editors Aerospace Medicine ...... Captain Frank H. Austin MC USN Dental Section ...... Captain C. A. Ostrom DC USN Nurse Corps Section ...... CDR E. M. Murray NC USN Occupational Medicine ...... Captain N . E. Rosenwinkel MC USN Preventive Medicine ...... Captain J. W. Millar MC USN Radiation Medicine ...... Captain J. H. Schulte MC USN Reserve Section ...... Captain C. Cummings MC USNR Submarine Medicine ...... Captain J. H. Schulte MC USN

Policy ceptible to use by any officer as a substitute for any The U.S. Navy Medical News Letter is basically an item or article, in its original form. All readers of the official Medical Department publication inviting the News Letter are urged to obtain the original of those attention of officers of the Medical Department of the items of particular intere~ t to the individual. Regular Navy and Naval Reserve to timely up-to-date items of official and professional interest relative to Change of Address medicine, dentistry, and allied sciences. The amount Please forward changes of address for the News Letter of information used is only that necessary to inform to Editor: Bureau of Medicine and Surgery, Depart­ adequately officers of the Medical Department of the ment of the Navy, Washington, D.C. 20390 (Code 18 ), ex istence and source of such information. The items giving full name, rank, corps, old and new addresses, used are neither intended to be, nor are they, sus- and zip code.

CONTENTS

SPECIAL ARTICLE AWARDS AND HONORS SECTION The Armed Forces Institute of Pathology: An Edu­ Silver Star, Bronze Star, Letter of Commendation, cational Opportunity ------Vietnamese Medal of Honor, Navy Commendation Medal ------17 MEDICAL ARTICLES DENTAL SECTION Serum Enzyme Determinations in Diagnosis of Is­ Immediate Denture Service Designed to Preserve chemic Heart Disease ------­ 3 Serious Ocular Complications Associated Oral Structures ------­ 17 With Blow- Personnel and Professional Notes ------18 out Fractures of the Orbit ------7 Acute Gastric Ulcers Induced by Radiation ______9 PREVENTIVE MEDICINE SECTION Evaluation of the Role of Neurosurgical Procedures New Public Health Service Vaccination Certificate in the Pathogenesis of Secondary Brain-Stem PHS 731 ------19 Haemorrhages ------12 Smallpox Vaccine ------­ 20 Cold-Weather Worry: Croup ------­ 21 MEDICAL ABSTRACTS Arachnidism ------­ 23 Circulatory Changes During the Pain of Angina Pec- Know Your World ------25 toris, 1772-1965 ------14 EDITOR'S SECTION Surgical Management of Complications to Arterial American Board of OB-GYN ------26 Puncture ------15 Availability of NBC Teaching Team ------26 Cavography Following Plication of the Inferior Vena Committee in Injuries ------27 Cava ------15 7th Annual AFIP Lectures ------27 Diagnostic Thoracoscopy 16 Surgery at Sea ------27 ------Advanced Course in Nuclear Science for Medical Experience with 1,000 Fibergastroscopic Examina- Officers (NSMO) ------28 lions of the Stomach ------16 Old Hands Gather ------29 Chronic Intestinal Ischemia ------16 Acknowledgment ------29 The issuance of this publication approved by the Secretary of the Navy on 4 May 1964.

U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 SPECIAL ARTICLE THE ARMED FORCES INSTITUTE OF PATHOLOGY: AN EDUCATIONAL OPPORTUNITY

CAPT Bruce H. Smith MC USN, Deputy Director, Armed Forces Institute of Pathology, Washington, D.C. 20305.

Founded in 1862 by Administrative Order of Sur­ in man and many lower animals. It is upon this re­ geon General William Hammond of the U.S. Army, pository that the educational and research activities the Armed Forces Institute of Pathology was known are based. The Institute's research efforts in many until 1946 as the Army Medical Museum. From fields in this area of anatomic pathology are well 1946 until 1 949 it bore the name Army Institute of known. Its efforts in this regard embrace many Pathology, and from 1949 to the present, it has unique capabilities and employ up-to-date tech­ operated under a Department of Defense charter as niques such as electron microscopy, fluorescence mi­ the Armed Forces Institute of Pathology. croscopy, lasers, x-ray diffraction, and immunoche­ Through its 105-year history the Armed Forces mistry. Institute of Pathology (AFIP) has had six homes, The educational facilities are voluminous and and has grown steadily into the current complex of constitute one of the largest single postgraduate four buildings, the primary one being located on the medical education programs in the world. Much of grounds of Walter Reed Army Medical Center. In this has been due to the support of civilian medical, accordance with its charter, it is a triservice organi­ dental, and veterinary societies through the Ameri­ zation operated under the Department of Defense can Registry of Pathology, one of the four major with the Surgeons General of the Army, Navy, and departments of the AFIP. The Registry is responsi­ Air Force constituting the Board of Governors. Its ble for the centralization of material from within present director, MGEN Joe M. Blumberg MC and outside the Federal Government into a unique USA, supported by Navy and Air Force deputies, repository to be used by both pathologists and clini­ commands what is probably the most unique staff cians. Although its name indicates that the AFIP is ever assembled in one medical organization. a pathology institute, it is frequently forgotten hat The triservice effort is quite ably supported not this discipline of medicine is common to all special­ only by Army, Navy, and Air Force but also by ties, and therefore approximately 70 percent of the Veterans Administration and Public Health Service educational product at the AFIP is utilized by clini­ personnel, as well as civilians from both govern­ cians seeking knowledge of pathology in their var­ mental and nongovernmental sources and foreign ious clinical specialties. countries. The educational facilities at the AFIP can be di­ It is this unique blend of pathologists and clini­ vided into two categories: (A) in-house training, in cians working side by side with basic scientists and which the student is required to come to the Insti­ auxiliary personnel that has firmly established the tute for varying periods of time; and (B) training by international reputation of the AFIP in the fields of mail, in which the educational material is forwarded consultation, education, and research. The acquisi­ to the student who is unable to make the trip to tion of specimens from various sources through its Washington. consultation service has built the largest single re­ A. In-house training. pository of pathologic material ever assembled by one institution. In this massive collection of almost 1. Fellowships. The Institute offers fellowships of one and a half million accessions can be found ex­ varying duration in the pathology of practically a ll amples of almost every pathologic condition known clinical specialties. Many of these are supported by

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 1 an individual medical society providing stipends for though most of these films are on subjects dealing nonmilitary personnel. with pathology, many pertain to other related medi­ 2. Residencies. Residencies are offered in neuro­ cal fields. pathology, forensic pathology, and general patholo­ 2. Lantern-slide sets. The present library contains gy on a fourth-year level. Although these are pri­ 1,443 2 x 2-inch lantern-slide sets on I 55 different marily for military personnel, residencies in subjects. Many of these are basic review sets de­ neuropathology and forensic pathology are offered signed especially to help the clinical specialist in his to civilian personnel as well, on a second-priority preparation for specialty-board examination. Each basis. set is accompanied by a syllabus giving the neces­ 3. Formal courses. Each year the AFIP conducts sary background, titles, and discussion. and 22 formal courses on subjects de­ between 1 7 3. Microscopic-slide sets. This portion of the li­ signed primarily for the practicing clinical specialist. brary contains 2, 798 slide sets under I6I titles. Al­ These run from 3 days to as long as 6 weeks. The though most of the sets contain I 00 glass micro­ changed each year in accordance with courses are scopic slides, several are combination sets containing the demand. Many are regarded as the best or the not only microscopic slides but lantern slides show­ only course available on a particular specialty. In ing the gross and x-ray aspects of the cases. Each addition, through the American Registry of Patholo­ set is accompanied by a syllabus containing a discus­ gy, a 3-month course is offered in radiologic pathol­ sion of the cases. ogy, correlating gross pathology with roentgeno­ ferences. The lending li­ grams. 4. Clinicopathologic con 642 titles, each of 4. Symposia. Each year the Institute conducts brary has 2, I 09 CPC's under which is a complete case report. Each CPC contains two or three closed-invitaiional symposia on ad­ a clinical summary, pathologic findings, discussion, vanced subjects. Examples of recent years are sym­ folder are 2 x 2 Koda­ posia on the pathology of the audiovestibular ap­ and references. Also in the illustrating clini­ paratus, advances in leprosy, biologic effects of the chrome photographic transparencies cal, gross, microscopic, x-ray, and other features of laser, and quantitative electron microscopy. importance. 5. Individual study. In addition to the more for­ mal in-house programs, the Institute makes available 5. Video tapes and kinescopic recordings. an individual study program that permits physicians Through the Walter Reed Army Medical Center to come to the Institute for short periods of time, Television Service, the AFIP has amassed a large primarily to review material on an individual basis, number of video tapes on lectures given at the Insti­ usually in preparation for examination by various tute. The AFIP is now in process of converting American specialty boards. This can be accom­ many of these into kinescopic recordings to be add­ plished either in the individual branch or in special­ ed to the lending library of motion pictures. In addi­ ized study rooms provided for visiting students. tion, selected prints of video tapes can be procured 6. Medical Museum. The AFIP also operates a through special arrangement with the National Na­ medical museum, located on the Mall at 7th Street val Medical Center. and Independence Avenue, S.W. This building 6. Printed material. The AFIP operates two houses a museum for the general public and a pa­ presses and is responsible for the production of thology museum available to professional visitors. many publications, including the Fascicles of the At­ las of Tumor Pathology, atlases, syllabi, mono­ B. Training by mail. graphs, technical manuals, and radiologic pathology Through the American Registry of Pathology and workbooks. These are sold at cost through the the Medical Illustration Service, the AFIP makes American Registry of Pathology. In addition, re­ available numerous training aids that account for prints of articles written by staff members and pub­ more than 26,000 loans each year. This educational lished in medical journals can be procured free on a material consists of motion pictures, lantern slide first-come, first-served basis as long as the supply sets, microscopic slide sets, combination lantern and lasts. microscopic slide sets, and clinicopathologic confer­ The educational facilities of the Institute are rap­ ences. These are available free of charge on a 2- idly expanding, and up-to-date information pertain­ week loan basis. ing to these training aids may be secured by writing 1. Motion-picture films. The Institute currently to The Director, Armed Forces Institute of Patholo­ has 2,393 motion-picture films in its library. AI- gy, Washington, D.C. 20305.

2 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 MEDICAL ARTICLES SERUM ENZYME DETERMINATIONS IN DIAGNOSIS OF ISCHEMIC HEART DISEASE PITFALLS IN APPLICATION

E. Boszormenyi MD,* F. Utsu MD,* V. Enescu MD,* H. Bernstein MD,t and E. Corday MD;t. (University of California School of Medicine and Cedars-Sinai Medical Center, Los Angeles.) Postgrad Med 40(4):418-424, October 1966.

The SGOT test is said to have greater sensitivity infarction. Other enzymes are present in the serum than electrocardiography in the diagnosis of myocar­ in substantial amounts but their practical diagnostic dial infarction. The LDH test is of particular aid significance has not been established. when testing is started several days following the in­ Serum enzymes are not released exclusively by farction. The temporal relationship between infarc­ myocardial tissue. Therefore, these determinations tion and enzyme elevations has an important bearing cannot be used as specific tests for myocardial in­ on the determinations. Consideration must also be farction. Proper interpretation of the results requires given to the many extracardiac factors that affect the a knowledge of the various extracardiac factors enzyme levels. which can cause an elevation of the enzymes.

Serum enzyme determinations are now established Serum Glutamic-Oxalacetic as valuable aids in the diagnosis of infarction of the Transaminase myocardium. Indeed, enzyme elevations have proved to be more effective in this diagnosis than It is believed that the SGOT becomes elevated in electrocardiographic infarction patterns. The basis 97 percent of cases of myocardial infarction. In a for diagnostic use of serum enzyme determinations study of 2,227 patients with clinical evidence of is liberation of the enzymes from injured or ischemic myocardial infarction the SGOT was found to be myocardial tissue into the plasma. However, extra­ elevated in 97 percent. ln a series of 1,255 cases of cardiac factors may also affect serum enzyme levels. proved myocardial infarction the test gave false neg­ Conditions other than myocardial infarction which ative results in 3 percent. Elevation of SGOT was cause elevations of serum enzymes will be enumerat­ recorded in 13 7 of 142 cases of myocardial infarc­ ed in this report. tion proved at autopsy. LaDue, Wroblewski and Karmen demcmstrated that the SGOT level begins to LaDue, Wroblewski and Karmen first established rise within 24 hours following coronary occlusion the diagnostic value of the serum glutamic-oxalace­ and remains elevated for a period ranging up to tic transaminase (SGOT) and lactic acid dehydro­ three days. Wroblewski and LaDue as well as genase ( LDH) tests in determining myocardial tis­ Chinsky and Sherry have indicated that the normal sue injury. Tests for these two enzymes, which are value for SGOT ranges from 5 to 40 units per milli­ the principal ones whose levels are increased in the liter. Whetzel described a rapid screening test. serum following myocardial injury, have been the Meyers and Evans compared the diagnostic capa­ most useful for diagnostic purposes. However, many bilities of the SGOT test and electrocardiography in other enzymes may also be freed by necrosis of the myocardium. The serum creatine phosphokinase 157 cases of myocardial infarction proved at au­ (CPK) and alpha-hydroxybutyrate dehydrogenase topsy. The SGOT was elevated in 97 percent where­ (HBD) also become elevated following myocardial as the electrocardiograms were diagnostic in 81.5 percent. These observations suggest that the SGOT • Research Fellow, Medical Research Institute, Cedars-Sinai Medical test has a greater sensitivity than the electrocardio­ Center; tClinical Instructor in Medicine, University of California School of Medicine; tAssociate Clinical Professor of Medicine, Uni­ gram in the diagnosis of myocardial infraction. versity of California School of Medicine, Los Angeles.

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 3 At one time it was believed that the size of a droxybutyrate dehydrogenase (HBD) using 2-oxo­ myocardial infarction could be judged by the degree butyrate as substrate is of considerable diagnostic of elevation of the SGOT. However, associated value in myocardial infarction. ischemia of organs served by the systemic circula­ It is stated that the serum HBD-LDH ratio has tion can cause liberation of the enzymes from re­ the utmost importance in detecting myocardial in­ mote organs such as the liver. When shock super­ farction. The ratio usually rises above the normal venes and causes liver ischemia, therefore, the level upper limit of 0.81. Liver LDH consists largely of of these enzymes does not truly reflect the size of the slowest isozyme, LDH. The HBD-LDH ratio of the myocardial infarction. liver extract is thus about 0.33. The serum HBD is said to be more specific than other enzyme tests. Lactic Dehydrogenase Heat fractionation has been utilized in attempts to It is believed that the LDH becomes elevated in refine the LDH determinations. It seemed that the 95 percent of cases of myocardial infarction. It has LDH from human heart muscle should be more been demonstrated that LDH actually constitutes a heat-stable than LDH from other tissues. Bell stated series of enzymes. Lactic acid dehydrogenase, an en­ the belief that activity of serum LDH in excess of zyme of the glycolytic cycle, reversibly catalyzes the 85 units after incubation at 60° C for 60 minutes is conversion of pyruvate to lactate, utilizing diphos­ diagnostic of myocardial infarction. phopyridine nucleotide (DPNH, DPN) as an oxidiz­ Determination of total LDH activity is considered able-reducible coenzyme for the reaction. to be chiefly a screening test. The discovery of LDH The serum LDH level rises during the second or isozymes presents new possibilities for testing third day following myocardial infarction, reaches a specific organ ischemia. peak on the fourth or fifth day, and then descends. If this test is used to detect myocardial infarction, Glutamic-Pyruvic T;:ansaminase (GPT) therefore, the blood will have to be collected at a The content of this enzyme in Lhe myocardium is time when the enzyme level is most likely to be ele­ rather small, and the GPT test is therefore of little vated. Bang and LaDue stated that the LDH deler­ value in the diagnosi:; of myocardial infarction. The mination is not more reliable than the SGOT test in serum level of the enzyme will not rise significantly the diagnosis of myocardial infarction except when unless secondary ischemia due to cardiogenic shock the patient is first seen later in the course of the or arrhythmia causes it to be liberated from remote infarct. The LDH test can be used to confirm the organs. The pyruvic transaminase test is more sensi­ SGOT elevation. Also, because the LDH level tive in depicting acute hepatocellular damage and is reaches a peak later than the SGOT, it is of particu­ less sensitive as an indicator of acute myocardial ne­ lar benefit if testing is started several days following crosis. The myocardium is approximately 20 times the myocardial infarction, when the SGOT level has richer in oxalacetic transaminase than in pyruvic already descended. transaminase. The normal serum pyruvic transamin­ Wieland and Pfleiderer demonstrated that LDH ase level ranges from 5 to 30 units per milliliter. from tissues could be separated into isozymes with species-specific and organ-specific electrophoretic Creatine Phosphokinase patterns. Plagemann, Gregory and Wroblewski Study of the serum CPK acttvtty was begun in identified five LDH isozymes in rabbit and human 1959 by Ebashi and associates. Increased levels of tissues and observed typical patterns for each tissue. CPK in the serum of patients with acute myocardial Other investigators have corroborated these observa­ infarction were first reported by Dreyfus and co­ tions. The LDH in heart muscle is relatively rich in workers. CPK elevation was believed to reflect the fast-moving isozymes. Therefore the electro­ ischemia of the myocardium more clearly than ele­ phoretic pattern of the serum LDH exhibits a pre­ vation of other enzymes because of a greater ponderance of these fractions after cardiac infarc­ specificity of the test for acute myocardial necrosis tion. Elliott, Jepson and Wilkinson demonstrated and because the enzyme has a low activity in other that the fast-moving isozymes have relatively high areas (erythrocytes, lung, liver, kidney, pancreas). hydrogenase activity with 2-oxobutyrate as the sub­ Hess and associates and Vincent and Rapaport strate, whereas the slow fractions showed compara­ found that the serum CPK level regularly rose early tively little activity with this substrate. Elliott and in the course of acute myocardial infarction but also Wilkinson reported that determination of the 2-hy- encountered elevations in the presence of damage to

4 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 brain and skeletal muscle. In contrast, patients with itive results may be obtained if the blood is allowed disease of the liver and lung consistently had normal to stand too long or if the test tube is wet. Only 10 serum CPK values. Normal levels were observed in mg of hemoglobin will cause a rise in GOT of 1 congestive heart failure, rapid supraventricular ta­ unit. chycardia or arrhythmias, and acute coronary Diseases and Injuries Causing insufficiency without evidence of infarction. There is Enzyme Elevations a transient increase in the serum activity of CPK in normal subjects after moderately severe exercise. Metastatic carcinoma of the liver often causes an The upper limit of normal for serum CPK, deter­ elevation of serum enzymes. Persistent elevations of mined by the method of Tanzer and Gilvarg, is 2 to serum GOT, LDH and GPT should arouse suspi­ 3 units per milliliter. Serial determinations reveal cion of such a malignancy. Hill and Levi found con­ that the serum enzyme level becomes elevated as sistent LDH elevations in patients with malignant early as six hours following its release and remains tumors. However, the level depends on the rapidity elevated through the third day. Elevation following of tumor growth (Wroblewski). myocardial infarction has been confirmed. Ten percent of patients with pericarditis were found to have elevation of SGOT of 50 to 150 units Timing of the Tests on the third to the fifth day of the condition. The Because of the temporal relationship between symptoms of pericarditis and of myocardial infarction myocardial infarction and elevation of the enzymes, are often identical, and differentiation of the two blood samples for the tests must be taken at the conditions by use of the enzyme tests might be very most advantageous time. In selecting the test to be difficult. performed, the physician should consider the proba­ Following a surgical procedure the serum enzyme ble time of occurrence of the infarction. If the inves­ level may increase considerably because of tissue in­ tigation is started several days after the infarction, jury. However, this rise is not constant. If one sus­ the serum GOT and CPK will have returned to nor­ pects that a patient might have sustained a myocar­ mal levels and only the LDH test will provide diag­ dial infarction during or immediately after an nostically helpful information. operation, enzyme tests may be of little aid in diag­ nosis. Slight elevations of SGOT have been reported Significance of Fixed Elevation following cardiac catheterization and after mitral SGOT and LDH elevations revert to a base line commissurotomy. Enzyme elevations were found in within about a week following myocardial infarction 72 percent of a group of patients with skeletal mus­ in the absence of other conditions causing an in­ cle injuries. If one suspects that a patient has sus­ crease in the enzyme levels. There are many disease tained a myocardial infarction after an accidental in­ states, such as hepatitis and cancer, in which the jury, the enzyme tests cannot be used in the levels do not descend. Fixed enzyme elevations differential diagnosis. therefore usually indicate that the increases are due Embolism to the lung, which causes pulmonary to other causes. infarction, elevates the SGOT to 50 to 100 units in 25 to 50 percent of cases. The LDH may also be Sources of False Test Results elevated. When the pain is similar to that of myo­ Drugs-Many drugs have been found to cause cardial infarction, transient elevation of serum bi­ false positive serum enzyme tests. Enzyme tests are lirubin or the presence of fat in the sputum may be very sensitive to drug-induced liver dysfunction and a helpful observation pointing to a diagnosis of pul­ are therefore an excellent means of demonstrating monary infarction. drug-induced parenchymal hepatitis. Rapid cardiac arrhythmias may cause extreme Laboratory error-Because different laboratories elevations of SGOT. Chinsky, Shmagranoff and may employ different technics and standards in the Sherry reported SGOT values as high as 2,000 units performance of the serum enzyme tests, all testing in following ventricular tachycardia. Because arrhyth­ a given case should be done in the same laboratory. mia may give rise to chest pain similar to that of Failure to use a constant-temperature apparatus to coronary occlusion, and because the patient might warm the stage on which the test tube is examined not be aware of a transient episode of tachycardia, may lead to error; there is a 7 percent variation in the an erroneous diagnosis of myocardial infarction is SGOT reading per degree of temperature. False pas- often made in this situation. Liver ischemia second-

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 5 ary to the tachycardia is probably the source of the zymes m red blood cells. Anemia has the same increased GOT in these cases. effect. Because the liver is so rich in enzyme content, Many muscular diseases are likely to cause eleva­ hepatic dysfunction is readily demonstrated by ele­ tion of the enzymes. vations of the enzymes. Hepatocellular damage in hepatitis may cause severe elevations of SGOT, Differentiation of Coronary Occlusion GPT, and LDH. By fractionation of isozymes, and Coronary Insufficiency Wieme found increases in the faster LDH fractions Following an attack of coronary insufficiency, the after myocardial infarction, increases in the slower enzymes are usually not elevated. Myocardial necro­ fractions during periods of active hepatitis, and in­ sis resulting from the episode usually is not sufficient creases in all LDH fractions in patients with malig­ to result in liberation of substantial amounts of en­ nant tumors. A number of investigators have point­ zymes into the plasma. Severe coronary insufficiency ed out that measurement of GOT is a sensitive and lasting several hours, however, may lead to reliable method of detecting asymptomatic carriers significant infarction of the myocardium and to en­ of hepatitis virus. In hepatitis the SGOT and GPT zyme elevations. might be elevated to 500 to 2,000 units. Infectious mononucleosis, hepatotoxic drugs, and cirrhosis of Conclusion the liver may cause elevations of the enzymes. The Accurate interpretation of serum enzyme tests SGOT is elevated in 70 to 90 percent of patients used for differential diagnosis of myocardial infarc­ with hepatic neoplasms, either primary or second­ tion requires a full knowledge of the many factors ary. Cardiac decompensation and hypotension also which can produce elevations of the enzymes. The might cause significant elevation of the enzymes due SGOT and LDH tests have been the most useful for to liver ischemia. Biliary obstruction, either intrahe­ diagnostic purposes. It is hoped that other enzyme patic or extrahepatic, also causes elevations. and isozyme tests will also prove to be of value in We have found that firm palpation of the liver in the differential diagnosis of myocardial infarction. the dog will liberate large amounts of these enzymes into serum. If this observation is applicable to man, Acknowledgment overly vigorous palpation of the liver during physi­ cal examination might cause a false elevation of the The technical assistance of the following is grate­ enzymes and lead the physician astray. Firm fully acknowledged: Willie Davis, Willis Pea, Myles compression of the kidney in experimental animals Prevost, Jeanne Bloom and Katherine Wasserman. also causes elevation of the enzymes but the rise is (The figures, tables and references may be seen in less significant. the original article.) Prolonged shock, e.g., following hemorrhage, pul­ monary embolus, or coronary occlusion, may cause (A Review Article, "The Clinical Significance of ischemia of the liver and give rise to an extreme Serum Enzyme Estimations," by D. N. Boron MD, elevation of all the enzymes. A study of a group of of the Royal Free Hospital School of Medicine, Uni­ patients with hemorrhagic shock and without evi­ versity of London, has been published in Abstracts dence of myocardial abnormalities showed elevation of World Medicine 40:377-387, December 1966. of GOT in 70 percent, elevation of LDH in 52 per­ This is a very comprehensive review. The author cent, and elevation of GPT in 37 percent. Hepatic emphasizes, in his conclusion that it is better for a ischemia or congestion secondary to cardiac decom­ pensation in heart failure may result in enzyme ele­ laboratory to measure a small range of enzymes ac­ vations. curately than a large number inaccurately and lists Infarction of the liver, kidney, spleen or gas­ estimation of the serum activity of amylase, acid and trointestinal tract due to embolus or arterial occlu­ alkaline phosphatases, aspartate transaminase, crea­ sion may result in pronounced elevation of the en­ tine kinase, lactate dehydrogenases, and pseudo­ zymes. colinesterase as those which can provide information Hemolysis may cause a significant rise in the en­ for the clinician unobtainable by other means.-Edi­ zyme levels because of the high content of the en- tor.)

6 U.S. NAVY MEDICAL NEWS LEITER VOL. 49 NO. 3 SERIOUS OCULAR COMPLICATIONS ASSOCIATED WITH BLOWOUT FRACTURES OF THE ORBIT

A. T. Milauskas MD and G. F. Fueger MD, (From the Wilmer Ophthalmological Institute and the Department of Radiology, The Johns Hopkins Hospital.) Amer J Ophthal 62(4):670-672, October 1966.

The literature is replete with reports concerning the Johns Hopkins Hospital, in whom the diagnosis the diagnosis and treatment of blowout fractures of of blowout fracture of the orbital floor was made by 3 4 the orbital floor. The clinical signs of vertical diplo­ plain X-rays, polytomograms, orbitograms • or sur­ pia, enophthalmos, lid ecchymosis, emphysema and gical exploration, 12 patients suffered severe occular infraorbital nerve hypesthesia are well known. How­ injuries as a result of the blunt injury that usually is ever, an important aspect of blowout fractures the cause of blowout fracture. somewhat neglected in the literature is that serious ocular injuries may be present, in addition to the Case Reports usual clinical signs and symptoms. Case 1 (J. H. H. 34-14-38) King and Samuel,' in 1944, in a paper entitled The patient was struck in the left eye with a fist. "Fractures of the orbit," described what is now Clinically, there was limitation of the extraocular known as a blowout fracture of the orbital floor, muscles in downward gaze and abduction; radiologi­ quoting from their description: cally, a blowout fracture of the orbital floor was I would add one other type of fracture of great demonstrated. Vitreous hemorrhage and dislocation importance, which is not infrequent. In this there is of the lens were also present. The lens was extract­ a downward displacement of part of the orbital ed. About one year after the injury phthisis bulbi floor, unassociated with any damage to the margin developed and vision became no light perception. of the orbit or surrounding facial bones. The cause of such a fracture is difficult to visualize. The most Case 2 (J. H. H. 107-29-99) ready explanation is trauma transmitted through the The patient was struck in the right eye with a fi st. eye to the orbital floor. If, however, this were the Clinically, there was limitation of downward gaze, explanation, gross damage to the eye would be ex­ infraorbital nerve hypesthesia, vertical diplopia and pected, which is not found in most cases. enophthalmos. A blowout fracture of the orbital floor was demonstrated with orbitography. King's hypothesis as to the pathogenesis of this A trau­ matic cataract was seen, which rapidly type of fracture was substantiated by Smith's classi­ matured and cal experiments on the pathogenetic mechanism of required extraction. blowout fractures. 2 The present report substantiates Case 3 (J. H. ,H. 38-93-86) the second part of King's hypothesis in that gross The patient had been attacked and struck in the damage to the eye should also be present; indeed a left eye. Clinically, there was limitation of upward significant number of patients do have ocular in­ gaze, vertical diplopia and infraorbital nerve hy­ juries associated with their fractures, although King pesthesia. He also had a subluxated lens and sec­ did not observe this occurrence. ondary glaucoma. The glaucoma has been under The relatively high incidence of ocular complica­ poor control during the two years since injury. The tions must b e e mphasized since this condition is not diplopia also persists. Initially, the diagnosis of a treated by ophthalmologists only; plastic surgeons, blowout fracture was confirmed by orbitography but otolaryngologists and oral surgeons also repair blow­ surgery for its repair was refused. out fractures of the orbital floor, and they should be aware that the possibility of a serious ocular injury Case 4 (J. H. H. 44-26-77) exists. The patient had been struck in the eye with a fist. In a series of 84 consecutive patients with blow­ Clinically, he had limitation of upward gaze, slight out fractures or suspected of having them, seen at enophthalmos and infraorbital nerve hypesthesia.

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 7 Vision in the injured eye was reduced to the fight. Clinically, vertical diplopia with limitation on 20/70-100 range because of commotio retinae; a upward gaze was present; a blowout fracture was choroidal rupture was also present. A blowout frac­ therefore s uspected. A partial anterior-chamber ture was demonstrated radiologically by orbitogra­ hemorrhage persisted for 10 days. Because plain phy. After surgical exploration, a large blowout films were equivocal for a blowout fracture, an orbi­ fracture of the orbital floor was repaired. Visual togram was performed after the hyphema cleared; it acuity in the injured eye gradually became normal. was negative for a blowout fracture. The patient's diplop'ia subsequently cleared. Case 5 (J. H. H. 111-50-65) The patient had been struck in the left eye with a Case 9 (J. H. H. 20-70-02) high-pressure water hose while working. On admis­ The patient had been attacked and hit in the left sion, the left eye could not be found in the socket; eye. Limitation of upward gaze was present; diplo­ several examiners first thought a traumatic enuclea­ pia was not present initially because of an anterior­ tion had occurred. The patient was taken to the chamber hemorrhage of 30%-40%. Radiologically, operating room and the socket was explored. Most a large blowout fracture was present. After the an­ unexpectedly, a huge blowout fracture of the orbital terior-chamber hemorrhage had cleared, a large floor was found, with total displacement of the in­ blowout fracture of the orbital floor was found and tact globe into the left maxillary sinus. The globe repaired. was then elevated surgically and the blowout frac­ ture repaired. Postoperatively, the visual acuity in Case 10 (J. H. H. 102-18-99) the left eye was 20/200. A macular scar, angle The patient had injured his left eye in a s leighing recession, a p ost traumatic ptosis, enophthalmos and accident. Radiologically, a fracture of the orbital ophthalmoplegia were present. floor and roof was present. The globe had been rup­ enucleation. Case 6 (J. H. H. 113-92-89) tured and subsequently required During a fight, the patient was hit in the left eye. Case 11 (J. H. H. 52-05-09) The patient was seen in the accident room where The patient was hit in and about the right eye; he X-rays demonstrated a blowout fracture of the or­ was admitted to another service with a suspected bital floor and fracture of the orbital roof. A total blowout fracture. The initial plain radiographs were anterior-chamber h yphema was present. Intraocular nonrevealing. Clinically, the patient had periorbital pressure was normal to s lightly elevated. In the next swelling and ecchymoses of the lids of the right eye, two weeks, the eye developed hypotony and no light infraorbital nerve hypesthesia and two mm of prop­ perception. A ruptured globe was suspected and nt initially and there was confirmed by exploration. An enucleation was per­ tosis. No diplopia was prese formed. Fracture of the orbital floor was also only minimal limitation of upward gaze. Vision in confirmed. the right eye was reduced to 20/ 200, due to macu­ lar edema. An orbitogram showed a large blowout Case 7 (J. H . H. 51-05-34) fracture of the orbital floor. During five days of ob­ The patient had been struck in the left eye with a servation, the macular edema improved and vision hammer. Examination showed marked proptosis of reached 20/ 50. At this time the patient began to the globe, a total anterior-chamber hemorrhage and appreciate diplopia. Surgical exploration showed a initial visual acuity of no light perception. X-rays large blowout fracture of the orbital fl oor; it was demonstrated a large blowout fracture of the orbital repaired. Vision subsequently improved to 20/ 25. floor and a fracture of the zygomatic arch. At surgi­ cal exploration, a large hematoma was evacuated Case 12 (J. H. H. 71 -15-72) and the blowout fracture of the floor was confirmed The patient was struck in the right eye by a bot not repaired. The zygomatic arch fracture was thrown b ottle. Clinically, proptosis, diplopia and reduced. No light perception persisted and the eye limitation of upward gaze were present. A blowout became hypotonic. On exploration a posterior rup­ fracture of the floor was demonstrated with orbitog­ ture of the globe was found and the eye was enu- raphy. With the pupil dilated the indirect ophthal­ cleated. · moscope revealed extensive peripheral retinal ede­ Case g (J. H. H. 41-52-49) ma. No retinal t ears were seen. Surgical exploration The patient had been struck in the left eye in a revealed a blowout fracture which was repaired.

8 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 Summary and Conclusion sential that a complete ophthalmologic examination be performed, with a slitlamp examination, tonom­ In this series of 84 cases, approximately 14% of etry, ophthalmoscopy (direct and indirect) with the patients had serious ocular injuries, including pupil dilation, to search for ocular injuries. rupture of the globe, vitreous hemorrhage, anterior­ chamber hemorrhage, chamber-angle recession, dis­ References located l ens, traumatic cataract, secondary glauco­ I. King, E. F., and Samuel, E.: Fractures of the orbit. T r. Ophth. Soc. U .K. 64: 134, 1944. ma, choroidal rupture, commotio retinae, a macular 2. Smith, B. , and Regan, W. F., J r.: Blowout fracture of the orbit: Mechanism and correction of internal orbital fracture. Am. J . Ophth. scar, macular and peripheral retinal edema, in addi­ 44 :733, 1957. 3. Milauskas, A. T ., Fueger, G. F., and Schulze, R. R.: Clinical tion to blowout fracture. experiences with orbitography for the diagnosis of blowout fractures of orbital n oor. Tr. Am. Acad. Ophth. Otol., 70:25, 1966. Since ocular injuries may be present in patients 4. Fueger, G. F., Milauskas, A. T., and Britton, W. W.: Roentgeno­ logic evaluation of orbital blowout injuries. Am. J. Roentgenol. with actual or suspected blowout fracture, it is es- 97:614, 1966.

ACUTE GASTRIC ULCERS INDUCED BY RADIATION

A. Sell and T. S. Jensen, (From the Radium Centre for Jutland [Prof. S. Kaae], Arhus, Denmark.) Acta Radio[ 4(4):289-297, August, 1966.

Gastric lesions as complications in high voltage afford no relief. The ulcer is radiologically indistin­ radiotherapy have become of interest in recent guishable from an ordinary ulcer; it may heal spon­ years, particularly in the treatment of malignant tu­ taneously, but submucous fibrosis generally produces mours of the testis. This communication is con­ antral stenosis. Friedmann recommended partial cerned with four cases of acute gastric ulceration gastrectomy. observed following postoperative irradiation of the 4. Unlike these late, chronic gastric sequelae, the lumbar lymph nodes in malignant testicular tu­ acute, radiation-induced ulcer appears as an early mours. complication, usually manifesting itself a month or Various forms of gastric lesions following external two after the radiotherapy has been completed. This irradiation have been r eported, especially from the ulcer is deep and penetrates the layers of the stom­ Walter Reed General Hospital, Washington, by ach, but perforation into the peritoneal cavity is Brick (1955), Hamilton (1947), Friedmann usually prevented by the omentum, the intestine, or (1959), Palmer (1948), and Warren (1942). the abdominal wall. The symptoms are severe and Friedmann described four types of gastric damage in consist of severe epigastric pain and often gastric a series of about 250 malignant testicular tumours: bleeding. Surgery is advisable before serious compli­ (I) dyspepsia, (2) gastritis, (3) late chronic ulcer, cations arise. and (4) acute ulcer, with or without perforation. The severity and frequency of the gastric lesions 1. Radiation-induced dyspepsia-to be distin­ depend upon the s ize of the dosage received by the guished from the common roentgen 'kater' occurring stomach. When this exceeds 4,500 R, the incidence during the treatment- arises 6 months to 4 years of gastric ulcer is 25 to 30%. The higher the dose later as vague gastric symptoms without clinical or the more serious the gastric damage leading to pene­ radiologic signs. tration and haemorrhage. 2. Radiation-induced gastritis sets in earlier than Friedmann has also mentioned the radiation dam­ the dyspepsia, as a rule 1 to 12 months after the age sustained by other structures involved in the ra­ completion of radiotherapy, and is accompanied by diation, such as the skin, s ubcutaneous tissue, mus­ radiologic evidence of spasm or stenosis of the an­ cles, small and large intestine, kidneys, spinal cord, trum. Gastroscopy reveals smoothened mucosal and bony tissue. Although the tolerance seems to be folds and mucosal atrophy. The pathologic basis is somewhat higher in the s mall and large intestine fibrosis of the submucous tis~ue. than in the stomach, ulceration as well as annular 3. Radiation-induced ulceration has its onset stenosis due to submucous fibrosis may arise. from 1 month to 6 years with an average of 5 Only a few other authors have described gastric months after r adiotherapy. The usual ulcer symp­ complications a fter the treatment of the retroperi­ toms are present, but food and antacids usually toneal lymph nodes. Sejourne (1952) reported a

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 9 case of atrophic gastritis without symptoms, which the patients had been subjected to hemicastration, had occurred after repeated irradiation of the upper but not to therapeutic or prophylactic lymphadenec­ lumbar lymph nodes. Mosimann (1959) described a tomy of the lumbar nodes. case of ulcer of the body of the stomach arising The radiation technique using telecobalt, initiated immediately after the completion of radiation to the 2 to 3 weeks after the operation, comprised en bloc lumbar lymph nodes through an abdominal field. irradiation of the para-aortic lymph nodes through The depth dose was not stated. Conservative treat­ two opposed fields, one ventral and one dorsal, of ment was tried but haemorrhage and penetration 200 to 240 cmt at 80 em FSD. The fields extended necessitated operation. Piet (1960) reported 4 cases from the middle of the body of the D 1 I to S I, the of slight, late gastric lesions in a series of 89 irra­ field width being about I 0 em, determined from the diated testicular tumours. There is no exact state­ lymphographic and urographic findings. Irradiation ment of the depth dose, but the skin dose ranged of the major parts of the kidney was avoided as far from 2,200 to 3,000 R , delivered through 2 lumbar, as it was possible. Only in patients with definite or convergent fields with 200 kV, lmm Cu + 2 mm probable signs of nodal invasion in relation to one 2 AI, FSD 50 em, field size 150 to 200 cm • Duodenal kidney, was this organ included in the field. After ulcer was observed in two cases within one year of the irradiation of the lumbar lymph nodes, the pa­ the completion of radiotherapy, while deformation tients received irradiation through a supplementary of the antrum accompanied .by mild dyspepsia was field to the iliac nodes on the operated side. present in two cases. These cases were diagnosed 4 The irradiation was administered through one years and 6 years, respectively, after the treatment. field daily, with a weekly central dose of about Wood et coli. (1963) reported a fatal case of nec­ 1 ,000 R and a maximum dose of about 1,100 R. As rotic ulceration of the stomach and intestine after a far as the seminomas are concerned, the central central dose of 3,000 R, administered in two sittings dose ranged from 3,500 R / 4 weeks to 4,500 R/ 5 at an interval of 8 days. weeks, but with the non-seminomatous carcinomas The gastroscopic appearances are said to be char­ the average dose was higher, the central dose being acteristic (Palmer 1948). The irradiated area, as a about 4,500 to 5,000 R in 41h to 5 weeks, the rule the antrum, is transformed into an almost stiff maximum dosage about 10 to 15 % higher. tube, with reduced or absent peristalsis, the re­ This irradiation technique always involves parts mainder of the gastric wall being oedematous. of the stomach, transverse colon, and small intes­ Where an ulcer is present, it is said to be typically tine, apart from the spinal cord. The material was deep and sharp-edged; if it heals, it does so slowly analysed with a view to the acute radiation effects and may leave no scar. upon the stomach, while as yet the late complica­ Histologic investigations have not disclosed any tions cannot be assessed owing to the short follow­ changes that could distinguish radiation-induced up time (from 5 to 25 months) for the majority of ulcers from simple ulcers. However, it has been em­ the patients treated. phasized (Wood et coil. 1963) that irradiation Three of the 38 treated patients exhibited mani­ produces particularly marked mucous and submu­ fest penetrating gastric ulcers, all of which required cous oedema, as well as vascular changes involving surgical treatment, in close relation to the comple­ proliferation of endothelial cells and thickening of tion of radiotherapy. the vessel walls. The submucous fibrosis and the end­ In the first 3 cases now reported upon, there were arteritic changes are also marked, without being large ulcers that required surgery, in two because of specific, in late lesions following irradiation. haemorrhage and in one because of the severity of Animal experiments performed inter alios by En­ the symptoms. gelstad (1938) have revealed lesions following irra­ Arc therapy with conventional roentgen irradia­ diation of the stomach similar to those in man. tion may also lead to such a high central dose that Present material. All testicular tumours referred an acute gastric ulcer results. This is exemplified by during the period March 1962 to December 1964 Case 4 in which the ulcer healed with scar formation have been treated postoperatively with telecobalt to during expectant treatment. the para-aortic and homolateral iliac lymph nodes. Histologic examination was carried out in all four A total of 38 patients were treated, distributed his­ cases, but no changes that could distinguish the ra­ tologically in 18 pure seminomas and 20 non­ diation-induced ulcers from simple ulcers were evi­ seminomatous carcinomas. Prior to radiotherapy, all dent.

10 U.S. NAVY MEDICAL NEWS LEITER VOL. 49 NO. 3 Discussion the stomach and intestine with this sort of dosage is quite high, and the danger should be borne in mind dose to the gastric mucosa ranged from The in weighing radiotherapy against lymphadenectomy, to 5,000 R / 5 weeks in the first three cases of 4,000 or possibly in combining the two in treating non­ ulcers arising in close relation to radiother­ definite seminomatous carcinomas (Muller 1962). No ran­ In the fourth case, treated by conventional apy. dom treatment series to afford a consistent answer to the dose in the first course of treat­ roentgen rays, these problems has as yet been published. ment was 1 ,600 R / 54 days and in the second (last) Owing to the close relation of the retroperitoneal course of treatment it was 4,800 R/ 24 days. These lymph nodes to the stomach and other radiosensitive doses are of the same magnitude as those which organs, such as the spinal cord and in particular the others have reported in cases of radiation-induced kidneys, nothing is gained by altering the field tech­ ulcers. According to Friedmann the tolerance dose nique, e.g. the multiple field or the arc therapy tech­ the stomach is about 4,000 R during 5 to 9 in nique. weeks, a tolerance dose being taken to be the upper It is impossible to say whether interstitial irradia­ limit which does not entail demonstrable damage, tion (Seitzman et coli. 1963), using .B-emitting iso­ acute or chronic. topes in Lipiodol Ultratluid (e.g. '"'1, '"'!) adminis­ The tolerance limit doubtless varies widely from tered through the lymphatics of the spermatic cord subject to subject. Twenty-seven of the 38 patients by the usual lymphographic technique, may be use­ of the present series received a central dose exceed­ ful in the prophylactic treatment of the lumbar and ing 4,000 R/4 to 5 weeks but only three of the iliac lymph nodes. The dose will be insufficient in group experienced acute symptoms. Five patients lymph nodes replaced by tumour tissue, as the latter even received a central dose exceeding 5,000 R and does not take up the contrast medium. Interstitial had no symptoms of dyspepsia to demand further radiotherapy can therefore be considered only for investigation. It must however be pointed out that prophylactic purposes or in the presence of mi­ the short follow-up periods of not more than two crometastases. years, do not warrant any assessment of the total The treatment of the acute radiation-induced number of gastric complications. be surgical owing to the The irradiation includes the stomach in the exter­ ulcers should presumably risk of haemorrhage and perforation. This accords nal irradiation of the regional lymph nodes in malig­ with the course in three of the present cases. Major nant testicular tumours. The radiosensitivity of the swelling in the epigastrium a short time lymph node metastases is extremely varied, but the palpable after radiotherapy, possibly accompanied by dyspep­ histologic type affords some guidance. In the case of should not be interpreted, without further inves­ a pure seminoma, Friedmann has given the fatal tu­ sia, tigation, as nodal metastases, as it may represent a mour dose as being between 1,500 R / 14 days and penetrating gastric ulcer with reactive changes in the 3,500 R/4 weeks, but large tumours would necessi­ neighboring tissues, e.g., the omentum. tate an increase in this dose. It is also advisable to use a minimum of 3,500 to 4,000 R / 4 weeks in Summary those instances of seminomas with considerable cel­ lular atypia or with any suggestion of transition into Previously reported gastric lesions produced by these the non-seminomatous carcinoma. As far as the semino­ radiotherapy are briefly reviewed and to mas are concerned the doses would appear to be authors add four cases of gastric ulceration follow­ within the limit of normal gastric tolerance. ing the irradiation of lumbar lymph nodes associated The dosage problems are on the whole unsolved with malignant testicular tumours. The tolerance in the case of non-serninomatous carcinomas. How­ limit of the normal gastric mucosa was found to be with ever, the fatal tumour dose appears to be considera­ about 4,000 R during 5 to 9 weeks, in keeping bly higher than for the seminomas, presumably in the experience of other authors. the range 4,500 to 5,000 R / 35 to 40 days (Notter (The figures and case reports omitted and refer­ & Ranudd 1964). The risk of radiation damage to ences may be seen in the original article.)

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 11 EVALUATION OF THE ROLE OF NEUROSURGICAL PROCEDURES IN THE PATHOGENESIS OF SECONDARY BRAIN-STEM HAEMORRHAGES '

G. K. Klintworth (From the Department of Pathology, Duke University Medical Center, Durham, N. C., U.S.A.) J Neural Neurosurg Psychiat 29(5):423-425, October, 1966.

During the experimental investigation of the oedema objectively, this diagnosis was accepted only pathogenesis of mesencephalic and pontine haemor­ when the weight and gross appearance of the brain rhages associated with supratentorial expanding le­ and the history were compatible with the diagnosis. sions, it became apparent that removal of the intra­ When oedema was associated with another supraten­ cranial mass during a particular period was often torial conditicn, e.g., cerebral infarction, cerebral critical to their development and accentuated their abscess, metastatic neoplasm, the lesion was severity (Klintworth, 1965). These observations classified according to the primary affection. Recent raise the question whether alleviation of intracranial traumatic supratentorial expanding masses were ex­ pressure under comparable circumstances predis­ cluded from the analysis, as haemorrhages in the poses to secondary brain-stem haemorrhages in brain-stem of such cases may have resulted from the man. This possibility is s trengthened by certain clini­ initial trauma. copathological studies which have revealed a high Surgically treated patients manifesting secondary incidence of lumbar puncture, pneumoencephalog­ brain-stem haemorrhages were classified according raphy , ventriculography, or neurosurgical proce­ to the clinical manifestations at the time of surgery dure in individuals manifesting secondary brain-stem as follows: haemorrhages (van Gehuchten, 1937; Le Beau, 1943; Carrillo, 1950; Cannon, 1951 ; Poppen, Ken­ Type Manifestations drick, and Hicks, 1962; Fields and Halpert, 1953; I Cabieses, 19 56) . Absence of clinically manifest intracranial dis­ ease The present study attempts to elucidate the role J r Focal neurological symptoms and/ or signs, such of neurosurgical procedures in the pathogenesis of as epilepsy, or hemiparesis, but no overt evi­ these bulbar vascular lesions in man. dence of increased intracranial pressure Jl£ Mild to moderate increased intracranial pres­ Materials and Methods sure with or without focal manifestations. This A prospective and retrospective clinicopathologi­ group includes patients with ( 1) lumbar spinal fluid pressures cal investigation was performed on over 1,200 pa­ of 150-400 mm., (2) mild papilloedema tients with supratentorial expanding lesions. The in­ IV Severe cidence and temporal relationship of neurosurgical increased intracranial pressure with or without focal manifestations. procedures to secondary brain-stem haemorrhages This group in­ cludes patients with (I) lumbar spinal fluid was analysed. The data reviewed were obtained pressures of more than 400 mm., (2) severe from the South African Institute of Medical Re­ papilloedema search, Johannesburg, South Africa, and the Duke v Moribund with an obvious intracranial expand­ University Medical Center and Durham Veterans ing lesion Administration Hospital, Durham, North Carolina, U.S.A. Results Discrete supratentorial lesions having a maximum Secondary brain-stem haemorrhages were asso­ diameter of less than 2 em. or a volume of less than ciated with a wide variety of supratentorial lesions 20 mi. were excluded from the review. Because of which were either large focal masses or extensive the difficulty in evaluating minor degrees of cerebral diffuse lesions (Table 1). Although over h alf of the 1 This work was supported by U.S.P.H.S. j!rant N.B.-06805-01. subjects with secondary brain-stem haemorrhages

12 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 did not experience any form of surgery, an impres­ Discussion of the latter survived post­ sive number did. A few An objective evaluation of the role of neurosurgi­ periods of more than three weeks and sur­ operative cal . procedures in the pathogenesis of secondary had no bearing on the secondary gery clearly bram-stem haemorrhages is extremely difficult, as haemorrhages. Recent spontaneous hae­ brain-stem the sample of case material is derived from postmor­ were present within the tumour masses of morrhages tem examination and is biased towards therapeutic who manifested second­ all six patients with gliomas failures rather than successes. Although it is clear haemorrhages after postoperative ary brain-stem that secondary brain-stem haemorrhages can occur of three months to four years. Two survival periods in the absence of surgery, the high incidence of post­ surgically treated ruptured intracranial patients with operative cases, particularly with slowly expanding 29 days after surgery. Both aneurysms died 25 and supratentorial lesions, warrants consideration. had recent massive supratentorial haemorrhage and In the present investigation most secondary brain­ infarction secondary to second bleeds. stem haemorrhages were associated with extensive Most postoperative patients with secondary brain­ supratentorial haemorrhage or oedema either alone stem haemorrhages who died within a week of sur­ or in association with a neoplasm, abscess, or in­ gery either underwent surgery for an intracranial le­ farct. However, in some postoperative patients with sion which was predominantly haemorrhagic or relatively slowly expanding masses haemorrhage and oedematous, or developed postoperative cerebral oedema were inconspicuous. Subjects with such su­ haemorrhage or oedema. In two cases the restora­ pratentorial lesions invariably underwent relief of in­ tion of cerebral blood flow by carotid endarterec­ creased intracranial pressure, sometimes only with a tomy for carotid artery thrombosis was complicated terminal ventricular tap, after a progressive increase by haemorrhage into the infarcted area. in intracranial pressure and generally when coma­ Many patients with slowly expanding supratentor­ to.se and manifesting hypertension and unilateral or ial lesions, such as cerebral gliomas or subdural hae­ bilateral fixed dilated pupils. Although caution gen­ matomas and secondary brain-stem haemorrhages, erally must be exercised in extrapolating from ex­ did not manifest any overt increase in intracranial perimental observations to clinical situations the mass. An outstanding feature of such cases .was the discovery that relief of intracranial pressure durlng a high incidence of craniectomy with relief of in­ particular period in physiological decompensation creased intracranial pressure by resection of tumour, predisposes to experimentally produced secondary evacuation of haematomas, lobectomy, subtemporal brain-stem haemorrhages (Klintworth, 1965) sug­ decompression, or ventricular drainage. These pa­ gests that some of the present data may represent a tients almost invariably underwent such procedures comparable situation in man. Such an explanation while comatose after manifesting a progressive in­ in part for the high incidence crease in intracranial pressure and many were mori­ may account at least bund before surgery. Characteristic of this group of neurosurgical procedures in patients with second­ was the failure to regain consciousness following ary brain-stem haemorrhages and for the well-estab­ surgery and death ensuing, usually within the first lished clinical observation that bilateral fixed dilated 48 postoperative hours. pupils generally indicates an ominous course in su- TABLE I SUMMARY OF SUPRATENTORIAL LESIONS ASSOCIATED WITH SECONDARY BRAIN-STEM HAEMORRHAGES Neurosurgically Treated Cases with Secondary Brain-stem Haemorrhages

Sample Incidence of Secondary Case.r with Secondary Preoperati\'e Postoperati•·e Supratentorial Lesion Size Brain-stem Haemorrhages Brain-stem Haemorrhages Classification Survival Without Neuro- With Neuro- I II J/1 IV v Less Greater surgery surgery than I Iran 1 week 3 weeks

Cerebral glioma 165 42(25.5%) 6(14.3%) 36( 85.7%) 0 0 8 19 9 30 6 Metastatic tumour 96 11 (11.5%) I( 9.1%) 10( 90.9%) 1' 0 0 3 6 10 0 Chromophobe adenoma 18 3(16.7%) 1(33.3% ) 2( 66.7%) 0 0 2 0 0 2 0 Craniopharyngioma 14 2(14.3% ) 0( 0 % ) 2( 100.0% ) 0 0 I 1 0 2 0 Intracerebral haemorrhage 168 53(31.5% ) 45(84.9 % ) 8( 15.1% ) 0 0 0 2 6 8 0 Cerebral infarction ( recent) 268 31 (11.6%) 21(67.7% ) 10( 32.3% ) 0 2 4 2 2 10 0 Cerebral abscess 84 6( 7.1%) I (16.7% ) 5( 83.3%) 0 0 I 3 1 5 0 Subdural haemorrhage 101 22(21.8% ) 14(63.6%) 8( 36.4% ) 0 0 0 2 6 8 0 Miscellaneous haemorrhage and infarct1 328 35(10.7% ) 25(71.4% ) 10( 28.6% ) 0 0 0 2 8 8 2 Total cases 1,242 205(16.5%) 114(55.8% ) 91( 44.2% ) I' 2 16 34 38 83 8 ; fhis gro~p includes supratentorial haemorrhages which were situ.ated at multiple sites as well as those associated with recent cerebral infarction. h1s pat.ent underwent a ~ron tal leucotomy for pam due to Widespread malignancy. Surgery was complicated by haemorrhage into un- suspected metastatiC tumour m the frontal lobe. an

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 13 pratentorial expanding masses even with adequate heights may be followed by paralysis instead of a surgery. release from the major compression symptoms. The The pathogenesis of secondary brain-stem hae­ occasion of this is readily brought out by postmor­ morrhages has yet to be fully established under con­ tem examination, which, under such circumstances, trolled conditions, but available clinicopathological oftentimes discloses a brain and medulla of a uni­ and experimental data strongly suggests that a com­ form cherry-red color, from the widespread extrava­ bination of a large supratentorial mass, a damaged sation of blood due to the multiple rupture of the brain-stem, as by displacement, and an active circu­ minute blood vessels. The external supporting pres­ lation through the brain-stem are essential to their sure of the high intracranial tension has been sud­ occurrence (Klintworth, 1965, 1966). It is clear denly removed, leaving the internal or intravascular that cerebral blood flow decreases, that the cerebral pressure too great for the strength of the vessel circulation time increases, and that it may be impos­ walls.' sible to demonstrate intracranial blood vessels by angiography in subjects with severe increased intra­ Summary cranial pressure (Kety, Shenkin, and Schmidt, 1948; A prospective and retrospective clinicopathologi­ Riishede and Ethelberg, 1953; Tonnis and Schiefer, cal investigation was performed "on over 1,200 pa­ 1954, 1959; Giinshirt and Tonnis, 1956; Greitz, tients with supratentorial expanding lesions. Most 1956; Horwitz and Dunsmore, 1956; Woringer, patients manifesting secondary brain-stem haemor­ Langs, Braun, and Baumgartner, 1956; Glinshirt, rhages had extensive supratentorial haemorrhage or 1957; Gros, Vlahovitch, and Roilgen, 1959; Lof­ oedema either alone or in association with a neo­ stedt and Von Reis, 1959; Pribram, 1961; Lecuire, plasm, abscess, or infarct. Although most secondary de Rougemont, Descotes, and Jouvet, 1962 ; Troupp brain-stem haemorrhages occurred in the absence of and Heiskanen, 1963; and Heiskanen, 1963). Su­ surgery, a large number of cases were postoperative. pratentorial decompression presumably restores Secondary brain-stem haemorrhages were almost in­ cerebral blood flow and initiates haemorrhages into variably associated with supratentorial expanding le­ the brain-stem only in those cases in which the vas­ sions in which there was either a culature of the brain-stem has been damaged as a relatively rapid increase result of mechanical shearing and/or anoxia. in supratentorial mass due to haemorrhage Although Cushing (1902) did not make specific or oedema, or increased intracranial pressure was reference to secondary haemorrhages in the brain­ partially or completely relieved while the patient stem, it is of interest that he appreciated the danger was comatose with unilateral or bilateral fixed dilat­ of relieving increased intracranial pressure under ed pupils and manifesting hypertension. When circumstances similar to those outlined above. He viewed in the light of previous experimental data the stated: 'It must be remembered, however, that the latter cases suggest that alleviation of intracranial sudden removal of pressure from the brain when the pressure under certain circumstances may predis­ blood-pressure has been forced to considerable pose to secondary brain-stem haemorrhage in man.

MEDICAL ABSTRACTS

CIRCULATORY CHANGES DURING THE In the first of these two reviews, after an exhaus­ PAIN OF ANGINA PECTORIS, 1772-1965 tive search of the literature, the authors report only 20 articles listing objective data obtained during the -A CRITICAL REVIEW pain of spontaneous or provoked angina pectoris. I. W. Roughgarden MD and E. V. Newman MD, Thirty attacks in 22 patients are described in these (From the Department of Medicine, School of Med­ reports. The data in these indicate that spontaneous anginal attacks uniformly are associated icine, Vanderbilt University, Nashville, Tennessee.) with rela­ tive systolic and diastolic hypertension, averaging 29 Amer J Med 41:935-946, December 1966. Circula­ percent increase in pressure over control levels and tory Changes Associated with Spontaneous Angina an increase of 30 percent in pulse rate. In 10 in­ Pectoris, J. W. Roughgarden, ibid, pp. 947-961. stances, the hypertension preceded the onset of sub-

14 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 jective pain; in the others, this relationship was not ed surgery in the treatment of the complications. observed. In only two cases were observations of Arterial punctures in this group were done for intra arterial pressures and electrocardiograms ob­ the following studies: coronary angiography ( 7), tained prior to, during, and after the relief of spon­ thoracic angiography ( 4 ), heart catheterization (9 ), taneous anginal pain. In exertional anginal attacks, femoral or pelvic angiography ( 4), abdominal angi­ they state that by far the majority appear to be asso­ ography ( 6) , carotid angiography (3), angiocardiog­ ciated with relative hypertension. In the summary raphy ( 4), and indwelling catheter for sampling ( 1 ). and conclusions, certain criticisms and suggestions The following points are stressed in their sum­ for further study are listed. mary and conclusion on the basis of their experi­ The second article describes and lists data ob­ ence: tained during 21 attacks of unprovoked anginal pain I . Arterial thrombosis (13 cases) should be diag­ in 10 patients observed by continuous monitoring of nosed and operated upon early, even if risk of gan­ systolic pressures and electrocardiograms. Pulmo­ grene seems remote. nary artery pressures were obtained in eight attacks 2. Pseudoaneurysms (15 cases) may cause only of unprovoked angina. The author's summary is as mild symptoms, but recurrent partial rupture and follows: expanding hematoma makes arterial repair impor­ Spontaneous or unprovoked angina pectoris is as­ tant. sociated with elevation of systemic and pulmonary 3. Arterio-venous fistulae (6 cases) cause subjec­ artery pressures which preceded the onset of pain in tive symptoms particularly when involving the verte­ 86 percent of cases. Increases in pulse rates are bral artery (2 cases). The loud machinery murmur much less striking than increases in pressure prior to in the neck is very annoying for the patient and the onset of pain. makes operative treatment necessary. Relief of pain, whether spontaneous or with nitro­ 4. Hematomata under the biceps tendon after glycerine, is associated with falling systemic and pul­ puncture of the brachial artery (3 cases) should be monary artery pressures. In more than half the cases removed to relieve flexion contracture of the elbow. the pressures had returned to within 10 rom. Hg of Retroperitoneal hematoma (1 case) may be massive control levels at the time pain was relieved. and cause shock by perforation of the posterior wall The changes in pressure resemble those occurring of the external iliac artery just above the inguinal with exertional angina, or exertion without pain in ligament. patients with coronary disease. Pulse rates are uni­ than with sponta­ formly higher with exertional pain CAVOGRAPHY FOLLOWING PLICATION neous pain. OF THE INFERIOR VENA CAVA The success of treatment with digitalis and/ or chlorothiazides suggests that heart failure plays a !. V. Blazek MD, R. L. Clark MD, and C. S. Her­ part in the pathogenesis of spontaneous anginal ron MD, (From the Johns Hopkins Hospital, Balti­ pain. more, Maryland.) Amer I Roentgen 98: 888-897, December 1966.

SURGICAL MANAGEMENT OF The authors refer to three general groups of sur­ COMPLICATIONS gical procedures currently employed to compartmen­ TO ARTERIAL PUNCTURE talize the vena cava: plication with mattress sutures, or by external clipping. These S. E. Bergentz MD, L. 0. Hansson MD, and B. with metal staples, to reduce the lumen of the inferior Norbiick MD, (From the Department of Surgery /, were all designed to multiple small channels to entrap cir­ Sahlgrenska sjukhuset, University of Goteborg, vena cava 2-3 rom in size and thus Goteborg, Sweden.) Ann Surg 164: 1021-1026, De- culatory emboli larger than yet avoid the cember /966. prevent massive and fatal embolism, postoperative sequellae which have been ascribed to The authors warn that arterial puncture (with or ligation. They report 22 patients in whom 28 vena without catheterization) is not without hazards al­ cavographies were performed after plication during though they agree that it has become an important the past five years. In 12 of the patients, the plica­ diagnostic step. They describe complications which tion site was patent and in 10 ·there was complete developed in 38 patients following percutaneous ar­ thrombosis following the surgical procedure. Evi­ terial punctures during the past five years. All need- dence of pulmonary embolization was present in

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LEITER 15 seven including one of fatal pulmonary embolus. Li­ in x-ray examinations were examined thoroughly be­ gation of the vena cava of the latter had been done fore the whole stomach was examined systemat­ following recurrent embolization after plication. In ically. There were 381 negative examinations. Be­ the other six of the patients with evidence of pulmo­ nign ulcer was diagnosed in 262 patients, gastritis in nary embolization postoperatively, there was pa­ 225, gastroenterostomies (for possible marginal ul­ tency of the plication and in two, there was sugges­ ceration) in 109 and carcinoma in seventy-nine. Hy­ tion of partial or complete breakdown of the perrugosity was noted in 52, polyps in 42, malignant plication site. ulcers in 29, marginal ulcers in 13 and there were Authors conclusion: "Plication of the vena cava 42 unsatisfactory examinations. Ninety-seven per­ does not appear to be the final solution as regards cent diagnostic accuracy is quoted in the report but the problem of pulmonary embolization." the authors believe that 90-95 percent is probably closer to correct since the diagnosis on examination with this instrument was in DIAGNOSTIC THORACOSCOPY doubt in 44 patients. They compare their accuracy figures with those of H. B. Hatch Jr. MD and P. T. DeCamp MD, the roentgenologists and the gastrofibroscopists have (From the Section on Chest Diseases and the De­ the edge. However, throughout the report, they em­ partment of Surgery, Ochsner Clinic, New Orleans, phasize the importance of radiology and endoscopy Louisiana.) Surg Clin N Amer 48: 1405-1410, De- as complementary examinations since their com­ cember 1966. bined accuracy is greater than that of either alone. Relative merits of fibroscopic versus gastroscopic This is a report of diagnostic thoracoscopy in 50 examination are discussed and the opinion is that consecutive cases of pleural effusion. The correct the former is better for several reasons the most im­ diagnosis was established in all. Diagnoses had not portant being absence of regularly occurring blind been made by other studies. There were no deaths areas, ease of passage, ready acceptance as an out­ and no serious morbidity followed the procedure. patient or office procedure, greater comfort to the The diagnoses established were: Neoplasm, 28 patient, ease of photography. Several more are list­ (Primary, 6; Metastatic, 22); inflammatory disease, ed. 17; Miscellaneous, 5 (Spontaneous pneumothorax, As a major complication, perforation occurred 2; Congestive heart failure, 2; trauma, 1). The au­ but in only three of 1,514 examinations (0.19 per­ thors describe the instrument and their technique in cent). Minor complications were bleeding of varying detail and they recommend that it be used more degrees (blood transfusion needed in one patient) commonly for diagnosis in cases of pleural disease and some with effusion. due primarily to the scope's flexibility, the instrument curling back on itself and the tip becom­ ing trapped in a hernial sac. It was extracted suc­ EXPERIENCE WITH 1,000 cessfully with the aid of external pressure under FIBERGASTROSCOPIC fluoroscopic guidance. EXAMINATIONS OF THE STOMACH N. N. Cohen MD, R. W. Hughes Jr. MD and H. E. CHRONIC INTESTINAL ISCHEMIA: A Manfredo MD, (From the Gastrointestinal Section COMPLICATION OF SURGERY OF THE of the Medical Clinic of the Hospital of the Univer­ ABDOMINAL AORTA sity of Pennsylvania, Philadelphia, Pennsylvania.) Amer J Dig Dis II: 943-949, December I966. C. Rob MD and M. Snyder MD, (From the Univer­ sity of R ochester School of Medicine.) Surgery 60: This is a report of fibergastroscopic examinations 1 141-I145, December I966. of 1,000 patients examined in 15 hospitals in the Philadelphia area from August 1961 to February The authors describe three patients who demon­ 1965. Actually this number was selected from the strate the interdependence of the celiac, superior first 1 ,200 patients examined solely on the basis of mesenteric, and inferior mesenteric arterial circula­ available records (unsatisfactory examinations were tions when pre-existing chronic arterial accusive dis­ not included in the calculations of reliability of diag­ ease had produced a satisfactory collateral ciFcula­ nosis). The method of examination differed from tion. In all, the loss of the inferior mesenteric artery the classic approach in that questionable areas noted as a source of collateral blood supply when it was

16 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 ligated during aortic resection resulted in chronic in­ They stress that ligation of any one of these three testinal ischemia and symptoms of visceral angina. arteries should be attempted only after adequacy of Continued atherosclerotic obliteration of the remain­ flow in the other two has been verified and that, ing celiac and superior mesenteric arteries so ex­ when indicated at the time of aortic resection, the cluded the patients' ability to form an effective col­ reconstitution of the mesenteric arterial flow by the lateral blood flow that gradual intensification of the insertion of a bypass prosthesis avoids the possible patients' symptoms from intestinal ischemia forced postoperative complications of chronic intestinal reoperation. ischemia.

AWARDS AND HONORS SECTION

SILVER STAR Hannahan, Dennis M., HN, USN Harrington, Robert P., HN, USN Bjishkian, Mark E. S. , HM3, USNR Gillespie, Martin L. Jr., HM3, USN LETTER OF COMMENDATION Greer, Gerald M. , HM3, USN Infkin, John C., LT, DC, USN (Civic Action) Leitner, Leny L., HM3, USN VIETNAMESE MEDAL OF HONOR Lewandowski, Michael J., HM2, USN Mayton, James A., HM1, USN Pojeky, Ruth M., CDR, NC, USN Mullen, Thomas A., HM3, USN McKay, Bernadette A., LCDR, NC, USN Scearse, Roger D., HM3, USN NAVY COMMENDATION MEDAL J. Jr., HM3, USN Szal, Anthony Aurelius, George M. Jr., HM3, USN (Also USN Wiggins, Delmar J., HM3, Bronze Star-U.S. Navy Medical News Letter Williamson, Michael L., HN, USN 48(9), 4 November 1966.) Drake, David L. Jr., HN, USN BRONZE STAR Dunham, Chester, J., LCDR, MSC, USN Allen, Alvin Y. Jr., HN, USN Gillespie, Martin L. Jr., HM3, USN Barabe, William D., HM3, USN Gordon, John J., CDR, MC, USN Cessna, Ralph H., HN, USN Roberts, James G., HMl, USN DeMarais, Richard D., HM3, USN Sampson, Donald E., LT, MC, USN Gluechstein, William R., HN, USN Scott, Richard B., LT, DC, USN (Civic Action) Graham, Curtis G., L T, MC, USN Shaffer, Carl R., HM2. USN

DENTAL SECTION

IMMEDIATE DENTURE SERVICE DESIGNED 2. Immediate dentures s hould be planned and TO PRESERVE ORAL STRUCTURES fabricated before any teeth are extracted. 3. The best time to start preserving the oral R. W. Bruce, J Pros Den 16(5): 811-821, Sep­ tember-October 1966. structures is at the time of extractions before oral collapse and ridge loss has occurred. The article outlines a technique for producing 4. Most patients do not require any removal of immediate dentures based upon the following princi­ bone or soft tissue at the time of delivery. Accepting ples: nature's contour of the remaining ridge simplifies the Diagnostic teamwork by the patient, prostho­ denture fabrication and ultimately cuts down on sur­ dontist, and the oral surgeon is very necessary in gical and postoperative problems. order to select only those patients adaptable to the immediate dentures. 5. Some undercut ridges may be improved at

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 17 time of denture delivery by ridge recontour proce­ The surgeon is asked to try to extract the teeth dures. without removal of bone or soft tissue. This may 6. Postoperative treatment must maintain the require sectioning of multirooted teeth. No sutures dentures firmly in place with good occlusion in order are used. to provide stimulation necessary for ridge mainte­ If the oral surgeon is expected to recontour an nance. undercut ridge, a plaster cast is prepared outlining The procedures necessary to accomplish the de­ the area to be recontoured to fit the previously pre­ sired results must begin with an accurate impression pared denture. Detailed instruction for preparation which includes the border supporting areas that of the dentures for recontour is given in the article. show least change following extraction of the teeth. The usual The resulting casts are mounted on an adjustable routine for a sectioned denture is to cut articulator using a facebow transfer and interocclu­ out a section of the denture leaving a hole for the sal records. Centric relation is carefully recorded to remaining natural teeth to fit through. The borders avoid using an acquired eccentric position often of the dentures are not disturbed and the removed found in partially collapsed mouth of immediate section is added with self-polymerizing acrylic (over denture patients. a matrix) when the remaining teeth are extracted. The stone teeth are cut from the casts without Soft liner (such as Hydrocast and Coe Soft) is changing the ridge contour. The artificial teeth are used as soon as needed to maintain a close fit on the arranged to give the esthetic effect that the patient's dentures. teeth had but with emphasis on balanced occlusion. After all teeth have been removed and healing is The dentures are processed in acrylic and re­ complete, the dentures are relined, rebased or re­ mounted to the original articulator mountings for made as found necessary by the prosthodontist. occlusal corrections. The instructions to the patient as The completed dentures are then delivered by the to his need for home care oral surgeon. Complete extraction of all remaining and check-ups by !lis dentist should in­ teeth under hospital conditions allows delivery of sure the maintenance of the maximum denture sup­ the complete dentures. The dentures can also be sec­ port and the least oral collapse possible for each tioned for delivery on an outpatient basis as a few person treated. teeth are extracted per office visit. (Abstracted by: CAPT R. W. Bruce DC USN.)

PERSONNEL AND PROFESSIONAL NOTES

PERSONNEL LOSSES AT EXPIRATION numbers of dental technicians; however, formal OF ENLISTMENT schooling cannot and is not expected to provide the operational experience Historically, one of the greatest problems facing and competence which can only be gained us is the Joss of personnel at the expiration of their at the operational level. Until this first enlistment. added experience is gained, the loss of the fully trained man will These are people that are trained to provide the be evident in the loss of effective­ ness. caliber of assistance needed to accomplish the mis­ sion of the Dental Corps. This is especially true Now these questions arise. What responsibilities since we are currently engaged in a broad program do I, as a dental officer, have in this respect? Isn't to provide preventive and periodontic treatment to someone at all commands assigned as the re-enlist­ all members of the Navy and Marine Corps. Severe ment officer and/or petty officer? Isn't this the re­ losses are occurring in the DT3 and DT2 areas, and sponsibility of the command? The answer to the last it is significant to note that these are the persons two questions is yes; however, the responsibility employed in the heartland of the program. T.hey evolves to each member of a command to aid and provide the major portion of the prophylaxis and assist in any way that he can. In this respect our stannous fluoride treatments so essential to success­ association is unique in that by the nature of our ful progress of the program. duties we are directly assisted by a small number of It is true that to some extent these losses of personnel. This is usually one assistant who spends trained personnel are replaced by training additional most of his day at our side. If, during the normal

18 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 ·the same pay course of the days operations, conversation can be et immediately. If he has over four at ,398.00. directed toward the technician's future plans and the grade, the amount increases to $1 from the insur­ possibility of continuing in a naval career beyond his To approach these young people to get- across. How­ first enlistment, a larger percentage may decide to ance angle is a difficult concept on remain in the Navy. In the end such a move will ever, it is one that might be worth expounding his twenty benefit not only the individual but the Navy-the for a few moments. The CPO who does at age 38, latter by reducing cost and loss of effectiveness coin­ years and transfers to the Fleet Reserve tables). cident with the never ending training process. will probably live to age 72 (latest actuarial refore be paid $233.30 each month for Many factors contribute to the loss of personnel He will the of his life. Based on an expected life and not all of them are readily solvable at any level; the remainder 72 years, returns to him will amount to nearly however, many misconceptions may be corrected by of It might be added that this is a substantial explaining the reasons and background for hard-to­ $100,000. for twenty years service. understand bureaucratic decisions and policies. In return at this $1 00,000 in another way (equity the area of explanation and counseling, we, as indi­ Looking this figures out to $5,000 per year viduals, can accomplish the best work. Face to face viewpoint), each year served. The young man who does talks are always better than statements written by for or four years and gets out, loses equity of those far removed from the sailor and his problem. three $15,000 and $20,000 respectively. His loss in equity In discussing the advantages of a career in the is actually greater than his annual base pay. Navy, time is well spent if you are able to express a The amounts quoted here are based on pay tables couple of dollar and cents examples with your tech­ today, twenty years service, and CPO pay grade. nician. Higher pay, additional years of service, and higher first eli­ At the young age, when these people are pay grades will make the examples significantly gible for re-enlistment, twenty years into the future greater in monetary rewards. is a segment of time they are unable to comprehend. These are some of the "money" examples that Therefore, the discussion must be kept in the con­ you might use to impress on the youngster the im­ text of now-not tomorrow. portance of weighing all the factors in making up his If he is a DT3 with three plus years of service, mind to re-enlist or to get out. bring to his attention that if he were to re-enlist for In these days of personnel shortages, we must all of trained six years that a $1 ,296.00 re-enlistment bonus plus devote maximum effort toward retention payment for unused leave would appear in his pock- personnel.

PREVENTIVE MEDICINE SECTION Health Organiza­ NEW PUBLIC HEALTH SERVICE cordance with Article 99, World Entries for VACCINATION tion International Sanitary Regulations. be authen­ CERTIFICATE PHS 731 smallpox, cholera, and yellow fever must ticated by the actual signature of the medical officer. 18th World At its meeting in May 1965, the PHS Form 731 (International Certificates of Vac­ of Health Assembly adopted the recommendation cination, yellow) ordinarily need not be prepared Quarantine to the Committee on International for military personnel traveling abroad unless travel­ of Vaccination amend the International Certificate ing on passport. In the event that a requirement for to indicate the or Revaccination against smallpox the use of this form for travel to or through a vaccine. The origin and batch number of smallpox specific area becomes evident, this information will on 1 January new certificate will come into force be disseminated appropriately. 1967. For nonmilitary personnel traveling abroad, The Department of Defense Immunization completion of the new PHS Forrri 731 will be ac­ Certificate (DO Form 737 white), when properly complished as described below and further elaborat­ completed and authenticated, serves as a valid ed by BUMED Instruction 6230 series. certificate of immunization for military personnel for travel, smallpox vac- international travel and quarantine purposes in ac- To be valid for international 19 10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER cinations performed after I January 1967, will have Recommendations for Smallpox Vaccination to be recorded on the new certificate in PHS 731 , f nternational Certificates of Vaccination, revised 1. Time of Vaccination. Schedules of vaccination 9! 66. Any previous issues of this form may not be appear in the triservice directive, "Immunization Re­ used and all stock on hand should be destroyed. quirement and Procedures", AR 40-562/BUMED­ Smallpox vaccination certificates issued prior to 1 INST 6230. ID/AFR 161.13. January 1967, shall continue to be valid for the pe­ 2. Site of Vaccination. On the skin over the in­ riod for which it was previously valid. sertion of the deltoid or on the posterior aspect of To be valid for international travel the certificate the arm over the triceps muscle. must be completed by the physician in detail, in­ 3. Methods of Vaccination. cluding his written signature. The origin and batch a. Multiple Pressure: Vaccine is placed on the number of the smallpox vaccine shall be entered in skin and a series of pressures is made. The site is the space provided. The traveler has the responsi­ left uncovered. bility to have his certificate authenticated by physi­ b. Jet Injection: Specifically manufactured vac­ cian signature and by the Department of Defense cine is inoculated intradermally and the site left un­ Immunization Stamp. covered. Supplies of PHS 731 (9-66) may be obtained c. Other Vaccination Techniques: Any other from appropriate cognizance Symbol "I," Forms devices which assure takes. and Publications supply distribution points in the 4. Interpretation of Responses. The site should Navy Supply System citing stock number 0108-400- be inspected 6 to 8 days after vaccination. 0703.-PrevMedDiv, BuMed. 5. Types of Response. a. Primary Vaccination. A typical Jennerian SMALLPOX VACCINE vessicle should be present. b. Revaccination. Two responses are possible. Morb & Mort Wkly Rpt, USDHEW, CDC, PHS (1) "Major Reaction." A vesicular or pus­ 15(47):404-407, Nov 26, 1966. tular lesion or an area of congestion surrounding a Introduction. Evaluation of the routine vaccina­ central lesion indicates successful revaccination. tion and revaccination of the population against (2) "Equivocal Reaction." Any other reac­ smallpox must continue. tion suggests revaccination should be repeated. The Risk of Introducing Smallpox. Present quar­ 6. Types of Vaccines. Both forms afford ade­ antine practices offer, at best, only partial protection quate protection. The glycerinated form requires against the introduction of smallpox. The increased constant refrigeration and is subject to improper travel by U.S. nationals increases the probability of storage. The lyophilized vaccine is much more stable introduction from endemic areas of Asia, Africa, and is only vulnerable after reconstitution. and South America. The potential spread of the dis­ 7. Contraindications to Vaccination. ease is enhanced by a lack of clinical experience a. If vaccination is necessary for an individual leading to a delay in diagnosis. with dermatitis, vaccinia immune globulin should be Risk and Efficacy of Vaccination. Data indicate administered at the same time as the vaccine. that there is a risk of complications resulting from b. Pregnant women should receive vaccinia im­ vaccination. One hundred and twenty-nine serious mune globulin simultaneously with the vaccine, par­ complications developed. From the 14 million vac­ ticularly if the woman is a primary inoculee. cinations in 1963, practically all among primary c. If vaccination of patients with leukemia vaccinees. The greatest rate was among those under lymphoma, reticuloendothelial malignancies or dys~ 1 year of age. Further investigation suggested that gammaglobulinemia, or those under therapy with the complication rate would be higher if adulthood immuno-suppressive drugs or receiving ionizing ra­ was reached before the primary vaccination. The diation is absolutely essential, vaccinia immune glo­ vaccine confers a high level of protection for 3 or bulin should be administered. more years with gradual waning of protection. 8. Vaccinia Immune Globulin (V/G). Other Prophylactic Agents. Vaccinia immune glo­ a. Prophylaxis. 0.3 ml/kg by intramuscular bulin and various antiviral compounds cannot re­ route. place vaccines since they are useless unless intro­ b. Treatment. 0.6 ml/kg by the intramuscular duced shortly after exposure and confer protection route. for only a few weeks. ( 1) In eczema vaccinatum, vaccinia necro-

20 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 g, and he may sum, or auto-inoculation vaccinia of the eye, VIG hurts, he has difficulty in swallowin may be effective. drool. (2) VIG may be helpful in treatment of se­ Diagnosis can easily be made by exammmg the vere cases of generalized vaccinia. child's throat; epiglottitis looks like a bright red (3) VIG is of NO VALUE for postvaccinal cherry obstructing the pharynx. When examined, the encephalitis. child will probably be sitting and leaning forward. you make 9. Thiosemicarbazones. Derivatives of thiosemi­ Better examine him in this position; if completely carbazones show protective effect against smallpox him lie down, his swollen epiglottis can rt suffocat­ and therapeutic effect for individuals with severe cover the laryngeal opening and may sta his tongue vaccinal complications. ing him. Be careful, too, about depressing for a better view of the epiglottis. It's not always necessary; an inflamed epiglottis usually can easily WORRY: CROUP COLD-WEATHER be seen. Vigorous attempts to depress the tongue By Sherwin V. Kevy MD, Consultant 6(10): 20-23, can cause sudden respiratory arrest. November-December 1966. Children with acute epiglottitis should be hospi­ talized so that if a tracheotomy becomes necessary, During these breath-freezing days, a more alarm­ it may be done right away. In this hospital, over the ing effect of cold weather on breathing can be ex­ last 20 years, 34 of the 71 children brought in with pected-croup in children. This acute inflammation acute epiglottitis needed immediate tracheotomy. In of the laryngotracheal area produces a characteristic 5 of these 34, tracheotomy had been delayed too barking cough, inspiratory stridor, sternal retraction long and they were dead on arrival at the hospital. and respiratory distress. It can proceed to complete Indications for tracheotomy in this condition are the respiratory obstruction in such short time that one same .as they are in any disease producing mechani­ must be sure beforehand of the cause, once deter­ cal respiratory obstruction. Any child who is cyano­ mined. tic or whose breath sounds are markedly decreased Most cases of croup result from an infection in almost certainly needs immediate tracheotomy. on a the larynx and trachea. Some result from other After tracheotomy, the child should be kept causes. All the possibilities have been listed in the cool atmosphere with high humidity. If crusts begin accompanying table. The author started with diph­ to form in the trachea, instill physiologic saline solu­ theria or "true croup." Luckily, because so many tion periodically into the tracheal cannula. children are immunized against it, rarely is diphthe­ At this hospital, acute epiglottitis is treated initial­ ria seen in this country. It should be suspected in ly with intramuscular chloramphenicol and penicil­ any child whose croup began slowly and progressed lin . However, during the past 2 years, ampicillin has slowly for 2 or 3 days before he developed severe been used instead of chloramphenicol whenever pos­ dyspnea, and membranous pharyngitis, laryngitis, or sible. The selection of the antibiotic depends, of tracheitis. An almost identical membrane formation course, on which microorganism is causing the can occur in severe infectious mononucleosis, so this croup. Ampicillin, effective against both gram-posi­ disorder must be ruled out in doubtful cases. tive and gram-negative microorganisms, is a good Unfortunately, another form of bacterial croup is starting drug. Continue it if H. influenzae is causing or a not so rare as diphtheria in this country. That is the croup. However, if it is a streptococcus If it is a staphy­ epiglottitis. In fact, practically every case of bacteri­ pneumococcus, switch to penicillin. synthetic penicillinase­ al croup in children between the ages of 2 and 5 lococcus, select one of the Steroids are not used. years turns out to be epiglottitis. This infection is resistant penicillins. generally believed to be caused by H. influenzae, Viruses Sometimes Implicated Group B. In a study at the Children's Hospital Med­ ts in tissue-culture techniques ical Center in Boston, in about 10% it was caused by Recent improvemen prove definitely that certain viruses can beta-hemolytic streptococci, and in 3%, pneumo­ have helped the influenza virus, hemadsorption coccus. Regardless of the organism, epiglottitis be­ cause croup: and the adenoviruses. Viral croup com­ gins abruptly and progresses rapidly-sometimes in virus type 2, in children between the ages of 3 as little as 9 hours-to severe respiratory obstruc­ monly occurs and 3 years. Unlike bacterial croup, viral tion because of the swollen, "cherry red" epiglottis. months ly preceded by an upper respiratory The child becomes increasingly restless, his throat croup is usual 21 10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER infection lasting 2 or 3 days. Viral croup does not bathroom into a steam room; the mother can hold progress with the rapidity of bacterial croup. The the child comfortably on her lap. physical examination in viral croup will show laryn­ Do not sedate the child unless absolutely neces­ gitis, tracheitis, or even laryngotracheobronchitis. sary. It seldom is. Do not give him atropine because Usually, the white blood cell count is normal or only it tends to thicken secretions, thus adding to the ob­ slightly elevated. The child may become restless and struction. apprehensive if the respiratory obstruction persists Do not give steroids. Although some laryngolo­ or becomes severe. It is stressed that respiratory ob­ gists advocate them, no advantage has been found, struction so severe as to require tracheotomy is not at all, in using prednisone or dexamethasone instead unusual in viral croup, especially if laryngotracheo­ of chloramphenicol. The only proved value reported bronchitis is present. Because of this it is recom­ is for allergic children treated with chloramphenicol mended that an otolaryngologist help you determine and prednisone; this steroid shortens duration of the extent of the inflammation. symptoms more readily than chloramphenicol alone Another form of croup that should be considered does. In nonallergic children with croup, the use of with viral croup is spasmodic croup or "false prednisone makes no difference. Dexamethasone has croup." It used to be thought of as an allergic reac­ been tried for allergic children in a dose of 1 milli­ tion. More recent evidence, however, indicates the gram per I 0 pounds of body weight-with only cause to be inflammation, an inflammation so mild, moderate success. though, as to be completely overshadowed by the What about syrup of ipecac? Well, this is even respiratory distress. Increasing evidence shows that more controversial than the use of steroids. Syrup of the laryngeal spasm may be triggered by and asso­ ipecac's relaxing effect upon the larynx presumably ciated with a viral respiratory infection. results f1 om vagal action, and, its full therapeutic Spasmodic croup is common in children between effect is not achieved without vomiting. Because of the ages of 6 months and 3 years. Usually it occurs this, syrup of ipecac is rarely given for croup in hos­ at night while the child is asleep and usually it will pitals. If you do give it, be sure the child is closely clear up by morning, though it may recur on one or watched for at least an hour afterwards to guard two following nights. against possible aspiration of vomitus. Let For viral croup, do not prescribe antibiotics un­ it be stressed again: Closely watch every child with croup for less it worsens and secondary infection· occurs. Care­ signs of increasing respiratory dis­ tress. Do not wait ful observation is a most important part of the treat­ too long before advising or doing ment. tracheotomy. Sometimes, in a tiring, restless child, early tracheotomy can prove the best conservative Managing the Child with Croup management. The author mentions some of the things that are Careful observation is important in all three not known about croup yet, some of the intriguing forms of croup. Until you know exactly which form questions that still need answers. Why, for instance, of croup you are dealing with, assume it is bacterial. does croup affect boys so much more often than If the disease is not progressing rapidly and respira­ girls? It's usually about 2~ to 1, and in croup asso­ tory obstruction is not severe, and if the parents are ciated with hemadsorption virus type 2, it's about 12 capable of intelligent observation and reporting, let to 1. Why are so many children who develop croup the child stay home. However, if the disease con­ obese? At our hospital, about 40% are. Why does tinues to worsen and the child looks as though he croup recur? Why will a child with acute epiglottitis may need tracheotomy, hospitalize him. either have had viral croup before, or will suffer it But whether at home or at the hospital, the child later on? Why, with a certain virus, will one child will probably be extremely apprehensive, so permit develop croup and another child only a mild respira­ only truly necessary procedures. tory infection? Is there a virus that causes only First of all, place the child in an environment of croup? high humidity. In the hospital, this can be done by Croup can best be managed by insisting on the surrounding the child with cool mist and giving him following essentials: moistened oxygen when necessary. By the way, the - high humidity practice of adding detergents to the oxygen is not -constant watchfulness useful at all. At home, steam may be used. Turning -antibiotics (in bacterial croup) the hot shower on full force will easily convert the -when necessary, tracheotomy in time.

22 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 Causes of Croup to Consider in width and adult brown spiders about 8 to 10 mm. Sub-species of Latrodectus mactans may be Bacterial found throughout the continental United States. -Diphtheria Latrodectus bishopi (the red-legged widow) is -Epiglottitis found principally in the southeastem United States Viral including Florida, and Latrodectus geometricus -CA virus, influenza virus, hemadsorption (the gray widow) is found in Florida and south­ virus type 2 ern California. Species of Loxosceles are also widely -Adenoviruses, CCA virus distributed. Loxosceles arizonica is indigenous to Spasmodic New Mexico, Arizona and western Texas, Loxos­ -Indirect, because of infection celes divia to southern Texas, Loxosceles reclusa to Mechanical southeastern and central United States, and Loxos­ -Secondary to intubation for anesthesia celes unicolor to areas of the western United States, -Foreign body from New Mexico and Utah to California. -Tumor The habits of Latrodectus and Loxosceles spiders Allergic are remarkably alike. They prefer dark, quiet, well­ -Angioneurotic edema sheltered places, although Latrodectus bishopi often builds its irregular webs 3 to 4 feet above the ARACHNIDISM ground, from palmetto to palmetto. Black widow spiders have been reported to frequent a variety of W. Peter Horen MS, Depart of Med, Univ of Calif habitats ranging from permanent holes and fissures Sch of Med, San Francisco, Calif, Clinical Med in river banks, in piles of bricks, rocks or trash, and 73(8): 41-43, August 1966. in sheds and garages to abandoned birds' nests, Arachnidism is considered a clinical entity be­ shutters, rain spouts, and-especially dangerous to cause of the characteristic symptoms produced by man-outdoor latrines. Brown spiders have been re­ the bite of spiders of the genus Latrodectus, espe­ ported to prefer dry dark areas, such as fruit cellars, cially that of the black widow spider, Latrodectus basements, areas beneath porches and porch furni­ mactans. Loxoscelism (caused by the bite of brown ture, as well as open fields and rocky bluffs, closets, spiders of the genus Loxosceles), previously report­ storerooms and other places close to human habita­ ed only from South America, has recently been ac­ tion. tually or presumptively diagnosed in the United Spiders of both genera spin irregular coarse webs, States. Bites by other species of poisonous spiders and the presence of this type of web is suggestive. have been reportetl in this country, but are of little Other spiders, such as Steotoda, spin similar webs, medical importance. Because arachnidism is caused however, and this criterion for identification should by the bite of both Latrodectus and Loxosceles not be relied on by the laymen. Both kinds of spiders, and the respective syndromes, treatments, spiders are shy and retiring, but the fact that many and prognoses differ considerably, the proposal is victims of the black widow spider were bitten in out­ made that the disease be divided into 2 clinical enti­ door latrines suggests that this spider is somewhat loxosce­ ties, latrodectism and loxoscelism. aggressive. In contrast, only 1 patient with A total of 615 cases of poisonous spider bites, lism was bitten in a privy, and in 75% of the re­ with 38 deaths, were reported in 18 states of the ported cases, the spider was found in the victim's United States up to the early 1940s. A recent review bed or clothing. in the of 460 fatalities caused by venomous animals Some Properties of Selected 1950 United States during the 10-year period from Spider Venoms through 1959 indicates that 65 (14%) of these were caused by poisonous spiders. The venoms of Latrodectus and Loxosceles spiders differ considerably in their effects on human Spiders and Their Habits victims. The black widow and other Latrodectus Lat. Rqdectus mactans is metallic black, usually venoms are predominantly neurotoxic; their effect with a reddish "hourglass" on the ventral aspect of appears to be mainly on the spinal cord. Liver ne­ the abdomen. Loxosceles reclusa is tan-brown, of crosis has occurred following injection of Latrodec­ unremarkable appearance. With legs outspread, adult tus mactans venom into rats, and one investigator black widow females measure about 11 to 12 mm. recently reported liver involvement in man following

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 23 the bite of the black widow. Experiments on the spasms, erratic acute pain involving the abdomen, venom of a common European species of Latrodec­ chest, back, arms and legs, and dyspnea, vomiting, tus have shown that it is capable of causing general­ nausea, insomnia, restlessness, delirium and pria­ ized injury to the liver, kidneys, spleen, lymph pism. Fever and a rapid weak pulse have also been nodes, thymus and adrenals by parenchymatous ne­ reported, and in I case hemiplegia has occurred. crosis of blood vessels and epithelial cells, as well as Symptoms from the bite of Latrodectus bishopi have affecting nervous and lymphoid tissues. A vasocon­ been reported for a single case occurring in Florida. strictor effect of this venom acting directly on the An adult male, bitten on the upper left arm, devel­ walls of blood vessels, especially those of the vis­ oped within 3 'h hours a round red eruption about cera, has been demonstrated experimentally in dogs. the size of a dime at the site of the bite wound, a The venoms of the Loxosceles species found in sharp burning sensation in the shoulder area, and a South America and in the United States have a cyto­ sensation of tightness in the chest. Speech difficulties toxic effect, although systemic effects often occur developed 4 hours after the bite. His temperature concurrently. Experimenta l study of the effects of was subnormal. Other symptoms resembled those of Loxosceles laeta venom on rabbits and dogs demon­ a typical mild case of latrodectism. strates a temporary increase in the erythrocyte sedi­ mentation rate shortly after the venom is inoculated; Loxoscelism marked leukopenia follows rapidly, and symptoms The bite of spiders of the genus Loxosceles feels of shock develop. These effects are attributed to a somewhat like a mild honeybee or ant sting, progressive release of histamine, instead of a direct but usually severe pain develops gradually action of the venom on the victim. Postmortem at the site of the examination reveals congestive hemorrhagic lesions, bite over an 8 to 10-hour period. Necrosis devel­ especially in the liver and kidneys, and a generalized ops typically with a central shoughing area that ul­ vasodilatation in all animals. This is noteworthy be­ cerates deeply, sometimes exposing the muscle cause of the extensive damage to the kidneys found planes. Healing progresses slowly over an 8 to 10- in a fatal case of loxoscelism in Argentina and the week period by means of granulation and scarring. considerable renal damage occurring in a nonfatal Systemic manifestations may include general mal­ case in the United States. Jaundice associated with aise, chills, fever (over I 04 degrees F.), fine morbil­ loxoscelism has often been reported, particularly in liform rash, hemolysis, hemoglobinuria, toxic neph­ the foreign literature. rosis, toxic hematosis, lymphoid hyperplasia, acute The toxicity of Latrodectus mactans venom shows laryngeal edema, asphyxiation, cyanosis, joint pains, seasonal variations. In one study, venom collected in headache, nausea, restlessness, and convulsions. One July caused greater mortality when injected into rats fatal case of presumed loxoscelism recently has been than that collected in October. In another study, reported from Oklahoma. venom collected in November was more toxic to Treatment mice than that obtained in April and May. The ap­ parent discrepancy probably occurred because of to­ A spider bite can be treated specifically through pographic and geographic variations. Venoms in the use of the correct antivenin or nonspecifically by first study came from spiders found in different lo­ means of symptomatic medication. Specific therapy calities and altitudes; those in the second came from of latrodectism consists of administration of black spiders found in the same area. widow spider antivenin (Antivenin (Latrodectus mactans), Lyovac®, Merck Sharp & Dohme, West Signs and Symptoms Point, Pennsylvania). It should Latrodectism always be given in cases involving children, elderly persons, and adults There is little or no local pain when a spider who show evidence of severe systemic poisoning or bites, although swelling and discoloration of the skin who have a history of hypertension. It should be at the site of the bite may occur. Necrosis and other emphasized that regardless of the victim's age or serious local effects are absent unless secondary in­ size, a f ull dose of the antivenin must be given. fection occurs. Common systemic manifestations are Spiders do not make allowances for a person's size severe pain, usually beginning 30 to 60 minutes when they bite. The antivenin is prepared from after the bite, development of a rigid abdomen, and horse serum; therefore the patient's sensitivity to perspiration. Other symptoms include muscle horse serum must be determined before it is used.

24 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 Nonspecific treatment of latrodectism depends South America, neostigmine has been successfully primarly on the use of cardiotonics and muscle re­ used to treat latrodectism. laxants, including hydrotherapy, as well as occasion­ Specific therapy for loxoscelism is not readily al use of general stimulants to relieve depression and available in the United States because the antivenin hypotension. Use of cortisone acetate, corticotropin, is manufactured in South America, and probably the and other steroids is of unproven value, and 10% demand for it is insufficient. Nonspecific therapy is calcium gluconate given intravenously is considered primarily based on prompt use of antihistamines to be of value only for temporary symptomatic re­ (i.e., hydroxyzine hydrochloride) and antibacterial lief. Recently, methocarbamol has been recommend­ medication. ed over calcium gluconate as a muscle relaxant, to Spider venom apparently is quickly absorbed and be given as follows: 10 mi. of injectable preparation necrosis rarely occurs after the bite of a spider of given intravenously over a 5-minute period, followed the Latrodectus species. Consequently, local over­ by infusion of 10 mi. in 250 mi. of 5% glucose and treatment with corrosive chemicals is to be avoided. water at a rate of 20 drops per minute. This should Because spiders often reside in dirty places, and be followed by 4 oral doses (800 mg. each) of the their mouthparts may be contaminated with pyogen­ drug every 6 hours for 24 hours. This medication ic or anaerobic spore-forming bacteria, topical anti­ has been reported to relieve muscle spasms and bacterial agents may be employed to prevent infec­ pain, headache, nausea and respiratory distress. In tion of the bite wound.

KNOW YOUR WORLD

DID YOU KNOW? duce people to fall for fakes and swindlers in the h ea l~h field? has been declared free of smallpox That Sarawak The Food and Drug Administration will conduct as of 5 December 1966? a nationwide s tudy in collaboration with other na­ The only case observed in Sibu was hospitalized tional and medical agencies for the protection of the on I 6 October 1966. Probable source of infection public against health frauds and quackery.4 was Kuching where 4 cases, with 1 death, had been reported from 26 September to 2 October 1966.' That Pennsylvania ranked first in the nation in I 965 in the total dollar value and number of con­ That since the latter p art of November 1966 there tracts awarded for the construction of new sewage has been an unusual increased incidence of influen­ treatment plants? za-like disease in Czechoslovakia? Pennsylvania provides a yearly grant of 2% of This began in eastern Slovakia and is spreading to the total costs for construction of these sewage treat­ the west. There are cases in central Slovakia, on the ment facilities toward the cost of operating the border between Slovakia and Moravia, and in Bohe­ plants.c. mia. All age groups are affected. Two strains have A , probably similar to the been identified as virus 2 That the Annual Report of the World Health Or­ since 1964 but different European strains isolated ganization lists 150 health projects in which the 2 from A ~/ Singapore/ 57. WHO has assisted in 9 countries of Southeast Asia, and 177 fellowships g iven to health workers from for 1965 That approximately 1,260,000 New York resi­ regional countries and a total expenditure dents suffer from arthritis of varying degree? of $4,436,970? These projects include malaria eradication, tuber­ Some 330,000 are limited in activity and 70,000 culosis control, vaccine production, leprosy, small­ are unable to work. This disease accounts for annual pox and cholera control, health laboratory services, loss in work days per year to $52 million. ~ health statistics, public health administration, mater­ nal and child health, nursing, mental health, nutri­ That more than 3,000 persons will be interviewed tion, radiation, environmental health, medical edu­ 6 in an 18-month study to determine factors that in- cation and quality control of drugs.

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 25 That about 7 million persons in the United States cases; the Americas-358,000; Asia-6,475,000; have various degrees of defective hearing and of this Europe-52,000; and Oceania-33,000.u number about 125,000 are totally deaf? This is based on the National Health Survey of That a program for control of Hansen's disease is July 1959 to June 1961. Males are more prone to underway in Texas since 1 October 1966? hearing impairment. 7 The Public Health Service has granted $267,734 for a 3-year survey, which is being administered by That brain tissue begins to die in 4 minutes and the Texas State Health Department. 10 the heart stops beating in 9 minutes if the human body is without oxygen?s REFERENCES I. WHO Wkly Epid Reed 41(49): 634, Dec 9, 1966. 2. WHO Wkly Epid Reed 41 (49): 634, Dec 9, 1966. That there are at present about 10,786,000 cases 3. ~~. York State Dept of Hlth Wkly Bull 19(46): 181, Nov 14, 4. U:.DHEW PHS Public Hlth Rpt 81 ( 12): 1108, Dec 1966. of leprosy in the world? S. USDHEW PHS Public Hlth Rpt 81(12): 1070, Dec 1966. 6. WHO Press Release SEAR 818 of Sept 21, 1966. Those undergoing treatment number 1,928,000 or 7. Metropolitan Life Ins Co Stat Bull 47: 3-S, Sept 1966. 8. Science News 90(1): 14, July 2, 1966. 18 % of the estimated total. Africa has 3,868,000 9. WHO Chronicle 20(11): 417-418, Nov 1966. 10. USDHEW PHS Public Hlth Rpt 81(11) : 1008, Nov 1966.

EDITOR'S SECTION

AMERICAN BOARD OF OB-GYN (I) estimated number of attendees at least 2 All candidates having previously passed the Part I weeks prior to team visit, (written) examination of this Board and have been (2) a briefing space (certified by the command­ in practice for at least eighteen months in their cur­ ing officer to meet security regulations), rent locality, may apply in January or February, (3) certification of security clearance and need­ 1967 to take the Part II examination November to-know of all attendees prior to first lecture, 6-10, 1967. Those applications postmarked after (4) positive access control (access badges and February 28th will not be acted upon in 1967. badge racks are provided by team), Application forms and Bulletins may be obtained (5) classified stowage space of 3 cubic feet with by writing to the office of the Secretary, Clyde L. access available to team security officer on day of Randall, M.D., 100 Meadow Road, Buffalo, New arrival, York 14216. Prospective candidates are urged tore­ (6) unclassified stowage space of approximately view the current Bulletin of the Board for complete 900 cubic feet in general proximity of briefing space, information as to the requirements and schedule for (7) accounting data for travel and per diem ex­ application. penses for 6 officers, 1 civilian instructor (GS-13) Diplomates and candidates are requested to keep and 1 enlisted individual, the Board office advised of their current address. (8) garage or secure parking space for 1 Navy 2Yz ton van, (9) exercise area 1,000 yards distant from in­ AVAILA-BILITY OF NBC TEACHING TEAM habited buildings and roads in use (1 hour, after­ During the past year the U.S. Naval Medical noon, 4th day) (or gas chamber), School has developed a mobile teaching team in the (I 0) stenographic support for typing names of medical aspects of NBC warfare. The most usual attendees on certificates, presentation consists of a five-day course at the SE­ (l 1) electric power llOV AC (total load of 340 CRET level. Shorter and longer briefings at other amperes). security levels can be arranged. If desired, a formal Funds are made available to the Commanding examination will be given, graded on a 0-100 nu­ Officer, Naval Medical School, for equipment, sup­ merical scale. plies, printing and other support costs of the team. The teaching team is completely self-contained Funds are not furnished CO, N A VMEDSCOL for and is now equipped with its own audio-visual travel and per diem costs since user requests cannot equipment. User activities are required to provide: be accurately forecast. Activities anticipating use of

26 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 in anatomic pathology the team should include team travel and per diem lation of recent information as they apply to funds in budget submissions. (and clinical pathology methods involving all of the various organs and Requests for the team should be submitted well in pathology) body systems. The review includes common pitfalls advance of desired date to the Commanding Officer, in diagnosis, review of unusual cases, statistical data Naval Medical School. Such requests should include as appropriate, review of articles published or to be accounting data in order that travel orders may be by staff members, new advances in histo­ issued.-Public Affairs Office, NNMC, Bethesda, published iques, application of newer histochemical, Md. logic techn bacteriological, biochemical, immunological and (Debut of NBC Teach Team at U.S. Naval toxicological methods in the daily practice of pathol­ of Aviation Medicine, U.S. Naval Aviation School ogy. Medical Center, Pensacola, Florida was described in B. Helwig, Chief of the Department of U.S. Navy Medical News Letter 47(2): 27, 21 Dr. Elson logy, AFIP, and Course Director, says the January 1966-Editor.) Patho Lectures as designed to give the busy practicing pathologist a concise combined period of instruction COMMITTEE IN INJURIES and review of the most recent developments at the advance of publication. This year, three Dr. Charles V. Heck, Secretary of the American Institute in optional programs will be offered includ­ Academy of Orthopedic Surgeons, announced that interesting on endocrine pathology, a seminar on CAPT WilliamS. Stryker MC USN, Chief of Ortho­ ing, a seminar stains as an aid to diagnosis, and a pedic Service at the Naval Hospital, San Diego has selected special veterinary pathology. been nominated for membership in the Committee seminar on in Injuries. It is anticipated that the appointment There is no charge for the course. Applications Armed will be confirmed during the annual meeting of the may be obtained by writing The Director, D.C. Academy in January 1967. Forces Institute of Pathology, Washington, Washington, D.C. The Committee's. primary function is to alert the 20305.-AFIP, doctor, as well as non-medical personnel, on the care of the injured. To accomplish this end the SURGERY AT SEA Committee in Injuries sponsors regional programs for physicians on trauma and strives to improve NOW quality of care of the injured. In addition, it assumes Fleet Aircraft Carrier USS BEN­ responsibility of continuing the program of educat­ The Seventh (CVS-20) played a vital role in sav­ ing the general public concerning accident preven­ NINGTON of a Nationalist Chinese sailor stricken tion. Programs for non-medical personnel, presented ing the life appendix in the South China Sea primarily for ambulance drivers, firemen and police­ with a perforated the night of December 15. men, deal in depth with rescue and survival prob­ of RADM Evan lems as they are related to effective discharge of du­ BENNINGTON, the flagship Warfare ties pertaining to these individuals. P. Aurand, Commander, Antisubmarine ONE (ASWGRU ONE), operating in the Chairman of the Committee in Injuries will be Group China Sea, received the call for help from Dr. Walter Hoyt of Akron, Ohio, and the Secretary South the Republic of China destroyer NAN YANG will be Dr. Charles S. Neer, New York City.-U.S. which was operating with ASWGRU Naval Hospital, San Diego, Calif. 92134. (DD-17), ONE. Admiral Aurand quickly ordered the units of his task group into action. AFIP LECTURES 7th ANNUAL USS EVERSOLE (DD-789) sent a boat to NAN ill sailor, Seaman Pathologists and other physicians interested in YANG to pick up the seriously . Once this specialty are invited to attend the 7th Annual Chiu Hsien-Cheng, 24, of Tainan, Formosa to the de­ Armed Forces Institute of Pathology Lectures to be aboard EVERSOLE, he was carried an SH-3A helicop­ held in the Post Theatre of the Walter Reed Army stroyer's landing platform where L. Hughes, Commanding Medical Center on 20-24 March 1967. Sixty-five ter, piloted by CDR Davis H!;!licopter Anti­ papers will be delivered by the staff of the Institute Officer of BENNINGTON-based picked him up and air­ on the latest developments in pathology. submarine Squadron EIGHT BENNINGTON. The five-day lecture series is a review and campi- lifted him to 27 10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER Navy Hospital Corpsmen were standing by on grenous appendix. The young sailor made a good BENNINGTON's flight deck as the helo bearing recovery and was sent eventually to Perth and was Seaman Chiu touched down. Minutes later, they had thence repatriated.-From: H. G. Dicks MBBS, rushed him to the carrier's sick bay. President, Royal Flying Doctor Service, (W.A.) Waiting in the examining room was Dr. (Lt.) Section, Perth, W.Va. To: VADM R. B. Brown MC Vincent A. Guardione, 28, of Springfield, Mass. USN. (Submitted by: LT J. T. Henderson, Code When Seaman Chiu arrived, Dr. Guardione began 13, BuMed.) his examination. Corpsmen took blood tests and X­ rays, while other Corpsmen prepared the operating room for surgery. ADVANCED COURSE IN NUCLEAR SCIENCE FOR The results of the tests and examinations showed MEDICAL OFFICERS (NSMO) Chiu had a perforated appendix. In a race against Sponsored by the Defense Atomic Support fatal peritonitis, Dr. Guardione quickly and skillfully Agency (DASA) at the University of Rochester, removed the appendix. Less than two hours after Rochester, New York. Chiu had been airlifted aboard, he was lying in BENNINGTON's Sick Bay ward out of danger. Al­ CLASS INCLUSIVE DATES though he couldn't speak any English, Chiu was ob­ #20 June 1967-July 1968 viously very happy at the quick, expert care he re­ DEADLINE DATE SECURITY CLEARANCE ceived-care that had saved his life. TO APPLY REQUIREMENTS THEN I March 1967 TOP SECRET During World War II, I was stationed at Port Mission: It is the mission of the NSMO Course to Hedland, North-West Australia, as a Government provide the opportunity for a limited number of se­ Medical Officer. The Royal Flying Doctor Service lected Army, Navy and Air Force Medical Officers supplied a De Havilland Fox Moth for me to fly. I to acquire the additional technical education needed was the only M.O. to cover about 600 miles of to cope with the radiobiological' problems involved coastline and its hinterland from Broome to Onslow. in all phases of the National nuclear energy pro­ I was attached to the three services as they had no gram. Medical Officers in the area most of the time. Scope: The course provides On an occasion in about 1943, I received a signal for a review of select­ ed portions of mathematics and from Perth Royal Aust. Navy advising that an physics during the refresher phase, followed by a full academic American tanker travelling from the Persian Gulf year of graduate study involving radiological had aboard a case of acute appendicitis. The tanker physics, health physics, biological effects of radiation, had no charts of the Australian coast, only a school­ evaluation of radiation hazards, environmental days atlas; there was a place called COSSACK hygiene and toxi­ cology, and as electives, related areas marked on the atlas. The tanker was heading for of industrial medicine and radiology. Completion of COSSACK and sulfasuxidine was being given to the the academic phase at acceptable patient to reduce the inflammation. performance levels may lead to a Master's Degree in Radiation Biology The signal asked me to give whatever help was in one year for those entering with doctoral degree, necessary in the circumstances. It was about sunset. and upon completion of additional research or special I flew out to sea and found the tanker about 25 studies for those not having previous professional miles out. As I circled it the pompoms followed me training. The academic phase is followed by a around and I hoped they were not (rigger happy. study of practi­ cal military nuclear medicine. During the The port of COSSACK was no longer in use and no course the medical aspects of nuclear radiation over people or facilities existed there. In answer to my the com­ plete range of intensity levels from low-level signal of circling the ship the tanker followed me as peace­ time laboratory situations through high-level I guided it to Point Samson where a launch met it full scale warfare situations are discussed. and took off the sick sailor. From Port Samson he was driven about 15 miles to Roebourne Hospital It is anticipated that this course will be as fol­ where the theatre was ready to receive him. lows: I had received the Admiralty signal late in the PHASE I (9 weeks)-Academic Refresher-Sum­ afternoon when I was 150 miles away at Marble mer School Session, University of Rochester, Bar. About 9:00 p.m. that night I removed a gan- Rochester, New York. 28 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3 J

- PHASE ll (10 months)-Radiation Biology­ medical fields who have had some graduate work School of Medicine and Dentistry, University of beyond the B.S. degree may also be eligible for se­ Rochester, Rochester, New York. lection. PHASE Ill (4 weeksj-Military Nuclear Medi­ Requests should be forwarded in accordance with cine-Field Command, DASA, Sandia Base, Albu­ BUMED INSTRUCTION 1520.10 Series and com­ querque, New Mexico or other appropriate installa­ ply with the deadline date as indicated above. All tions. requests must indicate that a security clearance of Eligibility: The course is primarily designed for TOP SECRET has been granted to the officer re­ officers of the Medical Corps. However, officers of questing attendance, or that action to obtain clear­ the Medical Service Corps, in very closely allied ance has been initiated.- Training Branch, BuMed.

OLD HANDS GATHER

At the combined Graduation, and 25th Anniver­ Hospital Corps Quarterly editorial renown; and sev­ sary of Pearl Harbor Attack Memorial Ceremonies en sons, just graduated from Hospital Corps School, at the Hospital Corps School, San Diego a number representing their fathers who were at Pearl Harbor of old hands who fought there gathered. The excep­ during the attack. tions were L T Ben F. Dixon HC USN (Ret) of

-Official U.S. Navy Photograph Persons present for Memorial Ceremonies at Hospital Corps School, U.S. Naval Hospital, San Diego, California 7 December 1966. Front row: MMC James Stark (USS McFarland) ; PNC Charles R. Bisplinghoff (USS Sumner); LT (HC) Daniel F. Blum (USS St. Louis); LT (HC) Ben F. Dixon (Hospital Corps Historian); RADM H. D. Warden (USS Breese); CDR (MSC) W. W. Wilgrube (USS Solace); CWO Wayne G. Aubrey (NAS Ford Island); CWO Waid Sooter (USS Solace) . Rear Row : CAPT (MSC) Edward F. Haase (USS Houston); CDR (MSC) Joseph P. Duane (USS Pompano); CDR (MSC) R. H. Laedtke (USS Solace); HMC P. H. Palmer (USNH, Pearl Harbor) ; HMCM Wm. R. Frederick (USS Sumner) ; HMCM Trine B. Moorhead (USS Nevada) ; HMCS Frances W. Browning (USS California); CAPT (MC) Hugo Wagner (USS Wright); and CDR (MSC) John Garrett (USS San Francisco). Sons of Pearl Harbor survivors-Names of fathers' duty station during attack in parentheses. Top Row, left to right: HN James B. Johnson (Marine Barracks, P.H.) ; HA John A. Moore Ill (USS West Virginia); HN Stephen W. Stark (USS McFarland); HA James 0. Bridges (Naval Base, P.H.); HA Charles J. Wager (US Army Scofield Barracks); HA Michael N. Nilssen (NAS, Ford Island); HA Frank V. Sunquist (Naval Base, P.H.).-U.S. Naval Hospital Corps School, San Diego, California 92134.

ACKNOWLEDGMENT of the insects with a chemosterilant, 90 females out In the U.S. Navy Medical News Letter 48(11 ): of 100 will be sterilized, and not reproduce, and in 13-15, 2 December 1966 an omission occurred on addition the 10 females that escaped treatment will page 15 in the first column, line 3. The sentence be subjected to mating competition by 90 sterile should read: " However, if we reach the same 90% males as well as 10 normal males."

10 FEBRUARY 1967 U.S. NAVY MEDICAL NEWS LETTER 29 DEPARTMENT OF THE NAVY POSTAGE AND FEES PAID DEPARTMENT OF THE NAVY

BUREAU OF MEDICINE AND SURGERY WASHINGTON. D.C. 20390

OFFICIAL BUSINESS

PERMIT NO. 1048

30 U.S. NAVY MEDICAL NEWS LETTER VOL. 49 NO. 3