NAVMED P-5088 Vol. 47 Friday, 25 March 1966 No.6 CONTENTS MEDICAL ARTICLES Effect on Serum Cholesterol of a Corn Oil and Skim Milk Mixture in Peptic Ulcer Patients ---------- Bacterial Endocarditis-A Changing Pattern ______ _ Systemic "Allergic" Vasculitis ------------------- Cross-Species Transfer of Learning: Effect of Ribonu- cleic Acid From Hamsters on Rat Behavior ------ DENTAL SECTION Dental Corps Training ---- --------------------- Officers Selected for FY 1967 Training to Date ---- Personnel and Professional Notes ---------------- PREVENTIVE MEDICINE SECTION Plague in Danang, Viet Nam, 1965 --------------- Use of Isoniazid Among Household Contacts of Open Cases of Pulmonary Tuberculosis -------~- 5 9 15 17 18 19 21 23 PREVENTIVE MEDICINE (Con.) Coxsackie Group B Virus Infections -------------- 24 Salmonella Surveillance-1963 ------------------- 24 Shipboard Cockroach l nfestation ----------------- 24 Methemoglobinemia-New York City ------------- 24 A Case of Multiple Bee Stings ------------------- 25 Dichlorvos Tested Against A. Aegypti in Virgin Islands --------------------------- ---------- 25 Know Your World --- -------------------------- 25 OPERATIONAL MEDICINE SECTION Tuberculosis Control 27 EDITORIAL DESK American Board of OB-GYN-SPECIAL NOTICE__ 28 Doctors Shaw and Summitt Shared Honors -------- Ground-Breaking Ceremonies at Jacksonville, Fla. __ _ Bronze Star to HM3 Galbally ------------------- 28 29 29 Vol. 47 United States Navy MEDICAL NEWS LETTER Friday, 25 March 1966 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 Aviation Medicine .. .. ....................... Captain Frank H. Austin MC USN Dental Section ...................... . ....... . . Captain C. A. Ostrom DC USN Occupational Medicine ........................ CDR 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 No.6 Policy The U.S. Navy Medical News Letter is basically an official Medical Department publication inviting the attention of officers of the Medical Department of the Regular Navy and Naval Reserve to timely up-to-date items of official and professional interest relative to medicine, dentistry, and allied sciences. The amount of information used is only that necessary to inform adequately officers of the Medical Department of the existence and source of such information. The items used are neither intended to be, nor are they, sus- ceptible to use by any officer as a substitute for any item or article, in its original form. All readers of the News Letter are urged to obtain the original of those items of particular interest to the individual. Change of Address Please forward changes of address for the News Letter to Editor: Bureau of Medicine and Surgery, Navy De- partment, Washington, D.C. 20390 (Code 18), giving full name, rank. corps, and old and new addresses. FRONT COVER: U .S.S. SOLACE (AH-5). Commissioned on 9 August 1941, the SOLACE joined the Fleet on 27 October and was the first hospital ship to be present in a naval battle when she cared for cas- ualties from the Japanese attack on Pearl Harbor. She won eight engagement stars for participation in this and seven other military operations: Gilbert Islands, 24-26 November 1943; occupation of Kwajalein and Majuro Atolls, 3-4 February 1944; capture and occupation of Saipan, 18 June to 2 July 1944; capture of Guam 24 July to 15 August 1944; occupation of Southern Palau Islands, 6 September to 14 October 1944; capture of lwo Jima 23 February to 10 March 1945; and the Okinawa Gunto operation, 24 March to 30 June 1945. The SOLACE was the first hospital ship to be refueled at sea while carrying a full load of patients, near the Gilbert Islands in November 1943, and the first to receive patients directly from the combat area (in the same campaign). As an illustration of her activity, during 1943 she traveled 37,069 miles, took part in 10 evacuations, six of them to transport patients from the New Hebrides area to Aukland and Wellington, New Zealand. Total admissions to the sick list that year amounted to 6,465, and she spent 5 months as a station hospital. During the Iwo Jima and Okinawa operations 1800 units of fresh whole-blood, 1,200 units of plasma, 136,000 sulfa tablets, and 2 Yz billion units of penicillin were administered. She admitted and treated about 25,000 patients altogether, 70 percent battle casualties, and steamed over 170,000 miles before VJ Day. Thereafter she engaged in transporting Pacific war veterans home, and was decommissioned 27 March 1946. The SOLACE had an overall length of 410 feet, displaced 8,650 tons, had a top speed of 18 knots and a cruising range of 7,000 miles. The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 EFFECT ON SERUM CHOLESTEROL OF A CORN OIL AND SKIM MILK MIXTURE IN PEPTIC ULCER PATIENTS By Benjamin M. Kaplan MD, Mitchell A. Spellberg MD, Margaret M. Norton MS, and Ruth Pick MD. From the Cardiovascular Institute and the Department of Medicine and Nutritional Sciences, Michael Reese Hospital and Medical Center, Chicago, Illinois. Amer J Med Sciences 250(6):621-627, December 1965. Clinical and exper~mental evidence is mounting to indicate a clear relationship between the quanti- ty and type of lipids in the diet and serum choles- terol levels in man. Likewise, there is work to sup- port the premise that the height of the serum cholesterol is one of the major risk factors in the production of coronary heart disease. Generally large quantities of milk and cream, which are high in saturated fatty acids, are consumed daily as part of the peptic ulcer therapeutic regimen. Since peptic ulcer is a chronic and recurrent ailment, individuals with this disorder consequently ingest a diet high in saturated fatty acids either constantly or intermittently for months or years. The incidence of coronary atherosclerosis appears to be increased in peptic ulcer patients. Briggs et al. have reported a statistically significant higher incidence of myo- cardial infarction in peptic ulcer patients treated with a Sippy diet than among peptic ulcer patients not so treated or nonulcer patients of similar ages. However, that the intake of large amounts of milk and cream over a prolonged period of time plays a major role in this increased atherogenesis has yet to be firmly established. The purpose of this study was to quantitate the effect on serum cholesterol of substituting corn oil and skim milk for milk and cream in the peptic ulcer regimen. If by this simple method of-increasing the ratio of polyunsaturated to saturated fatty acids, one could lower serum cholesterol significantly, the desirable high fat therapeutic regimen for peptic ulcer patients could be simply maintained without enhancing the potential for atherogenesis. Methods Eight ambulatory peptic ulcer patients (6 males and 2 females) were admitted to the Cardiovascular Clinical Research Unit for controlled study and therapy. Routine admission examination included a complete history and physical examination; an electrocardiogram; posteroanterior chest roentgeno- gram; complete blood count; urinalysis; blood V.D. R.L.; 3 stools for occult blood; fasting serum urea nitrogen, glucose, calcium, phosphorus, total protein, albumin-globulin ratio, protein-bound iodine; a diag- nox blue test; and other pertinent laboratory proce- dures. An upper GI series had been done in each patient shortly prior to entrance to the hospital and these roentgenograms were repeated prior to dis- charge. Seven serum cholesterol determinations, utilizing the technique of Schoenheimer and Sperry were performed on hourly specimens (8:00 a.m. through 2:00p.m.) at the beginning of the study and at the completion of each 2 week diet period. The average of the 7 determinations was used for tab- ulation. The results of the serum cholesterol deter- minations were unknown to the authors until after the discharge of the patients from the hospital. Ea-ch patient ingested a GI No. 1 diet for the entire hospital stay, the components of which are seen in Table I. During the initial 2 weeks, the GI No. 1 diet was supplemented by 9 hourly feedings of 90 ml of 1/2 milk and 1/2 cream (see Table 2). The GI No. 1 diet plus the milk and cream were designated as Diet B. The second 2-week diet period consisted of an identical GI No. 1 diet with 9 hou.ly feedings of 90 ml of a palatable corn oil and skim milk mixture constituting diet B,. The corn oil and skim milk mixture was prepared by one of us (M.M.N.) as detailed in Table 3. Three patients were studied for a third 2-week diet period, at which time they again received Diet B. The total calorie intake of the GI No. 1 diet when combined with either the milk and cream or with corn oil and skim milk varied between 2,000 and 2,600 calories, depending on the patients size and sex. Diets B and B, were similar for the individual patient as far as protein, carbohydrate and total fat content were concerned. Daily weights were recorded to make sure that the patient showed no appreciable weight gain or loss. 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 1 Table 1. Composition Of A Typical GINo. 1 Diet (Daily Amount) t Caloric Content 1194 Mono- Poly- Total Saturated unsaturated unsaturated Protein Carbohydrate Fat Fatty Acids Fatty Acids Fatty Acids Cholesterol (gm) (gm) (gm) (gm) (gm) (gm) (mg) Fruit 0 40 0 0 0 0 0 Bread 12 90 4.8 1.0 2.6 .8 6 Meat 42 0 19.5* 9.1 * 9.8* .6* 100* Egg 7 0 5.5 1.7 2.1 1.7 234 Jelly 0 15 0 0 0 0 0 Butter 0 0 11.4 7.6 3.6 .6 40 Total 61 145 41.2 19.4 18.1 3.7 380 • Average t Diet also contains vegetable A, which has negligible amounts of carbohydrate, protein and calories; vegetable B was not used. Each person received 600 mg of calcium carbonate hourly during the day as an antacid and 30 ml of magnesium oxide as necessary for catharsis. Other drugs such as propantheline bromide, codeine, or dextropropoxyphene were administered infrequently for alleviation of epigastric pain. Results Ingestion of Diet B (the milk and cream with a GI No. 1 diet) for a 2-week period was associated with a rise in serum cholesterol in 4 patients, no change in 2, and a decrease in the other 2. It is possible that the 4 patients who failed to show an in- crease in serum cholesterol had been on a high lipid or cholesterol intake, or both, prior to entrance on the study, causing maximum elevation of serum cho- lesterol at the outset of the study. The average pre- treatment serum cholesterol of the 8 patients was 226 mg per 100 ml and rose to 245 mg per 100 ml after the milk and cream regimen (Table 4). Pre- vious experience with an additional 8 patients under- going the same dietary program showed a similar rise in serum cholesterol in 7 patients, the average increase being 60 mg per 100 mi. Following substitution of Diet B, (in which corn oil and skim milk replaced the milk and cream), the serum cholesterol levels dropped significantly in all 8 patients. The average decrease in serum cholesterol was 53 mg per 100 ml from the milk and cream regimen and 35 mg per 100 ml from the pretreatment levels (Table 5). The p value for the difference of the means was less than 0.001 when comparing the skim milk and corn oil regimen with the milk and cream regimen. When equating the skim milk and corn oil regimen with pretreatment values, the p value was less than 0.05. Serum cholesterol rose appreciably in all 3 patients who returned to the milk and cream regimen after ingesting corn oil and skim milk (Table 4). From a clinical standpoint, there was no evidence that the course of the peptic ulcer healing was altered by the substitution of skim milk and corn oil for milk and cream. Presumably the corn oil and skim milk mixture is as effective as milk and cream in inhibiting gastric secretion and slowing gastric emp- tying. It has been demonstrated that polyunsaturated fatty acids, such as cottonseed oil and soybean oil can effectively reduce gastric acidity. Discussion Serum cholesterol levels have been significantly lowered in man by increasing the dietary polyun- Table 2. Composition of Milk and Cream (Daily Amount) Caloric Content 1154 Milk and Cream 2 Protein (gm) 24 Carbohydrate (gm) 45.9 Mono- Poly- Total Saturated unsaturated unsaturated Fat Fatty Acids Fatty Acids Fatty Acids Cholesterol (gm) (gm) (gm) (gm) (mg) 97.2 61.3 30.7 5.2 324 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 Table 3. Composition of Corn Oil and Skim Milk Mixture (Daily Amount) Caloric Content 1149 Protein (gm) Corn Oil 0 Corn Syrup 0 Egg White 4 Skim Milk 24 Vanilla 0 Total 28 Method of Preparation: Mono- Total Carbohydrate Fat (gm) (gm) Saturated Fatty Acids (gm) unsaturated Fatty Acids (gm) 0 85 10.5 31.6 0 0 .4 0 0 36 0 0 0 0 0 68.0 85 10.5 Ingredients Skim Milk ........................ . Corn Syrup .................. . .... . Vanilla ........................... . Corn Oil ................... .... .. . Powdered Egg White ................ . 39.0 0 0 0 0 39.0 Amounts 720 gm 40 gm 10 gm 85 gm 5 gm Poly- unsaturated Fatty Acids Cholesterol (gm) (mg) 35.5 0 0 0 0 0 0 0 0 0 35.5 0 I. To 'h of the amount of skim milk add the entire quantity of corn syrup. vanilla. and powdered egg white. Mix in blender. 2. Agitate at "low" speed and pour corn oil slowly into the mixture. ]. Combine the remaining 'h of the skim milk with this mixture. 4. Refrigerate several hours. The mixture may congeal but will quickly dissolve on shaking. S. Divide into 9 equal servings. Additional vanilla or other navors. such as commercial cherry juice or powdered coffee may be used to suit individual taste. saturated: saturated fatty acid ratio by the adminis- tration of corn oil. Others besides ourselves have noted a reduction in serum cholesterol levels in peptic ulcer patients by increasing the ratio of un- saturated to saturated fatty acids. Thus Sandweiss et al. have reported reduction in serum cholesterol in 12 of 13 peptic ulcer patients by the use of an unsaturated fatty acid ulcer diet, in which the poly- unsaturated: saturated fatty acid ratio ranged from 2.3:1 to 3.4: 1. Similarly, McHardy, Judue and Cradie and Cayes and Ruffin have noted a decrease in serum cholesterol in peptic ulcer patients using a preparation containing soybean oil, in which the dietary polyunsaturated: saturated fatty acid ratio ranged from 2: 1 to 3: 1. The particular merit of our study was that we were able to provide a very simple alteration in peptic ulcer regimen, one which re- quired no change in the usual GI No. 1 diet but depended entirely on the substitution of corn oil and skim milk for milk and cream. The polyunsaturated: saturated fatty acid ratio of Diet B 1 used in this study, in which the corn oil and skim milk mixture was added to GI No. 1 diet, was 1.33: 1. With this diet a significant decrease in serum cholesterol was obtained. Even though our studies and those of others show Table 4. Serum Cholesterol Levels in 8 Patients on Different Diets Pretreatment * Post Diet B Patient (mg/100 ml) (mg/100 ml) M.E. 278 R.J. 255 C.T. 192 C.M. 164 J.L.G. 246 H.K. 232 M.R. 134 F.C. 311 -- Average 226 Diet B = GI No. I diet with 9 feedings of 'h milk and 'h cream. Diet B, = GI No. I diet with 9 feedings of corn oil and skim milk. • Ad lib diet; some patients were on "peptic ulcer regimen." t Of the 3 patients so studied. 330 251 258 192 282 204 135 302 -- 245 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER Post Diet B1 (mg/100 ml) 232 202 223 138 216 141 111 269 -- 192 Post Diet B (mg/100 rnl) 284 196 348 276 :j: 3 Table 5. Changes in Serum Cholesterol Values in 8 Patients on Different Diets Pretreatment Diet B to Diet B1 to DietB (mg/ 100 ml) Pretreatment to DietB1 (mg/100 ml) to DietB Diet Bt Patient (mg/ 100 ml) (mg/ 100 ml) M.E. +52 -98 -46 R.J. - 4 - 49 -53 C.T. +66 -35 +31 -26 C.M. +28 -54 J.L.G. +36 -66 +68 +55 -30 H.K. -28 - 63 -91 M.R. + 1 -24 -23 F.C. - 9 -33 +79 + 67* -42 Average +18 ± 11.5 -53 Diet B = GI No. I diet and 9 feedings of \-2 milk and 1-2 cream. Diet B, = GI No. I diet and 9 feedings of com oil and skim mille • Of the 3 patients so studied. that serum cholesterol can be increased by ingestion of large quantities of milk and cream, only 43 % of 145 patients with chronic peptic ulcers ingesting a modified "Sippy diet" intermittently for years had serum cholesterol levels of over 250 mg per I 00 mi. One of us (M.A.S.) has noted a similar finding with a large number of peptic ulcer patients on chronic ulcer management. Although reports in the literature generally indicate a higher incidence of coronary atherosclerosis in persons with peptic ulcers, this correlation has been doubted by some. Why do these inconsistencies exist? Several possibilities exist to explain the discrepancies: (1) Eating habits have been shown to play a sig- nificant role in the level of serum cholesterol as well as in the production and regression of atherosclerosis in the experimental animal. It is entirely feasible that serum cholesterol levels in peptic ulcer patients may be significantly influenced by the frequency of feedings. However, to date our preliminary short- term studies in peptic ulcer patients have failed to reveal a significant serum cholesterol variation de- pendent on whether the milk and cream or the Gl No. 1 diet, or both, were ingested at frequent in- tervals in small quantities or at wide intervals in larger quantities. (2) The quantity of polyunsaturated fatty acids in the "peptic ulcer diet" may vary considerably, with significant effects on serum cholesterol levels. ( 3) Briggs et al. have indicated that while some patients with chronic peptic ulcers do follow a high saturated fatty acid and high cholesterol dietary regimen for many years, others do not. It is obvious that the dietary history is an important variable. Our study and review of the literature lead us to recommend the following proposal for peptic ulcer ±8.3 - 35 ±12.1 patients as far as the high fat diet, considered essen- tial in their dietary management, is concerned. From the serum cholesterol responses noted in these studies, it appears justified to suggest that corn oil (or some other palatable oil high in unsaturated fatty acids) and skim milk be tried instead of milk and cream as dietary supplement in the long-term therapy of peptic ulcer. As prepared by us, the corn oil and skim milk mixture is highly caloric and equal in calories to an equivalent amount of milk and cream. Since it is usually deemed important to avoid weight gain, the total number of calories ingested must be limited. This can be accomplished by re- ducing the caloric value of the other parts of the diet (Table I). Summary (I) The administration of a GI No. 1 diet sup- plemented by 90 ml of 1h milk and 1h cream 9 times per day over a 2-week period to 8 peptic ulcer patients was associated with a rise in serum choles- terol in a number of instances. (2) The substitution of skim milk and corn oil for milk and cream in the above regimen was ac- companied by a statistically significant reduction in serum cholesterol far below pretreatment levels in all patients. ( 3) The corn oil and skim milk mixtures were found to be palatable and effective in the peptic ulcer regimen. (4) Corn oil and skim milk, rather than milk and cream, would appear to offer a safer approach in the long term dietary management of peptic ulcer with respect to serum cholesterol levels and pre- sumably also to potential atherogenesis. (The references may be seen in the original article.) 4 U.S. NAVY MEDlCAL NEWS LETTER VOL. 47 NO. 6 BACTERIAL ENDOCARDITIS-A CHANGING PATTERN* Marwan M. Uwaydah MDt, and Arnold N. Weinberg MD:j:, Boston, Mass. New Eng J Med 273(23): 1231-1235, December 2, 1965. In recent years there have been changes in many of the factors which influence the development and outcome of bacterial endocarditis. These changes re- late to both the susceptible host and the causative organism. Rheumatic fever, for example, appears to be declining in incidence and severity. More cases of bacterial endocarditis are being encountered in elderly persons with no. history of valvular disease or murmurs. In addition, many more patients are being treated with corticosteroid hormones, immuno- suppressive agents and extensive radiotherapy, all of which interfere with normal mechanisms of host resistance. The use of newly developed technics in cardiac surgery, such as prosthetic valve replace- ment, are creating more opportunities for micro- organisms to gain access to the circulation and establish a foothold in the endocardium. Moreover, the wide use of multiple antibiotics has been asso- ciated with isolation of unusual and increasingly resistant organisms. In an attempt to evaluate the magnitude and sig=- nificance of recent changes in the clinical pattern of bacterial endocarditis and to assess the influence of both host and bacterial factors on this pattern, we have reviewed the experience with this disease at the Massachusetts General Hospital since July, 1958, using as a comparative series the cases presented from this hospital in· a review covering the period 1944 to Jt ne, 1958. Materials and Methods Records of all the patients with bacterial endo- carditis seen at the Massachusetts General Hospital between July, 1958, and June, 1964, were reviewed, including 26 cases diagnosed only at post~mortem examinati0n. fhe main criteria used for diagnosis included repeatedly positive blood cultures in the absence of an obvious noncardiac septic focus, evi- dence of valvular heart disease, peripheral manifes- tations of endocarditis or pathological diagnosis whenever available, even in the absence of a typical • From the departments of Medicine, Harvard Medical School and Massachusetts General Hospital (Infectious Disease Unit). t Research fellow in medicine, Harvard Medical School; clinical and research fellow in medicine, Massachusetts · General H ospital (In- fectious Disease Unit). t Associate in medicine, Harvard Medical School: assistant in medi- cine, Massachusetts General Hospital (Infectious Disease Unit). clinical picture. Excluding cases only diagnosed at post-mortem examination, blood cultures were posi- tive in 71 out of 74. The cases were divided into acute and subacute groups on the basis of a number of criteria. The acute group included patients with hectic fever, leukocytosis, extreme toxicity and rapid deterioration of cardiac function. The virulence of the causative organisms and the length of the clinical disease were also important factors in defining this group. In general, the patients with subacute endo- carditis had less violent disease, prolonged in time, without marked toxicity or high fever, and rapid de- terioration of cardiac function was not a major prob- lem. Admittedly, this classification is arbitrary, but it was found to be helpful and applicable in 98 per cent of these cases. Results The cases of 100 patients were reviewed, many of whom had been seen sometime during their iilness by one or more members of the Infectious Disease Unit. There were 56 males and 44 females, ranging in age from ten to eighty-nine years. As noted in Table 1, the average yearly number since 1944 was 15 cases, and there was little variation from year to year. The total hospital admissions increased very little during the period of study, so that the incidence of bacterial endocarditis did not change significantly during that interval. Excluding 2 cases that could not be classified as acute or subacute and were called "uncertain," the ratio of acute to subacute endocarditis increased ·progressively from I :3. 3 in the earlier series to 1 :0. 8 in the last two years of the current series. Depending upon their cardiac status before the onset of their illness, patients were divided into three categories: those with no apparent abnormality ( 19 cases); those with congenital or rheumatic val- vular disease (56 cases); and those with arterioscle- rotic or calcific heart disease (25 cases). Figure 1 presents the relation of the underlying heart disease and type of endocarditis to age. Al- though the highest incidence of both acute and subacute endocarditis was in the age group from thirty-one to sixty years, there were 38 patients over 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 5 Table 1. Bacterial Endocarditis at the Massachusetts General Hospital (1944 to June, 1964). Total Average Acute Subacute Uncertain Period Cases Yr Cases Cases Cases 1944*-June, 1958 228 15 53(23%) 175(77%) July, 1958-June, 1964 100 16 43(43%) 55(55%) 2 July, 1958, 1961 63 17 23(37%) 39(63%) 1962-June, 1964 37 14 20(55 %) 16(45%) 1 *Study of Morgan & Bland. D NORMAL ~ VALVULAR (Rheumatic- ConQenital) CALCIFIC and ASHD ( 2 8) (2 0) ( I 7) ~ 0 AGE ACUTE SUB ACUTE SUB ACUTE SUB 0- ~v 3/- 60 61-90 Figure 1. Relation of Underlying Heart Disease and Endocarditis to Age ( 1958-1964). sixty. The main cardiac abnormalities in the young and middle-aged patients were rheumatic and con- genital valvular disease whereas in the elderly pa- tients, calcific and arteriosclerotic disease predomi- nated. In 16 of the 43 patients (37 per cent) with acute endocarditis there was no evidence of overt predisposing heart disease, and only 3 of 55 patients (5 per cent) with subacute infection had clinically normal hearts. Endocarditis involving the right side of the heart was encountered twice in this review. The 2 cases were analyzed without special reference to the val- vular localization. Table 2 compares the etiologic agents isolated from patients in the two series. Alpha-hemolytic streptococci remained the most commonly isolated organism. The overall incidence of Staphylococcus aureus increased from 14 to 23 per cent, but its rela- tive frequency in acute cases remained unchanged, accounting for slightly more than 50 per cent of these cases. The prognosis was poor regardless of whether the staphylococcus was sensitive or resistant to penicillin. Other relevant observations were the increase in the number of infections due to Group A and Group D (enterococcal) streptococci and the surprisingly rare occurrence of gram-negative orga- nisms. The 2 patients with endocarditis due to gram- negative bacilli were sixty-seven and seventy-seven years old. In neither was the diagnosis suspected during life. Various other factors that may have affected the development of the disease are listed in Table 3. 6 U.S. NAVY MEDICAL NEWS LEITER VOL. 47 NO. 6 Table 2. Isolates from Patients with Bacterial Endocarditis 1944-June, 1958 July, 1958, June, 1964 Organism Isolated Alpha-hemolytic streptococci ..... . . . ... . Beta-hemolytic streptococci, Group A .... . . Nonhemolytic streptococci ... ... ........ . Streptococci, Group G ................ . Acute Cases I 0 0 Subacute Cases 116(66%) 2 0 0 Acute Cases 4 I 1 Subacute Uncertain Cases Cases 38(69%) I 0 2 I 0 Enterococcus, Group D ............... . . Staph. aureus ............ . ........ . .. . Staph. albus ....................... . . . 0 31(58% ) 0 5 3 4 3 3 0 23(53%) 0 0 0 2 0 Pneumococci ............... . ........ . 9 Friedlander-like organisms . . ..... .. ... . . 0 Proteus ........... . ................ . I Escherichia coli . ...... . ........ . ..... . 2 Haemophilus influenzae . . . . . . . . . . . . . . . . . 1 Brucella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Pseudomonas aeroginosa . . . . . . . . . . . . . . . . 0 (bacillus pyocyaneus) Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Totals ........................ . 53 Unfortunately, similar data are not available from the 1944-1958 series for comparison. Foci of in- fection, such as furuncles, pulmonary infections and pyelonephritis, were apparent in 65 per cent of the acute and 24 per cent of the subacute cases. Five infections followed cardiac surgery. Two were caused by penicillinase-producing Staph. aureus, and 1 patient survived. Another patient had an acute endo- carditis due to Group D streptococcus, from which she recovered with antibiotic therapy. The fourth patient, from whom Staph. albus was isolated, had a subacute illness and responded well to treatment. In the fifth case no organisms Wl!re isolated from blood, and the patient deteriorated rapidly and died. The diagnosis was established at post-mortem ex- amination. Table 3. Conditions Associated with Bacterial Endocarditis, July, 1958, to June, 1964 Acute Cases Subacute Cases Condition (43 Cases) (55 Cases) Dental problems 3 (7%) 15 (27%) Diabetes mellitus 7(16%) 3 (5%) Liver cirrhosis 4 (9%) 4 (7%) Focus of infection 28 (65 %) 13 (24%) Heart surgery 4 (9%) 1 (2%) General surgery 4 (9%) 2 (4%) Steroids 3 (7%) 0 0 0 0 2 1 0 41 175 2 0 1 0 0 0 0 7 43 0 0 I 0 0 0 0 0 0 0 0 0 0 0 7 0 55 2 The mortality rates for the two series are pre- sented in Table 4 and include 15 cases of acute endocarditis and 11 subacute cases not diagnosed until post-mortem study. During the past twenty years there has been essentially no change in the overall survival rate in cases of subacute bacterial endocarditis. Table 4. Gross Mortality Rates, 1944 to June, 1964 Year No. of No. of Acute Mortality Subacute Mortality Cases % Cases % 1944-June, 1958 53 July, 1958, Ju,e, 1964 43 85 75 175 32 55 30 : :tble 5 stresses the relation of "survival" to ·'r ..:cognition" and "age." "Recognition" refers to cases suspected strongly enough to initiate therapy, independent of the duration of therapy before death. The findings can be summarized as follows: In the younger group almost all acute and sub- acute cases were recognized, but over the age of thirty, recognition became progressively poorer espe- cially in the acute cases. In the young group recognition was associated with good prognosis, in both acute and subacute cases, but in the elderly (sixty-one to ninety years of age), the mortality was consistently high even 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 7 when the diagnosis was made. In the middle-aged patients recognition led to a favorable prognosis in subacute bacterial endocarditis, but survival in acute bacterial endocarditis remained low. The overall cu:.-e rate in recognized cases was 40 per cent for acute endocarditis and 87 per cent for subacute endocarditis. Regarding epidemiology, the only significant ob- servation was that all the hospital-associated cases were of the acute variety and frequently followed operative or other procedures (Table 6). Table 5. Recognition and Survival in Relation to Age, July, 1958, to June, 1964 Acute Cases Subacute Cases Age Total Recog- Survi- Total Recog- Survi- yr. nized val nized val 0-30 6 5 4 6 6 6 31-60 20 14 4 28 23 22 61-90 17 9 3 21 15 10 Totals 43 28 I 1 55 44 38 Discussion Despite the declining incidence of rheumatic fever and the more extensive use of antibiotics both prophylactically and therapeutically, the incidence of bacterial endocarditis at the Massachusetts Gen- eral Hospital has not changed appreciably during the past twenty years. Although the average number of cases has remained at approximately l 5 per year, the relative number of acute cases increased from 23 per cent in the earlier series to 55 per cent in the last two and a half years of this study. The Table 6. Type of Endocarditis in Relation to Probable Environmental Source of Infection, July, 1958, to June, 1964 Community- Hospital- Type of Acquired Associated Endocarditis Cases Cases Acute 30 13 Subacute 55 0 Uncertain 2 0 Totals 87 13 average age of the patients with acute cases re- mained fifty-five years, whereas that of patients with subacute endocarditis was fifty-four, as compared to forty-two in the Morgan-Bland series. The relation of mortality to age was striking in the latter group, being 16 per cent below sixty as compared to 50 per cent above that age. The increasing incidence of acute endocarditis observed at this hospital may reflect selection of only the sickest patients for ad- mission, but the series does include 13 patients whose disease was acquired in the hospital. A comparison of the underlying cardiac diagnoses between this series and the earlier cases reveals a declining frequency of rheumatic heart disease, from 71 to 46 per cent, and consistent with the older age of the patients, an increase in calcific and arterio- sclerotic disease. Various possible factors were of particular impor- tance as sources of bacteremia in this series. Ob- structive uropathy, prolonged urethral or intrave- nous catheterization, osteomyelitis and infected skin lesions may be cited as specific examples. Adminis- tration of steroids, diabetes mellitus, cirrhosis, cancer and other debilitating illness may have been respon- sible for altering host defense mechanisms in some patients and thereby predisposing to the develop- ment of endocarditis. These conditions complicated the clinical picture further by diverting attention from a consideration of the endocardial infection. Thus, in the elderly patient the possibility of endo- carditis was frequently obscured by some extra- cardiac underlying disease, and the correct diagnosis was delayed or missed entirely. The presenting symptoms may be those of unexplained fever, hematuria, progressive urt!mia without obvious renal cause, anemia, mental aberrations, cerebrovascular accident or meningitis, alone or in various combi- nations. Heart murmurs may be absent or of such in- significant intensity as to fail to alert the clinician to the possibility of endocarditis. In this series no mur- mur was detected in 7 of 38 patients in the group from sixty-one to ninety years of age. The differentiation of acute from subacute endo- carditis depends upon the virulence of the etiologic agent and the severity and rate of progression of the disease. Organisms characteristically producing indolent disease on scarred valves occasionally cause fulminating infections, as noted in cases from this hospital and as mentioned in the literature. Con- trary to some current opinion, we believe that dis- tinguishing between the two forms is useful prog- nostically and because it emphasizes the necessity for rapid institution and prolongation of intensive therapy in acute cases. The reasons for the increase in the number of acute as compared to subacute cases in this series are not clear. Although the overall percentage of endocarditis due to alpha-hemolytic streptococci dropped from 51 to 39 per cent during the two periods of study its 8 U.S. NAVY MEDICAL NEWS LEITER VOL. 47 NO. 6 frequency in the subacute group remained un- changed. On the other hand, an increase of endo- carditis due to other streptococcal species was no- ticeable during the present period. This is consistent with the reports of a rising frequency of infections with Group A streptococci and the increase in en- terococcal infections, particularly in association with genitourinary disease. In our series we did not have any streptococci other than Group D that showed significant resistance to penicillin. However, as pointed out by other workers, a stepwise increase of resistance of streptococci not of Group D to peni- cillin may occur in the patient who has been receiv- ing long-term penicillin prophylaxis. A striking feature of the bacteriology of this series was the infrequent occurrence of gram-negative bacilli, in spite of the definite rise in the incidence of septicemias and bacteremias due to these orga- nisms in recent years. This paradox cannot be easily explained. The different ways by which the host handles the gram-negative and gram-positive bac- teria are possibly important determinants. The ef- fectiveness of bactericidal serum factors in eradi- cating gram-negative bacteria may be instrumental in preventing attachment to and multiplication on the endocardium. Gram-positive organisms, which are usually disposed of by cellular phagocytic mechanisms, may establish an infection on the endo- cardial surface because of delayed cellular inflam- matory reaction in this area. In spite of all the advances in chemotherapy, the survival rate for bacterial endocarditis in our hos- pital improved only slightly, if at all, during the past twenty years. Further analysis of our data point to the fact that the poorest prognosis was in the elderly group, especially those with acute endocarditis. It is probable that lack of early recognition and therefore delayed treatment were important contributors to the high mortality rate in these patients. It is hoped that through better insight into the changing patterns of bacterial endocarditis, the disease can be recog- nized early enough for appropriate therapy to be effective. Summary At the Massachusetts General Hospital during the past twenty years the number of cases of bacterial endocarditis averaged 15 per year, with little vari- ation from year to year. The ratio of cases of acute to subacute endo- carditis changed from 1:3.3 in the 1944-1958 series to I :0.8 in the past several years. Among the predisposing cardiac abnormalities, congenital or rheumatic heart disease was present in 56 per cent of the cases, but in the elderly patients calcific and arteriosclerotic heart disease pre- dominated. Factors such as increasing age, in association with medical and surgical illnesses, tended to obscure early diagnosis and led to increased mortality. In this series, alpha-hemolytic streptococc"i and Staphylococcus aureus remained the most frequent causes of subacute and acute endocarditis, respec- tively. There was an increase in the number of cases due to Group A and Group D (enterococcal) streptococci, but there were only 2 cases due to gram-negative bacilli despite the rising incidence of gram-negative septicemia during the past decade. (The references to this article may be seen in the original article.) SYSTEMIC "ALLERGIC" VASCULITIS CLINICAL AND PATHOLOGICAL RELATIONSHIPS Robert P. McCombs MD'''. lAMA 194(10): 1059-1064, Dec. 6, 1965. The clinical manifestations associated with sys- temic "allergic" vasculitis are so protean that they have been described and reviewed under the heading of a variety of syndromes (Table 1 ). In these the vasculitis is often of primary importance and changes related to the blood vessel disorder may account for nearly all of the clinical manifestations. • From the Department of Medicine, Tufts University School of Medicine and the Allergy-Pulmonary Disease Service, New England Medical Center Hospitals, Boston. lt is not known why vasculitis produces different syndromes in different patients. It is obvious that tissues in the body can react to noxious stimuli only in a limited number of ways, and the various syn- dromes associated with vasculitis may well be ex- pressions of several pathogenic mechanisms in which local factors play a role. We have become aware, however, that there are many cases of systemic "allergic" vasculitis that can- 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 9 not readily be classified into one of the syndromes listed in Table 1, despite careful study and prolonged follow-up. We believe that attempts to classify rigidly such diffuse disorders as make up the syn- drome of systemic vasculitis often leads to serious errors in diagnosis, treatment, and prognosis. In order to try to resolve some of these difficulties we undertook a study of our cases of vasculitis to de- termine if there were some common denominators of clinical value. Methods All of the clinical records and pathological mate- rial of patients admitted to the New England Medical Center Hospitals during the years 1946 to 1963 in which the diagnosis of vasculitis was confirmed his- tologically were reviewed. Follow-up data was ob- tained whenever possible by personal examination, otherwise by communication with the family physi- cian or by consulting clinical records or autopsy re- ports from other hospitals concerning studies that followed the initial diagnosis of vasculitis. The va- rious important manifestations were reviewed in re- lationship to time of onset, time of diagnosis, and response to therapy. Results A total of 72 histologically confirmed cases of vasculitis were included in this study. Of these there Table I. Clinical Syndromes Associated With Systemic "Allergic" Vasculitis Periarteritis (polyarteritis) nodosa Microscopic polyarteritis Allergic granulomatosis Wegener's granulomatosis Serum sickness Hypersensitivity angiitis Drug hypersensitivity Vascular (anaphylactoid) purpura "Allergic" vasculitis (angiitis) Arteriolitis "allergica" cutis Nodular vasculitis were 38 females and 34 males. Ages varied from 6 to 74 years. Three of the patients were less than 31 years of age, 33 were between the ages of 31 and 50, and 36 were more than 50 years of age. Etiology.-In 26 of our patients there were un- mistakable drug reactions at the time of onset. The drugs associated with these reactions are listed in Table 2. Careful review of the evidence indicated that in 22 of our patients infection was probably present at or just prior to the onset, but of these, 12 also had reactions to drugs used to treat the in- fection. Table 2. Drugs Responsible for Reactions Associated With Systemic "Allergic" Vasculitis Penicillin Sulfonamide Chloramphenicol Chlortetracycline Phenylbutazone Propy !thiouracil Busulfan (Myleran) Pyrogen preparation (Pyromen) Vaccine (possibly penicillin) Iproniazid Potassium iodide TOTAL No. of Cases 9 3 2 2 2 2 2 1 1 1 1 26 Vasculitis is known to accompany some cases of rheumatoid arthritis, and corticosteroid therapy in this disease has been implicated as a possible causa- tive or aggravating factor for vasculitis. Twelve of our patients had chronic inflammatory arthritis weeks or months prior to the occurrence of other manifestations that led to the establishment of the diagnosis of vasculitis. Only four of these patients had received corticosteroids prior to the diagnosis of vasculitis. There was a history of allergic disease in 19 pa- tients. Seven of these had had bronchial asthma; five, hay fever; two, urticaria; and five, previous drug reactions; four of the patients with histories of drug reactions had second reactions that led to the diag- nosis of vasculitis and are included as drug-induced cases above. It may be of significance that in four cases chron- ic leukemia was present, and in one case low-grade lymphoma was present, at the time the diagnosis of vasculitis was made. Two of these patients had drug reactions. The various possible etiologic factors are sum- marized in Table 3. Manifestations.-The variety of manifestations of systemic vasculitis suggest that they are dependent upon a number of variables. Certain tissues are more susceptible than others, and therefore these are the major "shock organs." In this series the 10 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 skin, joints, and muscles, kidneys, lungs, and pe- ripheral nerves were affected much more commonly than other tissues. The extent of involvement of any organ was dependent upon the intensity of the reac- tion in vascular walls and in perivascular tissues. Local hemorrhage, edema, and inflammation were common, and when necrosis was present there o(ten also was vascular thrombosis; infarcts of skin, kid- ney, heart, and brain have been encountered. In some instances, it was apparent that the vascular reaction may have been altered by therapy. Table 3. Etiologic Considerations in 72 Cases of Systemic "Allergic" Vasculitis Infection Rheumatoid arthritis Lymphoproliferative disease No related disease TOTAL History No of Allergy Allergy 6(4)* 16(8) 3(1) 9(3) 0 10(3) 19(8) 5(2) 23(5) 53(18) Total 22(12) 12(4) 5(2) 33(8) 72(26) • Figures in parentheses indicate number of patients with drug reactions. Important manifestations of systemic vasculitis in our cases are summarized in Table 4. Systemic Signs.-Fever, when present, was usually of a low grade, except in fulminating cases. Weight loss, on the other hand, was often quite marked and occasionally was the presenting symptom. Skin.-Purpura was the most frequent manifesta- tion. In three of our cases purpura dominated the clinical picture and diagnoses of vascular purpura were entertained. In other cases, purpura was much less apparent, in some consisting of only a few scat- tered petechial spots, most often occurring over the lower third of the legs. Biopsy of purpuric lesions in most instances gave satisfactory evidence upon which to base the diagnosis of vasculitis. Erythematous maculopapular rashes were encoun- tered in slightly more than 20% of cases. Inflamma- tory nodules were not common, but when present, proved to be important clues to the diagnosis of vasculitis in that when biopsied they always gave evidence of acute necrotizing vasculitis. Musculoskeletal Symptoms.-In the 12 patients with preexisting rheumatoid arthritis the symptoms Table 4. Manifestations in 72 Cases of Systemic "Allergic" Vasculitis Systemic Signs Skin Musculoskeletal Pulmonary Renal Cardiovascular Neurological Gastrointestinal Hematological Other Laboratory Abnormalities Fever Weight loss Purpura Erythematous rash [nflammatory nodules Urticaria Prior rheumatoid arthritis Arthralgias Muscular pain and tenderness Bronchial asthma Pneumonitis Albuminuria, hematuria Renal failure Hypertension Edema Ascites Myocarditis Phlebitis Peripheral vascular insufficiency Neuropathy Encephalopathy Bleeding Anemia Leukocytosis Eosinophilia Elevation of blood sedimentation rate Reversal of albumin globulin ratio 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER No. of Cases 22 18 35 15 9 3 12 31 15 7 22 24 17 2 14 10 5 5 1 20 7 9 22 20 16 46/ 62 23/ 57 11 of joint inflammation became more severe during the acute episode that led to the diagnosis of vas- culitis. In 31 additional patients arthralgias accom- panied other manifestations of vasculitis and, during remissions, joint symptoms disappeared; in these no deformities occurred and progressive rheumatoid arthritis did not occur, although definite rheumatoid arthritis appeared three and five years later in two patients. Muscle pain, tenderness, and weakness were less frequent, but disabling when present. Proximal muscle groups were not primarily affected as in dermatomyositis. In the few instances :n which muscle biopsies were obtained there were inflamma- tory changes in small arteries in the muscles with some secondary changes in the muscle. Pulmonary Symptoms.-Bronchial asthma coin- cided with the approximate onset of other symptoms of vasculitis in only two patients and had been pres- ent in the recent past in only three others. In two additional patients there was a history of asthma. Hemoptysis, cough, and dyspnea were evident in nearly one third (22) of our cases and in most of these pulmonary infiltrates were demonstrable by roentgenographic examination. Intrapulmonary hem- r rrhage, associated with renal bleeding (possibly Goodpasture's syndrome), was evident in two cases. Migrating pneumonitis (possibly Loeffler's syn- drome) was apparent in three cases. Pleural effu- sions of moderate size accompanied the pneumonitis occasionally. Renal Symptoms.-Microscopic hematuria, albu- minuria of moderate degree, and the presence of granular and red blood cell casts were the most characteristic urinary abnormalities found, and these were present in 24 cases. When the disease was progressive and severe, gross hematuria and signs of renal failure became manifest. In most instances urinary findings were discovered, incidentally, during study for other manifestations of the disease. When performed at this stage, renal biopsies showed focal glomerulitis. Cardiovascular Symptoms.-Edema was a com- mon symptom. At times (eight cases) it was present in the absence of cardiac, renal, or hepatic disease and occasionally was the chief complaint. It is be- lieved that edema may be a manifestation of capil- lary damage associated with vasculitis. Ascites was less common than edema and was rarely associated with it, being more commonly associated with hypo- albuminemia, but in five cases ascites apparently represented a primary manifestation of vasculitis. Myocarditis, as evidenced by cardiac arrhythmias, diffuse electrocardiographic changes, and heart fail- ure, was evident during acute stages of vasculitis in a few patients; two of these made a complete recovery with no signs of re-sidual disease. Phlebitis occurred during the active stages of vas- culitis in five cases and seemed to be a manifestation of the disease. In one case peripheral vascular in- sufficiency was present that did not respond to sympathectomy but improved after corticosteroid therapy. Neurological Symptoms.-Peripheral neuropathies were quite common and were mild except in fulmi- nating cases. In some, at first there was only pain localized to the distribution of a peripheral nerve, being followed later by paresthesias and motor weak- ness involving more than one extremity. If corticos- teroid therapy was given soon after onset, symptoms subsided rapidly, but if nerve damage was extensive, signs of peripheral neuropathy persisted for months. Neuropathies involving cranial nerves were noted rarely, but in one case the sudden occurrence of bi- lateral permanent deafness in association with other signs of active vasculitis suggested simultaneous in- volvement of both auditory nerves, presumably by affecting nutrient vessels. En~ephalopathies, not associated with uremia, were evident in a few of the more seriously ill pa- tients. This manifestation was deemed to be present when there was mental confusion, delirium, diffuse alterations in the electroencephalogram, or spinal fluid abnormalities. In one case a cerebral throm- bosis occurred during a febrile episode associated with arthralgia, hematuria, and albuminuria. Gastrointestinal Symptoms.-Brisk gastrointestinal bleeding was the presenting symptom in three cases of systemic vasculitis and lesser amounts of intes- tinal bleeding were evident in six additional cases. In one case previously reported, abnormalities seen in x-rays of the jejunum permitted a roentgeno- graphic diagnosis of vasculitis. The patient improved temporarily with corticosteroid therapy, but died later from exsanguination. Autopsy revealed active vasculitis at the site of bleeding as well as focal glo- merulonephritis. It seems likely that bleeding was due to vascular damage, ulceration, and local mu- cosal necrosis. Hematologic Abnormalities.-Anemia was pres- ent in nearly one third of the cases but in most of these it could be attributed to gastrointestinal bleed- ing or associated renal failure. Abnormal hemoly- sins were not demonstrated in any of the cases. Leukocytosis, when present, was usually of moderate 12 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 degree with white blood cell counts between 11 ,000 and 20,000 with occasional exceptions. Leukopenia of significant degree was not recorded. Eosinophilia of greater than 5% occurred in about one fifth of the cases, and as might be expected, was usually encountered in those patients with histories of bron- chial asthma, allergic rhinitis, or drug hypersensitiv- ity. In a few instances, however, moderate eosino- philia was the only suggestion of allergy present. Other Laboratory Abnormalities.-Eievation of the blood sedimentation rate was by far the most common finding in systemic vasculitis. In several in- stances the rate ( Westergren) was more than 100 mm/hr, and in several instances the observation of a high sedimentation rate stimulated continuing search for its cause including tissue biopsy, thus leading indirectly to the diagnosis of systemic vasculitis. Abnormalities of the serum proteins also were common, with elevation of the globulins the most common fault. Decreases in serum albumin also oc- curred, possibly as a result of albuminuria or loss of albumin from the circulation to interstitial spaces. When search was made for lupus erythema- tosus (LE) cells, none was found. Fluorescent anti- nuclear antibody tests were negative in five of the seriously ill patients. Results from liver-function tests were abnormal in three of six patients tested. Prognosis.-Twenty-five of the 72 patients were known to be dead at the completion of the study and follow-up information was inadequate in 4. Forty- three patients were known to be alive from 12 to 132 months after the diagnosis of vasculitis was estab- lished. None of the deaths occurred in the 3 patients 30 years of age or less, nine occurred in the 33 patients between the ages of 31 and 50, and 16 of 36 patients more than 50 years of age died. The mortality rate and clinical course were favor- ably influenced by corticosteroid therapy. The re- Table 5. Prognosis in 72 Cases of Systemic "Allergic" Vasculitis Treated With Corti- Outcome Untreated costeroids Total Death Due to vasculitis 9 9 18 Other cause 7 7 Incomplete follow-up 2 2 4 Complete recovery 2 15 17 Continuing symptoms 4 22 26 TOTAL 17 55 72 Iationships of treatment and outcome are sum- marized in Table 5. Autopsies were performed in 17 of the 25 fatal cases. All of the untreated patients showed active focal or diffuse glomerulonephritis with evidence of vasculitis in various organs other than the kidney. Focal or diffuse glomerulonephritis was also evident in five of the seven patients autopsied who had re- ceived corticosteroid drugs. Death was due to causes other than vasculitis or its therapy in seven of the treated patients; four had leukemia that had been present at the time of diagnosis of vasculitis, two had carcinomas that were diagnosed more than three years after the diagnosis of vasculitis; and one died of coronary thrombosis. Autopsies were performed in three of these patients and there was no evidence of vasculitis present in any, but all had recently re- ceived corticosteroids. Of the 43 surviving patients, complete recovery was noted in 17 with no apparent residual and no need for maintenance corticosteroid therapy. Cor- ticosteroids had been used in 15 of these patients. They were used for periods of 1 to 3 months in nine patients; from 3 to 12 months in three; and in three patients for 24 months, 36 months, and 96 months, respectively. Only 6 of 17 untreated patients sur- vived more than one year after diagnosis, while 37 of 55 of the treated patients were alive 12 to 13 2 months after diagnosis of vasculitis. Symptoms continued in 26 cases, but it was diffi- cult in some to determine whether or not they were related to the vasculitis. For example, in seven of the surviving patients in whom rheumatoid arthritis antedated the vasculitis by several years, joint symp- toms continued, but in six additional patients mild joint symptoms persisted for from one to five years after they first appeared coincident with other mani- festations of vasculitis. Three patients continued to require intermittent corticosteroid treatment because of recurrent episodes of bronchial asthma. In four cases there were recurrent rashes. There were two cases of chronic leukemia, three cases of chronic renal disease, and one case of chronic debility fol- lowing multiple surgical operations necessitated by vasculitis of the small bowel. The clinical course in cases with renal involvement was quite variable. In two instances complete remis- sion of renal disease occurred, apparently influenced favorably by rather intensive corticosteroid therapy. In nine others, hematuria, albuminuria, and cylin- druria persisted for months or even years without progressive renal failure. Moderate degrees of hyper- tension appeared in only a few instances but, except 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 13 in fatal cases, was not a prominent feature of the disease. We have considered that the term periarteritis nodosa should be reserved for those cases of vasculi- tis in which there is clinical or pathological evidence, or both, of nodular inflammation of muscular arteries or arterioles. In this series there were 17 cases that fit this category. Most of them had a rapidly progres- sive disease with renal involvement and 12 deaths occurred, but five patients were known to be living from 24 to 132 months after the diagnosis was estab- lished and complete recovery was apparent in two. of these. Thirteen of our patients with drug-induced vascu- litis and 25 patients with "idiopathic" systemic vas- culitis were living from 15 to 132 months after the diagnosis of vasculitis was established; complete re- covery was evident in 15. The clinical manifesta- tions in these groups were quite similar in several respects to those in our cases of periarteritis nodosa. Comment In "allergic" vasculitis it is believed that large molecular complexes are formed by the union of antigen and antibody and these somehow become attached to endothelial cells in small blood vessels where local inflammatory reactions are induced, pre- sumably because of release of irritating substances from affected cells. This is the nature of the Arthus phenomenon in experimental hypersensitivity and is probably responsible for serum disease and drug hypersensitivity reactions in man. In erythema nodosum, in which vasculitis occurs, bacterial or drug hypersensitivity is often evident. Just what the antigenic stimuli are in idiopathic forms of systemic vasculitis can only be surmised. Some cases are associated with rheumatoid arthritis and chronic leukemia, in both of which associated immunologic disturbances are commonly present. One may spec- ulate that systemic vasculitis is an autoimmune dis- order. Certainly, there are many hypersensitivity phenomena in this group of cases. The diagnosis of periarteritis nodosa has long been associated with an ominous prognosis. There have been sporadic reports of cases of periarteritis nodosa with intermittent prolonged courses or apparent re- covery. For many years following its original des- cription periarteritis nodosa was considered to be a fatal disease characterized by involvement of mul- tiple systems in the body and necrotizing and aneurysmal arterial changes resulting in cerebral, coronary, mesenteric, renal, and other vascular in- farctions.' Later, it was recognized that there were localized and microscopic forms of the disease. Since the diagnosis of periarteritis nodosa is often based only up0n postmortem observations, descrip- tions of clinical abnormalities in this disease have undoubtedly been unfavorably colored by the serious nature of the cases reported. Zeek pointed out cer- tain differences between periarteritis nodosa and angiitis due to drug hypersensitivity, namely, that the necrotizing nodular lesions of periarteritis nodosa classically were to be found in large muscular arteri- oles near bifurcations or at the hilar regions of viscera, although small arterioles were involved at times as well, but the pulmonary circulation and spleen were usually spared; in contrast, in hyper- sensitivity angiitis only small arteries, capillaries and venules were ir.volved and the lungs and spleen were frequently affected. All of Zeek's patients who had hypersensitivity angiitis died within a few weeks of onset. Our cases of drug-induced vasculitis certainly fit into Zeek's category of hypersensitivity angiitis except that most of our patients recovered. We would agree that periarteritis nodosa deserves to be considered in a special category because of its poor prognosis. There are, however, many other cases in our series that fit neither of these groups, and these may be designated as cases of idiopathic systemic vasculitis or, because of the implications of allergy, we have chosen to use the term systemic "allergic" vasculitis. There were many similarities in the clinical find- ings in our cases of systemic vasculitis and those noted in systemic lupus erythematosus, the excep- tions being that a high percentage of our cases were males in contrast to the incidence of 80% of cases of systemic lupus erythematosus in females; also, in our cases of vasculitis the average age was more than 50 years while lupus occurs chiefly in young people; finally, none of our cases showed a lupus rash, LE cells, or positive antinuclear antibody tests. Perhaps there is some as yet undiscovered relationship other than vasculitis between these disorders. The manifestations of vasculitis depend upon a number of variables: the location and distribution of the lesions, the type and intensity of the reaction in the vascular wall, the location of the vessel, the duration of the disease, the persistence of etiologic agents in the body, and the degree to which the re- action may have been modified by therapy with cor- ticosteroids. The summation of these variables at any one time in any indivi~ual determines the clinical picture. Because the variables may be combined in many ways a large number of clinical syndromes have been described. It seems likely that basic 14 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 pathogenic mechanisms may be similar in all cases. The important fact to recognize is that vasculitis is present. Rather than to attempt to pigeonhole the diagnosis into this or that syndrome, it would seem wiser to recognize that the patient has systemic vasculitis with this or that manifestation, to eliminate the cause if it is apparent, and to initiate corticos- teroid therapy in full doses at once. In this manner, prognosis is apt to be improved. When periarteritis nodosa and its variants-allergic granulomatosis and Wegener's granulomatosis-are suspected, thera- peutic efforts should be doubled. The fact that manifestations of systemic vasculitis often persists for months or years after a single initiating allergic event suggests that an inherent susceptibility exists which becomes clinically mani- fest only after a triggering event. A similar mech- anism has been suggested in cases of systemic lupus erythematosus that have been induced by therapy with hydralazine hydrochloride, trimethadione (Tri- dione), aminosalicylic acid, and other drugs. (The references may be seen in the original article.) CROSS-SPECIES TRANSFER OF LEARNING: EFFECT OF RIBONUCLEIC ACID FROM HAMSTERS ON RAT BEHAVIOR By Frank R. Babich, Allan L. Jacobson, and Suzanne Bubash, Department of Psychology, Univer- sity of Calif., Los Angeles. Proc NAS 54(5):1299- 1302, November 1965. In two previous reports, we showed that if ribo- nucleic acid (RNA) was extracted from the brains of trained rats and injected into untrained rats, the latter then evidenced a marked tendency to perform the originally trained response, even though no re- ward was provided for this behavior. The response involved was approach to the food cup in a Skinner box upon presentation of a distinctive stimulus. The first of these papers showed that the transfer effect was strong and consistent; the second showed that the approach response transferred was specific to the stimulus (click or blinking light) employed during training of the donor animals and was not attrib- utable to differential handling or box adaptation of the donor animals. Ribonucleic acid has been implicated in memory functions in organisms as disparate as man and planarian. If the mechanism of memory is indeed this parsimonious, one might be able to transfer learning from one species to another. The present experiment investigated this hypothesis. In the fashion used in our earlier papers, one group of ani- mals was trained, another group injected and tested. In this study the donor animals were hamsters and the recipient animals rats. Subjects were 16 adult male hamsters weighing approximately 1 00 gm and 16 adult male Sprague- Dawley rats weighing approximately 220 gm. The rats were fed Purina Lab Chow for 1 hr per day during the course of the experiment. Hamsters re- ceived one hundred 45-mg Noyes pellets per day plus an hour of wet mash every few days and occa- sionally lettuce and carrots. Eight hamsters received magazine training in a standard Grason-Stadler Skinner box; that is, they were trained to approach the food cup upon hearing the distinct click produced by operation of the pellet dispenser. Magazine training of hamsters proved to be somewhat more difficult than is magazine training of rats; and accordingly, the Skinner box was modi- fied slightly to facilitate the process. Instead of being released by the food magazine, pellets were dropped by hand down a polyethylene tube to which a funnel was attached. The food magazine itself was emptied, but the click it produced was employed as the dis- criminative stimulus for approach to the food cup. Thus, the two components of training, click delivery and pellet delivery, could be controlled independent- ly. A final modification of the box consisted of placing an aluminum floor over the grid bars to enable the hamsters to locomote more easily. Magazine training was accomplished as follows. On the first day, a given hamster, deprived of food for 48 hr, was placed in the Skinner box and allowed to eat two 45-mg Noyes pellets which had been placed in the cup. Then, while the hamster was investigating the cup, the food magazine was operated a number of times in succession, producing a distinct click each time, and immediately after each click a pellet was dropped into the food cup. As training progressed, the click was withheld until the hamster moved first a short and later a longer distance from the cup. During this time, the hamster was permitted a number of interspersed cup investi- gations which were not preceded by the click and were not rewarded with food. On a few occasions, the hamster did not approach the food cup promptly when the click was sounded; in this case, no food was delivered. Each hamster was given 100 food-reinforced ap- proaches to the food cup per day for 5 days. On the whole, hamsters are more sluggish than rats, and a slightly lower level of performance was achieved than is typically obtained with rats. Still, by the end of training, each hamster approached the food cup 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 15 from most parts of the box when the click was pre- sented, and the approach behavior of the animals was clearly under the control of this discriminative stimulus. A control hamster was matched to each experi- mental hamster and was run simultaneously in an adjacent identical Skinner box. This yoked control animal received the click whenever the experimental animal did, but was not fed in the box. Instead, each control animal was given 1 00 pellets in a glass dish immediately upon being returned to its home cage at the end of a session. On the day of completion of magazine training, each of the 16 hamsters was sacrificed with ether and the brain was taken out as quickly as possible. A cut was made on a line joining the superior colliculus to the rostral end of the pons. The tissue posterior to this cut was discarded, as was the tissue of the olfac- tory bulbs. The average weight of the tissue retained was 0.8 gm. RNA was then extracted from this tissue by the following procedure. The tissue was placed in a cold mortar with 5 ml of phenol (90%) and 5 ml of isotonic saline, and was ground with purified sand for approximately 3 min. The mixture was then centrifuged at 18,000 rpm for 30 min at 0°C. The aqueous phase was carefully drawn off to avoid contamination wit'l phenol or with the inter- phase. The aqueous phase was then brought up to a concentration of 0.1 M MgC12 and 2 vol of cold ethanol were added to precipitate the RNA. Precip- itation time was I 5 min. The suspension was centri- fuged at 6000 rpm for 15 min, after which the super- natant liquid was poured off. The remaining ethanol was evaporated off, and the RNA was dissolved in 2.0 ml of isotonic saline. The amount of RNA was determined from the optical density at 260 m,u (~:P = 7450 in 0.2 M NaCl). The average yield was 2.0 mg/ 1.0 gm of tissue. In our earlier use of this ex- traction procedure, tests for protein and for DNA were negative. Approximately 8 hr after extraction, the RNA from each of the hamsters, experimental or control, was injected intraperitoneally with a %-in 22-gauge needle into an untrained rat (the xiphoid process was used as a guide for the injection). Prior to in- jection, each of the rats had been adapted to the Skinner box (without the aluminum floor) for 4 days, 15 min per day, and during each session the magazine had been operated two separate times, producing a distinct click each time. No food was ever given to these animals during the adaptation series, although food powder was sprinkled lightly over the grid floor to keep the animals active and to counteract any tendency on the part of the rats to approach the food cup on the basis of residual odor. The I 6 injected animals, then, consisted of 8 rats which received RNA from trained hamsters and 8 rats which received RNA from untrained hamsters. These I 6 rats were assigned code letters. All testing from this point on was conducted "blind"; the testers did not know the group membership of any animal until the completion of testing. The experimental and control rats were tested in a random sequence; a different sequence was used for each session. A session of testing for a given rat consisted of placing that animal in the Skinner box, permitting 30 sec to elapse, and then delivering a series of five clicks (produced by operation of the food maga- zine), spaced no less than 30 sec apart. Five such testing sessions were given, at 6, 8, 10, 22, and 24 hr after injection. Each test animal thus received a total of 25 trials. At the beginning of testing, all rats were approximately 24-hr food-deprived. After the third test session, each rat was fed 4-5 gm of Purina Lab Chow. A response on a test trial consisted of the rat's placing its nose inside a demarcated 63-cm" area surrounding the food cup, within 5 sec of click deliv- ery. The food cup was located in one corner of the box, the floor of which had an area of 670 em". That is, the rat had to approach to within a certain speci- fied distance of the cup in order for a response to be counted. Further restrictions were placed upon the test trials as follows: two judges scored all trials in- dependently, and a response was counted only if their tallies agreed; and trials were given only when the animal was facing away from the cup by more than 90°, was located at least a body length from the cup, and was not making gross locomotory move- ments. During testing, as during adaptation, food powder was sprinkled lightly over the grid floor. A comparison of the two judges' tallies revealed that they agreed on 398 out of 400 trials, i.e., on 99.5 per cent of the judgments. Table 1 presents the score for each test animal in terms of the number of cup approaches, as defined earlier, out of the 25 click-presentation trials. The mean number of responses for the experimental rats was 7.9; the mean for the control rats was 0.6. By a Mann-Whitney U test, the difference between the groups was significant at well beyond the 0.001 level. Total scores of the eight experimental rats for the separate test sessions, in order, were: 16, 12, 13, 12, 10. Experimental animals, then, showed a significantly greater tendency than controls to approach the cup 16 U.S. NAVY MEDICAL NEWS LEITER VOL. 47 NO. 6 Table 1 Total Number of Responses for Each Experimental Animal and Its Matched Control on the 25 Test Trials Pair no. Exptl. rats Control rats 1 4 1 2 5 0 3 7 0 4 8 2 5 9 0 6 9 1 7 10 0 8 11 1 area when the click was presented. Since the contro) group was equated to the experimental group in terms of feeding, handling, and adaptation to box and click, these factors cannot be invoked to explain DENTAL the results. "Learning" is sufficiently ill-defined that the possibility of a different interpretation of these results cannot be categorically rejected. Nonetheless, our several studies taken as a group suggest strongly that the effect being transferred is a specific learned response, and thus strengthen the hypothesis that RNA is an important element in the process of mem- ory storage. Further, to the extent that a specific learned response is involved, the present experiment supports the notion that the mechanism of memory storage may be essentially identical in different spe- cies. This appears to be the case for at least two re- lated species, the hamster and the rat. Finally, although our experiments do not conclu- sively demonstrate that RNA is the effective agent in the transfer effect, this would certainly appear to be the most tenable hypothesis at present. Additional experiments with purified RNA preparations and with ribonuclease should answer this question. SECTION DENTAL CORPS TRAINING The Dental Corps Training Committee met in the Bureau of Medicine and Surgery in January 1966. The Committee was impressed by the large number of applicants competing for the available training billets. Although the Committee made some selec- tions to training for FY 1967, it soon became clear that further deliberations would be necessary. Ac- cordingly the names listed below are but a partial listing of those selected for training during the en- suing academic year. An additional listing will be published following further selections by the Com- mittee. Graduate and postgraduate dental education is in a time of rapid change and advancement. The period reflects the scientific "knowledge explosion" that is occurring world-wide. The dental.profession and the population it serves is enjoying the benefits of this remarkable era. The U.S. Naval Dental Corps has not only been a recipient of these gains, but also has made notable contributions to both the scientific and the educational aspects of the period. It is thus that the objectives of the over-all educa- tional program of the Naval Dental Corps become delineated. Primarily, it has a responsibility to raise the educational level of the entire Corps from that which exists upon graduation from dental school. Secondly, it has the obligation of providing members of the Dental Corps with all the latest developments that may be applied to the clinical practice of dentis- try. It has a third responsibility in providing ac- credited specialists to be made available for consul- tation and the treatment of challenging or unusual patients. A fourth responsibility is that of assuring the availability of sufficient qualified instructors to staff the various training programs conducted by the Naval Dental Corps. And fifth, but by no means least, is the obligation of providing the Dental Corps with a staff capable of conducting a research pro- gram related to the needs of the Navy. From the above, it is obvious that the burden of responsibility placed upon the Training Committee is by no means light. It strives to distribute the training billets as equitably as is possible for the overall welfare of the Dental Corps. At the same time it endeavors to satisfy the individual desires of the applicants. It is regrettable that all applications cannot be fulfilled. In order to meet the changing requirements of evolutionary educational concepts, the present Grad- uate and Postgraduate Programs at the Naval Dental School are currently under survey. This is being ac- complished to fit the programs, in the most efficient manner possible, into the complexities of the chang- ing world in which we live. At the same time, the mission of the Dental School in serving the aims and needs of the Naval Dental Corps will not be compromised. All applicants for courses are, therefore, urged to 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 17 carefully consider their goals as related to the above philosophy prior to submitting requests for training. Applications should follow a carefully considered career plan of the individual officer that follows a realistic self-appraisal of his talents. For instance those applying for long courses in civilian institutions should be cognizant of the entrance requirements of most universities, for graduate study. Most graduate schools currently accept only applicants with a "B" average earned in pre-dental and dental school basic science courses. Accordingly, the applicant should tailor his request for advanced training in keeping with his known abilities and interest. 3. The Postdoctoral Fellowship Program-Prin- cipally for junior officers to obtain earlier advanced training in a clinical specialty or research field. Secondarily for other officers who desire increased competence in a specialty field, without attending the formal postgraduate courses of the Naval Dental School. To correct a popular misconception that exists, it should be stated that the Graduate and Postgradu- ate Courses at the Naval Dental School are not a prerequisite for promotion. The hard-charging, ca- pable, clinical operator stands an equal chance, all other factors being the same. At pn;sent there are three levels of advanced train- ing, which the applicant should consider: Accordingly, each officer in the Naval Dental Corps is urged to assume his responsibility in the full realization of the significant part he plays in the overall mission of the Corps. Non-selection to a course of instruction is not to be considered a re- flection on an individual or his career. Simply put, there are not enough training billets for each appli- cant-Dental Division, BuMed. I. The Graduate courses, Naval Dental School- Principally for applicants motivated for Board certi- fication, or for subsequent graduate training in a civilian institution. 2. The Postgraduate courses, Naval Dental School -For applicants desirous of refresher training or increased competence in a clinical specialty. 18 OFFICERS SELECTED FOR FY 1967 TRAINING TO DATE LCDR R. D. Baker LCDR 0. V. Hall LCDR E. G. Mainous LCDR H. 0. Scharpf CDR S. M. Smith LCDR D. D. Albers LCDR J. H. Charles LCDR D. E. Hayes LCDR J. (n) Koutrakos LCDR E. J. Messer L T T. E. Bollinger LT W. J. Fitzpatrick LT W. S. Harrison LT J. M. Mathers LCDR K. E. Brown LCDR D. N. Firtell LCDR D. M. Grove CDR D. L. Johnson LCDR L. E. Mark LCDR N. D. Wilkie CDR T . L. Whatley LCDR G. W. Eastwood L T T. L. Hurst LT J. C. Kelly, Jr. LT J. W. Porter Oral Surgery Training Second Year Residency Second Year Residency Second Year Residency Second Year Residency Second Year Residency First Year Residency First Year Residency First Year Residency First Year Residency First Year Residency Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Prosthodontic Training Long Course, Civilian Institution Residency Residency Residency Residency Residency Residency Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 I CDR R. J. Chutter LCDR R. C. Edwards L T S. V. Holroyd LCDR J. J. Lawrence LCDR M. R. Wirthlin LCDR C. J. McLeod LCDR J. R. Russell LCDR M. Brenyo, Jr. CDR E. J. Heinkel LT W. G. Housley LCDR A. G. Iandolo CDR R. H. Orrahood LCDR B. E. Pines LCDR E. J. Trusz L T A. R. Vernino LCDR R. N. Dodds LCDR J. S. Kitzmiller LCDR T. H. Chapman CDR B. F. Kresl LCDR M. Nissenson Periodontic Training Long Course, Civilian Institution Long Course, Civilian Institution (2nd year) Long Course, Civilian Institution (2nd year) Long Course, Civilian Institution Long Course, Civilian Institution Residency Residency Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Endodontic Training Residency Residency Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Dental Science and Research Training L T E. P. Leonard CDR W. B. Shreve CDR H. D. Tow Postdoctoral Fellowship Postdoctoral Fellowship Postdoctoral Fellowship Public Health/Preventive Dentistry Training CDR L. A. Counsell Long Course, Civilian Institution PERSONNEL AND PROFESSIONAL NOTES REQUEST FOR JOURNAL OF PROSTHETIC DENTISTRY. The Dental School needs the follow- ing copies of the Journal of Prosthetic Dentistry: 1963 Vol. 13 Nos, 1, 2, 3, 4, 5, 6 1964 Vo1.14 Nos.1,2,3,4,5,6 1965 Vol. 15 Nos. 1, 2, 3, 4, 5, 6 If anyone has any or all of these editions he would donate to the School, please contact the Command- ing Officer, U.S. Naval Dental School, National Naval Medical Center, Bethesda, Maryland 20014. DENTAL OFFICER PRESENTATION. CAPT J. F. Link DC USN, Chief of Dental Service, U.S. Naval Hospital, Great Lakes, Illinois, presented a lecture entitled "Hospital Dental Service and Train- ing in the Navy," before members of the U.S. Naval Reserve Dental Company 9-16, on Thursday, 27 January 1966, in Evanston, Illinois. ORAL CANCER CONFERENCE. Two naval dental officers attended the Oral Cancer Conference, Houston, Texas, 21-23 January 1966. CAPT V. J. Niiranen DC USN, Assistant Chief, Dental Division, Bureau of Medicine and Surgery, represented the American Academy of Maxillofacial Prosthetics. CAPT H. H. Scofield DC USN, Head, Oral Pa- thology Division, Naval Dental School, represented the American Academy of Oral Pathology. Those two officers respectively are president of those two academies. Sponsored by the Cancer Control Branch of the Division. of Chronic Disease, U.S. Depart- ment of Health, Education and Welfare, the program was devoted to all aspects, from public and profes- sional education, through surgical intervention, to rehabilitation. CAPT Niiranen presented a paper on the history of the American Academy of Maxilla- 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 19 facial Prosthetics and described plans for a work- shop scheduled for 12-16 September 1966. Captains Niiranen and Scofield participated in panel discus- sions. PROFESSIONAL MEETING. Navy Dental Corps Officers from the U.S. Naval Training Center, Great Lakes, Illinois, presented table clinics at the JOist Midwinter Meeting of the Chicago Dental Society at Chicago, Illinois on 27-28 February- 1-2 March 1966. "Use of Acrylic Prosthetic Teeth for Crown Veneers" L T W. J. Sweeney DC USNR "Indirect Crown and Bridge Technique Check- Bite Method" L T S. J. Chacouas DC USNR L T F. H. Farrington DC USNR "The Class V Gold Foil" CAPT L. M. Armstrong DC USN LCDR T. J. Lommel DC USN LCDR G. T. Ballard DC USN LCDR R. G. Schonbrun DC USNR LT J. M. Burgette DC USNR LT J. R. Schaefer DC USNR LT M. T. Cornell DC USNR LT R. G. Ottosen DC USNR LT J. L. Shaw DC USNR "Great Lakes Caries-Free Study" CAPT S. Hoffman DC USN LCDR J.P. Quinn MSC USN LT P. B. Carroll DC USN "Dental Office Asepsis" LCDR R. W. Longton DC USN "Preventive Periodontics" CDR C. F. Rau DC USN DENTAL OFFICER APPOINTMENTS. CAPT Philip J. Boyne DC USN, has been appointed an ex- aminer, and member of the Advisory Committee, of the American Board of Oral Surgery. With this appointment, two naval dental officers will serve this Board. CAPT Donald E. Cooksey DC USN, is President of the Board. CAPT Boyne is Director, Dental Re- search Department, Naval Medical Research Insti- tute; and CAPT Cooksey is District Dental Officer, 6th Naval District. CAPT Gordon H. Rovelstad DC USN, has been appointed to the Committee on Research, American College of Dentists, for a five year term. With this appointment, two naval dental officers will serve on this Committee. CAPT C. A. Ostrom DC USN, was appointed in 1963. CAPT Rovelstad presently is Director, Dental Research Facility, Administrative Command, U.S. Naval Training Center, Great Lakes, Illinois. CAPT Ostrom is Head, Professional Branch, Dental Division, Bureau of Medicine and Surgery. KNOW YOUR DENTAL CORPS The Dental Department of Marine Corps Air Station, lwakuni, Japan, is housed in a nine dental operating room clinic with one room being devoted to prosthodontics and another to oral surgery. There are three dental officers and two dental technicians in the station allowance. Spaces for approximately six dental officers and ten dental technicians are made available to the 11th Dental Company, 1st Marine Aircraft Wing which is based at Iwakuni when not deployed. The Commanding Officer, 11th Dental Company has additional duty as Station Dental Officer. The station, in addition to providing treatment for Marine, Navy and Army personnel, also serves a large number of dependents who have accompanied their Navy sponsors overseas. Iwakuni is located in Yamaguchi Prefecture ap- proximately 25 miles southwest of Hiroshima on the southern coast of the principal island of Honshu. It is an interesting city of 100,000 population. The Marine Corps Air Station occupies the site of the former Japanese Imperial Naval Air Station on a delta between two rivers (Imazu and Monzen) which flow into the Inland Sea at this point. The climate is temperate with heavy and prolonged rainfall occur- ring from the latter part of May until late July. The terrain in this area is mountainous with little level land and few beaches. At the conclusion of World War II, Iwakuni was occupied by the United States Marine Corps. In March 1948, the Royal Australian Air Force as- sumed command. With the beginning of the Korean War in June 1950, the U.S. Air Force started to operate from here, along with U.S. Navy Squadrons and Fleet Air Wing Six. The Air Force assumed command of the base on 1 April 1952. Then in 1954, Iwakuni became a U.S. Naval Air Station; but the Navy relinquished command to the U.S. Marine Corps in 1958, and on I January of that year the base was commissioned Marine Corps Air Facility, Iwakuni, Japan. The designation was subsequently changed in 1962 to U.S. Marine Corps Air Station. The water supply of the dependent's housing area has fluoride added and a base-wide fluoridation sys- tem is being planned. In addition to Navy dental 20 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 technicians, two Japanese female dental assistants perform preventive dentistry treatments. Japanese dentists are frequent visitors. Tours of the dental clinic are arranged for local Japanese dental societies. The Commanding Officer of the 11th Dental Com- pany is on the Special Staff of the Commanding General, I st Marine Aircraft Wing. He is cognizant of Wing dental matters and attends all staff confer- ences. Of particular importance in planning is the matter of training and equipping the Dental Com- pany for deployment. At the present time, the 11th Dental Company has over 60% of its personnel de- ployed in the Republic of Vietnam. PREVENTIVE MEDICINE SECTION PLAGUE IN DANANG, VIET NAM, 1965 LCDR P. F. D. Van Peenen MC USN, Officer-In-Charge, U.S. Navy Preventive Medicine Unit in VietNam, Dec 14, 1965. First Report of Plague in Danang, 1965 L Introduction. A case of Bubonic Plague in a Vietnamese civilian was diagnosed and reported by the Danang Civil Hospital on 19 September 1965. From that date until 18 November 1965, the date of admission of the last human plague case, the U.S. Navy Pre- ventive Medicine Unit (PMU) maintained careful plague surveillance studies in the Danang area. Re- sults of these studies, including rodent surveys, are incorporated in the present report. II. Epidemiology. Prior to 1956, the past history of plague in Danang is unknown. Since 1956, when the first nationwide report was published, no cases had been reported from this area, and Quang Nam Province was considered uninfected at the time of writing the I October 1964-31 August 1965 annual Progress Report of the U.S. Army Medical Research Team, Vietnam (USAMRTV). The possibility of importa- tion of the disease into this province was recognized in that and other reports. The plague focus in Danang appears centered around the railroad and marketing area. Interviews with several plague patients revealed that a number of dead or moribund rats had been sighted in this area prior to onset of human illness. Ratfalls oc- curred about I 0 days prior to illness. III. Clinical. Most patients complained of fever, malaise and inguinal tenderness. One 57-year old female had what appeared to be an infected flea bite on the an- terior right lower leg. On 19 September 1965, 3 febri le hospitalized patients were examined and found to have tender inguinal buboes. There were 2 fatal cases in September, but since that time all patients reportedly responded well to intravenous fluids and antibiotic therapy consisting of 1 Gm streptomycin twice daily, 3 Gms sulfathiazole daily and chlormycetin 2 Gms daily. A total of 62 indi- viduals were studied at the Civil Hospital during the 3 month period: 20 of these were considered to be confirmed plague cases (Table 1 ) . IV. Laboratory. Laboratory work was performed at the Danang Civil Hospital under the supervision of a senior U.S. Operations Mission technician, Miss Racheal West. Bubo aspirates were taken from all suspect patients and stained with Gram stain and methylene blue. Aspirates positive by smear were also studied by TABLE I. Patients Examined at Danang Civil Hospital Total Patients Number of Month Examined Positives Deaths 15-30 September 34 10 2 October 15 6 0 1-15 November 13 4 0 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 21 culture, and sub-cultures inoculated onto modified Stewart's medium for further study at the USAMRTV in Saigon. In many cases, it was pos- sible to obtain acute sera, but convalescent sera could not be drawn since patients did not return to the hospital after discharge. Table II shows results of laboratory studies performed by Miss West, the PMU and the USAMRTV. TABLE II. Laboratory Results of Danang Civil Hospital, PMU and USAMRTV Bubo Month Smears Broth Culture September 9 Pos 8 Pos 24 Neg No Growth October 4 Pos 5 Pos 5 Neg November 4 Pos 4 Pos 9 Neg V. Rodent Studies. A rodent survey program was initiated by the PMU shortly after announcement of the first plague case. Rodents were trapped using locally purchased live wire traps baited with bacon. Rodents were anesthetized with chloroform, identified as to species, bled from the heart and combed for fleas. Museum preparations were made from approximately one third of the specimens and forwarded to appropriate museums. Fleas from the same species and area were pooled in sterile normal saline; flea pools and spleen snips were preserved by freezing and even- tually tested by mouse inoculation at the USAMRTV in Saigon. Sera were examined for hemagglutinat- ing antibodies to Pasteurella pestis at the USAMRTV. Seriological and bacteriological proce- dures are believed to be standard and will not be described. Between 20 September and 15 November, 291 rodents, representing 8 different species, were exam- ined. Three rodents, representing 3 distinct species, Rattus norvegicus, R. exulans, and R. rattus subsp. had hemagglutination titers of 1.8 against plague antigen. These titers are considered significant for plague experience. Spleens from 2 Rattus norvegicus were positive for P. pestis. All flea pools were negative. The only fleas encountered were Xenopsylla cheopis, the oriental rat flea and usual plague vector. Rattus norvegicus was more heavily infested than other rodent species. Although as many as 18 fleas Bacteriological Hemagglutination Confirmation Titers No specimens (1:16) obtained from 2 Neg Civil Hospital 2 Pos 1 (1 :32) Unconfirmed 8 Neg No specimens No specimens obtained from obtained from Civil Hospital Civil Hospital were collected from one individual, the average ani- mal had only 1-3 fleas. In September, 15% of Rattus caught had oriental rat fleas; in October and November the percentages were 10% and 32% re- spectively. VI. Control Measures. Between 15 September and 29 October 1965, 143,000 Vietnamese civilians were immunized against plague by means of vaccine procured from the Institute Pasteur de Saigon. Immunizations were given by teams from the Agency General for Health and Development. This same Agency under- took residual insecticiding with a water emulsion of DDT and DDT dust in areas surrounding the central plague focus. No rodenticiding was attempted. Families and close contacts of plague patients were offered sulfathiazole prophylaxis. No U.S. military control measures were thought necessary. VII. Discussion. The occurrence of plague in Danang was not un- foreseen, and fortunately the present episode was either self-limited or effectively controlled. Since the monsoon rains commenced shortly after the onset of this outbreak, it is possible that climatic conditions contributed to its rapid termination. Because of rodent infection within U.S. Military compounds, and because of the present unsettled condition of many Vietnamese civilians including refugees in this area, it seems wise to continue sur- veillance studies. 22 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 THE USE OF ISONIAZ£0 AMONG HOUSEHOLD CONTACTS OF OPEN CASES OF PULMONARY TUBERCULOSIS Egsmose, T., Ang'Awa, J. 0. W. and Poti, S. J., Bull World Hlth Org 33:419-433, Summary, 1965. A total of 125 rural households were divided at random into 2 groups; the 376 contacts from the first group were given placebo tablets and the 399 contacts from the second group isoniazid tablets. Each household had a tuberculosis index case ex- creting tubercle bacilli detected in the sputum smear by direct microscopy and by culture. The 2 contact groups were, at the time of commencement of the study, comparable in respect of age, size of house- hold, tuberculin sensitivity and other criteria. The majority of the contacts were under 15 years of age and this corresponds to the age distribution in the general population. The prophylactic isoniazid was in the first instance prescribed for 1 year; the drug was distributed at three-monthly intervals and was taken in a single daily dose ranging from 5 to 10 mg per kg of body-weight. The intake to the study took place over 2 years and the observation period was 2-4 years. During the first year of medication a remarkable effect of isoniazid was found. Adverse findings were observed in 28 of the contacts in the control group, as compared with only 6 in the isoniazid group. A more precise expression of the isoniazid effect as in terms of tubercle bacilli excretors. In the control group 17 contacts began to excrete tubercle bacilli during the first year, whereas only 2 did so in the isoniazid group. In addition, 6 out of the 7 controls who excreted tubercle bacilli initially continued to be excretors, in contrast to the 4 initial excreters in the isoniazid group, all of whom were cured. In the subsequent period, after the first year, adverse find- ings were revealed in 4 contacts in the control group and in 3 in the isoniazid group. The number of observations during this period is small and, there- fore, possibly not representative. Neither during the first year nor during the whole period of ob- servation did the tuberculin reactors without pul- monary lesions appear to benefit to any significant degree from isoniazid. There is good reason for believing that the pro- phylactic effect of isoniazid observed during the first year of medication gives an indication of the benefit that would be obtained if a similar isoniazid scheme were integrated into a tuberculosis control program. One-third of a contact case per household (average 6.2 contacts) was prevented from excreting tubercle baciiii. Thus, prophylactic isoniazid has to be ad- ministered to 19 contacts in order to prevent 1 con- tact case. SIGNIFICANCE OF DIFFERENCE IN INCIDENCE RATES OBSERVED IN CONTROL AND ISONIAZID GROUPS Control group Isoniazid group Significance of the difference Initial status During first year of study Incidence Incidence at the 5% Rate( % ) SE Rate( % ) SE probability level Tuberculin conversion 13.19 3.13 5.68 2.07 Significant Tuberculin Development of pulmonary 4.32 1.95 1.86 1.09 Not significant non-reactors lesions Excretion of tubercle bacilli 3.78 1.53 0.00 0.00 Significant Tuberculin reactors Excretion of tubercle bacilli 1.60 0.87 1.04 0.72 Not significant Pulmonary lesions Excretion of tubercle bacilli 21.43 8.08 0.00 0.00 Significant (active and inactive) 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 23 COXSACKIE GROUP B VIRUS INFECTIONS Malcolm S. Artenstein, et al, Washington, D.C., Ann Intern Med 63:597-603, 1965, Mod Med 34 (2):126-127, Jan 17, 1966. Coxsackie group B virus infections are often as- sociated with pleurodynia epidemics; aseptic men- ingitis, orchitis, pericarditis, abdominal pain, grippe, or exanthem occurring in patients who have been exposed to a patient with pleurodynia; and neonatal myocarditis. During epidemic dissemination of Cox- sackie viruses, patients should be carefully observed in order to differentiate pulmonary or myocardial infarction, appendicitis, or other disease with similar symptoms. Since few signs and symptoms are char- acteristic of Coxsackie viruses alone, laboratory con- firmation is necessary. Aseptic meningitis is the commonest diagnosis and pleurodynia is next most frequent. Myocarditis, oc- casionally accompanied by pericarditis, is relatively mild in adults but can be fatal in newborn infants. Abdominal symptoms occur most often in patients less than 10 years old; pleurodynia is rare in children less than 6 years of age. Testicular involvement oc- curs only after puberty. Coxsackie virus infections are most prevalent from May to November and are unusual at other times of the year in temperate cli- mates. Although as many as 5 serotypes have been implicated over a wide geographic area, a single serotype usually predominates in a given year. Data are based on study of 180 patients in whom Coxsackie group B viruses were isolated. SALMONELLA SURVEILLANCE-1963 Virginia Dept of Hlth Morbidity Rpt for week ended 19 Dec 1964. The national program for salmonellosis surveil- lance was formalized on 1 January 1963. A sum- marized report of the first year of salmonella sur- veillance (28 December 1962-27 December 1963) was recently released. Reported human isolations of salmonella totaled 18,649 during 1963. In the United States, the peak incidence occurs in late sum- mer or early autumn. The peak month is October; the month of lowest incidence is February. During 1963, 124 of the 900 known serotypes were isolated from humans. The age group most often infected was one to four years. The highest attack rate was in those under one year. The mortality rate for salmonella was estimated to be 0.34 percent- Sani- tation Section, PrevMedDiv. SHIPBOARD COCKROACH INFESTATION COMSERVFORLANT Information Bulletin II:E-2, E-3, June 1964. A cockroach infestation aboard a COMSERV- LANT ship necessitated the formation of an unusual "hunter-killer" group for the specific purpose of eradicating the roach infestation. It was discovered that the infestation was particularly prevalent in in- accessible spaces behind flashing, false bulkheads, and coverings that had been installed in the interest of eye appeal and habitability, but unfortunately turned out to be excellent hiding and breeding places for roaches. The "hunter-killer" group, after a thorough study of the situation, decided on an all out attack on poor sanitation. Every effort was made to eliminate the most minute residues. Food preparation and serving areas were meticulously cleaned after each meal. Garbage cans were washed after each use. Installed galley equipment was repositioned to facilitate cleaning and eliminate roach harborages. Storage racks were designed to be easily removable for cleaning. Flashing behind sinks was eliminated. Counters and table tops were rebuilt eliminating overlapping seams and hidden corners which would harbor roaches. Old and infested insulation was re- placed and carefully sealed. The soft drink machine was suspended from the overhead to eliminate an- other troublesome roach harborage. Mixers, meat- saws, and similar equipment were disassembled down to the smallest component and thoroughly cleaned after each use. THE RESULTS OF THESE ACTIONS-A CLEAN AND ROACH-FREE SHIP. It is strongly recommended that all ships examine their cleaning and sanitation procedures with eradi- cation of cockroach infestation as a goal. No amount of insecticide will be effective unless coupled with good sanitation. False bulkheads and coverings should be designed to eliminate roach harborages. An "All Hands" effort in establishing and maintain- ing good sanitation will result in a roach-free ship.- Sanitation Section, PrevMedDiv. METHEMOGLOBINEMIA-NEW YORK CITY Morbidity and Mortality Weekly Rpt, HEW, Communicable Disease Center, Atlanta, Ga., 13(49):430, Dec Il, 1964. Five infants in a newborn nursery developed methemoglobinemia due to exposure to aniline dye. 24 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 On Oct. 13, a resident physician in a New York City hospital noticed that 2 infants in the newborn nursery had become cyanotic in appearance. Additional cases were searched for, and a total of 5 infants were dis- covered to be cyanotic. A blood sample was taken from one of the affected infants which contained 67% methemoglobin. Following this, all of the cya- notic infants were treated with concentrated oxygen and intravenous methylene blue. It was observed that the diapers the cyanotic in- fants were wearing had been freshly labeled and a definite phenolic odor was noted. These diapers had been clearly labeled with heavy ink stain across the entire surface. Because of an urgent need for diapers, and contrary to regulation, these diapers had been autoclaved rather than boiled prior to use. The dye contained 30% aniline. The situation was remedied by boiling all of the diapers and no further cases occurred. Editor's Note: There have been several previous outbreaks of methemoglobinemia in newborn infants due to cutaneous absorption of aniline dye in freshly stamped diapers. The first reported outbreak dates back to 1886, in London, England. (Rayner, W.: Cyanosis in Newly Born Children Caused by Aniline Marking Ink, Brit Med Jour 1 :294, 1886). A CASE OF MULTIPLE BEE STINGS Murray, J. A., Central African Jour of Med 10(7):249-251, July 1964. Abstract in Trap Dis Bull 62(1 ):56, Jan "1965. Survival following 2,243 stings by the common honey bee Apis mellifera is reported in this paper: the previous maximum number of stings survived is 600. The victim, a European male, aged 30 years, was walking along a river bank when he was attacked without warning or provocation and the upper half of his body was covered in a layer about 3 inches . thick. He dived into the river, but the bees continued to sting him. Headache, burning abdominal pain, persistent vomiting and diarrhea with incontinence ensued. He covered his head with his shorts but the bees stung through the material; he then plastered the shorts with mud but had to leave a hole for air, which the bees soon found; finally,he kept his mouth close to the hole biting the bees· as they flew in. De- spite having to swallow many bees, he had no diffi- culty with respiration. He was in the water 4lh hours being stung continuously and was ultimately found on the water's edge in a shocked and exhausted condition. The pulse was rapid and thready. The face, scalp, neck, trunk and upper limbs were black with stings and the hair matted with dead bees.There was considerable facial edema but he could see and talk. Response to intravenous hydrocortisone was satisfactory and after 5 days he was discharged from the hospital. He was later accidentally stung by a bee without any allergic reaction. The clinical picture illustrated the histamine effect: no haemolytic, haemorrhagic or neurotoxic effects were evident. Stings should be scraped as forceps may express further venom from the sac which re- mains attached to the sting. Tincture of iodine locally and adrenaline for systemic treatment are the drugs of choice. Analgesics should be used in low dosage if the blood pressure is low. DICHLORVOS TESTED AGAINST A. AEGYPTI IN VIRGIN ISLANDS Vector Control Briefs, HEW PHS, Issue No. 15:11 , Aug 1965. Thirty-two treatments of 20% dichlorvos resin- plastic dispensers were installed in 18 cisterns in Charlotte Amalie, St. Thomas, Virgin Islands, at rates of 114, Y2, I, 2, or 3 dispensers per cistern. Satisfactory mortalities of caged adult female A edes aegypti were obtained for 2 to 6 weeks at these dos- ages with the dosage of 3 dispensers per cistern giv- ing the most effective kills ( 4 to 6 weeks). A bioassay technique utilizing third instar larvae and chemical analyses of samples of the cistern water at no time indicated dichlorvos levels in the water to be greater than 0.1 ppm with most of the determina- tions at or below detectable limits of 0.01 ppm. KNOW YOUR WORLD Did You Know? That 533 cholera cases with a total of 32 deaths were reported by the USSR to the World Health Organization from 2 I August to 13 September 1965? (I) That about 75,000 persons were stricken with malaria after "Hurricane Flora" whipped through Haiti in October 1 963? The epidemic started 6-8 weeks after the hurri- cane and completely wiped out gains that may have been made by 2 years of spraying with DDT accord- 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 25 ing to the National Malaria Eradication Service, Port-au-Prince, Haiti. (2} That 2,922 cases of tuberculosis were reported for the first 38 weeks of 1965 in Belgium? This showed a decrease of about 3% as compared over the same period for the preceding year. In addition, there were 74 cases of diphtheria reported and 22 cases of tetanus; proving that immunization still has not reached 1 00% of the population. (3) That although rabies was eradicated from Uruguay in 1945, an epizootic erupted in August 1965 in Montevideo and environs, with 2 human deaths due to rabies and a total of 158 canine cases by 11 De- cember 1965? By 31 December, 27,199 dogs had been vacci- nated and 4,419 eliminated. The control program is being expanded and intensified in 1966. ( 4) That 116 bronchial asthma patients have been re- portedly successfully treated in the salt mines in Poland? Patients spend 4 hours a day in the treatment chambers of the mines, 417 to 703 feet underground. Treatment is in 30 sessions over a period of 6-8 weeks. The beneficial effect of the salt mine atmos- phere is attributed to the increased C02 pressure (0.! to 0.2% ), which stimulates the asthma patient's respiratory center and peripheral chemoreceptors. This stimulation, in turn, increases respiratory vol- ume and improves oxygen saturation of the circu- lating blood. The salt aerosols present in the mine atmosphere reduce the total number of positive ions that have been implicated in the pathology of bron- chial asthma. These patients had bronchial asthma, chronic upper respiratory diseases, allergic catarrh, chronic bronchitis, bronchiectasis, pulmonary em- physema, or protracted pneumonia. It is further re- ported by the Polish doctors that laboratory tests show that salt mine therapy decreases the number of leukocytes and eosinophilic granulocytes, and roent- genograms show improvement or disappearance of the inflammation in pulmonary tissue. Remissions last from 6 months to 5 years. Plans are being made to install underground chambers so that future pa- tients can sleep there at night and spend the day- light hours above ground. (5) That there is a world shortage of derivatives of the cinchona bark? Supplies of quinine and quinidine are imported from the Netherlands, Germany, Indonesia, and Latin America. While Latin America actually grows a tremendous number of trees of the cinchona fam- ily, the content of anhydrous quinines in them is less than the normal 3% expected in the bark of good cinchona trees. Only Bolivia has trees rich in alkaloid growth, but at present produces only about I 00 tons of bark. Newer sources are being devel- oped in the western hemisphere, such as Nicaragua, etc. In Indonesia and the Congo, changes in planta- tion ownership have been hindering the harvest of the prefered product. Twelve to eighteen years are required to grow a prime tree for supplying the best bark. Several American producers are spending a great deal of money on research to find the best methods for producing acceptable synthetic quinine and quinidine preparations, and to develop new compounds which could duplicate the action of quinine salts. (6) That there are 3 principal theories as to the cause of Reiter's disease? These are reported to be: infection by an unidenti- fied virus; infection by pleuropneumonia-like organ- isms (PPLO); and hypersensitivity of a delayed type of Neisseria gonorrhoeae or, perhaps, such organ- isms as Shigella dysenteriae. Investigations were carried out on the first two theories, and virological studies were undertaken in 24 instances, including 7 of Reiter's disease. (7) That industry lost 10 million man-days in 1965, with an estimated loss of 200 million dollars because of allergies of production personnel? The Allergy Foundation of America believes the annual loss is closer to 400 million dollars. (8) REFERENCES 1. JAMA 195(6): 509, 7 Feb 1966 (Med News, London, 31 Dec 1965). 2. USDHEW PHS Rpt 80(2): 120, Feb 1965. 3. JAMA 195(1): 55, 3 Jan 1966. 4. WHO WKLY EPID Rpt (PASBU) XXXVIII(5): 23.2 Feb 1966. 5. Med News World 6(47): 28·29, 17 Dec 1965. 6. JAMA 195(2): 153, 10 Jan 1966. 7. Clinical Med 73(1): 54-55, Jan 1966, (Reiter's Dis: Microbiologic Studies). 8. Mass Dept of Pub! Hlth, "This Wk in Pub! Hlth," 15(1): 2, 3 Jan 1966. 26 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 OPERATIONAL MEDICINE SECTION TUBERCULOSIS CONTROL With the discovery of streptomycin and isoniazid, the treatment of tuberculosis was greatly simplified. The use of these chemotherapeutic agents, however, has not simplified the overall problem of tuberculosis control. Tuberculosis continues to be an important health problem in the Armed Services. It is a special prob- lem in the Navy where men are aboard ships in close quarters for prolonged periods of time. A patient with an active case of tuberculosis aboard a vessel can infect many shipmates before he is diagnosed and hospitalized. lf tuberculosis is ever to be eradicated, the disease must be discovered early before the patient becomes infective. The Navy's program for tuberculosis con- trol and prevention has been diffusely outlined in various instructions and directives. BUMED In- struction 6224.1 B which deals with tuberculosis prevention is currently being rewritten. This revision will bring together all directives on the subject into one instruction. In addition new policies, methods, and procedures will be promulgated in this instruc- tion. The revised form will be officially released in the near future. However, since tuberculosis is such a pressing problem a brief preview of the instruction is presented. I. Tuberculosis is a highly infectious disease of insidious onset and progression. For this reason, a patient who becomes infected may not develop symp- tomatic disease for a year or even longer. Part of this time, however, he is infecting others; and so the cycle continues. 2. This viscious circle must be broken. This is best done by periodic surveillance of all naval per- sonnel and by vigorous contact studies when an index case is discovered. The new BUMED Instruction 6224.1 B contains several important modifications from the previous program. 3. Several changes regarding skin testing have been made. A positive tuberculin reaction is rede- fined. A diameter of induration greater than 9 mm at 48 to 72 hours after administration of tuberculin PPD shall be considered a positive reaction rather than 5 mm of induration. 4. Tuberculin skin testing of Navy and Marine Corps reserve personnel reporting for active duty in excess of 30 days is now required. 5. Only the Mantoux technique is to be employed in skin testing individuals 6 years of age and older. The multiple puncture technique is permitted in chil- dren under the age of 6. 6. Finally, annual tuberculin skin testing is recom- mended when practical on all personnel with pre- viously negative skin tests. Such an annual surveil- lance program would result in detection of minimal early disease and prevent the progression of tuber- culosis to an infective state. 7. The greatest modification is in regard to con- tact studies aboard a ship. In the past, "intimate" contacts were men in the patient's division or other close social contacts of the patient. Due to experi- ence gained from the past, in the new instruction it is recommended that the entire crew be placed in a contact study wht:n a case of tuberculosis is dis- covered aboard a ship. The contact study will con- sist of periodic chest X-rays and skin testing. 8. When personnel included in a contact study are transferred, it is imperative that the next duty sta- tion be properly notified. Such notification should include data regarding isoniazid prophylaxis, skin test reactivity, and dates of future testing. 9. Because of the high incidence of tuberculosis in the indigenous population of South Viet Nam, the threat to Navy and Marine Corps personnel in that area is quite serious. All personnel should have a base-line tuberculin test upon arrival. It is also recommended that tuberculin negative individuals be skin tested every 6 months while on duty in the area. If conversion of the skin test occurs, then BUMED- INST 6224.1 B should be consulted for proper dis- position. I 0. The ultimate goal of tuberculosis control is the eradication of the disease. It is only by aggres- sively applying the latest and most effective estab- lished principles and techniques of tuberculosis con- trol that this will be accomplished.-Tuberculosis Control, PrevMedDiv. 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 27 EDITORIAL DESK AMERICAN BOARD OF OB-GYN SPECIAL NOTICE The date of the next Part I (written) examination has been changed and is now scheduled for Friday, July 1, 1966, at 2:00P.M. Admittance Slips indicating where to report for examination will be sent several weeks in advance to all candidates scheduled for the Part I examination. Candidates are urged to inform the Board office of any change in address. Applications to take the Part II examination Feb- ruary 20-25, 1967 will be accepted during April or May, 1966. Each application is to include a dup- licate list of patients dismissed from all hospitals during the twelve months immediately preceding the month of application. Current Bulletins and application forms may be obtained by writing to the office of the Secretary, Clyde L. Randall MD Secretary and Treasurer American Board of Obstetrics and Gynecology 1 00 Meadow Road Buffalo, New York 14216 DOCTORS SHAW AND SUMMITT SHARED HONORS On 7 January 1966, twenty-eight medical officers graduated from the School of Submarine Medicine, a department of the U.S. Naval Submarine Medical Center, U.S. Naval Submarine Base New London, Groton, Connecticut. CAPT Walter A. McGuinness, USN, delivered the commencement address. CAPT McGuinness is the Commanding Officer, U.S. Naval Submarine Base New London, Groton, Connecticut. He was intro- duced by LCDR Julio C. Rivera, MC USN, Director of the School of Submarine Medicine. Diplomas were presented by CAPT McGuinness. Lieutenants James 0. Shaw and James K. Summitt were the hon- ormen of the class. Doctor Shaw is a native of Pontiac, Michigan and is married to the former Elizabeth Asher of Pontiac. They reside with their son in Ledyard, Connecticut. He graduated from the University of Michigan Medical School and has been ordered to the Gold crew of the USS James H. Polk, homeported in Groton, Connecticut. Doctor Summitt, a former Navy pilot from Searcy, Arkansas and a graduate of the University of Ten- nessee Medical School, was nominated to receive the Surgeon General's Award. He was selected just prior to graduation on the basis of academic and personal performance grades attained in the daily pursuit of his studies. His leadership qualities and military competence were also considered. The award in the form of a Certificate of Recognition was presented by CAPT Charles L. Waite, MC USN, Commanding Officer, U.S. Naval Submarine Medical Center. Doctor Summitt received the Surgeon General's Award in absentia, since an operational assignment with the Blue crew of the USS Casimer Pulaski re- quired LT Summitt's departure prior to graduation. Five other members of the class graduated with dis- tinction: LT Charles S. Crummy, LT Donald J. Jarzynski, LT Dan A. Kelly, LT William E. Powers and LT Robert D. Staub, all of the Medical Corps. Other graduates were: LT Anthony P. Belmont L T Robert L. Bonsanti LT Robert F. Brill LT Donald R. Eisert LT Robert F. Gomez LTG. William Hays LT Norman M. Heyman LT Michael J. Logan LT August D. Kropp LT Joseph D. McLaughlin L T David K. Miller L T Shelby W. Miller LT Presley J. Mock LT Larry W. Piebenga L T Charles N. Reed III LT James W. Reid LT William A. J. Ross LT James P. L. Schmidt L T Robert H. Wheelock LT William F. Wieting All twenty-eight of the graduates were assigned to Polaris submarines. While on their initial assign- ment as Submarine Medical Officers, they may earn their "dolphins", thereby adding "qualified sub- mariner" to their file. To accomplish this, they must receive the recommendation of their Command- ing Officer, publish a thesis pertaining to submarine or diving medicine, satisfactorily complete a compre- hensive examination, and serve three months in a submarine or diving billet. 28 U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6 j Submarine Medicine is the military medical spe- cialty which supports all underwater operations in the Navy. This includes providing medical services to the crews of all submarines, deep sea divers and underwater swimmers. In general the practice of submarine medicine can be considered a combina- tion of general practice, occupational medicine and research.-U.S. Naval Submarine Medical Center, U.S. Naval Submarine Base New London, Groton, Connecticut. GROUND-BREAKING CEREMONIES JACKSONVILLE, FLA. Ground-breaking ceremonies for the 7 million dollar 400 bed U.S. Naval Hospital at Jacksonville Naval Air Station were held Saturday, February 5 at 4 o'clock in the afternoon. RADM Robert 0. Canada, Jr., MC USN, Deputy and Assistant Surgeon General and former Com- manding Officer of the Naval Hospital ( 1961-1962) was the first to turn over a spade full of earth. He was followed by Congressman Charles E. Bennett, a senior member of the House Armed Services Com- mittee and the keynote speaker for the ceremonies. RADM Edward C. Kenney, MC USN, retired Sur- geon General of the Navy and a former Command- ing Officer of this hospital ( 1955) also turned over a spade of earth. Other Navy, government and community officials on hand to witness the ceremony were RADM H. H. Caldwell, Commander Fleet Air Jax; CAPT J. R. Mackroth, Commanding Officer NAS Jax; CAPT James A. Hiegel, Public Works Officer, NAS Jack- sonville and Resident Officer-in-Charge of Construc- tion; Mayor Louis H. Ritter; William S. Johnson, Naval Consultant to the Jacksonville Chamber of Commerce; and James D. Holmes III, President of the Jacksonville Chapter of the Navy League. U.S. Representative Charles E. Bennett of Florida in delivering the main address said there was a great need for new military hospitals to replace those overaged and temporary of which we have many. CAPT R. V. Berry, MC USN, Executive Officer of our hospital, was the master of ceremonies and CAPT W. S. Baker, Jr., Commanding Officer, gave the welcoming remarks and introduced the distin- guished guests. The 400 bed, eight story hospital will occupy 2 acres and will replace the present 34 temporary World War II buildings now occupying about 50 acres. The firm of Reynolds, Smith and Hills are the architects and engineers for the new hospital. The construction contract was awarded to W. E. Arnold Company of Jacksonville and it is expected that the structure will be completed in late 1967 or early in 1968.-U.S. Naval Hospital, Jacksonville, Florida. BRONZE STAR TO HM3 GALBALL Y Hospital Corpsman Third Class Thomas E. Gal- bally USN, was a recent recipient of the Bronze Star Medal with Combat "V" for his actions while serving with the Third Marine Division at Da Nang, VietNam. The accompanying citation read in part; "On the night of 9 August 1965 the Battalion Command Post was subjected to a sudden and intense mortar attack. Reacting immediately, Galbally proceeded to a tent which had received a direct hit. Seemingly oblivious to the incoming fire, he immediately commenced to administer first aid to the wounded occupants of the tent. By his skillful application of pressure and tourniquets, Galbally was able to keep alive a seri- ously wounded officer who had received multiple shrapnel wounds and was bleeding profusely. Con- tinuing his lifesaving efforts, he accompanied the wounded officer during the five mile evacuation trip to medical facilities. HM3 Galbally's exceptional professional ability, inspiring devotion to duty and courageous actions throughout were in keeping with the highest traditions of the United States Naval Service." The award was forwarded by the Commanding General, Fleet Marine Forces, Pacific, and pre- sented in the name of the President of the United States by CAPT J. W. Albrittain MC USN, Com- manding Officer, U.S. Naval Hospital, St. Albans, New York. Galbally is a native of Auburn, New York where he was graduated from Auburn East High School, later attending the University of New York. He is the son of Mr. and Mrs. James Galbally of 12 Brad- ford in Auburn. HM3 Galbally is currently a mem- ber of the St. Albans Naval Hospital staff where he works in Neurosurgical Service.-U.S. Naval Hospital, St. Albans, N.Y. 25 MARCH 1966 U.S. NAVY MEDICAL NEWS LETTER 29 30 l DEPARTMENT OF THE NAVY POSTAGE AND FEES PAID NAVY DEPARTMENT BUREAU OF MEDICINE AND SURGERY WASHINGTON, D.C. 20390 OFFICIAL BUSINESS PERMIT NO. 1048 - NOnV1N~d ·v ~L~~ r.oou *td30 XAVN · ~L0-20 (A3C t ONOO S3JN31~S 03111\1 :f CJ3W HO.!I .WV I SJ SSV - NSO ~IJ .U:30Hd •;a 1liVJ J.dVJ - - - U.S. NAVY MEDICAL NEWS LETTER VOL. 47 NO. 6