Letter No. 10May 24, 1945

Dear Doctor:

This letter is sent to you by the Surgeon Generals of theArmy, Navy and the U. S. Public Health Service, with the coopera-tion of the American Medical Association and under the auspicesof the Committee on Information of the Division of Medical Sci-ences of the National Research Council.

Under the title ,f A Common Masquerading Lung Disease, TT Dr.Richard H. Overholt has called attention to the importance ofearly diagnosis of primary cancer of the lung. He points outthat many patients ask for help at a time when the lesion isstill confined to the lung, that the earliest lesions will inalmost every instance give some telltale or suspicious shadowon a single x-ray film, and that there are two methods avail-able for settling the diagnosis: first, the majority of lesionsare visible bronchosconically and are accessible for biopsy, and,second, wrhen the diagnosis cannot be verified bronchos conically,it is possible to explore the chest safel3^^d{fTd~~th^o iagnosisand carry out curative treatment if necessary'. ‘ Rich-ard I.: ?, A Common Masquerading Lun" Di§4ase, T! DlS-dajBes ol theChest 9:197 (May-June) 1945.)

vs. JjJLpi i-Wx-ft-V JLIn an editorial published in Disea.ses Ehe official

publication of the American College of Chest Physicians, Dr.Cnarles M. Hendricks of El Paso, Texas, says that at best the4x5 film now in use for studying the chest should be consideredonly as a screen test. He emphasizes a report by Erlich, Shillerand Edwards, who said, "Following a complete study of rejectedcases by the New York City Health Department, it was found thatthe percentage reclassified as acceptable for army service afterprevious rejection, on the basis of 14x17 (paper) film was halfthat of those disqualified by the 4x5 film." The medical divi-sion of Selective Service headquarters in Tennessee states thata special board found negative 5,286 or 64.9 per cent of 8,139films of selectees rejected for tuberculosis. Dr. Hendrickssays that the results of these studies should encourage allinduction examining station commanders to insist on the ap-pointment of medical advisory boards. (Editorial, Diseases ofthe Chest 9:261 (May-June) 1943.)

A report by Brig. Gen. Charles C. Hillman indicates thatthe Army admission rates per thousand for tuberculosis in 1917and 1918 were 11.7 and 9.2 respectively. The present rate is2.7. Admissions in the Army during recent months have comelargely from those on whom it was impossible to get chest.roent-genograms upon induction. Men whose tuberculosis is service-connected are transferred to the Veterans Administration for

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further care. Those who are found to have tuberculosis not incidentto the service are transferred to Fitzsimons General Hospital.To provide facilities in the East to supplement those of Fitz-simons General Hospital in the West, a new general hospital isunder construction at Asheville, North Carolina.(“The Tubercu-losis Problem in the A.rmy,” Diseases of the Chest 9:265 (May-June) 1943.) **********

The diet of the peasant farming population of North Chinaand Manchuria, says Dr. H. S. D. Garven, is based on the factthat North China is a sorghum or tall millet growing area. Riceand noodles are little used. Dairy products, baked bread, whitepotatoes and beef are conspicuous by their absence. The millet,roughly ground or in whole grains, boiled to the consistency ofporridge, is the staple. This is supplemented with green vege-tables, fresh or pickled—mainly Chinese cabbage—a few rootvegetables, some sweet potatoes, soy bean products, ith occa-sionally a little pork, a little wheat flour and eggs. (Garven:H. S. D.: “Chinese Diets,” Bull. Vancouver Med. Assn. 19:210(April) 1945.)

Traction injuries to peripheral nerves are described by Drs.W. Bremner Highet and W. Holmes, writing from the Nuffield De-partment of Orthopaedic Surgery (Peripheral Nerve Injury Centre)of Oxford University in England. Their report in The BritishJournal of Surgery, January, 1943, page 212, describes in detaileight cases of traction injury to the lateral popliteal nervewrhich were treated surgically and the lesions examined histolog-ically. The traction lesion is characterized by much more ex-tensive damage to the nerve-trunk than is found after injury byincision, laceration or gunshot wound. Spontaneous recovery didnot take place even in cases in which nervous tissue was con-tinuous throughout the lesion. In three cases end-to-end suturewas performed after an extensive resection of the lesion; closureof the gap -was obtained by extensive mobilization of the nerveand flexion of the knee. Recovery did not take place in thesecases. It is concluded that failure of recovery after extensiveresection and suture may be due to injury inflicted on the nerveduring postoperative extension of the joint.

In a critical review entitled "Slow Union of Fractures,” in-volving a study of 804 fractures of the shafts of the tibia andfemur,°R. Watson-Jones, Consultant in Orthopaedic Surgery, RoyalAir Force, and Wing-Commander W. D. Coltart conclude that uncom-plicated fractures"treated by simple manipulation and plasterare uniting as quickly today as in former years. en to twelveweeks should be accepted as the minimal period of immobilizationof lower-limb shaft fractures; lengthy protection is not onlymore safe but accelerates functional recovery. They state thatonlv the minimal period of immobilization can be iixed; rhe average'period" is meaningless because there is such wp.de variation

between uncomplicated fractures which unite in about 12 weeks,difficult fractures in 12 to 24 weeks, infected and distractedfractures in 6 to 12 months, and avascular fractures In 1 to 3years. Delayed union results from interrupted immobilization,traction and distraction, infection, persistent angulation, tooearly weight-bearing and loss of blood supply to the fragments.They say that every fracture unites If it is immobilized long-enough. The greater use of skeletal traction accounts for re-cent increase in the frequency of slow union, particularly Infractures of the shaft of the tibia. The time required for unionis trebled, or more than trebled, by distraction, even if itamounts only to 1/4 In. and even If it is corrected within afew/ days. Traction without obvious distraction also causep markeddelay in fractures of the tibia. In skilled hands operativereduction does not cause delay, and it is better to preventredisplacement of unstable fractures of the tibia by internalfixation than by continuous traction. The decision to useinternal fixation should be made within a day or two of injury;it should not be a last resort. Early weight-bearing in plaster,in skeletal transfixion apparatus, or in a calliper splint, doesnot accelerate union; it delays it. The delay is most strikingif angulation of the fragments is imperfectly corrected, becausew/eight-bearing then causes distraction on one side of the frac-ture. Weight-bearing before the stage of clinical union is un-wise. Reduction of fractures of the shaft of the femur shouldbe secured imm.edla.tely by manipulation and not gradually by heavytraction; light continuous traction should then be used only tomaintain length and not also to control alinement. infection offractures and of neighboring soft tissues causes serious delayand should be minimized by early wound excision, early seques-trectomy and early replacement of destroyed skin by grafting.Infection of a fracture should not be a cause of non-union.(Watson-Jones, R. and Coltart, W. D. : ,! Slowr Union of Fractures,”British J. of Surgery 30:260 (January) 1943.

A report, assembled b; the British Ilir istry of Fee 1th andpublished by Drs. Paul B. Beeson anc Ethel • es terms, n of theAn rican Pel Cross Harvard Field Eosa it, 1 Unit ir tl e BritishHelical Journal (April £1, 1912, p. 497), analyzes 2,575 casesof cerebrospinal fever treated with sulfonamides. All but 19patients received sulfonamides; 965 also received some for . ofspecific serum therapy. I’he fatality rate for all petients v.as15.94/ - greatest at the extremes of life and least in the15-19-years age group. Of the eaths 38 per cent occurred \ it in24 hours of the time of admission to the hospital. Most frequentcomplications 1 ere cranial nerve paralysis, arthritis ana deaf-ness. The case fatality rate in which sulfonamides alone wereussd was 14•Z>% « In cases In which serum treatment was combinedith chemotherapy the fatality rate was 18.8/. The authors con-

clude that there is no indication that the administration ofserum as an adjuvant to sulfonamide therapy is beneficial.

The Bulletin of the Health Organisation of the League ofNations (Vol. 10, No. 1, 1945) is devoted largely to an articleby Dr. Yves Biraud, entitled, "The Present Meance of Typhus Feverin Europe r.m th* Means of Combating It." It Presents the condi-tions for an epidemic, a summary of the present situation inEurope, a Consideration of the possible extension of typhus, andsome observations on the use of vaccines. The violent epidemicwhich prevailed in Spain in 1941 and 1942 was associated withdestitution engendered by the Civil - sr. The appearance of typhusin France is relatea to the typhus which is hyperendemic in NorthArnica. There has been louse infestation among troops fron CentralFurope in the area of Poland anc in the invaded Soviet territories.Typhus is markedly on the increase in the endemic countries ofEastern Europe, Spain and North Africa, and has made its appearancein regions of Central anc Western Furope hitherto free from the dis-ease. Delousing should be carried out among those elements of thepopulation which are most exposed. Vaccination should in the firstinstance be applied to medical and sanitary personnel, using; akilled vaccine. If an epidemic becomes widespread and the popula-tion is a shifting one and is lousy, live vaccines should be used,according to Biraudf, because of the rapid preventive action o ' sucha vaccine followingsingle injection. Certain and absolute pro-tection of all -individuals vaccinated mu: t not be expected. "Killedvaccines, "says Biraud, "do, Indeed-, ive to all f certain a nount ofprotection, but this protection, which generally reduces theseverity of typhus infection, is not al ays sufficient to preventinfection. As for live vaccines, the protection they confer is, ase rule, greater, but, unfortunately, appears to be less constant.It is reported that two types of live vaccines were used in North

ica it! - lly favo results: the new method of Blanc(biliated flea virus) ad that of Laigret-Durand (mouse-brain).The article is complete i ith an extended bibliography.

Col. B. C. Leech of the R.C.A. .C. reports orj the usp ofanesthesia in handling the Die >pe " : ?i casualties in August .1942*His report appears in the Proceedings of the Royal SocietMedicine for ' 1945, p. 207. From handling these casualtiesthey say th t intravenous pentothal-so ium can, end likely will,take care of upwards of 5Q%> of anesthetic de . In the handsof experienced specialists, cyclopropane (often embracing endo-trachesl technic) is the anesthetic of first choice for surgeryof the head, neck, chest anc abdomen; vhenever profound muscularrelaxation is needed; and hen dealing vith patients who are inshock. It still remains the safest agent in relatively unskilledhands• The Oxford vaporizer may prove valuable for the mainten-ance of anesthesia by temporary, inexperienced anesthetists. TheU ffield Department of Anaesthetics of the University of Oxfordhas issued a pamphlet describing the use of the Oxford vaporizer.Kitrous oxide is no longer a popular agent with Canadian armyanesthetists. It is recommended thdt medical officers in eachunit be trained in the use of ether and of intravenous pentothal-sodiurn so that administrations of anesthesia will not be assignedto anyone - ho is not a graduate of medicine. (Freda B. Bannister,M.D., "The Oxford Vaporizer in Routine Hospital Practice," Pro-ceedings of the Royal Society of Medicine, March 19do, p. 205).

A review by Rrs. John Id. ■ cKibbin ar Fredrich J. Stare of"Nutrition in Blood Regeneration (journal of the American DieteticAssociation, "lay 1943, page 331) shows tit ?oods in iron andprotein in the diet of the average blood donor ill insure a morerapid return of the blood picture to normal. The diet should alsoinclude liberal amounts of other essentials sue as copper as wellas those factors whose relation to bloo regeneration has not beenclearly established, namely, some of th. vitamins of the B complex.A diet which meets the requirements of the Food and Nutrition Boardof the National Research Council , with increased e is on ironand protein foods, can be expected to provide optimum blood regener-s tion.

In a revise of the "local Therapy of Catarrhal Conjunctivitisith Sulfonamide Compounds fT irs. .Ppillips Thymeson arm. .Arson F.

Brailey (Archives of Ophthalmoidgy, May 1943, page 760) state thatacute catarrhal conjunctivitis of bacterial origin responded satis-factorily to treatment with 5 per cent sulfathiazole ointment, "’hetreatment is of- particular value in acute staphylococcic conjunctivi-tis vhicb under ordinary methods of treatment frequently becomeschronic. Chronic conjunctivitis caused by Staph, aureus and ciplo-bacilli, unmixed or mixed with other conjunctival pathogens, respondedsatisfactorily to treatment with sulfathiazole ointment, ’fixedstaphylococcic and diplobacillary conjunctivitis, lieu h- d beencompletely resistant to zinc sulfate, yielded readily to sulfathia-zole ointment. Ordinary antiseptic therapy was relatively ineffective.C ronic conjunctivitis in which there were no significant bacterio-logic pathogens failed to respond, -with a few exceptions, to localtherapy with a sulfonamide compound. A few local allergic reactionsto sulfathiazole were encountered..

Pudenz, *"0rising in, the Department of Neurosurgery ct 'AcGillUniversity, has found "by extensive experimentation .that tantalumclips are"less toxic to brain cells than those of silver. Suchclips are , the reforr, recommenced to replace silver in hemostasisin neurosurgical operations. (helical Press and Circular, CurrentTopics, Tt April 14, 1943, page 227),