Walter Reed General Hospital Research Articles

The Surprising Origins of a World War II-Era Mural That Was Nearly Lost.

Jack McMillen studied at the Minneapolis School of Art in the early 1930s and went on to work in the New Deal’s Federal Art Project as part of the Works Progress Administration. 1 One of McMillen’s murals still hangs on the wall of the U.S. Post Office in College Park, Georgia. Another McMillen mural is in storage at the Smithsonian. When the country entered World War II, McMillen was drafted at the age of 32 into the U.S. Army. Before he even finished boot camp he was put him in charge of a traveling art show being used to promote the sale of War Bonds (Fig. 1). McMillen traveled the country by train, setting up shop in major cities and small towns from the east to west coasts. In early 1944, immediately after basic training, McMillen quickly fell ill. He started to mysteriously lose weight, and after undergoing extensive tests at Walter Reed General Hospital, doctors determined he had a tumor obstructing his esophagus. The Army surgeons responsible for his care admitted they had never performed the kind of surgery needed to ensure his recovery, but the mass was successfully removed, and turned out to be benign. McMillen, like countless other soldiers of the day, recuperated at the Forest Glen Annex, a former girls’ school purchased by the Army for treating convalescing patients during World War II. It was here that Private McMillen painted the mural which now hangs prominently on display at the National Museum of Health and Medicine (NMHM). The semi-abstractionist painting features convalescing soldiers engaged in a wide range of activities on the Forest Glen campus, identifiable by its eclectic architecture. According to his son, Jack McMillen simply titled the original mural “Noon” (Fig. 2). In 1994, 50 years after McMillen finished the mural, NMHM learned that the painting had been bolted to a wall in a deteriorating building on the Forest Glen campus, with a leak in the ceiling. Despite extensive water damage, the generous support of the U.S. Army Office of the Surgeon General and the Borden Center for Excellence helped make its full restoration possible. Following the museum’s move to Forest Glen in 2011, the 7.1 ft × 10.6 ft mural earned a prominent spot in the National Museum of Health and Medicine, U.S. Army Medical Research and Materiel Command, 2500 Linden Lane, Silver Spring, MD 20910. doi: 10.7205/MILMED-D-15-00395 FIGURE 1. McMillen cherished this signed photograph he received from the movie actress Linda Darnell when she attended the U.S. Army’s traveling art show in Los Angeles in 1943. (Photo courtesy of Dr. Brian A. McMillen.)

Retinoblastoma

The2013annualmeetingof theAmericanAssociationofOphthalmic Oncologists and Pathologists was dedicated to celebrating the life and work of my father, Lorenz E. Zimmerman, MD. Although many may know of his contributions to the field of ophthalmic pathology and oncology, the story of his personal challenges in the field is not widely known. After earning his bachelor of science degree in 1943 and hisdoctorofmedicinedegree in 1945, both fromGeorgeWashington University in Washington, DC, my father completed a pathologyresidencyatWalterReedGeneralHospital.TheArmy then sent him to Korea to run a mobile Army hospital laboratory. That facility supported Chinese and Korean prisonersofwar, and themajorityof specimensobtained there werebacteriologic, thusprovidinganexcellentopportunity for the development of an interest in the pathology of infectious diseases. When he returned from Korea in 1951, he was stationed at Walter Reed General Hospital’s Armed Forces Institute of Pathology (AFIP); his intention was to become an expert in thepathologyofmycoticdiseases.Fortunately,however, the Army had other plans for him, and the result was a 50-year renaissance in the field of ophthalmic pathology. Theevolutionofophthalmicpathology in theUnitedStates began at the ArmyMedical Museum, which later became the AFIP.Early in the20thcentury,most enucleatedeyeswerediscarded because therewas no one trained in ocular pathology. Dr George Callendar, the director of the AFIP in the 1920s, developed aprocess for examining all the enucleated eyes of patients from military institutions, and by World War II, all of these specimenswere sent to theAFIP forhistopathology.This process resulted in theAmericanRegistry of Pathology,where ophthalmic pathology became the first registry. In the early 1950s, few general pathologists were interested in ocular pathology; in 1953,my fatherwas assigned to theDepartment of Ophthalmic Pathology at theAFIP.His response: “I thought it was a stroke of real good fortune for me personally, not because I had anypreconceivednotions or interest in pathology of the eye, but I just knew that itwas a goldmine...in the figurative sense...in terms of having a wealth of material available andhaving this tremendous inflowof cases,notonly from military institutions, but from the civilian sector.”1 Becauseof WorldWar II and the resulting lack ofmanpower, a backlog of 5000 eye pathology cases had accumulated, and this abundance of clinical andhistopathologicmaterialwas the perfect background for the development of my father’s interest in ocular oncology. My father’s willingness and enthusiasm to pursue passionately a field in pathology, aboutwhich he had no prior interest, set the stage for a series of more than 50 years of professionalandpersonalchallenges inandcontributions toocular pathology andoncology, particularly in the fieldof retinoblastoma. In his first 15 years at the AFIP, he publishedmore than 50ocular oncology articles, someofwhichwere landmark initial descriptions.2 This work became intimately intertwined withmyfather’spersonal lifewhen, in1967,myparents’youngest child, Larry, received a diagnosis of bilateral retinoblastomaat4monthsof age.Thisbegana seriesof ironies andcontributions, includingseveral “firsts” in retinoblastomascience, nomenclature, and treatment by 3 generations of theZimmerman family. At the time of Larry’s birth, my father was involved in a reviewofall the casesof retinoblastomaat theAFIP.Therewas no Zimmerman family history of retinoblastoma, but Lorenz E. Zimmerman Jr (Larry) developed bilateral retinoblastoma. Could this havebeenamere coincidence?Larryhada large tumor involving the macula of the right eye and 3 small perimacular tumors in his left eye. Routine treatment at the time was to enucleate the eye with the more advanced tumor and radiate the other. My parents were not satisfied with this and wanted to find a way to salvage vision and the right eye. Larry’s initial treatment, by Drs Algernon Reese and RobertEllsworth inNewYork,wasan intracarotid injectionof chemotherapy.When thiswas ineffective, hewas treatedwithbilateral external beam radiotherapy. Both were experimental treatments at the time. Although bilateral external beam radiotherapy later saved thevisionof countlesspatientsover the years, owing to amore than 30% chance of secondary tumors in the field of radiation,3 better treatments have replaced it. Larry responded positively to the treatment of his retinoblastoma, andhis visionwas salvaged inbotheyes (visual acuitywas counting fingersODand 20/40OS); hewent on to a careerasabanker inManhattan.Hemarried,andafterundergoing genetic counseling and after the identification of hisRB gene, he andhiswife, Anne, decided tohave a child. Perrywas born healthy,butby7weeksof age, shehaddevelopedbilateral retinoblastoma.DrDavidAbramsonsuccessfully treated these tumorswith laser therapy; she had no recurrence of intraocular retinoblastoma. Larry andAnnebecame aware of a newassisted reproductivetechnology, thatofpreimplantationgeneticdiagnosis (PGD), and they sought consultation at the Institute for Reproductive Medicine at NewYorkHospital. The team there developed the mutationanalysisprocedure for the retinoblastomagene (RB1) Related articles pages 605, 614, 622, 630 and 651 Opinion

The Founding of Walter Reed General Hospital and the Beginning of Modern Institutional Army Medical Care in the United States

When Walter Reed United States Army General Hospital opened its doors in 1909, the Spanish-American War had been over for a decade, World War I was in the unforeseeable future, and army hospital admission rates were steadily decreasing. The story of the founding of Walter Reed, which remained one of the flagship military health institutions in the United States until its 2011 closure, is a story about the complexities of the turn of the twentieth century. Broad historical factors-heightened imperial ambitions, a drive to modernize the army and its medical services, and a growing acceptance of hospitals as ideal places for treatment-explain why the institution was so urgently fought for and ultimately won funding at the particular moment it did. The justifications put forth for the establishment of Walter Reed indicate that the provision of publicly funded medical care for soldiers has been predicated not only on a sense of humanitarian commitment to those who serve, but on principles of military efficiency, thrift, pragmatism, and international competition. On a more general level, the story of Walter Reed's founding demonstrates a Progressive Era shift in health services for U.S. soldiers-from temporary, makeshift hospitals to permanent institutions with expansive goals.

Historical perspectives of The American Association for Thoracic Surgery: David J. Dugan (1910-1998)

David J. Dugan, the 56th president of The American Association for Thoracic Surgery (AATS), was born in Oshkosh, Wisconsin, on June 29, 1910 (Figure 1). Growing up in the Midwest, he attended John Carroll University in Ohio, from which he graduated in 1932. He matriculated at St Louis University Medical School, receiving his doctorate in 1936. Interested in general surgery, he completed training at St John’s Hospital in Cleveland in 1939 and embarked on a career in private practice in Lakewood, Ohio. With the involvement of the United States in World War II and 2 years of general surgery practice experience, he entered the Armed Service in September 1942. Dugan was assigned to the thoracic surgery service under the direction of Brian Blades (37th AATS president) at Walter Reed General Hospital. On entering the Army, Dugan and 9 other medical officers were handed instructions for ‘‘Temporary Duty for a period of approximately 6 weeks for the purpose of pursuing a course of instruction in thoracic surgery’’ at the University of Pennsylvania. It is by this route that Dugan began his training in thoracic surgery, a specialty that he ‘‘barely knew existed’’ and a specialty choice that was unsolicited and was ‘‘explained only by the unpredictable wisdom of the United States Army.’’ When the United States entered World War II, thoracic surgery was not yet considered a distinct specialty. Because of its undefined status during theWar, no consultant specializing in thoracic surgerywas formally appointed in any oversea theater. On the basis of subsequent surgical outcomes of the famed Second Auxiliary Surgical Group in the Mediterranean and European theaters, Lyman A. Brewer III (54th AATS president), Paul C. Samson (48th AATS president), Thomas H. Burford (51st AATS president), and others made a compelling case for the establishment of thoracic surgery as a distinct specialty. In the United States, the situation was different. By 1938, the AATS had 14 honorary members, 99 active members, 69 associate members, and 30 senior members. Largely from this AATS group, active and associate members were selected

Pediatric Infectious Diseases: 60 Years of Contributions by Military Pediatricians

* Abbreviations: AAP — : American Academy of Pediatrics CSD — : cat-scratch disease ETEC — : enterotoxigenic Escherichia coli NAMRU-3 — : Naval Medical Research Unit 3 RSV — : respiratory syncytial virus USUHS — : Uniformed Services University of the Health Sciences To describe the many contributions that uniformed pediatricians have made to the field of pediatric infectious diseases is a complicated task. Part of the difficulty is that for the decades after the end of World War II, a number of talented and brilliant physicians spent short periods of time in the military to fulfill their service obligations. Investigators such as Floyd Denny and Lew Wannamaker published their seminal works on group A β-hemolytic streptococci and rheumatic fever while on active duty in the US Air Force.1 Some of the early work on vaccines for common childhood infections was done by investigators who, at least for a portion of time, wore a military uniform. In addition, many of the contributions of military physicians were often made alongside and in concert with their civilian colleagues. In an attempt to illustrate some of the more significant contributions of military pediatricians to the field of pediatric infectious disease, however, a good starting point would be the work of Colonel Ogden Bruton. His early work performed over 60 years ago in many ways began the military legacy of clinical research in a variety of important areas of pediatric infectious disease but in particular those areas where the disciplines of clinical immunology and infectious disease have overlapped. While evaluating children at what was then known as Walter Reed General Hospital in 1951, Colonel Ogden Bruton observed an 8-year-old boy with recurrent pneumonia. Dr Bruton noted the unusual pattern of this child’s pneumonias, and while analyzing the child’s immune system, noted a lack of serum immunoglobulin. Dr Bruton’s observations eventually led to his reporting of the first primary immunodeficiency disease ever to be described, Bruton’s agammaglobulinemia. Both Dr Bruton’s discovery of the disease as well as his attempts at treating it with specific immunotherapy in the … Address correspondence to Michael Rajnik, MD, Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814. E-mail: mrajnik{at}usuhs.mil

The clinical use of albumin: the point of view of a specialist in intensive care.

In the last decades, research on albumin and its administration to critically ill patients have increased considerably, both in clinical and experimental settings. The observations obtained in research ground have gradually led, on the one hand, to important results1 with a potential clinical impact on the treatment of different pathological conditions, and, on the other hand, to discussions and controversies2–4. It is, therefore, mandatory to ask ourselves whether it is really so important to “care” about albumin when dealing with clinical research in intensive care and, if so, why. A rapid glance at the bulk of data available on the topic may guide the answer to these questions. In fact, it is very interesting to discover that a search for publications on “albumin” in Medline, as updated on October 2008, yields 158,083 items, which is surprisingly greater than the number of publications on “haemoglobin” (120,250), a protein that is undoubtedly quite important in human physiology and pathophysiology! Moreover, it is worth noting that almost 40% of all the publications on albumin have been concentrated in the last 10 years, once again underlying, as mentioned above, how “hot” and current this topic may be considered. The beginning of the research on the applicability of albumin in clinical practice has generally been ascribed to World War II, with the first case series of seven very severely burned patients treated with intravenous administration of human albumin after they had been injured during the Pearl Harbour attack5. Actually, the first report of clinical use of human albumin in a patient with traumatic shock had been made few months before, as results from the archives of the Office of Medical History of the United States (http://history.amedd.army.mil/). The case reported concerned a 20-years old man admitted to the Walter Reed General Hospital in Washington D.C. “after he had sustained bilateral compound fractures of tibia and fibula and fractures of five ribs; and associated pleural damage, pneumothorax, and subcutaneous emphysema”. The patient appeared confused and had severe systemic hypotension. After he had received two units of human albumin (for a total amount of about 50 g) over a short period of time (about 30 min), his systemic arterial pressure recovered progressively, and 2 hours later, once his main fractures had also been stabilised, the patient appeared to be completely normotensive. The report described successful complete fluid resuscitation during the next day with a further amount of crystalloids. Of note, at no time after intravenous administration of human albumin was there any evidence of allergic reactions and/or circulatory failure, which had been the main obstacles during a previous research project on bovine-derived albumin. Thus, this first clinical case presented all the potentially important primary and secondary functions of albumin, such as its critical role in determining intravascular oncotic pressure and, on the other hand, its anti-inflammatory properties. From that first case on, many steps have been taken towards a precise clarification of all the characteristics of human albumin with a potential clinical impact in treating critically ill patients. In the present article, we will briefly review the clinical use of human albumin in intensive care medicine and present our point of view on this subject. To this purpose, we will first summarise the physiology and pathophysiology of albumin, we will then given an overview of the evidence currently available on its clinical use, and finally we will discuss the potential clinical indications for its administration, also reporting the design of a new clinical trial recently started in Italy.

Dr. Norman M. Rich, The International Military Surgeon: His French Connection

In 1967, 1 was spending (and enjoying) a year at Duke University doing research with Dr. D. Silver, under the tutelage of Dr. D. Sabiston. Time was passing by very quickly. Before going back to Paris I wanted to visit Walter Reed General Hospital, which was for me the nec plus ultra of American military medicine. A colleague of Dr. Silver gave me the telephone number of a surgeon he met in Vietnam who was now the Chief of the Vascular Surgery Department at Walter Reed. His name was Norman Rich. I called him, we made an appointment, and I flew to Washington. That visit was the beginning of a true and long friendship which had an enormous influence, not only on my career, but also on my family life when I moved, with my wife, to the United States.

Professional Entry Education in Physical Therapy during the 20th Century

Background and Purpose. Professional (entry-level) education in physical therapy, as an enterprise distinct from, yet central to, the profession of physical therapy as a whole, has reached a level of maturity at which there is value in reviewing its development. The authors identify major elements of importance in professional education, including the nature and institutional setting of professional education programs, curriculum content and design, and characteristics of students and faculty. Major events and developments are highlighted for each major element. Methods and Materials. Information has been drawn from published materials dating from the 1910s through the end of the 20th century and from archival records maintained by individual professional education programs and professional organizations in or related to physical therapy. This information has been augmented by the authors' personal experience of professional education during the years from the 1940s through the end of the century. Summary of the Literature. Comprehensive reviews of professional education in physical therapy have been conducted at various points in time. Detailed analyses of different aspects of physical therapy education have been published throughout the 20th century. Comprehensive, but nonscholarly, histories of the profession of physical therapy, including discussions of events pertaining to professional education, also have been published, most recently in the mid 1990s. Conclusion. The article provides an overview of the history of professional education in physical therapy. Key Words: Physical therapy education. INTRODUCTION A thorough discussion of professional (entry-level) education in any field needs to address a variety of related topics, including curriculum content and format, institutional setting and program resources, faculty and student characteristics, and program standardization and accreditation. Fortunately, a number of these specific concerns are addressed in other articles in this special issue. This article, while not attempting to do complete justice to the remaining topics, will highlight the major issues and developments that occurred during the 20th century in regard to curriculum content and design, faculty and student characteristics, and institutional setting of professional education in physical therapy. Put yourself in the position of responding to the hypothetical requests for information that are interspersed throughout this article. What might you emphasize in response to each one? How might your response have varied in each circumstance? Lucy C_ Boston, Mass Dear Cousin Lucy, February 21, 1918 I was so excited to hear that you have decided to apply to be one of these new Reconstmction Aides. It sounds so thrilling! I have been thinking that maybe I could do that, too, if I could get into a training program this summer, rather than going to normal school as I had planned. Could you tell me more about it? Where would I have to go to get training, and what would it be like? I'm sorry you were not able to be home for Christmas . . . Your loving cousin, Beth The Cedars, Park City, Iowa If Beth was considering attending normal school in the fall, she almost certainly would have been much too young to become a Reconstruction Aide, the lower age limit for applicants being 25 years.2 Her cousin Lucy, if she was entering training in the Boston area, had open to her a choice of three programs that had been identified by the Office of the Surgeon General of the Army, the American School of Physical Education, the Boston School of Physical Education, and the Posse Normal School of Gymnastics.3 Another East Coast school also was identified by this time, the New Haven Normal School of Gymnastics. Later, in 1918, a new training program was instituted at Walter Reed General Hospital under the auspices of the Medical Department of the Army. …

The American Association for Vascular Surgery: Advocate for independence

The American Association for Vascular Surgery: Advocate for independence

The American Association for Vascular Surgery: Advocate for independence

The American Association for Vascular Surgery: Advocate for independence

Neonatology--A Six Finger Exercise Revisited 149

In 1958 at Walter Reed General Hospital the cartoon, “Neonatology--A Six Finger Exercise” was first used with special emphasis on the sixth finger--pediatrica iatrogenica. This area had been a major factor in the development of this new field and must always remain a concern for those who care for the newborn. The cartoon below will be discussed in light of the time. Figure

Bird T. Baldwin: a holistic scientist in occupational therapy's history.

Holistic patient care and the scientific research method are two important aspects of occupational therapy. Bird T. Baldwin contributed to the formulation of these tenets at the beginning of this century. Baldwin, a psychologist by training, became the director of the occupational therapy department at Walter Reed General Hospital in Washington, DC, during World War I. In his department, functional rehabilitation was achieved via scientifically analyzed purposeful activities. He believed that purposeful activity was superior to exercise. Activity choice was based on physical, vocational, social, and emotional considerations. True to his scientific approach, Baldwin designed and adapted devices to provide standardized treatment protocols. Because Bird T. Baldwin's approach to rehabilitation remains of value today, a review of his work is relevant to the occupational therapy community.

Primary malignant germinal tumors of the mediastinum. A study of 24 cases.

The malignant germinal tumors found in the testis (seminoma, teratocarcinoma, embryonal carcinoma, choriocarcinoma, and mixtures of these) can originate in the anterior mediastinum. An occult testicular tumor must be sought, but primary mediastinal germinal tumors constitute a true entity. The details of 24 such patients treated at Walter Reed General Hospital are presented. Of 19 patients who died, 2 were women; postmortem examination of the testes of 13 men failed to reveal a primary tumor. Five patients are alive and well with no testicular abnormality. It is important to distinguish the histopathologic types. Seminomas are readily controlled with modest doses of irradiation. Embryonal carcinomas are also radiocurable with somewhat higher doses; 2 long-term disease-free survivors are reported. Teratocarcinomas are highly malignant and require higher doses for control. Choriocarcinomas progress so rapidly that chemotherapy is necessary.

Prospects for para-aortic irradiation in treatment of cancer of the cervix.

The incidence of para-aortic node metastasis in cancer of the cervix ranges from 5%to 50% in clinical Stages i-iv. Extended field irradiation is being administered more frequently because of high incidence of extrapelvic disease. The cancer of the cervix material at Walter Reed General Hospital has been analyzed as to site and time of failure to determine who might have benefited from extended field irradiation. Of patients who fail, the majority will have uncontrolled pelvic disease regardless of other involvement. Diagnostic procedures including staging laparotomy are unable to predict pelvic failure or the presence of occult distant disease in lung and bone. The maximum number of patients who could benefit from pari-aortic irradiation is lessthan 3% of a total series. It is concluded that the salvage of patients with para-aortic metastasis will be small, but for those few long-term survivors, the benefit will be great.

Endobronchial Metastasis

An attempt was made to define the incidence of tumor metastasis to central bronchi that could clinically mimic primary bronchogenic carcinoma. In a retrospective review of 1,359 consecutive autopsies at Walter Reed General Hospital, metastatic involvement of a major airway was present in only 2% of patients who died with solid tumors. The most common extrathoracic tumors associated with metastatic involvement of a central airway are renal and colorectal carcinomas. The clinical and roentogenographic features of endobronchial metastasis and bronchogenic carcinoma were found to be indistinguishable. However, in the majority of cases the primary tumor site is clinically apparent before symptoms of endobronchial metastasis. In most cases of endobronchial metastasis, the histologic appearance of the bronchoscopic biopsy suggests the correct diagnosis. A central bronchogenic carcinoma should rarely be confused with a metastasis to a major airway from an extrathoracic source.

Endobronchial metastasis

An attempt was made to define the incidence of tumor metastasis to central bronchi that could clinically mimic primary bronchogenic carcinoma. In a retrospective review of 1,359 consecutive autopsies at Walter Reed General Hospital, metastatic involvement of a major airway was present in only 2% of patients who died with solid tumors. The most common extrathoracic tumors associated with metastatic involvement of a central airway are renal and colorectal carcinomas. The clinical and roentgenographic features of endobronchial metastasis and bronchogenic carcinoma were found to be indistinguishable. However, in the majority of cases the primary tumor site is clinically apparent before symptoms of endobronchial metastasis. In most cases of endobronchial metastasis, the histologic appearance of the bronchoscopic biopsy suggests the correct diagnosis. A central bronchogenic carcinoma should rarely be confused with a metastasis to a major airway from an extrathoracic source.

Sipple Syndrome and Acute Lymphoblastic Leukemia

ACUTE leukemia, to the best of our knowledge, has not been reported to occur with Sipple syndrome. Although acute lymphoblastic leukemia is not derived from neuroectoderm, it might arise in this setting because of excessive antigenic stimulation of the lymphoreticular system by products of synthesis released from medullary thyroid carcinoma. The presence or absence of chromosomal defects and the status of the immune system in patients with Sipple syndrome have not been established. These factors may also be important in the etiology of acute leukemia. In the following case, however, it must be admitted that acute lymphoblastic leukemia may have been only a fortuitous association. <h3>Report of a Case</h3> A 28-year-old man was admitted to Walter Reed General Hospital on June 21, 1966, with the chief complaints of severe dyspnea on exertion, dizziness, and blurred vision over the past few weeks. The patient had had episodes of palpitation, substernal pain,

Munchausen Syndrome With Renal Stones

HEMATURIA as a presenting symptom of Munchausen syndrome is unusual. Ireland et al, 1 in a review of all the reported cases of Munchausen syndrome, could only find four cases with hematuria. Several cases with hematuria have been reported since then, 2-5 but we have found no cases previously reported in which the patient presented an actual renal stone that was supposedly passed. We have treated such a patient who exhibited factitious urinary tract infection, hematuria, and a number of stones that she "passed." Report of a Case A 37-year-old white woman was referred to Walter Reed General Hospital (WRGH) from a nearby Army Hospital because of frequent passage of kidney stones. She gave a history of bilateral stag-horn calculi requiring nephrotomies when she was 16 and 17 years old. Since then, she allegedly passed one or two stones a year until she had a nephrectomy for a nonfunctioning right

Irradiation in the local control of malignant lymphoreticular tumors (non-Hodgkin's malignant lymphoma).

A retrospective study was undertaken of previously untreated patients with lymphosarcoma, reticulum cell sarcoma, and giant follicular lymphoma seen at Walter Reed General Hospital from 1949 through 1970. The original slides were reviewed and assigned the current histopathologic classifications (Rappaport) without prior knowledge of the clinical course of the disease. Of the 131 patients who were irradiated to 273 tumor-containing areas, failure of local control was infrequent. Modest total doses controlled tumors with a nodular histologic pattern. Those with a diffuse pattern required somewhat higher doses. Recurrence seems related more to location of the disease than to cytologic distinctions. Classical time-dose concepts have limited applicability to these tumors. A threshold dose is suggested by the data for these and perhaps other very radiosensitive neoplasms.

Upper Extremity Venous Thrombosis

ABSTRACT To the Editor.— The recent article Upper Extremity Venous Thrombosis With Pulmonary Embolism: A Complication of Excretory Urography (227:187, 1974) by Clagett et al drew my interest. In a review of 23 patients with primary subclavian-axillary vein thrombosis seen over a 16-year period at Walter Reed General Hospital, Washington, DC (Swinton et al, Circulation 38:737, 1968), we identified one certain and one probable pulmonary embolus resulting from primary upper extremity venous thrombosis: the former case has been previously reported by A. H. Aufses, Jr (Surgery 35:957, 1954). In addition, the potential for precipitation of venous complications following intravenous infusion of radiopaque media was observed in two patients. One suffered a transient chemical phlebitis and exacerbation of symptoms in the affected arm following phlebography; the other developed severe basilic-cephalic-antecubital chemical phlebitis in the contralateral normal extremity following bilateral diagnostic phlebography three months after the onset of the primary axillary thrombosis. We concluded