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FAT EMBOLISM
840 of this postural treatment should be combined with the routine preoperative treatment for up to perhaps 4 hours, but that this trial should be undertaken only in
hospital. Postgraduate Medical School of London, W.12.
A. K. MONRO.
part
of trauma and precipitates of the excess fat present in the blood in direct proportion to the amount of this I was unable to carry on with the enzyme present. investigations, but would like to have the comments of others who are in a position to test this theory.
P. R. SONDHI Port Blair.
PRIMARY PURPURA
SiR,- Your leading article of Sept. 29 failed to mention the value of alpha-tocopherol therapy in this condition. It was pointed out in 19461 that when thrombocytopenic purpura was treated with massive doses of alpha-tocopherol the clinical condition improved, capillary permeability became more normal, and the plateletcount increased. Indeed, in no disease condition have we ever seen a lowered platelet-count that massive doses of alpha-tocopherol would not quickly restore. Confirmation of these observations on purpura and platelet-counts has come from Vilanova and de Dulanto,2 and in some measure from Sterzi.3 Confirmatory evidence on capillary permeability has been published by Ames, Baxter, and Griffith4 and Minkowski.5 Shute Foundation, London, Ontario, Canada.
E. V. SHUTE.
AMERICAN DOCTORS’ INCOMES
SiR,-Referring to your annotation of Oct. 13, I fear there may be misunderstanding about pathologists’ incomes. The yearly income of$22,284 for pathologists refers only to those specialists deriving over 50% of their income from private or independent practice. Such persons are generally older men and represented only 0.5% of the total group of fully specialised individuals in private practice. Pathologists, on the other hand, made up 74% of the total number of fully specialised physicians in salaried practice. Their incomes were about half those of their confreres in independent practice11,745. The causes of the discrepancy in the incomes are varied. Not only are salaries in general always lower than income from fees, but the average age of the independent pathologist was 7 years greater than that of the highest paid independent specialist. In addition, the salaried pathologist was 8 years younger than the independent pathologist. St. Joseph Hospital, S. M. RABSON. Fort Wayne, Indiana, U.S.A.
FAT EMBOLISM
Sir,,-The
cause
of fat embolism has not yet been
While working as casualty accurately ascertained. registrar at Worcester Royal Infirmary I saw one case of fat embolism following a transverse fracture of tibia. This case presented a true picture of cerebral and pulmonary fat embolism. About a week after the onset we estimated the blood fatty-acid, which was over 1000 mg. per 100 ml. (the upper limit of normal being about 400 mg.). The level returned to normal in about six weeks. The increase could not possibly be explained by liberation of fat from the fracture site, and we thought it might be due either to failure of elimination of fat through defective liver function, or to failure of adrenal cortical secretion due to traumatic shock. It has lately been noted by Aldersberg et al.6 that blood-fat is directly influenced by A.C.T.H. Excess fat in the blood does not, however, amount to precipitation of fat in blood-vessels. Hence it may be that a substance (? lipokinase) is liberated at the site Urol. cutan. Rev. 1946, 51, 732. 1. E. V. 2. Vilanova, X., de Dulanto, F. Rev. clin. esp. 1948, 29, 297. 3. Sterzi, G. Arch. ital. Derm. 1950, 23, 257. 4. Ames, S. R., Baxter, J. G., Griffith, J. Q. Int. Rev. Vit. Res. 1951, 22, 401. 5. Minkowski, A. Arch. franç. Pédiat. 1949, 6, 276 ; Sem. Hôp. Paris, 1950, 26, 1275. 6. Aldersberg, D., Schæfer, L. E., Drachman, S. R. J. clin. Endocrinol. 1951, 11, 67.
Shute,
Senior Medical Officer, Andaman and Nicobar Islands.
THE PRACTICE OF B.C.G. VACCINATION
SiR,-In order to undertake the
B.C.G.
vaccination of
tuberculin-negative contacts of patients suffering from pulmonary tuberculosis, Dr. Arblaster (Oct. 20) has had to reduce the procedure recommended by the Ministry of Health from eight stages to four ; and that in a densely populated area and at a chest clinic employing
its own enthusiastic whole-time tuberculosis health visitors. Little wonder is it, then, that others, working in mixed rural and urban areas with no full-time tuberculosis health visitors but only rather distant contact through the public-health department with general area health visitors, have found it next to impossible to keep abreast of the current contacts of tuberculous patients requiring examination and vaccination. The full-time tuberculosis health visitor, experienced and fully trained in tuberculin skin-testing, is the essential part of Dr. Arblaster’s or other similar schemes. Without such an essential member in the team it is very difficult to undertake vaccination in an urban area and, in my experience, practically impossible in rural areas. One mother spent 6s. each time she brought her five children about five miles to the chest clinic. Even the most willing find it difficult to cooperate when travelling is so costly, and this added burden usually falls to the lot of the already financially depressed tuberculous
family. I
am
informed that many local health authorities,
particularly those administering large rural areas, are adopting a policy of employing general health visitors. Surely this is a retrograde step in the. prevention of tuberculosis ? The time has come for them to review the before it is pursued further.
position
Chest Clinic, St. Helen’s Hospital, Ipswich.
CHARLES J. STEWART.
SIR,-I have read with surprise the article by Dr. Arblaster. B.C.G. vaccination was introduced into this country with considerable diffidence. After it had been used for many years in the Scandinavian countries, where its reputation had been enhanced by a remarkable decrease in morbidity and mortality, it was decided here that every care should be taken not to bring this practice into bad repute. Dr. Arblaster describes a flimsy scheme which might be suitable for use amongst the backward countries where clinic and follow-up facilities are small. The generally accepted procedure now is to give one injection of 0-1 mg. Old Tuberculin. If the result is negative the patient is segregated for 6 weeks. The test is then repeated, and if negative B.C.G. is given immediately. After a further 6-8 weeks there is a final test of 01 mg. o.T. to see if conversion has taken place. This means six attendances in all, and not eight as stated. It has created no difficulty whatever in a city the size of
Coventry. In his article Dr. Arblaster does not say whether the health visitors visit regularly during the period of segregation and follow-up, or only to apply the jelly test. How, therefore, is the size of the local reaction to be accurately recorded, or, if there are any unusual reactions, such as an axillary adenitis, who is to bring this to the attention of the chest physician concerned ? Every local authority by now should be provided with an adequate number of tuberculosis visitors, and I cannot, therefore,
hospital. Postgraduate Medical School of London, W.12.
A. K. MONRO.
part
of trauma and precipitates of the excess fat present in the blood in direct proportion to the amount of this I was unable to carry on with the enzyme present. investigations, but would like to have the comments of others who are in a position to test this theory.
P. R. SONDHI Port Blair.
PRIMARY PURPURA
SiR,- Your leading article of Sept. 29 failed to mention the value of alpha-tocopherol therapy in this condition. It was pointed out in 19461 that when thrombocytopenic purpura was treated with massive doses of alpha-tocopherol the clinical condition improved, capillary permeability became more normal, and the plateletcount increased. Indeed, in no disease condition have we ever seen a lowered platelet-count that massive doses of alpha-tocopherol would not quickly restore. Confirmation of these observations on purpura and platelet-counts has come from Vilanova and de Dulanto,2 and in some measure from Sterzi.3 Confirmatory evidence on capillary permeability has been published by Ames, Baxter, and Griffith4 and Minkowski.5 Shute Foundation, London, Ontario, Canada.
E. V. SHUTE.
AMERICAN DOCTORS’ INCOMES
SiR,-Referring to your annotation of Oct. 13, I fear there may be misunderstanding about pathologists’ incomes. The yearly income of$22,284 for pathologists refers only to those specialists deriving over 50% of their income from private or independent practice. Such persons are generally older men and represented only 0.5% of the total group of fully specialised individuals in private practice. Pathologists, on the other hand, made up 74% of the total number of fully specialised physicians in salaried practice. Their incomes were about half those of their confreres in independent practice11,745. The causes of the discrepancy in the incomes are varied. Not only are salaries in general always lower than income from fees, but the average age of the independent pathologist was 7 years greater than that of the highest paid independent specialist. In addition, the salaried pathologist was 8 years younger than the independent pathologist. St. Joseph Hospital, S. M. RABSON. Fort Wayne, Indiana, U.S.A.
FAT EMBOLISM
Sir,,-The
cause
of fat embolism has not yet been
While working as casualty accurately ascertained. registrar at Worcester Royal Infirmary I saw one case of fat embolism following a transverse fracture of tibia. This case presented a true picture of cerebral and pulmonary fat embolism. About a week after the onset we estimated the blood fatty-acid, which was over 1000 mg. per 100 ml. (the upper limit of normal being about 400 mg.). The level returned to normal in about six weeks. The increase could not possibly be explained by liberation of fat from the fracture site, and we thought it might be due either to failure of elimination of fat through defective liver function, or to failure of adrenal cortical secretion due to traumatic shock. It has lately been noted by Aldersberg et al.6 that blood-fat is directly influenced by A.C.T.H. Excess fat in the blood does not, however, amount to precipitation of fat in blood-vessels. Hence it may be that a substance (? lipokinase) is liberated at the site Urol. cutan. Rev. 1946, 51, 732. 1. E. V. 2. Vilanova, X., de Dulanto, F. Rev. clin. esp. 1948, 29, 297. 3. Sterzi, G. Arch. ital. Derm. 1950, 23, 257. 4. Ames, S. R., Baxter, J. G., Griffith, J. Q. Int. Rev. Vit. Res. 1951, 22, 401. 5. Minkowski, A. Arch. franç. Pédiat. 1949, 6, 276 ; Sem. Hôp. Paris, 1950, 26, 1275. 6. Aldersberg, D., Schæfer, L. E., Drachman, S. R. J. clin. Endocrinol. 1951, 11, 67.
Shute,
Senior Medical Officer, Andaman and Nicobar Islands.
THE PRACTICE OF B.C.G. VACCINATION
SiR,-In order to undertake the
B.C.G.
vaccination of
tuberculin-negative contacts of patients suffering from pulmonary tuberculosis, Dr. Arblaster (Oct. 20) has had to reduce the procedure recommended by the Ministry of Health from eight stages to four ; and that in a densely populated area and at a chest clinic employing
its own enthusiastic whole-time tuberculosis health visitors. Little wonder is it, then, that others, working in mixed rural and urban areas with no full-time tuberculosis health visitors but only rather distant contact through the public-health department with general area health visitors, have found it next to impossible to keep abreast of the current contacts of tuberculous patients requiring examination and vaccination. The full-time tuberculosis health visitor, experienced and fully trained in tuberculin skin-testing, is the essential part of Dr. Arblaster’s or other similar schemes. Without such an essential member in the team it is very difficult to undertake vaccination in an urban area and, in my experience, practically impossible in rural areas. One mother spent 6s. each time she brought her five children about five miles to the chest clinic. Even the most willing find it difficult to cooperate when travelling is so costly, and this added burden usually falls to the lot of the already financially depressed tuberculous
family. I
am
informed that many local health authorities,
particularly those administering large rural areas, are adopting a policy of employing general health visitors. Surely this is a retrograde step in the. prevention of tuberculosis ? The time has come for them to review the before it is pursued further.
position
Chest Clinic, St. Helen’s Hospital, Ipswich.
CHARLES J. STEWART.
SIR,-I have read with surprise the article by Dr. Arblaster. B.C.G. vaccination was introduced into this country with considerable diffidence. After it had been used for many years in the Scandinavian countries, where its reputation had been enhanced by a remarkable decrease in morbidity and mortality, it was decided here that every care should be taken not to bring this practice into bad repute. Dr. Arblaster describes a flimsy scheme which might be suitable for use amongst the backward countries where clinic and follow-up facilities are small. The generally accepted procedure now is to give one injection of 0-1 mg. Old Tuberculin. If the result is negative the patient is segregated for 6 weeks. The test is then repeated, and if negative B.C.G. is given immediately. After a further 6-8 weeks there is a final test of 01 mg. o.T. to see if conversion has taken place. This means six attendances in all, and not eight as stated. It has created no difficulty whatever in a city the size of
Coventry. In his article Dr. Arblaster does not say whether the health visitors visit regularly during the period of segregation and follow-up, or only to apply the jelly test. How, therefore, is the size of the local reaction to be accurately recorded, or, if there are any unusual reactions, such as an axillary adenitis, who is to bring this to the attention of the chest physician concerned ? Every local authority by now should be provided with an adequate number of tuberculosis visitors, and I cannot, therefore,