- Email: [email protected]
TATTOOS
992 The evidence from animal experiments and clinical trial is now overwhelmingly in support of intra-arterial transfusion as the only measure which will save life in cases where shock from haemorrhage is of sufficient - severity and duration. It is sad, therefore, to think of the many lives lost every year which could probably have been saved by this measure. It is surely not too much to hope that soon every hospital of any importance will have the equipment for intra-arterial transfusions and staff who are prepared to use it. Crumpsall Hospital,
HERBERT HAXTON.
Manchester.
TATTOOS
SiR,ņI have read with great interest your annotation last week on this subject. However, it surprises me that you do not accord to viral hepatitis a place in the list of potential complications of deliberate tattooing carried out for purposes of adornment. Hobson et al.1 investigated this question among patients in a military hospital in Hong-Kong-a group among whom tattooing was popular and viral hepatitis prevalent. They found that, out of 143 patients admitted with viral hepatitis during a certain period, no fewer than 56 (or 39-2%) had been tattooed between 51 and 150 days prior to the onset of the disease. As controls, they took 152 patients admitted during the same period for other complaints. In this group the number tattooed during the corresponding period was only 16 (10-5%). They also describe the modus operandi of a local tattooist, their description lending eloquent support to the belief that the virus may be transmitted in this way. Department of Pathology, Guy’s Hospital, London. S.E.1.
G. A. K. MISSEN.
TUBERCULOSIS
SiR,ņMay answer the letters of Dr. Paul and Dr. (Oct. 10) ?’l Perhaps our differences are not so great as they appear, although it is necessary to correct impressions that may have been given concerning the I
Hoffstaedt
control of tuberculosis in cattle. It is true that bovine was virtually eradicated in the U.S.A. 23 after the years inception of a nation-wide campaign in 1917 ; but at that time the over-all incidence in adult cattle was only about 4%, compared with about 25% in Great Britain in 1935. Again, 16 years ago in Denmark 48-5% of all herds had been tuberculin-tested and 26% of these were free from infection. In Great Britain there was no effective scheme for the control of bovine tuberculosis until 1935, and owing to a Government decision no new attested herds were created during the war. In 1944 there were only some 600,000 cattle in these herds. By 1946 the number had increased to 1 million (about 13% of all cattle-i.e., roughly comparable with the Danish picture in 1937) and by 1952 to 31/2 million. There are now some 4 million cattle in attested herds out of a total of about 9 million ; so at the present rate of progress tuberculosis should be virtually eradicated in 10 or 12 rather than 34 years. To suggest that injection of the B.C.G. strain of avirulent tubercle bacilli increases the incidence of bacilli in the population is rather like saying that vaccination increases the incidence of smallpox virus-although one admits that even this procedure has its opponents. Dr. Paul still seems very unconcerned about the presence of virulent tubercle bacilli, and Dr. Hoffstaedt even suggests that it would be unfortunate if we attempted to " banish from our shores a virtually ubiquitous and mostly quite harmless germ." " Mostly quite harmless " seems a strange description to apply to an organism that, as Rich says in the last sentence of his book on The
tuberculosis
1. Hobson, A. C. S., Fraser, D. 1952, i, 1111.
E., Newman, N.
H.
Brit. med. J.
Pathogenesis of luberculosis, still kills more than twice as many people as any other single cause of death during the particularly productive and enjoyable period between the ages of 15 and 45. lIe points out that increased genetic resistance cannot possibly be the sole reason for the precipitous fall in the mortality-rate that occurred within a scant two generations. Even if it were entirely responsible, Sir Maciarlaue Burnet1 has indicated that it would take centuries before resistance fell to that of, say, the American Indian. The elimination of most infectious disease doubtless tends to increase the susceptibility of the population, but few people think it desirable that we should continue to have a good infection-rate with such organisms as or Treponema pallidum. If desirable to maintain tubercle bacilli in the population there would, of course, be no reason at all for public-health doctors to worry about tubercle bacilli in milk ; for, if one must be infected, the alimentary route is much less dangerous than the respiratory. Mr. L. Pitcher has devoted much energy to attempting to show that as one eradicates tuberculosis from cattle the death. rate from pulmonary tuberculosis increases. It is prob, ably true that under certain conditions, which may have prevailed in Great Britain, tubercle bacilli in milk2 decrease the total death-rate from human tuberculosis, but Dr. Daw 3 rightly questions Mr. Pitcher’s arguments and asks for more evidence. One may say briefly that the mortality from human tuberculosis has continued to fall steadily in the U.S.A. since the virtual eradication of bovine tuberculosis. This is also true in Tasmania and in Queensland (an area mentioned by Mr. Pitcher as having a low human mortality and at one time high incidence of bovine infection). Above all, both human and bovine infection have been eradicated from the island of Bornholm. I agree of course with Dr. Paul and Dr. Hoffstaedt
Cory nebacteriuiit d1-phtheriae
it
were
that
general improvement in living standards is probably the most important factor in reducing the mortality from tuberculosis. Various predictions that tuberculosis would become extinct by a certain date through the operation of such natural causes have however been falsified, and it is salutary to, remember that only 53 years after syphilis appeared in Europe a
"
Fracastorius wrote : Whatever may be the cause we must conclude that this disease has now entered its old age, and that the time is not far off when it will cease to propagate itself." As one would expect, the best results in the control of tuberculosis have been achieved where specific attempts to prevent the spread of tubercle bacilli have been combined with good living conditions, and the mortality-rate is now below 10 per 100,000 in Denmark and in certain States in the U.S.A., and is only 11 per 100,000 in Tasmania. Dr. Paul suggests that I am confusing the eradication of tuberculosis with the eradication of the tubercle bacillus. In an essay on the Natural History of Tuberculosis Sir Macfarlane Burnet1 wrote : " To prevent disability and death from tuberculosis the one out. standing requirement is to prevent primary infection with the bacillus." Or, as Sir John M’Fadyean wrote in 1901, " all efforts must be concentrated against the one great cause of the disease-the operation of contagion." Myers has said much the same thing on many occasions, but it would seem that the truth of these statements cannot be too often emphasised. Sir Macfarlane’s essay no doubt influenced the scheme for the control of tuberculosis in Tasmania,. and if he reads it Dr. Paul may discover some alternatives to the method of slaughter: incidentally we have eradicated tuberculosis from 40% of our herds without slaughtering, for this purpose, a Burnet, F. M. The Background of Infectious Diseases in Man. Melbourne, 1946. Lancet, 1950, i, 34. 3. Daw, R. H. Ibid, 1952, ii, 1272. 1.
2. Francis, J.
HERBERT HAXTON.
Manchester.
TATTOOS
SiR,ņI have read with great interest your annotation last week on this subject. However, it surprises me that you do not accord to viral hepatitis a place in the list of potential complications of deliberate tattooing carried out for purposes of adornment. Hobson et al.1 investigated this question among patients in a military hospital in Hong-Kong-a group among whom tattooing was popular and viral hepatitis prevalent. They found that, out of 143 patients admitted with viral hepatitis during a certain period, no fewer than 56 (or 39-2%) had been tattooed between 51 and 150 days prior to the onset of the disease. As controls, they took 152 patients admitted during the same period for other complaints. In this group the number tattooed during the corresponding period was only 16 (10-5%). They also describe the modus operandi of a local tattooist, their description lending eloquent support to the belief that the virus may be transmitted in this way. Department of Pathology, Guy’s Hospital, London. S.E.1.
G. A. K. MISSEN.
TUBERCULOSIS
SiR,ņMay answer the letters of Dr. Paul and Dr. (Oct. 10) ?’l Perhaps our differences are not so great as they appear, although it is necessary to correct impressions that may have been given concerning the I
Hoffstaedt
control of tuberculosis in cattle. It is true that bovine was virtually eradicated in the U.S.A. 23 after the years inception of a nation-wide campaign in 1917 ; but at that time the over-all incidence in adult cattle was only about 4%, compared with about 25% in Great Britain in 1935. Again, 16 years ago in Denmark 48-5% of all herds had been tuberculin-tested and 26% of these were free from infection. In Great Britain there was no effective scheme for the control of bovine tuberculosis until 1935, and owing to a Government decision no new attested herds were created during the war. In 1944 there were only some 600,000 cattle in these herds. By 1946 the number had increased to 1 million (about 13% of all cattle-i.e., roughly comparable with the Danish picture in 1937) and by 1952 to 31/2 million. There are now some 4 million cattle in attested herds out of a total of about 9 million ; so at the present rate of progress tuberculosis should be virtually eradicated in 10 or 12 rather than 34 years. To suggest that injection of the B.C.G. strain of avirulent tubercle bacilli increases the incidence of bacilli in the population is rather like saying that vaccination increases the incidence of smallpox virus-although one admits that even this procedure has its opponents. Dr. Paul still seems very unconcerned about the presence of virulent tubercle bacilli, and Dr. Hoffstaedt even suggests that it would be unfortunate if we attempted to " banish from our shores a virtually ubiquitous and mostly quite harmless germ." " Mostly quite harmless " seems a strange description to apply to an organism that, as Rich says in the last sentence of his book on The
tuberculosis
1. Hobson, A. C. S., Fraser, D. 1952, i, 1111.
E., Newman, N.
H.
Brit. med. J.
Pathogenesis of luberculosis, still kills more than twice as many people as any other single cause of death during the particularly productive and enjoyable period between the ages of 15 and 45. lIe points out that increased genetic resistance cannot possibly be the sole reason for the precipitous fall in the mortality-rate that occurred within a scant two generations. Even if it were entirely responsible, Sir Maciarlaue Burnet1 has indicated that it would take centuries before resistance fell to that of, say, the American Indian. The elimination of most infectious disease doubtless tends to increase the susceptibility of the population, but few people think it desirable that we should continue to have a good infection-rate with such organisms as or Treponema pallidum. If desirable to maintain tubercle bacilli in the population there would, of course, be no reason at all for public-health doctors to worry about tubercle bacilli in milk ; for, if one must be infected, the alimentary route is much less dangerous than the respiratory. Mr. L. Pitcher has devoted much energy to attempting to show that as one eradicates tuberculosis from cattle the death. rate from pulmonary tuberculosis increases. It is prob, ably true that under certain conditions, which may have prevailed in Great Britain, tubercle bacilli in milk2 decrease the total death-rate from human tuberculosis, but Dr. Daw 3 rightly questions Mr. Pitcher’s arguments and asks for more evidence. One may say briefly that the mortality from human tuberculosis has continued to fall steadily in the U.S.A. since the virtual eradication of bovine tuberculosis. This is also true in Tasmania and in Queensland (an area mentioned by Mr. Pitcher as having a low human mortality and at one time high incidence of bovine infection). Above all, both human and bovine infection have been eradicated from the island of Bornholm. I agree of course with Dr. Paul and Dr. Hoffstaedt
Cory nebacteriuiit d1-phtheriae
it
were
that
general improvement in living standards is probably the most important factor in reducing the mortality from tuberculosis. Various predictions that tuberculosis would become extinct by a certain date through the operation of such natural causes have however been falsified, and it is salutary to, remember that only 53 years after syphilis appeared in Europe a
"
Fracastorius wrote : Whatever may be the cause we must conclude that this disease has now entered its old age, and that the time is not far off when it will cease to propagate itself." As one would expect, the best results in the control of tuberculosis have been achieved where specific attempts to prevent the spread of tubercle bacilli have been combined with good living conditions, and the mortality-rate is now below 10 per 100,000 in Denmark and in certain States in the U.S.A., and is only 11 per 100,000 in Tasmania. Dr. Paul suggests that I am confusing the eradication of tuberculosis with the eradication of the tubercle bacillus. In an essay on the Natural History of Tuberculosis Sir Macfarlane Burnet1 wrote : " To prevent disability and death from tuberculosis the one out. standing requirement is to prevent primary infection with the bacillus." Or, as Sir John M’Fadyean wrote in 1901, " all efforts must be concentrated against the one great cause of the disease-the operation of contagion." Myers has said much the same thing on many occasions, but it would seem that the truth of these statements cannot be too often emphasised. Sir Macfarlane’s essay no doubt influenced the scheme for the control of tuberculosis in Tasmania,. and if he reads it Dr. Paul may discover some alternatives to the method of slaughter: incidentally we have eradicated tuberculosis from 40% of our herds without slaughtering, for this purpose, a Burnet, F. M. The Background of Infectious Diseases in Man. Melbourne, 1946. Lancet, 1950, i, 34. 3. Daw, R. H. Ibid, 1952, ii, 1272. 1.
2. Francis, J.