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THE GLASGOW SMALLPOX OUTBREAK
834 I. used no controls, since previous articles, which I quoted, had shown quite definitely that dietetic regimes do , not maintain adequate neutralisation of the gastric contents throughout the 24 hours.
A. M. CLARK.
Worcester.
THE CARNAGE ON THE ROADS
SIR,—The driving test may have its drawbacks, but it is a step in the right direction. I suggest extending the scheme by the institution of a probationary period for one year following the test. Such drivers would " since the majority of accidents carry " P plates, and P " drivers would be prohibited from are due to speed exceeding 30 m.p.h. The penalties for exceeding this limit would be the same as in a built-up area for the first two offences, but the third would automatically result in a return to learner-driver conditions and the cycle would begin again. The main advantage of this scheme is that the curbing of the instinct to speed would become almost automatic, and the existing machinery is adequate to deal with the administrative side.
steatorrhoea are manifestations of deficiencies caused by the underlying and hitherto unexplained defect, and that they vary from time to time in any given patient. Nevertheless, the underlying defect can be favourably influenced by strict adherence to a high-protein lowfat diet, and this must remain one of the foundations. of the treatment of these cases. W. TREVOR COOKE A. L. P. PEENEY of Department Medicine, University of Birmingham. C. F. HAWKINS. THE GLASGOW SMALLPOX OUTBREAK
Sir.,-The
"
E. B. LOVE.
Preston.
VITAMIN
B12 IN IDIOPATHIC STEATORRHŒA
SIR,—May we correct a misquotation in last week’s article by Dr. Tuck and Dr. Whittaker? We stated 1 that " the percentage fat absorption defect of less than 90% [not 95%] could not be regarded as normal" and " if the figure was between 85 and 90 and the presence of a defect not closely supported by other clinical manifestations, reinvestigation was made." Only 2 [not 4] of our cases had a percentage absorption of 90%, one of which was reported-to have a second balance of 80% absorption. Usually a single three-day balance is adequate for diagnosis, but in patients in whom the defect may not be marked we employ continuous or repeated three-day balances. The two excellent papers and interesting leading article last week afford timely emphasis on the occurrence of a fat-absorption defect in certain macrocytic anaemias. We would strongly support the observations made that the presenting symptoms and the macroscopic appearances of the stools may be no guide to the presence or absence of steatorrhoea, as indeed was originally pointed out by Samuel Gee and, more recently, by many other workers. In our first 100 cases of idiopathic steatorrhoea, intestinal disturbance was the presenting symptom in less than half, while of the remainder 10 were free from intestinal symptoms and had macroscopically normal stools. The latter group contained a number of patients with a macrocytic anaemia which was only distinguishable from pernicious anaemia by virtue of a fat-absorption defect and the failure to attain normal blood-values with adequate therapy with liver extracts. We have found that megaloblastic anaemias associated with idiopathic steatorrhoea invariably react favourably to folic acid, but of 9 cases studied in detail none at any time produced normal absolute values and in only 3 did any of the subsequent red blood-cell counts rise above 4,200,000 per c.mm., and reinforcement with oral liver Although preparations was without further effect. some patients will respond with a maximum reticulocyte response following parenteral vitamin B12 (we have studied 3 such cases), other patients who have similar haematological- findings and definite fat-absorption defects fail completely
opinion expressed
Cooke, A. L.
in 19482 that the
W. T., Elkes, J. J., Frazer, A. C., Parkes, J., Peeney, P., Sammons, H. G., Thomas, G. Quart. J. Med. 1946,
15, 141. 2.
Cooke, W. T., Frazer, A. C., Peeney, A. Thompson, M. D. Ibid, 1948, 17, 9.
L.
smallpox
at
Glasgow,
more
1. The truly disastrous consequences which may result from " missed " cases of smallpox. In view of the heavy mortality attending the outbreak no further emphasis on this is called for. 2. The effect of vaccination and revaccination in " masking the nature of the disease and so leading to " missed " cases. Had the well-vaccinated lascar sailor who was the cause of this outbreak been unvaccinated, it is in the highest degree unlikely that his illness would have been unrecognised, or at least unsuspected ; precautions would have been taken, the case isolated, and contacts vaccinated, and presumably six deaths would have been prevented. True, he would have had a much more serious attack and he might even have died, but six lives would have been saved. This is an aspect of the vaccination question which has been too long ignored. 3. The undesirability, when smallpox breaks out, of at once resorting to mass vaccination. We now know that in this latest outbreak, as in the outbreak in Glasgow in the summer of 1942 and in that in Edinburgh a few months later, spread of infection had ceased before mass vaccination was begun, so could have had nothing whatever to do with the cutting short of the outbreak. The price of a mass-vaccination campaign has to be paid in injury to health whether it has any effect or not in preventing the spread of the disease. Vaccination is not a trivial operation unattended by any danger to health. Amongst the 300,000 persons estimated to have been vaccinated in the Glasgow area, and not counting the many more thousands vaccinated in other parts of the country, we may assume that there will be some (an unknown number) who will have suffered permanent injury to health, and a much larger number who will have suffered at least temporary injury. In the Edinburgh mass-vaccination campaign of 1942, there were 22 cases ofpostvaccinal encephalitis reported, 8 of which proved fatal, making a total of 10 certified deaths. Let us hope that less unfortunate results will follow this latest scare. 4. The desirability of all doctors and nurses not only being vaccinated but of being kept immune by repeated vaccination as often as necessary. The safest rule would be once a year as a matter of routine. Any unpleasant reactions would then. be negligible or indeed non-existent.
varied hqematological responses which may be found in 1.
happily ended, is of
emphasised :
to react.
We are still of the
recent outbreak of
than usual interest, and it is not surprising that it has aroused more than usual Some important lessons taught by it may be concern. now
P., Summons, H. G.,
"
Leicester.
C. KILLICK MILLARD.
USE OF HOSPITAL RESEARCH FUNDS
SIR,—The position of medical research-workers under the National Health Service Act has not yet been fully clarified. There is one question which perhaps might readily be settled, but on which no authoritative ruling has been given. Many institutions have relatively small sums of money available earmarked for research as a result of gifts or bequests. Is it permissible for these moneys to be paid to doctors who are whole-time servants under the National Health Service ? The group most affected are registrars. It appears to be established that whole-time registrars cannot receive fees of any kind. If they carry out research outside their hours of duty, is it in order for them to receive payment from research funds ? The arguments for and against such payments are very evenly balanced. On the one hand, the registrar is assumed to be paid the full amount suitable for his age and duties, and it
A. M. CLARK.
Worcester.
THE CARNAGE ON THE ROADS
SIR,—The driving test may have its drawbacks, but it is a step in the right direction. I suggest extending the scheme by the institution of a probationary period for one year following the test. Such drivers would " since the majority of accidents carry " P plates, and P " drivers would be prohibited from are due to speed exceeding 30 m.p.h. The penalties for exceeding this limit would be the same as in a built-up area for the first two offences, but the third would automatically result in a return to learner-driver conditions and the cycle would begin again. The main advantage of this scheme is that the curbing of the instinct to speed would become almost automatic, and the existing machinery is adequate to deal with the administrative side.
steatorrhoea are manifestations of deficiencies caused by the underlying and hitherto unexplained defect, and that they vary from time to time in any given patient. Nevertheless, the underlying defect can be favourably influenced by strict adherence to a high-protein lowfat diet, and this must remain one of the foundations. of the treatment of these cases. W. TREVOR COOKE A. L. P. PEENEY of Department Medicine, University of Birmingham. C. F. HAWKINS. THE GLASGOW SMALLPOX OUTBREAK
Sir.,-The
"
E. B. LOVE.
Preston.
VITAMIN
B12 IN IDIOPATHIC STEATORRHŒA
SIR,—May we correct a misquotation in last week’s article by Dr. Tuck and Dr. Whittaker? We stated 1 that " the percentage fat absorption defect of less than 90% [not 95%] could not be regarded as normal" and " if the figure was between 85 and 90 and the presence of a defect not closely supported by other clinical manifestations, reinvestigation was made." Only 2 [not 4] of our cases had a percentage absorption of 90%, one of which was reported-to have a second balance of 80% absorption. Usually a single three-day balance is adequate for diagnosis, but in patients in whom the defect may not be marked we employ continuous or repeated three-day balances. The two excellent papers and interesting leading article last week afford timely emphasis on the occurrence of a fat-absorption defect in certain macrocytic anaemias. We would strongly support the observations made that the presenting symptoms and the macroscopic appearances of the stools may be no guide to the presence or absence of steatorrhoea, as indeed was originally pointed out by Samuel Gee and, more recently, by many other workers. In our first 100 cases of idiopathic steatorrhoea, intestinal disturbance was the presenting symptom in less than half, while of the remainder 10 were free from intestinal symptoms and had macroscopically normal stools. The latter group contained a number of patients with a macrocytic anaemia which was only distinguishable from pernicious anaemia by virtue of a fat-absorption defect and the failure to attain normal blood-values with adequate therapy with liver extracts. We have found that megaloblastic anaemias associated with idiopathic steatorrhoea invariably react favourably to folic acid, but of 9 cases studied in detail none at any time produced normal absolute values and in only 3 did any of the subsequent red blood-cell counts rise above 4,200,000 per c.mm., and reinforcement with oral liver Although preparations was without further effect. some patients will respond with a maximum reticulocyte response following parenteral vitamin B12 (we have studied 3 such cases), other patients who have similar haematological- findings and definite fat-absorption defects fail completely
opinion expressed
Cooke, A. L.
in 19482 that the
W. T., Elkes, J. J., Frazer, A. C., Parkes, J., Peeney, P., Sammons, H. G., Thomas, G. Quart. J. Med. 1946,
15, 141. 2.
Cooke, W. T., Frazer, A. C., Peeney, A. Thompson, M. D. Ibid, 1948, 17, 9.
L.
smallpox
at
Glasgow,
more
1. The truly disastrous consequences which may result from " missed " cases of smallpox. In view of the heavy mortality attending the outbreak no further emphasis on this is called for. 2. The effect of vaccination and revaccination in " masking the nature of the disease and so leading to " missed " cases. Had the well-vaccinated lascar sailor who was the cause of this outbreak been unvaccinated, it is in the highest degree unlikely that his illness would have been unrecognised, or at least unsuspected ; precautions would have been taken, the case isolated, and contacts vaccinated, and presumably six deaths would have been prevented. True, he would have had a much more serious attack and he might even have died, but six lives would have been saved. This is an aspect of the vaccination question which has been too long ignored. 3. The undesirability, when smallpox breaks out, of at once resorting to mass vaccination. We now know that in this latest outbreak, as in the outbreak in Glasgow in the summer of 1942 and in that in Edinburgh a few months later, spread of infection had ceased before mass vaccination was begun, so could have had nothing whatever to do with the cutting short of the outbreak. The price of a mass-vaccination campaign has to be paid in injury to health whether it has any effect or not in preventing the spread of the disease. Vaccination is not a trivial operation unattended by any danger to health. Amongst the 300,000 persons estimated to have been vaccinated in the Glasgow area, and not counting the many more thousands vaccinated in other parts of the country, we may assume that there will be some (an unknown number) who will have suffered permanent injury to health, and a much larger number who will have suffered at least temporary injury. In the Edinburgh mass-vaccination campaign of 1942, there were 22 cases ofpostvaccinal encephalitis reported, 8 of which proved fatal, making a total of 10 certified deaths. Let us hope that less unfortunate results will follow this latest scare. 4. The desirability of all doctors and nurses not only being vaccinated but of being kept immune by repeated vaccination as often as necessary. The safest rule would be once a year as a matter of routine. Any unpleasant reactions would then. be negligible or indeed non-existent.
varied hqematological responses which may be found in 1.
happily ended, is of
emphasised :
to react.
We are still of the
recent outbreak of
than usual interest, and it is not surprising that it has aroused more than usual Some important lessons taught by it may be concern. now
P., Summons, H. G.,
"
Leicester.
C. KILLICK MILLARD.
USE OF HOSPITAL RESEARCH FUNDS
SIR,—The position of medical research-workers under the National Health Service Act has not yet been fully clarified. There is one question which perhaps might readily be settled, but on which no authoritative ruling has been given. Many institutions have relatively small sums of money available earmarked for research as a result of gifts or bequests. Is it permissible for these moneys to be paid to doctors who are whole-time servants under the National Health Service ? The group most affected are registrars. It appears to be established that whole-time registrars cannot receive fees of any kind. If they carry out research outside their hours of duty, is it in order for them to receive payment from research funds ? The arguments for and against such payments are very evenly balanced. On the one hand, the registrar is assumed to be paid the full amount suitable for his age and duties, and it