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I. used no controls, since previous articles, which I

quoted, had shown quite definitely that dietetic regimesdo , not maintain adequate neutralisation of the gastriccontents throughout the 24 hours.

Worcester. A. M. CLARK.

THE CARNAGE ON THE ROADS

SIR,—The driving test may have its drawbacks, butit is a step in the right direction. I suggest extendingthe scheme by the institution of a probationary periodfor one year following the test. Such drivers wouldcarry " P

" plates, and since the majority of accidentsare due to speed

" P " drivers would be prohibited fromexceeding 30 m.p.h. The penalties for exceeding thislimit would be the same as in a built-up area for thefirst two offences, but the third would automaticallyresult in a return to learner-driver conditions and thecycle would begin again. The main advantage of thisscheme is that the curbing of the instinct to speed wouldbecome almost automatic, and the existing machineryis adequate to deal with the administrative side.

Preston. E. B. LOVE.

VITAMIN B12 IN IDIOPATHIC STEATORRHŒA

SIR,—May we correct a misquotation in last week’sarticle by Dr. Tuck and Dr. Whittaker ? We stated 1that " the percentage fat absorption defect of less than90% [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 clinicalmanifestations, 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 of80% absorption. Usually a single three-day balanceis adequate for diagnosis, but in patients in whom thedefect may not be marked we employ continuous orrepeated three-day balances.The two excellent papers and interesting leading

article last week afford timely emphasis on the occurrenceof a fat-absorption defect in certain macrocytic anaemias.We would strongly support the observations made thatthe presenting symptoms and the macroscopic appear-ances of the stools may be no guide to the presence orabsence of steatorrhoea, as indeed was originally pointedout by Samuel Gee and, more recently, by many otherworkers.

In our first 100 cases of idiopathic steatorrhoea,intestinal disturbance was the presenting symptom inless than half, while of the remainder 10 were free fromintestinal symptoms and had macroscopically normalstools. The latter group contained a number of patientswith a macrocytic anaemia which was only distinguish-able from pernicious anaemia by virtue of a fat-absorptiondefect and the failure to attain normal blood-valueswith adequate therapy with liver extracts.We have found that megaloblastic anaemias associated

with idiopathic steatorrhoea invariably react favourablyto folic acid, but of 9 cases studied in detail none at anytime produced normal absolute values and in only 3did any of the subsequent red blood-cell counts rise above4,200,000 per c.mm., and reinforcement with oral liverpreparations was without further effect. Althoughsome patients will respond with a maximum reticulocyteresponse following parenteral vitamin B12 (we have studied3 such cases), other patients who have similar haemato-logical- findings and definite fat-absorption defects fail

completely to react.We are still of the opinion expressed in 1948 2 that the

varied hqematological responses which may be found in1. Cooke, W. T., Elkes, J. J., Frazer, A. C., Parkes, J., Peeney,

A. L. P., Sammons, H. G., Thomas, G. Quart. J. Med. 1946,15, 141.

2. Cooke, W. T., Frazer, A. C., Peeney, A. L. P., Summons, H. G.,Thompson, M. D. Ibid, 1948, 17, 9.

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 favourablyinfluenced by strict adherence to a high-protein low-fat diet, and this must remain one of the foundations.of the treatment of these cases.

Department of Medicine,University of Birmingham.

W. TREVOR COOKEA. L. P. PEENEYC. F. HAWKINS.

THE GLASGOW SMALLPOX OUTBREAK

Sir.,-The recent outbreak of smallpox at Glasgow,now happily ended, is of more than usual interest, andit is not surprising that it has aroused more than usualconcern. Some important lessons taught by it may beemphasised :

1. The truly disastrous consequences which may resultfrom " missed " cases of smallpox. In view of the heavymortality attending the outbreak no further emphasis onthis 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 ofthis outbreak been unvaccinated, it is in the highest degreeunlikely that his illness would have been unrecognised, or atleast unsuspected ; precautions would have been taken, thecase isolated, and contacts vaccinated, and presumably sixdeaths would have been prevented. True, he would have hada much more serious attack and he might even have died,but six lives would have been saved. This is an aspect of thevaccination question which has been too long ignored.

3. The undesirability, when smallpox breaks out, of atonce resorting to mass vaccination. We now know that in thislatest outbreak, as in the outbreak in Glasgow in the summerof 1942 and in that in Edinburgh a few months later, spreadof infection had ceased before mass vaccination was begun,so could have had nothing whatever to do with the cuttingshort of the outbreak. The price of a mass-vaccinationcampaign has to be paid in injury to health whether it has anyeffect or not in preventing the spread of the disease. Vaccina-tion is not a trivial operation unattended by any danger tohealth. Amongst the 300,000 persons estimated to have beenvaccinated in the Glasgow area, and not counting the manymore thousands vaccinated in other parts of the country, wemay assume that there will be some (an unknown number)who will have suffered permanent injury to health, and amuch larger number who will have suffered at least temporaryinjury. In the Edinburgh mass-vaccination campaign of1942, 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 thislatest scare.

4. The desirability of all doctors and nurses not only beingvaccinated but of being kept immune by repeated vaccinationas often as necessary. The safest rule would be once a yearas a matter of routine. Any unpleasant reactions would then.be negligible or indeed non-existent.

Leicester. C. KILLICK MILLARD.

USE OF HOSPITAL RESEARCH FUNDS

SIR,—The position of medical research-workers underthe National Health Service Act has not yet been fullyclarified. There is one question which perhaps mightreadily be settled, but on which no authoritative rulinghas been given.Many institutions have relatively small sums of money

available earmarked for research as a result of gifts orbequests. Is it permissible for these moneys to be paidto doctors who are whole-time servants under theNational Health Service ?The group most affected are registrars. It appears

to be established that whole-time registrars cannotreceive fees of any kind. If they carry out researchoutside their hours of duty, is it in order for them toreceive payment from research funds ? The argumentsfor and against such payments are very evenly balanced.On the one hand, the registrar is assumed to be paidthe full amount suitable for his age and duties, and it

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may be suggested that, given the opportunity, researchforms a part of his duties, especially in the laboratory.On the other hand it may be argued that a registrarwho burns the midnight oil in research deserves encourage-ment in contrast to his colleague who may adhere closelyto his hours of duty and spend his leisure hours inremunerative activities such as, for example, writing his

autobiography or a textbook. In any case, if thesesums cannot be paid to whole-time salaried workers,what use is to be made of them 1 Should they be spentin the purchase of apparatus ’? To w1;tom would suchapparatus finally belong Should they be consolidatedso that the aggregate sum will support a whole-time research-worker ?, Is such consolidation legallypermissible ?

Full-time salaried doctors did not spring into existencewith the introduction of the National Health Service,and it used to be common practice for such men toreceive personal grants for research, although, of course,salaries were then much lower.

It would be convenient if an authoritative rulingwere given on this point, and when that ruling is givenconsideration should be given not only to the letter ofthe law as affecting registrar’s salaries, but also to thepossible effect of the ruling on the future of medicalresearch.

_____

R. J. V. PULVERTAFT.The John Burford Carlill Pathological Laboratories,

Westminster School of Medicine,London, S.W.1.

CARDIAC EFFECTS OF P.A.S.

Sm,-Dr. Cayley, in his article of March 11, recordscardiac irregularity in three patients under treatment withp-aminosalicylic acid (P.A.S.).

I performed electrocardiography (E.c.G.) on a youngman seriously ill with tuberculous peritonitis, who hadhad massive doses of P.A.S. for ten days and whose pulse-rate suddenly fell to 50 per min. from the usual highrate of 100-120 per min. Study of the E.C.G. tracingrevealed auricular fibrillation and apparent completeauriculoventricular block. The patient died before

serum-potassium estimation had been performed. In

retrospect it appears that this may well have been afurther example of the effect of P.A.S.

Royal Naval Hospital, Haslar,Gosport, Hants.

B. S. LEWIS.

THE OPEN WOUND IN TRAUMA

SIR,-It had to come. The debate remained undecidedat the end of the war. Tribute was paid to Trueta for hiscontributions to war surgery, but many surgeons con-tinued to criticise his methods much in the same wayas Mr. Essex-Lopresti has done in his article last week.

Trueta’s technique is not based wholly on the ideathat all wounds are contaminated (although one mustmake this assumption in the case of war wounds). Thefive points he emphasises are all important, and anydeviation from them in any respect cannot be describedas his method. Contamination is only part of the story.Equally important is the presence of non-viable tissue,especially muscle, which is easy to detect if it is dead ;and every bit of ischaemic muscle and haematoma mustbe excised in every part of the wound, which must beenlarged in each direction sufficiently to enable the

surgeon to explore every nook and cranny. It is fair to

say that the 10 cases which became infected in Birming-ham were not treated by Trueta’s technique. I have hadthe opportunity of working with, and seeing the cases of,Professor Trueta for some years, and I can categoricallystate that no wound or compound fracture treated byhim ab initio ever became infected ; osteomyelitis wastherefore unknown.Even more important are the unfortunate effects of

this article. It is admirable to hear that primary skincover has been successfully applied in compound frac-

tures treated in Birmingham ; but I am sure that the

pursuit of this precept would be highly dangerous in lessskilled hands, since, owing to inadequate excision, limbs,and perhaps lives, would be lost owing to tissue tensionand gangrene. -

Trueta has never said that wounds are to remain open.Even before the days of penicillin he was closing hiswounds after periods varying with conditions, and sincethe appearance of penicillin he has been getting early skincover over wounds which, I must repeat, are never

infected if he carries out the primary wound treatment.His teaching, properly applied, means the completeabsence of sepsis, early skin cover, and the minimumtime for the restoration of optimum function. Criticsshould understand Trueta’s technique before trying tosaddle it with failures which do not occur in the handsof Trueta, himself. ’

St. Margaret’s Hospital, Swindon. F. LOUIS.

TREATMENT OF DISSEMINATED CUTANEOUSHERPES SIMPLEX WITH AUREOMYCIN

SrR,—Baer and Miller 1 treated with oral and localAureomycin two adult cases of disseminated cutaneousherpes simplex (Kaposi’s varicelliform eruption). Theyfound that the aureomycin produced rapid healing of theskin lesions and prevented the development of furtherlesions. Bereston and Carliner 2 also reported a favourableresponse to aureomycin in an unusually severe case

of disseminated cutaneous herpes simplex. We were

encouraged by these reports to treat with aureomycintwo infants-with this condition.

CASE I.-A girl, aged 11 months, had had atopic eczemasince the 10th week of life. Three days before admission onJan. 15, 1950, she became febrile and the eczematous areasbecame cedematous and were covered with an eruption ofsmall umbilicated vesicles which also extended a short dis-tance on to previously normal skin. A history was elicitedof contact during the previous week with an aunt who wassuffering from labial herpes. A clinical diagnosis of Kaposi’svaricelliform eruption was made and treatment with oralaureomycin (125 mg. 8-hourly) and intramuscular penicillin(100,000 units 8-hourly) was initiated. Two days later newvesicles continued to appear on and near the eczematousareas. The dose of aureomycin was increased to 150 mg.6-hourly. Occasional further vesicles developed during thenext day or two. The child made a satisfactory recovery ;no secondary infection developed.The serum titre of herpes antibody increased from 2 units

in the acute phase to 32 units in the convalescent phase(Dr. J. A. Dudgeon).CASE 2.-A boy, aged 7 months, who had had atopic

eczema since his 3rd month, was admitted to hospital onFeb. 8, 1950. The clinical appearance on admission and thecourse of the disease differed very little from the previouscase and new vesicles continued to appear 2-3 days afterthe administration of aureomycin was started. An attack ofsevere diarrhoea was attributed to the aureomycin sinceno other cause was discovered.

Virus-antibody estimations were not undertaken.

In neither case did the aureomycin prevent the con-tinued development of new vesicles, nor did it obviouslymodify the natural course of the herpetic infection.

Any benefit derived from the aureomycin is to be attri-buted to the control of secondary bacterial infection ofthe vesicles. The course of the disease in these twoinfants treated with aureomycin did not differ from thatof two similar cases previously treated by one of us withpenicillin alone.

Our observations in these two cases lend no supportto the claim that aureomycin has any specific value inthe treatment of disseminated cutaneous herpes simplex.

St. Helier Hospital,Carshalton, Surrey.

A. J. ROOKC. C. UPJOHN.

1. Baer, R. L., Miller, O. B. J. invest. Derm. 1949, 13, 5.2. Bereston, G. S., Carliner, P. E. Ibid, p. 13.