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bowel wall of rotten fabric giving way under the loadof its contents, and not to a state of inertia due topotassium loss. Indeed, serum-potassium levels arenot consistently low in such patients, and serum valuesbelow 3’0 m.eq. per litre have been recorded withoutdilatation. Besides, potassium depletion as seen insteatorrhoea or Crohn’s disease causes a small-bowelatony leaving the colon relatively less disturbed,whereas the colonic distension of ulcerative colitis isseldom associated with similar small-bowel changes.The fabric seems to rot as ulceration advancesunchecked into the muscle, perhaps because cortisonehampers an adequate inflammatory response in thislayer. There is substance, therefore, in the suggestion 11that the degree or depth of damage to the bowel wallshould be assessed radiologically before corticoids aregiven. If pockets are seen outside the bowel lumenor if what has been called " pseudohaustration

" is

apparent, these should be taken as danger signals,since ulceration has then certainly reached thesubmissive muscle layer.

Annotations

POLIOMYELITIS VACCINE

IT is almost two years since poliomyelitis vaccine waslicensed for manufacture in the United States, and sincethen manufacturers, doctors, and the public have hadtheir share of anxiety. But there is little cause for alarmin last week’s news that distribution of the latest batchof the British vaccine must be delayed until a colourchange in certain vials of vaccine, in store since mid-November, has been investigated. As things have turnedout, it would of course have been better to defer theannouncement from the Ministry of Health about thedistribution of the vaccine until it had passed its finalscrutiny.The vaccine contains a colour indicator of pH which

is a useful guide to the metabolic state of the tissue-culture during growth of the virus. A change in pHduring storage (indicated by the vaccine changing frompink to yellow) might be due to bacterial contaminationwhich had escaped detection earlier in the manufacturingprocess. This has not apparently been a serious com-plication in the past. The cause of the pH change isnow being investigated. The delay thus involved, dis-

appointing though it is, illustrates the enormous carethat is being taken to make the vaccine as safe andeffective as possible.

There are clearly many difficulties still to be over-come in producing poliomyelitis vaccine, and at a

recent meeting of the New York Academy of SciencesDr. J. E. Smadel reported that, even after two doses ofpresent-day commercial vaccine, antibodies sometimesfailed to appear in children with no pre-existing antibodiesto any of the three poliomyelitis viruses. Smadel thoughtthat this might be due to the current practice of ensuringsafety by repeated filtration, and consequent loss of

antigenicity. From the start, the fundamental troublewith formalinised poliomyelitis vaccine has been thenarrow margin between a vaccine which has not beensufficiently inactivated and contains live virus and avaccine which has been over-formalin ised and is not a

sufficiently potent antigen. The result has been thatdifferent batches of vaccine, supposedly made by thesame methods, have varied greatly in their behaviour.It may have been unwise to invest so much in formalinisedvaccine, and the possibilities of inactivating the virus inother ways should still be investigated.

DOCTORS AND UNEMPLOYMENT BENEFIT

A FEW. years ago it would have been unthinkable thatdoctors should draw unemployment benefit, but someof them are doing so today. Most of these unemployeddoctors are no more than temporarily out of work, andthey are usually young men who have had difficulty ingetting a house-job, though there are rare instanceswhere a hard-pressed registrar has asked for help. Aswe have earlier observed,1 circumstances can arise

whereby weeks and even months may be lost by a newlyqualified man between his first and second preregistrationjobs ; and no longer can this period be filled profitablyby a locum tenancy in general practice. During oneappointment of six months few housemen can save muchagainst a rainy day and some of them naturally turn tothe State for support during the temporary lean period.Indeed, they have already contributed money as an

insurance against this very predicament.Another influence, perhaps more forceful than the

preregistration year, is the climate of the times. Astaxation eats into personal income and contributions toNational Insurance make further inroads, it seems hard’to reproach professional men for claiming their due fromthe State when they are in difficulties. On the otherhand, it was no doubt the prevalence of the " elaim-what-you-can " attitude, rather than real hardship, whichled a newly registered doctor, who had a month to waitbefore his next appointment, to claim unemploymentbenefit for that period, with allowances for his twochildren, though his wife, also a doctor, would be con.tinuing to earn. He even wondered whether he mightsuccessfully apply for National Assistance because themortgage-rates on his house were high. He had nodoubts about getting unemployment benefit for thewhole period, since it seemed unlikely that the labourexchange would be able to find him a job in his " trade"which he would in any case have to refuse because ofthe job to which he had already been appointed.

Such a story may shock doctors of an older generation;nevertheless, we hope they will not support the actionof the dean of one medical school who (we understand)refuses testimonials to any man who has drawn unem-

ployment benefit. Doctors have all the rights of othercitizens, including the right to behave how they wish insuch matters ; and there are undoubtedly instances ofgenuine need.

1. Lancet, 1955, i, 2402. Wusthoff, Dtsch, Z. Chir. 1923, 183, 73. 3. Blockley, N. J., Purser, D. W. J. Bone Jt Surg. 1956, 38B, 794.

FRACTURE OF THE ODONTOID PROCESSCONSIDERABLE violence is usually necessary to fracture

the odontoid process of the axis, and the injury is nowmost commonly seen after road accidents. The mechanismof the fracture has aroused much interest. Undoubtedlythe sudden movement of the head upon the uppercervical spine imposes an immense strain upon theodontoid, which is probably damaged by a combinationof traction and leverage through the alar ligaments.Wusthoff 2 has emphasised the importance of the trans-verse ligament in the production of odontoid fractures,but in certain lesions the anterior arch of the atlasmust be of equal importance. Patients with this injuryusually have severe pain, often radiating to the occipitalregion. The head is sometimes rotated, making X-rayexamination difficult, and the patient may support itwith his hands. Paraplegia is present from the startin about 10% of the patients who survive the immediateinjury ; but the proportion may really be much higher,since severe cord damage at this level is always fatal.Up to the age of 6 years the primary centre of ossifica-

tion of the odontoid is separated from the centre for thebody of the bone by a cartilage plate. Blockley andPnrser 3 have shown that in the young child the injury1>1 ""iln11fl.1’ to tm epiphyseal separation, <>.11(1 ia nnrmnllv

519

followed by firm bony union. In the adult, however,bony union is uncommon and occasionally a late para-plegia follows. Although this complication usuallyappears within the first year after injury, it has been

reported as long as 28 years later. If the paraplegia isdue to instability, then early spinal fusion might be

expected to lessen its incidence. ’

The early treatment of the fracture demands traction,and the skull calliper is undoubtedly the best method.Careful positioning may assist reduction if the frag-ment is displaced, and by flexing or extending the headaccurate alignment of the fragments is possible. Evenfor the undisplaced fracture, light traction affords a

convenient method of immobilisation. If the fracturecan be maintained in a good position for 3 months itmay well unite, although even then fibrous union is notuncommon. Such a result is compatible with goodfunction and freedom from pain, but nervous complica-tions may ensue.

1. Rubin, L., Slepvan, A. H., Weber, L. F., Neuhauser, I. J. Amer.med. Ass. 1956, 162, 953.

DEODORANTS AND THE SKIN

DEODORANTS are amongst the most commonly usedcosmetic preparations, and they are marketed in the formof liquids, creams, pastes, powders, or sticks. They areof two types : substances which destroy or obscure theodour and those which, being astringents, diminish theflow of perspiration. Most preparations contain a pro-portion of each type. The first group includes suchsubstances as sodium perborate, zinc peroxide, hexa-

methylenetetramine, chloramine-T, chlorothymol, oxy-quinoline sulphate, perfumes, and essential oils. Amongtheastringents, which act by precipitating skin proteins, thusblocking the ostia of the sweat-ducts, are formaldehyde,aluminium chloride, sulphate, and phenolsulphonate,zinc salicylate and phenolsulphate, tannic acid, and thetannates. Formaldehyde is now rarely used, since, in aneffective strength, it is a primary irritant. The veryefficient aluminium salts are often used in liquid prep-arations ; they are also primary irritants and sensitisers,but their irritant effect can be eliminated by bufferingthe solution with urea.Dermatitis caused by deodorants is usually confined

to the axillse, where it takes the form either of a sharplylimited erythematous vesicular eruption or a folliculitis.Patch testing will confirm the cause of the eruption anddistinguish it from dress-shield dermatitis. Rubin et al.1have lately described a new type of local skin reactionin the axilla after the use of certain deodorants. Theyrecord 4 cases in detail and they mention that they havealready seen 11 other similarly affected patients. Ofthe first 4 patients, 3 had used stick deodorants and 1 aliquid preparation. After periods varying from two daysto a month, irritation and an eruption suddenly appearedin the axillae. The rash consisted of dusky reddish-browndiscrete papules 1-4 mm. in diameter. They wereclosely set in the domes of the axillae and more sparselyplaced at the periphery. The lesions looked semi-translucent but no fluid could be extracted by puncture.An " apple-jelly " appearance was produced by diascopy.Treatment with superficial X rays and topical hydro-cortisone had little effect except for a slight yellowing incolour and moderate scaling.

Histological" sections from a biopsy specimen of anaxillary papule from each patient showed a tuberculoidgranuloma situated in the corium. It consisted ofepithelioid cells and Langhans giant cells surrounded bylymphocytes in typical tuberculoid pattern. Necrosiswas absent. The sharp delineation of tubercles as seenin sarcoidosis was lacking. The infiltrate lay along thecourse of the blood-vessels. Foreign bodies could notbe detected by polaroscopic examination. The stickdeodorant used by 3 patients contained, apart from the

commonly used ingredients, sodium zirconium lactate,but this substance could not be dernonstrated spectro-graphically in the biopsy specimen from 1 patient. Thelotion used by the 4th patient contained chlorhydroxy-aluminium sulphate but no zirconium.Rubin et al. say they cannot be certain of the cause

of this granulomatous eruption. They mention a lineardistribution of lesions and they are now investigating thepossible role of razor abrasions. They do not say whetherany or all of their patients wore dress shields and if sowhether sensitivity to them had been excluded. In anycase, this type of granulomatous reaction is unusual andfurther observation is needed.

1. See Poumon, 1954, 10, 465, and the next 7 articles.2. Hobby, G. L., Auerbach, O., Lenert, T. F., Small, M. J., Comer,

J. V. Amer. Rev. Tuberc. 1954, 70, 191.3. See leading article, Lancet, 1955, i, 599.4. Auerbach, O. Transactions of the 12th Conference on Chemo-

therapy of Tuberculosis, U.S. Veterans Administration, 1953 ;p. 224. Medlar, E. M. Amer. Rev. Tuberc, 1955, 71, part II, 92.

5. Auerbach, O. Amer. Rev. Tuberc. 1955, 71, 165.6. Thomson, J. It. Ibid, 1955, 72, 158, 601.7. Allen, A. R. Arch. intern. Med. 1956, 98, 463.8. Keers, R. Y., Riddell, R. W., Reid, L. Tubercle, Lond. 1956,

37, 404.

OPEN HEALING OF TUBERCULOUS CAVITIESEVEN after long periods of chemotherapy for chronic

pulmonary tuberculosis, tubercle bacilli can often becultured from the walls of cavities in resected specimensby simple 1 or elaborate 2 methods ; and we havereferred 3 to some of the changes in the lesions afterchemotherapy. Perhaps the most important, and

certainly one of the most interesting, aspects of chronictuberculosis is open cavity healing in the lings-a typeof healing recognised as very rare before the days ofchemotherapy.4 Auerbach 5 pointed out that open cavityhealing was commoner after chemotherapy (his examplesreferred to treatment with streptomycin plus p-amino-salicylic acid), that the cavity walls were thinner thesooner treatment was begun, and that the drainingbronchus was re-epithelialised. Thomson s showed thatthe incidence of open cavity healing had risen remarkablywith the introduction of isoniazid, and that two-thirdsof such cavities became completely healed, though areasof minute ulceration were still present in the other third.No tubercle bacilli could be seen in sections of the walls.In resected lesions including more than cavities, Allen 7found that over 10% were positive on culture and 10%on smear. In 10% of Allen’s patients the disease becameactive again after chemotherapy, even after conversion(by a combination of all three drugs) of gastric washingsand sputum ; and Allen recommends surgery afterthree or four months’ chemotherapy, especially for thick-walled cavities, caseous masses over 2 cm. in diameter,and bronchial stenosis or bronchiectasis.A careful clinical, pathological, and bacteriological

study of persistent thin-walled cavities has lately beenreported by Keers et al.8 From the first 10 out of 14

patients who had such cavities and whose sputum hadbeen converted by a few months’ chemotherapy ofvarious combinations, the lesions were resected after afurther four months’ or more chemotherapy. The wallsof the cavities were sometimes uniformly smooth andsometimes trabeculated ; and others showed large or

small granular areas with or without caseous material orthin pus. Histologically, the picture was just as variable,and there was evidence of activity even in cavities whichlooked smooth and shiny. None of the cavities showed

complete epithelialisation, though in several of them

epithelium had grown from the junction between cavityand bronchus for 2 or 3 cm. along the cavity wall. Else-where a smooth fibrous wall sometimes seemed to havea surface layer of flattened fibroblasts. Tubercle bacilliwere identified (4 times by culture and 4 times by smear)in 5 out of 9 cavities from 8 patients. Altogether 11

positive cultures were obtained from 3 patients (4