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theria toxoids is now being recommended in the U.S.A.for the immunisation of children, and in Britain a

case has been made out for the active immunisationof agricultural workers against tetanus. In civilian

practice reliance is usually placed on passiveimmunisation, although the prophylactic injection oftetanus antitoxin for accident cases in outpatient depart-ments is not by any means a universal procedure.

Other forms of tetanus infection that often attract

publicity are the postoperative, which is reckoned toconstitute 5-10% of all cases, and the puerperal, whichwas recently the subject of inquiry by a committeeof the Royal College of Obstetricians and Gyneecologists.3A high proportion of cases of puerperal tetanus followabortion, and it seems reasonable to conclude that inmany of them the infection was derived from unsterilisedcotton-wool or cellulose wadding used as packs. Thesematerials commonly harbour tetanus spores,4 and thedanger of unsterilised dressings was recently demon-strated by the astonishing report of 5 fatal cases oftetanus within 15 days among women who had beenattended by the same abortionist." Postoperativetetanus, most common after abdominal operations, hasoften been blamed on catgut or contamination fromthe bowel, but catgut has very rarely been found guilty,and in this country human carriers of tetanus spores arevery uncommon. 6Another more likely source of tetanus infection is

dust coming more or less directly from the street or fromcultivated land. Kerrin7 showed that domestic animals,and particularly dogs, are frequent carriers of tetanusspores, while Fildes 8 found the organism in 57 out of79 samples of soil from cultivated fields. During therecent war many surgical theatres were protected withsandbags (often containing more earth than sand),and the possibility of anaerobic infection from theseanti-blast devices was recognised. Last week (p. 152)Robinson, McLeod, and Downie reported two probableinstances of dust-borne tetanus following surgical opera-tion, one in a sanatorium where the windows of the

operating-theatre opened on to grazing pasture (01. tetaniwas isolated both from the dust of the theatre andfrom the adjacent field) ; the other following an opera-tion for haemorrhoids where the catgut and dressingsseemed to be satisfactory but the dust of the theatretaken 11 days after operation yielded toxigenic C7. tetani.Examination of dust in 15 other operating-theatresyielded only one positive result-from the theatreadjacent to that in which the case of haemorrhoidshad been operated on. However, the positive findingsindicate that dust must be regarded as a possible sourcefor yet another infection (it has already been circum-stantially incriminated in such diseases as scarlet fever,diphtheria, psittacosis, and, experimentally, tuber-

culosis), and measures must be taken to obviate thisadmittedly small but real risk of postoperative dust-borne tetanus. Operating-theatres are often not suffi-

ciently isolated from much-trodden corridors. Anair-lock should separate the theatre from such corridors,and new methods of ventilation are needed whereby apositive pressure of air is maintained in the theatreto prevent dust being aspirated into it. Dust-layingmeasures and the use of special theatre footwear shouldalso be enforced. Where some of these recommenda-tions cannot easily be put into practice, the surgeonshould consider the wider use of prophylactic tetanusantitoxin, particularly after bowel and gynaecologicaloperations.

3. Report of the Tetanus Committee, Royal College of Obstetriciansand Gynæcologists, 1941.

4. Pulvertaft, R. J. V. Brit. med. J. 1937, i, 441.5. Bush, W. L. J. Amer. med. Ass. 1941, 116, 2750.6. Kerrin, J. C. Brit. J. exp. Path. 1928, 9, 69.7. Ibid, 1929, 10, 370.8. Fildes, P. System of Bacteriology in Relation to Medicine,

London, 1929, vol. III, p. 321.

FUTURE OF DERMATOLOGY

THE Royal College of Physicians of London last weekpublished an interim report from its committee on

dermatology,’ who are here concerned with the medicalstaff, beds, and ancillary services needed for a compre-hensive dermatological service. In a National HealthService, they point out, the demands made on dermato-logical departments will be greater than at present, formore patients will be referred to special departments bypractitioners and more patients will want to have

specialist advice. The provision they recommend is

necessary, they believe, if standards of training-andpresumably facilities for practice and research-are to beraised to a level that will give the best results in termsof health.Assuming that, for purposes of organisation, the

country will be divided into regions, whose dermatologicalcentre will be in or attached to a university hospital(in London, a teaching hospital), the committee recom-mend that the head of each central department shouldbe of professorial rank and his appointment a full-timeone. His staff should include a dermatologist of readerstatus, two full-time registrars, and two resident medicalofficers, and a number of clinical assistants should alsobe appointed. The members of this department wouldbe available for consultation with dermatologists through-out the region, and in certain circumstances by dermato-logists of other regions. Facilities for pathological andbiochemical investigation, and for physical therapy, mustbe to hand ; a cadre of special personnel will be requiredfor nursing, secretarial, and other duties ; and either inthe university hospital or in an easily accessible hospitalthere should be a block of 50 beds for dermatological cases.In addition, in every area of population of 100,000 or250,000 persons a secondary dermatological centre shouldbe established. This would be staffed by one seniordermatologist with assistants of the status of chief

clinical assistants, the size of the staff depending on thedensity of population round any given centre andwhether the area is industrial or rural. In sparselypopulated districts small outlying hospitals could beused for collecting patients suffering from cutaneousdiseases, and beds could be provided in one of eachgroup of these establishments, which specialists from thesecondary centres should visit when required. Thecommittee think it important to have rehabilitationcentres for skin cases, and they discuss the purposes thecentre would fulfil-omitting, however, to mention thepioneer work done in this connexion by the Army duringthe war. They conclude their report by quoting a

statement by Sir Archibald Gray that there are at

present 85 part-time dermatologists of consulting rankin active work in England, Wales, and Scotland,and some 30 doctors in charge of skin clinics whoare either general physicians or general practitioners.On the basis of the committee’s recommendationsthe National Health Service will require no fewer than250 dermatologists; and if some work only half-timethe number will be larger.

Evidently the committee have been impressed by thepaucity of the facilities for inpatient treatment forcutaneous diseases, and would like to see more centralisa-tion than at present, especially in teaching hospitals.

Undoubtedly by the use of modern methods of therapy,under controlled conditions, much of the gross wastageof drugs, dressings, and time which now occurs in manyareas will be obviated, and much human suffering willbe prevented ; it has often been noted that while a man

1. The members are Lord Moran, P.R.C.P. (chairman), Dr. HenrylBlacCormac (vice-chairman), Sir Archibald Gray, Dr. H. BB.Barber, Dr. A. C. Roxburgh, Dr. R. B. Mumford, Dr. G. B.Dowling, Dr. M. Sydney Thomson, Dr. R. T. Brain, Dr. J. T.Ingram, Dr. W. N. Goldsmith, Dr. J. E. M. Wigley, Dr.R. M. B. MacKenna, Dr. L. Forman (hon. secretary), Dr. B. C.Tate, and Dr. J. H. Twiston Davies.

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suffering from occupational dermatitis or infectivedermatoses may attend as an outpatient for severalweeks without noticeable benefit, he will rapidly getwell when admitted to hospital and given the - sametreatment under controlled conditions. Further, bycentralising dermatological units, economies will be madein dispensing and equipment, which are both heavyitems in this specialty. Those who assess these recom-mendations will do well to remember, however, that,even where there are enough beds, the basic criterion instaffing (so far as doctors are concerned) is not, as is

usually supposed, the provision of so many doctors forso many beds: of more importance is the ratio ofmedical staff to the average number of outpatients whohave to be examined, trted, and " written up " eachday. An insufficiently staffed outpatient departmenttends to degenerate into a dispensary service : teachingmaterial and the time of doctors and patients is wasted,errors are made because of the pressure of work, andpatients who should not be admitted are sent hurriedlyto the wards because the outpatient physician has notthe time to assess the cases properly. It may be sug-gested that because the committee recommend muchbetter facilities for inpatient therapy this caveat will nolonger be valid ; but the majority of inpatients mustalways be admitted through the outpatient department,and the labours of this section’of the hospital are notnecessarily reduced because there are beds in which thepatients can be put. It is to be hoped that in a laterreport the committee will also consider what is suitableaccommodation. In this country the authorities (bothmunicipal and voluntary) are apt to relegate " skins "to old wards in ancient buildings, not always recognisingthat artificial lighting is a severe handicap to diagnosis.Skin diseases usually have a depressing effect upon thepatients, and this depression is intensified by gloomysurroundings. The teacher of any branch of medicine worksat a grave disadvantage if he has to give his instructionin unsuitable conditions and in lecture-rooms which, inthe graphic phrase of the engineers, are just " mock-ups."

Despite poor accommodation, deficiency of endow-ments and major benefactions, and the lack, until veryrecently, of a university chair, the work of British dermato.logists has been much admired by their contemporariesabroad. The appointment of Dr. Percival to be professor ofdermatology at Edinburgh, which is announced in ournews columns, foreshadows, we may hope, more supportin the future than our colleagues have generally received inthe past.

JAKE PARALYSIS ON MERSEYSIDE

IN the last week of January there were numerousaccounts in the daily press of a mysterious outbreak ofparalysis in the Rhuddlan district of North Wales andon Merseyside. The first cases, which occurred atRhuddlan early in December, were notified as- polio-myelitis, but it soon became clear that the conditionwas a toxic peripheral neuritis affecting the muscles ofthe legs and feet, arms and hands, with an acute onsetand a tendency to spontaneous recovery. Since many ofthe people affected were able to-get about, and someeven to- do their work, the total incidence will be- hardto estimate; but the present provisional figures are 21cases in North Wales and 19 in Cheshire. On another

page Dr. R. D. Hotston describes the clinical picture andreveals the cause of the ailment. This, it appears, isanother example of orthotricresol phosphate poisoning.The first record of this was in the- cases of " ginger ake,"reported in the United States in 1930 in people who haddrunk " soft " drinks fiavoured with tincture of gingerwhich had been adulterated with tricresol phosphate tomeet (or circumvent) the requirements of the U.S.P.,which specified a certain percentage of residue of specifiedsolubility; 20,000 people were affected and many died.1

1. Burley, B. T. J. Amer. med. Ass. 1932, 98, 298.

It next arose in a steamship, the Jean L. D., in avoyage from Durban to London in the autumn of 1937.Here 32 members of the crew of 34 were affected withgastro-enteritis followed 8-15 days later by motor paralysisof the lower limbs 2 Reports of about 40 similar casesin Durban 3 led to the incrimination of soya-bean saladoil containing tricresol phosphate ; this was the onlyarticle of food common to the Durban patients and thoseon the Jean L. D. In February, 1938, in Mauritius,there were 95 more cases, again ascribed to importedsoya-bean oil contaminated with tricresol phosphate.How the poison reached the oil is still unknown, but itseems likely that the containers used had previouslycontained tricresol phosphate for industrial purposes.A similar explanation seems likely in the present out-

break, for the tricresol phosphate has been traced tocotton-seed oil used in frying. This compound is usedin the manufacture of cellulose lacquers, varnishes, &c.,and being insoluble in water and non-volatile in steam isnot easily removed from metal casks or drums. Usersof second-hand containers should take note.

FUTURE OF DENTISTRY

THE inter-departmental committee on dentistry, underthe chairmanship of Lord Teviot, have now issued theirfinal report.4 4 They begin by urging that an entry of900 students a year to the dental schools should beachieved as quickly as possible. The attractions of adental career should be brought to the notice of boysand girls through the headmasters of schools, by films,broadcasting, lectures, and the like, and by visits todental schools and hospitals. In making the career moreattractive the fundamental factor is the greater demandfor dental treatment which will arise from public appre-ciation of the relation between dental disease and generalhealth ; this point was urged in the committee’s interimreport.5 5 Public authorities can help recruitment byabolishing the discrepancies in remuneration between

dentistry and kindred professions, and by providingadequate buildings and equipment and attractive con-ditions of service. In future, no suitable boy or girlshould be Aeterred by lack of means from embarking ona dental training. The curriculum should be made asshort as possible, compatible with a satisfactory standard.

In the committee’s view all dental schools should be

integral parts of universities, and should be distinctfrom, though closely associated with, their hospitals.This means that the extramural schools of Edinburghand Glasgow should seek affiliation with their univer-sities. New schools will have to be built, and old onesextended, to increase teaching capacity, and highpriority should be given to such building. Staffing ofdental schools should be generous enough to permitteachers to do research. A national scale of remunera-tion for dental teachers should be drawn up.A Government grant of 1,250,000 is suggested for

capital expenditure, with an annual sum of f:l50,00O,rising to 300,000, to pay for building and equipmentand meet the salaries of the increased number of teachersrequired. The committee urge that the professionshould be governed by a separate Dental Council,cooperating with the G.M.C. More dental research isurgently needed, and the committee ask for generoussupport from the public and Parliament for an extendedprogramme planned by the Medical Research Council.

AT the hall of the Society of Apothecaries of Londonon Tuesday, March 12, at 8 P.M., Lord MoRAN will delivera lecture entitled Into Battle.

2. Stock, P. G. Ann. Rep. Chief Medical Officer of Ministry ofHealth for 1938 ; appendix C, p. 189. In this appendix Dr.Monier-Williams suggests a simple test for tricresol phosphatein edible oils.

3. See S. Afr. med. J. 1942, 16, 1 ; Bull. Hyg. 1942, 17, 795.4. Cmd. 6727, H.M. Stationery Office, pp. 60, 1s.5. See Lancet, 1942, ii, 701.