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a survey of children who lived in the Channel Islandsduring the German occupation, the state of their teethwas compared with that of the children who had beenevacuated to England.23 The findings suggested thatthe teeth of children who had remained in the ChannelIslands were much better than those of children whohad been evacuated. A similar conclusion was reachedabout the teeth of the children living in HopwoodHouse in New South Wales, where they were givenwhat were considered to be natural foods.24 A morerecent inquiry 25 has been conducted in Eire to findout whether there was any significant connectionbetween, on the one hand, the type of diet generallyor the consumption of certain foods, and, on the other,the prevalence of caries. Some 2000 children werechosen, approximately equally from the countyborough of Dublin, other urban areas, rural areas,and congested districts in counties Mayo, Galway,Kerry, Donegal, and Leitrim. The dental examinationswere completed by the end of 1952, and the amountand the degree of caries were recorded for all thechildren. The parents of about 10% of the childrenhad been interviewed to collect information about the

possible significance of social and economic factors,heredity, and diet. The report gives a depressingpicture. The children received virtually no dentalcare for their deciduous teeth, and the permanentteeth were almost as badly neglected. By the age of13, most of the children had one in four of theirpermanent teeth either missing or decayed. There wasno striking difference in the incidence of caries amongthe children in the various areas, but children livingon plain and simple diets had slightly less caries.The difference, however, was nothing like so great asthat reported from the Channel Islands or from NewSouth Wales. It was impossible to connect carieswith particular foods ; and statistical analysis of thesocial factors which it was thought might affect theincidence of caries was inconclusive. Children fromthe same family resembled each other more closelyin caries experience than those from different families,but the causes of this difference could not be identified.No mention is made in the Irish report of the fluoridecontent of the drinking-water in any of the areas.Though the dental health of Great Britain seems

rather better than that of Eire, we have very littleto be pleased about. The prevalent attitude of thepublic is " wait until it aches and then have it out." 26Until this is corrected the aftermath of neglectedcaries will continue to add greatly to the cost of theNational Health Service, fluoridation or no fluorida-tion—and in spite of what some toothpaste manufac-turers say. Fear deters many people from seekingmore than emergency dental treatment ; and fearoften springs from unhappy experiences in childhood,when one unsympathetically given " gas " can letcaries run riot later on. Modern dentistry, if not alwayscompletely painless, need seldom be more than mildlyunpleasant ; and until we have applied effective

preventive measures we want fewer jokes about thehorrors of dentistry and more effective propagandaabout the importance of dental health.23. Bransby, E. R., Knowles, E. M. Brit. dent. J. 1949, 87, 236.

Knowles, E. M. Mon. Bull. Minist. Hlth Lab. Serv. 1946,5, 162.

24. Lancet, 1952, ii, 127.25. Dental Caries in Ireland. Nutrition Committee of Medical

Research Council of Ireland, Dublin, 1956.26. Lancet, 1951, ii, 71.

Annotations

THE OVERSEA MEDICAL SERVICE

THE Government’s recent white-paper’ on Her Majesty’sOversea Civil Service advances matters a little furtherfrom the proposals made in 1954 2 ; but many difficultiesremain when the latest development in policy is appliedto the medical profession. The new proposals deal

especially with Nigeria, where present-day events call forrapid action ; but it is made clear that similar arrange.ments will be offered to other territories " as and whenHer Majesty’s Government in the United Kingdom aresatisfied that circumstances make such action desirable."Briefly, the Government propose to recruit people withthe necessary qualifications for secondment to overseasgovernments as required. Such recruits will go on a" special list of officers of Her Majesty’s Oversea CivilService," and while seconded overseas they will receivesalaries and work under conditions prescribed by theUnited Kingdom Government after consultation with theemploying government. In the matter of entitlement topensions and compensation payments, it seems thatofficers on the special list must undertake to serve up tothe age of 50

" in any post to which they may be assignedfrom time to time " (with a vague no-detriment clause).If before the age of 50 an officer becomes unemployedthrough no fault of his own, he will be kept on full payfor a maximum of five years (or until he .reaches theage of 50 if that is earlier) while efforts are made to

place him.Nowhere in the recent proposals are doctors specifically

mentioned, and nowhere else does the white-paper dealwith the issue raised in our correspondence columns byMr. Seddon 3-namely, that although a very large propor-tion of doctors in the United Kingdom are in the NationalHealth Service the Ministry of Health as such can makeno promise of reappointment to a man who is secondedfor service overseas. The only medical officers " in theservice of Her Majesty’s Government in the United

Kingdom " in the strict and direct sense are presum-ably those on the staff of the Ministry of Health,the Treasury, or other Departments-or do the ArmedServices count as well ’? Is the plan to create a " list "of doctors who are in no specific post in the UnitedKingdom and who, therefore, on return from overseas,can hope to be rescued from the pool only by securing anappointment by the existing means ? Certainly the newproposals meet one of the difficulties raised by Mr.Seddon ; for the returning doctor can be maintainedfinancially for five years or up to the age of 50 ; but surelythose under this age would prefer to work. To be attrac-tive and effective, secondment in the medical servicesmust surely be from a specific post with a prospect ofreturn to that post or something equivalent. Mr. Seddon’sproposals were that regional boards and boards ofgovernors should be brought right into the whole businessof secondment. He pointed out that there was nothingin other professions wholly comparable with the situationin the National Health Service.

By apparently lumping all officers of Her Majesty’sOversea Civil Service together, the recent white-paperseems to disregard all sorts of practical difficulties. Manypeople would welcome a spell of duty overseas if a jobwas guaranteed them on their return. The Hospital forSick Children, Great Ormond Street, has done this withits senior registrar seconded to Kampala. Some of thoseseconded may well decide to stay overseas. A certainnumber of general-duty medical officers, as distinct fromspecialists, will probably continue to choose service

1. Cmd. 9768.2. Lancet, 1954, i, 1334.3. Ibid, 1956, i, 46.

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overseas as their career. The new proposals, however,do not even deal with an obvious distinction of this kind,and they not only classify doctors as Civil Servants ingeneral terms but they fail to recognise the existence offamily doctors, clinical specialists, and public-healthdoctors, for all of whom varying conditions will certainlybe necessary. The Colonial Office should give more detailsof what its new plans really mean for the medical profes-sion. Otherwise the uneasiness, of which Mr. Seddonwrote, in what used to be called the Colonial MedicalService will continue to grow and recruitment will bethe worse.

1. Times, June 27, 1956.2. Sevitt, S. Lancet, 1953, ii, 1121.3. Sevitt, S. Ibid, 1949, ii, 10754. Ibid, 1953, ii, 1133.5. See Ibid, 1955, i, 495.6. Doig, A., Shafar, J. Quart. J. Med. 1956, 25, 1.

TETANUS IN THE THEATRE ?

FROM time to time a disaster reminds us not to under-estimate the risk of surgical wounds being contaminatedin the operating-theatre ; and an unexplained infectionby tetanus, described at an inquest last week, may besuch a reminder. A woman of 35 died after an operation ;the immediate cause was embolism, but she was beingtreated for tetanus, which had developed after the

operation, and, in a pathologist’s view, the consequentimmobility was responsible for the embolus.Examination of material used at the operation gave

no indication that it was the source of the infection ;and a bacteriologist said at the inquest that he felt it wasimprobable that this infection was due to reactivationof spores implanted at an operation ten to fifteen yearsearlier. In the light of previously reported cases, itseems more likely that the tetanus bacilli were borneinto the wound by the air of the operating-theatre.In 1953, a young footballer had gas-gangrene and losthis leg after an open operation on a fractured ankle ;and Sevitt’s inquiries 2 left little doubt that the infectionresulted from the exhaust system of ventilating the

operating-theatre. The same ventilation plant hadearlier been incriminated in two postoperative cases oftetanus, one of them fatal.3 The exhaust system sucksair and dust into the theatre from the corridor and otherparts of the hospital ; the theatre, in fact, becomes an" air sewer," all too readily contaminated with sporingorganisms. As we noted in discussing 4 the tragedy ofthe footballer, one simple way to make this system saferis to reverse the extractor fans so that they draw airinto the theatre through their ducts, which can be

guarded by filters. In the design of many new theatresthe danger of airborne infection is greatly reduced bykeeping them at an air-pressure slightly greater thanthat of their surroundings. Are all surgeons fully awareof the risks their patients run in theatres where theexhaust system prevails ? And have they made surethat the hospital authorities fully understand the

expensiveness, in every way, of economies which favourinfection ’?

C.N.S. LESIONS AND THE ŒSOPHAGUS

GASTRIC erosion associated with intracranial lesionsmight hold the germ of the solution to the causationof peptic ulcer 5 : yet the explanation eludes us whilethe clinical evidence continues to accumulate. Gastric

haemorrhage is now reported by Doig and Shafar 6in 7 cases of spontaneous intracranial haemorrhage(4 cerebral, 1 pontine, and 2 subarachnoid). An interest-ing feature, well demonstrated in their patients, is therapidity with which gastric bleeding follows intra-cranial : in 5 patients, this interval varied betweenhalf an hour and eight hours ; in 1, hæmatemesis wasthought to be the primary condition, since the significanceof the headache which preceded it by half an hour was

not perceived until later. In another patient alimentarybleeding was demonstrated as occult blood in the stoolstwenty hours after the onset of cerebral haemorrhage andtherefore probably occurred early. The 7th patientdied twelve hours after admission and at necropsy thestomach was found to contain blood. The predominantlesion in all 7 was superficial mucosal haemorrhage ;the deeper aspects of the mucosa were rarely affected.In only 1 case did the resultant mucosal defect penetrateas deeply as the muscularis mucosae and no areas ofanaemic necrosis were seen. These 7 patients were not,therefore, candidates for perforation.When the oesophagus is involved the plot thickens :

Brooke Williams 7 described 2 cases of oesophagealperforation, one associated with poliomyelitis and theother with tuberculous meningitis. The lower third ofthe oesophagus of the first patient was softened andnecrotic in appearance, and this appears to have beena true perforation ; but in the other a linear tear wasfound, the surrounding wall appeared normal, and therewas also a laceration of the stomach near the cardia

(this patient had been vomiting). Maciver et al.8 have

lately analysed 17 cases of cesophageal rupture complica-ting central nervous lesions. 13 of the patients had beenvomiting. In 13 cases the rupture was a linear tear ;usually the oesophageal wall adjacent to the rupture wasnormal, and submucosal haemorrhage and congestionwas observed in only 3 cases and a large haemorrhagein only 1 of the 17. Two mechanisms seem thereforeto contribute to rupture associated with nervous dis-order : one is much the same as in perforation elsewherein the alimentary tract and depends on weakening ofthe wall through erosion or necrosis; the other ismechanical and associated with vomiting. Spontaneousrupture of the oesophagus, unconnected with trouble in thecentral nervous system, can occur when vomiting followsdraughts of beer on a Saturday night. Incoordination inthe normal mechanisms of vomiting may be due to reflexfailure caused by disease of the central nervous system,relayed to the autonomic system, or to its befuddlementby alcohol so that the vomit cannot escape rapidlythrough the gullet. Certainly the lesion from both causesis the same-a linear tear in the lower third of the

œsophagus nearly always on the left side. Perhaps thecricopharyngeus is a split second late in relaxing abovethe uprising, thus forming another kind of glottal stop.

7. Brooke Williams, R. D. J. Pediat. 1954, 45, 575.8. Maciver, I. X., Smith, B. J., Tomlinson, B. E., Whitby, J. D.

Brit. J. Surg. 1956, 43, 505.9. Oyama, T., Tatsuoka, M. Amer. Rev. Tuberc. 1956, 73, 472.

PROGNOSIS BY NUMBERS

PROGNOSIS is largely empirical. The future is forecast

by knowing what happened to similar patients in the past;and from the many particular observations are deducedgeneral prognostics. These may concern only one charac-teristic of the patient or his environment ; or they maycombine the separate effects of many. In the Hippocraticprognostics, for instance, there are simple generalisations.such as " when fits follow dropsy it is fatal " and morecomplex ones like " patients suffering from prolongeddiarrhoea associated with worms, in whom swellingsfollow the symptoms of colic and pain, have a pooroutlook if rigors supervene." It is possible by simpleobservation to deduce that one factor is more importantthan another, but without more detailed analysis the sizeof the contributions made by each to the after-historyof the patient cannot be expressed numerically.Oyama and Tatsuoka 9 have lately used the technique-

of discriminant analysis to assess the influence of certainfactors on the relapse of patients with pulmonary tuber-culosis after leaving hospital. They found that the mostimportant factors were the presence of a cavity on dis-charge and the extent and state of activity of the disease-This was not surprising. It has been accepted from