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which these graduates come, and perhaps on the

graduates themselves, that they might be even moreusefully employed elsewhere. Pursuit of this lively mythhas entailed gross reduction of that invaluable but

awkwardly incompatible group, the senior hospitalmedical officers; and, owing to the hint of denigrationthat lies behind this reduction, the plan for a career grade,under another title, below that of consultant has nevercaught on. Yet it is precisely to such a grade that thehospital service must look: the seemingly natural law ofthe 1930s, by which all non-consultant work was

comfortably absorbed by cadets and migrants, is clearlyshown in the different circumstances of the ’60s to be nolaw at all-a point with which Mr. DORAN makesmathematical play in a letter on p. 490. If this starkfact has evoked a formal response, it has been singularlymuffled. ,

Meanwhile junior hospital staff has found its voice, orrather voices. What these voices say, with differingemphasis, is that the hours are too long, the pay too low,the physical conditions too bad; and that a country whichtreats skilled and responsible people so heedlessly mustexpect to lose many of these people to other lands whichbeckon. Broadly speaking, none of these three maingrievances can be seriously disputed. What, then, is tobe done ? For over-long hours the long-term answer ismore doctors, and the mid-term answer is a continuouscareer ladder from registrarship to consultantship, withrespected places-some perhaps permanent-on themiddle of the ladder. But, if the trickle of emigrants isnot soon to become a flood, it is the short-term answersthat really matter. Here the Minister of Health has comeclose to admitting defeat, in suggesting that someservices may have to be curtailed.1 This may indeed be

so; but he might have balanced this negative idea witha more explicit call for rationalisation. If each hospitalgroup, or two or three adjoining groups, were to examinetheir resources without, regard to boundaries, profes-sional skill might well be conserved. And if, within theindividual hospital, each consultant were to loosen hisunrelenting grasp on his share of beds (which he toooften regards as some sort of insignia) and allowed moregive-and-take, the saving might be still greater. Further-more, in almost every hospital junior staff spend much oftheir day on work which could be undertaken by others.It would surely be sensible to examine their day’s workclosely in order to discover by how much and by whomthey could be relieved of their tasks as clerks and mes-sengers. There is probably no way of allaying completelythe acute-on-chronic discontent that has been induced bythe Government’s standstill on pay; but the Govern-ment should make a firm promise that the Review Body’saward for junior staff, which it now proposes to imple-ment from Oct. 1, will be backdated closer to the begin-ning of April (which was the time originally agreed),and that it will abandon the lodging charge for those whoare required to reside in hospital. Finally, physicalconditions. Here the complaints range from inadequatequarters to out-of-date wards; and these complaints

seem at last to be convincing the public that more shouldbe spent on the fabric of hospitals. That the public hasso long ignored this may be due to two factors. Thefirst factor is the generally improved standard of hospitalcare under the National Health Service, and the freeingof this care from the undertones of charity with whichthe old voluntary hospitals were associated. The secondfactor is the vaunted Hospital Plan, which deludedpeople that Britain was gaining in new construction,whereas, with a quarter of a century’s leeway still tomake good, the plan has not even kept pace with

dilapidation.The United Kingdom now spends on its health ser-

vices a smaller proportion of its gross national productthan almost any other advanced nation. The sharpquestion raised by the exigent junior hospital staff is:Does Britainwant, or does it not want, a NationalHealth Service ? If the country is to have such a Service,then this must be given much higher priority among thesocial services; but it is unlikely to win a higher placeunless the generality of people decide that it should. Thedecision on priorities is political; but Governments areseldom wholly impervious to the will of the people theyrepresent. It is to be hoped that junior hospital staff,however disgruntled, will remain on these shores and seewhere the hare they have raised will lead.

Annotations

TETANUS

THOUGH tetanus is almost completely preventable bywell-established methods, it remains one of the ten

principal causes of death in many countries (tetanus is

estimated to have killed 1 million people between 1951 and1960). It is common in the developing countries, oftencausing many more deaths than typhoid, poliomyelitis,smallpox, or cholera, each of which has been given farmore attention. This fairly new appreciation of the

importance of tetanus led to a second internarionalconference in Berne on July 15-19, almost three yearsafter the first, held in Bombay in 1963.1 The guidancewhich the conference decided to offer to doctors aboutthe prevention of tetanus (see p. 489) in many rebecsfollows the conclusions of Professor Rubbo in his alliedon p. 449.

In the developing countries the cost of an immunisecampaign is often prohibitive; and the skilled personnecessary to carry it out may not be available. Sinceneonatal and puerperal tetanus, as Dr. J. C. Suri estimatedfor India, accounts for about 50% of cases, hygienic mis’wifery could undoubtedly do much to prevent tetanusThus Dr. 1. Ebisawa illustrated how deaths from neona"-tetanus in Japan fell from 36-1 to 7-1 per 100,000 li"births between 1947 and 1961, because an increaseproportion of deliveries were conducted in medicainstitutions-an experience comparable with that in S.Kilda in the Outer Hebrides in the last century when the

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incidence of neonatal tetanus was reduced from about 50%to nil by clean midwifery and the application of iodoformdressings to the umbilical stump. In many parts of the

world, -however, improvements in hygiene are harder toachieve than immunisation, and it has been shown, notablyby Dr. F. D. Schofield working in New Guinea, that activeimmunisation of pregnant women with two spaced dosesof aluminium adjuvant toxoid will provide a mean

maternal serum-antitoxin concentration of 0-01 units perml., which passively protects the newborn infant againsttetanus.

In most developed countries only children and thosewho have served in the Forces have been immunised, andthe importance of extending active immunisation to allpersons was repeatedly emphasised in Berne. As ProfessorRubbo notes, the best protection for non-immunised

persons is passive immunisation with human tetanusimmunoglobulin. Apart from its freedom from hyper-sensitivity reactions and from rapid immune elimination,human antitoxin also has a long half-life, so that a smalldose will provide for a long time a serum-antitoxin con-centration above that believed to be protective. Dr.

J. A. McComb, working in Boston, has shown that aninjection of 250 units will provide a serum-antitoxin con-centration of over 0-01 units per ml. for four weeks, andthis dose of homologous antitoxin was accepted by theconference as adequate for prophylaxis. The main

problem concerning human antitoxin is to obtainsufficient high-titre human serum to meet the demand.This problem has largely been overcome in NorthAmerica and in many European countries but not,unfortunately, in Britain.

In the absence of human antitoxin, either horse anti-toxin or an antibiotic (or both) must be used when it isnecessary to supplement surgical cleansing of the wound.The choice between the two has been, as Professor Rubbosays, a matter of lively debate, and the Berne statementgives little guidance on this question. In the absence of

good field evidence the choice must be made partly onan assessment of the frequency with which they eachgive rise to hypersensitivity reactions and partly on thecondition of the wound and how early the patient is seen.Thus, if the patient is seen within six hours of injuryand the wound is not badly contaminated, antibiotic

prophylaxis may be preferred in countries where hyper-sensitivity reactions to horse serum are common. 2

How long does active immunity last ? Experience inAmerican veterans showed that it lasts for over twentyyears,3 The American Forces were particularly wellimmunised; and there has been little information aboutthose who have received only the usual three doses oftoxoid, though Professor Rubbo thinks it is reasonable toconclude that immunity is permanent after three injections.Work by Dr. I. Scheibel in Denmark and Dr. W. G.White at the Morris factories in Oxford indicated thatan acceptable serum-antitoxin concentration is presentbetween ten and twenty years after immunisation, and thata good response to a booster dose of toxoid is obtained inthis period.

In the final session of the conference, Dr. J. C. Patel, ofBombay, confirmed the findings of Vakil and his colleagues 4that antitoxin is of therapeutic value in tetanus and that2. Laurence, D. R., Evans, D. G., Smith, J. W. G. Br. med. J. 1966, i, 33.3. Gottlieb, S., McLaughlin, F. K., Levine, L., Latham, W. C., Edsall, G.

Am. J. publ. Hlth, 1964, 54, 961.4. Vakil, P. J., Tulpule, T. H., Armitage, P., Laurence, D. R. Clin.

Pharmac. Ther. 1964, 5, 695.

no advantage is to be gained from using a dose of over20,000 units. Human antitoxin is undoubtedly preferableto horse antitoxin, although adverse reactions occasionallyfollow its intravenous injection. Dr. J. W. G. Smithpresented evidence that the therapeutic dose of humanantitoxin, in contrast to the prophylactic dose, should bethe same as that of horse-serum antitoxin. With con-ventional treatment with antitoxin, sedation, and carefulnursing, the mortality-rate is about 90% tetanus in thenewborn and about 40% at other ages. With the expen-sive and demanding techniques of curarisation and

artificially controlled respiration, the mortality-rate hasbeen reduced to about 30% in the newborn and about20% at other ages.

MESOTHELIOMA SCHEDULED

ANOTHER occupational cancer (pleural and peritonealmesotheliomas in asbestos workers) has been scheduledas an industrial disease; and the fact that no particulartype of asbestos fibre is specified means that chrysotileas well as amosite and crocidolite asbestos must be

presumed to be carcinogenic until overwhelming evidenceto the contrary is forthcoming. This presumption is

important for many reasons-for example, chrysotileasbestos waste has been tipped near houses, as we

mentioned in these columns last month. 1

But approval of these new regulations must be qualifiedby reservations about certain restrictions (see p. 489).Apparently, if a man’s " loss of faculty" ceased on

Aug. 21 by reason of his death, his widow would not beentitled to benefit. No such restriction applied whentumours of the urinary tract were scheduled as " prescribedindustrial disease no. 39 ". The other questionable pointis the requirement, shared by P.D. 39, that exposure tothe carcinogen shall have taken place after July 5, 1948.This provision is likely to cause hardship and apparentinjustice, as it already has in relation to urinary-tracttumours, because of the long latent periods (the averagebeing about 20 years for urinary-tract tumours and

perhaps 40 years for mesotheliomas) between exposureto the carcinogen and the appearance of the disease.Bladder tumours have arisen in men who worked in therubber and cable industries in the 1939-45 war and thenleft this work altogether. When such a urinary-tracttumour appeared the patient could not claim benefit.Similar situations can easily be envisaged where asbestoshas been used.Has the time come when the provisions of the National

Insurance (Industrial Injuries) Act should be scrutinisedand.reformed to take account of the peculiar characteristicsof the occupational cancers (and other diseases, such asbone necrosis following " bends ", where there may bea long latent period) ?

SUGARS AND FATS

THE central theme of a recent symposium on dietarycarbohydrates in man, held at Guy’s Hospital MedicalSchool, was the influence that carbohydrates in the diethave on those changes in the serum-lipid levels whichprecede the development of ischaemic heart-disease. The

1. Lancet, July 23, 1966, p. 219.2. Statutory Instrument 1966, no. 987. H.M. Stationery Office. 8d.