756

easy, since, unlike the corneal vascularity, we have notbeen able to decide on their cause, nor even to definelimits of normality. All we can say is that, if in twoschools there is a significantly different distribution ofthe children among the five groups of epithelial findings,the factors concerned in their production must bepresent to a different extent in these schools. We canthen state definitely that, whatever the causes of thepositive findings in the epithelium which we heredescribe, they exist to a greater extent in the poor classjunior school than in the better class junior school. Ourresults indicate that the epithelial findings are associatedwith age, economic status and sex, being commoner in thepoorer class school compared With the better class school,in boys rather than girls, and in older rather than youngerchildren. But until further data are available it wouldbe speculative to do more than record these differences.

CORRELATION OF SLIT-LAMP FINDINGS WITH OTHER

FACTORS

The examination of the eyes of these children by slit-lamp was ’part of a more exhaustive survey. Amongother tests carried out were : clinical examination,especially for signs of dietary deficiency ; examinationof the fundus oculi and measurement of visual acuity;examination of the teeth ; measurements of height andweight ; estimation of haemoglobin ; estimation of gripwith a hand dynamometer ; measurement of intelligenceand of educational attainment. A record is also beingkept by the teachers of general behaviour and performancein schools and of absences and illnesses. These resultsare now being analysed with a view to determiningpossible correlations between the various measurements.We can already say that the slit-lamp findings, bothconjunctival and limbal, are not correlated with heightand weight (or Tuxford’s height-weight index), haemo-globin, dark-adaptation, intelligence or educationalattainment. a

SUMMARY ,

, An examination with the slit-lamp microscope hasbeen made of the eyes of 496 elementary-school childrenin Cambridge, aged between 8 and 11 years.

Corneal vascularisation, taken as an actual invasionof the clear cornea with vessels from the limbus, and saidto be indicative of deficiency of riboflavin, has been foundin about 4% of the children. The proportion wassignificantly higher in older than in younger children.The importance of examining the epithelial layer of the

conjunctiva is stressed. Reasons are given for supposingthat this is more likely to show changes due to dietarydeficiency, especially deficiency of vitamin A, thanexamination of the subepithelial tissues according to themethod of Kruse and his co-workers. Opacities in thesesubepithelial tissues have not been observed in thechildren examined by us.Our observations .have led us to classify the various

findings in the epithelium into 5 groups. The firstcontains those children whose conjunctival epithelium isperfectly smooth and transparent, while the other groupscontain those showing varying degrees of wrinkling andopacity. It is suggested tentatively that these represent5 grades of increasing severity of change.The factors which appear to affect the production of

’these epithelial changes are age, economic status and sex.Thus, children with smooth transparent conjunctivalepithelium (group 1) are less common at the higher ages,in the poorer school, and amongst boys rather than girls.It must be-emphasised however that we do not knowthe cause of these epithelial changes ; in particular, wedo not claim at this stage that they are due to deficiencyof vitamin A.

.. We wish to record our gratitude to the teachers of theCambridge schools, without whose cooperation this workwould have been impossible. ‘

REFERENCES

Bessey, O. A. and Wolbach, S. B. (1939) J. exp. Med. 69, 1.Berliner, M. L. (1942) Amer. J. Ophthal. 25, 302.Kruse, H. D. (1941) Milbank mem. Fd. quart. Bull. 19, 207; (1940)

Pub. Hlth Rep. Wash. 55, 157.Sydenstricker, V. P., Sebrell, W. H., Cleckley, H. M. and Kruse,

H. D. (1940) J. Amer. med. Ass. 114, 2437.Wiehl, D. G. and Kruse H. D. (1941) Milbank mem. Fd. quart. Bull.

19, 241.Yudkin, S. (1941) Lancet, ii, 787.

Reviews of Books

Annual Review of Physiology(Vol. IV.) Editors : J. M. LucK, V. E. HALL. StanfordUniversity, California : American Physiological Societyand Annual Reviews Inc. Pp. 709.$5.AN article in an annual review may range from a thinly

disguised card-index to a mature and critical appreciationof new conceptions. The former is too technical foranyone but the expert, and of little interest to himbecause he knows all about it already ; nevertheless, itis a useful record, and changing authorship makes suchsurveys stimulating. The present volume has used themto advantage, but also contains a high proportion of themore mature type of article. General physiology is asusual well represented (permeability, effects of neutronrays, genetics, development, growth) and distinguishedworkers have contributed to the six articles bearing onneurology, electrophysiology and physiological psycho-logy. Subjects often neglected, such as water metabolism,the skin, applied physiology and drug addiction areclearly handled, and metabolism is well represented.Reproduction, the kidney, the digestive system and theblood each receive a section, and there are two chapterson the circulation. The wide perspective embraced byPeters and Shannon in their respective fields of watermetabolism and the kidney, Ruch’s tabloid explanatorymethod of dealing with the technical field of reflexaction, and Long’s careful arrangement of material onendocrines and metabolism are examples of skill inpresentation especially worthy of note, though the samequalities appear in other articles. Inevitably the author-ship becomes more North American, but it is hoped thatafter the war the editors will enhance the value of theirseries by periodically introducing foreign points of view.

Management of the Sick Infant and Child

(6th ed.) LANGLEY POUTER, MD ; WILLIAM E. CARTER, MD.London : Henry Kimpton. Pp. 977. 57s. 6d.

SINCE it first appeared ten years ago " Porter andCarter " has won justifiable popularity among English-speaking paediatricians. This extensively revised sixthedition comes four years after the last. In the prefacemany colleagues of the University of California MedicalSchool and elsewhere are mentioned who have helped inthe process of revision, especially the sections on allergy,blood and its disorders and in various parts of the bookwhere the use of new sulphonamides is discussed.Nearly a third of the new volume deals with therapeuticand diagnostic procedures, dietetic details and drugs.This product of the California school is of a highstandard.

Illustrations of Surgical Treatment .

(2nd ed.) ERIC L. FARQUHARSON, MD Edin., FRCSE, majorRAMC; formerly clinical tutor and temporary assistantsurgeon, Edinburgh Royal Infirmary. Edinburgh: E. and S.Livingstone. Pp. 391. 25s.

Mr. Farquharson fills in some of the gaps left in mostsurgical textbooks, showing in detail how recommendedprocedures, apart from surgical operations, are most easilycarried out. Minor surgery demands attention to detail,and -these careful descriptions with photographs shouldenable even the novice to apply the methods correctly.The expert too will find much of value, for the book alsocontains many useful hints from a man who is obviously5nechanically-ininded. The first section deals withintravenous infusion therapy, describing the mostrecent methods and substances employed. The secondgives useful tips on the application of mechanical andplaster-of-paris splints for various fractures and deformi-ties, well illustrated by photographs. He shows theThomas wrench being used by the handle ; -some preferto see it used as Thomas hixnself-taught, with the opera-tor’s hands protecting the part, and his body-weightused as the correcting force. The book ends with a seriesof plates showing surgical instruments ; these have beenwell chosen and their uses are given in notes. This sec-tion will prove valuable to candidates for surgical exam-inations who nowadays have little time to hang aboutthe instrument rooms.

757TETANUS IN WAR-TIME

THE LANCETLONDON: : SATURDAY, DECEMBER 26, 1942

TETANUS IN WAR-TIMETETANUS, like gas gangrene, requires a particular

set of circumstances for its occurrence. It needs,firstly, a manured soil; for the causal organism and itsresistant spores live in and are shed from the intestineof many animals. Thus, Clostridium tetani was

found in 27 % of 193 samples of soil from the Europeanbattle-zones in the 1914-18 war 1; it was present in57 out of 79 samples from the cultivated fields ofEngland, but not at all from the " wilds of Scotland" 2 ;and now, in our opening pages, BOYD and MACLENNANadmit recovering it from only 8’8% of 91 samplescollected between Daba and Benghazi during thepresent campaign in the Middle East. The secondrequirement is a wound which will encouragegermination of the spore and toxin-production by thetetanus bacillus. Such are usually deep penetratingwounds with much necrosis of tissue or the presence of

foreign bodies, and the rarity of tetanus after civilianaccidents in peace-time is probably related more to thenature of the injury than to the absence of the infectingorganism. Occasionally, however, tetanus developsafter apparently trivial and surface wounds. Sepsis,and particularly the toxins of other anaerobes, alsofacilitates the onset of tetanus. The third requisite isthe bringing together of the infective material (soil orsoiled clothing or other foreign body) and the necrotictissue plus a time-interval to allow germination andtoxin-production. These three conditions are fre-

quently fulfilled in war-wounds, whether suffered onthe battlefield or in the bombed town, and prophy-lactic measures against tetanus therefore become ofprime importance in war-time.

Tetanus has apparently been uncommon among air-raid casualties in this country. There are two

possible explanations : (1) Most cases are quicklydealt with surgically, and surgical removal of necrotictissue or foreign body still plays an essential part in theprophylaxis of tetanus as of gas gangrene ; (2) tetanusantitoxin was given prophylactically to most of theair-raid casualties. Yet - cases of tetanus haveoccurred in spite of a prophylactic dose of antitoxin,e.g., RADLBY SMITH 3 reported 7 cases of tetanus with3 deaths among civilian casualties during a two-yearperiod in one London sector : 6 of them had beengiven one prophylactic dose of tetanus antitoxin.

During the same period, SMITH saw no case of tetanusamong a much larger series of Service casualties, manyof them evacuated from Dunkirk. Indeed, BENSTED 4"records only 8 cases of tetanus after the episode onthe Western Front, all of them in soldiers not activelyimmunised. As large-scale active immunisation hasnot been practised among the civil population, and asone dose of prophylactic antitoxin may not protectagainst tetanus, the instructions regarding the use oftetanus antitoxin for air-raid casualties have beenamended (E.M.S. Gen./33 and E.M.S.I. 351) so thatevery injured person, however trivial the wound, is tobe given an initial dose of 3000 units of antitoxin1. Zeissler, J. and Rassfeld, L. Veröff. Kriegs-u. KonstitPath.

1928, 5, 199.2. Fildes, P. System of Bacteriology in Relation to Medicine, London,

1929, vol. iii, p. 321.3. Smith, E. J. R. Proc. Roy. Soc. Med. 1941-42, 35, 340.4. Bensted, H. J. Lancet, 1940, ii, 788.

when first seen at F.A.P. or hospital, with two furtherweekly injections if the individual has not been

actively immunised. If the injury is severe, the dosesshould be increased two or threefold.

Active immunisation with tetanus toxoid is now aroutine procedure in the Services, and, though avoluntary measure, the rarity of reactions means thatsome 95% of recruits accept it. Two doses of toxoidat an interval of 6 or more weeks produce an antitoxinresponse above the 001 unit per c.cm. which is

regarded as the basal immunity level, but in a propor-tion of cases the titre falls below this level after somemonths s A third dose of toxoid is therefore given6-12 months after the primary inoculation, and thisthird dose " boosts " the antitoxin content to remark-

ably high levels (2-50 units per c.cm.) although theresponse may not occur until after 5 days.6 Becauseof this lag-period and because a few individuals mayfail to respond at all, it is a regulation in the BritishForces that every man shall be given a prophylacticdose of tetanus antitoxin at the time of wounding.These precautions are not always carried out, and evenwhen they are, tetanus may rarely supervene as

BOYD and MACLENNAN have shown in their MiddleEast series of 18 cases, 5 of them among immunisedtroops, giving an incidence of 0’13 per 1000 wounded,and 13 among non-immunised men, giving an

estimated incidence of 1-6 per 1000. That the risk ofcontracting tetanus was not inconsiderable is sug-gested by the finding of 18 toxigenic strains ofCl. tetani in 214 wounds of a severe type. Incidentally,it was perhaps more than a happy chance that abacteriological expert on the plectridia (the terminal-sporing anaerobes) was available to differentiate thewheat from the chaff, for plectridia are commonlyfound in war-wounds, and their isolation and identifi-cation is no mean task.

Interest in this series of cases attaches principallyto the occurrence of tetanus in men who had been

actively immunised. In one patient, who recovered,there was only hearsay evidence about the infection.The other non-fatal case was a Maori who had been

given two doses of toxoid a year previously and whodeveloped a mild tetanus 13 days after a bullet-wound of the forearm. Of the three fatal cases, thefirst, an Indian, developed signs of tetanus 6 weeksafter a cut in his hand, and he died 5 days later with aruptured pulmonic cusp. The development of tetanusin this case can only be explained on the ground thatthe patient was non-immunisable. The other twocases fall into a different category. In both there wasextensive necrosis of tissue without much franksepsis, so that the tetanus bacillus was left undisturbedto manufacture its potent toxin. In the one, whohad been immunised 20 months previously, symptomsdeveloped in 5 days and the patient died 36 hours later.In the other, who had been given a boosting dose oftoxoid three months earlier, the onset was delayeduntil the 9th day, but the large amount of toxinapparently swamped what should have been a morethan adequate immunity. More radical surgery at thetime of wounding would have probably saved bothlives. In neither case was prophylactic antitoxin

given, which raises the question " Would prophylactic’

antitoxin have prevented the onset of tetanus ? "

Opinion is still divided about the advisability of giving5. Marvell, D. M. and Parish, H. J. Brit. med. J. 1940, ii, 891.6. Evans, D. G. Lancet, 1941, ii, 628.