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between 4-2 and 6,million per c.mm." ; and the nextresult must be either less than 4-2 million per c.mm.or , greater than 6 million per c.mm. to be of anysignificance. The same applied to hæmoglobinestimations and white-cell counts.

NEW HOPE FOR REGISTRARSFINALITY marked the Ministry of Health’s instructions

last November 1 for reducing the number of registrars ;but a less uncompromising note is struck in a statement 2’On which the Ministry and the Joint Committee haveagreed. The statement reads as follows : .

" 1. The proposed future establishment of senior registrarsand registrars set out in R.H.B.(50)106 is a ’target figure’bearing in mind the needs of the hospital service and thecareer prospect of these posts. Clearly these figures cannotbe regarded as inflexible, and there is no intention of dictatingarbitrary establishments to hospital boards. Indeed, atthe present time regional boards and boards of governors

‘ jointly are considering the position in the light of the Ministry’sproposals, and they are submitting or will at an early datesubmit their formal proposals as to the numbers of registrarsand senior registrars they require. At the same time an

independent survey of medical staffing is being conductedby medical teams throughout the country. As knowledgeincreases, the position will from time to time be furtherreviewed and the figures adjusted as appears to be necessary.

2. The proposals for the reduction of the numbers of

registrars and senior registrars have been criticised for beingtoo precipitate. In fact the circular does not imply an imme-diate reduction but one spread over a period of at least 12months. There is no intention of immediately displacing.any registrar whose services are required by the hospitalwhether in an existing appointment or as a replacement.

3. The Ministry has agreed to enter into full discussionswith the Joint Committee on questions of general principleaffecting the employment of registrars and hospital juniorstaffing generally, but its present proposals for reviewing theregistrar grades cannot be postponed pending the outcome ofthese discussions."The wording is vague, but one thing is clear : at the

Ministry thoughts are turning to a less rigorous foimulathan was laid down in the November directive.

TRACHEOBRONCHIAL TUBERCULOSISIN some ways it seems a pity that the term " tracheo-

bronchial tuberculosis " has been coined to describetuberculous lesions of the trachea and of the part ofthe bronchial tree visible through the bronchoscope.Tuberculosis of the trachea is rare ; and to separatetuberculous lesions of the bronchi visible at bronchoscopyfrom those just out of range of the observer’s vision is-an artificial and possibly misleading subdivision of a

single pathological condition. On the other hand, thepresence of tuberculosis in the larger bronchi has animportant practical bearing on the treatment of the

lung disease-for instance, it is generally considered too.ontra.-indica,te the induction of an artificial pneumo-thorax. But, as is emphasised in the report of the

Streptomycin in Tuberculosis Trials Committee of theMedical Research Council on p. 253,

" Tracheobronchial.disease is not a separate condition from pulmonarytuberculosis," and the treatment of the bronchial diseaseis merely part of the treatment of the pulmonary tubercu-losis. The committee’s primary aim was to find out theresponse to streptomycin of bronchoscopically visibletuberculous ulcers and areas of granulation tissue. Ina little over three-quarters of the 35 patients treatedthe lesions appeared to be healed or greatly improvedwhen observed four to six months after the start oftreatment If there was no improvement in the bronchiallesion after two months’ treatment, there was unlikelyto be a satisfactory response later. As might be expected,the bronchial lesion healed more often in patients withoutobvious pulmonary cavitation than in those with cavita-tion. One of the most important findings was that

1. R.H.B.(50)106. See Lancet, 1950, ii, 537.2. See Brit. med. J. suppl. Jan. 27, 1951, p. 24.

stenosis of the affected bronchus developed in- 7 patientsduring the treatment, although in 5 the mucoaa. appearedto have responded satisfactorily. Moreover, of the15 patients who had narrowed bronchi before treatment,the degree of stenosis increased in 3 and diminished inonly 4. It is clear that streptomycin therapy will notnecessarily prevent the most important complication oftuberculous bronchitis-irreversible stenosis of thebronchus. Only one of the 35 patients had had theaffected lobe removed during the eighteen months of

,

observation ; but many more are likely to require surgicaltreatment in future, for the stenosed bronchi may lead torepeated attacks of secondary infection in that part ofthe lung and it may also be the site of persistent activetuberculosis. The increasing use of resection- in. thetreatment of pulmonary tuberculosis will provide an

excellent opportunity for correlating the bronchoscopicappearances before operation with the histology of thebronchus. Such an investigation may show that a normalappearance of the bronchial surface is quite compatiblewith gross tuberculous bronchitis. If this is true it isall the more necessary to bear in mind -that tracheo-bronchial tuberculosis is merely a part of bronchialtuberculosis, which is itself indivisible from pulmonarytuberculosis ; and it is the whole patient that we aretreating, not the bronchoscopic appearances of hisbronchial tree.

DELAYED EFFECTS OF ULTRAVIOLET BURNS

IN temperate climates the effects of excessive exposureto the sun are usually limited to redness, swelling, andperhaps blistering of the skin, with subsequent peelingand pigmentation ; and malaise, shock, and other toxicmanifestations may appear if the burned area is large.Thomson 1 has studied the delayed effects of ultravioletburns in tropical conditions after exposure to the sun orto a mercury-vapour lamp. He describes two varieties ofblisters. The more important type, probably identicalwith a thermal burn, arises between the dermis and theepidermis within forty-eight hours of injury. It containsa plasma-like exudate, and may enlarge during profusesweating from dilution of its contents with sweat ; itshould be treated in the same way as a thermal second-degree burn. The second variety (sudamina) arisessuperficially in the corneum from the second day onwardsafter injury, contains sweat, and requires no treatmentexcept for the alleviation of any itching. Such a blister

develops only if the exposure is strong enough to causeerythema with desquamation, and the environmentaltemperature must be high ; owing to-the reduction insweating there may be interference with heat loss unlesthe sweat-glands in unirradiated areas can compensateby increased secretion.Thomson reports two cases of collapse with hyper-

thermia under tropical conditions one day after the

development of ultraviolet burns in subjects who wereless sensitive than the average to ultraviolet irradiation.He has demonstrated under such conditions a reductionof sweating, which he attributes partly to sweat-ductocclusion by the necrosed superficial layer of the epi-dermis and partly to a reduction in the secretory pressureof the sweat. He points out that pyrogenic toxinsabsorbed from the damaged epidermis, or loss of eireti-lating blood from vasodilatation in the sunburned skin,might also have been responsible for the collapse.

O’Brien 2 showed that in prickly heat (tropical anhi-drosis, miliaria rubra) horny plugs block the openingsof the sweat-ducts ; the cause is the drying effect ofexcessive use of soap and water, powders, and spirituousapplications and degreasers. Relief with sweating maybe obtained by rubbing lanolin into the anhidrotic skin.1. Medical Research Council, Royal Naval Personnel Research

Committee : Delayed. Effects of Ultra Violet Burns in ManBy Surgeon Lieut.-Commander M. L. THOMSON, R.N.

2. O’Brien, J. P. Brit. J. Derm. 1947, 59, 125.

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It might be, a good plan to use this substance, perhapsin the form -of unguentum ’alcoholium lanae, as the basefor light-screening creams in the tropics, so as to achieveboth ultraviolet screening from chemical filters and theprevention of prickly heat. Russell and Anderson 3

found that, for the incorporation of light-screening sub-stances, a base containing stearic acid, glycerin, trieth-anolamine, oil of theobroma, and cetyl alcohol was moreeffective than ung. alcoholium lanae ; but with the lanolinointment a slight disadvantage in this respect and from thecosmetic point of view might be counterbalanced by itscapacity to prevent prickly heat. Russell and Andersonalso found spectrographically that para-aminobenzoicacid, ’Pyribenzamine’ (tripelennamine), quinine, salol,and tannic acid were all effective screens against thesunburn spectral range. These substances are usuallywell tolerated on normal skins, but tannic acid and salolare the safest because they are the least likely to sensitise.Quinine may set up severe reactions, and intolerance topyribenzamine has been reported in some 2% of cases 4 ;while para-aminobenzoic acid is best avoided if sulphon-amides, flavine, or benzocaine derivatives have ever beenused on the skin, owing to the risk that group sensitisationmay have been initiated by one or other of these sub-stances. Caution is particularly necessary if there is ahistory of eczematous sensitisation to any of these.

SOCIAL MEDICINE: A WIDENING VIEW

John Ryle, when he was appointed, in 1943, to directthe new Institute of Social Medicine at Oxford, wrotewith enthusiasm of this opportunity " to engage in

something creative- and live and necessary at the age offlftv-three." The six years he was able to give, beforehis death early in 1950, to the development of this

project are reviewed in a pamphlet ° which appearsat the same time as the annual report of the institutefor 1949, his last year of office. The team at Oxfordare in much the situation of stout Cortez and his followers ; ’:for, wherever they look, vast untravelled oceans confrontthem, and every voyage of discovery opens up newprospects. The institute studies communities insteadof individuals, examining the influence of social, economic,and genetic factors on the incidence of human diseaseand disability. The work done so far includes a long-term investigation of child health, a student health

survey, important work on tuberculosis in the boot-and-shoe and printing industries, and in house-to-housespread, and studies in occupational health and in airbornediseases. In the field of child health the institute staff have

established that the incidence of stillbirth is correlatedwith sex, length of gestation, parity, birth rank, birthintervals, maternal age, and social class, but not with- overcrowding, maternal employment, or antenatal super-vision-findings which suggest that the stillbirth-rateis one index of the nutritional status of the population,and that the lessening of regional differences since 1939may well be associated with rationing. Deaths from

injury at birth, unlike all other cause of infant mortality,are increasing, and are commoner in the upper than in thelower ranges of the Registrar-General’s five social classes.It is suggested that the rising rate is due to an increasingtendency among obstetricians to interfere surgically.The survey of student health has revealed that Oxfordundergraduates are taller and. heavier than other menof the same age called up for National Service. In both

groups there was a social gradient, men belonging tosocial classes I and II being heavier than men in classes IVand v ; but the undergraduates from classes iv and vwere actually taller and heavier than the National

3. Russell, B., Anderson, D. Lancet, 1950, ii, 247.4. Sulzberger, M. B., Baer, R. L., Levin, H. B. J. invest. Derm.

1948, 10, 41.5. A Report on the work of the Institute of Social Medicine, Oxford,1943-50. Pp. 17.

Service men from classes I and 11. Three physical typeshave been identified among the students, one character-ised by high academic ability, another by outstandingathletic achievement, and a third by proneness to

psychosomatic disease. A disturbing finding is the

high incidence, of psychological disorders : nervous break-down exceeded all other causes of sickness absence, andthe suicide-rate (for men only) was over five times ashigh as the average rate for men of the same age inEngland and Wales. Apart from their mental andemotional difficulties, students also run a somewhathigher risk of tuberculosis than other young people.The institute findings suggest that if all junior membersof Oxford University were to have a routine cheat

examination the first survey would reveal some 50 casesof unsuspected pulmonary tuberculosis, of which about15 would need sanatorium treatment, and the rest closeobservation. Other tuberculosis studies made by theinstitute indicate that the printing trade and the boot-and-shoe industry have been the centres of two slow-motion epidemics of the disease ; and many will feelinclined to wonder whether the country as a wholeis not embroiled in an epidemic of this kind. The idea

’

receives some support from another observation, madeduring the boot-and-shoe industry study, that cases oftuberculosis in next-door neighbours appeared morecommonly, and in a shorter space of time, than would beexpected if the cases had been distributed at random.Tn other words, there is evidence of house-to-house spread.

Studies of sickness and accident rates in industry haveproved useful to safety engineers and personnel managers,for the institute has been able to calculate standardrates of absenteeism for various working groups. Anydeviation from the standard gives warning of some" abnormal event." It is noteworthy that accidentsare commonest in the early morning, but tend to riseagain towards the end of the day : precision workers, likethe rest of us, do best when they have got into the swingof a job and before they get tired.

COST OF THE N.H.S.THE gross cost of the National Health -Service ill’

England, Scotland, and Wales during the year endedMarch 31, 1950, was £436,035,143. Of this, £91,334,591came from National Insurance contributions, paymentsfor services rendered, superannuation contributions, andother sources, leaving the Exchequer to find some i345million. This was roughly n3 million less than the sumsprovided in estimates and supplementary estimates forthe year, and the balance. has to be surrendered.1

’

JAMES BRIDIEFOR most people Dr. 0. H. Mavor. C.B.E., former

professor of medicine at Anderson College, Glasgow, who-died on Jan. 29 at the age of 63, had long been supplantedby James Bridie the writer of plays. But the dramatistowed much to the physician, as he showed in his One Wayof Living. From the beginning Mavor was anxious to giveBridie his chance : thus his successful theory that ana-tomy could be learnt in a fortnight left Bridie free to help ,

to edit the university magazine and to engage in endlessdiscussions on paramedical subjects. These arguments,still witty, inconclusive, and stimulating, were continuedon the stage, for Bridie’s characters never allowed con-siderations of dramatic construction to hinder them from

speaking their minds. Some purists and critics might,with justice, object that " the play’s the thing," but thebuzz of conversation during the intervals of a Bridie playamong an audience hotly continuing the argument off-stage suggested no lack of interest. The success of ASleeping Clergyman and Mr. Bolfry proved that, underBridie’s direction at any rate, even the English share theScots taste for philosophical discussion. ’

1. Civil Appropriation Accounts (Classes I-VIII). 1949-50. H.M.Stationery Office. Pp. 460. 9s.