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of great clinical relevance, though the Swiss workersclaim to have found it in the blood of burned patients.It is not produced in scalded skin and so would playno part in one of the commonest forms of thermal

injury in man. Perhaps the most provocative aspectsof this study, and those which warrant independentinvestigation, are the demonstration that animals canbe protected against normally lethal burns either bypassive immunisation with antitoxin IgG or by activeimmunisation with sublethal doses of the toxin, andthe finding that sublethal doses of the toxin increasesusceptibility to pseudomonas wound invasion. Rele-vant to this second finding may be the release intothe blood of burns patients of a cytotoxic antigen whichacts directly on lymphocytes.1o

STUDENTS AS PATIENTS

MosT of the best teachers in medical school spendmuch of the day in bed, and students often hesitateto approach them. In the usual system medicalstudents and doctors encounter the sickness role onlyfrom the outside, and have little direct insight intothe patient’s experiences and needs. Where a studentis assigned to specific patients, he has an opportunityto follow a patient and observe how the differentfunctions of the hospital can combine in the interestof the individual patient. With luck, he may, forperhaps the only time in his career, become aware ofthe deficiencies of the system of medical care from thepoint of view of the patient. There are more direct

ways to bridge the gap. Simpson 11 has proposed that" It would ... be beneficial for most students, wherethis can be arranged, to be seen personally at ... twodifferent hospital outpatient clinics as an ordinarypatient, and ... to be admitted to a ward of his ownhospital for a couple of days ". Similarly, for example,by attempting to spend some days in a wheelchair, oreven on crutches, a student could learn more aboutthe realities of physical handicap than the most skilfullecturer could hope to convey.At the 1974 scientific meeting of the Association for

the Study of Medical Education, in Edinburgh, K.Cox reported a response to this suggestion at theUniversity of New South Wales, Australia. It hadbeen found that, despite reasonably high, motivationto get involved in clinical medicine after three pre-clinical years, students rarely entered the wards exceptwhen on structured teaching sessions with a clinicaltutor. Discussions with small groups of studentsrevealed some of the factors the students described asinhibiting them from approaching patients. These

i included many aspects of insecurity and unfamiliaritywith the ward and ward routine, uncertainty about

! the new hierarchy in which they were now placed,embarrassment when undressing patients, fears theymight dry up when talking to patients, and discomfort atfeeling that they were invading the patient’s privacywith nothing to offer in return. A special workshopwas devised to help the students to understand the

10. Hakim, A. A. Experientia, 1973, 29, 865.11. Simpson, M. A. Medical Education: A Critical Approach. London,

1972.

feelings of patients in hospital, and to understandhow the hospital ward functions. As part of this

process, students were admitted to hospital with arange of simulated maladies. They were admitted viacasualty in the usual way, and were treated as normalpatients, including being taught on and having routineinvestigations such as X-rays and E.C.G.S. The em-

phasis was not on the student’s simulating the featuresof a particular illness, but on his experiencing theconcomitants of the management of such a condition.Thus, for instance, the student with " head injury "experienced regular observations of pulse, blood-

pressure, pupil size, and arousability all night; the"

eye injury " has both eyes bandaged; the " asth-matic " has breathing exercises; and the studentscheduled for " bowel surgery " is put on a fluid dietand intravenous infusion.The students and staff involved thought highly of

the experience. Valuable group discussions ensued,and a change of behaviour was seen. Students enteredthe wards and engaged with patients more readily,and (especially those who had needed to be mostdependent upon others during their admission)became more attentive to patients and prepared tospend more time with them. Planning for the workshop,involving as it did prolonged discussions across

different hospital departments and levels of seniority,led to useful improvements in communication.

ACUTE ARSINE POISONING

AFTER two cylinders of arsine (AsH 3) leaked in thehold of the containership Asiafreighter, 17 crew-

members were admitted to hospital, 4 seriously ill

(last week one was still very sick). The toxicity ofarsine-which was once tested as a possible chemicalweapon-is reviewed in a well-timed article by Fowlerand Weissberg. 1 The gas is colourless and non-

irritant, and smells of garlic. Symptoms come on2-24 hours after exposure to as little as 3 p.p.m., andthe main damage is to blood and kidneys. Abdominal

pain (with liver tenderness), dark-red’ urine, and

jaundice are typical presenting features. At this stagethere is a Coombs-negative haemolytic anaemia, withmuch haemoglobin in both plasma and urine; lepto-spirosis, malaria, paroxysmal nocturnal hsemo-

globinuria, and poisoning by other agents are possi-bilities, but arsenic in the urine will usually clinch thediagnosis. By the third day, acute oliguric renalfailure may have supervened, and in fatal cases this isthe usual cause of death. The renal tubules are

extensively damaged; later there is regeneration oftubular cells with thickening of glomerular basementmembranes, so that renal function may remain

deranged. Acute and severe poisoning is treated byexchange transfusion and, where there is renal failure,by haemodialysis. Dimercaprol has been tried, but itsefficacy is uncertain. Evidently, the gas on the

Asiafreighter was to be used in the manufacture oftransistors. Fowler and Weissberg believe that theburning of fossil fuels with high arsenic content maymake arsine poisoning more common.

1. Fowler, B. A., Weissberg, J. B. New Engl.J. Med. 1974, 29, 1171.