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<ul><li><p>1153</p><p>variations and gross obesity may call for alternativeprocedures. Dr. Davidson and his coworkers adopted thesubclavian approach in 83 patients for intravenous therapyand in 17 patients to obtain blood for biochemical analysis.The vein could not be found on 6 occasions (5 in the first20 patients); a pneumothorax was produced in 1 patientwho had had an operation for bilateral vagotomy andpyloroplasty the day before; and hsematomas formed in3 patients. There were no other complications, but thisgroup of workers warn of the potential hazard of air-embolism.The weightiest objection to the subclavian route for</p><p>intravenous medication is that the operator cannot seewhere the needle is going, and the vein is surrounded byimportant structures. Pneumothorax is an added burdento an already ill patient, and, although hxmatomas arecommon enough in arm-vein infusions, they are morereadily dealt with in the arm than in the non-compressibleroot of the neck where the brachial plexus and stellateganglion lie close to the vein. Ashbaugh and Thomsonmention as an advantage that fluids and blood can beadministered rapidly through the subclavian vein. But thevolume of fluid delivered into a vein is determined by thediameter of the cannula and not by the size of the vein;and if the cannula is inserted through a needle (as it mustbe, in the case of the subclavian vein) this can scarcelyexceed the diameter of the needles used ordinarily in arm-vein infusions. Also, the introduction of a plastic cannulathrough a needle which is then withdrawn sometimes endsin the disappearance of part of the tube into the vein. Ifthe vein is the subclavian, the cannula will almost certainlypass into the right atrium. Again, thrombophlebitis in thissituation is likely to arouse greater anxiety than when itaffects the veins of the arm and forearm.Subclavian venepuncture demands skill and practice;</p><p>so, of course, does arm-vein infusion. But if, as bothgroups assure us, subclavian venepuncture should bereserved for exceptional circumstances, the acquisition ofthe necessary skill may prove very difficult. And, even ifthis difficulty is overcome, the clinical benefit may proveno more than marginal. ,</p><p>NUFFIELD INSTITUTE OF COMPARATIVE MEDICINE</p><p>THE systematic study of disease in animals has contri-buted much to medical progress and it can clearly do muchmore. To speed this work, the Nuffield Foundation gavethe Zoological Society of London E140,000 towards thecost of building and equipping an Institute of ComparativeMedicine; and the building is already half finished on asite adjoining the societys offices in Regents Park.Sl 10,000 of the cost is being found by the ZoologicalSociety, but another E100,000 is needed for capitalequipment and E200,000 for operating costs in the firstfew years. An appeal committee, under the chairmanshipof Mr. Archibald Chisholm, is therefore at work to raisethis further sum, and they will be in touch with scientific,professional, industrial, and commercial organisations whomay be able to help. The operating costs of the Institutewhen it is fully under way are put at E50,000 a year, and asubstantial endowment is to be raised to secure thesecosts in perpetuity and to provide research fellowships.As its director designate, Dr. L. G. Goodwin, put it,</p><p>the difficulty in planning the work of the Institute is whatnot to do first. Among the earliest projects will be</p><p>1. Lancet, 1963, i, 762.</p><p>further studies (supported by the British Heart Founda-tion) of cardiovascular disease in animals, including ananalysis of their nutritional background. Clinical chemicaldata will also be collected from as many species as possible;and a third subject will be disorders of the nervous systemin stress and shock. Later work will include a survey of</p><p>pathogenic and " silent " viruses in wild animals and theirrelation to cancer.The new building, designed by Prof. Richard Llewelyn</p><p>Davies and Mr. John Musgrove, will house three depart-ments-pathology (under the societys pathologist, Mr.R. N. T.-W.-Fiennes), chemistry, and infectious diseases.The apparatus within will include X-ray equipment, anelectron microscope, and facilities for the use of radio-active materials. The basement will contain large work-shops where workers may devise their own equipment.The Institute will be an exciting new element in</p><p>cooperative research; and it will certainly draw workersfrom many countries and disciplines. To those organisa-tions whose support the society seeks in this importantventure, we warmly commend the appeal.</p><p>CHILD VICTIMS OF SEX OFFENCES</p><p>THE theme of the pamphlet on this subject by Dr.T. C. N. Gibbens and Miss Joyce Prince 1 can almost besummarised in one of the phrases they use when dis-cussing two pregnant girls victimised by strangers:" There is little doubt that many girls can make a goodrecovery from a disaster of this kind, if given the peaceto do so." Yet the present law requires interrogation bythe police, often more than once, a medical examination,perhaps giving evidence in a magistrates court in thepresence of the assailant, and then a delay of two to threemonths before the trial at a higher court. Appearance incourt, however, is not the main cause of harm. It israther that such appearance leads the parents, and indeedthe whole local community, to create an atmosphere,lasting for weeks or months, which turns the childs ideas" towards an adult interpretation of the offence and itspunishment ", and that she has to adjust to an alteredattitude within the family circle. It is well known tomoral welfare workers that a child may appear to be" wonderfully brave " in court, only to develop severedisturbances at home after the trial is over; and Dr.Gibbens and his colleague emphasise that the behaviourof the family is the main source of difficulty. Indeed ina section of the pamphlet on child victims and parents,they put forward convincing arguments that, quite apartfrom such obvious examples as incest, the parents arethemselves responsible by negligence, inconsistency, andcruelty in their methods of upbringing for producinga cooperative victim, if this paradoxical description maybe used. An inquiry made possible by the cooperation ofthe Federation of Committees for the Moral Welfare ofChildren showed that in only 27% of families of a childvictim was it possible to describe the home backgroundas </p><p>" all well ".</p><p>Clearly there is a place for more preventive work ingeneral, perhaps at the infant-welfare level as suggestedin a Harben lecture 2 earlier this year, and also for " anofficer trained in social casework and child welfare " towork with the family after the legal proceedings to try tolessen the effect on the child. Fundamentally, however,1. Institute for the Study and Treatment of Delinquency, 8, Bourdon</p><p>Street, London, W.1. 1963. 2s.2. Moncrieff, A. J. R. Inst. Publ. Hlth, March, 1963, p. 65.</p></li><li><p>1154</p><p>it would be a step forward if more could be done toavoid the childs appearance in court. The Children and</p><p>Young Persons Act, 1963, in section 27 tries to do thisby admitting written evidence, so that the child oftenneed not be called as a witness for the prosecution; butcertain exceptions still make it essential for the child toappear. A repeat appearance at a higher court might oftenbe avoided if, as the pamphlet recommends, it becamelegally possible to deal with the large number of firstoffences only in the magistrates courts.Another suggestion often made is that the medical</p><p>examination should only be by a woman doctor. If writtenevidence is to be acceptable, Dr. Gibbens and Miss Princepropose that women officers, trained in social caseworkand child welfare, should be given an additional shorttraining in police work and appointed as women policeofficers, possibly as special constables. This may becriticised as adding yet another to the list of social workers,and it may be asked why a probation officer or child-careworker should not do this work. Many women policeofficers already do it remarkably well, but they cannot,of course, provide the aftercare which is so important;and court proceedings, however managed, are only thevisible part of the iceberg.</p><p>Dr. Gibbens and Miss Prince have done an excellent</p><p>piece of work in calling attention to a numerically smallbut serious problem.</p><p>TETANUS</p><p>TETANUS is very common in many parts of the world:in rural India it is estimated to be the fourth commonestcause of death, and half the deaths in some Bombayhospitals are due to this cause. Earlier this month aninternational conference on Tetanus was held in Bombay.</p><p>Indian physicians described observations based ontreatment of many thousands of -patients. Some 20% ofcases of tetanus in India were attributed to growth of thebacilli in a chronically infected middle ear, although firmbacteriological confirmation of this is not yet available.About 50% of patients had injuries, the site of which wasunrelated to the severity of illness; about 20% of patients,in the majority of the series presented, had no detectableinjury. It was generally agreed that the period of onset-i.e., the interval between the first symptoms and the firstspasms-was the principal feature pf prognostic value;when this period was less than 48 hours the outlook wasgrave. In addition the degree of rigidity and the frequencyof spasms were of importance, probably because of therespiratory embarrassment they produced.</p><p>In treatment most contributors held antitoxin to be ofvalue, presumably because, after it is given, furtherintoxication of the central nervous system is prevented.In controlled trials by Dr. B. J. Vakil and his colleagues,20,000 units of antitoxin was found to be therapeuticallyas effective as 200,000 units. Other workers, notablyDr. J. C. Patel, believe that 5000 units of antitoxin is asufficient dose.1 Prof. E. B. Adams, from South Africa,discussed the treatment of severe cases by means of totalparalysis and intermittent positive-pressure respiration.By means of this highly skilled and demanding methodthe mortality-rate of tetanus neonatorum has been re-duced from over 80% to 36%, and reference was made tothe work of Dr. H. G. Garland and his colleagues inLeeds who have had no deaths in the last 65 patients1. See Patel, J. C., Mepta, B. C., Nanavati, B. H.. Hazra, A. K., Rao,</p><p>S. S., Swaminathan, C. S. Lancet, 1963, i, 740.</p><p>treated in this way. In most regions, where more con-ventional methods of treatment must be employed, themortality-rate in adult tetanus remains at 35-40% and inneonatal tetanus at over 80%.</p><p>Preventive measures can be very effective. The use ofhorse-serum antitoxin for prophylaxis has become acontroversial subject, and in the absence of a controlledtrial the argument for its use is open to criticism. Incountries where the incidence of reactions to horse-serumexceeds the incidence of tetanus, it is difficult to decidewhether an injured person should be exposed to the risksaccompanying an injection of horse-serum. In Swedenprophylaxis with horse antitoxin is not being encouraged,and, for patients in whom passive protection is thought tobe necessary, attempts are being made to provide humanantitoxic globulin, which is also favoured for the therapyof tetanus. In countries, such as India, where tetanus iscommon it is not felt possible to discourage use of horseantitoxin as a prophylactic measure. On the other handit is felt that, if an individual doctor decides, for goodreasons, not to give horse antitoxin to an injured patient,he should not be liable to censure in the courts if tetanus</p><p>develops.The conference repeatedly stressed that in tetanus</p><p>control the emphasis must be mainly on active immunisa-tion, which is not only highly effective but is the onlymeans whereby tetanus from trivial or unnoticed woundscan be prevented. It has the additional advantage of over-coming the problem of hypersensitivity reactions tohorse antitoxin, which is not needed in immunisedpatients. Tetanus toxoid is a very effective antigen, andDr. E. Eriksson and Dr. Karin Ullberg-Olssen, fromStockholm, reported that, in patients who had previouslyreceived only one injection of toxoid, acceptable responsesto a second dose of toxoid occurred 10 years later. Dr.</p><p>J. C. Suri described the preparation of potent absorbedtetanus toxoid in India; and it seems probable that, withthe use of such an antigen, a few properly spaced injec-tions will provide an adequate immunity for many years,thus avoiding the necessity of reinforcing immunity every5 years as is often recommended. For injured patientswho have at some time been actively immunised, a boosterinjection of toxoid probably provides adequate protection,even though the last toxoid injection was many yearsearlier.</p><p>VIRUS ENTERITIS</p><p>EVEN with the help of the most cooperative patho-logist it is exceptional in family practice to discover abacterial cause for acute vomiting and diarrhoea withoutserious systemic disturbance. To attribute this verycommon syndrome to beer or green apples is now out offashion. Omne ignotum est e viris. The evidence that someof these illnesses occurring in epidemic form are due toone virus or another is, in fact, very strong. Within acommunity they tend to arise either explosively or atregular intervals of a day or two. Unless complicated bybacterial infection they seldom persist for more than48 hours. In some instances the cell-free extracts offseces or the secretions of the respiratory tract of thoseaffected have been shown to produce a similar illness involunteers. Attempts at isolating a causal virus have not,so far, been very illuminating. Technical progress led tothe identification of many " new " viruses in the pastten years, but with a few exceptions these have not been</p></li></ul>