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scarce: at the end of 1969, 462 offenders were waitingin local prisons for places (of which there is a total of666) in young-prisoner centres, and 60 were in remandcentres. Young offenders are often therefore deprivedof the training which is the most important part oftheir sentence, and different types of prisoner have tobe herded together in establishments unsuited to theirneeds, although it has long been accepted that thiskind of mixing can be very harmful. For much of1969, between 40 and 60 trainees were held at Hollowayawaiting transfer to borstals, and, though efforts weremade to run a borstal training-scheme in the prison,lack of facilities made it virtually impossible.

Several prison medical officers made particular men-tion in their reports for 1969 of the problems createdby overcrowding-situations of emotional tension

among inmates, over-strain in the staff, and lack ofhygiene. Influenza epidemics were reported fromseveral establishments. The answer to the problem ofovercrowding is twofold: a " very large building pro-gramme " (to quote the report) and a further revisionof sentencing policies. During the year, two newestablishments were opened, both for male adults.One of these was a disused R.A.F. camp, and it hasbeen suggested that a widespread conversion of ex-Service camps would be the cheapest, and fastest, wayof solving the prison accommodation problem. At

present, only one prison is under construction, while,of over twenty " new establishments in design stage "listed in the report, only two have been allotted a dateby which building work will start (1971). While theGovernment insists on the necessity for severe re-trenchment, a bonanza of prison building seems out ofthe question. So judges, as well as the public, must bepersuaded that the alternatives to punishment byimprisonment are neither a soft option nor a secondbest. The probation service should be expanded, andmore offenders placed on probation and referred toattendance centres. The effect might be not only torelieve overcrowding in the prisons, but also to promotethe idea that training and treatment outside prison mayoften be a more effective and more humane method of

dealing with offenders than imprisonment.

DEATH TO THE SMALL LABORATORY?

PATHOLOGISTS throughout Britain should by now beaware of a memorandum entitled Hospital LaboratoryServices from the Department of Health. It isconcerned with the overall structure and function ofthe laboratories, and it comes out strongly in supportof the creation of an area laboratory to provide aservice for either a district general hospital or a seriesof hospitals, and general-practitioner services in aradius of twenty miles or one hour’s travelling time.The argument is that by centralisation of expensivestaff and equipment a more economical service can beprovided, and there are few who would dispute thisview. The memorandum unfortunately glosses oververy real problems which arise from such centralisation,notably the inevitable delay in the transportation ofspecimens and results and the provision of emergencyservices from a central laboratory when the clinical1. HM (70) 50.

services are not also centralised. But the suggestionby the Department that Boards should devote some oftheir resources to building temporary or permanentaccommodation for this purpose may induce patholo-gists working in unsatisfactory conditions to giveserious thought to the proposals.

Particularly welcome is a comprehensive definitionof the function of the laboratory services, includingnot only service functions but also the provision offacilities for approved research projects by clinicians,the undertaking of fundamental or applied research inpathology, and collaboration in teaching. A veryhelpful appendix contains information on the work ofthe various committees set up by the Department oncurrent problems in pathology. It is valuable for

pathologists to be aware of those areas which are beingstudied in detail and of the progress in laboratoryautomation and the evaluation of laboratory equipment.Many of the suggestions are the product of considerablethought and discussion and cannot be faulted onplanning grounds. That they may be difficult or

impossible to implement locally does not detract fromthe need for the basic principles to be stated clearlyand concisely.

POOR SHAPE

UNDER the Government’s scheme for reshapingDepartments, the Ministry of Overseas Developmentis to be subordinated to the Foreign and Common-wealth Office. This move will dismay those who wishto make British aid more supple, swift, and sympa-thetic. The shortcomings of the existing Ministry arefamiliar. It must be approached through Govern-ments, and accordingly it seems remote; and, with anadministration which has a strong whiff of the oldColonial Office, its operation is wooden. Moreover, theMinistry, being directly under political control, maybe suspected of being operated for political ends-a suspicion which will be strengthened by the rearrange-ment. For aid in medicine, as in other spheres, theneed is to reduce the political link, not to reinforce it.These weaknesses would be less prominent if out-

side bodies such as the universities or the MedicalResearch Council apportioned more of the funds; butsuch a change, however desirable, is unlikely to com-mend itself to the Treasury. More radically a freshlook might be taken at the old idea of reconstitutingthe Ministry as one of Overseas Service, with a per-manent staff who would undertake a series of short-term commitments abroad. (The existing Ministrysustains in British Universities a few experienceddoctors who are supposed to go overseas in responseto requests from other countries; but, since theirU.K. salaries cease the moment they leave these shoresto embark on the work for which they were primarilyengaged, even this small scheme is surrounded byfrustration.) Besides a permanent mobile force,volunteers who postpone, interrupt, or foreshortena career in the United Kingdom in order to workoverseas for a single limited spell can play a valuablepart. Some indeed already do this, often with thebacking of their employing authority. Idealism andinitiative would swell the number of volunteers if all

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were offered some security for themselves and theirfamilies to offset their losses-for example, in pensionrights-in going abroad. But this demands strongcentral machinery, oiled with block grants, which hasnot yet been created and which the Government’s new

step seems to place more firmly in never-never land.

CONTROL OF CEREBRAL BLOOD-FLOW

Regulation of the cerebral circulation in health anddisease was the principal topic at an international

symposium held on Sept. 16-19 by the CerebrovascularResearch Group of the National Hospital, QueenSquare, London.Under normal circumstances the blood-flow to the

brain is delicately adjusted to meet metabolic require-ments, and, although total cerebral perfusion remainsrelatively constant, local hyperaemia may result fromregional increases in neuronal activity. Metabolic

regulation of this kind is thought to be mediatedprincipally by changes in the chemical milieu ofcerebral arterioles, although neurogenic factors maypossibly influence the magnitude of the response. Thecapacity of cerebral arteries to react in this way may bedemonstrated by measuring the changes in blood-flowat different levels of Paco2. Cerebral arterioles alsohave the capacity, again largely independent of nervouscontrol, of altering in calibre in response to changes intransmural pressure gradient, thus maintaining vascularresistance in a constant relationship to pressure (auto-regulation). Within physiological limits, blood-flowis thereby buffered against variation in blood-pressureand intracranial pressure.In brain disease these precise homceostatic mecha-

nisms may be upset in several ways. Firstly, vascularsmooth muscle may be damaged by ischaemia and bycedema, or the lumen may be blocked by thrombus sothat arterioles no longer autoregulate and respond tometabolic stimuli. Biochemical alterations, notablyacidosis, also affect vascular reactivity not only in theischaemic area but in the surrounding brain. Undersome circumstances some vessels lose autoregulationwhile retaining sensitivity to C021; and in some lesions,notably tumours, shunt vessels bypassing the capillarybed may develop between arteries and veins. Secondly,a rise in intracranial pressure resulting from brainswelling or venous engorgement may reduce the effec-tive transmural pressure, and a severe rise may producecompression of the capillary bed with increasedvascular resistance. Thirdly, the metabolic require-ments of the brain may be altered so that a blood-supply which would normally be appropriate may beexcessive. Thus in the same pathological process someareas of brain may be overperfused while others areischaemic.

Changes in blood-pressure or CO on a backgroundof disturbed homoeostasis may complicate matters stillfurther. In the laboratory animal hypercapnia, byeffectively dilating vessels only in normal areas, maystill further reduce blood-flow to an isch2emic region. 2

1. Easton, J. D., Palvolgyi, R. Scand. J. clin. Lab. Invest. 1968, 102,suppl. 5.

2. Brawley, B. W., Strandness, D. E., Kelly, W. A. Archs Neurol.1967, 17, 80.

Conversely, hypocapnia, by constricting surroundingnormal areas, may increase flow to an ischzemic zone;and it has been shown experimentally that occlusionof the middle cerebral artery during hypocapnia causesless cerebral infarction than under normocapnicconditions. 3

These paradoxical reactions to CO: have clinicalimplications in occlusive vascular disease, and at thesymposium preliminary results of hyperventilationtherapy in recent cerebral infarction were reported.Although mortality was lower in the treated group thanin controls, no significant difference in residual dis-ability was detected. Possibly the treatment acts byreducing redema and cerebrospinal-fluid pressurerather than by redistributing blood-flow. These dis-appointing results should not inhibit further trials ofhyperventilation therapy in less severely affected

patients-especially when treatment can be started atan early stage. The growing interest in the measure-ment of cerebral blood-flow and of the effects of

therapy should help to dispel the aura of fatalisticpessimism which has for so long surrounded the

patient with an occlusive stroke.

COMPUTERS AND IMMUNISATION

THE West Sussex immunisation scheme is oftencited as an illustration of the successful use of

computers in performing routine administrative

procedures. In a detailed assessment of the cost ofthe first five years of this scheme (1963-68) Saunders 4has demonstrated that during this period infant-immunisation rates rose more rapidly in West Sussexthan in England and Wales as a whole, and that by1968 the cost was considerably lower than the nationalaverage. Saunders has estimated expenditure percompleted procedure (unit cost) as opposed to expendi-ture per 1000 population, because unit costs allow forthe fact that higher immunity-rates will result in

higher costs. Saunders assesses the saving in local-authority, executive-council, and general-practitionerclerical work, and concludes that the unit cost of theWest Sussex scheme is 2s. less than that of Englandand Wales (3s. 6d. as opposed to 5s. 6d.). Develop-ment costs-designing the computer system, changingfrom manual to automated record storage, and teethingproblems-are recoverable within two years of the endof the three-year transitional period. Saunders

suggests that if this scheme were introduced nationallythere could be a reduction of about E753,000 per yearin the cost of immunisation. There would also beadditional advantages in, for example, an improvementin immunisation status throughout Britain, the removalof the need for conventional health education, a

reduction in staff and storage space used for records,and the simplification and centralisation of admin-istration.

While acknowledging the usefulness of the WestSussex scheme, it is necessary to point out that itssuccess may have been due to factors quite unrelatedto the introduction of the computer. Over the past3. Soloway, M., Nadel, W., Albin, M. S., White, R. J. Anesthesiology,

1968, 29, 975.4. Saunders, J. Br. J. prev, soc. Med. 1970, 24, 187.