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given free or cheap board and lodgings, and carryout their treatment at the hospitals to which thehostels are attached. Not many adult prostitutesfind their way into them. A certain number of

young women who have just lapsed into prosti-tution are admitted ; but the greater number arewage-earners who for the time being are unable toearn their living. By taking them in hand, lookingafter their creature comforts, and giving them theshelter of a home temporarily such women. areoften saved from prostitution. One advantage ofthe system is that girls are not cut off from theoutside world, as they would be in a home, and sohave not to be reacclimatised to the world again.The disadvantages are that a hostel is not a suitableplace for women in the acute stages of venerealdisease, for pregnant women, or for girls on proba-tion. These require institutional treatment. InFrance this is given in hospital until patients are fitfor ambulatory treatment; but in England the LockHospital authorities have found from long experi-ence that such women do best if kept until cured.The London County Council have now followed thisexample, in spite of the extra cost entailed, becausethey too have found that women who are willingto remain as in-patients in the wards will not comeback regularly for treatment once they have left.

It may thus be seen that most European countriesare taking this problem in hand, and handling itafter some method adaptable to each country’snational character. The results of these experi-ments in social reclamation, if judged from thepercentage of genuine rehabilitation, are dis-

appointing. But if one thinks rather of theindividual women that have been rescued from

misery, and saved from spreading disease, it seemswell worth while to persevere and extend thiswork in spite of many disheartening failures.

THE THERAPEUTIC POSSIBILITIES OFHEPARIN

THE anticoagulant substance known as heparinwas discovered accidentally in 1916 by JAYMcLEAN while he was working in W. H. Howell’slaboratory ; it was subsequently investigated byHowELL and HoL (1918) but it is only withinthe last ten years that interest in the practicalexploitation of its properties has been revived.This revival is due in part to C. H. BEST and hisassociates in Toronto and in part to a group ofworkers in Stockholm. Until quite recentlypreparations of heparin have not been pure enoughto allow of its introduction into the body, thoughheematologists have found it a serviceable anti-

coagulant for drawn blood. The work of CHARLESand ScoTT (1933) and of E. JORPES (1935) hasnow, however, made the substance available in aform that can be introduced into the blood intra-venously without the production of untoward

symptoms. Studies of the chemistry of heparinhave led JosrES to believe it to be a mucotin

polysulphuric ester 1; and with others he has

1 Jorpes, E., Uppsala LäkFören. Förh. 1937, 43, 83.2

— Holmgren, H., and Wilander, O., Z. mikr.-anat.Forsch. 1937, 42, 242.

put forward reasons for suggesting that it is

produced by the tissue mast cells throughout thebody and that it may normally have the functionof a physiological anticoagulant. The possiblescope of heparin in medicine has been extendedby this work and its developments. WILANDER 3

has shown that heparinised samples of venous

blood may be used for routine haematologicalexaminations as well as for measuring the sedi-mentation-rate and also for determinations of

blood-sugar, calcium, uric acid, non-proteinnitrogen, and phosphatase. This discovery shouldreduce considerably the trauma which the haplesspatient now suffers at the hands of clinical patho-logists. Heparin has also been tried as an intra-vital anticoagulant for blood transfusion and inthe treatment, prophylactic or therapeutic, ofintravascular thrombosis. We published last yeara review by HEDENIUS of 150 transfusions forwhich the blood donor had been " heparinised,"no other anticoagulant being applied. Althoughno ill effects were observed this method seems tohave no advantage over the simpler technique ofadding sodium citrate to the shed blood and is ofinterest rather as a tour de force than as a usefuladdition to the armamentarium of a transfusionservice.

The hope that heparin in suitable dosage mayact as a prophylactic against post-operative throm-bosis has some experimental justification. BESTand his colleagues have shown that in hepariniseddogs thrombotic occlusion of traumatised veinsdoes not take place and, more recently, that insuch animals blood may be

" shunted " through aglass tube without the formation of white thrombiwhich occurs in such experiments in the normalanimal.4 4 The success and safety of these experi-ments has led them to administer intravenous

heparin to patients following operation 5 ; 1000units of heparin (10 mg. of the purified substance)are added to each 100 ml. of saline solution andthe fluid given by the intravenous drip method atsuch a rate as will keep the coagulation time atthree times its normal value. It is stated that" the injection is continued for varying periodsup to fourteen days after the operation." Already222 cases have received this treatment but no

analysis of the results is yet available. CRAFOORD(1937) has recorded a small series of cases whichshowed that the injection was without danger andwas not productive of a haemorrhagic tendency.It is impossible to draw any conclusions, as MURRAYand BEST are careful to point out, until figures fora much larger series have been published. Since,however, deaths from pulmonary embolism afteroperation occur only about once in every thousandcases the therapeutic endeavour is bound to seemdisproportionate to the results and only if almostcomplete success is attainable would post-operativeinjection of heparin be likely to become a routinepractice. Of more practical importance, for the

3 Wilander, O., Acta med. scand. 1938, 94, 258.4 Best, C. H., Dowan, C., and Maclean, D. L., J. Physiol.

1938, 92, 20.5 Murray, D. W. G., and Best, C. H., J. Amer. med. Ass.

1938, 110, 118.

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moment, anyway, is the suggestion of heparinisa-tion of patients following such operations as

embolectomy. We publish elsewhere in this issueaccounts of experiments in therapeusis which willhave a far greater interest to clinicians, as theysuggest the possibility that heparin might provevaluable in such serious and common conditionsas coronary and cerebral thrombosis. HOLMINand PLOMAN record an unusually favourable out-come of a case of thrombosis of the central retinalvein treated with heparin and in MAGN-ussoN’scase of thrombosis of the posterior inferior cerebellarartery an equally satisfactory recovery was

obtained. It is difficult to be convinced byMAGrrussorr’s report that heparin influenced thecourse of the illness. The negligible haemorrhagefrom an accidental abrasion of the pharynx suggeststhat blood coagulation had scarcely been affected

by the heparin. The observations on the bleedingtime following injection of heparin have no prac-tical significance ; this substance is known to

prolong coagulation by its action as an anti-thrombin and antiprothrombin but to have littleeffect on capillary haemorrhage. Further, to arguethat a normal bleeding time indicates that thereis no undue liability to haemorrhage is to virtuallydeny the existence of hoemophilia. MAGNUSSONhas. taken a gloomier view of the outlook in

Wallenberg’s syndrome than is usually held inthis country and the course of his patient’s illnessdoes not appear to differ greatly from that observedwhere no specific therapy has been employed. Itis to be hoped that evidence will be collected ofthe efficacy of heparin in the treatment of estab-lished thrombosis. Meanwhile its therapeuticpossibilities cannot be assessed.

ANNOTATIONS

HOSPITAL TICKETS

SINCE Lord Sankey, in presenting the report of thevoluntary hospitals committee to the British Hos-pitals Association conference last year, advocated aState grant through some procedure analogous tothat of the University Grants Committee, there hasbeen a movement of public opinion in its favour

although no specific recommendation was includedin the report. The Scottish Department of Healthhad already suggested that State assistance might berendered in the form of a teaching facilities grant inrecognition of the service rendered by hospitals inproviding facilities for medical teaching. Thisaccords with a practice well established in Scotlandby which the medical student is required to providehimself with a ticket. The rule on the subject atthe Edinburgh Royal Infirmary, for example, is asfollows :

Every student visiting the wards, operating andpathological theatres, attending any clinical class inthe Royal Infirmary, or acting as a clerk or dresser,must be in possession of a hospital ticket for theperiod during which he or she visits, attends, or acts.

A payment of this kind has been made since theearliest days of the Infirmary, two centuries ago. It

may well account for some of the thoroughness ofmedical education in Scotland, since not onlyhas the ticket-holder to record his attendance

regularly but his parent or guardian would naturallydesire to secure that the money is a profitableexpenditure. The fee for a "perpetual " ticket hasrecently been raised to :E18 from the 12 guineas atwhich it has stood for nearly one hundred years. Inthe last statement of account the amount receivedfrom this source by the Edinburgh Royal Infirmarywas jE5432. In a full year under the new regulationit will rise to about f8000. This provides an obviousbasis upon which a grant could be made by theState through the University Grants Committeewithout encroachment upon the freedom of the

hospital authorities. But before this practice couldbe extended by the committee throughout GreatBritain it would be necessary for English hospitalsto establish a similar procedure. Its adoption by thehospitals with medical schools in London wouldmean an addition of some 100,000 a year to theirincomes, outside London an addition of 70,000 a

year, taking as a basis the figures in the latest return

of the University Grants Committee. No legislationwould be necessary to carry out this arrangementwhich, if the medical schools agreed, could come intooperation with the acceptance of each new student.The establishment of a uniform practice in Englandand Scotland would afford a basis for an approachto the Chancellor of the Exchequer for a corre-

sponding grant from the Treasury to be devoted tothat portion of the work of a hospital which benefitsthe whole community.

THE "SAFE PERIOD"

THE belief, held by H. Knaus, K. Ogino, andother advocates of the " safe period" methodof birth control, that the period of fertility in themenstrual cycle can be accurately predicted hasa three-fold basis. It implies first, that ovulationis an event which occurs spontaneously at a fixedtime in each cycle; i secondly, that the ovum isfertilisable for only a brief period ; and thirdly, thatthe sperm is also short-lived. According to Steinand Cohen,l who have recently reviewed the problem,there is no reason for doubting the truth of thesecond and third of these propositions. They hold,however, that there is need for caution in acceptingthe theory that ovulation is a fixed event in the

cycle. Their initial criticism of this theory is thatseveral other workers have failed to confirm theobservations by Knaus on which his conclusion thatovulation is a mid-interval occurrence largely rests-that the uterus is non-contractile during the secondhalf of the ovarian cycle. Stein and Cohen are perhapsrather severe in this criticism, for while many workershave been unable to confirm Knaus’s observations,others have obtained results in good agreement withthem. Furthermore one must bear in mind the

possibility that those patients who show uterinecontractions in response to posterior pituitaryinjections in the second half of the menstrual cyclemay not have ovulated in that particular cycle-forthe occurrence of uterine contractions signifies onlythat the uterus was not at the time under the influenceof luteal stimulation. Stein and Cohen appear tounder-estimate this chance, for according to Mazerand his co-workers,2 30 per cent. of women who

1 Stein, I. F., and Cohen, M. R., J. Amer. med. Ass. 1938,110, 257.

2 Mazer, C., Israel, S. L., and Kacher, L., Surg. Gynec. Obstet.1937, p. 30.