The Australia (Hepatitis-associated) Antigen

INTRODUCTION The accidental discovery of the Australia antigen (HAA) in 1963 by Blumberg and his coworkers is a classical example of biomedical serendipity. Its recognition not only stimulated a substantial amount of research into viral hepatitis, thereby adding considerably to our knowledge about this important disease, but has had far-reaching implications in the understanding of several other hepatic and systemic diseases. Indeed, its discovery may well be seen in the future to have been the all-important breakthrough in attempts at culture of the virus as a means of vaccine preparation for future prophylactic usage. THE DISCOVERY OF THE ANTIGEN Blumberg, a cytogeneticist working in the Philadelphia Institute for Cancer Research, was conducting a systematic study of the serum of patients who had received multiple blood transfusions. Using a technique of double diffusion in agar gel (Ouchterlony method) he searched for precipitating antibodies to inherited donor serum protein antigens, particularly those to low density betalipoproteins. A precipitating antibody was identified in the serum of a haemophiliac patient which reacted with an antigen which was quite dissimilar from lipoprotein antigens. This antigen was present in the serum of an Australian aborigine, and the term Australia antigen was coined (1, 2, 3,). This antigen is almost certainly identical to Prince’s SH antigen (4), and to avoid confusion the term hepatitis-associated antigen (HAA) is now considered by many to be more appropriate (5).


Beta Blockade
Sympathetic innervation is mediated through I t is p a rtic u l a rly good to see the m ed ica l profession ru m in a te a lit t le less, and start to ca ll fo r and take a ctio n ove r th e p o p u la tio n p ro b le m .
M o s t people, in c lu d in g th e G o v e rn m e n t, te n d to feel o v e r-p o p u la tio n is a p ro b le m m a in ly co n fin e d to th e " u n d e rd e ve lo p e d " co u n trie s. I t is c e rta in ly tru e th a t fro m sheer w e ig h t o f n u m b e rs th e ir p ro b le m is th a t m u ch greater: also, because 40-45%, o f th e ir p o p u l a tio n arc u n d e r 15 years, th e ir p o p u la tio n s w ill c o n tin u e to rise fo r some fo rty years a fte r the f e r t ility level has fa lle n to th e re p la ce m e n t level.
B u t B rita in m u s t nonetheless do her share tow ards p o p u la tio n s ta b ility , n o t o n ly fo r th e w o rld 's sake b u t also fo r he r ow n. W e , the U .K ., are th e e ig h th m ost densely p o p u la te d c o u n try ; E n g la n d and W a le s alone w o u ld be second o n ly to F orm osa; and c u rre n tly b irth s arc exceeding deaths by 300,000 every year. The p ro b le m s o f o v e rc ro w d in g and p o llu tio n , w ith all th e ir a tte n d a n t d e trim e n ts to h e a lth (b o th physical and m e n ta l) arc n o t u n k n o w n to us already , and can b u t increase as th e p o p u l a tio n rises. U ltim a te ly , o f course, shortage o f fo o d and o th e r n a tu ra l resources can o n ly lead to m a ln u tr itio n , sta rva tio n , and loss o f neces sities such as he at and pow er. T h e in te g ra te d rate o f increase o f ecological de m an d on a g ri c u ltu re , in d u s try and m in in g is n o w 5-6% / year, and th e p o p u la tio n increase 2% -we ca n n o t w ith im p u n ity c o n tin u e to use up n a tu ra l resources at such an in crea sing rate. T h e m o st im p o r ta n t means o f p re v e n tio n th a t sh o u ld be take n is e d u ca tio n . A full-scale cam p aign is needed, e m p lo y in g a ll the means o f mass e d u ca tio n ava ila ble -te le visio n and rad io , newspapers and jo u rn a ls, in s tru c tio n at schools and u n ive rsitie s, and possibly even m a te ria l in ce n tive s as already given in In d ia .
In s u p p o rt o f such e d u ca tio n th e Government has a v ita l role: to ensure th e c o n tin u in g lib e ra l n a tu re o f th e a b o rtio n laws, w h ile ru lin g o u t reg io nal differences; to exte nd fa m ily p la n n in g fa c ilitie s in th e N . H .S., w ith p re s c rip tio n o f free con tra cep tives; to e xte nd the n u m b e r o f beds fo r a b o rtio n , vasectom y and s te rilis a tio n ; and, n o t irre le v a n tly , to legislate in fa v o u r o f b e tte r career prospects fo r w o m e n .
T h e m e d ic a l profession m u s t take u p o n its e lf the jo b o f b a n te rin g th e Government u n t il such steps arc take n, and its e lf in itia te mass educa tio n w ith a ll th e m eans a t its disposal.
Som e pe op le get fa n a tic a l a b o u t these m a tte rs, and cry Doom. D o o m is o n ly one a lte rn a tiv e -le t 's take th e oth e r.

IN T R O D U C T IO N
During last year about a quarter of the adult population of the United Kingdom tried to lose weight, demonstrating that our society is becoming increasingly aware of the problems of obesity. This may partly be cultural and attributable to Twiggy and the miniskirt but may also reflect the relatively recent medical appreciation that not only is obesity the com monest nutritional disorder in the United Kingdom but also a major health hazard. An American male 20% in excess of ideal weight carries an increased mortality of 30% or, in other words it is as dangerous to be 10 lbs. overweight as it is to smoke 25 cigarettes a day.

D E F IN IT IO N & IN C ID E N C E
Obesity is an excessive accumulation of body fat -but unfortunately it is difficult to make easy and accurate measurements of body fat. The practised fingers are probably as accurate as calipers in measuring skin fold thickness and although weighing by total body immer sion may be accurate the facilities to under take this are not readily available at Chemists or Airports. It seems likely in the meantime that obesity will be related to Ideal Weight which is a Life Insurance Company concept whereby weight is related to optimum life ex pectancy. This has obvious limitations; one has only to watch the caponised caperings of modern shot-putters or even the front-row of Scotland's present scrum to appreciate that not everybody who is overweight is obese; likewise some flabby women may carry considerable excesses of fat but remain within a few pounds of their ideal. In spite of these limitations it is usually accepted that patients who are more than 10% in excess of their ideal weight are " O V E R W E IG H T " and those more than 20% in excess are " O B E S E " .
Using these criteria it has been roughly estimated that 1 in 5 of the adult population of the United Kingdom is obese. CA U SES.
There are a number of rare endocrine causes for obesity; these include Hypothyroidism, Hypogonadal eunuchism, Cushing's Syndrome and Steroid therapy, Stein-Leventhal Syn drome, and various pituitary and hypothalamic disorders. The vast majority of patients suffer from non-endocrine or " Simple" Obesitya totally inappropriate adjective but it cannot be denied that people with simple obesity are eating or have eaten more calories than their metabolic requirements. This may arise in a number of ways.
1. Gluttony. A few people eat excessively because they enjoy food; I can recall one who admitted to eating 12,000 calories a day but whose problem was his alcohol consumption.
A pint of draught export contains about 200 calories. Bearing this in mind it is remarkable how few medical students are overweight.
2. Psychological. M any overeat in order to obtain psychological relief during periods of idleness, boredom, anxiety or depression. In some the cause of that depression may be their obesity and to others this is an additional factor. Thus a vicious circle can arise with obesity leading to depression causing over eating with further weight gain. An extreme example of psychological overeating is the rare syndrome of nocturnal gorging.
3. Altered Homeostasis. A normal person has a number of homeostatic mechanisms whereby he can avoid or burn off excess calorie consumption. Thus, lean subjects can accur ately evaluate the nutritive content of a liquid diet and only take their daily requirements; if deliberately overfed the resultant weight gain is less than anticipated. Obese patients either lose or never possess these homeostatic mech anisms and cannot assess nutritive values nor burn off excessive calories which are inevitably converted into body fat. T o eat an extra apple a day produces a theoretical weight gain of ½ stone a year.

METABOLIC CONSEQUENCES
Simple obesity produces a complex chain of metabolic changes. These include increase in serum insulin but reduction in peripheral insulin activity causing reduced Glucose assimilation by muscle; growth hormone levels tend to fall but adrenal cortical activity in creases.
Patients are resistant to ketosis. Th e net effect of these changes is that the patient becomes metabolically more efficient and thus a second vicious circle situation develops, obesity itself tending to perpetuate the obese state. Although it seems probable that complex enzyme mechanisms are involved one simple minded way of explaining the situation to a patient is to say that subcutan eous fat acts like double-glazing and by retain ing body heat reduces the daily caloric require ments. Although these changes may be re sponsible for aggravating and perpetuating obesity they are not the direct cause and are corrected by successful weight reduction. R e cently, however, it has been demonstrated in obese children that those who were overweight as infants possess more adipose cells than those who subsequently gain weight.
It is possible that this is of long-term prognostic signific ance in that the number of fat cells is related to eating habit in infancy, and the more fat cells one possesses the more difficult it is to reduce. Puppyfat is not 'benign" and the vast majority of obese children become obese adults. In view of the rarity of mal-or sub-nutrition and the hazards of childhood obesity the recent fuss about free school milk appears totally in appropriate. S IG N I F I C A N C E In addition to the very considerable increase in mortality almost exclusively due to ischaemic heart disease, obesity is also assoc iated with considerable morbidity. Examining from the toes upwards it may cause flat feet, ankle oedema, varicose veins, knock knees, osteoarthritis of the hips and other weight bearing joints, genital prolapse, menstrual irregularities, possibly urinary tract infections, gallstones, hiatus hernia, Pickwickian Syn drome, and a liability to respiratory infections in childhood. It also aggravates the symptoms of any co-existing respiratory or cardiac disease, is associated with diabetes and increases the incidence of post-operative and obstetric com plications. , In addition the grossly obese are invariably psychologically disturbed and the cheerful eversmiling " fatty" is wearing a mask to protect himself from his feeling of inadequacy which may be the product of years of inappropriate ridicule.

General Considerations.
Th e treatment of obesity comprises two phases, an initial period of weight loss and subsequent prevention of weight regain. T he second phase is often neglected but temporary weight loss is only of temporary benefit and many find it even more difficult to reduce a second time. It is thus very important to explain to patients that once they have reached an acceptable weight they will have " to watch their diet" and this usually involves a basic alteration in eating habit. Some patients will lose weight remarkably easily but others, parti cularly those with psychological problems, will require considerable encouragement and sup port. Unsuccessful attempts at weight loss may harm the more severely disturbed and it is essential to ensure that the patient is appro priately motivated before commencing treat ment. Patients should also have a realistic concept of the rate of weight reduction. M any anticipate a 2 week miracle but M agic W ands are not available on the N .H .S. T o gain w eigh t at the rate o f 1 stone per year is dis astrous but to reduce at 1 lb. per week m ay appear unacceptablely slow yet it produces a w eight loss of nearly 4 st. a year. M a n y give up because they expect too m uch and becom e disheartened b y perfectly acceptable progress. B ody fat stores w ill only be reduced when calorie expenditure'exceeds calorie intake.

Exercise.
T h e exercise required to burn o ff one pound o f fat is equivalent to playing 20 sets o f tennis or walking from G lasgow to Edinbu rgh . Such activities are often associated w ith increased calorie consum ption, b u t in spite of this, physical exercise is an im portant if subsidiary and som ew hat neglected adjunct to w eight reduction.
It is notew orthy that obese adolescents tend to take m uch less exercise than their lean counterparts.

Diet.
T h e sheet anchor o f treatm ent m ust be dietary restriction. N um erous different dietary regimens have been fashionable but a calorie is a calorie and the dram atic early w eight losses associated w ith high protein, or high fat diets m erely reflect the initial water diuresis that follow s restriction of carbohydrate. T h is m edical fact has been converted into financial gain b y the exponents of the " G rap efru it D ie t" and other off-beat regimens.
F o r a diet to be effective it m ust be reason ably cheap, easy to follow and provide flex ibility and variety. T h e norm al intake in the U nited K ingdom is such that these aim s and total calorie restriction can be achieved m ost easily by carbohydrate restriction, the sim plest of w hich com prises 3 groups of food, one for bidden, one to be taken in unlim ited quantities and the third in restricted quantities -the num ber o f portions perm itted depending upon age, occupation, etc.
Failure to lose w eight im plies lack of dietary adherence but som etim es this is unintentional as occurred w ith th e patient who was seduced by T .V . into thinking that Lucozade was good for her. T h ose w ho cannot adhere are either " nibbling" between m eals or "gorgin g" at m eals or doing both. Som e find it easier to adhere to m ore rigid regimes. T h e se include " T w o m eals per day" w hich reduces opport unities o f tem ptation and the " F ive m eals per day" diet which makes use o f the increased calorie expenditure th at occurs after meals.
O thers m ay respond to form ula diets using M etarcal or Lim m its, T rim m ets etc. though it m ust be em phasised that these replace rather than supplem ent meals. D ru g T herapy.
V ariou s drugs have been advocated; bu t should only be adm inistered in com bination with dietary control and only when this is fail ing to produce w eight loss. T h e y include T h yro xin e w hich is contra-indicated except in hypothyroidism and the bulk agents such as M eth yl C ellu lose -a substance rem arkably free from side -and therapeutic effects. A m p h etam ine and the am phetam ine deriv atives are C .N .S . stim ulants with definite w eight reducing properties.
T h e ir potential danger as drugs o f addiction is reflected by the price they com m and on the Black M arket, and there is considerable pressure to ban their use.
T h is appears extrem e but they should only be prescribed under close m edical control. T h e y lose their w eight reducing effect after 6 to 8 weeks, should be avoided in the psycho logically disturbed and are contra-indicated in patients w ith hypertension or cardiac disease. In term itten t therapy w ith courses of not m ore than 4 weeks duration is preferred as it is as effective as continuous therapy, cheaper, and presum ably less likely to cause addiction.
A lthough chem ically related to am ph et am ine fenfluram ine does not produce C .N .S . stim ulation and indeed often causes sedation. I f injected intra-arterially it has a fat m obilis ing effect and produces m etabolic changes com parable to exercise. Its m ode o f action when given orally remains uncertain.
It m ay be more valuable adm inistered continuously bu t its w eight reducing effect though som etim es dram atic is very variable and a significant pro portion of patients either fail to respond or develop troublesom e side-effects.
T h e D iguanides are another group of drugs which m ay be o f value. In obese diabetics they abolish G lycosuria w ithout producing the w eight gain which occurs w ith Sulplionylureas.
In som e non-diabetics they cause w eight loss, though w hether this is secondary to an anor ectic effect or alteration in body m etabolism is debatable.

DRASTIC METHODS OF W EIGHT REDUCTION.
In spite o f these various m ethods som e patients w ill fail to lose w eight or stop losing w eight w hile still grossly obese. Previous ex perience has shown that once " R efractory O besity" develops it is extrem ely d ifficu lt to achieve further sustained w eight loss w ithout resorting to drastic measures.
(a) Total Starvation. Although practised since biblical times starvation has only recently become medically acceptable. It is not with out risk and the complications include sudden death, cardiac arrhythmias, electrolyte and in particular Potassium imbalance, muscle cata bolism, various nutritional deficiencies, hyperuricaemia, menstrual irregularities, alopecia, alteration in libido and psychological stress. W ith a appropriate selection and replacement therapy the major complications can be avoided. There is, however, no evidence to suggest that the long-term results of starv ation are superior to more conventional therapy when undertaken for relatively short periods (i.e. up to 3 weeks) in patients without Refractory Obesity and in those with Refract ory Obesity the weight lost during such treat ment is almost invariably regained following discharge. However, a proportion of patients with gross refractory obesity starved to within 20% of their ideal will not regain weight but at best it seems probable that starvation is only indicated in a small proportion of grossly obese patients with Refractory Obesity.
(b) Surgery. Enthusiasm for bypass surgery has been rekindled by the reported successes of the 14 /4 operation in which 14 inches of proximal jejunum are anastomased to the terminal 4 " of ileum. T h e operation produces severe steatorrhoea and may lead to hepatic insufficiency.
Experience in Edinburgh is limited and disappointing but further evalu ation is probably justified. Surgery is also indicated to remove unsightly skin folds that sometimes develop following massive weight loss.

TREATMENT POLICY
It is important to try and prevent the development of Refractory Obesity by altering therapy whenever a patients stops losing weight. Although each patient must be treated individually one possible treatment scheme is summarised below, each step being continued until weight loss stops. 1. Establish rapport, assess motivation, give the patient realistic objectives, and pre scribe low carbohydrate diet. 2. Add in either fenfluramine or intermittent therapy with an amphetamine derivative, (e.g. Phentermine) or accept the status quo. 3. T ry one or more of the following in turn.
(a) Special dietary regimes (b) Diguanides (c) High Dosage fenfluramine or accept the status quo. 4. Consider total starvation or bypass surgery or repeat anorectic Therapy or accept the status quo.

Wm. A.
Sudden infant death h as only recently begun to attract widespread publicity and m edical investigation.
It is still largely ignored by the standard paediatrics textbooks and the only description of it given in form al lectures to Edinburgh m edical students com es in the Forensic M ed icine course. T h is perhaps helps to serve one useful purpose in that it m ay be an indication as to why the sudden infant death syndrom e is still alm ost com pletely un explained.
T h ese unfortunate children are usually found dead and, if they reach hospital at all, it is only as far as the accident and em ergency departm ent on their way to the m ortuary.
M o st go directly to a coroner's or procurator fiscal's post-m ortem , and are thus relatively insulated from the research-orientated clinician's attention and interest.
T h is syndrom e is certainly no new pheno m enon. U p to the end of the last century doctors were satisfied that these deaths were due to " teething" , a wide category that in cluded m any deaths for which an adequate explanation would now be found. T h e 18 39 Registrar-G eneral's returns showed a total of 5,016 infant deaths due to this " cause" . T h e fashion then changed towards attributing them to " status thym olym phaticus" , although exactly w hy seems to be unknown. G radually, however, the position is becom ing som ew hat clearer. W e rn e and G arrow in the U nited States produced som e o f the first significant papers during and im m ediately after the second world war. In Britain Professor Sir Sam uel Bedson and D r. F . E . Cam ps (19 5 1) subm itted a m em orandum to the M in istry of H ealth, estim ating an annual toll o f 200 child ren, and suggesting an official investigation which finally bore fruit under Professor Banks in the 19 65 R eport.

Branford
T h e 1st International C onference held in Seattle, W ashington, in 19 6 3 firm ly p u t the sudden infant death syndrom e on the m edical m ap, and although som e still persist in ascribing all these deaths to accidental suffocation, over w helm ing infection or infanticide, m ost will now accept the existence of this syndrom e as a d istin ct entity.
I f any w orthw hile com parable epidem io logical studies are to be m ade on this topic, then a d e fin itio n . o f the syndrom e m ust be universally accepted.
T h ere is considerable lack of agreem ent even on w hat to call it: cot or crib death, sudden unexpected death, sudden unexplained death in infancy, undiagnosed death in infancy and m any others have all been suggested and used, but the 2nd International C onference on Causes o f Sudden D eaths in In fants (1969), after m uch discussion, finally settled for Sudden In fan t D eath Syndrom e (S ID S ) as the term causing least confusion.
Pathologists have yet to com e up with any consistent finding and using this as a basis D r. J. B . Beckw ith produced the follow ing d efini tion at this C onference: " the sudden death of any infant or young child which it unex pected b y history and in which a thorough post-mortem exam ination fails to dem onstrate an adequate cause fo r death" .
It was also proposed that the m inim al acceptable investigation into one of these deaths should include: 1 . A dequate history 2. G ross exam ination includin g thorax, abdom en, brain, entire larynx (± spinal cord) 3. Blood culture 4. H istological exam ination including brain, liver, lungs, heart, kidneys and other organs as indicated by 1 and 2.

5.
A ncillary studies (toxicological, chem ical, special cultures, virological studies and so forth) as indicated b y results of above.
M o st o f the recently-reported epidem io logical investigations have used, as far as was possible, these criteria.
T h e first th ing to determ ine is its actual in cidence in the com m unity. H ow com m on is it? Is this a real problem or is it just another weird and w onderful syndrom e that makes good reading in the journals, bu t which few are ever likely to see? O ne m ajor difficulty has been that som ething " appropriate" was usually recorded on death certificates and SIDS or its equivalent was not used, m aking figures im possible to obtain from this source.
T h e Registrar-G eneral, does now allow the use of th e term " cot death syndrom e" . T h e 1965 M . o. H . report estim ated that 8 3 % o f deaths certified by coroners as due to " respiratory causes" were in fact " cot deaths" . although little data has com e from these nations. D octors working in underdeveloped countries have stated that sudden death in infancy is com m on, but no post-mortem is usually available and any com parison o f figures is therefore im possible.
In reviewing the statistics in T a b le 1, D r. M arie Valdes-D apena rem arked at the 1969 C onference that it w ould appear th at the in cidence o f S ID S increased w ith urbanisation and that the lowest figures seem to occur in rural areas.
T h e survey show ing the highest incidence was that conducted in C anada (Steele 1970), closer exam ination of th e figures revealing that it increased the further north one went. T h is would suggest som e relationship w ith the tem p erature or w eather conditions in general.
Froggart et al ( 19 7 1) have conducted a m ajor investigation in the U .K . by studying SIDS in N orthern Ireland. T h e ir results agree with m ost others by show ing an excess of deaths during the w inter m onths. T h is peak ing was greater during the first year o f study (August 19 65 to Ju ly 1966) and it is interesting to note that epidem ics of Influenza type B and type A 2 occurred in this area during January to February 1966 and F e b ruary to M arch 1966 respectively. In the Southern H em isphere A ustralian figures show a peak in Ju n e, again during the colder season. T h is w inter increase is not due to the relatively un im portant m onthly fluctuations in live births.
T h e re is som e disagreem ent as to w hether the incidence varies w ith the day of th e week. Som e state S ID S to be com m oner over the weekend, suggesting an elem ent of neglect, but other studies do not confirm this.
T A B L E 1 (Valdes-D apena 19  V irtu ally all arc, how ever, agreed that the m ajority of sudden infant deaths occur during th e norm al household sleeping hours, which is quite different from the other causes of death in infancy. M o st are discovered dead when the infant is looked at fo r the first tim e in the m orning.
W h a t then is found when individual cases are looked at? T h e N orthern Ireland study showed a slight predom inance of m ales, but this follow ed a sim ilar pattern for infant deaths generally. R esults o f other investigations have ranged from a m ale excess through equality to a fem ale excess, so there is probably no marked difference.
T h e m ost striking epidem iological finding is undoubtedly encountered w hen the age o f the infants is considered. It is a constant result that there is a genuinely low prevalence in the first two weeks of life, follow ed by a rise to a peak incidence at around three m onths and then a rapid decline. T h e very low incidence in the first two weeks of life contrasts markd ly w ith the other causes of in fan t m ortality. O n ly rare cases occur after one year of life.
T em p lem an (1892) was the first to record that SIDS is com m oner in fam ilies of low er social class. H e, how ever, considered that all these deaths were due to overlaying by their m others as a result o f carelessness, drunkenness or a desire to collect sm all sums of insurance m oney (up to 45/-). H e was probably right in a num ber o f cases, bu t it is thought that his description tallies closely enough w ith the m odern concept of SIDS to include it here. It m ust be rem em bered, however, that this reflects only a general pattern, and there are m arked devia tions from it: SIDS can strike at any fam ily.
A s can be seen from T a b le I, A m erican workers have found a h igher incidence in negroes: this holds good even w hen correction is applied fo r the h igher over-all negro infant m ortality.
T h e discrepancy between C a u casians and negroes is h ighest am ongst th e poor, A s I have already pointed out, m ost o f these children are found dead; few , if any, are seen to die. Som e m others claim to have found their babies alive but blue and have attem pted to resuscitate them . T h is, however, is pro bably a natural' reaction and the baby m ay well have been dead for som e tim e. A noth er characteristic feature is that these ch ild ren can die in the same bed as other children or in the same room as their parents and nothing is heard by them -the deaths are apparently silent.
SIDS has been reported to have occurred in children in hospital w ith ou t the staff detecting anything amiss (G ray 19 7 1) .
R etrospective studies have been carried out on the previous health o f these infants and that of th eir m others, especially during preg nancy. Prem aturity m ay slightly increase the risk, but there is no evidence o f an increase in " failure to thrive" in cases of SIDS. I t appears to be com m oner am ongst twins but this m ay be a reflection o f their low er birthw eight, which is an im portant factor in infant death generally. T h e N orthern Ireland group found no evidence o f heredity p laying any part, and the m others o f these children had no increase in foetal loss in their obstetric history.
H ealth o f the children im m ediately prior to death is d ifficu lt to assess due to recall bias on the part of the parents and the problem s of obtaining suitable control groups. Som e re sults suggest an increase in m inor illness (coryzal or digestive sym ptom s) in the week, and m ore especially the 24 hours, prior to death, but others disagree with this. T h e re is certainly n o history of m ajor illness or anything to suggest that the child w ould shortly die.
T h is then is very briefly w hat epidem iology has contributed in attem pting to unravel this problem . It is doubtful that it w ill produce m uch m ore o f significance. D r. A . B . Bergm an, at the 1969 C o nference, said " E pid em iology has only so m uch to offer -w e m ustn' t try to squeeze out m ore juice than the w hole orange possesses. I w ould m ake the rather dogm atic statem ent that except for the testing o f specific hypotheses, large-scale epidem iological field investigations arc apt to be repetitive and are not likely to produce new useful inform ation ." W ith this in m ind, com bined with the pathological findings, w hat then can we say about th e present theories as to the cause of SIDS? N o significant " at risk" factors can be isolated and this, com bined w ith the charact eristic age-range, m ediates against th e view that these infants have any as yet undiscovered 'disease' . Froggart et al (19 7 1) suggests that as th e infant is " passing through a develop m ental stage o f physiological vulnerability som e critical com bination of extrinsic and intrinsic factors occurs which proves leth al." Ju st w hat is the " fin a l com m on p athw ay" o f these deaths causes the m ystery and here epidem iology can be o f little help.
I do not intend to attem pt to discuss in any detail the enorm ous num ber of suggested causes, som e o f which are presented in T a b le I I I (an extension of one by Valdes-D apena (19 7 0 )).
T h is is, o f course, b y no m eans a com plete review of the literature. E vid en ce now exists, if not to refute, at least to throw doubt upon several o f these hypotheses. T h a t supporting others is, to pu t it m ildly, tenuous. Som e of them , although exterem ely ingenious, do not help at all to explain the epidem iological data. Perhaps the strongest support is given to viral infection being the-m ajor " extrinsic factor" , although there is good evidence to back m ilk allergy. Jam es' (1970) work on the develop m ent of the conduction pathways in th e heart m ay w ell provide a clue as to the " physiological vulnerability" although a recent study has failed to confirm his findings (V a ld es-Dapena 19 7 1) .
Froggart has called SIDS a "disease of theories" , and until m uch m ore detailed scientific investigation is undertaken, particul arly in trying to define w hether the deaths are prim arily pulm onary or cardiac, then little clarification can be expected. A great deal o f m oney and research effort is at present directed towards prolonging, in an often unsatisfactory m anner, the lives o f con genitally deform ed children, whereas little is spent in the U .K . on trying to establish the cause of this perplexing problem .
T h e se children, som e 2,000 a year in G reat Britain alone, are m ysteriously deprived o f their chance to becom e norm al, intelligent, active m em bers o f the com m unity w ith apparently little concerted effort to determ ine why.
V a lu ab le w ork in publicising SIDS and raising the m oney for research into it is under taken in the U nited States b y lay organisations, e.g. T h e N ational Foun d ation for Sudden In fan t D eath (N ew Y ork). R ecen tly sim ilar bodies have been form ed in the U .K .: T h e B ritish G u ild for Sudden In fan t D eath Study and T h e Foun dation for the S tu d y of In fan t D eaths. T h e latter organisation is attem pting to raise £500,000 to support research.
T h e y also provide m uch-needed help and com fort to fam ilies in which one of these tragedies occurs, help that is all th e m ore valu able as m any of the m em bers o f these organ isations have experienced SIDS w ithin their own fam ily group, and are thus uniquely qualified to be of assistance to those in need of it. E ven if the cause o f SIDS is never found and it can never be prevented, there is m uch that can be done even now towards reducing its effects on the other m em bers o f the fam ily. U nfortun ately th e necessary police investig ations to exclude unnatural death, the post-mortem and inquest, if held, all add to the parents' grief.
Som eone m ust take the tim e to explain to them w hat is known about S ID S , in particular that no blam e can be attached to anyone and that there is no indication that it is likely to recur in subsequent offspring. E m ery (1972) suggests that the best person to take on the role of counsellor w ould be the local paediatrician. T h e G eneral Practitioner w ould seem to be the obvious choice but approxim ately one-third of affected fam ilies have been found to change their G .P . after a " cot death" has occurred. T h e health visitor is similarly placed in a d ifficu lt position.
T h ere is a heavy psychiatric toll, particularly am ongst the m others of these children (Berg man et al 1969). T h e sym ptom s of grief should be discussed w ith the parents, m edication may be temporarily required for insomnia or anxiety and if possible a close w atch should be kept for m arital problem s and sym ptom s of em otional disturbance in siblings.
F uture children born to the couple m ay well be in danger from the effects of over-protection, excessive care and surveillance leading to alm ost inevitable consequences on their future em otional developm ent.
T h e sudden infant death syndrom e therefore embraces m ore problem s than its aetiology alone and should not, to m y m ind, be con fined to the realms of forensic m edicine.

INTRODUCTION
T h e accidental discovery of the Australia antigen ('HAA) in 19 6 3 by B lu m berg and his coworkers is a classical exam ple o f biom edical serendipity. Its recognition not only stim u lated a substantial am ount of research into viral hepatitis, thereby adding considerably to our knowledge about this im portant disease, bu t has had far-reaching im plications in the understanding o f several other h epatic and system ic diseases.
In deed, its discovery m ay well be seen in the future to have been the all-im portant breakthrough in attem pts at culture o f the virus as a m eans of vaccine prepartion fo r future prophylactic usage.

THE DISCOVERY OF THE ANTIGEN
B lum berg, a cytogeneticist w orking in the Philadelphia In stitute fo r C an cer R esearch, was conducting a system atic study o f the serum o f patients w ho had received m ultiple blood transfusions. U sin g a technique of double diffusion in agar gel (O uchterlony m ethod) he searched fo r precipitating anti bodies to inherited donor serum protein anti gens, particularly those to low density betalipoproteins.
A precipitating an tibod y was identified in th e serum of a h aem ophiliac p atient which reacted w ith an antigen which was quite dissim ilar from lipoprotein antigens. T h is antigen was present in the serum of an A ustralian aborigine, and the term Australia antigen was coined ( 1, 2, 3,).
T h is antigen is alm ost certainly identical to P rin ce's SHantigen (4), and to avoid confusion the term hepatitis-associated antigen (H A A ) is now con sidered b y m any to b e m ore appropriate (5).
It was som e tim e before it becam e apparent that the A ustralia antigen was closely related to, or m ight be located directly on, a hepa titis virus.
It was found in the serum o f som e 30 per cent o f patients institutionalised be cause o f D o w n 's syndrom e (m ongolism ) but did not occur in out-patients w ith this disease or in hospitalised patients w ith other causes o f m ental retardation.
In these institutional ised m ongoloid patients antigenaem ia was associated w ith chronic anicteric h epatitis, as shown by liver biopsy and elevated S .G .P .T . levels (6).
T h e antigen was isolated by density-gradient sedim entation, and under the electron m icroscope was found to be a particle of 200 A° in diam eter w ith knob-like subunits of som e 30 A° on the surface.
A gglutination o f these particles occurred on addition o f anti-H A A antiserum .
T h e liver cells o f patients w hose blood contained the antigen was then shown to have striking fluorescent granules in or on th eir nuclei when fluorescent an ti-H A A was added (7), a phenom enon n o t seen in patients w ith ou t h epatitis or in those w ho do not have th e antigen in their blood (3). C lin ical hepatitis was then found to result in a high proportion o f patients given transfusions of blood from donors who carried the Australia antigen (8).
E pid em iological studies sugges ted that the antigen was an infective agent, and supported the conclusion th at the Austrailia antigen was in tim ately associated with a virus that caused hepatitis. Subsequent studies suggested th at th e antigen was associated w ith clinically d ifferent form s o f h epatitis, the form d epending on the im m u ne status o f the p atient (9).
T h e antigen was also shown to b e rare in N o rth A m erica and th e U n ite d K in g d o m (0.1 per cen t) b u t was c o m m on in p eo p le livin g in th e tropics (2-20 per cen t).
In d eed , th ese p atien ts seem ed to be su scep tib le to ch ro n ic in fe ctio n w ith th e h ep a titis virus (10), a p o in t th a t w ill b e m ore fu lly discussed later.

THE NATURE OF THE ANTIGEN
T h e A u stra lia a n tigen w as show n b y th e B lu m b e rg gro u p to d iffer from the serum betalip op rotein s w h ich th e y had p revio u sly de scribed in th a t it h a d a high m o lecu la r w eigh t and co n ta in ed p rotein s w ith m in im a l am o u n ts o f lip id . E lec tro n m icro sco p ic studies o f antigen -positive serum , prepared b y sucrose density-gradien t ce n trifu g atio n and a negativestain in g tech n iq u e , revealed virus-like particles S in ce the sp ecific a n tib o d y to A ustralia a n ti pen w ill cause clu m p in g o f b o th these p arti cles (13) it is n ow gen erally agreed th at th e a r ticles th em selves co n stitu te the an tigen ) 14).
A lm eid a and W a te rso n (13) h a ve described th ree p a tte rns o f A ustralia antigen as observed un der th e electron m icro sco p e in relation to clin ical features.
1. In th e p a tie n t w ith fu lm in a n t h e p atitis, large a m o u n ts o f a n tib o d y separate the aggregated particles; 2. in th e p atie n t w ith ch ro n ic active h ep atitis, u n atta ch ed p articles o f antigenw ere seen, to g e th er w ith im m u n e co m plexes w ith antigen excess; and 3. in sym p to m -free carriers o f the an tigen , ran d o m ly distrib u ted sp herical and tu b u lar p articles w ere observed w ith o u t c lu m p in g b y a n tib o d y . It has been suggested b y D a n e et al ( 19 70) that th e large (42 A°) p a rticles are th e virus itself, w h ile th e tu b u lar form s are surplus virus co ated m aterial (15).
T A lm eid a and h er co l leagues h a ve fu rth e r suggested th at th e A u s tralia an tigen m ay b e an aggregation o f p rotein subun its derived from th e virus (13,16). Z u ckerm an, w o rk in g w ith A lm eid a , has described particles fo u n d on electro n m icrosco p y th a t dis played th e characteristics o f th e coronavirus group , and suggested th a t th e particles appeared to co n sist o f a n tigen -an tib od y Com plexes (17 , 18).
M o r e rece n tly this group h ave reported th e ap p aren tly successful p ro pagation o f th e serum h e p atitis virus in hu m an em b ryo live r organ cultures, co n firm in g th e ir results on electro n m icrosco p y.
M a te ria l harvested from these cultures has been su c cessfu lly passaged, so th a t th e fu ll elu cidatio n o f th e virus, and th e antigen w ith w h ich it is in ex trica b ly associated, m ay n o w n ot b e far aw ay ( 19 ).

DETECTION OF THE ANTIGEN
T h e earlier w orkers e licted the p resen ce of th e A u stralia antigen in serum using th e m icro-O u c h te rlo n y im m u n o d iffu sio n te c h n iq u e (1). S in ce th en , m ore sen sative m eth o d s h ave b e co m e available.
T h e se in clu d e co m p le m e n t fixation , im m u n o ele ctro p h o re sis, haem agglutinatio n , h a em ag g lu tin a tio n -in h ib itio n , radio im m un oassay, and electron m icrosco p y using n egative-stain ing tech niques.
T h e im m u n o d iffu sio n m e th o d is sim p le to perform , b u t n o t sensitive. C o m p le m e n t fixa tio n is m ore sen sitive, and is a m en ab le to q uantitative determ in atio n o f b o th A ustralia a n ti pen and sp ecific a n tib o d y .
Im m u n oeleetroosm oohoresis is a rapid and co m p aratively sim p le tech n iq u e w h ich is less sen sitive than co m p le m e n t fixation b u t m ore sen sitive than im m u n o d iffu sio n .
H aem a gg lu tin a tio n and In cm a eg lu tin a tio n -in h ib itio n are h ig h ly sen sitive fo r d e te ctio n o f a n tib o d y to the antigen. Electron m icroscopy is relatively elaborate to perform , but is a rapid and sensitive m ethod. Radio-im m unoassay is about twice as sensitive as com plem ent fixation, w hile im m unofluores cence is am enable to detection of the Australia antigen in liver biopsy specim ens.
T h e m ore recently developed m ethods include an im m une adherence-haem agglutination technique which lends itself to autom ation, and a latex agglutination test which is sim ple and rapid to perform , and sensitive.
T h e Australia antigen has been found, not only in serum, but in liver biopsy specim ens, where it can som etim es be dem onstrated by im m unofluorescence when negative in the serum.
Faecal antigens have also been des cribed (20, 28) w hile urinary spread seems probable, for chronic carriers o f the antigen m ay excrete it in their urine.
T h e antigen has also been detected in bile, and m ay well be present in saliva, as scrum hepatitis can apparently be spread b y kissing.

PREVALENCE OF THE ANTIGEN
C o m m u n ity studies have shown that the Australia antigen is rarely found in the healthy p opulation o f N orth Am erica and the U nited Kingdom (0.1 per cent), and is exceptionally rare here in those under 18 . In tropical coun tries, however, the antigen is found far m ore frequently in the serum of apparently normal people. Figures quoted by B lu m berg (3) for these countries include Costa R icans (2 per cent), Australian aborigines (2.1 per cent), Brazilians (2.5 per cent), M elanesians (3.6 per cent) Filipinos (4.8 per cent), V ietnam ese (6.3 per cent), M icronesians (7.2 per cent), G h a n aians (9.5 per cent), Taiw anese 13 per cent and Peruvian Indians (20.2 per cent).
T h e Australia antigen is also com m only found in patients with acute m yeloid leukae m ia, and with acute and chronic lym phatic leukaem ia.
M o st o f these patients, however, h ave received blood transfusions as part o f their therapy, and few have hepatitis. Patients with leprom atous leprosy also have an unusu ally high incidence of positivity in relation to their fellows in the com m unity and in com parison with patients with tuberculoid leprosy. T h is is presum ably due to their altered cellu lar im m unity, favouring persistence of the antisen , together w ith a high incidence of antigen in the com m unity.
Patients on chronic renal haem odialysis pro gram m es. who also have altered cellular im m unity due to their uraemia, and m ay in addi tion be receiving im m unosuppressive therapy, have an usually high incidence of positivity in com parison w ith other hospitalised patients often becom ing chronic carriers o f the antigen after incidents of m ild hepatitis.
High carriage rates have m ore recently been reported in " m ainline" drug addicts in Europe and A m erica, figures o f 7 per cent being recor ded in one recent survey.
T h e association between Australia antigen and D o w n 's syndrom e has long been recog nised, and was reported b y B lum berg in 19 67 (2).
Figures of between 27.7 and 35.1 per cent have been variously reported for mongoloid patients in institutions.
M an y of these patients have histological evidence of chronic active hepatitis, and their age at tim e of ex posure seems to determ ine long-term antigen carriage.
T h e chronic carriage of the antigen in these patients m ay also be related to im m unological deficiency.

SERUM HEPATITIS
A lthough B lu m berg and his workers recog nised that the Australia antigen was intim ately associated w ith a virus causing h epatitis and that its presence in serum was indicative of the presence o f that virus (2 1), it was not until later that the clear association o f the Australia antigen with serum or long incubation period hepatitis was shown.
Prince (2 2 ) reported a close association be tween the Australia antigen and lon e incuba tion period hepatitis in 1 968, calling the anti sen S H or serum hepatitis antigen.
It is identical with the Australia antigen and is absent from the serum of patients with com mon source outbreaks of short incubation period infectious hepatitis.
T h e finding of Australia antigen in patients with presumed infectious hepatitis has been reported and is due to the diagnosis being m ade solely on clinical grounds. W h atever one m ay think o f the ethics o f these experim ents -and they certainly provoked a world-wide outcry -the work was brilliantly conceived and m ethodically and scientifically done. B y infecting these children shortly after their admission to the school with serum from patients known to have infective and serum hepatitis and taken from these patients shortly before the developm ent o f jaundice a considerable am ount o f clinical, bio-chem ical, and other data was collected.
T h e trials were done with the acquiescence of the children's parents and were defended on the grounds that viral hepatitis was endem ic at the school and that the children, m ost of whom could not be toilet trained, would al m ost inevitably acquire hepatitis by the faecaloral route w hile resident in the school.
T h e experim ents were condoned and sanctioned by com m ittees set up in A m erica to m onitor hum an experim entation, and were conducted in accordance with the W o rld M ed ical Associ ation's D raft C o d e o f E th ics o n hum an ex perim entation.
T h e data accum ulated during those studies has contributed im m easurably to the under standing of viral hepatitis.
T w o quite dis tinctive varieties of infectious hepatitis were shown to exist.
O ne type resembled classical infectious hepatitis (IH ) and was characterised by an incubation period of 30-38 days, a rela tively short period o f liver function test abnor m ality and a high degree of infectivity.
T h e second type resem bled serum hepatitis (SH ) and was characterised b y a longer incubation period, a m ore protracted and severe clinical and biochem ical upset and m oderate infectiv ity. O n reinfecting the patients it was shown that one attack of IH protected the child from a second and that patients who had been given the S H type were in no way im m une from the IH variety of infection.
T h e y sub sequently showed also that IH could be trans m itted parenterally as well as orally and SH orally as well as parenterally.
T h e m ode of transmission did not affect the incubation period of the IH virus, this being essentially the same after oral and parenteral exposure. T h e incubation period for the S H virus how ever was longer follow ing oral than parenteral inoculation.
T h e y also showed that gam m a globulin protected against the infectivity of IH but not against that of S H serum.
T h e discovery of the Australia antigen allowed the Krugm an group then to extend their studies using the antigen as a marker. T h e y tested 25,000 specim ens of serum, col lected and stored during their earlier experi m ents on 700 patients with viral hepatitis, for the A ustralia antigen. T h is showed that the Australia antigen was consistently present in se ra from patients with long incubation period hepatitis (SH ) but was not present in sera from patients with short incubation period infective hepatitis (IH ).
M oreover, the anti gen was detected earlier after a parenteral ex posure to S H than to oral exposure, appearing jaundice.
T h e antigen was also found to be two weeks to two m onths before the onset of transient in 65 per cent of the children given S H , lasting a mean of 49 days.
It persisted for m any m onths, however, in the rem aining 35 per cent of children.
In addition, the children given S H infection were im m une fol low ing re-exposure to S H virus one year later. T h e ir observations am ply confirmed that the Australia (hepatitis-associated) antigen was specifically related to serum and not to infec tive hepatitis and showed that if the antigen was present for m ore than four m onths it was likely to persist indefinitely.
T h e y also showed that serum containing the antigen and obtained from patients who had never had overt hepatitis, was capable of causing serum hepatitis.
Indeed, it has been shown that less than 0.001 ml. of serum containing the A ustralia antigen was infectious (25)  T h is is further strong support for the hypothesis that the Australia antigen (H A A ) is an integral part of the serum hepatitis virus.

SEOUELAE OF IN F E C T IO N W IT H T H E AU STR ALIA A N T IG E N ( 1) Sources o f Infection
In the clinical context, the classical m ode of infection with the serum hepatitis virus and the Australia antigen is parenteral by the trans fusion o f infected blood or blood products, or by contam inated equipm ent, especially needles or syringes.
T h e increasing incidence of drug abuse ex poses larger num bers of the com m unity to potential syringe-borne infection.
Close con tacts with addicts, who are not themselves " m ainliners" can contract the disease.
It is probable on clinical grounds that kissing and sexual contact with antigen positive persons m ay well lead to serum hepatitis.
It has, of course, also been shown in the W illow brook experim ents that the disease m ay be spread by the faecal-oral route.
Hospital-acquired dis ease, for exam ple in uraemic patients on chronic renal dialysis, m ay also spread to the com m unity.
Indeed, eases have been repor ted where the spouse of such a patient has con tracted a fatal serum hepatitis illness.
T h e im portance o f mass screening o f blood donors is apparent in this context, especially as the antigen has been shown to have persis ted over 20 years in a patient who has remained apparently entirely well over that period (27). Shaving brushes, razors, toothbrushes, hairdressing implements, dental instruments and tatoo needles contaminated with Australia antigen positive blood have all been implica ted in the spread of serum hepatitis.
T h e identification of the Australia antigen in faeces (28) and urine and bile creates fur ther obvious possible sources for the spread of the disease.

(2) Consequences of Infection
This depends on the dose, virulence of the strain, previous exposure to the antigen, and the immune status of the individual.
In the latter context, depression of cellular immunity is particularly important.
T h e patient who is immunocompetent is likely to get severe or fulminant hepatitis, while the patient who is immunodepressed by disease or iatrogenically is likely to have mild hepatitis.
T he former patient, should he survive, will probably rid himself of the antigen within two months of the onset of clinical hepatitis. T he immunodepressed or immunosuppressed patient is, however, likely to have mild hepa titis with persistence of the antigen, often in definitely.
Some of this group will become apparently healthy long-term carriers of the antigen, while others may develop chronic active hepatitis that may proceed to cirrhosis. This has been well shown in the outbreaks of serum hepatitis in renal dialysis units.
T h e patients tended to have mild hepatitis followed by persistent antigenaemia while the staff had severe and often fatal hepatitis, but cleared the antigen from their blood.
The Australia antigen is detectable in the scrum some weeks before there is subjective or clinical illness and may be detcted in the liver after recovery, when the patient is seronegative. Some antigen positive patients show allergic manifestations during the late incubation period or early in the phase of active hepatitis with urticaria, arthralgia, angioneurotic oede ma and sometimes migrainous headaches. This may be related to the presence of circulating immune complexes of Australia antigen, its antibody, and complement.
The antigen becomes demonstrable in the hepatic parenchymal cells at this stage and can be nicely shown by immunofluorescent or E M studies.
T h e patient may then develop the fulminant picture, which is similar to that of acute massive necrosis from any cause. There is a high mortality rate in this group despite intensive therapy with colomycin, lactulose, parenteral glucose, heparin and fresh frozen plasma followed by extracorporeal perfusion, or exchange transfusion.
M ore often, how ever, the patient will recover after a protracted period of cholestatic jaundice.
M ost who are immunocompetent will clear the antigen with in four to ten weeks (29).
These are the group, however, who run the risk of destroying their liver, presumably by a vigorous antigenantibody reaction.
M any will have no lasting hepatic damage, although some may proceed to chronic hepatitis of the mild persistent or even the severe aggressive varieties.
Chronic persistent hepatitis often follows the classical attack of acute serum hepatitis, leading to cir rhosis, while chronic aggressive hepatitis tends to follow a mild or subclinical attack of antigen positive hepatitis.
Certainly, cirrhosis is most likely when the Australia antigen remains positive after the acute attack.
This persis tent antigenaemia is probably related to im munological defects, especially in cellular im munity.
It is at least possible that the SH virus may gain in virulence by passage through patients who are immunosuppressed either by uraemia or by azathiprine (Imuran), cyclop hosphamide and antilymphocytic serum, causing very severe or fulminant hepatitis when an immunocompetent person is infected. This is, however, conjectural.

CELLULAR IM M UN ITY AND THE ANTIGEN
It has been postulated that a complex series of interactions between the Australia antigen, the serum hepatitis virus and the immune re sponse of the host, both cellular and humoral, follows infection with H A A positive material although immune complexes of H A A and anti body are important in producing some of the varied clinical manifestations that follow infec tion, the cellular immune response seems to de termine the severity and persistence of the as sociated liver damage. It has recently been sug gested that the competence of the cell medi ated (T-lymphocyte dependent) immune sys tem determines whether the infection is selflimiting or persists with varying degrees of damage (30).
Krugman and his associates showed that in oculation of children with standard prepara tions of Australia antigen-positive scrum re sulted in a spectrum of clinical outcomes (24). Although transient antigenaemia was usual in association with either overt or anicteric hepa titis, persistence of the antigen could occur in association with either chronic active hepatitis, or w ith out apparent disease. Persis tence o f the antigen is seen frequen tly in patients w ith im paired T -lym p ho cyte function (lym phoproliferative disorders, leprom atous leprosy, chronic lym ph atic leukaem ia).
T h e h igh frequency o f antigen in m ongolism m ay also be related to an abnorm al im m unological status. H aynes et al (14 ) have shown hepatocytes. in antigen sero-positive patients to contain characteristic particles w ith m em brane bound cytoplasm ic vesicles.
T h e appearances of these particles was sim ilar to that of the A u s tralia antigen particles found in the serum. T h e y differed in both size and structure from the m ainly intranuclear particles described b y previous authors (3 1).
A lth ough a direct connection betw een the two types o f particles described above has yet to be established, it seem s likely that the diff erent types are related to stages in the develop m ent o f the serum hepatitis virus.
It has been shown that there is apparent intranuclear replication o f 22 A° particles, w ith consider able disruption o f the nucleus, and som etim es also with cytoplasm ic replication, occasionally with the production of rather different parti cles within the cytoplasm ic vesicles.
O thers have shown no intranuclear replication or dam age, but enormous production of particles, within the cytoplasm , o f the larger type -and a m uch greater degree of cytoplasm ic damage. W h eth er these two situations represent differ ent stages of a single process or arc alternative m anifestations of infection b y the S H virus is uncertain.
It seems unlikely, however, that either one could lead directly to the other. A n o th er possibility is that they arc related to the im m unological status of the patient (14).

CHRONIC ACTIVE HEPATITIS (C.A.H.) AND CIRRHOSIS
T h e rem arkable specificity of the A ustralia antigen for serum hepatitis and chronic active hepatitis in com parison to other form s of liver disease suggests that persistence of the antigen m ay be aetiologically im portant in som e cases of chronic active hepatitis and cirrhosis.

P R I M A R Y B I L I A R Y C I R R H O S I S A N D T H E A N T I G E N
Particles identical to those associated with the A ustralia antigen were found by E M in the sera of 1 1 out o f 1 2 patients w ith prim ary biliary cirrhosis.
A ntigen an d /o r antibody to Australia-antigen was also found in 9 out of 10 o f these cases by sensitive im m unological m ethods (34). T h ese findings remain to be confirm ed, but the suggestion is that the liver dam age in prim ary biliary cirrhosis m ay be due to either continuing replication of the SH virus, or be the result of the p atien t's im m une response to persistent antigenaem ia.
T h e presence of autoim m une (smooth m uscle and anti-m itochondrial) antibodies in this condi tion has led to the suggestion that the condi tion is either due to or associated with abnor m al im m une reactivity, the trigger possibly be ing the S H virus.

HEPATOCELLULAR CARCINOMA AND THE ANTIGEN
T h ere has recently been w orldw ide interest in the possible oncogenic properties of the SH virus and H A A .
In U ganda (35) 40 per cent of patients with hepatocellular carcinoma had the A ustralia antigen in their blood.
T h ese workers found a tendency for H A A positive individuals with hepatocellular carcinoma to be alpha-fetoprotein positive, and to have underlying cirrhosis o f the posthepatic type. Y o u n g patients tended to be H A A positive m ore frequently than the older ones who were often alpha-fetoprotein negative.
T h is data certainly suggests an association between per sistent antigenaem ia and the pathogenesis of hepatom a -at least in Uganda, especially as only 4 of their 12 2 controls (3 per cent) were antigen positive.
It is certainly tem pting to speculate that antecedent viral hepatitis plays a causative role in the neoplastic transformation of the liver cell.
O ther work ers have lent support to this theory, with marked differences across the globe.
In T h e sugges tion is that the syndrom e o f diffuse vascular damage observed in these patients was due to deposition of im m une com plexes in the blood vessel walls, and that these deposits were com posed o f Australia antigen, hom ologous Ig M antibody, and com plem ent com ponents (37).

THE HUMAN BEING AND HIS AUSTRALIA ANTIGEN
D uring the recent tragic Edinburgh serum hepatitis outbreak, the com m unity in general and hospital staff in particular cam e face to face with a new and terrifying reality -inocu lation with antigen positive m aterial m ight herald a fatal illness.
T h is transformed people, and created problem s that are only now being fully realised as the im m ediate danger seems past.
Patients were som etim es treated as were lepers, and m any are still aware of being ostracised, despite a long-standing negative Australia antigen.
M an y doctors and nurses did, however, behave in a m anner that does them very great credit, and signs are around that m edicine, in its broadest sense, is com ing to terms with the discovery that Blumberg fell upon quite by accident alm ost a de cade ago.
H e could hardly have realised then that he had, in truth, perhaps created more problem s in his discovery than have been solved by the now clear cut delineation of the two form s of viral hepatitis by the recognition of the Australia antigen.

Geoffrey D. Hargreaves
In the justifiable belief that the older collec tions of printed medical books in Edinburgh libraries are exceptional in both quality and quantity, the Royal Medical Society has in itiated a scheme for the production and, it is hoped, the publication of a composite cata logue of these collections for the benefit of scholars in the history of medicine and science. The institutions currently involved in the scheme are the National Library of Scotland, the Royal Botanic Garden, the Royal College of Physicians, the Royal College of Surgeons, the Royal Observatory, the Royal Society and the University of Edinburgh (including New College).
In addition, the Royal Medical Society is, of course, contributing its own residual but important collection of older books withheld from the 1969 sale as being unrepre sented in any other Edinburgh collection.
T he quality of the Edinburgh collections as a whole may perhaps be adequately suggested by noting their strength in the classics of medical literature. There are, for example, three copies of the De medicina (1478) of A. Cornelius Celsus, one of the first general medi cal treatises to be printed; four copies of the herbal D e historia stirpium (1542) of Leonhard Fuchs, and three of the anatomical work D e humani corporis fabrica ( 1543) of Andreas 'V esalius -books which, particularly through the quality of their illustrations, did much to release the study of medical botany and anatomy "from traditional inaccuracies; one of the three known copies of the Christianissimi restitutio (1553) of Michael Servetus, which includes the first Western account of the lesser circulation; no fewer than five copies (including one with the errata) of what is generally re garded as the most important work in the his tory of medicine, W illiam Harvey's account of the circulation in his De motu cordis (1628); five copies (including a presentation copy with the plate in colour) of another classic of medical botany, W illiam W ithering's An account of the foxglove (1785); and a copy of Sir Charles B ell's exceptionally rare Idea of a new anatomy of the brain (18 11), a pamphlet even more unprepossessing in appearance than the D e m otu cordis, yet -in the context of the nervous system -of comparable importance as an advance in medical knowledge.
Such classics are supported by the more ephemeral (and thus often more elusive) tracts in particular pharmacological, obstetrical and dietary instruction at a more popular level. Among the earlier works in this category to be found in Edinburgh may be mentioned the L iber servitoris de praeparatione medicinarum simplicium (1471) attributed to Albucasis and perhaps the first printed book of a wholly medical character; Aldobrandino's L e livre pour garder la sante du corps (c. 1481); the Secreta mulierum (two editions, c. 1495-1500) attrib uted to Albertus Magnus; the Regimen sanitatis (i486 and c. 1500) of Magninus; the pseudo-Aristotelian P roblemata de partibus Corporis humani (c. 1500); the T ractato mirabile contra peste (1503) of Baverius de Baveriis; and the E n n eas m uliebris (c. 1505) dedicated by the author, Ludovicus Bonaciolus, to Lucretia Borgia. Earlier Scottish medical printing also falls into this category, and is of course well represented with such rarities as Gilbert Skene's Ane breve descriptioun of the pest (1568) and Patrick Anderson's Grana angelica (1635).
In addition t o the texts, the provenance and associations of the books often reflect the his tory of Scottish medicine and science in general and of the Edinburgh Medical School in par ticular.
Some examples are the works on medical botany acquired during a continental tour in 1670 by Patrick Murray, Laird of Livingstone, whose collection of plants formed the basis of the Royal Botanic Garden; the extensive collection of medical books of the sixteenth to nineteenth centuries formed by Sir James Young Simpson; and the copy of the D e motu cordis (1628) owned by Professor Alexander Monro tertius.
But the owners of medical books have not always been medical or scientific men, especially in the period before 1700. T h e Edinburgh copy of the 1527 edition of Avicenna's monumental exposition of Arabic medicine, the Canon medicinae, is preserved in a fine binding for John Hamilton, Archbishop of St. Andrews from 1546; the Drummond Collection features several rare ephemeral medical tracts owned by the poet W illiam Drummond of H awthornden (1585-1649); while John Gray, minister at Aberlady in 1690, was another owner of an Edinburgh " Harvey" . In these ways the Royal Medical Society's project is likely to establish links with a wide range of Scottish studies.
If the quality of the collections is inviting, their quantity is daunting. T h e involvement of two major general libraries makes it essential that the project should work to a fairly strict definition of a " medical" book, especially for the period after 1700. Even so, sampling tech niques suggest that there are at least 50,000 " medical" books in Edinburgh printed before 18 5 1, the terminal date set by the Royal M edi cal Society for an " older" book. It should therefore be clear that the project must ulti mately be of a long-term or multi-staffed nature, possibly both. T he initial three-year term sponsored by the Society must be essen tially an exploratory effort, aimed at covering no more than a suitable early portion of the scheme in addition to assessing its long-term requirements. A t first it was hoped that this early portion might extend as far as 1600 or even 1640, but experience in attempting to co-ordinate a project spread over eight separate libraries, where the appropriate books have first to be isolated from the general stocks, has now shown that this is impracticable. The W ellcome Historical Medical Library and the United States National Library of Medicine both commenced publication of their cata logues with a separate account of their fifteenth century books. It is doubtful if Edinburgh's " medical" (as opposed to " scientific" ) incuna bula are sufficient in number to justify separate treatment, but the addition of the " post incunabula" (books printed up to about 1540 or perhaps 1550) would seem to offer a unit of sufficient scope for publication and of consid erable subject and bibliographical integrity, covering a period when both medical know ledge and the printed book remained to a large extent at " the cradle stage" . Accordingly it is here that the efforts of the project are cur rently concentrated.
A particularly important feature of the pro ject is the presence in Edinburgh of more than one copy of many of the books involved. T he ravages of time and readers, coupled with the technical vagaries of book production, have ensured that many copies of early books (and indeed some copies of more recent books) are physically incomplete and textually imperfect. In these circumstances, the complete copy often has to be reconstructed from an examin ation of several individual copies, all of which may be more or less defective in themselves. In many cases, therefore, the Edinburgh col lections can make a significant contribution to this process, and if the reconstruction is re corded in sufficient detail to indicate the full contents and make-up of a complete copy, the resultant description can be of great value to scholars, who may, for instance, find them selves reading what appears to be an incomplete copy and wish to ascertain how much is miss ing.
There are other ways in which a fairly de tailed description can be of value to scholars in the history of medicine and science. They may be interested in the popularity and success of a work, and a useful indication of these is available in the number of separate editions called for, as the printer would not normally go to the trouble and expense of resetting type for a new edition unless the work was in de mand. Distinct identification of editions is therefore required, and since they may be very closely related and (especially in the case of popular works) undated or of the same date, detailed description is often necessary if the distinguishing features are to emerge. Again, scholars may be particularly interested in printers who specialised in medical and scien tific printing, such as Bonetus Locatellus (fl. 1500) of Venice and Heinrich Sybold (fl. 1530) of Strassburg, who was himself a Doctor of Medicine as well as a printer. But Locatellus and Sybold, like many other printers before and after them, did not always indicate clearly in their books that they were the printers of them, and indeed many books carry no clear indication of printer, place or date. In these cases, it is desirable to present the identifying evidence of such features as printers' types and devices (this can also assist in the identification of editions), or at least to provide references to existing treatment of the problem.
For the incunabula and post-incunabula at least, some attempt has been made to take these considerations into account in the de scriptive method currently being employed for the main entries, of which an outline is appended to this survey. These entries in evitably represent a compromise between the fullest standards of bibliographical description, as reached for instance by A llan Stevenson in the Hunt Catalogue of eighteenth-century botanical books, and simplified listing, which denies to historians and bibliographers alike so much of the information that they require. Even so, eventual publication may have to be confined to a selection of the information compiled, but it seems important to base this information as widely as possible in the first instance so that the largest possible number of options are kept open for the final product. Th i s procedure also allows for the provision of full added entries and indexes of subsidiary works and persons, including editors, transla tors, illustrators, dedicatees, printers and pub lishers.
Finally, it is appropriate to emphasize that progress of any kind could hardly be made without the existing resources and organization of the participating libraries for the exploitation and retrieval of their collections in general. M any of these are covered by invaluable printed catalogues, and all individual items are readily available to the visiting student. It is also fitting to acknowledge the kind co operation of the authorities of the participating libraries, and a pleasure to thank their libra rians and the many members of staff who, de spite the pressure of their normal duties, are generously providing both practical help and technical advice.1

A P P E N D IX
D escriptive formula (main-entry) for inculabula and post-incunabula.
Heading. Normally includes author, short title, imprint (translated and given an arabic numeral date where necessary) and format. T h e form of the author's name follows the usage of the Edinburgh libraries themselves as far as possible; " established" usage is taken as the co-ordinating feature.
Transcription. In this period the informa tion normally found on the title-pages of later books tends to be scattered throughout the book on title-pages (if provided) and in headtitles, incipits, explicits and colophons. In formation is accordingly transcribed from these features, retaining the spelling, capital ization, punctuation and line-endings of the originals. T he amount of information trans cribed varies with each book in a flexible for mula, the aim being, as far as possible, to let the book speak for itself in support of the heading and in respect of the subject interest. Title-pages and colophons are generally trans cribed in full, but no attempt is being made to rival (or duplicate) the intensive descriptions already available for certain incunabula.
Collation. Given by signatures (Greg-Bowers formula) to indicate the precise make up of a complete copy and provide reliable reference notation in preference to foliation or pagination, which arc cither not present or are very erratic at this period. If present, foliation or pagination is noted after the signatures in a simplified formula. (In a few very early books, as in many modern books, the gather ings are unsigned; this does not prevent the construction of a formula to indicate make-up, but reference in these cases is by supplied true foliation.) Typography, illustration, contents. The number of lines to a (typical) page and the standard of measurement of twenty lines of type on that page are given to aid identification (of the edition and/or printer) and also visualization. There follows a note of any illustrative features (including printers' de vices); "full-page" woodcuts are distinguished from those "in text". A simplified contents note seeks in particular to bring out any feat ures (works, persons) of a complete copy not clarified in the transcription. Brief discussion of authorship and attribution problems may be added if necessary'.
References. Normally given to sources which either treat the book in a bibliographically useful way, locate other copies of it, or provide notes on its subject matter and im portance. Followed as required by notes on bibliographical problems. Copy or Copies. Location of the Edinburgh copy or copies examined, with notes on in dividual variation, defect, or special features (association, annotation, binding, etc.) as appropriate. (It is important to emphasize that apparent "duplicates" in Edinburgh are rarely proving, on close examination, to dupli cate each other in every significant feature).

October 1972
All Medical Under-Graduates and Pre-Registration Doctors are eligible to receive awards from the R.M.S. Travel Fund, to finance travel for the furtherance of their medical education. The amount of each individual award will vary with the merit of the project to be undertaken, but will not exceed £150 in any one instance. O ther specialties have developed more gradually as the total body of relevant know ledge has accum ulated, for exam ple, cardiology and neurology. O ther specialties have appeared as a direct response to the needs of the com m unity, and this is the category into which we place geriatric m edicine.
W ith the increasing num bers of old people consequent upon the m uch higher proportion who survive to old age, the needs of the elderly have esca lated and it has been necessary to attem pt to deal with this crisis in different and sometimes novel ways.
A t the same time as numbers of old people have been increasing, m any of the traditional fam ily patterns of care have been eroded by social alterations, and so we have both dem ographic and social reasons for a "geriatric crisis" .
It is com m onplace now to find that the married daughter (in her 30's or 40's) is unable to afford her m other more than token support because she herself is in paid em ploym ent and only available for housewifely and fam ily tasks in the evening.
T h e result has been a great increase in de clared demand for services for the elderly. N or is this the whole story, because m any studies in different areas of the W estern W o rld have shown that old people's needs are often un known until a crisis occurs (a fall, an acute in fection, a stroke, or som etim es sim ply illness of a custodial relative or neighbour) and the situation is then found to be very advanced and perhaps irreversible and preventible sequelae have occurred.
It is against this background of increasing dem and, unreported need and lim ited facilities that we have to try to take stock and assess the present situation.
It is often suggested that these are " m ainly social" problem s and therefore the doctor's role is a lim ited one. B u t the profession cannot wriggle off this particular hook so easily because when we exam ine these " social" difficulties m any turn out to have an im portant (even exclusively) m edical basis. T h u s we find the old lady who lives in the top flat in a tenem ent and is becom ing more and m ore disabled, unable to clim b stairs and thus shopping becom es perfunctory, her social life and diet suffer, and she is in danger of loneliness, isolation and all the sequelae of such a state.
A social problem? B u t what if the reasons for her increasing disability is dyspnoea associated w ith congestive cardiac failure and this is due to a rapid, unknown, uncontrolled atrial fibrillation.
This now becomes a medical problem, readily amenable to standard therapeutic measures with excellent results (and at almost negli gible cost to the N.H.S. and the com munity). I have an old patient who presented in such a state eleven years ago and who still lives on in her old family flat and has done since the diagnosis and appropriate therapy was instituted.
Unfortunately not all the prob lems of elderly patients are quite so simple and straightforward and the majority present with multiple pathology.
In many cases tradi tional medical measures are only partially suc cessful, and we are left with significant resi dual disability. In these cases modern rehabilit ation techniques must be employed -assessing the functional deficit in stroke cases, for ex ample, and using physiotherapy and occupa tional therapy to restore lost function. Where irrecoverable disability remains, then the patient's environment must be altered to suit. T hus family or neighbourly support can be mobilised.
Home helps can take over house hold management tasks and the house itself can be adapted to suit the old person's disabled condition (provision of ramps, handrails, wider doors in W .C ., etc.).
In this way the doctor's skill is employed to establish an accurate clini cal diagnosis; traditional therapies arc then em ployed to cure or alleviate those disease entities which are uncovered, and the doctor then has to invoke the rehabilitation team to restore lost function or to make up for the loss when full restoration is not feasible.
Geriatric medicine can claim great success in many fields over the last twenty years or so. More and more it is realised that early diag-' nosis and appropriate treatment will enable an increasing number of old people to remain longer in their own homes, thus staying out of institutions-and costing the rest of us less in terms of money and trained staff to look after them.
Despite increased efficiency how ever, the increasing numbers of old people in many areas continue to swamp the community services, and in this case the old people "over flow" into hospital beds where they often are seriously misplaced.
Thus every general ward in Edinburgh has its quota of "blocked beds" occupied by old ladies who should be some where else, for example, in sheltered housing (which virtually is non-existent in Edinburgh) or in old folk's homes (which themselves are occupied to a large degree by old people who could be in sheltered housing if this existed). These old ladies are often pathetic creatures -disabled, frequently demented, bereft of family support and guiltily aware that they are not very welcome in the "acute" ward situation in which they find themselves.
They are led to understand that they are "blocking a bed", that the bed "is needed for a more urgent case", etc.
This leads to frustrations among the medical and nursing staff, and if there are students in the ward, this is communicated to them.
The student thus gains the idea that somehow old people are "uninteresting", that they are "therapeutically unrewarding" and that their care scarcely impinges upon the activities of doctors (or at any rate "proper" doctors).
It is not all surprising therefore that the young graduate often emerges from the Edinburgh Medical School with a highly nega tive view of his role in relation to elderly patients.
This may last him a lifetime, although fortunately many manage to achieve a more useful attitude towards their older patients as they go through their professional career.
If anyone doubts the accuracy or truth of this statement, let him ask a represen tative sample of final phase students or young graduates what are their views of the care of elderly patients, or the function of the geriat ric services.
I know what the response will be because I have asked these questions.
Another sad fact is that the student's con tact with old age in his curriculum is almost exclusively in the wards of the teaching hos pital and he remains largely ignorant of the huge majority of other old people.
The importnace of this is emphasised by the fact that 94% of elderly persons are in private house holds and only 6% in any form of institution. O f this 6%, only a tiny fraction are to be found in teaching wards, most being in old folk's homes or old-fashioned psychiatric hospitals, well away from the medical student's accus tomed territory.
The result or this is that many students man age to become doctors with only a very incom plete and highly distorted view of the ageing process and the common problems which be set the older members of the communities he will be attempting to serve. This is particu larly serious in view of the fact that these doc tors (if they are to practise in a developed country) will be spending an increasing pro portion of their time with elderly patients.

T H E FU T U RE O F G E R IA T R IC M E D IC IN E
It has been pointed out that the specialty of geriatric medicine arose initially out o f the pressing community need. This declared need, com bined w ith a general lack o f interest and unwillingness on the part o f m ost doctors, led to the setting up o f special departm ents and a small num ber o f pioneers in the profession showed w hat could be done to help the appar ently " hopeless cases" of old people with m ul tiple and com plex needs. G rad ually geriatric hospital units have evolved and now there is som e sort of service for each area of the K in g dom .
It is, however, readily seen that there are stresses and strains, and it is necessary to review the present situation and to try to de vise m ore satisfactory plans for the future. T h ere is no denying that geriatric units are difficult to staff -there are well over thirty vacancies at consultant level in England and W a les alone, and it is com m onplace for posts to be advertised over and over again with fail ure to obtain satisfactory applicants.
It is therefore proposed by m any responsible geriatric physicians that the present arrange ments should be reviewed and that the recent trend for separation o f geriatric m edicine from general m edicine should be reversed.
T h is idea has m uch to recom m end it, and som e of us who initially were not too enthusiastic are now prepared to change our stance on this issue.
A fte r all, Geriatrics is defined as " that branch o f general m edicine which deals with the clinical, social and psychological problems o f elderly persons" , so that it is an integral and increasingly im portant part of general m edi cine. Indeed, som e would go further and claim that geriatric m edicine is by far the largest part of general m edicine since so m uch else of the general field has been pirated by nar rower specialists.
It w ould thus seem likely that we should encourage geriatric units to com e closer to general departm ents, to share junior staff (either in joint appointm ents or in rotational schemes), to share expensive diag nostic and treatm ent facilities.
T h u s we m ight envisage the m edical division of the future having as one o f its constituents the consultant in G eriatrics who would deal with the " purely geriatric" cases and at the same time be available for advice on other elderly patients who were receiving treatment from other specialists in the division.
T h is "loose specialism " could extend outside the hospital into general practice where som e general prac titioners would be encouraged to develop spec ial interests in the diagnosis and m anagem ent of elderly patients.
T h ese specially interested general practitioners would be those who had spent som e tim e in the geriatric departm ent and m any of them would retain an active role in the local geriatric unit. T h is general plan w ould reverse th e recent drift towards establishing a separate service for older patients -in m y view such a trend would result eventually in two standards o f service -a good and a bad -and there is little doubt which w ould be w hich! T h ere will, of course, always be a need for specialist geriatric units, especially in large centres where large num bers o f very difficult cases w ill occur. In addition there is a great need to encourage the establishm ent o f academ ic departm ents in geriatric m edicine, and it is difficult to escape the conclusion that until a m edical school has a D epartm ent of G eriatric M ed icine it cannot be said to. be m atching up to the dem ands of the late twentieth century.
T en years ago it could with justification be argued that the total b ody of knowledge on ageing and geriat rics was so scanty and disorganised that it could not justify being described as an acade m ic discipline.
T h e great advances in recent years in the practice and theory, o f m edicine in relation to old age and the success o f re search has changed this and there are now as good argum ents for academ ic departm ents in this subject as there were tw enty or thirty years ago for academ ic departm ents of Paedia trics (or m ore properly C h ild H ealth).
T h ese things, of course, cannot b e done at the stroke of a pen, and the first essential is to provide undergraduate instruction in geria tric m edicine.
T h e Edinburgh M edical School is well-known in Scotland for having been extrem ely slow to develop such instruc tion -indeed, it only started, on an y scale in , January, 1 972! E ven now the tim e allocated -two sessions in fourth year and the same in final phase -is so brief th at it is 'quite difficult to know where to start.
It is therefore suggested that the following, should be aimed at:

PRE-CLINICAL YEARS
T h e student should have an introduction to age topics im m ediately he enters medical school.
T h e biology of ageing is a fascinating and rapidly grow ing subject and should be taught in the biology class.
Sim ilarly, physiological changes o f senescence should be taught in the ph ysiology and ana tom y courses.
V isits to geriatric units should be arranged at this stage so students can see the significance o f what they are being taught in a clinical setting, for exam ple, the ageing of bone tissue could be dem onstrated in a dra-matic fashion by showing students the skeletal changes in elderly patients.
Psychological aspects of ageing require to be taught in the behavioural sciences class, and again visits to geriatric departments should be arranged in collaboration with consultants in geriatric medicine.
In the studies on community health, the place of the elderly and the stresses and strains they experience (and generate) would be included.
In this way the student would be made to realise from the start that senescence is some thing that will affect him personally and that a large part of his professional life will be spent on dealing with its effects.
If we believe that "normal" life span is three score years and ten, th en we must accept that senescence is a nor mal part of human development and hence justifies study just as much as embryology, infancy, childhood and adolescence.
A t pre sent our attitude to hum an development tends to suggest that once we reach maturity, noth ing changes until death!

CLINICAL YEARS
In the teaching of clinical methods there are great advantages to be had in bringing students to the geriatric department: a) there is a wealth of "clinical material" -heart mur murs, palpable masses, skeletal changes, malig nant disease, cataracts, etc.; b) it is important that the student should have an opportunity to realise the special problems of clinical ex amination and history taking in the elderly, c) the distinction between "normal" age changes and pathological ones. Here attempts should be made to show students healthy octoand nonogenarians in order to counteract the dismal impression he obtains of old age in the wards.
For the teaching of geriatric practice we need a good deal of experiment with different meth ods.
If lectures are an important part of the course, then there should be lectures on geria trics.
But it is not, I think, a subject which lends itself readily to treatment in large formal lectures.
It is better to develop topic teach ing by concentrating upon specially important aspects.
A good example is Stroke, which should be taught by a multidisciplinary approach -pathology, epidemiology, diag nostic procedures, management of "acute" phase, and finally assessment of functional loss and planning of rehabilitation.
The special contribution of the geriatric teacher would be in the last two items, but there is much to be said for involving other specialists in the same teaching session, (And, of course, physiothera pists, speech therapists and nurses as well'). There is a great scope for developing better teaching methods in these fields.
Lastly, some students should be encouraged to do " in depth" studies of ageing problems. The field of gerontology and geriatrics bristles with opportunities for special enquiry, and a keen young student could even at undergradu ate level readily provide new evidence on old problems which m ight lead to better ideas on management.
M uch of this could be done in the community, away from the restrictions of hospital-bound medicine, and this in itself would be valuable (and also in line with much current student aspiration).
In these ways I believe it is possible to brinp geriatrics back into the mainstream of general medicine before the separation has gone too far.
Psychiatry drifted away from general medicine in the 19th century, and it has been a slow and painful struggle to bring it back; let us not allow this to happen to geriatric medicine. His work into obesity is well-known to Edinburgh students and he has given a talk to the Society on the subject.  In recent years relatively few have taken this opportunity to express their know ledge and views on a subject of their own choice and to defend them if necessary in the face of all comers.

R.M .S. TRAVEL FUND AW ARDS 1971
O ne only needs to look at the list of topics chosen to appreciate that the interests of Soci ety m em bers are still as wide as they have ever been: " Lignocaine -its rational use in C lin i cal Practice" , T . F . Ben ton : " T h ere's now t as queer as F o lk " , R . Bolas: " T h e E ffects of Pro longed Spaceflight on M a n " . W . A . H appily, at the tim e of writing, a sneak pre view of the new syllabus reveals that the 236th Session also has its full quota o f Dissertations.
T h is resurgence of Society talent did not, however, prevent the usual im portation of guest speakers from outside the E dinburgh m edical school. course, open to all, so why is it that some draw only a mere handful o f students? It m ay be that they prefer to restrict their atten dance at 'lectures' to their U niversity tim etable or perhaps our new technicolour advertise m ents are still not enough.
W h atever the reason, one often wonders w hat happened to those am ong the 1,10 0 who flocked to hear D r. Issels who have never returned.
A further downward trend has also occurred in the attendance at Private Business.
T h is is however a different, a purely internal, m atter for the Society. Surely no-one will deny that these m eetings should be the core of the Soc iety's existence, w hatever fringe benefits it offers to its m em bers.
Y e t year after year m any pay their subscriptions and never even arrive to sign the O bligation (a convenient m ethod of introducing a new m em ber to his fellows), and to see for themselves w hat Private Business is about.
It is to be hoped that the measures to be introduced for the new session w ill im prove " com m unication" and result in more m em bers contributing to these m eetings.
D espite being delivered at tim es to a very " select" audience, these m eetings w ent on re gardless.
A m ong them were the first reports from recipients o f R .M .S . T ravel G rants. T ales and pictures from such far-flung places as the M alaysian jungles, the m ountains and valleys of N ep al and, o n a less exotic plane, the m et ropolises of N ew E ngland greatly impressed those present with the worth o f this venture.
A lthough m any applicants have unfortuna tely had to be disappointed, the second groups of recipients have already in som e cases started on their travels, and as a result o f their pre decessors' efforts we aw ait th eir reports with anticipation.
Controversy at the A .G .M . m ainly centered around the Revision o f the L aw s, in particular the annual subscription.
In this era of Society affluence it was argued that it could be reduced to a nom inal level to encourage an increase in m em bership.
In the end this view was narrowly defeated and m em bers will pay £2.00 as from O ctober. O n the 4th N ovem ber, 19 7 1 a short cere m ony was held outside the new M idlothian C o u n ty C o u n cil offices on G eorge I V Bridge, when Fred Ben ton , the Senior President, un veiled a plaque com m em orating the old pre mises at 7 M elbourn e Place.
W ith the start of dem olition on the site of the new R .M .S . building all the plans are at last beginning to take on an air of reality -who knows, per haps actual construction w ill have started be fore the next issue of " R es M ed ica " .

John
Livin g in a valley, lush and green, 4600-ft. above sea level, filled w ith paddy fields, sur rounded by terraced h ill slopes and dom inated by an inspiring backcloth of snow-capped H im alayas is a personal experience to be cher ished.
W o rkin g am ong a people, poor and poorer yet happy and cheerful, seeing textbook cases of gross, unattended pathology, tropical and " W estern " , is a m edical experience never to be forgotten.
T h e valley o f K a th m a n d u in N e p a l provides th e settin g.
U n til 1 9 5 1 , w h en th e K in g re gain ed co n tro l fro m the R a m a fa m ily , a h e rediitary lin e o f P rim e M in iste rs sin ce sin ce 18 4 6 , all N e p ale se b orders w ere closed to fo reign tra vellers.
T h e co u n try m ain tain ed a m ed iaeval life sty le w ith a m e d iaev al m ed ical care.
Since 19 5 1 the influx of foreign influence has been accelerating.
N o w Kathm andu is a popular tourist stop.
T h e people, however, are caught between the wealth and status of the visitors and their ancestral customs and poverty.
O w ing to the very rough terrain of the region and the poor com m unications w ith in the country, m ost areas outside the city still retain their original life-style and value system. It caters m ain ly fo r the N e p a li in h ab itan ts o f th e area b u t also exten d s its fo reign residents and tour ists.
C h a rity or cre d it con cessions are avail ab le to the p o o r w h ilst the rich an d foreign p atien ts are over-charged.
T h e hospital runs between the W estern and Eastern styles of m edicine.
T h e staff is inter national, providing wide scope in medical back ground and practice.
T h e nurses are m ainly N epali, efficient and elegant in their uniforms of white sarees.
T h e m ost im portant factor in the running of the hospital is finance -or lack of it.
Em phasis is always on out-patient care and admissions tend to be acute condi tions: there is little scope for the care o f the chronically ill.
T h e in-patients are cared for by their fam ilies who also help the nurses in their duties. D iagnostic investigations are lim ited so that clinical diagnosis is all the m ore vital.
B e in g a m ed ical stu d en t in such co n d itio n s PAL Parker allowed am ple opportunity for perform ing ward procedures, assisting in the operatingroom and even tackling m inor operations one self unsupervised.
N evertheless, w hat I found to be the m ost stim ulating was the necessity to improvise, com prom ise or reject.
So m any factors concerning the patient, the language, patient care and treatm ent available that are assumed in Britain, are altered so that it be comes essential to reassess their relevance. T o take a case history through two interpreters, auscultate the heart of a young girl who belie ves that baring h er breasts before marriage brings ill-luck in child-bearing, or a patient re fusing to have his haem oglobin estim ated be cause it is too expensive and he is too proud to accept charity, m ay seem ridiculous in Britain bu t arc com m only encountered in N epal. T o refuse admission to a person whose prognosis is hopeless m ay appear unethical, but to brand a hospital with too m any deaths would cause un lim ited harm.
T h e obvious advantage of " going E a st" to work the clerkship is to see gross pathology. Tuberculosis, leprosy, m alaria, elephantiasis, dysentery, tetanus and diphtheria, rarely seen in Edinburgh, were frequent in N epal. F u r thermore, " W estern " diseases such as heart disease, carcinomas, uneum onia, osteom yelitis, peptic ulcers and neurological disorders will usually present in advanced states whereas early diagnosis is stressed in Britain.
T h e m ost valuable lesson which I gained during m y visit to N epal was to appreciate the problem s and m ethods of setting up a m edical care system am ong a people totally ignorant in basic hygiene, in a nation where the m edical budget is 1/2 0 0 per m em ber of population of B ritain's.
T h e hospital becom es a capital ex penditure that cannot be afforded when pre ventive m edicine is im perative; the doctor is seen as an over-trained, easily frustrated and expensive m em ber of staff when emphasis is placed on economy.
No-matter-what, the opportunity of visiting a country where the priorities of m edical care are different, the relevance of every practice m ust be revised, the cost of every drug pre scribed m ust be justified and the satisfaction of treating diseases not previously encountered is so immense, should be missed b y no-one.

P. M. A. Calverley
It is with som e reluctance that I start another article, for another m agazine, about m y elective in India just over a year ago.
N o t that I feel any ingratitude to the R .M .S . who partly finan ced m y trip bu t m erely because I seem to have been talking about India, its culture, its m edi cine, its people and problem s, from the day I set foot again on the chalky soil of K e n t and I 'm beginning to feel a bit o f a fraud, rather like the A m erican who spends two weeks in E u ro pe and then starts to profess intim ate knowledge of its every nuance the m om ent he returns hom e.
A t the end of two m onths in India I had seen enough to realise that I 'd seen nothing yet.
M an y im pressions remain, of course, and I 'd like to focus on just two o f them .
O ne of the happiest is that of the wonderful hospita lity that we received.
T h e Indian people were,o n the whole, astonishingly friendly and h elpful despite the linguistic difficulties.
T h e latter were not as great as m ight be imagined as E nglish is w idely spoken am ong educated Indians, partly because it's a useful interna tional language, partly as a hang-over of 'our Indian E m p ire'. C ertainly at the N ew C ivil H ospital in A hm edabad, a post-war concrete structure with all the architectural grace of the S .M .M .P ., the m edical students were taught all their m edicine in English (despite their pre vious education in the G u jerati m edium ), and m uch of the professional practice was carried on in that tongue.
W h ilst less than satisfac tory for the budding G u jerati anatom ist, it was ideal for use as it opened all the necessary pro fessional and social laws.
W e stayed in the student hostels which were also sited on the same enormous cam pus and were quickly befriended by the other students who were anxious to m eet us and show us their city .
H ospitality is part of the Indian social tradition and at som e points, one alm ost felt a surfeit o f it.
C ertain ly two different sets of people showed us some of the same sites on two different occasions! T h e junior staff on our ward were also at pains to see us settled and one of the m edical internees soon became a good friend who took us to m eet his fam ily and to participate in the Indian festival of Rakshavon (pitiful phonetic spelling) when brothers and sisters exchange gifts.
T h e regi strars were equally friendly and when we start ed our journey hom e it was especially touching that three o f our special friends am ong them , along with my room-mate and friends, should turn up at the station at 1 1 o 'clock at night to see us off.
A s you m ight im agine w ith such a wide range of social contacts, som e of whom were non-medical, we were often invited out for meals.
H ow ever, I made the sad discovery quite early on that the only connection between V esta packed curry and Indian curry was the spelling of the word curry.
T h e people o f G u jerat like h ot foods and hence I once bit greedily into som ething I thought m ight be a Cornish pasty, only to discover it was a large green chilli pepper with a flaky pastry coat! Needless to say, it was not deem ed polite to deprecate the spiciness (or unpalatability) of on e's hosts' food and so bearing a fixed, slightly m aniacal grin I ate what I could.
It was only when someone showed signs o f offering me more from their own plate that I drew the line! T h e other thing about G ujerati food is that it's all veget arian and so to break the m onotom y we were taken out b y som e of our Indian friends to one of the city's posher meal-serving restaurants where we were treated to som ething that sounded, tasted and looked like " Chicken C ru cified " .
A fter that w e kept to scrambled cep for a while and certain less spicy Indian delicacies we grew. It was q uite an experience to live in an al m ost entirely Indian environm ent for 6 weeks and to see all sides of their city life from the cotton workers' 1 2-ft. x 4-ft. single room hom e for five people to the G overn or's select In de pendence D ay celebrations. A t times it was frustrating, often amusing and always challeng ing, but it was also m anageable because I had som eone from m y culture-society with me and because of all the kindness and consideration our hosts showed us. L oo kin g at the polyglot wards of the R oyal Infirm ary with their w illing post-graduates and exchange students, m any of whom m ust feel the same " culture-shock" in reverse, I wonder if we are anywhere near so friendly and what impressions of Edinburgh they w ill take back to their hom elands with them?
O f course, one noticed m any things which m ight be criticised as well as m any to praise. In the latter m ust com e Indian m edical edu cation (partly because it's one of the few things I feel able to criticise).
M u ch has been w rit ten about im m igrant doctors in this country, one of the best general reviews being found in Synapse, V o l. 2 1, N o . 1.
H aving seen m any such doctors in training their actions in Britain can be viewed a little m ore sym patheti cally.
M ed ical education in India resides in the 2 0 0 + m edical schools, som e of which receive G .M .C . recognition (but only a few), which are financed partly by the G overnm ent, partly by the fees their students pay.
Inevitably few of the population have sufficient funds to educate their offspring to the intermediate science level required before entry to medical school and, as with other aspects of Indian life, stories of corruption are rife regarding people who 'fixed' their admission.
O nce adm itted the ordeal has hardly begun for the student must now stop thinking and working in his native language and start to use English in stead.
H e m ust begin his 1 ½ years of work, with the emphasis on physiology and anatom y and a little biochem istry.
T h e standard anatom y book was G ra y 's and there were people who seemed to have read it cover to cover! (W ee C unn ingh am 's was used as a sort of hors d 'oeuvre for tlie " real A natom y" books).
O nce this chastening experience was passed successfully came the three clinical years tim etabled m uch as any British m edical school m ight have 20 years ago with large blocks of m edicine, surgery, social m edicine et al.
T h e students are taught by lectures and in groups of about 14 on the wards with little in the way of small group tuition.
T h e emphasis is on rote learning and the contrast between the 6year olds in the little school opposite, learning to read b y chanting the words to their teacher, and the m edical students doing much the same across the way, was not a great one.
T h e knowledge im parted was subject to regurgita tion in chunks and the emphasis was on know ing facts rather than knowing what to do with them. D espite these several difficulties m any of the students and teachers were very capable and managed to escape the confines this rigid system imposed.
Resits in at least some sub jects were assured for all but the best, each one involving 6 m onths repetition of the particular course.
T h e school record-holder for resits le ft just before we arrived, having taken 10 years to com plete his 4 ½ year course! T h e newly-qualified graduate, having com pleted his internship of 4 attachm ents in medicine, surgery, obstetrics and in the peripheral village hospitals each for 3 m onths, has then a career choice to make.
H e can set up in prac tice in the city which is very com petative; he can practise in the villages where he is needed but has few o f the com forts and distractions of the city where he trained; or he can continue in hospital and gain som e higher qualification in India and/or abroad.
T h e first two choices pose the same problem m any of us face but more acutely so for the Indian villages need doctors m ore than our " peripheral" towns and have fewer at present.
T h e last choice will lead the graduate to a training totally unsuited for the m edicine he w ill practise should he re turn hom e.
His hard-won skill in pneum o encephalography will atrophy through disuse and his intim ate knowledge o f fibrin degrad ation products w ill not be exploited to the full. A lternatively he m ay never return and instead choose to practise W estern m edicine in the W est, with little prospect of the prom otion he probably deserves, because as we all know " 90 % of registrars are Caucasian m ales" .
H is is not an enviable choice.
T h is is a deliberately harsh view of Indian m edical education but, I repeat, not of Indian doctors who despite all practise a remarkably high standard of m edicine considering. Per haps the difference between student and doc tor lies in the intern year when he is m ore than a student but still with less responsibility than a houseman.
T h e benefits that accrue from this form of learning should be recognised by the Indian G overnm ent and the traditional scheme revised.
W e too should (although B .M .S .A . are) agitate that the criteria for ad mission of overseas graduates be changed and that more realistic training be provided for them.
B u t perhaps we should attack our own beams before other peoples' motes, but then again that's another article.............. are not discussed but are occasionally m en tioned in relevant places.
It is unfortunate that this book is priced so highly for its size, a feature which w ill deter m any students from purchasing their own copy. N evertheless, an extrem ely inform ative little hook.
J . R. A.
Jamieson's Illustrations of Regional Anatomy, Sec tio n V II, Lower Limb: L ivingsone: £1. Revised by R obert W arm sley an d T. R. M u rp hy , 9th E d itio n.
In effect the new edition of these fam ous illustrations represents an attem pt to bring them into line with the reduced am ount of de tailed anatom y required to be learned by the m edical student of the seventies.
T h e content remains essentially unchanged. A ll the plates of the previous edition have been included except one, that of the Relations of the Transverse Tarsal Joint, an omission that will not be missed by m any students! T w o useful new plates have been added, a radio graph of the foot and one illustrating the der m atom es of the lower lim b.
U nfortunately, the illustrations themselves have been printed o n a poorer quality of paper than that of pre vious editions and they lack the same defini tion, clarity and pleasing colours of their pre decessors.
T h ere has been a reduction in the am ount of legend, which has the advantage of high lighting the m ore im portant structures, but the revisers have fallen into the prevalent m edical trap of excessive abbreviation.
T h u s, to take a florid exam ple, the Infrapatellar branch of the Saphenous N erve is slaughtered to Infrapat. br. saphen.n: this presentation of legend is irritat ing and constitutes the main criticism of the new edition.
W h ile undoubtedly these plates will con tinue to be widely pondered over by m edical students it is a pity to note changes in its re vision that cannot be said to be im provem ents. J.S .H .R.

Statistics in Small Doses. £2. A Livingstone M edical
Text. C h u rc h ill Livingstone. W . M. Castle.
T his book attem pts with little success to com bine program m ed learning with an infor mal approach.
Like all programm ed learning texts the question and answer ritual is fre quently repetitive and frustrating.
Answers are printed in the right hand colum n and a card is provided to cover the correct answer w hile the reader attem pts the questions.
T h e basic concept of building up the details of the subject gradually, com m encing with a description of num bers and m easurem ent, is laudable but explanations of the theory behind the form ulae used are seldom given.
As de scribed in the introduction, this allows the author to keep the length of the text to a mini m um but brevity seems to have been achieved at the expense of clarity.
B rief summ aries at the end of each chapter are helpful but m ight usefully have been extended.
T h e worked exam ples and num erous tests of progress are useful and are m edically-orientated.
Form ulae are repeated several times and the notation is clear.
On the whole this book provides a good guide to som e practical uses of statistics in m edicine but would require to be supplem ented with theoretical back ground for any basic understanding of the ele ments of the subject.
N . de P.
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