652 first infection was 98%, for second infections 75%, and for third infections 65%. These workers believe that the declining incidence of bronchiolitis with repeated infection owed something to age and something to immunity. There is no support to the contention6 that hypersensiti-


may be


in the




bronchiolitis-a notion which has been very much to the fore when the possibility of an R.s.v. vaccine has been discussed. Several centres are examining the relation of immune mechanisms to the clinical features of R.s.v. infection,7,8 and some observations in Rochester, N.Y., by Hall and others9 give useful information on neonatal victims. Symptomatic infection of neonates has rarely been recorded, and then only with mild symptoms.1o In their prospective study, Hall et al. found that 23 of 82 neonates (including some born prematurely), retained in hospital for 6 days or more, became infected-mainly, it is thought, via the nursery staff, of whom 18 out of 53 were infected during the outbreak. The infected babies were those with the shortest gestation time and lowest birth-weights. Two-thirds of them had a respiratory illness but the others had only non-specific signs

lethargy, irritability, or poor feeding. 1 had symptoms at all; 4 died and in 2 of them death was sudden and unexpected. The neonates shed virus for 3-22 days (mean 9) and the staff for 1-8 (mean 4) days-points to remember for infection control. Thus, contrary to what had been thought, neonates are readily infected but the infection may be so mild or so atypical as to be missed. The reason for this would be worth knowing. Is it due to persistence of maternal antibody, as the Chapel Hill group have suggested11-protecting from severe symptoms but not preventing infection? Or is the cell-mediated response more efficient in younger children?7 Or is the neonatal lung less hospitable to the virus on account of epithelial glycoproteins in the airways?12 Perhaps the severity of the disease is simply related to the amount of viral replication,9 which might be reduced by antibody acquired either across the placenta or from previous exposure. We are unlikely ever to see a vaccine suitable for such young children, perhaps we should be thinking of one for the woman of child-bearing age. As to the male oscuro of Naples, the remedy probably lies more in slum clearance and relief of social ills. - apnoea,


results: the degree of success is related to the which the fracture is reduced, particuwith accuracy as seen in the lateral radiograph, and failure may larly sometimes be due to weakness of the osteoporotic bone in an aged or rheumatoid patient, but the two main causes are non-union and avascular necrosis. Sepsis is not a major problem as it is with replacement. If these complications arise the treatment is then secondary replacement of the femoral head, necessitating a further

give good

operation. With primary prosthetic replacement all the above complications can be avoided. Fixation of the prosthesis in the medullary canal with acrylic cement allows early full weight-bearing without severe pain.2 The complications are postoperative dislocation, deep sepsis, and erosion of the acetabulum by the femoral head. Numerous workers have examined their cases retrospectively and drawn conclusions about the advantages of one or other method. Now a Norwegian group has done a prospective study which comes out in favour of primary prosthetic replacement. The postoperative mortality was similar in the two groups. Internal fixation proved to be a less time-consuming operation, gave a shorter time in hospital, and was associated with a significantly lower morbidity rate; no blood-transfusion was needed at operation. Primary prosthetic replacement was associated with earlier postoperative mobilisation, probably gave a more definitive treatment with fewer reoperations, and showed better results at one-year follow-up. Slavish adherence to one or other technique will lead to difficulties. Nor is some arbitrary age barrier a good basis for the decision on which method to use. In the younger patient, internal fixation is the treatment of choice and the femoral head should be preserved as far as possible. Prosthetic replacement in the younger patient is beset with the dire troubles of acetabular erosion. In a series of 354 patients, 22% in the age-range 60-69 had this complication.4 Where the metal femoral head is causing symptoms by boring into the acetabulum, total hip replacement is indicated. In the bed-ridden, demented, or incontinent patient, primary prosthetic replacement is not satisfactory because of the hazards of dislocation and deep sepsis. There is no simple formula for the successful management of the subcapital fracture.


SUBCAPITAL fractures of the neck of femur are seen almost daily in orthopaedic practice but there is still controversy as to the best method of treatment. The choice lies between internal fixation of the fracture and replacement of the femoral head with a prosthesis. Internal fixation was introduced in 1931 by Smith-Petersen, who used a tri-fin nail. Nowadays two cannulated screws are usually inserted. If it were uniformly successful this technique would obviously be preferable to a replacement operation. Unfortunately, pinning does not always 6. Gardner, P. S., et al. Br. med. J. 1970,1, 327. 7. Scott, R., et al. J. infect. Dis. 1978, 137, 810. 8. McIntosh, K., et al. ibid. 1978, 138, 24. 9. Hall, C. B., et al, New Engl. J. Med. 1979, 300, 393. 10. Nelligan, G. A., et al. Br. med. J. 1970, iii, 146. 11. Glezen, W. P., et al. Pediat. Res. 1978, 12, 492. 12. Reid, L. Pediat Res. 1977, 11, 210.

THE incidence of marital breakdown continues to rise. The divorced state is associated with high mortality and probably increased morbidity. Equally worrying, though less obvious, is the morbidity associated with intact but unhappy marriages. The part that such marriages play in the development of depression in women has been demonstrated by Brown and others,S and the association between parasuicide and marital conflict is Nobody has yet proved it, but many of the physical and psychological problems that present to the general prac-


1. Garden, R S. Injury, 1977, 9, 5. 2. Attenborough, C. G., Geriatric Orthopædics

(edited by M. Devas); p 119. London,1977. 3. Soreide, O., Molster, A., Rangsted, S. Br. J. Surg. 1979, 66, 56. 4. D’Arcy, J., Devas, M. J. Bone Jt Surg 1976, 58B, 219. 5. Brown, G. W., Bhrolcham, M. N., Harris, T. Sociology, 1975, 9, 225. 6. Bancroft, J., Skrimshire, A., Casson, J., Harvard-Watts, O., Reynolds, F Psychol. Med. 1977, 7, 289.

653 titioner may be

actually caused by long-term effects on problem of major social imporif not all this the


marital problems. Add children, and we have

to a


Methods of marital counselling therefore deserve careful scrutiny. How can we reduce this weight of unhappiness ? Marriage-guidance counsellors have been striving in this direction for many years, and now health professionals are increasingly involved. Methods of helping married couples have, however, received very little careful evaluation. A study by Crowe’ is therefore to be welcomed. He compared a "directive" or behavioural approach with an "interpretive" method, and added a third "supportive" regimen which avoided both advice and interpretation and aimed simply at encouraging discussion between the couple. This was seen as a control for some of the less specific factors in marital therapy. He found that both the directive and interpretive methods were

superior to the supportive, and on several measures the directive approach was more successful than the interpretive. The numbers were small (14 in each group) and the observed differences were of modest extent. Almost all the counselling was done by Dr Crowe himself. There are three kinds of reaction to such a study. First, some people will reject the findings as too inconclusive, the numbers too small, the results at best revealing Crowe’s treatment aptitudes or preferences. A more extreme version might be to reject such research altogether on the grounds that results always will be inconclusive and that clinical judgment is of more value. The second reaction, by contrast, will be to see the study as as conclusive, demonstrating that interpretive methods of marital therapy have no place and that no further evidence on such a question is necessary. The third, which needless to say is more reasonable, is to see these results as a small but useful contribution to our body of knowledge. Properly controlled outcome research with any kind of psychological treatment or counselling is difficult to achieve except with small numbers. A series of such studies is therefore required, each one attempting to replicate important findings as well as to test out interesting possibilities that have emerged from previous studies. The number of such studies of marital counselling so far is very small but Crowe’s findings were strengthened by their consistency with those previously reported. It is to be hoped that other studies will soon follow. The controversy over the relative merits of behavioural or directive and non-directive methods of counselling or psychotherapy goes deep. Perhaps it is a divisive issue not on pragmatic grounds but because it reflects fundamental differences in either personality or cognitive style of the counsellors and psychotherapists themselves. Some therapists only feel comfortable if there is a clearly defined structure to their therapy; the directive methods suit them well. Others feel uncomfortable with such structure and prefer to avoid the constraints that it imposes. Crowe’s findings that directive methods are modestly superior to interpretive forms, do not answer the question whether the best choice depends more on the characteristics of the therapist. Patients likewise vary, and there are some who feel more comfor7. Crowe, M. J. ibid 1978,8,623.

table with one type of approach than with the other. One of the suggestions from Crowe’s results is therefore of particular interest. Couples with lower educational status apparently did better with the behavioural approach and the drop-out rate was higher with the interpretive method. One of the main shortcomings of interpretive methods of psychotherapy has been their relative unsuitability for the less intelligent. It may well be that for most of the population, counselling methods which are practical and depend on "doing" rather than "understanding" things are going to be more acceptable and hence more effective. These are all questions that demand further research. There is however a dilemma; carefully controlled treatment research requires structure and therefore is more acceptable to the directive therapist than to the interpretive. This accounts for the fact that most such research is done by behaviourally oriented workers. But the reluctant researcher of either camp might bear in mind that whereas the gains that can be shared from such a study do depend on the quality of the design and method, there are many other lessons for the researcher himself to learn from the experience. Treatment research is a powerful method of acquiring valuable clinical experience. OMISSION OF CLASSIFIED N.H.S. ADVERTISEMENTS FROM THE LANCET The Lancet is among those publications affected by a dispute between T. Bailey Forman Limited, Nottingham, owner of the Nottingham Evening Post, and two printing unions, the National Graphical Association and the Society of Lithographic Artists, Designers, Engravers and Process Workers. This longstanding dispute is attributed by the N.G.A. to T. Bailey Forman’s "anti-union activities and refusal to give recognition to the printing trade unions". On March 6 the N.G.A. wrote to all its branches instructing members not to handle any advertisements or advertising material from 16 firms and organisations who had not complied with the N.G.A.’s request that they withdraw advertising from all publications of Forman-Hardy Holdings Ltd. The Nottinghamshire Area Health Authority (Teaching) was among those named and consequently four advertisements from this Authority were removed from last week’s Lancet and replaced by a sentence of explanation, which did not, however, mention Nottinghamshire A.H.A. (T). Last week’s British Medical Journal was not subjected to any changes. Five advertisements from the same Authority were due to appear in this week’s Lancet and we understand that they will not be included, though on this occasion the empty spaces will be occupied by a statement which identifies the advertiser. Individual subscribers in the United Kingdom should receive with this Lancet a typescript note giving brief details of the posts offered. On p. 626 last week The Lancet wished to publish a news paragraph about the dispute and the vacant Nottinghamshire posts, but this too was missing when the journal appeared. We hope that we are now to be permitted to give this explanation to readers. In an attempt to overcome the restriction on advertisements a number of national newspaper groups have brought an action against the unions. The hearing of this action was due to be resumed on March 20.

Marital therapy.

652 first infection was 98%, for second infections 75%, and for third infections 65%. These workers believe that the declining incidence of bronchioli...
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