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ANNOTATIONS

A CLINICAL RESEARCH UNIT

A NEW departure in hospital practice is announcedfrom the Middlesex Hospital, where a gift of 15,000has been received from Mr. S. A. Courtauld to founda Clinical Research Unit. The unit will be under thedirection of the medical school council, and itsactivities will be directed to the intensive investigationof selected diseases. Mr. Courtauld’s generous anddiscriminating donation is the culmination of a

magnificent series of gifts to the hospital and school,which he has already endowed with laboratoryservices fitting the institution to serve as a basis ofthis original and important departure. The unit willconsist of small wards of 1 to 3 beds, in all 15 to20 beds, and will be provided with clinical lecturetheatre, test rooms, and offices, and be under thecontrol of the heads of the Bland-Sutton instituteof pathology, the Courtauld institute of biochemistryand the department of physiology, while the workthroughout is to be conducted in collaboration withmembers of the staff as they happen to be particularlyinterested in any diseases or conditions upon whichthe investigations are being concentrated. A closelink is thus forged between the hospital, the medicalschool, and the research laboratories, for the profes-sorial staff will have direct contact with and share

responsibility in the treatment of patients, the fruitsof laboratory work being thus carried promptly intothe wards. The relations between the clinical andacademic staffs of the hospital will be strengthened.The patients, moreover, being in the care of the unit,will have the advantage of prolonged stay undertreatment when it is found advisable ; they will notlose by the compulsion that must exist in generalwards to discharge patients at the earliest momentthat they can be moved, their beds being urgentlyrequired. In particular those who are not respondingto treatment will obtain the advantage of morespecialised observation. This association of themedical school in the control over beds in the hospital,sharing in the ultimate responsibility of the Boardfor the patients, is almost a revolutionary departure,but it is one under which advantage should accrueto the patients concerned, to the students of theschool, and, what is more important, to the develop-ment of medical science.

DIABETES IN CHILDREN

IT is still too soon to estimate the expectation oflife in diabetics treated with insulin from childhood ;but we can say at least that this disease has nowbecome compatible not only with life but with normaldevelopment, growth, and activity. E. P. Joslin 1

has pointed out that whereas in pre-insulin days anelderly diabetic lived about five times as long as adiabetic child, the balance is now weighed in the otherdirection. Untreated, these children are quicklyreduced to a state of cachexia and misery, and if theylive sufficiently long are stunted and infantile ; butwith insulin and under suitable conditions they canhold their own with contemporaries and have everychance of attaining maturity and parenthood. This

change in prognosis was considered in our columnson April 14th by Dr. R. D. Lawrence, and he showedthat the result depends largely on the care withwhich treatment is carried out. Fortunately, how-ever, habits are readily acquired by the young, and

1 New Eng. Jour. Med., 1933, ccix., 519.

although strict dieting is never altogether simple,there is usually less alcoholic and dietetic excess tounlearn in childhood than in later life, while therelatively high carbohydrate diets now in vogue makethe regime much less trying than formerly. Theactual injection of insulin becomes with many childrena routine which is hardly more irksome than cleaningthe teeth or evacuating the bowels, and the measure.ment and administration of the drug can be under-taken by most normally intelligent children over ten.For those to whom the insertion of the needle remainsa focal point of unhappiness, an ingenious automaticsyringe has recently been devised by H. Busher 2 : thesyringe, after’ being filled, is held under tension bya spring ; the apparatus is

" cocked," placed firmlyagainst the skin, and released by touching a trigger;and the injection is thus effected, it is said, with greatrapidity and a minimum of discomfort.

Granted ordinary care there remain various unavoid-able complications-infections are far the most

important-which may need special and efficienttreatment if they are not to end with the patient incoma. In preventing such disasters it is obviouslyuseful to have frequent blood-sugar and urinaryexaminations and trained assistance at the firstevidence of ill-health ; but Dr. Leslie Cole’s paper,completed in our present issue, shows that good resultscan be got even in comparatively poor homes in anagricultural district, where hospital visits are infre-quent and medical help is hard to come by. His casereports make very encouraging reading, since nearly allthe children are within the ordinary limits of height andweight, show no limitation of physical or mentalactivity, and have developed normally, although insome of the older girls there has been amenorrhcea orirregular menstruation. When these things are

possible under difficult conditions one cannot but feelthat the outlook for the child with diabetes is reallyhopeful, and look forward to the time when somethingcorresponding to insulin can be given without injection.

TRAUMATIC SHOCK

William Clowes in 1568 attributed the prostrationfollowing severe injury to the action of some noxioussubstance produced in the wounded area. A more

complete knowledge of the anatomy of the circula.tory and nervous systems led subsequent workersto seek an explanation in a derangement of one orboth of these systems, but references to a toxicagent appear at intervals in the writings of the lastfour hundred years, and the toxic theory of shockdid not reach its apogee until towards the end of thelate war. Cannon and Bayliss 3 produced a state oftraumatic shock in cats by subjecting one extremity toblows, when the blood pressure declined and in a briefspace they died. As cause of death haemorrhage couldbe excluded, for the weight of the damaged extremityshowed that the local fluid loss was comparativelytrivial. Section of the femoral and sciatic nervesor even of the spinal cord failed to prolong life,and it appeared, therefore, that a third factormust be concerned. It was known that injectionof histamine-a substance which can be preparedfrom most animal tissues-causes a fall in bloodpressure and death in the experimental animal,and Cannon and Bayliss came to the conclusionthat this substance or some such product was

2 Jour. Amer. Med. Assoc., April 7th, 1934, p. 1152.3 See THE LANCET, 1919, i., 256.