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consists of murder and robbery, or of more respectableoffences like income-tax evasion, use of electric currentduring prohibited hours, or driving too fast in built-upareas. What he did not mention at all was the contri-bution of society itself to crime. Crime is correctlydefined as an infraction of law ; we are only just beginningto realise that both the law and the infraction may be

symptoms of a collective character disorder for whichwe are collectively responsible. Our collective short-comings are partly responsible for the present tangle ofrestrictive regulations with their infinite number of newoffences ; they have also, by binding upon the weakerbrethren burdens they are unable to bear, made inevitablemuch of the crime which is now beginning to cause usdiscomfort and anxiety. The problem of crime, while itcertainly calls for examination of the offender and hiscircumstances, calls even more loudly for an examinationof the social order against which he offends.

THE MULTIPLICATION OF COAGULATIONFACTORS

THE orthodox faith of blood coagulation, based onthe four agents, thromboplastin, prothrombin, calcium,and fibrinogen, has been able to survive repeated anddetermined heretical attacks because it offers the simplestexplanation of those facts with which the average physio-logist is familiar. It is now becoming clear, however,that only as a framework can it continue to exist. Despitethe notorious difficulty of obtaining reproducible resultsin this field of research it is apparent to even the mostconservative that modern findings require a considerableelaboration of the old theory, or a new theory altogether.So far the tendency is to try to fit new facts into the oldframework, though to some it may seem that the resultingstructure is becoming a little unstable. The additionsare in the form of " new factors." Some of these are

thought to oppose the action of the accepted clottingmechanism, as, for instance, the antithromboplastindescribed by Tocantins,’- which he considers to be presentin excess in haemophilia, and a similar, possibly identical,inhibitor studied by Feissly.2 On the other side of thebalance a number of agents have been added by therecognition of the complex nature of factors previouslystated to be simple. Thromboplastin is thought toconsist of an enzyme (kinase) and a co-factor of lipoidalnature related to cephalin or lecithin.3 -Kinase itself isprobably derived from an inactive precursor in the plasma,

. studied under the name of " plasmakinen "

by Laki.4Several workers have come -to the conclusion that

prothrombin is a complex of at least two components,5and even fibrinogen has not preserved its undividedidentity. -

Now, distinct from these fission products of the oldclotting factors, come the new "factors v and vi "described by Owren in our columns last week. Theevidence that he puts forward must be accepted as beingstrongly in favour of the existence in normal plasma of anaccessory to thromboplastin and calcium essential to theirproper action on prothrombin. In his present communi-cation the evidence for " factor VI" is less convincing,but will no doubt be presented in full later.The existence of an additional factor of the type postu-

lated by Owren had already been suggested by the workof Fantl and Nance s in which they found that, whilehighly purified preparations of prothrombin could beonly slowly converted to thrombin by thromboplastin1. Tocantins, L. M. Amer. J. Physiol. 1943, 139, 265.2. Feissly, R. Helv. med. Acta, 1944, 11, 177.3. Loathes, J. B., Mellanby, J. J. Physiol. 1939, 96, 38P ;

Macfarlane, R. G., Trevan, J. W., Attwood, A. M. P. Ibid,1941, 99, 7P.

4. Laki, K. Studies from the Institute of Medical Chemistry,University Szeged, 1943, vol. III, p.5.

5. Quick, A. J. Amer. J. Physiol. 1943, 140, 212 ; Nolf, P. Arch.int. Pharmacodyn. 1945, 70, 5; Feissly, R. Schweiz. med.Wschr. 1945, 75, 696.

6. Fantl, P., Nance, M. Nature, Lond. 1946, 158, 708.

and calcium, the addition of prothrombin-free plasmaresulted in a great acceleration of the reaction. Whether,as seems likely, these findings can be explained on thesame basis as those of Owren only future work candetermine. In any event a fresh impetus to research onblood coagulation has been given by Owren’s observa-tions, and, as always, a new discovery may haveunexpectedly wide and exciting results. The case offactor V deficiency he describes is obviously an example ofan extremely rare condition, but its intelligent investiga-tion has shown once again how important human materialcan be to the experimentalist, a fact often ignored inacademic circles. It provides, too, still another example ofhow increasing knowledge appears to reveal an almostinfinite complexity underlying even the simplest biologicalprocess. -

And yet, in this particular instance of blood coagulation,the intricacy seems almost too lavish. Do all thesefactors, whose number now runs into double figures,really exist in the blood for the express purpose of

controlling the occasional conversion of fibrinogen tofibrin, or do they, under other names, take part in otherand more continuous metabolic processes ’? Or is it,perhaps, that one’s dissection of the dynamic wholecreates a series of static artefacts ’?

DOCTOR DEMAND IN A HEALTH SERVICE

WHEN everyone can get medical advice withoutpaying directly for it, what increase may we expect inthe demand for doctors’ aid ? Sound planning for a newhealth service requires some estimate of the amountof professional attention people will want ; and this

problem has been studied in Canada, now also engagedon tentative plans for universal State-aided medicalcare.

Although it would be unwise to apply generally tothis country the experience of a particular town inEastern Canada, yet the results of a morbidity surveymade some time ago by Richter in two Nova Scotiancommunities are certainly relevant. This survey covereda year’s record of the services given by the local doctorsin Glace Bay, a typical mining town, and Yarmouth, anon-industrial town in the same area. There weredifferences in the age-sex composition, and the economicand industrial background of the populations, but themost important difference was in the method of

providing for medical care. In the mining town a contri-butory insurance scheme assures treatment by generalpractitioners, hospital care, operations, drugs, and

dressings for each worker and his dependants. In therather more amuent Yarmouth the fee-per-servicesystem operates, the usual charges being$2 (lOs.) fora surgery consultation and$3 (15s.) for a visit. Thecontributory scheme had been in operation in GlaceBay for about 80 years, and the level of demand hadbecome stabilised. Records were kept of the numberof professional services rendered by the practitionersin each town to all members of the communities duringthe 12 months of the survey, and comparisons betweenthe incidence-rates of treated illnesses were then made. "

Clearly such comparisons were complicated by the

occupational, economic, and demographic differences ofthe two populations, but some of the results which wererelatively unaffected by these difficulties are significant.

In both communities two-thirds of the services weregiven to the workers’ dependants, but an importantdifference was revealed : under the insurance schemethe larger families-with eight or more members-had twice as much medical care as families of the samesize had under the fee-for-service regime. It appearsthen that, when assured provision is- absent, the larger1. Richter, L. The Effect of Health Insurance on the Demand

for Health Services. Canad. J. Econ. polit, Sci. May, 1944,p. 179.

491

families get less than their share of medical service.Further results also indicate that where economies haveto be made the children suffer most because of thefinancial loss entailed by continued sickness in bread-winner or mother. Generally, the " treated illness "rates at all ages were appreciably higher among theinsured population ; presumably this does not necessarilyreflect any real difference in the incidence of disease butrather an increased readiness to seek a doctor’s advice.A cynic might attribute this alacrity to a very humandesire to get one’s money’s worth for one’s contribution,but there may be a widespread belief that promptattention to minor ailments is a preventive of seriousdisability. Under the insurance scheme common colds,tonsillitis, minor injuries, and digestive upsets are muchmore often treated by doctors than under the othersystem. There are differences, too, in the character ofthe services provided ; for the insured patients theirdoctors made more home visits and dispensed twiceas many drugs and four times the number of dressingsprescribed by their counterparts in the other town.Home visits, which are more expensive under a fee-for-service system, were much more frequently made to sickchildren in the mining town.From all this, those charged with the provision of

medical man-power and supplies for our new healthservice may reasonably infer that the removal of economicrestraint may entail a rise of perhaps 50% in the demandfor professional attention. For the general practitioners,whose numbers cannot increase in step with this demand,this will mean even heavier calls upon their time and

patience-a consideration which might be taken intoaccount in the forthcoming negotiations. Against this,of course, must be set the possibility that readier accessto the doctor’s care for apparently trivial illness may givefresh scope for the prevention of more serious develop-ments. The balance between sound.preventive medicineand merely harassed overwork is very finely set, andmuch will depend both on the technical and clinicalassistance made available and on the good sense ofthe public.

CONTINUOUS PENICILLIN APPARATUS

THE discomfort of repeated intramuscular injectionsin the administration of penicillin has stimulated manyingenious minds to contrive apparatus which willmaintain a continuous and accurate dosage in smallbulk. Most of these depended on hydrostatic principlesand were constructed essentially of a calibrated glasstube connected to the injection needle by a necessarilylong length of rubber tubing. Unfortunately, however,penicillin may deteriorate on protracted contact withrubber, and such bedside apparatus is in any case easilyoverset and very temperamental. Attention has thereforeturned towards mechanical devices. Professor Fleming’steam adapted a clock, deprived of its hands, to drive downthe plunger of a syringe, but rubber tubing was still usedto connect-the syringe to the patient. In this issue MajorBowie and Captain Borcar describe the Secunderabadapparatus, which has the precision workshop of R.E.M.E.behind it. Rubber tubing is eliminated by strapping thesyringe to the patient’s thigh at the site of injection,using a flexible speedometer-cable to connect the pistonmechanism with an electric motor. A rather similarapparatus, designed by Dieh and Jensen, was described 1by P. J. Dragsted, of Copenhagen, to the Danish Societyof - Internal Medicine in April, 1946; The Danish

apparatus is self-contained and driven by elockwork,so that the patient can’ move about -freely withoutdisconnecting the apparatus ; the clockwork is silent andruns without attention-for 24 hours. The’same technicaldifficulties have occurred to both inventors. Howeverwell the syringe plunger seems to fit the barrel there is

1. Nord, Med. Jan, 31, p. 288.

a tendency for it to leak under continuous pressure.Dragsted advises lubrication with liquid paraffin, while theSecunderabad apparatus is fitted with a plunger of" resilient material " which can be expanded by a

tightening device. Another common problem has beento allow for some movement of the intramuscular needleon the fixed syringe. Although this is not shown in theirdiagram, the Danes say that a short rubber connexionmay if necessary be inserted between the nozzle and theneedle. In the Secunderabad apparatus an ingeniousspring-coiled needle solves this problem but raises others ofcleaning and replacement. The syringe appears to be easilyremoved for recharging in the Danish model, so avoidingthe complexity of a’three-way tap and recharging syringe.While clinicians continue to think it important to keep

blood-penicillin levels constant there is likely to be ademand for apparatus such as these. If accuracy, easeof maintenance, and simplicity in operation are thecriteria, the published descriptions suggest that the Dich-Jensen has some slight advantages over the Secunderabad.

INDUCED VITAMIN DEFICIENCIES

THE investigator who wants to study specific vitamindeficiencies in human subjects finds his material hardto come by. Natural deficiencies are almost alwaysmultiple, and the grosser ones usually arise in remoteplaces, such as prisoner-of-war camps, enemy-occupiedcountries, or the less-frequented parts of the tropics.When his work seems of national importance he may beallotted volunteers-Servicemen or conscientious objec-tors, perhaps-but otherwise he must rely on himself,his colleagues, or his students, none of whom will relishdeprivations extending over years. The late war wasremarkable for the painstaking studies made among(and by) prisoners-of-war in the Far East; but thereagain the deficiencies were multiple and uncontrolledby the investigators. ,

In the United States Horwitt and colleagues, workingfor the National Research Council, have studied inducedvitamin deficiencies in the inmates of a mental hospitalover 21/2 years. One group of patients were subjected toa mild chronic thiamine plus riboflavine deficiency overthe whole period, and in a second group a more acutedeficiency was induced. An obvious drawback to theexperiment was that these patients could not be guaran-teed to have a normal vitamin metabolism-presumablymany of them were schizophrenics, whose metabolismin many fields is grossly deranged. The 36 male patientsstudied fell into two age-groups of 58-78 and 24-42 years.Each age-group was divided into three classes, A, B, andC, so that each class, consisted of 7 old and 5 youngerpatients. Class A received a daily diet’ containing2200 calories and- sufficient vitamins except thiamine(400 .g.) and riboflavine (900 {ig.). Class B had the samediet with 6 mg. of thiamine and 1-3 mg. of- riboflavineadded. Class C were the-controls, on the usual’hospitaldiet. The clinical effect of the diet in class A was at notime more than minimal. There was some dulling ofinterest and restriction of activity, but psychologicaltests were satisfactorily performed. The skin of some ofthe youriger subjects became thinner, making them-lookolder than they were, and some drying, thinning, andwrinkling or the lips was noted. Within nine months fromthe beginning of the deficient diet, an abnormally highlevel of lactic and pyruvic acid was found in the bloodin response to a standard exercise after ingestion of astandard amount of glucose. Tliis almorj:na1ity persisted.throughout the experiment. --

.. ’ .’..’"",

At the beginning of the tliird- y6Lr’6f . the experimentclass B were given, a daily diet coutairiing only 200g."ofthiamine and 8UO tig. of riboflavizie. Within three monthstheir levels of blood lactic and pyruvic acids after the1. Horwitt, M. K., Liebert. E,, Kreisler, O., Wittman, P. Science,

1946, 104, 407,