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nised in this country at present and it may have been sofor some time past. The investigation of an illness sohard to label is particularly arduous during a winter whenthe respiratory complications of influenza (described thisweek in an article by Dr. Grant and his colleagues onp. 449) are much in evidence.

PERINATAL MORTALITY

EVERY year in England, Scotland, and Wales about18,300 babies are stillborn and a further 11,500 die in thefirst week of life. This figure of 30,000 perinatal deathsdoes not improve much; and three years ago the NationalBirthday Trust Fund set up a committee to investigate.Valuable information could, their committee thought, beobtained from a nation-wide survey in which, over acertain period, every mother, midwife, and doctor con-cerned with a live birth or a perinatal death would takepart. A questionary was accordingly prepared (with dueregard to the fact that it will yield more accurate

information on social and administrative features than onclinical ones); and this was pruned, improved, and thentested in two pilot surveys-in Nottingham and in parts ofsouth-west England. The final version, as approved by thecommittee-which represents obstetricians, pxdiatricians,practitioners, statisticians, pathologists, public-healthofficers, Ministry representatives, midwives, and nurses-has been kept as short and simple as possible, but in-evitably it will mean extra work. This will fall especiallyon the midwives, who are asked to fill in the first part by" interviewing

" the mother, usually on the day of thebirth, and will fill in other details during the puerperium,with the help of doctors when necessary. Only by includ-ing social conditions, past obstetric history, bookingarrangements, antenatal care, methods of delivery, andthe circumstances and pathology of the perinatal deathscan a full picture be provided.A questionary will, it is hoped, be filled up for every

birth in England, Scotland, and Wales between March 3and March 9. During this period there are likely to beabout 13,500 live births and 500 perinatal deaths-thelatter being defined, for present purposes, as stillbirthsand deaths in the twenty-eight days following delivery.But to ascertain satisfactorily the features associated withperinatal death and to compare these features with thosefound in 13,500 survivors, 6000 cases are required.Accordingly, all perinatal deaths in March, April, andMay will be followed up by the questionary. Further-

more, it has been decided that for special histological andvirus studies 2000 postmortem examinations in cases of

perinatal death during March shall be conducted in

regional centres. The committee is grateful both to thosepathologists who have agreed to do this extra work andalso to those others who are handing on material thatmight have been interesting to themselves.

It says much for the organisation, and for the spirit ofcooperation in this matter, that nearly all authoritiescontacted-local health authorities, regional boards,teaching hospitals, pathologists, and coroners-have

agreed to join in the task. The fact that the inquiry is ona national scale does not mean that it takes the place of thevaluable local researches already in progress. But theaddition of fresh data from large numbers of people maymake it possible to see more clearly the directions mostlikely to lead to a reduction of perinatal mortality-areduction comparable, we may hope, to what has alreadybeen achieved in maternal mortality.

RESCUE FROM THE AIR

FEW of us bother to raise our eyes towards a passingplane, but the helicopter is still an attractive curiosity.Its unrealistic appearance, a clownlike element, a hintof flying saucers, may partly explain why we do not takehelicopters as seriously as we should. Outside the geniusof our aircraft industry and the Services, as an islandrace we seem quaintly slow to become airminded.On another page of this issue Flight-Lieutenant

Edwards describes some of the rescue techniques usedwith the Bristol Sycamore helicopter. This aircraftoffers much better opportunities for medical transportthan the earlier types, where it was not always possibleto stow the whole of the patient inside the cabin. (Itis not given to many of us to retain much peace of mindwhile slung in the slipstream.) Both the Royal Air Forceand the Royal Navy have built up a fine standard of

efficiency with their helicopters. Each year adds to theirroll of achievement in lifesaving and the relief of sufferingfor Servicemen and civilians alike. This valuable servicehas been developed in some areas to be an integral partof the local distress plan. For example, a North Walesnewspaper published an advertisement inviting the

general public to telephone R.A.F. Station Valley,Anglesey, for helicopter help in searching for lost children,evacuating ill people from difficult places, rescuingclimbers, swimmers, and shipwrecked sailors, and savingthose cut off by the rising tide. Ten minutes’ readiness,11/2-miles-per-minute flight to any scene within 35 miles’radius, cheerful acceptance of false alarms if the mistakeis genuine-that is Service indeed. No doubt similaroffers are made from R.N., R.A.F., and U.S.A.F. stationselsewhere.

Westland Dragonflies, Whirlwinds, and Widgeons andBristol Sycamores have pioneered aerial rescue workaround our British coasts. The American Forces havealso helped with their Service helicopters in various

emergencies-notably the wreck of the Goodwins light-ship. For high-altitude work in the Alps special patternshave been evolved, such as the Sikorsky models and theFrench turbo Alouette; and the use of both was illus-trated dramatically in the Mont Blanc tragedy a year ago.’

It would be unwise to be too starry-eyed about heli-copters. They have their limitations. Night flyingcan be tricky if not actually dangerous. The helicoptercan hedge-hop below the cloud base where conventionalaircraft would be useless, and in sea rescues the SARAHradio homing device on dinghies or Mae Wests helps topinpoint the casualty. But flying in winds over 45 knotsis difficult; and work in the mountains, apart from

problems arising from altitude rarification, introduces thehazards of vertical air currents and eddies. A lot dependson good ground-to-air communication. Helicoptersfitted with V.H.F. radio cannot talk direct to most ships.Some of the Royal National Lifeboat Institution crafthave been fitted with V.H.F. sets, but otherwise messagesmay have to pass along a chain of G.P.O. coast radiostations, coastguards, landlines, and flying-control stationswith chances of delay and distortion. Direct visualcommunication with Aldis lamps and the like is oftennot possible in civilian accidents. Some of the mostvital messages may be the minute-by-minute orders onthe spot. We seem to have a lot to learn. ;

1. Caernarvon and Denbigh Herald and North Wales Observer, Aug. 31, 1956.2. Paris Match, Jan. 12, 1957.

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We still tend to think of the helicopter finishing itsjob when the patient has been delivered to the waitingambulance on the shore or at the airfield. Surely weshould think much faster, and see that a helicopter land-ing-site is arranged alongside every major hospital.Various Cornish hospitals were reported to be doing this, 3

and no doubt there are others in the country besidesthose mentioned by Dr. Edwards. The time cannot befar off for a landing-ground to be a " must " for the self-respect of every management committee.Rescue by helicopter calls for knowledgeable coopera-

tion by the rescued; people need to know somethingabout the drill if they are to be prevented from choppingtheir heads off on tail rotors, falling out of strops, burningthemselves on exhausts, capsizing their sailing-boatunder the down-draught, and entangling the rescue cablein their backstays. Such avoidable misadventures notonly add to the difficulties of rescue but further imperilthe lives of the aircrew. There are notes for sailors 4 inareas where helicopters operate, but it seems that morewidespread guidance might help. Recent television

programmes have included helicopter mock rescues as

an entertainment feature, and there may be scope in thismedium for a more educational approach. We neverknow when we may be thankful for help from the skies.The Armed Services are the main source of helicopter

help in Britain, but many other countries have developedaerial aid by civilian enterprise. La Garde AerienneSuisse de Sauvetage (G.A.S.S.), set up in Zurich in 1952,is supported by voluntary effort.5 G.A.S.S. offers to helpin air accidents, avalanches, landslides, and floods, as

well as sailing and road accidents. It is essentially anauxiliary service to be called out by the normal rescueauthorities. It can provide planes, helicopters, and

parachute teams who are all trained volunteers. Blood-transfusion can be brought direct to the patient, andeven search dogs can be flown in. G.A.S.S. already has afine record of achievement, ranging from the simpleairlift of a seriously injured woodcutter between a remotehillside and hospital, within six minutes, to the evacuationof the victims from the tragic avalanches at Vorarlberg inAustria. The United States called on help from G.A.S.S.when two airliners collided in 1956 over the Grand

Canyon, falling in a most inaccessible place. Aerialrescue is assuming an increasingly important role in

many other countries. Soon it will be almost world-wide.

3. Times, Aug. 25, 1956.4. Notes for Yachtsmen: Sea Rescues by Helicopter. Ministry of Transport

and Civil Aviation. February, 1957.5. Rev. int. Croix-Rouge, 1957, 10, 5936. The Care of The Elderly Sick in General Practice. By W. F. ANDERSON.

Publication no. 9 of the Royal College of Physicians, 9, Queen Street,Edinburgh, 2. 1957.

CLINICAL GERIATRICS

THERE are probably no diseases peculiar to old age, butthe care of elderly people is associated with specialproblems, some of which have been reviewed by Ander-Son.6 For instance, in the aged, history-taking is liable tobe more difficult, and symptoms and signs less obvious,than in younger patients. A fractured femur may causeonly slight weakness in the affected limb after a fall;cardiac infarction may result in only a little breathlessnessor faintness; and acute appendicitis may lurk behindmild abdominal pain.Mental confusion is an alarming symptom which

usually precipitates a domestic crisis. Where the onsetis sudden it is often symptomatic of some acute physicaldisturbance such as pneumonia, urinary infection,

cardiac infarction, a cerebrovascular accident, or dehydra-tion. Sometimes it is due to a change of environment,and occasionally to drugs-especially bromides, hyoscine,and barbiturates. Nocturnal restlessness and wanderingare commonly due to reversal of sleep rhythm, and themore active an old person can be kept in the day time thebetter is his chance of a quiet night.Urinary and fxcal incontinence is a distressing problem

in the home and a common cause of admission to hos-

pital. Incontinence of urine is sometimes due to a

remediable local cause such as cystitis, prolapse, or

prostatism, and sometimes to a central cause such ascerebral thrombosis or an emotional upset. The polyuriaof diabetes and chronic nephritis may also cause incon-tinence. The trouble is always worse in patients con-fined to bed, and is sometimes cured by getting thepatient up. Fxcal incontinence is less common and more

distressing, but fortunately more remediable. It is oftendue to fxcal impaction, aggravated by apathy and bed-fastness. Impaction of faeces in the rectum is potentiallyfatal, and it is often unrecognised. It may present asrectal discomfort, as abdominal pain with vomiting, asfaecal incontinence, or as diarrhoea: constipation isseldom absolute. The diagnosis is readily made by rectalexamination; and repeated enemas, sometimes afterinitial manual removal, relieve the condition.

Hemiplegia due to cerebral thrombosis is one of thecommonest geriatric problems; but the extent to whichmost hemiplegics can be reabled needs to be more widelyknown. Early passive movement followed by bed-endexercises and walking between parallel bars or with awalking machine are the foundation of treatment. A

toe-spring or calliper with a heel-stop is a useful aid toprevent foot-drop. All this contributes to the main-tenance of activity, which is a fundamental principle ofgeriatric care. " The successful doctor and nurse of the

elderly are those who help their patients to die with theirboots on."7

DIAGNOSIS OF BRONCHIECTASIS

THE anatomical extent of bronchiectasis can be accur-ately assessed in life only by bronchography, and theusefulness of this investigation has increased with theintroduction in the past few years of new contrast mediathat are rapidly cleared from the lungs. Opinion is lessunanimous about the diagnostic value of a plain chestfilm. In 112 patients in whom the diagnosis was estab-lished bronchographically Gudbjerg 8 found that only7% had completely normal plain films. 31 % showedlobar collapse, unquestionably the most suggestive sign;43% showed honeycombing; and no less than 85%showed increased lung markings. This last figure mustbe treated with reserve because in the assessment ofincreased lung markings the subjective factor is immenselystrong, particularly when the observer knows beforehandthat the patient has proven bronchiectasis; but few willdispute Gudbjerg’s conclusion that a normal plain filmis on occasion compatible with severe bronchiectasis.

7. Rudd, T. N. The Nursing of the Elderly Sick; p. 15. London, 1953.8. Gudbjerg, C. E. Acta radiol., Stockh. 1957, suppl. 143.

THE INDEX and title-page to Vol. II, 1957, which wascompleted with THE LANCET of Dec. 28, is published with ourpresent issue. A copy will be sent gratis to subscribers onreceipt of a postcard addressed to the Manager of THE LANCET,7, Adam Street, Adelphi, W.C.2. Subscribers who have notalready indicated their desire to receive indexes regularly aspublished should do so now.