1377

the sooner it could be cooled the better. Mr. R. Y. Calne

reported excellent technical results from Westminster

Hospital, London, and thought that better methods ofselecting donors and recipients and of immunosuppressionwould give a still better chance of survival. The intro-duction of radioactive gold into the mesenteric lymph-nodes was promising. Dr. K. Reemtsma, of Tulane,Louisiana, had transplanted chimpanzee kidneys to man.The first 3 patients survived for nine weeks, seven weeks,and nine months; 3 others died from too much immuno-suppression, and 4 from too little. Blood matching was aserious problem.As regards the liver, Dr. Starzl had performed 6 cada-

veric transplants in man. The longest survival was

twenty-three days. He found considerable technical diffi-culty in removing the large diseased liver, and also prob-lems of blood coagulation. He had, however, performed84 hepatic transplants in dogs, and about a third livedlonger than fifty days. Rejection reactions about thefortieth day were often severe, with deep jaundice andhigh serum-transaminase values; these tended to returnto normal. The best results were in dogs which had norejection reaction, and in which immunocompatibilitywas presumably good. Immunosuppressant therapy couldsometimes be stopped in these animals.

WOMEN IN MEDICAL TRAINING

FOR a woman to take up medicine is coming to beregarded as almost unethical. The country needs doctorsand, more often than not, pays for their training. And, sothe argument runs, medical women are no longer dedi-cated to their career. They are given to marrying, andthen they abandon their studies or their practice. Their

skills, so expensively acquired, go to waste. This type ofgeneralisation need not be based on fact to be accepted astrue. Apparently, however, Dr. Gauvain and her asso-ciates (p. 1381) have more curiosity than faith. They havebeen moved to discover what has indeed been happeningto the women in medicine and whether their contributionto the profession has been as frivolous in fact as in repute.The paper we publish this week compares the per-

formances of men and women in training. Comparativeanalysis of their subsequent careers is to follow. Itturned out that women are roughly as likely as men to beaccepted for medical training, to complete their course,and to register after qualifying. If women medicalstudents are involved in the general trend towards earliermarriage and child-bearing, this is not apparently affect-ing their progress through the schools. Of the sample of70, only 4 had abandoned their studies for specificallymatrimonial or maternal reasons. Rather more surprisingwas the considerable number of men who, three yearsafter qualifying, were not registered. In the London

schools, for instance, 9-8% of the sample was still un-

registered. This is an apparent wastage that cannot beattributed to marriage. Neither can that-put at 10-15%-which each year’s intake of students is likely to sufferbefore the course is complete.’ At least 1 student in 10,that is, is wasting his own time and the public’s money.This Dr. Gauvain and her colleagues find cause for con-cern. Unsuitability and failure in examinations were thecommonest reasons given for abandoning training; butmore than that must be known if the accuracy of studentselection is to be improved.The half-made doctor is expensive-but not neces-

1. See Lancet, May 15, 1965, p. 1053.

sarily female. The production of women medical gradu-ates seems to present no particular difficulty. To findsensible ways of employing them once they marry istherefore both necessary and important.

CHEST INJURIES

THE translation of speculation and experiment into

dogma is not always to be deplored: it may sometimes besalutary. The practising doctor, for instance, welcomes astep-by-step, tried-and-tested programme of managinga given disorder, particularly when the disorder presentsas an emergency. In this respect at least, some of themedical dividends drawn from the experience of the latewar represent not so much dogma, in the pejorative sense,as capital gains. Trial and error in the management of warburns have in the end provided a reasonably clearcutmethod of handling civilian burns. Equally, the surgicalexperience of chest wounds in war-time can now be saidto have established an almost universally accepted set ofdogmatic principles in the successful treatment of civilianchest injuries.

Prof. A. L. d’Abreu 1 has set out these governingprinciples admirably. The patients, he points out, arenot fit young soldiers: they include persons of all agesand the chest injuries are often combined with abdominal,limb, and head injuries. At an early stage, injuries

- to the lungs and the heart may easily be obscured by moreobvious lesions and be overlooked: yet, whatever the other

injuries, respiratory failure is likely to be the final killingfactor. Carbon-dioxide retention, due to inadequateventilation of the lungs, may maintain or even raise thepatient’s blood-pressure temporarily. If, in addition,oxygen is being given, the combination of a good colourand a relatively undisturbed blood-pressure may mask theinsidious onset of failure of the respiratory centre. Again,in the presence of a head injury, mental confusion

(heralding coma) may be ascribed to the cerebral ratherthan the respiratory lesion. Multiple fractures of the ribs(sometimes accompanied by fracture of the sternum) arethe cause of most of the chest injuries seen in civilianpractice. They are largely the result of road accidents.Injury to the lung may result in an open or closed (tension)pneumothorax or (commonly) a haemothorax. A gravercomplication, paradoxical chest-wall movements, ariseswhen the fracture of a number of ribs at more than one

point leaves a part of the thoracic cage floating free-theflail-chest. The exact anatomical character of the injury,however, is relatively unimportant. What is importantis the effect of compression of the lung or heart by fluid orair, airway obstruction from mucous retention in thebronchi, and the disorganised movements of the chestwall. Arterial undersaturation and carbon-dioxideretention-manifested clinically by dyspnoea, mental

confusion, and cyanosis-are the pressing considerationsin chest injuries. Cardiac and respiratory function mustbe restored by adequate blood-transfusion, the establish-ment of a clear airway by tracheal suction of bronchialsecretions, oxygen therapy, and the removal of compressingblood or air from the pleural cavity.d’Abreu reminds us that the dangers of over-trans-

fusion of blood in pulmonary disease have been unneces-sarily emphasised in the past: there is a tendency to under-transfuse the chest casualty, who often loses a lot of blood.An intratracheal tube left in longer than six hours courtsinfection of the tracheo-bronchial tree: it must be regarded

1. d’Abreu, A. L. J. Bone Jt Surg. 1965, 46B, 581.