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first infection was 98%, for second infections 75%, andfor third infections 65%. These workers believe that thedeclining incidence of bronchiolitis with repeated infec-tion owed something to age and something to immunity.There is no support to the contention6 that hypersensiti-vity may be important in the pathogenesis of R.s.v.bronchiolitis-a notion which has been very much tothe fore when the possibility of an R.s.v. vaccine hasbeen discussed.

Several centres are examining the relation of immunemechanisms to the clinical features of R.s.v. infection,7,8and some observations in Rochester, N.Y., by Hall andothers9 give useful information on neonatal victims.

Symptomatic infection of neonates has rarely been

recorded, and then only with mild symptoms.1o In theirprospective study, Hall et al. found that 23 of 82neonates (including some born prematurely), retained inhospital for 6 days or more, became infected-mainly,it is thought, via the nursery staff, of whom 18 out of53 were infected during the outbreak. The infectedbabies were those with the shortest gestation time andlowest birth-weights. Two-thirds of them had a respira-tory illness but the others had only non-specific signs- apnoea, lethargy, irritability, or poor feeding. 1 hadno symptoms at all; 4 died and in 2 of them death wassudden and unexpected. The neonates shed virus for3-22 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 readilyinfected but the infection may be so mild or so atypicalas 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-protectingfrom severe symptoms but not preventing infection? Oris the cell-mediated response more efficient in youngerchildren?7 Or is the neonatal lung less hospitable to thevirus on account of epithelial glycoproteins in the air-ways?12 Perhaps the severity of the disease is simplyrelated to the amount of viral replication,9 which mightbe reduced by antibody acquired either across the

placenta or from previous exposure. We are unlikelyever to see a vaccine suitable for such young children,perhaps we should be thinking of one for the woman ofchild-bearing age. As to the male oscuro of Naples, theremedy probably lies more in slum clearance and reliefof social ills.

PIN OR PROSTHESIS?

SUBCAPITAL fractures of the neck of femur are seenalmost daily in orthopaedic practice but there is still con-troversy as to the best method of treatment. The choicelies between internal fixation of the fracture and replace-ment of the femoral head with a prosthesis. Internal fix-ation was introduced in 1931 by Smith-Petersen, whoused a tri-fin nail. Nowadays two cannulated screws areusually inserted. If it were uniformly successful this

technique would obviously be preferable to a replace-ment 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.

give good results: the degree of success is related to theaccuracy with which the fracture is reduced, particu-larly as seen in the lateral radiograph, and failure maysometimes be due to weakness of the osteoporotic bonein an aged or rheumatoid patient, but the two maincauses are non-union and avascular necrosis. Sepsis isnot a major problem as it is with replacement. If thesecomplications arise the treatment is then secondary re-placement of the femoral head, necessitating a furtheroperation.

With primary prosthetic replacement all the above

complications can be avoided. Fixation of the prosthesisin the medullary canal with acrylic cement allows earlyfull weight-bearing without severe pain.2 The complica-tions are postoperative dislocation, deep sepsis, and ero-sion of the acetabulum by the femoral head. Numerousworkers have examined their cases retrospectively anddrawn conclusions about the advantages of one or othermethod. Now a Norwegian group has done a prospectivestudy which comes out in favour of primary prostheticreplacement. The postoperative mortality was similarin the two groups. Internal fixation proved to be a lesstime-consuming operation, gave a shorter time in hospi-tal, and was associated with a significantly lower mor-bidity rate; no blood-transfusion was needed at oper-ation. Primary prosthetic replacement was associatedwith earlier postoperative mobilisation, probably gave amore definitive treatment with fewer reoperations, andshowed better results at one-year follow-up.

Slavish adherence to one or other technique will leadto difficulties. Nor is some arbitrary age barrier a goodbasis for the decision on which method to use. In the

younger patient, internal fixation is the treatment ofchoice and the femoral head should be preserved as faras possible. Prosthetic replacement in the younger pa-tient is beset with the dire troubles of acetabular erosion.In a series of 354 patients, 22% in the age-range 60-69had this complication.4 Where the metal femoral head iscausing symptoms by boring into the acetabulum, totalhip replacement is indicated. In the bed-ridden,demented, or incontinent patient, primary prosthetic re-placement is not satisfactory because of the hazards ofdislocation and deep sepsis. There is no simple formulafor the successful management of the subcapital frac-ture.

MARITAL THERAPY

THE incidence of marital breakdown continues to rise.The divorced state is associated with high mortality andprobably increased morbidity. Equally worrying, thoughless obvious, is the morbidity associated with intact butunhappy marriages. The part that such marriages playin the development of depression in women has beendemonstrated by Brown and others,S and the associationbetween parasuicide and marital conflict is striking.6Nobody has yet proved it, but many of the physical andpsychological 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.

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titioner may be aggravated if not actually caused bymarital problems. Add to all this the long-term effects onchildren, and we have a problem of major social impor-tance.

Methods of marital counselling therefore deservecareful scrutiny. How can we reduce this weight of un-happiness ? Marriage-guidance counsellors have been

striving in this direction for many years, and now healthprofessionals are increasingly involved. Methods of help-ing married couples have, however, received very littlecareful evaluation. A study by Crowe’ is therefore to bewelcomed.He compared a "directive" or behavioural approach

with an "interpretive" method, and added a third "sup-portive" regimen which avoided both advice and inter-pretation and aimed simply at encouraging discussionbetween the couple. This was seen as a control for someof the less specific factors in marital therapy. He foundthat both the directive and interpretive methods weresuperior to the supportive, and on several measures thedirective approach was more successful than the inter-pretive. The numbers were small (14 in each group) andthe observed differences were of modest extent. Almostall 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 incon-clusive, the numbers too small, the results at best reveal-ing Crowe’s treatment aptitudes or preferences. A moreextreme version might be to reject such research

altogether on the grounds that results always will be in-conclusive and that clinical judgment is of more value.The second reaction, by contrast, will be to see the studyas conclusive, as demonstrating that interpretivemethods of marital therapy have no place and that nofurther evidence on such a question is necessary. Thethird, which needless to say is more reasonable, is to seethese results as a small but useful contribution to our

body of knowledge. Properly controlled outcome

research with any kind of psychological treatment orcounselling is difficult to achieve except with smallnumbers. A series of such studies is therefore required,each one attempting to replicate important findings aswell as to test out interesting possibilities that have

emerged from previous studies. The number of such stu-dies of marital counselling so far is very small butCrowe’s findings were strengthened by their consistencywith those previously reported. It is to be hoped thatother studies will soon follow.The controversy over the relative merits of behav-

ioural or directive and non-directive methods of coun-

selling or psychotherapy goes deep. Perhaps it is a divi-sive issue not on pragmatic grounds but because it re-flects fundamental differences in either personality orcognitive style of the counsellors and psychotherapiststhemselves. Some therapists only feel comfortable ifthere is a clearly defined structure to their therapy; thedirective methods suit them well. Others feel uncomfor-table with such structure and prefer to avoid the con-straints that it imposes. Crowe’s findings that directivemethods are modestly superior to interpretive forms, donot answer the question whether the best choice dependsmore on the characteristics of the therapist. Patientslikewise vary, and there are some who feel more comfor-

7. 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 thereforeof particular interest. Couples with lower educationalstatus apparently did better with the behavioural

approach and the drop-out rate was higher with the in-terpretive method. One of the main shortcomings of in-terpretive methods of psychotherapy has been their rela-tive unsuitability for the less intelligent. It may well bethat for most of the population, counselling methodswhich are practical and depend on "doing" rather than"understanding" things are going to be more acceptableand hence more effective. These are all questions thatdemand further research. There is however a dilemma;carefully controlled treatment research requires struc-ture and therefore is more acceptable to the directivetherapist than to the interpretive. This accounts for thefact that most such research is done by behaviourallyoriented workers. But the reluctant researcher of either

camp might bear in mind that whereas the gains thatcan be shared from such a study do depend on the qual-ity of the design and method, there are many otherlessons for the researcher himself to learn from the ex-

perience. Treatment research is a powerful method ofacquiring valuable clinical experience.

OMISSION OF CLASSIFIED N.H.S.ADVERTISEMENTS FROM THE LANCET

The Lancet is among those publications affected by adispute between T. Bailey Forman Limited, Notting-ham, owner of the Nottingham Evening Post, and twoprinting unions, the National Graphical Association andthe Society of Lithographic Artists, Designers,Engravers and Process Workers. This longstanding dis-pute is attributed by the N.G.A. to T. Bailey Forman’s"anti-union activities and refusal to give recognition tothe printing trade unions". On March 6 the N.G.A.wrote to all its branches instructing members not tohandle any advertisements or advertising material from16 firms and organisations who had not complied withthe N.G.A.’s request that they withdraw advertisingfrom all publications of Forman-Hardy Holdings Ltd.The Nottinghamshire Area Health Authority (Teach-

ing) was among those named and consequently four ad-vertisements from this Authority were removed fromlast week’s Lancet and replaced by a sentence of

explanation, which did not, however, mention Notting-hamshire A.H.A. (T). Last week’s British Medical Jour-nal was not subjected to any changes. Five advertise-ments from the same Authority were due to appear inthis week’s Lancet and we understand that they will notbe included, though on this occasion the empty spaceswill be occupied by a statement which identifies theadvertiser. Individual subscribers in the United King-dom should receive with this Lancet a typescript notegiving 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 Nott-inghamshire posts, but this too was missing when thejournal appeared. We hope that we are now to be per-mitted to give this explanation to readers.

In an attempt to overcome the restriction on adver-tisements a number of national newspaper groups have

brought an action against the unions. The hearing ofthis action was due to be resumed on March 20.