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which could result in cerebral injury. His maincontention is that shearing strain-" the type ofdeformation which occurs in a pack of cards when itis deformed from a neat rectangular pile into anoblique-angled pile "-is the chief agent, and heproceeds to explain how this shear (or slide) may bedeveloped in the brain as the result of blows upon thehead. ’ /

Since the brain is incompressible, there is no

appreciable relative movement between its partsas a result of linear acceleration ; the notion-that coupor contrecoup injuries are the result of alternatecompression and rarefaction, due to free movementof the brain within the skull in the direction of theblow, must therefore be abandoned. A certainamount of shear may occur below the point of impact,particularly if the skull is broken, and this wouldaccount for coup. A much greater shear strain,however, develops as the result of rotation of theskull, and the fact that changes in rotational velocityare usually greater at the pole opposite to the pointof impact would account for the more extensive injuryof contrecoup.. HOLBOURN’S - observations do notabolish contrecoup, if the word is used to mean merelypolar contusion ; but they do refute the notion thatpolar contusion is caused by movement of the brainin a straight line till it bumps on the far side of theskull, since they show that contrecoup is really theresult of shear due to rotational injury.

It should be recognised that almost all blows on thehead rotate it, and the damage done to the braindepends on how firmly it is gripped by the meningesand internal conformation of the skull. An attractivefeature of HoLBOURN’s presentation of the effects ofshear is that it offers a clear mechanical explanationfor the observations of DENNY BROWN and RITCHIERussELL on cerebral concussion. Much remainsto be discovered : what, for example, shear actuallydoes to cerebral tissue ; whether it affects cells orfibres or synapses ; what it does to blood-vessels ;and whether it can be a direct cause of contusion.Even as a simple extension of the experiments nowdescribed it would be important to know what

happens when the forehead is struck, for we cannotaccept the suggestion that, merely because rotationoccurs in both cases, the effects are approximatelythe same as when the occiput is struck. Autopsies, ofwhich there is unfortunately no lack, must not beneglected as a check upon laboratory experiments ;for the damage done to the brain by a severe blow onthe forehead is often most extensive at sites otherthan those affected by striking the back of the head.

WHAT KIND OF CORPORATION?THE growth of public-utility corporations is one of

the features-of the twentieth-century British economicscene. In a timely review published in the last threeissues of the British Medical Journal Mr. D. H.KITCHIN 1 points out that the public corporation orboard embodies the principle that the best way toget a job done is to appoint capable and responsiblepeople to do it and leave them as free as possible.The motive of successful and creative public service,he says, has proved quite as dynamic as the motiveof private profit-making. This he considers not

surprising, for much of the initiative and efficiency1. Brit. med. J. 1943, ii, 369, 399, 423.

said to characterise private enterprise as opposed toofficial administration is provided by salaried workerswho gain nothing material from their success.An analysis of the constitutions of public corpora-

tions reveals two main types-those with boardsbuilt upon a representative basis, and those withappointed non-representative boards. Thus the

Metropolitan Water Board is elected to representthe various local authorities concerned ; the Port ofLondon Authority is in part elected by ratepayers,wharfingers, and owners of river craft, and in partcomposed of appointed members representing theAdmiralty, the Ministry of Transport, the LondonCounty Council, the City of London, and TrinityHouse ; and the General Medical Council is partlyelected by the profession and partly appointed torepresent interested bodies. Two examples of non-representative boards are those of the British Broad-casting Corporation, appointed by the King in Council,and the London Passenger Transport Board, ap-pointed by a group of trustees. Past experience hasshown that where a board exists to perform functionsthat confer advantages on a number of bodies, thereis much to be said for its being representative. If,however, its functions include the restriction of somebodies and the extension of others, for the commongood, then a representative board is liable to finditself shot, with dissension and reduced to impo-tence. In these circumstances, when a board is in

‘

effect a tribunal, its task is easier if it is non-

representative.Two types of corporate structure have been

suggested for the national health service. Medical

Planning Research and now the British MedicalAssociation 3 have proposed a national body, and theformer specified that it should have a non-representa-tive appointed board of governors, with representativeadvisory committees. In a special article a fewmonths ago we put forward an alternative proposalfor area corporate bodies, covering what we calledhealth provinces.4 These had governing councils.

representative of all hospital-owning authorities,health workers (including doctors) and local univer-sities. If it wishes the medical services to be in thehands of corporate bodies, the profession will have toconsider the relative merits of the different varieties-national and provincial, representative and appointed.Experience suggests that the structure should dependon the function they have to perform. We may sup-pose that a corporate health authority would have thefollowing functions : first to employ doctors and theirancillaries (nurses, social workers, pharmacists, tech-nicians, masseuses, dietitians, and hospital adminis-trators), but not necessarily such personnel as clerks,porters, cooks, and cleaners; secondly to assess thehealth needs of the community and formulate plansto meet them; and thirdly to arrange that the plansare carried out. The chief means of securing execu-tion of the plans would be to give or withhold financialgrants for maintenance or extension : thus it wouldbe necessary to reduce or even suppress the activities -.

of some hospital-owning authorities, while increasingthat of others. The first two functions-personneland planning-could be performed equally well byelected representative bodies or by appointed non-2. Lancet, Nov. 21, 1942 (Suppl.). 3. Ibid, Oct. 2, 1943, p. 423.

4. Ibid. 1943, i, 813.

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representative bodies. But the ultimate success ofa national health service will depend on the vigourwith which the plans are executed. Once the ques-tion of suppression of redundant inefficient institu-tions arises, there is a danger that representativebodies will split into groups according to the intereststhey represent. For a national health service tobecome maximally efficient in a minimum of time,its governors should probably be an appointednational non-representative board. This argument,however, will not convert those who believe that inthe long run democratic control at all levels givesgreater efficiency than a more authoritarian machine.

’FLU VACCINES UP THE NOSE FOR some years F. M. BURNET has pointed out the

theoretical advantages of immunising against in-fluenza by spraying an attenuated but still living virusup the nose. In general, where live virus vaccinescan be safely given they are more effective thankilled ones ; moreover, in an emergency it wouldnot be difficult to produce in a hurry a lot of influenzavaccine of the necessary type. In Australia attemptshave been made to test intranasal ’flu vaccines in thefields Influenza viruses of three different strainswere attenuated by amniotic passage in chick embryosand were administered by a de Vilbiss atomiser, eachsubject receiving 0.25 c.cm. Antibodies to the threevirus strains were estimated, before and after thevaccination, by the Hirst test (inhibition of the agglu-tination of fowl red cells). About half those inoculatedshowed a rise in antibody titre against one or othervirus-on the whole rather a poorer result than sub-cutaneous vaccination with inactivated influenza virushas produced here and in America. But it is urgedthat a virus given up the nose may produce antibodyrise only in those in whom it can gain a foothold,in other words only in those susceptible persons whomwe want to immunise ; we do not care whether or notantibodies increase in the others, who are immuneanyway. In support of this seductive argument itis recorded that when vaccinated people who hadshown a good antibody rise to an influenza B vaccinewere revaccinated 3 to 6 months later very few showedany further rise. No epidemic occurred among themto put their immunity to a real test.One argument against the use of live attenuated

influenza vaccines is based on a fear that they mightincrease in virulence by passage from man to man.There was no evidence that this happened in theAustralian trials, either in those conducted during

,

an influenza season or in those after it; the trialsinvolved " tens of thousands " of soldiers. Reactionsproduced by the intranasal vaccines were frequent butalmost all slight, mostly amounting to slight headache,coryza or stuffiness for a day or two, not going on tothe muoopurulent stage which so often follows a realcold. Among the soldiers no reactions were badenough to interfere with training. It is suggestedthat these reactions were allergic, as they were com-moner in those with an initially high antibody levelthan in those with a lower titre. They were also morein evidence after <8, second than after a primaryvaccination ; the possibility of sensitisation to thechick embryo fluids is not discussed.1. Burnet, F. M. Med. J. Aust, 1943, i, 385. Bull, D. R. and

Burnet, F. M. Ibid, p. 389. Mawson, J. and Swan, C. Ibid,p. 394.

There are virus-inactivating properties in humannasal secretions, and less certainly in tears, and thesemay have a great influence on liability to respiratoryinfection and response to intranasal vaccination.FRANCIS and others have lately found that theneutralising activity of nasal secretions rises aftersubcutaneous injection of inactivated influenza vac-cines, and suggest that on this, rather than on a risein circulating antibodies as such, depends any valuepossessed by such vaccination. BURNET now reportsthe surprising discovery that freshly isolated humaninfluenza strains differ from laboratory-adapted onesin not being neutralised by human tears ; he doesnot say whether nasal secretions also show up thisdifference. Other sharp differences between freshand laboratory-trained strains were observed ; we

must therefore be more cautious than ever in applyingconclusions from the laboratory to the field.The Australian work is likely to be applied to the

control of a pandemic rather than to the preventionof minor outbreaks such as we have had in recentyears.

Annotations

TROPICS NOT SO UNHEALTHY IF&mdash;

A REPORT from the medical department of a com-mercial airline operating a service from Bathurst, WestAfrica, down the Coast to Lagos, thence inland throughthe Sudan to Egypt (a distance of almost 5000 miles)and finally to India, shows how knowledge can be usedto prevent disease. The first 2000 miles took in thesemi-jungle country of the West Coast of Africa wherealthough the temperature rarely exceeded 90&deg; F. thehumidity was always high, the rainfall reaching in someparts 200 in. a year and the humidity in others notfalling below.90% for several months on end. Crossingthe African continent the temperature increased buthumidity fell, until in the Sudan and Egypt real desertconditions were encountered with average maximumtemperatures of 110-115&deg; F. and wide diurnal variationsof 60-80&deg; F., while in the Persian Gulf temperaturesreached as much as 127&deg; F.

Candidates for service with the airline were carefullyselected and the age-limits were set at 18-45 years. Afull clinical examination was supplemented by blood-counts, serological tests and X-ray, examination of thelungs. Some 16% of applicants were rejected, the chiefcauses being cardiovascular diseases (20%), visual defects(12%), genito-urinary diseases (11%), and respiratoryconditions (10%) ; those having a history of repeatedattacks of venereal disease, chronic alcoholism or pepticulcer were also regarded as unsuitable types. Acceptedapplicants were inoculated against smallpox, the entericfevers, tetanus, yellow fever and cholera, and wereprovided with mosquito nets, anti-mosquito clothing, asun helmet, and a supply of quinine and mosquito-repellant before sailing. Of the men sent to Africa lessthan 3% returned for medical reasons and none of thesewas seriously incapacitated. In Africa, hospital-bedaccommodation was provided for 10% of the personnel,but in fact 1% sufficed. In large stations a medical andsurgical officer was provided for each 600 men, but adoctor was posted to each station even when the numbersthere were small. Well-trained laboratory staffs andadequately equipped hospitals with properly planneddepartments, including laundry services,, played theirpart.

2. Francis, T. jun., Pearson, H. E., Sullivan, E. R. and Brown, P. M.Amer. J. Hyg. 1943, 37, 294.

3. War Medicine, 1943, 3, 484 and 619.