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HEEL LESIONS IN RHEUMATOID ARTHRITIS
1335 and in
Thus it is generally agreed that the proportion of siblings affected is about 1%-though the risk of a sil)lliig developing the disease is probably rather higher than this when allowance is made for age and for the degreeto which the probability of ascertainment is independent of the number of affected individuals in the family. The risk to parents and children is probably of the same order. But these figures mean little except in comparison with the risk to a random member of the general population, and this risk is less well established. Muller alone of these workers felt that the incidence he found in near relations might not differ significantly from that in the general population ; but he was not aware at the time of the findings in Northern Ireland. While this general risk no doubt varies from country to country, it seems unlikely to exceed 0-2%. Therefore the risk to near relations is probably at least five times greater than that to others. There are several possible explanations of these findings besides the obvious one that genetic factors predispose (though rather weakly) to disseminated sclerosis. One is common environment; but this is unlikely to extend over three generations. A more probable explanation is that the familial cases may have been, not disseminated sclerosis, but some form of genetically determined spinocprphellar ataxia. The workers concerned were all aware of this possibility (Allison and Millar show that the figures for the " probable " cases do not differ from those for the whole group), and they agree that differential diagnosis may be difficult. ACCIDENT-PRONENESS IN MINERS A NOT wholly unattractive picture of the accidentprone was drawn for us in 1943 by Flanders Dunbar.1
found them
seldom off work, ]iye];>-minded, government, and inarticulate about their feelings. Since she wrote about them, however, some doubt has been thrown on their existence. They are, in any case, difficult for statisticians to lay hands on, for after an accident anyone-accidentprone or not, and whether from choice or necessity-may change his job. However, as we have noted,2 some dinicians are inclined to think that temperamental qualities do affect liability to error, and so to accident. Mr. J. W. Whitfield3 in an investigation which should mullify the most exacting of statisticians, has studied disabling accidents in one colliery between July 1, 1944, and Dec. 31, 1946, and has drawn some conclusions based on an actuarial risk, calculated for each man according to the number of shifts worked, the place of work, and the type of work done. Discrepancies between calculated risk and actual accident experience were analysed, and accident-proneness demonstrated : that is. there were measurable individual differences in accident
unusually healthy,
happy-go-lucky, agin the
"
.susceptibility. Men who had worked in the mine for only a short That left 1384 time were excluded from the study. miners who, during the period covered, suffered 1265 accidents severe enough to keep most of them from earning full wages at their normal work for more than three days. Some accidents, presumably, are unavoidable : if a thunderbolt strikes one, or the earth abruptly swallows one up, no amount of resource and sagacity, no expertness in motor response, is likely to preserve one from damage. Such catastrophes apart, however, accidents can be considered, in Whitfield’s phrase, as failure to make an adequate response to a hazardous situation." We may fail either because we do not the hazard in time and decide what response appreciate to make, or because we do not make the appropriate response quickly enough. Such failures in appreciation 1. War Medicine, 1943, 4, 1. See also 2. Lancet, 1953, i, 730. 3. Brit. J. industr. Med. 1954, 11, 126.
Lancet, 1952, i, 1296.
be demonstrated by appropriate men in Whitfield’s study gave poor scores in one or other of the two groups of tests. The type of accident-proneness differed with age. The younger accident-prone miners were heavier and of better physique than their contemporaries, and their motor control and coordination were good ; but they scored very poorly on tests of perceptual, memory, and cognitive processes. The older accident-prone men, on the other hand, scored average or above average in the perceptual and cognitive tests, but were much poorer in motor control and coordination. Perhaps the younger accident-prone leave this industry before they reach middle age : or perhaps they learn to keep out of trouble. In the older men, accident-proneness may have been slowly developing as motor ability declined ; and perhaps perceptual and cognitive ability were declining too. A man who is deficient in motor ability commonly compensates for this by anticipation, but as age advances he may become less able to do this. Whitfield suggests that if further studies confirm his findings, the " older type " of accident-proneness might be watched for and detected early. Methods could then be devised to protect those in whom it was developing. Accidents are undesirable, in the interests not only of the men but of the industry : the older men are of great value, and the loss of their skill, even temporarily, is serious. The a and more different, younger accident-prone present difficult, problem. Whitfield found some evidence that their temperamental development might have been unfavourably affected by adverse factors in childhood and upbringing, but, as he rightly says, " this is not susceptible to direct action by the industry." The proper way of tackling them, he concludes, is by training : for though it may be impossible to teaeh caution to those who are temperamentally careless and happy-go-lucky, yet they can be taught to use specific working methods appropriate to their lack of foresight. It will be something, he thinks, if safety officers recognise that good motor coordination alone is not enough.
performance
can
tests, and the accident-prone
HEEL LESIONS IN RHEUMATOID ARTHRITIS IT is well known that in rheumatoid arthritis the distribution of the joint lesions spreads centripetally as the disease progresses, but in the early stages only the hands and feet may be affected. For- early diagnosis, therefore, attention is particularly directed to the hands, which show characteristic changes ;; in the feet early lesions are perhaps less easily recognised, and the changes produced in the tarsus by rheumatoid disease less well known. Bywatersl has described heel pain as an early or even a presenting symptom in rheumatoid arthritis, and has reported a small series of cases in which he investigated He found two different heel the underlying lesions. lesions, occurring with about equal frequency, and usually together, in 2-3% of unselected cases. The first, a su.hAchilles bursitis, involves the bursa which lies between the tendon near its insertion and the nbrocartilage of the posterior surface of the calcaneum. It is manifested
clinically by swelling, pain on walking, and tenderne&.s, and radiographically by rarefaction and erosion of the subjacent bone. The second lesion consists solely in erosion of the plantar surface of the calcaneum, involving the plantar spur and the area behind it. In both lesions the histological appearances of rheumatoid granulationtissue are found, including the cell formations typical of the rheumatoid nodule. Healed lesions examined at necropsy showed obliteration of the sub-Achilles space and loss of normal fibrocartilage from the bone surface at the site of erosion. 1.
Bywaters, E. G. L.
Ann. rheum. Dis. 1954, 13, 42.
1336 The
type of heel pain to whioh these lesions give rise
includes the "
achillodynia" described many years ago, and hitherto regarded as a complication of chronic infection-usually gonorrhaeal. Bywaters believes that rheumatoid arthritis may be the commonest cause of these lesions, and that this diagnosis should be especially kept in mind when heel pain is among the presenting symptoms. RECEPTION HOME " There are several doctrines about reception homes : the approach psychometric ; the approach analytical; and the approach nihilistic, the last displayed by those who claim to have opened such homes and closed them again. Perhaps more precious than any is our own pose of being plain honest-to-goodness social workers. That child, we say, is "best served by the reception home who never goes into it."
IN Case
Conference,
a new
journal
for social workers and
administrators, Mr. Kenneth I3ri11,1 from whom we quote above, describes the achievements of a reception centre during its first year of life, and with pleasant
irony tells something of the strength and weakness of social work in this setting. The aim of the staff is to get the children who come into the centre either safely back to their mothers or else into a settled home life with someone who will take the mother’s place ; and their results speak for themselves : of 47 children under the age of fifteen who came into the centre during the year ending March, 1953, 35 have since been restored to their families, 6 are in foster-homes, and 6 are still in group care. The children come into the centre for the usual reasons - own a place of safety " order, because of temporary difficulty at home (such as admission of the mother to a mental hospital or sanatorium), because the family has been evicted, or because they have been committed to care by a court, for delinquent behaviour. The first thing they notice is that they have not come to a permanent haven : they see other children coming and going, and they probably derive a feeling of safety from the fact that they are all in the same boat-temporarily away from a home to which they hope to return. This helps them to accept the situation and look forward to a coherent plan for the future ; and they are quite aware of what is going on, it seems. ’4
A boy of ten, committed by the juvenile court for larceny, and rejected by his mother, got tired of waiting in the home, and accosted the boarding-out officer with the inquiry, " When are you going to make a plan for me ? "
A child who has led a roving life with an evicted parent is sometimes at a loss to see why he should change his arrangements. They have, as far as he can see, worked fairly well, and they have, at all events, generally supplied him with an independent spirit. An eleven-year-old, sounded on the question of a foster-home, replied maturely : "I don’t want to live with any stinking auntie, whatever the Government wants." The results achieved by this reception centre form part of the experience of the Devon Children’s Committee, which set it up. The county as a whole can claim that of 233 children under fifteen who came into care in the year ending March, 1953, only 20 remained in institutions a year later. Children for whom the committee foresee the end of their stay in care (classed as short-stay children) are now nearly all sent into foster-homes from the start ; and, in particular, admission of short-stay children to a residential nursery has almost ceased. There were 132 short-stay children among the 233, and all are now back in their own homes. Moreover, nearly half the long-stay children, whether committed 1. Case
Conference, May, 1954, p. 12.
by the
courts or not, went home within two years, and two-thirds of the remainder are now in fosterhomes. This first year’s experience, Mr. Brill says, contains an administrative lesson. Nowadays children’s committees are urged to invest in plenty of qualified child-care officers ; and those who do so will be surprised at the dividend. The chief gain-which is both spiritual and financial-is that only a tiny fraction of the children received ever need to be in residential care : residential nurseries and family homes can be closed down. " Invest;" he says, " in bricks or mortar or in properly trained social workers, but not in both at once." The reception home has proved to be a terminus for several lines of social work ; and, since some twelve statutory agencies2 have an interest in protecting children from neglect and ill-treatment (quite apart from the children’s officer, her field worker, the staff of the
reception home, almoners, police, probation officers, private people such as doctors and clergy, and all the voluntary agencies), Mr. Brill advises those who are opening such homes to have a room large enough to take twenty social workers at a time at a case-conference. few families attract the interest of more than six or eight agencies ; but representatives of all these must be present at the case-conference, or else -as he illustrates from an authentic case-the one forgotten agency will take independent action astonishing to the rest. The difficulty, he says, is in forecasting which agencies to invite. Nevertheless the justification of such gatherings lies in the experience of children now back with their families or beginning a new life in foster-homes. or more
Fortunately
SURVIVAL OF DRIED CULTURES BACTERIA survivefor long periods in the dried state, and drying under controlled conditions is now a standard method for maintaining stock cultures for teaching or reference purposes. The techniques used may be simple or complex, but all involve the destruction of 90-99% of the organisms being dried. In September, 1953, the British Commonwealth Collections of Microorganisms organised a discussion of drying methods to which workers from different parts of the Commonwealth were asked to contribute their experiences. Papers circulated before the meeting are included in the report of the discussion,3 which ranged from the problems of the designer of apparatus to the technical methods for checking the viabilityof the dried cultures. The discussion showed that the fundamental principles underlying the method are still only imperfectly understood and that many of the procedures are empirical. The most important single factor affecting viability of the dried product seems to be the material in which the microorganisms are suspended, and of glucose, the addition of which was first suggested by Fry and Ure aves,4 is the most successful of the additives. Record and Taylor 5 have recently shown that bacteria themselves, presumably by autolysis, can contribute some protective factor, so the survival-rates of heavy suspensions are greater than those of lighter suspensions, but the difference is not as great as the glucose effect. Ultimately it may be possible to correlate survival-rates with residual moisture content, but technical difficulties of determining residual moisture have so far prevented this. Apparatus described at the discussion may bring moisture determination within the range of routine procedures. 2. Home Office Circular no. 157, 1950. 3. British Commonwealth of Nations Scientific Liaison Offices, B.C.S.O. (London) : A discussion on the maintenance of cultures by freeze drying. H.M. Stationery Office. Code no. 88-1311. 5s. 4. Fry, R. M., Greaves, R. I. N. J. Hyg., Camb. 1951, 49, 220. 5. Record, B. R., Taylor, R. J. gen. Microbiol. 1953, 9, 475.
Thus it is generally agreed that the proportion of siblings affected is about 1%-though the risk of a sil)lliig developing the disease is probably rather higher than this when allowance is made for age and for the degreeto which the probability of ascertainment is independent of the number of affected individuals in the family. The risk to parents and children is probably of the same order. But these figures mean little except in comparison with the risk to a random member of the general population, and this risk is less well established. Muller alone of these workers felt that the incidence he found in near relations might not differ significantly from that in the general population ; but he was not aware at the time of the findings in Northern Ireland. While this general risk no doubt varies from country to country, it seems unlikely to exceed 0-2%. Therefore the risk to near relations is probably at least five times greater than that to others. There are several possible explanations of these findings besides the obvious one that genetic factors predispose (though rather weakly) to disseminated sclerosis. One is common environment; but this is unlikely to extend over three generations. A more probable explanation is that the familial cases may have been, not disseminated sclerosis, but some form of genetically determined spinocprphellar ataxia. The workers concerned were all aware of this possibility (Allison and Millar show that the figures for the " probable " cases do not differ from those for the whole group), and they agree that differential diagnosis may be difficult. ACCIDENT-PRONENESS IN MINERS A NOT wholly unattractive picture of the accidentprone was drawn for us in 1943 by Flanders Dunbar.1
found them
seldom off work, ]iye];>-minded, government, and inarticulate about their feelings. Since she wrote about them, however, some doubt has been thrown on their existence. They are, in any case, difficult for statisticians to lay hands on, for after an accident anyone-accidentprone or not, and whether from choice or necessity-may change his job. However, as we have noted,2 some dinicians are inclined to think that temperamental qualities do affect liability to error, and so to accident. Mr. J. W. Whitfield3 in an investigation which should mullify the most exacting of statisticians, has studied disabling accidents in one colliery between July 1, 1944, and Dec. 31, 1946, and has drawn some conclusions based on an actuarial risk, calculated for each man according to the number of shifts worked, the place of work, and the type of work done. Discrepancies between calculated risk and actual accident experience were analysed, and accident-proneness demonstrated : that is. there were measurable individual differences in accident
unusually healthy,
happy-go-lucky, agin the
"
.susceptibility. Men who had worked in the mine for only a short That left 1384 time were excluded from the study. miners who, during the period covered, suffered 1265 accidents severe enough to keep most of them from earning full wages at their normal work for more than three days. Some accidents, presumably, are unavoidable : if a thunderbolt strikes one, or the earth abruptly swallows one up, no amount of resource and sagacity, no expertness in motor response, is likely to preserve one from damage. Such catastrophes apart, however, accidents can be considered, in Whitfield’s phrase, as failure to make an adequate response to a hazardous situation." We may fail either because we do not the hazard in time and decide what response appreciate to make, or because we do not make the appropriate response quickly enough. Such failures in appreciation 1. War Medicine, 1943, 4, 1. See also 2. Lancet, 1953, i, 730. 3. Brit. J. industr. Med. 1954, 11, 126.
Lancet, 1952, i, 1296.
be demonstrated by appropriate men in Whitfield’s study gave poor scores in one or other of the two groups of tests. The type of accident-proneness differed with age. The younger accident-prone miners were heavier and of better physique than their contemporaries, and their motor control and coordination were good ; but they scored very poorly on tests of perceptual, memory, and cognitive processes. The older accident-prone men, on the other hand, scored average or above average in the perceptual and cognitive tests, but were much poorer in motor control and coordination. Perhaps the younger accident-prone leave this industry before they reach middle age : or perhaps they learn to keep out of trouble. In the older men, accident-proneness may have been slowly developing as motor ability declined ; and perhaps perceptual and cognitive ability were declining too. A man who is deficient in motor ability commonly compensates for this by anticipation, but as age advances he may become less able to do this. Whitfield suggests that if further studies confirm his findings, the " older type " of accident-proneness might be watched for and detected early. Methods could then be devised to protect those in whom it was developing. Accidents are undesirable, in the interests not only of the men but of the industry : the older men are of great value, and the loss of their skill, even temporarily, is serious. The a and more different, younger accident-prone present difficult, problem. Whitfield found some evidence that their temperamental development might have been unfavourably affected by adverse factors in childhood and upbringing, but, as he rightly says, " this is not susceptible to direct action by the industry." The proper way of tackling them, he concludes, is by training : for though it may be impossible to teaeh caution to those who are temperamentally careless and happy-go-lucky, yet they can be taught to use specific working methods appropriate to their lack of foresight. It will be something, he thinks, if safety officers recognise that good motor coordination alone is not enough.
performance
can
tests, and the accident-prone
HEEL LESIONS IN RHEUMATOID ARTHRITIS IT is well known that in rheumatoid arthritis the distribution of the joint lesions spreads centripetally as the disease progresses, but in the early stages only the hands and feet may be affected. For- early diagnosis, therefore, attention is particularly directed to the hands, which show characteristic changes ;; in the feet early lesions are perhaps less easily recognised, and the changes produced in the tarsus by rheumatoid disease less well known. Bywatersl has described heel pain as an early or even a presenting symptom in rheumatoid arthritis, and has reported a small series of cases in which he investigated He found two different heel the underlying lesions. lesions, occurring with about equal frequency, and usually together, in 2-3% of unselected cases. The first, a su.hAchilles bursitis, involves the bursa which lies between the tendon near its insertion and the nbrocartilage of the posterior surface of the calcaneum. It is manifested
clinically by swelling, pain on walking, and tenderne&.s, and radiographically by rarefaction and erosion of the subjacent bone. The second lesion consists solely in erosion of the plantar surface of the calcaneum, involving the plantar spur and the area behind it. In both lesions the histological appearances of rheumatoid granulationtissue are found, including the cell formations typical of the rheumatoid nodule. Healed lesions examined at necropsy showed obliteration of the sub-Achilles space and loss of normal fibrocartilage from the bone surface at the site of erosion. 1.
Bywaters, E. G. L.
Ann. rheum. Dis. 1954, 13, 42.
1336 The
type of heel pain to whioh these lesions give rise
includes the "
achillodynia" described many years ago, and hitherto regarded as a complication of chronic infection-usually gonorrhaeal. Bywaters believes that rheumatoid arthritis may be the commonest cause of these lesions, and that this diagnosis should be especially kept in mind when heel pain is among the presenting symptoms. RECEPTION HOME " There are several doctrines about reception homes : the approach psychometric ; the approach analytical; and the approach nihilistic, the last displayed by those who claim to have opened such homes and closed them again. Perhaps more precious than any is our own pose of being plain honest-to-goodness social workers. That child, we say, is "best served by the reception home who never goes into it."
IN Case
Conference,
a new
journal
for social workers and
administrators, Mr. Kenneth I3ri11,1 from whom we quote above, describes the achievements of a reception centre during its first year of life, and with pleasant
irony tells something of the strength and weakness of social work in this setting. The aim of the staff is to get the children who come into the centre either safely back to their mothers or else into a settled home life with someone who will take the mother’s place ; and their results speak for themselves : of 47 children under the age of fifteen who came into the centre during the year ending March, 1953, 35 have since been restored to their families, 6 are in foster-homes, and 6 are still in group care. The children come into the centre for the usual reasons - own a place of safety " order, because of temporary difficulty at home (such as admission of the mother to a mental hospital or sanatorium), because the family has been evicted, or because they have been committed to care by a court, for delinquent behaviour. The first thing they notice is that they have not come to a permanent haven : they see other children coming and going, and they probably derive a feeling of safety from the fact that they are all in the same boat-temporarily away from a home to which they hope to return. This helps them to accept the situation and look forward to a coherent plan for the future ; and they are quite aware of what is going on, it seems. ’4
A boy of ten, committed by the juvenile court for larceny, and rejected by his mother, got tired of waiting in the home, and accosted the boarding-out officer with the inquiry, " When are you going to make a plan for me ? "
A child who has led a roving life with an evicted parent is sometimes at a loss to see why he should change his arrangements. They have, as far as he can see, worked fairly well, and they have, at all events, generally supplied him with an independent spirit. An eleven-year-old, sounded on the question of a foster-home, replied maturely : "I don’t want to live with any stinking auntie, whatever the Government wants." The results achieved by this reception centre form part of the experience of the Devon Children’s Committee, which set it up. The county as a whole can claim that of 233 children under fifteen who came into care in the year ending March, 1953, only 20 remained in institutions a year later. Children for whom the committee foresee the end of their stay in care (classed as short-stay children) are now nearly all sent into foster-homes from the start ; and, in particular, admission of short-stay children to a residential nursery has almost ceased. There were 132 short-stay children among the 233, and all are now back in their own homes. Moreover, nearly half the long-stay children, whether committed 1. Case
Conference, May, 1954, p. 12.
by the
courts or not, went home within two years, and two-thirds of the remainder are now in fosterhomes. This first year’s experience, Mr. Brill says, contains an administrative lesson. Nowadays children’s committees are urged to invest in plenty of qualified child-care officers ; and those who do so will be surprised at the dividend. The chief gain-which is both spiritual and financial-is that only a tiny fraction of the children received ever need to be in residential care : residential nurseries and family homes can be closed down. " Invest;" he says, " in bricks or mortar or in properly trained social workers, but not in both at once." The reception home has proved to be a terminus for several lines of social work ; and, since some twelve statutory agencies2 have an interest in protecting children from neglect and ill-treatment (quite apart from the children’s officer, her field worker, the staff of the
reception home, almoners, police, probation officers, private people such as doctors and clergy, and all the voluntary agencies), Mr. Brill advises those who are opening such homes to have a room large enough to take twenty social workers at a time at a case-conference. few families attract the interest of more than six or eight agencies ; but representatives of all these must be present at the case-conference, or else -as he illustrates from an authentic case-the one forgotten agency will take independent action astonishing to the rest. The difficulty, he says, is in forecasting which agencies to invite. Nevertheless the justification of such gatherings lies in the experience of children now back with their families or beginning a new life in foster-homes. or more
Fortunately
SURVIVAL OF DRIED CULTURES BACTERIA survivefor long periods in the dried state, and drying under controlled conditions is now a standard method for maintaining stock cultures for teaching or reference purposes. The techniques used may be simple or complex, but all involve the destruction of 90-99% of the organisms being dried. In September, 1953, the British Commonwealth Collections of Microorganisms organised a discussion of drying methods to which workers from different parts of the Commonwealth were asked to contribute their experiences. Papers circulated before the meeting are included in the report of the discussion,3 which ranged from the problems of the designer of apparatus to the technical methods for checking the viabilityof the dried cultures. The discussion showed that the fundamental principles underlying the method are still only imperfectly understood and that many of the procedures are empirical. The most important single factor affecting viability of the dried product seems to be the material in which the microorganisms are suspended, and of glucose, the addition of which was first suggested by Fry and Ure aves,4 is the most successful of the additives. Record and Taylor 5 have recently shown that bacteria themselves, presumably by autolysis, can contribute some protective factor, so the survival-rates of heavy suspensions are greater than those of lighter suspensions, but the difference is not as great as the glucose effect. Ultimately it may be possible to correlate survival-rates with residual moisture content, but technical difficulties of determining residual moisture have so far prevented this. Apparatus described at the discussion may bring moisture determination within the range of routine procedures. 2. Home Office Circular no. 157, 1950. 3. British Commonwealth of Nations Scientific Liaison Offices, B.C.S.O. (London) : A discussion on the maintenance of cultures by freeze drying. H.M. Stationery Office. Code no. 88-1311. 5s. 4. Fry, R. M., Greaves, R. I. N. J. Hyg., Camb. 1951, 49, 220. 5. Record, B. R., Taylor, R. J. gen. Microbiol. 1953, 9, 475.