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Reablement Reviewed
LEADING ARTICLES
481
other of the organisations, and technical advice of course, always forthcoming ; but no full programme for reablement would be offered. Last year, however, the United Nations Economic and Social Council passed a resolution asking the SecretaryGeneral " to planjointly with the Specialised Agencies, and in consultation with interested non-governmental organisations, a well-coordinated international programme for the rehabilitation of physically handicapped persons." As a result, a small reablement unit has been set up under UNDSA to study the problems of reablement for all classes of physically handicapped, including the blind, in all countries of the world. A technical working party on reablement has also been set up by the Administrative Committee on Coordination, to prepare the international programme asked for in the resolution. The working party are one or
was,
THE LANCET LONDON:SATURDAY, SEPT. 15, 1951
Reablement Reviewed ONE healthy sign in our still sickly times is a greater sharing of responsibility among nations. It is no longer enough that each country should provide its own services for the ill and disabled : we begin to feel that knowledge should be pooled and that backward countries should benefit by the experience of others The World Congress of the Intermore advanced. national Society for the Welfare of Cripples met at Stockholm on Sept. 9-14 to discuss " complete services for the disabled-a world goal " ; and Dr. HAROLD BALME, in the opening paper, reviewed the progress we have already made towards it. Such crippling disorders as blindness, tuberculosis, poliomyelitis, and cerebral palsy, he said, are nowadays all being studied on a world-wide scale, and authorities exchange their ideas on them at international conferThe organisations which go to make up what ences. he pleasantly called " the United Nations family " are all contributing to this common cause. The International Labour Organisation (I.L.O.), oldest member of the family, has encouraged the use of safety devices in industry, and has taken steps to prevent children and young people from undertaking dangerous jobs, to protect workers from industrial diseases and other occupational hazards, to improve working conditions, and to arrange vocational guidance and training for disabled workers. The World Health Organisation (W.H.O.) has helped to reduce the incidence of crippling by campaigns for better maternity and child-welfare services, a pure milk-supply, and measures to reduce the dangers of infective disease. The United Nations Educational, Scientific, and Cultural Organisation (UNESCO) has contributed to the education of the handicapped, particularly the blind ; the Food and Agriculture Organisation (F.A.O.) has been attacking problems of nutrition and deficiency diseases ; and the International Refugee Organisation (I.R.O.) has set up a chain of centres for the reablement and training of disabled refugees in Germany, Austria, and Italy. The United Nations International Children’s Emergency Fund (UNICEF) has saved hundreds of children from actual starvation and has allotted funds for the reablement of those who are physically handicapped. The United Nations Department of Social Affairs (UNDSA) has trained social workers and granted fellowships to men and women wishing to study modern methods of reablement. This is much ; but until recently the various activities, as Dr. BALME pointed out, were carried on in relative isolation. Governments seeking advice on any subject to do with reablement would apply to able
as
well
as
already planning
widespread publicity campaigngovernment officials, doctors, teachers, social workers, employers, trade-union officials, and the reading public-on modern methods of treating, training, and employing the disabled, and on the a
to
services which the United Nations and the Specialised Agencies can offer. Technical advice, beginning with a fact-finding mission, will be available to governments of the less developed countries. For those where services are well developed, help will be given in setting up training centres for staff-the United Nations providing technical experts, equipment, publications, scholarships, and fellowships. Three or four governments have already asked for help in establishing such centres. Special training opportunities are already being arranged for those who will have the task of building up clinics, centres, schools, or training centres. Last spring, as we have already recorded,1 seven European countries sent teams for an intensive course of training in the reablement of physically handicapped children, sponsored jointly by the United Nations, W.H.O., and UNICEF, organised by the British Ministries of Health and Education, and administered by the British Council. Each team consisted of an orthopaedic surgeon or paediatrician, a physiotherapist or remedial gymnast, an occupational therapist or handicraft teacher, a teacher of crippled children, a social worker, a vocational training instructor, and a prosthetic and surgical appliance technician. The teams saw treatment and training centres, clinics, and workshops,
attended lectures and films, did a month’s intensive training in modern reablement technique, and wrote some illuminating reports. They were enthusiastic about the value of the course. Dr. BALME reminded his hearers how greatly, in the work that lies ahead, the United Nations will need the help, advice, and close cooperation of the voluntary agencies, both national and international. The part played by the voluntary bodies in our national reablement schemes was emphasised just as strongly by Mr. ALFRED ROBENS, the Minister of Labour, at a conference held in London by the British Council for Rehabilitation last week. He said that since the start of the vocational training scheme for the disabled, 43,900 people have completed courses arranged by the Ministry and by voluntary bodies, technical colleges, and employers. Of these, 38,600 are known to have 1.
Lancet, 1951,i, 1078.
LEADING ARTICLES
482
satisfactorily settled in jobs. Many others have been trained for agricultural work either by the Ministry of Agriculture or by special voluntary organisations. In addition, financial help is given to many voluntary bodies providing sheltered workshops ; and Remploy Ltd., the non-profit-making company set up some years ago, now has 87 works manned by 5559 severely disabled men and women. Lord WEBB-JOHNSON, who opened the conference, spoke of the responsibility of the surgeon : he should from the outset have in mind the restoration to work of the sick or injured man, and not only his immediate treatment. Mr. HILARY MARQUAND, the Minister of Health, urged wise economy in the use of beds : ifby the full use of physical and social methods, and of modern methods of reablement-the length of stay of sick or injured patients in acute general hospitals can be cut down by even 5%, this will be the equivalent of releasing 25,000 new beds for treatment. The work of American and Canadian hospitals shows that the length of stay could be reduced by this amount. been
approximate osmotic equilibrium does exist between plasma and ascitic fluid, increase in the plasmaalbumin is rapidly followed by a similar rise in the ascitic-fluid albumin, owing to increased diffuan
This is further supsion from the blood-stream. for 5 cases that he PosT’s figures ported by describes in detail. In 4 of these cases diuresis followed the intravenous administration of albumin, but the difference in albumin concentration between the plasma and the ascitic fluid increased during treatment by an average of only 0-25 g. per 100 ml. In the 5th case diuresis did not ensue, and the change in concentration difference varied between + 0-5 g. and - 0-3 g. per 100 ml. It is therefore quite unjustifiable to attribute diuresis to change in the albumin-concentration difference. It seems from the work of GRAY 3 and others at the Mayo Clinic that the source of ascitic fluid is excessive filtration of lymph via the hepatic sinusoids, as a result of hepatic congestion. (It is well known that these sinusoids are unusually permeable to the plasmaproteins, and normal hepatic lymph contains about Albumin Ascites Treated with 2% of protein.) This view is compatible with composition of ascitic fluid, the albumin level of which THE accumulation of ascitic fluid is sometimes a with the plasma-albumin level, and with the fluctuates distressing feature of hepatic cirrhosis. Many proceof intravenous albumin to reduce ascites dures, surgical as well as medical, are used to counter inability or to induce diuresis by its colloid osmotic properties. this condition ; indeed their number testifies to the The evidence given by POST and his colleagues difficulty of finding a satisfactory remedy. One of does indicate that intravenous albumin has some the latest methods is the intravenous administration value in hepatic cirrhosis, but for an therapeutic human albumin. The of salt-poor theory underlying explanation we must seek elsewhere than in its osmotic this method is that ascites is due to increased transudation of fluid from diminished osmotic pressure of the properties. It is of course a protein of high biological and nutritive value. In the dosage used by POST plasma colloids, and that this fall in osmotic pressure it would provide 50 g. of protein daily. His patients results largely from the fall in plasma-albumin. taking the full basal diet received 173 g. of protein POST and his collaboratorshave tried this method daily. On such a diet a further 50 g. would not be in 34 patients with " decompensated hepatic cirrhosis." any obvious benefit. 16 of his Owing to the scarcity of appropriate cases each patient expected to produce were in coma or semi-coma; acted as his own control by a preliminary period of patients, however, and in 5 the remainder the control period of eight of treatment and observation. Only when the clinical weeks was cut short because of clinical deterioration, condition seemed to be static or seriously deteriorating a feature of which was a decline in food conspicuous was treatment with intravenous albumin started. There thus to believe that is intake. reason good At first 100 ml. of a 25% solution was given twice a two-thirds of the had serious nutritional patients daily, and then the amount was adjusted to keep the such cases In deficiency. protein protein parenteral level between 4 serum-albumin g. and 5 g. per 100 ml. This regime was continued indefinitely. The results therapy is particularly beneficial. The value of a high-protein intake in chronic liver disease is now are, unfortunately, not clear-cut ; this is not surprising well known ; but often it is difficult to persuade since the method of control is not really satisfactory such patients to eat enough, because of impaired unless the therapeutic result is almost 100% satisand gastro-intestinal function ; and intrafactory. Of the 34 patients 21 had an adequate appetite venous alimentation in general, with salt-poor albumin diuresis with complete clearing of ascites. The particular, is an excellent solution. It is extremely remaining 13 did not respond ; and 8 of these died in difficult to get patients to eat a high-protein diet within three weeks of the beginning of albumin therapy. in salt ; yet the patient with ascites must be deficient PosT concludes that " salt-poor albumin has a place of salt as far as possible. EISENMENGER et al.4 deprived as a therapeutic adjunct in the management of patients have indeed shown that rigid salt restriction may with severely decompensated hepatic cirrhosis for cause ascites to disappear, despite the presence of portal whom adequate dietary therapy cannot be provided." hypertension, hypoalbuminaemia, and increased urinary This conclusion does not, however, follow logically from the results presented, and is presumably based excretion of an antidiuretic factor. By means of on previous experience with this type of case. There intravenous salt-poor albumin the protein intake can be greatly augmented without any accompanying is in fact little evidence that the level of the serumincrease of salt. It remains to be seen, however, -albumin has much influence on ascites. In a detailed whether the same clinical results cannot be obtained study of the osmotic factors influencing the formaless by expensive and simpler methods of intravenous tion of ascites, in 10 cases of cirrhosis, MANKIN and feeding. LOWELL2showed quite conclusively that although
Salt-poor
3.
1. Post, P., Rose, J. V., Shore, S. M. Arch. intern. Med. 1951, 87, 775. 2. Mankin, H., Lowell, A. J. clin. Invest. 1948, 27, 145.
Gray, H. K. Ann. R. Coll. Surg. 1951, 8, 354 ; see Lancet, 1951, i, 1402. 4. Eisenmenger, W. J., Ahrens, E. H. jun., Blondheim, S. H., Kunkel, H. G. J. Lab. clin. Med. 1949, 34, 1029.
481
other of the organisations, and technical advice of course, always forthcoming ; but no full programme for reablement would be offered. Last year, however, the United Nations Economic and Social Council passed a resolution asking the SecretaryGeneral " to planjointly with the Specialised Agencies, and in consultation with interested non-governmental organisations, a well-coordinated international programme for the rehabilitation of physically handicapped persons." As a result, a small reablement unit has been set up under UNDSA to study the problems of reablement for all classes of physically handicapped, including the blind, in all countries of the world. A technical working party on reablement has also been set up by the Administrative Committee on Coordination, to prepare the international programme asked for in the resolution. The working party are one or
was,
THE LANCET LONDON:SATURDAY, SEPT. 15, 1951
Reablement Reviewed ONE healthy sign in our still sickly times is a greater sharing of responsibility among nations. It is no longer enough that each country should provide its own services for the ill and disabled : we begin to feel that knowledge should be pooled and that backward countries should benefit by the experience of others The World Congress of the Intermore advanced. national Society for the Welfare of Cripples met at Stockholm on Sept. 9-14 to discuss " complete services for the disabled-a world goal " ; and Dr. HAROLD BALME, in the opening paper, reviewed the progress we have already made towards it. Such crippling disorders as blindness, tuberculosis, poliomyelitis, and cerebral palsy, he said, are nowadays all being studied on a world-wide scale, and authorities exchange their ideas on them at international conferThe organisations which go to make up what ences. he pleasantly called " the United Nations family " are all contributing to this common cause. The International Labour Organisation (I.L.O.), oldest member of the family, has encouraged the use of safety devices in industry, and has taken steps to prevent children and young people from undertaking dangerous jobs, to protect workers from industrial diseases and other occupational hazards, to improve working conditions, and to arrange vocational guidance and training for disabled workers. The World Health Organisation (W.H.O.) has helped to reduce the incidence of crippling by campaigns for better maternity and child-welfare services, a pure milk-supply, and measures to reduce the dangers of infective disease. The United Nations Educational, Scientific, and Cultural Organisation (UNESCO) has contributed to the education of the handicapped, particularly the blind ; the Food and Agriculture Organisation (F.A.O.) has been attacking problems of nutrition and deficiency diseases ; and the International Refugee Organisation (I.R.O.) has set up a chain of centres for the reablement and training of disabled refugees in Germany, Austria, and Italy. The United Nations International Children’s Emergency Fund (UNICEF) has saved hundreds of children from actual starvation and has allotted funds for the reablement of those who are physically handicapped. The United Nations Department of Social Affairs (UNDSA) has trained social workers and granted fellowships to men and women wishing to study modern methods of reablement. This is much ; but until recently the various activities, as Dr. BALME pointed out, were carried on in relative isolation. Governments seeking advice on any subject to do with reablement would apply to able
as
well
as
already planning
widespread publicity campaigngovernment officials, doctors, teachers, social workers, employers, trade-union officials, and the reading public-on modern methods of treating, training, and employing the disabled, and on the a
to
services which the United Nations and the Specialised Agencies can offer. Technical advice, beginning with a fact-finding mission, will be available to governments of the less developed countries. For those where services are well developed, help will be given in setting up training centres for staff-the United Nations providing technical experts, equipment, publications, scholarships, and fellowships. Three or four governments have already asked for help in establishing such centres. Special training opportunities are already being arranged for those who will have the task of building up clinics, centres, schools, or training centres. Last spring, as we have already recorded,1 seven European countries sent teams for an intensive course of training in the reablement of physically handicapped children, sponsored jointly by the United Nations, W.H.O., and UNICEF, organised by the British Ministries of Health and Education, and administered by the British Council. Each team consisted of an orthopaedic surgeon or paediatrician, a physiotherapist or remedial gymnast, an occupational therapist or handicraft teacher, a teacher of crippled children, a social worker, a vocational training instructor, and a prosthetic and surgical appliance technician. The teams saw treatment and training centres, clinics, and workshops,
attended lectures and films, did a month’s intensive training in modern reablement technique, and wrote some illuminating reports. They were enthusiastic about the value of the course. Dr. BALME reminded his hearers how greatly, in the work that lies ahead, the United Nations will need the help, advice, and close cooperation of the voluntary agencies, both national and international. The part played by the voluntary bodies in our national reablement schemes was emphasised just as strongly by Mr. ALFRED ROBENS, the Minister of Labour, at a conference held in London by the British Council for Rehabilitation last week. He said that since the start of the vocational training scheme for the disabled, 43,900 people have completed courses arranged by the Ministry and by voluntary bodies, technical colleges, and employers. Of these, 38,600 are known to have 1.
Lancet, 1951,i, 1078.
LEADING ARTICLES
482
satisfactorily settled in jobs. Many others have been trained for agricultural work either by the Ministry of Agriculture or by special voluntary organisations. In addition, financial help is given to many voluntary bodies providing sheltered workshops ; and Remploy Ltd., the non-profit-making company set up some years ago, now has 87 works manned by 5559 severely disabled men and women. Lord WEBB-JOHNSON, who opened the conference, spoke of the responsibility of the surgeon : he should from the outset have in mind the restoration to work of the sick or injured man, and not only his immediate treatment. Mr. HILARY MARQUAND, the Minister of Health, urged wise economy in the use of beds : ifby the full use of physical and social methods, and of modern methods of reablement-the length of stay of sick or injured patients in acute general hospitals can be cut down by even 5%, this will be the equivalent of releasing 25,000 new beds for treatment. The work of American and Canadian hospitals shows that the length of stay could be reduced by this amount. been
approximate osmotic equilibrium does exist between plasma and ascitic fluid, increase in the plasmaalbumin is rapidly followed by a similar rise in the ascitic-fluid albumin, owing to increased diffuan
This is further supsion from the blood-stream. for 5 cases that he PosT’s figures ported by describes in detail. In 4 of these cases diuresis followed the intravenous administration of albumin, but the difference in albumin concentration between the plasma and the ascitic fluid increased during treatment by an average of only 0-25 g. per 100 ml. In the 5th case diuresis did not ensue, and the change in concentration difference varied between + 0-5 g. and - 0-3 g. per 100 ml. It is therefore quite unjustifiable to attribute diuresis to change in the albumin-concentration difference. It seems from the work of GRAY 3 and others at the Mayo Clinic that the source of ascitic fluid is excessive filtration of lymph via the hepatic sinusoids, as a result of hepatic congestion. (It is well known that these sinusoids are unusually permeable to the plasmaproteins, and normal hepatic lymph contains about Albumin Ascites Treated with 2% of protein.) This view is compatible with composition of ascitic fluid, the albumin level of which THE accumulation of ascitic fluid is sometimes a with the plasma-albumin level, and with the fluctuates distressing feature of hepatic cirrhosis. Many proceof intravenous albumin to reduce ascites dures, surgical as well as medical, are used to counter inability or to induce diuresis by its colloid osmotic properties. this condition ; indeed their number testifies to the The evidence given by POST and his colleagues difficulty of finding a satisfactory remedy. One of does indicate that intravenous albumin has some the latest methods is the intravenous administration value in hepatic cirrhosis, but for an therapeutic human albumin. The of salt-poor theory underlying explanation we must seek elsewhere than in its osmotic this method is that ascites is due to increased transudation of fluid from diminished osmotic pressure of the properties. It is of course a protein of high biological and nutritive value. In the dosage used by POST plasma colloids, and that this fall in osmotic pressure it would provide 50 g. of protein daily. His patients results largely from the fall in plasma-albumin. taking the full basal diet received 173 g. of protein POST and his collaboratorshave tried this method daily. On such a diet a further 50 g. would not be in 34 patients with " decompensated hepatic cirrhosis." any obvious benefit. 16 of his Owing to the scarcity of appropriate cases each patient expected to produce were in coma or semi-coma; acted as his own control by a preliminary period of patients, however, and in 5 the remainder the control period of eight of treatment and observation. Only when the clinical weeks was cut short because of clinical deterioration, condition seemed to be static or seriously deteriorating a feature of which was a decline in food conspicuous was treatment with intravenous albumin started. There thus to believe that is intake. reason good At first 100 ml. of a 25% solution was given twice a two-thirds of the had serious nutritional patients daily, and then the amount was adjusted to keep the such cases In deficiency. protein protein parenteral level between 4 serum-albumin g. and 5 g. per 100 ml. This regime was continued indefinitely. The results therapy is particularly beneficial. The value of a high-protein intake in chronic liver disease is now are, unfortunately, not clear-cut ; this is not surprising well known ; but often it is difficult to persuade since the method of control is not really satisfactory such patients to eat enough, because of impaired unless the therapeutic result is almost 100% satisand gastro-intestinal function ; and intrafactory. Of the 34 patients 21 had an adequate appetite venous alimentation in general, with salt-poor albumin diuresis with complete clearing of ascites. The particular, is an excellent solution. It is extremely remaining 13 did not respond ; and 8 of these died in difficult to get patients to eat a high-protein diet within three weeks of the beginning of albumin therapy. in salt ; yet the patient with ascites must be deficient PosT concludes that " salt-poor albumin has a place of salt as far as possible. EISENMENGER et al.4 deprived as a therapeutic adjunct in the management of patients have indeed shown that rigid salt restriction may with severely decompensated hepatic cirrhosis for cause ascites to disappear, despite the presence of portal whom adequate dietary therapy cannot be provided." hypertension, hypoalbuminaemia, and increased urinary This conclusion does not, however, follow logically from the results presented, and is presumably based excretion of an antidiuretic factor. By means of on previous experience with this type of case. There intravenous salt-poor albumin the protein intake can be greatly augmented without any accompanying is in fact little evidence that the level of the serumincrease of salt. It remains to be seen, however, -albumin has much influence on ascites. In a detailed whether the same clinical results cannot be obtained study of the osmotic factors influencing the formaless by expensive and simpler methods of intravenous tion of ascites, in 10 cases of cirrhosis, MANKIN and feeding. LOWELL2showed quite conclusively that although
Salt-poor
3.
1. Post, P., Rose, J. V., Shore, S. M. Arch. intern. Med. 1951, 87, 775. 2. Mankin, H., Lowell, A. J. clin. Invest. 1948, 27, 145.
Gray, H. K. Ann. R. Coll. Surg. 1951, 8, 354 ; see Lancet, 1951, i, 1402. 4. Eisenmenger, W. J., Ahrens, E. H. jun., Blondheim, S. H., Kunkel, H. G. J. Lab. clin. Med. 1949, 34, 1029.