- Email: [email protected]
Young People Starting Work
1026
coarsely ground asbestos is applied to the denuded surface ; and, finally, mediastinal fat is brought into contact with this area so that it can act as a graft. None of these the
is new ; but each step in sequence is said to contribute
measures
carefully planned
to the final result.
Whatever criticisms may be levelled against this operation—several modifications have already been proposed 8-10—it has the merit on first principles of seeking to imitate and supplement rather than to distort a natural process. Post-mortem findings in men confirm experimental findings in dogs that an intercoronary circulation is established across the anatomical watersheds with progressive occlusion of any of the major coronary arteries 11 12 ; and this seems to be the heart’s natural defence against Furthermore, it seems that threatening anoxia. about 9% of people have congenital inter-coronary communications 12 ; and patients who make spectacular recoveries from major coronary occlusions The may well belong to this fortunate minority. of BECK’S rests on justification operation experimental and post-mortem evidence that occlusive coronary disease cannot promote an effective intercoronary circulation until it is severe, and on clinical evidence of dangerous oxygen differentials even with mild or moderate stenosis. The purpose of the is to more place operation people into the favourable have an who abundant inter-coronary [9%] group " network of arteries. Negative merits of the procedure are its remarkablv low immediate mortality (no death in the last 100 consecutive cases in the series of BECK and BROFMAN 4) and technical simplicity, which eliminates from the operation the dangerous element of haste. In the absence of congestive heart-failure, gross cardiac enlargement, and progressive symptoms (and not less than six months after an infarct) BECK advocates it for all cases of angina pectoris and of coronary insufficiency, and even for selected symptoinless patients with a strong family history of early death from coronary disease. It must be admitted, on the other hand, that-though BROFMAN e contrasts the expected mortality of 30%7with the postoperative mortality of 18% in 137 consecutive patients 5—a follow-up period of from six months to five years cannot be regarded as adequate for so unpredictable a disease. There is no accurate way of measuring either the degree of coronary insufficiency or the number of natural inter-coronary channels in any individual patient ; and a carefully controlled trial, over at least ten years, of large, comparative groups will be necessary before the value of the operation in prolonging life can be assessed. In their evaluation of symptomatic relief BECK and BROFMAN have been gratified by the results ; but there are notorious5 pitfalls when patients " act as their own controls," especially when they have a disease where a strong psychologial element is increasingly difficult to exclude. Nevertheless there is a good case for giving the operation an extensive trial, and results so far offer grounds for sober optimism. "
"
"
King, E. S. J. Surgery of the Heart. Balt imore, 1941. 9. Mason, G. A. Lancet, 1951, i, 359. 10. Thompson, S. A., Plachta, A. J. Amer. med. Ass. 1953, 152, 678. 11. Zoll, P. M., Wessler, S., Schlesinger, M. J. Circulation 1951, 4, 797. 12. Beck, C. S., Leighninger, D. S. J. Amer. med. Ass. 1955, 159, 1264. 8.
Young People Starting Work as he was then instruments of the earliest created called, was in its to the health safeguard attempt by the State of young people. Originally, his primary function was to aet its a check on their employment in contravention. of age-limits imposed by statute ; and his critics said that he was sometimes too willing to believe that stunted youngsters were of the prescribed age. The Factory Act of 1874 made it necessary for a child to have a surgeon’s certificate that he was 13 before he entered on full-time work free from schooling, HousDEN1 tells but the Act was often evaded. how a Birmingham brass-founder, seeing a lad who looked very young, asked his age. The boy replied that he was 13 : he knew he was 13 because his mother told him so. But when asked how old he was before his mother told him he was 13, he replied " 9 " ; and further investigation showed that, though duly certified, he was only 9 years old. Another side of the certifying surgeon’s job-one that assumed added importance with the years-was to satisfy himself that the children passing before him were physically fit for the work they were required to but disability was prevalent and standards and it low, may have been that here again the surgeon felt that he could not afford to be too critical. " Passing before " is perhaps the correct expression: remuneration was small and facilities for any examination were sometimes absent. Under the prevailing conditions it was hard to do good work. Now circumstances have greatly changed, though there are still some difficulties. The newer outlook is intended to be much more positive. It is the declared intention of the State that the work of supervising young entrants to industry should dovetail with that of the School Medical Service, the records of which are available to the Appointed Factory Doctor on request. In practice, these records are not very often sought, and when sought they cannot always be produced by return of post ; and there are inevitably cases in which the recorded findings of the school health service do not altogether coincide with those of the factory doctor.
TnM
Certifying Factory Surgeon., one
perform :
HERFORD,2 as ’an appointed factory doctor, presents
study of adolescents at work in the Slough area (predominantly light industry). His experience leads him to conclude that the work of the appointed factory doctor, suitably reoriented to make full use of his unique opportunities, could contribute far a
constructive medicine than it has done hitherto. He points out that the Ince Committee, which considered in detail most of the agencies concerned with the welfare of youth in industry, made no mention of the work of the appointed factory doctor, and that the Youth Employment Service, set up in 1948 as a result of the Ince report, has had little contact with him. From this, HERFORD goes on to make recommendations for the improvement of the appointed factor doctor’s work and the increase of his contribution to the welfare of young people. He comes to the conclusion that the appointment of such doctors should be essentiallv wholemore
1.
to
Housden, L. 1955.
2.
The Prevention of
Cruelty to Children. London,
Herford, M. E. M. Youth at Work. London : Max Parrish & Co. 1957. Pp. 154. 18s. 6d.
1027
time ; that they should belong primarily to the staff of H.M. Medical Inspectorate of Factories, though they should also hold an appointment with the local .authority as an assistant school medical officer ;
that all young persons should be examined regardless of occupation ; that the appointed factory doctor should be medical adviser to the Youth Employment Service and should be provided with a secretary seconded from the staff of that service ; that school niedical records should be submitted automatically to the appointed factory doctor when the children leave school; and that it would be an advantage to have the appointed factory doctor associated with a
university department. There will be general agreement about the need for skilled vocational guidance for young people entering industry (especially for those at either end of the scale of physical and mental fitness) ; for even in these days the choice of a career is left to blind chance-very much a matter of trial and error. The best use is by no means always made of our really able young people, and man3- of the handicapped eould be helped to better things.3As to how improve3.
A. N., MeVean, M. I. Employment Problems of Disabled Youth in Glasgow. Medical Research Council memorandum no. 28, 1952.
Ferguson, T., MacPilail,
PREGNANCY
AND
THE CHILD
MEDICINE is frequently enriched by contributions from other disciplines, and Dr. Stott’s article from an institute of education, which we publish this week, could prove to be the starting-point of a new approach to some of the processes concerned in mental retardation. In a carefully controlled study of 102 mentally retarded children he has found an association between retardation, congenital malformation, and frequent ill health in early life, and he has connected this syndrome with physical and emotional disorders in the mother during pregnancy. He therefore suggests that stress in pregnancy may determine biological inferiority in the child, either directly But in or by facilitating a latent genetic influence. considering the evidence for this hypothesis it should be noted that the survey was retrospective and that the analysed data are based on the mothers’ recollection supported by medical records and health visitors’ cards. No genetic histories were obtained ; and, apart from the knowledge that the retarded children were of normal appearance, we have no details of their clinical classification. Little is yet known about the genesis either of undifferentiated mental retardation or of congenital malformations in man. Certainly, normal development can be altered by prenatal environmental influences, but in the case of congenital malformations there is general agreement that the noxious influences must be in operation at the time of organ differentiation, which in the human feetus is completed by the 12th week of intrauterine life. Anomalies arising after this must be traumatic or regressive changes due to mechanical or chemical agents ; and for an illustration of the fact that grave damage to the mother does not necessarily affect the infant in utero one need look no further than the remarkable case recorded by Mr. Rowbotham and his associates on
p. 1016.
animals have confirmed this timeExperiments specificity of environmental influences and have also indicated the wide variety of physical and chemical disturbances which may produce congenital malformaon
can
nor
are
entirely medical ;
tions. The present position has been summarised Gluecksohn-W’aelsch 1 :
Annotations THE
be made, the issues
neither entirely decisions turn the and inclination of the on background largely on the attitude of and often the youth parents. It would, we believe, be right for the family doctor to take a more active part in vocational guidance, especially of the handicapped child : if he would familiarise himself with the nature and demands of the industry of his area, none could do it better ; and it is fascinating and rewarding work. This would not remove the need for a person specially appointed to do the kind of work done by the appointed factory doctor (who has, of course, other statutory duties) ; but in general we are not persuaded that the multiplication of official doctors would be a good thing, or even economically sound. In practice, HERFORD’S would probably imply organisation on proposals a geographical basis corresponding to that of the major health authorities ; and whether that offers the best prospect of an improvement is open to doubt. The questions he has raised call for careful study. How best to further the well-being of young people starting work is not just a problem of industrial health ; is not this important task one that should fall within the ambit of the general health service itself ? ment
industrial
by
"...thus we have reached... the central problem facing allteratologists,’ namely that of the mechanisms by which causal agents produce malformations. It is of utmost importance to realize that the nature of these mechanisms is independent of the nature of the causal agent. In this respect genetically caused abnormalities do not differ in any way from those produced by deleterious agents, e.g., X-rays, hormones, anti-metabolites, nutritional deficiencies or others. The pathways by which they achieve their end effects may be the same or different but they are independent of whether the original deviation from normal was caused by a gene or some other factor."
Though it is evident that in animals many different maternal conditions may produce a common final syndrome in the embryo, experience with man is by no means so clear. The syndromes associated with maternal rubella and irradiation appear not only time-specific but also to some extent type-specific. Rubella is associated with deafness, cataract, and congenital heart-disease, while irradiation is associated with microcephaly. Apart from these two conditions, no other environmental factors have been proved consistently to cause congenital defects in the human foetus. Among several surveys, those of Carter2 and Creamer3 are specially valuable here. Carter investigated many maternal illnesses during pregnancy with negative results, and Creamer in a controlled follow-up study of the children of mothers with pregnancy toxaemia found no preponderance of either congenital malformations or early ill health. The known associations of congenital malformations with multiple pregnancy, prematurity, multiparity, pregnancy in very young or elderly mothers, and male infants 4 5 are probably not environmentally determined. Even less clear are the facts in regard to mental retardation. A high proportion of mental defectives may have congenital malformations of the brain,6 but these Moreare not necessarily due to noxious environment. mental caused defect is sometimes over, undoubtedly by 1. 2. 3. 4. 5. 6.
Pediatrics, 1957, 19, 777. J. Obstet. Gynœc., Brit. Emp. 1950, 57, 897. Ibid, 1955, 62, 914. H. Obstet. Gynec. 1955, 6, 592. Potter, E. L. Pediatrics, 1957, 19, 719. N. Amer. J. ment. Defic. 1954, 58, 138.
Gluecksohn-Waelsch, S. Carter, C. O. Creamer, B. Hendricks, C. Davis, M. E.,
Malamud,
coarsely ground asbestos is applied to the denuded surface ; and, finally, mediastinal fat is brought into contact with this area so that it can act as a graft. None of these the
is new ; but each step in sequence is said to contribute
measures
carefully planned
to the final result.
Whatever criticisms may be levelled against this operation—several modifications have already been proposed 8-10—it has the merit on first principles of seeking to imitate and supplement rather than to distort a natural process. Post-mortem findings in men confirm experimental findings in dogs that an intercoronary circulation is established across the anatomical watersheds with progressive occlusion of any of the major coronary arteries 11 12 ; and this seems to be the heart’s natural defence against Furthermore, it seems that threatening anoxia. about 9% of people have congenital inter-coronary communications 12 ; and patients who make spectacular recoveries from major coronary occlusions The may well belong to this fortunate minority. of BECK’S rests on justification operation experimental and post-mortem evidence that occlusive coronary disease cannot promote an effective intercoronary circulation until it is severe, and on clinical evidence of dangerous oxygen differentials even with mild or moderate stenosis. The purpose of the is to more place operation people into the favourable have an who abundant inter-coronary [9%] group " network of arteries. Negative merits of the procedure are its remarkablv low immediate mortality (no death in the last 100 consecutive cases in the series of BECK and BROFMAN 4) and technical simplicity, which eliminates from the operation the dangerous element of haste. In the absence of congestive heart-failure, gross cardiac enlargement, and progressive symptoms (and not less than six months after an infarct) BECK advocates it for all cases of angina pectoris and of coronary insufficiency, and even for selected symptoinless patients with a strong family history of early death from coronary disease. It must be admitted, on the other hand, that-though BROFMAN e contrasts the expected mortality of 30%7with the postoperative mortality of 18% in 137 consecutive patients 5—a follow-up period of from six months to five years cannot be regarded as adequate for so unpredictable a disease. There is no accurate way of measuring either the degree of coronary insufficiency or the number of natural inter-coronary channels in any individual patient ; and a carefully controlled trial, over at least ten years, of large, comparative groups will be necessary before the value of the operation in prolonging life can be assessed. In their evaluation of symptomatic relief BECK and BROFMAN have been gratified by the results ; but there are notorious5 pitfalls when patients " act as their own controls," especially when they have a disease where a strong psychologial element is increasingly difficult to exclude. Nevertheless there is a good case for giving the operation an extensive trial, and results so far offer grounds for sober optimism. "
"
"
King, E. S. J. Surgery of the Heart. Balt imore, 1941. 9. Mason, G. A. Lancet, 1951, i, 359. 10. Thompson, S. A., Plachta, A. J. Amer. med. Ass. 1953, 152, 678. 11. Zoll, P. M., Wessler, S., Schlesinger, M. J. Circulation 1951, 4, 797. 12. Beck, C. S., Leighninger, D. S. J. Amer. med. Ass. 1955, 159, 1264. 8.
Young People Starting Work as he was then instruments of the earliest created called, was in its to the health safeguard attempt by the State of young people. Originally, his primary function was to aet its a check on their employment in contravention. of age-limits imposed by statute ; and his critics said that he was sometimes too willing to believe that stunted youngsters were of the prescribed age. The Factory Act of 1874 made it necessary for a child to have a surgeon’s certificate that he was 13 before he entered on full-time work free from schooling, HousDEN1 tells but the Act was often evaded. how a Birmingham brass-founder, seeing a lad who looked very young, asked his age. The boy replied that he was 13 : he knew he was 13 because his mother told him so. But when asked how old he was before his mother told him he was 13, he replied " 9 " ; and further investigation showed that, though duly certified, he was only 9 years old. Another side of the certifying surgeon’s job-one that assumed added importance with the years-was to satisfy himself that the children passing before him were physically fit for the work they were required to but disability was prevalent and standards and it low, may have been that here again the surgeon felt that he could not afford to be too critical. " Passing before " is perhaps the correct expression: remuneration was small and facilities for any examination were sometimes absent. Under the prevailing conditions it was hard to do good work. Now circumstances have greatly changed, though there are still some difficulties. The newer outlook is intended to be much more positive. It is the declared intention of the State that the work of supervising young entrants to industry should dovetail with that of the School Medical Service, the records of which are available to the Appointed Factory Doctor on request. In practice, these records are not very often sought, and when sought they cannot always be produced by return of post ; and there are inevitably cases in which the recorded findings of the school health service do not altogether coincide with those of the factory doctor.
TnM
Certifying Factory Surgeon., one
perform :
HERFORD,2 as ’an appointed factory doctor, presents
study of adolescents at work in the Slough area (predominantly light industry). His experience leads him to conclude that the work of the appointed factory doctor, suitably reoriented to make full use of his unique opportunities, could contribute far a
constructive medicine than it has done hitherto. He points out that the Ince Committee, which considered in detail most of the agencies concerned with the welfare of youth in industry, made no mention of the work of the appointed factory doctor, and that the Youth Employment Service, set up in 1948 as a result of the Ince report, has had little contact with him. From this, HERFORD goes on to make recommendations for the improvement of the appointed factor doctor’s work and the increase of his contribution to the welfare of young people. He comes to the conclusion that the appointment of such doctors should be essentiallv wholemore
1.
to
Housden, L. 1955.
2.
The Prevention of
Cruelty to Children. London,
Herford, M. E. M. Youth at Work. London : Max Parrish & Co. 1957. Pp. 154. 18s. 6d.
1027
time ; that they should belong primarily to the staff of H.M. Medical Inspectorate of Factories, though they should also hold an appointment with the local .authority as an assistant school medical officer ;
that all young persons should be examined regardless of occupation ; that the appointed factory doctor should be medical adviser to the Youth Employment Service and should be provided with a secretary seconded from the staff of that service ; that school niedical records should be submitted automatically to the appointed factory doctor when the children leave school; and that it would be an advantage to have the appointed factory doctor associated with a
university department. There will be general agreement about the need for skilled vocational guidance for young people entering industry (especially for those at either end of the scale of physical and mental fitness) ; for even in these days the choice of a career is left to blind chance-very much a matter of trial and error. The best use is by no means always made of our really able young people, and man3- of the handicapped eould be helped to better things.3As to how improve3.
A. N., MeVean, M. I. Employment Problems of Disabled Youth in Glasgow. Medical Research Council memorandum no. 28, 1952.
Ferguson, T., MacPilail,
PREGNANCY
AND
THE CHILD
MEDICINE is frequently enriched by contributions from other disciplines, and Dr. Stott’s article from an institute of education, which we publish this week, could prove to be the starting-point of a new approach to some of the processes concerned in mental retardation. In a carefully controlled study of 102 mentally retarded children he has found an association between retardation, congenital malformation, and frequent ill health in early life, and he has connected this syndrome with physical and emotional disorders in the mother during pregnancy. He therefore suggests that stress in pregnancy may determine biological inferiority in the child, either directly But in or by facilitating a latent genetic influence. considering the evidence for this hypothesis it should be noted that the survey was retrospective and that the analysed data are based on the mothers’ recollection supported by medical records and health visitors’ cards. No genetic histories were obtained ; and, apart from the knowledge that the retarded children were of normal appearance, we have no details of their clinical classification. Little is yet known about the genesis either of undifferentiated mental retardation or of congenital malformations in man. Certainly, normal development can be altered by prenatal environmental influences, but in the case of congenital malformations there is general agreement that the noxious influences must be in operation at the time of organ differentiation, which in the human feetus is completed by the 12th week of intrauterine life. Anomalies arising after this must be traumatic or regressive changes due to mechanical or chemical agents ; and for an illustration of the fact that grave damage to the mother does not necessarily affect the infant in utero one need look no further than the remarkable case recorded by Mr. Rowbotham and his associates on
p. 1016.
animals have confirmed this timeExperiments specificity of environmental influences and have also indicated the wide variety of physical and chemical disturbances which may produce congenital malformaon
can
nor
are
entirely medical ;
tions. The present position has been summarised Gluecksohn-W’aelsch 1 :
Annotations THE
be made, the issues
neither entirely decisions turn the and inclination of the on background largely on the attitude of and often the youth parents. It would, we believe, be right for the family doctor to take a more active part in vocational guidance, especially of the handicapped child : if he would familiarise himself with the nature and demands of the industry of his area, none could do it better ; and it is fascinating and rewarding work. This would not remove the need for a person specially appointed to do the kind of work done by the appointed factory doctor (who has, of course, other statutory duties) ; but in general we are not persuaded that the multiplication of official doctors would be a good thing, or even economically sound. In practice, HERFORD’S would probably imply organisation on proposals a geographical basis corresponding to that of the major health authorities ; and whether that offers the best prospect of an improvement is open to doubt. The questions he has raised call for careful study. How best to further the well-being of young people starting work is not just a problem of industrial health ; is not this important task one that should fall within the ambit of the general health service itself ? ment
industrial
by
"...thus we have reached... the central problem facing allteratologists,’ namely that of the mechanisms by which causal agents produce malformations. It is of utmost importance to realize that the nature of these mechanisms is independent of the nature of the causal agent. In this respect genetically caused abnormalities do not differ in any way from those produced by deleterious agents, e.g., X-rays, hormones, anti-metabolites, nutritional deficiencies or others. The pathways by which they achieve their end effects may be the same or different but they are independent of whether the original deviation from normal was caused by a gene or some other factor."
Though it is evident that in animals many different maternal conditions may produce a common final syndrome in the embryo, experience with man is by no means so clear. The syndromes associated with maternal rubella and irradiation appear not only time-specific but also to some extent type-specific. Rubella is associated with deafness, cataract, and congenital heart-disease, while irradiation is associated with microcephaly. Apart from these two conditions, no other environmental factors have been proved consistently to cause congenital defects in the human foetus. Among several surveys, those of Carter2 and Creamer3 are specially valuable here. Carter investigated many maternal illnesses during pregnancy with negative results, and Creamer in a controlled follow-up study of the children of mothers with pregnancy toxaemia found no preponderance of either congenital malformations or early ill health. The known associations of congenital malformations with multiple pregnancy, prematurity, multiparity, pregnancy in very young or elderly mothers, and male infants 4 5 are probably not environmentally determined. Even less clear are the facts in regard to mental retardation. A high proportion of mental defectives may have congenital malformations of the brain,6 but these Moreare not necessarily due to noxious environment. mental caused defect is sometimes over, undoubtedly by 1. 2. 3. 4. 5. 6.
Pediatrics, 1957, 19, 777. J. Obstet. Gynœc., Brit. Emp. 1950, 57, 897. Ibid, 1955, 62, 914. H. Obstet. Gynec. 1955, 6, 592. Potter, E. L. Pediatrics, 1957, 19, 719. N. Amer. J. ment. Defic. 1954, 58, 138.
Gluecksohn-Waelsch, S. Carter, C. O. Creamer, B. Hendricks, C. Davis, M. E.,
Malamud,