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SCHMIDT 10 this offers considerable promise, though thenecessity for the intra carotid injection will limit itsappeal., -

It is evident that measurement of the cerebralblood-flow is becoming established, alongside measure-ment of the renal and hepatic blood-flows, as a

recognised procedure in clinical research. UnlikeFlCK, the modern reviewer is more embarrassed by theplethora than the paucity of experimental data.

1. Obtainable from the Central Council for the Care of Cripples,34, Eccleston Square, London, S.W.1. Pp. 12.

2. Memorandum and Evidence submitted to the Piercy Committee,British Rheumatic Association, 5 Tite Street, S.W.3. Pp. 34.

3. Report of the General Purposes Committee (no. 2), Agenda forMay 4.

4. Circular no. 7152.

The DisabledALL those who have to do with the care of disabled

people seem agreed on one thing-that the servicesdesigned for their benefit are at present chaotic.The Central Council for the Care of Cripples 1 (C.C.C.C.)the British Rheumatic Association 2 (B.R.A.), andeven the London County Council (L.C.C.), in theevidence they have submitted to the Interdepart-mental Committee of Inquiry on the Rehabilitationof Disabled Persons (the Piercy Committee), mentionformidable gaps in existing arrangements. It isworth recalling what these arrangements are.The Disabled Persons (Employment) Act, 1944,

provides for the maintenance of a register of disabledpersons suitable for employment, and requires allemployers of more than 25 people to give work to aquota of such people (at present 3%). Moreover it

provides for the reservation of certain categories ofwork for the registered disabled, for the establishment ofrehabilitation and training centres, for sheltered employ-ment in factory and at home by the formation of limitedcompanies, and for the appointment of disablementresettlement officers (D.R.O.). In addition, the NationalHealth Service Act, 1946, its Amendment Act, 1949,and the National Assistance Act (Part in), 1948, providebetween them for the supply and maintenance ofappliances, for the well-being of people temporarily orpermanently disabled, and for the home care of the sick.

Registration, however, has some drawbacks of itsown. If, for instance, a registered disabled man

earning trade-union rates has to call in a fellow-worker, occasionally, to help him with some task,he causes this helper to lose time and hence money ;and so may meet a surly response. A system intendedto make for equity may in fact penalise anyone whofeels inclined to give a disabled workmate a helpinghand. Again, the provisions made for different kindsof disability vary greatly. Strong voluntary associa-tions, as well as statutory provisions, give reasonablesupport to the blind and the deaf ; but the tuberculousand the epileptic are not so well served. Many peopledislike working alongside such patients ; and peoplewith these disabilities, are therefore apt to avoidregistration and conceal their disorders as long as

they can. Many infective tuberculous patients, theL.C.C. believes, are at work in industry without eithertheir employers or their workmates knowing anythingabout it. The Ministry of Health 4 has recommendedthat people with known infective tuberculosis shouldbe employed in normal industry provided that they,and their conditions of work, are -under medicalsupervision ; but some chest physicians think theremust be a change of attitude among employers and

;workmates before this will be practicable. Certainlysuch a plan would expose susceptible workers to morechances of encountering the disease-which mightmean a greater danger of spread. The L.C.C. isconfident that if enough alternative sheltered employ-ment, offering satisfactory pay, were available, mostof the patients now engaged in work which is unsuit-able for them would come forward, and be glad tochange.. It would like to see more Remploy factoriesfor these patients, and it also suggests that bothGovernment factories and factories owned by privatefirms should set aside sections where people disabledby tuberculosis could be employed.

Those disabled by the rheumatic diseases also needmuch more help than they are getting. Last year,in the Survey of Sickness,5 rheumatoid arthritis wasreported in 1.4-1.6 men, and 6-7 housewives, per1000 people (over 16 years of age) who were inter-viewed ; and the comparable figures for chronicrheumatism were much higher--41-67 men and 157housewives, per 1000. Many people disabled by thesediseases would be capable of doing part-time work,if this were to be had ; many would be less disabledif their disease had been treated in its early stages ;many are occupying hospital beds from which theymight have been excluded, either temporarily or

permanently, by active treatment; and many coulddo more if they had appropriate appliances.The problem of appliances, indeed, badly needs

reconsidering. Prof. THOMAS FERGUSON s has reportedthat the lack of much-needed appliances, and of

adequate treatment, was a cause of the weariness anddislike with which many of the disabled youths inhis Glasgow study regarded doctors and hospitals ;it also partly accounted for a high unemployment-rate among them. The C.C.C.C. mentions the timewasted when an appliance needs repair : even ifit only needs a new screw or strap, the patient hasto " see the doctor " in hospital before he can be givena chit to take to the workshop. The medical inter-view might surely be waived when the lesion is notin the patient but only in the instrument. TheC.C.C.C. also’ recommends that the schedule of

appliances should be extended to include such thingsas stocking-gadgets, which enable the patient todress himself, and such special kitchen or other

equipment as a housewife needs to carry out householdtasks. Moreover, it suggests that disabled people whoma consultant thinks unfit to use public transportshould be entitled to have motor chairs.

It is still not easy to find jobs for the disabled.The quota system works well up to a point, but theC.C.C.C. finds that some employers make up the

quota by engaging people whose disability does nothamper them for the work in hand : a bank clerkwith a gastric ulcer, for instance, is not disabled forhis task and should not count towards the quota.The regulations might well be tightened so that thosedisabled people whose prospects of getting work arepoor are given fairer apportunities under the quotasystem. All parties seem agreed -that training coursesare very inadequate at present. Professor FERGUSONhas emphasised the need for more courses for dis-

, abled young people leaving school, when most of

5. Brooke, E. Mon. Bull. Minist. Hlth. Lab. Serv. 1953, 12, 114.6. M.R.C. Memorandum no. 260. 1952. See Lancet, 1952,

ii, 120.

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them have a positive and enthusiastic attitude towork. Only too often they are allowed to driftinto unskilled manual labour, to which they are

unsuited but which is comparatively well paid.If they are then urged to go into skilled work, wherethe pay is less during training, they often think them-selves better off where they are. It is only later,when they see their friends in skilled work earninghigher wages, that they realise their own chance hasbeen lost; and " the crisis of school leaving is neverrepeated."

Disabled school leavers are mainly handicappedby congenital disorders ; and they need, as theC.C.C.C. says, an education which will equip themmentally, and as far as possible physically, to enterindustry when they leave school. People disabledlater in life need a course of reablement which will

give them a new outlook on work. Even when coursesare provided these may not suffice to launch thetrainee successfully. Some trade-union organisationsare reluctant to admit those whose training hasbeen shorter than that of able employees, no matterhow high the standard of proficiency reached. But,in fact, it is not wholly a question of proficiency :a severely handicapped young adult entering employ-ment for the first time may need as long as threeyears at a training college to fit him for life in openindustry. The C.C.C.C. therefore believes that sub-stantial encouragement should be given to employersto train within industry ; and it doubts whetherthe cost of this would exceed the amount now spenton special training centres. The L.C.C., on the otherhand, is thinking of providing a combined reablementunit and sheltered workshop for the physically dis-abled, to be linked if possible with a placement serviceand an arrangement for including outworkers. Clearlythere is room for useful discussion here. Bothmethods of training have their advocates, and it willbe helpful to know the advantages and drawbacksof each, as seen through the impartial eyes of thel’ierey Committee. The system of sheltered work-shops provided by Remploy is criticised by the B.R.A.because it caters for only some 6000 disabled workers(albeit these are the most severely disabled, beingjudged unfit for open industry, anyhow at the timeof their engagement), and because it makes no

deliberate attempt at medico-industrial reablement.The C.C.C.C., however, holds that the value of

Remploy factories to those for whom they are

intended would be greatly increased if more hostelswere available, and more transport provided, fordisabled people who live too far away to seek workin them.The disabled, like the rest of us, need incentives

to bring out their best work. The experience of theMichael Works 7-that " Men who had been listlesslyand unenthusiastically doing their jobs, sprang tolife when they knew that additional effort wouldmean a larger pay packet "-deserves to be kept inmind. Indeed, it is a weakness of many sheltered

workshops that they do not take this very humanquality into account. The C.C.C.C., regretting theheavy Remploy subsidy (&7 6s. weekly to each factoryworker, after crediting sums obtained by the sale ofproducts), suggests that a wise policy would be to7. Arthur, J. Through Movement to Life. London, 1952 ; see

Lancet, 1953, i, 1054.

give pensions on assessment of disability, and there-after-as an incentive to the fullest possible production-the r.ate for the job. It has to be borne in mind,of course, that an ambitious worker may be led inthis way to drive himself too hard ; but the factorydoctor should be able to guard him against this risk.The disabled, it seems clear, are not only being

given care of a patchwork and piecemeal kind : theyare also being hindered in doing as much towards theirshare of the country’s work as they might. It is

widely held that part of the trouble comes from theirbeing under the care of so many departments-theMinistries of Labour and of Pensions and NationalInsurance, the National Assistance Board, and the localauthorities. The C.C.C.C. recommends setting up a co-ordinating committee, representing all the departmentsconcerned ; and the B.R.A. goes further and asks fora public corporation (on the lines of the British

Broadcasting Corporation), under the aegis of theGovernment but independent of it, represented inParliament by a Minister without portfolio, andfinanced-to the amount already spent on the dis-

abled-by Government funds. This policy-makingbody would be responsible for the welfare of all thehandicapped, from school-leaving age onwards. Thereseems a risk that so large a body, paid for out ofpublic funds, might in time develop into yet anotherGovernment department, with all the weaknesses,as well as the delights, attendant on such things.The interests of the disabled might be more success-fully-and certainly more flexibly-safeguarded bya coordinating committee; or even by a littlecoordination.

1. Dible, J. H., Hunt, W. E., Pugh, V. W., Steingold, L., Wood,J. H. F. J. Path. Bact. 1954, 67, 195.

Annotations

FŒTAL HEPATITISJAUNDICE in the neonatal period is extremely common,

and it may be difficult to establish its cause. The mildtransient form usually described as physiological is

undoubtedly the _most usual ; but syphilis, umbilical

sepsis, erythroblastosis, and congenital atresia of thebile-ducts should all be excluded before this diagnosis isconfidently accepted. Infective hepatitis, the commonestcause of jaundice in adults, has usually been disregardedbecause of its long incubation period ; but it now seemsthat the foetus may be infected in utero. Dible and hisassociates describe 4 cases of infants, including 1 withsevere jaundice, who died in the first two days of life.At necropsy there was moderately severe hepatitiswhich was so far advanced that the lesions must have

begun in utero. In all 4 there were the usual histologicalfeatures of hepatitis : necrosis of liver-cells, bile-duct

proliferation, histiocyte reaction, fibrosis, and liver-cellregeneration. Multinuclear giant-cells, apparently derivedfrom parenchymal cells, and iron-containing pigmentgranules in liver-cells and histiocytes, were also con-

spicuous. Since the amount of iron, determined chemi-cally, was not increased, Dible takes this finding as

evidence of impaired capacity of the damaged liver-cellsto_incorporate iron in its usual organically bound form.Another notable difference from the picture in adults wasthe presence of foci of active haemopoiesis. Such fociare an important feature of the liver in erythroblastosis,and the possibility that haemolytio disease underlay thehepatic lesions was carefully excluded. Haemopoiesis inthe liver is normal up to the time of birth, and foci areusually recognisable up to about twenty-four hours