1173

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

1174

postnatally; and their presence in these cases representsonly some delay in the normal maturation ’process of theliver-which is scarcely surprising when that organ isgrossly abnormal in other respects. Dible and his col-leagues justifiably conclude that the pathological findingsin these infants were attributable to their stage ofdevelopment and were in no way incompatible with viralhepatitis.The relationship of this neonatal hepatitis, apparently

contracted in utero, to juvenile cirrhosis is next con-sidered by Dible and his associates. In 2 infants who

developed jaundice within a few days of birth and diedafter three and seven weeks, necropsy showed distinctdiffuse hepatic fibrosis such as occasionally follows infec-tive hepatitis in adults. In the absence of any other

aetiological factor Dible et al. conclude that these 2 casesmay represent the sequelae to the acute type of diseaseseen in the 4 previous cases.

It seems unlikely that the virus of ordinary infectivehepatitis is responsible for in-utero infection, for there isno evidence that infective hepatitis in the mother istransmitted to the fcetus. On the other hand, Stokeset a1.2 have reported the case of a woman, subsequentlyshown to be a carrier of an icterogenic virus, whoseinfant developed jaundice at four months and died withhepatic cirrhosis at eighteen months. In view of the

frequency of icterogenic virus in blood-plasma, the rarityof in-utero infection implies either a considerable resistanceto transplacental transmission of the virus or a simulta-neous transmission of antibodies. Possibly neither typeof infective-hepatitis virus is responsible, but some otheragent such as herpes virus.3 Virological studies in furthercases should answer this very important question.

2. Stokes, J. jun., Wolman, I. J., Blanchard, M. C., Farquhar,J. D. Amer. J. Dis. Child. 1951, 82, 213.

3. France, N. E., Wilmers, M. J. Lancet, 1953, i, 1181.4. Brown, J. J. M. Brit. J. Surg. war suppl. no. 2, 1948, p. 354.5. DeBakey, M. E., Simeone, F. A. Ann. Surg. 1946, 123, 534.6. Ziperman, H. H. Ibid, 1954, 139, 1.7. Maybury, B. C. Brit. med. Bull. 1944, 2, 142.8. Moore, H. G. jun., Nyhus, L. M., Kanar, E. A., Harkins, H. N.

Surg. Gynec. Obstet. 1954, 98, 129.

VASCULAR INJURIES IN WAR

IT has long been known that primary ligation of majoiperipheral arteries gives poor results. In the 1939-4fwar the results were possibly worse than those previousl3reported,4 and DeBakey and Simeone found that o:

2471 patients with arterial wounds only 135 had beertreated by primary repair and reconstitution of th{

damaged artery. Since division of " critical " arterie:

(axillary, brachial, femoral, and popliteal) so often lead,to loss of limb or life, it is understandable- that a mor(active policy of arterial repair was initiated by th(American medical services in the Korean conflict. Som{

encouraging preliminary reports are now appearing.The interval between wounding and arrival at th{

surgical centre is vitally important ; and in Koreaevacuation by helicopter reduced the average intervalbelow the critical level of ten hours. Ziperman notesa definite correlation between lack of vascular-surgicalexperience and amputation-rate ; this was so evidentthat a special centre for the teaching and practice ojvascular surgery was established in Korea. Zipermanreviews 218 peripheral vascular injuries, of which 162involved " critical " arteries. In 132 cases the arterialwounds were repaired by end-to-end anastomosis, arteri-orrhaphy, and vein grafting. The outstanding featureis the proportion of extremities lost-20% in the wholeKorean series, compared with 40% in a 1939-45 series.5Results were especially impressive in partial arterialtears which after debridement can be repaired by evertionsutures. Longitudinal closure of a defect may be followedby such narrowing of the lumen that thrombosis ensues. 7Moore et al.8 emphasise that damage of the intima alwaysmuch exceeds that of the adventitia, and conclude thatresection of the entire length of the injured vessel followed

by end-to-end anastomosis gives the most satisfactoryresults with the least disturbance of blood-flow. Wherethe severed ends of the artery cannot be safely approxi-mated a free vein graft seems to be the best method ;the place of preserved arterial grafts has not been fullydetermined. The use of ’Vitallium tubes and other

prostheses has apparently been abandoned. Zipermanstrongly advises against ligation of the concomitant

undamaged vein-a point which most surgeons wouldendorse.

1. Dowling, G. B., Wetherley-Mein, G. In Modern Trends inDermatology. Edited by R. M. B. MacKenna. London, 1954.

2. Griffith, A. S. Lancet, 1916, i, 721.3. Jensen, K. A. Cited by Marcussen (footnote 9).4. Lomholt, S. Acta tuberc scand. 1946, 20, 136.5. Ustvedt, H. J. In Modern Practice in Tuberculosis. Edited by

T. Holmes Sellors and J. L. Livingstone, London, 1952.6. Tolderlund, K. Cited by Marcussen (footnote 9).7. Kalkoff, K. W. Hautarzt, 1950, 1, 366.8. Gilje, O. Acta derm.-venereol., Stockh. 1952, 32, 51.9. Marcussen, P. V. Brit. J. Derm. 1954, 66, 121.

LUPUS FROM B.C.G.

Lupus vulgaris usually starts with the implantationof tubercle bacilli from an external source. In childrenit may develop from a primary tuberculous sore. Inadults, who have probably already done battle with thetubercle bacillus in the lungs or bowel, bacilli implantedin the skin more commonly give rise to a different kindof lesion-verrucous skin tuberculosis. This suggests toDowling and Wetherley-Mein 1 that the type of immunityderived from primary infection of the skin differs fromthat derived from extracutaneous foci. The bacillusrecovered from the lesion of lupus is of low virulence,and such strains are rarely found in tuberculosis in othersystems,2 so it seems probable that the organism isattenuated in the skin itself ; once lupus is initiated,the attenuated strain is of sufficient virulence to maintainthe characteristically chronic process.

Jensen 3 predicted the production of lupus vulgaris bythe intentional inoculation of artificially attenuatedtubercle bacilli-i.e., B.C.G. Lomholt 4 first reportedsuch a case. Ustvedt 5 thought that the lupus must havearisen through superinfection, but Tolderlund 6 con-sidered that the bacillus recovered from this case wasindistinguishable from B.C.G. 2 further cases of lupusfollowing B.C.G. vaccination were reported 7 8 but withoutbacteriological proof of the causal organism. Marcussen 9has now described 3 cases, in 2 of which there was goodclinical and bacteriological evidence that the lupus wasnot due to superinfection. In all 3 cases the lesion

spread from the site of B.C.G. vaccination, and in 1 ithad persisted for three years. All 3 patients weretuberculin-negative before vaccination. 2 had no knowntuberculous contact, and a tubercle bacillus recoveredfrom their lesions proved identical with B.C.G. in culturalbehaviour and pathogenicity.

In B.c.G.-vaccinated patients who subsequently developtuberculosis of organs other than the skin, it is usualto find tubercle bacilli of high virulence ; and such casesare attributed to fresh infection. The close similaritvof the bacillus of lupus to B.C.G. makes this attributionless convincing in cases of skin tubercle. If, however,the laboratory criteria for their separation are valid,B.C.G. vaccination can probably give rise to progressiveinfection of the skin for at least several years. It has

long been known that B.C.G. can survive in the tissuesfor up to eighteen months, and a case of tuberculouslymphadenitis attributed to B.C.G. was diagnosed threeyears after vaccination.

Marcussen raises the question of variation in the

potency of the vaccine. If this were a material factor,one might have expected many more cases of lupus.Also, the accidental injection of enormous doses of B.C.G.has not provoked long-standing local infection. Variationin the host’s response is a more probable explanationof these rare cases. It may be significant that one ofMarcussen’s cases was inoculated four times before