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Doctors for Industry

THE LANCETLONDON: SATURDAY, OOTOBER 20, 1945

A COMMITTEE set up by the Association of IndustrialMedical Officers x holds that " no national healthservice can be adequate that does not include, as anintegral and properly coordinated part of the whole,an industrial health service," and regrets that " sofar, no plan of any kind for the development of thisservice has been evolved by a responsible Governmentdepartment." But believing that national provisionof an industrial health service cannot and should notbe long deferred, it maintains that " adequatefacilities for education and training of those doctors,nurses, and others who take part in it must be pro-vided at the earliest opportunity." This is an opinionwhich is easy to share. Never at any time wasthere more opportunity or more reason for encourag-ing the development of the industrial health services.War-time experience in factories has proved notonly their social but also their industrial value : it is

generally recognised that they have aided efficiency,increased production, and reduced absence of workersthrough minor illnesses and injuries.Hitherto the full development of such a service

has been handicapped by lack of people trained, oravailable for training, in this specialised work. Asdemobilisation proceeds, many doctors, nurses, andorderlies seeking fresh employment may be attractedto this new and important branch of medical practice,and it should not be difficult to recruit enough men andwomen to satisfy the full needs of the service, if onlythey can be offered proper training, and pleasantenough prospects thereafter. The committee leaves usin no doubt about the scope and variety of thework to be done in connexion with factories, mines,,quarries, docks, shipbuilding yards, railways, shipping,the building industry, agriculture, and commerce-not to mention research and teaching. But whenit turns to the provisions so far made for training inindustrial medicine it finds them very far short ofwhat is needed. Recent developments, includingthe foundation of chairs or readerships in industrialhealth at Manchester, Durham, and Glasgow, are

helpful, but it would like to see similar departmentsin the universities of London, Birmingham, and Liver.pool. Moreover, throughout the teaching of medicalundergraduates, more should be said not only aboutthe effect of occupation on illness but also about theeconomic repercussions of illness on the patient andhis family. The student should learn to recognisethat when he treats a patient, the " treatment is notcomplete until he is again able to earn his living."The committee demands that " teachers of medicineand surgery should themselves understand somethingof the principles of industrial health." It suggests,too, that the student should have " a course of atleast six lectures on occupational medicine and spend1. The members were Dr. W. E. Chiesman (chairman), Dr. J. C.

Bridge, Dr. Donald Hunter, Dr. R. E. Lane, Dr. T. A. LloydDavies, Dr. T. Gwynne Maitland, Dr. D. C. Norris, Dr. C. L.Potts, Dr. R. S. F. Schilling, Dr. Donald Stewart, and Dr.K. M. A. Perry (secretary).

at least three days within the factory when the normalwork of the industrial medical officer can be explainedto him."The main vocational training of those who seek a

career in industrial medicine, , will, however, not

begin until after qualification : indeed, the committeedoes not want it to begin until the aspirant has had,after qualifying, " at least two years in which togain clinical experience, both in house appointmentsand in general practice." It will then be necessary" to offer three distinct types of training: (i) for theman who is to devote his life to this type of workand who intends to become a consultant in it; (ii)for the man who intends to become an industrialmedical officer, whether part-time or whole-time ;and (iii) for special appointments (such as-those ofthe present examining surgeons and factory medicalinspectors)." (The apparent implication in this groupingis that medical inspectors of factories are not to beclassed as consultants ; but the truth is that no othergroup of doctors has had a wider experience of indus-trial affairs and none has a better claim to consultantrank.) From this the report goes on to differentiatebetween the type and length of training neededfor these different groups. For our part we couldhave wished that the committee had concentratedmore on the steps necessary to attract and train a muchlarger number of part-time and whole-time industrialdoctors ; for these are the men and women needednow. Doubtless in their ranks suitable candidateswill later be found to train as consultants, teachers,research-workers, and medical inspectors of factories ;and admittedly, all these groups will have to have alonger and more specialised training than the ordinaryworks doctor. But would it not be better for themto have this special training after they have gainedpractical experience in industry, rather than make anacademic decision to specialise while:still at -hospitalor university ? "

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However this is decided, the urgency lies in thetraining of the -rank and file, and we are glad thatthe committee everywhere recognises -the necessityof training for part-time as well as whole-time service.The part-time industrial doctor (risually spending the.rest of his time in general practice) can play animportant part; for much of the industry of thiscountry is organised in units which are too small ortoo scattered profitably to use or to share theservices of a whole-time medical officer. In the

proposed syllabus of training prominence is rightlygiven to the physiology and psychology of work, theprinciples of social and preventive medicine, and the.working environment, and to reablement andresettlement in industry. Naturally, occupationaldiseases have also to be studied, but they are notallowed to dominate the picture. If we are designinga service that will bring health to industry, rather thanone that will merely treat industrial disease, this isthe right approach.

Finally, the committee discusses the advisabilityof offering diplomas in industrial health. Despitestrong arguments which it draws from the experienceof other specialties, it eventually decides that sucha diploma is now a necessity, and " recommends thatif a Diploma in Industrial Health is instituted itshould be given by the Royal Colleges. It would notbe in the best interests of industrial medicine if

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, diplomas in the subject were instituted by separateuniversities or other bodies throughout the country."This last eventuality, however, seems not unlikely.As announced in our issue of Oct. 6, the Society ofApothecaries of London have already declared theirintention of granting a special diploma, and otherexamining bodies may follow. In our view it isimportant to train as many doctors for industry as isfeasible ; but the course of training of three (or atmost six) months sufficing for this purpose wouldhardly justify the award of a special diploma. If theestablishment of a diploma were to have the effect ofexcluding from industrial posts all those who did notpossess it, a disservice would undoubtedly have beendone to industry. For those who do seek academic

recognition of special study and special experiencein this branch of medicine, an alternative wouldbe to modify the course for the diploma in publichealth so that (after initial training in environmental

. and preventive medicine) the candidate could

specialise in different groups of subjects, one ofwhich might be industrial medicine. The new

syllabus proposed in a report from the Society ofOfficers of Health (seep. 514) includes a basic course fordoctors undertaking any form of public-health work.

Normal Life of the Red CellBECAUSE it is easily removed from its normal

environment and easily replaced, more is knownabout the behaviour and chemistry of the blood thanof any other tissue. But there is still much specu-lation about the individual red cell. Is each cell justa protoplasmic mass, an envelope for the carriage ofhaemoglobin, or is it a tissue cell which by evolutionhas lost its nucleus but retains the biological propertyof having a more or less fixed life ? On the formerview one would expect that destruction would beindiscriminate ; on the latter that each cell wouldlive its normal life-span, wear out, and be removed ata set time, which could be determined.Many attempts have been made to estimate the

average life-span of the individual red cell throughtransfusion experiments. ASHBY 1 in 1919 evolved a

technique for identifying heterologous but compatibletransfused cells in a recipient’s circulation-e.g.,0 blood in an A recipient. The principle of thismethod is to count the donor’s cells by using as adiluting fluid not Hayem’s or another routine diluentbut a serum which will completely agglutinate therecipient’s own red cells, leaving the donor’s cells

unagglutinated. By following the inagglutinablecell-count from the time of transfusion until it reachesthe low level of the pretransfusion

" blank " count,one can calculate the life of the donor’s red cells in the

recipient’s circulation. ASHBY’S own early resultswere somewhat variable, but later modifications ofthe method have increased its accuracy. Using DACIEand MoLrsorr’s 2 modification, CALLENDER and hercolleagues in WITTS’s department at Oxford haveconfirmed the estimate of ASHBY and others4, thatthe life of the red cell under these conditions is about120 days. Unlike most of the previous workers they1. Ashby, W. J. exp. Med. 1919, 29, 267.2. Dacie, J. V., Mollison, P. L. Lancet, 1943, i, 550.3. Callender, S. T., Powell, E. O., Witts, L. J. J. Path. Bact. 1945,

57, 129.4. Weiner, A. S. J. Amer. med. Ass. 1934, 102, 1779 ; Mollison, P. L.,

Young, I. M. Quart. J. exp. Physiol. 1942, 31, 359.5. Brown, G. M., Hayward, O., Powell, E. O., Witts, L. J. J. Path.

Bact. 1944, 56, 81.

used normal subjects as the recipients. These subjectshad been bled over the preceding few hours an amountof blood equal in red-cell content to that of the bloodtransfused, so that the recipient’s erythropoiesis wasdisturbed as little as possible. Their careful follow-upof the elimination of the donor cells showed that,apart from a slightly increased rate of destruction insome cases in the first few days, a fixed proportion ofthe blood was eliminated each day. From this it was

possible to prove mathematically that each cell mustlive for a fixed time and then be destroyed. It wouldhave been .preferable in these experiments to haveused absolutely fresh blood instead of blood stored upto six days ; otherwise the planning of the experimentwas admirable. In almost all the previous investi-gations the subjects were suffering from some form ofanaemia or other disease, or were normal personsunder conditions of considerable physiological stress.When normal subjects have been used the methodsof examination have often been open to gravecriticisms. Oxford workers 5 had previously shownby the Ashby method that in certain diseases andanaemias the destruction of transfused cells, whiledirectly proportional to time, was more rapid thanin the normal subject. On the other hand, in somehaemolytic anaemias the elimination curve was notlinear but roughly exponential. The factors which

produced curvature in the decay curve resided in therecipient and were probably related to his disease.Indiscriminate destruction of red cells, regardless oftheir age, would give an exponential decay curve.This indiscriminate process may be active in somehaemolytic states.

It is sometimes possible to deduce the life-span ofthe red cell mathematically=for instance, from thetime the red-cell count takes to reach its maximumwhen man is exposed to low atmospheric pressure athigh altitudes or from the time it takes to returnto its pretransfusion level after transfusion of largeamounts of blood (as in cases of aplastic anaemia),’or from the time it takes to reach the normal levelagain after a haemorrhage.8 These deductions givea life-span of 14-35 days. But it is notable that thesubjects of the experiment have grave disturbances oferythropoiesis either from disease or from physio-logical stress. ScHipDT,? who summarises much ofthis work, also quotes the observations made on pig-ment excretion, from which it is possible to calculatethe red-cell life. The average amounts of bilirubinexcreted daily by patients with bile fistulee can beassessed, and from these figures red-cell life has beenestimated as from 15 days 9 to 40 days; 10 but part ofthe bilirubin produced by red-cell destruction maybe retained. Urobilinogen excretion has also beenused as a basis for the calculation. If no urobilinogenwere re-absorbed and used again, the life-span wouldbe 100-200 days, but it is claimed that three-quartersof the total produced is re-absorbed.12 WATSOrr 13severely criticises almost all the methods used for

measuring the daily excretion of urobilinogen. He

6. Escobar, R. A., Baldwin, F. M. Amer. J. Physiol. 1934, 107, 249.7. Isaacs, R. Physiol. Rer. 1937, 17, 291.8. Schiødt, E. Amer. J. med. Sci. 1937, 193, 313; Acta med. scand.

1938, 96, 49.9. Brugsch, T., Retzlaff, K. Z. exp. Path. Ther. 1912, 11, 508.

10. Bingold, Folia hœmat., Lpz. 1930, 42, 192.11. Broun, G. O., McMaster, P. D., Rous, P. J. exp. Med. 1923,

37, 733.12. Eppinger, H., Charnas, D. Zeit. klin. Med. 1913, 78, 387.13. Watson, C. J. in Downey’s Handbook of Hæmatology, London,

1938, Vol. IV, Arch. intern. Med. 1937, 59, 196.