of 1 /1
1132 No form of compulsion or of painful treatment is of any value. This will succeed as a method only when the patient is away from the strain and on the way to spontaneous recovery ; in fact, any small suggestion will remove the symptom when it is no longer re- quired as a defence, and this need not be a painful stimulus. While the patient is still under strain, he will suffer almost any torture to retain the symptom which is his sole defence, and painful treatment is cruel as well as useless. If the treatment is too pain- ful to endure, he will exchange one symptom for another-e.g., aphonia changes to stammer. From the beginning the patient should be left in no doubt about the nature of his symptoms, but the whole condition should be taken seriously, and he need not be made to feel any humiliation because he has a physical symptom without a pathological basis. The symptom should be left alone, no matter how strong the temptation to try and remove it. It serves as an indicator to the physician of the progress of the case. The purpose of the symptom having been explained to the patient, he can be reassured that it will dis- appear spontaneously when the strain has been re- lieved, and his treatment thereafter follows along the lines laid down for the anxiety cases-the rehabilita- tion should not be hurried because he shows no signs of emotional strain. This type of case has been dealt with at length because such patients are incor- rectly handled more often than are the anxiety cases. ORGANISATION The scheme above outlined should be easy to organise. The only increase of personnel is the pro- vision of a psychologist at each suitable base hospital and the equipment of a special rehabilitation camp, remote from the war activities, also in the charge of a psychologist. This expense would be more than com- pensated by the fact that the need for neurological hospitals in England would be greatly diminished. HEALTH OF LONDON BUSMEN ONE of the main factors leading to the stoppage of the London Central Omnibus services in the spring of 1937 was the widespread feeling amongst the drivers and conductors of the vehicles that the conditions of their work had, with the modern growth of traffic, become so exacting as to be definitely injurious to their health. In particular they believed that these con- ditions led to an abnormally high incidence amongst them of illness of the digestive system. Some evidence to this effect was placed before the court of inquiry appointed by the Minister of Labour to inquire into the stoppage, but it was not sufficient to convince the court that the busmen’s occupations were in fact unhealthy. It was, however, sufficient to lead the court to advise further investigations. In consequence the Minister of Labour arranged for an inquiry by the representatives of three bodies-the London Passenger Transport Board, the Transport and General Workers’ Union and the Medical Research Council-with Sir John Forster as their chairman. The result of their labours has now been published.1 From the statistical aspect they accept the main conclusion of Bradford Hill’s report to the Industrial Health Research Board which was published after the court of inquiry had completed its task-namely, that in the years 1933-35 the London omnibus workers in comparison with its tramway workers showed a 1. Health of London Central Busmen. H.M. Stationery Office, 1939, p. 49, 1s. 2. Industrial Health Research Board report No. 79, 1937. small relative excess of gastric illnesses. This result they confirm by means of a similar comparison of the omnibus workers with the transport board’s main- tenance workers employed at Chiswick. With an eye to the possible errors of diagnosis in panel practice (only the first diagnosis being available), they sought more precise data from hospital records but were unable to devise any practical means of obtaining these both for the busmen and for appropriate control groups. Mortality data were equally uninformative. On the other hand evidence is given that the sickness- rate from all causes of illness, both of drivers and conductors, has not risen between 1931 and 1938, in spite of the growth of traffic which led to the opera- tives’ complaints of the present intensity of their work. Despite the ameliorative changes in working conditions which followed the stoppage of 1937 those complaints were reiterated by the men’s representatives whom the committee interviewed. They therefore made a careful study of those conditions, which are set out briefly in the report, and took medical advice upon the general question of the causation of gastric illnesses to see whether any special features of the work might appear to predispose the men to such forms of sickness. The committee was particularly impressed by two aspects of the busman’s work, the irregularity of the hours of duty and, in consequence, of meal-times, and the nervous tension and anxiety which operating a bus in central London probably involves. Irregularity of work is an inevitable feature of a bus service and the present agreement between the board and the union provides that turns of duty shall change weekly. So frequent a change clearly demands a considerable power of adaptation from the gastric system. On the other hand, a system of rotation of shifts on, say, a monthly basis, would mean that a proportion of the bus crews were engaged continuously on the heavier duties while others were working for a similar length of time on lighter duties. This, no doubt, accounts for the lack of desire of the men themselves for any such change. Medical opinion was unanimous regarding the undesirability of irregular meal-times and the com- mittee therefore advises the board _and the union to consider a system providing a longer interval between changes of shifts. They also conclude that some spells of duty are too long and in these instances an earlier meal relief should be introduced. The actual duration of time allowed for a meal relief was not apparently a specific matter of complaint by the men, but, in view of their attitude to the "intensity of the work" and the problem of nervous tension, the committee advises that consideration should be given to a reduction in those reliefs which at present provide less than 40 minutes (a considerable proportion of the total). For the same reason they lay great stress on the provision of rest-pauses between journeys, the adequacy of which has been called in question by the busmen. These, they say, should be kept under constant review in the construction of schedules. The provision of facilities for the adequate use of such rest-pauses - canteens and rest-rooms, washing and lavatorv accommodation-are being steadily pushed forward by the board. The committee took expert evidence on the question of the absorption of carbon monoxide and other fumes by the bus crews, but were unable to determine whether, as the men believe, they contribute to the incidence of gastric illness. In general, however, it seems that under normal peace-time conditions the London busman feels the strain of his work. The ways and means of amelioration suggested in this report will, no doubt, be closely considered by all parties.

HEALTH OF LONDON BUSMEN

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1132

No form of compulsion or of painful treatment is ofany value. This will succeed as a method only whenthe patient is away from the strain and on the way tospontaneous recovery ; in fact, any small suggestionwill remove the symptom when it is no longer re-quired as a defence, and this need not be a painfulstimulus. While the patient is still under strain, hewill suffer almost any torture to retain the symptomwhich is his sole defence, and painful treatment iscruel as well as useless. If the treatment is too pain-ful to endure, he will exchange one symptom foranother-e.g., aphonia changes to stammer. Fromthe beginning the patient should be left in no doubtabout the nature of his symptoms, but the wholecondition should be taken seriously, and he need notbe made to feel any humiliation because he has a

physical symptom without a pathological basis. The

symptom should be left alone, no matter how strongthe temptation to try and remove it. It serves as anindicator to the physician of the progress of the case.The purpose of the symptom having been explainedto the patient, he can be reassured that it will dis-appear spontaneously when the strain has been re-lieved, and his treatment thereafter follows along thelines laid down for the anxiety cases-the rehabilita-tion should not be hurried because he shows no signsof emotional strain. This type of case has beendealt with at length because such patients are incor-rectly handled more often than are the anxiety cases.

ORGANISATION

The scheme above outlined should be easy to

organise. The only increase of personnel is the pro-vision of a psychologist at each suitable base hospitaland the equipment of a special rehabilitation camp,remote from the war activities, also in the charge ofa psychologist. This expense would be more than com-

pensated by the fact that the need for neurologicalhospitals in England would be greatly diminished.

HEALTH OF LONDON BUSMEN

ONE of the main factors leading to the stoppageof the London Central Omnibus services in the springof 1937 was the widespread feeling amongst the driversand conductors of the vehicles that the conditions oftheir work had, with the modern growth of traffic,become so exacting as to be definitely injurious to theirhealth. In particular they believed that these con-

ditions led to an abnormally high incidence amongstthem of illness of the digestive system. Some evidenceto this effect was placed before the court of inquiryappointed by the Minister of Labour to inquire intothe stoppage, but it was not sufficient to convince thecourt that the busmen’s occupations were in factunhealthy. It was, however, sufficient to lead thecourt to advise further investigations. In consequencethe Minister of Labour arranged for an inquiry bythe representatives of three bodies-the LondonPassenger Transport Board, the Transport andGeneral Workers’ Union and the Medical ResearchCouncil-with Sir John Forster as their chairman.The result of their labours has now been published.1From the statistical aspect they accept the main

conclusion of Bradford Hill’s report to the IndustrialHealth Research Board which was published afterthe court of inquiry had completed its task-namely,that in the years 1933-35 the London omnibus workersin comparison with its tramway workers showed a1. Health of London Central Busmen. H.M. Stationery Office,

1939, p. 49, 1s.2. Industrial Health Research Board report No. 79, 1937.

small relative excess of gastric illnesses. This resultthey confirm by means of a similar comparison of theomnibus workers with the transport board’s main-tenance workers employed at Chiswick. With an eyeto the possible errors of diagnosis in panel practice(only the first diagnosis being available), they soughtmore precise data from hospital records but wereunable to devise any practical means of obtainingthese both for the busmen and for appropriate controlgroups. Mortality data were equally uninformative.On the other hand evidence is given that the sickness-rate from all causes of illness, both of drivers andconductors, has not risen between 1931 and 1938, inspite of the growth of traffic which led to the opera-tives’ complaints of the present intensity of their work.Despite the ameliorative changes in working conditionswhich followed the stoppage of 1937 those complaintswere reiterated by the men’s representatives whom thecommittee interviewed. They therefore made a carefulstudy of those conditions, which are set out briefly inthe report, and took medical advice upon the generalquestion of the causation of gastric illnesses to see

whether any special features of the work might appearto predispose the men to such forms of sickness.The committee was particularly impressed by two

aspects of the busman’s work, the irregularity of thehours of duty and, in consequence, of meal-times, andthe nervous tension and anxiety which operating a busin central London probably involves. Irregularity ofwork is an inevitable feature of a bus service and thepresent agreement between the board and the unionprovides that turns of duty shall change weekly. Sofrequent a change clearly demands a considerablepower of adaptation from the gastric system. On theother hand, a system of rotation of shifts on, say, amonthly basis, would mean that a proportion of thebus crews were engaged continuously on the heavierduties while others were working for a similar lengthof time on lighter duties. This, no doubt, accountsfor the lack of desire of the men themselves for anysuch change.Medical opinion was unanimous regarding the

undesirability of irregular meal-times and the com-mittee therefore advises the board _and the union toconsider a system providing a longer interval betweenchanges of shifts. They also conclude that some spellsof duty are too long and in these instances an earliermeal relief should be introduced. The actual durationof time allowed for a meal relief was not apparentlya specific matter of complaint by the men, but, in viewof their attitude to the "intensity of the work" andthe problem of nervous tension, the committee advisesthat consideration should be given to a reduction inthose reliefs which at present provide less than 40minutes (a considerable proportion of the total). Forthe same reason they lay great stress on the provisionof rest-pauses between journeys, the adequacy ofwhich has been called in question by the busmen.These, they say, should be kept under constant reviewin the construction of schedules. The provision offacilities for the adequate use of such rest-pauses- canteens and rest-rooms, washing and lavatorvaccommodation-are being steadily pushed forwardby the board.The committee took expert evidence on the question

of the absorption of carbon monoxide and other fumesby the bus crews, but were unable to determinewhether, as the men believe, they contribute to theincidence of gastric illness. In general, however, itseems that under normal peace-time conditions theLondon busman feels the strain of his work. The waysand means of amelioration suggested in this reportwill, no doubt, be closely considered by all parties.