947

Brain-power

THE LANCETLONDON: SATURDAY, DEO. 28, 1946

THE present man-power shortage is particularlyacute in the professions and the upper ranks of indus-try, commerce, and the public service. This state ofaffairs is due partly to the seven years’ gap in recruit-ment to some callings and partly to reduction in thenumber of university students during the war ; butit derives also from greater efforts to make industryefficient and to develop the social services. In theirlatest broadsheet 1 P.E.P. estimate that ideally theannual intake to the professions should exceed the pre-war level by 80% in 1946-50, and by 55% in 1951-55.For the next ten years teaching alone will need 23,000recruits a year ; and there ought to be substantialincreases in the number of nurses, scientists, dentists,social workers, and medical auxiliaries. The BarlowCommittee has advised that the annual output ofpure scientists should be twice the pre-war total of2500 ; and there should be about the same increasein technologists. According to the Teviot Committee,the annual output of dentists, which was 340 beforethe war, should be raised to 800 as soon as possible.By comparison, the medical profession is well served:the Goodenough Committee’s 1944 estimate was thata 20% increment would be enough ; and the committeeheld that this could be achieved in six years by a15% increase on the pre-war annual output of 2000doctors. Professions in which the pre-war intake willsuffice, after the war-time fall-in recruitment has beenmade good, include accountants, company secre-

taries, and librarians. Those in which present numbersare enough comprise opticians, pharmacists, and

possibly also solicitors. ’

Nobody can say how much demand there will be foruniversity graduates in arts, but P.E.P. suggest thatin order to balance the tendency towards specialisa-tion more young men and women should study thehumanities. The risk of encouraging them to takean arts degree is that those who are not absorbedelsewhere may reluctantly turn their hand to teaching,with unhappy results for themselves and for that

profession. Much of course will depend on industry’sliking for men and women with university qualifica-tions. Owing to the replacement of smaller under-takings by large ones, managers are now usuallyappointed on their merits, and it has become unusualfor a firm to recruit its senior staff in their teens.The Cambridge University Appointments Boardfound that 73% of employers favour a preliminaryuniversity education, because it induces an indepen-dent and critical outlook, capacity for responsibility,and social ease. With opportunities for higher educa-tion depending more and more on ability, rather thanon the parents’ capacity to pay, industry may in anycase have to look to the universities if it wants brains.Recruitment to the professions and administration

should be planned with three aims : the recruits shouldbe of high quality; the supply should be adjusted to1. Britain’s Need for Brainpower, Planning, no. 259: obtainable

from P.E.P., 16, Queen Anne’s Gate, London, S.W.1. Pp. 19.1s. 7d.

the demand ; and there should be fair distributionbetween the various callings. All this can best beachieved by offering advice and information aboutcareers ; by financial aid for suitable people whocannot meet the cost of education ; by improvingmethods of, selection; by balancing salaries andconditions between the major callings; and bytapping all sources. Perhaps only the Governmentcan give wide enough publicity to training and pros-pects of employment; but the Ministry of Labourhas not yet taken the steps to issue " reports ontrends of employment in relation to higher appoint-ments " which the Hankey Committee recommended.An annual Government prediction, imperfect thoughit might be, could be no wider of the mark than thatof parents who act on rumours of excellent prospectsin some particular profession. If the best recruits are

to be secured, the opportunity for training must dependsolely on ability ; and the P.E.P. report urges thatselection should be both by intelligence, as judged bywritten examination, and by character, as assessed byinterview, some university scholarships being awardedfor outstanding personal qualities combined with goodintelligence. Factors influencing the intake of recruitsto the various callings include the financial rewards,the prospects of promotion, and the conditions ofservice ; but happily there are also other incentives-.the interest of the work, the sense of purpose it

bestows, the esteem in which it is held, and the scopeit offers for initiative and responsibility. These con-siderations, which do not weigh equally with all youngmen and women, must be reviewed in occupationswhere entrants are too few or of poor quality. Thusthe McNair Committee recommended an increase insalaries and improvement in the status of teachers,and the Government have lately taken action on similarlines in relation to the nursing profession. The TeviotCommittee reported that " dental appointmentsshould compare with those available to medical

personnel more favourably than they do at present, asregards status, remuneration, and opportunities."The P.E.P. survey underlines the urgency of

marshalling the country’s brain-power, including thatof the refugees now among us. In the final count,however, success will depend on the careful sieving ofthe nation’s youth, the training of all who are suitable,and a balanced allotment between occupations. Here,as in other tasks where resources are scanty, prioritiesmust be decided. Teachers in universities and schoolsshould, perhaps, come first, but other competingdemands are not easily settled : what, for example,of the rival calls for pure scientists and doctors ?It would be useful to have from time to time anestimate of the relative force of the various claims onour stock of trained intelligence.

Liver-function TestsTHE object of tests of liver function is twofold :

to express the extent of liver damage quantitatively,and to aid in the diagnosis between jaundice due toobstruction of large ducts and that due to a diffusehepatitis. The functions of the liver are many, andthe tests based on them are so numerous that theclinician may well wonder which will serve his purposebest. Until recently, evaluation of the tests was basedon findings obtained in typical examples of a givendisease. If these results were consistent, then similar

cc 3

948

data in atypical forms of the disease would influencethe physician in his ultimate diagnosis. The assess-ment of tests has therefore rested in the first place onthe clinical diagnosis of so-called typical cases, backedby a proportion of observations made at operations ornecropsies. Such a basis is not entirely satisfactory,so the correlation of liver tests with the histologicalappearances of material obtained by liver puncturehas a special value. Such a correlation has now beenattempted by SHERLOOK.!SHBRLOCK has considered serum bilirubin, phos-

phatase, cholesterol, protein, albumin-globulin ratio,the intravenous galactose test, and the intravenoushippuric-acid synthesis test in the light of liver

biopsies. She finds that in hepatitis the serum-bilirubinlevel parallels cell damage, but in duct jaundiceit depends on the degree of duct obstruction ratherthan on damage to the parenchyma. The hippuric-acidsynthesis test shows deficient function in most formsof jaundice, but since this does not parallel the histo-logical picture the test is unsatisfactory. Total proteinwas also not considered a useful test, though, as

SHERLOOK remarks, it is often low in all forms ofjaundice; this reduction should provide a useful

pointer to the need for plasma transfusion in surgicalcases. The albumin-globulin ratio was usually low inhepatitis, from a decrease in albumin with a normalor raised globulin. In duct jaundice the albumin-globulin ratio was also sometimes low, from a decreasein albumin rather than an increase in globulin; thisis probably an index of associated cell damage.(Some cases of obstructive jaundice do have a raisedserum globulin, probably those in which there is anadded infection.) The galactose-tolerance test corre-lated best with the histological findings, and accordingto SHBBLOCK this test was positive in 15 out of18 cases of obstructive jaundice. Tbjs contrasts withMACLAGALIZIS 2 59% of normal results. The difference

may be due to the fact that in all SsERocg’a casesthe duct obstruction was complete ; the value of thetest in partial duct obstruction would then be corre-spondingly less. In view of this, the bromsulphone-phthalein test, less popular here than in the UnitedStates, might also be worthy of investigation withhistological controls.Only one test offered some hope of distinguishing

between hepatitis and duct obstruction. SHERLOOKfound the phosphatase raised, but not above 30units, in most cases of toxic hepatitis, and above 30units in nearly all cases of complete duct obstruction.In the latter group it was more or less independentof liver-cell damage; but it may be supposed thatin incomplete obstruction phosphatase would often beless than 30 units, so the test would be inconclusivein that difficult group of cases presenting variablejaundice, pain, dyspepsia, and possibly fever. Theso-called empirical tests therefore deserve more

consideration. In a recent series,3 the cephalin-cholesterol flocculation test 4 was positive, and thethymol turbidity test 5 greater than eight units in22 of 29 cases of hepatitis, the 7 weak reactionsoccurring in cases which cleared up in a week or two.These same tests were negative in 90% of patients

1. Sherlock, S. P. V. J. Path. Bact. 1946, 58, 523.2. Maclagan, N. F. Proc. Ass. clin. Path. 1945, 1, 22.3. Maizels, M. Lancet, Sept. 28, p. 451.4. Hangar, F. M. J. clin. Invest. 1939, 18, 261.5. Maclagan, N. F. J. exp. Path. 1944, 25, 234.

with obstructive jaundice, even when this was

severe and of three or four weeks’ standing or

associated with moderately extensive metastases. Thefew positives were associated with severe infection,very extensive malignant metastases, or long-standingobstruction.

It seems that, apart from the empirical ones, thesetests of liver function have little value in the differen-tial diagnosis of jaundice. The serum-bilirubin and

galactose-tolerance tests have a quantitative value inhepatitis, though their prognostic significance is not

great since in most instances the damage indicated,whether great or small, is quickly made good. In

surgical jaundice a positive galactose test maysuggest that a given case is a poor operative risk, but,since in the absence of surgery the outlook is dim, thesurgeon might well decide to ignore the biochemicalfindings.

Pituitary Control of Water ExcretionNEARLY fifty years ago it was recognised that

extracts of the pituitary gland contain substanceswhich influence the renal excretion of water, and forthe last twenty-five years Prof. E. B. VERNEY, F.R.S.,has been working on the problem. His Sharpey-Schafer lecture at Edinburgh, published in pur issuesof Nov. 23 and 30, summarised his results, which domuch to explain the r6le of the posterior pituitary inthe regulation of urinary excretion.

If a dog is given 250 ml. of water by stomach-tubeit will usually respond by a diuresis reaching itsmaximum in about 50 minutes ; but if, after the

ingestion of water, it is subjected to muscular exerciseor emotional stimuli, the rate of water excretionusually falls suddenly, the maximum not beingregained for some 40-50 minutes. The obvious inter-

pretation of this was that the emotion or exercise

produced vasoconstriction in the kidney, either

directly through the nervous system or through thesecretion of adrenaline. This interpretation, however,has been proved wrong : in the first place, the responseoccurs equally after denervation of the kidney ;secondly, the fall in urinary output which followsclamping the renal artery lasts only as long as theobstruction persists ; and, thirdly, the fall inducedby adrenaline is just as temporary. Where, therefore,are we to seek the cause ? VERNEY has clearly shownthat the time-water-output curve can be exactlyimitated by giving the animal an appropriate dose ofposterior-pituitary extract, and it seems probabletherefore that the change in water output followingexercise or emotion is conditioned by a sudden out-pouring of an antidiuretic hormone by the posteriorpituitary gland. This probability is supported byVERNEY’s further work. He finds that when an isotonicsolution of sodium chloride is injected into the exterio-rised common carotid artery the rate of urinaryexcretion is unchanged ; but with hypertonic solutionsthere is an inhibition of urinary flow of the same formas that obtained by injection of pituitary extract.

(With sodium chloride, saccharose, and glucose in anequivalent strength of

"

hypertonicity " the inhibitionis approximately the same : urea, on the other hand,has no effect, because it diffuses easily from extra-cellular fluid to cells.) If the pituitary gland has beenpreviously removed, or the internal carotid arteryhas been tied, infusion of hypertonic solutions has