1040
of a patient with Raynaud’s phenomwith a proper history and full physical examination which may give obvious clues to the cause such as drugs, collagen disease, occupation, or the thoracic-outlet syndrome. Further investigation for underlying disease will usually be superfluous--except in males and in patients with unilateral disease, unusual presentations suspicious of a
Whole-body Vibration
Diagnosis
enon starts
secondary disorder, or rapid progressive changes. Blood tests and particularly the blood-picture, erythrocyte-sedimentation rate, antinuclear factor, and investigation of immunological status may give helpful leads.26 Irrespective of the aetiology, the attacks of episodic vasospasm may need treatment. In most cases with the milder forms of the disorder all that will be required is reassurance and advice to avoid cold exposure. Loose-fitting gloves help. Smoking decreases skin blood-flow, so the patient should stop.27 For the minority whose symptoms are more severe a multiplicity of drugs have been tried, most aimed at securing vasodilation in the affected digit. Vasodilators,:l6 oral reserpine,28 triiodothyronine, 29 guanethidine, 30 and methyldopa3’ have all been used with varying degrees of success. Griseofulvin is reported to relieve Raynaud’s phenomenon,32 but this claim has been disputed.26 A beta-adrenergic stimulant, terbutaline, is the latest in this long line of drugs. 33 A more logical approach, perhaps, has been to try to lower blood viscosity with ancrod (pit-viper venom).34 All drugs carry the risk of serious side-effects, so they should be reserved for patients with disabling vasospasm. Local relief with avoidance of systemic side-effects may be secured with intra-arterial reserpine, but the benefits are short-lived.36 When drugs have failed, surgical sympathectomy can be undertaken.3’ Initially the limb is dry and vasodilated, and often the symptoms are dramatically relieved. Again the results are seldom long-lasting, and 2-5 years later the troubles return.26 Results tend to be better in patients with primary Raynaud’s phenomenon. They are particularly poor in patients with disorders. associated autoimmune Despite into both aetiology and continuing research therapy, Raynaud’s phenomenon remains the diagnostic and therapeutic enigma it was in the time of MAURICE RAYNAUD.
IN addition to the
and
body motions produced by jumping, man is exposed to
walking, running, whole-body mechanical vibration in buses, trucks and tractors, in large industrial machinery, and in piloting fixed-wing and helicopter aircraft. Oscillatory motions are sometimes enjoyable. Adults buy rocking chairs, children of all ages pay to be exposed to violent motions at fun-fairs, and babies like to be joggled. Much of the research on wholebody vibration has nevertheless been in the military sphere1—and the subjects have tended to be young and fit. Unfortunately very little research has been done on the effects of vibration on the worker in industry. Although the human responses to vibration have been well reviewed2-s it is not always easy to say which variables should be examined in a particular industrial process. The usual criteria are preservation of comfort, effect of vibration on working eSiciency, and effect on health. These in turn depend on the character of the vibration stimulus-frequency, amplitude, duration, direction, point of application, interaction between body and vibration input, and effect of clothing. The intrinsic vari-
ables, equally important, relate to body size, posture, tension, age, experience, and attitude. For plant engineers and industrial medical officers the main source of help is the Guide for the Evaluation of Human Exposure to Whole-body Vibration.6 This makes clear that comfort, performance, and health may be adversely affected by certain stimuli, but it gives only an outline of the possible hazards. Comfort has obvious commercial applications; and the effects of vibration on vision and manual control receive attention because they are believed to be relevant to pilots and drivers. But the effects of vibration on health in general have not been given the emphasis they deserve. French investiga.. tors have reported evidence that helicopter vibration predisposes to back disorders.’ A welldesigned German project!! suggested that tractor vibration contributes to gastric disorders and premature bone changes in the thoracic and lumbar vertebrse. Workers in many countries have expressed 1. Wasserman, D. E.,
26. 27. 28. 29. 30. 31. 32. 33. 34. 35.
Coffman, J. D., Davies, W. T. Prog. cardiovasc. Dis. 1975, 18, 123. Coffman, J. D. Am. Heart J. 1967, 74, 229. Kontos, H. A., Wasserman, A. J. Circulation, 1969, 39, 259. Peacock, J. H. Lancet, 1960, ii, 65. Leroy, E. C., Downey, J. A., Cannon, P. J. J. clin. Invest, 1971, 50, 930. Veradi, D. P., Lawrence, A. M. Archs intern. Med. 1969, 124, 13. Allen, B. R. Lancet, 1971, ii, 840. Thune, P., Fyrand, O. Acta chir. scand. 1976, suppl. 465, p. 84.
36. 37.
McFadyen, I. J., Housley, E., Macpherson, A. I. S. ibid. 1973, 132, 526. Adson, A. W., Brown, G. E. J. Am. med. Ass. 1925, 84, 1908.
Ehrly, A. M. ibid. p. 92. Romeo, S. G., Whalen, R. E., Tindall, J. P. Archs intern. Med. 1970, 125, 825.
Badger, D. W., Doyle, T. E., Margolies, L. J. Am. Soc. Safety Engrs. June, 1974. 2. Beevis, D., Hughes, J. Final report EM1 no. 1 MP-F4,1439,1970. 3. Guignard, J. C., King, P. F. Aero-medical Aspects of Vibration and Noise. 4.
AGARDograph no. 151, 1972. M. J. in The Vibration Syndrome (edited by W. Taylor). New York,
Griffin,
1974. 5. Hanes, R. M. Human
Sensitivity to Whole-Body Vibration in Urban Transportation Systems. Transport Programmes Report APL/JHO-TRP 004, John Hopkins University, 1970. 6. British Standards Institution. BSI Draft for Development. Guide to the Evaluation of Human Exposure to Whole-body Vibration. BSI DD 32:1974. 7. Sliosberg, R. Backache in helicopter pilots. Analysis, ætiology, treatment and prevention. Royal Aircraft Establishment Library Translation, no. 1857, 1975. 8.
Rosegger, R., Rosegger, S. J. agric. Eng. Res. 1960, 5, 241.
1041
about the vibration to which patients are in exposed ambulances. To this small total of wholebody-vibration data two investigations can now be added-on the health of workers using heavy vibratory equipment in the Californian construction industry.9, 10 The morbidity pattern of those construction workers exposed, not to segmental but to whole-body vibration, was compared with that in an unexposed control group eligible for benefits under the same health plan. A significantly increased risk (at the 5% level) was found among the vibration-exposed group for diseases of the male genital organs (primarily prostatitis), referred to in the U.S. Armed Forces as "jeep drivers’ disease". Furthermore, the California data point to a continuing selection process whereby workers leave jobs involving vibration exposure as they acquire certain diseases. Such a drift is obvious in handarm vibration processes," where, with increasing social impairment due to attacks of vibrationinduced white fingers and advancing digital-artery disease, employees ask for an inter-works transfer or even give up work. This dilution of the longterm damaging effects of both segmental and whole-body vibration partly explains why the effects of vibration are often described as trivial. In forty-five "walk-through tours" of industrial plants in the U.S.A., WASSERMAN and his colleagues’ encountered plants where there was close coupling between the workers and the vibrating machinery, often around the major body resonance area of 4-8 Hz. Input vibration in this range reaches dangerous levels. Clearly there is great scope for further work in industry: much better than the epidemiological approach employing sickness-absence statistics is acquisition of medical data direct from plants where vibration characteristics are known and occupational histories are reliable. concern
before therapy is a reasonable proposition for men who want it; such an offer will at the least transmit to the patient the physician’s optimism about his prognosis. For women the pattern is similars,6 and normal pregnancies after successful treatment for A.L.L. have been reported.7 The question of what to do with a pregnancy already established when leuksemia is diagnosed is more tricky, but useful data are accumulating. Most of the available cytotoxic drugs cross the placental barrier, and they may cause abortion or fetal abnormalities when given during the first trimester.8,9 Cytotoxic drugs administered during the second trimester are less harmful. Maurer et al.10 noted an apparent fetal trisomy C after chemotherapy administered at the 20th week of pregnancy, but four case-reports"-’a record delivery of normal infants after chemotherapy initiated between the 25th and 32nd weeks. Durie and Gilesl4 diagnosed acute myeloid leukaemia in a woman aged 20 in the 31st week of pregnancy and treated her with cytarabine, vincristine, and prednisone. She quickly went into complete remission and had a normal male child at 39 weeks. They emphasise the value of sonography, cestriol measurement, and amniocentesis for monitoring the progress of the fetus. Their advice seems very sensible: therapeutic abortion should be recommended to patients with acute leuksemia for whom chemotherapy is essential in the first trimester of pregnancy; in the second, chemotherapy can be administered cautiously without recommendation of abortion, but the mother must accept the risk of fetal abnormality, especially if the drugs are started early in that trimester. In the third trimester, treatment should be relatively safe for the fetus. One extra caveat-of all cytotoxic drugs the teratogenicity of the alkylating agents is particularly well-documented ; these, and procarbazine too, are best avoided at all stages of pregnancy if possible. About potential delayed toxicity to the fetus, such as the risks of leukaemogenesis in childhood or the transmission of acquired genetic disorders, it is still much too early to speak.
ing
THE DOCTOR’S ROLE IN FERTILITY REGULATION
PREGNANCY AND LEUKÆMIA
greatly improved prognosis for patients with lymphoblastic leukaemia (A.L.L.) and Hodgkin’s
THE acute
disease has directed attention inter alia to their reproductive capacity after completion of treatment. Men treated with cytotoxic-drug combinations that include alkylating agents usually become sterile, but this sterility sometimes reverses itself with time.I-3 Because such men may father children with deformities,4 semen bank-
THERE are do-it-yourself methods of contraception, such as coitus interruptus, there are backstreet abortionists, and there are even one or two doctors who have performed their own vasectomies; but increasingly individuals are requiring the assistance of a second person to plan their families. That second person, by necessity or tradition, is usually a medical practitioner. But doctors are not always aware of the special role into which they are cast when giving family-planning advice. For people trained in diagnosis it is seductively easy to see a request for fertility control in diagnostic terms. In re-
9. Milby,
T. H., Spear, R. C. Relationship between whole-body vibration and morbidity patterns among heavy equipment operators: H.E.W. publication no. NIOSH 74-131, 1974. 10. Spear, R. C., Keller, C. A., Milby, T. H. Archs envir. Hlth, 1976, 31, 141. 11. Vibration White Finger in Industry (edited by W. Taylor and P. L. Pelmear). New York, 1975. 1. Kumar, R., Biggart, J. D., McEvoy, J., McGeown, M. G. Lancet, 1972, i,
1212.
2. Qureshi,
M. S. A., Goldsmith, H. J., Pennington, J. H., Cox, P. E. ibid. 1972, ii, 1290. 3. Sherins, R. J., DeVita, V. T. Ann. intern. Med. 1971, 79, 216. 4. Russell, J.A., Powles, R. L., Oliver, R. T. D. Br. Med. J. 1976, i, 1508.
5. Warne, G. L., Fairley, K. F., Hobbs, J. B., Martin, F. I. R. New Engl. J. Med. 1973, 289, 1159. 6. Siris, E. S., Leventhal, B. G., Vaitukaitis, J. L. ibid. 1976, 294, 1143. 7. Estiú, M. Lancet, 1977, i, 433. 8. Toledo, T. M., Harper, R. C., Moser, R. H. Ann. intern. Med. 1971, 74, 87. 9. Garrett, M. J. ibid. 1974, 80, 667. 10. Maurer, L. H., Forcier, R. J., McIntyre, O. R., et al. ibid. 1971, 75, 809. 11. Pawliger, D. F., McLean, F. W., Noyes, W. D. ibid. 1971, 74, 216. 12. Au-Yong, R., Collins, P., Young, J. A. Br. med. J. 1972, iv, 493. 13. Raich, P. C., Curet, L. B. Cancer, 1975, 36, 861. 14. Durie, B. G. M., Giles, H. R. Archs intern. Med. 1977, 137, 90.
of a patient with Raynaud’s phenomwith a proper history and full physical examination which may give obvious clues to the cause such as drugs, collagen disease, occupation, or the thoracic-outlet syndrome. Further investigation for underlying disease will usually be superfluous--except in males and in patients with unilateral disease, unusual presentations suspicious of a
Whole-body Vibration
Diagnosis
enon starts
secondary disorder, or rapid progressive changes. Blood tests and particularly the blood-picture, erythrocyte-sedimentation rate, antinuclear factor, and investigation of immunological status may give helpful leads.26 Irrespective of the aetiology, the attacks of episodic vasospasm may need treatment. In most cases with the milder forms of the disorder all that will be required is reassurance and advice to avoid cold exposure. Loose-fitting gloves help. Smoking decreases skin blood-flow, so the patient should stop.27 For the minority whose symptoms are more severe a multiplicity of drugs have been tried, most aimed at securing vasodilation in the affected digit. Vasodilators,:l6 oral reserpine,28 triiodothyronine, 29 guanethidine, 30 and methyldopa3’ have all been used with varying degrees of success. Griseofulvin is reported to relieve Raynaud’s phenomenon,32 but this claim has been disputed.26 A beta-adrenergic stimulant, terbutaline, is the latest in this long line of drugs. 33 A more logical approach, perhaps, has been to try to lower blood viscosity with ancrod (pit-viper venom).34 All drugs carry the risk of serious side-effects, so they should be reserved for patients with disabling vasospasm. Local relief with avoidance of systemic side-effects may be secured with intra-arterial reserpine, but the benefits are short-lived.36 When drugs have failed, surgical sympathectomy can be undertaken.3’ Initially the limb is dry and vasodilated, and often the symptoms are dramatically relieved. Again the results are seldom long-lasting, and 2-5 years later the troubles return.26 Results tend to be better in patients with primary Raynaud’s phenomenon. They are particularly poor in patients with disorders. associated autoimmune Despite into both aetiology and continuing research therapy, Raynaud’s phenomenon remains the diagnostic and therapeutic enigma it was in the time of MAURICE RAYNAUD.
IN addition to the
and
body motions produced by jumping, man is exposed to
walking, running, whole-body mechanical vibration in buses, trucks and tractors, in large industrial machinery, and in piloting fixed-wing and helicopter aircraft. Oscillatory motions are sometimes enjoyable. Adults buy rocking chairs, children of all ages pay to be exposed to violent motions at fun-fairs, and babies like to be joggled. Much of the research on wholebody vibration has nevertheless been in the military sphere1—and the subjects have tended to be young and fit. Unfortunately very little research has been done on the effects of vibration on the worker in industry. Although the human responses to vibration have been well reviewed2-s it is not always easy to say which variables should be examined in a particular industrial process. The usual criteria are preservation of comfort, effect of vibration on working eSiciency, and effect on health. These in turn depend on the character of the vibration stimulus-frequency, amplitude, duration, direction, point of application, interaction between body and vibration input, and effect of clothing. The intrinsic vari-
ables, equally important, relate to body size, posture, tension, age, experience, and attitude. For plant engineers and industrial medical officers the main source of help is the Guide for the Evaluation of Human Exposure to Whole-body Vibration.6 This makes clear that comfort, performance, and health may be adversely affected by certain stimuli, but it gives only an outline of the possible hazards. Comfort has obvious commercial applications; and the effects of vibration on vision and manual control receive attention because they are believed to be relevant to pilots and drivers. But the effects of vibration on health in general have not been given the emphasis they deserve. French investiga.. tors have reported evidence that helicopter vibration predisposes to back disorders.’ A welldesigned German project!! suggested that tractor vibration contributes to gastric disorders and premature bone changes in the thoracic and lumbar vertebrse. Workers in many countries have expressed 1. Wasserman, D. E.,
26. 27. 28. 29. 30. 31. 32. 33. 34. 35.
Coffman, J. D., Davies, W. T. Prog. cardiovasc. Dis. 1975, 18, 123. Coffman, J. D. Am. Heart J. 1967, 74, 229. Kontos, H. A., Wasserman, A. J. Circulation, 1969, 39, 259. Peacock, J. H. Lancet, 1960, ii, 65. Leroy, E. C., Downey, J. A., Cannon, P. J. J. clin. Invest, 1971, 50, 930. Veradi, D. P., Lawrence, A. M. Archs intern. Med. 1969, 124, 13. Allen, B. R. Lancet, 1971, ii, 840. Thune, P., Fyrand, O. Acta chir. scand. 1976, suppl. 465, p. 84.
36. 37.
McFadyen, I. J., Housley, E., Macpherson, A. I. S. ibid. 1973, 132, 526. Adson, A. W., Brown, G. E. J. Am. med. Ass. 1925, 84, 1908.
Ehrly, A. M. ibid. p. 92. Romeo, S. G., Whalen, R. E., Tindall, J. P. Archs intern. Med. 1970, 125, 825.
Badger, D. W., Doyle, T. E., Margolies, L. J. Am. Soc. Safety Engrs. June, 1974. 2. Beevis, D., Hughes, J. Final report EM1 no. 1 MP-F4,1439,1970. 3. Guignard, J. C., King, P. F. Aero-medical Aspects of Vibration and Noise. 4.
AGARDograph no. 151, 1972. M. J. in The Vibration Syndrome (edited by W. Taylor). New York,
Griffin,
1974. 5. Hanes, R. M. Human
Sensitivity to Whole-Body Vibration in Urban Transportation Systems. Transport Programmes Report APL/JHO-TRP 004, John Hopkins University, 1970. 6. British Standards Institution. BSI Draft for Development. Guide to the Evaluation of Human Exposure to Whole-body Vibration. BSI DD 32:1974. 7. Sliosberg, R. Backache in helicopter pilots. Analysis, ætiology, treatment and prevention. Royal Aircraft Establishment Library Translation, no. 1857, 1975. 8.
Rosegger, R., Rosegger, S. J. agric. Eng. Res. 1960, 5, 241.
1041
about the vibration to which patients are in exposed ambulances. To this small total of wholebody-vibration data two investigations can now be added-on the health of workers using heavy vibratory equipment in the Californian construction industry.9, 10 The morbidity pattern of those construction workers exposed, not to segmental but to whole-body vibration, was compared with that in an unexposed control group eligible for benefits under the same health plan. A significantly increased risk (at the 5% level) was found among the vibration-exposed group for diseases of the male genital organs (primarily prostatitis), referred to in the U.S. Armed Forces as "jeep drivers’ disease". Furthermore, the California data point to a continuing selection process whereby workers leave jobs involving vibration exposure as they acquire certain diseases. Such a drift is obvious in handarm vibration processes," where, with increasing social impairment due to attacks of vibrationinduced white fingers and advancing digital-artery disease, employees ask for an inter-works transfer or even give up work. This dilution of the longterm damaging effects of both segmental and whole-body vibration partly explains why the effects of vibration are often described as trivial. In forty-five "walk-through tours" of industrial plants in the U.S.A., WASSERMAN and his colleagues’ encountered plants where there was close coupling between the workers and the vibrating machinery, often around the major body resonance area of 4-8 Hz. Input vibration in this range reaches dangerous levels. Clearly there is great scope for further work in industry: much better than the epidemiological approach employing sickness-absence statistics is acquisition of medical data direct from plants where vibration characteristics are known and occupational histories are reliable. concern
before therapy is a reasonable proposition for men who want it; such an offer will at the least transmit to the patient the physician’s optimism about his prognosis. For women the pattern is similars,6 and normal pregnancies after successful treatment for A.L.L. have been reported.7 The question of what to do with a pregnancy already established when leuksemia is diagnosed is more tricky, but useful data are accumulating. Most of the available cytotoxic drugs cross the placental barrier, and they may cause abortion or fetal abnormalities when given during the first trimester.8,9 Cytotoxic drugs administered during the second trimester are less harmful. Maurer et al.10 noted an apparent fetal trisomy C after chemotherapy administered at the 20th week of pregnancy, but four case-reports"-’a record delivery of normal infants after chemotherapy initiated between the 25th and 32nd weeks. Durie and Gilesl4 diagnosed acute myeloid leukaemia in a woman aged 20 in the 31st week of pregnancy and treated her with cytarabine, vincristine, and prednisone. She quickly went into complete remission and had a normal male child at 39 weeks. They emphasise the value of sonography, cestriol measurement, and amniocentesis for monitoring the progress of the fetus. Their advice seems very sensible: therapeutic abortion should be recommended to patients with acute leuksemia for whom chemotherapy is essential in the first trimester of pregnancy; in the second, chemotherapy can be administered cautiously without recommendation of abortion, but the mother must accept the risk of fetal abnormality, especially if the drugs are started early in that trimester. In the third trimester, treatment should be relatively safe for the fetus. One extra caveat-of all cytotoxic drugs the teratogenicity of the alkylating agents is particularly well-documented ; these, and procarbazine too, are best avoided at all stages of pregnancy if possible. About potential delayed toxicity to the fetus, such as the risks of leukaemogenesis in childhood or the transmission of acquired genetic disorders, it is still much too early to speak.
ing
THE DOCTOR’S ROLE IN FERTILITY REGULATION
PREGNANCY AND LEUKÆMIA
greatly improved prognosis for patients with lymphoblastic leukaemia (A.L.L.) and Hodgkin’s
THE acute
disease has directed attention inter alia to their reproductive capacity after completion of treatment. Men treated with cytotoxic-drug combinations that include alkylating agents usually become sterile, but this sterility sometimes reverses itself with time.I-3 Because such men may father children with deformities,4 semen bank-
THERE are do-it-yourself methods of contraception, such as coitus interruptus, there are backstreet abortionists, and there are even one or two doctors who have performed their own vasectomies; but increasingly individuals are requiring the assistance of a second person to plan their families. That second person, by necessity or tradition, is usually a medical practitioner. But doctors are not always aware of the special role into which they are cast when giving family-planning advice. For people trained in diagnosis it is seductively easy to see a request for fertility control in diagnostic terms. In re-
9. Milby,
T. H., Spear, R. C. Relationship between whole-body vibration and morbidity patterns among heavy equipment operators: H.E.W. publication no. NIOSH 74-131, 1974. 10. Spear, R. C., Keller, C. A., Milby, T. H. Archs envir. Hlth, 1976, 31, 141. 11. Vibration White Finger in Industry (edited by W. Taylor and P. L. Pelmear). New York, 1975. 1. Kumar, R., Biggart, J. D., McEvoy, J., McGeown, M. G. Lancet, 1972, i,
1212.
2. Qureshi,
M. S. A., Goldsmith, H. J., Pennington, J. H., Cox, P. E. ibid. 1972, ii, 1290. 3. Sherins, R. J., DeVita, V. T. Ann. intern. Med. 1971, 79, 216. 4. Russell, J.A., Powles, R. L., Oliver, R. T. D. Br. Med. J. 1976, i, 1508.
5. Warne, G. L., Fairley, K. F., Hobbs, J. B., Martin, F. I. R. New Engl. J. Med. 1973, 289, 1159. 6. Siris, E. S., Leventhal, B. G., Vaitukaitis, J. L. ibid. 1976, 294, 1143. 7. Estiú, M. Lancet, 1977, i, 433. 8. Toledo, T. M., Harper, R. C., Moser, R. H. Ann. intern. Med. 1971, 74, 87. 9. Garrett, M. J. ibid. 1974, 80, 667. 10. Maurer, L. H., Forcier, R. J., McIntyre, O. R., et al. ibid. 1971, 75, 809. 11. Pawliger, D. F., McLean, F. W., Noyes, W. D. ibid. 1971, 74, 216. 12. Au-Yong, R., Collins, P., Young, J. A. Br. med. J. 1972, iv, 493. 13. Raich, P. C., Curet, L. B. Cancer, 1975, 36, 861. 14. Durie, B. G. M., Giles, H. R. Archs intern. Med. 1977, 137, 90.
