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THE HOSPITAL SERVICES
905
LETTERS TO THE EDITOR BLOOD-COLLECTION TECHNIQUE SiR,-The booklet recently circulated by the Medical Research Council describing blood-transfusion methods contains a section on the adaptation of certain apparatus to the vacuum method of bloodcollection described by us in THE LANCET, 1939, 1, 388. The advice given in this section is unsatisfactory and, if followed, will lead to so many failures that its circulation is regrettable. The chief mistakes are as follows :-
have commonly a large number of The number of vacant beds has in recent years been increased in towns in which, with none but beneficial results, the scarlet-fever admissions have been reduced by a half, no case being admitted if a separate room can be providedfor the patient,or the patient and mother. So it is that generally there is a large excess and a larger potential excess of beds in our fever hospitals. Considering that in the near future our hospital accommodation may be taxed to capacity and patients may have to be nursed in overcrowded conditions would it not be well to make use, in part at least, of unoccupied fever beds and to see to it that scarletfever patients are only removed to hospital when such removal is necessary?° This could be done by concentrating fever work as far as possible in the large well-equipped and well-staffed fever hospitals and using the smaller fever hospitals for general work; the country fever hospital would be ideal for convalescents. Such a procedure might well put 10,000 additional beds at our disposal. I trust that this matter will have serious consideration now, rather than later when our time may be fully occupied in other directions. I am, Sir, yours faithfully,
bigger hospitals unoccupied beds.
(1) Type of tubing to be used for blood collection.It is necessary for smooth working that pressure tubing should be used. If the tubing distributed by the M.R.C. (No. 8, 3/16-in. internal bore) is used, as they suggest, it will collapse under the influence of the vacuum, and the flow of blood will be impeded. A 6-in. length of tubing is also too short for convenience ; about 9 in. should be used. (2) Type of collecting needle.-The 15/10 needle has great advantages over the 24/10 size recommended by the M.R.C. In the first place it simplifies venepuncture, which is an important consideration when blood has to be collected by workers with little experience from donors who are not specially selected for the large size of their veins. The smaller needle will fill the bottle just as efficiently as the larger one, which is, in fact, more likely to be obstructed by collapse of the vein on to its orifice. The 15/10 DUNCAN FORBES, needle has the further advantages of lower cost and Medical Officer of Health for the lately uniformity with the needles recommended by the County Borough of Brighton. M.R.C. for the administration of blood. (3) Preliminary filling of the tube with citrate.-We have now performed several hundred collections with THE HOSPITAL SERVICES dry-sterilised apparatus as originally described and SIR,-Correspondence in your columns and other have never encountered any difficulty due to clotting evidence point to a wide-spread and, I submit, do of blood in the tube. We not therefore see any reason for this measure, and we disapprove of it justified dissatisfaction with the present arrangebecause it increases the risk of contamination which ments of the Emergency Medical Service regarding the our method was designed to minimise and has almost visiting staffs of the voluntary hospitals in London. succeeded in eliminating. We have cultured seventy At some date between the end of June and the end bottles of preserved blood collected at this hospital of August it would seem that the Ministry reversed during the early days of the war, in some cases by their previous resolution to maintain the voluntary junior officers recently introduced to the technique. system at the teaching hospitals and embarked upon After removal from the refrigerator these bottles the scheme of full-time service for all members of the were incubated for twenty-four hours before the cultures were made, and they have all been found staffs, both senior and junior. In his answer to a questo be sterile. This desirable standard of sterility tion put by me yesterday in Parliament, the Minister of will not be maintained if unnecessary manipulations Health declared that " recruitment to the Emergency are introduced. Medical Service is on a voluntary basis " and that We are,
Sir, yours faithfully,
Mile End Hospital, E.1, Oct. 9.
C. R. BOLAND, N. S. CRAIG, A. L. JACOBS.
FEVER BEDS IN WAR
SiR,—It is stated in the annual report of the Ministry of Health that, in England and Wales, 37,500 beds are reserved for the isolation and treatment of infectious disease. Although county schemes have facilitated the establishment of isolation hospitals of sufficient size to constitute efficient and economical self-contained units there are still large numbers of small fever hospitals; thus 74 district councils provide 1875 beds in their own fever hospitals (average 25
beds),
and 812
grouped in 181 areas provide 9902 Only in 43 districts requiring
beds (average 55).
260 beds have arrangements been made for cases to be admitted to the relatively large fever hospitals of
adjacent county boroughs. Accommodation having been provided to ensure a sufficiency of beds in epidemic periods, it follows that small isolation hospitals are often empty and the
"
salaries and conditions for this service were fixed in consultation with representatives of the medical
profession." With regard to the first statement that " recruitment is voluntary " it may be true in the letter but is not true in the spirit, and in certain instances within my
own
knowledge
sector officers have taken up the
position that members of the visiting staff of a teaching hospital who refused to undertake the Emergency Medical Service thereby ceased to b3 members of the staff of the hospital concerned. With regard to the second contention, I think I voice the opinion of many of my colleagues that the " salaries and conditions " fixed for consultants under the earlier scheme of full-time service, and the later concession of part-time, demonstrated that these " representatives of the medical profession " cited by the Minister were very unrepresentative of the consultant section of that
profession. The chaos immediately supervening on the withdrawal from London of practically all the members of the visiting staffs of the great hospitals, brought about by full-time enrolment, and the grievous injury inflicted upon the civil population by the sudden
906
relinquishment of nearly all responsibility of London hospitals for treating the civilian sick, very soon compelled a r adical alteration in the earlier plan. After some tentative and completely unsuccessful experisecond scheme was announced in a circular Ministry of Health dated Sept. 18, which apparently is now to be regarded as the official and operative proposition. It is this scheme which is clearly indicated in your leading article of Sept. 23; the complacence with which you seemed to accept it in that pronouncement is not, I think, widely shared by those members of the profession whom it chiefly concerns, namely the visiting staffs of the voluntary hospitals. It was, of course, designed to meet the most serious difficulties which had become apparent in the operation of the earlier scheme, chief amongst which was the abolition of private practice and the withdrawal from the voluntary hospitals of the staffs which had been responsible for the treatment of civilian patients. The scheme may be thus briefly summarised, The Minister is prepared to transfer " some (the italics are his) of the medical personnel who have already been called up from whole-time to part-time in order that they may be free to engage in private practice." This concession concerns only the visiting staff, and the Minister reserves the right to re-impose full-time service at his discretion at any moment upon persons so released. The terms announced are that any officer accepting part-time service is " to make his services available to the State, if required, for the equivalent of , four days in every week, the remainder of the time being at his own disposal." He is to receive, for doing four-sevenths of the work, only one-third of the pay accorded to full-time service, and he is to be deprived of allowances for billeting, travelling expenses, and extra petrol available to the full-time officer.’ It is not surprising that these terms have been regarded as inequitable, a view which was clearly manifested at a special meeting of the comitia of the Royal College of Physicians held last Thursday to discuss the position of fellows serving in the Emergency Medical Service. In response to urgent representations made to me by certain of my parliamentary medical constituents I obtained an interview with the Minister of Health ments
a
from the
.
Wednesday and upon my instance he then expressed himself willing to add a third category of service to those at present offered, namely (i) full-time service, (ii) part-time, on the conditions just cited. The Minister was good enough to embody the suggestions
last
made in our conversation in a letter to me, which I received on the morning of October 12, and which he authorised me to read at the meeting of the comitia that afternoon. The concession now offered is enrolment of " certain senior men of the standing of fellows not in the emergency service who would like to put down their names with the Minister as willing to give practically unlimited service if a major emergency arises but are desirous of remaining without obligation and without remuneration till such time as that emergency occurs." This, I submit, in effect, restores the voluntary system of service which was entirely successful in the last war, and I have reason to think would be acceptable to a large number of the members of the visiting staffs of hospitals in London. I believe that there would be no difficulty in transferring members " of the standing of fellow&bgr; " at present in the Emergency Medical Service to the new category if they The importance to my mind of insisting so wished. now upon some measure of voluntary service is urgent, in view of the changes in the medical profes-
sion which may follow upon the termination of the Already there has been an ominous indication of what some members of the profession expect, and apparently hope, will be the result of the emergency scheme, as at present operated. I quote from a recent editorial pronouncement in a medical journal: war.
"
The organisation of this scheme will have a bearthe future of medicine which will be of the utmost importance. For the first time there is Government control of those most stout and gallanthearted last-ditchers of the medical profession, the consultant and specialist groups. Whereas the National Health Insurance scheme started by attracting the general practitioner, what may possibly prove to be the genesis of a State Medical Service has been precipitated by war, and its initial step has been the enrolment of the consultant groups. The difficulties attending such an enrolment could only have been solved so quickly during a national crisis, and the advent of the emergency has probably put medical politics forward ten years. A great struggle is still in store, for the voluntary system, well-suited to the national character, and with many advantages as compared to a rigid State service, will have many adherents."
ing
on
How far this consummation may be
successfully will, I think, depend upon the measure of acceptance given to the new third category, and it is in the hope that some indication will be given in your resisted
columns of its prospects of success that I ask your hospitality for this letter. I am, Sir, yours faithfully,
E. GRAHAM-LITTLE. FREUD’S INFLUENCE SiR,—Though most of your readers will not fail to note the antisemitic complex responsible for the letter entitled Freud and Sex in your issue of October 14, I feel that it should not pass unanswered. The example of Nazi Germany is before us to demonstrate the ease with which ideas of being persecuted (be it by
Jews, Catholics or Freemasons) can spread rapidly among the masses through the influence of suggestion and constant iteration. To be brief, I would only make two points : (1) Wars between tribes, races or nations were and frequent before Freud was born, and indeed long before the Jews existed. (2) Dictatorships of one kind or another are recorded in the histories of Babylonia and Egypt. They numerous
are
not
an
invention of the Jews.
It is no doubt convenient to blame one single factor for all the evils of this world, and this appeals to lazy minds as it helps to simplify problems which are in reality complicated and require great effort of thought to unravel. Life becomes so easy if one can blame the Jews for the existence of wars, bolshevism, capitalism,
socialism, unemployment, prostitution, a declining birth-rate, venereal disease and so forth, as taught by the Nazi
ideology, but I am confident that the vast majority of your readers will think otherwise. I am, Sir, yours faithfully, I. ATKIN. Park Prewett Mental Hospital, Basingstoke,
Hants, Oct. 13.
SiB,—I agree with Mr. Rugg-Gunn that it is sometimes right not entirely to hold to the old maxim, De mortuis nil nisi bonum, especially in regard to outstanding lights of progress such as the late Sigmund Freud. Though at first there is a real danger that something against the hero may be remembered more than his great achievements, snch
LETTERS TO THE EDITOR BLOOD-COLLECTION TECHNIQUE SiR,-The booklet recently circulated by the Medical Research Council describing blood-transfusion methods contains a section on the adaptation of certain apparatus to the vacuum method of bloodcollection described by us in THE LANCET, 1939, 1, 388. The advice given in this section is unsatisfactory and, if followed, will lead to so many failures that its circulation is regrettable. The chief mistakes are as follows :-
have commonly a large number of The number of vacant beds has in recent years been increased in towns in which, with none but beneficial results, the scarlet-fever admissions have been reduced by a half, no case being admitted if a separate room can be providedfor the patient,or the patient and mother. So it is that generally there is a large excess and a larger potential excess of beds in our fever hospitals. Considering that in the near future our hospital accommodation may be taxed to capacity and patients may have to be nursed in overcrowded conditions would it not be well to make use, in part at least, of unoccupied fever beds and to see to it that scarletfever patients are only removed to hospital when such removal is necessary?° This could be done by concentrating fever work as far as possible in the large well-equipped and well-staffed fever hospitals and using the smaller fever hospitals for general work; the country fever hospital would be ideal for convalescents. Such a procedure might well put 10,000 additional beds at our disposal. I trust that this matter will have serious consideration now, rather than later when our time may be fully occupied in other directions. I am, Sir, yours faithfully,
bigger hospitals unoccupied beds.
(1) Type of tubing to be used for blood collection.It is necessary for smooth working that pressure tubing should be used. If the tubing distributed by the M.R.C. (No. 8, 3/16-in. internal bore) is used, as they suggest, it will collapse under the influence of the vacuum, and the flow of blood will be impeded. A 6-in. length of tubing is also too short for convenience ; about 9 in. should be used. (2) Type of collecting needle.-The 15/10 needle has great advantages over the 24/10 size recommended by the M.R.C. In the first place it simplifies venepuncture, which is an important consideration when blood has to be collected by workers with little experience from donors who are not specially selected for the large size of their veins. The smaller needle will fill the bottle just as efficiently as the larger one, which is, in fact, more likely to be obstructed by collapse of the vein on to its orifice. The 15/10 DUNCAN FORBES, needle has the further advantages of lower cost and Medical Officer of Health for the lately uniformity with the needles recommended by the County Borough of Brighton. M.R.C. for the administration of blood. (3) Preliminary filling of the tube with citrate.-We have now performed several hundred collections with THE HOSPITAL SERVICES dry-sterilised apparatus as originally described and SIR,-Correspondence in your columns and other have never encountered any difficulty due to clotting evidence point to a wide-spread and, I submit, do of blood in the tube. We not therefore see any reason for this measure, and we disapprove of it justified dissatisfaction with the present arrangebecause it increases the risk of contamination which ments of the Emergency Medical Service regarding the our method was designed to minimise and has almost visiting staffs of the voluntary hospitals in London. succeeded in eliminating. We have cultured seventy At some date between the end of June and the end bottles of preserved blood collected at this hospital of August it would seem that the Ministry reversed during the early days of the war, in some cases by their previous resolution to maintain the voluntary junior officers recently introduced to the technique. system at the teaching hospitals and embarked upon After removal from the refrigerator these bottles the scheme of full-time service for all members of the were incubated for twenty-four hours before the cultures were made, and they have all been found staffs, both senior and junior. In his answer to a questo be sterile. This desirable standard of sterility tion put by me yesterday in Parliament, the Minister of will not be maintained if unnecessary manipulations Health declared that " recruitment to the Emergency are introduced. Medical Service is on a voluntary basis " and that We are,
Sir, yours faithfully,
Mile End Hospital, E.1, Oct. 9.
C. R. BOLAND, N. S. CRAIG, A. L. JACOBS.
FEVER BEDS IN WAR
SiR,—It is stated in the annual report of the Ministry of Health that, in England and Wales, 37,500 beds are reserved for the isolation and treatment of infectious disease. Although county schemes have facilitated the establishment of isolation hospitals of sufficient size to constitute efficient and economical self-contained units there are still large numbers of small fever hospitals; thus 74 district councils provide 1875 beds in their own fever hospitals (average 25
beds),
and 812
grouped in 181 areas provide 9902 Only in 43 districts requiring
beds (average 55).
260 beds have arrangements been made for cases to be admitted to the relatively large fever hospitals of
adjacent county boroughs. Accommodation having been provided to ensure a sufficiency of beds in epidemic periods, it follows that small isolation hospitals are often empty and the
"
salaries and conditions for this service were fixed in consultation with representatives of the medical
profession." With regard to the first statement that " recruitment is voluntary " it may be true in the letter but is not true in the spirit, and in certain instances within my
own
knowledge
sector officers have taken up the
position that members of the visiting staff of a teaching hospital who refused to undertake the Emergency Medical Service thereby ceased to b3 members of the staff of the hospital concerned. With regard to the second contention, I think I voice the opinion of many of my colleagues that the " salaries and conditions " fixed for consultants under the earlier scheme of full-time service, and the later concession of part-time, demonstrated that these " representatives of the medical profession " cited by the Minister were very unrepresentative of the consultant section of that
profession. The chaos immediately supervening on the withdrawal from London of practically all the members of the visiting staffs of the great hospitals, brought about by full-time enrolment, and the grievous injury inflicted upon the civil population by the sudden
906
relinquishment of nearly all responsibility of London hospitals for treating the civilian sick, very soon compelled a r adical alteration in the earlier plan. After some tentative and completely unsuccessful experisecond scheme was announced in a circular Ministry of Health dated Sept. 18, which apparently is now to be regarded as the official and operative proposition. It is this scheme which is clearly indicated in your leading article of Sept. 23; the complacence with which you seemed to accept it in that pronouncement is not, I think, widely shared by those members of the profession whom it chiefly concerns, namely the visiting staffs of the voluntary hospitals. It was, of course, designed to meet the most serious difficulties which had become apparent in the operation of the earlier scheme, chief amongst which was the abolition of private practice and the withdrawal from the voluntary hospitals of the staffs which had been responsible for the treatment of civilian patients. The scheme may be thus briefly summarised, The Minister is prepared to transfer " some (the italics are his) of the medical personnel who have already been called up from whole-time to part-time in order that they may be free to engage in private practice." This concession concerns only the visiting staff, and the Minister reserves the right to re-impose full-time service at his discretion at any moment upon persons so released. The terms announced are that any officer accepting part-time service is " to make his services available to the State, if required, for the equivalent of , four days in every week, the remainder of the time being at his own disposal." He is to receive, for doing four-sevenths of the work, only one-third of the pay accorded to full-time service, and he is to be deprived of allowances for billeting, travelling expenses, and extra petrol available to the full-time officer.’ It is not surprising that these terms have been regarded as inequitable, a view which was clearly manifested at a special meeting of the comitia of the Royal College of Physicians held last Thursday to discuss the position of fellows serving in the Emergency Medical Service. In response to urgent representations made to me by certain of my parliamentary medical constituents I obtained an interview with the Minister of Health ments
a
from the
.
Wednesday and upon my instance he then expressed himself willing to add a third category of service to those at present offered, namely (i) full-time service, (ii) part-time, on the conditions just cited. The Minister was good enough to embody the suggestions
last
made in our conversation in a letter to me, which I received on the morning of October 12, and which he authorised me to read at the meeting of the comitia that afternoon. The concession now offered is enrolment of " certain senior men of the standing of fellows not in the emergency service who would like to put down their names with the Minister as willing to give practically unlimited service if a major emergency arises but are desirous of remaining without obligation and without remuneration till such time as that emergency occurs." This, I submit, in effect, restores the voluntary system of service which was entirely successful in the last war, and I have reason to think would be acceptable to a large number of the members of the visiting staffs of hospitals in London. I believe that there would be no difficulty in transferring members " of the standing of fellow&bgr; " at present in the Emergency Medical Service to the new category if they The importance to my mind of insisting so wished. now upon some measure of voluntary service is urgent, in view of the changes in the medical profes-
sion which may follow upon the termination of the Already there has been an ominous indication of what some members of the profession expect, and apparently hope, will be the result of the emergency scheme, as at present operated. I quote from a recent editorial pronouncement in a medical journal: war.
"
The organisation of this scheme will have a bearthe future of medicine which will be of the utmost importance. For the first time there is Government control of those most stout and gallanthearted last-ditchers of the medical profession, the consultant and specialist groups. Whereas the National Health Insurance scheme started by attracting the general practitioner, what may possibly prove to be the genesis of a State Medical Service has been precipitated by war, and its initial step has been the enrolment of the consultant groups. The difficulties attending such an enrolment could only have been solved so quickly during a national crisis, and the advent of the emergency has probably put medical politics forward ten years. A great struggle is still in store, for the voluntary system, well-suited to the national character, and with many advantages as compared to a rigid State service, will have many adherents."
ing
on
How far this consummation may be
successfully will, I think, depend upon the measure of acceptance given to the new third category, and it is in the hope that some indication will be given in your resisted
columns of its prospects of success that I ask your hospitality for this letter. I am, Sir, yours faithfully,
E. GRAHAM-LITTLE. FREUD’S INFLUENCE SiR,—Though most of your readers will not fail to note the antisemitic complex responsible for the letter entitled Freud and Sex in your issue of October 14, I feel that it should not pass unanswered. The example of Nazi Germany is before us to demonstrate the ease with which ideas of being persecuted (be it by
Jews, Catholics or Freemasons) can spread rapidly among the masses through the influence of suggestion and constant iteration. To be brief, I would only make two points : (1) Wars between tribes, races or nations were and frequent before Freud was born, and indeed long before the Jews existed. (2) Dictatorships of one kind or another are recorded in the histories of Babylonia and Egypt. They numerous
are
not
an
invention of the Jews.
It is no doubt convenient to blame one single factor for all the evils of this world, and this appeals to lazy minds as it helps to simplify problems which are in reality complicated and require great effort of thought to unravel. Life becomes so easy if one can blame the Jews for the existence of wars, bolshevism, capitalism,
socialism, unemployment, prostitution, a declining birth-rate, venereal disease and so forth, as taught by the Nazi
ideology, but I am confident that the vast majority of your readers will think otherwise. I am, Sir, yours faithfully, I. ATKIN. Park Prewett Mental Hospital, Basingstoke,
Hants, Oct. 13.
SiB,—I agree with Mr. Rugg-Gunn that it is sometimes right not entirely to hold to the old maxim, De mortuis nil nisi bonum, especially in regard to outstanding lights of progress such as the late Sigmund Freud. Though at first there is a real danger that something against the hero may be remembered more than his great achievements, snch