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PULMONARY EMBOLISM IN LIBERATED PRISONERS-OF-WAR
703
Letters
to
the Editor
A COMPREHENSIVE MEDICAL SERVICE BY NEXT JANUARY? SIR,—In putting forward my compromise plan for setting up a comprehensive medical service by Jan. 1, 1946 (discussed in your issue of May 19, p. 635), I had in view the many complexities of the situation as between‘ the medical profession, hospital authorities, local-’ government authorities and the Government. But I had also in view the possibility, if not the probability, that political indecision would prevent a beginning being; made before an election. The political decision to hold a General Election in July justifies my fears. Whatever may be the political complexion of the new Government, it will have before it its own programme of immediate urgency. What I still fear is the postponement of the coming into operation of the National Health Service to a date later than originally contemplated-for instance, after the defeat of Japan. My suggestion of using the EMS organisation in the jpegions into which Great Britain was divided for war purposes-one of which regions is, of course, Scotland as a whole-was based on the fact that this organisation was (1) of a temporary character, and (2) medically speaking had worked very well. Part reason for the working of the EMS hospital scheme being so good is that it secures the cooperationusually intimate coöperation—of voluntary and publicly owned hospitals in each region under the general supervision of the principal medical officer of the region. To continue this hospital service, and that of consultants, specialist advisers, and special services that go with it, as the compromise arrangement for providing necessary services under the National Health Service, would help and not hinder a final settlement, and it could be inaugurated by Jan. 1, 1946. It is certainly not -easy under any circumstances to arrange for a 100% domiciliary service at the present time. And to put the duty of seeing that this service was provided on the shoulders of the regional organisation of the EMS for each region puts a new duty upon the EMS. But it will not be easy to provide a 100% domiciliary treatment in any case, and in the beginning the service may not be complete under whatever auspices it is inaugurated. My proposal to charge the EMS with this duty would involve them in surveying the field of private medical practice and offering appointments on a temporary basis to provide for the essential needs of medically depleted areas. They would do this in cooperation with the Central Medical War Committee. There are very many difficulties in carrying out any scheme of National Health Service at the present time and I claim only for my proposal that it would get things done quickly and that it would be temporary in its application. It would in this way bridge the gap between the present, when we are only at the position of white-paper discussions, and a future time when definite conclusions as to organisation will have been reached. During this interim period it would provide for the civilian population and for the demobilised doctor looking for a job. Without this bypass arrangement, as I have called it, this interim period may pile up practical, administrative, and political difficulties which will make the inauguration of a National Health Service very much harder than it need be. And unless we arrive at a working compromise, the date of the inauguration mav be much nORt;noned. L. HADEN GUEST. House of Commons. ’
’
,
’
THE MEDICAL
SUPERINTENDENT
SIR,—I expect that most of the hospitals in the country will be taking a part in some form of State health service within the next few years. They will probably, therefore, come to adopt a fairly uniform system of administration. I wrote my letter of April 21
because I believe it would be
a mistake to appoint, as practice, medically qualified superintendents His experience as defined by Mr. Somerville Hastings. of these officers is very great ; in fact there is probably
standard
no-one
Hence
else with so many under his administration. may accept his opinion that a good clinician
we
is rarely a good administrator. This must mean that the two attributes are rarely combined in the same individual. While freely admitting that there are’ notable exceptions to the rule, it cannot be wise to apply universally a system which demands such a combination. I do not foresee the continuation of flag-days, appeals, and advertisement in aid of individual hospitals. The house-governor of the future should be free to apply himself to administration without these harassing distractions. If, as I advocate, he hr,s had a long, special training followed by experience i- junior administrative posts on hospital staffs he wi have acquired ample medical knowledge to suffice for. s routine work by the time he reaches senior rank in hi profession. I do not recommend that the chairman of the hospital should DT’ffeT’aMv be
a
medical
Ttin’n
W. A. LISTER.
PULMONARY EMBOLISM IN LIBERATED PRISONERS-OF-WAR SIR,—Between May 1 and May 9 about 300 men were admitted to Barnsley Hall EMS Hospital suffering from the effects of privations as prisoners-of-war in Germany. About 200 were stretcher cases. In only 2 of them was the state of malnutrition severe enough to cause anxiety, but it was noticed during the first week that the majority were running a temperature. On May 9 one of the patients died in five minutes of pulmonary embolism, confirmed post mortem : he had been allowed up for a day or two, but had been put to bed again because of recurrence of oedema on the legs. Nine days after admission another man died of pulmonary embolism six hours after the first manifestation. The question arises whether some of the symptoms and signs noted in the other men were not also due to pulmonary embolism. Most of them had marched 500-1000 miles between January and May on very short rations. During the last month of the march almost all of these developed diarrhoea and swelling of the legs. The oedema was usually limited to the lower shin but sometimes extended above the knee, and in some cases it was asymmetrical. Among the symptoms which they developed were paroxysmal dyspnoea while at rest. chest oppression or pain, palpitation, cough (with bloodspitting in at least one case), and sudden collapse : and the diagnoses made by medical officers examining the prisoners after liberation included pleural effusion, bronchitis, bronchopneumonia, lobar pneumonia, and pulmonary tuberculosis. There were cases of sudden death and " pneumonia that kills in a few hours." In some of the men the signs remaining in the chest on admission to Barnsley Hall were attributed at first to unresolved pneumonia or atypical pneumonia, but we now suspect that at least a proportion of them were the results of pulmonary infarction, while some of the other signs so often seen in these ex-prisoners (slight cyanosis of lips, pyrexia, tachycardia) may have been caused by small emboli without infarction. Paul White, who believes that pulmonary embolism commonly goes unrecognised, states that its outstanding cause is thrombosis of the leg veins, beginning as a rule in the calf and extending into the long saphenous and femoral veins. Such thrombosis would explain the oedema developing in so many of these prisoners as their malnutrition increased. (This osdema is less readily attributable to hypoproteinaerriia, for it was absent in a case where the plasma protein was 2-2 g. per 100 c.cm. but present in cases with readings of 6-0 g. upwards.) In the two patients dying of pulmonary embolism the iliac and femoral veins were found normal, but unfortunately the deep calf veins were not examined. The increase of pulmonary embolism after the war of 1914-18 was attributed by Burwinkle to malnutrition. If, as our experience suggests, there is serious risk of pulmonary embolism in men and women recovering from severe privations, it is very necessary that doctors looking after them should have this risk in the forefront of their minds. My desire to make our observations known at once has increased on hearing of cases in which symptoms suggestive of pulmonary embolism have developed in returned prisoners-of-war while they were at home on 42 days’ leave. H. L. MILLES.
Letters
to
the Editor
A COMPREHENSIVE MEDICAL SERVICE BY NEXT JANUARY? SIR,—In putting forward my compromise plan for setting up a comprehensive medical service by Jan. 1, 1946 (discussed in your issue of May 19, p. 635), I had in view the many complexities of the situation as between‘ the medical profession, hospital authorities, local-’ government authorities and the Government. But I had also in view the possibility, if not the probability, that political indecision would prevent a beginning being; made before an election. The political decision to hold a General Election in July justifies my fears. Whatever may be the political complexion of the new Government, it will have before it its own programme of immediate urgency. What I still fear is the postponement of the coming into operation of the National Health Service to a date later than originally contemplated-for instance, after the defeat of Japan. My suggestion of using the EMS organisation in the jpegions into which Great Britain was divided for war purposes-one of which regions is, of course, Scotland as a whole-was based on the fact that this organisation was (1) of a temporary character, and (2) medically speaking had worked very well. Part reason for the working of the EMS hospital scheme being so good is that it secures the cooperationusually intimate coöperation—of voluntary and publicly owned hospitals in each region under the general supervision of the principal medical officer of the region. To continue this hospital service, and that of consultants, specialist advisers, and special services that go with it, as the compromise arrangement for providing necessary services under the National Health Service, would help and not hinder a final settlement, and it could be inaugurated by Jan. 1, 1946. It is certainly not -easy under any circumstances to arrange for a 100% domiciliary service at the present time. And to put the duty of seeing that this service was provided on the shoulders of the regional organisation of the EMS for each region puts a new duty upon the EMS. But it will not be easy to provide a 100% domiciliary treatment in any case, and in the beginning the service may not be complete under whatever auspices it is inaugurated. My proposal to charge the EMS with this duty would involve them in surveying the field of private medical practice and offering appointments on a temporary basis to provide for the essential needs of medically depleted areas. They would do this in cooperation with the Central Medical War Committee. There are very many difficulties in carrying out any scheme of National Health Service at the present time and I claim only for my proposal that it would get things done quickly and that it would be temporary in its application. It would in this way bridge the gap between the present, when we are only at the position of white-paper discussions, and a future time when definite conclusions as to organisation will have been reached. During this interim period it would provide for the civilian population and for the demobilised doctor looking for a job. Without this bypass arrangement, as I have called it, this interim period may pile up practical, administrative, and political difficulties which will make the inauguration of a National Health Service very much harder than it need be. And unless we arrive at a working compromise, the date of the inauguration mav be much nORt;noned. L. HADEN GUEST. House of Commons. ’
’
,
’
THE MEDICAL
SUPERINTENDENT
SIR,—I expect that most of the hospitals in the country will be taking a part in some form of State health service within the next few years. They will probably, therefore, come to adopt a fairly uniform system of administration. I wrote my letter of April 21
because I believe it would be
a mistake to appoint, as practice, medically qualified superintendents His experience as defined by Mr. Somerville Hastings. of these officers is very great ; in fact there is probably
standard
no-one
Hence
else with so many under his administration. may accept his opinion that a good clinician
we
is rarely a good administrator. This must mean that the two attributes are rarely combined in the same individual. While freely admitting that there are’ notable exceptions to the rule, it cannot be wise to apply universally a system which demands such a combination. I do not foresee the continuation of flag-days, appeals, and advertisement in aid of individual hospitals. The house-governor of the future should be free to apply himself to administration without these harassing distractions. If, as I advocate, he hr,s had a long, special training followed by experience i- junior administrative posts on hospital staffs he wi have acquired ample medical knowledge to suffice for. s routine work by the time he reaches senior rank in hi profession. I do not recommend that the chairman of the hospital should DT’ffeT’aMv be
a
medical
Ttin’n
W. A. LISTER.
PULMONARY EMBOLISM IN LIBERATED PRISONERS-OF-WAR SIR,—Between May 1 and May 9 about 300 men were admitted to Barnsley Hall EMS Hospital suffering from the effects of privations as prisoners-of-war in Germany. About 200 were stretcher cases. In only 2 of them was the state of malnutrition severe enough to cause anxiety, but it was noticed during the first week that the majority were running a temperature. On May 9 one of the patients died in five minutes of pulmonary embolism, confirmed post mortem : he had been allowed up for a day or two, but had been put to bed again because of recurrence of oedema on the legs. Nine days after admission another man died of pulmonary embolism six hours after the first manifestation. The question arises whether some of the symptoms and signs noted in the other men were not also due to pulmonary embolism. Most of them had marched 500-1000 miles between January and May on very short rations. During the last month of the march almost all of these developed diarrhoea and swelling of the legs. The oedema was usually limited to the lower shin but sometimes extended above the knee, and in some cases it was asymmetrical. Among the symptoms which they developed were paroxysmal dyspnoea while at rest. chest oppression or pain, palpitation, cough (with bloodspitting in at least one case), and sudden collapse : and the diagnoses made by medical officers examining the prisoners after liberation included pleural effusion, bronchitis, bronchopneumonia, lobar pneumonia, and pulmonary tuberculosis. There were cases of sudden death and " pneumonia that kills in a few hours." In some of the men the signs remaining in the chest on admission to Barnsley Hall were attributed at first to unresolved pneumonia or atypical pneumonia, but we now suspect that at least a proportion of them were the results of pulmonary infarction, while some of the other signs so often seen in these ex-prisoners (slight cyanosis of lips, pyrexia, tachycardia) may have been caused by small emboli without infarction. Paul White, who believes that pulmonary embolism commonly goes unrecognised, states that its outstanding cause is thrombosis of the leg veins, beginning as a rule in the calf and extending into the long saphenous and femoral veins. Such thrombosis would explain the oedema developing in so many of these prisoners as their malnutrition increased. (This osdema is less readily attributable to hypoproteinaerriia, for it was absent in a case where the plasma protein was 2-2 g. per 100 c.cm. but present in cases with readings of 6-0 g. upwards.) In the two patients dying of pulmonary embolism the iliac and femoral veins were found normal, but unfortunately the deep calf veins were not examined. The increase of pulmonary embolism after the war of 1914-18 was attributed by Burwinkle to malnutrition. If, as our experience suggests, there is serious risk of pulmonary embolism in men and women recovering from severe privations, it is very necessary that doctors looking after them should have this risk in the forefront of their minds. My desire to make our observations known at once has increased on hearing of cases in which symptoms suggestive of pulmonary embolism have developed in returned prisoners-of-war while they were at home on 42 days’ leave. H. L. MILLES.