- Email: [email protected]
SERVICE PATIENTS IN SANATORIA
822
picturing large
succulent patches of it in the summer. If I had been asked why I planted it I should have rationalised the process and explained that it was a wartime effort to increase food supply in a simple way. But that wouldn’t be the- whole truth. When I was a boy I was doing the same sort of thing, carrying pails with tench in them for miles to stock barren ponds. I generally get the same sort of urge every autumn ; for the last few years it has been an irresistible desire to plant fruit trees. Probably men on the one hand and hens, cabbages, sheep, and water-cress on the other live in the same sort of loose symbiosis as the algae and fungi in some lichens, and I have been instinctively fulfilling my side of the bargain. .
*
*
*
The Quartermaster and the M.O. have fallen out, and it is supposed to be less dangerous to walk through the line of fire of a Lewis gun than quarrel with the Q.M. But the Doc is holding his own. It started after our seventh (since August) move. The Q.M. went with the advance party, and took for his stores the room which the previous battalion had allotted to the M.O. for his medical inspection and casualties. He gave our M.O. a rather ordinary room, up the narrowest flight of stairs I have ever seen. The M.O. asked for what he considered his own room back. The Q.M. refused ; but the Doc scored a minor triumph by getting an advance booking for the best rooms at our eighth (and present) place of location. Then the Q.M. scored a small verbal win. After lunch, when every officer was in the anteroom, he announced (quite untruthfully) that he had been along and chosen the Doc’s room-"with roses and carnations over the door." The night we got to our new home, these premises were destroyed by a bomb. So now the M.O. is on the warpath again. His present temporary place is well out of the town ; and when the Q.M. said it would do the Doc good to walk there, the Doc replied in injured tones that he did not mind how far he walked but he was not going to see sick men walking x miles to visit him. This retort was so good that we very nearly lost the magnificent officer’s mess. Now we are all on tenterhooks wondering for which building the M.O. will make an impassioned plea nextbattalion headquarters, signals house, the motor transport, or the Quartermaster’s stores. *
There are, I
imagine,
* *
many
foreigners, especially
Teutons, who fail to appreciate the humorous third leader of the T z7nss, and who might wonder what your peripatetic correspondents are doing in a medical galley. They would be out of place In England Now, or, let us
hereafter. In the German medical weeklies which I read leading articles and annotations by the editorial staff are absent. Articles of the kind are, I think, useful to us all, especially to the overworked and the lazy. They often give a synopsis of work done or in progress, and are reminders that a subject is still fluid to those who fancy they know its ultimate physio-pathology-say the lipoidoses, or the functions of the posterior pituitary. One’s legal friends are annoyed when some judge, setting up a new ruling, punctures the snug cocoon in which they are ensconced ; let them survey the tables covered with current literature in a well-stocked medical library. The leaders in ’our journals also serve as an exercise in clear and succinct expression, an art in which our profession is not strong. The German weeklies give from time to time a comprehensive survey of some subject by an authority, followed by a heart-breaking bibliography ; all done with that unswerving thoroughness, diligence and dullness for which their people are renowned. It would take a Voltaire’s mordant wit and many cups of coffee to deal faithfully with such a Sammelreferat. Another German practice is to publish monthly or bi-monthly reference-numbers as supplements to journals dealing with special lines of work. I can speak wdth knowledge of only one, that attached to the journal dealing with neurology and psychiatry. To produce regularly a work of this kind requires editorship, many skilled collaborators with knowledge of languages, industry, money. That the English-speaking world is content to leave this and like fields to Germany is, to my mind, discreditable.
hope,
Letters to the Editor ANÆSTHESIA IN THE SHOCKED PATIENT Sin,—The letter by Mr. Ruscoe Clarke and Mr. Kessell (Lancet, Nov. 23, p. 664) and your leading article of Dec. 21 invite comment. It is possible that your correspondents have made the error common on the continent of comparing results following local anaesthesia given by a skilled surgeon with those following
general anaesthesia supervised by
a
hospital orderly
or
While it is true that " methods of local aneesthesia should be further explored " there is little to suggest that a general anaesthetic, skilfully administered, adds to shock. It cannot be stressed too strongly, however, that a clear airway must be maintained throughout the whole period of unconsciousness, that the patient must be kept adequately oxygenated, and that only enough’ anaesthetic should be given to allow the operation to be performed satisfactorily. The shocked, exsanguinated, or heavily morphinised patient is already well on the way towards unconsciousness, and the required depth of anesthesia is achieved in a patient depressed by any means with a much smaller dose of anaesthetic drug’than would be needed for the same patient in normal health. This point has been emphasised by anaesthetists with experience in France. S. Rowbotham tells me that he found that the shocked patient needs much less local or general anaesthetic than does the fit, and Rex Binning (Brit. med. J. Dec. 7, 1940, p. 794), reminding us that in the shocked a very small amount of anaesthetic suffices, writes " they (the patients) were very tired as well as suffering from the effects of their injuries and it was noticeable that a much higher proportion of oxygen, sometimes as high as 30%, was required in ansesthetising them with nitrous oxide." If ether, Vinesthene, Pentothal, &c., had been used the results would probably have been almost equally satisfactory provided the necessary amount had been given. As your leader points out the safeguard of nitrous oxide is that an overdose cannot be given provided the patient is kept well oxygenated. Your leader, too, stresses the practical difficulties in the use of local anaesthesia. Even those of us who work under satisfactory conditions realise the extra work, attention and time needed if they are employed widely. In some cases the technique is easy and the results striking-e.g., brachial-plexus anaesthesia for operations on the upper limb, or in abdominal surgery. Blocking of the abdominal wall, however, may well be difficult to carry out in cases of penetrating wounds of the abdomen, and in any,case injection of the splanchnic plexus is nearly always necessary, and is inevitably followed by a fall in blood-pressure. For major surgery in other parts of the body the technique is not so easy, nor are the advantages so manifest. Binning points out the help of the practice followed in this and other hospitals of having a label attached to the patient showing what premedication he has had and when it was administered. On the reverse side of the label the anaesthetist writes the anaesthetic which has been given, and any postoperative instructions. ;rhese details all play their part in the prevention of postoperative complications to which the shocked patient is nurse.
so
susceptible.
Radcliffe Infirmary, Oxford.
R. R. MACINTOSH.
SERVICE PATIENTS IN SANATORIA
SIR,-A peripatetic correspondent in your issue of Dec. 14 writes of the difficulty in getting hospitals to involve themselves in Army board procedure. As a medical officer in one of the’seven sanatoria which take cases of tuberculosis from the Service hospitals for " boarding " I see many of the points that create this difficulty. The turnover of patients is large, the average length of stay being two or three weeks, and a large number of forms have to be dealt with. In view of the short period of residence little can be attempted or accomplished in the way of treatment, and one gets the feeling that a lot of time is being spent where it is possible to do very little, probably at the expense of civil patients on whom it might be more beneficially employed. The majority of service patients do not feel ill while they are in the sanatorium, and with no military
823 authority it is difficult to enforce discipline. If cases get really bad an example is made, and either the patient is transferred under guard to a military hospital (only to come back for the actual boarding) or a military court sits here with great ceremony and at least a temporary effect. Lesser breaches of discipline have to be ignored, and it is these that make it much harder to keep civil patients in order ; if the soldiers can play up why shouldn’t they ? Although it is admittedly wise for a patient suspected of tuberculosis to have the advantage of sanatorium facilities before being definitely labelled, it might be better for the military to take over sufficient complete sanatoria or parts of sanatoria, and to run them with both clerical staff to deal with the forms, and officers to maintain discipline. We are told that such staff can only be allowed when the number of patients reaches 150. ROBERT FLEW. Middleton-in-Wharfedale. THE SICK IN BOMBED AREAS
-
SiR,-The letter signed " Cockney " in your issue of Nov. 30 was, in its comments on the casualty services,-so obviously the product of an active and untrammelled mind that it calls for detailed consideration. Unfortunately the reaction of medicine to total war has not been so thorough as the situation demands. The assumption has been that the system in force in August, 1939, was an efficient if not an ideal one, and that the only adaptation called for was a scaling up of the existing services to meet the larger needs of war. No-one seems to have realised that the problems of war-time medicine differ in nature as well as in size from those of peace. Doctors tend to take it for granted that casualty services dealing with surgical cases are still engaged on civilian as distinct from military medicine. Even where they accept that the surgical problems are new they still do not make any great changes in their fundamental technique. As for the rest of medical practice, including preventive medicine, that, they feel, can carry on much as before. The truth is that if we are to wage a total As far as war successfully we must accept its totality. the dangerous areas are concerned all medicine is now military medicine. Appreciation of this fact is the first stage in proper organisation, and failure to grasp it accounts for much of the confusion in our local services. The principles of military medicine are :Flexibility.-Aid, in the first instance, must be conveyed to the patient rather than the patient to the aid. Accuracy.-Immediate deterioration of the patient’s condition having been checked and his exact needs having been determined he must be evacuated from the danger zone route to a point organised for specialised and definitive treatment. Continuity.-The entire treatment of the patient from casualty point to convalescence must be a continuous process ; like the manufacture of a Ford car, the problem must be
along
a
pre-selected
on conveyor-belt lines. Totality.-Mass prophylaxis is imperative. This, on surgical side, will include intelligent use of body-armour
tackled
the and tactical cover ; and on the medical side will extend over the whole field of hygiene and immunology, including in its scope the entire civil population of any military area.
Applying
these
principles,
our
needs
casualties, a system of rapid rescue, early, accurate classification, and evacuation along chosen routes to hospitals outside the casualty-producing area, in which only urgent ’
surgery would be performed. 2. For medical cases, a permanent diagnostic service (the skeleton of which exists and has been greatly improved of late by the Ministry of Health), backed by adequate and highly organised facilities for hospitalisation. 3. For prevention, mass prophylaxis, and drastic preventive hygiene covering every known vector. Given a slight extension of statutory power in the direction of compulsion, we have already in the Ministry of Health and in the local government services all the machinery needed for this work. 4. For the medical profession as a whole, the recognition that medicine must be re-planned to serve new units-not only the units of the Army, but the community units as represented by the shelter crowd. This implies the abandonment of the organisation of medicine on its present individual ’
RADON DOSAGE use of radon calls for easy reference between equivalent physical doses when radium and radon are used ; the graph reproduced here allows of this over a range largely used in treatment ; each smooth curve represents a product of radiummilligramme-hours (M.E.H.), the corresponding hours of treatment with any stated number of millicuries being read off from the coordinates. Some radiotherapists are making a virtue of necessity and seeing whether there are any essential differences
Sir,,-The extended
MILLICURIES
between the tissue reactions to radium and radon. Although it is of the first importance, there have been few attempts at determining between what limits the equation Qt qT holds in the field of treatment. Provided radon supplies can be augmented in the near future, we should be in a position to provide sources having quite a large value of Q (millicuries), and if a series of patients could be treated during the period of decay it might be practicable to use the radon when the quantity q was no more than 1/10 Q. ’Besides being of medical interest, such a prolonged use of a single radon source would be economical. SIDNEY RUSS. The Middlesex Hospital. =
now are :—
1. For
lines.
Medicine has ceased to be an affair of contract between two individuals. It is the concern of the nation as a whole ; it can only be served by what in effect must become a state medical service. Already in the bombed areas the evening surgery is impracticable and its work will inevitably be covered by the medical aid-posts placed in shelters by the Ministry of Health. As a profession we must decide whether we are willing to plan boldly to meet obvious necessities, thus building up a service which will continue in utility when the war is long past ; or whether we are going to shuffle from stage to stage under the pressure of events, meeting each catastrophe with half-hearted improvisations. K. W. C. SINCLAIR-LOUTIT, SINCLAIR-LoUTIT, G. B. SHIRLAW. SHIRLA.W. London.
THE TREATMENT OF BURNS
SiR,-It might appear from the remarks of speakers at the meeting of the Royal Society of Medicine on Nov. 6 that the problem of the severely burnt hand is a product of this war. It has certainly been neglected but as certainly is not new. Many of these derelict members, deformed and practically useless, are scattered about the country. Many thousands of pounds have been paid out by insurance companies by way of compensation for them and so great has been the disability that the question of amputation has at times been raised. These s
unfortunate results are not confined to the smaller towns and hospitals where treatment may fall short of the specialist standard. They have occurred in spite of expert supervision at noted surgical centres. In the last case sent to me the ends of the middle, ring and little fingers were shrunken, dry and necrotic. Although the damage was five months old the dead tissue had not completely separated, a characteristic
picturing large
succulent patches of it in the summer. If I had been asked why I planted it I should have rationalised the process and explained that it was a wartime effort to increase food supply in a simple way. But that wouldn’t be the- whole truth. When I was a boy I was doing the same sort of thing, carrying pails with tench in them for miles to stock barren ponds. I generally get the same sort of urge every autumn ; for the last few years it has been an irresistible desire to plant fruit trees. Probably men on the one hand and hens, cabbages, sheep, and water-cress on the other live in the same sort of loose symbiosis as the algae and fungi in some lichens, and I have been instinctively fulfilling my side of the bargain. .
*
*
*
The Quartermaster and the M.O. have fallen out, and it is supposed to be less dangerous to walk through the line of fire of a Lewis gun than quarrel with the Q.M. But the Doc is holding his own. It started after our seventh (since August) move. The Q.M. went with the advance party, and took for his stores the room which the previous battalion had allotted to the M.O. for his medical inspection and casualties. He gave our M.O. a rather ordinary room, up the narrowest flight of stairs I have ever seen. The M.O. asked for what he considered his own room back. The Q.M. refused ; but the Doc scored a minor triumph by getting an advance booking for the best rooms at our eighth (and present) place of location. Then the Q.M. scored a small verbal win. After lunch, when every officer was in the anteroom, he announced (quite untruthfully) that he had been along and chosen the Doc’s room-"with roses and carnations over the door." The night we got to our new home, these premises were destroyed by a bomb. So now the M.O. is on the warpath again. His present temporary place is well out of the town ; and when the Q.M. said it would do the Doc good to walk there, the Doc replied in injured tones that he did not mind how far he walked but he was not going to see sick men walking x miles to visit him. This retort was so good that we very nearly lost the magnificent officer’s mess. Now we are all on tenterhooks wondering for which building the M.O. will make an impassioned plea nextbattalion headquarters, signals house, the motor transport, or the Quartermaster’s stores. *
There are, I
imagine,
* *
many
foreigners, especially
Teutons, who fail to appreciate the humorous third leader of the T z7nss, and who might wonder what your peripatetic correspondents are doing in a medical galley. They would be out of place In England Now, or, let us
hereafter. In the German medical weeklies which I read leading articles and annotations by the editorial staff are absent. Articles of the kind are, I think, useful to us all, especially to the overworked and the lazy. They often give a synopsis of work done or in progress, and are reminders that a subject is still fluid to those who fancy they know its ultimate physio-pathology-say the lipoidoses, or the functions of the posterior pituitary. One’s legal friends are annoyed when some judge, setting up a new ruling, punctures the snug cocoon in which they are ensconced ; let them survey the tables covered with current literature in a well-stocked medical library. The leaders in ’our journals also serve as an exercise in clear and succinct expression, an art in which our profession is not strong. The German weeklies give from time to time a comprehensive survey of some subject by an authority, followed by a heart-breaking bibliography ; all done with that unswerving thoroughness, diligence and dullness for which their people are renowned. It would take a Voltaire’s mordant wit and many cups of coffee to deal faithfully with such a Sammelreferat. Another German practice is to publish monthly or bi-monthly reference-numbers as supplements to journals dealing with special lines of work. I can speak wdth knowledge of only one, that attached to the journal dealing with neurology and psychiatry. To produce regularly a work of this kind requires editorship, many skilled collaborators with knowledge of languages, industry, money. That the English-speaking world is content to leave this and like fields to Germany is, to my mind, discreditable.
hope,
Letters to the Editor ANÆSTHESIA IN THE SHOCKED PATIENT Sin,—The letter by Mr. Ruscoe Clarke and Mr. Kessell (Lancet, Nov. 23, p. 664) and your leading article of Dec. 21 invite comment. It is possible that your correspondents have made the error common on the continent of comparing results following local anaesthesia given by a skilled surgeon with those following
general anaesthesia supervised by
a
hospital orderly
or
While it is true that " methods of local aneesthesia should be further explored " there is little to suggest that a general anaesthetic, skilfully administered, adds to shock. It cannot be stressed too strongly, however, that a clear airway must be maintained throughout the whole period of unconsciousness, that the patient must be kept adequately oxygenated, and that only enough’ anaesthetic should be given to allow the operation to be performed satisfactorily. The shocked, exsanguinated, or heavily morphinised patient is already well on the way towards unconsciousness, and the required depth of anesthesia is achieved in a patient depressed by any means with a much smaller dose of anaesthetic drug’than would be needed for the same patient in normal health. This point has been emphasised by anaesthetists with experience in France. S. Rowbotham tells me that he found that the shocked patient needs much less local or general anaesthetic than does the fit, and Rex Binning (Brit. med. J. Dec. 7, 1940, p. 794), reminding us that in the shocked a very small amount of anaesthetic suffices, writes " they (the patients) were very tired as well as suffering from the effects of their injuries and it was noticeable that a much higher proportion of oxygen, sometimes as high as 30%, was required in ansesthetising them with nitrous oxide." If ether, Vinesthene, Pentothal, &c., had been used the results would probably have been almost equally satisfactory provided the necessary amount had been given. As your leader points out the safeguard of nitrous oxide is that an overdose cannot be given provided the patient is kept well oxygenated. Your leader, too, stresses the practical difficulties in the use of local anaesthesia. Even those of us who work under satisfactory conditions realise the extra work, attention and time needed if they are employed widely. In some cases the technique is easy and the results striking-e.g., brachial-plexus anaesthesia for operations on the upper limb, or in abdominal surgery. Blocking of the abdominal wall, however, may well be difficult to carry out in cases of penetrating wounds of the abdomen, and in any,case injection of the splanchnic plexus is nearly always necessary, and is inevitably followed by a fall in blood-pressure. For major surgery in other parts of the body the technique is not so easy, nor are the advantages so manifest. Binning points out the help of the practice followed in this and other hospitals of having a label attached to the patient showing what premedication he has had and when it was administered. On the reverse side of the label the anaesthetist writes the anaesthetic which has been given, and any postoperative instructions. ;rhese details all play their part in the prevention of postoperative complications to which the shocked patient is nurse.
so
susceptible.
Radcliffe Infirmary, Oxford.
R. R. MACINTOSH.
SERVICE PATIENTS IN SANATORIA
SIR,-A peripatetic correspondent in your issue of Dec. 14 writes of the difficulty in getting hospitals to involve themselves in Army board procedure. As a medical officer in one of the’seven sanatoria which take cases of tuberculosis from the Service hospitals for " boarding " I see many of the points that create this difficulty. The turnover of patients is large, the average length of stay being two or three weeks, and a large number of forms have to be dealt with. In view of the short period of residence little can be attempted or accomplished in the way of treatment, and one gets the feeling that a lot of time is being spent where it is possible to do very little, probably at the expense of civil patients on whom it might be more beneficially employed. The majority of service patients do not feel ill while they are in the sanatorium, and with no military
823 authority it is difficult to enforce discipline. If cases get really bad an example is made, and either the patient is transferred under guard to a military hospital (only to come back for the actual boarding) or a military court sits here with great ceremony and at least a temporary effect. Lesser breaches of discipline have to be ignored, and it is these that make it much harder to keep civil patients in order ; if the soldiers can play up why shouldn’t they ? Although it is admittedly wise for a patient suspected of tuberculosis to have the advantage of sanatorium facilities before being definitely labelled, it might be better for the military to take over sufficient complete sanatoria or parts of sanatoria, and to run them with both clerical staff to deal with the forms, and officers to maintain discipline. We are told that such staff can only be allowed when the number of patients reaches 150. ROBERT FLEW. Middleton-in-Wharfedale. THE SICK IN BOMBED AREAS
-
SiR,-The letter signed " Cockney " in your issue of Nov. 30 was, in its comments on the casualty services,-so obviously the product of an active and untrammelled mind that it calls for detailed consideration. Unfortunately the reaction of medicine to total war has not been so thorough as the situation demands. The assumption has been that the system in force in August, 1939, was an efficient if not an ideal one, and that the only adaptation called for was a scaling up of the existing services to meet the larger needs of war. No-one seems to have realised that the problems of war-time medicine differ in nature as well as in size from those of peace. Doctors tend to take it for granted that casualty services dealing with surgical cases are still engaged on civilian as distinct from military medicine. Even where they accept that the surgical problems are new they still do not make any great changes in their fundamental technique. As for the rest of medical practice, including preventive medicine, that, they feel, can carry on much as before. The truth is that if we are to wage a total As far as war successfully we must accept its totality. the dangerous areas are concerned all medicine is now military medicine. Appreciation of this fact is the first stage in proper organisation, and failure to grasp it accounts for much of the confusion in our local services. The principles of military medicine are :Flexibility.-Aid, in the first instance, must be conveyed to the patient rather than the patient to the aid. Accuracy.-Immediate deterioration of the patient’s condition having been checked and his exact needs having been determined he must be evacuated from the danger zone route to a point organised for specialised and definitive treatment. Continuity.-The entire treatment of the patient from casualty point to convalescence must be a continuous process ; like the manufacture of a Ford car, the problem must be
along
a
pre-selected
on conveyor-belt lines. Totality.-Mass prophylaxis is imperative. This, on surgical side, will include intelligent use of body-armour
tackled
the and tactical cover ; and on the medical side will extend over the whole field of hygiene and immunology, including in its scope the entire civil population of any military area.
Applying
these
principles,
our
needs
casualties, a system of rapid rescue, early, accurate classification, and evacuation along chosen routes to hospitals outside the casualty-producing area, in which only urgent ’
surgery would be performed. 2. For medical cases, a permanent diagnostic service (the skeleton of which exists and has been greatly improved of late by the Ministry of Health), backed by adequate and highly organised facilities for hospitalisation. 3. For prevention, mass prophylaxis, and drastic preventive hygiene covering every known vector. Given a slight extension of statutory power in the direction of compulsion, we have already in the Ministry of Health and in the local government services all the machinery needed for this work. 4. For the medical profession as a whole, the recognition that medicine must be re-planned to serve new units-not only the units of the Army, but the community units as represented by the shelter crowd. This implies the abandonment of the organisation of medicine on its present individual ’
RADON DOSAGE use of radon calls for easy reference between equivalent physical doses when radium and radon are used ; the graph reproduced here allows of this over a range largely used in treatment ; each smooth curve represents a product of radiummilligramme-hours (M.E.H.), the corresponding hours of treatment with any stated number of millicuries being read off from the coordinates. Some radiotherapists are making a virtue of necessity and seeing whether there are any essential differences
Sir,,-The extended
MILLICURIES
between the tissue reactions to radium and radon. Although it is of the first importance, there have been few attempts at determining between what limits the equation Qt qT holds in the field of treatment. Provided radon supplies can be augmented in the near future, we should be in a position to provide sources having quite a large value of Q (millicuries), and if a series of patients could be treated during the period of decay it might be practicable to use the radon when the quantity q was no more than 1/10 Q. ’Besides being of medical interest, such a prolonged use of a single radon source would be economical. SIDNEY RUSS. The Middlesex Hospital. =
now are :—
1. For
lines.
Medicine has ceased to be an affair of contract between two individuals. It is the concern of the nation as a whole ; it can only be served by what in effect must become a state medical service. Already in the bombed areas the evening surgery is impracticable and its work will inevitably be covered by the medical aid-posts placed in shelters by the Ministry of Health. As a profession we must decide whether we are willing to plan boldly to meet obvious necessities, thus building up a service which will continue in utility when the war is long past ; or whether we are going to shuffle from stage to stage under the pressure of events, meeting each catastrophe with half-hearted improvisations. K. W. C. SINCLAIR-LOUTIT, SINCLAIR-LoUTIT, G. B. SHIRLAW. SHIRLA.W. London.
THE TREATMENT OF BURNS
SiR,-It might appear from the remarks of speakers at the meeting of the Royal Society of Medicine on Nov. 6 that the problem of the severely burnt hand is a product of this war. It has certainly been neglected but as certainly is not new. Many of these derelict members, deformed and practically useless, are scattered about the country. Many thousands of pounds have been paid out by insurance companies by way of compensation for them and so great has been the disability that the question of amputation has at times been raised. These s
unfortunate results are not confined to the smaller towns and hospitals where treatment may fall short of the specialist standard. They have occurred in spite of expert supervision at noted surgical centres. In the last case sent to me the ends of the middle, ring and little fingers were shrunken, dry and necrotic. Although the damage was five months old the dead tissue had not completely separated, a characteristic