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MEDICAL PREPARATION FOR " EMERGENCIES "

THE discourses of statesmen, leading articles in

newspapers, and letters in lay and professionaljournals during the last few weeks have not beenreassuring. No doubt some accusations of nationalmedical unpreparedness have been exaggerated ; buta sufficiency of admitted evil remains. The bestservice we can perform in such circumstances is toset out as dispassionately as possible the nature ofthe problems to be solved and the means availablefor their solution.The burden of virtually all complaints has been

a lack of coordination ; local authorities, centralauthorities, professional or semi-professional organisa-tions and individuals have exchanged recriminations.Before going any further, we should seek to see these-elements of our public life in perspective.

THE CENTRAL AUTHORITIES

In the first place stands the central governmentitself, which for present purposes chiefly means thesenior members of the administrative civil service.

It is easy on the one hand to write a lampoon onmandarins and limpets of Whitehall or on the otherhand to compose a panegyric on the public servicesof men whose successful labours are credited to" statesmen " and whose personal rewards would bebeneath the notice of a very minor merchant prince.It is more difficult to be fair. In his character of

George Grenville, Burke spoke of Grenville’s earlyintroduction to the " business of office " and madethis comment :-

" Much knowledge is to be had undoubtedly inthat line : and there is no knowledge which is notvaluable. But it may be truly said that men toomuch conversant in office are rarely minds of remark-able enlargement. Their habits of office are apt togive them a turn to think the substance of businessnot to be much more important than the forms inwhich it is conducted. These forms are adapted toordinary occasions ; and therefore persons nurturedin office do admirably well as long as things go intheir common order ; but when the high roads arebroken up, and the waters out, when a new andtroubled scene is opened, and the file affords noprecedent, then it is that a greater knowledge ofmankind and far more extensive comprehension ofthings is requisite, than ever office gave, or thanoffice can ever give."

Among the things a comprehension of which officehas never yet given is modern scientific knowledge.Even in these days of precocity few men will riseto commanding positions in the public service under45 and many will be past 60. Even if the career of anadministrator allured young scientists (which it doesnot), the civil service system of competitive examina-tion twenty to forty years ago hardly encouragedany scientist but the mathematician and gavepreference to a literce humaniores candidate before amathematician. There are some public offices thesenior staffs of which could still read Aristotle withenjoyment ; few whose senior administrators reallyknow what any man of science, sanitarian or clinician,would regard as truisms.

This, however, is not to say that the administratoris an ignoramus and the physician or scientist all-knowing. In intellectual quality senior administratorsare not inferior to the leaders of any other profession,nor are they less patriotic. They have knowledgeand skill which clinicians and scientists easily under-rate. Burke’s wording has a touch of derision ; intruth the forms of office are not things which every

fool either knows or may easily learn. Every man’sbusiness is important to himself, and may be importantto his country in a crisis. But the administrator isalways in Whitehall; the machine must always func-tion ; before the emergency as well as during theemergency.

R. L. Stevenson’s remark that it is not wise to saveup one’s appetite for dessert before one is sure thereis going to be any dessert would be even more pointedif the guest prevented other guests who desired todine from doing so. An administrator has to rememberthis ; if he forgot it for a moment, the newspapersand his parliamentary chief would remind him of it.Before we reach to-morrow we must pass throughto-day. We may illustrate the point from what wassaid by a deputation to Sir Thomas lnskip as reportedin the Supplement to the British. Iledical Journal ofNov. 19th. One speaker is credited with the followingremarks :-

" It was obvious that the ordinary voluntaryhospital could not be organised for war service untilit was known what demands were going to be madeupon the personnel for other purposes, what wasgoing to happen with regard to civilians in theneighbourhood of the hospital, and what would bedone with the younger men who could be sparedfor war service."

To most of us, accustomed as we are to use languageloosely but intelligibly, this does not mean, is notintended to mean, any more than that those respon-sible for the control and organisation of hospitalsshould be told plainly and quickly what is in theminds of administrators ; that in preparation for

emergency the administrator should not take therole of Sherlock Holmes while the hospital staffs aretreated like the faithful Watson. But to an adminis-trator, who admires (and sometimes achieves) preciselanguage, such a sentence is horrifying. How could

any administrator foretell exactly the course of an"

emergency " ? Even if he were a dictator he couldnot see into the minds of the gentlemen on the otherside of the hill. Any plan may have to be changed ;he must try to think out moves on the chessboardwhich will not irrevocably alter the position.The administrator must weigh the claims of to-day

against those of to-morrow. He is hampered bothby his knowledge and by his ignorance. By hisknowledge because he appreciates far more trulythan the scientist the difficulties of any plan ; byhis ignorance because he does not grasp the signi-ficance of what seem to him mere technical detailsand cannot foresee accurately the nature of an emer-gency. We have a sufficient literature of the grossblunders in the use of scientific knowledge and of thewholly erroneous forecasts of the course of hostilitiesmade by statesmen and soldiers in 1914-18 to establishboth propositions. Many of these mistakes must

inevitably be made again. All we can hope to do isto diminish their importance.We might begin by dividing Preparation for Emer-

gencies into two parts: Preparation which involveseither no government control, at the most benevolentapproval; Preparation which involves either a

delegation of official power or the direct exercise ofthat power.

THE COLLECTION OF INFORMATION

A typical and important example of the first classis the compilation of a register of personnel. It will beinstructive to consider the compilation of an ideal

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register simply as a scientific problem. It is, in asense, easier to compile a catalogue raisonnée of themedical profession than any other. A layman whoattempted to classify lawyers from the Law Listwould not get very far. Our " Medical Directory " ismore illuminating. From it alone an intelligentperson might classify not too badly our heterogeneousprofession into what the public calls specialists,general practitioners, and laboratory or public healthworkers. But the result would not be very helpfulin an emergency. The voluntary questionnaire ismore satisfactory and this has been adopted by theBritish Medical Association. But the questionnairemethod has its defects. Human vanity (or modesty)involves limitations. It is not only that A may bemistaken in holding that operative surgery is hisforte ; he may correctly think himself a technicallycompetent surgeon but incorrectly suppose that hecould work well in a team.Then again a classifying committee which can

judge well the merits of surgeons may be no judgesat all of biochemists. If we had a complete returnof questionnaires, their occupational classificationmust be made by a very expert body. That wouldbe the first and easiest stage-it might well meanthe handing over of defined occupational categoriesto different committees. The next stage is the vettingof individuals. This is a harder business. For certaincategories it would be comparatively easy-e.g., forthe laboratory workers-because these hardly everwork isolated from opportunities of expert appraise-ment. The same remark applies to public healthspecialists. indeed the fact that for several yearsmost of the entrants to public health services havebeen trained in a small number of schools rendersa well-informed catalogue easy to compile.With the much larger class of clinicians, the

difficulty is greater. Naturally it is not hard to judgethose who are already or aspire to be " specialists " (in the popular sense). Their contacts with greathospitals and medical schools must needs be close.But for the greater body of practitioners the positionis different. Modern conditions of practice havebridged the gulf between general practitioners andspecialists; the supply of men competent to do thework of hospital physicians and surgeons is much

greater than in 1914. To make a record of clinical

ability fit for various services would involve morelabour than that of a sessile committee, howeverexpert, reading documents in London. Local inquiry,not through forms and circulars, would be necessary.All this, however, could be done and some of it hasbeen done. A numerically complete, detailed recordcould be made. It could be supplemented by anequally detailed study of the medical students withinsight of qualification. Respecting them very preciseinformation is available. One could go further andestimate very closely the probable accession-rate tothe profession under existing and hypotheticalconditions. Suppose, for instance, that militaryreasons require that cities A, B, and C should ceaseto be places of medical education, how would thisaffect the accession-rate ? ° Would it be practicableto increase the output at D ? If so, under whatconditions ?

Such a complete account of the personnel of thepresent and immediately future medical professioncould be rendered without any direct official inter-ference ; all that would be needed would be a

benevolent neutrality. (Perhaps also an assurancethat some official Sherlock Holmes would not

duplicate part of the work. There is a limit to theamount of inquisition human beings can tolerate.)

But the criticism any practical man will make isthis. I will suppose that the work you have describedhas been faithfully and accurately performed. That

you really have not merely a complete statistical

analysis but dossiers of a large proportion of themen and women whose names appear on the BritishMedical Register ; so that your directing committeecan not only say how many surgeons, pathologists,&c., there are and in what age-groups, but can saywhat sort of people they are. Who will use thisinformation ? It will be a formidable collection ofcards, relating to persons scattered over thousandsof square miles. Suppose that the Navy requires100 surgical specialists, the Army 200, the RoyalAir Force 300, and the Home Office 400. Who is tohave first pick ? Suppose that the best 1000 includesall the clinicians practising in the county borough ofBarchester, is Barchester to be sacrificed in thenational interest ? Is it not probable that in reallife your beautiful card-index will hardly be consultedat all, or at best be used as a rough indication ofthe scope of medical possibilities, individuals, anddepartments making the best bargains they can? 1These objections bring us to the second stage : officialaction.

THE DELEGATION OF POWER

It was to meet such objections that the BritishMedical Association formed a central emergencycommittee, and the proceedings of Nov. 8th lastdeserve particular attention.

Before, however, discussing these something mustbe said of the history of the undertaking. The BritishMedical Association were officially requested to

compile a register on the lines of what we havediscussed above, and the qualifications of the B.M.A.to organise such a work were great. It is true thatthe Association is primarily concerned with the

interests, material and moral, of the medical professionand that not only does its membership not include thewhole of the profession but that a certain number ofmedical men objected to its proceedings and advisedtheir colleagues to give it no information ; butthese objectors were a small minority and the5 per cent. who supplied no information, or insuf-ficient information, perhaps even over-estimates theirstrength. It is also possible that the officers andactive members of the Association are less familiarwith the personnel and conditions of work of thescientific specialist activities of the profession thanwith those of general practice. But any defect herecould be and no doubt has been remedied by cooption.So far then as the compilation and completion of anadequate record are concerned, the machinery con-structed was efficient. But if this body were to passfrom research to action, it needed to be strengthened.In the eyes of the general public the B.M.A. had someof the attributes, good and bad, of any sectionalbody, whether trades union or employers’ association.Hence the need to have cooperation between theAssociation and the Royal Colleges with theirimmense traditional prestige. It is clear from thereport to which we have already referred, that thiscooperation had been secured before the deputationwent to Whitehall.The deputation submitted their proposals in the

form of two resolutions which were not, perhaps,very happily worded, but their intention was quiteclear. It was this. That all requisitions for medicalpersonnel should pass before a single professionalcommittee and that the several government depart-ments should be estopped from dealing with indi-viduals. The method was apparently to be this. The

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requisitions of the various departments would bereviewed and perhaps modified by some member ofthe Government with plenary powers and then passedto the professional committee. This committee wouldthen allocate individuals who would receive theirinstructions from the Minister or GovernmentDepartment having plenary power.In other words the professional committee did not

seek authority to order any individual to do anything.They did not even seek the power to challenge thedepartmental requisitions. All they asked was thatthey should be empowered to choose the men, andthat orders for personnel should not be placedindividually. Customers were not to go to marketbut to use a central buyer, a buyer who was a muchbetter judge than they could be of the quality ofgoods.

IMPLICATIONS

Prima facie such a proposal is so eminently reason-able, that it may seem difficult to raise objections.There are, however, many objections, good and bad.Unless these are faced, the plan will inevitably fail.In the first place, unless the professional committee

is taken very seriously, both by the Government andthe general public, and its members are prepared toregard the work as a first charge upon their time, notmerely in a crisis but long before a crisis, the committeewill be a mere window-dressing. If the requirementsof departments are to be met, if they are really to beforbidden to make their own arrangements witheager individuals, these requirements must come

quickly to the committee and must come from all

departments. That means that the internal govern-mental control of departmental orders (the analogueof Treasury control on financial requisitions) mustbe efficient and swift. In the next place, it wouldnot be sufficient simply to forward requisitions andto have them dealt with. The committee must bekept informed of military plans which affect thenumber and location of hospitals. It might be theirduty to point out that the fulfilment of such or suchan approved requisition would render unworkablethe existing plan for hospitalisation or, conversely,that some new plan of evacuation was inconsistentwith a disposal of personnel already sanctioned.To satisfy these requirements demands heavy

sacrifices of administrators. It is, we think, inferentialfrom the report that, while administrators havereserved an opportunity to accept the scheme withoutloss of face if compelled, they will do nothing withoutcompulsion. The sacrifices demanded are of powerand secrecy. It was a little amusing, or would havebeen amusing had not the subject been a grave one,to note the administrative horror of the thoughtthat this coordinating authority might be a directingauthority, " with powers of disposition over membersof the profession." Sir Kaye Le Fleming’s instantrepudiation of so horrible an idea may have satisfiedSir Thomas Inskip, but hardly the administrators.After all, university examiners have no power to

pass candidates ; those lists scanned anxiously atSouth Kensington by youthful crowds are provisionalonly, until confirmed by the senate; but candidateshave, rightly, more respect for examiners than thesenate. If what the deputation wanted were reallydone, civil service administrators would lose muchpower. Further, for the reasons given above, muchwhich is officially secret would have to be madeknown to persons not formally in the public service.Both sacrifices are painful. It is easy to see that theplan can be stultified in deed and accepted in wordWithout any difficulty.

What is at present proposed is verbally quitevague. Let us take the two resolutions as printed :-

" That in view of the experience gained in therecent crisis, there is urgent need for the setting upby the Government of an authority for the centralco-ordination, in time of emergency, of all Govern-mental and other civilian medical services and ofthe medical services of the armed forces-that isto say, a Government body to control demands formedical personnel."

" That the Emergency Committee, reconstituted tomake it fully representative of all branches of theprofession, be given full authority, in consultationwith the appropriate Government organisation, forallocation to the various services of medical personnelin time of emergency."As we have said, what was really desired is quiteclear ; but litera scripta manet. These are the formalresolutions. They would be literally implemented bya minute constituting any three civil servants or

ministers the " authority " of the first resolution,and empowering the emergency committee (or a

rump of it with additional members) to act "inconsultation " with this authority as asked in thesecond resolution. Of course nothing quite so absurdwould be done. A middle course would be followed,which would look as much like what was asked andbe as much like its opposite as possible.

If, as we believe, the proposals of the emergencycommittee are fundamentally sound, much morethan a deputation, or a dozen deputations, to Ministerswill be necessary. We think that the proposals mayrequire amplification and must be given much widerpublicity. We make the following suggestions foramplification, but these are plainly mere suggestionsto be discussed.

PROPOSALS

The professional committee when formed should,we think, lose its present nominal connexion with theBritish Medical Association but should not acquirea direct official status.To the B.M.A. belongs the credit of not only

initiation but a solid basis of achievement. But the

general public might prefer the new body to appearas well as to be wholly independent of any professionalbody. It should be small, composed of men of estab-lished professional reputation in the prime of lifeprepared to make this national task a primaryinterest. It should not be representative, in the senseof having as members persons expert in all thespecial branches of relevant knowledge. Such a bodywould be too large to act decisively. To meet thenecessary defects of specialist knowledge in the

professional committee, panels or subcommitteesof experts should be formed. In this way an effectiveliaison with other committees could be maintained.We are naturally concerned with medical personneland defects of medical organisation. But we neednot suppose that other scientific personnel was

registered, organised, and distributed in Crisis Weekany more competently than our own colleagues.Evidently a competent secretarial organisation andtherefore a considerable expenditure of money are

implied. Upon this rock the whole enterprise mayeasily founder. Or, put in a different form of words,it can easily be represented that it would be far

simpler to attach the committee (as advisers) to anexperienced civil servant invested with appropriatepowers.We stated at the beginning what arguments can

be advanced in favour of such a course. We believe,however, that the public might be convinced that

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these arguments are unsound. The essential point tomake is that the powers of the committee must bemore than advisory-that they must, within definedlimits, be executive. Plainly there must be limits ;the committee must not seek to be dictators of thenation or even of the medical profession. Havingrecommended such or such a distribution of personnel,the committee must submit if the highest executivepower in the land, His Majesty’s Ministers, rejector vary that recommendation. But nothing must

intervene between the committee and the highestauthority having final responsibility.

It is idle to expect that this plan, or any plan, canbe free from defects. Should a crisis come upon uswithin a few months it will inevitably fail. If publicinterest in the position is allowed to die down or isdiverted into some domestic channel, then againultimate failure is inevitable. But at the present timethere is at least a chance of effecting a permanentreform in our method of preparing for emergencies.

POST-GRADUATE LECTURES

THREE weeks ago we published summaries of twoof the lectures delivered at post-graduate courses

held at London hospitals at the opening of the wintersession. Of the two that follow, Dr. Cooksey’s wasgiven at King’s College Hospital and Mr. Winterton’sat the Middlesex Hospital.

HEAT THERAPY

(DR. F. S. COOKSEY)THE increasing use of electricity has brought

a number of new methods of applying heat to thetissues. With these methods the clinical indicationsfor heat have been somewhat extended by the intro-duction of deep heat therapy, but the more importantadvance is the greater precision with which heatcan be applied.Heat is transferred from a hotter to a cooler body

by conduction, convection, and radiation. Conduc-tion occurs when the cooler body is in close contactwith the hotter, such as a fomentation, poultice, orelectrically heated pad or blanket. The amountof heat transferred depends upon the difference intemperature between the two bodies, the time theheat is flowing, and the ability of the bodies toconduct heat. The difference in temperature islimited by the skin tolerance, and is sustainedfor only a short time when using a fomenta-tion and for a little longer with certain poultices.The electrically heated pad has the advantage thatthe difference in temperature can be maintained andthe uncomfortable initial high temperature of afomentation is avoided. The common practice of

allowing patients to use these pads for indefinite

periods is an abuse of a valuable therapeutic agent.The tissues become accustomed to heat if it is pro-longed, and the stimulus to the circulation is lost ;further, the pain of many acute suppurative andneuritic conditions is relieved by the correct dosageof heat and increased by an excess. Improvedresults are obtained if the pads are applied at statedintervals, and the duration of application should beprescribed by the doctor.The poor heat conductivity of the skin precludes

transferring large quantities of heat by conduction,and, furthermore, the heat so conducted is rapidlydissipated by the. superficial circulation so that thedeeper structures are not heated directly. The

dissipation of heat by the circulation is analogousto loss of heat by convection, and it must beremembered that in conditions in which the localcirculation is impaired the amount of heat appliedmust be reduced or there will be a risk of burns.The transference of heat by radiation depends upon

the fact that a hot body is at a given temperatureby virtue of energy produced within it, and that thisenergy is constantly emitted as a wave-like disturb-

ance of the ether in the same manner as light. Theenergy of heat or light as it is transmitted throughthe ether is referred to as a ray of heat or light.When heat rays fall upon another body they may betransmitted unchanged, reflected from its surface, orabsorbed and converted back into heat so raisingthe temperature of that body.

Heat rays are one of the forms of radiant energyof which other examples are light, wireless waves,ultra-violet rays, X rays, and the gamma rays ofradium ; they all travel at the speed of light andtheir characteristics depend upon their wave-lengthand frequency. Since the velocity is a common

factor it follows that the wave-length varies inverselyas the frequency. The heat rays are situated beyondthe red end of the visible spectrum ; they are invisibleand are known as the infra-red rays.As the temperature of a body rises so the wave-

length of the energy it emits becomes shorter. Theextent to which this radiant energy penetrateshuman tissues before it is absorbed and convertedinto heat varies with its wave-length and hence withthe temperature of the radiating body. It is generallyheld that penetration is greatest with wave-lengthscorresponding to a body just below dull red heat,and infra-red generators are constructed to operateat this temperature. Since a dull black body is themost efficient radiator of heat the radiating elementsof infra-red lamps may be constructed of graphite;these are the so-called " black body " generators.An older form of lamp is the incandescent electricbulb with a carbon filament. This operates at asomewhat shorter wave-length and emits visiblelight as well as infra-red rays, but in practice itsaction on the tissues does not materially differ fromthe true infra-red lamp.The advantage of the infra-red lamp over fomenta-

tions and electrically heated pads is that a proportionof the incident radiation penetrates the tissues to thedepth of a centimetre or so, and hence a greateramount of heat can be applied without overheatingthe skin, and a measure of direct heat reaches thesuperficial structures.

Infra-red lamps are simple to use, and it is easierto instruct a patient in the use of such a lamp thanin the efficient application of a fomentation.Inexpensive models are satisfactory provided care

is taken that a misshapen reflector does not bringthe rays to a focus on the skin and so form a hotspot liable to cause a burn. A much greater quantityof heat can be applied with a lamp than with fomenta-tions, and whilst this is an obvious advantage inmany circumstances, it must be remembered that tooprolonged application may be detrimental. Dosageshould be regulated by using the lamp at a fixeddistance and varying the time of the exposure. Theworking distance depends upon the strength of thelamp and can be determined by finding at whatdistance from the skin a just visible heat erythema