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THE LANCET.

LONDON: SATURDAY, OCTOBER 23, 1915.

The Supply of Medical Men forthe Army.

THE call for medical men to join the RoyalArmy Medical Corps remains urgent. How fine the

response to that call has been hitherto is known

only to those who appreciate the circumstancesin which many medical men have accepted com-missions, the sacrifices which they have made, andthe anxieties which they are bound to be enduring;and yet it is necessary to ask, and to ask in-

sistently, that more men should come forward. Theparamount national will is that the war should bebrought to a successful end as soon as possible,and day by day it is borne in upon all that

every man who can carry arms must be readyto do so. It follows that our army, as it growslarger, must possess a medical staff of pro-

portionate expansion. The Army Medical Depart-ment demands that medical officers shall be

supplied in due quantity for every battalion, thateach medical unit shall have a full complement ofofficers, and that the military hospitals shall beserved so that, on the one hand, our sick andwounded may have that best of care which is dueto them, and that, on the other hand, their servicesmay have a good economic result as shown by thenumbers enabled to return to the fighting line.

Civilian medical men have made notable sacri-fices in order to obey the call to the army. A greatnumber of practitioners have left their practices, andat very short notice, to serve with the army, actingthus with the full knowledge that they are losingfor the time a certain amount of income-which

may be borne in some cases with equanimity, andare also endangering their future prospects-whichis a more lamentable matter to contemplate. The

position which the medical man occupies in his

profession is a tribute to his personal worth,and public influence of this sort is not likely to bemaintained after any long interval of time,especially if nothing is done to preserve it. Had

it been possible to ensure that both the publicand the medical men in the different localitiescould and would unite to safeguard the interests ofpractitioners joining the army, the voluntary offerswould undoubtedly have been more numerous

than they have been, although they have alreadyexceeded the confident expectations of many. Butthere has been a feeling that the man who wentout to fight for his country might find on his returnthat his practice had suffered, and even had dis-appeared, and this is in particular the situationwhich requires to be remedied. The National

Health Insurance Joint Committee, acting jointly

with the Insurance Commissioners, have certifiedthat a new regulation should come into opera-tion forthwith which will not be without its

good effect. Under this regulation the insured

person, whose name is1included in the list of any

panel practitioner who at the end of November isabsent on military service, shall not, be entitled toselect another practitioner or method of treatmentat the end of the year without giving reasonablegrounds for his action. This provisional regulationshows us that the National Health Commissionersare trying to relieve a situation which is perfectlywell known to them, even while they necessarilyview with apprehension too great a depletion formilitary needs of the number of panel doctors

available. Again, in certain localities, we are

informed, arrangements have been made withsome completeness for the taking over of the

practices of absent members of the medical pro-fession by their colleagues who remain behind,but this is a very difficult matter to arrange and

requires much further development before the

apprehensions of many men who might otherwisebe ready to join the army can be removed.

It is well known that the War Om ce require alarge number of medical men by January next, andthe need having been communicated to the WarEmergency Committee that body has been for sometime attempting to meet the deficiency. Theformation of a register and of local committees hasbeen followed by a request to those committees tosend from the various districts a proportionatequota of doctors. The local committees have beenrelied upon to find the number and to select

the proper persons to be sent, and the hope of theWar Emergency Committee has been that in thisway the men who could be best spared by thecommunity, and whose circumstances were bestable to meet the call, would be selected. This is a

method of recruiting medical men for the armywhich has met with success in Scotland, and inEngland the response under such a system of

voluntary conscription has been fairly good, butthe number of men enrolled is not large enough towarrant the belief that by the end of January thedemands of the War Office will be forthcoming.A more economical use of the medical officers

serving with home service battalions may beevolved and may help to lighten the situation, butit is easy to see that the supply of medical officerspromises to become very short.

Traumatic Asphyxia.THE multiplicity of injuries, some of them of

bizarre and peculiar character, produced by thewholesale use of modern military instruments ofdestruction, is rightly claiming special attention atthe present moment. Our knowledge as regards thepathology and treatment of both gross and fine

injuries will be greatly increased when time hasbeen given for the adequate analysis of the casesnow being accumulated in official reports, in medical

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journals, and in the proceedings of learned societies.The clinical experience of the country is largelyconcentrated on the practice of surgery in con-

nexion with the war, but the conditions imposedupon many districts by military necessities must invarious directions tend to increase the accidents andcasualties to civilians. The rare cases in civilian

practice deserve as much notice now as at any othertime, though they are much more likely to escapechronicling.We publish this week a case which is of singular

interest, to which we draw attention with specialemphasis, not only on account of its rarity and ofthe illustrations which serve to bring out themain features of the case so dramatically, but

also because of the interesting and ingeniousexplanation of these features offered by Mr. W. W.LININGTON, of Folkestone, to whom we are in-

debted for the record of the case. The patientwas a girl aged 11 years, who was knocked downby a motor-bus and imprisoned under the guardin front of the rear wheels. She sustained certain

bruises and abrasions and a vaginal wound,but the peculiar feature of the case was the lividcolour of the face and neck, which terminatedabruptly at the line of the clavicles and themanubrio-sternal joint. The conjunctivas werecherry-red in colour, apparently from subcon-

junctival haemorrhage, and the ears were at first

unaffected, as is shown in the first figure of the

plate accompanying the record. Careful examina-tion of the skin showed the discolouration to be dueto innumerable punctiform spots, so closely set asto appear continuous and not to any macroscopicextravasation of blood, and this was confirmed bythe fact that on firm pressure the colour faded some-

what and returned on the release of the pressure.On the second day the affected area became swollenand deeper in colour, and on the third day the earsbecame involved and the discolouration spreadslightly below the line of the clavicles. Recoverywas rapid, and in 14 days after the injury all dis-colouration had disappeared, having faded gradu-ally without the series of colours seen in bruises,except in the conjunctivae. The explanation offeredof cases of this type by Mr. LININGTON is both

ingenious and plausible, and is based uponanatomical considerations. He regards the con-

dition as of purely mechanical origin, and as due toparalysis of the veins, venules, and capillaries fromover-distension. He points out that the openingof the inferior vena cava into the right atrium hasonly a rudimentary valve, while the orifice of the

superior vena cava immediately opposite to ithas no valve. Of the veins tributary to the

superior vena cava through the innominateveins he states that the axillary veins have

good and effective valves, whereas the internaland external jugulars, the vertebrals and their

tributaries have either no valves or at most in-

effective ones, as can be shown in the dissecting-room, where injection of the vena cava distends

the last-named veins, leaving those of the arm

empty. Mr. LININGTON therefore explains thecharacteristics of these cases of so-called trau-

matic or local asphyxia as due to the continued

pressure on the abdomen forcing the blood fromthe liver and the abdominal veins into the rightatrium, causing distension of its cavity and inturn engorgement of the superior vena cava.

Owing to the efficiency of the valves of the axillaryveins the arms are protected, and the stress of theengorgement falls upon the other tributaries, espe-cially upon the external and internal jugularswith their ineffective valvular mechanisms. The

consequence is that if the abdominal compressionis severe and prolonged these tributaries becomeparalysed from over-distension, and may remainso for several days, gradually recovering, as inthe recorded case.On the basis of this hypothesis Mr. LININGTON

accounts for some of the puzzling features of thesecases. They are rare because a postulate for theiroccurrence is an even continuous pressure sufficientto squeeze all the blood out of the abdomen withoutother severe injury, and this condition is seldom ful-filled. The rarity of cerebral symptoms he believesto be owing to the support afforded to thevertebral veins and internal jugulars by their deapsituation, and in the case of the latter by theirspecial fibrous sheath as well. The absence of pul-monary symptoms is made clear by the supposi-tion that the engorgement of the right atrium ismore easily transmitted to the superior vena cavaand its tributaries than to the right ventriclewith its muscular walls, while the pulmonary veinsand left atrium are protected by their deep positionfrom direct pressure. The extension of the dis-colouration below the clavicles noted in the caseunder his charge he attributes to the fact that thesuperior intercostal veins empty into the innomi-nate veins or occasionally into the vertebrals.The cyanosis is regarded as arising from the

great distension of the veins, without any corre-sponding arterial dilatation, with the consequencethat the blood stream is slowed, giving time forthe abstraction of all, or nearly all, of the oxygenfrom the oxyhaamoglobin of the red corpuscles.From the literature it would appear that thesecases are of great rarity, and a graphic recordof the condition is of considerable value. Mr.

LININGTON’S interesting hypothesis seems to usof wider application, for it may explain why con-junctival haemorrhages and cutaneous petechialextravasations occur not infrequently in the headand neck area in cases of whooping-cough and aftersome conditions of severe and prolonged vomiting,while cerebral haemorrhages under these conditionsare extremely rare. A teleological explanation of thevenous mechanism concerned would have appealed <t

strongly to some scientists of a former generation, iand it is difficult to resist the suggestion that the !

ineffective valvular mechanism of the superficialveins of the head may have been evolved as a pro-tective agency against sudden increase of pressurein the superior vena cava.