Throughout the decade following the war the Medical work of the
Ministry of Pensions, though necessarily decreasing, continued on an
immense scale. Medical boards were called upon to make some five
million examinations. The Ministry's own hospital accommodation alone
averaged 8,000 beds, while pensioners altogether received 80,000
courses of in-patient treatment and were fitted with 11,000 artificial
limbs, annually. Last year the number of medical boards had declined
to 5,200, and the number of beds in Ministry hospitals to 1,800-still
requiring a nursing service of 200 and some 800 other subordinate
hospital staff. The numerical diminution from earlier years is so
considerable that it might be assumed the medical work of the Ministry
is now circumscribed within a narrow routine
This is far from being the case, since the decrease in the quantity of work has to a large extent been balanced by its complexity as the war becomes more distant. In the years closely following the war it was relatively easy to decide on the relation of current pathological conditions to the effects of war service. Now, -after nearly twenty years, the ex-service man is passing into later middle age and has suffered a long continued period of civilian economic stress. The connexion of his present clinical condition with war service raises many difficult problems. Does it of necessity follow that, because a man who is now becoming a chronic rheumatic or bronchitic suffered from a slight attack of rheumatism or bronchitis during the war and even received a pension for it, his present condition is directly related to war service, and how far is the need for treatment to-day the outcome of war service, to the exclusion of the effects of civilian life and advancing age? What is the possible connexion with war service in the case of a man in whom keratitis or tuberculosis is now found to be developing? Or again, on the death of a pensioner, to what extent has his war service determined the cause and the time of his death?
These are the kind of intricate medical problems to which the
Ministry must find an answer compatible with the most recent medical
knowledge and fair alike to the pensioner, his dependants, and the
State. The need for such allocation of pathological causation to
different, often indeterminate and largely interlocked, factors is
for the most part foreign to normal medical practice, though
analogous to compensation insurance work, and the medical staff of
the Ministry has been navigating a largely uncharted sea. Its
consultants, drawn from the teaching hospitals, have naturally played
a large part in the determination of these problems, but even so it
not seldom becomes necessary, in order to co-ordinate differing
specialist opinion, to refer cases to independent medical experts
appointed by the Presidents of the Royal Colleges of Physicians and
Surgeons, and in the last year the number of such references was 141.
As might be expected, the problems were mainly medical and
neurological rather than surgical. The relationship between
thrombo-angiitis obliterans and gunshot wounds, that of latent
keratitis to gassing, of gastric ulcer to a previous dysentery, or
tuberculosis to gunshot wounds of the chest or gassing, are among the
conditions to be sifted each on its individual merits. Naturally, in
considering the fresh claims to pension at this date, attention must
be given to the experience derived from a mass of clinical records,
the evidence from which often throws considerable doubt on many of
those statements which are handed on from one textbook to another as
to causation, and connexion with disease or trauma, of which there had
been little experience.
Apart from its pension problems (increasingly widows' cases) and those of medical administration, a large part of the Ministry's work is to treat disabilities peculiar to war service, and a visit to any one of its hospitals will show that its continuous aim is to keep abreast of thetimes- ; indeed it would be lacking in its duty if it did not do so, since during 972 Nov. 13, 1937 SURGICAL RESEARCH THIE BRITISH MEDICAL JOURNAL the last year over 6,000 out of 14,000 cases were treated in its hospitals, and the number of new artificial limbs required was 4,200, and were dealt with by the Ministry's own limb-fitting surgeons at sixteen centres. While the majority of these cases were renewals, in seventy-seven cases the provision became necessary as the result of primary amputation during the year. Ministry clinics, which were always predominantly for the provision of physiotherapy, continue to function, but on a very much diminished scale. The whole of the Ministry's pathological work is now carried out by means of a postal service, the central laboratory being located at Roehampton. This work required 25,000 examinations during the year, and it is of interest to learn that to-day, out of all the tens of thousands of tropical cases with which the laboratory has had to deal, while the entamoeba is occasionally found the presence of malarial parasites is so rare as to be virtually non-existent. Among those cases which are cared for on behalf of the Ministry by local authorities there are 5,500 men in mental hospitals, each of whom is visited yearly by the Ministry's mental specialist.
Of general interest will be the experience of the Ministry that with the decline in in-patient treatment there has occurred an increase in out-patient treatment. This is attributed, on the one hand, to the finding that out-patient treatment is likely to be as effective as in-patient in those cases in which repeated admission to hospital has failed to effect a cure, and, on the other, to the fact that with improved conditions of employment men wish to hold their work, and for them evening clinics are provided. The marked increase in the demand for surgical appliances seems undoubtedly due to the inability of pensioners to withstand the onset of general loss of ton,e inseparable from advancing years. Lastly it may be noted that the day-to-day functions of the Ministry still require the employment of some eighty whole-time medical officers, quite apart from a considerable number working on part-time.
