165COLLECTION OF CASUALTIES

the red-cell fragilities in relatives of cases of Cooley’sa,naemia, it has been found that the syndrome is

actually very widespread in its mild forms and thatthere is a definite hereditary basis for it. CAMPINO-METROS,! working in Sicily, thought that there mightbe a Mendelian recessive mode of inheritance. DAME-SHEK,2 who has recently described a further series,is less dogmatic, but finds the target-cell syndromepresent in both parents and certain siblings of casesof Cooley’s anaemia. Van RAVENSWAAY, SCHNEPPand MOORE 3 have described a case in a Greek patientwho had reached the age of 34 ; out of his 4 children,3 had died of Cooley’s ansemia and there is suggestiveevidence that his parents’ families were widelyaffected. SMITH 4 of New York investigated 16 familiesin whom children had developed classical Cooley’sdisease or a moderate but refractory ansemia ; outof 63 persons, blood changes typical of Mediterraneananaemia were found in 54. SMITH regards the de-creased fragility to hypotonic saline as the most usefulsingle test and points out that, though target cells wereonly found in half his cases, all except one had de-creased fragility and their blood-films showed otherevidence of the presence of thin cells such as hypo-chromic polychromatic macrocytes-an unusual com-bination. The sternal marrow showed normoblastichyperplasia with the same red-cell abnormalitiesas the peripheral blood. SMITH is in no doubt aboutthe hereditary nature of the disease and points outthat a mildly affected patient may have severelyaffected children ; but he has not sufficient evidenceto determine the exact mechanism. The mild casesseem to live normally without inconvenience ; forthe others no treatment has had any effect-iron, liverextracts. vitamin-B complex in various forms are no

use ; splenectomy makes them worse. A severe

anaemic episode or an intercurrent infection is the nor-mal termination. Van RAVENSWAAY’s patient des-cribed a local Greek method of treatment that he hadhimself experienced ; it consisted in a primitive formof wet-cupping, with pressure on the spleen appliedby hooking the edge of the enlarged organ over thetop of a fence and then hanging suspended with bothfeet off the ground.In the Mediterranean area the most important

differential diagnosis isfrom chroniemalaria. The com-bination of chills, fever and splenomegaly occurs inboth, and van RAVENSWAAY quotes a statement froma Greek source about " hereditary malaria " ; were

these ’really cases of Mediterranean anaemia andwould target cells have been found in their blood ifthey had been looked for ? It is notable that most ofthe observations on Mediterranean anaemia have beenmade on persons born in Italy, Greece or Syria andtheir children who had emigrated to the USA ; recordsfrom the Mediterranean countries themselves are few.These countries are now much in the news and thetime may be near when relief measures among theirdebilitated populations, many of them anaemic, willhave to be undertaken. To the common causes ofmalnutrition and malaria, it will be well to add thisMediterranean anaemia syndrome. We do not knowhow widespread it really is, but the characteristic

1. Campinometros, J. Ann. Méd. 1938, 43, 27 and 104.2. Dameshek, W. Amer. J. med. Sci. 1943, 205, 643.3. Van Ravenswaay, A. C., Schnepp, K. H. and Moore, C. J. Amer.

med. Ass. 1943, 122, 83.4. Smith, C. J. Amer. J. Dis. Child. 1943, 65, 681.

red-cell changes are not difficult to detect even if

fragility tests are impracticable in the field, and we doknow that it is refractory to treatment ; a search forthese features in the blood of patients not respondingto antiansemic or antimalarial treatment may give usnew knowledge of this syndrome, and prevent mistakesin assessing the value of these treatments.

Annotations

COLLECTION OF CASUALTIES

IN the British Army each battalion or equivalentunit has a regimental medical officer. In the ordinaryway the RMO is the sole representative of the RAMCattached to the unit, and he must find his assistants fromits strength : thus his orderlies, NCOs and stretcher-bearers may be infantrymen, sappers or gunners, trainedin first aid, but they are seldom members of his owncorps. The United States Army works on the oppositeprinciple. An American regiment, which correspondsto our brigade, normally has its own regimental medicaldetachment from the Medical and Dental Corps, and thisis divided so that each battalion has a substantialmedical section, comprising officers, NCOs, and other" medical soldiers." The arrangements are such thatevery platoon has the services of a trained orderly fromthe Medical Corps who accompanies it into action. TheAmericans like this system because there is never anyquestion of reducing the fire-power of combatant unitsby assigning combatant personnel to medical duties ;because training as a combatant is not wasted on someonewho will be stretcher-bearing ; and because they thinktheir litter-bearer, as they call him, will be better trainedif he is trained exclusively for his medical task.! The

arguments in favour of the British system need not bestated here ; but it must be admitted that the regularprovision of medical personnel for our troops is on a lessgenerous scale.The Americans have lately described their routine for

picking up wounded.2 Each man carries, fastened to hisbelt, a first-aid package and a package containingsulpha diazine in tablets and powder. If conscious andable to do so, he is expected to dust the powder into hiswound, apply his field dressing, and take the tablets bymouth. " In all probability, however, a hospital corps-man has reached him before he has a chance to do this."This hospital corpsman is the aid-man of his platoon,whose job it is to give urgent first aid, including aninjection to stop pain. " He does not remain with thefallen soldier, as he has to move forward with the attack.After treatment he ties a tag to the soldier’s belt tellingwhat type of treatment was administered, fixes a bit ofgauze to a bayonet or stick to mark the place where thesoldier is, and goes ahead. Now come the litter-bearers,attracted by the white cloth " ; and the patient is takento the battalion or regimental aid station, where he maybe given a transfusion of plasma, and is made ready forthe first stages of his journey to the base.

Picking up casualties, however, is not always as easyas it may seem. Compared with his predecessor on theWestern Front in 1914-18, the stretcher-bearer today hasless to fear from mud, and is helped both by wirelessinformation and by an abundance of motor transport.Indeed, he may become almost superfluous where a

vehicle can be taken to the patient instead of taking thepatient to a vehicle ; and this has-generally been possiblein the recent North African campaign. On the otherhand, the rapid movement of mechanised units meansthat casualties may be scattered over wide areas, andduring contact with the enemy the troops may be unable1. Army med. Dept. Bull., No. 19, January 1943.2. Report on Recovery of American Wounded. U.S. Office of

War Information. May, 1943.

166

to spare time even to apply field dressings to theirwounded comrades. In considering these factors MajorMurray 3 concludes that stretcher-bearers must bedisposed so as to provide immediate and essential first-aid, and he has devised a battle-drill for them whichreduces searching to a fine art. The squads are trainedto make systematic hunts in fields, scrub, woods andhouses. During the search each bearer works singly,and when he finds a casualty his duty is merely to stophaemorrhage and mark the man’s position so that thiscan readily be found again. The squad then re-forms,and, where necessary, removes the wounded in turn tothe most accessible place at which they can be trans-ferred to motor transport. As became customary inCivil Defence work during air-raids, first aid on the spotis reduced to a minimum, being mostly left until thepatient is in a vehicle. When accompanying troops inaction, the bearers must practise fieldcraft and personalcamouflage ; for they must never be responsible forgiving the unit’s position away to the enemy. And skillis also called for in " medical fielderaft "-the approachto, and removal of, the wounded man under fire bothby day and by night. In urging the importance of thisside of medical work in the field, Murray demonstratesthat it often needs a trained mind in a trained body ;but undoubtedly motor transport has lightened the

physical burden on the stretcher-bearer, and very oftenit can take his place.

ETHICS FOR THE YOUNG PRACTITIONER

IN an address to Guy’s students, Sir Herbert Eason 4has summarised the standards of professional ethics withthe authority of the president of the tribunal responsiblefor their enforcement. Mention of the Warning Noticeissued by the GMC naturally led him to an early referenceto the risks of lax certification. He had been appalled, 0-he said, in his hospital experience, to see house-officerssigning certificates in blank for sisters or nurses or

dressers to fill up afterwards-statements that the patientwas suffering from some disability or disease and wasunfit to follow his or her employment. He advisedstudents never to sign a blank certificate or any docu-ment for the entire accuracy of which they were unableto vouch. "It is no good saying’ I have today examinedSo-and-so’ when in fact you examined him yesterday."Next he expounded the warning against assistingunqualified practitioners. This was " infamous con-

duct " because it traversed the whole aim of the MedicalActs by obscuring the statutory distinction between thequalified and the unqualified. Administering an anaes-thetic to help an osteopath’s treatment of patients wascovering an unqualified practitioner. But this did notmean that the qualified man cannot ask a masseuse tomassage a patient. " You can even ask an osteopathor a chiropractor to assist you in treating a patient solong as the patient is under your own care." Of fourother classes of conduct often brought to the notice of theGMC the commonest was that of the practitioner founddrunk. The council, explained Sir Herbert, seldom takesa man off the Register for a single conviction of drunken-ness ; it will give him a warning. A second convictionfor drunkenness probably means a stiffer warning. Athird is likely to involve action. If a doctor habituallygets drunk, can he be fit to be in charge of patients ‘1 It is,of course, a grave matter to remove a man from the

Register for three cases of drunkenness. The councilmay perhaps suspend judgment and put the respondenton probation for a year or so, requiring certificates as tohis behaviour in the interval and insisting on an under-taking for good behaviour in future. Drunkenness in

charge of a motor-car is more seriously regarded. Itshows not only over-indulgence in alcohol but also areprehensible absence of responsibility. A man who,

3. Murray, R. O., J.R. Army med. Cps, June, 1943, p. 291.4. Guy’s Hosp. Gaz. July 10, 1943, p. 147.

when under the influence of alcohol, thinks himself fitto drive a dangerous machine like a car is a menace bothto his patients and to the public. The other threeclasses of professional misconduct were described as thethree As-advertising, abortion and adultery. Thefirst includes those flattering little paragraphs about thedistinguished surgeon or. eminent physician and hiswell-known patients-laudation which a few practi-tioners signally fail to avoid, to the detriment of theirmore honourable and reticent brethren. The second,abortion, is, as the law stands, a felony punishable withpenal servitude. Whatever views practitioners may holdabout birth control, whatever appeals may be made tothem to save an innocent’s girl’s reputation and herfamily’s credit and social standing, they must realise thatthe GMC cannot ignore what the state regards as a

serious crime. Lastly, a charge of adultery means thatthe council, without pretending to be a court of morals,must protect the public. Adultery per se is not infamousconduct in a professional respect, but, if committed witha patient or a member of a patient’s household, it is abreach of trust and an abuse of confidence. To hisadmirable exposition of the professional code, and hisvirile statement of the things which are " not done,"Sir Herbert Eason added two precepts of worldly wisdom.The practitioner who is charged in the police-court withdrunkenness or other offences should never allow himselfto be persuaded to plead guilty by the argument that hewill thus escape publicity. Secondly, as soon as he isqualified, he should join one of the well-establishedmedical defence societies. This will protect him fromthe formidable risks of practice, whether they arisefrom the accusations of female patients or from any othersource. It will ensure for him legal advice and assistancefrom the day of his registration to the day of his retire-

ment, amid unforeseen dangers which even the greatestcare can hardly avoid.

CONTINUOUS SPINAL ANÆSTHESIATHE continuous technique frees spinal anesthesia from

the disadvantages of single-dose administration ; and

though the minimum dose which must be given forabdominal anaesthesia will allow sufficient operating timefor most cases there are occasions when a chance to

lengthen anaesthesia is welcome. The method willtherefore apply chiefly to operations lasting longer than1-2 hours. In the last few years, though simpler andsafer methods have been developing, spinal anaesthesiahas once again suffered from the enthusiasm of its newrecruits, and those contemplating using the continuousmethod should take to heart Nosworthy’s advice, quotedby Lee (p. 156), to learn the old technique first and thenthe new one developed from it. Lemmon and Pascha1,1who first described the method, found it difficult tomaintain a good puncture with the patient lying, on hisback. The divided mattress and the malleable needleovercame this trouble. The malleable needle may in thelong run prove the best safeguard against breakage of thespinal needle, an accident sufficiently serious to make theuse of a hard steel needle a real danger. Reports so farindicate that spinal anaesthesia maintained over severalhours does not produce any detectable damage to thecentral nervous system ; but the use of 5% procaine inglucose may be compared (not without apprehension)with the 0-5-1% used for nerve blocking elsewhere.Fraser 2 obtained satisfactory results with 1 % procaine,and it should be borne in mind that lesions of the caudaequina have followed the use of strong procaine solutions.$Except perhaps in the hands of experts, the use of thistechnique for operations like appendicectomy, hernio-tomy and colostomy, seems unjustified, for the chance ofanaesthesia wearing off before the operation is finished1. Lemmon, W. T. and Paschal, G. W, jun. Ann. Surg. 1940, 111, 141.2. Fraser, R. J. Anœsth. & Analges. 1943, 22, 38.3. Ferguson, F. R. and Watkins, K. H. Brit. J. Surg. 1937-38,

25, 735.