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CARE FOR HOME GUARD CASUALTIES

THE LANCETLONDO,N: SATURDAY, AUGUST 16, 1941

THE collection, evacuation and hospital treatmentof Home Guard casualties is the duty of the localA.R.P. authorities and of the hospitals of the Emer-gency Medical Service. They owe a similar dutytowards civilian casualties, but whereas A.R.P.ambulances will proceed right up to the spots at whichcivilians have been injured, and will send out first-aidparties to collect those outside the reach of ambu-lances, they are not allowed to extend these particularfacilities to Home Guard casualties. Their ambulancesand first-aid parties are forbidden to go further forwardthan casualty collecting posts which must be estab-lished by the Home Guard, and to which the HomeGuard must carry their own casualties. They mustalso be responsible for the care of these casualtiesuntil they are actually placed in ambulances. These

arrangements have made it necessary for HomeGuard medical authorities to consider how long thearrival of ambulances may be delayed, The airattack on Crete went on for several days and pre-sumably—though there is no precise information-any urban hospitals there were out of action longbefore active invasion ceased. One of the chief aimsof parachute troops, or of other invaders from the air,is to obtain motor transport, and the ambulanceoffers ideal camouflage for an enemy. A further

difficulty to be anticipated is the breakdown, partialor complete, of telephone services. To get a woundedHome Guard removed by ambulance at least threetelephone calls must be made : from the place ofwounding to the local control office thence to thehospital to see what wounded can be accepted ; andfrom the hospital to the ambulance centre withinstructions for the journey. In some circumstancesambulances might not be available for days ratherthan hours. Some are prepared to write off the

resulting death-roll and suffering as one of theincidental risks of war which cannot be avoided, butmedical officers cannot accept this view as long as itis within their power to plan the care of H.G: casualtiesand incidentally of civilian wounded, who could

hardly be excluded from H.G. posts when no otherhelp was available.

It is impossible to set up complicated posts like thefirst-aid posts of local authorities, but, as Dr. GORDONWARD has shown,1 it is possible to arrange, on a

voluntary basis, for protection from the weather ;warmth ; rest on beds, palliasses or cushions-; simplecooking (soups and hot drinks) ; and such skilled careas may be possible (in many cases a doctor will beavailable, in others a trained nurse or V.A.D., inothers simple home nursing). The Government

provides for each post 52 pad and bandage dressings,2 small tubes of tannic-acid jelly, 2 triangular band-ages, and a set of splints of which the longest measures17t in. This supply is intended only for the mostelementary first-aid treatment and was not intendedfor use during a period when ambulance traffic mightbe indefinitely suspended. There are other sources

1. Lancet, May 31, 1941, p. 708.

from which further supplies may be obtained-fromdoctors’ surgeries, chemists’ shops and private houses,where the supplies are much larger than is generallyappreciated ; and from the Red Cross societies. Fromthese each county could equip enough casualtycollecting posts for its needs. Mr. A. L. ABEL tells uson another page that in his area the difficulty has beencompletely overcome through the generosity of theCanadian Red Cross, but in general the H.G. medicalofficer can only tap these supplies if he first collectsfunds, and this is a duty which may well fall to his lot.Supplies are also being held in reserve by militaryand E.M.S. hospitals, and a portion of this stock mightbe dispersed among casualty collecting posts, where itwould be ready for an immediate emergency, ratherthan concentrated in vulnerable centres. Official

authority would have to be given by the Minister ofHealth before this could be done.The number of posts to be established must be

decided. The officially recognised plan is to sitesuch posts within reasonable distance of strongpoints which may be held by the Home Guard. Thedifficulty is that such posts are necessarily staticand cannot be moved about if a Home Guard unit

proceeds from one position to another. The alterna-tive is to dot the posts about the country or town insuch a way that wherever a Home Guard may bewounded he will find assistance within the distanceit is practicable to convey him by stretcher. To carrya man on a stretcher as much as a mile is a serioustask but it is scarcely possible to fix up the postscloser than this. Even if every sort of hospital andcivilian aid-post is counted as an already establishedcasualty collecting post, many more will have to beset up before such a network is established’ but the taskhas already been accomplished in at least one county.

PENICILLIN IN ACTIONSINCE it was first described by FLEMING in 1929,

penicillin, an active principle of the mould Penicilliurnnotatum, has been used in some bacteriological labora-tories for the isolation of Pfeiffer’s bacillus andBacillus pertussis because of its rather selectivebacteriostatic action on gram-positive organisms.Last year a stable product, obtainable in liquid orpowder form, was shown by a team of workers 1 inthe department of pathology at Oxford to have highclaims as a chemotherapeutic agent if only it couldbe produced in quantity. The Oxford workers havenow shown that large-scale production and purificationis a practical possibility. By a fine piece of concertedwork they have prepared a substance which seems tohave unique properties even in an age which will godown in history as the second chemotherapeutic era,although neither in their first nor present report is thereany clue to the chemical formula of penicillin.The optimum conditions-temperature, gaseous

environment, pH, substrate, adjuvant and inhibitoryfactors-for a good yield of penicillin were first deter-mined. Once the surface felt of the mould was wellformed over a shallow layer of fluid medium, severalbatches of penicillin could be prepared by withdrawingthe underlying fluid and adding fresh medium, butstrict sterility was essential because penicillin is

destroyed by certain bacteria. It -is also destroyed1. Chain, E., Florey, H. W., Gardner, A. D., Heatley, N. G.,

Jennings, M. A., Orr-Ewing, J. and Sanders, A. G. Lancet,1940, 2, 226.

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by exposure to highly acid or alkaline reactions, andoccasionally, for no obvious reason, little or no

penicillin was obtained from a particular batch.From the crude penicillin-containing fluid, the activeprinciple was extracted in an organic solvent-amylacetate was used-from which the penicillin was re-extracted by shaking with phosphate-buffer or waterat a pH of 6-7. Evidence of the presence of a pyro-genic substance at this stage meant treatment withcharcoal, re-extraction with ether, absorption byalumina, and further extractions until an aqueoussolution-the non-pyrogenic or therapeutic penicillin-was obtained as a deep reddish-orange fluid. This

substance, saturated with ether, is stable, and can bestored as such in the refrigerator, or dried and left inthe desiccator since the powder is hygroscopic. For

dispensing, the ether-containing solution would beused after removal of the ether by suction. The whole

process is complicated and would have to be carriedout with great care, but large-scale production shouldbe well within the compass of a biological instituteengaged in the preparation of bacterial toxins andantisera. About 100 litres of medium are requiredto produce 1 g. of therapeutic penicillin, which repre-sents about a third of the total substance in the crude

liquid. Obviously penicillin cannot yet be easily pro-duced on a large scale like the sulphonamides, or at acost which would allow it to be freely used, eventhough the dosage for generalised infections is no morethan 1 g. per day. As with other biological products,a stable standard and a reliable method of assay are

required; the Oxford workers’ method is to test the bac-teriostatic activity of penicillin by adding the fluid toan open cylindrical tube set in a plate of agar-mediumseeded with Staphylococcus aureus, and measure thediameter of the inhibitory zone after incubation. This

technique is also used for determining the presence ofpenicillin in the blood or urine of treated patients.

In-vitro tests of the bacteriostatic activity of penicil-lin on a wide variety of bacterial pathogens broughtout two remarkable features-( 1 ) its selective actionon certain gram-positive organisms, so that the

amazingly low concentration of 1 in 1-2 million couldprevent growth of the staphylococcus, Streptococcuspyogenes, and the anthrax and Welch bacilli ; and (2)the lack of any interference with its bacteriostaticaction by pus, serum or protein autolysates. In thislatter property penicillin has a great advantage oversulphonamides, as it also has power to inhibit the growthof relatively large inocula of organisms in any nutrientmedium. Thus, penicillin should act beneficially inheavily infected wounds and where there is much

purulent discharge. Because it is bacteriostatic andnot bactericidal-thus resembling the sulphonamidesbut differing from gramacidin-penicillin requires theactive help of phagocytic cells in dealing with an infec-tive process. It was therefore essential to find out ifit had any toxic effect on leucocytes or other tissuecells. Tests carried out with great thoroughnessshowed that penicillin was devoid of toxic action onliving cells and delicate tissues in concentrations of1 in 500-1000, which is considerably greater than theeffective therapeutic strength. Here again penicillinproved superior to the sulphonamides and to pro-flavine, which is probably the least toxic of the usefulantiseptics. For therapeutic use in systemic infectionsan immediate difficulty was the susceptibility of

penicillin to acid, so that administration by mouthseemed to be ruled out if a high concentration in thetissues was desired. Absorption from the intestine ofthe cat and of man (given by stomach-tube) was

moderately good, and means of avoiding destructionof the active principle by gastric juice can no doubtbe devised. In one of the Oxford cases a bactericidalconcentration was in fact maintained in a child’s urine

by giving the penicillin by mouth with sodiumbicarbonate. Given intravenously to man, an injectionof 200 mg. produced no obvious toxic effect ; blood-

samples still had slight bacteriostatic action after ’

2 hours and urinary excretion continued for at least6 hours. Half or more of the total dosage given totwo patients was excreted in the urine and part of thesubstance was recovered for future use.

Unless chemical synthesis becomes possible, thedifficulties and cost of production of penicillin will

probably limit supplies. If so its use should be largelyconfined to infections not likely to benefit from sul-phonamide therapy. Chief among these are infectionswith local thrombus-formation and metastatic lesions,such as acute and subacute staphylococcal pyamia,bacterial endocarditis and the septic thrombo-

phlebitis produced by anaerobic streptococci and

Bacterium necrophorum. The efficiency of a chemo-therapeutic agent in these infections depends not onlyon its potency against the infecting organism but alsoon its diffusibility into infected and dead tissue.Experiments to test this property should be carriedout with penicillin as HAWKING 2 has recently donewith the sulphonamides ; meanwhile the post-mortemfindings in a case of staphylococcal pyaemia withcavernous-sinus thrombosis suggest that penicillinhas this power of diffusion. A substance that can

produce so remarkable an amelioration of symptoms inthree classical cases of acute staphylococcal pyaemiamust be ranked high among chemotherapeutic drugs,for despite the claims on behalf of sulphathiazole,staphylococcal antitoxin and bacteriophage, there isas yet no sovereign remedy for generalised staphylo-coccal infection. The excretion of penicillin in cat’sbile may be an indication for trying its effects in

typhoid fever and typhoid carriers. In their pre-liminary report, the Oxford workers described thebenefit obtained in animals infected with staphylo-coccus, streptococcus and Clostridium sept<ique; ;it seems a promising step to extend this partof the investigation to animal infections which simu-late the sulphonamide-refractory infections of man.

THE THREAT OF TUBERCULOSISjitXpERiENCE shows that war-time conditions &iacute;avour

an increase in the incidence of tuberculosis. D’ARCYHART’s figures demonstrated such a rise during theperiod 1914-18, and it has recently been elicited inreply to Parliamentary questions that already thetrend of tuberculosis incidence has again turned

upwards. Doubtless many factors contribute toincreased tuberculosis prevalence in time of war, andit may be that some of the responsible factors areunavoidable. It is not easy to influence the strainsthat necessarily emerge from the complex tissue ofwar environment, and it becomes increasinglyimportant on that account to control so far as possiblethe factor of infectivity. There is still a considerable

2. Hawking, F. Ibid, 1941, 1, 786.