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committees which would know more about the peopleconcerned. On the other hand, it would be manifestlyunfair to allot each region a quota calculated on anyrigid scale, and there appear to be strong arguments forleaving the ultimate decision to a central body. Weshare the opinion of Dr. Cochrane Shanks, who was amember of the Spens Committee; that the principle ofmaking the higher salaries conditional on special meritand ability is a proper and necessary means of encouraginginitiative, and we are glad to note that he pictures thenational committee making its final selections " onlyafter considering most carefully the recommendationsfrom regional boards, teaching hospitals, Royal Collegesand Corporations, and specialist associations."

Other related questions which burn brightly are theremuneration of doctors directly employed by theGovernment and local authorities and the remunerationof teachers. The Minister has already shown himselfaware of the anomalies that arise from payment of teachersin medical schools at rates far below those obtainablein the public service by men and women of equal orinferior qualifications,2 and we are glad to hear that thecouncil of the British Medical Association is seekingimmediate negotiation to secure that the recommenda-tions of the Spens Committee on the remuneration ofspecialists are made applicable to full-time teachers andlaboratory workers.

ADRENALINE AND INFECTIONS

WHEN a bacterial suspension is inoculated into guinea-pig skin and muscle, the resulting infection is much moresevere if a small quantity of adrenaline is injected atthe same time. Evans and colleagues 3 show that thedegree of enhancement varies with the species ofbacterium used from twice to a hundred-thousand-foldand is most pronounced with 01. ’I1)fJhii and Cl. septicum.In their experiments the effect of bacterial toxins wasincreased only slightly by the addition of adrenaline,and there is reason to think that the enhancement ofinfections was due to the inhibition of diapedesisof leucocytes and to interference with the mobilisation ofthe other primary defences of the body ; possibly thelocal ischaemia also prevents the early removal ofbacteria from the site of infection. The dose ofadrenaline used was insufficient to damage the tissuespermanently, and the effect must not be confused withthat of such substances as calcium chloride which pro-duce sterile necrosis in the absence of bacterial infection.Have these findings any application to clinical practice ? If

Cooper 4 reported a case of gas-gangrene in man followingthe injection of adrenaline and showed experimentallythat 62-5 ILg. of adrenaline reduced the minimumlethal dose of OZ. welchii for a guineapig-to 1/10,000 ofthe dose without adrenaline. The dose used by Evansand colleagues was only 2 I-Lg. Even allowing fordifferences in body-weight (which are probably of smallimportance for a drug having a strictly local action)doses many times as great as these are used daily_ inlocal anaesthesia, and experience has shown that, giventhe usual aseptic precautions, local infections after theuse of adrenaline are extremely rare. Many surgeonsavoid local anaesthesia in the presence of gross sepsis, andwith good reason ; but it must be remembered that theearly local anaesthetics themselves had some slightcytotoxic action. With the improvement of these

drugs it might be worth while to investigate the validityof this old tabu.There are several established practices based on

laboratory work whose application to clinical medicine

1. Sunday Times, June 20.2. See Lancet, 1948, i, 374, 911.3. Evans, D. G., Miles, A. A., Niven, J. S. F. Brit. J. exp. Path.

1948, 29, 20.4. Cooper, E. Lancet, 1946, i, 459.

is on unsure ground. For example, is the doctorjustified in withholding anti-typhoid inoculation duringan epidemic for fear of rendering the patient moresusceptible to infection during the negative phase ? qThe answer is that we just do not know, but the objectionis raised in every outbreak of enteric infection. Similarlythe paper under discussion may lead to the omissionof adrenaline from local anaesthetics with which it hasbeen incorporated for very good reasons. The careful

experiments of Evans and colleagues do not pretend toreproduce the conditions of clinical practice and theydo not seem to call for any change in current procedure.They do suggest however that someone might profitablymake a detailed clinical and bacteriological examinationof the effects of local anaesthesia in the light of modernknowledge. ,

IN SEARCH OF BETTER HOSPITALS

IMPRESSED by the need for a re-examination of thepurpose and pattern of our hospitals, the NuffieldProvincial Hospitals Trust has joined with the Universityof Bristol in sponsoring a detailed investigation. Thetime, as we have suggested,1 is apt ; for years mustelapse before new construction makes good existingdeficiencies and meets the fresh needs of the new service.The Nuffield research programme concentrates principallyon aspects which may be clarified in the 2-3 years thatthe inquiry will continue. It will be undertaken by awhole-time team, including representatives of a numberof interested professions, under the direction of Mr. JohnMadge, A.R.LB.A., with Mr. L. Farrer-Brown, secretaryof the trust, as coordinating chairman. The investigatorsare setting themselves to gain a panoramic picture ofthe hospitals’ structure and life, and at points their studywill run parallel with the hospital job-analysis which isalready proceeding under the segis of the trust. But

beyond that an attempt will be made to look at planning" with fresh unprejudiced eyes," and to review thedistribution of work between hospitals and other healthagencies-a scrutiny that is long overdue. Not the leastof the advantages that may accrue from this programmeis the stimulation of long-term research in the samefield.

DAMAGE AT ENDOSCOPY

INJURY to the pharynx and oesophagus, whether byswallowed foreign bodies, endoscopy, or flying missiles,has always carried a grave risk of death from suppurativemediastinitis and toxemia. Thoracic suction and theloose bed of cellular tissue in which the mobile pharynxand cesophagus lie give rise to a rapidly developingsurgical emphysema and spreading infection whichordinary surgical drainage has little power to arrest.In consequence of this, an ultra-conservative attitude-has been adopted in cases of accidental perforationsoccurring during cesophagoscopy or gastroscopy, treat-ment being limited to chemotherapy and prohibition offluids by mouth. Some endoscopists have advisedincision of the neck to open up the fascial coveringsin the region of the tear and packing of the wound toprevent surgical emphysema and spreading cellulitis,and this is a method whioh has given excellent resultsin penetrating wounds of this region in the recent war.2Before the days of penicillin, cellulitis and sloughing ofthe tear in the pharynx or oesophagus either preventedadequate suturing or ruined it through postoperativeinfection, but, now that penicillin can prevent this,prompt surgery can undoubtedly save patients who havesustained a tear of the oesophagus through endoscopy.Fletcher and Averv Jones pointed out that the commonsite for tears after cesophagoscopy and gastroscopy is

1. Leading article, Lancet, 1948, i, 373.2. Lichtenstein, M. E. Surg. Gynec. Obstet. 1947, 85, 734.3. Fletcher, C. M., Jones, F. A. Brit. med. J. 1945, ii, 421.

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the posterior wall of the lower pharynx and upperoesophagus, and Hermon Taylor 4 indicated how thisresulted from pressure between the instrument and theprominent convexity of the extended cervical spine,rather than from any anatomical weakness of pharyngealwall. In his article last week (p. 985) Mr. J. C. Golighertakes the view that the cesophagopharyngeal wall shouldalways be explored in patients developing surgicalemphysema in the neck after endoscopy, providedthe endoscopist can exclude damage, for exampleby biopsy or dilatation, to the lesion for whichthe examination was undertaken. Most gastroscopistsand cesophagoscopists would perhaps advocate a morecautious approach, since clinicians with experience inthis field will recall many cases with excessive sorenessin the throat and perhaps a degree of swelling in theneck which they have felt must have been due to a smalllaceration, and which have readily recovered with

chemotherapy and the withholding of fluids. However,if such a case shows no sign of limitation, Goligher’s planof prompt operation is the correct one, with the objectof suturing the tear as he describes ; and if this isimpossible, the wound should be packed and drained.

DISTRIBUTION AND SAFETY OF MILK

THE Williams Committee on milk-distribution, whichreported last month, recommended the setting up of anindependent commission to take over the responsibilityof the Ministry of Food for the marketing of milk. It

suggested that the commission should operate experi-mentally as processor and retailer, with monopoly powers,in one or more of the new satellite towns* Such acommission would take over some of the functions ofthe Milk Marketing Board, which has done much tostabilise prices for the farmer since the depression ofthe 1930’s. It is therefore not surprising that thereshould be strong opposition from farmers to these

proposals.5 I) The committee believes that its schemewould be preferable to the alternative of public ownershipboth now and in the more distant future, but two ofits members consider that public ownership and operationwould ultimately secure greater economies.The committee urged the application of compulsory

heat-treatment to all milk except in remote areas. Forthe present it would exempt T.T. milk, " which largelyprotects the consumer from at least the most seriousof the milk-borne diseases," but it would prohibitfrom the outset the retail sale of accredited milk in anyarea scheduled for heat-treatment. The Governmenthave now decided to introduce a Bill to prevent milkfrom being sold retail unless it has been heat-treated oris sold as T.T. milk or accredited milk from a singleherd. There is no scientific justification for the exclusionof accredited milk from heat-treatment, even if it comesfrom one herd. Accredited milk is usually cleaner thannon-accredited, but it has no greater freedom from disease.On the average, milk from any one herd will containtubercle bacilli less often than bulked milk, but when itdoes the infection will usually be much more severe.

The Government’s reason for not accepting this recom-mendation of the Williams Committee appears to be the

practical one that facilities for heat-treatment are --in-sufficient. The Milk Marketing Board will be establishingan experimental creamery in Durham which will offerproducer-retailers facilities for heat-treatment which

they could not afford for themselves individually. Ifthe scheme is successful these facilities will presumablybe extended to other areas as rapidly as possible.

It is of the utmost importance to dairy farmers andmilk consumers that better progress should be madewith the attested herds scheme, so that within the next

4. Taylor, H. Ibid, p. 543.5. Farmers Weekly, 1948, 28, 27.

few years groups of parishes and then whole countiescan be cleared of bovine tuberculosis. A recent summary 6of the progress already made shows that there are nowover a million cattle in attested herds. As was emphasisedduring the Parliamentary debates on the VeterinarySurgeons’ Bill, the control of tuberculosis and otherdiseases of cattle contributes directly to public healthand also increases the efficiency of milk production.

PHARMACY IN THE SERVICE

ALL dispensing in the National Health Service, exceptthe relatively small volume done by doctors in ruralareas, will be in the hands of retail pharmacists and islikely to remain there at least until health centres arefirmly and widely established. No extensive examina-tion of the position of pharmacy has been attempted sincethe inquiry instigated by the Pharmaceutical Societyover a decade ago, but a concise picture of present-dayconditions emerges from the report 7 of a working partyset up by the Minister of Health and the Secretaryof State for Scotland to study the dispensing practicesin their respective domains. The working partyestimates that in England and Wales 80% of practi-tioners now undertake dispensing for their privatepatients, whereas in Scotland the figure is only 10%.Hence the English pharmacist must expect a largeincrease in his " non-insurance " dispensing and this willusually involve enlarging the dispensary. Shortage ofstaff may prove an additional difficulty, but most

qualified dispensers are not fully employed on this work ;the average usual output per dispenser was found to be6390 prescriptions in England, 4040 in Wales, and 5120in Scotland, whereas an expert dispenser, working ina properly equipped dispensary, might be expected todeal with 9000 prescriptions a year, or about 4 per work-ing hour. This potential output could be increasedin areas where prescribing follows a common form butin a London West End pharmacy, following the besttraditions of the craft, 3 prescriptions an hour is perhapsthe maximum capacity of the pharmacist. Man-powershortage can be reduced by the use of non-dispensers formany ancillary tasks in the pharmacy.

Prescribing habits differ widely in the two countries ;in England over 83% of mixtures in insurance practiceare prescribed from formularies, either the National orthe B.P.C., and 37.8% in private practice, against only3.5% and 1-3% respectively in Scotland. In Scotland,however, about 19% of mixtures are prepared fromdoctors own formulae, a feature which is absent fromEnglish and Welsh prescribing ; ointments prescribedshow a similar trend. The shelves of English pharmaciescontain an average of 12 stock mixtures, all of whichare prepared on the premises and used within a fewdays ; these time-saving devices are not used in Scotlandor in Wales. Concentrated stock mixtures are littleused throughout Great Britain. Scottish pharmacistslook on each prescription as a thing apart, ordered forthe needs of a particular patient, and maintain that itshould be compounded from scratch ; the Englishpharmacist contends that the small errors which areinseparable from all processes of measurement are reducedto a minimum in the larger quantities involved in stockpreparations.The terms offered to English and Welsh pharmacists

for participation in the new service have been acceptedwith only a token resistance movement in a few areas.A conference of pharmaceutical committees and branchesof the National- Pharmaceutical Union, which representsproprietor chemists, first rejected - the terms offered,but then accepted an amended offer, regarded as equal6. Vet. Rec. 1948, 60, 302.7. Report of the Working Party on Differences in Dispensing

Practice between England and Wales and Scotland. H.M.Stationery Office. 1948. Pp. 46. 1s.