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REGULATIONS

THE Government have now made a series of regula-tions governing general medical, dental, and pharma-ceutical services, and service committees and tribunal.These were laid before Parliament on March 15 andcame into operation on March 24-on which day theywere first obtainable from H.M. Stationery Office.

Copies will be sent to general medical and dental

practitioners, and to chemists, by the local executivecouncils. ’

The regulations amplify our information about the’intended methods of operation of the new service.Though they mainly follow the pattern of the regulationsof the National Health Insurance Acts, already familiarto insurance practitioners, they show some interestingand important differences. Some of these are intendedto simplify and improve upon present panel procedure,while others relate to new features of the service. Onanother page we publish some of the main provisions ofthe regulations concerning general medical services, andwe hope next week to deal similarly with the rules

governing the powers and procedure of the statutoryservice committees and those of the tribunal.

SIALOGRAPHY

SIALOGRAPHY is a radiological examination which is

employed less often than its usefulness warrants. Thisis perhaps because of the difficulty of catheterising theducts of the salivary glands, without which it is of courseimpossible to introduce radio-opaque substances intothe duct systems. There is no special difficulty in

catheterising the parotid duct, which is reasonablylarge, but no-one would guarantee that he could alwaysintubate the submaxillary duct. The sublingual ductis too small for catheterisation to be feasible.The technique of salivary-duct catheterisation requires

some preliminary organisation, a good light, considerablepatience, and a modest capacity in the operator for fineand gentle movement. Everyone who has thought aboutsalivary catheterisation has probably devised his owncannula. The type resembling a thin thiopentone-mixing needle, with or without an olive end, is suitableif it can be obtained. Some use an Andrews retrogradepyelography needle. But probably the best cannula isa short fine Pasteur pipette, its tip smoothed off in aBunsen flame and its butt connected to a small syringeby a length (varied to suit the operator) of rubber tube....It is exceedingly important to avoid injury to the ducts.Anything thin, hollow, and smooth which will enter theduct can be used as a cannula provided it does not

unduly dilate the orifice or injure the lining. The

syringe, connecting rubber tube, and cannula are filledwith warmed iodised oil, a substance which showsa remarkable propensity for getting too hot. With thepatient sitting for parotid catheterisation or lying forsubmaxillary catheterisation, the cannula is introduced

¼-½ inch into the duct. During this manoeuvre it isa great comfort to have an assistant holding, the syringe,to prevent its weight dragging on the cannula and its’piston sliding out to draw unwanted air into the cannula.The injection is then made slowly. Rather less than0-5 ml. is the usual quantity of oil required, but thepatient will give a clear indication when the ducts aregetting uncomfortably full.The normal sialogram is a thing of fairy-like beauty.

The ducts are seen ramifying in the gland substancelike the branches of a tiny fir tree. It is, however, in thedemonstration of obstructions to the duct that sialo-

graphy has its greatest practical value. Mr. B. Truscott,in a paper given at the Royal Society of Medicine onMarch 3 and as yet unpublished, emphasised the fre-

quency with which the sialogram will reveal both thefact and the site of partial obstruction in those puzzlingcases of recurrent sialitis in which neither clinicalexamination nor a straight X-ray film shows a calculus.One of four appearances may indicate an incompleteobstruction in a gland which neither swells after meals,nor shows suppression of salivation. The sialogram mayshow an abrupt cessation of the duct in its extra-

glandular course ; dilatation of the duct behind anobstruction ; a filling defect, ’often near the hilum of thegland ; or the beading and clubbing of the intiaglandularduct system which has been termed " sialectasis." Allfour types of obstruction, whether due to stricture orto a small radiotranslucent stone, yield to dilatationwith fine probes. Sialography is also useful on occasionin elucidating the anatomy of an external parotidfistula, and it may sometimes show up a salivary tumourby a curving deformity of the duct system or a failureof a part of the gland to fill. Sialography is not oftenneeded, but in suitable cases it may give a precisediagnosis which is unobtainable by other means.

STREPTOMYCIN SENSITISATION IN NURSES

THERE have been a few reported examples of dermatitisarising in laboratory technicians and others who havebecome sensitised to penicillin from constantly hand-ling solutions. Rauchwerger and his colleagues 1 in theU.S.A. now suggest that acquired sensitivity to strepto-mycin constitutes

’’ a definite occupational hazard for

nurses, pharmacists, laboratory technicians, or any oneconcerned with the administration or handling of thedrug." During twenty months in a thousand-bedtuberculosis hospital streptomycin was given to. 233

patients, and 6 nurses developed symptoms of sensitisa-tion. An initial erythema was followed by severe pruritusand a papulovesicular eruption on the fingers, and in5 cases there was also oedema and itching of the eyelids,presumably from rubbing this area with the fingers.The anti-histamine drug Pyribenzamine’ effectivelyrelieved the itching. These symptoms did not-developuntil the nurses had been handling streptomycin for atleast six months. Intradermal tests with 100 units of

streptomycin were done on 97 nurses ; definitely positivereactions were noted in 7 and’ doubtfully positive reac-tions in 6. The possibility that sensitisation had arisenfrom an actinomycotic infection was considered, butno evidence of sucn an infection was found.

By way of prophylaxis, Rauchwerger and colleaguesadvise all who handle streptomycin or the syringes andneedles used in its administration to wear rubber glovesand to wash their hands thoroughly after possiblecontamination. They would also submit all such peopleto periodic intradermal tests, to detect sensitisationbefore symptoms have developed.

SURGERY FOR INTERMITTENT CLAUDICATION

THE muscles of the calf are often the site of severe

disabling pain brought on by exercise though the patienthas no other symptoms of peripheral arterial obstruction.If this pain can be relieved the patient may again becomea wage-earner and a useful member of the community.In many patients lumbar ganglionectomy is of greatbenefit; prolonging the " claudication time " or even

effecting a symptomatic cure ; but in many cases thereis no improvement. These are the candidates for myo.neurectomy of the gastrocnemius or of the soleus as

described by Mr. E. Jepson at a meeting of the sectionof surgery of the Royal Society of Medicine on March 3.The pain must be assigned to the correct muscle by

injecting hypertonic saline into the tender spots alwayspresent in the calf. Briefly, if the severe claudication-like

1. Rauchwerger, S. M., Erskine, F. A., Nalls, W. L. J. Amer. med.Ass. 1948, 136, 614.

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pain caused by the injection is referred to the back ofthe knee it originates in the gastrocnemius, whereas painoriginating in the soleus is referred to the heel. This painof injection can be immediately relieved with procaine.The ideal case for operation is obliterative arterial diseaseaffecting the arterioles but leaving the main vessel patent.When the main vessel is obstructed the symptoms areusually more diffuse, and, owing to the development of a

collateral circulation, more likely to be relieved byganglionectomy. The operation is an anatomical dissec-tion of the muscular branches of the medial poplitealnerve at the back of the knee and the upper part of thecalf, and the division of those branches supplying theaffected muscles. Since the affected muscles are ischaemic,gTeat care must be taken to ensure accurate healingwithout sepsis-the only complication likely to arise.After operation the patient is free from exercise painand soon walks actively and well. Before denervationthe ischaemic muscles were wasted, so the patient learntto walk, and even run, without using them more thannecessary ; his rehabilitation therefore started before

operation, a fact which explains his rapid recovery.Probably many patients are quicker to walk normallyif they do not know that a muscle has been paralysed.This simple operation must not be performed withoutcareful investigation of the site of pain, or it will soonfall into disrepute.

RADIO-SODIUM STUDIES IN HEART-FAILURE

THE use of radioactive or stable isotopes in biologicalresearch makes it possible to follow the distributionand fate of a single element in the body, for it can beassumed that the normal elements behave similarlysince the body usually cannot differentiate between oneisotope and another. At St. Mary’s Hospital on March 19,Prof. G. E. Burch, in the fourth of the series of MedicalResearch Society invitation lectures, described thestudies carried out by his group at Tulane University,New Orleans,’ -with radio-sodium in chronic congestiveheart-failure. They set out not to confirm or refuteany theory of mechanical failure of the pump but ratherto increase our understanding of the abnormal-waterand electrolyte metabolism underlying cardiac cedema.The two radioactive isotopes of sodium with half-livesof suitable length, Na24 with 14-8 hours and Na22 with3 years, have both been available to Burch, but his

present paper dealt only with short-term studies withNa24, though unpublished observations with Na22 overperiods up to 9 months in single patients have pro-duced substantially the same findings. The outstandingabnormality of sodium metabolism in cardiac failure isthe slow " turn-over " rate. In normal subjects halfthe total amount of sodium in the body is replaced inabout 11 days, whereas in cardiac failure this takesabout 40 days. The sodium retention runs parallelwith a reduced clearance of plasma-sodium by thekidneys. Futcher and Schroeder 2 showed that hypertonicsaline given intravenously was retained longer in

patients with cardiac failure than in normal people,and they postulated that this depended on increased

reabsorption by the renal tubules. Burch found a

large increase in the percentage tubular reabsorption ofsodium filtered by the glomeruli. Merrill 3 and Mokotoffet al. maintain that the decreased sodium excretion

is secondary to diminished glomerular filtration in thepresence of constant tubular reabsorption ; in spite ofreduced renal blood-flow there is an extraordinarilyhigh filtration fraction (glomerular filtrate expressed aspercentage of the total renal plasma flow) in congestive1. Burch, G. E., Reaser, P., Cronvich, J. J. Lab. clin. Med.

1947, 32, 1169.2. Futcher, P. H., Schroeder, H. A. Amer. J. med. Sci, 1942.

204, 56.3. Merrill, A. J. J. clin. Invest. 1946, 25, 389.4. Mokotoff, R., Ross, G., Letter, L. Ibid, 1948, 27, 1.

failure- which makes it difficult to accept the viewof diminished sodium filtration. Whatever the renal

dynamics are in detail, the sodium retention can beabolished by mercurial diuretics.As yet these studies have yielded no new concept of

the disturbances in cardiac failure, though they suggestthat the oedema which forms part of the congestive-failure complex is secondary to a disturbance in renalfunction rather than to some imbalance in capillarydynamics. More striking are the findings of sodium

exchange in the normal subject. In following the

equilibration of intravenously injected radio-sodium (atmost a few mg. of sodium is introduced) between intra-vascular and extravascular fluid spaces it may beassumed that the movement of Na24 is only a reflectionof the movement of ordinary sodium (Na23). Some

32% of the total plasma sodium diffuses out from thevascular bed per minute, while an equal quantity ofsodium moves in from the extravascular spaces. Thisrate of exchange is very similar to that found by Gellhornet al. 5 working with dogs. Expressed as total sodiumchloride which crosses vascular capillaries in eitherdirection in the 24 hours, this amounts to 40,000 g. ormore picturesquely to " half a sack of salt." If therelative rates of sodium and water diffusion are the’same in man as in the guineapig,6 this would be equivalentto a movement of 6300 litres of water in the day.COMMEMORATION OF FRANCIS CHAMPNEYSON March 25 a service was held at the church of

St. Bartholomew-the-Great on the centenary of thebirth of Sir Francis> Champneys, obstetric physician toSt. Bartholomew’s Hospital, vice-patron of the RoyalCollege of Obstetricians and Gynaecologists, and chair-man of the Central Midwives Board for 27 years afterits establishment in 1902. The congregation includedrepresentatives of Australia, Canada, New Zealand, SouthAfrica, India, and Pakistan; Mrs. Attlee and Lady Cripps;the presidents of the three Royal Colleges, the RoyalSociety of Medicine, the Royal College of Nursing, theRoyal College of Midwives, and the Society. of MedicalOflicers of Health ; the Dean of St. Paul’s, the masterof the Society of Apothecaries, the secretary of the_Medical Research Council, and the chairman of theCentral Midwives Board ; many governors and membersof the staff of Barts,.with the matron and nurses ; anda number of midwives from the Royal College of Mid-wives and nurses from the Royal College of Nursing.The hymns and anthem were among those composed bySir Francis Champneys himself, and the lesson read byLord Moran was the passage from Ecclesiasticus in honourof physicians. Sir William Fletcher Shaw, who deliveredthe address, said that Champneys is remembered aboveall as one who gave continuous labour and ability to thetask of improving the midwifery service of this country.That service was his permanent memorial. Whenlargely through his efforts-and against much oppositionfrom the laity, the profession, and the midwives them-selves-the Government set up the Central MidwivesBoard, he was given the difficult task of raising standardswithout interfering too much with the existing service :under a chairman with less faith and vision and dynamicforce, progress would have been slower, and under onewith less patience and insight it might have been chaotic.The improvement made in forty years bore witness tothe success of a man who touched public and professionallife at many points but whose most characteristic featurewas his fearless honesty.

ON March 22 Lord MORAN was re-elected president ufthe Royal College of Physicians of London.5. Gellhorn, A., Merrell, M., Rankin, R. M. Amer. J. Physiol.

1944, 142, 407.6. Merrell, M., Gellhorn, A., Flexner, L. B. J. biol. Chem. 1944,

153, 83.